Researchers Behaving Badly ANZCA BULLETIN

September 2012 ANZCA Bulletin

Researchers behaving badly

Plus: A vision for the ANZCA 10 years College: ANZCA Curriculum on from strategic plan Revision 2013 The Bali 2013-2017 update bombing 8 ANZCA Strategic Plan 2013-2017 The College has developed a strategic plan for the next fi ve years.

ANZCA Strategic Plan 2013-2017

Advancing anaesthesia, improving patient care

24 The revised curriculum and you Next year’s training program will benefi t all.

22 Bali bombing 10-year anniversary October 13, 2002 started as an ordinary day at the Royal Darwin Hospital but things soon changed.

ANZCA Bulletin

Medical editor: Dr Michelle Mulligan Contacts Editor: Clea Hincks Head ofﬁ ce 630 St Kilda Road, Melbourne Production editor: Liane Reynolds Victoria 3004, Australia Sub editor: Kylie Miller Telephone +61 3 9510 6299 Facsimile +61 3 9510 6786 Design: Christian Langstone [email protected] Advertising manager: Mardi Mason www.anzca.edu.au Submitting letters and other material Faculty of Pain Medicine We encourage the submission of letters, news and Telephone +61 3 8517 5337 feature stories. Please contact ANZCA Bulletin Editor, [email protected] Clea Hincks at [email protected] if you would like Copyright: Copyright © 2012 by the Australian The Australian and New Zealand College of Anaesthetists to contribute. Letters should be no more that 300 words and New Zealand College of Anaesthetists, all rights (ANZCA) is the professional medical body in Australia and must contain your full name, address and a daytime reserved. None of the contents of this publication may and New Zealand that conducts education, training and telephone number. be reproduced, stored in a retrieval system or transmitted continuing professional development of anaesthetists in any form, by any means without the prior written and pain medicine specialists. ANZCA comprises about Advertising inquiries permission of the publisher. 5000 Fellows and 2000 trainees across Australia and To advertise in the ANZCA Bulletin please contact New Zealand and serves the community by upholding Mardi Mason, ANZCA Marketing and Sponsorship Please note that any views or opinions expressed in the highest standards of patient safety. Manager, on +61 3 9510 6299 or email this publication are solely those of the author and do [email protected]. not necessarily represent those of ANZCA.

2 ANZCA Bulletin September 2012 16 Researchers behaving badly Recent cases of scientifi c misconduct have thrown the spotlight on anaesthesia.

78 STEPS in the West Researchers A program in WA is helping many behaving badly people with persistent pain.

40 Anaesthesia in war zones Dr Jenny Stedmon has decades of experience working for the Red Cross in disaster areas.

Contents

4 President’s message 26 How anaesthesia departments are 54 ANZCA Trials Group 6 Chief Executive Offi cer’s message affected by the revised curriculum 56 New Zealand news 7 News 28 College launches training and 60 Australian news accreditation handbook 8 A vision for the College by 2017 68 Special interest group events 29 Investing in a world-class training 10 ANZCA in the news program 70 Faculty of Pain Medicine 11 Anaesthesia stories: People and 32 Anaesthetic history: Dr William Russ 76 Hypnosis research brings events shaping a modern specialty Pugh’s eventful life new awareness 11 Continuing professional development 34 Propofol misuse among anaesthetists 78 STEPS in the West for people going mobile – is it a problem? with persistent pain 12 Three councillors farewelled 36 Overseas Aid: Central American 80 Library update 13 Professor of Anaesthesia specialists learn Essential Pain 82 ANZCA Council meeting reports – University of Melbourne Management 86 Obituaries 14 ANZCA and government: 37 Overseas Aid: Oximeter donation 89 Future meetings building relationships helps to save lives in Papua New Guinea 91 life&leisure: Early adapting 16 Researchers behaving badly anaesthetists buzz with 22 Remembering a day of terror and 40 War zone anaesthesia new technology 44 Quality and safety triumph: 10 years on from the 94 life&leisure: Visit Spain Bali bombing 50 New Fellows Conference 2013 24 How the revised curriculum will 52 Anaesthesia and Pain Medicine benefi t you Foundation – a clear purpose

3 President’s message

Strategic Plan 2013-2017: Quality and safety What’s in it for Fellows? ANZCA’s professional documents set the standard for anaesthesia practice in This month, ANZCA launches its strategic Australia and New Zealand. Currently in plan themed “Advancing anaesthesia, development or review are documents on improving patient care”. Developing this airway management, the expert witness, plan has involved extensive consultation anaesthesia and echocardiography, with Fellows, along with trainees, staff infection control, and pain relief and end- and external organisations. The College of-life issues. Recently, ANZCA established is listening to its Fellows, and building the Anaesthetic Allergy Sub-Committee, services and products to assist and under the leadership of Dr Michael Rose, support them. While the plan officially to produce guidelines and other resources commences next year, the foundation for for prevention and management of many of the 16 objectives underpinning anaesthesia-related allergy. Participation the four strategic priorities is already in web-based anaesthesia incident under way, as outlined below. For more reporting continues to increase with more information about the plan, see page 8. than 40 hospitals now reporting through Strategic priority 1: Advance the tripartite ANZTADC website www.anztadc.net. standards through training, education, accreditation and Accreditation research Heads of department will be planning for the introduction of the revised curriculum Training for clinical supervisors and ANZCA has set up a webpage headed For the launch of our world-class training “Supporting departments”. The release program in 2013, ANZCA is ensuring that this month of the ANZCA Handbook for all Fellows who supervise trainees have Training and Accreditation and Regulation access to training for their important roles. 37: Training in anaesthesia leading to Options include face-to-face workshops FANZCA and accreditation of facilities to and the online Foundation Teachers deliver this curriculum will provide even Course, which runs over eight weeks. To more detail about requirements. ANZCA date, more than 60 per cent of supervisors has advised all jurisdictions in Australia of training plus an additional 350 and New Zealand about the revised Fellows have attended workplace-based curriculum. assessment (WBA) workshops, many led by the 25 WBA champions. Evidence for our clinical practice The ANZCA Research Committee Continuing professional development adjudicated and the Anaesthesia and Dr Lindy Roberts and continuing medical education Pain Medicine Foundation allocated President, ANZCA support more than $860,000 for research projects Later this year, access to the ANZCA/FPM in 2012. The ANZCA Trials Group, led Continuing Professional Development by Associate Professor Tim Short, Program will be improved by the launch generates internationally recognised of a new mobile continuing professional outcomes through its involvement in large development (CPD) platform, configured multicentre trials. Additionally, it nurtures for smartphones. ANZCA and FPM, with emerging researchers and develops the input of many Fellows and trainees, new ideas through its annual strategic run numerous high quality continuing research workshop. medical education events including the annual scientific meeting (ASM), Strategic priority 2: Build tripartite special interest group meetings, engagement, ownership and unity workshops and other meetings across Australia and New Zealand. We also are Improved online services providing more online resources. So far Projects are under way to streamline this year, we have offered 16 podcasts, services to Fellows through digital nine webinars and our well-regarded ASM channels. Examples include online e-newsletter with daily updates for those registration for events, mobile access unable to attend. to CPD through smartphones and the development of the training portfolio system.

4 ANZCA Bulletin September 2012 Focus on Fellows: seeking your feedback History and heritage Working for the whole community I am aware that time-poor Fellows are The College is working to ensure access The Indigenous Health Committee is sometimes concerned about the level of to our rich history for current and future developing eight podcasts about working service they receive when contacting the generations. Most recently, this has with indigenous communities. These College. Under the leadership of our new resulted in the “Anaesthesia stories” will be released in coming months in the chief executive officer, customer service series, led by Dr Christine Ball. These e-learning section of the website. charters for staff are being developed are short interviews with luminaries in to ensure that Fellows and trainees are anaesthesia and pain medicine. Watch out Overseas aid assisted quickly and efficiently. La Trobe for the first three – Dr Duncan Campbell, The Overseas Aid Committee is continuing University is undertaking a study of Fellow Professor Tess Cramond and Dr Nerida to expand the delivery of the Essential engagement with the College. The 2013 Dilworth – on the website. Pain Management course, recently holding fellowship survey is in development. Both it for the first time in Central America (see will inform further activities to support Strategic priority 3: Develop page 36). The teaching materials have Fellows. I encourage you to respond to and maintain strong external now been translated into Spanish. Earlier ANZCA surveys. this month, committee chair Dr Michael relationships Cooper and Adelaide anaesthetist Dr Chris Our binational College Policy submissions Acott attended the Papua New Guinea Fellows, including councillors, on both This year so far, ANZCA and FPM have annual medical symposium. Dr Cooper side of “the ditch” embrace the richness provided more than 30 submissions delivered 93 pulse oximeters arising out and strength of our diversity in having to the Australian government and of donations from Fellows and trainees strong representation and input from both more than 20 in New Zealand. These at the Perth ASM. Australia and New Zealand. The College have been on matters as diverse as engages externally with other colleges accreditation standards for medical Strategic priority 4: Ensure ANZCA and organisations through the Committee schools, dextropropoxyphene withdrawal, is a sustainable organisation of Medical Colleges in New Zealand (of international criminal history checks and Using our resources effectively which Dr Geoff Long, ANZCA NZ National the Medical Board of Australia (MBA), As a non-government, not-for-profit Committee Chair, is a member) and in proposals for prescribing by non-doctors organisation we depend upon the Australia, the Committee of Presidents of and MBS access for training. In New resources provided through Fellows’ Medical Colleges (of which I am a member Zealand, ANZCA continues to work with subscriptions as well as training and other and Immediate Past-President Professor Health Workforce New Zealand on the fees, along with judicious management of Kate Leslie is chair). development of regional training hubs our investments, to deliver core activities. and the physician assistant project. ANZCA and the Faculty of Pain Medicine The ANZCA Council, along with the chief Increasingly, outside bodies are seeking executive officer and senior management, working together ANZCA’s input to important matters that Associate Professor Brendan Moore, is aware of our responsibility to ensure determine how healthcare is provided that these resources are used wisely. Our Dean of FPM and ANZCA councillor, to our community. and I welcome opportunities for new CEO, Ms Linda Sorrell, is ensuring collaboration, building on the work of The profile of anaesthetists and that our staff and systems are working former presidents and deans. Apart from pain specialists effectively and focusing on quality joint documents and events, recently we Publicising our messages about safe outcomes. An example of this is reflected have had opportunities for co-ordinated and high quality anaesthesia and pain in her Bulletin message (page 6) where development of strategic plans as medicine is enhanced by a broader public she describes the IT roadmap. well as sharing around curricula and profile. A potential audience of more than Acknowledgement of contributions international medical graduate specialist 13.5 million people has been exposed Finally, as an organisation we are assessment processes. to the work of ANZCA and FPM through indebted to the input of numerous Fellows coverage by 576 media outlets of 30 media Publications and trainees in the many roles that they releases and other news generated by the undertake, both in and outside their ANZCA seeks to continually improve Communications Unit this year. ANZCA its publications including the quarterly places of work. Notwithstanding that as issued media releases for most regional contributors we receive as well as give, it is ANZCA Bulletin, the monthly ANZCA and special interest group meetings, E-Newsletter, FPM’s Synapse and the vitally important that these contributions for publications including the Safety of are acknowledged. The ANZCA Council Training E-Newsletter. Australasian Anaesthesia report (2006-2008), edited Anaesthesia 2011 (the “Blue Book”), edited will examine closely the results of the by Dr Neville Gibbs, and Australasian La Trobe study and fellowship survey by Associate Professor Richard Riley, and Anaesthesia, as well as to promote results containing 26 articles written by Fellows, to ensure its efforts are focused on of research by Fellows. Nine media appropriate recognition. was promoted in electronic format for the releases were issued for the Perth annual first time with hard copies available on I commend the strategic plan to you – it scientific meeting, resulting in 347 provides a roadmap to build the strength request. This is in response to concerns media reports. expressed by some Fellows about our and collegiality of our college as we support environmental impact and increasing Fellows and trainees in the delivery of safe comfort with electronic formatting. and high quality clinical care. I welcome your feedback.

5 Chief Executive Officer’s message

In recent months, the College has focused By the end of September, the much attention on its information “workplace-based assessment” technology (IT) capabilities. component testing should be completed. We are acutely aware of the need for This key component of the training our Fellows and trainees to be able to portfolio system allows trainees and their undertake College-related activities in supervisors to record the different types different environments – at different of assessments required for progression hospitals, in different operating theatres through the training program. or at home – so much of what we are Components to be tested over coming developing can be used on smartphones weeks (prior to the launch of the TPS and tablets. in December) include “rotations and One project being undertaken by placements”, which records training the College that recognises this is site information; “clinical placement CPD for mobile, the online continuing review”, which replaces the in-training professional development (CPD) mobile assessment process; “core unit review”, application. This allows Fellows to record which records the progression from one their CPD activities via their smartphones training period to the next; and “courses at a time and place that suits them. and events”, which records completion of Fellows will be able to view in real-time such activities as Effective Management their CPD status, enter activities on the go of Anaesthetic Crises (EMAC) and Early and email a statement or certificate to a Management of Severe Trauma (EMST). nominated email address. See page 11. Finally, the “dashboard” component, By the end of the year, the College which gives an overview of where a website will feature event registration trainee is at in the training program, online. This will enable Fellows to register will be tested. for all ANZCA events through online Developing online learning is also an facilities integrated into their ANZCA important focus for the College. Activities ID. This easy-to-use feature also should include the trial of the online Foundation save time. Teacher Course, which provides a rich The website’s event calendar also has environment for participants to share been updated to provide better visibility learning experiences and resources. Four and search capability. modules have been developed covering One of the biggest IT projects “Doctor as educator”, “Planning effective being undertaken by the College, the teaching and learning”, “Interactive establishment of the new training teaching and learning” and “Teaching portfolio system (TPS), is being developed in the anaesthesia clinical setting”. Two to support ANZCA’s revised training further modules, “Teaching practical program, which commences in the 2013 skills” and “The supervisory role” are due Ms Linda Sorrell hospital employment year. It is a web- for completion at the end of the year. Chief Executive Officer, ANZCA based system that can be accessed via Overseeing many of these projects is

computer and smartphone. the new Strategic Project Office, a unit The TPS has been built by a recently established (within existing professional software developer and is staffing) following a review of IT that was now undergoing testing. completed this year. This review resulted The “cases and procedures” component in the development of a strategy around IT of the system, which allows trainees to log and information management (IM), also their clinical experience, has been tested. known as the IT/IM roadmap. So too the “training time” component, The IT/IM roadmap and the Strategic which records the time trainees spend in Project Office will help us to deliver the the program and includes hospital and many projects we are undertaking to rotation information. move the College forward.

6 ANZCA Bulletin September 2012 A vision for the College by 2017 ANZCA Strategic Plan 2013-2017 In this 20th anniversary year of our A strong College College, it is exciting to reflect upon Collegiality remains the foundation of how far ANZCA has travelled since its our strength as an organisation. We must Mission establishment, thanks to the hard work recognise, support and acknowledge and defining contributions of former contributions. It is critical that we work leaders, other Fellows, trainees and our together to embrace opportunities, and staff. These provide a solid foundation be proactive in the way we collaborate upon which to build our shared future. with and influence others. The College The development of this strategic plan should seek feedback from its members presented an important opportunity and use that wisely to further our joint to consult with many key groups and aspirations. We must remain responsive individuals, both within and outside the to changing needs and new challenges, College. Their responses have provided as well as fostering work environments the basis upon which this strategy is that support and advance education and crafted. The outcome is a modernised scholarship. Above all, we must ensure mission and a clear, achievable vision – a that messages about safe and high quality flexible yet robust roadmap for the next anaesthesia, perioperative care and pain five years. medicine are heard, understood and acted upon. Changes, challenges and opportunities On behalf of the ANZCA Council, I Some things are unchanged: ANZCA’s 8 commend to you this strategic plan. It core mission, the driver for everything will guide decision-making and resource we do, keeps us firmly focused on the allocation as we work towards achieving To serve the community provision of safe, high quality patient our vision for the College by 2017. I look care for our community. Also unwavering forward to being a part of the College’s by fostering safety and is the dedication and expertise of all evolution during my two years as those who work to advance standards high quality patient president and to witnessing, when ANZCA of training and practice. However, the celebrates its 25th anniversary, just how care in anaesthesia, economic, political and social landscape much stronger we have become. in which we deliver on our mission has perioperative medicine changed, and will continue to do so. Curriculum Revision 2013 is a good Dr Lindy Roberts and pain medicine example of how ANZCA stays true to its President, ANZCA core purpose whilst leading innovation and improvement. Twenty years ago, our training program was entirely paper- based; now it includes an electronic portfolio system, e-learning and other internet resources. Learning will also be supported by workplace-based assessment tools and regular feedback on performance.

ANZCA Bulletin September 2012 Advancing anaesthesia, improving patient care Vision Strategic priorities Objectives

- Deliver a world-class training program - Provide a professional development framework that supports ongoing Advance standards through development and maintenance of skills and training, education, accreditation expertise and research - Promote and support research in anaesthesia and pain medicine - Set clinical standards that reflect best practice and support safe, high quality patient care

- Enhance the delivery of services to Fellows and trainees - Promote and demonstrate the value of ANZCA will be a Build engagement, ANZCA fellowship ownership and unity - Strengthen connections within and between recognised world all parts of the College leader in training, - Expand and strengthen the collaborative education, research, relationship between ANZCA and the Faculty of Pain Medicine (FPM) and in setting standards for anaesthesia and - Develop productive collaborative pain medicine relationships - Engage and influence government and other key stakeholders Develop and maintain strong external relationships - Raise the profile of anaesthesia, perioperative medicine and pain medicine - Advocate for community development with a focus on indigenous health and overseas aid

- Develop and retain the best people - Ensure ANZCA’s systems and processes are focused on quality outcomes Ensure ANZCA is a - Acknowledge and support Fellows’ sustainable organisation and trainees’ involvement with, and contributions to, the College - Promote anaesthesia and pain medicine as professions

9 ANZCA in the news

A potential cumulative audience of more • Perth anaesthetist Dr Mary Hegarty’s Since June this year, than 2.8 million people has accessed landmark Australian research on news about ANZCA and the Faculty of the effects of anaesthesia on young ANZCA has generated… Pain Medicine since June. ANZCA has children, which was published in issued nine media releases, generating 172 Pediatrics. Nearly 750,000 people 24 print stories media reports to promote most regional across 44 media outlets were exposed and special interest group meetings, the to reports about this study. 49 online stories publication of Australasian Anaesthesia • Melbourne anaesthetist Professor Paul (“the Blue Book”), and research Myles’ work on the effects of general 99 radio reports conducted by Fellows. anaesthesia on redheads and their Topics that generated the most interest recovery time after surgery, which was included: published in Anaesthesia and Intensive Media releases distributed by ANZCA since June this year • Ballarat anaesthetist Dr Rob Ray’s Care. The story was covered by 45 presentation to the Rural Special media outlets and reached a potential Do redheads feel more pain? (August 27) Interest Group meeting on dealing with cumulative audience of 1.2 million Landmark Australian study on anaesthesia in-fl ight medical emergencies. Dr Ray people. and young children (August 21) gave 13 radio interviews on the topic, New device for weight loss and diabetes heard by more than 327,000 people, and Meaghan Shaw control discussed (July 27) Media Manager, ANZCA also was reported in print and online, Better pain focus at hospital helps cut appearing across 45 media outlets. stays by nearly fi ve days (July 26) • Christchurch anaesthetist, Dr Ben New book highlights the latest van der Griend’s fi ve-year study of innovations in anaesthesia (July 23) children undergoing anaesthesia at ANZCA Bulletin out now: Ventilator the Royal Children’s Hospital, where inventor honoured; New anaesthetic he used to work. The study, presented allergy group, Helping in Dili (July 11) to the Queensland combined medical education conference, suggested there Healthy children at low risk from was little or no risk of death related anaesthesia-related death (July 6) to anaesthesia in healthy children Is there a doctor on board? Responding undergoing operations. This story was to in-fl ight emergencies (July 5) read or heard by more than 337,000 Old drugs offer new uses for pain relief people and was picked up by 13 online (June 15) news outlets. All media releases can be found at www.anzca.edu.au/media

10 ANZCA Bulletin September 2012 Three councillors farewelled

A dinner was held at the College in June in honour of Dr Leona Wilson and Dr David Jones on their retirement from ANZCA Council and Dr Justin Burke who completed his term as the new Fellow representative. Dr Wilson from Wellington is a former ANZCA president and is now the director of professional affairs (IMGS) and presented the College with representational cloak made from paua shell, which is unique to New Zealand. Dr Jones, from Dunedin is the immediate past dean of FPM, and presented the College with a framed print of a white heron called a “Kotuku”. In Maori oratory, the most telling compliment is to liken someone to Kotuku.

Clockwise from top to left: Professor Kate Leslie, Dr Lindy Roberts, Dr Genevieve Goulding and Dr Leona Wilson; Dr David Jones and Dr Lindy Roberts; Dr David Jones addresses guests; Dr Kate Leslie and Dr David Jones; Dr Justin Burke and Sally Burke; Dr Vanessa Beavis, Dr Leona Wilson and Dr Alan Merry.

12 ANZCA Bulletin September 2012 Professor of Anaesthesia – University of Melbourne

Communications, who recognised the “If this chair is a success, the status of advances anaesthesia has made in anaesthesia within the medical and wider teaching and research in the past 20 years. community will be greatly enhanced.” “They have been wonderfully Professor Story completed his BMedSci supportive of this new initiative,” said in altitude physiology in 1986 and Associate Professor Michael Davies, who graduated in medicine from Monash led the process of consulting with the 10 University in 1989. He obtained his directors of anaesthesia of the hospitals FANZCA in 1997. He was awarded his MD affiliated with the MMS. in acid-base disorders from the University A unique model for the chair emerged of Melbourne in 2004. from these deliberations. His main clinical interest is Professor Story will be based at the perioperative care for high risk patients, MMS, rather than in a hospital, and including anaesthesia for cardiac surgery will develop the Centre for Anaesthesia, and liver transplantation. Perioperative and Pain Medicine. His research focuses on serious He will have a variety of appointments postoperative adverse events and clinical at the affiliated hospitals and there will chemistry. Apart from his teaching of be staff at each hospital with a role at the ANZCA trainees, he has been involved Professor David Story has been appointed centre. These affiliated hospitals perform with teaching medical students about the inaugural Chair of Anaesthesia in the about 160,000 anaesthetics per year, a perioperative medicine. Melbourne Medical School (MMS) of the great potential for teaching and research. Professor Story has been a staff University of Melbourne. Professor Story will also have the anaesthetist at Austin Health. He was This position is the result of two years opportunity to develop basic research chair of the ANZCA Trials Group from of discussions, meetings and exchanges with the MMS biomedical science 2005 to 2011, a role that will assist him of ideas between representatives of the departments of physiology, anatomy and when co-coordinating research related university, the president of ANZCA, pharmacology. to anaesthesia at the MMS. He is also directors of anaesthesia, possible “The formation of this chair is a primary examiner in physiology. applicants and the chief executive officers potentially the most significant advance Professor Story has a sound research of the metropolitan teaching hospitals in academic anaesthesia in Melbourne background with more than 100 affiliated with the MMS. Associate in the past 30 years,” said Associate publications and having obtained Professor Michael Davies played a key role Professor Davies. more than 15 research grants. in driving this process and developing the “The University of Melbourne is the concept model for the role. highest placed Australian university in Leading the process for the university three of the four major world rankings. were Professor James Best, head of The MMS is ranked first in Australia and the MMS, and Professor Glenn Bowes, 14th in the world. Associate Dean, Advancement and

13 ANZCA and government: building relationships

• Victorian Department of Health on the The project manager for the Specialist Australia midwifery-prescribing project. Training Program, Donna Fahie, has Submissions • Australian Commission of Safety visited Australian regions to explore ANZCA continues to advocate on behalf and Quality in Health Care on the opportunities to expand training capacity. of Fellows, providing submissions to National Safety and Quality Healthcare Each visit includes a presentation to government and health stakeholders in Standards. regional committees about the program, a variety of areas. ANZCA has recently meetings with hospitals with existing made submissions to: ANZCA’s past submissions, including the Specialist Training Program funding, and • Health Workforce Australia on College’s accreditation submission to the key medical workforce units in state and anaesthesia and pain medicine chapters Australian Medical Council, can be found territory heath departments. Donna has for the Health Workforce 2025 report. at www.anzca.edu.au/communications/ visited South Australia and Queensland submissions. • Australian Medical Council (AMC) on and aims to visit all regions this year. the implication of MD programs on AMC Australian Government grants For further information, please email accreditation. Specialist Training Program [email protected]. • Australian Medical Council on the ANZCA is progressing well against the Plain packaging – tobacco review of accreditation standards for aims and objectives of the Specialist The Australian Government welcomed a medical schools. Training Program. The College received decision by the High Court of Australia in nine new training positions, including • Medical Board of Australia’s August to reject the legal challenge by big three allocated to pain medicine, as part tobacco against Australia’s world-leading consultation on international criminal of the 2013 Specialist Training Program history checks. plain packaging of tobacco laws. application round. This means the Plain packaging, a vital preventative • Department of Health and Ageing College will manage 48 positions in 2013, public health measure, will restrict on draft guidelines and access to the including 11 positions managed on behalf tobacco industry logos, brand imagery, Medicare Benefi ts Schedule. of the College of Intensive Care Medicine. colours and promotional text appearing • Australian Council of Healthcare In addition, 15 hospitals across rural and on packs. Brand and product names will Standards on a review of its regional areas received funding from the be in a standard colour, position and constitution. Rural Support Loading Program to help standard font size and style. • Rural Doctors Association Australia on with the costs of training specialists in All tobacco products sold in Australia National Advanced Training Program. rural settings for the 2012 training year. must be in plain packaging by December 1. These hospitals will share in $330,000 • Therapeutic Goods Administration on available from the Rural Support dextropropoxyphene. Loading Program.

14 ANZCA Bulletin September 2012 New Zealand to identify how and where • Health Workforce New Zealand New Zealand the College can support its trainees via on funding priorities for medical Review of the Health Practitioner the hubs, and how the hubs might also disciplines training. Competence Assurance Act 2003 provide opportunities for Fellows outside • Medical Sciences Council on continuing The Health Practitioner Competence main centres to link in with continuing professional development for Assurance Act 2003 provides the medical education activities happening anaesthetic technicians. framework for regulation of health in other regions. • Medical Council of New Zealand on professionals in New Zealand, with the In the physician assistant sphere, guidelines for doctors on caring for aim of protecting the health and safety Health Workforce New Zealand has themselves and others close to them. of the public. The Ministry of Health has requested ANZCA’s advice on whether announced that it will conduct a high- there is a need for the physician assistant level review of the act in 2012. role in the perioperative space and if so, AMC/MCNZ The Ministry of Health will consult what scope such a role could have. The with stakeholders through meetings and New Zealand National Committee has accreditation a written document, to be released soon. formed a small group to provide this Work continued on the College Ministry representatives will discuss the advice to Health Workforce New Zealand. accreditation process with a preliminary review with the New Zealand National meeting held in June between the ANZCA Committee at its November meeting. Submissions Executive, pain medicine representatives Pharmac, New Zealand’s drug buying and the Australian Medical Council Health Workforce New Zealand agency, has been conducting ongoing assessment panel. Surveys have been ANZCA continued to work with consultations with stakeholders on the sent from the Australian Medical Council Health Workforce New Zealand on the development of its preferred medicines list. to Fellows, trainees and international development of the regional training St John Ambulance is reviewing its medical graduate specialists to inform the hubs, and the physician assistant project. clinical guidelines. The Medical Council review process, and site visits to hospitals The hubs are a Health Workforce New of New Zealand is reviewing its document will commence with New Zealand in Zealand initiative designed to support Good Medical Practice. The New Zealand September and Australia during October. effi cient health-professional training, National Committee is considering the The assessment panel will have further looking for opportunities for cross- proposed amendments. meetings with College representatives specialty and cross-profession training. in Melbourne in October. Each hub will develop specifi c areas A number of other submissions have been made to: of expertise and lead in those fi elds. John Biviano ANZCA is working with Health Workforce • The Ministry of Health on the General Manager, Policy classifi cation of ephedrine. ANZCA

15 Researchers behaving badly Scientifi c misconduct is not a Figure 1. subject we like to talk about, but earlier this year Japanese RISE OF THE RETRACTIONS anaesthetist Associate In the past decade, the number of retraction notices has shot up 10-fold (top), even as the literature has expanded by only 44%. It is likely that only about half of all retractions are for researcher Professor Yoshitaka Fujii was misconduct (middle). Higher-impact journals have logged more retraction notices over the past decade, sacked by Toho University but much of the increase during 2006–10 came from lower-impact journals (bottom). after serious questions were 350 PubMed notices raised about his research. 300 Web of Science notices Investigations continue. Dr 250

Richard Waldron explores 200 recent examples of research 150 fraud and what it means for anaesthetists. 100 50 There has been a dramatic increase in the notices Number of retraction number of retractions of medical papers 0 over the past few years and anaesthesia, 1977 1981 1985 1989 1993 1997 2001 2005 2009 unfortunately, is one of the areas in the spotlight. Although about half of MISCONDUCT the retractions arise following “honest Self-plagiarism Honest error Other errors”, there is a disturbing increase in percentage of retractions arising from “misconduct”. Disappointingly, this % 7% 6% 28% % 7% 50:50 split is not refl ected in the fi eld Fabrication Plagiarism Irreproducible of anaesthesia – it appears that with or falsi cation results anaesthesia, retractions of recent years JOURNALS WITH MORE THAN 7 RETRACTION NOTICES IN WEB OF SCIENCE*, 2006–10 lean signifi cantly more towards the (journals ordered by decreasing impact factor for 2010) “misconduct” end of the spectrum. There also has been a dramatic increase in 25 retractions related to anaesthesia in the 2001–05 2006–10 past fi ve years. 20 Figure 1 is from a 2011 article by Richard Van Noorden, assistant news 15 editor at the journal Nature.1

5 Number of retraction notices Number of retraction “ Historically, those who detect 0 Cell

or reveal a fraud are not the Blood Nature Science FASEB J. FASEB Sci. USA Analgesia

institution of the person Anesthesia Tissue Eng. J. Immunol. Regen. Med. J. Biol. Chem. Res. Commun. Phytother. Res. Phytother. Anesthesiology perpetrating the fraud, his Haematologica Proc. Natl Acad. NATURE.COM J. Hazard. Mater. or her colleagues or even the Read more about retractions: Biochem. Biophys. go.nature.com/2uweok co-authors. Whistleblowers *Not shown: Acta Crystallographica E saw 81 retractions during 2006–10.

are usually lab technicians, Reprinted by permission from Macmillan Publishers Ltd: Nature (Science publishing: statisticians and journalists.” The trouble with retractions), copyright (2011)

16 ANZCA Bulletin September 2012 How do retractions resulting (plagiarism was excluded from the study). Although not a trained anaesthetist, his from research misconduct impact on On top of this, 15 per cent of the survey research impacts signifi cantly on the anaesthetic practice? It is a delicate respondents indicated that they were also practice of perioperative medicine. He is subject and there is little information aware of colleagues engaging in such also an honorary member of the Dutch available in peer-reviewed journals – misconduct. Society of Anaesthesiologists. perhaps not surprising since many peer- The areas of anaesthesia research The existence of bad research or reviewed journals have been affected. misconduct covered in this paper include deliberate scientifi c fraud should come However, journals such as Anaesthesia2,3,4, acute pain (Professor Scott Reuben), fl uid as no surprise. The journal Anaesthesia Anaesthesia & Analgesia,5,6 the European resuscitation (Professor Joachim Boldt), & Intensive Care published an editorial Journal of Anaesthesia7, BMJ8, as well as post-operative nausea and vomiting on the subject in 199111. There was an the above-quoted article from Nature have (Associate Professor Yoshitaka Fujii), and editorial in the New England Journal of all published editorials addressing recent perioperative management of patients Medicine12 in 1983 and a review article in research misconduct. Where possible I with cardiac conditions (Professor Don the BMJ the same year13. One of the invited have attempted to use verifi able sources. Poldermans). There are three anaesthetists speakers at the ANZCA ASM 2011 in Hong Some information comes from media involved with a possible combined total Kong, editor-in-chief of Anaesthesia Dr releases and some is web-based. of 284 retractions (Reuben 21, Boldt 91, Steve Yentis, addressed delegates on the In general terms, research misconduct Fujii 172), all within the last fi ve years. subject of medical research fraud. The involves plagiarism, fabrication, One of them will hold the record for the Euroanaesthesia Congress in Paris in June falsifi cation or alteration of data or images most retracted medical research papers 2012 held a session entitled “Fraud or (including graphs). In 2009, Fanelli9 ever. The fourth person included in this fl awed? Which data and recommendations conducted a meta-analysis of 18 surveys of article is Professor Don Poldermans, who should we trust?”. 10 some 12,000 scientists (including medical was dismissed in November 2011 from his (continued next page) researchers) and found that 2 per cent of position as Professor of Medicine and head these researchers admitted to fabricating, of the Perioperative Cardiac Care Unit at falsifying or altering their own data Erasmus Medical Center, Netherlands.

Professor Scott Reuben the signatures of co-authors and had In January 2010, Professor Reuben was Professor Scott Reuben has been not conducted many of the 21 clinical sentenced to six months prison with a described by Scientiﬁ c American, March studies that he had published in journals, further three years supervised release and 10, 2009 as “A Medical Madoff”34, a including Anesthesia & Analgesia. was fi ned $480,000. He has 21 retracted reference to Bernie Madoff, the fi nancial Many of the so-called studies gave papers (including journals such as advisor who was jailed in 2009 for losing favourable results to drugs produced by Anaesthesia & Analgesia, which has run billions of investor funds in a Ponzi Pfi zer, including Celecoxib (Celebrex), editorials on Professor Reuben’s conduct). scheme, the largest fi nancial fraud in Valdecoxib (Bextra), Gabapentin Evidence of his falsifi ed and fabricated US history. (Neurontin). Professor Reuben was a research dates back to 2000. It appears Professor Reuben was a Professor of member of the Pfi zer Speaker’s Bureau that Professor Reuben’s co-authors were Anaesthesiology and Pain Medicine at and had received fi ve research grants unaware of the fraud – in some instances Bayside Medical Center (Tufts University from Pfi zer between 2002 and 2007. Professor Reuben had forged their School of Medicine) Springfi eld, Professor Reuben was also a major signatures when the articles had been Massachusetts. He was director of Acute invited speaker at the Australian Faculty submitted for publication. Pain Management. In May 2008, his of Pain Medicine meeting in September hospital was conducting a research week 2008 and seven of his papers were used as for which he had submitted two studies. references in the second edition (2005) of An audit found there was no ethics ANZCA publication Acute Pain Medicine: approval for the studies, which triggered Scientiﬁ c Evidence. All references to his an investigation. In March 2009 Professor papers have been removed in the third Reuben admitted fabricating data, even edition (2011). inventing patients. He had also forged

17 Researchers behaving badly continued

Anaesthesia is not the only specialty cardiac management in non-cardiac These 180 papers were cited a total of 5503 affected. Other recent signifi cant areas of surgery18 are under review19 (Poldermans times bringing the total number of “at research misconduct include psychologist chaired the taskforce). risk” treated patients to 70,501 (excluding Diedereck Stapel (BMJ in 201114), physicist Research misconduct can adversely controls). Jan Hendrick Schon (16 articles retracted affect clinical practice, putting patients Another example of this is the cessation from Science, Nature, Physics Review at risk. The perioperative use of beta- or near cessation of major ongoing clinical between 2000 and 200115), Dr Dipak Das blockers and statins is being reviewed research such as the recently completed (a 60,000-page investigation this year as a result of issues around Poldermans’ Colloid versus Hydroxyethyl Starch Trial documented 145 counts of fabrication and DECREASE studies. Perhaps the greatest (CHEST)25. Sudbo’s fraud was uncovered falsifi cation of data and lists 11 scientifi c example is the decreasing rate of measles, just before the National Cancer Institute journals affected16). mumps and rubella vaccination in the was about to start a 300-patient trial Why am I, an ordinary working community after The Lancet published looking into prevention of oral cancer26. anaesthetist, concerned about research Dr Andrew Wakefi eld’s paper of 199820. At a local level, the publication by misconduct? Unfortunately, the impact of In 2004, 10 of the 13 authors published ANZCA of the 2nd edition (2005) of Acute research misconduct can be extensive and a “retraction of an interpretation” in Pain Management: Scientiﬁ c Evidence diverse. The type of research involved has The Lancet21. In 2010 The Lancet editors includes seven now-retracted Reuben been used in evidence-based medicine published a retraction22 after a fi ve- papers. The 3rd edition (2010) has ceased and to develop clinical guidelines. Recent member statutory General Medical to quote these references. A major retractions have led to the withdrawal of Council tribunal found Wakefi eld guilty Australian scientifi c meeting in 2008 had guidelines. In 2011, the British consensus of “serious professional misconduct”23. the principal author of those retracted guidelines on intravenous fl uid therapy for Wakefi eld was struck off the UK Medical papers as a major invited speaker adult surgical patients17 were withdrawn Register in May 2010. (obviously prior to the retractions being as a result of Boldt’s retractions. The 2009 In his 201124 paper, Steen reviewed 180 announced). European guidelines for pre-operative primary papers retracted between 2000 to How extensive is this “collateral cardiac risk assessment and perioperative 2010 for which 9189 subjects were treated. damage” – that is, the damage to research

Hospital Presents Results of Final Report: Committee Completes InvestiÉ dt È 2012 È Pressearchiv È Aktuelles / Presse È Klinikum Ludwigshafen 13/08/12 6:08 PM

Hospital Presents Results of Final Report: Committee Klinikum Ludwigshafen Completes Investigation in the Case of Dr Boldt

09.08.2012

After an investigation lasting approximately 18 months and involving the examination of 91 scientific articles, the independent committee convened by Ludwigshafen Hospital to investigate allegations of scientific fraud brought against Dr. Joachim Boldt has published its final report. As a result of the allegations against him, Dr Boldt left the Hospital in November 2010. Following his departure an Investigation Committee, consisting of six investigators, was convened to examine allegations of scientific fraud and to investigate potential infringements of patients' rights and/or instances of patient harm. The Committee's report concludes that no patients were harmed as a result of the former consultant's professional and research conduct. However, the CommitteeÕ s report also establishes several instances of misconduct on the part of Dr Boldt. The Committee's findings are based on the examination of 91 articles authored or co-authored by Dr Boldt, and published between 1999 and 2011. Examination of these articles revealed that study files were either missing or incomplete for the large majority of the studies concerned, suggesting that Dr Boldt failed in his duty as principal investigator to comply with current regulations pertaining to the retention of study data. None of the studies examined had received an ethical opinion from the Rhineland-Palatinate Medical Association (LandesŠ rztekammer Rheinland-Pfalz). In the majority of these cases, the principal investigator had failed to register planned research projects with the Rhineland- Palatinate Medical Association, and the relevant office at Ludwigshafen Hospital. Many cases revealed no record of formal consent by study participants or indeed evidence that study participants had been provided with sufficient information prior to enrolment. The Committee reports that in a large number of the studies investigated, the conduct of research failed to meet required standards. False data were published in at least 10 of the 91 articles examined, including, for instance, data on patient numbers/ study groups as well as data on the timing of measurements.

The Committee's findings include clear evidence of procedural irregularities and research misconduct on the part of Dr Joachim Boldt. However, the Committee was also able to report that no patients had been physically harmed in the process. The Committee was able to establish the identities of 455 patients whose data had contributed to Dr Boldt's research studies. These patients' medical records were examined for possible adverse events and serious adverse events as defined by current GCP (Good Clinical Practice) classification criteria. The majority of the patients identified in this manner were older patients with multiple comorbidities. Administration of the study drug, which at the time was in routine use within Ludwigshafen Hospital and other hospitals, was shown to be associated with only one such event. Fortunately, this episode was resolved without the patient suffering any lasting harm. A further patient was successfully treated following a serious adverse event and suffered no lasting harm. A possible causal relationship with the study drug, however, could not be excluded. Both patients concerned were duly notified by the appropriate clinical directorate. "We strongly disapprove of the conduct of Dr Boldt and distance ourselves from his actions and regret that these incidents occurred,Ó said Ludwigshafen Hospital's Managing Director, Dr. Joachim Stumpp. Ò The independent inquiry's conclusion, that there is no evidence of any study-related adverse effects, has come as a great relief," The Hospital has also passed the CommitteeÕ s report on to the appropriate public prosecutor's office. Shortly after the allegations against the former consultant anaesthetist were made public, Ludwigshafen Hospital responded by tightening procedural requirements relating to the conduct of clinical studies. Of particular significance was the decision to create a Scientific Steering Committee (Gremium der Wissenschaft, or GW). The GW's remit will be to monitor all clinical studies conducted within the Hospital, thus ensuring that appropriate quality standards are maintained, and that participating study doctors are able to access detailed guidance and support. "The Hospital's response to this unfortunate incident has been to review internal processes and procedures,Ó said Dr. Stumpp. Ò We have done everything within our power to ensure that Ludwigshafen Hospital can meet the highest possible standards in terms of the statutory requirements pertaining to the conduct of research studies, including those relating to patients' rights,"

Akademisches Lehrkrankenhaus der Johannes Gutenberg-UniversitŠ t Mainz

http://www.klilu.de/content/aktuelles___presse/pressearchiv/2012/hospiÉ mittee_completes_investigation_in_the_case_of_dr_boldt/index_ger.html Page 1 of 2

Martin Tramer’s June 2011 editorial in based on the examination of 91 articles Professor Joachim Boldt 38 Professor Joachim Boldt was chief the European Journal of Anaesthesiology published between 1999 and 2011. In anaesthetist at Klinikum Ludwigshafen is also worth reading. Professor Boldt had the large majority of studies, Professor Hospital in Rhineland. His main area 19 articles published in this journal alone. Boldt failed to comply with regulations of research was the use of colloids, in The ramifi cations have been pertaining to the retention of study particular hydroxyethyl starch (HES or widespread. In February this year, the data. None of the studies examined Voluven™), and his papers were used European Journal of Anaesthesia withdrew had received an ethical opinion. False as references for the British consensus a further article authored by doctors data was published in at least 10 of the guidelines in intravenous fl uid therapy working at the Klinikum Ludwigshafel 91 articles examined. The committee for adult surgical patients. after it was revealed that false ethics was, however, able to report that no approval had been quoted in a paper by patients had been physically harmed On March 4, 2011, BBC News reported 39 on “unethical” anaesthetics research Ochmann C et al . (the committee was able to identify 455 35 In his 2012 editorial retracting this patients whose data had contributed to being retracted and the BMJ reported 40 the withdrawal of the intravenous fl uid particular paper, Tramer says that Professor Boldt’s research studies). guidelines6. On February 4, 2011, the Professor Boldt and a co-author submitted The fallout also reached Australia and editors-in-chief of 11 medical journals, the original study protocol in 2003. New Zealand, specifi cally the Crystalloid including Anaesthesia, European Professor Boldt had been named as a co- versus Hydroxyethyl Starch Trials Journal of Anaesthesia, British Journal author on previous drafts but had been (CHEST), a multi-centre trial sponsored of Anaesthesia, published an open letter removed on the fi nal submission. Tramer by the George Institute in conjunction retracting 92 articles (out of 104 reviewed, notes that some of the authors in this with the University of Sydney and the including one that was unpublished) for paper had been co-authors on many of Australian and New Zealand Intensive lack of ethics committee approval36. At Professor Boldt’s retracted papers. Care Society Clinical Trials Group. An the time, it was the record for the highest On August 8, 2012, the Klinikum outline of what the CHEST team had to do number of retracted papers by a single Ludwigshafen released a press to save the study is summarised in John statement41. It outlines the fi ndings of Myburgh’s 2011 editorial in the journal author, outstripping the previous record 25 held by Dr John Darsee, of Harvard37. a six-member investigation committee Critical Care and Resuscitation .

18 ANZCA Bulletin September 2012 based on papers that are later retracted? the medical school. The German defence students have revealed shockingly high The four cases mentioned have been minister, Karl-Theodor zu Guttenberg, rates of cheating to get into medical going for many years. Fujii’s papers date was dismissed in March 2011 after it was school or in medical school. The students back some 15 years, Reuben’s about 10 suggested that his 2006 doctoral thesis cheating aren’t the dumb ones. They’re years years, Poldermans’ at least 15 years. had been heavily plagiarised. Dr Hwang often the brightest”. There is also a These papers have been cited a number of Woo-suk was named “supreme scientist” 2011 paper by Nasseri et al (“Phantom times. For example, of Poldermans’ 500 by the South Korean government in publications among applicants to a papers, it appears that 16 of his studies recognition of his paper on cloned stem colorectal surgery residency”) where have been cited at least 100 times and cells published by Science in 200427. In citations quoted by 24 per cent of one has been cited more than 700 times. 2009 he was convicted of research fraud applicants could not be verifi ed30. Retracted papers can “live on”. Van in South Korea. He is alleged to have So, as an ordinary anaesthetist working Noorden1 quotes work done by John Budd. embezzled $705,000 of research funds in clinical practice, how do I decide which Budd examined 235 articles retracted over and illegally bought human eggs for papers to rely on to guide and improve 30 years between 1966-96 and found they embryonic stem cell research28. my clinical practice? Can I rely on articles were cited more than 2000 times after A number of factors are cited including from highly reputable, peer-review their retraction (fewer than 8 per cent career advancement, fame and recognition journals? History would suggest no, not acknowledged the retraction). by peers, money (including research always. The Lancet, Nature, Science, Why does this type of fraud occur? grants, the lecture circuit), work contracts Anaesthesia & Analgesia and European Some would say why not? There is fraud that include a so-called “publish or Journal of Anaesthesia all have retracted in many fi elds of endeavour, including perish” clause and others. papers. In his editorial, Shafer asks how art fraud, political fraud, economic fraud, One factor of particular concern is a peer reviewed journal like Anesthesia literary fraud and so on. In 2011, a vice- learned behaviour. A 1983 Journal of the & Analgesia missed 21 fraudulent chancellor at the University of Queensland American Medical Association article, submissions by Reuben over 21 years? was dismissed for “bending the rules” to soon after the scandal involving Dr John The answer is clearly not simple. 29 allow a family member to gain entry to Darsee , stated “studies of medical (continued next page) Erasmus MC : Erasmus MC dismisses professor 13/08/12 9:10 PM

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Erasmus MC dismisses professor

Erasmus MC dismissed Prof. D. Poldermans on 16 November because of violation of academic integrity. Research carried out under his leadership was not always performed in accordance with current scientific Direct to standards. News archive An inquiry committee on Academic Integrity Press releases concluded that the professor was careless in collecting the data for his research. In one Mail us study it was found that he used patient data without written permission, used fictitious data and that two reports were submitted to conferences which included knowingly unreliable data.

Regret The professor agrees with the committeeÕ s conclusions and expressed his regret for his actions. Poldermans feels that as experienced researcher he should have been more accurate but states that his actions were unintentional.

Action The study that gave rise to the inquiry committee having to take action was the health of patients who had to undergo surgery. The aim of the study was to identify which factors can contribute to being able to better estimate the risks of complications. There were no medical implications for the patients who took part in the studies.

Apologize Erasmus MC will, however, endeavor to inform the patients concerned personally and apologize to them.

For more information, see the press release.

Date published: 17 November 2011

© 2012 Erasmus MC 010 704 0 704 About this website Disclaimer Privacy Your feedback Professor Don Poldermans editor of the European Journal of been cited more than 700 times. At Professor Don Poldermans was dismissed Echocardiography and an editorial board the time of writing (August 2012) there from Erasmus Medical Centre in the member of American Journal of Cardiology, are no retractions of any of Professor Netherlands in November 2011 over Heart, Journal of Coronary Artery Disease Poldermans’ papers on PubMed. “allegations that the researcher fabricated and Journal of the American College of His areas of research include data and committed other misconduct in Cardiology. He is a Fellow of the European identifi cation and treatment of patients his studies”42,43. Society of Cardiology and had been chair at cardiovascular risk prior to, during The Erasmus Medical Centre issued a of the European taskforce charged with and after surgery. In particular, he is media statement reporting that an inquiry developing guidelines for preoperative well known for the perioperative use of committee concluded “that the professor cardiac risk assessment and perioperative beta-blockers (particularly Bisoprolol) cardiac management in non-cardiac and the Dutch Echocardiographic was careless in collecting data forhttp://www.erasmusmc.nl/corp_home/corp_news-center/2011/2011-11/ontslag.hoogleraar/?lang=en his Page 1 of 1 surgery, published in the European Cardiac Risk Evaluation Applying research” and in one study “used patient 17 data without written permission and used Heart Journal in 2009 . He was an Stress Echocardiography Study Group fi ctitious data” and “that two reports honorary member of the Dutch Society (DECREASE) studies. He was involved were submitted to conferences which of Anesthesiology. with the DECREASE VI study at the time included knowingly unreliable data”. It Professor Poldermans has published he was dismissed. This study has been said that “the professor agrees with the more than 500 manuscripts in several discontinued. The primary studies that committee’s conclusions and expressed peer-reviewed journals, including the are in question are the DECREASE VI, IV, regret for his actions”8. New England Journal of Medicine, The III, and II studies. Professor Poldermans was the Lancet, Journal of the American Medical The investigation into Professor Professor of Medicine and Head of the Association, Circulation and the Journal Poldermans’ work appears to have been Perioperative Cardiac Care Unit. He is of the American College of Cardiology. triggered by a junior researcher who board-certifi ed in internal medicine, Of this, 16 of his studies have been felt uncomfortable with the data to be 44 intensive care medicine, and vascular cited at least 100 times and one has submitted for the DECREASE VI study . medicine. He has been an associate

19 Researchers behaving badly continued

Can I always rely on articles whose Can I rely on articles emanating from Other examples include research scientist authors or co-authors include professors reputable institutions? No, not always. In Phillip Vardy and medical journalist and department heads? Again the answer 1983, the Journal of the American Medical Norman Swan in the McBride Debendox is not always. Boldt, Reuben, Poldermans, Association mentions Boston Medical case, and journalist Brian Deer in the and Das were heads of departments. There Center, Massachusetts General Hospital, scandal involving Andrew Wakefi eld. is also the 1995 case involving Dr Malcolm Mount Sinai School of Medicine, Yale There is a recent disturbing trend Pearce, an assistant editor of the British University School of Medicine, Sloan- towards high-level frauds occurring over Journal of Obstetrics and Gynaecology. In Kettering Memorial Cancer Center and a prolonged period. This is highlighted by 1994, Pearce published two papers in that Harvard Medical School28 as institutions the cases mentioned here. journal, a clinical trial and a case report31. at which research fraud has occurred. Firstly, it seems that authors with high Both were fabrications. His co-author for So, how do I, the end user of research rates of publications of clinical trials the case report was Professor Geoffrey and evidence-based medicine, fi nd out within a short period of time may be Robertson, his head of department, also about research fraud or misconduct? How suspect. Examples include John Darsee, then president of the Royal College of has research misconduct been detected or Jan Hendrick Schon and Robert Slutsky. In Obstetrics and Gynaecology and the uncovered in the past? 1985, Dr Robert Slutsky of the University journal’s editor. Robertson was unaware Historically, those who detect or of California, San Diego was found to that the case was fraudulent. The case reveal a fraud are not the institution have published 12 fraudulent papers with highlights the issue of “gift authorship”, of the person perpetrating the fraud, another 48 questionable. Slutsky had that is co-authors who have made no his or her colleagues or even the co- published 137 articles in seven years (one signifi cant intellectual contribution to a authors. Whistleblowers are usually lab paper every 10 working days33). Schon is paper. There are many cases where co- technicians, statisticians and journalists. another, more recent example. In 2000, he authors appear to be either unaware that For example, Camilla Stoltenberg, a had fi ve papers published in Science and they were involved in a fabricated clinical physician and medical researcher, picked three in Nature (all as fi rst author). In 2001, trial or even of their inclusion in the up Jon Subdo’s 2005 fraud after noticing he was listed as an author on an average of research paper. that 250 of the 908 patients in Subdo’s The one research paper every eight days. Lancet paper shared the same birthday32.

The Results of Investigation into Dr.Yoshitaka Fujii’s papers

Toho University Faculty of Medicine announced on March 8, 2012 that 8 manuscripts of Dr.Yoshitaka Fujii had been retracted because of execution of these clinical studies without proper ethical approval. In addition, an article [Appendix 1] entitled "The analysis of 169 randomised controlled trials to test data integrity." was published on-line as a Special Article in Anaesthesia, the Journal of the Association of Anaesthetists of Great Britain and Ireland, on March 8, 2012. Three Editorials [Appendix 2] have simultaneously been published in Anaesthesia. Accordingly, the Japanese Society of Anesthesiologists set up a Special Investigation Committee to investigate this issue on March 10. On April 6, a group of editors representing 23 medical journals sent an inquiry to seven Japanese institutions about 193 papers published by Dr. Fujii [Appendix 3]

Appendix 4 lists 249 papers based on a reconciliation of Appendix 3 in the Joint Editors –in-Chief Request for Determination and a comprehensive online research. Appendix 5 lists 212 original papers which the JSA Special Investigation Committee looked into.

The JSA Special Investigation Committee: 1. Investigated original research data, lab note books and the relevant records at institutions. 2. Interviewed with Dr. Fujii and with co-authors of Dr. Fujii’s papers

1)The Results of Investigation

All papers were evaluated based on submitted original research data, the record of animal uses, the number of subjects, the record of medication and the reliability of randomized controlled trials (RCTs).

A㧦NOT Fabricated Papers which the original data and the number of subjects in papers have been verified authentic and Dr. Fujii had not related to any data collection and processing: 3 papers (No.101,112,150㨇Appendix 5㨉㧕

Associate Professor appears to have been precipitated by Anesthesiologists (JSA), reviewed 193 an analysis of Associate Professor articles at risk of retraction. On June 29, Yoshitaka Fujii 46 Associate Professor Yoshitaka Fujii was Fujii’s paper by John Carlisle , which 2012, a letter signed by the vice-president dismissed from Toho University Faculty of was published in Anaesthesia. Carlisle of the JSA (also chair of the special Medicine in February 2012. analysed 169 randomised controlled trials investigation committee) reported that the In a statement, Toho University said by Associate Professor Fujii (one was committee found that 172 papers had been 48 that the credibility of nine publications duplicated so only 168 were analysed), fabricated. was “put in doubt in August 2011”45. It including 141 human studies and 26 This was not the fi rst time that appears that Associate Professor Fujii canine studies between 1991 and Associate Professor Fujii’s research admitted to an investigating committee July 2011. had been challenged. In 2000, Kranke that the studies were done without ethics A signed open letter from 23 editors- et al published a letter in Anesthesia & approval and Associate Professor Fujii has in-chief of different journals (including Analgesia provocatively titled “Reported sent letters of retraction to the affected Neville Gibbs from Anaesthesia & data on granisetron and postoperative journals. Intensive Care) outlines the areas of nausea and vomiting by Associate Associate Professor Fujii was a prolifi c concerns with an intention to retract Professor Fujii et al. are incredibly 49 researcher in the area of postoperative the papers and was referred onto the nice!” . The paper reviewed 47 articles 47 nausea and vomiting and was fi rst author relevant Japanese institutions . The published by Associate Professor Fujii in all nine papers, published between letter also lists Associate Professor Fujii’s et al between 1994 and 1999, most with 2008 and 2011. The Toho University 193 papers (including six published in Associate Professor Fujii as fi rst author. investigating committee has cleared his Anaesthesia & Intensive Care). Seven The Retraction Watch website outlines co-author. Japanese institutions, as well as a special what the authors did to notify authorities The discovery of this misconduct committee of the Japanese Society of about their concerns.

20 ANZCA Bulletin September 2012 18. The Task Force for Preoperative Cardiac Risk Assessment Secondly, it seems that people with Also, on the issue of retracted Guidelines for pre-operative cardiac risk assessment access to raw data are able to assist. The publications continuing to be cited or and perioperative cardiac management in noncardiac surgery. Euro Heart J 2009; 30:2769-2812 traditional approach of peer review, “living on”, it might be worth considering 19. Dismissal of Professor Don Poldermans from the Erasmus Medical Center (NL) ESC Press Office Statement coupled with software, can usually pick some better way of notifying readers of 23 Nov 2011 http://www.escardio.org/about/press/press- up plagiarism but not data fabrication when a publication has been retracted. releases/pr-11/Pages/Dismissal-Don-Poldermans.aspx 20. Wakefield AJ, Murch SH, Anthony A et al Ileal-lymphoid- or subtle data manipulation. In the past, retraction notices have not nodular herplasia, non-specific colitis, and pervasive Examples of this are Stoltenberg been well publicised; some readers may developmental disorder in children. Lancet 1998; 351; 637-641 with Subdo, Vardy with McBride, be unaware of some of the retractions 21. Musch SH, Anthony A, Casson DH et al Retraction of an lab technicians with Darsee and lab mentioned here. Hopefully a system can interpretation. Lancet 2004; 363; 750 22. The Editors of The Lancet. Retraction – ileal-lymphoid- technician Walter DeNino with Eric be devised on search engines such as nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 2010; Poehlman, who became the first US PubMed to notify individuals if an article 375:445 academic to be jailed for falsifying data they are viewing has been retracted. It 23. www.gmc_uk.org/Wakefield_SPM_and SANCTION. pdf_32595267.pdf in a grant application. Journals and/or may be that archived articles by respective 24. Steen RG Retractions in the medical literature: how many patients are put at risk by flawed research? J Med institutions may have to conduct routine journals could be watermarked (as done Ethics 2011; 37: 688-692 random audits of clinical and laboratory by Anesthesia & Analgesia for example) 25. Myburgh J. CHEST and the impact of fraud in fluid resuscitation research. Crit Care Resus 2011; 13 (2): 69- trials. A number of editors have proposed to highlight their retracted status. 70. this. Interestingly, Yoshitaka Fujii’s fraud Finally, as Steve Shafer mentioned at 26. Vastag B. Cancer fraud Stuns research community, prompts reflection on peer review process. JCNI 2006; was uncovered following a statistical the 2008 Sydney ANZCA annual scientific 98 (6): 374-376 analysis by John Carlisle of a large number meeting, another element in good 27. Hwang W-S, et al. Patient-specific embryonic stem cells derived from human SCNT blastocysts. Science of papers. research is the ability to reproduce results 2004;303:1669-74 28. Sang-Hun C Disgraced Cloning expert convicted in Thirdly, journals must require evidence at another institution. This would be South Korea NY Times October 26 2009 http://www. of a co-author’s involvement with a paper, something like waiting for version 1.1 of a nytimes.com/2009/10/27/world/asia/27clone.html?_ r=1&ref=hwangwoosuk not just the lead author. Some journals new software program, rather than going 29. Knox R The Harvard fraud case: where does the problem are already doing this. In some cases out to get version 1.0. It may be that as an lie? JAMA April 8, 1983; 249: 1797-1807 30. Nasseri T et al Phantom publications among applicants co-authors have been used without their end user, I should be more critical in my to a colorectal surgery residency. Dis Colon Rectum 2011; knowledge to cover fraudulent activity. evaluation of research. And perhaps, as 54(2); 2201-225 31. Court C, Dillner L. Obstetrician suspended after research In some cases, co-authors have been Van Noorden states, as we see “the rise of inquiry. BMJ 1994; 309: 1459 32. Gerber P What can we learn from the Hwang complicit with the deception (Hwang, the retractions”, we may also witness “the and Sudbo affairs? MJA 2006; Sudbo). There should be a mechanism return of the journal club” or some other 184 (12): 632-635 33. Engler RL, Covell JW, Friedman PJ et al. to verify a co-author’s intellectual forum for rigorous debate of published Misrepresentation and responsibility in medical contribution to a paper and familiarity medical research. research. NEJM 1987; 317 (22): 1383-1389 34. Brendan Borrell A Medical Madoff: Anesthesiologist with the raw data. This may require the faked data in 21 studies. Scientific American March 10, 2009 signatures of co-authors confirming their Dr Richard Waldron, FANZCA 35. BBC News “Unethical” anaesthetics research involvement and verifying the data prior Hobart, Tasmania is retracted. March 4, 2011 36. Rasmussen LS, Yentis SM, Schuttler J, et al. Editors- to publication. in-chief statement regarding IRB approval for clinical Some organisations and journals References: trials by Joachim Boldt. http://www.aaeditor.org/ 1. Van Noorden R The trouble with retractions Nature 2011: EICJointStatement.pdf are making an effort to address this 478;26-28 37. Kochan CA, Budd JM. The persistence of fraud in problem. One of the pleasing aspects 2. Yentis, SM. Lies, damn lies, and statistics. Anaesthesia, literature: The Darsee case. J Am Soc Information 2012: 67;455-456 Science 1992; 43(7); 488-493 of the Boldt and Fujii episodes is the 3. Wager E. Who is responsible for investigating suspected research misconduct? (ed) Anaesthesia 2012; 67: 455-473. 38. Tramer MR. The Boldt debacle. (ed) EJA 2011: collaborative effort by journal editors-in- 28 (6); 393-395 4. Moore RA, Derry S, McQuay HJ. Fraud or flawed: chief. One of the other outcomes of this adverse impact of fabricated or poor quality research. 39. Ochmann C, Tuschy B, Beschmann R et al. Supplemental Anaesthesia 2010: 65; 325-330. oxygen reduces serotonin levels in plasma and platelets collaboration appears to be the Committee during colorectal surgery and reduces postoperative 5. Schaefer SL. Tattered threads. (ed) Anesth Analg 2009: nausea and vomiting. EJA 20120; 27: 1036-1043 108 (5); 1361-1363 on Publications Ethics (COPE, http:// 40. Tramer, MR. Ethical requirements and authorship: not publicationethics.org), which is a forum 6. White PF, Rosow CE, Shafer SL. The Scott Reuben saga: much room for interpretation. (ed) EJA 2012; 29(3): 113- One last retraction.(ed) Anesth Analg 20111: 112(3): 115 512-515. for editors and publishers, which was set 41. Press release “Hospital presents results of final report: 7. Tramer MR. The Boldt debacle. (ed) Committee completes investigation in the case of Dr. up in 1997 soon after the affair involving EJA 2011: 28 (6); 393-395 Boldt.” Malcolm Pearce. Other institutions include 8. Smith R Time to face up to research misconduct. BMJ 42. Marcus A. Dutch researcher Poldermans ousted in 1996; (312); 789-790 the US Office of Research Integrity (http:// misconduct investigation. Anesthesiology News 2011 9. Fanelli D. How many scientists fabricate and falsify 43. Myklebust JP Netherlands: World heart research expert research? A systematic review and meta-analysis of fired. University World News 23 November 2011; 199 ori.hhs.gov) and the UK Research Integrity survey data. PLoS One 2009; 4 (5): e5738. 44. Larry Husten. New perspective on the Dutch Office (www.ukrio.org). There is also 10. Erasmas MC Dismisses professor. 17 November 2011 Cardiovascular Research Scandal http://www.forbes. http://www.erasmusmc.nl/corp_home/corp_news- com April 17 2012 a website called Retraction Watch that center/2011/2011-11/ontslag.hoogleraar/?lang=en 45. Masaru Kuroda MD & PhD Dean Toho University updates regularly on potential research 11. Roberts JG. Publishing in our journals: Ethic and Faculty of Medicine. Disciplinary action concerning Dr. honesty (ed). Anaesth Intens Care 1991:19; 163-4 Yoshitaka Fujii www.toho-u.ac.jp/english/information/ misconduct (http://retractionwatch. 12. Relman A Lessons from the Darsee affair. N Eng J Med march_6_2012.html wordpress.com). This site was founded 1983; 308; 1415-1417 46. Carlisle JB. The analysis of 169 randomised controlled 13. Altman L, Melcher L. Fraud in science trials to test data integrity. Anaesthesia 2012: 67:521-537. by Ivan Oransky, the executive editor at BMJ 1983: 286; 2003-2006 47. Joint Editors-in-Chief Request for Determination Reuters Health, and Adam Marcus, the 14. Wise J Extent of Dutch psychologist’s research fraud was regarding papers published by Dr. Yoshitaka Fujii “unprecedented.” http://www.aaic.net.au/pageBANK/documents/Fujii_ managing editor at Anesthesiology News, BMJ 2011; 343:d7201 Joint_Editorial_Request_Regarding_Dr_Yoshitaka_Fujii. in August 2010, and covered more than 15. Brumfield G Misconduct finding at Bell labs shakes pdf physics community. Nature 3 October 2002; 419:419-421 48. The results of investigation into Dr. Yoshitaka Fujii’s 200 retractions in just over a year. 16. DeFrancesco C. Scientific journals notified following papers http://www.anesth.or.jp/english/pdf/ research misconduct investigation. UConn Today http:// news20120629.pdf today.uconn.edu/blog/2012/01/scientific-journals- 49. Kranke P, Apfel CC, Roewer N. Reported data on notified-following-research-misconduct-investigation/ granisetron and postoperative nausea and vomiting 17. Clare Dyer. Guidance on intravenous fluid therapy is to by Fujii et al. are incredibly nice! Anesth Analg 2000: be reviewed after six quoted articles are withdrawn. BMJ 90:1004-1007 2011; 342:d1492

21 Remembering a day of terror and triumph: 10 years on from the Bali bombing

October 13, 2002 dawned we know he was the fi rst of many to come. Management Australia and government Driving into the conference centre that agents met in Canberra to delineate the as another balmy, tropical morning, the radio had sketchy details of best plan. As the critical nature of the Sunday in Darwin. The an explosion overnight in Bali. incident evolved, they decided to bring A mobile phone rang repeatedly the severely injured casualties to Darwin inaugural Northern Territory during the morning session – plans were by military aeromedical evacuation to be Anaesthesia Continuing developing to evacuate severely injured stabilised at Royal Darwin Hospital before Medical Education (CME) Australians from Bali and the Australian sending them on to major burns centres Defence Force was activating its reservists around Australia. meeting was under way and around the country. Dr Su Winter, a staff At Royal Darwin Hospital, our mass- we’d recovered from dinner specialist anaesthetist at Royal Darwin casualty plan swung into action. By a Hospital and the convener of our CME stroke of luck, there had been a mock the previous night. meeting, boarded the fi rst C140 aircraft external disaster exercise the week before, As I awoke at 6am for the second to Bali, along with other reservists from which ironed out a few glitches. A meeting day’s proceedings, a young man was Royal Darwin Hospital and around the was convened with all of the hospital’s presenting to Royal Darwin Hospital nation. senior clinicians and disaster-response (RDH) emergency department with a Australia had been dragged into the personnel to inform them of the event relatively minor burn injury. However his age of terror with a major attack on its and details as they were known. Plans story, as it unfolded, was about a horrifi c citizens, who were holidaying in Bali. were clarifi ed for each of the clinical explosion in a nightclub full of tourists. The number and severity of injuries areas, capacity was delineated and The patient had run directly from the quickly overwhelmed the health facilities preparations were made for management Sari Club in Bali, got himself to Denpasar at Sanglah Hospital in Denpasar and in the emergency department, intensive Airport and boarded a plane to Darwin patient survival would to depend upon care, operating theatre and a combined in the early hours of the morning. He had a time-critical evacuation to high-level ward area. The co-located private hospital come directly to the hospital. Little did healthcare in Australia. Emergency created capacity and took patients from

22 ANZCA Bulletin September 2012 “ A great sense of camaraderie between all the hospital workers was palpable as everyone readied their areas for a surge of severely injured patients.”

the public hospital to free up ward beds severely injured during their transport to department, intensive care unit and for Bali casualties. We rang all the staff the hospital by ambulance. operating theatre. There are more to ensure everyone was aware, and got as Anaesthetists provided an excellent staff and a huge number of training much rest as possible before the casualties continuity of care to these severely injured opportunities. Royal Darwin Hospital arrived. A specialist burns surgeon and patients as they coursed from retrieval, is now the site of the National Critical a retrieval team from the Royal Adelaide the emergency department, intensive Care and Trauma Response Centre Hospital arrived to help with case care, to the operating theatre and back (NCCTRC); this not only enhances local management. to intensive care. Senior clinicians capacity and response, but also provides A great sense of camaraderie between could stay with a single severely injured co-ordinated training in mass casualty all the hospital workers was palpable as patient through this critical-care journey. response to anaesthetists and surgeons everyone readied their areas for a surge Following stabilisation and emergent from Australia, New Zealand, Indonesia of severely injured patients. The petty surgery, civilian retrieval or military and the Pacifi c through the AusMAT rivalries that often exist in hospitals aeromedical evacuation teams transported (Australian Medical Assistance Teams) melted away. The number and severity of the patients to major burns centres around training courses. injuries was unclear, but we knew that Australia. The volume of work was huge: Since the Bali bombing, Royal Darwin there were many and that some were jet retrieval services fl ew in from around Hospital has managed several more very badly burnt. Extra resuscitation the country and Darwin Airport was a mass tragedies including a second major bays were prepared in the emergency who’s who and what’s what of retrieval bombing in Bali in 2005, a boat explosion department, outpatients was transformed organisations at the time. The local and near Ashmore Reef and police riots in into a treatment area for the less critically national organisation was impressive East Timor. We are better equipped and ill and staff busied themselves in the – the fi rst casualties were being fl own organised. But a strong sense of cohesion operating suite, opening an extra theatre onwards before the last of the victims remains among those who were working on Sunday to clear the list of patients on arrived from Bali. on that tragically memorable day of October 13. the emergency list and preparing multiple Over the course of the response, 66 theatres for simultaneous major trauma patients were treated at Royal Darwin cases. Hospital, 20 required intubation and Dr Brian Spain At 2am, 25 hours after the bombing, ventilation, 19 had procedures in the Director of Anaesthesia, the fi rst C130 Hercules landed in operating theatre and many others had Royal Darwin Hospital Darwin. Every available ambulance in escharotomy in the intensive care unit the Northern Territory’s Top End lined or emergency department. Physicians up to receive and transport patients to co-ordinated the treatment and care of any the hospital, 10 minutes by road. The patients not requiring intensive care unit Above panorama: The emergency anaesthesia department was asked care in conjunction with surgeons. department of Royal Darwin Hospital after to assist with meeting casualties at It was an extraordinary 48 hours of the Bali bombings. the airport as they arrived with the frenetic activity across the hospital. Opposite page from left: The fi rst victims of military aeromedical evacuation team. Then suddenly it was over. the Bali bombing are unloaded at 2am in The patients were handed over by the Ten years on, the hospital has Darwin from an Australian Defence Force evacuation teams and we were to assist transformed in many ways. There is a C130 into ambulance; Patients are unloaded with the ongoing management of the most bigger and better equipped emergency from the second Australian Defence Force C130 at 7.30am. Dr Phil Blum is accompanying the patient down the ramp.

23 How the revised curriculum will benefit you

Alongside the ANZCA Clinical Fundamentals, the revised curriculum will place greater importance on the seven ANZCA Roles in Practice, which are based on the CanMEDS roles devised by the Royal College of Physicians and Surgeons of Canada, and ensure trainees have skills as medical experts, communicators, collaborators, managers, health advocates, scholars and professionals. ANZCA Vice-President and Chair of the Education and Training Committee, Dr Genevieve Goulding, says previously the CanMEDS roles were given “lip service” in the curriculum. Now, rebadged as the ANZCA Roles in Practice, their place will be “totally overt”, with the learning outcomes set for each role having a special anaesthesia emphasis. Greater clarity, and improved “Previously, things like airway “They will emphasise that we’re management were scattered willy- not just medical experts; we are team and continuous assessments, nilly through all phases of surgical workers and we’re interested in patients will ensure the revised management and weren’t gathered as humans and not just people with diseases having certain operations,” Dr curriculum benefits everyone, together as a specific anaesthetic expert area,” Professor Baker says. “You might Goulding says. “The way it’s structured as Meaghan Shaw reports. have come across difficult airway enables trainees entering the program management issues in the old way of to understand from the very beginning ANZCA’s revised curriculum, which what the art of anaesthesia is and what comes into effect next year, will be the doing things but now we’re focusing on it and separating it out as a specific item.” they’re meant to achieve, and for teachers first in the world to break the nexus to realise it’s not just about teaching skills between anaesthesia training and ANZCA President, Dr Lindy Roberts, says the clinical fundamentals mean or putting knowledge into people’s heads. surgical procedures. It’s about behaviour. It’s actually about Whereas other countries’ training that for the first time, the curriculum will define what it means to be a specialist how you behave with patients and with programs are linked to surgical sub- the other health professionals you deal specialties, for example, anaesthesia for anaesthetist, which is important not only for training but to demonstrate to with. It gives a breadth that I don’t think burns, cardiac surgery or neurosurgery, has been there before.” ANZCA’s curriculum for the first time others, including government agencies, other specialties and the public, what Other features of the revised will be based on anaesthesia clinical curriculum include improved and fundamentals, which define an anaesthetists do. “It’s a new way of thinking about continuous assessment procedures, anaesthetist’s scope of practice. feedback from non-anaesthetists on ANZCA’s Dean of Education, Professor anaesthesia practice,” Dr Roberts says. “By defining the scope of practice and the each trainee’s performance, clearer Barry Baker, says the establishment of learning outcomes expected at each the seven ANZCA Clinical Fundamentals importance of the interactions between our different roles, we illustrate why it is stage of training, and a return to having – airway management; general a compulsory provisional fellowship year anaesthesia and sedation; pain medicine; that care is so safe and why it takes the amount of time it does to train a fully to help trainees transition to being perioperative medicine; regional and a specialist. local anaesthesia; resuscitation, trauma fledged specialist anaesthetist.” She says the revised curriculum Ultimately, the revised curriculum and crisis management; and safety and is expected to provide more clarity for quality in anaesthetic practice – will set will also ensure the College continues to produce specialists with a general trainees, supervisors of training and the benchmark for other countries. Fellows about the training program and “This is a world first and we are very scope of practice. “That means that the anaesthetist at the end of their its outcomes, and produce more well- proud of the fact that we’re out in front of rounded anaesthetists. the bunch on this one,” Professor Baker training is able to work across a wide says. range of practice settings, including in Benefits for trainees The ANZCA Clinical Fundamentals rural and regional parts of Australia Trainees will receive continuous and isolate each part of an anaesthetist’s and New Zealand, in operating suites immediate feedback on how they are practice and emphasise the importance of and outside operating suites in things progressing under the revised curriculum, gaining skills and expertise in each area. like pre-admission clinics and on pain and will have a greater understanding of rounds, and in retrieval and trauma what is expected of them through explicit management,” she says. learning outcomes.

24 ANZCA Bulletin September 2012 ANZCA Curriculum Revision 2013

Mandatory workplace-based Coupled with better monitoring “ This is a world first and we assessments, which can take the form through the new online training portfolio of a mini-clinical evaluation exercise, system, where trainees will record their are very proud of the fact a direct observation of procedural skills, training experiences and monitor their that we’re out in front of a case-based discussion, or multi-source progress against training requirements, the bunch on this one.” feedback, will ensure trainees have a supervisors of training will be able to say clear idea about how they are going. with greater confidence that trainees are Dr Goulding says trainees have performing at the required level. confided in her that they’re often told “From the supervisors of training point when they’re not performing well, of view, it enables the progress of trainees but rarely when they are. They don’t to be better monitored and they can get know where they are on the spectrum on top of problems quicker because the Dr Roberts says the introduction of performance compared with other monitoring is more regular and repeated of multi-source feedback as a form of trainees, or how to improve. and formalised, so it’s more readily workplace-based assessment will mean “The learning objectives and the way available,” Professor Baker says. that non-anaesthetists, including nurses the workplace-based assessments are Benefits for Fellows and other specialists, will provide structured allow trainees to see forward Fellows will benefit from the tools and feedback on the performance of trainees what they have to know and what they resources being developed as part of the and how they perform within a team. have to do in order to improve and they revised training program. “That will provide a lot of reassurance know what the standard expected is,” Dr Roberts says ANZCA is developing to the general public that the anaesthetist she says. new podcasts and other written is actually working well as part of the The revised curriculum also introduces and online resources, including for whole team that looks after them when the concept of spiral learning, with specialised study units such as ear, nose they come in for surgery or another type the teaching of the ANZCA Clinical and throat anaesthesia and paediatric of procedure,” she says. Fundamentals threaded throughout the anaesthesia. These resources also will ANZCA plans to continually evaluate curriculum. This means trainees will be available to Fellows to help them stay the revised curriculum to ensure it continually build on the knowledge they up-to-date with the latest practice and evolves and remains up to date with have gained. aid them in their continuing professional changes in the delivery of healthcare. A compulsory provisional fellowship development. Over the past 10 years, more of an year has been reintroduced, to allow “There are a lot of exciting anaesthetist’s practice has moved outside trainees to consolidate their skills in opportunities there for us to use some of the operating theatre into areas such as a special practice area in preparation the outcomes of the curriculum to benefit perioperative medicine, pre-admission for their desired type of specialist specialists as well,” she says. clinics and post-operative pain rounds, practice. This final year also gives Dr Goulding says many Fellows with as well as procedures in gastroenterology trainees the opportunity to take on a particular interest in a specialised area and radiology suites, Dr Roberts says. greater responsibility and participate in of anaesthesia, such as airways or pain “All of that makes it very important continuing professional development to management, will be thrilled that their to continue to evolve our curriculum,” help them transition to specialist practice. area of expertise has been recognised in she says. Benefits for supervisors of training the ANZCA Clinical Fundamentals. Dr Goulding says trainees, supervisors The ANZCA Handbook on Training and And those Fellows involved in training of training and other Fellows will be Accreditation, which will be available will have greater support and clarity encouraged to be a part of the continuous soon, will provide an important resource about their role when interacting with evaluation. for supervisors of training, giving them trainees and greater confidence when “We will be asking for feedback and more support and clarity for their role. being responsible for trainees on-call. that way we can keep the curriculum With clearer and more frequent modern, alive, relevant, exciting and Benefits for the community workplace-based assessments, interesting,” she says. An increased focus on the ANZCA supervisors of training will be able to Roles in Practice, including the way a identify problems with trainees sooner Meaghan Shaw trainee communicates and collaborates and provide feedback on ways to improve Media Manager, ANZCA with others, will ensure the public can performance. continue to expect the highest standards The competency-based nature of the of safety and patient care. assessments means trainees will need to be able to show they have the skills required, rather than simply answer knowledge-based questions during exams.

25 How anaesthesia departments are affected by the revised curriculum

The ANZCA fellowship The structure of the revised ANZCA curriculum includes seven ANZCA Roles ANZCA Roles in Practice training program consistently in Practice interwoven with seven ANZCA Medical expert provides excellent specialists Clinical Fundamentals, which focus on Communicator and trainees that assist us to the components that make up anaesthesia practice. These are covered over three Collaborator staff anaesthesia departments core study units (introductory, basic Professional throughout Australia and and advanced) and, simultaneously, Scholar New Zealand. 12 specialised study units, which cover Manager knowledge and skills in specific areas Maintaining excellence in any area of of practice. All trainees finish with 12 Health advocate medicine is never static and we must months of provisional fellowship training. periodically review our training to ensure ANZCA Clinical Fundamentals Changes it evolves as anaesthesia and education Airway management practice also evolve. Specific changes have been made to the ANZCA undertook a comprehensive 2013 ANZCA curriculum, which will affect General anaesthesia and sedation review of its training program from the way departments are managed: Pain medicine 2008 to 2010, offering all stakeholders – • The first six months of the program, Perioperative medicine called introductory training, will focus including training providers, anaesthesia Regional anaesthesia and local on development and assessment of basic departments and ANZCA Fellows – a anaesthesia chance to provide feedback and comment. clinical competence. Resuscitation, trauma and crisis The outcome was the ANZCA This will ensure that trainees and management Curriculum Framework and trainers focus on basic clinical Recommendations for Curriculum competence to a level of being able Safety and quality in anaesthetic Change, both of which guided the to handle uncomplicated cases practice development of the 2013 ANZCA independently. This will be assessed curriculum and can be found on the internally by the introductory Specialised Study Units ANZCA website. assessment of anaesthetic competence The Australian Medical Council (IAAC). Trainees will only be eligible Cardiac surgery and interventional (AMC) oversees medical training in to sit for the primary examination after cardiology Australia from undergraduate courses completing the IAAC and introductory General surgical, urological, to specialist training; the New Zealand training. The introductory training gynaecological and endoscopic Medical Council (NZMC) has the same period also will mean that when procedures responsibility in New Zealand. These trainees have difficulty with basic Head and neck, ear nose and throat, organisations review training programs clinical competencies, this will be dental surgery and electro-convulsive to provide accreditation and ensure recognised and documented early to therapy that high standards are maintained. facilitate early remediation. Any training program in Australia and Intensive care • Re-introduction of a provisional- New Zealand must meet AMC and NZMC Neurosurgery and neuroradiology fellowship training year for all trainees standards respectively. as the final component of training. Obstetric anaesthesia and analgesia The structure, learning outcomes Ophthalmic procedures and assessments of the 2013 ANZCA After completing the requirements of curriculum are detailed in the curriculum advanced training, including the final Orthopaedic surgery document, which can be downloaded examination, trainees will be eligible to Paediatric anaesthesia commence the provisional-fellowship (currently password protected) from the Plastic, reconstructive and burns training period. This will allow trainees ANZCA website: surgery (www.anzca.edu.au/training/2013- to focus on consolidating their training Thoracic surgery training-program/pdfs/anaesthesia- and a particular area of interest. training-program-curriculum.pdf) Departments will have these trainees Vascular surgery and interventional The “Training” section of the ANZCA for a full 12 months (or the period of radiology website includes a wide range of the appointment). information on aspects of the curriculum with specific sections for trainees, departments and trainers.

26 ANZCA Bulletin September 2012 ANZCA Curriculum Revision 2013

• Introduction of workplace-based • Clinical fundamental tutors Regulations assessments to provide a more formal (seven – see table) ANZCA has thoroughly reviewed all assessment of clinical and procedural • Specialised study unit supervisors its regulations relating to training in skills. (12 – see table) anaesthesia and the ANZCA Council has approved Regulation 37: Training The four types of workplace-based • Departmental scholar role tutor: This in anaesthesia leading to FANZCA and assessments will allow comprehensive position will co-ordinate the assessment accreditation of facilities to deliver this assessment of trainees throughout the components that relate to the scholar curriculum. training periods and ensure structured role. Some of these are internal and The ANZCA Handbook for Training feedback occurs progressively. They are: some externally assessed. and Accreditation supports the training - Direct observation of procedural skills It will be important for supervisors of program curriculum and regulations. The (DOPS). training to have sufficient rostered, handbook provides detailed information - Mini clinical evaluation examination non-clinical working time to meet with on all aspects of the training program, (MiniCEX). trainees for the clinical placement reviews including requirements for hospital - Case-based discussion (CdD). and core unit reviews. department accreditation, processes for Other supervisor and tutor roles will - Multisource feedback (MSF). remediation of trainees, where required, also need time allocated to fufil the duties and detail on the implementation of Each type of workplace-based of their roles. regulations. assessment will look at different aspects Many of the specialised study unit The 2013 ANZCA curriculum is poised of trainee’s performance in terms of supervisor roles are small and a single to take training for anaesthetists into the knowledge, skills and attributes. Each person may hold several. Similarly, future. The new curriculum addresses one is formative and together they one person may hold several clinical previous training problem areas and contribute to summative assessment fundamental tutor roles. embraces clinical practice changes of trainees at the end of each training and education evolution to ensure we period. Training portfolio system The training program will have an maintain the excellence of our training Detailed information on the workplace- electronic portfolio to enable easy program. based assessments is available on the tracking of a trainee’s progress in volume ANZCA website. of practice, assessments and reviews. Dr Brian Spain Supervisory roles Trainees will enter data progressively Curriculum Revision Steering Group To facilitate training and assessment, as an electronic logbook of cases, as there has been considerable change to the well as documenting weeks worked and supervisory roles that each department all their assessments. Supervisors of will need to have in place. training will have access to their trainees’ ANZCA provides guidance on how portfolios, but other supervisors will departments can transition from the need the trainee to sign them in so they “ The ‘Training’ section of the current roles to new roles on the ANZCA can complete the specialised study unit ANZCA website includes website: reviews. information on aspects www.anzca.edu.au/training/2013- All supervising anaesthetists training-program/pdfs/Roles- (FANZCAs, provisional Fellows and of the curriculum with Departments-2013.pdf non-FANZCA specialists) will be able to specific sections for trainees, • Supervisor of training: This position complete workplace-based assessments departments and trainers.” remains and is pivotal to training and its – and are encouraged to do so. These co-ordination in the workplace. can be entered directly into the training portfolio system. • Introductory training tutor: This People can access the training portfolio position will oversee trainees in the system through all devices with an introductory training period. There internet connection, including computers, will be advantages if they have an tablets and smartphones. appointment as a supervisor of training. Departments are encouraged to In some institutions they may be in facilitate wireless-internet access where addition to the principal supervisor possible, but otherwise ensure ready of training. access to the internet via cabled devices.

Detailed information relating to the curriculum can be found at www.anzca.edu.au/training

27 College launches training and accreditation handbook

The fi rst edition of the ANZCA ANZCA Council approved the “ The handbook will link handbook at its August 2012 meeting, Handbook for Training and following many months of work by the closely with regulation 37 Accreditation is on track for TE-Document Development Group, as well as other educational release in late September. commencing in May 2011. The chair of the resources under the The handbook, which has been written working group and ANZCA President, Dr “Training” tab on the Lindy Roberts, steered the development to guide trainees and Fellows using ANZCA website” the revised training program, will of the document, supported by ANZCA be available on the ANZCA website staff, Fellows and representatives of the along with an updated version of the ANZCA Trainee Committee. ANZCA is very Anaesthesia Training Program Curriculum grateful to the Fellow participants of the document and the new Regulation 37: group who most generously contributed Training in anaesthesia leading to FANZCA their time and expertise, Dr Suzanne and accreditation of facilities to deliver this Bertrand, Dr Genevieve Goulding, Dr ANZCA Handbook for curriculum. Mark Reeves and Dr Janet Smith, and Training and The beginnings of the handbook date trainee representatives Dr Scott Douglas, Accreditation back to November 2011 when a new policy Dr Michael Lumsden-Steel and Dr Jennifer model relating to the revised curriculum Myers. was approved by the ANZCA Council. The handbook will link closely with The model included developing the new regulation 37 as well as other educational handbook and regulations with phasing resources under the “Training” tab on out of the training and education (TE) the ANZCA website. There will be regular professional documents. reviews of the handbook, on an annual It was agreed that regulation 37 basis or as required, and it is envisaged would prescribe the training essentials that there will be ongoing improvements and an accompanying handbook would to the usability of the resource, informed provide additional interpretation of by feedback from Fellows, trainees and the regulations and expand on related others. processes for trainees, supervisors, heads The ANZCA Policy Unit co-ordinated of department and other users. This the development of the handbook with model was designed to maximise clarity, input from the Education Development, accessibility and effi ciency for all. Records Management, and Training and The handbook has been informed Assessment Units. by consultation with the Curriculum Redesign Steering Group, College John Biviano committees, supervisors of training, General Manager, Policy regional/national education offi cers and committees, the Faculty of Pain Medicine Board, relevant special interest groups and trainees who responded to the 2011 questionnaire regarding the TE professional documents.

Above: The cover of the handbook which can be found at www.anzca.edu.au/training

28 ANZCA Bulletin September 2012 Investing in a world-class ANZCA Curriculum training program Revision 2013

As most would appreciate, the The fee structure is based on the “ The fee structure is based on principle that the user pays – if there are College has invested heavily to high levels of costs for an activity, such as the principle that the user develop a revised world-class engaging the expertise of the director of pays – if there are high levels training program to ensure professional affairs (assessor) the fee will of costs for an activity, such Australia and New Zealand reflect this. In keeping with this principle, as engaging the expertise of Fellows’ subscriptions will continue to remain at the forefront support Fellow-related activities. the director of professional of postgraduate medical While there is no change to the affairs (assessor)... the fee education in anaesthesia. structure of most fees for trainees (for will reflect this.” example, registration, annual training, More than 100 Fellows on ANZCA’s examination and examination withdrawal education and training committees, sub- fees) there is a new application fee for Examination costs include, but are not committees and working groups and all training. The application fee is a one- limited to: current and past members of the ANZCA off fee that covers the administration • Training and Assessment unit staff Trainee Committee, as well as members of costs of applying to the College, as costs. For example, co-ordinating the special interest groups and many others, well as indicating an interest in joining communications between, and activities have been involved in developing the the ANZCA training program in the of, examiners and candidates. This curriculum which will commence in the future. It benefits prevocational doctors includes determining the availability 2013 hospital employment year. by ensuring online access to College of examiners, rostering examiners and Knowing how to conduct workplace- resources (much of which is password dealing directly with candidates. Every based assessments (WBA) will be an protected) including the ANZCA Library, candidate is individually assessed for essential component of the revised past exam questions, podcasts, webinars their eligibility to sit each examination curriculum. Twenty five WBA champions and communications including College and this involves significant time for along with key ANZCA staff have led e-newsletters. staff including the DPA assessors. training sessions. To date, more than 60 Once the application fee has been • Examinations committee costs. These per cent of supervisors of training and a paid, doctors will have up to three years include teleconferencing costs and face- further 350 Fellows have attended WBA to secure a hospital training position and to-face meetings that involve travel and workshops. enter the ANZCA training program. Until accommodation costs. Over many months, the College has a post is secured or the applicant chooses • Examiner costs. While examiners are engaged IT experts to develop the state- not to pursue anaesthesia training, he or of-the-art training portfolio system (TPS) not paid for their time, the College she must also pay an annual application must cover all air and ground travel, which will allow information pertaining maintenance fee that gives access to the to each trainee and their progress through accommodation, catering and meal College resources mentioned above and allowances. the curriculum to be recorded and stored covers the associated administration for use by them and their supervisors. costs. • Venue hire, including catering, security More than 50 per cent of ANZCA staff When a hospital training position has and office equipment. throughout Australia and New Zealand, been secured, the doctor will pay the one- • Staff costs at venues including and a team of project management off registration fee and then the annual invigilators, support for examiners, experts brought in specifically for this training fee for the duration of training. transport and accommodation. In 2012, project, have also been involved in In general fees associated with training this included 12 venues in Australia, developing the revised curriculum – cover the many ongoing complexities of five in New Zealand, and three in Asia from organising more than 200 meetings conducting the training program. As an for the primary exam and seven for the involving Fellows, trainees and others example, the cost of examining trainees is final exam. to co-ordinating the development of not just about running the exam itself but • Costs associated with patients for the the ANZCA Handbook for Training and involves year-round activity by College final exam medical vivas at seven Accreditation and the new Regulation 37: staff in the Training and Assessments venues in Australia, New Zealand and Training in anaesthesia leading to FANZCA unit, IT, education development, Hong Kong. and accreditation of facilities to deliver communications and so on that support • Costs associated with the oral this curriculum. The regulation, which the exam processes. was approved at the August 2012 ANZCA component of the primary exam held in Council meeting, will govern all aspects Melbourne and Hong Kong, and with the of the revised curriculum, including the final examination anaesthesia vivas in fee structure. Melbourne and Sydney. (continued next page)

29 Investing in a world-class ANZCA training program Curriculum Revision continued 2013

• Exam paper printing and examiner • Records management. This team • Support for training activities at a postage costs. receives queries and processes regional level and in New Zealand, • IT costs associated with the exams documentation on a range of training such as running courses, meetings and management system (EMS) which program components each year workshops for supervisors of training. includes candidate lists and results, including approximately 4000 in- The above are examples of the ongoing examiner rosters and performance, as training assessments (about 400 costs that ensure the College delivers well as ongoing evaluation and other in hard copy), 450 applications for a training program that produces quality improvement processes to registration, 3500 module completion anaesthetists who can deliver safe, high ensure that the examinations meet the forms, maintenance of the supervisor quality anaesthesia to the community. requirements of accrediting bodies of training and module supervisor The details of the training fee structure (the Australian Medical Council and data base for about 800 ANZCA are in regulation 37 which will be released the Medical Council of New Zealand). representatives (updated twice a year), on the College website in late September 2000 training fees, 350 fellowship • Examiners training and question 2012 with the handbook. Annual fees applications, 400 special requests (such writing workshops in Melbourne which are part of the ANZCA annual as part-time training, overseas training, involving travel, accommodation as budgeting process are determined each provisional fellowship program well as administrative and education October for the following calendar year. application and recognition of prior development costs. learning) and 300 formal projects. Dr Michelle Mulligan There are many other training program • IT costs. There are many costs involved Treasurer, ANZCA costs. These include: in running the systems that support • DPA (assessor) and DPA (deputy training, including the online in- assessor) costs. DPAs are experienced training assessment (ITA) system and clinicians employed by the College for maintaining the College database iMIS. their expertise. The DPA (assessor) and These require not only maintenance to DPA (deputy assessor) verify training ensure they are kept fit for purpose, but “ Fellows’ subscriptions will documents to ensure the eligibility of also input from educational experts to continue to support Fellow- candidates to sit exams and make other ensure that they support educational related activities.” decisions, for example, in relation to best practice. recognition of prior learning, completion • Online educational resources including of training requirements and admission publication of high quality podcasts to Fellowship. delivered by expert Fellows and delivery • Helping trainees experiencing difficulty of interactive webinars for trainees including, where required, undertaking preparing for examinations, as well as trainee performance reviews (TPRs), to access to all library resources, such as assist trainees to get their training back journals and online text books. on track. • Support for the educational committees • Hospital accreditation. There are 209 and working groups committed accredited hospitals in Australia, New to ensuring the training program Zealand and Asia that require regular continues to improve over time. inspections to ensure that they are able • Support for the ANZCA Trainee to deliver the training program to an Committee and the regional trainee appropriate standard. Co-ordinated by committees to ensure that trainees College staff, these inspections also have a voice in decisions made about include travel and accommodation costs their training, including at the ANZCA for experienced Fellow inspectors. It is Council which is attended by the ANZCA critical that assessments are unbiased, Trainee Committee co-chair. so this requires team members from outside the hospital’s region, as well as representatives of the regional and national committees to provide a local perspective.

30 ANZCA Bulletin September 2012 Anaesthetic history: Dr William Russ Pugh’s eventful life

William Russ Pugh is best when Cornelia gave birth to a stillborn was completed successfully. After a short daughter. In 1838, a second daughter, while she declared herself pleased with known for administering Cornelia, was born, but tragedy struck the procedure and walked home. The Australia’s fi rst general again when she died from croup at the second patient, a 60-year-old, almost- anaesthetic for a surgical age of seven months, two days after she blind man, had a successful cataract was baptised. The couple had no further operation, previously aborted twice operation in Launceston children. because he was unable to tolerate the on June 7, 1847. His other Pugh is well known for administering pain. After a painless procedure, he achievements are less the fi rst general anaesthetic for a surgical quickly recovered and walked home. The operation in Australia in Launceston on fi rst surgical etherisation in Australia had well known. June 7, 1847. been successful. Born in London in 1805, William Russ The late Dr Gwen Wilson established that But his other achievements are less Pugh was educated in Edinburgh and the Illustrated London News of January 9, well known. Dublin and qualifi ed as a surgeon and 1847, containing the news of ether use, Pugh also assisted Count Paul Edmund accoucheur. arrived in Hobart on May 27, 1847 having Strzelecki, the Polish explorer of south- Aged 29 he made the four-month left London on January 26 and reaching eastern Australia and Van Diemen’s Land, journey to Hobart, Van Diemen’s Land, Launceston on Saturday May 29. to analyse Tasmanian coal samples by as ship doctor aboard the Derwent. Also Mrs Pugh probably fi rst claimed the providing laboratory space and equipment. travelling was Cornelia Kerton, single and papers since we know that she received Subsequently, the Pughs lit their 10 years his senior, coming to accept a several periodicals, and was eager for Launceston home with coal gas in 1844. legacy from her deceased brother’s estate. news from “home”. On Saturday evening, Pugh performed forensic analyses for Arriving in Hobart on December under the gaslight, it is possible she said: coroners in poisoning cases. He advised 10, 1835, Pugh sought a position in “Look at this Pugh. I’m sure you could on the safe disposal of a ship’s cargo Hobart. None was available. The make one of these in your laboratory!” of zinc sulphide, which threatened to Derwent proceeded to Sydney so Pugh Nine days later he had prepared the spontaneously ignite in Launceston’s port. tried his luck there. There were still no equipment and the ether essential to In 1838 Pugh became a founding and opportunities. He returned to Hobart on successful etherisation. During that active member of the Tasmanian Society the Derwent and decided to walk the 200 week he selected suitable patients. for Natural Science, Agriculture, Statistics kilometres to Launceston to seek work. A number of medical and other &c., which subsequently became the Arriving in Launceston on March 6, witnesses attended Pugh’s private Royal Society of Tasmania. He made 1836, Pugh found Cornelia, who had hospital on the morning of Monday presentations on geology, zoology, botany travelled to Launceston by coach after June 7, 1847. First, a woman with two and meteorology to both societies. disembarking from the ship. He proposed decayed molars and an abscess in her His interests must have contributed and they married on May 7. Eight months jaw breathed the ether vapour through the knowledge and motivation to after the marriage, tragedy struck a tube for fi ve minutes before becoming encourage him to confi dently initiate insensible, after which the operation ether anaesthesia. His scientifi c training

32 ANZCA Bulletin September 2012 meant that he documented his experience The banker refused so Pugh fi xed a “ His interests must have in detail in the Australian Medical notice to the door of the club accusing Journal on the same day. the banker of being a coward and a contributed the knowledge Eleven days later, he had critically liar. The banker sued for defamation and motivation to encourage assessed his experience and wrote in the Supreme Court, seeking £2000 him to confi dently initiate another report, pointing out that an in damages. The jury heard that the uncritical use of etherisation was defamation was proven but they should ether anaesthesia. His dangerous and potentially lethal. decide the damages. Not being fond of the scientifi c training meant Pugh was appointed Sub-Agent for banker, the jury recommended damages that he documented his Immigration and Health for Launceston of one farthing, and said that each party and a member of the Court of Medical should pay their own costs. Pugh’s experience in detail in the Examiners. tattered reputation was partially restored. Australian Medical Journal Professional jealousy was alive and Scarcely was this case over, than Pugh on the same day.” well in Launceston in 1842. Following a charged Dr Haygarth with “malicious surgical case in which he operated for prosecution” seeking damages of £1000. hernia on a patient who died fi ve days The same judge heard this case. The jury later, three jealous colleagues persuaded gave a verdict in Pugh’s favour, awarding Dr Haygarth, a naive and recently arrived damages of £250. Haygarth, unable to pay doctor, to accuse Pugh of manslaughter. the fi ne and Pugh’s costs was jailed in After sitting from midday until midnight, Hobart for 12 months. the magistrate hearing the evidence A bright spot in 1844 was the award concluded that Pugh had no case to of an MD from Giessen University for his answer. thesis on treating fractures. No sooner was this over than Pugh Pugh continued to practise in became embroiled in a dispute with a Launceston until 1854, when, perhaps banker over a lost invitation to a ball. The drawn by the gold-rush inspired banker, who was losing money because prosperity of Melbourne, he moved to of a depression engulfi ng Van Diemen’s Melbourne with his wife. He practised as Land, sought to recover funds from a surgeon and oculist from rooms at 131 Pugh after presuming he was a wealthy Collins Street before returning to England gentleman. After he goaded Pugh with in 1872 or 1873. Pugh died aged 91 and Above from left: William Russ Pugh, portrait; insulting letters and attempting to expel is buried in Brighton cemetery. Pugh’s carriage and home in Collins Street, him from the Launceston Club, Pugh – Melbourne; formerly St John’s Hospital and exasperated beyond reason – challenged Dr John Paull, FANZCA Dispensary 1845-52 (author’s photo); Cornelia him to a duel. Launceston, Tasmania Pugh, portrait, 1871.

33 Propofol misuse among anaesthetists – is it a problem?

Preventative campaigns and Opioids were responsible for 66 per One way of combatting the problem cent, benzodiazepines 5 per cent, and would be to introduce and easily vigilance are essential to save inhalational agents 5 per cent of substance accessible substance folder within the the lives of specialists at risk, abuse cases in the 2005 survey. department. This should include details of writes Lisa Zuccherelli. There is an obvious attraction to substance abuse committee members and propofol as a drug of abuse. It is short a designated intervention team. Substance Addiction is an occupational hazard for acting and allows a rapid, clear-headed abuse committees are integral to both the anaesthetists, who have easy access to recovery with no residual hangover, ideal prevention and management of substance highly addictive drugs and the requisite for on-the-job use because it is less likely abuse, and perform an administrative, not knowledge and skills to use them. to signal a substance-abuse problem. therapeutic function. Among other duties, Current US literature reports an incidence The restful, refreshed quality of sleep the committee should be responsible for of general substance abuse of 1 to 2 per cent 1,2 afforded by propofol administration, often education, investigating of reports of drug among anaesthesia care providers . referred to as “pronapping”, is attractive to diversion, appointing an intervention The untimely death in 2009 of pop insomniacs and shift workers. It imparts a team, monitoring of treatment and superstar Michael Jackson, largely thought strong sense of euphoria at subanaesthetic follow-up support. Only 20 per cent of to have resulted from a propofol overdose, doses, secondary to enhanced dopamine Australasian anaesthesia departments triggered a resurgence of interest in release in the reward areas of the brain. surveyed had a substance abuse policy in 4 propofol as a drug of abuse. Undoubtedly ease of access plays a place in 2005 . More than 80 per cent of propofol role in the growth of propofol misuse. Other preventative strategies include misuse is found among healthcare The drug is unrestricted, unsecured and witnessed discarding of unused providers, probably because of ease unregulated, and available in a wide anaesthetic agents at the end of every of access. However, the drug is freely variety of clinical settings within most case, and the regulated dispensing of available for purchase without a medical facilities. Because it has such propofol. prescription on many websites and a short duration of action and rapid Regulated dispensing, used in many experts fear there could be a spike in recovery, it may be self administered up other parts of the world, is a highly the number of non-medical personnel to 100 times a day. controversial subject and many see it becoming addicted to propofol following Finally, there is a lack of routine testing as both inconvenient and potentially the publicity surrounding Jackson’s death. for propofol, and it needs to be specifically dangerous – impeding ready access The incidence of propofol misuse is requested in drug-screening panels. to propofol in an urgent or emergent quoted as 0.1 per cent among anaesthesia procedure could be disastrous. As propofol 3 Unfortunately, the properties that providers. In a US survey in 2007 , 18 make propofol so attractive as a drug is used in large volumes, regulated per cent of 126 responding academic of abuse are accompanied by a narrow dispensing would have a significant anaesthesia departments reported one therapeutic index, and accidental or impact in many hospital, outpatient or more incidents of propofol abuse intentional death is a real possibility. and clinic settings, and could pose a or diversion in the past 10 years. This It is highly addictive and sudden regulatory nightmare. It also has been represents a fivefold increase in reporting withdrawal after chronic misuse gives found to be ineffective for the determined from previous surveys. rise to an intense craving, despite a lack diverter. Some experts believe this is the tip of compelling evidence of a physical Nevertheless, regulated dispensing of the iceberg because many propofol withdrawal syndrome. allows earlier detection of drug diversion, misusers start with opioids or other The management of propofol abuse which may save lives. Proponents sedatives and graduate to propofol. is described in detail in the Welfare of of regulated dispensing say that They also often misuse more than one Anaesthetists Special Interest Group preventing deaths is more important than drug at a time, so propofol abuse may be resource document 20, found on the inconvenience in practise. underreported. The survey also found that ANZCA website. In the US, many hospitals use an about 30 per cent of the cases present with Prevention remains the most important automated anaesthesia drug-dispensing death as the first indication of a substance aspect of any management strategy, system, which provides drugs to individual abuse problem, and the vast majority of and includes raising awareness through anaesthetists and records usage. The database can identify abnormal usage deaths occur among trainees, particularly education. patterns. Interestingly, fospropofol, within five years of medical school. It is important that departments or a water-soluble prodrug of propofol In an Australasian survey of substance group practices establish a substance introduced into clinical practice in the US abuse among anaesthetists published abuse policy and offer a proactive 4 in 2009, has been labelled as a schedule in 2005 , 44 substance abuse cases were program, which may include regular four drug (which requires a doctor’s reported in 100 responding programs. tutorials, compulsory e-learning and prescription). All programs reporting In 15 per cent of cases, the initial mentoring. Mentoring can be both deaths from propofol abuse in the US presentation was death and death was preventative and therapeutic. A mentor survey occurred in centres where there was the eventual outcome in 24 per cent of may be able to identify an anaesthetist no pharmacy accounting for the drug. cases. Induction agents were responsible who is at risk long before a report of drug Another preventative measure used in for 20 per cent of cases of substance abuse diversion. They can guide and support a (compared to only 6 per cent in a similar the US is mandatory, random drug testing, return to clinical practice and assist with which also has been used successfully survey from 1993). Unfortunately, the ongoing monitoring and rehabilitation. breakdown of agents was not reported. in the aviation, transport and military industries.

34 ANZCA Bulletin September 2012 “It is highly addictive and sudden withdrawal after chronic misuse gives rise to an intense craving despite lack of compelling evidence of a physical withdrawal syndrome.”

The Boston Massachusetts General in a facility, such as a dialysis centre or References: Hospital has introduced a $US50,000 primary-care facility, where exposure to 1. The drug seeking anesthesia care provider, program that allows one to two urine tests propofol is unlikely. Bryson & Hamza. Inter Anesth Clinics 2011; per year plus pre-employment screening Although many substance-abusing 49:157-71. for approximately 80 registrars5. This is anaesthetists return to work, the literature 2. Substance abuse among physicians: a survey weighed against the cost of diagnosis and suggests that fewer than half make a of academic anesthesiology programs, Booth JV et al Anesth Analg 2002 Oct; 95(4): 1024-30. management of one substance-abusing long-term recovery, and only 20 per cent 3. A survey of propofol abuse in academic doctor – more than $US100 000. Issues will make a long-term recovery within 4 anesthesia programs. Wischmeyer et al. reported include false negatives and the specialty of anaesthesia . Sadly, Anesth Analg 2007;105:1066-71. positives, and the fact that mandatory successfully completing a treatment 4. Substance abuse by anaesthetists in Australia testing may screen out substance abusers, program does not guarantee a specialist and New Zealand. Fry RA. Anaesthesia & who then apply to other academic programs. won’t relapse. Intensive Care 2005;33:248-55. Another controversial issue concerns US literature shows propofol misuse 5. Random drug testing to reduce the incidence the return to work of a detoxifi ed and among anaesthetists appears to be of addiction in anaesthesia residents: rehabilitated anaesthetist – in particular increasing3. An emphatic prevention preliminary results for one program. whether or not the specialist should return campaign and vigilance is key to reducing Fitzsimmons et al. IARS 2008;107:630-5. to work in anaesthesia6. The Medical the likelihood of a tragic outcome. There 6. Should anaesthesia residents with a history Board of Australia determines limitations also needs to be ongoing discussion and of substance abuse be allowed to continue training in clinical anaesthesia? The results on practice, and makes recommendations debate about the issue of tighter control of a survey of anaesthesia residency program regarding ongoing monitoring and testing, over propofol dispensing and whether this directors. Bryson E. J Clin Anesth 2009; level of supervision and restricted working is feasible and/or desirable. 21:508-13. hours. There is no formal policy regarding these conditions because every case is Dr Lisa Zuccherelli, FANZCA dealt with individually. Canberra Hospital, ACT Unfortunately, the initial relapse symptom in 15 to 25 per cent of cases is death, most commonly in the early period of recovery. Because relapse is associated with signifi cant mortality, a period away from clinical practice after initial detoxifi cation may reduce the rate Further doctors’ welfare information, including Doctors’ Health Advisory Service of relapse. This may require placement Hotline numbers and access to the Welfare of Anaesthetists Special Interest Group, can be found here www.anzca.edu.au/resources/doctors-welfare.

35 OvERSEAS AID: Central American specialists learn Essential Pain Management

Pain by the numbers • 70 per cent of the world’s cancer deaths and 99 per cent of HIV deaths occur in low and middle-income countries but only six per cent of the world’s opioids are consumed in these countries.1 • 80 per cent of the world’s population lacks adequate access to pain treatment.2 • In over 150 countries, morphine is not available.3

The ground-breaking Essential Pain anaesthesiologists from around the Pharma, Menarini, Novartis, Pfizer Management (EPM) course has been region and there were representatives and Sanofi. held in Central America for the first time, from seven countries: Honduras, The outlook for EPM in Latin America bringing new hope to pain sufferers Nicaragua, Guatemala, El Salvador, is bright. All teaching materials have been in some of the poorest countries in the Dominican Republic, Panama and Mexico. translated into Spanish and there is now a region. Anaesthetic societies from these countries group of enthusiastic instructors who are The EPM course aims to improve pain are part of a grouping called FESACAC keen to run more courses in Central and knowledge, provide a framework for (Federacion de Sociedades de Anestesia de South America. managing pain cases and address pain- Centroamerica y del Caribe). The EPM workshop was developed by management barriers. I was initially concerned that the EPM Dr Wayne Morriss and Associate Professor A series of EPM workshops was run teaching materials would be too basic for Roger Goucke with the assistance of in San Pedro Sula, Honduras, in early a group of anaesthesiologists, but there ANZCA to improve pain knowledge, to August. A small country in Central was good understanding that EPM offers provide a simple framework for managing America, Honduras has a population a “system” for managing different types pain and to address pain-management of about eight million and is one of the of pain and also a method for teaching barriers. The program was developed poorest countries in the region. Its health others. following discussion with Papua New services are very unevenly distributed. The group attended the half-day Guinean anaesthetists on the lack of San Pedro Sula is the country’s second instructor workshop on August 3 and then available training in pain medicine in largest city and main business centre. ran two concurrent EPM workshops on PNG. Pilot courses were held in Papua New The president of the Honduran Society the final day. In total, 29 instructors were Guinea in April 2010 and workshops have of Anaesthetists, Dr Carolina Haylock trained and 64 people completed the one- been held across the Pacific, Asia, Africa Loor, hosted the pilot series after it was day course. and Central America. discussed during meetings at the World The workshops identified a number For further information on the Essential Congress of Anaesthesiologists in Buenos of pain management barriers, including Pain Management program please visit Aires in March. At one of these meetings problems related to staff knowledge and www.fpm.anzca.edu.au/fellows/essential- Dr Haylock Loor offered to translate the attitudes, absence of basic analgesics pain-management. teaching materials into Spanish and host (for example, liquid morphine or an the courses in Honduras. equivalent) and the absence of pain Dr Wayne Morriss, FANZCA A vital part of the EPM course is management protocols. The newly trained Past-Chair, Overseas Aid Committee, that local instructors quickly take over instructors were positive that the EPM ANZCA responsibility for running the course. To would help them to address these barriers. do this, we typically run a “one-half-one” The workshop series was exceptionally References: series of courses. well organised by Dr Haylock Loor and 1. Union for International Cancer Control. Global Ac- her colleagues at the Sociedad Hondurena cess to Pain Relief Initiative [internet]. 2011. From: On day one, we run a one-day www.uicc.org/programmes/gapri. Accessed 23 interactive workshop. On day two, de Anestesiologia, Reanimacion y August 2012. participants from the first day attend a Dolor (SHARD). This pilot was an 2. Lamas D, Rosenbaum L. Painful inequities – Pallia- half-day instructor workshop. On day excellent example of collaboration tive care in developing countries. The New England between three organisations – SHARD, Journal of Medicine 2012;366:199-201. three, the newly trained instructors run 3. Lamas D, Rosenbaum L. Painful inequities – one or two courses with the help of the the World Federation of Societies Palliative care in developing countries. The New visiting team. of Anaesthesiologists and ANZCA. England Journal of Medicine 2012;366:199-201. In San Pedro Sula, 29 doctors attended Participants were asked to contribute the first one-day EPM workshop on a nominal sum and the EPM team was Above from left: Carolina Haylock Loor, Maria August 2. Dr Haylock Loor had invited grateful for the support of local companies Elena Mariona, Angela Enright, Claudia Alvarez, including Asopharma, Janssen, Merck, MD Wayne Morriss, Juan Carlos Duarte, Alex Shelton.

36 ANZCA Bulletin September 2012

Oximeter donation helps to save lives in Papua New Guinea

The distribution of College- Dr Cooper said the death rate in “The evidence is clear and really it goes developed countries, such as Australia a long way to give us the encouragement donated pulse oximeters has and New Zealand where pulse oximeters and strength to start the push to bring been a real blessing to PNG as were standard equipment, was one in delivery, health and wellbeing and Meaghan Shaw reports. 200,000 anaesthetics administered, quality of life to many of our people compared to one in 133 in Africa. who have not had access to it for many, ANZCA donated nearly 100 pulse “The majority of these deaths are many years.” oximeters to 40 hospitals throughout respiratory deaths, three-quarters of Dr Cooper later distributed the 93 pulse Papua New Guinea in September thanks them,” he said. “Aspiration, tube in the oximeters to anaesthetic scientific officers to fundraising efforts by Fellows and wrong place, post-operative hypoxia, at the 25th anniversary of the Society of trainees at this year’s annual scientific overdose of drugs or they can’t sort the Anaesthetists of Papua New Guinea’s meeting in Perth. airway out. All of these cases could have specialist meeting, which was attached The Chair of ANZCA’s Overseas Aid been identified by pulse oximetry.” to the symposium. Committee, Dr Michael Cooper, presented He said pulse oximeters were able to One of the recipients, anaesthetic 93 pulse oximeters to the PNG health increase the detection of hypoxia nearly scientific officer Mr Paul Jeff from Mt department at the annual PNG Medical 20-fold, as well as if a tube was in the Hagen General Hospital, said he was Symposium in Port Moresby in front of wrong place or a patient not breathing “overwhelmed” by the donation. about 400 medical specialists. properly or ventilated properly. They also “It’s really a blessing to us,” Mr Korowa The pulse oximeters were provided decreased the frequency of myocardial said. “It will help improve our patient from the nearly $50,000 raised by ischemia and cardiac arrest, because they care and make our job easier.” ANZCA specialists and the Overseas Aid can pick up hypoxia earlier. At the specialist meeting, the Overseas Committee through the Lifebox project, Dr Cooper said senior anaesthetists in Aid Committee also distributed 40 packs a global initiative arising out of the PNG had identified a need for 320 pulse of 11 key medical textbooks specific World Health Organization’s safe surgery oximeters for operating theatres and to developing anaesthesia for use by checklist. recovery areas around the country, but his hospital anaesthetic departments. For $US250, the Lifebox project “gut feeling” was this was a low estimate, The books included Melbourne provides a robust pulse oximeter and not taking into account other specialist anaesthetist Dr David Pescod’s Developing educational material to hospitals in wards and units. Anaesthesia Textbook, the Oxford Handbook of Anaesthesia, Understanding developing countries. The PNG Deputy Secretary of Health Paediatric Anaesthesia, Care of the Dr Cooper told the symposium Lifebox Dr Paison Dakulala, who represented the Critically Ill Patient and the Westmead estimated about 77,000 operating theatres Secretary of Health Mr Pascoe Kase at the Anaesthetic Manual. around the world did not have access to presentation, said the donation would these oxygen monitors, putting at risk the make a huge difference to PNG’s health lives of about 35,000 patients each year. services and the care provided to patients. Above from left: PNG Chief Anaesthetist Dr So far, the Lifebox project has provided “This is a very, very important life- Duncan Dobunaba, Adelaide anaesthetist Dr Chris about 1700 pulse oximeters to 48 countries, saving device and equipment that will go Acott, President of the Society of Anaesthetists including efforts by Australia and New of PNG Dr Harry Aigeeleng, Australian and New a long way to bringing life and health to Zealand College of Anaesthetists’ Overseas Aid Zealand to provide five units to Tonga, 15 our people, especially in all the theatres Committee Chairman Dr Michael Cooper, Deputy to the Solomon Islands, 20 to Fiji and 20 throughout the country, as well as in Secretary of Health Dr Paison Dakulala and senior PNG anaesthetist Dr Gertrude Marun; Anaesthetic to Samoa. “As of today, will have red dot the health facilities where this is most on Papua New Guinea as well,” he said, to scientific officer Paul Jeff, from Mt Hagen General needed,” he said. Hospital, with the chair of the Overseas Aid spontaneous applause from the audience. Committee, Dr Michael Cooper.

37 War zone anaesthesia

“ I haven’t really felt any extreme danger myself despite being in war zones and hearing shelling and gunﬁ re. I’ve always had great trust that you’re there because they want you to be there and they will do their best to make sure you get out again.”

The former chair of the WA Her house is fi lled with a fabulous Having just passed her fellowship, art collection, which includes a Picasso she dropped her training program – an Regional Committee, Dr Jenny lithograph and work by Mexican artist unpopular move with her hospital – and Stedmon, has decades of Rufi no Tamayo, and loads of books. Her left for three months of rudimentary 11-year-old boxer, Bubbles, lolls on the anaesthesia, where the “bread and experience working for the couch, snoring loudly as Dr Stedmon butter” surgery involved treating Red Cross in disaster areas, talks about her 22-year involvement with landmine injuries. as Meaghan Shaw reports. the International Committee of the Red There she witnessed the skill of Cross, her work as WA Chair of the Red surgeons who were experienced at As an anaesthetist working for the Red Cross’s International Humanitarian Law amputating injured limbs, cleaning Cross, Dr Jenny Stedmon has helped Committee, and her interest in disaster and debriding the wounds, and leaving to treat landmine victims on the Thai- anaesthesia, planning and engagement them open for about fi ve days before Cambodian border, attended to casualties with the Australian medical assistance performing a delayed primary closure of a civil war in Yemen, gained experience team (AusMAT). to prevent infection. She marvelled at in tropical medicine in Kenya and provided Dr Stedmon lived in Nigeria from the adaptation of the locals, who made medical support in East Timor, following the ages of six to 11 with her teacher their own Braun Frames from bamboo, the withdrawal of Indonesian troops. parents, who were motivated to try and and used re-fi lled one-litre fl uid bottles, “You get hooked,” she says of her Red improve education standards in the newly equivalent to one kilo, to provide traction Cross experience. “You make loads of independent republic during a time that for lower limb injuries. friends, and the ideals of the movement fi t coincided with Nigeria’s Biafran civil The trip was followed in July 1994 by with your own ideals as a medic. Once you’re war. It was a formative experience, and a two-month stint at the Revolutionary actually in these places, you realise how infl uenced her involvement in the Red Hospital in Taiz, the stunning intellectual disadvantaged both the local population and Cross. “I think that kind of thing does get capital of Yemen, in the wake of Yemen’s in your blood a bit,” she admits. healthcare workers are and you just want to civil war. Once there, she helped set up a But her interest also “happened by stay part of the group.” mobile fi eld hospital, known as a “Finn chance”, prompted by a talk she heard Dr Stedmon, an unpretentious UK-born Hosp”, which arrived packed in steel as an anaesthetic registrar at St George’s consultant anaesthetist at Fremantle trunks and ready to go – complete with Hospital in Tooting, London, from a medic Hospital and Immediate Past Chair of a set of detailed instructions written in ANZCA’s Western Australian Regional who had been involved with the Orbis eye-care plane. Finnish. She created the anaesthetic Committee, is relaxing at her home in department inside one of the trunks, Fremantle near the beach, an idyllic She applied to do the British Red Cross training course and, within a week of which was fi lled with a “grimly small location for the Rottnest Island swim amount of drugs” including thiopentone, team member and medal-winning former completing it in July 1990, received a call to go to the Khao-I-Dang refugee camp lignocaine, vecuronium and ketamine, triathlete. hospital on the Thai-Cambodian border. but no other analgesia.

40 ANZCA Bulletin September 2012 “ Once you’re actually in these places, you realise how disadvantaged both the local population and healthcare workers are and you just want to stay part of the group.”

Her third assignment was at the Dr Stedmon visited, the hospital had some end of 1998, after she had moved to sophisticated monitoring equipment, but Australia and was based in Maryborough, the one donated ventilator was kept in the Queensland, when she was sent to the cleaning cupboard because no one knew Lokichokio Red Cross Hospital on the how to use it. A defi brillator lay idle for the northern border of Kenya and Sudan, an same reason. isolated outpost familiar to many Red Future lengthy trips were put on hold Cross workers. in 2001 after Dr Stedmon married and At the hospital, Dr Stedmon treated “inherited a 12-year-old son”, and she not only victims of the Sudanese civil wanted to be around to watch him grow war but also a varied stream of general up. However, she was on stand-by to go to and elective surgery cases from the Georgia in 2008 following the unrest there, over-crowded Kenyan refugee camps and and remains on the Red Cross’s “active” surrounds, often requiring careful airway list for short-term assignments. management in basic circumstances. The The constants throughout her cases ranged from spear attacks, a snake deployments have been the rudimentary bite and a hyena bite to a boy’s face, to nature of the facilities, the lack of removing a massive goitre, dealing with sophisticated equipment and the paucity tropical diseases, and anaesthetising for of anaesthetic drugs. an operation on a Turkana woman whose “I used almost entirely ketamine and neck, weakened by wearing numerous some local and regional techniques,” she necklaces, broke when she fell while explains, outlining ketamine’s profound tending camels. The Turkana woman’s analgesic effect, good use as an induction agent, and ability to protect airways accident again highlighted the ingenuity relatively well. of Red Cross surgeons, who applied She says the experience made her a traction to her neck by making several better anaesthetist, requiring hands-on burr holes in her skull and threading interaction with the patient, and not the them with wires attached to a pulley over-reliance on anaesthetic machines and contraption at the head of the bed. gadgets, which she believes has become This trip was followed in 2000 by Above left to right: Dr Jenny Stedmon; the norm. Dr Stedmon and Red Cross colleagues a month at Dili General Hospital in (continued next page) in Khao-I-Dang; the Khao-I-Dang hospital; East Timor. The most modern and well a locally-made Braun Frame at Khao-I-Dang. equipped of all the Red Cross hospitals

41 War zone anaesthesia continued

“I’m a bit old fashioned,” she says. “I don’t think cluster bombs or needed an escort to go to the hospital out “Give me some ketamine and a patient landmines are a very good idea,” she says. of hours. Following the civil war, there who really needs some help, with no “I’ve worked among the effects of them was religious sensitivity because the Red machine and no oxygen, and I can give and I don’t think when they make them Cross hospital accommodated patients of them a safe anaesthetic with my fi ngers they realise the after-impact. There are both sexes in some wards due to the small and my ears and my stethoscope. And I landmines all over Cambodia and they number of staff. The team was extracted take my stethoscope everywhere.” haven’t removed them all and it’s the quickly from the country. Dr Stedmon is also on the books civilians who are always affected after the But Dr Stedmon says Red Cross workers for AusMAT deployments to provide confl ict ends.” are trained to psychologically cope with medical help following disasters: “I There is also a personal link. Flying the possibility they may be attacked, suppose because I believe that I can out of Geneva on her fi rst mission to Khao- ambushed or taken hostage, and are do a reasonably good job in an austere I-Dang, Dr Stedmon met New Zealand usually debriefed in Geneva when their environment with limited equipment,” nurse and long-time Red Cross worker, work is over. she says. Sheryl Thayer. The pair worked together, “I haven’t really felt any extreme Her AusMAT work has involved helping became friends and holidayed together. danger myself despite being in war zones after the devastation of Cyclone George in In December 1996, Ms Thayer was one of and hearing shelling and gunfi re,” she Port Hedland, WA, in 2007, participating six Red Cross delegates assassinated in a says. “I’ve always had great trust that in simulation training exercises in brutal attack by gunmen at the Red Cross you’re there because they want you to be Karratha, regular AusMAT training, as hospital in Novi Atagi in Chechnya. No there and they will do their best to make well as committee work. She ruefully one has ever claimed responsibility and points out that she was mobilised in the sure you get out again.” wake of the Indian Ocean tsunami in 2004 the murders were never solved. Ultimately, she says, the work is about but never left Australia, instead sitting “I was really shocked when Sheryl got helping those in need. “You’re actually in Sydney’s Darling Harbour for three killed,” Dr Stedmon says. “At the time, just following your Hippocratic Oath: one, days watching others head off. A call to it was seen as a one-off (attack). But it do no harm and, two, treat the patient action following the 2006 Yogyakarta seems to be a bit of a pattern nowadays. in front of you. You’re not interested in earthquake also failed to eventuate. Doctors, nurses and healthcare workers their politics. I suppose that’s why I’ve A spin-off from Dr Stedmon’s are an easy target.” become really interested in international overseas and disaster work has been her To raise awareness of the dangers humanitarian law, because it is fair. interest in the Red Cross’s International health workers face, Dr Stedmon has been It’s actually about fairness.” Humanitarian Law Committee and her involved in the Red Cross’s Healthcare work as the chair of the committee’s in Danger project, which aims to ensure Western Australian branch. safe access to effective and impartial She passionately believes all countries healthcare during armed confl ict and – rich and poor – should follow the body other situations of violence. of established international humanitarian She has only felt in danger once, Above left to right: A hospital ward at Lokichokio; law, including a ban on weapons, such while working in Yemen, where the small Turkana women waiting at Lokichokio hospital; as landmines, that are designed to maim, team was forced to follow a curfew and a Turkana woman in improvised traction. not kill.

42 ANZCA Bulletin September 2012 Quality and safety

Acute Elective New Zealand was the Maternal Deaths The New Zealand admission % admission % Assessment Committee, set up in 1962, Colo-rectal and in Australia the first committee Perioperative Mortality resection 9.8 2.1 was the NSW-based Special Committee Hip joint Investigating Deaths Under Anaesthesia, Review Committee replacement 7.3 0.24 set up in 1960. At the same time, there Inaugural report Knee joint was increasing interest in the medical The New Zealand Perioperative Mortality replacement n/a 0.21 community critically reviewing healthcare, Review Committee (POMRC) released its Cataract reflecting on it and improving both inaugural report in February. The report extraction n/a 0.2 individual practice and healthcare systems. showed that same and next day all-cause New Zealand anaesthetists had mortality after an admission requiring Older age and higher ASA scores are identified that there was a problem with general anaesthesia was approximately always risk factors for mortality, variable anaesthetists (and other healthcare 0.02 per cent (elective) and 0.38 per cent and lower value risk factors are male professionals) being convicted of (acute); cumulatively 0.1 per cent. More gender, non NZ European/pakeha manslaughter, when there was not than half of those patients died of cardiac ethnicity and lower socio-economic status. necessarily an element of gross negligence or cardiovascular-related causes. While the overall rate for acute colo-rectal or recklessness. Alan Merry led the Download the full report at: www. resection was 9.8 per cent, for those aged successful pan-professional campaign to hqsc.govt.nz/assets/POMRC/Publications/ 80 years or over 19 per cent died. Similarly, have the law changed (this occurred in 1997). As part of the lobbying, we assured POMRC-2011-Report-Lkd.pdf for those with ASA status of four, 26 per the then minister of health that if the law The New Zealand Perioperative cent died within 30 days of the procedure. regarding manslaughter was changed, Mortality Review Committee differs from we would be committed to continuing the Australian profession-based mortality While these data could enable benchmarking and longitudinal tracking, mortality review. reviews in that it takes a national, whole- The 1990s were spent concurrently care needs to be taken with use of the of-system approach to understanding and working on this campaign and developing thus reducing perioperative mortality. data. Of note, unlike deaths after other new models for mortality review. The To do this it cumulatively collects procedures, the deaths after cataract profession agreed that it would be better accurate data on the epidemiology of extraction do not show any temporal to have all those involved in the care of perioperative deaths (who dies) and peer relationship with the procedure. This the patient involved in mortality review, review of targeted cases (why they die). would support the thesis that the “cataract and hence the NZ Perioperative Deaths Having multi-disciplinary membership, rate” shows the underlying death rate of Working Party was born, involving including nursing, allows all aspects of the population having such a procedure. anaesthetists, surgeons, obstetricians care to be analysed, rather than taking As far as the committee could tell, the and gynaecologists as core members. one profession’s perspective. For example, mortality rates are comparable with those Progress was slow. There was considerable for the same case, anaesthesia review in comparable countries. change in the Ministry of Health. The may find inadequate pre-assessment and/ Maternal Deaths Assessment Committee History met a similar fate to the Anaesthesia or preparation, surgical review may find The NZ Perioperative Mortality Review delay in performance of the operation, Mortality Assessment Committee, despite Committee was established in April considerable effort being put into lobbying and nursing review may find inadequate 2010, under the New Zealand Public for the reinstatement of mortality review recognition of worsening clinical status Health and Disability Act 2000 and by the College, the New Zealand Society of and inadequate staffing levels. While each rose from the ashes of the Anaesthesia Anaesthetists and individual anaesthetists. of these factors has some remedies, they are Mortality Assessment Committee, which Discussions with several governments far more effective if an integrated whole is was set up in 1981. The Anaesthesia resulted in mortality review committees considered. In taking this whole-of-system Mortality Assessment Committee, being set up within the new New Zealand approach, the committee is cognisant of which was similar to the Australian Public Health and Disability Act 2000. the dangers of losing the advantages of the state anaesthesia mortality committees, The first to be set up was the Child and profession-based approach. operated successfully for about 10 years Youth Mortality Review Committee (2002), followed by the Perinatal and Maternal 2011 report: Other headlines until the police obtained a report to it as part of their investigation into a charge Mortality Review Committee (2005), An epidemiological approach to data Family Violence Deaths Review Committee collection and analysis will provide of manslaughter against an anaesthetist. This led to consternation among reporting (2008), and finally the Perioperative accurate information on anticipated Mortality Review Committee in 2010. The anaesthetists, and reports to the mortality resulting from common committees initially reported directly to procedures. These data will be a valuable committee dried up. the minister, but with the establishment tool in the informed consent process. From Despite this, there was a commitment of the Health Quality and Safety the first report, the 30-day mortality for to continuing mortality review once Commission, chaired by Alan Merry, the patients in NZ from 2005 to 2009 was: a system was established to ensure mortality review committees came under confidentiality for all participants. The its auspices. medical community had been committed to mortality reviews; the initial one in

44 ANZCA Bulletin September 2012 Composition Existing data collections include Future directions Perioperative Mortality Review the National Minimum Dataset and the In response to the consultation questions Committee is multidisciplinary; it has two National Mortality Collection. These within the 2011 report, there was broad anaesthetists (Leona Wilson and Michal data sets can be matched, allowing support for the proposed direction, with Kluger), three surgeons (Cathy Ferguson, identification of deaths after healthcare many emphasising their desire for the Jonathan Koea and Jean-Claude Theis), procedures, whether in the first hospital, qualitative component to be added in to one obstetrician and gynaecologist (Digby a second hospital, or in the community. help understand the preventable causes of Ngan Kee), one intensivist (Tony Williams), The National Minimum Dataset has nearly death. two nurses (Rosaleen Robertson and complete information on publicly funded Work is now underway to develop Teena Robinson) and one epidemiologist procedures, and both have relatively a standardised mortality review form (Phil Hider). It was initially led by Iain complete demographic information. that will be common to all facilities Martin, who resigned at the end of last However, there is limited coverage of year. The epidemiological analysis for the and practitioners, and the processes privately funded procedures in private to consider deaths at multiple levels first report was performed by Liz Craig and facilities. The reason for a perioperative her team from Otago University. (national, regional, within facility). death is sometimes hard to ascertain from The 2013 report will explore the Terms of reference the coded data because of the coding additional information contained Perioperative Mortality Review Committee rules. For example, many of the patients within the coronial database, provide is to review and report on deaths within dying after having a total hip replacement information on progress with development its scope in order to reduce the number have their death ascribed to a fall. While of processes, and information on specific of such deaths and promote quality this is probably the cause of their injury, classes of deaths. assurance program, to advise on matters and need for a procedure, it does not related to mortality as asked by the indicate why the patient died after their Summary Health Quality & Safety Commission, and procedure. These data also provide The 2011 report finally arrived after more to develop plans and methodologies to few insights into the circumstances than 15 years of lobbying for a replacement reduce morbidity and mortality, relevant surrounding the death, or any systems for the Anaesthesia Mortality Assessment to the committee’s functions. These issues involved in their deaths. Committee. The NZ Perioperative functions are set out in s59e of the New Mortality Review Committee has taken Recommendations for improved Zealand Public Health and Disability a national, whole-of-system approach to Act 2000. data collection The following recommendations focus perioperative mortality review. No other The scope of deaths includes: within 30 jurisdictions have been found that take days of a procedure or before discharge, on enabling more complete data the same approach, so the committee whichever is the longer, or under the care collection of healthcare procedures. is developing its processes. Current of a surgeon even if no death occurred. 1. All places that provide healthcare An operative/invasive procedure is one national administrative datasets are being procedures should be certified as used as a basis for data collection, with that requires anaesthesia (general, local healthcare facilities under the Health or regional), and specifically includes additional data collection (expert, peer- and Disability Services (Safety) Act 2001. reviewed opinion) to aid consideration endoscopy and angiography, including This would bring in day-stay facilities those occurring in endoscopy or radiology of the practitioner and systems factors that don’t offer 24-hour care, and would underlying those deaths. The aim is to rooms. It was decided to defer “deaths require a change to the legislation. under the care of a surgeon where no develop recommendations that focus on procedure occurred” until the initial stages 2. All healthcare facilities should submit improving health quality and safety. of the committee have been completed. data to the National Minimum Dataset. Some private providers do not submit Acknowledgements Legal protection data, and thus the data is incomplete. The Perioperative Mortality Review The committee and all its agents have This would be best achieved by Committee would like to acknowledge statutory protection of the data and legislative change. the leadership of the inaugural chair, Iain indemnity for their actions (New Zealand Martin, the support of Health Quality Public Health and Disability Act 2000 3. The death certificate should contain a ‘tick-box’ to indicate that the death was & Safety Commission New Zealand, schedule 5). This places strict limits on especially the chair, Alan Merry, and all of how and when the committee can disclose within 30 days of a procedure of interest to the Perioperative Mortality Review those who have worked tirelessly for many data and the penalties (which include years to develop national perioperative a fine of up to $NZ10,000) for illegal Committee. This would be best achieved mortality review. disclosure of information. The committee by legislative change. is able to obtain the data it needs for its The Perioperative Mortality Review purposes from a wide range of sources, Committee is working with the appropriate Dr Leona Wilson, FANZCA as long as it is relevant to its needs. bodies to propose these changes. The Chair, New Zealand Perioperative Mortality Review Committee 2011 report: Data collections recommendation “identifying existing The report covered both the quantitative conditions from those acquired during data on selected procedures (above), as well that admission” in the National Minimum as information on the potential data sources, Dataset is due to be implemented from and proposals for analysis of data. January 2013.

45 Quality and safety continued

12.4 per cent (Warner et al1) and 4 per webAIRS from ANZTADC cent (Kluger et al2). Several fatal cases of aspiration also were reported by Victoria Consultative Council on Anaesthetic Morbidity and Mortality in the 2007 annual report3. In this series, 14 cases were associated with a supraglottic airway but temporary harm only occurred in three, and none were admitted to an intensive care unit or high dependency unit. Endotracheal tubes were associated with six instances of temporary harm, four of which required IPPV in an intensive care unit and one required CPAP in high dependency unit. Finally, fi ve cases were associated with a facemask or Hudson mask and one of these required IPPV in an intensive care unit. The number of airway devices used exceeds the total number of cases; Incident analysis In this issue, the ANZTADC Analysis this is because in some instances of The Australian and New Zealand Sub-Committee presents its analysis of airway diffi culty, multiple devices were Tripartite Anaesthetic Data Committee respiratory incidents, which accounted used. Also some cases aspirated either (ANZTADC) has been collecting for 232 of the 1015 incidents (22.85 per immediately prior to intubation during data using the webAIRS (Web-based cent). We have further drilled down to 27 management with a facemask or post- Anaesthetic Incident Recording System) incidents involving regurgitation with or extubation. program since September 1, 2009. This without aspiration. This represents 11.6 Interim recommendations, in keeping fi gure shows the main categories for the per cent of all respiratory incidents and with the literature, are that although 1015 incidents collected and analysed 2.66 per cent of all incidents reported. regurgitation and/or aspiration are events up to May 11 this year. The results Fourteen cases involved probable with the potential for serious morbidity were presented during the Safety in aspiration or confi rmed aspiration and or death, most published cases may be Anaesthesia session at the ANZCA Annual these were classed as aspiration events. managed conservatively in the absence Scientifi c Meeting in Perth on May 13. Thirteen cases involved regurgitation of signifi cant respiratory consequences There will be a further session with without suspected or confi rmed or signs in the fi rst two hours post- updated data at the Australian Society aspiration. Of the cases classed as operatively1,2. This is supported by the of Anaesthetists’ 71st National Scientifi c aspiration, fi ve cases (38.46 per cent) were webAIRS data collected so far. In cases Congress in Hobart on October 2. A paper managed by intermittent positive pressure where there is doubt, close post-operative also will be presented during the Human ventilation (IPPV) in an intensive care monitoring is recommended. If there Factors session of the New Zealand unit and one was managed by continuous are signs of respiratory deterioration, Anaesthesia Annual Scientifi c Meeting positive airway pressure (CPAP) in a consider respiratory support (for example combined with the 13th International high dependency unit. The remaining CPAP, Bi-phasic Positive Airway Pressure Congress of Cardiothoracic and Vascular seven cases of aspiration (53.84 per cent) or IPPV) in an intensive care unit or high Anesthesia on November 17, titled “Fix it were managed without admission to an dependency unit. ANZTADC plans to twice – using this methodology to reduce intensive care unit or high dependency publish a full report in the form of a peer- medical error”. unit. Although temporary harm occurred reviewed article when enough cases have Of the incidents reported, the largest in 11 of the 27 cases (40.7 per cent) in these been reported. main categories were respiratory/airway two categories, no cases were reported At the Australian Society of (22.86 per cent), medication (17.54 per as fatal or resulting in serious harm. Anaesthetists’ National Scientifi c cent), medical devices and equipment However, other studies have noted the Congress in Hobart, Dr Antonio Grossi (16.95 per cent) and cardiovascular incidence of fatal complications to be will present management strategies (16.65 per cent).

46 ANZCA Bulletin September 2012 for managing respiratory incidents, Shiley Size 8 Reusable Cannula including updated methods for dealing ECRI alerts Cuffed Tracheostomy Tube: with hypoxia during anaesthesia and The ECRI Institute is a non-profit leakage or disconnection regurgitation with or without aspiration. organisation that issues alerts from Covidien, the manufacturer of these Come along to the session and give your four sources: the ECRI International tracheostomy tubes, has received several opinion on the best way to manage these Problem Reporting System, product reports. These reports have entailed types of incidents. He will also discuss manufacturers, government agencies volume leakage and/or disconnection the role of various airway devices in the including the US Food and Drug between inner and outer cannulae, management of respiratory incidents. Administration (FDA) and agencies in usually during mechanical ventilation. More than 40 hospitals report to Australasia, Europe and the UK, as well It is possible that the tube may need ANZTADC using the webAIRS software as reports from client hospitals. immediate replacement. An urgent and we wish to thank all the registered Some alerts may only involve single device recall has been initiated. sites for taking part in the ANZTADC or small numbers of cases, there is no denominator to provide incidence and project and for all the useful feedback. Timesco Larygoscope Handles: there is not always certainty about the If you would like to register your loose contact disks regions where the equipment is supplied. hospital please do so via the link on The contact disks of these laryngoscope This section highlights some of the the ANZCA website or www.anztadc. handles may become loose after alerts that may be relevant. Hospitals net/RegisterAccount.aspx?org=658365. autoclaving potentially causing flickering should follow up with the manufacturer’s The secure ANZTADC program is free of or failure to function. This confirms the representatives if they have not already charge to ANZCA Fellows, members of importance of checking the blade before been contacted. the Australian Society of Anaesthetists, case commencement and having a second and members of New Zealand Society functioning laryngoscope available for of Anaesthetists. If you need help with CareFusion Alaris Pump Modules every case. ethics or other approvals at your hospital, (Model 8100) Two problems have been reported with ANZTADC will assist with the relevant MAQUET HL30 Heart-Lung machines: the 8100 Alaris pump modules: applications. arterial pump shut down due to 1. Motors of the pump modules may stall electrostatic discharge Professor Martin Culwick, Dr Antonio intermittently, particularly at high Maquet has received reports of Grossi, Mrs Heather Reynolds and infusion rates (>900ml/hr). There will unexpected cessation of the arterial pump Professor Alan Merry be a visual error code and an audible during bypass. Investigation has revealed ANZTADC Analysis Sub-Committee alarm followed by termination of that this is due to electrostatic discharge members infusion. This may result in patient (ESD) at the pump control panel, most morbidity if the infused medication likely occurring when a static electricity References: is critical. charge builds up on an individual, who 1. Clinical Significance of Pulmonary 2. The keypad overlay in the door then adjusts the pump controls. In all Aspiration during the Perioperative Period. cases, the perfusionists used the hand Mark A. Warner, Mary Ellen Warner and assembly of the pump module may Joseph G. Weber. Anesthesiology 78: 56-62 delaminate potentially allowing fluid crank while the pump was replaced with 1993. ingress, which may lead to keypad an emergency back-up pump. 2. Crisis management during anaesthesia: malfunction or termination of infusion. Maquet claims that immediate restart regurgitation, vomiting, and aspiration. M Carefusion has notified customers of the pump should be possible but can T Kluger, T Visvanathan, J A Myburgh, R N of affected serial numbers and also provide an ESD upgrade kit on Westhorpe. Qual Saf Health Care 2005;14:e4 request. http://qualitysafety.bmj.com/content/14/3/ these pumps should be individually e4.full.html examined. 3. Victoria Consultative Council on Anaesthetic Dr Phillipa Hore Morbidity and Mortality (VCCAMM) annual Communications and Liaison Portfolio reports http://www.health.vic.gov.au/ Quality and Safety Committee vccamm/vccamm-reports.htm

47 Anaesthesia and Pain Medicine Foundation – a clear purpose

The ANZCA Council has approved a The ANZCA application process is new statement that clarifies the purpose modelled on the process used by the Overseas aid of the Anaesthesia and Pain Medicine National Health and Medical Research The foundation is working with the Foundation. The new statement affirms Council. Three reviewers with relevant ANZCA Overseas Aid Committee to the foundation’s role in supporting expertise assess each application. In develop a plan to increase resources research and education projects mid-September the ANZCA Research for Fellows’ efforts to bring better pain conducted by ANZCA Fellows and ANZCA Committee examined all applications management and anaesthesia knowledge and integrates the previous objectives and reviews, and will make funding and skills to people in less developed and purpose statements: recommendations to the ANZCA Council communities, including the successful To raise funds for medical research for 2013 grants. Successful applicants will Essential Pain Management course. and education in Australia, New Zealand be notified and listed in the December Donations – or requests for information and internationally, to: ANZCA Bulletin. – can be directed to the foundation. • Increase the safety and comfort Thank you to all those generous of patients undergoing anaesthesia Fellows and donors who support and sedation. Renewed healthcare the Anaesthesia and Pain Medicine • Improve outcomes for critically ill industry support Foundation. Donations or inquiries patients following surgery or trauma. related to any of its activities are welcome The five-year sponsorship terms of our and can be made by calling Rob Packer, • Improve the treatment of acute pain, founding sponsors, Mundipharma, Pfizer General Manager, Anaesthesia and Pain cancer pain and persistent non-cancer Australia and St Jude Medical, expired Medicine Foundation on +61 3 8517 5306, pain. in 2011. The foundation is delighted that or emailing [email protected]. Mundipharma has since advised that Research grants 2013 it will continue its sponsorship, and Robert Packer positive discussions are in progress with General Manager, update St Jude Medical. Anaesthesia and Pain Medicine The foundation is contacting a range The Anaesthesia and Pain Medicine Foundation, ANZCA of other companies in the sector regarding Foundation has received 38 applications the potential to sponsor the foundation for grants in 2013, including project, to help maintain and increase the support simulation/education, academic for research and education in pain enhancement and novice investigator medicine and anaesthesia. grants, and the Douglas Joseph Professorship. The number of high-quality applications Philanthropic from Fellows continues to increase each year, underscoring the urgent need to grantmakers To donate, or for more information increase donations to maximise funding The foundation has made several contacts on supporting the foundation, and research outcomes. The foundation and lodged expressions of interest with please contact Robert Packer, greatly appreciates contributions from philanthropic trusts and foundations as General Manager, Anaesthesia and Fellows, trusts, corporate sponsors and part of a strategy to access new funding Pain Medicine Foundation on philanthropic donors, who are vital to the from this sector. foundation’s capacity to fund important, +61 3 8517 5306 or email life-saving work. [email protected].

52 ANZCA Bulletin September 2012 ANZCA Trials Group strategic research workshop in Palm Cove,

The ANZCA Trials Group held analysis, followed the next day by a Associate Professor David Story presentation on cluster randomisation presented a pilot grant application on its fourth strategic research within individually randomised trials. behalf of Dr Dean Cowie (Vic): “Cerebral workshop in the warm environs Her presentations were coupled with talks oximetry to reduce peri-operative of Palm Cove, Queensland from from the current chair of the Australian morbidity”. This research project was later and New Zealand Intensive Care Society- approved to receive a pilot grant award August 10-12. This is the second Clinical Trials Group (ANZICS-CTG), for 2012. time the workshop was held at Professor Steve Webb. Professor Webb Current multicentre research updates spoke on the need for clinical trial groups were given by Professor Paul Myles Palm Cove. to focus their strategic research planning on Aspirin and Tranexamic Acid for About 60 participants including three on programs rather than individual Coronary Artery Surgery (ATACAS) and guest speakers attended a full program projects. His second talk examined Nitrous Oxide Anaesthesia and Cardiac that brought together experienced and evidence for clinical intervention: what is Morbidity after Major Surgery-2 (ENIGMA emerging researchers from Australia, it, and what should be done with it? II). ATACAS continues to seek greater New Zealand, Hong Kong, the US, the The quality of new proposals presented surgeon participation as well as new Netherlands and the UK. The primary aim at the workshop was high. There were centres internationally, while ENIGMA II of these meetings is to present, mentor 14 proposals that covered topics such is on track for completion in 2013. Other and encourage new ideas for multicentre as cardio-pulmonary exercise testing; multicentre research updates were the research in anaesthesia, perioperative ketamine infusion to avoid chronic pain REstrictive versus LIbEral Fluid Therapy medicine and pain medicine. Another post surgery; high-dose dexamethasone in Major Abdominal Surgery – The aim is to update existing research activity and major surgery; tranexamic acid in RELIEF Study (Myles); the Balanced Study and encourage participants to engage in lower limb arthroplasty; a perioperative by Associate Professor Tim Short; and current multi-centre trials. model of care; oxytocin infusion for Professor Matthew Chan spoke on two This year there were two invited elective caesarean section; anaesthesia pain studies that are underway; persistent speakers, including a biostatistician and cognitive decline; oxygen levels pain after surgery and the chronic who was invited back to the meeting during cardiopulmonary bypass; fluid pain sub-study of the ENIGMA II trial. following delegate feedback in 2011 for rationalisation after cardiac surgery; Professor Chan also presented updates an ongoing statistical component in the videolaryngoscopy use; intravenous on the vascular events in non cardiac program. Dr Katherine Lee from the iron intraoperatively; pharmacokinetics surgery patients’ cohort evaluation Murdoch Children’s Research Institute and pharmacodynamics of sevoflurane; studies (NeuroVISION and cardiac (Royal Children’s Hospital, Melbourne) cerebral oximetry to reduce perioperative computed tomography angiography gave a presentation on intention to treat morbidity; and, readability of research (CTA) Vision Studies). Associate Professor patient information forms for patients. Tomas Corcoran’s presented his work

54 ANZCA Bulletin September 2012 on dexamethasone and peri-operative Breakout sessions for the large number the trials group and research fits into infection risk as well as tranexamic acid of research coordinators who attend the this. The ANZCA Trials Group Executive in burns surgery. workshop were first planned in 2011. This Committee moved to appoint Professor The Balanced Study, the NeuroVision year two breakout sessions were arranged Leslie as deputy chair. Study and RELIEF study were recipients and the group had their own guest Conference delegates enjoyed welcome of the ANZCA Pilot Grant Scheme in 2010, speaker. Rachel Parke, chair of ANZICS- drinks and a buffet meal on a balmy 2011and 2011 respectively. The Balanced CTG Research Coordinators Special terrace at Sea Temple Resort on Friday study has also been awarded the highest Interest Group, attended the meeting night, while Saturday evening was a grant awarded to anaesthesia research from New Zealand, where she is based at little cooler for the conference dinner. in New Zealand of $NZ1.2 million. Auckland City Hospital. She spoke to the Nonetheless it was the perfect tropical The Peri-operative Ischemic group about her work with the ANZICS- setting to think about research and escape Evaluation-2 Trial: POISE-2 Trial is well CTG, and how the anaesthesia research wintery weather! under way in Australia and New Zealand, co-ordinators might learn from her The trials group executive would like and Palm Cove was the setting for another experience. Sofia Sidiropoulos is the chair to thank Dr Shiva Malekzadeh (Vic) for POISE-2 investigators meeting chaired of the anaesthesia research co-ordinators being our “in-house” photographer. by the National Coordinator for POISE 2, group. She spoke on consent issues and Professor Kate Leslie. organised other members to speak on Stephanie Poustie Professor Leslie updated 34 research audit and serious adverse event ANZCA Trials Group investigators and research coordinators reporting. She also attends the trials Research Fellow and Co-ordinator on the study progress. There are 11 active group executive committee meetings sites, 18 in progress. Sixty seven patients as a non-voting member. Opposite page clockwise from top left: have been recruited to date; 29 of these The ANZCA Trials Group Executive Sea Temple Resort and Spa, Palm Cove; from Royal Adelaide Hospital; two from Committee takes the opportunity at Professor Stephan Schug (WA), ANZCA President the Royal Hobart Hospital; eight from the the ANZCA Annual Scientific Meetings Dr Lindy Roberts (WA) and Dr Britta Regli-Von Royal Melbourne Hospital; seven from and the research workshops to meet in Ungern (WA); Palm Cove; Davina McAllister Geelong Hospital; six from Dandenong person rather than conduct its meetings (NZ) presenting at the breakout session; Sofia Hospital; three from The Alfred hospital; by teleconference. This year ANZCA Sidiropoulos (Vic) and Anisa Abu Baker (WA). and, two from Western Hospital. The President Dr Lindy Roberts attended the This page clockwise from left: Palm Cove rest of the meeting was open to each meeting as a guest. Dr Roberts had earlier signage; Rochelle Cotter (Vic), Professor Kate centre to report on their progress with addressed the workshop about the College Leslie (Vic) and Joana Amorim (Vic); Delegates recruitment and difficulties that they have strategic plan for 2013 to 2017, and how at Saturday’s session; Associate Professor David Story (Vic) and Professor Paul Myles (Vic); encountered during the trial. Professor Tomas Bruessel, Dr David Bramley (Vic) and Dr Stefan Dieleman (the Netherlands).

55 New Zealand news

53 per cent to 45 per cent). Females 2012 NZ The New Zealand were significantly under-represented in Anaesthesia ASM medical workforce the surgical scopes. Only eight per cent of doctors working in surgical scopes were Although the early-bird registration has in 2011 female, down from 13 per cent in 2010. closed, there is still time to register The proportion of doctors who identified for this year’s NZ Anaesthesia Annual New Zealand’s medical workforce continues to increase and its age themselves as M ori dropped to 2.8 per Scientific Meeting being held in Auckland cohort reflects New Zealand’s general cent while the proportion of Pacific doctors on November 14-17 with pre-conference demographic, according to the Medical increased from 1.3 per cent to 1.6 per workshops on November 12-13. Council of New Zealand’s (MCNZ) 2011 cent – both far less than their proportion By combining with the International medical workforce survey, released in of the population. Congress of Cardiothoracic and Vascular August. International medical graduates now Anesthesia, this conference has attracted The survey shows that the number of make up 41.5 percent of the medical the best ever line-up of speakers for active doctors increased by 3.2 per cent, workforce – with 43 percent of GPs being a New Zealand anaesthesia meeting. from 13,883 in 2010 to 14,333 in 2011. an international medical graduate. The combined meeting offers a superb This compares with increases of 3.5 per For all active doctors, the average general stream, a specialist cardiac cent in 2009 and 2010. number of hours worked was 43.7 per stream and a third stream that crosses In 2000-03, the largest group of week with the data showing that doctors the divide between those two so there is doctors (almost 20 per cent) was in the aged in their twenties worked the most plenty to appeal to everyone. Registrants 40-44 year age group. By 2009, the hours (52.8 hours) each week on average. are not limited to a particular stream but largest group was aged 45-49 and in The survey shows that, on average, 84 can choose sessions from across the 2011, the largest group was aged 50-54. per cent of graduates are retained in the whole program. There is a huge range of The younger age groups of doctors have New Zealand medical workforce two years workshops as well as an extensive choice more females than males: 45 per cent of after graduation. By the third year, 78 per of plenary sessions. To read the program females in the workforce are under the cent are retained, rising to 79 per cent and to register, go to www.iccva2012.com. age of 40, compared with 27 per cent of five years after graduation. Retention rates males. Only five per cent of females are level out to between 61 and 67 per cent in over the age of 60, compared with 18 per years eight to 14 years after graduation. cent of males. However, fewer than 53 per cent While the overall proportion of females of international medical graduates are in the workforce remained at 40 per cent, retained in the year immediately after females continued to outnumber men in initial registration, with doctors who held house officer roles, making up 57 per cent their primary qualification for between 11 of this category. and 20 years when they came to New The proportion of females increased Zealand having the highest retention rate. in accident and medical practice from 34 Doctors from the UK and the Americas per cent to 44 per cent but decreased in have the lowest retention rates. obstetrics and gynaecology (from 54 per The full report is available at www.mcnz. cent to 41 per cent) and paediatrics (from org.nz/assets/News-and-Publications/ Workforce-Surveys/2011.pdf

56 ANZCA Bulletin September 2012 The rationale for the project is that Christchurch citation Major research grant the optimal depth at which anaesthetics The ANZCA Council has awarded an for anaesthetist should be given is unknown. Recent ANZCA Citation to the Christchurch observational studies have shown a 20 An international team led by Dr Tim Short, Hospital Department of Anaesthesia in per cent increase in mortality in patients a specialist consultant at Auckland City recognition of the work its staff undertook undergoing major surgery, who receive Hospital, has been awarded $NZ1.2 in extreme circumstances during and after relatively deep anaesthesia. million to fund a major project looking the February 22, 2011 earthquake and its Dr Short says that in particular his trial at the influence of anaesthetic depth on numerous aftershocks. will look at the death rate at one year and outcome. Departmental staff performed also whether there are differences in other Dr Short is also the Director of magnificently both in the hospital and complications of surgery and anaesthesia, Anaesthetic Research and Chair of out in the field as casualties streamed including wound infection, cardiovascular the Auckland District Health Board in to a hospital that was without power and neurological complications, pain and Research Review Committee, the clinical and water at times. They continued this awareness. associate professor in the department of work despite many of their homes being He says the study will have important anaesthesia at the Auckland University ruined, damaged or inaccessible and implications for how anaesthetists should School of Health Sciences and an ANZCA concern about their family members. The run anaesthetics with findings that can be examiner. citation will be presented during the NZ easily translated into daily practice. The money was awarded in the 2012 Anaesthesia Annual Scientific Meeting in Various centres around New Zealand Health Research Council funding round. Auckland in November. are assisting with the trial. Others It will help fund a large-scale randomised interested in participating may contact trial of 6600 patients to definitively answer Dr Short at [email protected]. the question of whether anaesthetic depth alters surgical outcome.

57 New Zealand news continued

Dr Levine’s fellowship will enable Dr Barnett is an anaesthesia trainee him to expand his skills in his special with the South Island anaesthesia training interest of regional anaesthesia. St Luke’s program, most recently in Dunedin, Roosevelt Hospital Centre operates the where Dr Jason Henwood states in his New York School of Regional Anaesthesia, nomination that she “worked tirelessly to and is considered one of the world’s facilitate the educational needs of fellow premier regional anaesthesia centres. Dr registrars”. Dr Henwood commented on Dr Levine looks forward to learning regional Barnett’s high standard of academic and anaesthesia from world experts and clinical achievement. She enjoys teaching Three BWT Ritchie bringing that information back to New and presenting, won the Ritchie Prize for Scholarships awarded Zealand to share with colleagues. her formal project and recently published Dr Lightfoot is a provisional fellow at in Anaesthesia & Intensive Care. Dr The NZ Anaesthesia Education Committee Middlemore Hospital in Auckland and has Barnett is Chair of ANZCA’s New Zealand has awarded BWT Ritchie Scholarships impressed Dr Helen Frith, who nominated Trainee Committee. to Dr Matt Levine, Dr Nicholas Lightfoot him, with his conscientiousness, Dr Barnett’s fellowship at the Royal and Dr Sheila Barnett to support them in willingness to learn and work, and his Children’s Hospital in Melbourne will overseas fellowships in 2013. commitment to keeping the welfare of the comprise nine months in anaesthesia Each of the three candidates was patient in mind at all times. He has been and three months in neonatal intensive highly recommended by their department enhancing his ultrasound guided regional care (NICU). Dr Barnett says that the and has secured an overseas fellowships anaesthesia skills and developing an anaesthesia experience will provide regular that will contribute to the development interest in transthoracic echocardiographic of their skills, knowledge and experience, techniques as well as pursuing research involvement on major craniofacial cases, and bring benefi ts to anaesthesia in New interests in cardiac outcomes of non- and complex cardiac and transplant cases. Zealand when they return. cardiac surgery. Dr Lightfoot has been She expects her time at the NICU to be Dr Levine’s fellowship at New York’s involved in teaching and supervising extremely valuable and fascinating, as St Luke’s Roosevelt Hospital Centre anaesthesia trainees and technicians the unit receives babies with complex and Dr Lightfoot’s fellowship at Toronto and has recently joined the NZ Society of conditions transferred from other tertiary General Hospital both begin in July 2013, Anaesthetists’ executive as deputy trainee centres. The Royal Children’s Hospital while Dr Barnett begins her fellowship at representative. performs more than 18,000 anaesthetics Royal Children’s Hospital in Melbourne in Dr Lightfoot’s fellowship at Toronto a year as well as running the Children’s February 2013. General Hospital will focus on anaesthesia Pain Management Service, which sees Dr Levine is currently chief resident for hepatobilary surgery, surgical oncology around 8000 consultations a year. and a provisional fellow in the Department and intra-abdominal transplantation. He Dr Barnett believes that working in a of Anaesthesia and Pain Management believes that his experience at Toronto will centre so profi cient in research and pain at Wellington Regional Hospital. When offer a good mix of cutting-edge clinical management will give her experience and nominating Dr Levine, Professor Sandy experience where he will be challenged to ideas that will be useful on her return to Garden commented on his high degree of learn new skills, along with more routine the South Island. This will be particularly clinical competence with a commonsense call work that will build and further develop relevant since Christchurch expects to approach to clinical anaesthesia, his skills obtained through his New Zealand have a dedicated children’s hospital within academic achievements and his leadership training. Dr Lightfoot anticipates returning the 10 years. skills. Dr Levine is an enthusiastic teacher to New Zealand with a blend of skills on Wellington-based crisis management learned during New Zealand-based training From top left: Dr Matt Levine, Dr Sheila Barnett courses and the FANZCA fi nal exam and in the North American setting, which and Dr Nicholas Lightfoot. course. He is a member of the ANZCA New will allow him to confi dently anaesthetise Zealand Trainee Committee, an experience patients with a diverse range of clinical he says has given him a broader insight and pathological conditions. into the issues that face anaesthesia trainees, and the inner workings of the College. 3574

58 ANZCA Bulletin September 2012

3574_AD_Perseus_A4_Motiv3_engl_250512_outlined.indd 1 25.05.12 10:04 Australian news

Queensland

New office bearers Office bearers were appointed at the first meeting of the 2012-2014 Queensland Regional Committee, held on May 30. The new office bearers are: Chair: Dr Mark Young Deputy Chair: Dr Sean McManus Secretary/treasurer: Dr Charmaine Barrett Obstetrics, paediatrics and law: Regional education officer: Dr Jeneen Thatcher little gems all anaesthetists Formal project officer: Dr Kerstin Wyssusek should know ANZCA/ASA CME Chair: Dr Chris Breen The 36th annual Queensland ANZCA/Australian Society of Quality and safety officer: Dr Charles Willmott Anaesthetists Combined Continuing Medical Education Conference New Fellows representative: Dr Dale Kerr was held at the Brisbane Convention & Exhibition Centre in July. The event focused on obstetric and paediatric anaesthesia, as The committee welcomes new members Dr Joe Williams and Dr well as medico-legal principles relevant for anaesthetists. The day Brian Lewer and sincerely thanks outgoing members, Dr Emile comprised a series of lectures and a panel discussion, followed by Kurukchi and Dr Pal Sivalingam for their contribution during the an ultrasound workshop, a paediatric resuscitation workshop and life of the previous committee. problem-based learning discussions in the afternoon. The Queensland Regional Committee also acknowledges the The program began with a presentation by solicitor Justine significant achievements of Dr Sean McManus, the previous Beirne on the subject of ‘Consent: no one size fits all’. Dr chair, and Dr Michael Steyn, the previous deputy chair, both Peter Waterhouse of the Royal Children’s Hospital then gave a of whom will serve on the new committee. presentation on ‘Avoiding Brutane: an approach to the reluctant paediatric patient’. The keynote speaker was Dr Ben Van der Griend, of Christchurch, who spoke on ‘Is it safe to anaesthetise children?’ Conference convenor Dr David McCormack said the standard of education delivered was very high in both content and form with the successful implementation of a tripartite theme. The use of a new venue also led to a high level of delegate, sponsor and committee satisfaction, he said. The Queensland Regional Committee Chair, Dr Mark Young, congratulated Dr McCormack and the Continuing Medical Education Committee Chair, Dr Chris Breen, on the outstanding Above from left: Dr Brian Lewer, Dr Kerry Brandis, Dr Paul Nicholas, success of this conference. Dr Mark Gibbs, Dr Charmaine Barrett, Dr Chris Breen, Dr Mark Young, Dr James Hosking, Dr Kerstin Wyssusek, Dr Jeneen Thatcher, Dr Sean McManus, Dr Genevieve Goulding, Dr Dale Kerr. Above from top left: Guest speakers Dr Ben van der Griend, Justine Beirne and Dr Peter Waterhouse; Delegates mixing with healthcare industry Absent: Professor Michael Steyn, Associate Professor Kersi representatives during morning tea. Taraporewalla, Dr Joe Williams, Dr Charles Willmott and Dr Peter Duff.

60 ANZCA Bulletin September 2012 Australian Capital Territory

2012 Queensland primary viva practice course A residential viva course was held over the weekend of August 18-19 at the Sheraton Noosa Resort in Queensland. Twenty trainees travelled from as far as Tasmania and Darwin, Orange and Cairns to participate in this intensive viva weekend. The co-ordinator, Dr Guy Godsall, of Nambour Hospital, together with 20 of his peers from the local area, worked with the trainees to further develop their skills. This popular training opportunity is limited by the number of available examiners, so places are allocated first to trainees from regional areas who are preparing for the next viva sitting.

Difficult airways workshop The ACT regional committee recently held a difficult airways workshop at the Hyatt Hotel in Canberra on August 4. Convened by Dr Stephen Brazenor the workshop had a wide variety of equipment for review by the delegates. Dr Ian McKenzie, the Director of Anaesthesia and Pain Management at the Royal Children’s Hospital was a guest speaker on our Panel of Experts along with various local Fellows. There was a revisiting of the Difficult Airway Algorithm by Dr Stephen Brazenor. Videolaryngoscopy and approach to fibre optic intubation techniques were reviewed by Dr Simon Robertson. The interesting presentations combined with the hands-on aspect College citation of the workshop combined to make the day a large success. In ANZCA President Dr Lindy Roberts presented Dr Kerry Brandis other news the ACT regional committee will be holding their AGM an ANZCA Council Citation on September 12 at the Queensland in November with the date to be confirmed. Regional Committee meeting. The ANZCA Council Citation was established in 2000 and is made at the discretion of the ANZCA Council in recognition of significant contributions to College activities. Dr Brandis has had a career in anaesthesia spanning 26 years during which time he has made significant contributions to advancing the profession in Queensland, and nationally, with Above from top: Dr Stephen Brazenor and the panel of experts particular achievements in education and training and service on discussing assessment of the airway; Delegates participating in the the ANZCA Council and committees. hands-on workshop.

61 Australian news continued

South Australia and Northern Territory

Above clockwise from top left: Business Development Manager South Registrar’s Scientific Australia and Northern Territory Michael Lardner, winning Registrar Dr Rowan Ousley, SA and NT CME Committee Chair Dr Nathan Davis; Meeting 2012 Registrar Dr Andrew Thomas; CME Committee Member Dr Bill Wilson The 2012 Registrar’s Scientific Meeting was held at the and guest speaker Professor Guy Ludbrook; Registrar Dr Simon Roberts. Women’s and Children’s Hospital on August 8. The guest speaker, Professor Guy Ludbrook from Royal Adelaide Hospital, spoke about research being undertaken at the Royal Adelaide Hospital and ANZCA’s commitment through the Anaesthesia and Pain Medicine Foundation, which contributes more than $600,000 a year to research in Australia. He also highlighted the work of the ANZCA Trials Group, which was founded in 2005 to improve the evidence base of anaesthesia by developing and conducting high quality, multicentre randomised controlled trials and related research. The winning registrar was Dr Rowan Ousley for her research project titled “Block height assessment for satisfactory spinal anaesthesia during caesarean section”. Presentations by Dr Simon Roberts and Dr Andrew Thomas were highly commended. This continuing medical education (CME) event is an important part of the CME calendar for encouraging trainees to demonstrate their knowledge and fostering scientific enquiry among others.

62 ANZCA Bulletin September 2012 Education meeting hears about indigenous experiences On June 27, the South Australia and Northern Territory Continuing Medical Education Committee held their evening continuing Part 0 Induction Course medical education meeting at the Women’s & Children’s Hospital On August 5, the South Australia and Northern Territory regional on the subject of “indigenous health and anaesthesia”. office held the Part 0 Induction Course for new trainees joining Dr Janelle Trees, a GP anaesthetist, addressed the meeting the SA and NT Rotational Anaesthesia Training Scheme. The chair via videoconference from Uluru-Kata Tjuta National Park, in the of the SA and NT Trainee Committee, Vicki Cohen, facilitated Northern Territory. the course. Topics included GASACT, the new ANZCA curriculum, An indigenous Australian, Dr Trees works in a closed Aboriginal Part 1 Course and trainee welfare. We wish to thank consultants community in Mutijulu, near Alice Springs, and provided an Dr Margaret Wiese, Dr Thien LeCong, Dr Christine Hildyard, insightful and personal talk on indigenous spiritual beliefs, “spirit Dr Elizabeth Chye and Dr Ken Chin for presenting at the course. in and out”. Her talk highlighted the importance of trust between the anaesthetist and an indigenous patient as indigenous patients believe the spirit leaves the body during a procedure and that the anaesthetist is the doctor that guides the spirit back into the body before they wake. The meeting was video-linked to 14 consultants and trainees at the Royal Darwin Hospital and six at Alice Springs Hospital. Dr Phil Blum, an anaesthetist at the Royal Darwin Hospital for 13 years, spoke about issues of consent and communication and told interesting stories about how communication breakdown can lead to unpredictable outcomes. He also pointed out that a junior patient was rarely accompanied by a “natural parent” and doctors were sometimes required to take a flexible approach with consensual protocol. It was fantastic to hear about the Royal Darwin hospital and its outstanding work within the community, of which 20 per cent is indigenous. Finally, an anaesthetist at the Royal Adelaide Hospital, Dr Tony Pearce, spoke on “my indigenous family”, telling how he came to have “eight mothers-in-laws” and how he and his wife, a midwife, came to be adopted by the people of a Katherine indigenous community.

Above from left: SA and NT CME Chair Dr Nathan Davis acknowledging the Kaurna people and their lands; Video conferencing to The Royal Darwin Above from left: Mei Quinn (Quinnie) Tan, Richard (Branden) Emmerson, and Alice Springs Hospital and the Uluru-Kata Tjuta National Park. Danielle Carlson, Tim Donaldson, Johan Smit, Brigid Brown.

63 Australian news continued

New South Wales

New Challenges in Anaesthesia meeting at the Sydney Hilton On June 16 the New South Wales Continuing Medical Education Committee held their major continuing medical education meeting at the Sydney Hilton on “New Challenges In Anaesthesia” with more than 340 attendees enjoying this day. The workshops and PBLDs continue to be very well subscribed, attended and well received. These included workshops on new airway devices, new pacemakers and implantable and benchtop defibrillators and anaesthetic ventilators. There were 24 workshops and PBLDs conducted throughout the day. For the first time we included a session with registrar scientific presentations and this was well attended by Fellows and trainees. Dr Jennifer Reilly was the recipient of the award.

Above clockwise from top left: Dr Tony Padley workshop; Delegates at the meeting; Dr Chris Thompson; Dr David Postie and Dr Phil Melksham; Dr Nicole Smith, Dr Michael Bennett and Dr Catherine Downs; Dr Jane Brown, Dr Vivian Walsh and Dr Anne Rasmussen.

64 ANZCA Bulletin September 2012 Spinal surgery and pain – current directions in spinal surgery for pain On Thursday June 7, NSW Faculty of Pain Medicine Fellows, trainees and allied health and Fellows from the Chapters of Addiction and Palliative Care Medicine from Sydney and the surrounding area gathered for the NSW Regional Committee’s Continuing Medical Education (CME) dinner meeting. The CME meeting was a successful mind-stimulating event on spinal surgical pain management by Dr Jonathon Ball. It was complementary to the holistic concepts given by the physicians last year. The wonderful neurosurgical presentation was held at the College offi ce followed by Brazilian cuisine at a stylish cosy restaurant. This South American tastings provided a warm friendly atmosphere to complete a fantastic social event. We thank Mundipharma and Janssen for the joint sponsorship.

Above from top: Invited guest speaker, Dr Jonathon Ball, specialist spine surgeon and neurosurgeon, Royal North Shore Hospital; Dr Martine 1/2 pageHolford andad Dr Milton Cohen.

Saturday 24 November 2012 For more information please contact NSW ACE Ph: +61 2 9966 9085 Fax: +61 2 9966 9087 Email: [email protected] The University of Sydney Web: www.nsw.anzca.edu.au/events

NEW SOUTH WALES SECTION NSW REGIONAL COMMITTEE AUSTRALIAN AND NEW ZEALAND THE AUSTRALIAN SOCIETY COLLEGE OF ANAESTHETISTS OF ANAESTHETISTS Australian news continued

Tasmania Western Australia

2013 Combined ANZCA/ASA Office news The Western Australian regional office has had a change in crew Annual Scientific Meeting since the last ANZCA Bulletin with Melanie Roberts joining ANZCA The joint meeting of the ANZCA and the Australian Society of as the regional co-ordinator and Louise Burgess appointed to the Anaesthetists will be held at The Tramsheds in Launceston from role of regional administrator. The WA office farewelled Sandra February 22-24, 2013. It is anticipated the meeting will have Box at a dinner following the committee meeting in July and a perioperative theme. also farewelled Bree Toussaint, wishing them well in their new A Part 0 course, along with an update on the new curriculum endeavours. and an airway/advanced life support (ALS) session for all The Bunker Bay Updates in Anaesthesia conference will be registrars will be held on the Friday prior to the meeting. held from October 12 to 14, and is convened by King Edward Memorial Hospital and led by Dr Celine Baber. “Hectic obstetrics and frenetic anaesthetics” is the final conference of the year for WA and registrations are filling quickly. Professor Warwick Ngan Kee from Hong Kong is the keynote speaker for this conference and will be a highlight for those with an interest in intensive care obstetrics. Professor Ngan Kee was born and educated in New Zealand. He is Professor and Director of Obstetric Anaesthesia in the Department of Anaesthesia and Intensive Care at the Chinese University of Hong Kong. He is an editor of the International Journal of Obstetric Anesthesia, an editorial board member of Obstetric Anesthesia Digest, executive member of the Obstetric Anaesthesia Society of Asia and Oceania and co-editor of the forthcoming edition of Chestnut’s Obstetric Anesthesia. The Surgical Careers Expo is scheduled for the September 26 at the University of Western Australia and will be attended by David Hoppe and Marlene Johnson. The expo aims to provide information on vocational training and career pathways regarding the anaesthetic training program in WA. Oliver Jones and Allan Meers presented to the Western Australian Regional Committee and the Supervisors of Training Committee to communicate important updates for the new curriculum in 2013. Thank you Oliver and Allan. The primary and final exams are done and dusted for the year, but Part 2 tutorials will continue to run for the rest of the year. Trainees are encouraged to attend if they plan to sit the exams next year.

66 ANZCA Bulletin September 2012 victoria

33rd ANZCA/ASA Combined Continuing Medical Education meeting The 33rd Annual ANZCA/Australian Society of Anaesthetists Combined Continuing Medical Education meeting was held at the Sofitel Melbourne on Collins on Saturday July 28. The meeting was called “the ultra meeting”, and was well supported by Victorian and interstate registrants, including the trade. The sessions included topics such as: the bariatric patient with a multidisciplinary approach including the surgical, anaesthetic and intensive care aspects; resuscitation, focusing on the adult patient, the obstetric setting and anaphylaxis; and ultrasound use in regional anaesthesia, invasive line insertion and echocardiography in non-cardiac surgery. A lively and entertaining debate concluded the formal proceedings, which were followed by drinks and dinner.

Above clockwise from top left: Dr Peter Seal, Convenor/CME Officer ASA Victoria, Dr Mark Suss, Chair ASA Victoria, Dr Craig Noonan, Chair VRC, Dr Mark Hurley, Co-Convenor, CME Officer, VRC; Dr Craig Noonan, Chair VRC presenting a SOT Certificate of Recognition to Dr Peter Howe; Dr Andrew Schneider and Dr Andrew Buettner; Dr Craig Noonan, Chair VRC presenting a SOT Certificate of Recognition to Dr Rob Dawson.

67 Special interest group events

Obstetric Anaesthesia Special Perioperative Medicine/Acute Interest Group meeting Pain Special Interest Group meeting

The 3rd Quadrennial Obstetric Anaesthesia Special Interest Group meeting was held at the Quay West Resort, Bunker Bay, following the ANZCA Annual Scientific Meeting (ASM) in May. The location was on the edge of the renowned Margaret River wine region and gave the delegates the opportunity to unwind after the ASM. The theme of the meeting was “High risk obstetric anaesthesia” and the speakers included a number of well-known “When worlds collide: perioperative medicine – the new specialty anaesthetists from Australia and New Zealand. In addition, the on the block?” was the title of the inaugural meeting of the new invited speakers included intensivist Dr Luke Torre, haematologist Perioperative Medicine Special Interest Group, which was held Dr Nicole Staples, lawyer and anaesthetist Dr Andrew Miller and in conjunction with the Acute Pain Special Interest Group. gynaecologist Professor Yee Leung. The program included a The program, which was highly practical, comprised number of interactive sessions, workshops and problem-based guest speakers from diverse areas of medicine such as liver learning discussions with a large number of practical tips and transplantation and fluid management to the role of perioperative tricks for the delegates. psychiatry. The social program included a welcome reception at the Expert panels examined controversial questions facing this resort, a wine tour visiting well-known vineyards in the Margaret potential new specialty. The two big questions to arise from the River region and a conference dinner at the Wise Vineyard. During conference were: Which kind of doctor is best suited to practice the meeting, delegates raised over $1000 for the Lifebox project perioperative medicine and how should a perioperative medicine through raffles supported by sponsors, adding to the success service work? of this initiative from the Perth annual scientific meeting. The conference was held at the beautiful Byron at Byron The meeting attracted 120 delegates and six healthcare Resort and Spa in NSW, on the same weekend that 20,000 industry representatives, all of whom took away new ideas, friends and colleagues. Thank you to all the delegates, speakers people descended on Byron Bay for a music festival! The and workshop and problem-based learning discussion facilitators meeting was limited to 150 delegates and no sponsorship was for attending and contributing to the success of the meeting, required. A welcome reception and dinner facilitated discussion a number of whom travelled a long way. A special thank you to and collaboration of perioperative enthusiasts from throughout the conference secretariat, Kirsty O’Connor from ANZCA, for all Australasia. her help with organising the meeting. I thank the members of the Perioperative Medicine SIG for their contributions, our entertaining speakers, and of course Dr Nolan McDonnell Kirsty O’Connor from ANZCA for making this conference such Convener a great success. Dr Dick Ongley Convener

68 ANZCA Bulletin September 2012 2012 Rural Special Interest Group meeting

The Rural Special Interest Group (SIG) held its annual meeting at the Peppers Resort, Torquay, on Victoria’s Great Ocean Road from July 6 to 8. The conference, now in its fi fth year, returned to the theme of the original meeting with the title “Staying afl oat on the shipwreck coast: The return of the accidental intensivist”. The meeting was well supported by more than 80 delegates, including many GP anaesthetists and large number of trade displays. The meeting covered a variety of topics more usually associated with the intensive care unit that country-based anaesthetists might fi nd themselves dealing with. “Shipwreck tales” covered a challenging paediatric case report along with how to deal with a major incident in a small town and responding to in-fl ight emergencies. “A treasure chest” covered all aspects of chest trauma before “Raising the respiratory wrecks” discussed ventilation all the way from non-invasive strategies to ECMO. The fi nal morning sessions included “Avoiding the CVS capsise”, which took us through ECHOs, cardiac output monitors and inotropes, before a thought-provoking fi nal session entitled “When to man the lifeboats”. This session introduced the ethics of intensive care unit treatment, some thoughts about when to say yes or no to admissions and fi nally a discussion about respecting patients’ end-of-life decisions. The meeting again hosted workshops with a continuation of the education theme from 2011, and offered module 3 from the ‘Teaching on the Run’ program. Dr Craig Mitchell and colleagues from Ballarat ran an ultrasound workshop and Dr Nick Jansen and colleagues from the Royal Melbourne Hospital ran an ALS update. This year’s meeting also held a poster prize for the fi rst time and offered prizes courtesy of a grant from Rural Health Continuing Education – stream 1. The quality of posters was very high with the Fellow’s prize going to Dr Pat Coleman of Western Australia and the registrar’s prize going to Dr Rosie Zacher from Queensland. We will run a poster competition again next year and posters may be on any topic that is relevant to rural anaesthesia. We were blessed with sunny weather on the Great Ocean Road, which enabled delegates to enjoy the golf course and the coastal walkways when not in lectures. The social events were well attended with delegates able to network at a drinks reception on the ﬁ rst evening and over dinner at Truffl educk at Balmoral on the Saturday evening. The meeting was a great success and I would like to mention the contribution of the Rural SIG Chair and co-convenor, Dr Craig Mitchell, and the sterling work of Ms Hannah Burnell who, in her role as SIG co-ordinator, assisted in planning and hosting the meeting as well as all the speakers, whose high quality presentations ensured the meeting was a great success. Above clockwise from top: Golf course, Peppers the Sands, Torquay; The fi nal business of the meeting was the Rural SIG annual Ultrasound workshop demonstration by Dr Rob Ray; Dr Pat Coleman general meeting, where plans for next year’s meeting were presenting in the poster symposium; Dr Nick Jansen presenting; discussed. The meeting will be held at the Millennium Hotel, Dr Craig Mitchell demonstrating at the ultrasound workshop. Rotorua, New Zealand, from July 12 to 14, and the theme will be “Obstetric anaesthesia in the bush”.

David Rowe Co-convenor

69 Faculty of Pain Medicine Dean’s message

The release of the details of this strategic Once again on the Olympic theme, the plan is imminent. Like our athletes, we have Paralympics holds special significance for the foundations in place to direct our growth us as a Faculty. So much of our management and strength as a Faculty over the next five of pain requires assessment and years, which, like our Olympians, will keep management of disability. Convincing and us firmly on the “leaders’ board” nationally inspiring patients to be the best they can and internationally in the years ahead. be, to focus on what can be done and not The recent announcement by the NSW what cannot, to live a full life despite pain government of $26 million of funding and disability rather than to let their pain for pain services in NSW is reason for defeat them. To find that source of control celebration. Tireless contributions by and confidence within themselves, to be the our NSW Fellows over many years to master of their pain rather than believing documenting and quantifying pain and the solutions are beyond their control. its costs and to, most recently, planning The Paralympic Games are full of athletes solution via contributions to the Agency for who have conquered these enemies. Each Clinical Innovation as well as advocacy by has mastered their disability and often pain We have recently witnessed that four- Pain Australia. Money has been allocated and has lived their dream of competing at yearly event, so mesmerising for many, to increased numbers of training positions, the highest level. Each can be an example the Olympic Games. It is an event that educational initiatives and for the electronic and provide hope to our patients. symbolises so many of our aspirations as Persistent Pain Outcome Collaboration Our challenge as specialist pain a society. Where extremes of hard work (ePPOC). Congratulations to all contributors medicine physicians is to help our patients and dedication by athletes are put to the and to the NSW government on this much- find the confidence and inspiration to measure against the best in the world. For a needed commitment. master their pain and reach their own full small minority, the ultimate goal of “gold” The NSW funding announcement adds potential in life. is achievable. For others, one hundredth of to the momentum of previous commitments Our challenge as a Faculty and fraternity a second can be the agonising difference in to funding by governments in Queensland is to keep Australia and New Zealand on falling short. Australia and New Zealand and Victoria and by the federal government the worldwide leader board when it comes have again performed and achieved success to fund $5 million in February 2012 for to advancing the standard of care for far beyond our comparatively meagre an online, electronic, controlled-drugs our patients and lifting the complacency populations would warrant. It is inherent monitoring system. We must maintain surrounding the silent epidemic of pain in the character of our two nations to our representations to government and sufferers in our midst. unapologetically step up, to be counted advocacy initiatives to see these projects In our strategic plan for the next five and lead on the world stage. to fruition and to maintain this momentum years we have a map for our own success. So it is in the field of pain medicine. in the future Bring on the new Olympiad!! Our proud history of leadership in both The significant and onerous undertaking opinion setting and structural organisation that is the Australian Medical Council is evident. Our Faculty, our recognition of Associate Professor Brendan Moore reaccreditation process in Australia us as a medical specialty, our advocacy Dean, Faculty of Pain Medicine is ongoing. The Faculty has benefited through contributions to government immensely from the experience and collaborations, the National Pain Summit contributions of ANZCA in support of our and National Pain Strategy attest to the reaccreditation process, as well as the energy and vision that thrives in our tireless, invaluable contributions of our fraternity. Director of Professional Affairs, Associate As one Olympiad ends, the athletes of Professor Milton Cohen, General Manager, the future, our would-be heroes in Rio de Helen Morris and our dedicated Faculty Janeiro in four years’ time, map out their staff. On behalf of our Faculty, I offer a training strategy for the next four years to sincere thank you. deliver their dreams. That planning now is The process of assessment by the New essential for success. Zealand Medical Council for recognition of Like our future Olympians, as a specialty pain medicine as an independent specialty and Faculty we have been looking towards in New Zealand continues. This remains one the future. Our mission, our vision, our of the highest priorities for us as a Faculty. strategic goals and a business plan to take As would be expected, the process is us there. During the first half of this year, necessarily extensive and thorough. We are we have had our ongoing strategic review nearing the finalisation of this process and process in parallel with the complementary have presented our cause well. We hope for initiative of ANZCA, to finalise our strategic a decision from the Medical Council of plan for the next five years. New Zealand this year.

70 ANZCA Bulletin September 2012 Faculty of Pain Medicine News

Faculty of Pain Medicine Board 2012 Back Row: Dr Chris Hayes, Dr Frank New, Associate Professor Andrew Zacest, Dr Dilip Kapur, Associate Professor Ray Garrick, Ms Helen Morris (General Manager). Front Row: Dr Kieran Davis, Dr Michael Vagg, Professor Ted Shipton (Vice-Dean), Associate Professor Brendan Moore (Dean), Associate Professor David Scott, Dr Meredith Craigie, Professor Stephan Schug.

Admission to Training unit Examination dates fellowship of the accreditation November 23-25, 2012 (Friday to Sunday) The Melbourne Pain Group and the Peter Auckland City Hospital, Auckland NZ Faculty of Pain MacCallum Cancer Centre have been Closing date for registration: Medicine accredited as the Faculty’s first tier two October 5, 2012 By examination: units for pain medicine training following June 6, 2012 successful initial reviews. This takes to 30 the number of accredited pain units. Dr Pieter Carel Le Roux, FACEM (Qld) Dr Duncan Morris Wood, FANZCA (NZ) Dr Jordan Gardiner Wood, FANZCA (NSW)

72 ANZCA Bulletin September 2012 FPM Board meeting report

PowerPoint presentations has been FPM terms of reference August 13, 2012 developed for Fellows to use as teaching The board approved terms of reference Faculty Board aids. This library of presentations for the roles of: ANZCA Council’s representative to the endorsed by the Faculty and including • Dean. Faculty of Pain Medicine Board, Associate high quality animations and effects Professor David Scott, was welcomed to will be available for download from the • Board members. the board. ANZCA President Dr Lindy resources section of the Faculty website. Roberts also attended the meeting and A demonstration stand will take Fellows • Treasurer. was welcomed. The Faculty Board will through accessing the GP Active Learning • Training unit accreditation reviewer. next meet in Melbourne on October 29. Module and how to download the PowerPoint presentations developed for Committee appointments Honours and awards their use. The full online Active Learning Committee appointments were approved The dean conveyed on behalf of Module will be launched at the GP12 for 2012-13. It was agreed to include the Faculty, acknowledgment and meeting on October 26. representation from New Zealand on the congratulations for the following Research Committee. appointments: Australian Rheumatology Association The President of the Australian Professional • Dr Genevieve Goulding has been Rheumatology Association (ARA), NSW pain management plan appointed Vice-President ANZCA. Associate Professor Sue Piper, met with On July 18, the NSW Minister for Health • Dr Leona Wilson has been appointed the Faculty Board in August to discuss and Medical Research, Jillian Skinner, Director of Professional Affairs (IMGS) opportunities for collaboration between announced a significant funding ANZCA. the organisations. Both parties agreed increase for pain management services that the National Pain Strategy would be in NSW. The plan, which incorporated • Associate Professor Victor Callanan has greatly strengthened by the support of extensive input from both a ministerial been awarded the ANZCA Medal. the ARA, which has not yet endorsed it. taskforce and the Agency for Clinical FPM international medical graduate The Faculty’s Spring Meeting in Coolum Innovation (ACI) Pain Network, commits specialists (IMGS) process will include a session on the profile an additional $26 million over four years ANZCA’s Director of Professional Affairs of new medications in rheumatology. to support the development of new pain (IMGS), Dr Dick Willis, and Manager Opportunities will be explored for management services in regional areas, ANZCA IMGS and Accreditation Renee collaboration on a future spring meeting. enhance existing teaching hospital McNamara presented a proposal for a services, and support research into Corporate Affairs chronic pain. process for the assessment of Faculty FPM Strategic Plan IMGS applicants. The process will be only The board approved the FPM Strategic Electronic Persistent Pain Outcomes for applicants intending to practice in Plan for 2013-2017. The structure of the Collaboration Australia, pending accreditation of pain Faculty’s strategic plan is defined by its As part of the funding package medicine as a specialty by the Medical mission (shared with ANZCA), its vision announced by the NSW Government, Council of New Zealand. The board and its strategic priorities and objectives. $300,000 of annual recurrent funding has resolved that the FPM IMGS Working Strategic priorities are to: been allocated to support benchmarking Group, including representation from the of outcomes across NSW through the ANZCA IMGS Committee, will continue • Build fellowship and the Faculty. Electronic Persistent Pain Outcomes to develop the assessment process in • Build the curriculum and knowledge. Collaboration. There will be an emphasis alignment with ANZCA’s. on moving towards implementation in • Build advocacy and access. Relationships NSW and also on planning the national benchmarking process, working Australian Pain Society Activities to put the plan into action will collaboratively with FPM, Australian Pain The board nominated Dr Chris Hayes be contained in the Faculty’s Business Society and New Zealand Pain Society. as the FPM Board representative to the Plan, developed annually. A business Australian Pain Society’s Relationship plan is being developed for the 2013 NSW Government approval for pain and Communications Committee, calendar year and will inform the budget medicine early recruitment 2012 replacing Dr Penny Briscoe, who retired process for that year. The board noted that the NSW from the board in May. Government had approved the advertising Board handbook of funded pain medicine provisional Royal Australian College of General The board approved a handbook for Fellow positions for the 2013 clinical year Practitioners use as an orientation resource for new in May 2012, two months earlier than the The Royal Australian College of General board members. The handbook provides annual recruitment period. Practitioners/FPM GP online learning an introduction to the governance initiative is in the final stages of arrangements and various duties, (continued next page) development and remains on track for responsibilities and workings of the a launch at the FPM Spring Meeting in board and its relationships, both within Coolum on September 29. As part of this the FPM and in other jurisdictions. initiative, a library of complimentary

73 Faculty of Pain Medicine FPM Board meeting report continued

Recognition of pain medicine as a for FFPMANZCA may be supported Fellowship specialty – New Zealand by a specialist qualification from an Three new Fellows were admitted in Faculty representatives participated international jurisdiction. Regulation June, taking the total number of in a teleconference with members of 3.1.1.6 has been amended to remove admissions to 331. the Medical Council of New Zealand’s reference to a requirement for an Accreditation Committee and responded Australian or New Zealand specialist Education to queries, including the Faculty’s qualification acceptable to the board. FPM curriculum revision continuing professional development The board will now undertake a process The board was advised about key changes requirements. New Zealand Fellows are of evaluating relevant international being proposed by the Curriculum to be reminded of the Medical Council specialist qualifications to determine Revision Sub-Committee and the critical of New Zealand continuing professional those that are acceptable for this purpose. issues in relation to these changes. development requirements. Consideration of any application is The board resolved that: assessed based on the formal structure Submissions • The two-year program will be of examination and training required for restructured. The Faculty recently has contributed their primary specialist qualification. to the following submissions, which • There will be entry-level knowledge can be viewed at www.anzca.edu. Following the decision of the board to required for the structured year of au/communications/submissions/ consider specialist qualifications of training; these may take the form of government-submissions-2012. international medical graduate trainees pre-requisite courses. as acceptable pre-requisite specialist • Health Workforce Australia – Health qualifications for FFPMANZCA, the • A range of new teaching/learning Professionals Prescribing Pathway qualification Associate Fellowship of approaches will be used. (HPPP) Australia – May 2012. FPMANZCA became redundant, as the • Trainees will complete three • AMC review of the approved Accreditation only differentiating criterion was whether examinations throughout the year, Standards for medical schools – August the applicant held a fellowship of an along with some other hurdle 2012. Australian and New Zealand specialty. summative assessments. Thus, the decision was also made to The Faculty also responded to: rescind FPM Regulation 3.5: Admission • A budget will be created to cater for • Pharmaceutical Benefits Scheme to Associate Fellowship by Training the initial high-level processes for – a review of current listings of opioids and Examination. design of the program. – August 2012. A separate issue is the decision of Supervisor of supervisors of training • Health Workforce Australia – Pain quantifying any retrospective credit of appointment Medicine Chapter, July 2012. prior training and experience that is Board approved the appointment of relevant to pain medicine. This decision Dr Faizur Noore, FRANZCP, FFPMANZCA • Therapeutic Goods Administration depends on the individual’s actual as the FPM supervisor of supervisors – proposed withdrawal of products prior experience rather than the formal of training. containing dextropropoxyphene structure of their primary specialist Training unit accreditation (DPP) – August 2012. qualification. Applications for fellowship The Melbourne Pain Group and Peter from international medical graduate • AMC accreditation assessment RANZCP MacCallum Cancer Centre have been specialists applying for FPM training will and RACMA – July 2012. accredited as Tier 2 units, for up to six be assessed on a case-by-case basis to months full-time equivalent of structured • Pharmaceutical Benefits Advisory determine the quantum of recognition of training. Committee – PBS access to gabapentin prior learning to be credited towards the – August 2012. Faculty’s training time requirements. Continuing professional development Upcoming FPM events include: Communications Current trainees with international It was agreed that the Synapse qualifications will not be disadvantaged • 2012 Spring Meeting – September e-newsletter will be opened to paid by these decisions. 28-30 – Palmer Coolum Resort, advertising in line with ANZCA practice. Sunshine Coast Rates and publication dates will be A list of specialist fellowships, published on the Faculty website. international as well as those of • 2013 Annual Scientific Meeting Australian and New Zealand, which are and FPM Refresher Course Day Trainee Affairs acceptable to the board as satisfactory – May 3 and May 4-8 – Melbourne IMGS trainees pre-requisite qualifications for fellowship, In May, the board resolved to revise the is being developed and will be generally Finance earlier decision to restrict fellowship of available. At the end of July, the Faculty remained FPMANZCA to those holding a fellowship in a positive position against the budget. of an Australian and New Zealand Training agreement specialist college. It was agreed that The board accepted a revised training in future, the training and assessment agreement, which will be circulated to criteria to be met by those applying current trainees and all new trainees with registration documentation.

74 ANZCA Bulletin September 2012 Hypnosis researchresearch brings newnew awarenessawareness

Hypnotherapy is increasingly Following the establishment of activity in the anterior cingulate cortex, used to replace or supplement pharmacological anaesthesia – with its which links the limbic (emotions) and used to replace or supplement greater effectiveness and reliability – sensory cortical areas of the brain during pharmacological anaesthesia, the practice of hypnosis languished for hypnotic pain relief. This appears to with surprising results, write decades, becoming little more than a allow sensations that would normally be writeAllan DrCyna Allan and Cyna Marion and Dr parlour trick. It was almost forgotten experienced as painful to no longer have until relatively recently. the suffering or negative emotions that MarionAndrew. Andrew. This article This is article Unfortunately, the term hypnosis has would normally be associated with them. isreprinted reprinted with with permission permission many negative connotations and its use A labour contraction, for example, can from The Conversation. by stage hypnotists as entertainment has be felt as either the most terrifying and probably contributed to many doctors painful of sensations or a wonderfully In one form or another, hypnosis has In one form or another, hypnosis has not taking the clinical use of hypnosis fulfifulfilling lling experience that tells the been around for thousands of years, but been around for thousands of years, but seriously. mother she is getting closer to her baby. until recently, evidence to support its until recently, evidence to support its These very different perceptions may biological and clinically powerful effects How it works biological and clinically powerful effects be experienced despite the intensity of has been lacking. Today clinicians around Contrary to popular belief, hypnosis is not has been lacking. Today clinicians around uterine contractions being identical. the world use hypnosis to help manage sleep; hypnotic responses can be elicited the world use hypnosis to help manage Anaesthetists in Belgium have pain, childbirth, phobia and anxiety in minutes or less; and a conscious belief pain, childbirth, phobia and anxiety successfully used hypnosis to help – particularly in children. that it will be effective is not required to – particularly in children. thousands of patients minimise their achieve a benefibenefit. t. Patients experiencing What is hypnosis? need for general anaesthesia during What is hypnosis? hypnosis can hear what’s happening Hypnosis is thought to be a state of thyroidectomy (surgical removal of the Hypnosis is thought to be a state of around them and can halt the process conscious awareness, which most people thyroid gland), mastectomy (removal conscious awareness, which most people at any stage if they wish. experience transiently many times each of the breast) and plastic surgery. experience transiently many times each The success of hypnosis in a clinical day. Hypnotic experiences and responses Meanwhile, US researchers are day. Hypnotic experiences and responses setting requires trust between doctor tend to involve: investigating the effectiveness of tend to involve: and patient to go along with the process. hypnosis and suggestion in the • Absorption or a state of focused But a borderline, and sometimes • Absorption or a state of focused management of chronic and procedural concentration or attention. frank, hypnotic state frequently occurs concentration or attention. pain, including burns. spontaneously in hospital patients where • Dissociation, where the patient’s Our own institution is researching the the overwhelming stress of the external perception of the external environment effectiveness of hypnosis in managing environment – or the thought of painful diminishes. childbirth pain, along with investigators procedures, or feelings of being a victim • Suggestibility (the ability of an individual in Denmark, the United Kingdom and the • Suggestibility (the ability of an individual to illness – can facilitate an internal focus to respond, in a non-volitional way, to a University of Tasmania. diverse as bedwetting, pain, and helping The main value of hypnosis as to respond, in a non-volitional way, to a of attention. verbal or non-verbal communication). children comfortably use hypnotic a technique is to assist patients to verbal or non-verbal communication). This can make patients highly How is it used? anaesthesia with needles and renal have drips and needles inserted more People describe the hypnotic mindset responsive to suggestions, positive or Hypnosis in the formal sense – where People describe the hypnotic mindset dialysis. comfortably and to supplement a less- in different ways such as, “being beside negative. And it means that when a a patient receives an induction, in different ways such as, “being beside Today, several paediatricians and than-perfect local anaesthetic. The belief oneself”, “out of body experiences”, doctor says, before a potentially painful treatment and an alerting procedure oneself”, “out of body experiences”, anaesthetists at our institution are trained that the patient can do more than he or “daydreaming”, “tuning out” or a procedure, “this is going to sting”, – is more commonly practiced by “daydreaming”, “tuning out” or a in hypnosis and use it to supplement she thinks (and more than the doctor meditative state. the communication can function as clinical psychologists and not widely meditative state. patient care where indicated. believes is possible) is likely to generate Until the 19th century, hypnosis a hypnotic suggestion and is likely to used in hospitals. Although a number of Until the 19th century, hypnosis As anaesthetists, we use hypnotic surprising therapeutic responses. was the only means of having surgery increase pain. In contrast, the positive hospitals around the world use hypnotic was the only means of having surgery techniques to help patients feel more in comfortably. James Braid, a Scottish suggestion, “the local anaesthetic will techniques, the main clinical application Further reading: Handbook of comfortably. James Braid, a Scottish control and to supplement and enhance surgeon working in Bengal in the 1840s, numb the area and allow us to perform is to use suggestions to supplement Communication in Anaesthesia & Critical surgeon working in Bengal in the 1840s, their anaesthesia experience. Common operated on several hundred patients the procedure more comfortably” is likely anaesthesia drugs and techniques as part Care: A Practical Guide to Exploring the Art. operated on several hundred patients examples include assisting children and using hypnosis and his success received to decrease pain of local anaesthetic of a multimodal approach to patient care. using hypnosis and his success received adults with their induction of anaesthesia, widespread acclaim. injection. Hypnosis has been used at Adelaide’s Dr Allan Cyna widespread acclaim. burns dressings, treatment of needle Over the years, clinicians have Women’s and Children’s Hospital for Anaesthetist and researcher at SA Health Over the years, clinicians have What does the research say? phobia, assistance with childbirth pain reported dissociation from pain, more than 30 years, since Dr Graham Advances in brain-function imaging using and preparation of patients for surgery. Dr Marion Andrew decreased bleeding and reduced Wicks, a medical hypnotherapist at the functional magnetic resonance imaging It’s very rare for procedures to be Anaesthetist and researcher at SA Health infection, suggesting an evolutionary hospital, pioneered its use. Over the infection, suggesting an evolutionary (fMRI) and positron emission tomography performed entirely using hypnosis. basis for why we have the ability to enter years, hypnosis has been used to treat basis for why we have the ability to enter (PET) scanning techniques have allowed a hypnotic, trance-like state when under thousands of children with problems as a hypnotic, trance-like state when under us to see that hypnosis modulates extreme stress.

76 ANZCA Bulletin September 2012 77 Hypnosis research brings new awareness

Hypnotherapy is increasingly Following the establishment of activity in the anterior cingulate cortex, pharmacological anaesthesia – with its which links the limbic (emotions) and used to replace or supplement greater effectiveness and reliability – sensory cortical areas of the brain during pharmacological anaesthesia, the practice of hypnosis languished for hypnotic pain relief. This appears to with surprising results, write decades, becoming little more than a allow sensations that would normally be Allan Cyna and Marion parlour trick. It was almost forgotten experienced as painful to no longer have until relatively recently. the suffering or negative emotions that Andrew. This article is Unfortunately, the term hypnosis has would normally be associated with them. reprinted with permission many negative connotations and its use A labour contraction, for example, can from The Conversation. by stage hypnotists as entertainment has be felt as either the most terrifying and probably contributed to many doctors painful of sensations or a wonderfully In one form or another, hypnosis has not taking the clinical use of hypnosis fulfilling experience that tells the been around for thousands of years, but seriously. mother she is getting closer to her baby. until recently, evidence to support its These very different perceptions may How it works biological and clinically powerful effects be experienced despite the intensity of Contrary to popular belief, hypnosis is not has been lacking. Today clinicians around uterine contractions being identical. sleep; hypnotic responses can be elicited the world use hypnosis to help manage Anaesthetists in Belgium have in minutes or less; and a conscious belief pain, childbirth, phobia and anxiety successfully used hypnosis to help that it will be effective is not required to – particularly in children. thousands of patients minimise their achieve a benefit. Patients experiencing need for general anaesthesia during What is hypnosis? hypnosis can hear what’s happening thyroidectomy (surgical removal of the Hypnosis is thought to be a state of around them and can halt the process thyroid gland), mastectomy (removal conscious awareness, which most people at any stage if they wish. of the breast) and plastic surgery. experience transiently many times each The success of hypnosis in a clinical Meanwhile, US researchers are day. Hypnotic experiences and responses setting requires trust between doctor investigating the effectiveness of tend to involve: and patient to go along with the process. hypnosis and suggestion in the But a borderline, and sometimes • Absorption or a state of focused management of chronic and procedural frank, hypnotic state frequently occurs concentration or attention. pain, including burns. spontaneously in hospital patients where • Dissociation, where the patient’s Our own institution is researching the the overwhelming stress of the external perception of the external environment effectiveness of hypnosis in managing environment – or the thought of painful diminishes. childbirth pain, along with investigators procedures, or feelings of being a victim in Denmark, the United Kingdom and the • Suggestibility (the ability of an individual to illness – can facilitate an internal focus University of Tasmania. to respond, in a non-volitional way, to a of attention. diverse as bedwetting, pain, and helping The main value of hypnosis as verbal or non-verbal communication). This can make patients highly How is it used? children comfortably use hypnotic a technique is to assist patients to anaesthesia with needles and renal have drips and needles inserted more People describe the hypnotic mindset responsive to suggestions, positive or Hypnosis in the formal sense – where dialysis. comfortably and to supplement a less- http://theconversation.edu.au in different ways such as, “being beside negative. And it means that when a a patient receives an induction, Today, several paediatricians and than-perfect local anaesthetic. The belief oneself”, “out of body experiences”, doctor says, before a potentially painful treatment and an alerting procedure anaesthetists at our institution are trained that the patient can do more than he or “daydreaming”, “tuning out” or a procedure, “this is going to sting”, – is more commonly practiced by in hypnosis and use it to supplement she thinks (and more than the doctor meditative state. the communication can function as clinical psychologists and not widely patient care where indicated. believes is possible) is likely to generate Until the 19th century, hypnosis a hypnotic suggestion and is likely to used in hospitals. Although a number of As anaesthetists, we use hypnotic surprising therapeutic responses. was the only means of having surgery increase pain. In contrast, the positive hospitals around the world use hypnotic techniques to help patients feel more in comfortably. James Braid, a Scottish suggestion, “the local anaesthetic will techniques, the main clinical application Further reading: Handbook of control and to supplement and enhance surgeon working in Bengal in the 1840s, numb the area and allow us to perform is to use suggestions to supplement Communication in Anaesthesia & Critical their anaesthesia experience. Common operated on several hundred patients the procedure more comfortably” is likely anaesthesia drugs and techniques as part Care: A Practical Guide to Exploring the Art. examples include assisting children and using hypnosis and his success received to decrease pain of local anaesthetic of a multimodal approach to patient care. adults with their induction of anaesthesia, widespread acclaim. injection. Hypnosis has been used at Adelaide’s Dr Allan Cyna Women’s and Children’s Hospital for burns dressings, treatment of needle Over the years, clinicians have What does the research say? Anaesthetist and researcher at SA Health more than 30 years, since Dr Graham phobia, assistance with childbirth pain reported dissociation from pain, Advances in brain-function imaging using Wicks, a medical hypnotherapist at the and preparation of patients for surgery. Dr Marion Andrew decreased bleeding and reduced functional magnetic resonance imaging hospital, pioneered its use. Over the It’s very rare for procedures to be Anaesthetist and researcher at SA Health infection, suggesting an evolutionary (fMRI) and positron emission tomography years, hypnosis has been used to treat performed entirely using hypnosis. basis for why we have the ability to enter (PET) scanning techniques have allowed thousands of children with problems as a hypnotic, trance-like state when under us to see that hypnosis modulates extreme stress.

76 ANZCA Bulletin September 2012 77 STEPS in the West for people with persistent pain

People with persistent pain questions on demographics, their pain Patients, their families and carers can story, PainDETECT, HADS (now DASS21), access STEPS in Western Australia through face many challenges. life events, red, yellow and disease “fl ags” referral by a health professional to: While it may be true that healthcare and pain-management strategies. • The Fremantle Hospital and Health professionals can’t independently change Over the next 18 months, assessors Service Pain Medicine Unit (funded by societal views of illness and disability, or tracked the progress of 204 patients who the WA Department of Health). There move people’s beliefs towards outcomes attended STEPS and found that 52 per is a six-week waiting time for STEPS evidence-based practice, what happens cent of patients didn’t organise further and a two to three month wait for when individuals and the system work individual appointments at the tertiary patient-initiated assessments (including together to support a system change so pain medicine unit. Patient surveys Telehealth) by either the pain team or a evidence-based care can occur at the indicated that these patients were happy single doctor. There is no charge to the “coalface”? to self manage or to receive healthcare in patient and more than 750 new patients In 2007, the Western Australian their local community. access the service each year. Department of Health started to offer STEPS also resulted in reduced costs, • Perth North Metro Medical Local, 137 annual translational research grants. The with the cost per new patient falling from Main St, Osborne Park (funded by key drivers for funding were translating $A1805 to $881. Of this, $541 was the cost the federal Department of Health and evidence into practice and reducing the of running the program. Wait times for Ageing). Perth North Metro Medical cost to the WA health department. group and clinic appointments also fell, Local has had 137 referrals and 87 The two-day Self Educative Pain dropping from two years to four months people have attended STEPS to date. Sessions, followed by patient-initiated at one pain unit and seven months to 1 There is a two-week waiting time for assessments, aimed to reduce some of the 3.75 months at the second . The patients STEPS and the pain team assesses healthcare barriers. The program, known reported an increase in the use of active all patients four weeks after they as STEPS, offers patients knowledge pain-management strategies and patient have completed the two-day group and skills from clinical psychologists, satisfaction. program. The service is free to patients occupational therapists, physiotherapists In the 21 months from October 2007 and includes a lunch of gourmet and pain medicine physicians to to the end of 2009, 1075 patients booked sandwiches. emphasise a whole-person integrated to attend the two-day STEPS program at approach to managing persistent pain. Fremantle Hospital and Health Service, of The pain team includes a medical pain The patient is involved in each step which 854 attended and 221 (20 per cent) consultant, a clinical psychologist and of their care in the evidence-based were “no shows”; 667 patients (78 per a physiotherapist. The team encourages management of pain. A maximum of 12 cent) attended all fi ve sessions. A further the use of local health resources to patients are booked per program, with 1000 patients had booked to attend STEPS ensure best patient outcomes and partners or carers also invited to attend. to August 2012. connects the patient with local healthcare Opportunity met crisis at the Fremantle STEPS provides up-to-date information professionals and resources if required. Hospital and Health Service where newly and advice about how to effectively Fremantle Hospital and Health Service referred patients had to wait more than manage persistent pain, including and Perth North Metro Medical both offer two years to attend the Pain Medicine Unit medications and procedures, movement opportunities for healthcare professionals and referrals for more than 600 people and exercise, pacing everyday activities to attend STEPS as a learning experience with pain were nested in eight lever-arch and approaches to pain. It helps patients (bookings are required with a maximum fi les. The system had to change to allow to understand the complex puzzle of of two professionals per group). more effective triage of patients. pain, and appreciate discussions about The WA Department of Health also An opportunity to address the crisis neuroplasticity, the immune system and worked with the Fremantle Division of arose when the State Health Research the multimodal range of options that work GPs (now Fremantle Medicare Local) and Advisory Council and Fremantle Hospital together. Osborne Park GP Division (now Perth funded an assessment of the effects The program is a resource for co-care North Metro Medicare Local) in 2008 of pre-clinic group education sessions (that is co-ordinated or combined care) for and 2009 to deliver general practitioner- (STEPS) on tertiary pain medicine units people with persistent pain, their carers, focused one-day inter-professional and patient outcomes. families and health professionals. It pain-education programs. The health At the time of their referral, patients supports wHOle Person Engagement department funded the fi ve programs were asked to complete a seven-page – the “HOPE model of care”. and research via the State Health patient triage questionnaire, including

78 ANZCA Bulletin September 2012 Research Advisory Council. The research References: demonstrated strong clinically important 1. Preclinic group education sessions reduce and statistical evidence for encouraging waiting times and costs at public pain GPs to adopt more self-reported evidence- medicine units. Davies Stephanie, Quintner John, Parsons Richard, Parkitny Luke, based attitudes, beliefs and clinical Knight Paul, Forrester Elizabeth, Roberts behaviours in their management of Mary, Graham Carl, Visser Eric, Antill Tracy, 2 patients with non-specifi c low back pain . Packer Tanya, Schug Stephan A, Pain Med, An exciting partnership between 2011, 12/1, 59-71. WA Department of Health, Arthritis 2. Slater H, Davies SJ, Parsons R, Quintner Foundation (WA), Curtin University and JL, Schug SA. A Policy-into-Practice RuralHealthWest co-ordinated “rural Intervention to Increase the Uptake of Evidence-Based Management of Low Back roadshows” in 2010-11 for the STEPS Pain in Primary Care: A Prospective Cohort team to deliver a modifi ed version of the Study. PLoS One. 2012;7(5):e38037. Epub 2012 general practitioner-focused programs May 25. PubMed PMID: 22662264; PubMed to other healthcare professionals. Called Central PMCID: PMC3360643. hPEP: Health Care Professional Pain 3. Slater H, Briggs AM, Bunzli S, Davies Education Program, the workshops were SJ, Smith AJ, Quintner JL. Engaging delivered on a Saturday to 60 healthcare consumers living in remote areas of Western Australia in the self-management of back professionals. A modifi ed STEPS program pain: a prospective cohort study. BMC followed on Sunday and was attended by Musculoskelet Disord. 2012 May 11;13(1):69. more than 80 people, including carers, [Epub ahead of print] PubMed PMID: in three remote and rural locations in 22578207. Kununurra, Kalgoorlie, and Albany3. Translating evidence into best practice Above: STEPS being conducted as part of the care is enhanced when the patient is Rural Roadshow in Albany, Western Australia. fi rmly in the driver’s seat with a skilled healthcare professional alongside them!

Adjunct Associate Professor Stephanie Davies Associate Professor Helen Slater Mrs Kylie Birkinshaw

79 Library update

• Anesthesiologist’s manual of surgical • Basic and clinical pharmacology / New online textbooks procedures / Jaffe, Richard A [ed.]; Samuels, Katzung, Bertram G [ed]; Masters, Susan B. The ANZCA Library has recently added Stanley I [ed.]. -- 4th ed -- Philadelphia, PA: [ed]; Trevor, Anthony J. [ed]. -- 12th ed -- New Wolters Kluwer/Lippincott Williams and York: McGraw-Hill, 2012. two new collections of e-books - the Wilkins, 2009. OVID Anesthesiology and Pain collection • Ganong’s review of medical physiology / and the Lange Basic Science Collection • Cousins & Bridenbaugh’s neural blockade Barrett, Kim E. [ed]; Barman, Susan M. [ed]; through Access Medicine. : in clinical anesthesia and pain medicine Boitano, Scott [ed]; Brooks, Heddwen L. [ed]; / Cousins, Michael J [ed]; Carr, Daniel B [ed]; Ganong, W. F. -- 23rd ed -- New York: McGraw- The packages provide access to a Horlocker, Terese T [ed]; Bridenbaugh, Phillip Hill Medical, 2010. combined total of over 65 titles including O [ed]. -- 4th ed -- Philadelphia: Wolters Kluwer / Lippincott Williams & Wilkins, 2009. • Vander’s renal physiology / Eaton, Douglas books on ultrasound-guided regional C; Pooler, John P. -- 7th ed -- New York: anaesthesia, airway management, pain • Bonica’s management of pain / Fishman, McGraw-Hill, 2009. and intensive care medicine. Some titles Scott M. [ed]; Ballantyne, Jane C. [ed]; Rathmell, James P. [ed]. -- 4th ed -- Baltimore, Reminder: All material provided by the Library of interest are: MD: Lippincott Williams and Wilkins, 2010. is for the benefit of financial Fellows, trainees and IMGS of the College and Faculty. Material • the ‘Practical Approach to ... Anesthesia’ is for authorised users only and should not series. be shared with non-ANZCA members. When using online resources, members are agreeing The Lange Basic Sciences package is to abide by the terms of use for the resource. specifically suited to trainee examination preparation including four books from the Access the OVID e-books, the Basic Sciences Primary Exam recommended reading list: e-books and many more online textbooks through the ANZCA Library Online Textbooks • Basic and clinical biostatistics / Dawson, list or library catalogue: www.anzca.edu.au/ Beth; Trapp, Robert G. -- 4th ed -- New York: resources/library/online-textbooks Lange Medical Books/McGraw-Hill, 2004.

New journal – New ECRI publications Evidence-based Perioperative Medicine Health Devices, Vol. 41, No.6, June 2012 practice corner - The Big Picture – a focus on medical Perioperative Medicine is an open access video equipment needs peer-reviewed journal that publishes – recent reviews highly topical clinical research relating Health Devices, Vol. 41, No.7, July 2012 American Society of Anesthesiologists to the perioperative care of surgical - Saving on CT, CT Test Criteria and Task Force on Perioperative Visual Loss. patients. Its essence is the distillation, Safety Matters Practice advisory for perioperative visual loss associated with spine surgery: an examination and application of clinical Health Devices, Vol. 41, No.8, August 2012 evidence to improve surgical outcome. updated report by the American Society Modern perioperative medicine is a true Operating Room Risk Management of Anesthesiologists Task Force on multidisciplinary speciality and the - Anesthesia Information Management Perioperative Visual Loss. Anesthesiology journal welcomes research in all areas Systems – this analysis focuses on 2012;116(2):274-85. relevant to perioperative medicine from quality improvement, patient safety, American Society of Anesthesiologists any healthcare professional. risk management, and compliance Task Force on Preanesthesia Evaluation. implications of anesthesia information Practice advisory for preanesthesia Recent articles include: management system use. evaluation: an updated report by the Perioperative fluid management: American Society of Anesthesiologists Consensus statement from the enhanced Task Force on Preanesthesia Evaluation. recovery partnership. Mythen MG, et al. Anesthesiology 2012;116(3):522-38. Perioperative Medicine 2012, 1:2 (June 27, 2012) American Society of Anesthesiologists Task Force on Acute Pain Management. Access through the ANZCA Library Practice guidelines for acute pain online journal list: www.anzca.edu. management in the perioperative setting: au/resources/library/journals/online- an updated report by the American Society journals.html of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012;116(2):248-73.

80 ANZCA Bulletin September 2012 Handbook of critical care and emergency Practice MCQs for the New titles ultrasound / Carmody, Kristin [ed]; Moore, fi nal FRCA / Hardman, Christopher L. [ed]; Feller-Kopman, David [ed]. Jonathan G.; Mahajan, Books can be requested via -- 1st ed -- New York: McGraw-Hill Professional, Ravi P. -- 1st ed -- the ANZCA Library catalogue 2011. (Online book) Available through Access Edinburgh: Churchill Livingstone, 2000. www.anzca.edu.au/resources/ Anesthesiology library/book-catalogue.html MCQs for the fi nal Anesthesia and uncommon diseases / FRCA / Elfi turi, Fleisher, Lee A [ed]. -- 6th ed -- Philadelphia: Khaled; Arthurs, Elsevier-Saunders, 2012. (Online book) Graham. -- 1st ed -- Available online through MDConsult Cambridge: Cambridge University Press, 2007. Reconstructing medical practice: Get through fi nal engagement, FRCA : MCQs / Bahal, professionalism, and Nawal; Khan, Mubeen; critical relationships Manoras,Aliki. -- 1st in health care / Jorm, ed -- Oxford: Oxford Christine. -- 1st ed University Press, 2010. -- Farnham, Surrey, England: Gower, 2012.

Smith CA, Levett KM, Collins CT, Nishimori M, Low JHS, Zheng H, Troianos CA, et al. Guidelines for Crowther CA. Relaxation techniques for Ballantyne JC. Epidural pain relief versus performing ultrasound guided vascular pain management in labour. Cochrane systemic opioid-based pain relief for cannulation: recommendations of the Database of Systematic Reviews 2011, abdominal aortic surgery. Cochrane American Society of Echocardiography Issue 12. Art. No.: CD009514. Database of Systematic Reviews 2012, and the Society Of Cardiovascular Issue 7. Art. No.: CD005059. Anesthesiologists. Anesthesia & Analgesia Kranke P, et al. Hyperbaric oxygen therapy 2012;114(1):46-72. for chronic wounds. Cochrane Database of Garewal D, et al. Sedative Systematic Reviews 2012, Issue 4. Art. No.: techniques for endoscopic retrograde Husain T, et al. Strategies to prevent CD004123. cholangiopancreatography. Cochrane airway complications: a survey of adult Database of Systematic Reviews 2012, intensive care units in Australia and New Bennett MH, Lehm JP, Mitchell SJ, Wasiak Issue 6. Art. No.: CD007274. Zealand. British Journal of Anaesthesia J. Recompression and adjunctive therapy 2012;108(5):800-806. for decompression illness. Cochrane Perel P, Roberts I. Colloids versus Database of Systematic Reviews 2012, crystalloids for fl uid resuscitation in Nemeth J, Maghraby N, Kazim S. Issue 5. Art. No.: CD005277. critically ill patients. Cochrane Database Emergency airway management: the of Systematic Reviews 2012, Issue 6. Art. diffi cult airway. Emergency Medicine Bennett MH, et al. Hyperbaric oxygen No.: CD000567. Clinics of North America 2012;30(2): therapy for late radiation tissue injury. 401-420. Cochrane Database of Systematic Reviews Bunn F, Trivedi D. Colloid solutions for 2012, Issue 5. Art. No.: CD005005. fl uid resuscitation. Cochrane Database of Bleakley A, Allard J, Hobbs, A. Towards Systematic Reviews 2012, Issue 7. Art. No.: culture change in the operating theatre: Costley PL, East CE. Oxytocin CD001319. Embedding a complex educational augmentation of labour in women with intervention to improve teamwork climate. epidural analgesia for reducing operative Oppedal K, Møller AM, Pedersen B, Medical Teacher 2012; 34(9):e635-e640. deliveries. Cochrane Database of Tønnesen H. Preoperative alcohol Systematic Reviews 2012, Issue 5. Art. No.: cessation prior to elective surgery. CD009241. Cochrane Database of Systematic Reviews Contact the ANZCA Library 2012, Issue 7. Art. No.: CD008343. www.anzca.edu.au/resources/library Derry S, Moore RA. Single dose oral Phone: +61 3 8517 5305 aspirin for acute postoperative pain in Fax: +61 3 8517 5381 adults. Cochrane Database of Systematic Email: [email protected] Reviews 2012, Issue 4. Art. No.: CD002067.

81 ANZCA Council meeting report

August 2012 Rani CHAHAL (Vic) Scott Anthony SMITH (Qld) Report following the meeting Council Richard John CHURCH (SA) Tamsin Melissa SUPPLE (Vic) of the Australian and New Zealand Peter John CLARKE (Vic) Eric Jiong-Chang TAI (WA) College of Anaesthetists held on August 18. Timothy James Hannam CRICHTON (SA) Li Yen Lena TAN (NZ) Death of Fellows and trainees Nicholas Patrick CRIMMINS (Qld) TANG Pui Yan (HK) Council noted with regret the deaths Allan Michael CYNA (SA) Andrew Gethyn THOMAS (SA) of Fellows Dr Alan Marshall Barr (UK), Dr Peter Gartrell (SA), Dr John Patrick Andrew FOSTER (SA) TSE Yee Wah (HK) Keneally (NSW) and Dr Hilton David Swan Matthew Lee GEALL (NSW) Andrew Robert WALLACE (SA) (WA), and trainee Dr Van Tu Bui (NSW). As a mark of respect, the president has Tiffany Sheryn GLASS (SA) YAU Wing Sze (HK) written to their families. Christopher GORRINGE (NSW) Annual scientific meetings: Honours and awards Jagdeep GREWAL (NSW) The 2019 ANZCA Annual Scientific Professor David Story (Vic) has been Meeting will be held in Kuala Lumpur, appointed Chair of the Centre for Maryam HEZAR (NSW) Malaysia (May 3-8). Anaesthesia, Perioperative Medicine Christine Louise HILDYARD (SA) and Pain Medicine, School of Medicine, The 2020 ANZCA Annual Scientific University of Melbourne. Zoe KEON-COHEN (Vic) Meeting will be held in Melbourne, Australia (May 1-6). Dr Leona Wilson (NZ) has been awarded Huey Ling KOH (Qld) the Robert Orton Medal for distinguished All future College ceremonies held in Rebecca Anne LEWICKI (Vic) service to Anaesthesia. Australia and New Zealand will include an acknowledgement of the traditional ANZCA Strategic Plan 2013-17 Siv Eing LIM (NSW) owners of the land. Council endorsed the strategic plan, Nina LOUGHMAN (NSW) which will be launched shortly and will ASM meeting of ANZCA Council and allow prioritisation of decision-making, LUI Frances (HK) regional and national committee activities and resource allocation over Fousia MANTHODI KULANGARA (Qld) chairs to cease: With the engagement the next five years. The plan arose out between councillors and the regions of broad consultation and the council Kameel Yousif MARCUS (Vic) increasing, regular teleconferences with acknowledges those contributions. Andrew John MARRIOTT (Vic) the president and vice-president, and declining attendance due to competing Fellowship affairs Steven James MITCHELL (NZ) commitments, the annual face-to-face Admissions to fellowship: To ensure ASM meeting of ANZCA Council with timely admission of new Fellows, ANZCA Premala NADARAJAH (Qld) regional and national committee chairs Council has delegated admissions to Ruta NERLEKAR (Vic) will no longer be held. fellowship (under regulation 6.4 and 6.5) to the ANZCA Executive Committee. William Chuk Kit NG (HK) Terms of reference: Terms of reference have been approved for the Anaesthesia New Fellows: The following are James John OLSON (NZ) and Pain Medicine Foundation Board, congratulated on their admission to Desmond Niall O’REGAN (NZ) the ANZCA Trials Group executive, the ANZCA fellowship: Anand PARAMESWARAN (Qld) honorary and assistant curators, the Adly Ariff ABAS (WA) honorary archivist, the ANZCA medical Namita Jhamb RAKHEJA (NSW) editor (ANZCA Bulletin, e-newsletters Nada ALRAWI (Vic) Thimali RAJAPAKSA (NZ) etc) and ANZCA/FPM representatives to Gerry ANDERSON (Tas) external organisations. These will be Gauri Sangeeta RESCH (Vic) available on the website soon. Nicola BEAUCHAMP (Qld) Paul Andrew ROSS (NSW) Role Terms of Reference Working Jennifer Elizabeth BENEDICT (Qld) Group: Council acknowledge the efforts Elitza Vaneva SARDAREVA (NZ) Anton Willis Gerard BOOTH (Qld) of this working group in developing terms Timothy Theodore SCHOLZ (NSW) of terms of reference for all the roles held Daniel Edward BOYD (NZ) by ANZCA/FPM Fellows and trainees and Allanah Catherine SCOTT (Vic) Silke BRINKMANN (Canada) the group was disbanded. Raymond SINNADURAI (WA) Eoin David CASEY (Vic)

82 ANZCA Bulletin September 2012 Quality and safety (see ANZCA website) ANZCA scholar role: The 2013 training Asian transition arrangements: Patient Blood Management Guidelines: program will require trainees to complete The Asian Transition Working Group Module 2 – Perioperative a range of scholarly activities overseen is communicating regularly with ANZCA Council formally endorsed this by the Scholar Role Panel (Australia representatives in Asia and the following National Blood Authority publication. and NZ-wide) and scholar role tutors recommendations were approved: (departments). Council approved an PS54: Minimum Safety Requirements 1. A dedicated regulation for ANZCA approach to option B exemptions for for Anaesthetic Machines for Clinical training in Asia, regulation 38, along trainees with prior research publications Practice (previously T03) with an explanatory handbook will or relevant university qualifications. The change in code reflects the ANZCA be developed. Decisions about such exemptions will Council’s recent decision to abolish the be made by the chair of the Scholar Role 2. ANZCA training in Asia will cease at the technical (T) category of professional Panel (or nominee) and will usually be end of the 2018 hospital employment documents and relabel them professional for work undertaken in the previous five year (that is mid-2019). standards (PS). A definitive version of years. More detail is in the handbook. PS54 will be presented to ANZCA Council 3. In Asia, ANZCA-registered trainees who for approval in October 2012, with an Provisional Fellowship Assessment have not accumulated any approved accompanying background paper. Panel: This will be established to approve training time at the beginning of the provisional fellowship training in the PS40: Statement on the Relationship 2013 hospital employment year will Between Fellows, Trainees and the revised curriculum. lose their trainee status. Healthcare Industry Supervisors of training and education 4. Capping of examination attempts for This document and its background paper officer agreements: Council supported, trainees in Asia will commence from were approved. in principle, a proposal to develop the beginning of the 2013 hospital PS46: Guidelines on Training and education officer and supervisor of employment year. training agreements outlining the Practice of Perioperative Cardiac Internal affairs responsibilities both of the College Ultrasound in Adults Whistleblowers’ Policy: Council and of the education officer/supervisor Council approved a major rewrite of approved this policy, which is available of training. The ANZCA Council will this document and a newly developed on the ANZCA website. background paper. These will be consider a detailed proposal in October. 2013 calendar: Council approved the circulated to the regional and national Trainees experiencing difficulty calendar for 2013. A copy of the calendar committees, the Faculty of Pain Medicine process: ANZCA Council approved a is attached to the report. Board, the ANZCA Trainee Committee process to allow additional training time and relevant special interest groups for as part of the remediation process for Dr Lindy Roberts consultation. trainees experiencing difficulty. This President A01: Policy for the Development and will provide an interim step between the Review of Professional Documents ‘trainees experiencing difficulty’ process Dr Genevieve Goulding Minor amendments were made to and the high-level ‘trainee performance Vice President this professional document and the review’ process. Decision-making will accompanying background paper. involve the supervisor of training, the relevant education officer and the Training program director of professional affairs assessor. Regulation 37 – Training in More detail is in regulation 37 and the anaesthesia leading to FANZCA and handbook. accreditation of facilities to deliver this curriculum: Council approved Regulation 33 – Trainee Performance further amendments to regulation 37, Review: ANZCA Council approved including the fee structure for the revised amendments to more explicitly ‘close curriculum. This will be available on the the loop’ in the trainee performance College website in late September and will review process. A report will go to the be implemented from the beginning of the Education and Training Committee and 2013 hospital employment year. ANZCA Council about whether the trainee has achieved the required outcomes of ANZCA Handbook for Training and the process, allowing a decision about Accreditation: This was approved the future of the trainee in the training subject to further editing of flow and program. Further information is available style, and will be released on the website on the ANZCA website. in late September.

83 ANZCA Council meeting report

Admissions to fellowship Education and training June 2012 The following are congratulated on their ANZCA Handbook for Training and Report following the meeting Council admission to fellowship of ANZCA: Accreditation: Council has approved, in of the Australian and New Zealand principle, a further draft of the ANZCA Andrew James CLUER (NSW) College of Anaesthetists held on Handbook for Training and Accreditation June 16. Edward Michael DEBENHAM (WA) prior to wider consultation including with regional and national committees. Death of Fellow Samuel Patrick FROST (Vic) Feedback is welcomed. Council noted with regret the death of Dr Sally Liza Barlow (NZ) FANZCA 2010. Martin William Arthur GRAVES (NSW) ANZCA training program in Asia and As a mark of respect, the president has Long Ha LE (NSW) formation of the Asian Transition written to Dr Barlow’s family. Working Group: Council approved a LEE Meng Li (Malaysia) College honours and awards series of recommendations about the Sir Roderick Deane (NZ), a member of Janet Ellen LOUGHRAN (Ireland) ANZCA training program in Hong Kong, Malaysia and Singapore, which will be the Anaesthesia and Pain Medicine Kirsten Naomi MATHESON (NZ) Foundation Board, has been awarded the made available on the website. Council Knight Companion of the New Zealand Heather Alicia MATTHEWS (UK) also supported formation of the Asian Order of Merit in the 2012 Queen’s Transition Working Group, chaired by Glenn Andrew MULHOLLAND (NZ) Birthday and Diamond Jubilee Honours Dr Genevieve Goulding, to undertake List (New Zealand). Christopher James POYNTER (NZ) policy development, monitoring, and consultation with the regional training The following Fellows were recognised in Brett Elliott Fabian SEGAL (Qld) committees and trainee representatives the 2012 Queen’s Birthday Honours List in the three countries. (Australia): Dr David Henry McConnel Jonathan Ying Tang TRINH (NSW) (Qld), awarded the OAM for service to Carolyn Maree WILLS (Qld) Trainee Committee: To improve anaesthesia; Associate Professor Drew continuity of the ANZCA Trainee Cecil James Wenck (Qld), awarded Yoke Mooi WONG (WA) Committee membership and retain corporate knowledge, regulation 16 the OAM for service to intensive care Jordan Gardiner WOOD (NSW) medicine; and Dr Malcolm Wright (Qld), and the committee terms of reference awarded the AM for service to intensive Lilian Eva YUAN (NSW) have been amended to increase the care medicine. number of annual face-to-face meetings Helen ZOIS (NSW) from one to two, to include the General New councillors Arnold Russel BEETON (Vic) Manager of Training and Assessments The president welcomed councillors Dr as a committee member and to allow a Vanessa Beavis, Associate Professor Caroline COLLARD (Qld) junior observer from each regional and Brendan Moore (FPM Dean) and Dr Florence Tsitsi CHIKWANHA (Vic) national trainee committee to participate Gabriel Snyder (New Fellow Councillor) in teleconferences. as new members of the ANZCA Council. David FINDLOW (NZ) ANZCA Education Framework Review: Mahesh GANJI (NT) Council approved a review of the College’s Saira HUSSAIN (Qld) educational governance structure to ensure that the curriculum remains Tilo Willy KLINGER (Tas) contemporary by robust evaluation, innovation, clear decision-making and Jesco KOMPARDT (WA) reporting processes. A consultation and Andreas Rassamy MANOPAS (WA) communication plan will seek feedback from key Fellows, trainees and staff Timothy William PARRIS-PIPER (NZ) involved in college educational activities Ivan Lyle RAPCHUK (Qld) to identify priority areas and inform the development of a revised ANZCA Eric McKenzie ROBINSON (Tas) education and training governance Kumari SANTHI (Vic) structure for the future. The project will report to the February 2013 council Christopher Elwyn THOMAS (Qld) meeting. Victoria Louise UPSHON (NZ)

84 ANZCA Bulletin September 2012 The Courses Working Group has TE04: Policy on Duties of Regional been changed to the EMAC Course Education Officers in Anaesthesia and Subcommittee to be chaired by Professor TE05: Policy for Supervisors of Training Sandy Garden from New Zealand. in Anaesthesia: The council has approved minor amendments to these professional Two-stage trainee registration documents. process: Council gave in-principle approval for the implementation of a Airway Management and Algorithm two-stage registration process for ANZCA professional document: Council has trainees, effective August 31, 2012, to more approved the membership and terms clearly separate employer and College of reference for the expert group to responsibilities. Those ANZCA trainees develop this professional document. who have not accumulated training time College awards on this date will be transitioned to the • The Department of Anaesthesia new pre-registration and login access of Christchurch Hospital has been category. Further detail will be provided awarded the ANZCA Council Citation in due course. to acknowledge their exemplary Fellowship affairs contribution to the community during 2014 ANZCA ASM: Dr Philip (PJ) the earthquake in February 2011. Deveraux will be the 2014 ANZCA • Dr Kerry Brandis had been awarded the ASM Visitor. ANZCA Council Citation in recognition of his contribution to the College. NZ Anaesthesia Workforce Study: The results of the study have provided an • Professor Ian Victor Callanan has opportunity to engage with a number of been awarded the ANZCA Medal stakeholders including the New Zealand in recognition of major service to Minister of Health. anaesthesia, pain medicine and intensive care medicine. The NZ ASM will be held in conjunction with the 13th ICCVA in November 2012, Dr Lindy Roberts which will include both a cardiac President anaesthesia stream as well as more general streams including workshops. Dr Genevieve Goulding Vice President Appointment to external organisations: Council approved the following appointments: Dr John Moloney as the ANZCA representative on the RACS Disaster Preparedness Committee and Dr Ross Wallace as the ANZCA representative on the group to Review Medicare-Funded Pulmonary Artery Catheterisation. Indigenous Health Committee: Dr Rodney Mitchell has been appointed the chair of this committee. Quality and safety PS09: Guidelines on Sedation and/ or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures: This professional document and accompanying background paper have been approved by the council and will be circulated to regional and national committees, FPM, ANZCA Trainee Committee and relevant special interest groups for comment.

85 Obituary Dr John Patrick Keneally AM 1943 – 2012

thoughtful, caring clinician with a general division of the Order of Australia genuine interest in his patients and their in the Australia Day honours. It was families. He was a wonderful teacher typical of John’s humble nature that he and mentor to the many trainees that was almost embarrassed by the award, passed through the children’s hospital, but I know that he was proud to share a knowledgeable colleague who was the award with his family to whom he always more than ready to offer practical was devoted. John was a passionate help and advice. John was involved in republican, as befitted his Irish Catholic many areas of hospital management background, and it was a relief to me that and was the immediate past head of his award was announced on Australia the anaesthetic department, after being Day and not on the Queen’s birthday! deputy head for many years. He oversaw John was a gentle, kind-hearted man much of the planning for the operating who always looked for the good in people. suite of the new hospital at Westmead, He had an encyclopaedic knowledge requiring skill, thoughtfulness, foresight and took great pleasure in discussing all and equanimity, especially when dealing sorts of things with all sorts of people. He with officialdom. Perhaps sometimes the had a genuine interest in everyone and equanimity was not always there! treated all with respect and consideration. John made an enormous contribution The huge attendance at his funeral, and to the wider anaesthetic profession as the messages from the large number of well. He was the federal secretary of the friends and colleagues who could not John Keneally was a doyen of Australian Australian Society of Anaesthetists from attend, attests to the esteem in which he paediatric anaesthetic practice, but with 1976-80, and assistant secretary from was, and is held. true modesty he would have been the 1981-83. He was a founding committee It was unfortunate that John’s latter last to have accepted this. Nevertheless, member of the Society for Pediatric years were something of a battle with JK – as he was lovingly known – touched Anaesthesia in New Zealand and the progression of prostate cancer, the lives and careers of many hundreds Australia, vice president from 1999 to although he managed to make use of of anaesthetic trainees, as they passed 2002, and president until 2004. He was this time by visiting places previously he through the Royal Alexandra Hospital also a board member of the pediatric had not previously explored, including for Children (RAHC), and thousands of anaesthesia standing committee of a wonderful trip to Antarctica. He anaesthetists through his contributions to the World Federation of Societies undertook a challenging labour of love, anaesthetic literature and journalism. of Anaesthesiologists. As a 15-year transcribing Jane’s grandfather’s World John completed his medical studies member of the NSW Special Committee War I diaries and researching the events at the University of Sydney before Investigating Deaths Under Anaesthesia, and people mentioned in the writing. This undertaking his intern and resident he provided a wealth of knowledge and was also a time to spend with Jane, his years at St Vincent’s Hospital, where he real-world experience from which the children Ben, Tim, Kate, Josie and Patrick, met his future wife, Jane. This was the committee could draw. and their partners and his grandchildren, start of a wonderful loving partnership, I think John thought of himself as to whom we extend our sincerest which lasted 40-odd years and formed the brother of a famous Australian condolences. He passed away peacefully the foundation on which he built an author, although we at the children’s surrounded by his family whom he so exceptional career. John was drawn early hospital saw him as the famous brother loved and of whom he was so proud. to anaesthesia and began his anaesthetic of an Australian author! Whatever Although we will all miss JK, we can training at Royal Prince Alfred Hospital the arrangement, literary talent in the take comfort in the legacy he left behind with a subsequent rotation in 1971 to Keneally family must have a genetic – that of an honest, caring and committed RAHC, then at Camperdown. He had a basis as John used his evident editorial clinician, loving and loved husband, brief senior appointment at the children’s skills on the boards of Anaesthesia father, grandfather, knowledgeable hospital before seeking further paediatric and Intensive Care (1990-2001) and colleague, supportive mentor and giving experience in the UK at the Alder Hey Pediatric Anaesthesia (1991-2011), as well friend. His commitment to his family, Hospital, Liverpool, and Great Ormond as editing the highly-regarded “Blue the hospital and the wider anaesthetic Street Hospital, London. He returned to Book” – Australasian Anaesthesia – from and general community will stand as Sydney and the children’s hospital in 1974 1996-2005. He was widely published, an example for others in years to come. where he remained on the staff until his especially in the area of paediatric pain Rest peacefully, JK. retirement in 2006. management, an interest close to his John contributed at a number of heart. Associate Professor David Baines levels to the subspecialty of paediatric John’s huge contribution to the Childrens Hospital at Westmead anaesthesia, and to the broader specialty was recognised this year when anaesthetic community. He was a he was appointed as a member in the

86 ANZCA Bulletin September 2012 Dr Sally Liza Barlow 1974 – 2012

Sally had struggled with depression for Sally had been unwell for some time many years but at work you would never and despite her best efforts, on May 9 she have known of her inner struggle. She gave up her struggle. We need to respect bounced into work with a grin from ear to Sally’s decision to leave when she did ear and visible enthusiasm for her job as and not let that define her wonderful, specialist cardiac anaesthetist. although short, life. In just 38 years she She was an excellent anaesthetist who packed in a lot of living and achieved was highly regarded by her colleagues. much, left her footprints in our lives and Her expertise was impressive and the memories in our hearts. cardiac surgeons with whom she worked, Sally’s parents, John and Marilyn, and often through demanding, intense and her sister, Emily, were an integral part very complex cases, described Sally of her life and she was a proud aunt to as “an exemplar in her commitment, Emily’s daughter, Isla. expertise, mentoring and enthusiasm”. In farewell, with apologies Sally was a vibrant, glamorous and to Emily Bronte: beautiful woman, but she was also an We bid you farewell our friend, but not adventurer. She loved a challenge and farewell to our fondest thoughts of you was an accomplished skier, a passionate runner and excellent cyclist. Everything You will dwell in our hearts and that she did, she took on with energy and joy will be our comfort and she loved to be out in nature, hiking Our lives are sweeter because you lived and camping and being with her friends. Born and educated in Dunedin, New Nothing that you gave is lost Zealand, Sally Barlow spent a great deal She travelled the world both in her work of her childhood in the outdoors and and just purely to do the many things she Nothing that you did is destroyed. enjoyed. At home, she loved to cook and developed a lifetime bond with the beauty May she rest in peace. of the South Island, graduating from the she shared her talent by hosting many a University of Otago Medical School with wonderful dinner. Dr Marian Hussey, FANZCA Distinction in 1997. Sally loved people and was always Specialist Anaesthetist Sally was a high achiever and before gentle and kind and supportive. As Greenlane Department of Cardiothoracic graduating she had won the John Russell supervisor of training for anaesthesia, and ORL Anaesthesia, Auckland Ritchie Prize in Anaesthesia in 1996. she encouraged young anaesthetists and Other awards were the University of was a role model for our speciality. Her Otago Prize for First Year Geography departure from anaesthesia is a sad loss (1992), University of Otago Federation of for all. In her personal and work life, Sally Women’s Prize in Biology (1992), Senior had many, many friends whose lives she Scholarship in Medicine (1994) and Sir touched and influenced. Gordon Bell Prize for Clinical Surgery (1997). House officer and senior house officer jobs from Tauranga to London gave Sally an opportunity to travel and develop her interest in anaesthesia. She joined the Auckland anaesthesia training scheme in 2003, achieved FANZCA in 2007 and Doctors welfare a postgraduate diploma in perioperative If you are concerned about yourself or a colleague, and critical care echocardiography contact the Doctors’ Health Advisory Service Hotline in 2009. nearest to you. She did a fellowship in cardiothoracic and ORL and cardiothoracic and vascular Australia: intensive care before taking on a New South Wales/Northern Territory +61 2 9437 6552 specialist job in Seattle at the University Australian Capital Territory +61 407 265 414 of Washington Medical Centre. There, Queensland +61 7 3833 4352 Sally so impressed her colleagues that Victoria +61 3 9495 6011 Western Australia +61 8 9321 3098 they have established an annual award to Tasmania 1300 853 338 be called the Barlow Prize for Simulation South Australia +61 8 8273 4111 Research. In 2011, she returned to the Greenlane Department of Cardiothoracic, New Zealand: 0800 471 2654 Vascular and ORL Anaesthesia at Information about the Welfare of Anaesthetists Auckland City Hospital. Special Interest Group can be found at: www.anzca.edu.au/resources/doctors-welfare

87 Dr Hilton David Swan 1964 – 2012

Hilton was a popular and skilled member He was obsessive yet passionate and of the anaesthetic community in Perth, a little shambolic, a loveable figure who taken from us aged just 48 years after a somehow reconciled a disdain for the three-year dogged battle with cancer. mundane (such as opening his mail He and Michelle MacDonald have two or parking in any marked bay) with children, Anneka, 13, and Aedan, 10, and sustained clinical excellence. His focus he is survived by his mother Sue Harvey, was on the patients and their families; and siblings Alan, Anne-Marie, Dean they adored him because he cared for and Brandon. them as kindly and carefully as he would Having started his schooling in his own children, before, during and Cape Town, South Africa, Hilton moved after their operations. His colleagues to Perth in 1980 with his family and regarded him as a clinical leader. He had within a year had completed year 12 and an apparently effortless grasp not just of gained entry to the University of Western anaesthesia but medicine more broadly, Australia medical school. He was a true which he gleaned from wide experience, all rounder with high level academic and unrestricted reading and marvellous sporting achievement, the latter in rugby recall. at a state level and marathons over many He faced his treatment bravely, years. A relaxed and popular student he with determination and good humour. was a magnetic figure who had that rare He underwent repeated rounds of ability to befriend all comers from across chemotherapy and radical surgery yet the university and wider spectrum. bounced back with a disarming ability A talented paediatric and adult and determination to enjoy every day anaesthetist, Hilton won the Cecil Gray in spite of it all. Prize for the second part ANZCA exam in He loved being an anaesthetist and 1995. He was appointed to the role of chief looked forward to (almost) every list. His fellow at the Hospital for Sick Children in greatest regret in contemplating an early Toronto and remained on staff at Princess death was that his time with his children Margaret Hospital for Children in Perth was not to be longer. Family, friends and throughout his career, while also building colleagues alike will miss Swanny very a highly regarded private practice. much – now and always.

Dr Andrew Miller Perth, WA

88 ANZCA Bulletin September 2012