Surgicalthe royaL Australasian CoNewsllege of Surgeons June 2013

The College of Surgeons of Australia and New Zealand Friendly Meeting Traditional Maori welcome marked a successful Annual Scientific Congress in Auckland 2013 c ntents 14 Annual Workshops & Activities Scientific Congress Professional development supports life-long learning. College activities NSW All smiles in Auckland are tailored to the needs of surgeons and enable you to acquire 15 July, Sydney 21 Medico-Legal new skills and knowledge while providing an opportunity for reflection Writing Medicolegal Reports about how to apply them in today’s dynamic world. 13 August, Sydney Advertising – know your Supervisors and Trainers for SET Code of Conduct (SAT SET) Management of Acute Supervisors and Trainers for 22-24 November, Sydney 22 Pledge your Procedure Process Communications Model Neurotrauma SET (SAT SET) Support your Foundation 10 July, Melbourne 13 August, Sydney QLD for Surgery in June You can gain skills to deal with cases of acute This course assists supervisors and trainers to effectively 31 July, Brisbane neurotrauma in a rural setting, where the urgency of fulfil the responsibilities of their very important roles. Keeping Trainees on Track (KToT) 24 Your new Library a case or difficulties in transporting a patient demand You can learn to use workplace assessment tools such as Discover new resources rapid surgically-applied relief of pressure on the the Mini Clinical Examination (Mini CEX) and Directly brain. Importantly, you can learn these skills using Observed Procedural Skills (DOPS) that have been SA 28 International equipment typically available in smaller hospitals, introduced as part of SET. 12 September, Adelaide Development including the Hudson Brace. Polishing Presentation Skills 28 Finance for Surgeons Scholar training has let to regular pages new services for Myanmar Writing Medicolegal Reports 19 July, Melbourne TAS 2 PD Workshops 15 July, Sydney; 28 October, This whole day course establishes a basic 20 September, Hobart Non-Technical Skills for Surgeons 30 Regional News 6 Relationships & Advocacy Melbourne understanding of how to assess a company’s (NOTSS) 8 Surgical Snips performance using a range of analytical methods and Aside from the ASC in This 3 hour evening workshop helps you to gain 10 Curmudgeon’s Corner greater insight into the issues relating to providing financial and non-financial indicators. It reviews the New Zealand VIC 13 Poison’d Chalice expert opinion and translates the understanding three key parts of a financial statement; balance sheet, income (profit and loss) and cash flow. 10 July, Melbourne 32 Successful Scholar 21 Case Note Review into the preparation of high quality reports. It also Management of Acute Neurotrauma explores the lawyer/expert relationship and the role of 27 Dr BB G-loved 19 July, Melbourne John Beer’s travel an advocate. You can learn how to produce objective, Preparation for Practice Finance for Surgeons scholarship has widened well-structured and comprehensive reports that 24 - 25 August, Melbourne 24 - 25 August,Melbourne communicate effectively to the reader. This ability is Preparation for Practice his knowledge one of the most important roles of an expert adviser. This two day workshop is a great opportunity to learn about all the essentials for setting up private 18 September, Melbourne 36 Audits of Surgical This activity is proudly supported by Avant and Keeping Trainees on Track (KToT) 44 mlcoa. practice. The focus is on practicality and experiences Mortality provided by fellow surgeons and consultant speakers. Participants will also have the chance to speak to A reviews of ANZASM Finance for Surgeons WA Fellows who have experience in starting up private 24 - 26 October, Perth 19 July, Melbourne practice and get tips and advice. This activity is Surgical Teachers Course 40 Intuition This whole day course establishes a basic proudly supported by The Bongiorno National Felix Behan on that gut understanding of how to assess a company’s Network and mlcoa. feeling performance using a range of analytical methods and Contact the 40 financial and non-financial indicators. It reviews the Non-Technical Skills for Professional

SurgicalTHE ROYAL AUSTRALASIAN COLLEGENews OF SURGEONS JUNE 2013 three key parts of a financial statement; balance sheet, Surgeons (NOTSS) Development income (profit and loss) and cash flow. Participants Correspondence to Surgical News should be sent to: learn how these statements are used to monitor 20 September, Hobart; 29 October, Department on [email protected] financial performance. Gold Coast +61 3 9249 1106, Letters to the Editor should be sent to: [email protected] This workshop focuses on the non-technical skills by email Or The Editor, Surgical News, Royal Australasian College of Surgeons, College of Surgeons Gardens. 250-290 Spring Street, East Melbourne, Victoria 3002 Keeping Trainees on Track which underpin safer operative surgery. It explores PDactivities@ T: +61 3 9249 1200 F: +61 9249 1219 W: www.surgeons.org The College of Surgeons of a behaviour rating system developed by the Royal Australia and (KToT) surgeons.org or visit New Zealand College of Surgeons of Edinburgh which can help ISSN1443-9603 (Print) ISSN 1443-9565 (Online) www.surgeons.org FRIENDLY MEETING 31 July, Brisbane you improve performance in the operating theatre All smiles after a successful Annual Scientific Congress in Auckland Surgical News Editor: David Hillis / © 2013 Royal Australasian College of Surgeons / All copyright is reserved. This 3 hour workshop focuses on how to manage in relation to situational awareness, communication, - select Fellows then click on The editor reserves the rights to change material submitted / The College privacy policy and disclaimer apply – www.surgeons.org on the cover: trainees by setting clear goals, giving effective feedback decision making and leadership/teamwork. Each The College and the publisher are not responsible for errors or consequences from reliance on information in this publication. Statements represent Maori welcome at the and discussing expected levels of performance. You of these categories is broken down into behavioural Professional the views of the author and not necessarily the College. Information is not intended to be advice or relied on in any particular circumstance. Annual Scientific Congress can also find out more about encouraging self- markers that can be used to assess your own Development. Advertisements and products advertised are not endorsed by the College. The advertiser takes all responsibility for representations and claims. in Auckland. Photo by directed learning at the start of term meeting. performance as well as your colleagues. Published for the Royal Australasian College of Surgeons by RL Media Pty Ltd. ACN 081 735 891, ABN 44081 735 891of 129 Bouverie St, Carlton. Vic 3053. John Aloysius Henderson.

Surgical News June 2013 / Page 3 2013 Definitive Surgical Trauma Care (DSTC) and Definitive Perioperative Trauma Nursing Care Courses President’s Perspective DSTC Australasia in association with IATSIC (International Association for Trauma Surgery and Intensive Care) brings you courses for 2013

2013 COURSES: Sydney (Military Module): 23 July Sydney: 24 – 25 July An innovating Congress Auckland: 29 – 31 July Auckland hosted another successful congress, with sustainability the key Perth: 7 – 8 November Melbourne: 11-12 or 22-23 Nov he Annual Scientific Congress (ASC) in Auckland drink for athletes is now in production. A truly inspiring (to be confirmed) was a great success. It was probably the most friendly story and one where innovation is a constant message. The DSTC course is an exhilarating educational ASC I have attended. The theme was Sustainable Over the past 10 years, innovation has been an ongoing opportunity focusing on T • surgical decision-making in complex scenarios Surgery. The plenary sessions were excellent with some theme at the ASC. Ansell sponsored the “Virtual Congress”. exceptional speakers highlighting New Zealand and in Ten years ago, it was a brave ASC committee that mandated • operative technique in critically ill trauma patients particular its innovation in many areas. There was also a the use of PowerPoint presentations and did not support • hands-on practical experience with experienced instructors course on negotiation. Amazing how useful these skills can the ubiquitous ‘slides’. This ASC saw the availability of the (national and international) be! Congratulations to the Organising Committee with RACS ASC ‘App’ which combined an electronic program • insight into difficult trauma situations with learned techniques of haemorrhage control and the ability to handle John Windsor as the ASC Convener and Andrew Hill as the where customisation is fully achieved plus integration major thoracic, cardiac and abdominal injuries Scientific Convenor as well as the team of College staff led into the Virtual Congress. The Virtual Congress is now President’s Lecture by Roger Wale and Lindy Moffat. almost ‘real time’ and certainly same-day. Technology was Ray Avery As noted in the introduction, one of the ongoing themes also embraced to ensure that questions can now be asked The DSTC course is recommended by the Royal Australasian College of Surgeons for all consultant surgeons and final year of the ASC was innovation and I was particularly struck through ‘Twitter’ rather than the more traditional standing Trainees who participate in care of the injured. It is considered by the presentations by Sir Ray Avery. There is no doubt and queuing in auditoriums. essential for surgeons involved in the management of major New Zealand ‘punches above its weight’ in the world of Equally the support from industry is moving from trauma and those working in remote, regional and rural areas. innovation, but his personal story was inspirational. static displays to active simulation of devices that provides The Definitive Perioperative Nurses Trauma Care Course Now described as a pharmaceutical scientist, inventor even more support for surgeons in adapting innovation (DPNTC) is held in conjunction with many DSTC courses. It and social entrepreneur, he spent his childhood in English and bringing new technology to their surgical practice. is aimed at registered nurses with experience in perioperative orphanages and foster homes. His lifetime interest in science To the hundreds who took the opportunity of updating nursing and allows them to develop these skills in a similar grew from when he escaped the cold of living on the streets their practice profile on the College website, understood setting. of London by finding warmth in public libraries. the possibilities of our now annual CPD system or started The Military Module is an optional third day for interested Sir Ray went on to have an outstanding career within the entering data in the new MALT system (Morbidity and surgeons and Australian Defence Force personnel (this course is pharmaceutical industry, and then became the Technical Audit Logbook Tool), the innovation that was ever-present only offered in Sydney). Director of the Fred Hollows Foundation where he designed was much appreciated. and commissioned intraocular lens manufacturing facilities Our International Visitors continue to highlight how in Nepal and Eritrea. Sir Ray’s innovations led to a massive outstanding this event is, in comparison to what is available DSTC is recommended by The Royal reduction in the cost of lens production. in other parts of the world. Plans are already well advanced Australasian College of Surgeons for all Sir Ray gifted the technology to the Hollows Foundation to see how the 2014 Singapore meeting running in parallel Consultant Surgeons and final year trainees. ensuring cost competitive lens production in the world’s with the College of Anaesthetics will progress innovation poorest nations. With a focus of taking the products or even further. concepts found within wealthy countries to the people of the Again, congratulations to the 2013 Convenors and to poorest, he has also redesigned incubators for infants with Auckland for being a wonderful host city. Please register early to ensure a place! a low cost, long life model requiring minimal maintenance, Contact Sonia Gagliardi on +61 2 8738 3928 and cheap peptide supplements for malnutrition. An Mike Hollands or email: [email protected] interesting addendum is that a commercially viable energy President auckland asc

Page 4 / Surgical News June 2013 Surgical News June 2013 / Page 5 Relationships and Advocacy of 2011 business excellenceWinner award

broaden their understanding and skills in the latest surgical techniques, technologies and treatments. Through our support, the Foundation provided ENT equipment to the Tharawal Aboriginal Medical Service in NSW which is enabling them to conduct regular outreach clinics and school screening services to more than 3,800, primarily Indigenous, active patients. The Cherbourg Health Clinic, which services Queensland’s third largest Aboriginal community, has also been provided with ENT equipment to help them gain a more accurate diagnosis of ear disease and to better monitor and treat the condition. The conferment of scholarships and grants is vital for the expansion of surgical research and the provision of advanced study opportunities for Fellows Rooms With Style offers 3 core services and Trainees. Our donations enabled the Foundation to award more than 40 scholarships and grants last exclusively for Surgeons year to surgeons who are now undertaking research > Medical Fitouts across a wide range of surgical specialities and to > Practice Management Consulting young surgeons who have embarked on further study in Australia, New Zealand and overseas. > Recruitment It is not possible to list all of the activities of the Foundation, but it is worth recording that the Call today Foundation is planning to continue the provision of surgical training and quality patient care in many of to find out how we can our neighbouring developing countries, including tailor our services to suit Papua New Guinea, Timor Leste, the Pacific Island your practice. countries and Myanmar. It will also support research across all surgical specialties and sub-specialties, and provide assistance to young surgeons of promise 1300 073 239 Your Foundation through the conferment of scholarships and grants [email protected] Make a difference through pledging your procedure to enable new research, advanced study and surgical related travel opportunities. Our College, through the www.roomswithstyle.com.au s a surgeon I knew a little about And surgeons have supported the Founda- orthopaedic surgical procedures and in activities of the Foundation, is the major supporter of the Foundation for Surgery, tion establishing a significant corpus of the advanced management of all levels of surgical research in our two countries. The Foundation has become an integral part of Athe College’s philanthropic funds that has been invested wisely thanks trauma. Consulting Rooms, Sessions arm. As Vice President, I get to know to the highly qualified and talented Col- Donations have also enabled the the College, but its continued activity is reliant on a lot more sitting on the management lege’s financial advisers who freely give of College to assist in the development of support from surgeons. To help fund these initiatives, Located in Drummoyne in Sydney’s inner-west are modern, fully-furnished Board of the Foundation and keeping their expertise, knowledge and time. emergency medicine in Myanmar and to the Foundation for Surgery is again conducting its consulting suites. Spacious with lots of natural light. Features include a large annual fundraising campaign ‘Pledge a Procedure’. I waiting room, air-conditioning and broadband. Pathology, radiology and Council informed of the Foundation’s Through the work of the Foundation, deliver a Diploma of Emergency Medicine physiotherapy services are also in the building. Close to public transport activities. I have to tell you that I have surgeons have demonstrated a at the University of Medicine in the would particularly appeal to you to consider donating with public car parking spaces adjacent to building. Available on a the proceeds of just one of your most common an overwhelming sense of pride that professional willingness to assist country’s capital, Yangon. These programs sessional basis. surgeons have proven to be great colleagues working in very difficult train health specialists to implement major operations during the month of June. Such Contact Daniel on 0404 048 051 philanthropists and have achieved so conditions in countries where access to emergency care systems in a country a donation is tax deductible in Australia and New or email [email protected]. much for Indigenous communities, surgical care is at best precarious. Health where previously there had been little Zealand and will make a tangible difference. for developing countries less fortunate projects, training and research across all or no primary trauma care. Pleasingly, Having now become closely involved with the than our own and for surgical research. surgical fields have been supported in the skills of course participants have Foundation, your Foundation, I can testify that Offer –Special Rates I am proud to be part of a professional Australia, New Zealand, across the Asia improved noticeably and their patients are the funds raised are entirely devoted to altruistic Consulting Rooms available for first½ 3price months organisation that is mature enough to Pacific region and beyond. Through these now receiving better quality care. endeavours and not swallowed by administrative in Purpose Built Centre with 7 fully equipped suites, costs. Please consider the Foundation as a worthwhile currently accommodating 20 Medical Specialists & have a view that extends beyond our activities, surgeons have demonstrated Donations also enabled more than immediate self-interest. that improved patient care is something 14 specialists from South East Asia, the means of making a difference in so many ways. Allied Health Professionals who consult on a weekly, Surgeons have established the Founda- that transcends national boundaries. Pacific Island countries and Papua New fortnightly or monthly basis. tion and financially supported its continu- Donations have previously supported Guinea to participate in practical training Well supported by Reception staff, on-site pathology, on-site parking with disabled access and close to a busy General Practice Medical Centre. ing activities. Perhaps this is as it should be. programs such as the annual trauma and attachments in Australian, New Zealand It is difficult to inspire the general public fracture management course in Fiji. These and Singapore teaching hospitals. These Located 5 minutes from the Heatherton Road M1 freeway exit. Endeavour Hills Specialist Clinic, 26 Erica Close, Endeavour Hills that a surgeon’s charity should be favoured courses, conducted by volunteer Fellows, attachments are crucial in building over so many other worthwhile and de- successfully build surgical capacity surgical capacity in developing countries To discuss your requirements or for a tour of the premises Michael Grigg Contact Jane or Anne on 03 9708 1200 (or Gayle on 0411 211 413) serving charities. by training local surgeons in complex and enable talented health specialists to Vice President

Page 6 / Surgical News June 2013 Surgical News June 2013 / Page 7 Surgical Snips Surgical Snips

More than just money College President Michael Hollands has written to the Australian Financial Review in response to the coverage of the Australia 2.0 Not Hollywood healthcare round table. Angelie Jolie’s brave revelation of her double mastectomy has been praised by the Cancer Council, though the support and research group Ban the quad bike push The President noted his disappoint- The College has joined forces with the Royal Children’s says that women should be aware of all the issues ment at the lack of clinician involve- Hospital, Ambulance Victoria, Kidsafe and the Australian surrounding the surgery. ment in the discussion, with AMA Medical Association to call for a ban on children riding A 2011 study led by WA Fellow Christobel Saunders Head President Steve Hambleton the only quad bikes. Doctors are calling on the State Government found that many woman underestimated the copy practising clinician quoted. to stop children from riding the bikes in the hope it will impact of the surgery on their lives, after initial paper, date “Doctors who care for the real stake- prevent more horrific injuries and save lives. happiness gives way to effects such as early Road Trauma Submission holders in this debate, our patients, An editorial in the Herald Sun backed the call. menopause and low libido. Road safety campaigns should be re-evaluated a state are ideally placed to identify prob- “There can be no question in anyone’s mind, least of all “I think it’s good that we have a public conversation parliamentary inquiry into serious injury has been told. lems in healthcare delivery and to in the minds of Victoria’s legislators, that they must move about managing cancer in women who have a In its submission, The Royal Australasian College of Surgeons propose solutions.” quickly to stop this terrible toll of young lives and injuries high risk, but [following mastectomies] they can said that although safety campaigns had understandably been Australian Financial Review, May 20 that are sometimes responsible for lifetime disabilities.” have a lot of grief reaction down the line and that is directed at reducing fatalities, “this might have been at the Herald Sun, May 22 our experience,” Professor Saunders said. expense of preventing serious injuries.” Sunday Age, May 19 Herald Sun, May 21

The Alfred Provincial Surgeons of Australia General Surgery Meeting 2013 49th Annual Scientific Conference

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Thursday 3 - Saturday 5 October 2013 Further information: Palmer Coolum Resort, Coolum Beach, E: [email protected] ‘Practical Updates Sunshine Coast, Queensland T: +61 3 9249 1139 for General Surgeons’

Further information: 25 - 27 July 2013 T: +61 3 9249 1273 www.nsa.org.au PROVISIONAL PROGRAM NOW AVAILABLE. To download visit: For more information visit www.anzhncs.org Hilton Queenstown E: [email protected] www.surgeons.org/member-services/college-resources/conferences New Zealand Contact T: +61 3 9249 1273 E: [email protected]

Page 8 / Surgical News June 2013 Surgical News June 2013 / Page 9 Curmudgeon’s Corner Letters to the Editor

In Memoriam

Our condolences to the family, friends and colleagues of the following Fellows whose death has Surgeon health been notified over the

past month: both being essential for neurological and muscular function. Magnesium [sulphate] is now recognised to reduce the likelihood of cardiac arrhythmias, pregnancy induced convulsions, and probably Alan Innes-Brown, reduces the likelihood of cerebral Cultural and language problem vasculature to spasm. However, given how dim and distant Dear Sir, our biochemistry, we overlook that it is an New South Wales Fellow essential co-enzyme for efficient glucose handling, and together with B vitamins helps activate enzymes for digestion, absorption and the utilisation of proteins, read with interest your article headed In the March issue of Surgical fat and carbohydrate. Magnesium may not be a wonder drug, but it is a missing George Owe-Young, element that plays a role in many Hidden benefits common conditions. “Culture eats strategy for breakfast” from News (Vol 14, No 3), Dr BB Missing an essential element? The bibliography of peer reviewed evidence in high impact journals is Victorian Fellow impressive. There is a link between magnesium deficiency, hyperinsulinaemia Surgical News (April edition, Vol 14, No 3). G-loved’s article on ‘Hidden and the laying down of body fat, particularly abdominal adipose tissue. My ne of my favourite patients Magnesium advocates also warn of comment at the start about ‘approaching I attended the other day – a an association between fluorination of type 2 diabetes’ alluded to the years of As a general rural surgeon I find the attitude normally convivial, middle-aged water and deficiency, which is the result of William (Bill) Swaney, O hyperinsulinaemia during middle-age, the Benefits’ fails to note that surgeon, Ms Ng Magna, with the usual insoluble magnesium fluoride deposits in generation of adipose deposits, visible to health issues of many busy professionals bone and cartilage. many of us each morning as our struggle at the same stage of life. I advised Ms Ng Magna to try of many of my city colleagues very difficult to with weight gain despite reasonable Embracing a slight tendency magnesium supplements promising her Victorian Fellow discipline in diet, and worry about the magnesium is the prosthetic to be overweight, hypertension, no ill effects other than the tendency of eventual onset of diabetes in later life. hyperlipidaemia, and approaching some magnesium salts to cause diarrhoea. Magnesium is critical to cholesterol type 2 diabetes, my patient could have Ms Ng Magna was not sleeping well understand and it makes it very difficult to work balance, dampening down the HMG-CoA been in better shape, but was at least because she was suffering from night reductase involved in its synthesis. It is making time for exercise and taking some cramps. She blamed too busy a practice element of chlorophyll – just used in reactions by enzymes that lower Caleb Tucker, holidays. She was tired, not sleeping well, combined with the demands of and LDL (bad), raise HDL (good) and convert and not quite the usual bouncy self. worries about teenage children causing with them. Omega 3’s and 6’s to prostaglandins. The consultation was timed to discuss too many topics of disturbance. But I The magnesium deficiency could the latest results. I had done all the usual can tell you once her night cramps were as iron is of haemoglobin. be contributing to Ms Ng Magna’s New Zealand Fellow annual review tests, but also had included relieved by magnesium supplements, hyperlipidaemia. The evidence suggests magnesium and red cell magnesium she started to sleep better and her Former Trainees of mine who have learnt LDL is lowered 10-18 per cent and HDL levels, something I’ve been checking more hypertension improved. raised by 4-11 per cent. and more in recent years. The diet of Dr BB’s The results Magnesium may be all Ms Ng Magna will Though the serum magnesium The improvement in her hypertension need. Time will tell. But it’s safe and without their bread and butter operating skills on was in the lower range of normal John H Cloke, terrible side-effects. She started on 150mg (0.72mmol/l), the red cell magnesium was the result of magnesium being a elemental magnesium (there are various was low at 1.5mmol/l (normal range natural calcium channel blocker. Both salts and preparations) and, once certain patient with regard to 1.70-2.90mmol/l). As only 1 per cent of the minerals are important in smooth muscle she was not suffering from its laxative effect, cholecystectomies turn into breast surgeons body’s magnesium is in the blood, with 40 function and must be in balance. Victorian Fellow Each is a co-enzyme of many of the increased in stages to 400mg. per cent in the cells, it is a better reflection When I next saw her she was smiling, of magnesium status to work on the red body’s reactions (think back to your she was sleeping well, her night cramps cell magnesium. days of biochemistry), some important the consumption of had gone, her blood pressure had or colorectal surgeons who are incapable of Many diets are deficient in magnesium, for glucose homeostasis. A number dropped, mood bright and she felt particularly where ready-made meals, of patients respond to magnesium generally better. Her teenagers hadn’t John Hogg, refined and junk food or snacks comprise alone in regard to their tendency to be stopped worrying her but then when does a significant part of the diet. There’s less hypertensive. green vegetables was not that happen? Maybe they should take removing a gallbladder on a public hospital on magnesium in today’s food, particularly In the medical mind, magnesium has not gained the clinical limelight that magnesium too? But that’s another story. as, unless organic, it is normally grown in Dr BB G-Loved New South Wales Fellow magnesium deficient soil. its brother mineral calcium has, despite apparently inquired into. Surgical News March 2013 / PAGE 13 call roster in Melbourne. Richard Taunton Surely advice regarding A small but significant number of people are Southwood, diet should precede the measure, will usually “green fairly derogative about country surgery in general South Australian Fellow prescription of pills. them up” again. The trees and this is not helpful for patient management and it is certainly not helpful for ongoing Incidentally, if the leaves of absorb these elements better Kenneth Bruce Cornwell, workforce training and commitment. citrus trees begin to yellow, a through their leaves than Victorian Fellow Certainly in Western Victoria we also have spray of magnesium sulphate through their roots. Marx Wald, a major cultural and language problem with solution, with some copper Yours faithfully West Australian Fellow many of our referring general practitioners. It Looks good, but practical? sulphate added for good B. N. Catchpole can be difficult to form a satisfactory working Philomena McGrath, Why must we sacrifice logic for good looks? relationship with someone who rarely stays more New South Wales Fellow then the immigration requirements of two years in a country town, never comes to any of the post here is one thing that I stayed at The Hotel graduate education we offer at the Base Hospital We would like to notify readers really annoys me and that Windsor. Now there Dr BB G-loved’s reply: and certainly has difficulty with spoken English that it is not the practice of is design – not all design, is a place of taste and on the telephone. Surgical News to publish obituar- T but things that are said to be refinement, style and design Mag up those Mitochondria There is no easy answer to any of these ies. When provided they are Dr Catchpole is quite correct that Magnesium is the central molecule of published along with the names “arty” design. This little annoyance – perhaps from another era, problems, but at least you and the College of deceased Fellows under In came to a peak on a recent trip to but style that fits in. Muted chlorophyll and that without magnesium there is no photosynthesis. It Council are aware of them. Memoriam on the College web- Melbourne. The RACS building colours, lovely pictures on is considered a secondary nutrient of plants together with calcium and Mr Ian Campbell site www.surgeons.org go to the in Melbourne is an interesting the wall, lovely chandeliers, sulphur. General Surgeon Fellows page and old style building. I have never ornate ceilings. However, the We do get dietary magnesium from green leaves, pumpkin seed, click on In Memoriam. } been sure if I like it or loathe it. door man wears a purple wheatbran and nuts. Acid rain, magnesium deficient fertilisers, and Informing the College It probably depends on what waist coat. I can perhaps overuse of soil all contribute to magnesium deficiency in plants and If you wish to notify the College argument I am having with the forgive that as it is a royal the underlying cause as to why Ms Ng Magna was deficient – like so of the death of a Fellow, please College at the time. purple. many other patients. President’s contact the Manager in your Perspective Regional Office. They are The external style is 1930’s neo- In the bathroom is an I must confess to not being enough of a Neville Longbottom at classical at a guess. However, I am happy assault on the eyes, but in the opposite school and university – I just didn’t pay enough attention in Herbology. Culture eats strategy for breakfast he College maintains important partnership ACT: [email protected] arrangements with the RACP and the Canadian to bow to an expert in architecture if I direction. When I was in the bath However, once one is deficient, supplements are needed, not just TCollege of Physicians and Surgeons. In mid-March we held a number of workshops on issues like CPD and revalidation, work-based assessment and clinical decision making in conjunction with an open one day seminar NSW: [email protected] on ‘Serving the Community: Training Generalists and am wrong. In any event I am sure that it (yes, we curmudgeon’s have baths, not dietary adjustment. That’s why herbologists (horticulturalists) – as Extending Specialists’. This follows on our highly successful seminar last year about ‘The Medical Professional in the 21st Century: Competent, Fit and Safe’ and again was successful in NZ: [email protected] is not modern. In one of the corridors I showers) I noted that I could not read Dr Catchpole rightly points out – spray their plants with magnesium bringing key educational and regulatory decision makers from Australia, New Zealand and Canada to discuss the important issues that will be impacting on surgeons in the very near future. sulphate. Generalism and Specialisation are key strategic issues QLD: [email protected] noted a smell of fresh paint. Around the the labels on the little bottles as the for our College and affect all branches of surgery. They can be considered from different perspectives, the individual surgeon, the professional organisation and also the views of the community, government and its jurisdictions, and our corner came an assault on the eyes – an print was in a small font and it was pale Thank you for reminding us that green leaves and spinach is good employers. SA: [email protected] The latter stakeholders in particular are keen to promote But it is not only our recognised specialties where there generalism and are less than enthused about the increasing is concern with Obstetricians and Gynaecologists as well as trend to super specialisation. During the seminar many Ophthalmologists and Radiologists working in smaller and orange red “feature” wall. Feature of blue on a pale grey background – it for us. I am sure that Popeye’s ‘mag’d up’ mitochondria and well scenarios were discussed and both the joys and sorrows of smaller areas of anatomical interest. This has been analysed programs highlighted. by health economists as well as health managers. There was TAS: [email protected] It is becoming increasingly evident that unless we an interesting discussion how this drive to sub-specialties continue to recognise the importance of our generalist is now producing a totally uneconomical model of ‘on-call’ training from an individual and professional perspective, arrangements in major and metropolitan health services. balanced nerves were the secret behind his ability to beat Bluto and Not surprisingly some hospitals have now responded in what? Poor taste? Colour blindness? It looked beautiful and very “arty” design, then employers and regulators will step in and enact the outcome they require. their recruitment processes to a ‘commitment’ to on-call VIC: [email protected] The drive to specialisation is occurring across all of the availability in the ‘overall specialty’ that cannot be sub- nine specialties in which the College awards a specialty divided or delegated. is not in keeping with the building as a but quite unreadable. win the heart of Olive Oyl. Now Olive Oil – that’s something else that – not just general surgery and orthopaedic surgery. In the future, jurisdictions will demand surgeons The gastrointestinal tract seems to be divided into ever maintain a commitment to the breadth of their specialty. If decreasing lengths, individual joints now have nominated a surgeon requires ‘back-up’ when they are on-call, then that specialists, otolaryngologists now often specialise in is all possible, but they will need to maintain the role of ‘on- WA: Angela.D’[email protected] call’ surgeon, will need to maintain CPD in generalist skills is good for us which I must write about another time! one small component such as voice and plastic and whole. I hoped that it was an undercoat And yes, I did wash my hair in body and if necessary ‘re-skill’. “I do not do those anymore…” will reconstructive surgery have watched the breadth of their practices skewed to an extreme. no longer be acceptable. NT: [email protected] – but no. lotion. Dr BB G-loved PAGE 4 / Surgical News April 2013

Page 10 / Surgical News June 2013 Surgical News June 2013 / Page 11 Audits of Surgical Mortality Surgical Services

When we are afloat on a full sea, we must take the current when it serves “ Julius Caesar (Act 4, Scene 3) ” their leisure time negotiating rapids. It simply means that one is too busy trying Anastomotic leak following stoma to keep afloat rather than remembering where it is it that they actually want to go. This case study can be found on the blog discussion at: /my-page/racs-knowledge/ Shakespeare also chose a water analogy blogs/all-blogs/anzasm-case-note-reviews/2013/anzasm-case-note-review-june-2013/ in Julius Caesar (Act 4, Scene 3), where he makes comments about the tide in the frail, elderly patient with made good progress for the first few days. is, the patient’s refusal to allow a stoma affairs of men: “When we are afloat on a known respiratory and cardiac Patient was weaned off inotropes and ‘under any circumstances’. This is a very full sea, we must take the current when it A problems presented with small extubated, but then began to deteriorate. serious limitation of the surgeon’s options. serves.” I like to think that Shakespeare is bowel obstruction. Anaesthetic risk At this point faeculent fluid from the Simple exteriorisation of the bowel ends reminding us to maintain a ‘vision’ about assessment confirmed a high risk for midline incision was noted, consistent might have led to a different outcome. where we want to get to, being alert to surgery. After some time a decision to with anastomotic leak or leakage from The patient has an absolute right to opportunities rather than be reduced to proceed to surgery was made. During damaged small bowel. Treatment was refuse any aspect of treatment, or all flotsam ending up where happenstance the surgeon’s discussion with patient and withdrawn at request of patient and treatment, but as surgeons we have a determines. family regarding the need for surgery, family and the patient died. responsibility to ensure that this is a In many ways, the ability to have and the patient made it clear they did not Overall, the management of this case fully informed decision. We do not know develop a vision is the most difficult want to be resuscitated in the event of appears to have adhered to a reasonable the seniority of the registrar in this case, aspect of leadership, but running a close cardiorespiratory arrest. care pathway. There appear to be no nor the mental capacity of the patient, second is the ability to ‘sell’ the vision, Just prior to administration of grounds for concern about the initial or when and under what circumstances getting others on board. Without this anaesthesia, the registrar informed the conservative management, the decision the consent was revised. Nobody wants component, vision becomes an ‘agenda’ surgeon that the patient had indicated to operate and its timing, the quality and a stoma, but in many patients the fear of – is there a more effective derogatory they did not, under any circumstances, skill of the surgery or the postoperative such is quite uninformed. Most patients label in hospital politics? (If you want want a stoma. This refusal of a stoma had management. will accept the necessity, if the nature and to undermine an ‘opponent’ on the not been conveyed to the surgeon during management of stomas, and, in many Executive, just spread the word that he or the earlier discussion with patient and Reviewer’s comments cases, their temporary nature, is fully she is running their own agenda – and family. A decision to proceed with the An adverse event in the form of an explained. We do not know if this was if you really want to stick the boots in, surgery was made. anastomotic leak has occurred. The done, or if the registrar had sufficient simply add the word secret!) At laparotomy, a torted ascending colon risk of leakage, either from the surgical experience to do so and to realise what a Having raised the issue of Hospital with a patch of necrosis and extensive anastomosis or from damaged small serious limitation this constituted. ‘The Vision Thing’ Executives, I feel compelled to emphasise small bowel adhesions were found. bowel, in a frail, elderly patient with The patient’s decision should have been the distinction between politically correct, Extensive adhesiolysis was necessary to significant comorbidities undergoing conveyed to the consultant well before aspirational “vision statements” and mobilise the ascending colon for a right this sort of surgery after nearly a week surgery commenced, so the consultant true vision – one is noble, notable and hemicolectomy, resulting in several serosal of obstruction, with necrotic bowel could have the opportunity to discuss noteworthy, while the other is not. Alas tears which were oversewn. A sinus present, is very substantial. Once such that specific limitation again with the Poison’d Chalice there is an exception to the rule. There tachycardia and hypotension occurred leakage occurs, a fatal outcome is patient and family and could be satisfied is one vision statement that caught my during the procedure. Because of the probably inevitable, even if the family that it was an informed, reasonable and erhaps I have been around too long latter requires focus, the former, among attention during my travels. It is “curanda patient’s refusal of a stoma, the simpler had not ultimately refused further active final decision. There appears to have been – past Trainees of mine are now other things requires vision. And by vision, vita” – Latin, translated – “life is to be and safer option of then removing the treatment. a significant failure of communication in Passuming leadership roles around I do not mean breadth of observation, but cared for”. Could there be a better vision ascending colon and simply ‘bringing It is reasonable, therefore, to suggest this this instance. the country. And each year I seem to need rather the ability to see how things might statement for a hospital? out the ends’ was not available. A case is one where the outcome was not an increasingly powerful pair of reading be in the future – something beyond However, back to my lecture on right hemicolectomy with side-to-side preventable. The case does, however, raise glasses – after all I need to be able to see! horizon scanning – the ability to position leadership, focusing on vision. I anastomosis was performed. one interesting area for consideration in This is good and bad. Good in that I have in order to create. Of course the danger opened with one of the best quotes The patient required inotropes and relation to informed consent, or in this Guy Maddern a very attractive Optometrist who it is is that ‘vision’ is the first casualty of the that Shakespeare has given us. From ventilatory support postoperatively, but case informed limitation of consent – that Chair, ANZASM a pleasure to see each year, and who is constant buffeting of increasingly urgent A Midsummer Night’s Dream (Act 4, clearly attracted to me since she always demands – the constant requirement for Scene1): “I have had a most rare vision. I insists that I have the very best frames immediate solutions to problems that have had a dream, past the wit of man to autumn Lifestyle notwithstanding that they are always the today are of paramount importance, but say what dream it was.” post op most expensive in the store. Bad in that by tomorrow are forgotten, or simply I reached inside my pocket for my

12page lifestyle she is my wife’s best friend! replaced by a new set of issues. Herein lies Been somewhere interesting lately? section expensive glasses to consult my notes A more practical manifestation of my the essential difference between effective before continuing. Blast! They are not We are looking for travel and hobby stories for Post Op. approaching obsolescence is the request management and leadership. there, where did I leave them – again? I Contact [email protected] to let us know! for me to deliver lectures on ‘leadership’ Management courses refer to the suddenly realised that I was in a bad place rather than surgical technique – the two, phenomenon of constant ‘white water’ – a – lecturing about vision without vision! Cycling through of course, are diametrically opposed. The term familiar to those who choose to use Professor U.R. Kidding post op appears in The Tasmanian surgeon who loves to ride Surgical News each Europe season Page 12 / Surgical News June 2013 Surgical News June 2013 / Page 13 ASC 2013 this year’s Annual Scientific Congress (ASC) of the College addressed the theme of sustainable surgery with presentations, not only on the future of sustainable surgical training,“ research and innovation, but scientific papers describing the use of limited health resources. ” Dr Tracey Barnes, a Surgical Registrar “Our early experience suggests that in at Invercargill’s Southland Hospital told carefully-selected patients, ambulatory the Congress that Consultant Surgeons partial and hemi-thyroid surgery can be and hospital management had structured safely achieved and is feasible within an a model where the on-call surgeon had Australasian tertiary hospital setting.” no elective responsibilities while covering Saving health dollars through call for the week with the on-call surgeon’s improved hospital care could be achieved usual elective sessions used by other through the use of a checklist during General Surgeon Colleagues. surgical ward rounds, according to Comparing data from before the Associate Professor Graeme Thompson. introduction of the new system and after, A General Surgeon at Melbourne’s Dr Barnes found that both acute and Western Health, Professor Thompson elective admissions remained similar, with presented a study at the ASC that elective surgery throughout remaining involved the use of a structured checklist similar per consultant. during ward rounds and the recording of “Our review led us to the conclusion key aspects of surgical care. that in a provincial hospital with just “Initially, the team was unaware of five General Surgeons it is feasible to run the nature of the observations or that a an acute surgical service model with a formal study was in progress,” he said. consultant having on-call responsibilities “During the second phase team only,” she said. members were informed of the study and “This can improve acute inpatient told that a designated prompter would care without reducing or compromising alert the team when areas of care had not elective services.” been considered.” The mandatory transfer of paediatric Professor Thompson found significant patients with appendicitis to dedicated improvement occurred via the use paediatric surgical units does not appear of the checklist including a notable to be justified, according to research improvement in communicating with conducted by Dr Hasitha Balasuriya. patients and nursing staff, attending to Dr Balasuriya, a Surgical Resident at Venous Thromboembolism prophylaxis, Gosford Hospital in NSW, said the cost fluid balance, catheters and drains, and possible morbidity associated with referring to drug charts and discharge mandatory transfer, as well as the inevitable planning. Dr Shakerian concluded from the burden on such centres should be formally data that early and increased consultant reviewed against patient outcomes. Challenges to overcome The friendly input reduced length of stay and time The sustainability of a paediatric surgical spent in the Emergency Department Similar outcomes service in Vanuatu was the subject of a This year’s Annual Scientific Congressmeeting (ASC) of the College despite a 73 per cent increase in acute Dr Jacques Marnewick, who was a presentation made by Dr Basil Leodoro, a held in Auckland, New Zealand, addressed the theme of sustainable surgery. admissions during the operation of the Trainee endocrine surgeon in Hamilton, general surgeon from Vanuatu. new service. NZ, told the ASC that although it is not He said that while infant mortality n a global climate of fiscal restraint and separating elective and acute surgical 2011 in response to an increase in acute In 2011, the RACS wrote to all health standard practice in Australasia, well- in the country had fallen dramatically and economic adjustment, this year’s streams in smaller hospitals. general surgical and trauma cases. ministers and senior health department selected patients could safely undergo in recent decades, mostly due to early IAnnual Scientific Congress (ASC) Other papers described the appropriate She said data gathered from February officials in Australia and New Zealand, hemi-thyroid surgery as day patients. diagnosis and treatment of infectious of the College addressed the theme of selection of patients for day surgery, 2011 to January 2012 showed that the EGS enclosing a comprehensive report which Analysing the outcomes of patients diseases, a specialist paediatric surgical sustainable surgery with presentations, questioned the need for treating children service managed 4523 patients during the demonstrated that the establishment of who had been operated on by a single service had only been made available not only on the future of sustainable with appendicitis at dedicated paediatric study period. dedicated acute care surgical units leads high-volume endocrine surgeon, Dr there since 2010 under the Pacific Island surgical training, research and innovation, centres and outlined the results of “Hospital length of stay was reduced to greater efficiency and better patient Marnewick said that while 82 partial/ Program (PIP) funded by AusAID and but scientific papers describing the complex cancer surgery undertaken at a from 5 to 4.1 days and a 20 per cent outcomes. hemi-thyroidectomy patients had been co-ordinated by the College. optimal use of limited health resources. low-volume tertiary centre. improvement was noted in the proportion While the separation of elective and treated during the study period, 58 were “From a local perspective, questions Delegates to the 82nd ASC, held in Dr Rose Shakerian, a General Surgeon of patients admitted from the Emergency acute surgical streams is increasingly considered suitable for discharge as must be raised as to how independent Auckland last month, were given presen- at the Royal Melbourne Hospital, Department within eight hours,” she said. common in large city hospitals, the ambulatory surgical patients. Vanuatu can become in sustaining a tations on the efficiencies derived from presented research on the effects of the “The percentage of surgical cases viability of such a model of care in “Of all these patients, there was only one specialised surgical service, given the having dedicated consultant-led acute establishment of an Emergency General conducted within hours was found to be smaller provincial hospitals has only re-presentation of surgical complication local and external challenges that must care surgical centres in tertiary hospitals Surgery (EGS) Service at the hospital in 50 per cent.” recently been tested. with an infected seroma,” he said. be overcome,” Dr Leodoro told the ASC. u

Page 14 / Surgical News June 2013 Surgical News June 2013 / Page 15 ASC 2013

“These include delayed presentation of patients with paediatric surgical disease, a shortage of medical resources and ASC in pictures staffing, limited funds for investigation, assessment and management of paediatric surgical cases and a need for specialist paediatric surgical training of surgeons, anaesthetists and nursing staff. “(Yet) some of the solutions to these problems may not be as remote as one might assume. For example, there are well-established ties with the College, 05 06 PIP teams, regional consultants and donors who regularly assist local surgeons in both clinical and training capacity. “These efforts and relationships must be sustained and fostered.” Away from the central theme of sustainability, scientific papers were presented on the dangers of magnet ingestion in children and the growing demand from patients who have had bariatric surgery for follow-up surgery to remove excess skin. 07 Dr Brooke Rule, a Registrar in the ICU 08 of Royal Perth Hospital, told delegates that when multiple magnets are ingested Convocation they can be attracted to each other across the bowel wall which may lead to pressure necrosis, perforation, fistula formation and/or intestinal obstruction. She called for a campaign to increase public and clinician awareness of the dangers of magnet ingestion along with a review of regulations pertaining to the use of magnets in toys. Dr Heather Leaver, an Auckland- based surgical Trainee and Mr Jonathan Wheeler, a Plastic and Reconstructive Surgeon, presented a study of New 09 10 Zealanders who had undergone bariatric surgery which suggested that most would 01 02 like some form of body contouring surgery after the initial weight loss procedure. Dr Leaver said 87 per cent of the 115 patients who responded to a questionnaire felt they had excess abdominal skin while 84 per cent said they would be interested in its removal. She told delegates that it was likely that the study cohort was representative of the increasing number of people undergoing 03 04 11 12 bariatric surgery in New Zealand and that a growing demand for post-operative 01: Sir Peter Gluckman 05: Maori women welcome surgeons 06: Sean Hamilton, Michael Grigg, David Thiele & Ian Bennett body contouring surgery could be 02: Sarita & Brent Eastman, Ian Ritchie & Spencer Beasley 07: Kingsley Faulkner & Ian Civil 08: John, Deborah, Simon, Amelia Quinn & Marianna Campbell anticipated. 03: Phillip Carson & Colin Summerhays 09: John & Angela Masterton 10: Luc Malemo Gwen & Neil Wetzig 11: Mike Hollands With Karen Murphy 04: John Woodfield, Sam & Siraj Rajaratnam 12: Gayl Pollard, Rob Atkinson, Cliff Pollard & Pauline Atkinson u

Page 16 / Surgical News June 2013 Surgical News June 2013 / Page 17 plenary

01 02

09 10 11

03 04 presentations

12 13 14

05 06 16 15 Exhibitors drinks

07 08 17 18

01: Media with Mike Hulme-Moir Bowel screen Launch 02: John Mitchell Crouch Lecture Russell Gruen 09: David Watters & Simon Williams 10: BJS Lecture Murray Brennan 03: Edward Weary Dunlop Lecture Major General Professor Alan Hawley 04: Dragon makes an appearance through the Exhibitors 11: Stephen Tobin 12: Cathy Ferguson 13: Alan Merry & Guy Maddern 14: Michael Gorton Hall to promote the ASC in Singapore next year 05: Michael Wertheimer Lecture Ian Civil 06: Gordon Trinca Medal Cliff Pollard 15: Rebecca Hartley, Brian Swain & Wahida Roshan 16: Camille Furnandiz & Aaron Morgon 7: Rowan Nicks Lecture Eddie McCaig 08: American College of Surgeons Lecture Nancy Baxter 17: Chantal Summerton, Hanile Both & Bernice Dobbs 18: Marcos Serrano & Ben McCluer u

Page 18 / Surgical News June 2013 Surgical News June 2013 / Page 19 ASC 2013 Medico-Legal

Advertising by surgeons Make sure you know the College Code of Conduct

he College has recently dealt with complaints under the TCollege Code of Conduct against surgeons for inappropriate advertising of their practices and themselves. The Code highlights professional 01 congress dinner and legal obligations of privacy and confidentiality owed to patients. The particular use and potential consequences of identifiable information and photos should be carefully considered by surgeons. Whilst consent may be obtained, each surgeon should still consider their professional obligations and the appropriateness of using identifying advertising or promotional material.

The College Code of Conduct 0102 0103 0104 requires that surgeons: a. The MBA Guidelines prevent the be particularly sensitively handled. 1 Provide only clear, factually correct use of testimonials or purported De-identified children’s photographs, and verifiable information. testimonials. appropriate to the clinical situation, may 2 Not advertise in a manner that b. Failure to disclose health risks be used with fully informed parental could mislead any patient. associated with a treatment. consent. 3 Not advertise in a manner that c. Containing price information that is Surgeons should also consider the promotes the perception that their inaccurate. appropriateness of multiple images services are better than their peers. d. Using graphic or visual representa- or excessive use of photography in 4 Not use testimonials or “before tions which are inaccurate or unfair, promotional material. Consistent with and after” photographs that including “before and after” photo- other forms of medical education, create unrealistic expectations of graphs which do not contain similar photographs are useful to illustrate a outcomes. backgrounds, camera angles, lighting, point; but in the context of a website do 5 Not encourage indiscriminate or posture, make up or alteration to make not need to cover all possibilities. The web 0105 0106 0107 unnecessary interventions. the “after” photograph appear better. is readily and very widely accessible. It 01: Singer Anna Coddington entertains the Congress diners 02: John Windsor 03: Campbell Miles & Peter Woodruff 04: Ian Ritchie, Mike & 6 Not exploit a patient’s vulnerability should be noted that web images can be Jane Hollands 05: Johnson & Johnson Gavin Fox-Smith 06: American College of Surgeons President Brent Eastman 07: Roger & Michelle Wale or fears. Similarly, the MCNZ Statement easily copied and used inappropriately. 7 Not impugn the reputation of others. suggests the use of photographs should The College continues to monitor these not be unrealistic, and should be typical issues. Any Fellows may report, and The College has also adopted, and of what can be expected. Photographs some have reported, breaches of these surgeons will otherwise be required should not be altered in any way, and Guidelines and the Code of Conduct to comply with, the Medical Board of again contrasts between “before and to appropriate authorities and/or the Australia “Guidelines for Advertising” after” shots should not have used College. and the Medical Council of New Zealand techniques to create unrealistic or unfair The College will act on complaints. “Statement on Advertising”. representations. The Statement and Guidelines from It is also important that the use the MBA and MCNZ reflect some of of photographs or other patient 08 09 10 the requirements of the College Code of information should only occur with fully informed consent. Use of photographs 08: Richard Marton, Jason Cheun & Mike Hollands 09: Holly Keane, Sze Ling Wong Conduct. Additionally, they address issues Michael Gorton, & Jacqui Slater 10: Mary Corboy Richard Hanney Jane Mike Hollands younger fellows such as: with children, for example, should College Solicitor

Page 20 / Surgical News June 2013 Surgical News June 2013 / Page 21 Foundation for Surgery Yes, I would like to donate to our Foundation for Surgery

All donations are tax deductible

Name: Promising young surgeons from such That program involved the provision the leading cause of hearing loss in regions have also been fundedAddress: to train and delivery of 19 Primary Trauma Care IndigenousTelephone: communities. in Australia and New Zealand,Email: with (PTC) courses to local surgeonsSpeciality: and These projects, funded by the Pledge particular support given to those who doctors who then took ownership of the a Procedure campaign, achieve great will go on to train members of their courses to train others across the nation. things for struggling communities but Enclosed is my cheque or bank draft (payable to Foundation for Surgery) for $ . local medical communities upon So successful was this initiative that also say a great deal about the College their return. Please debit my creditMyanmar card account health for authorities $ requested. the and its Fellows. • Research scholarships and help of the College to develop emergency While our core function is to deliver grants: The College is committed Mastercard to Visamedicine AMEX skills and Diners systems, Club with NZtraining Bankcard world-class surgical care to our patients supporting advances in the science programs now underway. in Australia and New Zealand, and to of surgery. Donations allocatedCredit toCard No: This aid program to Myanmar has been train the next Expiry generation /of surgeons, scholarships or research grants facilitate a great success, not just for the people we also play an important role in Yourscientific passi oworkn. in the Fellows’Card Holderpreferred’s Name of- block that letterscountry but also in termsCard of theHolder ’s Signatureinternational outreach, we recogniseDate specialty or sub-specialty by providing international standing of the College. It that Indigenous communities in Youropportunities skill. for quality research andI would likeis my a great donation example to help of the support: work we can do Australia and New Zealand need extra Youradvanced legac researchy. training. General withFoundation the support Programs of Fellows. International Dcare,evelopment and we Prog supportrams the research that ScholarshipBack and atFell home,owship we Prog haverams funded Indigenousan ENT Healthunderpins Programs our profession. You may be aware that, so far, I have a operatingpotential contribution microscope to for the the Cultu Indigenousral Gifts Prog ram I urge you all to prove this ‘Pledge a Procedure’ has helped fund health clinic at Tharawal in New commitment once again. Donations I do not give permission for acknowledgement of my gift in any College publication Youan enormouslyr successful trauma South Wales, and have donated to the can be sent to the College and are tax skills program in Myanmar which Please sendCherbourg your donation Health to: Clinic in Queensland deductible. Fouhas an particulardati onfocus .on training theA USTRALIAsurgical & OTHER COUNTRIequipmentES for theNEW treatment ZEALAND Kingsley Faulkner Foundation for Surgery Foundation for Surgery trainers. 250 - 290 Spriofn gchronic Street suppurative OtitisPO Box 745Media,1 Chair, Foundation for Surgery East Melbourne , VIC 3002 Newtown, 6242 Wellington Make a difference Australia New Zealand The College Foundation’s annual fundraiser is upon us, support Pledge a Procedure in June (vic asm) “Surgical Practice and Training - confronting and tackling the regional issues” he Foundation for Surgery is address the health inequities in Australia’s You will have received a letter from 55th Victorian Annual Surgeons Meeting the College’s philanthropic arm remote and Indigenous communities, the Foundation asking you to support Tand is the sole charitable entity implement Indigenous surgical programs programs in the area of surgical FRIDAY 18 - SUNDAY 20 OCTOBER 2013 PRIZES in Australasia representing the wider and encourage Indigenous doctors to endeavour that is most important to Novotel Forest Resort, Creswick / Friday 18 October There are prizes for the following categories: surgical fraternity. It supports health consider a career in surgery. you by donating the proceeds of just one Welcome Dinner and Show - Sovereign Hill (Families are encouraged to attend) 2013 DR Leslie Prize – Best clinical registrar paper projects and research across all surgical They will increase surgical capacity and performance of your most common major 2013 RC Bennett Prize – Best laboratory based Saturday 19 October; Meeting Dinner - Novotel Forest Resort, Creswick fields and supports projects in Australia, enable the provision of surgical training operation during the month of June. research paper presented New Zealand and across the Asia Pacific and quality patient care in many of our CALL FOR ABSTRACTS DCAS Scholarship – Best presentation region. neighbouring developing countries, I can assure you that 100 per cent of all appropriate to academic surgery. I wish to thank Fellows for their including Papua New Guinea, Timor donations will be used to fund projects Medical Student Prize – Best presentation by generous support of the work of the Leste, the Pacific Island countries and within the following areas: Please indicate that your abstract is for VIC ASM 2013 and which area you a Medical Student Foundation. Your willingness to assist Myanmar. • Indigenous health: Indigenous wish your topic to be submitted under. All successful abstracts will be printed Audio visual instructions will be sent to all colleagues working in disadvantaged They will also support research across populations in both Australia and New Submissions Are Now Open successful authors. communities, and your commitment to all surgical specialties and sub-specialties, Zealand suffer higher rates of chronic in the Final Program & online. Please note that single case reports will not be surgical training and research is greatly and provide assistance to young surgeons disease and trauma-related injuries Submissions must include: appreciated. of promise through the conferment of than other members of the community, accepted for presentation or poster – A title However, there is always more to be scholarships and grants to enable new while remote medical centres often – An abstract of 250 words or less MEETING ORGANISER done and our sustained support is vital research, advanced study and surgical lack the surgical equipment needed to ensuring the Foundation for Surgery related travel opportunities. for treatment. Donated funds are used – A short presenter bio (50 words) to facilitate the Chairperson’s introduction Denice Spence, Victorian Regional Manager is able to expand and thrive. In doing The Foundation is an integral part to upgrade equipment and improve – Authors (Presenter in CAPS and UNDERLINED, i.e. J.L.M Peterson, Royal Australasian College of Surgeons so, it will continue to facilitate a range of the College and I encourage all clinical care. A.K.MATTHEWS, A. Thomas, N. Bravo) College of Surgeons Gardens of worthwhile and effective health Fellows to help maintain and expand its • International medical programs: – Address and Contact Details 250 - 290 Spring Street, East Melbourne programs that measurably improve the programs. To help fund these initiatives, Donations help provide urgently – Conflict of Interest Declaration VIC 3002 Australia lives of many people in less fortunate the Foundation for Surgery is again needed specialist medical services T: +61 3 9249 1254 F: +61 3 9249 1256 circumstances than ourselves. conducting its annual fundraising and increase surgical capacity in Email abstract submissions by Friday 16 August to: [email protected] E: [email protected] These programs will continue to campaign ‘Pledge a Procedure’ in June. some of the world’s poorest regions.

Page 22 / Surgical News June 2013 Surgical News June 2013 / Page 23 Library Report

reported problems is that Clinical Key Register for Clinical Key to The College is keen to The Library staff welcome your does not work well with Internet Explorer access more features promote the publications feedback and suggestions. 8 or 9. If you find you are not getting Clinical Key has some useful tools “ You can contact the Library and research of our Fellows directly through to specific full resources, available if you register for an individual ” or if images are not displaying, the easiest account. These tools include Saved by email College.Library@ solution is try a different browser. Firefox, Searches where you can formulate surgeons.org or phone Safari and Internet Explorer 10 are all good searches and rerun them regularly to get +61 3 9249 1272. alternatives. Please don’t hesitate to contact the latest updates on your topic. the Library if you have any questions. Reading lists allow you to create a Registering for an individual account personal list of specific Clinical Key is as easy as entering your email address Image Library resources for easy reference. and there is no cost incurred. The link Clinical Key has millions of images in You can use the Presentation to Register is in right hand corner of the its database. Fellows and Trainees can Maker to export text and images to blue bar at the top of the Clinical Key use these for your own personal, non- PowerPoint. The Presentation Maker home page. commercial, informational or scholarly will automatically insert citations. The We hope you enjoy your new Library. use, provided that you keep intact all Library home page includes a mini copyright and other proprietary notices. tutorial video on using the Presentation Please note, the licence does not allow Maker that you may find helpful. the reproduction of Clinical Key images If you want to download book chapter Cathy Ferguson for other publications, including the PDFs rather than reading them as web Chair, Fellowship internet. pages, you need to register. Services Committee Discover your new Library Have you seen the new look Library yet?

Multidisciplinary Series he Library has been redesigned right hand column) and a separate page General Surgery sub- to provide improved access to for Trainee resources (half way down the 6th National Pelvic Floor and Anorectal specialty approach Disorders Course Tan increased range of resources. right hand column). Both these pages are General Surgery is the largest specialty 13-14 September 2013 The redesign has given us the space complemented by the Specialty pages. and the sub-specialties are very well and opportunity to group the Library Endorsed by: CSSANZ Sponsored by: Medtronic and Johnson & Johnson Medical developed. The Library has moved This 1½ day course for Surgeons, Convenors: resources in a way that is more intuitive Physiotherapists and interested GI A-Z listing towards reflecting this approach by A/Prof Ian Bissett Clinicians will focus on the management for Fellows, Trainees and IMGs. Colorectal Surgeon, Auckland If you are looking for a specific resource replacing the long list of general surgery of patients with faecal incontinence & The Library home page now features a Mr Rowan Collinson obstructed defaecation, including imaging and can’t find it on the library pages, you journals and books with Library Colorectal Surgeon, Auckland current news service drawn from journals and surgical advances. can always use the A-Z listing (top left hand resources organised under sub-specialty International Guest Lecturers: All Day Friday including the ANZJS, BJS, Annals of corner of the Library home page). There are headings. The categories of sub-specialty Dr Peter Stewart • Anatomy and pathophysiology of Surgery, The Lancet, NEJM, Medical Colorectal Surgeon, Sydney colorectal pelvic floor disorders, in literally thousands more resources included are based on recommendations from Prof Peter Dietz particular the events surrounding Journal of Australia and Medical Journal Obstetrician and Gynaecologist, Sydney parturition. in the A-Z listing that haven’t been listed General Surgery Fellows consulted at the • Radiology techniques – proctography, Ms Sue Croft of New Zealand. The aim of the news endoanal and dynamic transperineal separately on the Library pages. recent ASC in Auckland. Physiotherapist, Brisbane service is to help keep Fellows informed ultrasound. The Library plans to extend the • Physiotherapy methods. Venue: of the latest research and news published • Operative technique and indications Specialty hubs sub-specialty approach to Orthopaedic Advanced Clinical Skills Centre for anal sphincter repair, laparoscopic in the bigger multi-disciplinary journals. Gate 3, 98 Mountain Road ventral mesh rectopexy, transanal Specialty hubs provide current news from Surgery in the near future. Epsom, Auckland rectocele repair, STARR, and sacral The College is keen to promote neuromodulation. key specialty journals, with links to the For further information, or to obtain the publications and research of our a live link to the online registration • Multidisciplinary interactive panel discussion of challenging patient full text articles. Each hub brings together Clinical Key below, contact: Fellows so if you are aware of any new scenarios. all the specialty related information from The acquisition of Clinical Key has Registration Administrator or forthcoming articles of interest to the Phone: +64 9 923 9304 Saturday Morning across the web site, along with prominent brought a vast new range of books, Email: [email protected] • For Surgeons: Setup of an Anorectal surgical community, please email the Physiology Lab. access to the related Societies. journals and multimedia to the Library. Library so these can be highlighted. Registration: • For Physiotherapists: Interactive Specialty hubs can be accessed from It can take a while to become familiar Registration fees (NZD), all GST inclusive: Physiotherapy Workshop. Full Course, Surgeons $446.20 My Page after you log in to the College with the approach and scope of this new Full Course, Physiotherapists $322.00 Registration closes on 1 September 2013. Full catering is included. New pages web site. There are also links from each of resource. The Library has a user guide Day 2 Physiotherapists Only $103.50 The redesign has created a new page for Please register online at: the Library specialty pages to the relevant and link to a mini-tutorial that new users resources relevant to all specialties (top https://ecommerce.auckland.ac.nz/shop/acsc/courses/c-40.htm specialty hub. (Top left hand corner). may find helpful. One of the commonly

Pelvic Floor Advert_2013_02P.indd 1 24/05/2013 1:46:11 p.m. Page 24 / Surgical News June 2013 Surgical News June 2013 / Page 25 ASC 2013 Surgeon health

pics by John Aloysius Henderson

by cytokines, those inflammatory markers that activate microglia in our brain, which are themselves acutely responsive to stress and inflammatory signalling. Oxidative and nitrosative stress, mediated through free radicals, potentiates the 0105 process, resulting in damage to proteins, fatty acids and nucleic acid epitopes often with resultant autoimmune reaction. One can measure the cytokines (IL2, IL6 and TNF), and inflammatory markers (including CRP) both in Cytokines sing the blues laboratory animals and in humans. The Even surgeons can get depressed evidence is strong, but it has only been accumulated in the past 20 years, well after Ms Erabel graduated from medical 0106 school. The microglial activity affects neurotransmitter pathways. Her CRP urgeons receive a great deal of expectations, complained about being was raised, her bloods showed a high positive feedback during the course constantly under pressure to perform, LDL to HDL ratio. We didn’t measure the 01 Sof their work. Despite those terrible was irritable and stressed. She had been cytokines. complications that a small percentage feeling like this for two or three months. Antioxidants such as Vitamin E, Zinc, of your cases suffer, patients generally I asked whether she could think of CQ 10, can modulate these processes opine their surgeon is ‘the best’ and few any precipitating events, giving her an by resisting the effects of free radicals. of you show any enthusiasm to dispel this opportunity to unload. She’d operated They also enhance the function of our absurd belief in your adoring public. on a young patient, thought she’d done mitochondria. Omega 3 PUFAs (fish oil) reduces inflammation and so protects 0107 However, I recognise that much of the a great procedure, but a week or so later positive feedback surgeons receive is well there was a major complication. against inflammation mediated damage deserved, as the majority of cases do fare In the past month or two recognising to proteins, fatty acids and DNA within well and the procedures you perform that her confidence was shattered, our brains. We need to protect our 0103 [or the advice you give not to undergo a she’d been putting off some of the neurotransmitter pathways, particularly procedure] represent major milestones in more challenging procedures whenever the serotonin ones and avoid rogue an individual’s life. possible. She’d referred a couple of more damage to the molecules within our As a result surgeons don’t usually get urgent, but difficult cases to a colleague brains. depressed though they can burn out and was really frightened she was losing I wasn’t sure whether Ms Erabel would through overwork and lack of play. They her nerve. She had a disrupted and respond sufficiently to antioxidants and are also particularly vulnerable when disturbed sleep pattern and though her Omega 3s alone so recommended she 0801 their domestic life suffers major setbacks, family relationships still seemed sound, take also anti-depressants and that she through broken relationships, illness or no one was finding her mood easy should exercise every other day. Being challenging behaviour in children. and she admitted to having withdrawn a surgeon she went away and read it all I’ve always thought it would be nice to from most social commitments. She felt up, came back and thanked me profusely. be able to prescribe a magic bullet that constantly tired and when prompted, Within a month she felt positive, re- would fix the blues without significant admitted to having little libido. engaged with life and confidence was 0102 0104 side effects or a wait of a few days for Even a surgeon would be able to restored. I was able to withdraw the improvement. So many of those on whom diagnose she was suffering from antidepressants without relapse some convocation I consult are depressed, though among depression, but Ms Erabel seemed to be months later. 01: Mike Hollands 02: Lee Brewster & Glenn Guest my surgical patients it is extremely rare. a little surprised. Surgeons shouldn’t be She chose to stay on the fish oil and 0901 03: Brian Morgan & Phil Truskett Some three months ago, a normally depressed should they, she grunted. It’s the antioxidants. Cytokines may sing 04: Russell Gruen, David Watters & Ikau Kevau the blues, but I chorus it is time to THANK-YOU TO ALL WHO gregarious, confident surgeon slouched almost that depression is a form of failure, congress dinner anti-oxidise, mop up those free radicals, ATTENDED THE 2013 ANNUAL slowly into my consulting room, having not a condition that needs treatment. 05: Pam & John Henderson 06: Cliff & Elizabeth Hughes and and strum to a different rhythm. Our SCIENTIFIC CONFERENCE requested a lunchtime appointment Don’t I just need to pull myself together, Beverley & Bruce Barraclough 07: Stephen & Anne Deane microglia and mitochondria couldn’t IN AUCKLAND ... between operating list and rooms. she asked? 08: Campbell & Vivienne Miles, John & Angela Masterton agree more. ‘TIL NEXT YEAR! Ms Erabel had lost interest in her I explained that depression is actually 09: Michael and Jane Hollands work, felt she was trapped by others’ a pathophysiological disorder. It is driven Dr BB G-Loved

Page 26 / Surgical News June 2013 Surgical News June 2013 / Page 27 International Development

“There is such need in Myanmar that the impact of an Operation Open Heart visit in terms of patient numbers is negligible while the up-skilling, mentorship and New services support of local surgeons is, in my opinion, invaluable.” Leadership qualities Professor French said Dr Kyaw was a junior for Myanmar cardiovascular surgeon when he first met her during a team visit to Yangon General Hospital and over the Experience for a following years found her to be a committed and careful Rowan Nicks Scholar surgeon with leadership qualities recognised by local health authorities who sent her to Mandalay to help has led to a new establish an open-heart surgical unit. cardiac unit in He believed she demonstrated those qualities envisioned Yangon Children’s by the late Rowan Nicks when he established the scholarship to support surgical leaders in developing Hospital countries and the committee agreed. As the then Clinical Director of the Cardiovascular Clinical Stream of South West Sydney, Professor French agreed to be her mentor during her stay in the country. “The key to me was providing Dr Kyaw with ideas during her time here rather than technical skills,” he said. “Therefore we discussed ideas around leadership, communication, dealing with stress, surgeons as team Archive photo of Win Win Kyaw and Supervisor Bruce French with Rowan Nicks. leaders and team dynamics. “She attended meetings with me to see the unit will have a tremendous impact on the quality administrative and management interaction as well as and availability of surgical treatment for people with patient interactions via consultations in my rooms. cardiac disease. “I was also keen to offer her exposure to the multi- “Yangon and Sydney have similar populations, yet disciplinary team element of cardiac surgery where surgeons, Sydney has eight or nine cardiac units which conduct perfusionists, anaesthetists and theatre staff all work very around 4000 surgeries per year while Yangon has two closely to ensure the best possible outcome for our patients. hospitals conducting only around 300 procedures,” he “We also often debrief after stressful situations in theatre said. and Dr Kyaw attended one of those after we lost a patient Win Win Kyaw operating “That shows the need just in one part of the country. In in theatre who had come to us in very severe distress. with Bruce French assisting; Mandalay, Myanmar’s second city, and other centres the “The cardiac surgical environment can be a very need is even greater. stressful one and those stressors need to be addressed and “Such is that need that health authorities asked Dr managed, particularly for those surgeons asked to take on Rowan Nicks International Scholar from Myanmar the opportunity to assist in open heart surgery cases and Kyaw to establish a new cardiac unit where she could leadership roles. who received training and mentoring in Australia to attend related clinical meetings. treat adults within the children’s hospital and she has “Cardiac surgeons are not the emotionless god-like A in 2010 has recently led the development and On her return to Myanmar, Dr Kyaw resumed her done an amazing job building a team, training staff and figures of yesterday and I wanted Dr Kyaw to see not only opening of a desperately-needed new cardiac surgery unit position as second in charge of the cardiovascular unit at setting up systems to monitor patient outcomes which is how we addressed these issues, but that we did address in Yangon. Yangon General Hospital until she was asked to set up a still not common in Myanmar.” them before she returned home and was asked to take on Dr Win Win Kyaw was a consultant cardiovascular new adult cardiac unit at the Yangon Children’s Hospital. Professor French, who has a particular interest in more responsibility.” surgeon at the Yangon General Hospital at the time of her Dr Kyaw spent six months planning the design and surgical training and skills transfer, is attached to the Professor French said he had also given Dr Kyaw basic arrival in Australia and spent her time here on attachment operation of the unit, built a team, trained operating University of Western Sydney and the University of New software, modelled on a data-base used at Liverpool to the Cardiothoracic Surgery Unit at the Liverpool theatre, intensive care and ward staff and designed England and has been a member of the Rowan Nicks Hospital, to help her monitor patient numbers, outcomes Hospital in Sydney under the mentorship of cardiothoracic computerised patient data records. Scholarship Committee for the past two years. and mortality rates given that such systems are not widely surgeon Associate Professor Bruce French. Myanmar is the largest country in South-East Asia with So far he has made 12 visits to Myanmar since his used in Myanmar. The main objective of her three-month visit was to a population of almost 60 million people, but is so under- first in 2006, using each one to facilitate safe practices Having last visited her in February this year, during a improve her skills in surgical leadership. Dr Kyaw attended resourced that only hundreds of cardiac surgeries are in coronary by-pass surgery and teach new skills and week-long visit at the new cardiac unit at the Children’s administrative and management meetings at Liverpool carried out each year, despite an enormous need because techniques to local surgeons. Hospital, Professor French said he was extremely hospital, theatre staff debriefings and team consultations of rheumatic fever, congenital heart disease and acquired “I see my role as a facilitator in the development of impressed with her progress. and was a participant of the 2010 “Surgeons as Teachers cardiac disease. new techniques rather than the primary surgeon on these “Dr Kyaw is now leading a team conducting coronary Course” held in Adelaide. She was introduced to surgical Professor French, who mentored Dr Kyaw after first visits because the key is to enable the surgeons to safely by-pass surgery and heart valve surgery and her technical audit and was assisted in constructing a database relevant meeting her during an Operation Open Heart* visit undertake procedures when visiting teams are not there,” skills are more advanced in this new environment while to the needs in her Yangon surgical unit. Dr Kyaw also had to the country in 2006, said the opening of her new he said. her leadership and management skills are very good. u

Page 28 / Surgical News June 2013 Surgical News June 2013 / Page 29 International Development Regional News

and discharge communication, electronic transfer of patient’s Aside from the ASC records between practices, needs care analysis of the elderly (InterRAI) and widespread access to laboratory and radiological A number of new initiatives are being investigation. A new patient and provider health index database introduced in New Zealand is replacing the existing 30-year-old system which has had a 10 per cent duplication rate. t was New Zealand’s pleasure to be the host country for the All these components will be linked through a single portal 2013 Annual Scientific Congress. The scientific program through which the patient and their health care providers will Iwas of a very high standard and it is just a pity that the have a variable level of access to the information available. There same can’t be said for the weather! I would like to take this are four hubs nationally (three in the North Island and one in opportunity to publicly thank all of the New Zealand surgeons the South Island), each with regional populations of approxi- (and the Trainees) who gave so much of their time to develop mately 1,000,000, where this information will be shared through a the programs and help to make this a successful event. central repository. The four hubs will be linked nationally so that There are a number of initiatives under way in New healthcare providers will, depending upon their authorisation, Zealand with the intention of improving patient care and have access to some/all electronic information in respect to the medical training and education. Just a few of these have been care of each of their patients. Win Win Kyaw with cardiologists on the surgical ward. highlighted below. Considerable work has been undertaken in the The [ASC] scientific program was of a very development of a shared care plan, which will be available high standard and it is just a pity that the Medical Council of New Zealand – on the patient portal and capable of constant updating by “She is now the lead surgeon with two junior surgeons “ same can’t be said for the weather! working with her and they are tracking patient results proposed changes for PGY1 & PGY2 all health care providers and the patient. It is anticipated that which is a useful exercise in rigour while providing the In the second round of consultation with the profession on shared care plans will be developed for patients who, because ” information needed to demonstrate that they are doing training in prevocational years one and two (PGY1, PGY2), of the complexity of their illness or disability, require repeated At the end of March, under the auspices of our Health useful work. the Medical Council of New Zealand (MCNZ) has indicated interaction with a range of health care providers. Quality and Safety Commission (HQSC), prospective “She is also looking to learn paediatric heart surgery its preference to continue with three-month runs enabling Consumers/patients have been widely involved in the data collection in respect to deep infection following because of the high number of children born with registration in general scope at the end of the first year. It development of this IT work and are extremely supportive hip and knee arthroplasty commenced in eight of New congenital heart disease and I am hopeful she will be is envisaged that all runs (including relief runs) will have while emphasising the need for patient confidentiality and Zealand’s 20 DHBs. After identifying and removing any supported in this so that her skills can continue to components which will contribute appropriately to the new security of information. This aspect has been carefully difficulties with data collection it is anticipated that the expand given the enormous need for them in Myanmar.” graduates ongoing training and education. considered at each stage of the development and there has remaining 12 DHBs will be participating also from the Professor French described Dr Kyaw’s achievement as These doctors will be required to have a Professional been good assurance (although obviously never absolute) beginning of July. The consistent collection of this data of great value to the country and said she epitomised the Development Plan throughout these years and the move to that this can be ensured. The potential power and utility of will permit the accurate determination of the incidence of type of surgeons Mr Rowan Nicks was hoping to assist general scope registration will be contingent upon a Plan having this IT support is becoming increasingly evident as clinicians serious deep infection following major joint arthroplasty. when he set up his scholarships. been developed for PGY2. MCNZ’s objective is to ensure all access a diverse range of information in respect to their The recognition of any variance across the country will He said he remained in close contact with her via doctors have a broad basic training, including some exposure patients. The full integration in the near future represents an result in closer scrutiny to identify any differences in the email and had found the experience as mentor to an to community medical practice, and to enable progression into exciting prospect. perioperative care which may be contributory factors; and international scholar an extremely rewarding one. subsequent postgraduate programs. This initiative has been developed from bottom-up, and been hopefully result in changes in practice that can lead to a “I found this an invaluable experience as a surgeon While the proposed changes have the potential to driven by clinicians (including the EDSA, NZ, Allan Panting) reduction in the rate of infection. interested in skills transfer and teaching while it also offer improved experience and training for interns this is working alongside IT vendors and consumers. The costs, when This initiative is the first in a series to collect accurate added meaning to my life on a personal level and I would dependent upon District Health Boards (DHBs) recognising compared with those of some other international health systems, data in respect to surgical site infection following elective thoroughly recommend taking on such a role to any the importance of training as well as service commitments have been comparatively modest. procedures across New Zealand. Allan Panting (EDSA, surgeon wanting to help build a surgical service in a less whereby the quality of each attachment can be improved. NZ)) represents the College on the HQSC group developing fortunate country or even here at home,” he said. There is an associated expectation that senior medical staff, as Surgical site infection this program. Once it has been introduced successfully for Operation Open Heart is an arm of the Sydney key participants in this process, will make a more significant It is recognised that surgical site infection accounts for these arthroplasty procedures, consideration will be given to Adventist Hospital’s Healthcare Outreach Programme contribution to both training and regular assessment of the approximately 20 per cent of all hospital acquired infections. auditing cardiac surgery and caesarean sections in a similar and the Myanmar component was developed in 2003 by intern working with them. This increased expectation will come On average patients spend an additional seven days in manner. Further surgical procedures with sufficient volume, Professor Alan Gale. at the cost of some decreased productivity; and that can be hospital at an average cost of $1000 per day and with whereby the data can achieve statistical significance, will be Professor Gale, an Australian cardiothoracic surgeon expected to have a significant impact upon those DHBs that are significant additional costs following their discharge from included subsequently. While initially data collection will be a currently in Queensland, mentored the first Rowan already struggling to meet Ministry of Health targets. hospital. Deep infection following hip and knee replacement mixture of web-based and hardcopy, it is anticipated that this Nicks scholar from Myanmar, Dr Khin Maung Lwin, at surgery frequently results in repeat surgery on one or more will move quickly to electronic entry at all sites once the IT the Prince Charles Hospital in 2005. Dr Lwin is now the Shared health record occasions and, not infrequently, complex revision surgery. support has been further developed. head of cardiovascular surgery at the Yangon General Work is progressing remarkably efficiently as New Zealand moves In these instances, the total costs are frequently several Hospital. towards a goal of a shared, widely accessible patient health record times the cost of the primary arthroplasty (approximately Professor Gale has been awarded the College’s by the end of 2014. Numerous separate items contributing to $20,000). Therefore, a reduction in the incidence of surgical International Medal in recognition of his humanitarian patient care have been developed and refined and are already in site infection has the potential to permit additional funding and mentoring work in the South Pacific and in Asia. increasing clinical use. This includes medicines reconciliation, to be directed to primary surgery and the treatment of more Scott Stevenson With Karen Murphy electronic prescriptions, maternity record, electronic referral patients. Chair, New Zealand National Board

Page 30 / Surgical News June 2013 Surgical News June 2013 / Page 31 Successful Scholar

technique is the one that most young plastic surgeons in Melbourne are trained Papers Presented to do,” Mr Beer said. “I attended several cases with him Ultrasound Assessment of which allowed me to see the approach DIEP Perforators and the philosophies which he applies to Annual Scientific Congress of The Royal head and neck reconstruction. Australasian College of Surgeons “I also had the pleasure to meet May 2008 Hong Kong Dr Hiroo Suami, the director of the Contributing Author: D McCombe microsurgical research laboratory at MD Radial Artery Anomalies for Cardiac Anderson. Surgeons “His particular area of interest is in Annual Scientific Congress of The Royal the lymphatic system and through him I Australasian College of Surgeons was able to learn more about some of the May 2006 Sydney recent advances in lymphatic surgery that Contributing Author: M Yii are taking place in several places around the world. Inguinal Canal Soft Tissue Sarcomas “Later in my travelling Fellowship I Annual Scientific Congress of The Royal was able to visit three centres in Japan Australasian College of Surgeons due to introductions provided to me by May 2005 Perth Dr Suami.” Contributing Author: M Henderson Mr Beer said that while the type of Subcutaneous Neurovascular procedures performed at MD Anderson Advancement Flap with Full Thickness was similar to those conducted here, the Skin Graft in Finger Tip Amputations enormous resources available and the Annual Scientific Congress of The Royal large caseloads led to markedly different Australasian College of Surgeons systems. May 2003 Brisbane “There, surgeons are divided into teams Contributing Author: WA Morrison to assist in particular reconstructions with each surgeon often assigned to multiple Simultaneous Avulsion of Two cases through the day and because all Adjacent Flexor Digitorum Profundus the surgeons are on staff, they are often Tendons available for cases at fairly short notice, Annual Victorian Hand Surgery Society an approach which is different to what we Meeting tend to have in Australia. While in Texas…. John Beer November 2007 Melbourne plays extra at the site of the “The enormous resources at centres like Contributing Author: J Burt Apollo 13 in Houston. this, where patients fly in from overseas A world-class view just for an out-patient appointment, are great to experience, but impossible to replicate in a country the size of Australia. Travel made for invaluable experience for this plastic and reconstructive scholar He said he had returned home which covers a geographical area similar “Yet while the on-staff team approach with new skills and new approaches in size to the Melbourne CBD. has its advantages in that it fosters group lastic and Reconstructive surgeon Sloan Kettering and Lennox Hill Eye global research odyssey which also took to complex cases, a desire to build With a special interest in reconstructive interaction and expertise and allows Mr John Beer was last year given and Ear Hospital in New York and the him to Europe, Japan and East Asia to consultative surgical networks to discuss microsurgery particularly as it applies surgeons dedicated research time, it can Pprivileged access to some of the Massachusetts General Hospital in Boston. observe leaders in the field of plastic and difficult reconstructive cases and also with to the head and neck region, Mr limit skills by limiting exposure to the largest and most prestigious medical He said that having recently completed reconstructive surgery such as Professor a greater understanding of the world-class Beer was given access to operating wide variety of cases that we are asked to centres in the US with the support his training, he was grateful for the Isao Koshima at Tokyo University standard of Australian surgical training. theatres, clinics and clinical meetings treat as plastic surgeons in Australia.” provided by the College’s Hugh Johnson College support to allow him to see Hospital, a leader in the field of super- Now back working at the Austin and worked alongside Dr Peirong Yu, Mr Beer, who travelled with his wife ANZ Chapter American College of the advances being made in plastic and microsurgery, Professor Hung-Chi Chen Hospital, the Skin and Cancer an internationally-regarded figure Dr Alicia Au, an ophthalmologist and Surgeons Travelling Fellowship. reconstructive surgery, to learn from in Taiwan, a pioneer in novel approaches Foundation in Carlton, Monash Health in Microvascular Head and Neck oculoplastic surgeon, next visited the In America, Mr Beer spent time at leaders in the field and to compare to head and neck reconstructive surgery, and with a private practice based in Reconstructive surgery. Paces Plastic Surgery Centre, the private the MD Anderson Cancer Centre in different medical and education systems. and Mr Barry Jones in London, a Melbourne’s eastern suburbs, Mr Beer “Dr Yu has authored many papers on practice of Dr Foad Nahai, author of Houston, Texas, the Paces Plastic Surgery Mr Beer’s time in America became recognised international figure in facial said he was unprepared for the sheer refinements and the anatomical basis plastic and reconstruction surgery texts Centre in Atlanta, Georgia, the Memorial part of what turned into an 18-month aesthetic and reconstructive surgery. scale of the MD Anderson Cancer Centre to the anterolateral thigh flap and his used by most Australian Trainees. u

Page 32 / Surgical News June 2013 Surgical News June 2013 / Page 33 Successful Scholar

of his technical skills and knowledge, but also in relation to consultative problem-solving and professional cross- pollination. “As an individual surgeon in Australia, I think we have more experience than our counterparts in the US despite their enormous resources, not only because we have a broader case mix, but also because all of us here have to constantly take into account the limitations of our resources and ensure we put them to the best possible use,” he said. “At the same time, in Australia an average patient at every major hospital The 2012 American College of Surgeons International Scholarship & Fellowship recipients with Stephen Deane, chairman of the International Relations Committee. A warm welcome with Professor Yoshihiro Kimata - Okayama Japan. gets world-class treatment whereas in the US, a patient is not guaranteed He said that of the many cases of aes- After a month in New York, Mr Beer has been noted that some patients The final stop in the US for Mr Beer, Travelling Fellowship, attended many of that level of care outside major centres thetic and reconstructive surgery that he visited the Massachusetts General receive dramatic improvements in the before he headed to the UK to work for the scientific sessions and, along with and I think we should be very proud saw there the greatest point of difference Hospital at the invitation of the hospital symptoms of migraine which has led to three months at King Edward VII hospital other international scholars, delivered a of that. was in the use of acellular dermal matrix chief, Dr William Austen, who had the development of surgical procedures in in London under Mr Barry Jones, was presentation. “We may lack the same resources, in breast reconstruction which is used to mentored Mr Beer for the Fellowship and selected patients. attending the Annual Scientific Congress but not the skills or expertise or control the inframammary fold, to assist co-ordinated his travels through the US. “We know that it works, but the real of the American College of Surgeons held New career focus commitment and I grew in confidence in pocket control, help cover the inferior “One area that I had no previous key is choosing the right patient and in Chicago. Looking back, Mr Beer described his during this visit knowing Australian half of a breast implant and in some cases experience with was migraine surgery of I believe over the next decade it will There he participated in many time overseas as an extraordinary surgeons and Australian surgical to minimise the effects of rippling or which Dr Austen is a pioneer,” he said. become much clearer where surgery fits formal aspects of the ASC as part opportunity and one which he felt had training are up there with the best.” contour problems. “From our brow lift experience it into the treatment of migraine.” of the commitments attached to the helped shape his career, not just in terms With Karen Murphy 05398-Medical Personnel (90x130mm) Advt_Layout 1 1/08/12 12:08 PM Page 1

Specialist Consultants in permanent and temporary medical staff placements. Contact Carol Sheehan

Telephone 03 9429 6363 Facsimile 03 9596 4336 After hours 03 9596 4341 Email [email protected] Website www.csmedical.com.au Address 22 Erin St Richmond 3121

Page 34 / Surgical News June 2013 Surgical News June 2013 / Page 35 A survey was Audits of Surgical Mortality conducted in January 2013 to seek feedback from participants about the mortality audits. Two reminder emails were sent over the break period and Review of ANZASM survey feedback was An overwhelming majority of surgeons felt that the Surgical Mortality Audit was useful anonymous.

Key Points gave me the courage to take on some more complex cases in The Australian and New Zealand Audit of Surgical Mortality emergency situations, with good results so far. Figure 3: The audit is likely to make surgeons averse WORKSHOPS & SEMINARS (ANZASM) is an external peer-review audit by surgeons of Being aware that our work will be reviewed, there has been to risk taking in surgery deaths that occur under their surgical care. improvement in outcomes in the regions with the institution Figure 5: ANZASM has identified the following topics for further workshops • 92 (10 per cent) of invited surgeons responded to the survey of the audit. This has previously been seen in institutions and 4% 3% – are these relevant? • 83 per cent of respondents indicated that they completed the overseas, so there must be some changes! 18% surgical case form (SCF) We should be auditing PROCESS as well as outcomes. Out- 17% • 54 per cent of participants completed the SCF online via the comes are not as powerful an assessment tool, nor do they provide TechnicalTechnical misadventure misadventure Fellows Interface a solid template for protocol change and process evaluation. Early diagnosisEarly diagnosis and treatment and treatment of of sepsis sepsis • 80 per cent of Fellows found the feedback from second-line All comments are most valuable. Whether they lead to change will PatientPatient Transfer Transfer Issues Issues assessments useful depend on the individual circumstances and whether modifications CommunicationCommunication in handoverin handover • 79 per cent of respondents felt that the annual report are needed, required or appropriate. All input is valuable. publications and case note review booklets were informative 30% DVT prophylaxisDVT prophylaxis and and PE 26% • 73 per cent of participating surgeons felt that the ANZASM ManagingManaging the deteriorating the deteriorating patient patient FigureAudit 12: Annual Value reports are informative process could influence and improve patient outcomes Figure 12: Annual reports are informative Fluid balanceFluid balance and andresuscitation resuscitation • 48 per cent of participants felt that the audit made them risk Figure 1: Annual reports and case note booklets are informative Strongly agree Agree Neutral Disagree Avoiding delayAvoiding in delaydiagnosis in diagnosis and and treatment treatment 5 Strongly2% agree3% 8 9% averse in surgery 5 Strongly1% agree 9% 8 9% Strongly disagree No response to the question 4 Agree1% 2% 3% 9% 64 70% 0%0% 20% 20% 40% 40% 60% 80% 60% 100% 80% 100% • 82 per cent of surgeons agreed that they felt comfortable 4 Agree 64 70% 3 Neutral 14 15% Yes YesNo NotNo Sure NotNo response Sure No response with the audit process, reporting and assessor’s feedback. 3 15% Neutral 14 15% 2 15% Disagree 1 1% • Conversely, surgeons felt in 48 per cent of cases that 2 Disagree 1 1% 1 Strongly disagree 2 2% the audit made them averse to risk taking in surgery. 1 Strongly disagree 2 2% The aim of the survey was: 6 No response to the q3 3% • 21 per cent of surgeons felt that they disagreed that • Workshops on the subject of the deteriorating patient and 6 No response to the q3 3% • To ascertain if the audit was useful to surgeons. 92 100% the audit made them feel averse to risk taking in early diagnosis and treatment of sepsis continue to be popular 92 100% • To establish whether it had improved or influenced their surgery. educative topics. Future workshops could include topics such practice. 70% as fluid balance and communication in handover issues. • To enquire about the surgeon’s attitude towards the audit. 70% • To elicit information that would improve the audit and Figure 4: I feel comfortable, within the audit process, Comments from surgeons on how the process address any dissatisfaction surgeons might have. Strongly agree Agree reporting & comments on areas of concern & adverse can be improved: NeutralStrongly agree DisagreeAgree events relating to patient management StronglyNeutral disagree NoDisagree response to the question If the death is expected as the patient is elderly, then we shouldn’t Strongly disagree No response to the question Demographics have to fill out the whole form. I can see the value in the audit • 79 per cent of participants agreed that they found the annual • 83 per cent of participating surgeons completed the surgical 2% 1% 3% for people who have preventable deaths or management issues reports and 4case noteAgree booklets they received47 as informative.51% case form themselves. 3 Neutral 16 17% 23% and the audit generally is an excellent way of an external body 12% • 54 per cent of participants used the online web-based • 3 per cent of2 participantsDisagree disagreed however5 that5% the reports reviewing patients care. In those circumstances, I am sure the audit and booklets1 wereStrongly informative. disagree 0 0% Fellows Interface to complete the surgical case form. 0% would help the surgeon involved and hopefully lead to improved 6 No5% response4% to the q4 4% Processing and turnaround time is significantly reduced Figure2: ANZASM can influence and improve22% patient outcomes patient care. It is a good idea to continue to ensure that we don’t 92 100% when forms are submitted online. 0% have surgeons out there with excessive deaths. Otherwise who will 5% 4% Figure 13: ANZASM17% can influence and improve patient outcomes Figure 13: ANZASM can influence and improve22% patient outcomes monitor that? College would be required to intervene if a surgeon Audit Process and Feedback was clearly unsafe in practice with poor judgement and decision 17%5 Strongly0% agree4% 20 22% 5% 0% making. • Nearly half of respondents (48 per cent) were unaware that they 5 Strongly5% agree4% 20 22% could appeal against the findings of an assessor’s feedback. In It is difficult to ascertain whether the results of the POM circumstances where the treating surgeons did not agree with the 59% (Perioperative Mortality) data are actually causal in any reduction assessment, they are within their rights to request another assess- in mortality or improvement in outcomes. It has happened in some 51% Strongly agree Agree areas, contemporaneously, but probably as a general improvement in ment to be conducted. Neutral Disagree Strongly agree Agree preoperative and perioperative care, case selection and involvement • 80 per cent of participating surgeons felt that the feedback 51% Strongly disagree No response to the question Neutral Disagree by senior staff in more complex emergency cases and decision they received from a second-line assessment was useful to Strongly disagree No response to the question their practice. Feedback was considered not useful by 9 per Strongly agree Agree • 82 per cent of surgeons felt that they were making. This is most likely parallel to the introduction of POM data Figure 14:Neutral The audit is likely to make surgeonsDisagree averse to risk taking in surgery cent of respondents. Strongly disagree No response to the question comfortable with the overall audit process, gathering. There is now enough data published to show: especially when it came to feedback on areas of • 73 per cent of5 participantsStrongly agree agreed that they17 felt that18% the 1. Widespread variation in supervision of cases for emergency and Comments and feedback from surgeons on the ANZASM ANZASM process4 Agree could influence and28 improve30% patient concern and adverse events. assessment process: outcomes. 3 Neutral 24 26% • 3 per cent of participants disagreed however that they complex care Receipt of two successive assessments that were critical of • 5 per cent of2 participantsDisagree disagreed however16 that17% the process were comfortable with the feedback they received 2. Variation in DVT prophylaxis processes (internal subspecialty referrals causing delays), could not influence1 Strongly patient disagree outcomes. 4 4% from the audit process. 3. Variation in access to and utilisation of high level care u 6 No response to the q 3 3% Page 36 / Surgical News June 2013 92 100% Surgical News June 2013 / Page 37

Figure 15: The audit is leading to more consultant surgeons taking an active pa

5 Strongly agree 8 9% 4 Agree 25 27% 3 Neutral 40 43% 2 Disagree 12 13% 1 Strongly disagree 3 3% 6 No response to the q 4 4% 92 100% Audits of Surgical Mortality

These issues should be identified, and advice given to centres whose data show a systematic variation from the norm. To support the findings of Open workshops where actual cases from previous audits could be this survey: presented and discussed particularly controversial cases would be of great • Peer-reviewed feedback has benefit. been provided directly to It is an excellent peer reviewed activity. individual surgeons, via There needs to be a mechanism for more than one surgeon to be officially assessors’ comments, on involved in a patient’s report (maybe by producing multiple, duplicate forms individual cases. This is an for each patient). It would be useful in these cases if the feedback went to all essential component of the the consultants who had been involved. In some cases; nearly all of the forms audit as it provides specific are completed by registrars, without the consultant even seeing the request. targeted information on a case These have to be done on paper because the registrars can’t access the on-line by case basis. forms. The registrars rarely get feedback, even when they have effectively • Workshops and seminars been the treating doctor. When the assessments were passed back to the have been facilitated based registrars involved, they were astounded, because they had no idea the forms on regional reports and in- led to feedback. depth investigations of issues Although the paper form can be quicker, I try to complete forms on-line identified. These activities because it is easier for the audit. I still have to do a paper form if I complete have increased the quantity it the day the patient dies because I can’t generate my own blank electronic and quality of information form. disseminated on issues that One should ask whether there was something in the management of this have greatly affected clinical patient that could have led to more than 12 months of quality survival. There governance and patient care should be a second category of patient. The person, who has committed across the country. to a Nursing home or is in a facility requiring assisted living, should be • The audits will continue assessed in a separate category. Our biggest dilemma is how and will the to encourage the use of the ageing patient and the appropriate level of care be given, to an elderly person ‘Fellows Interface’ web-based who has accepted that their life is nearing its end and is ambivalent about tool as an important initiative intervention. which provides users with a Sometimes more robust clinical criticism may be necessary, but must dynamic, user-friendly tool to remain within craft group of experience. One must avoid being seen as enter online surgical case and imposing management/clinical ‘rules’ for an ‘ideal world’ which can be far complete first-line assessment ® from providing in all settings, e.g. rural. forms. This minimises data UpToDate entry time, the risk of errors Comments from surgeons on what further information could be collected: in data entry and hastens To learn more or to Major complications that do not result in death, but near death. There is a turnaround time. lot to learn from these cases. • The audit will continue to subscribe risk-free, visit External factors influencing care such as the reason for delay – having six produce and deliver an annual learn.uptodate.com/UTD fractured neck or femur cases in one day does not realistically allow any report and national case note Patients don’t just expect you to have all the right answers. hospital sterilisation department and other infrastructure to respond ideally. review booklet for distribution Or call +1-781-392-2000. Everything that is done is a compromise assisting the health system to assist to surgeons, Trainees and other They expect you to have them right now. Fortunately, there’s patients. clinical staff involved in patient UpToDate, the only reliable clinical resource that anticipates your Closer inspection is needed at the ageing patient. Also look closely at care. These cases in the booklet Trauma patients, as this is an area for constant improvement. were identified as offering questions, then helps you find accurate answers quickly – often in clinical insights and have been the time it takes to go from one patient to another. Over 700,000 Conclusions well received by the surgical clinicians worldwide rely on UpToDate for FAST clinical answers As the audit grows and develops, the ability to identify trends across community. Australia will further add to the ongoing knowledge of the particpants, and • Improvements have been made they trust. Shouldn’t you? Join your colleagues and subscribe to potentially lead to better outcomes for all surgical patients. to the surgical case form in UpToDate risk-free today! order to streamline the data and to collect more detail Linked in around a patient mortality with Guy Maddern infection. Follow UpToDate Chair, ANZASM

Page 38 / Surgical News June 2013

RACS_Print_Ad.indd 1 4/4/13 8:31 AM MUNCHAUSEN SYNDROME K Y M C Factitious disorders

Plate: Musings about Munchausen Syndrome, are there three types?

Surgical sketches and silhouettes

later that evening discharged herself. This clin- As we know musing is gazing meditatively ical history stimulated me to recount the story and refl ectively in a literary context. This led

OpusOPXIII XXVI of some of my other Munchausen experiences me to ponder the Munchausen syndrome. over the last three and a half decades, and three Whether by proxy or direct involvement FelixFelix Behan Behan cases in particular spring to mind – I wonder in the public or the private sectors, this VictorianVictorian Fellow Fellow if this is the statistical average (one every ten psychiatric disorder is classifi ed as a facti- years and I would welcome other comments). tious sequence of clinical episodes - fancied, n a recent theatre list I had an inter- The second case makes an interesting feigned or self-infl icted-. It is interesting how into his economy class seat for 24 hours; After repeat laparotomies, I think the background of thinking about intuitionesting clinical experience even at narrative, in the 1980’s. In those days the medi- this eponym arose: Richard Asher in 1951 was this may have been the aetiological abdominal cavity was eventually closed and the gut feelings or heuristic “rulesmy age. of In the Anaesthetic room a cal administrator allowed us to transfer insur- the fi rst to describe such self-harm, recall-

Date: 27-SEP-2009 O A Clinical Story about link (or kink). Following a stopover in after the fourth return to theatre which thumb” which apply in clinicalpatient medicine.was awaiting surgery. My registrar was ance patients to the private domain. Over a two ing Baron Munchausen in an article in the Singapore, he arrived back in Melbourne included finally a Hartmann’s procedure. My clinical diagnosis innot this there with me to present the details on his month period a general surgeon and I operated Lancet. He mentioned how the Baron had a with gastro-intestinal symptoms. His local Incidentally, Hartmann worked at the instance was absolutely linewrong, of management. but He had mentioned before- on this young man a number of times. He had list of fantastic stories, beyond belief, refl ect- GP diagnosed gastroenteritis from food Hospital Dieu in Paris, Dupuytren’s old my hunch was that his conditionhand that this lady had presented for removal sustained abdominal injuries in a motor vehi- ing daring exploits, quite unbelievable. In his poisoning and reassured him it would haunt and described this procedure in was life threatening. Hisof restricted something off her leg. cle accident, a perfectly credible story until I obituary in the British Medical Journal, it was IntuitionHunches come from right brain activity and should be trusted more often settle. His son phoned me that afternoon 1921 and he himself died in 1952; I got breathing was not of cardiacWhen I addressed the patient in this later questioned the multitudinous mature mentioned how Asher respectfully dedicated and said “you are the only guy my father this pearl from Professor Ellis’s notes origin, but the result of abdominalcontext, my question was “now what am I abdominal wall scars – another warning sign. this syndrome to the Baron will listen to – can you speak to him?” on Clinical Surgery – a person I met in distension restricting respiratoryremoving andtoday?” She said “I have a scar on the Knowing full well that I could do next London in a recent presentation I did diaphragmatic movement.leg Howeverat a skin graftthe site and I was told you could n the March 2013 edition of to nothing over a phone I offered some at The Royal College of Surgeons. He MICA ambulance team expeditiouslypossibly fi x it”. Previous attempts at serial scar “As one of my mentors and later colleagues said Surgical News, in the section of consolation. I then rang the father. In our even bought my textbook for the Kings transported him to the closestrevision hospital. had been unsuccessful. People knew years ago “Plastic surgeons are sometimes described Audits of Surgical Mortality a case conversation he just said “Felix, I don’t feel College Library. He was a sparkling and They short circuited anyI delayhave throughsuccessfully closed similar defects in as psychiatrists with knives” – but not always.” of delayed diagnosis of a perforated well, I can’t breathe and I feel distended”. dynamic wit in his eightieth year and held the Emergency Department.melanoma The pre- patients with the usual keystone ischaemic intestine was reviewed, That to me was a key indication of some the audience in his palm, the Michael operative imaging with aneurysmaltechnique. speed Iunder the authorship of Guy Maddern. impending disaster – thinking it may Parkinson of surgery. would have been completedLike in transit any experienced to surgeon, I exposed Three days before discharge he asked a The Baron served in the Russian mili- For those who missed it, this was a have been a heart problem. I asked the My friend, finally left ICU, but there is theatre. A surgical team wasthe whole available lower that limb to examine it and found, young nurse for $15 so that his clothes could tary forces against the Ottoman Empire and case study of an elderly patient with simple question, “Have you had any heart a funny twist in this tale. The ICU team evening and subsequentlyto mywith horror, the series she had a donor site dressing on be dry-cleaned. I asked the young lady some acquired a reputation for witty and exagger- co-morbidities including dementia and disease in the past?” He told me he had asked the family, during this crisis period, of laparotomies to assessher bowel upper viability thigh. On further questioning, it months later whether she had ever received her ated tales and became the subject of numerous Page: 40 an earlier admission for a small bowel had coronary stents at the Epworth some to sign a document stating the patient in a combined consultativetranspired, manner. this had been there for six months. money. She was never paid. texts published in 1862 by Gustav Doré, from obstruction managed conservatively. time back. was “not for resuscitation”. Some say this This resulted in a successfulI then outcome glanced at her notes on the anaesthetic Some years later, I was doing Monday balloon fl ights, to taming wolves to shooting Subsequently on re-admission he had I exclaimed dramatically and my tone must is a feature characteristic of ICU staff against all the odds; thanksbench. to this There team were and fi ve volumes, each about fi ve morning rounds when I encountered the fl ocks of ducks and being mauled by bears (en. signs of abdominal distension and have reflected my anxiety – “holy s_ _ _ !” where they handle death regularly and the public hospital system,inches the outcome thick – “a warning sign”. At this stage the same individual, recently admitted again wikipedia.org). vomiting associated with multiple fluid just came out. I advised him to phone the the management team make decisions was favourable (if you are alarmreally sickbells go were to a ringing and I asked her “why with abdominal trauma. Needless to say he However the idea occurred to me that levels on X-ray. He was reviewed by the MICA ambulance immediately in case he about the impending outcome of a person public hospital). From myhave general you surgical been in hospital so often?” suspect- signed himself out within the hour when I this recollection had a similar ring to another consultant the following day. The patient was having an impending infarction. His dangerously ill. days, we always learnt a softing abdomen some major is clinical catastrophe like neph- confronted him. particular person who also wrote about was assessed as becoming pre-moribund wife even asked “Should I go with him?” Once more the son phoned me on a soft option, but when thererotic is syndrome.guarding, She gave a history of repeat A further story relates to a nursing aide fi ctional and fanciful adventures. He was far due to the acute abdomen, and proceeded I responded “You had better – it might be that Saturday morning, 10 days after the this must galvanise activityoverdose – it sounds needing like ICU admission. It transpired who burnt her fi nger on a steriliser. The regis- more readable and he became the second most to laparotomy as a life saving option. the last time you hold his hand”. acute admission, to ask me whether or something Bertie Coates mayshe washave seen said, in and our unit six months earlier and trar in the Emergency Department referred translated author of all time, (second only to A perforated ischaemic terminal ileum not they should sign as it was still touch perhaps he did. it was found that she has been putting oven her to me for grafting (which failed), which Agatha Christie). Having written Journey to was identified, associated with gross Bowel necrosis and go regarding recovery. My response So I publicly thank all cleanerinvolved on (the the skin graft donor site. was repeated and failed a second time before the Centre of the Earth in 1864, then 20,000 peritonitis. A series of open laparotomies By then the patient was in a pre-deathly was simply “under no circumstances do surgeons involved will recogniseI took the her into theatre and manually debri- doing a cross fi nger fl ap. The resultant stiff Leagues Under the Sea in 1869, and Around the World in 80 days in 1873 – none other than the followed. Then the premature removal state. The ambulance diverted to a you sign that document, as without it, story) from the ambulanceded team the woundto the under general anaesthesia and fi nger years later resulted in a ray amputation dressed it with the usual donor site techniques, of the middle fi nger, by another specialist, as great Jules Gabriel Verne (1828-1905) of staples from an infected wound in regional teaching hospital thinking they the onus remains on the ICU team to nursing staff and other surgical personnel. reinforced with soft topical non-removable I discovered when she came back to me for a He lived along the Loire Valley. At the ICU led to wound dehiscence which would not make it to Melbourne – an carry on active treatment.” Yes, the patient My friendPub: is CMC TOTS still alive and well and still dressings, and signed it “not to be removed medico legal report seeking compensation for school of St Donation College, one of his accelerated his demise. The patient’s hour away in peak hour traffic. Yes on recovered. He went back to the ward alive buying art on the international art scene without my permission”. I heard that she had this work related injury. tutors in drawing and mathematics was possi- condition deteriorated and with the family admission, he was able to bypass the with all his mental faculties and eventually in Paris on a regular basis. He is now a in consultation the decision was made to wait in the Emergency Department. Pre- went home with a colostomy after a 3-4 little wary of internationalSURGICAL travel and NEWS I am P40 / Vol:10 No:8 September 2009 withdraw active treatment. operative imaging must have confirmed week stint in hospital, one of the minority sure he might even upgrade his future The assessor’s comments in Surgical the bowel necrosis and fluid levels and (I think 5 per cent) to survive ischaemic travel arrangements. News highlighted certain aspects of the he was on the table for a laparotomy in bowel necrosis. On another tack I read recently Ross case including an absence of suspicion of a rapid time frame, for this perforated Gittins’s recent in The Age quoting the the severity of the case before the overnight This article brought to my mind an a buying trip in Paris. He had done this ischaemic intestine. The consultant on Hunch was right German psychologist Gigerenzer of the deterioration. Guarding of the abdomen experience of my own where intuition almost yearly throughout his commercial call resected the bowel and left the open An interesting valete comment came from Planck Institute from his recent book “On should ring bells in relation to the urgency worked and “gut feelings” (my own this life. His touch of frugality meant he did laparotomy wound for the next stage. one of the senior ICU staff, when all was Gut Feelings”. He goes on to say that since of surgical management and with poor time) led to a fortunate outcome which not waste money on Business Class (like The next day one of the academics from done. After the chocolates and champagne The Age of Enlightenment, universities parenteral nutrition and subsequently was not based on logical deduction. Here the chairman of IKEA, who had the same a major teaching hospital came to assist had been passed around, his son was have taught students to think logically, the issue of mistakenly removing sutures is that story. philosophy, one often seen in people who and further resection was completed over asked, “Has someone been tutoring analysing problems to arrive at a definitive prematurely, all these factors contributed to Some years back a friend of mine in recall the frugal days of the Depression). the ensuing days because of the degree of you in the background throughout this conclusion. But often better results are his demise. the Art and Antiques trade returned from This tall man, of 74 years, was cramped questionable bowel viability. crisis?” Interesting. This brings me to the achieved by employing the subconscious.

Page 40 / Surgical News June 2013 Surgical News June 2013 / Page 41 Surgical sketches and silhouettes College Awards

Congratulations and instinctively. He goes on to state on your achievements A photograph of the musical that deliberation takes away any instrument, made by Naderman intuitive influence. In conclusion, he who was the harp maker to Marie states that cognitive limitations exist Previous medal winner Brandon Adams and Ruth Blackham with Susan and Mary Corboy. Antoinette. In the label inside the when too much information confuses instrument it reads Luthier Facteur and misleads. de Harpe ordinaire de service de la Reine – Harp maker in the service of the Queen. In 1797 the Instinctive behaviour word Reine is crossed out which is a These instinctive mental shortcuts are subtle reference to the be-heading what psychologists sometime describe of Marie Antionette in 1792. Simply as “heuristic” and may seem quite the maker was divorcing himself illogical to the academically trained from any Royal connections to mind. Any fast and frugal decisions are save his own head. The harp was likely to work. An instinctive behaviour purchased in Paris by my friend after produces a successful result without his recovery and is now housed relying on any logical sequence. It is in an important art collection in the intelligence and the subconscious Melbourne. This may never have awareness, without thinking, which occurred if he had not been one of produces a beneficial outcome. the lucky 5 per cent. According to the renowned neuropsychologist Roger Spery, 1: The instrument in the antique intuition is a right brain activity, while John Corboy Medal 2012 Recipient: Dr Ruth Blackham “restorer’s cave” (or the “dealer’s factual and mathematical analysis are den” – I know not which) left brain activities. Intuition can also r Ruth Blackham has Junior Medical Officer Committee, of the medical staff and interdisciplinary health 1 with a single action paddle be noted in writings which might have demonstrated and continues Postgraduate Medical Council of Western professionals. Ruth has also been active mechanism with crochettes a spiritual flavour. As Thomas Merton to demonstrate all the qualities Australia. More recently, Ruth is a member academically and is currently undertaking craved and glided with D discusses in his essays, is it a transition the John Corboy medal recognises and of the Ethics and Medicolegal Committee, a Masters in Surgery with a focus on Chinoiserie decoration and a between the common touch of the celebrates. an AMA Federal Council subcommittee, Simulation in Surgical Education. She painted sound board. earthly knowledge and the spiritual A General Surgical Trainee based the RACS Surgeons as Educators recently published an article “Surgical 2: The maker’s mark for this 18th inclination beyond, which appear as in Perth, Western Australia, she is a Committee, the Australian and New Simulators in Training: Are we there yet?” century musical instrument flashes of illumination. competent and compassionate surgeon, Zealand Gastro Oesophageal Surgeons in the ANZ Journal of Surgery. Ruth also dated 1784. Three years before 2 To cap it all, even Einstein gets into who regularly makes time to supervise, Association, and the AMA Doctors in has an interest in legal medicine. the French Revolution. the act when he said that “the intuitive educate and encourage surgical Trainees to Training. Truly a remarkable role model and 3 3: This is external signature mind is a sacred gift and the rational expand their surgical abilities. Her commitment to the representation accomplished clinician, Ruth is a regular important verification for mind is a servant forever.” Ruth’s service to the surgical community of Surgical Trainees has not distracted guest speaker for both Western Australian authenticity - The harp maker to Yes I had a little bit of luck in this is commendable. She was elected as her from her surgical training. As a SET 5 Medical School Surgical Societies. She Marie Antoinette case/story, I suspected something the General Surgery Representative of Trainee at the Royal Perth Hospital, Ruth has demonstrated exceptional leadership Daniel Kahneman in his book ominous. Fortunately, the public the RACS Surgical Trainees Association continues to perform as an outstanding qualities and continues to inspire post ‘Thinking Fast and Slow’, for which hospital system was available, experts from 2009–2010 while serving on other registrar while balancing a multitude graduate medical students in their pursuit he won the Nobel Prize for economics, were on hand, time was of the essence committees including AMA Doctors in of other interests around education and of a surgical career. demonstrated the value of such and what a fortunate outcome – all over Training WA Committee (2008-2010) and research, including advocating for junior Ruth is a worthy recipient of the John decisions which we make spontaneously the phone. prior to that in 2006 she was the Chair, doctor wellbeing and teaching junior Corboy Medal.

Please write to The Editor, Surgical News, Royal Australasian College of Surgeons, Surgical News always welcomes letters from readers. 250-290 Spring St, East Melbourne. Victoria 3002 or email: [email protected]

Page 42 / Surgical News June 2013 Surgical News June 2013 / Page 43 Article of Interest

You begin to wonder whether you’ve “done the right thing by the patient ”

Limited resources The hospital was located in a two-storey house in the centre of the village. On the ground floor we had a resuscitation room, an X-ray facility, a sterilising area and the operating theatre. If a patient needed an emergency operation they came through A Letter from Syria the system very quickly. Upstairs, we had three wards and an office, then an open rooftop with our laundry. I had to adapt to not having the same Dr Tamaris Hoffman, a surgeon from Wangaratta, Victoria, recently spent six weeks resources that I’m used to in Australia, such as a CT scanner, or a mobile X-ray machine. in Syria on her first field placement with Médecins Sans Frontières. Here she talks But it didn’t make much difference manag- about her experiences working as a surgeon in conflict conditions. ing patients. We worked on first principles (basic clinical facts and knowledge in the absence of elaborate diagnostic investiga- was working in a surgical project in devastated. You begin to wonder whether a dressing change, and sometimes he’d tions) and I think it made me a better the north of Syria, mostly doing war you’ve done the right thing by the patient. wake up from the anaesthetic and think I surgeon in some ways. It makes you aware Isurgery on people who had injuries But there were few other options for was his mother, so he’d hold my hand and that you can cope with just about anything. due to gunshots. There were two broad this young man. We also had to graft want to kiss me! We dressed his burns It builds your confidence. categories of injuries – orthopaedic his burns, and he ended up spending every second day for three weeks, and his I was mostly confined to the hospital injuries and abdominal injuries. Many four weeks in the hospital. I would often wounds healed beautifully. He eventually and the house. We had a 50 metre walk orthopaedic injuries were unsalvageable think how terrifying it must have been left hospital without needing any grafting, between the two, so I saw nothing else of and I performed five amputations, for him, being hit by a rocket in Aleppo which shows what a good job nature Syria. That confinement was difficult to including an amputation of an arm. and running down the street with such does on children. When I said goodbye cope with; it drove me mad actually! That Gunshot wounds to the abdomen also serious burns. He’ll have that in his to him I cried… it was awful! He was a was the most challenging aspect of my caused a great deal of damage and I memory forever. lovely little boy and very brave. He put up time in Syria. performed nine laparotomies for these with those dressing changes without any The most rewarding thing was realising injuries alone. A brave young boy complaint. wards whatsoever. We also had a no- survive will be disabled. There’ll be many that people want the same things from One young man I remember well was As well as the war surgery, another We responded to one mass casualty weapons policy that was strictly enforced families without a means of support, and life, no matter where they are in the a 19-year-old who was hit by rocket fire large component of the work was event when I was there, after fighting and worked very well. there won’t be a fit workforce to rebuild world. In Syria, which has such a different and unfortunately sustained extensive surgery among children who had been around Idlib. There were heavy casualties the country. culture to Australia, people want a secure burns. He wasn’t a fighter, just a civilian accidentally burned as I was in Syria on both sides, plus a number of prisoners A lost generation Part of my role was working with and place for their family, they want education who happened to be in the wrong place during winter, and families were using were freed from the local prison. We In Syria I operated for 10 to 12 hours a day, training Syrian staff. I was impressed for their children and they want to make at the wrong time. He had extensive, full fuel for heating. One boy who made received about 30 patients in all, including for 35 days straight. I kept a log of all my with how well trained the Syrian theatre sure they can provide for their family. thickness burns to his arms and legs. a big impact on me was aged 12, with patients from the prison, from the rebels operating and overall I did 219 operations assistants were. We learnt a lot from each You realise that no matter what religion He’d also sustained shrapnel injuries to extensive burns from playing with fuel. and from the regime. As soon as they on 80 patients, 75 of whom were men. other, and chatted about our lives outside you are or what colour you are or what his pelvis, so I had to remove his entire He had burns on the back and front of walked through the door, they were just The average age of the patient was 24. The the hospital. The Syrian staff had a huge language you speak, people all want the bowel and give him a permanent stoma. his trunk, on his legs, feet, arms, hands patients – there wasn’t any problem at all problem is, you wonder about the future thirst for knowledge of the outside world same basic things. When he woke up and I told him he now and face. I thought he might not make it. that they were from different sides of the of the country when so many young men and wanted to know all about my home Tamaris Hoffman had a colostomy bag, at age 19, he was He needed anaesthetic every time he had conflict. I don’t recall any conflict in the have been killed, and many of those who and family in Australia. Victorian Fellow

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Page 46 / Surgical News June 2013 Surgical News June 2013 / Page 47 Foundation for Surgery

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Signature: ...... Credit Card No: Expiry / Please send this form to: The College has produced a book, Timor Leste Program Your passion. Card Holder’s Name - block letters Card Holder’s Signature Date called My Timor Heart, to celebrate College of Surgeons’ Gardens Your skill. our achievements in Timor Leste. Royal Australasian College of Surgeons I would like my donation to help support: My Timor Heart will recognise the 250-290 Spring Street, Your legacy. General Foundation Programs International Development Programs extraordinary efforts of the medical East Melbourne. VIC 3002 Scholarship and Fellowship Programs Indigenous Health Programs AUSTRALIA I have a potential contribution to the Cultural Gifts Program volunteers in Timor Leste, and the I do not give permission for acknowledgement of my gift in any College publication life-changing impact their work has Email: [email protected], I would like to donate Your on people living in a country that Phone: +61 3 9249 to o u1230r Foundation for Surgery Please send your donation to: Fax: +61 3 9249All donations 1236 are tax deductible Foundation. AUSTRALIA & OTHER COUNTRIES NEW ZEALAND continues to struggle with the legacy Foundation for Surgery Foundation for Surgery

of years of civil war and violence. Name: 250 - 290 Spring Street PO Box 7451 The RoyalAddress: Australasian College of Surgeons takes the issue ofTelephone: security and privacy East Melbourne , VIC 3002 Newtown, 6242 Wellington Email: Speciality: Australia New Zealand seriously. Information contained in this form will not be used for any other purposes Enclosed is my cheque or bank draft (payable to Foundation for Surgery) for $ .

Please debit my credit card account for $ .

Page 48 / Surgical News June 2013 Mastercard Visa AMEX Diners Club NZ Bankcard Surgical News June 2013 / Page 49

Credit Card No: Expiry /

Your passion. Card Holder’s Name - block letters Card Holder’s Signature Date

Your skill. I would like my donation to help support: Your legacy. General Foundation Programs International Development Programs Scholarship and Fellowship Programs Indigenous Health Programs I have a potential contribution to the Cultural Gifts Program Your I do not give permission for acknowledgement of my gift in any College publication Please send your donation to: Foundation. AUSTRALIA & OTHER COUNTRIES NEW ZEALAND Foundation for Surgery Foundation for Surgery 250 - 290 Spring Street PO Box 7451 East Melbourne , VIC 3002 Newtown, 6242 Wellington Australia New Zealand The Royal Australasian College of Surgeons Royal Australasian College of Surgeons The Royal Australasian Member Advantage Benefit Program Nominations invited for the College of Surgeons seeks a SURGEONS INTERNATIONAL AWARD

The Surgeons International Award provides for doctors, Obstetrician & nurses or other health professionals from developing communities to undertake short term visits to one or Gynaecologist to more Australian or New Zealand hospitals to acquire the work in Timor Leste (East Timor) knowledge, skills and contacts needed for the promotion of improved health services in the recipient’s country. The Award may cover a return economy class airfare, Are you up for the necessary accommodation costs and living expenses for the recipient. The value of the award varies up to a total challenge? amount of AU $12,000, depending on the requirements of [ ] the candidate’s program. Fellows participating in the RACS International Development Program or international outreach work are encouraged to nominate worthy individuals they have identified while undertaking outreach work. Fellows who nominate worthy individuals with whom If you are: they have had contact must be willing to accept the • A formally qualified and registered Obstetrician & responsibility for arranging a suitable program and acting Gynaecologist with a FRANZCOG (or similar qualification) as a personal host to the award recipient. • Keen and experienced to teach junior medical staff • Passionate about contributing to women’s NOMINATIONS MUST INCLUDE health in a developing context > Personal and professional information concerning the nominee; • Sensitive and adaptable to cultural differences Escape the cold, enjoy the savings > Objectives of the proposed visit; • Available for deployment in early 2014 for at > Anticipated benefits to the nominee and their home country; least 12 months Take advantage of your RACS Benefits this winter with great offers on travel > Names of the International Development Program team … then we would love to hear from you! members responsible for organising the visit (including accommodation, training program and travel within Australia); > An outline of the proposed training program and ACTIVITIES activities; and The Faculty of Medicine and Health Sciences of the > Letters of recommendation from the nominee’s hospital National University of Timor Leste has started delivering and/or Health Department with an indication of the local an 18-month Post Graduate (PG) Diploma course in five Accommodation HotelClub Travel Insurance* Range of cover options importance of any upskilling resulting from the Award. streams: Surgery, Anaesthesia, Obstetrics, Paediatrics and Explore the world and enjoy up to 15% off accommodation rates at thousands of Choose from a range of cover options, including short trip, annual and corporate Internal Medicine. RACS is an important implementing hotels worldwide. Compare rates from lists of hotels available at your destination travel insurance. Convenient online quotes and booking facility is available via the partner funded by AusAID, the Australian Government’s through our easy-to-use reservation facility. Bookings accessible online. Member Advantage website. overseas aid agency. An experienced and passionate Obstetrician & Gynaecologist is required to join the Timor Leste Program. Packaged Tours Intrepid Travel Car Rental AVIS Your role has one primary aim; you will mentor and teach Enjoy a 10% discount on all land tours through Intrepid Travel. Trek through the Access specially negotiated rates and reduced excess liability for passenger vehicle junior doctors enrolled in the PG Diploma in Obstetrics jungles of Borneo, stroll along the Great Wall or enjoy a gourmet food adventure in rental in Australia, New Zealand and other locations worldwide. Quote RACS AWD together with national and other international faculty Europe. Browse your options today via the Member Advantage website. number P203701 when making a booking. Available online or over the phone. members. Clinical work forms part of the job, but is always directed towards mentoring and training the junior medical staff and trainees. Airline Lounge Memberships Qantas Club Accommodation Best Western Dr Malemo Luc Kalisya from the Democratic Republic of Congo was supported to participate at the RACS ASC 2013 in Auckland, An attractive remuneration package includes Take advantage of our corporate rates and save hundreds on Qantas Club airline Save 10% off the best available rate at any Best Western location across Australia, and undertook a four week hospital attachment at Princess accommodation in Timor Leste’s vibrant capital city. lounge memberships. Save $355 (AUD) on new two year memberships, and $253 New Zealand and Fiji. To make a booking, call Best Western on 131 779 (Australia) Alexandra Hospital under the mentorship of Dr Neil Wetzig. Dr (AUD) on 1 year memberships. or 0800 237 893 (NZ) and mention the corporate discount number: 01340340. Wetzig has been working with Dr Luc and his colleagues during LOCATION annual visits to the D.R. Congo for over 10 years. You will work at Hospital Nacional Guido Valadares (HNGV), the national hospital in Dili Airline Lounge Memberships Koru Club Money Transfers Ozforex CONTACT INFORMATION Enjoy savings of up to $186 (NZD)^ on Koru Club memberships; Air New Zealand’s Ozforex offers a range of money management services to Fellows and Trainees, For further information or to submit an application Interested? airline lounge. Members enjoy access to both Air New Zealand and Virgin Australia including Travel Money cards and international transfers for business transactions International Scholarships Officer Send your CV & Cover Letter to RACS today! Royal Australasian College of Surgeons lounges across New Zealand and Australia. and bill payments. College of Surgeons’ Gardens Contact: 250 – 290 Spring St, East Melbourne VIC 3002, Australia Ms Kate Groves, Senior Program Officer Or by fax or email to: [email protected] +61 3 9276 7413 Telephone: +61 3 9249 1211 Fax: +61 3 9276 7431 The Timor Leste Program currently employs six full-time clinicians at HNGV and coordinates around 16 specialist team visits across Timor Call Member Advantage on 1300 853 352 Email: [email protected] Leste per year. or visit www.memberadvantage.com.au/racs NZ Fellows & Trainees call +61 3 9695 8997

Page 50 / Surgical News June 2013 ^ Savings include $100 off the joinng fee, and an $86 discount on a two year membership. All Fees and savings are quoted in NZD. * Available to Australian residents only.Surgical News June 2013 / Page 51 ADVANCED ALLERGY PROTECTION & SENSITIVITY

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