Anaesthesia Points West

Autumn 2OO7 rssN 0265-9212 THE SOCIETY OF ANAESTHETISTS OF THE SOUTH WESTERN REGION

PRESIDENT: DR JOHN CARTER Frenchay

VICE PRESIDENT: DRNEVILLE GOODMAN Southmead

PRESIDENT-ELECT: SIRPETERSIMPSON Frenchay

IIONORARY SECRETARY: DRE. MORRIS Southmead

SECRETARY TO HON. SECRETARY: Ms K. PRYS-ROBERTS UBHT

HONORARY TREASI]RER: DRA. BURGESS Plymouth

LOCAL ORGAMSERS: DR S. SHINDE Frenchay (Jubilee meeting) DRA. BURGESS Plymouth/Guernsey

TRAINEE REPRESENTATIVES: DR S. CARTY South West School DRI. THOMAS Bristol School

EDITORIAL COMMITTEE: DRJ. PITTMAN Editor, Exeter DRF. DONALD Assistant Editor, Southmead Ms K. WILKINSON/ Secretaries to Editor, Ms G. HUSBAND Exeter

WEBSITE: DRK. SPOONER Cardiff

www.saswr.co.uk ANAESTHESIA POINTS WEST

CONTENTS Vol.40 No.2 Autumn,2007 Page Committee Members I Contents 2 Editorial Dr.I Pittman J Future Meetings of the Society 4 News of the West 5 Examination Successes and Honours t7 Society Takes Budapest By Storm Dr E Morris l9 A Survey ofAnaesthetic Practice for Dr G Werrett 24 Carotid Endarterectomy in the Southwest Dr N Preston Region of the UK Dr Q Milner Epidural Analgesia in a New Zealand Dr G Werrett 28 Tertiary Hospital before and after Dr H Horton publication of the MASTER study - Dr R Craig Evidence Based Medicine in action? Dr R French Michael Turstall andthe Development of DrTDawes 32 Entonox MMC & MTAS - a Trainer's View Dr C Johnson 36 Clinical Systems Engineering DrN Williams 4t SASWR Members And Anaesthesia In Dr B McCormick The Developing World Dr I Wilson 47 Reflections on Thirry-Thee Years of Dr P Marshall 5l Anaesthesia in The South West Region Securing the Airway: DrD Snow 55 The Torbay Experience Dr M Stocker DrA Varvinskiy Dr S Medakkar More Thoughts on Anaesthesia - Dr H Blanshard 57 A Decade on and into the Future All of the following are true: DrN Goodman 60 MCQs in anaesthesia exams Three Days by the Sea GAT 2007 Dr M Thomas, Dr A Binks, 62 Dr C Dowse, Dr J Gatward, Dr A Mayell lst West of England Anaesthesia Update, DrA Johnson 64 St Anton, 2007 Wine Column Dr T Perris 66 Poem R Forward 67 Crossword B Perriss 68 Society Prizes 69 Notice to Contributors 1l

@2001 The Society of Anaesthetists of the South Western Region Editorial

The Society of Anaesthetists of the South West NHS and Hannah Blanshard provides us with some Region (SASWR) has reached its 60th Anniversary more of her thoughts on where anaesthesia is going and is still going strong. Regional Societies were in the future. For many years Torbay Consultants founded at the suggestion of the Minister of Health have been developing a nationally recognised in 1947 with the aim of spreading knowledge, expertise in managing the difficult airway. How this promoting friendship and encouraging co-operation came about is described by Dr Snow et al. Their between local colleagues in specialties across the department organise an excellent course for those United Kingdom. Enlightened thinking which helped wanting any further training. Supporting the establish good professional development of our advancement of anaesthesia in the developing world specialty and ourselves. We should be proud that has been a long-term concern of many south west SASWR continues to meet these goals and remains anaesthetists. Plenty of individuals have done their an excellent example of an effective regional society. bit and are mentioned in the article by Iain Wilson Congratulations to everyone who over the last sixty and Bruce McCormick. Both authors have dedicated years has given their time and energy to keep the huge amounts of time and energy to improving the organization so buoyant. desperate state of anaesthesia in many parts of the Anaesthesia Points West did not arrive through world. It remains a real on-going challenge and your post box for another twenty-one years but since plenty ofopporhrnities exist for those interested. The then has reliably reached the members of the Society excellent articles by Chris Johnson and Nicky twice yearly. It remains an integral part of the Williams show us that working in the NHS has its Society filled with a wide array of articles covering real challenges too, be they in training or the delivery all aspects of anaesthesia. The structure of the ofpatient care. journal has remained consistent with core articles With sixty years on the clock the Society is such as 'News of the West' being particularly probably the most vibrant regional anaesthetic popular. There are many Anaesthetists, particularly society in England. However the next 60 years may those trained in the south west, who learn more about prove a far greater challenge. The Society is its their friends in this article than they ever do from the members, and recruitment must continue yearly Christmas card! The Perris crossword has enthusiastically. Ten years ago it was proposed that been a regular feature almost since the first edition Linkmen be selected in all the hospitals of the south and the poetry of Robin Forward is a long west to represent the Society. Their responsibilities established and much loved item. Another author included encouraging existing (especially new) who has produced a continuous stream ofinteresting, consultants and trainees to join the Society and humorous and thought-provoking articles over the attend its meetings. This remains an imporlant role. last twenty years is (Vice-President), Dr Neville Large numbers of new Consultant Anaesthetists have Goodman. Opening each new communication from come to work in the south west from other regions Neville always generates a certain level of and have not been affrliated with the SASWR during excitement for the Editor. You can never predict the their training. We need to encourage these colleagues subject matter in advance and of course there will be to join up. Run Through training will mean trainees no need for any editorial input. As he has reached stay in the south west for long periods of time and retirement, he has decided to make this his last piece through Anaesthesia Points West and SASWR there of writing, so I must thank him for the many years of are excellent opportunities to win prizes, publish contributing. articles and make contacts. Linkmen spread the There are several articles in this Diamond Jubilee word. edition that I requested the authors write. Some history seemed appropriate; Paul Marshall gives us James Pittman an insightful account of 30 years working in the Exeter Future Meetings of the Society

Spring 2008 Spring 2009 Plymouth/Guernsey, final dates to be arranged Cheltenham

Autumn 2008 Autumn 2009 North Bristol, final dates to be arranged Exeter News of the 'West

This is where you are kept uplo-date on all the news and gossip from each departrnent in the South Western Region. The name of the correspondent appears at the end of each contribution and he/she is also SASWR LINKPERSON for that department. Anyone wishing to find out more about SASWR or wishing to join should search out the local linkperson who will readily supply details and qn application form. In addition to other benefits, members receive the twice yearly editions of APW- FREE!

Barnstaple Operating Theatre Orderlies (aka Porters). The No doubt every department in the region has a fund Orderlies were a great bunch of characters who not of horror stories about the MMC debacle so I'll only moved patients around but "lubricated" the spare you the grisly details. Suffice to say that most working of the operating theatres in a hundred and of our excellent trainees found a job somewhere, one unSung tways. Surprise, surprise this many after months of anxiefy and not always what masterstroke has strangled at birth the plan to they really wanted. With a bare two weeks to spare "improve theatre efficiency" which is one of the we acquired a mixed bag of trainees, just sufficient main planks of the Trust's strategy to meet the l8 to run a rota. Thanks to Kate Tipping for hanging on week target: - pure genius! in there and fighting our corner. Steve Forster We have also been forhrnate in acquiring two new Staff Grades; Nick Sheppard (well known in Truro) Bath & Katrina Scholer, who was an SHO with us about We very much hope our neighbours just north of us five years ago before leaving to expand her have recovered from the terrible summer flooding in anaesthetic horizons in Sheffield. Nick is away in Gloucester and Cheltenham. Having been one of the Spain as I write this (mid September) getting hitched last to inch through on the gravel of the M5 central to Maria in her home town of Jerez; best wishes to reservation with all six lanes under two feet of them. water, I can only imagine the havoc and misery it The new department accommodation has been a must have caused. great success, particularly for educational and The department here is a hive of feverish physical management activities. We now have almost an activity, presumably in preparation for 2012. Tom embarrassment of computers; this makes the Simpson has taken up triathlons, which is how favourite excuse for not having read an e-mail, "I Lance Armstrong started out. Talking of which, couldn't get on", redundant (pity). Malcolm Thornton completed the most gruelling leg The whole department are in awe of Rod of this year's Tour de France; we should all put our Lindenbaum who followed in the footsteps of Guy hands together and applaud how, even at work, our Rousseau and completed the Etape du Tour (a stage Chairman has broken with tradition and gone out on of the Tour de France). It was over 200km, five a limb to wrestle with his fitness levels whilst still Pyrrenean mountain passes and a very hot day. managing to get to grips with the trainees. Vaughan Showing his usual cool judgement Rod paced Martin continues to complete his annual cycle to himself so that he had just one and a half minutes to London to raise yet more funds for Medical spare before the barrier came down. Well done! Research (l7th time in 24 years). Jeff Handel has To bring you bang up to date last night the been off roaming Edinburgh by moonlight wearing a anaesthetists lost the "Sevo" trophy at the annual large pair of false breasts (allegedly for charity). Pool match against the ODAs/ODPs. At least we put Beccy Leslie has also been doing superb charitable up a better fight than England in their defence of the work for the Kenyan Orphanage Project (KOP), Rugby World Cup. Thick heads all round today so giving many children a future and putting one young please excuse any syntax or spelling errors in this man through Medical School. report. Steve Hill has been the 'doc' on an Everest Finally let me fill you in on the latest bit of expedition. The purpose was to see if a paraglider management lunacy. They have abolished the could be flown over the top of Everest without being shot down by the Chinese. We are still trying to from the always 'top notch' Services contingent work out exactly what the hypoxia has done to him. when Curtis Whittle returned from Australia, to take He has nearly finished building his own aeroplane, over from Tim Hooper (despite twisting his arm to so when a large chunk of metal impacts on the stay etc.). This was followed by an outburst of boos bonnet of your car don't be fooled into thinking it's and cries of 'shame' as we saw a large part of the some disintegrating Russian space station. department leave en masse at the end of July; Drs The Anaesthetists triumphed over, nay thrashed, Daniela Tonucci, Fiona Kelly, Katie Ben, Raj the surgeons at the annual PSC Cricket trophy. As Srivastava, Ben Gibbison, Mark Campbell, Becky our roving player/correspondent Jon 'Ivor Fullbox' Brooks, Chris Marsh, Mel Bloor, Ali Johnstone, Gatward reported for the local press: "The gasmen Richard Pierson and Andreas Zaf,rropoulos, with the declared on only 281 with some sound MTAS candidates more or less happy with their swordsmanship against a wayward attack; as skipper destinations. They provided unstinting service Tim Cook put it 'to make a bit of a game of it'. "The during a very difficult period, and seemingly surgeons made some early inroads against survived albeit older and wiser. Thank you all very complacent bowling, with the opening batsman, "the much and good luck. red-haired assassin", having a proper jumper on and We found ourselves in the anomalous position of so must have been a ringer. With hope fading, the starting August with a full complement of staff. surgeons brought on the "old guard" - a strange Starters included Ewa Zasada, Pete Forster and tactic in the gathering gloom. A dubious run out Natasha Joshi all returning for another tour of duty decision followed when a lightning fast strike by (and very warmly welcomed back), and newcomers rampaging Raj clearly caught Mr Budd out of his Erika Grech, Kamran Banan, Jeremy Preece, Pavan ground, but was not given as it was judged 'far too Battu, Deepak Subramani, Sadiq Bhayani, Adrian good for the level of cricket being played'. The Clarke, Becky Leslie, Natalie Robinson, and Keith surgeons failed to put bat to ball in the last over, Davies. This flushed state of affairs is already on the brilliantly bowled by Cook junior, and the trophy cusp, as Jon Gatward is off for a year in Australia returned to its rightful owners. leaping in and out ofhelicopters in dry and barren There was an interesting article in this week's places. He will be followed by Aidan Marsh who, BMJ careers section, talking about the stages of following some paternity leave, takes up his new becoming a good doctor: unconsciously post as a Consultant in Frenchay from the end of incompetent, consciously incompetent, consciously November. Our heartiest congratulations to him and competent and finally unconsciously competent. The our heartiest congratulations to Frenchay! worst stage to be in, supposedly, is the first, but Bob Marjot most of our orthopaedic colleagues seem blissfully happy. Apparently, what we are meant to do is root Cheltenham out all those unconsciously competent in each Astonishing what you can achieve if you put your department, tie them to a chair, and beat them until mind to it, isn't it? Trevor Johnson taking part in the they share the secrets of their success with the rest Tour de France, who'd have thought it? The peloton ofus. whizz past up the twisting alpine road, all the It finally dawned on management that we had a commotion dies down and our hero thinks his departmental black hole in our midst by June. moment has arrived. He steps off the verge and sets Inside this particular black hole resided extra theatre off in pursuit in his baggy shorts on his rusty old lists, maternity leave, more preoperative clinics, mountain bike. After all if you're that talented, who work out in Devizes hospital (which sounds like needs all the latest carbon fibre gear or even to look some kind of exercise class), insufficient staff to like you're really trying? Oblivious to the jeers of cover the trainee on call rota, and of course the l8 the crowd he pedals on up for few hundred metres week initiative. So we managed to grab a couple of only for, shock horror, the unexpected arrival of locum consultants in Vashek Vanek (we've now peloton number two, which quickly swallows him challenged the surgeons to an ice hockey match) and up and spits him out the back. No stage win, no Michael Duncan, and yes, we saw the refurn of WLI yellow jersey, no mounting the podium with a bevy to hll the gaps - hurrah. Last year's bleak shadow of of moddles, but our Trevor was there! job losses seems to have vanished for now. There were more cycling faux pas (and needless At the start of July, we had a change of personnel mots frangais) in the postscript to this tale - strapped 6 to the roof rack on the way home the bike was sadly husband's ex-wife move in after her nearby home written off on a motorway toll barrier. Trevor was flooded), but undoubtedly worst of all was obviously hadn't learnt from Rob Orme who had a having to cope for a whole month without a hot brush with the Old Bill when similarly he had tried water making machine in the anaesthetic to dismantle the local drive-through Macdonald's department. Rarely can the Dunkirk spirit have been restaurant by driving into the low roof with the so sorely tested. The start of August, with an influx family's bicycles on top. of freshly washed trainees from outside More mundane but substantial successes were Gloucestershire, came at just the right time. achieved by many of the trainees in tackling the And finally well done to our aforementioned MTAS assault course. Claire Kaloo, Kate O'Connor, amateur cyclist, who was somewhat alarmed when Ben Huntley, Jaz Ahmed, Jon Horsnell (all to he returned from holiday to be told out of the blue Severn), Rob Glasson, Owen Bodycombe (both he had been given two weeks' paternity leave. Oops! West Midlands) and Joy Sanders (Wessex) were all Ted Rees appointed to 'run through' posts. Zeenat Bhalla is continuing as a locum staff grade for a year while Exeter David Hamilton is retaining an interest in The sun has risen on the dawn of MMC and run anaesthetics by taking a trust post in Gloucester through training. In many ways little has changed; leaving him some time to concentrate on property the majority of our trainees found training posts, development. (Anyone know of any old barns in several have stayed with us, and all that has changed Wales he could tart up and make a killing on?) Off is their title. We've printed out a forest of paper, to back to Bristol went Dave Barnes, Gareth Gibbon, create the new style portfolio, complete with DOPS, Kieron Rooney and Raju Poolacherla to spread the CEX, CBD. Oh yes, I've read the trillion page news what a fantasticidire* place Cheltenham is to documents that James P sent out for information, work (*delete as appropriate). and have survived to tell the tale. Our on-call rotas We have been invaded by a talented and are a little sparse now, with consultants taking the dedicated new posse in the last few weeks - SpRs strain at present. But possibly, even probably, Claire Gleeson, Murli Krishna (for a second time), training will improve. Yeli Horswill, (on a pain fellowship) and James So, who has left and who has joined our Armstrong (before his new job as adviser for the department? There has been a lot of movement MDU), anaesthetic ST2s Mark Wigginton, Ed during the past 6 months. Phil Cowlishaw and Ben Scarth, Nancy Boniface and Nicki Bosley joined by Gupta have both gone down under, James Limb and LATs Khaled Girgirah and Alex Stefan with ACCS Fin O'Sullivan are in Scotland, Max Hodges (of bods Hamish Breach, Matt Edwards and Reston Daily Telegraph fame) is in Birmingham, Nicky Smith as well as STI medical intensivists Fran Bosley is in Gloucester, Adrian Clarke in Bath, Neuberger and Sarah Holden. Utam Bandari in London, Tim Bowles, Alia Three cheers both to staff grade Mirela Krotki, Darweish and Nick Preston (lovely chap, but who has successfully adopted two siblings in Poland trouble) all in Bristol, Aubrey Theron in Wales, Nila - we wish her and Roman well - and belatedly to a Cota in Torbay, David Pappin and Richard Hughes sleepless Sunny and run-ragged Ronnie Karadia on in Plymouth and Chris Oscier in Truro. Stuart the arrival of their now eight month old second son Dickson, Omar Islam, Will Key and Shariq Ali Fabian. Khan have also moved on, but I apologise for not We welcome back David Goodrum in rude health knowing exactly where. The image of Aubrey with following a long absence and we are fortunate to his broad South African accent, in Welsh speaking have Ann Young as a locum consultant partly filling Wales makes me smile. David's (red) shoes and partly keeping the pain We welcome SpRs, Rebecca Applebaum clinic from drowning under the weight of lS-week- (congrats on the Children's Hospital job), Matt Hill wait edicts. (again), Jo Loder, Paul Margetts (again), Dominique On the subject of drowning, the Trust were full of Mumby (also congrats on the BCH job), and Paul praise for the way staff coped with the summer Moore (good luck in Afghanistan in November). floods and subsequent loss of mains water. Away Welcome to ST I and2 and FTSTAs James Brown, from work it was bad enough (one of our anaesthetic Zoe Brown, Tim Davies, James Gagg, Claire sisters who lives in Tewkesbury even had her Hamer, Rob Hawsley,Hamzeh Hussein, Anand

7 Jayaraman, Michelle Pearce, David Portch, Alex making it to 40. Despite the weather, which Shearman and Nikki Ross (who we wish goodluck). surpassed the department BBQ by being not only cold We also welcome Trust grades Tariq Dean, Peter but also having torrential rain plus gales, it was an Ricketts and Susie Baldwin, and Staff grades Monali evening to remember, unless you are Paul T of course Dash and Amarie Harmes. who remembers very little. Paul's band, The Sux We have appointed two more consultants; Pete Pistols, comprising Paul on drums, Matt Grayling on Ford, who has been a locum here for a while, and bass, Roland Black and John "Saddlebags" Saddler Alasdaire Hellewell, from Wessex. We look forward on guitar, played some fine funes, and a good time to them joining us. Well done too, to Gilly Ansell on was had by all. Despite the weather, Matt G decided securing a job in Plymouth. Sheena Hubble is back to camp (wisely his wife went home), and awoke to from maternity leave, so the ITU trainees had better find he had apparently pitched his tent in a sea of sharpen themselves up, and Vanessa Helliwell will vomit. It must have been a dodgy crisp. be back from mat. leave in November. It is lovely to So that's all from Exeter for now. The have Paul Marshall back on board as a locum Princesshay shopping centre has been officially firstly as I could go waltzing off on unpaid leave, opened, so ifyou want a shopping experience, then and now to stand in for Mark Daugherty who has you know where to come. LOL. had a hip replacement - best wishes to him. Any Pippa Dix. moment now our peace will be shattered by the retunr of Jo Maclntyre from New Zealand - is it a Frenchay whole year alneady? I expect he will have calmed As the dust settles following the MTAS debacle, down during his time away. Frenchay has emerged relatively unscathed, with As always we have had a clutch of babies (boys most of our trainees settled into their first choice as ever). Congrats to James Gag on the birth of training posts. However, elsewhere it appears that Rhys, Gilly Ansell for Charlie, and hot off the press, the frustration felt by some applicants drove them to Bruce McCormick for Stanley. Congrats too to Kris desperate measures, culminating in a bomb attack on our secretary on the safe arrival ofEve. Glasgow airport using a variation on the now Ben Ivory managed to fit in an Australian infamous 'chapati bomb'. Luckily, no innocent wedding around MTAS, and Max Hodges has also people were hurt, especially our very own Ruth managed to tie the knot, despite the Daily 'Lightning Conductor' Spencer, who was standing at Telegraph. the very same taxi rank not five minutes before the There's an unsubstantiated rumour that Richard bombers arrived. Given Ruth's ability to attract Telford has celebrated the big 50. If it's a vicious trouble, it's a moot point as to whether one is safest lie, I apologise. You don't look a day over 30 to me, standing very close to Ruth, or as far away as and it was Greer who started it. possible. Ruth is joining Samantha Shinde as And so we move on to social events. This year the College Tutor, so if any trainees spontaneously department summer BBQ was held at the Turf combust, don't be too surprised. For any future Locks, on what was possibly the coldest evening out bomb attacks, given the poor performance of the of a series of very cold summer evenings. The guys chapati bombs, I can heartily recommend the Chilli from the Southem Hemisphere, who know a thing or Bomb (O Yakuchi Curry House, Cotham Hill, two about barbies (and rugby, but that's too painful Redland, Bristol). Following exposure, this has the to mention), turned up in shorts, and took their ability to cause severe burns and a sensation of places at the BBQ, burning meat with gay abandon. imminent death, followed the next moming by an The rest of us wore as many clothes as we could overwhelming sense that death would, in fact, be hnd, including hats and scaryes, and shivered until preferable. the earliest opportunity to leave without seeming In related developments, two other plotters were rude. As always, a few folks turned up by boat, and arrested, one driving down the M6 and the other on somehow Mark Daugherly got home safely, despite the eastern seaboard of Australia, both presumably having no lights on his boat and taking in water. fleeing rashly accepted FTSTA posts, but then Maybe next year it will be warrn... thinking better of it. Medical Staffing's motto, "We Possibly the social highlight of this year was always get our man." Woodburystock, the celebration of Paul Thomas, Steve Coniam has taken on the role of chairman along with Dave Standley and Simon Harries, of the department, which now entails being formally 8 interviewed for the post, despite the absence of pay ends badly) rule of life came as no surprise as a and conditions. small, die-hard group insisted on dancing late into Good news on the recruitment side is that we have the night. If ever the thought, 'I'm dancing finally, as far as it is humanly possible, made honest particularly well tonight, therefore I shall reward women of Sarah Martindale and Caroline Oliver. myself with a large brandy' crosses your mind, go They were appointed to substantive Consultant home immediately. Claire's building work has fared posts, along with Rupert Harris and Raju better than James Nickells', who, due to a loose Poolacherla who joined the paediatric anaesthetists, waterpipe, has become the unwitting owner of a Ben Walton and Aidan Marsh to ITU and finally swimming pool beneath his kitchen. Apparently it Rhys Davis, who arrives from London to join the shouldn't take more than six months, otherwise neuroanaesthetists. Caroline attended her Consultant known as winter, to dry out. So dust that caravan interview in a plaster as she had ruptured her down one more time James! achilles tendon highland dancing at the The summer barbeque was generously hosted by Neuroanaesthetic Society conference in Edinburgh, Kate and John Bullen, and attended by numerous a severe case of 'Stripping the Achillo' perhaps. offspring who engaged in some extreme fruit- Samantha Shinde and Jane Olday selflessly picking and pruning of the flora. As a parent, there abandoned the ceilidh and accompanied Caroline to exists a fine line between being proud at one's hospital. Jane recently needed rescuing herself as children's behaviour and being just plain appalled. she managed to lock herself in her attic whilst alone This was typified by William Dell managing to in the house. Only by telephoning all the people in knock a tooth out with his own racquet whilst her mobile telephone's address book did she playing badminton. It was also an opportunity to eventually hit upon Steve Sale who broke in to let mark Peter Simpson's retirement from anaesthesia her out. and the significant mark he has made and he was John Carter celebrated the completion of his new presented with a painting as a retirement present boat by falling off his shed roof and fracturing his from the department (see photo). The Walton Prize, ankle, despite calm conditions prevailing at the time. awarded for two years, went deservedly to Fiona Undaunted, he still managed to sail 'Kira' back Kelly and Nicky Weale. The problem with awarding across the North sea (see photo), and at least we know where all the anaesthetic department mugs have disappeared to. Apparently he doesn't wash them, he just throws them overboard after use. "It's quicker!" Oh dear, oh dear. Claire Jewkes celebrated a significant birthday with a parly in the new extension of her house. That it followed the predictable S.W.E.B (starts well,

John Carter relaxing on his boat "Kira'. Peter and Jane Simpson with his retirement painting.

9 prizes is that it can give the impression that the say it was cancelled. Having no running water for l0 efforts of the other trainees are less valued, which days was also a new experience and the least said isn't the case. As usual, we seem to have been the better. The only upside was a bit of communal blessed with extremely capable and likeable showering at other people's houses outside the trainees. That they also remain uncomplaining, stricken area. despite the iniquities of shift systems, MTAS (lots of After the floods came D Day or lst August with all whingeing, in fact) and having to sleep on the sofa the new Doctor's starting en masse. I had sensibly in the anaesthetic department's coffee room, is a taken the most of August off but I'm relieved to say miracle. Honourable mentions have to go to Sarah life goes on and so far we are managing. Without Love-Jones, who balanced childcare, work and doubt the hardest hit was the ITU rota where the organising the trainees rota while husband Al spent Junior Doctor on Call was likely to be any flavour several months stationed in Afghanistan. Mark other than anaesthetics. Wigginton also impressed, this time with his We were very pleased to see a bunch of Registrars football skills, a result of being in Crystal Palace's we'd seen before, Katy Leuchars from BRI, Dave youth team, back when they were any good. Ben Barnes and Gareth Gibbon from Cheltenham and Howes refurns, although he'll have to work hard to Rachael Prout from Bristol. Congratulations to Katy improve on his last visit which inspired one of the who will be married by the time you read this. Our nurses to circulate a video message of dubious taste, new anaesthetic trainees include Raj Srivastava, to say the least. Our new novice trainees have also James Walters, Helen Cain, Matthew Drake, Juan impressed, with Sonia 'Uma Thurman' Payne and Graterol and Dave Windsor. To cope with the Anna Hutchings taking anaesthesia in their stride. changes in rotas we also have two new Staff Grade Judging from the success the trainees have doctors, David Hamilton and Biju Peringathara. enjoyed in the FRCA examination, leisurely pursuits Anne Young is helping out as Locum Consultant in have been abandoned, so the only births to report are Pain and Anaesthesia working across the county. those of Isabella Poppy, to Dominic and Katie With so many new bodies we have obviously said Janssen, and Madeline Anne, to Ian and Lisa goodbye to lots of others. Claire Gleeson has moved Thomas. to Cheltenham and Jill Homewood is doing a Locum And finally pop-pickers, those of you who were Consultant post in Bristol. Jon Anns has gone disappointed when Kate Bullen fell out of the Top abroad to Toronto and Will English and Mark 40 movers and shakers in Medicine can relax as she Haslam have returned to the mother ship in Bristol. is now back in at Number 2 as Deputy Chairperson SHOs Hamish Breach, Gemma Nickols, Geoff of the BMA. Congratulations Kate. Muller and Manish Pagaria have been allotted ST Richard Dell posts in various places. As far as the Consultants go Colin Green and Liz Gloucester Spencer have celebrated their 50th Birthdays. Global warming: a long hot slrnmer I thought but no Intensivist Kay Chidley had a funny turn in recovery . . . torrential rainfall and catastrophic floods were one moming and fell off her stool leaving her foot what we experienced in Gloucestershire. That fateful behind. This resulted in a nasty ankle injury. Friday began like any other this summer albeit with Consultants Ian Crabb and Orthopod Chris Curwen very heavy rain but by the time I attempted the came to the rescue and had her in theatre within journey from Gloucester to Cheltenham I drove minutes. Kay very sensibly decided to do her physio through scenes reminiscent of the film "The Day in Australia (as you do) but we're hoping she'll be After Tomorrow". What used to be roads were now back at work by Christrnas. rivers and the M5 was a car park. Gloucester Royal Malcolm Savidge is leaving in November for a 6 Hospital was on Major Alert which seems ironic as month sabbatical in New Zealand. Congratulations the theatre complex was almost deserted; we were to Debbie Burton who gave birth to her second son down to emergencies and urgent surgery only for Fergus in July and as a result we're keeping Sock almost two weeks. So much for all the extra waiting Koh in permanent employ as a Locum Consultant. lists that had occurred in order to meet the 18 week Very sadly, earlier this year Mike Hills one of our target, now we're struggling. Our Department retired consultants died. One spring afternoon Mike, Summer BBQ had been planned for that very who was 13 and fitter than most of us, was out weekend at The McCrirrick Mansion; needless to burning up the tarmac on his motorbike when he had l0 an accident. Mike was a fantastic, charming, funny earlier this year and was dined out at the Royal man who was loved by all who knew him and will Western Yacht club. We will all miss his comments be sorely missed. Our condolences go to his family at the directorate meetings, his love of management especially his wife Muriel and their two sons. and the way he can dismantle equipment and explain Belinda Pryle everything! Trainee teaching will never quite be the same without the ice-cold bucket . . .! Plymouth The military continue to deploy and all of our Once again it's time for the autumn accounts! service consultants have, or, will shortly, be tasting Plymouth it seems has had an interesting time all life at the sharp end either in Afghanistan or Iraq. change! Just when we were getting over the fun of Tom Woolley is the latest to join the department, new contracts, new targets, new deadlines etc, it was currently as locum consultant. time to change the whole way that the organisation Ian Anderson got married in Oakham during the works! The Trust have realised that PbR means that summer to Sonal Dighe, an Aberdonian Obs and the more we work, the more they get funding and Gynae consultant. He still finds time to help develop have upped the pressure on efficiency. They have the liver resection service in Plymouth which goes taken the leap of faith decision to scrap the idea of from strength to strength passing the 70 cases point daycase units and integrate in- and daycase-patients recently. Other notable performances in the family into newly configured theatres throughout the stakes include baby girls for Tom Gale, Chris hospital - all this whilst giving us a newly improved Sweeting and Rachel Hom, whilst the Erasmus's, pre-assessment service, pre-admission and discharge Lacquire's and Lewis's all increased the Y- wards and (in time) the staff and equipment to do it chromosome count in the household. Meanwhile all. The jury is still out on the final outcome as these Jonathan and Pat Coghill can finally relax after the last two essentials have been in short supply to date build up to the wedding of the summer when in a number of areas, however it is clearly here to daughter Katie married Ben Hunter, an ENT stay for the immediate future and we have all been surgeon. scurrying around to new pastures at varying times of No Burrator Bike Ride (Race!) this year after the day as the dreaded three-sesssion-day has previous threatened civil actions!! Nonetheless the arrived! All change too with management of the department has had its share of sporting activity, the department as I have just taken on a military clinical most notable probably being input to the London director's role and stepped down as the department's Triathlon by Pete Davies, Chris Seavell, Simon clinical director handing the battle-damaged baton to Courtman and Martin West. All finished with good Sophia Wrigley who has her work cut out whilst we personal times but Chris did particularly well and witness such big changes. The handover for once almost got himself up amongst the professionals. was able to take place in relatively palatial settings Pete did his effort for his pet charity as we finally managed to take over half a floor of the (for epidermolysis bullosa) and anyone wishing newly opened "Lewis Towers" Cardiac Building to donate should go to www.justgiving.co.uk/ and at last get back together as a department in one prfdavies. The Superstars event was held on Bigbury place. What a relief. Beach once again in July. The best of the extreme More work needs more staff and from a position athletes (Davies, Seavell, Courtrnan) were dubiously of holding off on jobs nearly a year ago, we have beaten by a bunch of tearaway trainees (D. Adams, been recruiting with gusto: Paul Sice, Karen T. Hinde, K. Holmes) who clearly cheated in the egg Grimsehl, Lesley Thomson and Gary Minto have all catching competition. It was the first presentation of obtained substantive posts and we are currently out the Ross Davis Trophy. Glad to report that there to advert for 3 paediatric jobs and staff grade posts. were no rescues this year during the sea swimming But to every positive there is a negative and MTAS and board paddling events and the barbeque reached has had its way with us and our SHO numbers are its usual high standard. down meaning that evening work has become Rob Sneyd and I followed the sun west earlier this increasingly more difficult to cover without year to take part in the Antigua Sailing Week - 7 significant consultant input. Where will it all end...? days ofhard sailing, socialising and very little sleep What of those leaving? - well the grand master of (much like the good old days of being a houseman the terrible pun/joke, equipment meister himself, really!). Joining a crew that included a vet, lawyer, John Chapman finally hung up his laryngoscope accountant, manager, GP and surgeons, one can l1 imagine that a good time was had by all ... and we seems to be able to turn his hand to anything and is a even came away with a trophy, coming second in consistently cheerful presence in the department. our international class of 10. I'm not sure Southmead could have coped with Rob was also directly involved with the MMC without him. Thank you very much. University this summer when the Medical School Our trainees did very well in getting themselves produced their first graduates in Medicine. Another hxed up with training posts but it did mean we had to dayinight to (try and) remember. The video tribute say goodbye to almost all of them. Yvette Coldicott including him and others that found its way onto the has gone to London and Ellie Carter to Plymouth. worldwide web no doubt had something to do with Janine Talbot, Dom Huford, Anthony Carey, Kate the decision of the Trust to stop us having access to O'Connor and Steve Tolchard are all still in the You-Tube in future! Bristol School but have been distributed around the No doubt I have missed out some important region. Congratulations to all of them. Sarah and Jo, events but as usual the brief is only as good as the our Anaesthetic Practitioners are coming to the end snippets that I'm fed! Apologies to those that feel oftheir training. Sarah has actually already left us to left out but it's time to close it's raining outside take up a place at medical school and we are really and the river will be swollen with fish soon - hoping to be able to create a job for Jo who will be temptation looms! ... or should I stay to do the an excellent addition to the department. we evening waiting list. . ..? After what seems like an eternity of waiting Andy Burgess hnally appointed some new substantive consultants earlier this year. Simon Lewis has slipped Southmead seamlessly from locum to permanent hxture and Jill We triumphed over adversity this year and managed Holmewood will join us in November. We're very to find a sunny, well not rainy, evening on which to pleased to welcome both of them. Ed Morris and I have our department barbecue. With the aid of are particularly huppy that we managed to palm off several fleecies, but no planet-destroying patio some of our least favourite jobs to Simon whilst he heaters, the absolute diehards were still drinking al was still a locum and desperate to please. Khaled fresco (a fine Italian cocktail) at midnight. The Moaz is still doing a stalwart job supporting the highlight of the evening for many people, me AOC almost singlehanded and Para Ray has come included, was being literally led up the garden path back from maternity leave to join us as a consultant by John Leigh in order to admire his landscaping locum. We also have two new Staff Grades, Ndollo skills. A once in a lifetime, never to be forgotten Eboumbou from France and Zoly Kudela from experrence. Hungary. They will be filling out our somewhat I mentioned the build up to MMC in my last anorexic obstetric rota which has been sliced from a missive and I can now follow up with our summer healthy 7 to a skeletal 3 by MMC. The current fad survival story. Like most people we had a mixture of for size 0 is obviously more prevalent than even the planned and unplanned shortfalls in staffing. tabloid press had appreciated! Our secretarial pool Kathryn Holder and Jonathan Wills have become (more of a puddle in size but not quality) has been experts in hnding excellent locums but must surely boosted by the arrival of Sam who is coping have made some sort of pact with the devil in order extraordinarily well so far. We look forward to to be so successful. Thanks must go to Ruth Mathes, many years of her company. Justin Marshall, Niranjan Jayasheela and Malinka More babies have been bom over the summer (in Vrabtcheva who have all worked like Trojans (ie fact we've been so busy in obstetrics that I would very hard whilst under siege with no hope of relief, have to say more than enough babies have been only to be lulled into a false sense of security by a bom). Congratulations to Alex Brederode and Pia wooden horse) to keep the department's head above Lieber who have had a baby boy, Luca; to Khaled water. Justin has now emigrated to Australia (for Moaz and Manal who have had a girl Hannah; to love rather than in despair at MMC) and Ruth is Izzie Iqbal and Dave Gillat who have had a boy, leaving us soon to return to Germany so good luck Adam, to Jas and Jackie Soar who have had a girl, to both of them. I would like to make special Anika and to Natasha Clark and Curtis Whittle on mention of Niranjan who is currently working as a the birth of Alexander. Graham Knottenbelt has staff grade in our department. Over the years he has returned to us as the father of twins, so got us out of many a tight staffing situation. He congratulations also to him and to Jay. Anthony l2 Carey sneaked off and got married without telling us but we found out anyway so congratulations to him. "Message of the Day" has arrived in North Bristol. This is a helpful hint or fact that pops up on your computer screen when you log on. The first message featured a picture of our Chief Executive and it was said that the eyes would follow you around the room. I couldn't possibly comment. Fiona Donald

Swindon Just one birth to announce this time. Gary and Leah Baigel have had a daughter - Emily. Poor Gary's study has been commandeered and turned into a nursery and he is suffering from sleep deprivation. Well, following an anxious few months and serial Somerset Village People. interviews, all of our SHOs were successfully reconstituted into STs by the MTAS magimix. hurricane Dean hit Jamaica. Thankfully everyone Richard Hodgson went to Birmingham, Alla Belhaj got a job - not all their first choice but no one to London, Tom Green and Abi Lind to Wessex, and was left high and dry. We say goodbye to an all the rest to Bristol (yeah-but-no-but, or is it excellent bunch of SHOs. Nicky Campbell surfs off Severn?) that's Daisy Turner, David Windsor, to Barnstable, Zoe Brown to Exeter and Anna Natasha Joshi, Becky Leslie, Andy Georgiou, Mala, Lewis crosses the border to Wales. Ed Scarth, Juan and Steve Tolchard. Good luck to you all. Somehow Graterol and Helen Cain venture north to Bristol I managed to miss working on lst August. What was and beyond, while Alex Day and Simran Minhas go it like? We have been joined by a fine and propitious even further to York and Shefheld. Vrjaya Ramaiah band of STs who with the aid of various acronymous secured a staff grade post whilst Julie Lewis and educational tools are being lovingly honed into top- Jamie Biddulph remain with us in Taunton - it's notch gas-bods or ACCSers. SpRs Paul nice to keep some familiar faces. Our departing Trumplemann and James Dinsmore have moved on juniors had a fantastic send off with 'Chez Phillips' in their Wessex careers and have been carefully hosting a Karaoke BBQ evening. With cocktails and replaced by Andy Cowan and Aneeta Sinha. beer in abundance and inhibitions vanished On the permanent staff,rng side Eva Fresco and everyone picked up the microphone and sang their Lucy Williams have arrived as Staff Grades and hearts out. I think the highlight of the evening was Fourie de Kock has moved on. Anisa Dale is due to the rendition of YMCA by Ian (Go-Gauntlett-Go), return in the near future following her maternity Stu (Come-on Collins), Pete (Raving Ravenscroft) leave, but this time as Dr Sabrine. Not content with and Geer (Huggable Hubregste) - they knew all the merely being lead clinician for anaesthesia, Tony actions too! (See photo). Pickworth has landed the job of lead clinician for We have had a bit of a change on the Registrar surgery - apparently a free flakjacket is included in front as well. Dominique is off to the Children's the welcome pack. Hospital in Bristol via a stint back in Plymouth and And finally. May was highlighted by a Bath vs Tracey Prior is on maternity leave having had a Swindon golf challenge. An injury struck Bath team little girl (Farah) - congratulations. Resident Aussie picked up the gauntlet to face some of our f,rnest Roger Wong is managing to juggle his 'Tour golfers over 36 holes. In true Ryder cup style, it all d'Europe' with his work commitments - I have came down to the final match and our boys lifted never seen anyone pack so much into such a short the trophy. space of time. Aody McEwan remains with us - but Matt Ickeringill now a married man! Congrats. We welcome Daryl Thorpe-Jones and Will Fox from Plymouth along Taunton with Craig Pope and Nigel Hollister. James Griffen MTAS and MMC has come and gone and we are all joined us intially part-time having had an extended left somewhat shell-shocked - a bit like after time away but is now back full on! Jane Bellamy l3 and Suzanne Carty continue to support the wheelchair, which we didn't have. Fortunately, department alongside their' domestic commitments' Chris Monk "found" one at the BRI up the road. We - I still think they should be called DDCs rather got her up to the conference rooms in the goods lift, than flexible trainees! And so on to the new "STs" which all seemed a bit undignihed for our first ever as we should now call them. Claire Blandford and lady President. Violet was not the only President I Katherina Tober join us from Torbay, Anthony have been privileged to chauffeur. During the early Bradley from Barnstable, Robert Dawes from 1980s, in Oxford, Sir Robert Macintosh (President, Southampton, Dermot Gardiner from Plymouth, 1955 - 56 ) was often in the departmental library. Gemma Nickols from Gloucester and Adam Duffen One dull evening he asked me if I went home via the from Truro. Oh . . . it doesn't stop there . . . come Woodstock Road, and I was delighted to drop him November we have Ella Chaudari and Tim Wilson offnear to his house. swapping places with Gemma and Adam (c/o the Our Department continues to flourish. Whatever new ACCS training grade). Richard Innes has got the current mechanism is for appointing trainees (I the task to sort out where they are all going, and for refer to the controversial MTAS concept ), we have how long and on which rota . . . good time to pass again been fortunate to acquire a group of talented on the College Tutor baton Justin!! and keen doctors who want to become anaesthetists. Talking of baton changes, Tim Zlll

FRCA Tessa Bailey Frenchay James Sidney Frenchay Katrine Mattheus Frenchay Chris Bordeaux Frenchay Ben Howes Frenchay Tamas Veto Frenchay Hugo Wellesley Frenchay AdrainUpex Frenchay Simon Webster Frenchay Kieran Rooney UBHT

PrimaryFRCA Jo Connell Frenchay Janine Talbot Southmead Yvette Coldicott Southmead Eleanor Carter Southmead

Southwest School of Anaesthesia

FRCA Mike Spivey Plymouth Paul Moor Plymouth Richard Eve Plymouth David Elliott Plymouth David Laqcuiere Plymouth David Adams Plymouth Paul Warman Plymouth Helen King Plymouth Matthew Harper Plymouth Tanya Pommereit Truro Kevin Patrick Truro

Primary FRCA Theresa Hinde Plymouth Gemma Crossingham Plymouth Steve Lewis Plymouth Kathy Clarke Plymouth Greena Matthew Plymouth Alex Mills Torbay Ben Titford Torbay Julie Lewis Taunton Nicki Campbell Taunton Ben Gupta Exeter Finbar O'Sullivan Exeter Alia Darweish Exeter Max Hodges Exeter Uttam Bandarri Exeter Jjin Joseph Trwo

l7 Examination Successes and Honours Cont.

Primary FRCA cont. Alistair Lockwood Truro Rob Jackson Truro Suzie Davies Truro Tom Martin Truro George Bostock Truro Juan Graterol Bamstaple Claire Hamer Torbay

Socie8 of Anaesthetists of the South West Region Prizes

Fenely Travelling Scholarship Matt Thomas Budapest Overseas Meeting Trainee Prize Gavin Werrett

I am sorry if anyonefrom the region (has not been included in this list) thst shoald have had an qamination success or any other honour acknowledged. I can only publish the names senl to me by each deparfinent's SASWR linkman and college tutor.

l8 Anaesthesiq Points ll'est Vol. 40 No. 2 Report Society Thkes Budapest by Storm Meeting Report May 2007

Dr Ed Morris, Honorary Secretary SASWR

In May, one hundred and two members, partners and Social Programme guests travelled to Budapest for the Society of A large part of any overseas meeting of the Society Anaesthetists of the South West Region's triennial is the social programme, and this trip did not overseas scientific meeting. This year it was held disappoint. Most of the guests stayed in the Marriott jointly with the Society of Anaesthetists of the Hotel in cenffal Budapest, with impressive views of Central Hungarian Region. Despite the the River Danube and the Castle district of Buda. An disappointment of Easyjet cancelling their direct informal welcome reception on the first evening was flight from Bristol to Budapest after the meeting held in the hotel bar, the venue for several other venue had aheady been decided, members arrived impromptu gatherings later in the week. On by several ingenious routes to a city which, freed Wednesday morning 60 of us boarded coaches for a from the grasp of communism over 15 years ago, is forward looking, energetic, and remarkably beautiful. Thanks to a link initially provided by Tamas Veto, a Hungarian SHO working in Bristol, the local society had embraced our request to hold the meeting at the former centre of the Austro- Hungarian Empire wholeheartedly. Their then- president Dr Laszlo Vimlati had attended the Society's Bristol meeting in November 2005, and had assembled a local organising committee which had worked hard with our own representatives to put together a scientific prograrnme that was relevant, interesting and embraced both the similarities with and differences between our two health systems.

The President and his wife are, as usual, last onto Professor Vimlati struggles to understand BM jokes. the coach. l9 brieftour ofthe Pest area ofBudapest - a chance to look at the baroque architecture of the long boulevards, get our bearings, and see the impressive Hero's square - before crossing the Danube to be dropped in the spectacular castle district on the Buda side of the river. Three knowledgeable tour guides walked us around the famous fisherman's bastion and old castle, which now serves as a museum and administrative buildings. The dizzle in the air failed to dampen our mood as the tour culminated in the l3th century Matthias Church - a mixture of eastern Viewfrom the Secretary's hotel room. and western church architecture. As the skies brightened most members then took the funicular railway and walked back across the Chain Bridge to museum was not actually made of marzipan but the hotel. merely described the history of that delicacy. A The weather remained bright for the President's short trip by coach took us to the Nagyvillam Reception on Wednesday evening, which took place restaurant perched high on a hilltop overlooking the on a boat, which cruised along the Danube. The Danube valley; the views were spectacular and a President, Dr John Carter, and his wife were joined long lunch of local food and wine ensued. One of by officers of the Hungarian Society and with a our travelling party (the guest of one of our finger buffet, a musical duo playing in the speakers) was, it transpired, a professional opera background, and apparently limitless supplies of singer from New York, and so as the bemused Hungarian sparkling wine, the event was a chance to waiters looked on we were treated to an impromptu catch up with old friends and to make new ones in rendition of several opera standards by Mr Doug advance of the scientific meeting. McConnell. The crowd yelled for more and there Thursday saw an all day coach trip to the hills were several encores before it was time for the above Budapest, first to the mediaeval village of rather somnolent coach joumey home. Szentendre, with winding streets, old churches, and In addition to the organised social events, a variety of museums. Whilst the scientists among members got together to explore Budapest the party marvelled at the 'miniature museum' with themselves in the evenings which were not its microscopic woodcarvings, and the traditionalists otherwise filled. Several members visited climbed the steps to the l5th century Catholic Budapest's famous spas, and there was an organised Church, a procession of other (mainly female) tour of the parliament building for partners during members set off purposefully in search of the one of the academic sessions. The city has fine renowned 'Marzipan Museum'. There was some restaurants, many impressive buildings and a vibrant disappointment when it was discovered that the social life. Rumours that the Hon Treasurer and Hon Sec were seen falling out of a nightclub in the company of a large group of trainees early one morning are almost certainly ill-founded. The story of the ex-president of the Society who received an on-the-spot fine for fare dodging (he claims to have simply misunderstood the complicated tariff system) is almost certainly true. What is in no doubt is that all present from SHO to retired members, enjoyed each others' company in a beautiful setting.

Academic Meeting The academic meeting took place in the ornate Danube Palace Theatre in central Budapest, a stone's throw from the Danube and only a few minutes' walk from the conference hotels. The President tries his hand at Hungarian. Originally a concert theatre, it has been renovated in importance of organised training schemes in regional anaesthesia, and predicted the increasing importance of ultrasound in regional anaesthesia. In his talk on lower limb blocks, Dr Brederode was able to show a video ofultrasound in action during a femoral nerve block, and discussed the risks associated with regional anaesthesia. He emphasised that in contrast to upper limb blocks, nerve blocks for lower limb surgery rarely remove completely the need for sedation and opiates as adjuncts. After coffee Peter Ritchie from Cheltenham chaired a lively session on Medical Education, which benefited from speakers from the UK, Hungary, and America. Sir Peter Simpson, recent president of the European Society of Anaesthesiology, spoke of the role of that organisation in drawing together European training, education, clinical practice and research and predicted further integration of national and European societies in the future. Prof Laszlo Vimlati, president of MAITT (the Hungarian national anaesthesia and intensive care society) gave a brief history of the specialty in Hungary and outlined the anaesthetic training prograrnme in that country, which interestingly includes a practical in- vivo assessment of ability in its final examination. Lastly Dr Wolf Vogel, ar attending anaesthesiologist from Connecticut, USA, explained The Treasurer sails under the Hungarian Navy Jlag the nature of anaesthesiology training in North for the first time. America with an outline of the matching scheme used to place accredited trainees into permanent positions a very pertinent topic in the light of the recent times to a conference - centre, and the setting recent MMC / MTAS developments! Much for the meeting itself was the original theatre hall, discussion followed the three talks, particularly complete with 19th century carvings and decorations around the subject of integration of qualifications but fortunately 21st century sound systems and air within Europe, and the necessary alignment of conditioning. Around 60 UK delegates and between training schemes. 30-50 Hunganan anae ting After a lunch which matched the ornate over the two days. Th the surroundings of the dining area, the meeting presidents of the two and continued with a session on Intensive Care Dr Barbara Volgyes. In recognition of our thanks for Medicine. Dr Csaba Hermam, one of the youngest their hospitality, our president presented the ITU directors in Hungary, spoke about the recent Hungarian Society with an engraved ornamental establishment of a surgical HDU and associated bowl in Bristol Blue Glass. outreach team in his own hospital. Many of the The first session on Regional Anaesthesia saw challenges he faced arranging staffing of the unit talks from Dr Tibor Pataki of Hungary and Alex - and ensuring regular surgical review of patients, as Brederode, from Southmead Hospital in Bristol. well as establishing funding for the outreach After discussing some of the more popular service, were depressingly familiar to the UK delegates. approaches to upper limb nerves in Hungary, and James Pittman of Exeter followed with an extremely explaining how blocking those neryes could reduce informative lecture on the measurement and morbidity even when used in combination with manipulation of preload, with particular reference to general anaesthesia, Dr Pataki stressed the measurement techniques such as systolic pressure 2l The trainees assemble before their night of shame. Ex-presidents travel well.

variation, central venous saturation, and the attendance and they were rapidly corralled for a oesophageal doppler, referring both to the photograph; apologies to Martin Coates who wasn't advantages and pitfalls associated with such quick enough to get into frame and so may need to techniques. In the question session afterwards Dr be 'photoshopped' in at a later date. Socialising Pittman and Professor Wolf entered into a continued back at the Marriot Hotel later in the discussion which they clearly both understood, but evening, with the Hon Sec being persuaded to host a which went straight over the head of your round of drinks on the society's behalf, to the correspondent! delight of the fifty or so members assembled and the A special trainees' competition had been bemusement of the long suffering waiter. integrated into the meeting at the request of the Hungarian Society, who had been impressed by our The morning after own prize during their earlier visit to Bristol. Of The meeting continued the following morning with nine UK submissions, three were chosen for oral an excellent turnout to hear Dr Steve Coniam of presentation and the remaining six were exhibited as Frenchay Hospital and Prof Lajos Bogar of Hungary posters during the meeting, along with a similar talk on different aspects of pain management. Dr number of Hungarian projects on display. The two Coniam gave wise advice on the management of prizes - judged by Dr Kerri Houghton and Prof acute pain in chronic opioid users, with some useful Andy Wolf from the UK, and Dr Volgyes and Prof insights into equivalent hospital and'street' doses of Darvas from Budapest - were won by Dr Gavin opioids, and Prof Bojar presented the results of a Werrett of the Plymouth School (for an audit of national 3-day audit of postoperative pain relief epidural usage in Australia before and after a large which had raised important points for debate about regional anaesthesia study was published) and Dr where the responsibility for postoperative pain relief Vera Juhasz of Budapest, for her comparative lies, and the usefulness of intravenous opioid examination of the inflammatory response to analgesia in the early postoperative period. After oesophagectomy and other intra-abdominal surgery. coffee the final clinical session on patient safety featured talks by two national experts on the subject: Gala Dinner the aforementioned Dr Bogar and our own Mike The historic surroundings of the library of the Durkin from Gloucester. While Dr Bogar focussed Hungarian Academy of Sciences, an elegant on the history ofpatient safety, discussing root cause building on the bank of the Danube River, was the analysis, models of safety systems from the aircraft venue for the gala dinner that evening. A champagne industry, and stressing the need for a 'culture of reception and typically witty grace from Surgeon safety', Dr Durkin described the development of Captain Andy Burgess were followed by a patient safety organisations such as the NPSA and sumptuous four course dinner with musical described the success of various pilot schemes accompaniment. After dinner it was realised that at which were taking place, particularly in the South least a dozen of the Society's ex-presidents were in West of the UK. 22 The final presentation of a very wide-ranging Many members stayed on to enjoy a final meeting was the guest lecture, given by Bugar evening in Budapest before returning to the UK, Meszaros Karoly, the director of the Hungarian taking the opportunity to sample more of the Institute of Architecture. In an impressively illustrated city's bars, restaurants, and entertainments. lecture, he talked about the history of Hungarian Another highly successful overseas meeting has interior architecture, with particular reference to passed, confirming the enthusiasm of our buildings used as pharmacies and libraries, both members to travel, learn, and socialise together medical and general. We were left in no doubt that on a regular basis. Whisperings of a trip to Budapest has a rich medical history and continues to Rome in Spring 2010 are currently being make a significant contribution to medical knowledge investigated by your committee - start saving in Hungary, Europe, and further afield. AirMiles now!

23 Anaesthesia Points West VoL 40 No. 2 Article A Survey of Anaesthetic Practice for Carotid Endarterectomy in the Southwest Region of the UK

G.C. Werrett, N.T. Preston, Q.J.W. Milner Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW

Summary patient provides an indirect but sensitive monitor of Carotid endarterectomy (CEA) is an increasingly cerebral perfusion particularly at the time of carotid frequent operation for the prevention of cross clamping. Systematic reviews appear to cerebrovascular events. Opinion is divided over the endorse such techniques but do state that much of ideal anaesthetic technique for this procedure. We the evidence is retrospective.''2 conducted a postal survey of all consultant A previous survey of anaesthesia for CEA looked anaesthetists in the Southwest region who regularly at practice by members of the Vascular Anaesthesia anaesthetise for carotid endarterectomy (CEA). Of 33 Society of Great Britain and Ireland (VASGBI) in (77%) respondents, only 7 (23%) used general 20003, however, it lacked specific details of the local anaesthesia, 20 (61%) used a regional anaesthetic anaesthetic technique used. It showed that 690/o of technique and 6 (18%) used both, in their standard respondents always used general anaesthesia for practise for CEA. Of those using regional anaesthesia, CEA, with 66% using cerebral monitoring 13 (50%) used a deep cervical plexus block as part of techniques such as stump pressure or transcranial their routine technique. The majority (88%) ultrasonography. Our survey was designed to supplemented their block with local anaesthetic along determine if local practice in the Southwest differed the line of incision. During regional anaesthesia, only significantly from previous UK studies and one respondent used the transcranial ultrasonography simultaneously give those interested in vascular in addition to assessment of the awake patient to anaesthesia a perspective on the varied practices detect cerebral ischaemia. During general anaesthesia across the region. l0 of l3 anaesthetists (17%) used no specific monitoring for assessment of cerebral perfusion. A Methods carotid artery shunt was routinely inserted by 7 (23%) All I I hospitals in the Southwest region of the UK of surgeons. In addition, Propofol was the most were contacted, (see Table 1) and the anaesthetic favoured drug for sedation. department asked to identify their consultant staff who regularly anaesthetise for carotid Introduction endaderectomy. Whilst we await the completion of the GALA A questionnaire (Appendix A) was mailed (general anaesthetic versus local anaesthetic for personally to those consultant anaesthetists carotid endarterectomy) trial, an international identified, at the end of 2005. The questionnaire prospective randomised trial comparing general and asked about the use of general or regional local anaesthesia for carotid surgery, there is no anaesthetics for CEA and for specific details about definitive consensus on whether a general or local regional anaesthetic techniques. Further sections technique is preferable for patient outcome in CEA. looked at the frequency of routine shunt insertion There has however been a trend towards the use of and also to look at the anaesthetist's response to a regional anaesthetic techniques since the conscious perceived fall in cerebral perfusion. 24 Table I. Hospitals contacted in Southwest region Of those respondents using a regional rcchnique, 2l (81%) used bupivacaine as their LA of choice (4 Ilospitals contacted of the 26 using the isomer L-bupivacaine) in varying quantities. Ropivacaine 0.75% and Lignocaine 2% Cheltenham General Royal United Hospital were also used. (see Table 2) Hospital Bath Table 2. Local anaesthetics used by responders Gloucestershire Royal Taunton & Somerset Hospital Hospital Local Anaesthetic used No. of Pcopb

North Bristol NHS Torbay District General None stated/unclear t Trust Hospital I Bupivacaine 0.37 5% 20-30mls 5 Plymouth Hospitals United Bristol NHS Trust Healthcare Hospital Bupivacaine 0.5% l5mls & Bupivacaine 0.25Yo 30mls 3 Royal Cornwall Yeovil District Hospital Trust Hospital Bupivacaine 0.5% l0mls & Lignocaine 2oh 70mls 2 Royal Devon & Exeter Hospital Bupivacaine 0.5% 25-30mls 6

Results Ligrrocaine 2Yo wl Adrenaline Personal questionnaires were posted to the 43 l:200,000 20-3Omls I consultant anaesthetists who were identified. Completed replies were received from 33 L-Bupivacaine 0.375% anaesthetists equating to a 77Yo response rate. By w/Adrenaline <40mls 3 targeting consultant anaesthetists known to regularly anaesthetise for CEA, our survey aimed to reflect Ropivacaine 0.7 5% (3mg/kg) J actual practice in the region accurately. Of the 33 responders 20 (61%) only ever use a Bupivacaine 0.25o/o 20 -3 }mls I regional anaesthetic technique, 7 (21%) only use general anaesthesia and 6 (18%) use both techniques L-Bupivacain e 0.25Yo 20mls I (Figure l). The predominant regional anaesthetic techniques @ used are shown in Figure 2. @ @ w @ @ @ @

Figure,1. Anaesthetic technique used for CEA Figure 2. Predominant regional technique used for amongst 33 responders. CEA. 25 In addition to the predominant technique shown in Sedation: Figure 2, 88yo of respondents also infiltrated Of the 20 respondents who used a regional additional local anaesthetic along the jaw line and technique, ll (55%) used propofol, usually alone the surgical incision line. An inferior alveolar nerve but sometimes in combination with block was used by 3 of the respondents. Deep alfentanil/fentanyl, as sedation. Four (20%) used cervical plexus block alone, cervical epidural and remifentanil and 3 (15%) used no sedation at all. subfascial (intermediate plus superficial cervical One respondent used temazepam and one plexus) blocks were chosen by one anaesthetist in midazolam. each case as their predominant technique. Where a deep cervical plexus block was used, 6 Discussion (46%) used multiple injections. Of those using a There continues to be a wide variation in anaesthetic single injection technique 7UVo used a nerve provision for CEA. General anaesthesia was the stimulator. The fourth cervical (C4) nerve root was default technique in 23% of replies. These figures sought twice as frequently as the third cervical (C3) are markedly different to the 69oh of respondents nerve root. choosing GA as the preferred technique in 2000'. The majority of cases performed under regional Monitoring: anaesthesia were anaesthetised with either a Only I of 26 respondents who employed a regional superficial or a combined deep and superficial anaesthetic technique used a formal monitoring cervical plexus block. device for cerebral ischaemia, which was transcranial Contrary to established belief, recent work on ultrasonography (TCD). The vast majority chose to cadavers suggests that there is communication use verbal and motor skills in the awake patient for between the deep and superficial cervical spaceso''. assessment. Of the 13 respondents who regularly or Dye placed under the indwelling fascia of occasionally performed CEA under general stemocleidomastoid muscle was found to track down anaesthesia, 10 specifically stated they used no onto the cervical nerve roots. This might explain the additional tool to monitor for cerebral ischaemia. Two efficacy of the superficial cervical plexus block in anaesthetists used the transcranial ultrasonography comparative studiesi'. There is debate about what and one anaesthetist used stump pressure to guide exactly constitutes a "superficial" cervical plexus shunting. A shunt was reported to be inserted block and perhaps we should be calling a block deep routinely by the surgeons in7 (23%) of replies. to the investing fascia an "intermediate" or "subfascial" block8. However, the fact remains that Cerebral hypoperfusion : adequate anaesthesia appears to be produced without In response to cerebral hypoperfusion, 18 (55%) of the need for the deep injection(s). Our survey shows respondents chose to increase both the fractional that 50Yo of respondents were regularly performing a concentration of inspired oxygen (FI0) and the mean deep cervical plexus technique, often with multiple arterial blood pressure (MAP). 3 (9%) of respondents injections. chose to increase FI02alone,7 (21%) ofrespondents Since the majority of serious complications occur chose to increase MAP alone (Figure 3). with the deep block (intravascular injection/seizures, high cervical blockade, diaphragmatic paresis, recurrent laryngeal nerve palsye), we surmise that the traditional deep cervical plexus block may be unnecessary. One of the proposed benefits of the patient remaining awake during surgery is that any deterioration in mental status caused by cerebral hypoperfusion may be rapidly noted. This can sometimes be managed successfully by increasing the mean arterial pressure or by increasing oxygen administration.'q " Fifty-five percent of respondents increased both MAP and F102 whereas others chose to increase just the MAP or the F102. One striking Figure 3. Response to cerebral ischaemia. difference between this survey and that performed in 26 2000r is the difference in techniques of cerebral Regional techniques predominate and the use of monitoring. At that time, only 26 of '17 respondents additional cerebral monitoring is rare. (34%) used the awake patient as the sole monitor of Large volumes of local anaesthetics are used in cerebral ischaemia after cross clamping, instead combined deep and superficial cervical plexus preferring to measure stump pressure or transcranial block; the frequent use of racemic Bupivacaine was ultrasonography. Twenty-five of 26 respondents surprising given the widespread availability of the (96%) use the awake patient as the sole monitor of L-Bupivacaine isomer. cerebral firnction in the Southwest. This survey provides a fair reflection oflocal and Acknowledgements possibly national anaesthetic practice for CEA. The authors would like to thank everyone who completed the survey for their time and effort without which it would not have been possible.

Appendix A - Questionnaire sent to Anaesthetists in Southwest Region t. Do you ilaesthetis CEA GA tr - Proce€dtoQuestior6 References wdq LA tr - Praeed io Qwstion 2 I Rerkasem K Bond R, Rothwell PM. Local versus general anaesthetic for carotid endarterectomy. Cochrane Database Syst Rev 2004;2: CD000126. 2 Tangkanakul C, Counsell CE, Warlow CP. Local versus Approxirote volme mg/kg _ general anaesthesia in carotid endarterectomy: a systematic What method do vou u*? review of the evidence. European Journal of Vascular and Deep eruical blek tr Endovascular Surgery 1997 ; 13: 491 -9. Subfmial ceruical plexus blck o endarterectomy a Superficial cenical plens blck tr 3 Knighton JD, Stoneham MD. Carotid freep qDd superticia! cwical o survey of UK anaesthetic practice. Anaesthesia 2000; 55: plexw blmks 48 l-5. Cewical epidural tr lnliltmtion tr 4 Pandit JJ, Dutta D, Morris JF. Spread of injectate with superficial cervical plexus block in humans: an anatomical sh:,dy. Br J Anaesth;91: 733-5. 5 Nash L, Nicholson HD, Zhang M. Does the investing layer of If you u* a deep ceruical plexus block. the deep cervical fascia exist? Anesthesiology 2005; 103: do you ue Nfle simulalor tr 962-8. Single deep injection E Level: 6 Stoneham MD, Doyle AR, Knighton JD et al. Prospective, Multiplc dep injetior E Level: randomised comparison of deep or superficial cervical plexus block for carotid endarterectomy surgery. Aneslhesiology 1998;89:907-12. 7 Pandit JJ, Bree S, Dillon P et al. A comparison ofsuperficial Do you u* supplementary No D versus combined (superhcial and deep) cervical plexus block Lsaj Anestlletic? prospective, Yes O - Along incision line tr for carotid endarterectomy: a randomised sfudy. Along t}ejaw line tr Anesth Analg 2000; 91:78 1 -6. In midline for Telford RJ, Stoneham MD. Correct nomenclature of mntralrenl tr 8 imeryation superficial cervical plexus blocks. Br J Anaesth 2004;92: 775. How do you monitor for rebml ishaemia? 9 Weiss A, Isselhorst C, Gahlen J et al. Acute respiratory Verbal/motor skills in awake patimt fl EEG E failure after deep cervical plexus block for carotid TCD tr endarterectomy as a result of bilateral recurrent laryngeal Nore D nerve paralysis. I cta Anaesth Scand 2005; 49: 715-9. l0 Stoneham MD, Martin T. Increased oxygen administration during awake carotid surgery can reverse neurological deficit I)o you sg@N roulirely us a shunt? Yes tr NoD following carotid cross-clamping. Br J Anaesth 2005;94: 582-s. 8. In Espons 10 cerebral ln@s tr lncrqse E iwhamia do you, . Fi()2 MAP ll Stoneham MD, Warner O. Blood pressure manipulation during awake carotid surgery to reverse neurological deficit after carotid cross-clamping. Br J Anaesth 20Ol;81:. 641-4.

27 Anaesthesia Points West VoL 40 No. 2 Article

Epidural Analgesia in a New Zealand Tertiary Hospital Before and After Publication of the MASTER Study - Evidence Based Medicine in Action?

Werrett GC', Horton H', Craig R, French R' Specialist Registrar, Department of Anaesthesia, Plynouth Hospitals NHS Trustl Consultanl, Departrnent of Anaesthesiq, Christchurch Hospital, Christchurch, New Zealanil

Abridged and modified version. Full version acceptedfor publication in Anaesthesia and Intensive Care.

Summary benefits'0. The MASTER trial,0 prospectively We audited the total number of peri-operative evaluated 915 "high-risk" patients in an attempt to epidurals performed at Christchurch Hospital, New clarify previously demonstrated outcome benefits, Zealand, for 3 years, before and after The Lancet but besides showing improved analgesia during the published the MASTER Araesthesia Trial in 2002. first 3 postoperative days and a reduction in We also looked specifically at the number of respiratory complications, no significant benefrt of epidural anaesthetic and analgesic techniques epidural anaesthesia and analgesia was performed in combination with general anaesthesia demonstrated. for colonic snrgery over the same period. Audit data from the Acute Pain Management In both cases we found a statistically significant service were reviewed to obtain the number of fall in epidural rate in the years after the publication patients receiving epidural analgesia or intravenous (P<0.001). A subsequent survey of local specialist patient controlled analgesia (IV PCA) in the 3 years anaesthetists, who had worked throughout this before and after the MASTER trial publication. To period, revealed the majority (75o/o) were knowingly provide a more clearly defined study group we performing fewer epidural techniques and that the reviewed colonic surgery over the same period, findings of the MASTER Anaesthesia Trial had comparing numbers for general anaesthesia plus influenced their decisions. epidural anaesthesia/analgesia against general anaesthesia plus IV PCA. Introduction A questionnaire was sent to all the anaesthetists The role of epidural anaesthesia and analgesia in who had worked in Christchurch over that 6-year the peri-operative period has long been highly period to help establish reasons for any change in contentious, with contrasting messages from the practice. available literature. Proponents cite benefits such as improved analgesia'' 2, a reduction in ileus after Materials and Methods colonic surgeryt'0, and perhaps, improved outcomel6. Christchurch Hospital is the largest hospital on the Sceptics tend to focus on the rare but potentially South Island of New Zealand with a broad mix of devastating complicationsr *, the hypotensive effect surgical specialities. Elective orthopaedic and all of sympatholysis in the postoperative periode, but obstetric services are provided at separate sites, and above all, the lack of convincing outcome are not included in this audit. 28 In deciding on data to be collected it was usages before and after release of the MASTER trial necessary to decide on a suitable denominator group results revealed a significant reduction in epidural to compare epidural usage against. We decided to usage compared with IV PCA usage, before and use the total number of major analgesic after June 2002 (P<0.001). interventions in the first instance. A major analgesic intervention was defined as the use of epidural analgesia or IV PCA. Total epidural techniques The availability of the Acute Pain Management Service (APMS) data allowed retrospective audit of 400 the 12 monthly totals of patients receiving post- 300 operative epidural analgesia and IV PCA from lst o- June to May 3lst between 1999 and 2005. The € zoo MASTER trial was published in The Lancet in April z too 2002, thus providing numbers for 3 years before and 3 years after the publication date. 0 We also reviewed the total number of colonic '99-'00 '00-'01 '0t-'02 '02-'03 '03104 '04-'05 surgical cases performed, with and without epidural Year catheters placed in addition to general anaesthesia, between July 1999 and July 2005. All theatre data is Figure I. coded according to the International Statistical Classification of Diseases and Related Health Colonic Surgery Data Problems. Colonic surgery is listed under Block 193, The epidurals performed specifically for colonic and includes right, left, subtotal and total colectomy. surgery show a similar proportionate reduction These data were obtained from the Clinical Coding (Figure 2). There was a 59% reduction in the department of Canterbury District Health Board. frequency of epidural use for colonic surgery after The third part of the study was to send a the MASTER publication date (P<0.001). The questionnaire to all senior anaesthetists who had proportion of cases in which an epidural was used in worked at Christchurch Hospital during the 6-year addition to general anaesthesia fell from 30Vo to period. The anaesthetists were unaware of the study t3%. findings when answering the first section of the questionnaire. Data analyses were performed using the Chi Type of anaesthetic for colonic square test (Web Chi Square Calculator) to analyse surgery the number of epidural techniques versus IV PCA numbers for the APMS data and the number of general anaesthesia plus epidural anaesthesia o 7OO or S eoo analgesia versus the number of general anaesthesia 3 soo f- + plus IV PCA for the colonic surgery patients, E 400 lr GA Epidural l comparing usage before and after the MASTER trial ; 300 EGA ] publication. 9 200 z0! roo Results Pre Post Acute Pain Management Service Datu MASTER MASTER The mean number of epidurals performed during each twelve month epoch in the 36 month period Figure 2. prior to MASTER publication was 343. The twelve monthly mean in the three years after MASTER publication in 2002 was 197. This represents a Questionnaire reduction of 43o/o and inspection of the data The questionnaire was sent to 37 specialist graphically (Figure 1) shows a stepwise reduction anaesthetists of whom 36 (97%) replied. around the time of MASTERpublication. Twenty seven (75%) considered they were Aralysing the total number of epidural and IV PCA performing fewer epidurals when comparing the 29 past 2 years with a similar period 4 or 5 years ago. was indeed associated with a major shift in practice Not one anaesthetist considered they were in our institution. Whilst other factors undoubtedly performing more epidurals. existed, they had not gathered suff,rcient weight to Twenty five (690/o) indicated that the f,rndings of precipitate the change. We believe MASTER trial the MASTER trial had influenced their rate of findings acted as a "tipping point" for a change in epidural usage, resulting in a decline in epidural practice. This represents an interesting example of a rates. When the anaesthetists were informed about single, prospective randomized study leading to the decrease in epidural rate locally in Christchurch reduction in use of a commonplace therapeutic Hospital, 3l (86%) said they were not surprised. option. The final two questions asked for comments about An interesting question that arises is whether the the MASTER trial and as to whether the respondent change in practice we observed is supported by the had other reasons to explain the reduction in evidence base that is currently available. The epidural rates. Common themes to explain this Australian and New Zealand College of (besides the MASTER trial results) included Anaesthetists and Faculty of Pain Medicine surgical preference, concern about rare but publication "Acute Pain Management: Scientific devastating complications, inability to run low-dose Evidence", emphasizes improved analgesia, bowel vasopressor infusions for postoperative hypotension recovery and reduction in pulmonary complications on the ward, recent use of wound catheters, the associated with epidural anaesthesia and analgesia, advent of spinal morphine techniques and the use of although it recognises the diffrculties in comparing multimodal analgesic regimens. studies of different drugs, at different levels, for different operationsrs. Ballantyne et al. give a very Discussion balanced view of the positive and negative effects The data presented shows a reduction in usage of of epidural anaesthesia and analgesia, thoroughly epidural anaesthesia and analgesia at Christchurch review the available evidence, and stress that Hospital over the audit period. This reduction beneficial effects are more likely when epidural appears to have chiefly occurred in a stepwise anaesthesia and analgesia is tailored to specific fashion, around the time of the MASTER trial groups of patients'a. Liu et al note that, given the publication. increasing safety of surgical procedures, with low The combinations of IV PCA with epidural mortality and major morbidity, the numbers of analgesia to define the "major analgesic intervention patients required to demonstrate significant group" could produce the impression of a outcome differences in randomized controlled trials proportionate decrease in epidural use ifIV PCA use may be unfeasibly high. Instead they suggest had increased. Whilst PCA use did increase between looking at more patient-orientated outcomes such as the study periods, the increase was small compared quality of recovery, patient satisfaction and quality to the reduction in epidural usage. Indeed some of life''. increase in IV PCA would be inevitable, because it Such issues are at the core of much of the represents the commonest alternative method to epidural anaesthesia and analgesia practice abroad. epidural analgesia. Therefore we believe the Along with some Australasian centres, many reduction in epidural analgesia use to be a genuine centres in the US and Europe are pursuing "Fast- event, rather than an artefact produced by an Track" or "Enhanced Recovery After Surgery" increase in IV PCA usage (ERAS) programs. These programs use epidural It is well documented that the MASTER trial has anaesthesia and analgesia in combination with been subject to significant criticism. This criticism minimally invasive surgical techniques, aggressive has been chiefly aimed at poor protocol compliance, postoperative rehabilitation, early oral nutrition and the lack of specific information about the epidural ambulation. Such programs have not only been regimen and the fact that those patients in the shown to shorten hospital stay but also lead to epidural group were not also assigned to specific earlier resumption of normal activities, with less rapid rehabilitation programmes. fatigue and need for sleep postoperatively,n ,'. Not However, the temporal association of MASTER only does this appear to benefit patients (although publication with the decline in usage of epidural readmission rates are possibly increased) but also it analgesia, plus the response of the surveyed is logical in a healthcare system under increasing specialists, suggests that MASTER trial publication fiscal pressure. 30 In conclusion, this audit has shown a significant mortality md morbidity with epidwal or spinal anaesthesia: results fiom overview of nndomised rials. dM"/2O00:,321'.1493-97, drop in epidural rates that occurred around the time Wu CL, Huley RW, Anderson GF et al- Effect of postoperative of the MASTER trial's publication. In combination epidwl analgesia on morbidity and mortality following surgery in with similar work performed in Australia", the medicae patients. Reg Anuth Pain Med 2004;29:525-33, Moen V, Dahlgren N, Irestedt L. Severe neurological complications results strongly suggest that selective interpretation after central neuraxial blockades in Sweden 1990-1999. of the available evidence-base for epidural Anesthesiologt 2004; 101:950-59. anaesthesia and analgesia has resulted in a marked Lee LA, Posner KL, Domino KB et al. lnjuries associated with regional anaesthesia in the 1980s md 1990s: a closed claims malysis. change in local practice. However, given the Ane s th e sio I ogt 2004 i l0l : I 43 -52 changing role of epidural anaesthesia and analgesia, Block BM, Liu SS, Rowlingson AJ, Cowan JA Jr, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 2003; the focus on patient-centred outcomes and 29O:2455-63. increasing fiscal pressures, we postulate that the rate 10 Rigg JR, Jamrozik K, Myles PS et al. Epidural anaesthesia and of epidural anaesthesia and analgesia may yet analgesia and outcome of rojor surgery: a randomised tial. Lancet 2002;359:1276-82. increase again. Power GE, Warden B, Cooke IC Chmging pattems in the acute pain service: epidural versus patient-controlled znalgesia. Anaeslh Inteuive Cre 2O05; 33:501-5. I2 Davies RG, Myles PS, Graham JM. A comparison of the analgesic References efficacy and side effects of pamvertebral vs epidural blockade for l. Wu CL, Cohen SR, Richman JM et al Effrcacy of postoperative thoracotomy: a systematic review and meta-analysis of rmdomised patient-confiolled and continuous infusion epidural analgesia venus tnals. Br J Anaesth 2006:, 96:418-26. intravenous patient-controlled malgesia with opioids: a meta-analysis. l3 Ausfalim and New Zalmd College of Anaesthetists and Faculty of Anesthxiologt 2O05; 103: 1079-88. Pain Medicine. Acute Pain Manogemenl: Scientific Evidence 2nd 2. Werawataganon T, Chanluman S. Patient controlled intravenous edition,2005. opioid analgesia versus continuous epidural malgesia for pain after t4 Ballantne JC, Kupelnick B, McPeek B, Lau J Does the evidence intra-abdoninal strgery. Cochrane Databue Sys/ Xev 2005(l): CD support the w of spiml and epidural anesthesia for swgery? J Clin 004088. Anesth 2005: l7:382-91 3. Liu SS, Carpenter RL, Mackey DC et al. Effects ofperioperative l5 Liu SS, Wu CL. Effect of postoperative analgesia on major analgesic technique on rate of recovery after colon surgery. postoperative complications: a systematic update of the evidence. Anesth uiol ogt 199 5 ; a3:7 57 -65 Anesth Analg 2007; lO4:689-702. 4. Jorgensen H, Wettersley J, Moiniche S et al. Epidural local 16. Hjort Jakobsen D, Sonne E, Basse L et al. Convalescence after anaesthetics vesus opioid-based analgesic regimens on postoperatiye colonic resection with fast-track versus conventional carc. Scand J gastrointestinal paralysis, PONV and pain after abdominal sugery. Surg200/;;93:24-8. Cochrane Databue Syst Rev 2000(4): CD 001 893. l7 Kehlet H. Fast-track colonic surgery: status md peFpectives. Recenl 5. Rodgers A, Walker N, Schug S et al. Reduction of postoperative Rffihs CMw R6 2005; 165:8-13.

3l Anaesthesia Points West Vol. 40 No. 2 Article

Michael Tirnstall and the Development of Entonox

Tim Dawes Senior House Officer in Anaesthetics Yeovil Foundation Trust, East Somerset

An extended version of this paper won the Abbot History Prize, GAT meeting, Brighton, 2007

Introduction removing teeth, and by the 1860s it had become In 1961, Michael Tunstall, a Senior Registrar at common in dentistry and later on in general sugery Portsmouth Hospital, contributed significantly to the too. From the outset it was recognised that nitrous techniques of inhalational analgesia by convincing oxide had low potency as a sole anaesthetic agent the British Oxygen Company (BOC) to undertake an and therefore high concentrations were required, unusual proposition, the bottling of nitrous oxide often to the detriment of normal oxygen supply. and oxygen together at high concentrations. Despite Edmund Andrews, Professor of Surgery in Chicago the BOC's misgivings, Tunstall convinced them it Medical College, noted that high concentrations of would be a clinically useful mixture and overcame nitrous oxide led to clinical hypoxia, and warned the technical diffrculties that ensued. At the time against its use in high concentrations in the Chicago

inhalational analgesia was in a difficult state: Medical Examinef . nitrous oxide delivered alone had already proved to be lethal and the gas-and-air machines of the day, The Twentieth Century despite almost thirly years' refinement, had recently Despite the gathering bank of evidence that nitrous been proven to be at best ineffective and at worst oxide was a useful sedative and pain-reliever, the dangerous. Tunstall's determined intervention was development of nitrous oxide focussed on using it well timed. for anaesthesia largely because the alternatives, The following is a discussion of the events before and after 196l and aims to highlight the work done by Dr Tunstall in the development of Entonox.

A Brief History of Nitrous Oxide

The Eighteenth and Nineteenth Centuries - Priestley, Davy, Wells and Andrews In 1776 Joseph Priestleyr, an English chemist and Presbyterian minister, heated iron hlings pre-treated with nitrous air obtaining nitrous oxide. He discovered a gas that was to play a unique role in medicine over the next 200 years. It took a further 23 years, until 1799, before the idea was pursued by Humphrey Daly, who produced nitrous oxide at the Pneumatic Medical Institution in Bristol. Davy recorded that the gas helped to relieve his toothache and suggested that "it may probably be used with advantage in surgical operations"2. Figure l: The Minnitt Apparatus. With kind In the 1840s, Horace Wells in the USA permission of the Association of Anaesthetists of introduced nitrous oxide as an anaesthetic agent for Great Britain and lreland.

32 ether and chloroform, were seen as difficult to use concentrations, but with considerable risk of and potentially immediately lethal. Several hypoxia. Added to this was that one of the main innovators of the early twentieth century contributed groups at which it was targeted were women in to gas delivery techniques, and so indirectly to childbirlh who were poorly placed to endure even nitrous oxide's future. Perhaps the greatest briefperiods ofhypoxia. The apparatus was heavy, contributor was Robert James Minnitt, who in 1933 requiring at least two cylinders as well as delivery developed an adaptation of a McKesson oxygen apparatus and Cole and Nainby-Luxmoore's work machine which delivered a mixture of nitrous oxide clearly demonstrated that current "approved" and air (see figure 1). After approval by the Central machines were at best inadequate and at worst Midwives Board of England the apparatus was used downright dangerous. A solution was needed. successfully by obstetric patients until the 1960s when it became clear that there was a dangerous Pre-mixed nitrous oxide and oxygen - problem - the delivery of hypoxic mixtures. the birth of Entonox In March 1961, enthused by the obvious advantages The Hypoxia Problem of nitrous oxide analgesia, Dr. Michael Tunstall Despite the prolonged career of the Minnitt wrote a somewhat speculative letter to the British apparatus, it was suggested, even before it was Oxygen Company (BOC) in Brentford, Middlesex endorsed by the Royal College of Obstetricians and asking whether "equal portions ofnitrous oxide and Gynaecologists in 1936, that delivering high oxygen would come off a cylinder containing equal concentrations of nitrous oxide with air might result parts of these two gases". At the time, Tunstall was in fetal hypoxia. Nicholson Eastmana of Johns a senior registrar at Portsmouth Hospital and had Hopkins Obstetrics Department analysed arterial developed an interest in inhaled anaesthetics. He and venous blood samples from fifty hve mother hoped to solve the problems of inconsistent mixing and baby pairs. The eleven mothers receiving 80%o in previous machines by storing both gases in the nitrous oxide and 20Yo oxygen gave birth to infants same cylinder, though he was aware that the with an average arterial saturation of 40% - a full pressures required to store large quantities would ten percent below the fetal arterial saturation value liqueff nitrous oxide and alter the proportions of the obtained from his control group. Further study gases delivered from the cylinder. identified five infants with diagnosed asphyxia Tunstall was not the first to consider putting neonatorum born from mothers using inhalational nitrous oxide and oxygen in the same cylinder. Both analgesia - in four cases, the mother had received Klikovich, of St. Petersburg University in the 1880s, 950lo nitrous oxide for periods of between ten and and then Barach and Rovenstine'(1945), after twenty minutes. The average arterial oxygen highlighting the dangers of anoxia during nitrous saturation in these five infants was 6.70/o. The oxide anaesthesia, recommended of the use of a Minnitt apparatus delivered a 50:50 mix of nitrous mixture of 80% nitrous oxide and 20Yo oxygen in oxide and air, providing only 10.5% oxygen. It the same cylinder, at the relatively low maximum therefore routinely delivered a hypoxic mixture. cylinder pressure of 7001b imploring colleagues Worse still, Cole and Nainby-Luxmoore's work in to consider patient safety above financial the early 1960s suggested that few gas-air machines considerations. However, Tunstall was the first to could even reliably do this. They audited the approach the topic ofwhat happens to nitrous oxide performance of thirty-frve gas-air machines in daily when it is stored at higher pressures in combination use in the region. Thirty three of the machines with a second gas, oxygen. delivered less than 10.4% oxygen (the CMB's In early 1961 Tunstall wrote to the British guideline) over some portion of the delivery Oxygen Company to ask if they would consider spectrum, and five machines delivered less than 5% creating such a pressurised mixture so as to store oxygen when set to their smallest minute volume clinically useful volumes. Dr. Arthur Bracken, the (V1250mL, RR 12 minr). manager at the BOC's Scientific Centre in Morden, quickly wrote back to Tunstall, pointing out that Where Next? there was no record of the mixture in the literature, The findings of the early 1960s had thus left a and that analogy with carbon dioxide and oxygen problem. Nitrous oxide was known to provide good mixtures suggested that the nitrous oxide would analgesia, and even anaesthesia at high liquefy at low pressures, making the contents JJ unreliable and unsafe for clinical usage. Tunstall raying the cylinders for fluid levels, the solution was was not deterred, and encouraged the BOC to found to be very simple. With the help of Donald's attempt the experiment via a series of letters ice-cream factory, Tunstall cooled 21 cylinders of through early 1961. In August, Bracken and 50o% nitrous oxide to a range of low temperatures Tunstall met again in Portsmouth, and Bracken and assessed the gases emitted after re-heating them announced that a 7 5oh nitrous oxide and 25oh over a period of days. In some, he added "inversion oxygen mixture could be maintained as a single manoeuwes" to agitate the cylinder contents. If the gaseous phase in a cylinder with oxygen at 2000 oxygen content of the emitted gas was the same as p.s.i. at room temperature. The finding hinged on that before cooling, or the same for various positions the fact that although the nitrous oxide in the of the outlet valve, then the cylinder was assumed to cylinder was at a high enough pressure to cause it to be in a single gas phase in even mixture. If the liquefy, at these pressures the compressed oxygen oxygen percentage measuredjust before the cylinder had a solvent effect (the Poynting effect) allowing became empty was the same as at the beginning of more nitrous oxide to remain in the gaseous phase. the experiment, it was assumed that the cylinder Bracken filed a patent for the idea immediately6 and would have been safe to use. Tunstall's results settled on the nime of "Entonox" for the combined suggested that inversion of a re-warmed cylinder preparation. appeared to agitate the liquid phase into evaporation almost instantly. On this basis, he recommended 1962 - Experiments in Oxford warming cylinders to room air and inverting them As the second leg of his joint appointment with "briskly three times" if there were concerns as to the Portsmouth, Tunstall moved to Oxford in early temperature at which the cylinder had been stored. 1962. By J:ur:'e 1962, trials of 50%o nitrous oxide / The higher percentage nitrous oxide preparations 50%o oxygen had been received well by midwives were more susceptible to this problem - 7 5Vo nitrous and patients as well as local dentistry practices. oxide mixes precipitated out at only 20"C, compared However, a problem had become apparent. In a to the -8'C required for 50%o nitrous oxide (both at personal communication with Tunstall, Cole of the 13.7MPa) but in either case a solution was at hand. Radcliffe Infirmary, Oxford, pointed out that if the 507o nitrous oxide cylinders were cooled to -SoC the Central Midwives Board Review nitrous oxide would liquefy. This was not After Cole and Nainby-Luxmoore's observations surprising. However, if the cylinders were then and Tunstall's solution of the precipitation problem, warmed to room temperature, the nitrous oxide the CMB reviewed their policy with regard to the would not immediately revert to the gaseous phase, administration of inhalational analgesics by leaving the contents of the cylinder split between a midwives. Tunstall and co-authors reinforced the nitrous oxide rich liquid phase, and an oxygen rich safety of their mixture with a timely publication in gaseous phase. The importance of this was that the British Medical Journal in 19648. Here, they Entonox might not prove to be stable under discussed the cooling problem in full, including the conditions of storage or transport at low straightforward solution and presented data from the temperatureT, and so cylinders brought into a labour Meteorological Office suggesting that the chances of ward from freezing outdoor conditions might a cylinder being cooled to -8"C or below in the UK initially provide a high concentration ofoxygen, and were 0.0013, or 13 in 10,000 rare indeed. In 1965 progress to a high concentration ofnitrous oxide. In the CMB approved the use of Entonox for use by the same year Cole published his damning unsupervised midwives, and in 1970 the license for discussion of gas-and-air delivery machines (see gas-and-air was revoked. Entonox has now above discussion) with Nainby-Luxmoore, and it expanded to filI roles as a rapid onset analgesic in seemed that neither of the nitrous oxide emergency services, for painful procedures such as combinations had a future in clinical practice. joint relocation, and for dressing removal in the hospital and in paediatrics for distressing minor t'Manoeuvre" 1963 - The Inversion procedwes - a thirty year career already. After moving to Aberdeen in December 1962 to take up a consultant post, Tunstall was determined to Credit where it was due? tackle the problem of cooling and re-warming In his publications of 1963 and 1964, Tunstall cylinders. After many experiments, including X- tackled and solved the problems of low temperature 34 precipitation. Arthur Bracken and colleagues also the BOC too, failing to acknowledge Tunstall's work, researched these problems, publishing their data in knowingly or not, in their repetition of his 1968' and 1970'o confirming Tunstall's findings. experiments of the early 1960s. It can only be hoped The 1968 paper's acknowledgement of Tunstall's that Tunstall's steadily increasing body of work will contribution is solely as one ofthree authors to point ultimately secure his place as a true innovator of out that cooling might result in hypoxic delivery. It inhalational anaesthesia, and his contribution to the makes no reference to his solutions to the problem, development of Entonox will be properly understood though it post-dates his publications by five years. as one stage in this. Their 1970 publication supplies data through a wider range of physiological parameters but ultimately Acknowledgem€nts also concludes that cooled cylinders of 50o/' nitrous The author would like to thank Professor Michael oxide could be safely used after a period of re- Tunstall and Dr Jeremy Reid for their comments on warming and agitation. What is striking is apart the text. from Tunstall's initial publication of l96l (publicising the fact that 50yo nitrous oxide could be References stored at high pressures without precipitation) 1. Ross JAS, Marr IL, Tunstall ME. Entonox and its Development, from Smith EB, Daniels S, eds. Gases in Bracken's and colleagues publications fail to Medicine: Anaesthesia. London: Royal Society of Chemistry. acknowledge Tunstall's ensuing work in this area, 1999. p27-41. including his solution of the cooling problem, 2. Davy, H. Researches, Chemical and Philosophical, chiefly despite the seven years which had elapsed since conceming nitrous oxide or dephlogisticated nitrous air and its respiration. Bristol: Biggs and Cottle; I 800. Tunstall's data were published. 3. Andrews E. Liquid Nitrous Oxide as an Anaesthetic. Chicago In an effort to "summarize the main publications Medical Examiner 1872; l3:34-36. on Entonox"r', the BOC published the first edition of 4. Eastman NJ. Fetal Blood Studies - The Role of Anaesthesia the "Entonox Digest" in 1970. This 35 page in the Production of Asphyxia Neonatorum. American document recorded the history and usage ofEntonox Journal of Obstetrics and Gynaecologt 1962; 3l:563-572. 5. Barach AL, Rovenstine EA. The Hazards of Anoxia During and included references to 33 research papers. Nitrous Oxide Anaesthesia. ln aeslhesiologt 1945 ; 6:449. Tunstall's contribution: a single discussion paper of 6. Bracken A, Wilton-Davies CC. Patent specification number September 196812, in which he described the 967930. LIK Patent Office. motivations for discovering a pre-mixed gas 7. Cole PV. Nitrous oxide and oxygen from a single cylinder. and part lecture gave in Ansesthes ia 1 964; l9''3 -l l - solution, of a he 8. Gale CW, Tunstall ME, Wilton-Davies CC. Premixed Gas Copenhagen in 196711 . His initiation of the idea, his and Oxygen for Midwives. British Medical Journal 1964 clinical work with midwives and his solution of the Mar27. problem of hypoxia on cooling are entirely omitted. 9. Bracken A, Broughton GB, Hill DW. Safety Precautions to be Observed with Cooled Premixed Gases. Britrsft Medical Joumal 1968 Sep 2l:715-716- Conclusions 10. Bracken A, Broughton GB, Hill DW. Equilibria for mixtures In his book "The Human Guinea Pig", Maurice of oxygen with nitrous oxide and carbon dioxide and their Pappworth cynically articulated the idea that original relevance to the storage of NrOiO2 cylinders for use in research is nearly always a re-circulation ofprevious analgesia. Journal of Physics, Series D,: Applied Physics l97O:3:174'l-l'157 ideas be original you must not read it has all -'to - 11. Entonox Digest. 3rd ed.. London; Medishield; 1976 Nov. been described before". In Tunstall's case this applies 12. Tunstall ME. Implications of premixed gases and apparatus twice. His initial conception of single-cylinder nitrous for their administration. British Journal ofAnaesthesia 1968 oxide and oxygen was not a new idea Barach and Sep; 40(9). - Tunstall oxide with special reference Rovenstine suggested, in 1945, that delivery would be 13. ME. Nitrous analgesia, to relief of pain in labour. Lecture given at the Fourth pre-mixed improved if single cylinder gases could be Refresher Course, WHO, Copenhagen on l9th September used. Ultimately, Pappworth's comment applied to 196'7.

35 Anaesthesia Points West Vol. 40 No. 2 Article

MMC & MTAS - a trainer's view Chris Johnson Regional Adviser in Anaesthetics Bristol School of Anaesthesia

This year's debacle in the appointment of junror nebulous, leaderless and apparently rudderless doctors can have escaped no-one's attention. In an organisation within the Department of Health, era of constant and frequently ill-managed change, MTAS proved unfit for purpose at every stage in no previous "H.R." issue (Human Resources : the process, but was impossible to challenge "medical staffing" in oldspeak) has led to five because it refused to consult, listen or indeed parliamentary debates, numerous resignations by declare itself. senior medical politicians, or such a constant A few specialties, anaesthesia among them, have stream of newspaper and television reports. Retired been consistently innovative in their training. physicians may wonder how such a mess could Under various terminologies we have provided develop - it cenainly wouldn't have happened ten uniform basic training at SHO level and higher years ago. Those juniors caught up in the chaos specialty training within the Registrar and, until have had a very worrying few months. Most the Calman reforms of the mid-90s, the Senior consultants are only too happy to leave the Registrar levels. Training has become complexities of the organisation and assessment of standardised, with competency logbooks and trainees to others education has never been regular 'RITA' (Record of In-Training glamorous - but in the end many got stuck in and Assessments) reviews of progress introduced to helped with the mammoth tasks consequent on the ensure that all trainees are capable of undertaking change. Finally a small core of educational work safely and effectively. But this consistency enthusiasts was faced with the local implementation was not universal. In 2005 only three of the 65 of the biggest transformation in medical training accredited specialties had a recognisable since the NHS began, amid a support system that competency-based training system. Many SHOs became progressively more dysfunctional. This around the country were left without close article tells some of the background to the story educational supervision to make their own way from the perspective of someone whose spare time through an increasingly problematic system. was wholly occupied by these events for almost In August 2004 the European Working Time two years. Directive came into force, reducing working hours To understand the problems it is important to from around 72 hours per week to 58, with tighter distinguish between "Modernising Medical regulations to follow. Dire predictions were made Careers" (MMC) and the Medical Trainee that the service would collapse, but in the event Appointment System (MTAS). MMC involved posts were created and doctors were found to keep discussions and a series of position papers aimed at the service working. Few people questioned how restructuring and improving the medical training this was achieved, but GMC figures on medical system. For reasons I shall explain, many of the registrants indicate that huge numbers of overseas suggested changes made sense, although the details doctors were enticed to take the PLAB of their inception became progressively divorced examination and register with the GMC. No one from the original ideals. MTAS was, and still is, the took count of how many of these doctors appointments mechanism by which the doctors eventually obtained a UK medical post, but in the should be appointed into their reformed posts. A four years (2002-2005) 60,000 new doctors

36 tlc, of doctor egbtcftE wth th€ c}{e applicants per post that had been the norm since the Calman reforms, we saw huge increases in the number of applicants, culminating in 165 applicants for five places in November 2006, the last old-style appointments process. More than twenty of these applicants had memberships, :IMGI fellowships or higher degrees. We had reached the "4IEA point where the only way to get a job in IUK : anaesthetics in Bristol was to spend at least four years working in research or another specialty - good for experience, but hardly efficient - and many very capable SHOs were unable to obtain registrar posts. So the principles underlying the MMC proposals - an altered balance of numbers Figure I. within the training grades and better structured IMG : International Medical Graduates training for most specialties - were sensible. EEA: European Economic Area MMC was always a difficult finesse. The UK: United Kingdom original intention was to avoid hordes of junior doctors milling around for long periods in poor quality posts, but still permit some flexibility in career choice. But as time progressed, the Applicant:job ratio in impossibility of simultaneously providing control and flexibility was realised and the decision was Bristol School of taken to head down the route ofcentral control and Anaesthesia increased rigidity. Each specialty was required to design a 'run-through' programme that would enable a trainee who had completed the two-year 35 Foundation programme to select a specialty and so, 30 E after a few years of 'seamless training', acquire 25 their specialty training certificate or CCT. Within the Bristol School our ability to manage 20 this transformation was made more complex by 15 three radical changes in Deanery management 10 structure and by the knowledge that the Great Western Hospital at Swindon would be joining our 5 School. A census in early 2006 revealed the extent 0 n C ofour problems: our School had99 SHO posts and 2004 2005 2006 2007 73 SpR posts, a ratio of 1.36:1, but after the MMC reforms we had to end up at a ratio of 0.27:l .lt took eighteen months work, numerous computer spreadsheets, much negotiating at many different Figure 2. levels, and lots of sleepless nights to solve this. In the early nineties I can recall it taking many registered in the UK against a pre-existing committees to create a single new registrar post; on workforce around 200,000 (Fig of doctors l). The this occasion we eventually agreed over 30 new majority of these doctors aspired to becoming registrar posts in one hour's meeting with the consultants principal posts or acquiring within the Dean. Recently about 15 SpRs a year have UK health system. completed their training at our School, following In the Bristol School of Anaesthesia we saw the MMC we now plan (at least initially) to produce 6 effects these changes indirectly. of Over the next accredited intensivists, 2 chronic pain doctors and three years, competition for SpR jobs increased I I anaesthetists per year. A few posts were exponentially (Fig 2). From a typical level of four transferred from training to permanent grades but 37 effectively we planned to manage the transition by the first of many computer failures, the marking having exactly the same number of anaesthetists in schemes were not released until several days after post on the I st August 2007 as on the 3 I st July. we were supposed to begin marking the answers. An important innovation was the development of The Bristol School of Anaesthesia had received the ACCS or 'Acute Care Common Stem' well over 700 applications. The trainers were given programme, a two-year introduction to a three-week window in February to short-list the Anaesthesia, Emergency Medicine, Acute applicants for five different levels of training: for Medicine and Intensive Care involving rotations the first of these three weeks, there was silence within these specialties. Having had to dismantle from MTAS. The computers gave no access to the something similar before we started reforming the applications; there was no information about when School, we decided to support this development, the situation would be resolved. It was school half- which meant appointing a new training Director term; the members of my team, looking after the and organising forty new rotations within the ST3 applications, were due to go on holiday in the School. And so, by autumn 2006 we were ready to middle of the second week. By the first Friday the appoint to our new scheme and came in contact Deanery had limited access to the forms, gave me a with MTAS. single printed copy of each application, and two of MTAS was supposed to be a uniform us spent seven hours photocopying the 5500 pages appointments scheme based on a fully of A.4 required. Amazingly the department computerised application system. This system had photocopier survived, though the smell of functioned, albeit with some technical hitches, for photocopying progressively percolated through the appointments to Foundation posts (the old PRHO whole department. I then drove 140 miles in the and first-year SHO jobs) and the difference was snow to deliver the forms in time for the weekend. seen as one of scale rather than substance. But The entire weekend and most of Monday was spent those organising the system wished for more. They short-listing, a mind-numbingly awful task given asked educational psychologists to produce a new the quantity of indistinguishable politically-correct application form designed to test the core skills verbiage to wade through, and the results were regarded as essential by the GMC, rather than the alarming in that pairs of experienced trainers were previously accepted norm of looking in detail at ending up with very different scores for the same technical experience and expertise. Such an individuals. Variations of four points out of ten approach is not unreasonable for evaluating the were not unusual - and when the scores were doctors emerging from the Foundation years, who totalled 40 candidates, nearly a quarter ofthe field, are very similar in their background experience. lay within +/- 3 points of the cut-off score for But the approach was taken without consulting or interview. involving the training programme directors and That Bristol was not alone in having problems College advisers, and the instigators did not accept rapidly became clear from e-mail discussions that there were differences in the selection between the College Regional Advisers and requirements of the various craft specialties. One Training Programme Directors. Simultaneous with day's training on the new appointments system was concerns about the marking system, it became provided, which provoked a certain number of apparent that the number of MTAS applicants had sceptical comments from the trainers, but we were been greatly underestimated; vast numbers of assured that it would all work very effectively. doctors from outside the training grades had Lacking hard data, it was impossible to oppose a applied. We quickly realised that anyone who nebulous system promoted so assertively. Imbued failed to get an interview at the first attempt was with the language of educational theorists, the unlikely to get appointed to a decent training psychologists failed to recognise that senior rotation, but many very capable doctors had not trainees and consultants alike would regard the coped with the psychobabble effectively and so had psychobabble forms with bafflement and scorn. not been called for interview. Lacking support Incredibly, those responsible for marking the from both trainers and trainees, and trying to applications were never shown the actual explain away a computer system that failed at application forms and had to beg copies from their every stage in the process, the MTAS organisation trainees to even see the questions. Owing to collapsed. problems with the distribution of the digital files, Left without any form of central support the 38 Deaneries could barely cope and those of us trying supposedly leading the transition had no idea ofthe to sort out rankings and scores were left creating complexity or difficulty of their task. A talk in our own computer score sheets or shuffling scraps summer 2006 by the lead Dean in Anaesthesia, one of paper around on the floors of offices. It was of the initial drivers of MTAS (though he later truly awful. There was considerable pressure on opted out) missed the mark so widely that I was trainers to abandon the task, but we knew that the driven to comment to him that his remarks "were alternative to carrying on would be a complete as relevant to the present situation as Bruce melt-down of the service - trainees at the top end Ismay's conversations with Captain Smith of the of the programme were leaving, but there was no- Titanic as the ship entered the Greenland current." one to replace them. Though they learned fast, senior staff at our Despairing of the application form, we put a Deanery initially had no concept of the complexity huge effort into creating a new interview system. of running a competency-based training scheme for The traditional panel interview is inefficient and 180 trainees scattered over nine hospitals. Trying puts excessive emphasis on verbal skills. By to convert so many levels of training at once while moving towards a "sequential" interview system, simultaneously trying to introduce a completely rather like an OSCE examination, we could both new appointments system using an untested see more people each day and test their technical government computer system indicated an utter abilities in greater depth. Creating the new failure to understand the basics of risk assessment stations involved much effort but the management. It is unclear whether the faults with results were gratifying. In mid-March five different the computer system lay in its specification or with panels were seeing between 24 and 30 candidates a its programmers, but it is known that the complex day, yet each candidate had between forty and sixty algorithm needed to allocate the ranked trainees to minutes direct questioning as well as carrying out jobs would never have worked. To cap it al7, a other tasks. Apart from examining their simple human error then resulted in the personal professional portfolios, we were able to assess their details of many medical students becoming clinical abilities, their management and generic accessible to Channel 4 News. This was the death skills, and to judge their decision-making under knell for that particular item of information pressure. Feedback from the trainees suggested that techlology, and once again Deaneries and trainers we had succeeded in making the appointments were forced back into relying on their own process relevant and fair, with most trainees resources. preferring the new format to the classical panel The whole process has been a tragedy. Trainees interview. But, in another of the absurdities of the have had an awful time and may not have got the MTAS system, we knew that less than a third of jobs they wanted. The Deaneries had to cope with the trainees that we had interviewed would actually tasks that they were neither staffed nor equipped to opt to come to our School. undertake; many of their best staff felt overwhelmed Various of the Great and Good had become and resigned. Several senior medics have fallen on involved in trying to salvage something from the their symbolic swords. Introduced for the best of chaos in the DoH and we received instructions that motives to improve the quality of training - the we would have to go back and interview many process was abysmally managed. A small group of more doctors. Establishing who these would be trainers and College Tutors in each specialty has took time, but in mid-May we were back, this time been left clinging to the wreckage of a catastrophic in the Bristol Rugby Club stadium, to complete this failure, trying to ensure that there were doctors in round of interviews. And at the end of this post to care for patients. Yet there have been some immensely frustrating and time consuming process, positive outcomes. We have expanded the number we were still left with many unmatched doctors of senior training posts and many excellent SHOs and considerable gaps in the rotas, which we who were struggling to get jobs under the previous struggled to fill during June and July to meet the system will now obtain the training they deserve. August lst deadline. We have introduced the ACCS training rotations, So how could things go so badly wrong? The which look to be a constructive way forward for the Tooke enquiry has been established by the DoH acute hospital specialties. The new appointments and may provide some of the answers, but probably process is we think more efficient and more not all. My impression throughout was that those effective than what it replaced. 39 In the end, we managed to fill over 95%o of our services running belongs to the two programme posts by the August deadline. True, several directors: Su Underwood (Anaesthesia) and Anne excellent UK graduates have emigrated overseas Whaley (ACCS). Fiona Donald, our Education and have been replaced by overseas graduates Officer, led the reform of the interview process, and whose capabilities we are assessing - not a sensible thanks also go to the many consultants who use of resources. Hopefully most of our volunteered to help with short-listing and departments have continued functioning over the interviewing the applicants to our School. We are summer and most trainee anaesthetists have been also most grateful to Dr Geoff Wright at the able to pay their mortgages. Not a huge Deanery who had a completely thankless task trying achievement you might think, but one that has to control the entire process and managed to required an enormous expenditure of time and maintain his cool when all around were losing theirs. energy. And what we now have in place should Finally (as he approaches retirement) I must thank provide a better career structure for future medical Nev Goodman for suggesting improvements to the graduates. text of this article. Nev & I have written much together over the years and his influence on many Acknowledgements medical writers has been profound. As always his Much of the credit for keeping our anaesthetic comments were pertinent and constructive.

40 Anaesthesia Points l4/est Vol. 40 No. 2 Article

Clinical Systems Engineering

Dr Nicky Williams Consultant Anaesthetist, Gloucester Royal Hospital

I was scanning the job section of the BMJ one cycle. They also help ensure that the design of the sunny afternoon in July 2003 looking as always for system is safe and comfortable to work in, and the perfect job - 3 days a week, no on call, no work to reduce the errors and accidents on the general surgery etc. The advert read "Have you got factory floor. Edward Deming, the quality guru of to the stage where you would like to sort the system the 1950s, coached Japanese manufacturing system out because you have had enough of the system engineers and they now epitomize this discipline. sorting you out? Could you help your local clinical The science of quality improvement underpins all teams redesign their whole system for healthcare? they do and the tools and techniques form the basis Could you help them to look at it systematically for what is now widely known as "Lean thinking" from the patient's point of view? Could you help - of which more later. them make the system safe, with no delays and with So what has any of that got to do with effective measures of clinical and service healthcare? We don't work in factories, we don't priorities?" Having been in post as a consultant for make products and we don't put patients on 5 years and getting increasingly frustrated by conveyor belts. But we do "process" patients; we working in a system that seemed to find it nigh on do put them through many steps in their pathway impossible to get a patient, anaesthetist, surgeon, from sickness to health and we do work in a theatre team and the right kit in the right place at complex system beset with problems, where the right time, my interest was immediately quality is paramount - but not always delivered, aroused. I made a few enquiries, filled in the which is constrained by frnite resources and seems required forms, passed the selection process and in to have long delays built in to it. Kate's unique January 2004 I started a 2 year secondment, with combination of engineering expertise and West Midlands South Strategic Health Authority, as knowledge of healthcare systems combined with a one of 9 doctors nationwide being trained as passion to improve healthcare for both patients and Clinical Systems Engineers as part of the innovative staff led to her joining the NHS Modernisation Osprey Project. It was the start of, if not a life Agency and starting to apply her engineering skills changing, certainly a job changing experience. to healthcare with remarkable results (Action on Cataracts being an example). The techniques that So what is a clinical systems engineer? developed for managing manufacturing systems, The project was conceived and run by Kate such as that at Toyota curiously reflect some of the Silvester. Kate, a doctor, had started her career as a basic principles of physiology, so a hypothesis trainee in Ophthalmology and then changed evolved that doctors would be ideal people to train direction to retrain as an engineer, spending many in these tools and techniques and would also be in years working as a manufacturing systems engineer positions to apply them to improve healthcare. The in industry. Manufacturing engineers have been Osprey Project was conceived as a pilot project to around since the beginning of the 20th Century and train doctors in this new role of clinical systems are responsible for designing the manufacturing engineer, bringing together medicine, engineering, facility and systems for making a new product to the human dynamics of change and quality meet the customer's expectations in terms of improvement science to help clinical staff to see quality, dependability, variety, delivery and cost. the whole system, to redesign and continuously They work on the shop floor helping the engineers improve their own part of the system. and workers improve the product throughout its life So what sort of things did I learn? 4t techniques and approaches that can be useful in Quality and Cost healthcare improvement projects. The NHS Finance and accounting have always been a bit of a Institute for Innovation and Improvement (the mystery to me - my bank manager can vouch for rebranded Modernisation Agency) have developed this - and there is very little hope of me ever an approach called Lean Six Sigma which is being getting to grips with this aspect of the NHS, but a tested in healthcare. key thing I have learnt is that highly successful Thinking about quality and reducing businesses have something called the cost of poor opporhrnities for things to go wrong in healthcare quality (COPQ) on their "bottom line". They leads directly to unpicking the pathway the patient recognize that every faulty product they make, takes on their journey from sickness to health, every returned item, every unsatisfied customer commonly known as process or value stream represents a waste of resources and because they mapping. Healthcare pathways are incredibly see the financial burden of that, they continuously complicated with many steps and "hand-offs". Any strive to release those resources by improving their contact needed between members of staff to processes to ensure that they only make high achieve a task is known as a hand off and each quality products that meet their customers' needs. hand off is a source of potential delay and an COPQ is not something that currently appears on opportunity for error. A mapping event revealed the accounts of any NHS organization in which I more than 250 hand-offs to complete a complex have worked, but how powerful would it be if it patient discharge - and discharge is only one step did? I have not managed to get a total for how in the patient's journey. Figure I shows the much my Trust currently spends on complaints, relationship between likelihood of success (or a litigation, medical indemnity, processing adverse high quality outcome) and number of steps in the clinical incidents, re-doing things that have gone pathway. A key requirement to improve the wrong, treating DVTs/PEs in patients who have not quality in healthcare processes is to reduce the been given recommended prophylaxis, wound number of steps, making sure that only those that infections in cases where antibiotic prophylaxis has are really necessary (add value from the patient's been overlooked etc, etc, etc. The list is endless perspective) remain and that each step is designed and the sum must run to many millions and what a to be error proof. No small task and certainly one huge opportunity to improve the finances of the that needs good clinical input. Once the steps in the NHS and improve the quality of the care given to process have been identified further information is patients. added to give the number of patients at each step, Designing processes to ensure quality is the how much time each step requires, how much time principle that underpins a management philosophy is spent waiting at each step and also the called "Six Sigma" pioneered by Motorola in the 1980s and more widely adopted by other manufacturers in the 1990s. It uses evidence, data Amplification of variation and statistics in a robust improvement methodology where the aim is to deliver a quality Probability of Performing Perffiy grcccss, standard of less than 3.4 errors per million l.,lo. i Plobobility of Eoch fuoccss Snep opportunities. That would be 3.4 patients per Pr.occss million treated who had a complication, or were stF harmed by an adverse event or who were unhappy o.95 o.999 o.w with their treatment. Or, for all 325 million NHS primary care patient consultations there would only 0.28 0.98 o.996 be about 1000 who were not happy, or less than 50 o.@ 0.95 o.995 of the 14 million people attending A&E would experience a problem. The sigma score for 0.@6 0.90 0.99 healthcare projects currently is about 2 i.e. processes defective more than 30% of the time Source: Corol Horoden fHI (308,538 patients with an error per million treated). Healthcare is probably not yet ready for the full Figure l. "Six Sigma" treatment, but there are a lot of tools, 42 information flows. All this information builds up a value stream map from which the process time i.e. The 7 Wastes of Lean value adding, and non value adding time can be determined. An example would be of a GP referral Defiecb/Rework repeating task done inconectly first for a simple day case procedure where referral to time eg. Repeating blood samples discharge takes 31 weeks but only 100 minutes of MovemenVTransportation: unnecessary movement of patients that time are value adding for the patient. or materials Overproduction: producing more than the next stage in the process can deal with Lean Thinking Waiting: staff waiting for things to happen, queues of The acme of quality improvement in manufacturing patients waiting to be treated is the Toyota Production System - often referred to Motion: unnecessary movement of statf or patients as Lean Thinking - and the principles that underpin eg. A commonly used piece of equipment kept in a this system are being applied to service industries remote location and healthcare with impressive improvements in lnappopriate Processing: u nnecessary process steps that adds features the customer does not want quality and efficiency. The 5 main components are: lnvefltoryr inlormation or materials waiting in a queue Speciff value: asking the customer (patient) what are the important aspects of the service/product and Figure 2. ensuring that the service meets their specifications. Current healthcare systems have often evolved to There are some excellent articles listed at the meet the needs of the healthcare providers rather end of this article which will supply more detail, than those ofthe patient e.g. batching ofpatients in but Lean is really about developing a continuous to clinic or theatre sessions, bringing in all patients improvement culture and managing healthcare for theatre lists in one large group organizations in a completely different way so that Identify value streams: the sequence of steps that the short term firefighting currently experienced adds value for the patient from the start to end of becomes a thing of the past. It sounds improbable, their journey and designing and managing each but it is possible to improve quality for patients, value stream as a single integrated whole. make the working lives of staff more rewarding Currently each department that a patient moves and less stressful and at the same time improve through is managed as an independent unit. It is efficiency and productivity without major financial interesting to note that only a small number of investment. It requires release of resources diagnoses account for most of our workload and currently consumed by poor processes and "waste" sorting out the flow in these "green" value streams (Figure 2) in healthcare systems and such would make a rapid improvement in quality, cost transformational change takes time. The principles and timeliness of care. Chest pain and ischaemic of Lean challenge the current NHS management heart disease, respiratory infections and abdominal philosophy (benchmarking, targets, unit cost, pain account for about 50% of emergency performance management, batch and queue, admissions. utilization, restructuring), seem counterintuitive to Create pull: provide services in line with demand a lot of NHS staff, and are at odds with the short- and pull all works, materials and information term approach adopted to deliver financial balance towards the task when needed. That requires at the end of each financial year. Challenging the knowledge of demand (referrals and decision to current mind set of senior and middle NHS admit rather than waiting list figures), a move away managers and clinicians, and persuading them to from working to meet productivity or unit cost think and act differently has been the most difficult targets and removal of "waste" - waiting or and frustrating part of the Osprey Project work, but queuing also the most rewarding when the change starts to Make the system flow: ensuring that the patient happen. moves on to the next step without any delay, identifying and removing any blockages or Delays obstacles Those of us who work in healthcare are in a highly Pursue perfection: all staff strive to continuously privileged position. We know that if we need an improve the service by addressing problems as they operation we can pretty much chose when and who arise and redesigning systems to prevent recurrence will do the operation. Not so for most NHS patients 43 r*-ho considerable delays erperience - although Demandrcapacity for Rapid Access Chest Pain clinic these have decreased in recent years. Waiting lists are a well established feature of the NHS and were 14 r-idely believed to be caused by insufficient 2rz capacity; "If only we had more beds or more g8t,o clinics the patients would not have to queue". o- o!D However when you look at the shape of most NHS AA 3) u,aiting lists you realize that they are flat 2' 0 that in to the system is -suggesting what is coming 900000000000000s

Improvement Leaders Guides; boxed set produced Operations management, Slack Chambers Harrison by NHS Institute for Innovation and Improvment Harland Harrison and Johnstone,2nd Edition FT Pitman publishing, ISBN 0273-626688-4. Books The Tipping Point, Malcolm Gladwell, Abacus, Lean Thinking; James Womack & Daniel Jones; ISBN 0-349-t1346-7 1996 rSBN 0-7 432-3164-3 Six Sigma for Everyone; George Eckes, John Wiley & sons Inc, ISBN 0-471-28156-5

46 Anaesthesia Points West Vol. 40 No. 2 Article

SASWR Members and Anaesthesia in the Developing World

Dr Bruce McCormick" Dr Iain H Wilson Consultant Anaesthetists, Exeter

As the Society of Anaesthetists of the South methodology, reported a preventable mortality of I Western Region celebrates its 60th anniversary, it in 150 anaesthetics with 50% of deaths being can reflect on a strong specialty with good working obstetric. conditions and easy recruitment. An improving NHS, with rising investment, has increasingly The World Health Organisation (WHO) recognised the importance of anaesthesia with its The WHO is currently promoting a worldwide many roles in facilitating surgery, intensive care, alliance for patient safety lead by the UK Chief resuscitation and education. Although there are Medical Officer, Sir Liam Donaldson. One of the aspects of our professional life that we correctly important strands of this work involves safer surgery seek to improve, they pale into insignificance when as it is recognised that many patients die compared to anaesthesia provision in developing unnecessarily in the perioperative period. As part of countries. this initiative, an intemational anaesthesia team led A number of organisations, both intemational and by Professor Alan Merry from New Zealand are national, are active in promoting anaesthesia as an rewriting some of the recommended safety standards issue that needs investment. This paper summarises to improve anaesthesia services, particularly in some of these current activities, but in particular poorer parts of the world. This focus on anaesthesia highlights the involvement of our South West and surgery by the WHO is encouraging. anaesthetists over the years. The World Federation of Societies of Anaesthesia In The Developing World Anaesthesiologists (WFSA) Put simply, Anaesthesia in the developing world is The WFSA, whose aim is to promote the highest in crisis. In war torn regions there is often no standards of anaesthesia for all people in the world, surgery or anaesthesia; in many other locations is active in supporting education and publication for impoverished medical services try their best on anaesthesia related projects. Several specialist limited budgets. Seen as a technician-based anaesthesia fellowships are run in Africa, South speciality of limited importance, Anaesthesia is last America, India and Israel, including paediatric, in line when it comes to promotion or investment by obstetrics and intensive care. Many UK anaesthetists ministries or aid organisations. In a recent survey in continue to contribute to this worka. Dr John Zorub, Uganda, only 60/o of anaesthesia providers had an eminent name from the South West, was adequate supplies of drugs and equipment to safely President of the WFSA from 1988-1992, and was anaesthetise a patient requiring Caesarean section. influential in starting the refresher courses which The corresponding figure for an adult for have now been held in many places throughout the laparotomy was 23o/o, and l3o/o for a child'. world. Many of us remember his kindness in The avoidable anaesthetic mortality in poor supporting our ideas as young anaesthetists. countries is very high. Compared with the UK, the The Global Oximetry project (GO project) is a situation appears to be worsening. In the 1980s a collaboration between the WFSA, the Association preventable mortality rate due to anaesthesia was of Anaesthetists of Great Britain and Ireland reported fromZambia to be around 1 in 1900'?; in (AAGBI) and GE Healthcare to promote the 2006 a study from Togo', using the same widespread adoption of pulse oximetry, with a 47 particular emphasis in developing countries. The refresher courses in Uganda, where she now lives project is evaluating current oximeter design and and works with her husband Andrew, who is a cost, the educational requirements for their effective plastic surgeon. They work as a team performing use and barriers to their widespread adoption in reconstructive procedures for Ugandan patients, appropriate settings worldwide. Four initial projects including many with cleft lip and palates. The in Uganda, Vietnam, the Philippines and India are work done by the Hodges is well known focused on these different environments to provide internationallys, and the Peninsula are very proud feedback to the project team. of their achievements. During the next 12 months, Andrew and Sarah are building a new The Association of Anaesthetists Great Britain reconstructive hospital in Kampala to increase the and Ireland (AAGBI) capacity for their specialist services in East Africa. The AAGBI has had an International Relations The AAGBI Overseas Anaesthesia Fund (OAF), Committee for many years and supports which was started in 2006 to allow members to anaesthetists working in developing countries with donate directly to work in developing countries, travel grants, educational material distribution and hopes to buy equipment to assist the Hodges with sometimes funds clinical schemes or equipment their vision. All contributions are gratefully aimed at raising standards in the poorer parts of accepted! This year OAF has supplied a handbook the world. Many accounts of these schemes have of anaesthesia to the anaesthesia providers in appeared in Anaesthesia News. Over the last two Ethiopia, Zambta, Malawi, Tanzania, Kenya, years we have assisted Dr Sarah Hodges (a former Uganda, Botswana, Nigeria, Sudan, Ghana, Exeter and Plymouth trainee) to run national Liberia and Sierra Leone.

48 In October 2O07, Ihe AAGBI produced a world, and are also published for download from supplement to Anaesthesia, with the theme of the WAS website and at www.anaesthesiauk.co.uk. Anaesthesiq in Developing Countries. This special ATOTWhas proved tremendously popular and this supplement was a part of the Council of Science part of the website received 40,000 hits last year. Editors initiative to raise awareness of the issues of The CVs of many of the South-West's poverty and healthcare. The supplement will anaesthetists have at least one line dedicated to represent anaesthesia on the global stage, to make publications in Update and ATOTW and future the case for investment and representation at the authors for either of these projects would be highest level. welcome - please email [email protected]. The World Anaesthesia Society (WAS) World Anaesthesia News, published biannually, The World Anaesthesia Society (WAS) was is edited by Bill Casey a former consultant in founded in 1992, on the premise of forming a Gloucester and Cheltenham, who has contributed network of anaesthetists with a common interest in greally to the activities of the WAS over many promoting our specialty and supporting education years, The newsletter is distributed to all WAS in countries with poor resources and few trained members and contains reports of recent courses anaesthetists. Some founding members of the abroad, feature articles and scientific papers. WAS, now a Specialist Society of the AAGBI, are Because of the nature of the work that the WAS based in the South West region and there has undertakes, there has been a tendency for consistently been an enthusiastic contribution by individuals with prior overseas experience to the members of the South West Society for become involved. Whilst the experience that projects related to the aims of the WAS. The seasoned campaigners offer is invaluable, there is figure shows a selection of the countries where our a risk that anaesthetists without hands-on society members have contributed to supporting developing world experience will feel excluded anaesthesia developments in recent years, and from the activities of the WAS. The conflicting indicates those who are in a position to provide demands of family life, work commitments and information about certain projects or countries. financial pressures mean that relatively few UK- A major achievement of the WAS has been the based anaesthetists get the opportunity to take up provision offree or low-cost educational resources long-term posts overseas. Our goal is that the to anaesthetists working in isolated situations with WAS will become an accessible portal, allowing little educational support. Update in Anaesthesia interested anaesthetists, with all levels of has been produced for 14 years by Iain Wilson. experience, to participate in this rewarding field of The journal is highly regarded, both in the UK and anaesthesia. Individuals can participate and overseas, as a reliable source ofclear, accurate and contribute at a level that suits them, whether practical review articles on a wide variety of writing for our publications, contributing as anaesthetic and critical care topics. The journal lecfurers on Refresher Courses or taking up short has become the offrcial journal of the WFSA and term posts with organisations such as M6decins as a result is funded by the publications committee Sans Frontidres or the Mercy Ships. for free distribution in many countries. The With this in mind, development of the WAS English version of Update is distributed to over website has been a major focus over the last year 4000 recipients in countries in Asia, Africa and and this has been achieved single-handedly by the Eastern Europe. The Russian, Mandarin, Spanish endeavours of Carl Stevenson, formerly a South- and French versions reach a further 4000 West trainee, who is now a Consultant in anaesthetists around the world. The complete Hereford. Please visit www.worldanaesthesia.org; back-issues of Update are available as pdf any feedback or suggestions that you have will be downloads on the WAS website, very helpful. We hope that in the near future the www.worldanaesthesia. org. website will stand out as the clear starting point to A more recent innovation is Anaesthesia any anaesthetist who plans to contribute to Tutorial of the Week, an electronic resource of supporting education and development for weekly tutorials that is continually expanding. anaesthesia in a developing country. Membership The tutorials are emailed to several hundred of the WAS costs f,35 per year and subscription recipients each week, many in remote parts of the forms are available on the website. 49 The South West Region with global anaesthesia issues and have done so in a The South West region, perhaps more than any number of different forums. This article recounts other, has had many individuals over the years who contributions made by some of the individuals but have contributed time and energy to trying to assist will miss some apologies to those we have not included. The Frenchay Hospital developing countries course has been run over many years by John Carter, Claire Jewkes, James Rogers and Debbie Harris. Many aspiring travelling anaesthetists have made their first appearance on the course and then returned to lecture after gaining their own unique experiences of working abroad. Roger Eltringham in Gloucester has dedicated the last decade to producing an anaesthetic machine designed for the rigorous conditions of the rural district hospital overseas. The resulting machine, the oxygen concentrator based Glostavent (see figure 2 and www.glostavent.com) has undergone successful field trials in Zambia, Malawi, Ghana and Vietnam and shows a lot of promise for the future. Many individuals who have spent a number of months overseas are shown in the world map - we would like to acknowledge the contributions of many over the years, but would also suggest that there is much left to do. For the two of us who worked abroad, it was a life-changing experience to see the real importance of anaesthesia, good training, adequate equipment and drugs, and effective management. We recommend the experience to anyone - we learned far more about anaesthesia and life than we taught!

References 1. Hodges SC, Mijumbi C, Okello M, McComick BA, Walker lA, Wi lson IH Anaesthesia seruices in developing countries: defining the problems Anaesthesia 2007 ; 62:4-1 I 2. Heyvood AJ, lH Wilson, and JR Sinclair Perioperative mortality in Zambia Annals of The Royal College of Surgeons of Englancl 1989;71:354-8. 3. Ouro-Bang'na Maman AF, Tomta K, Ahouangbevi S, Chobli M. Deaths associated with anaesthesia in Togo, West Africa Tropical Doctor 2005;35:220-2. 4 Enright A, Wilson IH and Moyers JR The World Federation of Societies of Anaesthesiologists: supporting education in the developing worl d, A naes t he sia 2007 ; 62:567 -1 1 . 5. Hodges SC, Hodges AM. A protocol for safe maesthesia for cleft lip and palate surgery in developing countries. Anaeslhesia 2000; Figure 2: Roger Eltringham's Glostavent 55:436-41.

50 Anaesthesia Points West VoL 40 No. 2 Article

Reflecfions on Thirty-Three Years of Anaesthesia in the South West Region

Dr Paul Marshall, Retired Consultant Anaesthetist Royal Devon and Exeter NHS Trust Hospital

This year the Society is looking back at sixty years cyclopropane cylinder. There was also a Carbon of history, and much has altered since its inception Dioxide cylinder, which was used at the end of the in 1947. When I retired in April 2007, I began to case to restore the drive to ventilation. A guess at the reflect on the changes that have occurred in required minute ventilation was usually an Anaesthesia and the NHS in the 34 years since I overestimate. All tubing and masks were made of started as an Anaesthetic SHO in Plymouth. There black antistatic rubber and of course the are many and they occur at an ever-increasing pace. endotracheal tubes were non-disposable red rubber. After discussion with the Editor he persuaded me These often had herniating or leaking cuffs and were that it would be interesting to put some of these easily kinked. Although we had hot water baths for memories and thoughts down on paper. warming fluids and ways of minimising heat loss we had nothing to compare with the Bair Hugger and 1973-1974 SHO Anaesthetist, Freedom Fields patients would often need ventilating post- and Greenbank Hospitals, Plymouth operatively until they warmed up. Systems for scavenging were primitive and it was common to Anaesthetic Monitoring leave the theatre with a halothane headache, We measured blood pressure using a Von particularly after a list of children. After other lists I Recklinghausens oscillotonometer although one used to find that my hands and arms were aching senior Consultant did not believe in taking the blood from long periods of holding a facemask. I have pressure at all. We made sure we had access to a since felt we all owe a huge debt of gratitude to Dr finger or toe in order to be able to make our own Archibald Brain, inventor of the LMA. assessment of temperature, colour and perfusion. There was no pulse oximetry or capnography Anaesthetic Drugs available so filling out the anaesthetic chart was Thiopentone was the standard induction agent with relatively simple. We were never far from the Methohexitone for day cases. Suxamethonium was patient as we \ryere usually holding on a facemask, used for intubations, often preceded by a small dose or, if the patient was intubated, ventilating the of Gallamine, a short acting non-depolarising patient manually via a carbon dioxide absorber. muscle relaxant to reduce muscle pains. Pancuronium was the standard non-depolarising Anaesthetic Equipment long acting muscle relaxant. I believe many patients The Boyles machine was not that different but there were taken to recovery with residual block. The were no ventilators or monitoring integral to the standard vapour was halothane but Trichlorethylene machine. Some locations had no piped oxygen. One (Dry Cleaning Fluid) was also common. Standard consultant only ever used a Waters circuit with an analgesia was papaveretum or pethidine as required. absorber and would ventilate manually if necessary. Local anaesthesia was seldom used as part of a The anaesthetic machines usually had a Trilene balanced technique and there were no assessments Boyles bottle with a Halothane vapouriser and a ofpain scores.

51 Premedication Despite a rather austere atmosphere in the operating Premedication given I hour preoperatively was theatres the unexpected still occurred. On one routine except for ill emergency cases. occasion there was a problem with the irrigating Intramuscular Om and Scop (Papaveretum and fluid to be used by the Consultant Urologist - a Hyosine) was the standard or Pethidine and Atropine gentleman aptly called Mr Willie Waterfall. The if the patient was asthmatic. Some preferred an oral inigating fluid in those days was prepared in a large premedication of Diazepam (2Omg-30mg) and glass jar mounted on a stand and covered with a Droperidol (5mg-l0mg), the use of which resulted sterile green drape. On removal of the drape the in the patient not remembering anything until the problem was revealed in the form of two lively following day. goldfish! Fortunately this was before the days of incident forms! Running Out As an anaesthetic SHO it was usual to be 1979-1982 Senior Registrar, Bristol and Soulh anaesthetising emergency patients late into the night West Rotation on our own. For ill and elderly patients having a laparotomy an accepted technique was to use a I returned to the South West Region in October 1978 suxamethonium infusion for relaxation together with having been a registrar in Southampton. The rotation Nitrous Oxide and no vapour. On one occasion late started with a year in Exeter. This was followed by at night the suxamethonium drip and the nitrous three months in Bristol, followed by a year in oxide cylinder (there was no piped nitrous oxide) Aarhus, Denmark when I swapped jobs and homes both ran out simultaneously. I was not paying close with a Dane called Tage Mors Nielsen. Tage had to enough attention; the patient did not have his eyes buy a suit and a tie to come to England! My family taped, nor was there a screen between the patient and I exchanged our house in Clifton for the and the surgeon. The patient suddenly moved and experience of living in his windmill, deep in the opened his eyes. As I reached over to turn on a new countryside. One of the highlights of our visit to nitrous oxide cylinder the surgeon leaned over and Denmark was enjoying the hospitality of Dr John asked the patient if he was all right. Much to my Challenger. John had previously been a Consultant amazement I saw the patient nod. Fortunately he Anaesthetist in Bristol and had been President of the did not recall anything untoward afterwards. Society of Anaesthetists of the South West Region in 1969-70. Anaesthetic Education and Training Weekly tutorials were held in preparation for part I I 9 8 2- 2 0 0 7 C onsaltant Anuesth etist Exeter. of the Fellow of the Faculty Anaesthetists in the Royal College of Surgeons (FFARCS) examination. Anaesthetic Practice These were run by the Senior Registrars and It has been exciting to see the improvements in recently appointed Consultants. Teaching in theatre patient experience thanks to the use ofsuch drugs as was excellent but there was considerable variation Propofol. Techniques like regional blocks, thoracic between the practice of different consultants in the epidurals, fibreoptic intubation, and oesophageal use of drugs, equipment, monitoring and recording. Doppler monitoring have become commonplace. For advice and worries we relied to a large extent on With increasing complexity comes increasing the Senior Registrars who were an important link specialisation and we now have regional block between the consultants and the junior members of anaesthetists, paediatric anaesthetists, airway the department. specialists, and trauma specialists to name but a few. It has become acceptable and sensible to seek advice Hygiene and Cleanliness from colleagues in areas outside your own expertise. I remember highly polished floors with a sense of Debate no doubt will continue as to what should space. Beds were further apart and there was no constitute core anaesthetic skills for the trainees and clutter lying around in wards or corridors. Going us and what should be regarded as specialised. If into an operating theatre without wearing a mask forced to pick the two most significant innovations invited trouble. In addition it was forbidden to go for me I would choose the Laryngeal Mask Airway outside the theatre in blues. Tea, coffee and sweets and the use of Ultrasound in Anaesthesia. If in the theatre were strictly taboo. someone had told me in 1973 that there would be a 52 machine which would not only visualise the nerves matter of time before big brother will be monitoring but the local anaesthetic that was injected, I would all our movements. have found it hard to believe. Yet ultrasound was already in common use in Medicine in 1973 - it just Intensive Care took a long time to come to anaesthesia. Dr John Searle arrived in Exeter in l9l4 in the year that the hospital moved from Southernhay. He ran Productivity the ITU almost single-handedly with 5 staffed beds Pronouncements continue to be made by various until 1986, working 7 out of 9 weekends on call. Dr official bodies on the so called lack of productivity Paul Ballard ably assisted him on Thursdays and for following the introduction of the new consultant 3 weeks in August. Contemporary surgeons are contract. At the same time there has been continuing uniformly enthusiastic about Intensive Care for their change in our patterns of working. One example patients, unlike many of their predecessors who concerns the increased numbers of "same day were reluctant to lose control of their patient's admissions". It has now become common to see the medical management. It has become more usual for patient the same day, rather than the night before, patients to have beds booked in advance for sometimes leading to delays in the start of the list complex elective surgery and shortage of beds led to whilst explanations are made to the patient. cancellations. This became a major factor in arguing Whereas in the old days a surgeon might just say for more provision. We now have 15 beds with full gruffly "sign here" on a simple consent form the consultant cover morning and afternoon, 7 days a correct procedure is now time consuming. week with additional consultant sessions for Peninsular Medical School Teaching. Private Practice In early years there was a certain amount of tension Pain Management. within the department relating to private practice. I was appointed to help Dr Keith Lupprian expand This had even extended on occasion to physical the Pain Clinic. At the time of appointment we had animosity. On one occasion an Anaesthetist was seen no office space, no desk and no pain nurses. We did grappling with one of the surgeons on emerging from have a fraction of an overworked secretary. We one of the lifts in the private hospital. Sadly CCTV now have three consultants and a multidisciplinary was not available at the time to record the encounter! team. Regular team meetings and mutual support Paul Ballard, Charlie Collins and myself started the have been extremely helpful in enabling us all to private practice group in Exeter in 1987. cope with a difficult and challenging area of Membership of this Anaesthetic Group has since practice. Acute and Chronic Pain are a continuum been open to all consultant anaesthetists in Exeter. and I feel it has been helpful that the Pain Team This has been instrumental in the creation of a deals with both under one umbrella. unified and cohesive Department in the face of all the Until 1982 there was no provision for specialist changes occurring in subsequent years. terminal care, as it was then known. Morphine was often withheld until patients were about to die. Dr John Searle had seen this gap in provision and Dress Code decided something needed to be done. He If not a suit and tie it was a white coat in 1982 and launched Hospiscare in January 1982 with a basic one could order a named supply of these which nursing domiciliary service. A twelve bedded would be washed in the hospital laundry. The white Hospice was opened 10 years later and the first coat has gradually disappeared as has the suit and Consultant in Palliative Medicine in Exeter was tie. The Lycra dress ofthe keen cyclist has gradually appointed. Attitudes towards the terminally ill both become more common and I have heard some in hospital and the community have been members of the nursing staff being particularly transformed in the years since. enthusiastic about the legs of a certain male anaesthetist. One Orthopaedic surgeon has been Manpower and Training know to visit his private patients in Lycra. Whilst In 1982 there were 9 Consultants, 6 SHOs, 4 the formality of the dress has decreased a name Registrars and 2 Senior Registrars as well as a badge is mandatory if only to be able to access clinical assistant and a number of GP sessions. certain areas of the hospital. Perhaps it will only be a There are now 77 anaesthetic staff in Exeter 53 including 2 Anaesthetic Practitioners. Numbers of Medicine and Dentistry, will have led (by the time consultants have almost quadrupled to 35, including this is published) to the trainees feeling more positive 8 female consultant anaesthetists. In 1982 there were about training in the future. As for manpower, no female consultant anaesthetists or Srugeons and it planning this continues to be inadequately addressed, has been a change for the better. The numbers of part of the problem being that no one knows if trainees have doubled in 25 years. Sadly the days manpower expansion in the next 20 years will be when everyone knew everyone in the department are comparable to that which has occurred in the last 20. over. The standard of training and trainees has remained The Future high. The job of the College Tutor has become ever I could go on but where do you stop? I have tried to more difficult due to increasing numbers of trainees, cover a broad range of issues and bring out some increased service demands, the European Working important points. For the more senior readers these Time Directive and the increased need for may evoke similar memories; the younger readers documentation. In the last year the trainees have maybe surprised by the changes that can occur over suffered from poor morale regarding an uncertain a working career. No one can predict the futwe but future. There are relatively few consultants of my age I am sure of one thing. Based upon the ability of my likely to retire in the next few years so that unless younger colleagues and the quality of our trainees, I there is continuing expansion ofthe consultant body, have every confidence that the Anaesthetic competition for jobs is likely to be even higher than Department and indeed the Speciality of in the past. I hope that the Inquiry into MMC led by Anaesthesia, will continue to deliver a high quality Professor Sir John Tooke, Consultant Physician in service in the future. I sincerely hope that you will Exeter and Dean of the Peninsula College of all enjoy your work as much as I have done.

54 Anaesthesia Points West VoL 40 No. 2 Article

Securing the Airway: The Torbay Experience Dr's David Snow, Mary Stocker, Andrey Varvinskiy, Sudheer Medakkar Torbay Hospital NHS Trust Hospital

Back in 1982 the Anaesthetic Departrnent at Torbay Pappin placed a successful bid with Torbay League Hospital was composed of 7 Consultant of Friends for a video trolley at f,I,050, a digital Anaesthetists and two GP Clinical Assistants. The catrrera) f2,950, a xenon light source, f,4,385, Sony airway equipment was limited to the Macintosh colour monitor, f,|,375 and a LFDP scope at f8,750 laryngoscope, Guedel airway, the bougie and red with the aim of improving training and being able to rubber endotracheal tubes. The standard anaesthetic teach from the screen directly. training at the time included the technique of blind We then realised that as we now had the correct nasal intubation and staff also had great depth of equipment and experience we could run the first experience in direct laryngoscopy and intubation Torbay Difficult Airway Course which was through working rotas of l:2 and l:3 as trainees. organised for March 2000. The aim of this course The three choices of anaesthetic technique were was to help doctors develop strategies to recognise, spontaneous respiration on halothane, intubation assess and manage a difficult airway. Although it using Thiopentone and Alcuronium or included fibreoptic management of the difficult d-Tubocurare followed by Halothane or airway, it had a much broader remit. At the initial Neuroleptanaesthesia using Fentanyl and planning stage we involved the secretarial staff who Droperidol. Around 1983 Torbay Hospital bought its took on thejob ofbooking places, course materials, first fibreoptic laryngoscope at a cost of f8,000. co-ordination of Reps and making sure we all kept to This was purchased with money from the League of orn deadlines. The cowse was run by John Pappin, Friends. It was guarded like the Crown Jewels and Andrea Magides, Sudheer Medakkar, Mary Stocker, with warnings that those who inappropriately used Guy Rousseau, David Snow and our two very or damaged it would be shot by Dr Pappin, one of enthusiastic ODPs, Martin Copeman and James the senior Consultant Anaesthetists. Huntingdon. This course was attended by l0 people John Pappin taught himself and then promoted and consisted of a mixture of lectures, a fibreoptic awake fibreoptic intubation to trainees. The major show with one of the course organisers being change in airway equipment subsequent to that was intubated and a session in which candidates were the introduction of the laryngeal mask airway which encouraged to use fibreoptic scopes and other airway first became available at Torbay Hospital in January equipment. Clinical cases with x-rays were 1990. The cost was f,40 each and the use of the discussed at the end ofthe course. laryngeal mask progressed rapidly with it becoming The following year the course numbers increased the first option in any airway problem. One would to 16 and in 2002 the decision was made that the place the laryngeal mask, maintain oxygenation and course should go digital with all course information get some help. In 1997 a difficult airway box was provided on a CD Rom including video clips. assembled taking advice from experts around the Money from the course was used to buy a country including Ian Calder. Within this box was a departmental laptop for people to take to meetings first McCoy laryngoscope at f,440, a Quictrack, for presentations. In 2003 the course size was again Manujet jet ventilation system and a VBM doubled with the course being run over two days but cricothyroid cannula. It was designed to sit in the the numbers kept at 16 per day. Money from these emergency theatre and to be taken to any location courses was invested in airway trolleys to be located within the hospital as necessary. in main theatres and the Day Surgery Unit. These Then in 1999 Nuala Campbell, when College contained intubating laryngeal masks, Quictrack, Tutor, applied to the Research Trust Fund at Torbay cricothyroid cannulas and Manujets. In 2004 we Hospital for an airway training mannequin. Max the decided to spend around f,480 on the making of a airway mannequin cost f,I,450. In that year John fibreoptic video with the idea that it could be looked 55 at prior to performing a fibreoptic intubation and push things forward. We have also been very would give you all the information required. At fortunate to have had the support of the Torbay around this time we also decided to spend about League of Friends and money from the Trust fund f2,000 affending the Norwich Instructors course in without whom we would never have been able to which candidates intubated one another. Four of us buy equipment. Keymed have been first class in attended and also visited the Keymed factory en providing scopes and support for the courses over route. Once we had attended the Norwich course we the last seven years. We would like to give then decided to set up our own course along similar particular thanks to John Pappin for his enthusiasm lines after we had approval of the Trust. The first in starting us all off and encouraging us to branch in course in which candidates intubated one another different directions improving the quality of care to happened in March 2006. Once this course was patients. Also we would like to thank Nicola established, it was felt that a third course could be Woodbridge-Smith, Medical Secretary, for her started, aimed primarily at improving airway efficient and competent coordination of the various management for ODPs and allied medical courses over the last 6 years. As a spin off to our professionals. Therefore the Torbay Difficult successful courses we are now offered equipment to Airway Management Course for ODPs, Anaesthetic trial, for example the Airtraq which only became Nurses and Paramedics took off in October 2006. available about a year ago at Torbay. We now have So in the last year we have run three different types our own fund to buy equipment we would not of courses, the first aimed at doctors who wish to otherwise be able to obtain. We enjoy the positive improve their management of the difficult airway, a feedback from the courses and plan to expand our second course for those interested in gaining teaching role to set up a regional teaching module. experience by intubating each other and a third We can recommend setting up similar projects to course aimed at non-medical practitioners. incorporate your own interests which may lead you We think that we have been very fortunate to have to branch off into many different areas that you a very motivated department who have been keen to would not necessarily envisage at the outset.

56 Anaesthesia Points West Vol. 40 No. 2 Article

More Thoughts on Anaesthesia - A Decade on and into the Future

Dr Hannah Blanshard, Specialist Registrar Bristol School of Anaesthesia

Just over a decade ago I wrote an article in the due to the fact that the systems, which were Golden Jubilee issue of Anaesthesia Points West introduced, were far too complex. However, there is speculating on how Anaesthesia would change in the the occasional success story and surely the following twenty years. So were my predictions introduction of these is only a matter of time. totally off the mark or did any of them turn into Computerised record keeping is now a feafure in at reality? least one of the Intensive Care Units in the South Due to advances in Anaesthesia and minimally West. To everyone's surprise the installation went invasive surgery, I predicted that there would be a very smoothly without the expected tearing out of significant increase in the numbers of patients having hair, and now charts seem an archaic remnant ofthe surgery as a day case procedure. The NHS plan set a past. Consultants can view the charts at home and subsequent target that 75o/o of elective surgical 'Big Brother is watching you' has become a grim admissions should be performed as day cases. reality! The computerised weaning of patients from Although the number of day surgery admissions has the ventilator has been attempted, although there increased over the last decade, this has been more have been a few glitches delaying this possibility. due to the groMh in overall demand, rather than by I looked at what the basic infrastructure of the conversion of inpatient surgery to day case anaesthetic training would be like in 20 years time surgery. However, with the introduction of a second and thought obtaining the FRCA would return to a wave of independent sector treatment centres doing three-part assessment including an exit exam. more day surgery procedures, this is likely to change Fortunately, so far this has eluded us (particularly so in the not too distant future. for the eternal flexible trainees who, having done the I predicted that total intravenous anaesthesia old three part exam a decade ago, might end up (TIVA) would become the sole means of giving doing an exit exam as their fourth part!) but the latest anaesthesia, limiting the use of volatiles to report from the Royal College of Anaesthetists circumstances requiring gaseous induction. From my means an exit exam is soon to become arealily. experience, the use of TIVA appears to be totally Ten years ago, the proposed new training scheme dependent on the individual anaesthetist, with some described completing two years as a Senior House anaesthetists and departments zealously promoting Officer followed by a bottleneck, leading to fewer the technique and others indifferent to its claimed training numbers at a Specialist Registrar level. benefits. Whether this choice is secondary to an Unsuccessful candidates would then be conveniently intricate costing exercise or merely due to a reticence propelled into a 'Staff Grade' type of job (called to get up from their place of repose to change the Clinical Fellows) until they obtained a substantive syringes on a regular basis remains to be seen! training post. This would therefore help to expand I suggested that over the next two decades the the junior rotas and protect the Consultants from anaesthetic charts would become computerised with being resident on call. Little did I know that the voice recognition. This certainly is still in the future. Modernising of Medical Careers (MMC) would be As for the computerised records themselves, attempts instigated to create a single training scheme from have been made to bring them in, but with a SHO through to Consultant, and that despite a discouraging lack of success. This has mainly been reasonable number of trainees on rotas, Consultants

51 *-ould end up being first on call in some hospitals in for further research. the South West within l0 years. As well as not having the perfect opioid, we are far As a way of coping with the increased workload from finding the perfect neuromuscular blocking and decreased numbers of anaesthetists, anaesthetic agent. Ideally, this would have no side effects, work practioners were predicted to fill the gap. Despite the as soon as it was given and then be reversible as soon predictions of swarms of them taking on anaesthetic as its effect was no longer needed. Unfortunately, roles, this does not seem to have materialised so far. this does not exist. However Org 25969, or Maybe the govemment has realised that they are not Sugammadex as it is now known, has gone some such a cheap option after all. way to achieving this ideal. It is a novel drug that I did not predict other advances in anaesthesia that reverses the steroidal neuromuscular blocking drugs, have occurred. One ofthese is the increase in use of mainly rocuronium, and to a progressively lesser ultrasound to facilitate insertion of central venous extent vecuronium and pancuronium. Instead of lines, from a decade ago when it was unused to the blocking acetylcholinesterase like the other reversal situation now where some trainees have never agents, it forms a ring-shaped structure around inserted a line without it. This precipitous change rocuronium and thus prevents its access to the was caused by the National Institute for Clinical nicotinic receptor. This then promotes the Excellence (NICE) guidelines in 2002, with the dissociation ofrocuronium from the receptor. Since consequence that it would be difficult to defend it has no effect on acetylcholinesterase or indeed any complications of central venous cannulation where receptor system in the body, it can be given as a sole ultrasound had not been used. Using ultrasound agent. It can reverse very deep neuromuscular guidance to insert nerve blocks is also becoming blockade induced by rocuronium and therefore will more popular and it is probable that in 10 years time facilitate the use of rocuronium for rapid sequence we will be performing all our blocks with ultrasound induction of anaesthesia by providing a faster onset- guidance. offset profile than succinylcholine. It is now So what about pharmacological advances? Are undergoing phase III trials and, to date, there have there any new drugs that are about to be launched been no serious adverse events, even in overdose. that will radically change our anaesthetic practice? Although its use so far has been limited solely to the The inert gas xenon (Xe) was first discovered in reversal of rocuronium, it is nevertheless an exciting 1898 and its narcotic effects recognised more than 50 new development. years ago. At a glance it has ideal propedies for an Other new developments have been precipitated anaesthetic agent. It is more potent than nitrous oxide by advancing surgical techniques and improving with a MAC of 7lVo, and has a very low blood:gas control over the administration of intravenous partition coefficient (0.14), which gives rapid anaesthetic agents. Already off-pump coronary artery induction and emergence. It also does not have bypass surgery and on-pump aortic valve environmental issues (since it is a normal constituent replacement have been performed in awake, of air unlike N2O). The fundamental problem, which spontaneously breathing patients. I still maintain that has limited its clinical application, is its high cost, in the future all anaesthetic agents will be (2000 times more expensive than nitrous oxide) and administered intravenously with precise control over low availability (in nature the gas is present in scarce their concentration and effect. Since most surgery amorurts). So with an ever more cost-conscious NHS, will be performed as minimally invasive procedures, I cannot see Xenon becoming part of our everyday respiratory depression will no longer be an practice in the near future. unintended side effect, and thus ventilators will Epibatidine is an alkaloid that is found in the skin rarely be needed. oftropical poisonous frogs. It has been found to be a Mathematical models to obtain a specific target powerful analgesic with potency about 200 times that concentration at the effector site will be signifrcantly of morphine. Since it is found in nature in only small upgraded with intricate closed feedback mechanisms. quantities, several laboratory syntheses have been These multidimensional models will calculate the developed. It acts by binding and activating nicotinic synergism between many anaesthetic agents and acetylcholine receptors rather than opioid ones like suggest appropriate combinations of target morphine and therefore does not have a respiratory concentrations. We will be able to assess the true depressant effect. It is too potent to be used in depth of anaesthesia by assessing nerve activity at clinical practice, but so far has provided a useful lead the higher brain centres so that the anaesthetist can 58 adjust the target concentration to provide the ideal will be able to insert intravenous cannulas and take depth ofanaesthesia for each patient. over our new highly technical anaesthetic machines. All this talk of the future must include robots If so many feedback mechanisms are put in place, taking over the role of man. Robots have already surely robots must be able to give a 'safe' been used as assisting tools for endoscopic anaesthetic. Well, I can tell you that no insufance procedures. Robot cardiac surgery is now well company in the world at present would give a established with some papers stating there is better company the liability coverage it would need for the instrument control and improved performance software involved. It couldn't enter into a contract or yersus standard "hands-on" surgical technique. It try to get a patent, from a business perspective, has also been used for laparoscopic without the insurance. So knowing this, I feel I can cholecystectomy, but the long surgical times and relax a little. Robots may take over our jobs one day, costs have precluded its widespread use there. but to be honest, I can't see it in my lifetime. After Surely then, it is only a matter of time before robots that, who knows?

59 Anaesthesia Points West Vol. 40 No. 2 Article

AII of the Following are Tfue: MCQs in anaesthesia exams Dr Neville Goodman, Southmead Hospital, Bristol

Multiple choice questions (MCQs) are here to stay. Except for minor changes to single branches of When well written, they are good at testing factual three questions, the paper remained the same from knowledge objectively, reliably and repeatedly (see, course to course, which meant that I knew how each for example, Moss's review l). The pass standard for question tended to be answered. Attendees did not MCQ papers can be norm-based, with a fixed pass take the question papers away, and were asked not to percentage or a fixed pass mark; but the standard is divulge questions to later attendees, and I saw no better when criterion-based, which assumes an evidence that this happened. The cowse was usually accepted level of knowledge. For the Royal College about two months before the next sitting of the of Anaesthetists' MCQs, each paper's difficulty is examination. judged by the use of questions that have been asked From the l0 courses, there were 217 papers. before, and which behave well. At each sitting, the Overall, the mean mark was 56% (the range on the pass mark is adjusted accordingly, which is as close l0 courses was 48% to 62%). The mean score of the to criterion-based marking as it is possible to get top six on each course was 73Yo, and of the bottom without an explicit listing of all the facts that six 39o/o. On average across the l0 courses, 43% of anaesthetists are expected to know to pass the the difference between the top six and bottom six examinations. depended on 22%o of the paper; ie, almost half the This makes it theoretically possible for every difference between good and poor candidates candidate to pass the MCQ examinations. It never depended on just six or seven questions of the 30, happens. There are (or were for the 12 years that I and unsurprisingly they tended to be the same was a College examiner) remarkably consistent pass questions. A question on simple (and I do mean rates between different sittings of the same simple) pharmacokinetics was a differentiator eight examinations, and they did not approach 100%. If times out of the ten; questions on atropine, ffansport we allow for some candidates who lack the of gases in blood, and simple statistics were motivation or the intelligence, most trainees who differentiators five times. I suspect analysis of the take our examinations do evenfually pass. Critics of College's MCQs would show the same; I do medical professional examinations point at low pass remember from my time marking the MCQs that rates as a criticism of the examinations, but I think questions on statistics were always good the problem lies with the candidates. The main differentiators. reason that failure rates remain what they are, and Now I accept that the attendees were still some remain so consistent, is that human nafure is what it time from the examination but let me give just a few is: trainees don't do enough work. examples. A normal fit man breathes 100% oxygen. I do not have access to the actual questions and After five minutes, his PaO2 will be about 80 kPa marks fiom the College's exams, but between 1991 (600 mm Hg): true or false? Only one third of the and 1995,I set an MCQ paper of 30 questions to bottom six candidates knew this was true (mind you, groups of about 20 anaesthetists attending a twice- it was only two thirds of the top six). Everyone yearly Primary course in Bristol. There were 15 taking Primary knows that the shunt equation is questions on each ofphysiology and pharmacology, important, yet to a full question of five branches on the pharmacology including two on statistics. Each the topic (eg, a two-compartrnent model is assumed - question had five branches, each to be answered which is 'true') 55o/o of responses by the bottom six 'true', 'false' or 'don't know'; each branch was were 'don't know'. Even the risk of misreading the marked +1 if correct, -l if incorrect, and 0 if question is more likely if your overall knowledge is answered 'don't know' or left blank. poorer: 30% of the bottom six correctly answered 60 '5Yo of carbon dioxide is carried as that most of those others would - if only they would carboxyhaemoglobin' as 'false', compared with 45% do enough work. of the top six; and twice as many in the bottom six But enough of polemic. Excluding book reviews, answered 'don't know'. For the top six,92%o this is my 36th article in Anaesthesia Points West. answered correctly as 'true' that the plasma Some have been serious, and some not. All have osmolarity was generated mainly by the electrolytes, been fun to write. I must thank all the editors I have compared with 68% for the bottom six. worked with for indulging my whimsy, and with So, we can argue about whether these facts, and retirement take leave of regular contributions. others asked in MCQs, need to be known - at least at some time in their careers - by practising Reference anaesthetists; but we can't argue that some trainees l. Moss E, Multiple choice questions: tbeir value as an assessment tool. do seem to know them and that others don't. I think Cm Op Arcuthesiol 20Ol :14:661 -6.

6l -lnaesthesia Points West Vol. 40 No.2 Article

Three Days By The Sea GAT 2OO7 Dr's Matthew Thomas, Andrea Binks, Claire Dowse, Jon Gatward

Specialist Trainees, Bristol School of Anaesthesia

Dr Antonia Mayell, Specialist Trainee, Peninsulqr School of Anaesthesia

Several of the South West's trainees made their way what can happen and how to avoid it; don't to Brighton this year by train, plane and automobile innovate! Learning from the Aviation Industry was for the GAT 2001 Conference. also a popular lecture. The poster judging followed The first session was on 'Anaesthesia and The and despite no prizewinners the South West Region Law', which was informative if somewhat worrying should be proud that our trainees contributed over as the first slide showed how many Anaesthetists are 25 percent of the entries. I learnt lots from all our charged with manslaughter. We then learned about entries and as one of the entrants I am sure we must the ethics of pandemics and disasters. We now have only just missed out on the prizes. know that if a plane is going to hit your hospital it's The prestigious Registrar's Prize competition OK to run away. The final session was about followed and the first presentation was by Andrea advanced directives and birth plans. Apparently Binks from Bristol. Her talk was on the dangers of women having babies are capable of giving consent. using Aprotinin in people on ACE inhibitors. The No one mentioned the dads although I remember competition was stiff with research on aortic being a gibbering wreck during my wife's labour! In stenosis, successful epidurals and the baricity of the afternoon, we learned a lot about blood. It costs intrathecal diamorphine but Andrea was duly a lot, there isn't a lot of it, so don't waste it. Following tea there was a session on Intensive Care Medicine. This included talks on bums and what to do, non-invasive ventilation and 'optimisation of patients'. The Oesophageal Doppler seems to be the 'must have' piece of kit at the moment and as the probe fits down the gastric port of the Proseal LMA it can be used in selfventilating patients. At six o clock we were finally released to enjoy the evening's activities. We made our way to the pier through the driving rain. Unfortunately the funfair we were supposed to go to was closed due to weather and we were forced to spend all evening in the pub. A fish and chip supper and karaoke were provided. The Peninsula trainees took to the stage whilst the Bristol lot seemed intent on forging links and improving relationships with other deaneries! The next morning started bright and early with a talk from Dr Forsyth who had been branded Dr Dr Andrea Binlc is awarded the Registrar's Prize Death by the Daily Mail. It was a timely lesson in by the President of AAGBI.

62 announced as a thoroughly deserving winner. The his essay on the beginnings ofEntonox. He gave a winners of the history prize then gave a brief lecture. very entertaining lecture and had obviously Dr Tim Dawes of Yeovil was the joint winner with thoroughly researched his topic. Another prize for the South West in the bag! Buoyed by taking all the honours we went off to the masked ball at Brighton racecourse. A great time was had by all with the highlights being Sarah Love Jones on the flying carpet and the President of AAGBI playng twister with 6 Bristol trainees! I will let the photos speak for themselves regarding how much we enjoyed it. The Friday moming of a GAT conference must be one of the worst lecture slots there is! A brave few struggled manfully in to learn about working overseas and wildlife anaesthesia whilst others conducted personal research on the effects ofsea air and fried food on profound dehydration and lack of sleep. By mid morning the lecture hall was full for the Pinkerton and Wylie lectures on 'Error Management' and 'The Law and Medicine'. More food for thought mixed with quite a lot of fear. The triumphant South West Trainees try to hide their The overriding message from GAT has to be - identitv. think before you act and write everything down.

63 Anaesthesia Points West Vol. 40 No. 2 Article

lst West of England Anaesthesia Update St Anton,l5th-z0th January 2007

Dr Anna Johnson, Derriford Hospital, Plymouth

The idea for this meeting was as a result of chair retired to the large hotel bar whilst others went lift chatter between a group of like minded further afield to sample aprds ski in St Anton. I colleagues high above the snowy Alps. I really hear the Russian bar was popular. can't think how I got involved but perhaps I do The presentations were of a very high standard like a little natter sometimes. It is well known that covering many varied and diverse topics and consultants in the south west have been regular promoting much discussion from the floor and attenders at a certain ski meeting with some later in the bar, which was one of the aims of the hospitals better represented than others. Many meeting. Particularly memorable and fascinating thought it was time for a change of venue and was Professor Rob Sneyd's look at future perhaps a more intimate meeting allowing for advances in medicine which was presented with greater discussion, networking and socialising. St Rob's usual flair and kept the audience Anton was the chosen resort and the team of mesmerised. Dr Susanne Krone from East organisers led by Bill Boaden started a flurry of Grinstead talked on Ultrasound for Regional emails between themselves, travel agents and the Anaesthesia showing lots of excellent videos and tourist information centre of St Anton. There was she also ran workshops ably assisted by Dr Ali no going back once deposits were paid and hotel Diba also from East Grinstead, which were very and travel arranged, so this soon focused our popular. attention on attracting delegates and arranging the The lectures were aimed at general anaesthetic scientific programme. consultants with useful updates on vascular On Saturday l3th January the Hotel Arlberg anaesthesia and cardiopulmonary testing, welcomed alarge contingent of anaesthetists and a paediatric anaesthesia, neuroanaesthesia and few accompanying spouses including a intensive care. Mr J Unsworth White, cardiothoracic surgeon. All were keen to enjoy the cardiothoracic surgeon, entertained us both with day and a half of skiing prior to the start of the his lecture and skiing and is returning again this conference which commenced with registration in year. The lectures ended with a lively debate on the bar on the Sunday evening, welcome drinks 'The Sub Consultant Grade is Necessary' with Dr kindly provided by the hotel. Most delegates were Chris Seavell and Dr Cate Powell. The final show from the South West but a great turnout from of hands of the conference was how many Portsmouth, a few from the South East and a very delegates now wore helmets after a concerted noisy one from Bournemouth! effort by the organisers to promote safe skiing. Lectures started on Monday morning at 08.00 The ski shops in St Anton certainly sold a lot that with Dr Alex Mayor setting the standard with his week. 'Splat of the Week' was fiercely contended opening talk on 'The Toyota Wuy', looking at by El Professori, Dr J Langton and Dr Bruce management Japanese style. The morning session McCormick all luckily helmeted. ended at 09.30 so time to head to the slopes and Midway through the week we had a sponsored get networking. The evening sessions ran from coach trip to Lech where we all skied the 'White 17.00 to 18.30 helped along with some delicious Ring', a circular route ending in a rather rowdy refreshments. Excellent food was provided by the outside bar. Well it was certainly noisy that hotel with substantial breakfasts and dinners to evening! This was a great day out meeting up with keep even the hungriest happy. After dinner many various groups throughout the day either at lifts or 64 Networking. Refreshments after skiing the 'White Ring'

Dr Paul Erasmus 'Cardiopulmonary Testing More Networking in restaurants and all completed it safely, even the novlces. It was extremely gratifying that all participants provided excellent feedback for the conference, resort and hotel so it's all happening again this year 72th l9th January 2008. If you would like to attend please contact any of the organlsers: Dr Bill Boaden Royal Devon and Exeter Hospital Dr Jon Purday Royal Devon and Exeter Hospital Dr Alex Mayor Derriford Hospital Dr Anna Johnson Derriford Hospital Who's got a new helmet?.

65 Anaesthesia Points West Vol. 40 No. 2 Article The \Mine Column 1947 - 60 Years Ago Dr Tom Perris

Some things change and some stay the same. In an absolute blockbuster. 1947, Gloucester and Tewkesbury were deluged by It is widely regarded as the best year of the flooding after heavy winter snows melted and this Century for Sauternes and also the sweet whites year, it was time for the wellies again. Summer rains from the Loire, particularly Vouvray. They are, this time so at least it was warmer. (apparently), still drinking superbly even at this India and Pakistan were fledgling independent advanced age, tasting of toffee, brown sugar and nations and have rarely played nicely together ever cinnamon. Your correspondent was unable to sotuce since. Likewise, the UN voted to partition Palestine any for research, it being a bit thin on the ground in November 1947 and that argument is still running nowadays. Burgundy produced a hot ripe year for too. Perhaps if Mikhail Kalashnikov hadn't invented early drinking, Champagne excelled with delicious, the AK47 that year it might have been over by now. long lived wines and the Rhone prospered as always But on a lighter note, Walter Morrison introduced the in a hot year. Italy was great too and Portugal had a Frisbee. David Bowie, Elton John, Meat Loaf and fine vintage year for Port. Mark Bolan were born so it was a mixed year for But it was the Red wines of Bordeaux which were music. David Blunkett, Tessa Jowell, Hilary Clinton, the undoubted stars. Following an "Edwardian" and Dan Quayle also drew their first breaths in 1947 summer of long warm days, a milestone, perfect so it was an inauspicious political year. The Queen vintage was produced. The American troops married Prince Phillip on November 20th, and stationed in France obviously developed a taste for women got the vote in Argentina so it wasn't all bad! the frner things as post war exports rocketed. The Communists were ever5rwhere it seemed, taking superb quality of both the '45 and'47 vintages power in Poland and Hungary causing such combined with the export boom did much to paranoia in the US that President Truman issued the stabilise a distinctly unsettled period for post-war National Security Act founding the CIA. In a viticulture allowing reinvestment and restoration of related effort to stop the spread of communism in damaged vines and infrastructure. Europe, the Truman Doctrine offered $400 million The wines were ripe, powerful, fleshy and in military aid to Turkey and Greece. Shortly after generous. Enormously long lived, the top chateaux's this display of largesse, in August, a military coup bottlings are still being eulogised over the internet lead by General Vafiadis (a communist) ousted the and at tastings in the more affluent parts of the Greek government once more confirming world. Matched only by the legendary 1945 and America's outstanding record of success in foreign 1961 vintages, a single bottle of a Latour, Lahtte or policy interventions. Like I said, some things Mouton will set you back at least a thousand change . . . pounds. Most has been drunk by now, so unless your Striking Communist workers spent December long lost millionaire uncle shows up you and I may battling riot police throughout France after the arrest never get our hands on some. However, if someone of 4 steel workers and the closure of several does offer you a glass of the'47 Petrus, get it in communist publications. However, the wine harvest writing before he changes his mind. And call me - r.r.as in by then which was indeed forhrnate as it was anytime, I won't mind!

ffi Moments

Sipping champagne alfresco and legless, in a spa, bubbles floating you to stars...

Midnight skinny dipping offa coral reef with a French lover, but you can't remember if first time you met her was back in Rheims that shadowless weekend or was it just a dream?

Finding Time basking in the corner of a summer day with clouded yellow wings. Touch it and it flies away...

Playing Hamlet, strutting the stage, finding Truth on the wafer edge of madness. Or in a forest, lost in wonder at the words of a soothsayer, on a date with odd numbers.

Robin Forward

67 Crossword

Dr B. W. Perriss

Clues Across

1. Pocket artist mad to receive grace. (l l) 7. The most insubstantial is irate, apparently. (7) 8. Student got peer agitzted. (7) 10. Two have gone to get together. (4, 3) I 1. People gather to watch ATLS manoeuwe. (3, 4) 12. Useless at fashionable "Environmental Protection Technology". (5) 13. Disciplinarian then races awkwardly. (9) 15. Sample clear for urinalysis. (4, 5) 18. Practise in old Eastem crty. (5) 20. Wayr,vard, wayward CarIier. (7) 22. Deadlock father's fitted in newly-built semi. (7) 23. These birds suffer a small twitch. (7) 24. 1980's pop star is a hard case. (7) 25. Scream at receiving a beamer playing cricket. (4, 7)

Solution to Crossword in SPRING 2007 Anaesthesia Points West

Clues Down

l. Start tennis game with worship. (7) 2. Revolutionary radical goes for a smoke. (7) 3. Picture if one can initially, but hesitate to call mechanic. (9) 4. Tum out for outlaw. (5) 5. Have a notion whilst allowing time. (7) 6. Told personal story but had to rest. (3, 4) '7. Date for a2p medicine. (l l) 9. Greenmantle made into a bigger pictwe. (l l) 14. Aparish priest of 5l unable to be petitioner. (9) 16. Withdraw because of an itch? (7) 17. Cannot stand a painting session. (7) 18. Arraign every devil first. (7) 19. Don't sit down else be erected. (7) 21. Inexpensive fiuit? (5)

68 FENELEY TRAVELLING FELLOWSH I P

A variable sum of money awarded annually to support a "mission abroad". Applications to Dr E. Morris, Hon. Sec., Southmead, Bristol.

Society of Anaesthetists of the South \ilest Region - Abbott Prize REGISTRAR PRIZE: f 1,000

Entries in the form of an essay of about 2000 words on any topic related to Anaesthesia and Intensive Care to be submitted to the Hon. Secretary,Dr E. Morris, Southmead, Bristol (by end July 2008). The winning entry will be presented at the next meeting of the Society.

69

Society of Anaesthetists of the South West Region ODANURSE PRIZE: f,500

Entries in the form of an essay of about 2000 words on any topic related to Anaesthesia and Intensive Care to be submitted to the Hon. Secretary Dr E. Morris, Southmead, Bristol by end July 2008. The winning entry to be published in the next edition of Anaesthesia Points West

Society of Anaesthetists of the South West Region Merchandise

Society Ties - f10.00 Society Brooches - f15.00 Available -fro* Hon. Sec. and at all home meetings

71 Notice to Contributors

of the Society. lies transfer of copyright to the Society of Anaesthetists

Editor Secretary to Editor Assistant Dr J. Pittman Editor Greer Husband Dr Fiona Donald Department of Anaesthesia Department of Anaesthesia Department of Anaesthesia Royal Devon and Royal Devon and Exeter Hospital Southmead Exeter Hospital (Wonford) Hospital (Wonford) Bristol Barrack Road Barrack Road, Exeter, Devon EX2 5DW BSIO 5NB EXETEREX2 5DW Tel:01392 402474 Tel: 0l 17 323 Tel:01392 402475 5tI4 e-mail: e-mail: e-mail : James.Pittman@rdeft .nhs.uk kris.wilkinson@rdeft .nhs.uk fi ona. [email protected]

E-mail address for articles etc. _ [email protected]

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