Research Issue: the Challenges COVID-19 Has Placed on the Research Community

November 2020 Remote pre-assessment for cancer surgery during the COVID-19 pandemic

Transforming paediatric major trauma care

Simulation training – ‘It’s just like flying a plane’

Research issue: The challenges COVID-19 has placed on the research community

rcoa.ac.uk @RCoANews Bulletin | Issue 124 | November 2020 RCoA Events Anaesthetic updates % 4 March 2021 rcoa.ac.uk/events Bristol [email protected] AaE: Introduction EVENTS AND COVID-19 % @RCoANews 11 March 2021 FULLY BOOKED Due to the ongoing COVID-19 situation we have Developing World Anaesthesia moved the majority of our events on to virtual % 15 March 2021 platforms, where this is not possible some of these RCoA, London Developing World Anaesthesia Anaesthetists as Educators: events may be postponed or cancelled. NOVEMBER % November 2020 % Advanced Educational Supervision Global Anaesthesia Virtual event 26 January 2021 % Please keep up to date by visiting our webpage: RCoA and RA-UK joint webinar: 16 March 2021 Birmingham blocks for the many RCoA, London Airway Workshop rcoa.ac.uk/events (not just the few) % November 2020 Anaesthetic Updates Leadership and management: 10 November 2020 29 January 2021 % Virtual event The Essentials Evening webinar Southampton 16–17 March 2021 Clinical Directors Network DECEMBER Glasgow Meeting FEBRUARY Leadership and management: 16 November 2020 AaE: Advanced % Personal Effectiveness Virtual event Winter Symposium Presentation of Diplomates 26 March 2021 % 3–4 December 2020 Ceremony RCoA, London Educational Supervision Leadership and Management: Virtual event 1 February 2021 % Working well in teams and Central Hall, London Ultrasound Workshop 26 January 2021 making an impact Less than full time (LTFT) Invitation only % 29 March 2021 18 November 2020 Birmingham % matters webinar RCoA, London RCoA, London AaE: teaching and training in 9 December 2020 % the workplace Anaesthetic updates Virtual event Anaesthetic Updates 2–3 February 2021 % March 2021 % 19 November 2020 Primary FRCA Online Revision RCoA, London RCoA, London Virtual event % Course FULLY BOOKED Anaesthetists as Educators: December 2020 – February 2021 Innovations and interlectual APRIL % Anaesthetists’ Non Technical Virtual event % property conference Skills (ANTS) After the Final FRCA Final FRCA Online Revision Course 3 February 2021 20 November 2020 21 April 2021 % December 2020 – March 2021 RCoA, London Virtual event RCoA, London Virtual event Anaesthetic updates Anaesthesia Research % 24–26 February 2021 Cardiac Symposium 24 November JANUARY RCoA, London % 22–23 April 2021 Virtual event RCoA, London GASAgain (Giving Anaesthesia RCoA and BJA joint webinar: MARCH AaE: Teaching and training in the % Safely Again) how BJA Editors decide which % workplace 13 January 2021 Airway workshop papers to publish 28–29 April 2021 Bradford % 1 March 2021 24 November 2020 Edinburgh Evening webinar To be confirmed

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

The President’s View 4

News in brief 8 Contents Guest Editorial 12 From the editor SAS and Specialty Doctors 14

Revalidation for anaesthetists 16 Dr Helgi Johannsson Faculty of Pain Medicine (FPM) 17

Faculty of Intensive Care Medicine (FICM) 18 Welcome to the November Bulletin.

Patient perspective 20 As you open your November edition of the Bulletin, I sincerely hope we have managed to prevent a large second Society for Education in wave of coronavirus infection. But as I write we are finally seeing the increase in cases predicted of a second 22 Anaesthesia (UK) wave. Still, in my hospital there are no patients with coronavirus on the intensive care unit, which gives me some Creating capacity in a crisis 24 hope that we may be able to continue with the enormous task of getting the NHS’s elective work back on track Perioperative Journal Watch 28 and reversing the colossal disruption that has affected all our lives.

Health Services Research Centre 29 COVID-19 has dominated the news and our conversations, and so it is no surprise that this month’s edition of

Frailty and delirium 30 the Bulletin contains a lot of pandemic-related articles. It’s not all bad news however, and the articles on pre- assessment show how the pandemic has focused our minds and streamlined so many pathways. In order to Guest editorial 32 Perioperative cardiac arrest access an operation, a patient may previously have had to attend several face-to-face appointments at different What a difference a year makes! NELA: fellows past and present 34 times, many of which now occur remotely and at the mutual convenience of patient and clinician. It is also A year of two halves 36 wonderful to see the empowerment of nursing staff taking on extra roles, and the innovative use of technology. I Dr Lindsay Forbes gives a personal glimpse into personally found the tips on remote meetings very useful and hope that incorporating them will avoid humiliating In a changing landscape 38 the experience of undergoing bariatric surgery and technical glitches happening at awkward moments – as we have all witnessed on TV and radio just as the person A fellow in the field of rapid being interviewed is coming to the crucial point of the whole interview. explains why it’s not a ‘quick fix’ qualitative research 39 This month we showcase research in anaesthesia, and I am delighted to see that, after the first wave, research Page 12 Compassion through the activity is up and running again. The topics covered are as important as ever – COVID-19 cannot be allowed to COVID-19 crisis 42 stop our progress as a specialty. The same applies to education, where the article on remote simulation shows A practical guide to improving that it can be done. The President’s View Health Services Research teleconferencing 44

The challenges COVID-19 Centre (HSRC) Pop-up simulation suite Your representatives – the College Council members – feature again in this edition, where Dr Kirstin May reflects on where we have come, and how SAS-grade doctors have not only been indispensable in the response to has placed on the research HSRC share how their work has utilising Zoom videoconferencing 46 COVID-19, but still are as we try to get elective work back on track. In our ‘As we were’ article we hear from Janice community been affected by the pandemic in Training outside the box 48 Fazackerley, our previous vice-president. Throughout her tenure she was a sensible voice of reason with a passion Page 4 their 2020 Annual Report Simulation training – ‘It’s just like for the doctors and patients she represented. She will be much missed from Council, but I’m pleased to say that flying a plane’ 50 Page 29 she very much remains a friend and a source of excellent advice. Remote pre-assessment Transforming paediatric Meghana Pandit Safety Fellowship: for cancer surgery during patient-safety perspectives in a Finally, I want to extend my gratitude to Lyndsey Forbes for the moving and highly personal account of her major trauma care different healthcare system 52 experience of obesity and weight-loss surgery. What we say in the coffee-room and see as mere ‘banter’ can hurt. the COVID-19 pandemic We may forget what was said, but we will never forget how it made us feel. Substantial work has seen ‘New to the NHS’ national MTI A success story on delivering simulation programme 54 transformation of the paediatric Here’s hoping we’ll be able to spend Christmas in groups larger than six! cancer care during lockdown from trauma service from conception to Why become a the Royal Marsden hospital clinical practice College event speaker? 56 Page 26 Page 40 As we were... 58 New to the College 60

Notices, adverts and College events 63

Professor Ravi Mahajan Professor Iain Moppett President Deputy Director, Health Services [email protected] Research Centre

The COVID-19 pandemic has had significant impacts on research. Some have been positive, while some are causing short-term and possibly longer-term problems. Now is a good time to take stock of where anaesthesia and critical care research is and how it is placed to face challenges going forward.

When the pandemic hit, most clinical research was the other hand, some researchers are highlighting halted or restricted to activities that were essential the benefits of enforced virtual meetings, with less to maintain participant safety or the integrity travel time and fewer barriers to collaborations with of the studies. Research-active clinicians and geographically dispersed colleagues. research support teams across the country shifted their work patterns to support their local clinical In addition to the changes it has prompted in services. Inevitably this has delayed development, clinical practice, COVID-19 has given a kick to recruitment, analysis and publication of research some perhaps overdue changes in research projects, but with the easing of ‘surge’ rotas, practice. Virtual/telephone consent and follow- colleagues are starting to catch up. There is a up is becoming much more the norm alongside double-hit of reduced and variable clinical work electronic data capture. impacting on the ability of studies to recruit in a The pandemic has highlighted an undoubted timely fashion. strength of the NHS research infrastructure and The limitations on face-to-face working have culture. Landmark studies such as RECOVERY changed the nature of research, from the laboratory (Randomised evaluation of COVID-19 therapy) through to large clinical trials. Universities have and REMAP-CAP (Randomised, embedded, the same requirements for COVID-safe working multifactorial, adaptive platform trial for community- environments as other businesses, and it is not clear acquired pneumonia) would not be possible without The President’s View exactly how social distancing requirements will a national research infrastructure. Nor would they impact on traditionally close-working environments happen without the willingness of clinicians to enrol such as laboratories. It is almost certain to increase and care for patients within randomised controlled costs. Teleconferencing is the new normal for trials. The importance of clinicians supporting RESEARCH AND COVID-19 research groups, but only time will tell how much patients’ participation in trials when there is scientific the social and academic interactions within and equipoise, regardless of their own personal views, between research groups in coffee rooms, seminars, cannot be overstated. Prior to RECOVERY, many and conferences will affect future research. On clinicians may have held strong views for or

against the use of steroids, but only by put into the public domain, whether on social media, Bulletin recruiting to the trial do we have the Only by recruiting to studies will or as pre-prints or peer-reviewed publications. Sadly, of the Royal College of Anaesthetists answers. It would be good to see this but not unpredictably, much of this ‘research’ has not Churchill House, 35 Red Lion Square, London WC1R 4SG approach spill over and continue in we find the answers to important withstood scrutiny. Game-changing claims have been 020 7092 1500 future non-COVID research. quietly forgotten, and even the major journals have had to rcoa.ac.uk/bulletin | [email protected] retract papers. We are fortunate that the anaesthesia and clinical questions. @RCoANews However, the situation moving forward critical care community has articulate and well-respected /RoyalCollegeofAnaesthetists remains uncertain. Funding of research researchers who have been able to offer context and projects is likely to become more critique for both the clinician and the wider public. Dr Registered Charity No 1013887 community. NHS and university data that can provide answers to some difficult. Social distancing effects Charlotte Summers from Cambridge has won praise for Registered Charity in Scotland No SC037737 clinicians and researchers have for a of the questions about how safe and may increase laboratory costs. Major her ability to explain complex and sensitive topics in an VAT Registration No GB 927 2364 18 long time contributed to this exposure effective care can or should be delivered. funders such as the National Institute engaging and informative way. through medical student projects. The This isn’t to say that high-quality for Health Research will be hit by the President Hugo Hunton College, alongside the Association of randomised controlled trials are not costs of overrunning studies, not to It would be remiss not to mention some of the work Ravi Mahajan Lead College Tutor Anaesthetists, BJA Anaesthesia, and important. We are delighted to report that anaesthetists in training and fellows have somehow mention the the wider economic impact Vice-Presidents Emma Stiby the Neuroanaesthesia and Critical that the first Perioperative Medicine managed to pull out of the bag at the height of COVID. of COVID. Universities are facing Fiona Donald and SAS Member Care Society, provides competitive Clinical Trials Network (POMCTN) Hopefully many members will have contributed to significant shortfalls in the coming William Harrop-Griffiths financial support through the John Snow led trial (Volatile vs total intravenous IntubateCOVID (Dr Danny Wong), reflected on the Susannah Thoms years due to loss of income from Intercalated Award. Many of these anaesthesia for major non-cardiac early analysis of deaths in healthcare workers (Dr Emira Editorial Board Anaesthetists in Training teaching, hospitality and research. The smaller projects have been laboratory- surgery [VITAL] trial, led by POMCTN Kursomovic), and digested the systematic review of ICU Committee opportunities to replace or appoint staff Helgi Johannsson, Editor based or volunteer-based work. There Deputy Director, Dr Joyce Yeung) outcomes following COVID (Dr Richard Armstrong and Carol Pellowe are likely to be few and far between. Jaideep Pandit may need to be a reimagining of how has been funded (£1.4 million) by the Dr Andrew Kane). Lay Committee Universities are under pressure to Council Member such projects will work in the future. NIHR Health Technology Assessment deliver high-quality online and virtual COVID-19 has brought many challenges to the research Gavin Dallas programme. VITAL will be comparing Krish Ramachandran teaching to more medical students High-quality-data science research may community, with many more to follow. Anaesthesia and Head of Communications patient outcome between inhalational Council Member than ever before. Inevitably, university- play an increasing role in the future. critical care research are well placed to meet these, but will and total intravenous anaesthesia and is Jonathan Thompson Mandie Kelly employed clinical academics will be The NHS – as well as Health Services be working in an increasingly constrained and competitive a data-enabled trial which will use the Council Member Website & Publications Officer asked to provide more support to these Research Centre projects such as the environment. Above all, we could not be delivering existing PQIP infrastructure. Anamika Trivedi important roles. National Emergency Laparotomy research for the benefit of our patients and colleagues Duncan Parkhouse Website & Publications Officer Audit (NELA) and Perioperative Quality It will not have escaped the notice of without the continuing support of our members. Lead Regional Advisor Early exposure to research is vital to Improvement Programme (PQIP) – College members that an awful lot of Anaesthesia If you have any comments or questions about any of a healthy and continuing research provide high-quality, routinely collected COVID-related ‘research’ has been the issues discussed in this President’s View, or would like Articles for submission, together with any declaration of interest, to express your views on any other subject, I would like should be sent to the Editor via email to [email protected] to hear from you. Please contact me via All contributions will receive an acknowledgement and [email protected] the Editor reserves the right to edit articles for reasons of space or clarity.

Turn to page 29 to read more about how the The views and opinions expressed in the Bulletin are solely Health Services Research Centre’s (HSRC) work those of the individual authors. Adverts imply no form of endorsement and neither do they represent the view of has been affected by the pandemic in their the Royal College of Anaesthetists. 2020 Annual Report. © 2020 Bulletin of the Royal College of Anaesthetists All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any other means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission, in writing, of the Royal College of Anaesthetists.

ISSN (print): 2040-8846 ISSN (online): 2040-8854

NEWS IN BRIEF News and information from around the College

Council Election Don’t forget to vote in the election to Council, where you’ll be choosing your representatives for one Consultant place and one SAS place. Ballots will be sent by email on 16 November and voting will close on 14 December. Council members play a hugely important role in the working life of the College and in Translations of patient information leaflets advocating for all our members, so do get your vote in. The College is working in partnership with the international translation charity Translators Those eligible to vote are: without Borders to provide translations of our most popular patient information leaflets in the

■ Fellows (apart from Honorary Fellows), Members, Associate Members, 20 most common languages used in the UK, including Welsh. Trainees and Senior Fellows and Members for the Consultant vacancy You and your anaesthetic, Your spinal anaesthetic and Your child’s general anaesthetic are now ■ Members and Associate Members for the SAS vacancy available in the current selection of translations. Soon to follow – Anaesthetic choices for hip or ■ If your membership fits one of these categories and after 16 November you Scottish Board knee replacement. haven’t received a ballot email, please contact [email protected], including your college reference number. Election Please see our website for further details: rcoa.ac.uk/patientinfo/translations Nominations for places on the RCoA Scottish Board open on 4 November. Put your name forward before the closing date of 2 December for the chance to join a board of colleagues who meet three times a year to provide an important link between the College RCoA responds to ‘Reducing and Fellows and Members based in SAFE Scotland. Bureaucracy’ consultation ANAESTHESIA The College has submitted its response to a consultation LIAISON GROUP Further information can be found on the from the Department for Health and Social Care (DHSC) on College website and you can discuss the issue of ‘Reducing bureaucracy in the health and social the opportunities in more detail with the care system’. See the full response at: current chair, Dr Sarah Ramsay ■ rcoa.ac.uk/rcoa-responds-reducing-bureaucracy-consultation ([email protected]) The College response highlights that the perioperative pathway could be a solution in improving the bureaucratic SALG-BIDMC Fellowship pressures associated with the above areas, as supported by The Safe Anaesthesia Liaison Group (SALG) is pleased to comprehensive evidence in the CPOC impact review. announce the next round of its exciting programme of fellowships for anaesthetists interested in patient safety. In collaboration with the Association of Anaesthetists and the College, SALG are offering a unique programme Proving the case for perioperative care of formal training through Harvard Medical School that The Centre for Perioperative Care (CPOC) has published comprehensive evidence that aims to develop international expertise in perioperative the perioperative pathway is associated with higher quality clinical outcomes, reduced quality and safety. financial cost and better satisfaction for surgical patients. Never has there been so Further information and application details can be found important a moment to institute rapid large-scale transformation. at: bit.ly/SALGFellowship Read CPOC’s report at: bit.ly/3imZYiy

NEWS IN BRIEF News and information from around the College

e-Learning Anaesthesia revision guides We have now published all three new titles in the e-learning Anaesthesia revision guide series to Young complement e-LA and support Primary Exam preparation. The series now covers Physics as well as Pharmacology anaesthesia and Physiology. These guides are available to download Anaesthetic teams awarded for for free onto your device for use offline and contain links directly to useful e-LA learning sessions. high quality patient care

artist 2020 Download the Revision Guides at: This year the College is very proud to have recognised seven rcoa.ac.uk/e-learning-anaesthesia anaesthetic departments for providing the highest quality care to their patients. Departments at the five Trusts of the Countess e-LA is always looking for volunteer module editors and of Chester, Frimley Health, Leeds, North Bristol and South authors to make up the e-LA editorial board. Applications Tees achieved accreditation and the two trusts of Kingston While COVID has impacted us all as healthcare workers and, with some of will be considered from all College members and and St Georges achieved re-accreditation under the Colleges us needing to spend more time away from our family than usual, it’s also anaesthetists in training who have achieved or are within prestigious peer review scheme Anaesthesia Clinical Services a year of achieving their CCT. Accreditation (ACSA). taken its toll on the little people we love and care so much for. To find out more please email: [email protected] As well as meeting the standards, the departments demonstrated We’d like to offer your young daughters, sons, nieces, Postal submission instructions: many separate areas of excellent innovative practice. These

nephews or grandkids the opportunity celebrate with us as ■ drawing or painting on paper or card included collaboration between hospitals in their trust, integrated we take our first tentative steps to re-open your College, services, flexibility of patient care and many more, these have now ■ artists’ first name and age, with parent or guardian’s full by asking them to send in their drawings or paintings of been highlighted for sharing through the ACSA network. name and email address clearly written on the back of their interpretation of either what you did whilst caring for the submission your patients, or of something they’ve enjoyed during the To receive accreditation, departments are expected to ■ strange times they’re living though at the moment. posted to: Young anaesthesia artist 2020, c/o RCoA demonstrate high standards in areas such as patient experience, Facilities Team, Churchill House, 35 Red Lion Square, patient safety and clinical leadership. Whilst the pandemic has We hope that seeing this new world through the eyes of London, WC1R 4SG. meant that onsite visits are postponed until March 2021, new our young family members will be a powerful and emotive anaesthetic departments can still register for the peer-review insight into how this global pandemic has impacted on and Digital submission instructions: scheme and hold phone or video conferences to discuss the is being perceived by the next generation. ■ A4 portrait or landscape drawing or painting – scanned benefits of engaging and get advice on the challenges involved. or photographed We’re planning to give this project pride of place in our The College’s website has all the information required for you ■ high resolution (300dpi) digital file to be emailed to: building’s entrance area, with each and every submission to understand how ACSA could work for your anaesthetic [email protected] with a subject heading of: being put on display – we’d of course love to receive as department (rcoa.ac.uk/acsa). many as possible! Young anaesthesia artist 2020 ■ artists’ first name and age, with parent or guardian’s full Format: name provided within the email. Remember to get your flu jab! ■ A4 portrait The College would like to encourage you all to get your free annual flu jab as soon as you Deadline for submissions is 20 December 2020. ■ landscape is also welcome. can. This is a critical step to keep you, your family and your patients safe. With COVID-19 We hope this provides our young artists with an enjoyable in circulation it’s especially important to get the flu vaccine this year to protect those most creative outlet and lots of fun. We can’t wait to see the vulnerable and control pressures on NHS staff and services by reducing staff absence. creations from our UK and international members alike. More information can be found at: bit.ly/2ZOdrst

My declaration of interest on this is bias towards these patients; they are options – tell folk, or don’t go out quite clear. Having been obese for most likely already terrified. socially. I decided it would be much most of my life, I had a revision from easier for ‘life’ just to tell ‘my people’. I originally had bariatric surgery back gastric band to gastric bypass in June An excellent decision. in 2007 when I got a gastric band. 2019. I corrected someone on twitter I worked with it fairly well for about a few months ago who called bariatric Its not all been a challenge though. a year, then I went off to Australia, surgery a ‘quick fix’ – I’d say its I’m much less tired; I sleep better; fell out of follow-up, and did what anything but. More about recognising I don’t have the anxiety that there all 25-year-old junior doctors do in that there is a scary permanent option won’t be scrubs that fit every morning, Australia – PARTY! that involves not being morbidly and don’t stockpile them in my locker anymore. The biggest anaesthetic obese. A year and a half on, it remains It’s hard to recognise when something achievement has clearly been coming one of the hardest but best decisions isn’t working; in reality I’d probably third out of 73 on the Strava cycling I’ve made. been thinking about revision to segment on the way home from bypass for a few years before I My first recollection of being work; I need to gain 21 seconds decided to do it. There is usually a overweight was in primary school, to get second – I am considering trigger that spurs you into action. For when I first got a nickname that the addition of a sail to the bike to me, as a coffee addict, that trigger stuck right through to the end of achieve this. was experiencing shoulder pain, not secondary school – ‘Fatty Forbes’. It is only with eating but also on drinking unfortunate being round and having As usual, I’ll add my Oscar-esque my morning latte – DISASTER! a surname that starts with F when finale and thank all my Chichester crew for being awesome, in particular Ruth Guest Editorial you’re seven years old. In medical Undoubtedly the worst part was Prosser and Guy Slater. And I will finish school I was given a paper to present going to theatre as a punter, even with a reminder to us all: people will to my group by the professor of when you’ve handpicked the pharmacology in a fifth-year special forget what you said, people will forget Dr Lyndsey Forbes anaesthetist and surgeon. The week study module. After looking me up what you did, but people will never before, my anaesthetics had involved 4 Consultant Paediatric Anaesthetist, and down, he had handed me a paper forget how you made them feel. Royal Hospital for Children, Glasgow liberal doses of both emergency on Orlistat and told me that it was the drugs and buzzers. So my triple-figure [email protected] References ‘most appropriate’ paper he could tachycardia was perhaps unsurprising, find for me. Nowadays I’d have pulled 1 Tamara A, Tahapary DL. Obesity as a despite the Remifentanil hitting like a predictor for a poor prognosis of COVID- him up on it, but at the time I certainly full bottle of tequila. 19: a systematic review. Diabetes Metab didn’t have the confidence or self- Syndr 2020; 14(4):655–659. esteem to follow it through. You just Initially, the most challenging aspect of 2 RCGP apologises after backlash over want to keep your head down and having a bypass for me was eating out. branding Covid-19 a ‘lifestyle’ disease get on with it; you’re mortified when About three months post op, I was at (bit.ly/32ozO8l). WHAT A DIFFERENCE a conference when I declined a beer 3 Selak T, Selak V. Communicating risks anyone brings it up, but know it’s an of obesity before anaesthesia from the issue as you do actually own a mirror. from an old boss I hadn’t seen in 12 patient’s perspective: informed consent or years. On declining the offer of beers fat-shaming? Association of Anaesthetists Fast forward a few years to the place I was firstly asked if I was pregnant. 2020 (doi.org/10.1111/anae.15126). A YEAR MAKES! where I’ve probably heard the most ‘No!’ Secondly, I was asked if I was an 4 Maya Angelou quote, goodreads We have heard a lot about obesity in 2020 – that it predisposes to judgement about obesity – the alcoholic. ‘No!’ And thirdly I was asked (bit.ly/32lHRD3). a worse outcome in COVID-19;1 that the Royal College of General anaesthetic coffee room. Never why on earth I didn’t want a dessert. It aimed at me, but I’ve definitely made me feel uncomfortable and very 2 Practitioners has branded COVID-19 a ‘lifestyle disease’; and that noticed that, as a group, we are very selective about going out socially for a judgemental. From a ‘harpooning few months. the Society for Obesity and Bariatric Anaesthesia are considering whales’ on labour ward, to a having a formulating guidelines regarding consent for obese patients, ‘right heifer’ on the list, to an ‘OMG I kept it very quiet till about six leading to the question of at what point this should happen they’re h-u-u-u-ge’. It might be just months post op, because I thought I’d coffee room ‘banter’, but we all need be judged. Then came the Christmas 3 preoperatively in an Association of Anaesthetists’ editorial. to be mindful of our perceptions and party, when I decided I had two

Locally, outside of London, we have risk factors. In my personal experience had enough warning of the first wave of more than 26 years in the NHS this SAS doctors to organise ourselves, crosskill, upskill, is a shift-change away from a ‘one and practise multidisciplinary drills. size fits all’ approach. We are learning are a much The sense of common purpose was a different way of looking after staff, palpable in my hospital and has greatly and some of that has been achieved improved interdisciplinary working and with the help of the public: better food needed staff team spirit. The improvement in morale provision, availability of shower and rest I have witnessed is reflected in some of facilities, soap and handcream, etc. group our College COVID survey results. Most of us have in the past gone Who knew how many consultations to work even if feeling unwell. The could be done electronically to mutual pressure to not leave your colleagues innovation and harnessing fresh satisfaction? How multidisciplinary – already stretched – with your work thinking, and an opportunistic abuse of and anticipatory care plans, made on on top of their own has led many a an exhausted, distracted workforce. admission, would be the new normal, sniffly nose, a hacking cough, a fever, not a much-chased ideal? How we could and an ‘iffy’ stomach to turn up at work. When meeting you at College change our working patterns or areas Those who are sick have felt guilty events, many of you talk to us about of practice at a moment’s notice? How and often returned too early. We now dissatisfaction with job plans and terms specialists who had barely ever crossed have to provide a safer workforce and and conditions. While such employment its threshold could become valued team protect ourselves, our colleagues and issues are not part of the College’s members in intensive care? How we our patients better. Personal protective remit, we try and signpost in the right would run clinical governance meetings, equipment has taught us to take breaks. direction – which is usually the BMA. business meetings, and educational Presenteeism is dead! However, we can also give you the events via videoconferencing, with confidence that we as SAS doctors are a better attendance than before? Roll up your sleeves much needed and difficult to recruit staff group with a significant vacancy rate. The pause or slowdown in many We have learned new things about Many of you have worked in the same services has now created a large ourselves: we – and the NHS – can job and same location for years and are backlog, and the consequences will Dr Kirstin May be very flexible if required. Changes understandably reluctant and anxious to only gradually come to light. We need contemplated for years can be change. If you have recently changed RCoA SAS Member of Council, Banbury to use some of the clinical innovations [email protected] implemented quickly if desired. We the way you work and where you work, and gains made to create momentum can regain our common sense of taken on different areas, taken part in as quickly as possible to get work done. purpose. We can create efficient different rotas, or been successfully Relaxation of bureaucracy and flexible SAS and Specialty Doctors teams with flattened hierarchies and redeployed, maybe this is the time to thinking should help. We must resist made up of previously considered reconsider your options… attempts to return without question to unlikely team members. We can refresh business as before. Work desperately old knowledge or learn new things, Opinions are my own and not the views needs doing, but rest and recuperation KEEP THE CHANGE…? regardless of age. The public values of the RCoA. are important. It is our duty to look after the NHS and can adapt to new rules or ‘The greatest danger in times of turbulence is not the turbulence, it is to act with yesterday’s logic’ ourselves and our colleagues for us to Further reading ways in which healthcare is offered. Peter Drucker be able to look after our patients. 1 Third Covid Membership Survey, RCoA. Focus on wellbeing and (rcoa.ac.uk/news/third-rcoa-covid-19- Is this relevant to SAS membership-survey). As we look back over the last few months (time of writing is August), we are personal risk doctors? 2 Workforce Data Pack 2018. RCoA reflecting on the many changes the COVID-19 pandemic has forced us to Doctors from ethnic minorities are (rcoa.ac.uk/media/5256). Attempts have been made to use over-represented among SAS and make within a short timeframe. There have been myriad changes to the way changes in working patterns agreed as trust-grade doctors, and their increased short-term measures during the crisis to we work, and many of us are feeling exhausted and psychologically affected vulnerability to COVID has focused embed longer-term changes, leading to attention on personal risk and how to by the experience. Among the chaos and upheaval it has been astonishing to an erosion of job plans and terms and manage it. This does not only apply to conditions. There is a fine line between see how everything has suddenly come to a stop and we have reconfigured. ethnic background, but also to other

Revalidation for anaesthetists Faculty of Pain Medicine (FPM) ‘Top tips’ for making PAIN MEDICINE – Dr John Hughes a successful CPD Chris Kennedy MOVING FORWARD Dean, Faculty of Pain Medicine RCoA CPD and [email protected] Revalidation Co-ordinator [email protected] I am writing this FPM strategy update just before the schools return. This event application seems strange, as COVID-19 has overtaken much of this year’s work, It was reported in the September edition of the Bulletin how the College’s introducing both dilemmas and opportunities. Clinically there have been CPD accreditation process has now been extended to virtual learning events. significant challenges, but redeployments are reversing, allowing the practice An increasing number of these are being provided in response to ongoing of pain medicine to return. Many centres have maintained some service for concerns about local lockdowns and social distancing measures, potentially those most in need, which has been very encouraging. resulting in short-notice cancellations of face-to-face versions. Last September the FPM reviewed its strategy. This has allowed consistent Consideration can be given to We would like to use this article to ■ CPD skills – the incorporation messaging across the areas of training; events which are appropriate to the provide some ‘top tips’ on how to make of CPD into the LLP has seen a professional standards; research; professional development needs of a successful application, and one which Framework of CPD Skills replace and public, professional and political non-trainees and for events which will be most visible and attractive to what was formerly the CPD Matrix. interaction. There have been disruptions are targeted at a regional, national or your potential audience: This is an entirely optional resource and delays, but we can list here international audience. There is no to map events against, although ■ highlights going forward. charge for NHS trusts and hospitals, event URL – all events accredited doing so, and also mapping against registered charities and specialist for CPD appear in the Lifelong the Good Medical Practice domains ■ Pain management needs to societies and associations, and the Learning platform (LLP) and on the and the Domains for Medical be attractive and sustainable if event reviews are completed by College website, and so you are Educators, will further increase the patients are to benefit. Anaesthesia independent, specialist CPD assessors, encouraged to provide a direct URL visibility of your event in the LLP is a cornerstone for pain to increase visibility specialist development, and pain who are clinicians experienced in the ■ supporting documents – while the ■ keywords – events are searchable management is a fundamental subject matter. application process requires event (with the Medicines Advisory Group relationship with the British Pain by keywords in the LLP, and so component of the anaesthetic providers to submit three mandatory leading), and includes maintaining Society. These interactions have adding some unique words will curriculum. There is also a role for documents – the event programme, the ‘Opioids Aware’ resource. allowed statements and publications further increase visibility broader access to pain medicine; information on the speakers and a to be co-released (both those that this is being actively explored with ■ aims and learning outcomes copy of the feedback form, you can ■ This all feeds the strategy to get the are COVID-related and those that are the GMC credentialing process, – the overall aim(s) and learning specify which of these, if any, you best service for our patients. This more general). Closer to home, there which is now back up and running. outcomes of your event should be would like to be visible in the LLP. common objective is shared with the is ongoing engagement with the clearly defined so as to manage the ■ These link with the strategic aim of ‘Core standards for pain management Centre for Perioperative Care. We hope that this information will help; expectations of the delegates as well looking at the Faculty’s educational services’ document, with outcome as to provide guidance for the target for further guidance please contact The Faculty staff team provides the role with respect to healthcare as measures, with commissioning audience. The learning outcomes [email protected]. a whole. They comprise several support that enables these activities to support, and with dialogue with NHS should be measurable and should independent strands that are being be undertaken and delivered in a timely England and other statutory bodies. indicate what knowledge or skills the focused within a single hub to manner. I salute them, as they have This has continued throughout the participants are expected to obtain ensure consistency, improve access, achieved this against the background of COVID pandemic, with new links as a result. These are particularly and make the best use of resources. distance working, and the arrival of a new important because the attendees’ being forged. The multidisciplinary Associate Director of the Faculty together reflection will be based on these. The appropriate use of pain nature of pain management is with other staff changes. therapies is topical and important reflected in the good working

Dr Carl Waldmann Dr Joel Meyer and Dr Andy Slack Chair, Life After Critical Deputy Chairs, Illness (LACI) Working Party, Life After Critical Illness (LACI) FICM Working Party, FICM [email protected]

evidence base to justify their funding quality indicators. In 2017, NICE These benefits include feedback from or their existence, many failed to be published its Quality Standard (NICE patients and caregivers (family) to sustainable. Some centres did manage QS 158), and since then there has ICU staff that can influence changes to evolve rehabilitation and outpatient been more of a concerted effort for in practice within the ICU, the follow-up services for patients after all intensive care services nationally enabling of revalidation for healthcare critical illness/injury. However, unlike to provide rehabilitation and follow- professionals, and the provision of specialties such as trauma, cardiology, up. However, there still remains the a narrative of individual patients’ respiratory medicine, and stroke problem of how to fund such services. outcomes for staff, which can improve medicine, where rehabilitation pathways To date, this has been primarily morale. The ICU multidisciplinary team are now quite well established, intensive achieved by local intensive care are expertly placed to understand, care has been unable to develop a units developing and submitting a interpret and plan the recovery phase specific rehabilitation pathway. business case to local commissioners. of the patients’ illness and signpost Unfortunately, these efforts often fail them appropriately to other hospital or © ICCU, City Hospitals Sunderland NHSFT In 2009, NICE provided guidance due to a lack of supportive clinical community-based specialties. with the headline statement ‘Given evidence and a challenging financial The patient feedback for these critical the individual impact on patients, and climate in the NHS. ripple effects on families and society in illness recovery clinics consistently Faculty of Intensive Care Medicine (FICM) general, poor-quality rehabilitation and It is clear that recovery from critical highlights the benefit of hearing a impaired recovery from severe illness illness is complex. Since 2010, the term narrative account of their ICU stay, should be regarded as a major public ‘post intensive care syndrome’ (PICS) along with the review and normalisation health issue.’ [NICE CG83]. has been increasingly used to describe of their ICU delirium experience. LIFE AFTER CRITICAL ILLNESS the complex long-term sequelae of Some patients will have very severe Unfortunately, this only achieved limited critical illness affecting both survivors The development of the critical illness aftercare service has been in the forefront ongoing disability following discharge, traction. In 2015, the Scottish Intensive and their families. PICS has three key which requires specialist inpatient of the Faculty of Intensive Care Medicine’s strategy and formed a part of Care Society Quality Improvement patient-centred domains at its core or community-based rehabilitation. Group published guidance making that can be impacted upon by critical the publication in 2017 of Critical Futures. Life After Critical Illness (LACI) was Others require a variety of community- critical care rehabilitation one of its illness: the physical, the cognitive and based rehabilitation/support deemed to be an important workstream for the Faculty to undertake, working the psychological domains, the latter services, including cardiopulmonary affecting both patient and family. across multiple organisations. rehabilitation, sports and exercise The question of who should provide medicine, psychological, vocational The aims of the workstream are to: Provisional guidance has been published to support the intensive care aftercare services has support, etc. All of these services need a present a UK-wide survey of current practice pandemic and provide a national framework for future stimulated debate about whether it to be working in coordinated networks critical illness recovery services. The Life After Critical Illness should be intensivist-led or otherwise. b provide an outline of existing service models to optimise the care of patients who Working Party (LACIWP) of the Faculty will now continue its The argument for these services being have been critically ill. c present examples of business cases work on their full guidance document, and this will take into provided by intensive care staff is hard d make recommendations about the future need for account any additional learning from the pandemic. to contest, with numerous benefits for resources for these programs patients as well as for staff. Until recently there was little in the literature about what e outline future research proposals to evaluate existing happened to survivors of critical illness after they left hospital. services and outcomes. In 1989, a King’s Fund report stressed that ‘there is more to Download the FICM Position Statement and The multiple organisations involved reflect the requirement life than measuring death’. Following on from this, there were Provisional Guidance at: bit.ly/2Qob36Y for close collaboration across a spectrum of multidisciplinary several attempts in the UK to establish outpatient follow-up organisations when exploring the optimal approach to programmes, some of which were successful. However, due planning and delivering. to a lack of funding and because of the perceived lack of an

Patient perspective SPOTLIGHT ON CRITICAL CARE

Pauline Elliott Lay Representative, FICM

[email protected]

Imagine that you’re an awake patient or their relative in a critical care unit. Representative on the FICM Board, a straightforward way. They very environment. This helps ensure that had the idea of creating a multimedia generously offered these to the what the patient wants is always the You’re in a frightening, alien environment. There are unfamiliar machines. hub for the FICM website. The aim was project. The videos explore different focus of decisions about their care. Lots of them. They flash. They glow. They display restless neon numbers and to answer some of those challenging themes associated with critical care. questions people ask about critical care, Importantly they cover rehabilitation tracings. It’s often noisy. Very noisy. Equipment bleeps continuously. Raucous presenting the information in different and recovery, including the physical and alarms sound insistently. Staff, dressed in identical scrubs, focus intently formats using everyday language. psychological consequences of critical care. Each video includes frank narrative on their patients or huddle around charts and computer screens. They talk I was very pleased to be asked to provide from real critical care patients which is quietly in an unfamiliar language which seems to consist solely of letters and lay support for Richard’s initiative. Dr deeply moving. Everyone involved in Will English and Sarah Bean from the critical care should watch those videos; numbers. Mainly numbers. Royal Cornwall Hospitals NHS Trust also they’re a clear window into the reality of joined the group. They have considerable life after critical care. Then there’s a sudden, unexpected burst There were straightforward questions ‘It is really important to not lose sight of experience of successfully producing of activity as a new patient is admitted. about everyday activities, like eating who is the focus of our work. We may information for critical care patients and The hub is live on the FICM website all have our own views and ideas but, at at: ficm.ac.uk/intensive-care-guide- After 20–30 minutes of toing and froing, and drinking. There were also difficult their families. Anna Ripley, Education the end of the day, if this is not what the patients-families-friends. Richard’s everything settles down and anxious questions, especially about decision- and Standards Manager from FICM, also patient would want it is irrelevant.’ vision is that it will be expanded and relatives are shown to the bedside. making. ‘What if I don’t want to be joined us. ICUSteps, a charity working continually developed to fulfil its ventilated?’ Who makes decisions I’m the Lay Representative on the FICM with patients and families who have Most people haven’t experienced this potential as a key information source about my care when I’m unconscious?’ Board, where I support FICM’s work and experienced critical care, gave invaluable and hadn’t thought much about critical for patients, their families, and critical ‘Will my family be involved in those particularly help critical care professionals lay feedback on draft materials. illness beyond hoping it didn’t happen care professionals. decisions?’ ‘Who decides whether my communicate effectively with patients to them – until COVID-19 came along. The group decided to work around the ventilator is switched off?’ and the public. Dr Pittard succinctly sums For most patients and their families, theme of the patient’s journey in critical Then the spotlight was switched on. up the value of the lay role: critical care units are strange, care. That became the focus for a series People (and the media) started asking These are extremely challenging scary, alien places. Accessible The hub can be ‘Having someone to represent the of plain English FAQs for critical care questions about critical care. They questions for critical care professionals information, produced through accessed at: patient voice keeps us grounded and on patients and their families. wanted to know what it was all about and they have to be answered clearly effective collaboration the right track.’ ficm.ac.uk/intensive- and what it would be like for them and and openly. As Dr Alison Pittard, between professionals and lay Will and Sarah’s work in Cornwall care-guide-patients- their families if they became critically ill Dean of the Faculty of Intensive Care When the spotlight turned onto critical resulted in a series of excellent videos representatives, can help people understand the critical care with COVID-19. Medicine (FICM), says: care, Dr Richard Benson, Trainee offering accessible information in families-friends

B- ABY BOOMERS GENERATION X MILLENNIALS GENERATION Z

Society for Education in Anaesthesia (UK) Intergenerational differences and medical education

Dr Janet Barrie Consultant Anaesthetist, or organisation, and they may value also may need support in critical analysis Of course these descriptions are Royal Oldham Hospital the chance to make a difference. of information available online. oversimplifications – perhaps to [email protected] They have been entirely raised in the the point of being caricatures. It is digital era with immediate access to Despite the differences, some common important both to recognise that information, and dislike uncertainty themes emerge. Both Millennials and people are individuals and to treat and waiting for situations or answers to Generation Zs may respond better each other as such. Part of this A new generation is said to evolve every 20 years or so1 with attributes, emerge. However, their interaction with to learning which is immersive and individuality, however, reflects the information and reality has changed interactive and includes visual as well ‘social, environmental and technological as audio input. They appreciate a attitudes and motivations different from preceding and succeeding with the emergence of digital ‘echo influences’ 2 on doctors of different degree of freedom in determining how generations. They are based on defining historical events and societal trends, chambers’ which reinforce viewpoints generations, and an understanding of their learning objectives are met. They and close down meaningful discussion these differences may help trainers to appreciate feedback, particularly when rather than strict genealogical generations as such. with little critical analysis or engagement. better support their trainees. In addition, they may have an active this is given at, or shortly after, the event Our anaesthetic department in a large learners may not be optimum for They may therefore respond positively digital persona which may or may not rather than at interim meetings. References district general hospital comprises Generation Z, while both may be to teaching which has clear goals and reflect their true identity. This may lead 1 Schenarts PJ. Now arriving: surgical trainees staff from across these generational foreign to their Baby-boomer trainers. timeframes and which aims to develop These differences may be summed from Generation Z. Journal of Surgical to distress if the digital and real personae up in attitudes to email. A technique boundaries. While the majority of critical thinking skills rather than rote Education 2019; 77:246-253. Millennials entered adulthood at or are in tension or if their real life is felt consultants are ‘Generation X’ with learning, yet includes a degree of which did not exist when Baby-boomers (doi.org/10.1016/j.jsurg.2019.09.004) around the year 2000. Their view to be less perfect than the online life of birthdates between 1965 and 1985, a freedom in how the learning outcomes entered training is seen by Millennials 2 Roberts DH, Newman LR, Schwartzstein of authority has been described as their peers. This may be one factor in few of the older consultants lie in the are achieved.1,2 They have also grown up and Generation Zs as old-fashioned, RM. Twelve tips for facilitating Millennial’s ‘unimpressed’, and they may need to the increase in depressive symptoms and learning. Medical Teacher 2012; 34:274-278. tail end of the ‘Baby-boomers’ (born with social media and may need a more taking too long, and obsolete! be convinced of the value of rules self-harm in Generation Z individuals, 3 Shatto B, Erwin K. Moving on from 1947–1964). Similarly the majority of collaborative, team-based approach to rather than expected to accept them with increasing numbers seeking help There is virtually no peer-reviewed Millennials: preparing for Generation Z. anaesthetists in training are ‘Millennials’ learning than earlier generations. Journal of Continuing Education in Nursing uncritically. This can lead to frustration from mental health services. For this research into this area in medical (born 1981–1993 or so), but an 2016; 47: 253-254. in Baby-boomer trainers, who are more reason, Generation Zs too may need education, and the references increasing number of foundation and The characteristics of Generation Zs as likely to be rule followers. Millennials are access to support during training.1,3 They given here are just opinion pieces. core trainees belong to ‘Generation Z’ adults are only just being revealed. It is technologically sophisticated and used (born after 1993). Our department is predicted that they will have a strong to immediate access to information, probably not atypical, and there is the work ethic and be more risk-averse and which they appreciate being presented potential for generational differences traditional than Millennials. They are in an engaging, interactive manner. to lead to misunderstandings. Different predicted to be achievement-focused However the legacy of ‘helicopter generations also prefer to teach and rather than participation-focused and There is the potential for generational parents’ means that they may need learn in different ways – which increases to want their careers to have a positive guidance and focus in their learning the potential for misunderstandings, impact. This may be harnessed to affect with opportunities for support available. differences to lead to misunderstandings and techniques preferred by Millennial positive change in the department

Dr Frances Parsons Dr Ching Ling Pang Perioperative Fellow, Consultant Anaesthetist, The Royal Marsden and The Royal London Hospital The Royal London Hospital [email protected] CREATING CAPACITY IN A CRISIS The COVID-19 pandemic has had a significant impact on the ways in which our hospitals and services run. The need to provide elective cancer surgery during this period has necessitated many changes to the way we work, and this has produced unanticipated benefits. In this article we discuss the way our pre-assessment clinic (PAC) at the Royal London Hospital (RLH) has adapted to reintroduce safe and timely elective surgery when faced with staff shortages and the risk of infection to patients and staff. While the pandemic has significantly impacted on service delivery in other clinical areas, in pre- way in which we were able to reduce hospital visits and risk of infection. ensure thorough pre-assessment, assessment it has resulted in a more self-sufficient and efficient service. exposure and maintain self-isolation Having our surgical colleagues in investigation, and optimisation in the most vulnerable part of our clinic on the same day has provided of high-risk patients for complex Challenge 1: enabling managerial skills. We approached these such as brain natriuretic peptide (BNP), population. This has also led to the other benefits in facilitating dual major surgery. Through this, they biggest unanticipated benefit – the conversations with our patients, and decision-making in the through protocol-driven pathways iron studies, echocardiograms, and created a highly efficient ‘one-stop upskilling of our nursing staff to this comes very close to our ideal for investigations such as spirometry, spirometry. shop’ pre-assessment model which absence of a continuous accommodate this. model of shared decision-making. increasing the level of autonomy and has ensured thorough and holistic consultant presence nurse-led decision-making. This holistic approach has allowed us Since the pandemic, the clinic is more patient assessment and facilitated Prior to the pandemic, the PAC at RLH to identify patients at risk of requiring Going forward With the lower initial throughput, the self-sufficient. The members of our shared decision-making during a involved daily nurse and consultant- additional care in the postoperative We are mindful of the impact this PAC nurses were able to utilise the team with additional skills such as time of crisis. It is a highly deliverable led clinics. Investigations such as period and to complete the necessary model has on our patients and skills they learned on the ‘Principles of spirometry and venepuncture have iron infusions, echocardiograms and referrals to social services early, thus nursing staff, with the potential for and replicable service, and COVID- physical assessment’ course run at RLH. trained others in the delivery of these spirometry were arranged to take place reducing length of stay. It has also information overload and fatigue 19 was the main driving factor. We After taking a full clinical and social services. We also introduced teaching in other outpatient departments. As a facilitated consultant-led virtual reviews, in both groups. Our next goal is have come back to an unexpectedly history and conducting an examination, and training so that the nurses are result, high-risk patients were likely to and allowed us to diagnose silent disease to reduce some of this burden more streamlined and self-sufficient nurses now routinely perform screening now able to deliver iron infusions. It attend hospital a number of times and in and optimise patients with remote input by improving access to virtual service, and this model allows us for frailty and cognitive impairment requires careful logistical planning various locations prior to their operation. from our colleagues in other specialties. information with video follow-up. to have more time for meaningful using the Edmonton Frailty Scale and and management, but this upskilling consultations with our patients Within days, the PAC saw a greatly the Montreal Cognitive Assessment. This Challenge 2: minimising the means that these interventions can COVID-19 initially posed a huge reduced consultant presence. While is followed by an objective assessment be carried out for a patient on the around their risk, expectations, risk of infection to patients threat to the smooth running of this was of less consequence in the of fitness, such as the incremental same day, and in the same area. our pre-assessment clinics and to concerns, and patient journey. initial phase, the re-introduction of shuttle walk test or a stairs assessment – and staff This significantly reduces patient our goal of providing safe, urgent The authors would like to thank elective surgery posed a number of particularly useful investigations in view One of the key considerations the movement around the hospital, and elective surgery for high-risk patients our nurses, the matron for pre- challenges to our pre-COVID pathways. of the suspension of cardiopulmonary COVID-19 pandemic has raised is the has resulted in the evolution of a at RLH. However, our PAC nurses It became clear that there would be a exercise testing during the pandemic. need to re-assess the ways in which ‘one-stop shop’, with the surgical were empowered and motivated assessment, the anaesthetic greater dependence on the nurses to Finally, appropriate protocols were patients are prepared for surgery. clinic, preoperative assessment, to learn new skills, collaborate, and department, and the management support and supplement the service written to enable nursing staff to request Minimising hospital attendances for investigations, and optimisation done share their knowledge and expertise. team for their enthusiasm, drive, by taking on new clinical, practical and and perform additional investigations multiple clinics and investigations is one on the same day, thus minimising They came together as a team to and support during this time.

Dr Urvi Sanganee Dr Eleanor Harvey, Perioperative Medicine Fellow ST6 Anaesthetist, Dr Jennifer Walters, ST7 Anaesthetist Royal Marsden Hospital Trust Dr Michelle O’Mahoney, Consultant [email protected] Royal Marsden Hospital Trust

We are anaesthetic registrars, who, using the Dukes Activity Status Index home doesn’t mean being available due to shielding restrictions, worked was positive, and we felt the resulting to them, and that parents being key remotely for the RMH admissions and scores matched the subjective workers when they are shielding doesn’t pre-assessment unit in the newly set up impression of a patient’s status during allow for them to go to school. hub, new roles which posed an array telephone assessment. Patients were The biggest change to our job of clinical challenges. We assessed risk-stratified and their consent gained responsibilities was the removal of patients with nursing staff on site and an for anaesthetic risks as well as for practical skills and having to redefine overseeing consultant to whom cases perioperative COVID infection risk. our role as ‘working from home’ could be escalated. To keep COVID transmission rates low anaesthetists. Our practical nature and The hub was set up rapidly to address within the hospital, all patients were our involvement in rapidly changing the needs of cancer patients during advised at the time of referral by their clinical situations defines our role in the the early phase of the coronavirus base hospital to self-isolate for 14 days hospital setting, and without that we pandemic. Initially, seeing patients while pre-operatively. Then, following remote had to adapt. We were grateful to be new pathways were being established pre-assessment, patients came in person part of something very relevant during meant pulling together as a team, to a single preoperative clinic visit this time, though it seemed far removed with doctors seeing patients before 48 hours prior to surgery for COVID from what we would have thought we nursing staff, and without administrative swabs and also routine observations would be doing in a pandemic. support. After the first month, the and investigations. Aware of this small We have collected cancellation data and clinic ran in a similar framework to window of time to act on results, we had compared it to the same time period the pre-lockdown model, albeit with to pre-empt any potentially abnormal last year to assess if we provided an a proportion of the doctors working results and often chase historical results equivalent service despite changes due remotely. Significant challenges from GP and hospital records to help to the pandemic. We found that, once Remote pre-assessment for included the fact that the time frame gauge whether to bring patients in cancellations due to positive COVID between referral and surgery was often earlier for investigations, knowing that an screens were excluded, the overall less than a week, and that patients were additional hospital visit means increased cancellation rate was comparable. cancer surgery during the often referred to the clinic with little exposure risk. background information, challenging us Overall, the remote pre-assessment Though the day was often busy, we felt to optimise care in a timely manner to was a success. It allowed staff members that we were able to give more time to facilitate oncological surgery. who were shielding to work in a relevant COVID-19 pandemic patients and, in their home environment, and fulfilling role while also assessing Patient assessment is standard practice they seemed more forthcoming with patients in the safety of their own for any anaesthetist, but key elements their histories and were appreciative home. Feedback received from visiting The COVID-19 pandemic has been the biggest health threat the NHS has were different when consulting of the time spent with them. Working surgeons has been very positive, and remotely. Asking patients for an from home was different, and we had to faced. The enforcement of lockdown came with uncertainty for cancer care, this was rewarding to receive. The estimation of their weight, airway learn to switch off, which is difficult to Cancer Hub will continue to provide though cancer services did continue, coordinated by specialist cancer hubs, issues and functional capacity is asking do in an environment where you don’t for patients across London as long as based on the NHSE surgical prioritisation system for elective cancer surgeries. them for information usually attained actually leave work – it is easier to walk there is a need for its service. Ultimately, objectively and gathered over a face- away when your work space isn’t also we hope we have created a framework The Royal Marsden hospital (RMH) was one of the hubs providing essential to-face consultation. However, instead your dining table. Juggling childcare, that can be used in other institutions to cancer surgery to patients from 10 trusts across London, seeing 600 patients of assessing functional capacity with home schooling, and working from help with remote assessment of patients cardiopulmonary exercise testing or home were also new, with children not requiring surgery in the COVID era. through surgery and pre-assessment during its first three months. six-minute-walk tests, our experience understanding that parents being at

PERIOPERATIVE JOURNAL WATCH Dr Charlotte Crossland, ST4, Kent, Surrey & Sussex Deanery and Dr Jia Liu Stevens, ST6, Central London School of Anaesthesia

Association between Personalised haemodynamic Perioperative use of Accuracy and feasibility intraoperative intravenous management targeting gabapentinoids for the of clinically applied frailty lidocaine infusion and survival baseline cardiac index in management of postoperative instruments before surgery: a in patients undergoing high-risk patients undergoing acute pain: a systematic review systematic review and meta- HEALTH SERVICES RESEARCH CENTRE pancreatectomy for pancreatic major abdominal surgery: and meta-analysis. analysis. cancer: a retrospective study a randomised single-centre Annual Report 2020 clinical trial The aim of this systematic review The association of frailty with This study evaluated the was to assess the analgesic poorer perioperative outcomes is outcomes of 2,239 patients This trial randomised 188 high- effect and adverse events of well established. This systematic Professor Ramani Moonesinghe Professor Iain Moppett after pancreatic surgery, which risk patients undergoing major perioperative gabapentinoids in review looked at the association Director, Health Services Deputy Director, Health Services included non-lidocaine and abdominal surgery to routine care adult patients. 281 randomised between individual frailty scales Research Centre Research Centre lidocaine groups. Propensity or personalised haemodynamic controlled trials were included; and clinical outcome, and also score matching was performed management. In the latter, a the primary outcome was assessed feasibility of individual to minimise bias. Lower opioid personal cardiac index was intensity of postoperative pain, tools. 70 studies were included analgesia was used both intra- targeted using algorithm guided with secondary outcomes with 35 different frailty tools. The As with every aspect of College work, HSRC has been affected by the COVID IV fluids and dobutamine. and postoperatively in the including chronic postoperative primary outcome was mortality. pandemic. Perhaps the most important part of this HSRC update is to say lidocaine group. The length of The primary outcome was a pain, cumulative and persistent Most strongly associated with stay was similar between groups. composite of major complications opioid use, and adverse events. accuracy in predicting mortality a big thank you to all those working with HSRC who have adapted to new, or 30-day mortality. 30% of The overall survival rates at one Although gabapentinoids and discharge-not-to-home was uncertain and constantly changing ways of working over recent months. and three years were higher in patients in the intervention group were associated with lower the Clinical Frailty Scale (odds the lidocaine group than in the experienced complications postoperative pain intensity ratio, 4.89; 95% CI, 1.83 to 13.05 Our fellows and clinical leads current and recent fellows putting their the Healthcare Quality Improvement non-lidocaine group (68.0% compared with 55% of controls on a 100-point pain scale (at and odds ratio, 6.31; 95% CI, supported clinical work in their local talents to good use in projects related Partnership, the Health Foundation, vs 62.6%, P<0.001; 34.1% vs 2 (relative risk: 0.54, [CI]: 0.38 6 h, 12h, 24h and 48h) (mean 4.00 to 9.94, respectively). The areas and still found time and energy to to COVID-19 and outside the HSRC the Association of Anaesthetists, the 7.2%, P<0.011). The multivariable to 0.77). 30-day mortality was differences, −10, −9, −7, and −3 Edmonton Frailty Scale predicted make progress with HSRC projects. The remit. Danny Wong has been a driving Association of Paediatric Anaesthetists, analysis indicated that 1/94 patients in the personalised points respectively). However, complications best, and the HSRC team at the College continued force behind the IntubateCOVID the National Institute for Health intraoperative lidocaine infusion therapy arm compared to these effects were not clinically Frailty Phenotype was most their admirable support – albeit from registry; Emira Kursomovic’s work on was associated with a prolonged 5/94 patients receiving routine significant (set at >10 points strongly associated with delirium. Research, and the University College their virtual offices, gently reminding COVID-related deaths in healthcare overall survival (HR=0.616; 95% care (P=0.097). There were no out of 100). No effect was The Clinical Frailty Scale had the London Surgical Outcomes Research us all when we are (yet again) talking at workers was picked up by national CI, 0.290–0.783; P<0.013). clinically relevant differences for observed on pain intensity at highest reported measures of Centre. But that support would achieve length on mute. media; and the NAP7 fellows, Richard However, there was no secondary outcomes, including 72h, or on subacute and chronic feasibility. The Fried phenotype nothing without the engagement and Armstrong and Andrew Kane, somehow difference in disease-free survival length of stay, 90-day mortality pain. Postoperative nausea and scored highly in general During the peak COVID-19 period, encouragement of members of the and postoperative morbidity. managed to produce a systematic between groups (HR=0.913; 95% vomiting was slightly lower accuracy but lower in feasibility. various HSRC projects went on hold, College and our many colleagues from The authors conclude that review of ICU outcomes following CI, 0.821–1.612; P=0.316). with use, but adverse events of The authors conclude that the while some such as NELA carried on in a other professions. Thank you. a personalised approach to COVID-19 in a matter of weeks. dizziness and visual disturbance Clinical Frailty Scale had the best reduced form. We don’t know what the Zhang H et al. BJA 2020; haemodynamic management were greater. This meta-analysis combined results in accuracy perioperative landscape is going to look Talking of congratulations, Danny Wong We hope you find this year’s update on 125(2):141-148 reduces major postoperative calls into question the routine and feasibility. like in the future, but most projects are successfully defended his PhD thesis – HSRC activities interesting. We can’t complications or 30-day mortality. use of gabapentinoids in the now back on stream, collecting data as based on his work on SNAP–2. Another fit everything in to one issue of the Aucoin SD et al, Anesthesiology perioperative period, as their before, or planning for starts next year. PhD in the HSRC library – many Bulletin, so we’ll keep you posted on Nicklas JY et al. BJA 2020; 2020; 133(1):78-95. benefit appears very limited. 125(2):122-132 congratulations, Danny. our projects in future issues. If you want One of the things we are proud of to find out more, just get in touch. Verret M et al. Anesthesiology within HSRC is providing opportunities The work of the HSRC relies on 2020; 133(2):265-279 and development for trainees. It has numerous external funders who provide [email protected] The College is committed to developing a collaborative programme been a real pleasure for us to see support for individual projects, including niaa-hsrc.org.uk for the delivery of perioperative care across the UK: cpoc.org.uk 28 | | 29 HSRC Annual Report | 2020 HSRC Annual Report | 2020

the Perioperative medicine for Older Timescales Sprint National Anaesthesia Project 3 (SNAP-3) People undergoing Surgery (POPS) There is considerable uncertainty about service and is an expert on frailty. The what surgical services will look like in team also includes Dr Akshay Shah the medium term, but we are hoping (Specialty Registrar in Anaesthesia that we might be collecting data in FRAILTY AND DELIRIUM and Intensive Care Medicine, Oxford 2022. Hopefully, we will have settled Deanery); and Dr Jugdeep Dhesi (Vice- Professor Iain Moppett, Lead Investigator, SNAP-3 into some sort of new routine by then. President of the Centre for Perioperative Coronavirus may have delayed things a little, but preparations for SNAP-3 are Care, geriatrician, and lead for POPS). I hope that College members will find well underway. So what is SNAP-3 all about, who’s involved, and when is it Dr Tom Poulton is helping us from the the project interesting and relevant to other side of the world, with plans to them and their patients. We’ll keep you going to happen? collaborate with centres in Australia and updated on progress. New Zealand too. Dr Judith Partridge will be co-leading Frailty and delirium ■ identify the role of frailty in ■ develop and internally validate a the SNAP-3 project The success of SNAP-3 will depend on predicting perioperative outcomes risk-prediction tool for postoperative The headline aim of SNAP-3 is to the engagement and enthusiasm of the across all surgery types (day surgery, delirium. describe the impact of frailty and anaesthetic community, particularly our elective, urgent/emergency) colleagues in geriatric medicine to see amazing trainees. We’ll be looking for delirium, and their management, on how SNAP-3 might create opportunities ■ identify associations between Who’s involved? senior trainees who want to coordinate outcomes following surgery. This will for collaboration. hospital-level and patient-level This is very much a collaborative effort. their local sites and for folk to help with involve data collection from around frailty-related interventions and We’re delighted to have Dr Judith data collection. Getting your name on Trainee lead investigator The SNAP team 12,000 older people undergoing outcomes Partridge co-leading the project. Jude is a publication isn’t everything, but it is There is a key role for a trainee lead can be contacted surgery over one or two weeks. Like all ■ describe the variation in hospital- a consultant geriatrician based at Guy’s one way we will be acknowledging all investigator – hopefully they will have good projects we’ve got some outline level and patient-level frailty-related and St Thomas’ Hospital, London, who those who are actively involved. We via email at been appointed by the time you read this. objectives to achieve this aim: interventions has been heavily involved in developing are exploring potential links with our [email protected]

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Dr Jasmeet Soar National Audit Project 7 (NAP7) we addressed COVID-19 related is also important for us to understand NAP7 Clinical Lead, RCoA issues, such as the COVID-19 status and track the return to normality within of patients, whether they have been departments, and the NAP team will Dr Andrew Kane vaccinated, the use of PPE, and the be undertaking further surveys of local HSRC Clinical Research impact of COVID-19 on perioperative coordinators in the coming months to Fellow, James Cook PERIOPERATIVE cardiac-arrest care. Another message assess changes in activity levels and University Hospital, was that data collection for the three departmental organisation. Middlesbrough parts of NAP7 (baseline survey, activity CARDIAC ARREST Finally, the key to NAP7, as with survey, individual case reviews) had to Dr Emira Kursumovic previous NAPs, is you! We will depend HSRC Clinical Research move away from the paper processes In early March, the NAP7 team decided to delay on all UK anaesthetists to work together Fellow, Royal United used in previous NAPs. In response to the project’s planned May 2020 launch. Despite this survey and to feedback from the to take part in the baseline surveys and Hospitals, Bath activity surveys, report eligible cases, the postponement, work has continued with regular stakeholders’ panel, the tentative plan Dr Richard Armstrong is to launch NAP7 in about May 2021 and support their local co-ordinators. HSRC Clinical Research meetings with both the stakeholder panel and the HSRC and we are exploring simpler ways to Further details Fellow, Southmead leadership team. collect data. Hospital, Bristol Full details, FAQs and the name One challenge (and potential of your local co-ordinator can be A key decision was to survey all the NAP7 current NAP topic. Many co-ordinators Professor Tim Cook opportunity) for NAP7 is the impact found at nationalauditprojects.org. local co-ordinators about their views on felt that departments would not be ready Director of the National COVID-19 has had on anaesthetic activity uk/NAP7-Home If your local Audit Projects, RCoA relaunching NAP7. The local co-ordinators to start NAP7 until the new year, with next and how this will impact on our ability to have a vital role in the running and success spring the most popular choice (ie, about a determine an estimate of total anaesthetic You can now also follow us on co-ordinator changes, of the National Audit Projects (NAPs), year later than planned). The main reasons activity. To determine the denominator Twitter @NAPs_RCoA and for all queries, and their opinions have helped inform were concern about a second wave of and build a picture of national anaesthetic please contact us at: decisions about the project. Most of infections and allowing time for a return to activity, we will capture data on every [email protected]. the co-ordinators responded (72%) and a more normal situation. The co-ordinators case under the care of an anaesthetist gave huge support to continuing with the also told us that they were keen that in every department over four days. It

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Dr Tom Poulton

HSRC NELA Fellow 2016 to present

As one of the earlier NELA HSRC fellows, I began my OOPE in February 2016. With no research background, and no real plans for research to be a major part of National Emergency Laparotomy Audit (NELA) any future job, it started out as being just for a year. While it came with a number of challenges, the role was such an enjoyable and positive experience overall that one year quickly became two. I returned to part-time training after the first 12 months and have since CCT’d, but I have remained affiliated with the HSRC because I FELLOWS PAST AND PRESENT found myself taking on an MD(Res), which was later converted to a PhD. Now, more than four years later, I am (hopefully) a few months from submitting my thesis. I say Research fellows have been part of the National Emergency Laparotomy hopefully, not because I’m tired of the work, far from it, but simply because I have developed a habit of saying yes to opportunities that have subsequently presented Audit (NELA) project team since 2012. In the early years they contributed to themselves, and the next project awaits. I don’t have a single regret for taking the time to do the original fellowship and establishing the audit, and they have gone on to use the data collected to am hugely grateful to the wonderful people I’ve been able to learn from along the way. explore ways to improve care for some of our highest-risk patients.

NELA research fellows represent the multidisciplinary nature of the audit, and include anaesthetists, surgeons, and care-of-the- elderly physicians. With the support and supervision of the project team, fellows are not only involved in the organisation and Miss Hannah Javanmard running of NELA but can also undertake their own research, with the option of working towards the attainment of a higher degree. Current NELA Surgical Research Fellow (PhD in progress)

Dr LJ Spurling I had been involved in research from early on in my career, through my undergraduate degree and later an academic foundation training programme. Higher surgical training is so busy, and I didn’t find that I had sufficient time to HSRC NELA Fellow 2017 to present get involved in large-scale research outside of working hours. The previous NELA The first NELA meeting I attended was the annual ‘awayday’ where the strategy for Surgical Research Fellow had such great things to say about their experience that the next year of the NELA project was planned. This gave an immediate (and mildly when the opportunity came up, I jumped at it! So far it has been a really interesting overwhelming) feel for the sheer scale of the project and for how many elements behind-the-scenes look at what it takes to run a huge national project. need to be balanced to keep the project going. The NELA Project Team has experts in so many fields: quality improvement, data analysis, research, project management – to name but a few. With the breadth of work and this concentration of knowledge and experience, any fellow will be able to find their niche. Dr Emma Stevens Thanks to the support of two outstanding academic supervisors, the project team and, of course, all those who participate in the NELA project, I am currently writing HSRC NELA Fellow 2019 to present up my PhD thesis. The work done so far with the incredible volume of data has only scratched the surface. Opportunities abound for a future fellow to take on research and quality improvement projects, big or small. I am incredibly grateful to After completing core anaesthetic training, I undertook an Improving Global Health everyone I’ve had the pleasure of working with while on this journey. fellowship focusing on an interest in quality improvement and system-strengthening work. I was initially concerned that, as a junior trainee with no clinical research experience, applying was a bit of a long shot, but I was delighted to be offered the post and can only recommend that you don’t let these things discourage you from applying!

The year has passed incredibly quickly, and despite COVID-19 obviously having had a significant impact for a large part of that, I have still had a fantastic time. I got a real insight into the complexities of running a national audit and the breadth of skills and backgrounds needed within the team, and I’m incredibly grateful to everyone I’ve met for sharing their experience and enthusiasm. Although I am looking forward to going back into training, I’ll The NELA team can be contacted via email at [email protected] definitely be looking out for the opportunity to undertake a similar role in the future

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Perioperative Quality Improvement Programme (PQIP) A YEAR OF TWO HALVES Dr Samantha Warnakulasuriya, Post-CCT HSRC Fellow It has been a year of two halves for PQIP. In September 2019 we released our second annual report1 highlighting our top priorities for improvement, and we were excited to welcome our local contributors from around the country to our collaborative event at Kings Place.

At this event, leading experts in During the COVID-19 allowing local teams choice in deciding perioperative care discussed the pandemic how to structure their recruitment improvements in care revealed by processes in a socially distant manner. As has happened with most research PQIP data, how to make the most use In addition to restarting at our existing studies, during the period when NHS of local data, and opportunities for sites, we’re excited that new sites will be resources have been stretched as a result participating in PQIP going forwards, future change. of the pandemic, our collaborators have and we look forward to welcoming our had to focus on the pressing need of With 124 sites recruiting around 1,000 first site in Northern Ireland. managing the surge. patients each month before COVID-19, ©J D Williamson.co.uk The baseline database of nearly 30,000 the PQIP dataset includes risk, process However, elective surgery has and outcome data on more than 30,000 patients recruited before COVID-19 continued during the COVID-19 changes, for example in pre-assessment funding to deliver a randomised patients undergoing major elective non- which changed all of our lives offers pandemic, due to the time-critical services, and thus to overcome inertia in controlled trial of total intravenous cardiac surgery. a unique opportunity to compare nature of major cancer surgery. Thirty- previously entrenched processes. anaesthesia vs. inhalational anaesthesia processes and outcomes of care four of our collaborative sites have in patients undergoing major surgery, As the previous year’s data had shown, before, during and (hopefully) after the continued to recruit during these An example of how we will be supporting for which recruitment will begin in 2021. while improvements such as in drinking, difficult times, and we are very grateful COVID-19 pandemic overall, and to sites in their quality improvement work eating and mobilising have been to all our collaborators, who have evaluate the changes in NHS structures can be seen in the QI initiative designed If you’re not already involved in PQIP, encouraging, there remained some gone above and beyond to ensure that and processes of care resulting from to optimise perioperative anaemia, one of please do visit our website at: areas where it had been difficult to we capture data reflective of these COVID-19 surges. this year’s Commissioning for Quality and pqip.org.uk and explore what our bring about change, for example risk unprecedented times. Innovation (CQUIN) targets.2 Additions project and dataset has to offer. assessment, HbA1C measurement, and The future to the PQIP dataset and the tools on our perioperative pain management. We Post-COVID-19 recovery As sites recover from COVID-19 related website will allow local teams to track References their performance and plan improvement have aimed to improve collaboration The PQIP national team is aware of constraints and recruitment picks up 1 PQIP Project Team. Perioperative Quality Improvement Programme Annual Report through greater sharing of information pace, we will continue to support teams as required to meet the CQUIN target. how local research teams have been 2018-19. RCoA, London 2019. between surgeons, nurses and in delivering their quality improvement stretched, and will be offering support We are also delighted that a 2 Commissioning for Quality and Innovation allied health professionals, and to sites that will be moving to restart (QI) goals, both through resources on collaboration between PQIP and the (CQUIN): CCG indicator specifications for encouragement of regular, multimodal 2020-2021. (bit.ly/3lQyOTy). recruitment. Patient and staff safety is a our website and targeted support of Perioperative Clinical Trials Network, The PQIP team can be communication and the building of priority, and therefore we have applied local teams by the national PQIP team. led by Dr Joyce Yeung from Birmingham contacted via email at discussion of PQIP data into routine for approval to approach and consent Restructuring of hospital pathways and Warwick, was awarded NIHR clinical meetings. patients by telephone or video call, offers an opportunity to integrate [email protected]

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A fellow in the field of rapid qualitative research Dr Georgina Singleton, HSRC Fellow After completing my ST5 year, I commenced my fellowship with the HSRC in February 2020 working with the PQIP team. However, owing to the COVID-19 pandemic, much of my planned work was disrupted. The Children’s Acute Surgical Abdomen Programme (CASAP) Given my growing interest in qualitative understanding of the current global During the last few months, I have had research. I was presented with the measures employed to preserve cancer the opportunity to attend workshops IN A CHANGING LANDSCAPE opportunity to work with Dr Cecilia care during the pandemic and will on interviewing and qualitative analysis Dr Amaki Sogbodjor, CASAP Research Fellow Vindrola and the RREAL team. To date, inform the response in the event of a and have felt very supported by I have contributed to several streams future wave. the research group. I have enjoyed CASAP is the Health Services Research Centre’s first paediatric perioperative of work, the first of these being the numerous aspects of the work, from medicine endeavour. Supported by the Association of Paediatric Anaesthetists research study which aims to explore I am currently involved in another interviewing to report writing, during healthcare workers’ perceptions and project relating to cancer care during what has been a challenging time and the British Association of Paediatric Surgeons, this cohort study is experiences of COVID-19 in the the pandemic. This ongoing study, for many. It has been a privilege evaluating the care and outcomes of children undergoing emergency UK. My role has involved enrolling using semi-structured interviews, throughout my interviewing to listen to participants into the study and people’s genuine thoughts and feelings, abdominal surgery across the UK. aims to explore both patient and staff conducting telephone interviews with experiences of cancer surgery delivered knowing that these reflections should a wide range of healthcare workers influence future practice. CASAP’s first participant was recruited the new set-up is somewhat fluid and is unique insight by comparing processes using a regional-hub approach. across several trusts. A large part of my Individual reflections should provide in November 2019, and study sites likely to be subject to further changes, of care and outcomes for children Although the year has been totally work has involved the analysis of data – important learning, which may result in were joining by the dozen when the it is crucial – arguably now more than having emergency abdominal surgery different from the one that was from identifying the early themes to the future changes in both processes and COVID-19 pandemic arrived in full ever – to understand the degree to before COVID-19 existed, during the planned, commencing my fellowship in-depth analysis of key topics. force. During this time, the priorities of which variations in the provision of height of the pandemic, and then behaviours during a pandemic. at the time of a pandemic has been the research world also shifted towards perioperative care to children exist. beyond into 2021. RREAL has undertaken a significant a very interesting, challenging and supporting efforts to combat COVID- As a result, we have updated the Through my affiliation with the RREAL volume of work exploring the impact enjoyable experience. During my 19. As a result, data collection for study protocol to account for this Children and young people aged team I was invited to join several of COVID-19 on cancer care. One of fellowship so far I have gained some CASAP stopped in many sites between new landscape. Changes include between 1 and 16 years on the date national and international meetings of surgery are eligible for inclusion. these projects was a global mixed- invaluable insights into the field of March and June, but it is picking up questions to understand COVID-19 during which clinicians’ experiences Prospective data on risk, processes and methods survey of the implications of qualitative research. The value of again and for that we are truly grateful status in children having surgery, and of managing patients with COVID-19 inpatient complications will be linked COVID-19 for the delivery of systemic qualitative research comes from how to our many collaborators. the opportunity to gain consent using were discussed. My role involved the to NHS Digital databases to determine anticancer treatments. This work the data are collected, processed, virtual means rather than face to face. recording, extraction and synthesis involved a multidisciplinary team of interpreted and framed, and how these Importantly, it has become apparent We are also now able to gain consent longer-term outcomes over 10 years. of data to facilitate the production that the research aims of CASAP retrospectively from parents of children At the time of writing we have 77 sites both researchers and clinicians. Given are contextualised and communicated. of a report which could be widely remain critically relevant as we find who had surgery during the pandemic participating, with almost 600 individual my clinical background, I assisted in In addition, I have seen the importance disseminated among critical care teams. ourselves living alongside the virus peak in the spring, so that we can participants having been recruited and the design of the questionnaire from of delivering findings in a timely way in My knowledge of anaesthesia and and children continue to present with capture important information about additional sites waiting to join our team. conception to ‘roll-out’, ensuring that order to inform the pandemic response acute abdomens. In response to the the care and outcomes of children We are open to more centres joining our the questions were both relevant and critical care enabled me to review the effort. I look forward to my continued pandemic, children’s services underwent treated when NHS services were under efforts, so if you’d like more information clear to our multidisciplinary target data from a clinical perspective, and this work within this field and to gaining considerable reconfiguration across the such unusual pressure. All of these email us at [email protected]. audience. It is hoped that findings complemented the work performed by further knowledge and experience of UK, with the increased centralisation amendments will enable us to gain a from this survey will enable a better the research team. qualitative research methodology. of services in some regions. Although

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Bulletin | Issue 124 | November 2020 Bulletin | Issue 124 | November 2020

1. Clinical initiatives These are shown in Figure 1 below:

TRANSFORMING RLH Service developments 2017–2020 Figure 1

■ Dedicated paediatric pathways ■ Previous pathway – paediatric neuro- developed for major haemorrhage, trauma requiring surgery transferred PAEDIATRIC MAJOR serious head injury, regional analgesia off-site (as elective paediatric and interventional radiology neurosurgery not on-site) ■ Standardisation of equipment and paediatric development ■ Development of a paediatric emergency Dr Hannah Lewis paediatric-specific protocols patient-centred of neurotrauma neurotrauma service: enabling time Paediatric Anaesthetic TRAUMA CARE pathways service critical injury management on-site Trauma Fellow, ST7, ■ Neurosurgical liaison with quarternary neurosurgical centres to maintain high The Royal London Hospital governance standards [email protected] Paediatric trauma is the leading cause of mortality ■ Development of paediatric code-black pathway Dr Naomi Edmonds 1 and disability in children worldwide. However, ■ Three-month rotations of paediatric staff Paediatric Anaesthetic and over the past decade since the creation of regional services for joint working to adult theatres to gain experience in Intensive Care Consultant, the vulnerable policy with elective neurosurgery and trauma trauma networks in England, management of major adolescent co-located Joint Paediatric Trauma cohort adult teams Lead, The Royal London paediatric trauma has transformed. Trends in injury ■ Increased violence-related adolescent ■ Penetrating trauma and major Hospital admissions haemorrhage are more frequently seen pattern have also changed, with a notable rise in the ■ Creation of a unified management team in the adult setting ■ Dr Breda O’Neill 2 ■ Injury prevention service with ongoing This enables case management in adult incidence of penetrating trauma in adolescents. follow-up after discharge or paediatric theatres depending on staff skill mix, availability of theatre, age and Paediatric Anaesthetic ■ Peer working group created for injuries of child Consultant and Joint Four networks form the London Major Clinical adolescents with traumatic brain injury ■ This reduces time to intervention Paediatric Trauma Lead, Trauma System (LMTS). The Royal ■ set up a joint working policy with The Royal London Hospital London Hospital (RLH) forms the ‘hub’ co-located adult trauma teams of the North East London and Essex 2. Educational initiatives The Paediatric Advanced Trauma Skills assessment showed that trauma units ■ develop the paediatric neurotrauma Trauma Network. RLH provides all Novel simulation and lecture-based and Simulation course encompasses would benefit from additional support in service to enable time-critical paediatric specialist care except elective trauma courses have been developed a multidisciplinary two-day course of the management of paediatric trauma. emergency neurosurgery on site neurosurgery and cardiac surgery. to support clinical developments. small group discussions and simulations. ■ establish a transitional service for Conclusion Following NHS England peer review in adolescent trauma The Paediatric Theatre Team Trauma 3. Research and quality improvement Current research is focusing on 2017, it was recommended that time ■ create patient-centred paediatric course (PTTT), aimed at healthcare Principal projects since 2017 have paediatric outcome measures and should be allocated to lead clinicians trauma pathways assistants, scrub staff and anaesthetic reviewed and standardised care across the creation of novel trauma-scoring for the ongoing development and practitioners, is a one-day course the entire London network. The Pan- systems specifically for paediatrics. Education management of the paediatric trauma of theoretical lectures, expert- London Paediatric Trauma Guidelines service. Moving forwards, specialty leads ■ establish courses to promote led skills stations and simulation were published in 2020 following a Substantial work has seen transformation from paediatric anaesthesia, intensive multidisciplinary team working scenarios. It targets time-critical review of literature to provide evidence- of the paediatric trauma service from care and surgery combined to develop trauma emergencies encountered based best-practice guidelines.3 This conception to clinical practice. Research and quality improvement the RLH service in a multidisciplinary less frequently in paediatric practice. provides a gold standard of care across fashion. This extended to create the Pan- ■ standardise trauma care across the References Feedback from participants report the network. London Paediatric Trauma Group with London system increased knowledge and confidence; 1 World Health Organization. Violence and injury prevention: child injuries. nominated leads from each network. ■ assess current delivery of paediatric staff non-technical skills, including The Paediatric Evaluation of London (bit.ly/32XEaoJ). trauma care across London. communication and situational Trauma System (PELoTS) project 2 Jones S et al. Patterns of moderate Objectives awareness, have improved. Theatre reviewed care across the London Trauma A successful bid was made to appoint and severe injury in children after the To map the existing paediatric trauma staff participants are now invited System from 2018 to 2019. This provides introduction of major trauma networks. a paediatric Darzi leadership fellow service at RLH with the identification to teach new staff members on a quality-of-care assessment and shows Arch Dis Child 2019; 104(4):366-371. in 2017, followed by the creation of of key areas for development. This was the course to consolidate and the burden of children’s trauma and 3 London Major Trauma System.Paediatric paediatric trauma anaesthetic and Trauma Manual.2020. 1–106. divided into three main areas: maintain skills. Rotations in adult outcomes across the LMTS. A substantial surgical fellowships in 2018. This opened (bit.ly/2CPlSvo). theatres, including emergency and proportion of presentations are self- the door to improved data collection, neurosurgical lists, have developed referrals bypassing normal pre-hospital research, and service development. transferable skills and expertise. triage systems. The quality-of-care

Dr Philippa Horne Dr Tony Allnatt CT3 Anaesthesia Consultant Anaesthetist, Royal London Hospital Royal London Hospital Dr Lindsey Iles [email protected] ST4 Anaesthesia, Royal London Hospital

at acknowledging the potential Following feedback, breakout sessions The daily sessions are continuing for the psychological impact of events we were introduced with smaller groups, foreseeable future, with plans to expand witness. tailoring sessions to different people’s the activities available. We hope that, requirements. Once weekly, three with time, they’ll become a natural The coronavirus pandemic presented breakout sessions run simultaneously. part of our work environment. With a new challenge, and with it came Mindfulness remains, but the addition increasing NHS pressures not expected concerns that staff would experience of morning yoga, led by a generous to subside soon, morale is likely to emotional strain and moral injury as never colleague, has proved hugely popular suffer without increased support. We before.2 Seventy-five theatre staff were with up to 20 attendees per session. must continue to improve access redeployed to the intensive care unit, A breakout experiential exchange to wellbeing resources for all staff, anaesthetists in training were dispatched session specifically for theatre staff displaying compassionate leadership in to procedural teams and temporary ICUs, now also runs, supervised by a clinical times of crisis and ensuring a positive, and the entire department’s working psychologist, while our regular Coffee caring and supportive climate.3 This pattern changed overnight. Staff no Club for trainees has continued on will foster greater staff wellbeing and longer worked in their normal teams alternate days throughout the pandemic. ultimately better patient care.3 As our and lacked their regular safety network. COMPASSION THROUGH Anxiety surrounding coronavirus, PPE, project continues, the feedback of one It was clear that extra support would be and personal safety has proved high, staff member stands out as key: ‘Thank needed after the peak to reduce the and the sessions have attempted to you; this is making a real difference.’ THE COVID-19 CRISIS psychological impact of the event. alleviate feelings of uncertainty and loss Many thanks to Polly Fitch, Joy McInnes, Supported by management, a small of control. Overall, they provide a safe Shreya Bali, and the wider wellbeing team Recent years have seen a drive to improve the wellbeing of doctors, wellbeing team enlisted the expertise space for staff to reflect, while providing tools to nurture a kinder and more for their continued help with this initiative. particularly trainees, yet burnout and low morale extend across the NHS of several trust psychologists and constructed a programme of wellbeing- inclusive work environment. 1 References workforce. As the system comes under unprecedented pressure to do related activities. On 6 May, as numbers Formally capturing the impact of 1 Wilkinson E. UK NHS staff: stressed, more with less, all healthcare staff are at risk, particularly recently with the of COVID-19 patients declined and staff wellbeing interventions is notoriously exhausted, burnt out. Lancet 2015; 385: began returning from redeployment, the 841-842. (bit.ly/3iZDkNF). 2 difficult, but evidence comes from the coronavirus pandemic. How we deal with these issues is paramount to first session opened to all theatre staff. numbers attending – an average of 2 Greenberg N et al. Managing mental health challenges faced by healthcare workers securing the future of our NHS workforce. The protected sessions take place daily 50 attendees per day. These moments during covid-19 pandemic. BMJ 2020;368: for 30 minutes before theatres start. A of quiet calm reach beyond the m1211. (doi.org/10.1136/bmj.m1211). The Royal London Hospital Theatre colleague. In an attempt to reduce the exchange peer-support session for psychologist provides various mindfulness immediate theatre team to the wider 3 Covid-19: why compassionate leadership psychological distress of staff exposed to matters in a crisis, The King’s Fund 2020. Wellbeing Project is a grass roots, anaesthetists in training, became the and relaxation sessions while colleagues multidisciplinary network. Staff feedback such incidents, the project was born. (bit.ly/3cnX3UN). multidisciplinary initiative. Started in next success story. These meetings reflect over breakfast provided by the is unanimously positive, with sessions 2018 by two consultant anaesthetists, it offer facilitated discussions where scoring 4.7 out of 5 for enjoyment, and Initially, the project focused trust. Theatre nurses, surgeons, healthcare aims to provide a multifaceted approach trainees share experiences or eliciting multiple unsolicited ‘thank you’ around wellbeing sessions on our assistants, and anaesthetists in training all emails. Importantly, when asked whether to improving wellbeing at work. The departmental audit day. Theatre staff discuss wellbeing-related topics. partake together. Baseline questionnaires were distributed to survey levels of the sessions have improved their ability hospital is a major trauma centre, and rotated through themed sessions, The sessions run fortnightly during work-related stress, previous access to to cope with stress, staff score them 4.5 in the preceding two years, theatre staff sharing experiences, and learning protected teaching time, and follow wellbeing resources, and development out of 5, describing them as ‘powerful’, had witnessed three major incidents proactive techniques to deal with Chatham House rules. They are not suggestions. ‘calming’, and ‘amazingly helpful’. and the suicide of a much-loved stress. ‘Coffee Club’, an experiential aimed at problem solving, but rather

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Bulletin | Issue 124 | November 2020 Bulletin | Issue 124 | November 2020

2 Audio Generated noise on an imaginary horizontal line one third of the way down from the top The loss of natural psychoacoustic cues ■ Type with a remote keyboard. of the screen. during the telecommunication process ■ Be alert to transmitted noise and reduce intelligibility, comprehension vibrations through furniture. ■ Check the composition for framing, 1, 2, 3 straightness and gestalt (plants and recall. Capturing high-fidelity ■ Take care if using notes: rustling paper growing out of your head etc). source audio is vital. Modifiable variables sounds particularly disagreeable include acoustics, environment, and when broadcast and amplified. ■ Slight movements are exaggerated: generated noise. mount your device on a stable Feedback surface or use a tripod. Acoustics Audio feedback is an unpleasant The pickup characteristics of in-built screeching sound produced when a Background microphones plus an untreated acoustic microphone picks up its own amplified ■ Check what is behind you in shot. environment combine to hamper signal. To control feedback: ■ Background clutter disrupts your intelligibility. Key improvements include ■ reduce microphone input level (gain) outline and competes for attention. choosing the appropriate environment, ■ ■ Neutral, light-coloured backgrounds Dr Sean Doherty increasing the ratio of direct to reduce loudspeaker volume (without patterning) focus attention ST7 Anaesthetics, Aintree reflected sound and using an alternative ■ increase the distance between on the speaker. University Hospital microphone. microphone and loudspeakers [email protected] ■ orientate the rear of any ■ Stay at least 1m from walls. unidirectional microphone towards Conclusion ■ Select a reasonably-sized room with the loudspeakers Simple changes can vastly improve the non-parallel walls (where possible). teleconferencing experience without ■ use a headset. If this geometry isn’t feasible orient needing to add an AV Technician to the A practical guide to yourself along a diagonal with on-call rota! your back to a corner to reduce 3 Visual troublesome reflections, flutter Modern camera technology is References improving teleconferencing excellent. High quality source material echoes and audio colouration. 1 Ericson MA, McKinley RL. The intelligibility makes the best of its capabilities. Teleconferencing, webinars and remote educational events have become ■ Minimise reverberation by choosing of multiple talkers separated spatially in noise, a carpeted room with plentiful soft in binaural and spatial hearing in real and a regular feature of the anaesthetist’s working-life during COVID-19, not to Lighting virtual environments (eds. RH Gilkey and TR furnishings. Anderson). Lawrence Erlbaum Associates, ■ Ensure your face is adequately mention an increasingly useful means of communication between socially- ■ Avoid areas with extensive tiled, glass Mahwah, New Jersey 1997;701-724. or hard reflective surfaces. illuminated. 2 Baldis J. Effects of spatial audio on memory, distanced patients, relatives and clinicians. However, technical issues impairing ■ comprehension, and preference during ■ Daylight is an excellent diffuse Sound intensity varies with the desktop conferences. Proc. of the SIGCHI lightsource. audiovisual (AV) quality can significantly impact on effective communication. square of distance: move nearer the Conf. on Human Factors in Computing As a former audio professional I can happily report that some simple changes microphone to increase the balance ■ Sit facing directly towards a window Systems 2001; 166-173. of direct to reflected sound. (north-facing windows prevent harsh 3 Blauert J. Spatial hearing: the psychophysics of human sound localisation. MIT Press, can vastly improve things for no additional expense! ■ shadows caused by direct sunlight). Use a headset with integrated Cambridge, Massachusetts 1997. microphone (try the one provided Turning slightly off-axis adds depth ■ Close all unused browser tabs and ■ If you must use Wi-Fi stay in line 1 Technical with your mobile phone). to your image. windows. of sight of the router with minimal ■ Avoid strong light sources behind you. Conferencing applications span a variety ■ Use a stand-alone unidirectional obstacles between it and you. of platforms. Insufficient processing ■ Clear your internet browser cache microphone (but avoid getting closer ■ A diffuse lightsource aimed at the ■ power and internet bandwidth are and delete cookies. 5Ghz Wi-Fi provides the highest than 15cm). backdrop minimises cast shadows common causes of problems regardless bandwidth (at the expense of lower (as will staying 1m from the wall). of device or software. These aspects are Maximise bandwidth signal strength and penetration). Environment easily optimised. ■ Connect directly to your router using ■ Disconnect all other devices from ■ Choose a quiet indoor location. Camera ■ an ethernet (Cat 5) cable. the Wi-Fi network. ■ Close all windows. Activate high definition (HD) video Increase processing power where possible. ■ Powerline adaptors can help extend ■ Choose an uncongested local Wi-Fi ■ Be alert to background noise within ■ Use the most modern device wired ethernet connectivity in channel (bit.ly/2YE2NUV). the room. ■ Elevate the camera to eye level and available to you. address it directly. installations where direct connection ■ Reduce traffic: dissuade others from ■ Maximise the distance between ■ Quit all unnecessary applications. is impractical. internet use while on a call at home. yourself and other noise sources. ■ Compose the shot with your eyes

Figure 2 Gallery View of Z-Sim

Dr Peter Steed Dr Mark Gosling HINTS AND TIPS Anaesthetic Consultant, Clinical Fellow, Royal United Hospitals Bath ■ explain audiovisual set-up and Royal United Hospitals Bath confirm that trainees are happy to Dr Dipayan Choudhuri [email protected] participate Clinical Fellow, Royal United Hospitals Bath ■ ensure all devices are charged and bring additional chargers/ battery packs

■ perform sound check

■ ensure adequate soundproofing between simulation location and remote location

■ only have one microphone turned Pop-up simulation suite on in simulation room (mute others)

■ you can temporarily unmute in fixed simulation suites. As a To create your own pop-up simulation microphone on laptop to simulate utilising Zoom videoconferencing ‘Voice-of-God’ department we were already using suite you will need: ■ a chest-mounted smartphone Zoom videoconferencing for regular ■ standard in-situ simulation-session provides a first-person view with The coronavirus disease (COVID-19) pandemic has had a significant impact departmental updates, and we equipment (mannequin, airway improved audio quality upon educational opportunities. One of the groups of anaesthetists in training hypothesised that with minimal set-up equipment, etc) ■ Zoom meetings can be recorded time and expenditure such software ■ at least three smartphones most disadvantaged by this have been novice trainees working towards could also be used to recreate a and footage can be incorporated ■ one tablet computer achieving the Initial Assessment of Competence (IAC). mobile audiovisual simulation-suite into the debrief (seek prior ■ one laptop (large screen preferable) environment. permission). Factors that have limited airway- To address this training deficit, we pandemic, providing a safe environment ■ Wi-Fi/4G signal management training opportunities produced an in-situ simulation in which to test the preparedness of We have now run two such sessions ■ Zoom software include: teaching programme mapped to the healthcare workers and systems.2 for the novice trainees, one on rapid References ■ SimMon Medical Simulation app or ■ redeployment to cover critical care IAC. Simulation is a well-recognised sequence inductions and the other 1 Simulation, RCoA. (rcoa.ac.uk/simulation). equivalent surge rotas method for the delivery of education In order to maintain social distancing on failed intubation management. 2 Li L, Lin M, Wang X et al. Preparing and ■ variety of stands/grips/chest-mounted responding to 2019 novel coronavirus ■ and training, as outlined in the RCoA during the sessions, we were keen Feedback has been very positive, with cancellation of elective operating with simulation and technology-enhanced Simulation Strategy.1 It has played an to explore methods to recreate a smartphone harness (optional) lists trainees reporting improved confidence learning for healthcare professionals: important role during the COVID-19 typical audiovisual set-up as found and highly valuing the opportunity ■ external microphones (optional). challenges and opportunities in China. ■ performance of BMJ STEL. Published Online First: 11 March procedures under to train in a real theatre environment. Figure 1 Suggested configuration for audiovisual device Set-up (allow 5–10 minutes) 2020. doi: 10.1136/bmjstel-2020-000609. regional anaesthesia Larger numbers of observers, and even Device 4 1 Set up mannequin and equipment to reduce aerosol remote access from home, could be as for standard in-situ session. generation accommodated. It may also provide opportunities for members of the 2 Pair SimMon Monitoring app on ■ guidelines advocating smartphone and tablet. minimising the multidisciplinary team who have been number of people in avoiding face-to-face patient interactions 3 Set up cameras (see Figure 1 for theatre and intubation to safely maintain their skill set. suggested configuration). by experienced 4 Set up Zoom meeting on laptop in Device 2 Utilising existing equipment and free anaesthetists remote location. videoconferencing software, it is ■ cancellation of courses Device 1 possible to create a ‘pop-up’ audiovisual 5 Log devices in steps 2–4 into Monitor and temporary closure simulation suite for in-situ training in a Zoom meeting. of resources such as The suggested composition of the theatre simulation room. Device 1 runs matter of minutes. The ability to view 6 Trainee is briefed and then enters simulation suites. the SimMon App and acts as the patient monitor. Device 2 looks directly at the monitor. Device 3 (not shown) and device 4 give an overview of the remotely improves scenario fidelity and simulation room – remaining environment. Dotted red line indicates camera angle. Device 2, 3 and 4 each connect to a Zoom conference call. A laptop in the adjacent anaesthetic room enables multiple healthcare workers to trainees observe on laptop in also connects to the same call and allows the teaching group to observe. train while maintaining social distancing. Gallery View (See Figure 2).

Dr Lucie Weatherall Fellow in Paediatric Retrieval Medicine, Children’s Medical Emergency Team (CoMET), University Hospitals of Leicester [email protected]

The Job As with any job, audit, education and COVID-19 things like morbidity and mortality As anaesthetists we know the Being out of anaesthetic practice during presentations fill the rest of the importance of checking equipment and COVID-19 has been both a blessing time. I also spent some shifts on the being intimately familiar with its use. On and a curse. I do feel that I missed PICU, which provided further crucial transport this is even more important – out on significant experience by not experience in a less time-critical and you can’t just ask for your nurse to grab being there to help my colleagues. I isolated environment. something because you don’t have it did spend some shifts on ITU during nearby. We undertake twice-daily checks the pandemic, but nowhere near as of the equipment, including trolley, Challenges many as I would have done. Paediatric ventilators, syringe pumps, suction, and Although managing the airway, transport had its own challenges, and I kit bags. Any problems are sorted, or are breathing and circulation is ‘what we do’ helped develop protocols and deliver reported at handover along with traffic, as anaesthetists, paediatric intensive care simulation and training for the transport weather and logistical issues. medicine is a different game to its adult of suspected COVID-19 patients. cousin. For example, fluid management We then await a referral. Some calls are is much more tailored and precise. Drug Summary just for advice, but a majority require dosing and infusions are obviously a Although an unusual choice of us to retrieve a child, which can mean challenge but aide-mémoires and an fellowship, working in paediatric anything from a 2 kg baby up to an experienced PICU nurse make things intensive care medicine/retrieval 18-year-old. Their presentations range much easier! The biggest challenge that is a very useful experience for from bronchiolitis and congenital cardiac I found as an anaesthetist was a lack those interested in either paediatric conditions, to those that we are more of general paediatric knowledge, for anaesthesia, or in careers where familiar with in adults, such as significant example of metabolic conditions that we stabilising unwell children will be part overdoses and cardiac arrests. After just don’t see in adult practice. However, of their job, such as intensive care ensuring we have the correct equipment these problems are usually ones that medicine in some district general for the patient, we travel via ambulance can be managed after a phone call hospitals. Approach your local team to the referral hospital. for advice; managing A, B and C can’t (every area is covered by one) and ask if wait! Consultant support has been solid On arrival at the referral hospital we they have any vacancies coming up. and, although often many miles away, is take handover and assess the child, always forthcoming and enthusiastic. For those thinking of gaining experience performing any additional procedures ‘outside the box’, I would encourage TRAINING OUTSIDE THE BOX or investigations that are necessary to you to go for it. Gaining more safely transfer them. This can include Disadvantages experience in a field that interests you When exam issues meant I had to take a year’s break from training after CT3, things like intubation, lines or imaging. Deskilling is an issue; however, the will never be detrimental to your career We then ‘package’ the patient and take experience gained is useful for the rest I thought hard about what to fill the next year with. I was encouraged to and will be looked upon favourably by them to a regional paediatric intensive of your career. Like trainees who take a those employing you in the future. continue on the general duties rota, but after a stressful year I felt I needed care unit (PICU) for further care. year out of clinical practice for research, to step out of that and gain some different experience. I wanted to face parental leave, etc, you are able to After travelling back to base, cleaning access return-to-work days, and I have something that scared me. the equipment and completing found my anaesthetic colleagues have paperwork we await another referral. welcomed my return. As is the case for many of us, sick children terrified me more I was initially very nervous; I had no general paediatric than anything else that the emergency bleep could throw at experience and only core paediatric anaesthesia me. At that point I found a vacancy for a junior fellowship in competencies. However, I was assured that the skills I had paediatric retrieval and intensive care medicine and applied from core training in anaesthetics and intensive care medicine Gaining more experience will never be for it. Despite being an anaesthetist and not a paediatrician, would come in handy. That didn’t stop imposter syndrome I got the job. My anaesthetic consultant colleagues had a overshadowing the first six months though! mixed reaction; a minority felt it was a waste of time. detrimental to your career

The area of interest to me was what we ‘IT’S JUST LIKE call ‘non-techs’, essentially the human FLYING A PLANE’ performance element How one tertiary centre collaborated working together was very interesting, to be forearmed! Our work day starts has proved vital in aviation, as many as many of the skills needed for success with a briefing, and we hold update incidents could have been avoided in with the aviation sector to provide directly transfer between the two fields. briefings as the day goes on: every take the past if junior crew members had It was amazing to be able to feed back off, landing or approach will always be been prepared to speak up. It was simulation training to staff working a few points on the day to the doctors pre-discussed. This means that both of encouraging to hear how the medical during the COVID-19 pandemic. involved and to see how these skills, us on the flight deck are aware at all profession continually strives to promote which people don’t necessarily realise times of what is expected to happen, open channels of discussion so that they possess, can come in handy in a and are therefore more likely to pick up no one feels scared to speak up, even totally different environment. on any deviation from the plan that may though it may take real courage to do so. occur. I remember this was particularly Dr Sarah Crabtree Henry Walker In all, Project Wingman has been a After the success of the simulation interesting to some ward staff who had ST4 Anaesthesia, fascinating experience for me over Pilot session, a round-table discussion recently implemented a more formal

St George’s Hospital the last few months. I never realised was held a few weeks later involving handover discussion at the change [email protected] how such different workplaces share two of us flight crew and some staff of every shift. The conversation then so many of the same challenges, from a number of different hospital moved on to other areas of similarity, and how processes often developed departments to discuss the overlaps in particularly the growing use of checklists At the beginning of the pandemic, St Prebriefing and debriefing occurred provide sympathy and pastoral support through necessity in the aviation sector our industries. This time we focused on in medicine, a staple of the aviation Georges Advanced Patient Simulator before and after scenarios. Fruitful are finding new homes and bringing to stretched NHS workers. I signed up as the attitude to safety in our respective world. The final topic of discussion was (GAPS) set up a COVID-19 boot camp. improvements to the medical sector. discussions emerged, and these soon as I could and was allocated to St workplaces, with the discussion ranging what we call the hierarchal gradient, We upskilled approximately 800 regularly focused around non-clinical George’s Hospital, Tooting. from accountability to how we mitigate and the concept of even the most junior members of staff, from foundation aspects of tasks. Communication One month in, having made connections risk. Aviation has a long history of member of a team being able to speak doctors to consultants, who were and team working in unfamiliar with the educators at the simulation briefing – after all, to be forewarned is up to their leader without fear. This redeployed to acute medicine from environments with uncomfortable PPE, centre, we were invited to observe a diverse specialties ranging from clinical were frequently touched upon. COVID-19 boot camp simulation session genetics to dermatology. Figure 1 Simulation room layout showing ‘clean’ and ‘dirty’ areas indicated by the dotted lines and with labelled equipment. Pilot, Henry Walker, explains here how for F1 junior doctors. Xs represent possible locations of the clinical team during a ‘ward round’ (usually 3 or 4 staff) with the ‘runner’ in the ‘clean’ We wanted to reintroduce staff to our aviation colleagues developed our This was the first time I had ever area of a COVID-19 Acute Medical Unit. [Courtesy of Huon Snelgrove, Educationalist at GAPS] assessment of medical patients, and to thinking in new ways – encourage them to think about early witnessed a medical simulator session, It was not long after this pandemic and some interesting things became BAY 1 BAY 2 treatment escalation planning. This Tape on floor Tape on floor started that I found myself grounded Monitors was achieved via a simulated board apparent. Whichever way you look at it, along with most of my peers. round. Teams were then encouraged flying a plane has little in common with a Immediately a call for volunteers came medical procedure on a technical level, Crash Airway Medicines O2 O2 to allocate roles, before being asked to x Trolley and Supply through, initiated by a couple of captains review two patients in a simulated acute so the area of interest to me was what Lead from EasyJet and British Airways who had Clinician medical unit. we call ‘non-techs’, essentially the human Work Tables ties with the medical profession and who performance element – team work, BinsBins Patient notes/ Bins Bins x x iClip Further learning revolved around realised how useful their skillsets could leadership, and workload management. Table with Table with gels, Assessing gels, gloves clinicians x x personal protection equipment (PPE). be to the NHS. They set up a charity In aviation we are all carefully trained in Utility Utility Assessing gloves Trolley Trolley clinicians The simulation centre demarcated called Project Wingman, with the aim these disciplines, because when you are x x clean and dirty zones, and simulation of creating a rest zone in the middle of working with one other person on the Runner Runner scenarios necessitated participants hospitals for all staff from cleaners to flight deck it is crucial that you form a x FFP3 Masks, surgical masks, aprons, gowns, Lead donning non aerosol-generating- consultants. The idea was to draw on the tight-knit team. This is easier to achieve gloves, gels clinicians Bay 1-2 Equipment area’ telephone, procedure (AGP) PPE, before doffing experience of airline crew, who regularly when there are only two people present. O2 O2 medications PPE this to put on full AGP PPE. find themselves in stressful situations, to Watching six F1 doctors in a session MonitorsMonitors

Dr Amar Singh Jessel, ST5 Anaesthetist, Warwickshire School of Anaesthesia [email protected]

Meghana Pandit Safety Fellowship: patient-safety perspectives in a different healthcare system

Development and mastery of technical skills is emphasised throughout training – for example, an unexpected difficult airway, obstetric emergency simulation and advanced resuscitation and trauma management. However, problems continue Despite some noticeable differences in safety helped minimise variability thus and to flatten the hierarchy and the perioperative pathway, the underlying maintaining efficiency, particularly in a disseminate learning. to arise as a result of failings in human interaction, behaviours, and team-working essence of patient care and provision system with a close eye on the bottom I would like to extend my thanks ability. Furthermore, the World Health Organization (WHO) estimates that 50 per of treatment was the same as in the line. The link between safer care and to Professor Meghana Pandit 1 NHS. However, there were aspects lower costs was more obvious in the cent of cases of patient harm within hospital care are wholly preventable. These (Oxford University Hospitals) for the of anaesthesia that were different and American healthcare setting than in opportunity that was created while non-technical skills need work, with a shift in the culture away from individual offered a degree of improved patient the UK’s, where the provider sits some she was Chief Medical Officer at safety. Omnicell drug-storage units distance from the financial implications blame to a focus on patient safety to foster a system of learning. UHCW, and also Warwick University, were present in the OR enabling the of healthcare provision. BIDMC, and Harvard Medical School. anesthesiologist to have personal control Working at University Hospitals improvement was developed to design theory, ensuring interventions The fellowship offers a wide scope for In addition, I am grateful to Dr of their drug inventory. Operative Coventry and Warwickshire (UHCW) identify wasteful processes, drive generated by RCAs remain successful improving the principles of delivery Sailesh Sankar (Director of Medical events were recorded seamlessly onto during my ST4 year offered a different change, and learn from errors. and are integrated within the system. of safe care that we employ in the Education, Warwick), Dr Satya Krishna an electronic patient record, and there perspective to training. Alongside UK. The NHS and the College have Ramachandran and Dr Cullen Jackson In December last year, I was successful Although we have a mandatory annual was a convenient option to report my conventional training needs, I some particular advantages through (BIDMC) for their help and guidance in an application to the ‘Meghana expectation of involvement in audit or safety incidents, following which all was exposed to a way of thinking nationwide sharing of knowledge throughout the programme. Pandit Safety Fellowship – UHCW’, quality improvement (QI) within the UK, the information would be immediately geared towards looking at the bigger (National Audit Projects, National a bespoke two-week programme there is little or no formal teaching on available to the safety team. Mortality picture of healthcare provision. In Emergency Laparotomy Audit) and References based at the Beth Israel Deaconess how to undertake this. During anesthesia and morbidity meetings presented a 2015, UHCW was selected by the objective assessment of current 1 World Health Organization, (2019). Medical Centre (BIDMC), Boston, residency training (three years) at BIDMC, full RCA of each patient-safety incident, then Trust Development Authority practice (Care Quality Commission), Patient Safety. (bit.ly/34wEhZy). doctors are expected to be involved in which highlighted system failures and (now NHS Improvement) as one of US. The first week involved a formal which contrasts with the silo approach 2 NHS Improvement, (2016). NHS Partnership only one project, but conduct a RCA weaknesses that could have been five hospital trusts to partner with Quality Improvement Week held for seen in American healthcare. However, with Virginia Mason Institute. (bit.ly/2CVigIi). and generate a high-quality change or instrumental to the event. As a result, there Virginia Mason Institute (VMI) in the anesthesia interns, conducted by it is essential to encourage an open 3 Patterns in medication incidents: a intervention. Formalised training with an was a greater buy-in to the proposed 10-yr experience of a cross-national Seattle.2 Having been through its own members of the managerial team and and transparent environment in which opportunity to learn and develop in the solutions and a shared appreciation of anaesthesia incident reporting system. difficulties, the VMI developed the the department of anesthesia. Human completing an incident form isn’t seen BJA 2020; (2):197-205. doi: 10.1016/j. field of QI is unique, and BIDMC feel that pitfalls within the current set-up. 124 Virginia Mason Production System as a factors principles, organisational as a reflection of bad practice, but bja.2019.10.013. Epub 2019 Nov 25. this is how they can foster a culture of means of empowering staff to identify structure, hospital financial systems, and It would be naive of me to ignore more as an opportunity for growth continuous improvement. potential issues within the patient the methodology for conducting a root the impact that billing and financial and improvement.3 In order to change pathway. Through the concept of Lean cause analysis (RCA) were introduced. During the second week, I spent time in revenue had upon development of we need to be able to empower all principles, a culture of continuous The week culminated with lessons on the operating room (OR) environment. these strategies. Ultimately, focusing on members of the team to contribute,

For more information about the MTI programme please enactive experience to facilitate in the British Medical Journal visit our website at: reflection, learning, familiarisation, awards 2019 and shortlisted and connections to real events, with for the Health Services Journal rcoa.ac.uk/medical- growing evidence for their use in value awards. Medway runs training-initiative medical education.2 the only two-day course in the programme. Previous experience The team In 2017, I started the simulation-based reading material is also provided. human factors, communication and Dr De Silva and I firmly believed that An observer for each centre, either critical incidents course for IMG establishing national simulation courses from the RCoA Global Partnerships doctors at Lancashire Teaching tailored to the needs of MTI doctors committee or the MTI leadership Hospitals NHS Foundation Trust, would benefit this cohort. We took group, both for support and quality with support from our simulation our proposal to the RCoA and its MTI assurance, has been proposed. We lead Dr James Wilson. Various leadership group, who were supportive. have so far run two successful courses factors contributed to the successful We identified trusts around the of this programme, and feedback establishment of this course – my country that had the capacity and were received has been very positive and knowledge of the IMGs’ medical interested in running a similar course. encouraging. More information on the training programmes in their own Of the interested centres, we had to centres, including the dates of future countries (including cultural/clinical select those who were geographically courses, can be found at: Lancashire Teaching Hospitals NHS Foundation Trust (LTHTR) Simulation team aspects), and Dr Wilson’s previous well spread so that MTI doctors across bit.ly/RCoA-MTI-UK. experience on simulation training. the UK can widely access the courses. Dr Shashikumar Chandrashekaraiah Dr Ruwanmali De Silva A survey of all the IMGs who Wth our support five centres have been Plans for the future set up as outlined in Table 1. Consultant in ICM and Anaesthesia, Consultant Anaesthetist, attended the course showed marked The simulation course is primarily LTHTR, Faculty of Intensive Care MTI MTI Lead, Medway NHS improvements in various aspects of for MTI doctors. MTI numbers are Lead Foundation Trust communication, familiarisation with the The course increasing every year (112 in 2019 NHS, and team working.3 The centres have the option of running compared to 43 in 2014). In coming a one-day or a two-day course (they years we may require more centres to Medway NHS Foundation Trust runs a can apply for CPD points from RCoA), help us run this programme to meet similar simulation-based induction for depending on their previous experience the existing demand. Providing that IMGs, which is conducted by and the resources available. Topics to we manage to increase capacity, we ‘New to the NHS’ national Dr Ruwanmali De Silva. Their course be covered, with the intended learning may be able to offer places to other significantly reduced agency locum outcomes for standardisation of the IMG doctors in anaesthesia and spends by early integration of IMGs course, have been agreed. These include intensive care medicine. into the NHS, building familiarity with MTI simulation programme familiarisation with working in the NHS, policies/protocols, and training in communication and interpersonal skills, References human factors, and communication The Medical Training Initiative (MTI) is a national scheme designed to allow a human factors/situational awareness, and 1 Hashim A. Educational challenges faced and interpersonal skills. Their first five- critical incidents related to anaesthesia/ by international medical graduates limited number of international medical graduates (IMGs) to work in the NHS day course was highly commended in the UK. Adv Med Educ Pract 2017; intensive care. Comprehensive pre-course 8:441–445. for a maximum period of two years before returning to their home countries. 2 Hing Yu So et al. Simulation in medical Table 1 Support centres education, J R Coll Physicians Edinb 2019; MTI doctors will benefit from world- anaesthesia, intensive care medicine hospital in the following areas: dealing 49:52-57. Simulation Centre Lead class clinical training, and also develop and pain medicine through their Global with medical emergencies, protocols/ 3 epostersonline.com/soa2019/ node/827?view=true. non-clinical skills, such as medical Partnerships team. guidelines, and non-clinical skills related Hull and East Yorkshire Hospitals NHS Trust Dr Dave Wright education and leadership, which will to communication and interpersonal Lancashire Teaching Hospitals NHS Trust Dr Shashi Chandrashekaraiah Acknowledgement benefit not only the individual doctors, Background skills, social and cultural issues, NHS Medway Maritime NHS Trust Dr Ruwanmali De Silva We would like to thank David but also the healthcare systems and As IMGs come from various cultural work culture, end-of-life decisions, Calderon-Prada, Global Partnerships Aberdeen Royal Infirmary Dr Manisha Kumar patients in their home countries. backgrounds, their major challenges confidentiality and consent.1 Administrator, RCoA for all his are to adapt to British culture and Northampton General Hospital Dr Pushpa Bheemappa support in setting up this programme. The Royal College of Anaesthetists integrate into the NHS. IMGs tend to Simulation activities followed by manages the MTI scheme for require extra support from their UK debriefing are a powerful form of

Associate Professor Helen Higham Consultant Anaesthetist, John Radcliff Hospital, Oxford AN INSIDER’S VIEW [email protected] WHY BECOME A COLLEGE EVENT SPEAKER? More than 1,700 of our fellows and members selflessly contribute their time, energy and skills enthusiastically to the work of the College. These roles range from examiners, to committee members, to ACSA leads.

In this issue, we have Professor Helen What was your lecture for the when you start your job. I currently Higham, a consultant anaesthetist, 25th anniversary? mentor two of our consultants. We from the John Radcliff Hospital in It focused specifically on the role of make sure that the pastoral side of care and thinking that it’s worthwhile – is really enjoy a member of faculty who I’ve got one last question for Oxford. She is one of our wonderful anaesthesia in the development of for new colleagues is addressed pretty very important. In all honesty, it is is keen to inject some sense of levity you: if you could give one piece part of the reason that you get good into the proceedings. It really helps with regular contributors to events at the human factors training in healthcare. robustly. In the current extraordinary of advice to someone thinking feedback – it’s when things are run attention and with engaging people as College. Please read on for an edited I’m proud that as a profession we’ve COVID-19 circumstances, it’s become about becoming an event- well, people connect well and are well as encouraging attendees to speak version of the interview with Professor been at the forefront of those very evident why those mentorship speaker what would it be? communicated with. to you after you’ve finished speaking. Higham, recorded in June 2020. To developments. We wrote an article roles are so important. To be honest, it is to just do it and to listen to the full interview, visit our about it for the journal which really contact the College. There will no doubt Can you share any experiences, What are important qualities an Can you share your most website at: rcoa.ac.uk/insiders-view- crystallised some of the things I felt be someone in your hospital that is event-speaker should have? interesting experience from your why-become-event-speaker strongly about regarding what we professional and personal already doing this. Go and talk to them I’ve taken a further qualification in adult time as an event-speaker so far? deliver, not just in our clinical work, learning, or skill-sets that you ‘What is it like?’, ‘How do I do it?’ And education, and what that does is really I wouldn’t say that there is any one Please tell us a bit about but the extent of what we do in patient have gained through your work certainly don’t be afraid, just do it. clarify the way that you design and particular thing that stood out, but it’s yourself. Did you have previous safety (bit.ly/2EwVG9F). with the College? deliver the educational experience. Of more that when you are sitting in a room Since the interview, Dr Helen Higham event-speaker experience? It has reinforced the importance of course, that starts with defining what and the whole audience is either smiling has been made an associate professor. As well as being a consultant anaesthetist You mentioned having a mentor. good educational design for me. your learning outcomes are. Alongside or laughing with the presenter, you know We would like to wholeheartedly in Oxford, I am the director of our Have you considered or are you There are a number of things that that, is the importance of a careful you’ve got them engaged and that they congratulate her on this achievement. simulation centre. I have a long-term already mentoring others? are involved in delivering a really choice of faculty, and understanding are likely to take something useful away interest in education, and have been We’ve had a mentorship programme good learning experience. I would the format in which you are going to from the session. teaching and speaking at events ever like to stress the importance of good for new consultants for a while now in deliver this learning experience. since I was a registrar. So, it felt perfectly Oxford. When I arrived, I nominated infrastructure, communication, and Hopefully, this interview will natural when my wonderful long- my own mentor. This was someone administration for any of the teaching I think there are three key factors encourage more people to time mentor and supervisor Professor I had admired as a trainee and a activities. I think the College really regarding choosing faculty for an event. come forward and think about Pierre Foëx, invited me to speak at the research fellow, consultant anaesthetist has that nailed now. We feel very The first and foremost is expertise. becoming an event-speaker. College at a cardiac risk symposium. Matthew Sainsbury. He was a supported when we’re running an Secondly, you need someone who can Absolutely. I believe people need to be That opportunity was my first foothold, tremendous support to me in my early event, which is especially important deliver the content of their talk well – encouraged by realising that the College and since then I’ve also done work in consultant career. I think the mentor as you are usually setting things up entertaining as well as having a clear is a welcoming place, that it is easy to For further information, the ‘train-the-trainer’ area, some human has a vitally important role when you’re from a distance. Many attendees are direction – and who is comfortable engage and get involved, and that please visit the Get involved factors work, and lectured at the 25th beginning your career. There are all also coming from quite a distance, interacting with the people in the they should feel very comfortable anniversary celebrations, which was a sorts of issues and concerns which may therefore the College looking after room. The third, I would suggest, is a section of our website: doing that. really nice thing to be able to do. not be things you think about initially people – making them feel welcome good sense of humour. I think people bit.ly/RCoA-Involved

Dr Janice Fazackerley Associate Medical Director for Medical Appraisal, Warrington and Halton Hospitals [email protected]

Nottingham Forest retained the ...six weeks in, I was on-call European Cup (Champions League).

Meanwhile in Liverpool, I entered alone, scared, but valued... Walton and Fazakerley Hospitals as a novice anaesthetist and immediately loved my new job. Led by Tom much more than they ever cost the university department in Liverpool Forrest, an exemplary ‘administrative hospital. It is sad that at the end of my recruited novices and provided anaesthetist’, this was a happy ship. career, I helped the College produce classroom training for Primary FFARCS. Neither leadership and management the 2017 RCoA Morale and Welfare This was fortunate, because there was qualifications nor wellbeing and Report, which presented ‘a moral and no curriculum or exam syllabus and few resilience training had been heard of, financial imperative to safeguard the relevant texts. No clinical knowledge but Tom was a born leader whose staff health and welfare of the anaesthetic was required, simply the 3Ps: felt that he cared. We belonged, and workforce’, after listening to the woes of physiology, pharmacology and physics/ his cheerful consistent support and contemporary anaesthetists in training. encouragement, given without fear of clinical measurement. The lecture notes blame or managerial interference, was Despite the lack of ideal drugs and from Steve Snowden, Jennie Hunter and a lifeline for me. By six weeks in, I was of reliable anaesthetic machines and John Utting provided the sum total of on-call alone, scared, but valued for the monitors, anaesthesia in 1980 was my knowledge when after five months I essential service I could now provide interesting for the variety of options on presented myself at Queen Square, and – with a little help from my friends the offer and the challenge of providing ‘satisfied the examiners’. operating department assistants, whose the ‘least-worst’ anaesthetic. Most immense ability and Scouse wit saved drugs needed perfect hepatic and/ The purpose of ‘As we were’ is surely many a day. or renal function for inactivation, to provoke thoughts on ‘how we and had multisystem side-effects; are’. Anaesthesia in 1980 had many AS WE WERE... The happy ship was, of course sailing so my technique was more cookery challenges. They were different from in a different era to which we cannot, than science – mixing, timing, and today’s, and we never met a pandemic and should not, return. Patient balancing drugs like methohexitone, challenge. To recall again the 2017 HAPPY EVER AFTER outcomes, other than alive or dead, althesin, propanidid, fortral, gallamine, College Morale and Welfare Report, ‘The years go by, as quickly as a wink were not considered, litigation was fazadinium, enflurane and trilene (ask Liam Brennan stated that ‘anaesthesia Enjoy yourself, enjoy yourself, its later than you think’ in its infancy, the general public were an over-60-year-old) to achieve sleep is highly valued for its clinical deferential to doctors, and had no Herb Magidson, 1949 with minimal trouble. Pain relief was recourse to medical advice on the challenges, team working, application optional. The re-usable rubber airway internet. Developments in all these of basic scientific knowledge at every Six months ago, ‘As we were’ offered the thoughts of David Bogod as he adjuncts, in black or red with ill-fitting fields are to be welcomed. Our long, patient encounter, and diverse career connections and no airway monitoring, retired. We both demitted College Council on the same day, but I left dangerous and antisocial hours were opportunities. It is the system in which taught me from the start the importance tolerable only because there were anaesthetists work and train which is the anaesthesia a year before him, also with 39 years on the clock. The invitation of constant vigilance beside the patient. sympathetic consultants, the good- problem’. The qualities of anaesthesia are to follow him in reflecting on a career leaves me wondering what can I add? I must owe my sanity and longevity to humoured understanding of theatre propofol, sevoflurane, laryngeal masks, enduring, and while we cannot solve the staff, managers’ appreciation of The backdrop to ‘As we were’ in 1980 was ‘not for turning’, and an ageing and ‘Newsnight’. Elsewhere in the world, and disposable plastic, but mostly to problems of the system, I would like to medical expertise, and a few home was, as now, a troubled Britain. Inflation Labour party leader whose dress at smallpox was pronounced eradicated, fentanyl, the only drug to appear in my think that every anaesthetist in training is comforts. Waking up after on-call to was at 21%, the economy shrinking the Cenotaph was judged improper. Iraq declared holy war on Iran, while first and last anaesthetic. supported by a Tom Forrest equivalent by 4% annually, unemployment at We drove the new Austin Metro, were presidents Carter and Brezhnev the tea lady offering ‘one cup or two’, on the ‘shop floor’, running a happy ship. 1.5 million, riots in Bristol, a female self-sufficient in North Sea oil, and continued the Cold War. Rishi Sunak was served in bed, or afternoon bread and Support for exams was provided then, Conservative prime minister who watched the launch of ‘Yes Minister’ born, John Lennon died, and amazingly jam provided in the mess, meant so as now, by day-release teaching. The

Amr Hassan Northern Stoke Deepak Choudhry Rachel Horner Mohamed Elriedy Sachin Alva Michael James Felicity Avann Radha Kunte Neil Hall Roshan Thawale Mark Dalton Wales Abhik Guha Christopher Bailey East of Scotland Craig Beaton Dual ICM Rafiqu Shabiyulla Northern Ireland Naveeta Maini Nauman Iftikhar Wessex Alasdair Taylor Bronagh McKay Rachel Montgomery Katie Misselbrook Matthew Grimes Dual ICM Said Seifalian James Bowness Thomas Hargreaves Andrew Burton Ryan Sykes Hugh Cutler Imperial Brian McAlary Stephen Phillips Jennifer Abthorpe Dual ICM Nathan Oliver West of Scotland Kevin O’Donoghue Oxford Jacqueline Harkins Dual ICM Rachel Fulton Kent, Surrey & Sussex Aoife Fitzgerald Katie Russell Amanda Milligan Shyam Laxman Henry Lewith James Small Gregory Waight Naveed Karim Sarvesh Zope Peninsula West Yorkshire East of England Gareth Meredith Deborah Webster Dual ICM Selin Kabadayi Dual ICM Julia Neely Andrew Woodgate Roshan Rao Meike Keil Dual ICM Omar Jundi Dual ICM NEW TO THE COLLEGE Rachael Morris Severn Lisa Grimes Helen Williams August The following appointments/re-appointments were approved (re-appointments Daniel Stolady Rebecca Williams Birmingham marked with an asterisk). James Blackburn PHEM Mersey Miriam Namih Matthew Kerton PHEM College Tutors West Midlands July Samuel Howitt David Radley Sarah Schofield Defence London Stoke Barts & The London Victoria Bell Diane Murray Dual ICM Matthew Boyd Dr Vivekanand Eli (Princess Royal James Self South East Beki Baytug Timothy Furniss Hospital) in succession to Dr Saiprasad Priya Shinde East Midlands Dr Rachel Addison (Princess Royal Owen Chambers South East Annadurai Ching Pang Lohita Rilesh Nanda University Hospital) in succession to Dr James O’Carroll Dr Adilah Miraj (Queen’s Hospital North Central London Helen Statham Sarah Muldoon Imperial Burton) in succession to Dr Manab Birmingham Ravi Bhatia Dual ICM Richard Lin Jonathan Breeze North West Haldar Charlotte Small Samuel Al-Kadhimi Joseph Seager Hoi Wong Dr Neelam A Patel (Wrightington, Ryan Howle South East Scotland Wigan and Leigh Teaching Hospitals Certificate of Completion East & North Yorkshire North West Thomas Ballantyne Mersey NHS Foundation Trust) in succession to of Training Elspeth Paterson Alexander Bell Gareth Kitchen Duncan Hughes Dr Paul Clements To note recommendations made to John McLenachan Sarah Raut David Freeman the GMC for approval, that CCTs/ North Central London Dr Vivek K Sinha (The Royal Oldham Matthew Smith Dual ICM South Yorkshire CESR (CP)s be awarded to those set Girish Narasimha Murthy Hospital) in succession to Dr Joanne East Midlands out below, who have satisfactorily Stephen Traynor Claire Cruikshanks Stefan Sevastru Humphreys Nicholas Brazel Dual ICM completed the full period of higher Laura Cooper William Lindsay Vivienne Hannon specialist training in anaesthesia, William Tomlinson Simon Bluhm James Turnbull or anaesthesia with intensive care William Rattenberry Geoffrey Ryder North West Jake Turner PHEM St George’s medicine or pre-hospital emergency Charles Cross Essam Abul Magd medicine where highlighted. Louise Potter Mark Sapsford

Northern Ireland Caroline Martin APPOINTMENT OF MEMBERS, ASSOCIATE MEMBERS APPOINTMENT OF FELLOWS TO Diarmaid Dillon AND ASSOCIATE FELLOWS CONSULTANT AND SIMILAR POSTS Gasping for a Associate Fellows Dr Robin Gregor MacGillivray The College congratulates the following fellows on their Oxford Dr Ummara Farooq Dr Tyng Yan Ng consultant appointments: Breath Anna Petsas Joint ICM Dr Sofia Kalogeropoulou Dr Amr Essameldin Hussein Ezzat Dr Shelley Barnes, North Bristol Trust Michael Holland Before I got on the ventilator Dr Dimitar Georgiev Terziiski Shalaby Dr Nicholas Brazel, Nottingham University Hospitals NHS Dr Jan Hanot Dr Ahmed Mohamed Abdelrahman Salem I never knew how important it was Peninsula Trust Member Dr Emmanouil Liolios To breathe. Deborah Sanders Dr Neil Hall, South Tyneside and Sunderland NHS Dr Tom Joseph Hannan Dr Neha Baduni Before they put me in coma Shelley Barnes Foundation Trust Associate Members Dr Neethu Raj Dr Amr Hassan, Nottingham University Hospitals NHS Trust I never paid attention South East Dr Amir Ishak Roshdy Mekael Dr Marta Montero Baladia Dr Israa Elsayed Mohamed Elfouli Dr Omar Jundi, Bradford Royal Infirmary To being conscious. Nicholas Dodds Dual IC Dr Valentina Camarda Dr Hanneke Heynen Dr Shyam Kumar Laxman, East Kent Hospitals NHS Before I lost my taste and smell Mitul Patel Dr Abdelrahman Ali Mohamed Abdelhadi Eleshmawi Dr Dominika Danuta Raciborska Foundation Trust I ignored the fragrance of nature and taste of water. Simon Fitzgerald Dr Divya Joseph Dr Rachel Elizabeth Friman Thomas Atkinson Dr Caroline Martin, Ulster Hospital, Belfast Before all my blood was run through machines Dr Laknath Prasantha Rajasiri Dr Menikhitihami Mudiyansela Erandi Dr Lohita Rilesh Nanda, Kettering General Hospital I was indifferent to the life within. South East Scotland Dr Ivan Pavlu Darshika Dissanayake Dr Gareth Roberts, Princess of Wales Hospital. Cwm Taf Dr Amy Farrow Dr Amy Chimei Frances Chan-Dominy Before I got a tube in my throat Jonathan Hetherington Morgannwg University Health Board Dr Shaminder Kaur Olney Dr Wesam Fawzy Abdelfattah I never admired my voice, my speech. Mohamed Alyeddin Dr Matt Smith, East Lancashire Hospitals NHS Trust South Yorkshire Dr Mohamed Yousef Saad Before I had my eyes closed Dual ICM Abusheashea Dr Sunita Gurung Dr Will Tomlinson, Sheffield Teaching Hospitals John Bramwell I never adored the shades of sunset. Dr Hani Dourado Al-Khatib Dr Mohamed Yehya Mohamed St George’s Dr Naomi Mooya Shamambo Mahmoud Before I said goodbye to my family Dr Umme Sumayyah Nauman Emma Tyson Dr Rudy Cathapermal I never said ‘I love you’ enough. Dr Ammar Ali Shah Thomas Girdler-Hardy Dr Tushar Subhash Patil DEATHS And now it’s time to go Dr Rakesh Sethi Dr Nesreen Adel Nasreldeen Ahmed With sadness, we record the death of those listed below. Far, far away. Wales Dr Craig Kirk Shaban Dr Maurice McConnell Burrows, Birkenhead If only I could get a breath, there is so much left to say. Lalindra Bandara Dr Nayer Nabil Mikhail Guirguis Dr Achyut Sharma Dr Douglas Edward Falconer, Newton of Argyll Gareth Roberts Dr Rhiannon Harling Dr Mahaboob Subhani Shaik Dr Balaji Badrinarayan Putti Rhys Clyburn Dr Nour Mohamed Ahmed Youssef Dr Trevor Anthony Thomas, Bristol Dr Lubaina Bahar Ramamurthy Paul Carter ElShafei Dr Bertram Winston Sebastianpillai, Australia ICM Fellow, Royal Brompton Hospital, London Dr Janis Berkis-Bergs Dr Ola Seifeldin Salih Mohammed To submit an obituary that will be displayed on our Warwickshire Dr Jaseem Baliyambra Dr Nilay Chatterjee website (rcoa.ac.uk/obituaries), please email your text Nicholas Talbot Dr Tarek Ibrahim Elsayed Hassan Dr Paige Mitson (500 words) to [email protected] Dr Ahmed Mostafa Hassan Eldesoky Dr Melissa Joy Hartley Wessex Dr Ayman Mohamed Abdelaziz Ibrahim Dr Maissara Katran Al-Rikabi Thomas Daubeny Joint ICM Hassan Dr Christopher Tong Mun Lewis Dr Sonam Bi Dr Ruth Clara Warne West of Scotland Dr Khaled Ahmed Ibrahim Mahmoud Dr Claire Patricia O’Doherty Jacqueline McCarthy Sharaf Dr Emma Louise Lang Philip McCall Dr Ahmed Yehia Mahmoud Mohamed Dr Emma Jane Carter Raising Mahfouz Dr Alfred Hill Dr Natashia Amod Yigit Dr Gautam Vinubhai Prajapati the standards Dr Shakti Askoorum Dr Amit Sharma Dr Yashraj Gupta Dr Thomas Kong new edition of the quality improvement Dr Dasha Faith Tjanara Newington Dr Alveena Bilal compendium now available Dr Junaid Ahmed Desai Affiliates Dr William Pemberton Mrs Kelly Illingworth at: bit.ly/RCoAQIComp Dr Aileen Ling Wan Tan Ms Vala Barzinji Dr Lokeswaraiah Nagaraju Morubagal Dr Jodie Hughes

VACANCY: DIRECTOR The UK Perioperative Medicine Clinical Trials The College has developed a toolkit that offers Network (POMCTN) was established in 2015 patients the information they need to prepare as a national network to deliver world-class for surgery, including the important steps multi-centre clinical trials in anaesthesia and they can take to improve health and speed up perioperative medicine. recovery after an operation. The POMCTN is now recruiting a new director as the current director term nears its end. This role The Fitter Better Sooner toolkit consists of: will include overseeing the successful delivery of ■ one main leaflet on preparing for surgery all network-led clinical trials, working closely with chief investigators to ensure that trials are well ■ six specific leaflets on preparing for some of supported, as well as leading and developing the the most common surgical procedures strategy of the Network. COVID-19 RESOURCES ■ an animation which can Stay up-to-date with all our latest clinical resources and guidance for anaesthetists & intensivists. Find out more at: The POMCTN is a collaborative national network be shown on tablets, of active local and principal investigators who smart phones, laptops icmanaesthesiacovid-19.org are running clinical trials recruiting NHS patients. and TVs. The Director will have appropriate skills and qualifications including direct experience in leading large clinical trials, strong leadership You can view the toolkit and interpersonal skills, communication and here: rcoa.ac.uk/ presentation skills to effectively chair meetings fitterbettersooner and events.

This is a three-year fixed term appointment, subject We have also created to annual review and we are currently seeking printable posters, flyers funding renewal for one PA backfill for the post. and stickers to help you The post can be renewed for one additional term signpost patients to to a maximum of six years. the toolkit. The Further details on the role including a full job animation can be shown description and person specification are available on TVs in waiting areas. on the POMCTN website at: You can find all these pomctn.org.uk/article.php?newsid=158. If you additional resources and would like to discuss the role with current Director Professor Rupert Pearse please email: instructions on how to download the animation [email protected]. in MP4 format (or request a version in PowerPoint) on our website here: Closing date for applications: Monday 22 February 2021. rcoa.ac.uk/patientinfo/healthcare-professionals Interviews will be held in March 2021 Please share this toolkit with colleagues in both [date TBC]. primary and secondary care settings.

ONLINE WINTER SYMPOSIUM: 3–4 December 2020

We will be live streaming this event from our Lecture Theatre at Churchill House, as well as bringing in national and international experts to join the discussion from their locations both in the UK and across the world.

Programme includes: Virtual events

■ Christmas lecture 19 November 2020 ■ panel debates Clinical Content Lead Dr Nagendra Prasad, Consultant Anaesthetist ■ innovations

■ artificial intelligence Topics include: ■ Perioperative analgesia ■ quick fire abstract talks. ■ Airway management

■ Obstetrics

Future dates Southampton London Bristol Full programme 29 January 2021 24–26 February 2021 4 March 2021 Due to the ongoing COVID-19 situation, we are monitoring the guidance on events and if it is available online at not possible to run these events face to face, then we will move these to virtual platforms. rcoa.ac.uk/events For further information and to book please visit: rcoa.ac.uk/events

68 | | 69 Bulletin | Issue 124 | November 2020 Off your second course if booked within six months of the first 10% or if two booked at the same time. DISCOUNT REVISION COURSES Primary FRCA Online Revision Course Start date 1 December 2020 Content will be available until the exam in February Leadership Final FRCA Online Revision Course Start date 14 December 2020 and Management Content will be available until the exam in March These courses include: Run by practicing NHS clinical directors and experienced management ■ video lectures

facilitators – start with our signature two-day introduction course and follow up ■ powerpoint presentations

with one of our suite of management courses. ■ mock exams

■ chat room for discussion between trainees Personal Working Well in Teams and ■ effectiveness the opportunity to send in questions to lecturers and Making an Impact receive feedback. 18 November 2020 Book online now at: rcoa.ac.uk RCoA, London The essentials Introduction to leadership and Working well Managing management: The essentials in teams change UPCOMING WEBINARS 16–17 March 2021 RCoA and RA-UK joint webinar: Glasgow Blocks for the many 10 November 2020, 6.30pm–8.00pm (GMT) Personal Effectiveness RCoA and BJA joint webinar: How BJA Editors decide which papers to publish 26 March 2021 24 November 2020, 6.30pm–8.00pm (GMT) RCoA, London New webinars are released regularly. Please visit our website for dates, topics and speaker information.

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

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

18–20 May 2021 Old Trafford, the Home of Manchester United

Co-badged with: SAVE 10% early bird places available until 31 January – quote EARLY10 when booking

Book your place at: rcoa.ac.uk/anaesthesia-2021