Trainee Issue: Growing Resilience and Developing Excellence

May 2019 The trainee role in achieving ACSA

Reflections on SNAP-2 and collaborative research successes in the UK

Enhancing perioperative care: a novel model

Trainee issue: Growing resilience and developing excellence

www.rcoa.ac.uk @RCoANews 20–22 May etc.venues St Paul’s, London

The opioid epidemic: Developmental The future of A disaster in waiting? anaesthetic neurotoxicity anaesthesia

Dr Cathy Stannard Professor Hugh Hemmings Professor Ramani Moonesinghe NHS Gloucestershire British Journal of University College CCG Anaesthesia London Hospitals

Patient Professional Fitness, exercise Safety conduct and surgery

Dr Aidan Fowler Dame Clare Marx Professor Denny Levett National Director of General Medical University of Southampton and Patient Safety Council University Hospital Southampton

BOOK NOW www.rcoa.ac.uk/anaesthesia Bulletin | Issue 115 | May 2019 Bulletin | Issue 115 | May 2019

The President’s View 4 News in brief 8 Contents Guest Editorial 12 From the editor The Perioperative Medicine Roadshow: running a national event 14 RAFT and the power Dr David Bogod of citizen science 16 Global reach of the perioperative Welcome to the May Bulletin. medicine ‘MOOC’ 18 It gives me great pleasure to be able to introduce this trainee issue of the Bulletin, featuring a series of Growing resilience and emotional contributions by anaesthetists in training, and led by the redoubtable Katie Samuel from the College’s intelligence 22 Anaesthetists in Training Committee. The chosen title for the front page, ‘Growing resilience and developing 24 Faculty of Pain Medicine excellence’ elegantly captures in five words the competing challenges that face the modern doctor. Stressed by Faculty of Intensive Care Medicine 26 working hour demands, patient pressures and demands for increasing efficiency, while maintaining and improving Revalidation for Anaesthetists 27 quality of care would be daunting task for anybody, but I am sure that readers of this issue will be left in no doubt of the commitment and drive of our future leaders. From perioperative medicine to research and national audit, SAS and Specialty Doctors 28 anaesthetists in training are at the forefront, and it is comforting to know that, as I descend into old age and Guest Editorial Patient Perspective 30 physical infirmity, my care will be delivered by such skilled, knowledgeable and committed professionals. Technology Strategy Programme 34 Stress, resilience and burnout feature elsewhere in the Bulletin as well, with thought-provoking articles from Growing resilience and Feedback: Google Forms Lucy Williams and Carol Pellowe. Mental health and well-being of practitioners are, of course, very ‘trendy’ 38 developing excellence and QR codes issues, and while some of us might be tempted to make light of them, I believe that their importance cannot be Can you improve the world? 40 overstated. Not only do we owe it to ourselves and our loved ones to be as emotionally healthy as we can, but Welcome to the Trainee Issue Pain medicine training: Reaching out we owe it to our patients as well. A stressed, burnt-out doctor is unlikely to be giving of his or her best. Page 12 to the developing world 42 Anaesthetists in training feature elsewhere in the journal as well. I would highlight the article by Tom Munford, Quality improvement book – Seetal Aggarwal and Thomas Fletcher, where they describe how they became involved as key members of recipes for success 44 the ACSA preparation team when the College were invited to Nottingham to credential the quality of their Reflections on SNAP-2 Drop a day’s work – and The multidisciplinary team in action: anaesthetic care. As well as being able to represent the views of trainees to the assessors, they describe a and collaborative research lose no pay? applying perioperative medicine to valuable exposure to and insight into the issues that face clinical directors and training leads tasked with the high-risk surgical cancer patient 46 successes in the UK Professor Jaideep Pandit looks at the delivering high quality care. The lessons to trainees are clear: encourage your department to seek ACSA accreditation and get involved in the process. Recap on the success of SNAP-2 workforce challenges in anaesthetic Dundee RCoA Membership Engagement Focus Group 48 and the appetite for research on the departments Jaideep Pandit continues his series of stimulating articles, and here turns away from his recent focus on theatre frontline NHS Page 36 Simulation and multiprofessional crisis efficiency to a topic that exercises many of us; workload versus income. From its name alone, the ‘Income Page 20 resource management (CRM) team Death Zone’ is not a place where any of us would want to be, and his careful financial analysis is recommended 52 Enhancing perioperative training to anyone considering doing a few extra waiting list initiatives. Are you sure you want to work for no extra The trainee role in care: a novel model Perioperative Journal Watch 53 income? Or would you rather reduce your tax burden by gift-aiding to the World Federation of Societies of achieving ACSA Sandwell and West Birmingham As We Were 54 Anaesthesiologists, as suggested by David Wilkinson? Something of a no-brainer, I would suggest. NHS Trust discuss its introduction A look at how trainees helped their Letters to the Editor 56 Finally, as befits a forward-thinking and eclectic journal like the Bulletin, we have published a poem! Reena Ellis’ of the dedicated ‘perioperative hospital achieve ACSA accreditation contribution illustrates the tension between professional satisfaction and emotional and physical exhaustion anaesthetist’ model NIAA Research, Education and Page 32 Travel Grants 60 that comes with an obstetric night on call, and in doing so reflects the reality of some of the more conventional Page 50 articles in this issue. Any other poetical contributions will be gratefully received. NIAA Research Grants 62 New to the College 64 Notices and adverts 65 RCoA Events 68

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Professor Ravi Mahajan Dr Sarah Muldoon President RCoA Council Member, ST7 Registrar, London

Ravi Mahajan (RM): You raise quite a RM: Well in those situations, the College I think this generation acknowledges our few issues. Firstly, I’d like to highlight the can definitely provide a greater steer on individual and collective impact on the new curriculum that we are introducing what good looks like – achieving the world around us, and this is in parallel from December 2020 onwards, which right balance between service provision to our increased awareness of our own will be outcome-focused and not so and individual decision-making. wellbeing, and by extension that of our fixated on how much time you’ve spent patients. doing one thing. SM: How do you feel that, as anaesthetists in training, we might I want to safeguard my personal welfare, We are mindful that rotas can be inflexible, be better empowered to challenge as ultimately I can’t deliver patient care so how can flexibility be introduced? Part institutions and the way of doing things effectively if I don’t have my basic needs of the problem is the rigidity of training in our own departments when the met. I do think that staff wellbeing is structures. It’s like an elevator that you consultant says ‘…back in my day…’? being recognised as a patient-safety step into, press the button, and then are This may be in clinical scenarios where issue, so ‘pandering’ to what might be whisked to the top floor without much time a suggestion of using newer equipment perceived as ‘snowflake’ issues, is actually to think. So where are the opportunities to is disregarded, or it might be related to going to improve the service for patients. step off at the sixth floor and consolidate fatigue or wellbeing… RM: When I was a registrar we were your experience – in my view, that’s what called something different: we were the we need more of. RM: If you are in a position where you ‘privileged generation’. The answer is The President’s View are made to feel like a subordinate, you not to look back, but to look at what we SM: I think that anaesthetics is ahead will find it very difficult to challenge need now, regardless of what it used to of other specialties in this respect, but orthodoxy. That is a very bad position be like. In conversation with Dr Sarah Muldoon, I wonder how possible it is to embed to be in for your own professional greater flexibility when service provision development, but it’s also a danger to SM: I think anaesthetists in training is so stretched? ST7 Registrar and new Council Member patient safety, and that makes it a bad are coming to realise that we are not RM: Local leadership from place to place position for the consultant to be in too. automatons, and we shouldn’t be demonstrates that this can be handled in expected to be martyrs for patient care In this month’s Bulletin we wanted to put the focus on anaesthetists in training. I don’t think we have a strategy for different ways, and that some ways are but, rather, we should have expectations cultural change, but things are changing So I invited newly elected Council member and anaesthetist in training, Dr better than others. Different deaneries of the system for the support of our where the patient-safety agenda makes take very different approaches, but I hope health and wellbeing. Sarah Muldoon, to provide the perspective of a current registrar. Originally the case for change. that the College’s new outcomes-based Related to what we’ve been talking about, from Kilmarnock, Sarah is an ST7 working in London who has been active in curriculum will provide some uniform [The interviewer raised the issue of media I want to talk about resilience. Particularly, improvement. NHS affairs, including being an outspoken critic of government policy during depictions of a ‘snowflake’ generation, and I wanted to hear your thoughts on asked how this impacted upon relationships the junior doctors’ contract dispute. SM: There’s also the issue at the the somewhat cynical suggestion that between junior and senior staff] individual department level… organisations may be training healthcare We were also joined by the College’s Sarah Muldoon (SM): I put myself One of the key issues is the design professionals to be more resilient as a SM: There are parallels between the Head of Policy and Public Affairs, who forward for Council because I believe of rotas, since these can make it very RM: Some training programme directors solution to workforce pressures, rather media depiction of the ‘snowflake’ or the acted as an ‘interviewer’ and is referred the College has been a strong difficult to sustain a satisfying social and are very hands-on and will tailor as much than addressing the root causes of staff ‘millennial’ generation and the depiction to in the piece. advocate for its trainees and has stood family life or interests like a sporting as they can, while there are others that, shortages and patient demand. of the current cohort of doctors in up for us on issues such as wellbeing. activity or artistic hobby, as often we every six months, introduce a ‘master The following article is a write-up of the training, and that doesn’t help. But, more But, there are a couple of areas where don’t have any control of our working rota’, and then you’re told you’ll have to RM: I think that we need doctors who conversation Sarah and I had in mid- than just the attitudes and expectations I feel our work/life balance could be patterns. We can’t easily personalise postpone your wedding… I’m taking an are able to adjust their performance, in February, just a few weeks before she of anaesthetists in training has changed improved and there could be a role for our shift patterns or explore approaches extreme example… realtime, when adversity presents itself. took her seat on Council. the College to do more. such as self-rostering. What are your in the past 20 years: everything has Having the confidence to change your thoughts on this? SM: Hmmm, well extreme, but not transformed – the environment, the approach and adjust your performance unheard of… technology, the types of patients... is what I would understand as being

resilient in a clinical setting. What you are availability of rest facilities, we will step SM: I want to ask you about the Some of it is to do with the split between clinical and alluding to is an idea that trainees should teaching time. I think that this is too rigid, and that for Bulletin in – often in partnership with the BMA or expanding role of physicians’ assistants of the Royal College of Anaesthetists learn to work when they are hungry, the Association of Anaesthetists. anaesthesia (PA(A)s), and how you would trainers and anaesthetists in training the demarcation is tired or dehydrated, and then calling that address any concerns that this might unhelpful. Churchill House, 35 Red Lion Square, London WC1R 4SG SM: There are some changes to the resilience. I cannot accept the idea that compete with the training opportunities 020 7092 1500 format of the final exam; both the SM: I know from speaking to friends that there is a lot of putting up with poor welfare standards available for those in the specialty www.rcoa.ac.uk/bulletin | [email protected] variation from department to department in the level of can be synonymous with resilience. structured oral exam and the written training programme @RCoANews component. Why did those changes to autonomy and responsibility that registrars get… /RoyalCollegeofAnaesthetists I would like to know of examples the exam have to be made? RM: It is a theoretical possibility that RM: And that variation from place to place is natural, and and correct misconceptions – that is arises every time a new layer is added. one thing I want to communicate is the opportunities Registered Charity No 1013887 absolutely something the College will RM: I was an examiner for 11 years, and in We heard similar concerns when SAS that perioperative medicine can offer to anaesthetists to Registered Charity in Scotland No SC037737 do. I would point to the Long Term Plan that period we changed the exam format doctors were introduced. With the get a more varied role, in which you spend more time VAT Registration No GB 927 2364 18 and the future-workforce plan as an three times. The short answer is that the demand we face, there is always room supporting patients to get fit for their operation and fit opportunity to pivot away from some current exam is too labour-intensive for highly skilled healthcare professionals after their surgery. President Sudhansu Pattnaik tactics that haven’t worked. for examiners to assess – particularly at every level of our team. We need Ravi Mahajan Lead College Tutor the SOE. We need to keep the exams SM: Potentially, anaesthetists in training could find that The issues of rest, hydration and (PA(A)s to be regulated, and it looks as Vice-Presidents Emma Stiby evolving, but we can’t change too much the development of perioperative medicine offers availability of basic facilities are something if that will happen. Making sure that we Janice Fazackerley and SAS Member too quickly. If you are an anaesthetist many more opportunities to get involved in a patient’s I raise at every opportunity with have the right training opportunities Simon Fletcher in training who is well prepared, I don’t journey and influence patient care. It also gives us Katie Samuel government and national NHS leaders. in place brings us full circle to our opportunities to help design and improve clinical and Editorial Board Trainee Committee In my mind this is the starting point to think being examined a bit differently conversation about the new curriculum. logistical pathways, so that we are giving our patients David Bogod, Editor improve all doctors’ lives and is the urgent should make a big difference… Carol Pellowe SM: It’s not just the clinical skills that are more effective care and, hopefully, making the system priority, as having greater control of rotas Jaideep Pandit Lay Committee SM: … then how does the College’s important to be a well-rounded doctor, more efficient. This aligns with our ‘millennial’ aspirations is of limited value if your wellbeing is not Council Member Gavin Dallas Examinations department ensure there is but also the professional and managerial to make the world, or at least the NHS, a better place. provided for when you’re working. Krish Ramachandran Head of Communications consistency in exam quality and difficulty skills. I’m an ST7 now, and I feel that [To bring the conversation to a close, the interviewer asked Council Member Mandie Kelly SM: Obviously, there was a lot of as it changes? I have a solid clinical skill set, but I’m both Sarah and Ravi what one change they would make if Website & Publications Officer contention surrounding the introduction less confident that I’ve developed the Joanna Budd RM: Many trainees won’t be aware of they had a ‘Magic Wand’ for the NHS] Lead Regional Advisor of the new junior doctors contract, skills needed to run a list or coordinate Anamika Trivedi this, but when changes are made to the Anaesthesia but what we have ended up with does with other teams within a hospital. Do : I would like every department to introduce a ‘Lead Website & Publications Officer exam, many examiners will try it out and SM include a number of components that you think the final years of training for Humanity’ whose role is to make sure everyone was sit it themselves. Then we have people Articles for submission, together with any declaration are meant to ensure that we have a adequately prepare us for the whole well rested, had time to eat and hydrate, take scheduled who have passed the exam take the new of interest, should be sent to the Editor via email to better experience – exception reporting, scope of the role of consultant? breaks and had been able to plan clinical commitments exam as a mock as a way of piloting. [email protected] personalised work schedules, among for the coming weeks alongside their life outside of work. We don’t change the exam without RM: With a competency-based clinical others. Is delivering these aspects of All contributions will receive an acknowledgement and the proper safeguards in place, but as I say, curriculum, we lost some focus on the : I would ‘boundary bust’ wherever I could: between the contract something the College has RM Editor reserves the right to edit articles for reasons of space we need to keep the exam up to speed professional skills you’ve mentioned, and primary and secondary care, between surgical and been involved with? or clarity. with contemporary practice, and it will one of the aims of the new outcomes- anaesthetic teams, and across all our specialties. I like RM: Our College Charter says we are here change regularly. based curriculum is to bring that back. specialties, but I don’t like specialism where that makes The views and opinions expressed in the Bulletin are solely to educate and train our members and you think about your own narrow area and not about the those of the individual authors. Adverts imply no form of support research for the benefit of patients. whole person. endorsement and neither do they represent the view of We do not have a direct role in contractual the Royal College of Anaesthetists. issues in the way the BMA does. That *The interview was conducted on Monday 11 February doesn’t mean we have washed our hands 2019 at the College. Thanks to Sarah for her time and to © 2019 Bulletin of the Royal College of Anaesthetists of the issue, and we do have a role – as RM: I cannot accept the idea her department for allowing her the time away. All Rights Reserved. No part of this publication may be reproduced, we’ve discussed – in understanding stored in a retrieval system, or transmitted in any form or by any other As ever, if you have any comments about this month’s how the impact of the new contract is that putting up with poor means, electronic, mechanical, photocopying, recording, or otherwise, President’s View, please do get in contact by emailing without prior permission, in writing, of the Royal College of Anaesthetists. impacting on the delivery of safe patient [email protected] care, as neither exists in isolation. welfare standards can be ISSN (print): 2040-8846 ISSN (online): 2040-8854 So indirectly, if there are elements of the synonymous with resilience contract that might affect patient safety, for example the issues of fatigue and the

NEWS IN BRIEF News and information from around the College

Advisory Professor Bryn Anaesthetic Appointments Baxendale discusses CCT Curriculum Committee News the merits of the Review 2020 The College is pleased to announce College’s new Following publication of the General the appointment of Dr Ewen Forrest Medical Council document Excellence and Dr Sian Jaggar as joint leads for Simulation Strategy by design: standards for postgraduate the College’s Advisory Appointments curricula in 2017, the curricula for The College has recently released a digital The College to launch the Centre for Committee (AAC) work stream. Dr all medical specialties must be recording of an interview with Professor Bryn Baxendale (Chair of the Simulation Forrest has recently demitted as lead revised in line with these standards Perioperative Care Working Group) discussing the launch of the new five year Simulation Strategy. regional advisor for the College by 2020. The existing Anaesthetic During Anaesthesia 2019 on 20–22 May, College Council member, (2015-18), after many years of acting Certificate of Completion of Training Simulation is a recognised method used to enhance education and training Professor Mike Grocott will launch the Centre for Perioperative Care as regional advisor for Mersey. He Curriculum was launched in 2010 opportunities for the anaesthetic profession. It is also used to examine standards of (CPOC). He will outline how the College (along with partners) will develop is a consultant anaesthetist at the following approximately a two- practice, and ‘stress test’ the safety of existing or new systems and processes. a centre for perioperative care with its aim to facilitate closer and more Countess of Chester Hospital in year development process. Various effective cross-College and cross-organisation working on perioperative Liverpool. Dr Jaggar is a Training The simulation strategy aligns with key principles of the College’s overall strategic changes and additions have been care for patient benefit. Programme Director for ST3-4 at plan to support anaesthetists, improve standards in clinical practice, research made to it since that time, however the Imperial School of Anaesthesia, and development. Please find further information about this strategy bit.ly/ a full, wholesale review of its clinical The Anaesthesia 2019 programme incorporates many chances for attendees to and is also deputy chair of the RCoASimulationStrategy and to listen to the interview with Professor Bryn content has not been undertaken since get closer to the ideals for the centre. Talks by Professor Denny Levett discussing Primary FRCA for the College. She Baxendale bit.ly/RecSimulation. it was first written. the benefits of health and fitness prior to and post surgery and Dr Chris is a consultant anaesthetist at Royal Snowden discussing GIRFT, a clinician-led programme aimed at improving Read more about simulation and multiprofessional crisis resource management All medical specialties must align Brompton Hospital. patient care by reducing unwarranted variation in service provision and clinical (CRM) team training on page 52. their curricula to certain requirements practice, will all help build a vision for the centre. The last day of Anaesthesia including: 2019 includes a panel discussion on the vision for perioperative care and those ■■ introducing generic professional in attendance will be encouraged to ask questions about CPOC plans. capabilities From a physical space within the College and working alongside the Royal The College marks NHS Sustainability Day with the ■■ be structured round a limited College of Physicians, Royal College of Surgeons, Royal College of Nursing, number of ‘learning outcomes’- Royal College of General Practitioners and others, CPOC will coordinate launch of its Sustainability Strategy activities that describe the work of perioperative care initiatives across the health and social care landscape. The College celebrated NHS Sustainability Day (21 March) with the launch of its Sustainability Strategy an independent clinician in each Multidisciplinary working groups will be established in specific topic areas www.rcoa.ac.uk/sustainability-strategy. The vision for the College clearly states its commitment to particular discipline such as prehabilitation and post-operative care, which will inform the embedding sustainability in everything it does and Council member, Dr Lucy Williams created a robust development of College and stakeholder initiatives. Further information and regular updates and comprehensive strategy to encompass this. The strategy outlines priorities, implementation and about the curriculum review on specially Effective delivery of perioperative medicine within the UK will be achieved how the College’s Sustainability Strategy will be measured to ensure that achievements clearly align to created webpages can be found at: through regional coordination to augment national efforts. These will include the College’s vision. bit.ly/RCoA-Curriculum2020. building on the College’s existing network of perioperative leads and local NHS Sustainability Day celebrates the importance sustainable development plays within the UK’s national health services. The networks as well as supporting multi-disciplinary regional education, training, The 2020 Anaesthetic Curriculum College undertook social media activity on NHS Sustainability Day not only to support how members celebrated but also to quality improvement and research initiatives in conjunction with other specialties. must be fit for purpose for now and the showcase the College’s strategy. In addition, a blog bit.ly/RCoABlogMar19 written by Dr Lucy Williams was also released on the future so your input and support will be This is an exciting and ambitious project and we look forward to keeping you day which took a closer look at the aims of the Sustainability Strategy and why it was created. vital to contributing to this review. informed of developments in the coming months. The College is a founding partner of the UK Health Alliance on Climate Change (UKHACC) and worked with UKHACC to share messages about the College’s Sustainability Strategy and the blog to its network.

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NEWS IN BRIEF News and information from around the College

FACULTY OF Latest news from the Guidelines for Provision of Anaesthetic PAIN MEDICINE of the Royal College of Anaesthetists #FightFatigue Working Group Services 2019 World Sleep Day (15 March 2019) marked one year since the launch of the Affiliate Fellowship The College is pleased to announce that national Fight Fatigue campaign, a joint initiative of the College, the Association of ACSA The Faculty of Pain Medicine (FPM) the Guidelines for Provision of Anaesthetic Anaesthetists and the Faculty of Intensive Care Medicine. Anaesthesia Clinical Services Accreditation has created an Affiliate Fellowship SNAP3 call for Services 2019 (GPAS) have now been route to open up membership for The campaign aims to raise awareness of the impact of fatigue and shift work on published. This is the first time that all Acute Pain / Inpatient Medicine our NHS workforce. Despite growing support for the campaign there is still much topics chapters have been updated using our NICE accredited development process. doctors to join the FPM family. The to be done and fatigue continues to impact the health and wellbeing of those The College is seeking topic proposals ACCREDITATION NICE accreditation gives additional Board has been undertaking work on working in the NHS. for SNAP3 – the next Sprint National Acute Pain Medicine (from training credibility to GPAS, providing independent To celebrate the day, the team released a short animation across social media about Anaesthesia Project. Proposals are to membership) over the last two assurance that the guidelines are robust and evidence based. the importance of getting enough sleep and the impact that sleep deprivation has on a welcome from anaesthetists, other years and there was a strong view person’s physical wellbeing. healthcare professionals and members First published in 1994, GPAS is designed for anaesthetists with managerial from within the Faculty that there was of the public. responsibilities to set recommendations which inform how anaesthetic departments a need for it to be an all embracing In addition, the #FightFatigue Working Group were also honoured with the SNAPs are short observational clinical are run. Not only does GPAS shape the standards used by the Anaesthesia Clinical home for doctors active in all types of Humphry Davy award. Given to individuals or teams, for sustained contributions to research studies examining an area Services Accreditation (ACSA) scheme, but national regulators also recognise them. pain medicine. This route is also open the College. of importance for patient benefit, to pain medicine consultants without We are always looking for ways to improve GPAS. In line with the College strategy The following team members were awarded: which aim to recruit a large number the examination who are not eligible on perioperative medicine and the establishment of the Centre for Perioperative of patients from as many NHS for fellowship by any other route. ■■ Dr J-P Lomas ■■ Dr Nancy Redfern Care (CPOC), in partnership with the Royal Colleges of Surgeons, GPs, Physicians hospitals as possible in a short period. ■■ Dr Felicity Corcoran ■■ Dr Kathleen Ferguson and Nursing – GPAS work has begun on a new chapter for the perioperative care www.rcoa.ac.uk/node/28825 An additional important feature of of elective and urgent care patients. ■■ Dr Emma Plunkett ■■ Russell Ampofo SNAPs is engagement of ‘grass-roots’ ■■ Ms Nicola Heard ■■ Gavin Dallas anaesthetists, particularly trainees, in

e-Learning is evolving ■■ Dr Roopa McCrossan ■■ Daniel Waeland their delivery.

Our award winning e-Learning resource ■■ Professor Jaideep Pandit Previous SNAPs examined patient is evolving. Find all the latest BJA reported outcomes after surgery and Survey into Children’s Acute Education articles and MCQs to help anaesthesia, and the epidemiology Abdomen Surgery with your study and gain CPD points. and decision-making around The improved e-Learning resource offers postoperative critical care admission. an even easier navigation experience Proposers of shortlisted topics will for members by combining the article be invited to present the topic at a link with MCQs within the session. There selection meeting on Monday 1st July. is also improved user functionality with Proposing a topic does not commit the the e-Learning Physiology module proposer to leading the topic; the lead CASAP (Children’s Acute Surgical Abdomen Programme), the HSRC’s first reorganised into a new structure with for SNAP3 will be selected through a paediatric initiative, is now running its organisational survey. Should your nine easy to find sub-topics. separate process in Autumn 2019. hospital be participating in this important pilot programme to characterise e-Learning is free to those within an Please complete the SNAP3 Proposal the type and quality of care being delivered to children undergoing NHS email address – but if you do not Form available at www.niaa-hsrc. emergency abdominal surgery (including appendicectomy)? have an NHS email address, you can org.uk/SNAP3-Home and submit Visit www.niaa-hsrc.org.uk/CASAP-Home for more information. purchase a licence through e-integrity at to [email protected] before 9am on bit.ly/2HlPDVx Friday 31 May 2019.

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Bulletin | Issue 115 | May 2019 Bulletin | Issue 115 | May 2019

Dr Katie Samuel RCoA Trainee Committee

No doubt, most will be aware of the recent National Anaesthesia Project) respectively. developments concerning fatigue, wellbeing Dr Laura Carrick will outline the power and resilience in the anaesthetic and wider and reach of RAFT (Research and Audit healthcare community. One of the first Federation of Trainees) in enabling steps in recognising the prevalence of the anaesthetists in training to be involved problem among anaesthetists in training was in high-quality research alongside their the College’s morale and welfare survey, clinical training, in addition to discussing published in 2017. It worryingly identified the innovation of a large-scale, digitally- that 61 per cent of anaesthetists in training run study. As his PhD draws to a close, felt the job had an adverse effect on their Dr Danny Wong shares his reflections mental health, with all grades of training at on the SNAP-2 study that has drawn the significant risk of burnout. These results have attention of the UK press in its observations since been echoed by the SWeAT study on cancelled operations, and shares his (Satisfaction and Wellbeing in Anaesthetic thoughts on the infrastructure needed for Training), with recent work being undertaken successful research delivery. by the government-initiated Behavioural Perioperative medicine has evolved Insights Team, searching for focal process- to become a mainstay of the training level interventions. curriculum, with rapidly expanding service While life as an anaesthetist in training development implications and interest as can no doubt be challenging at times, this an area for specialist training. We begin by issue pays respect to that challenge and hearing from Drs Anas Zyada, Samantha the improvement initiatives that have been Moore and Nicole Greenshields about undertaken, while taking the opportunity the National Perioperative Medicine to celebrate the successes and excellence Roadshow, an innovative initiative to bring that have been achieved notwithstanding quality perioperative-medicine education to this. We will hear from anaesthetists in doctors in training around the country with training from around the country who have the aim of progressing from London-centric Guest Editorial led and achieved excellence nationally and national perioperative-medicine events. internationally, as well as reflecting on the Continuing the theme, and recognising advances made in understanding our own the need for education of the whole Growing resilience and limitations and supporting our specialty’s multidisciplinary team to effect change and members. The themes of collaboration, the importance of safer surgery globally, camaraderie and team work are openly I will then outline the global progress and incorporated and (quite rightly!) embraced success of the massive open online course developing excellence in the articles that follow. (MOOC) ‘Perioperative Medicine in Action’.

Welcome to the annual issue of the Bulletin led by anaesthetists in training. It has been a record-breaking 18 months The developments that have been made in In this issue we focus on the national movement towards improving resilience for research led by anaesthetists in training, the last year in supporting wellbeing and and we will hear about both of the largest- resilience at work have been remarkable, in anaesthesia, while celebrating the work of anaesthetists in training who have ever consenting and non-consenting trials and Dr Sally El-Ghazali closes the edition achieved national excellence in the fields of education, research and innovation. in anaesthesia to date – DALES (Drug by celebrating the initiatives led by Allergy Labels in the Elective Surgical anaesthetists in training, while making a case population) and SNAP-2 (Second Sprint for the transition to emotional intelligence.

12 | | 13 Bulletin | Issue 115 | May 2019 Follow us on twitter at @triperioperati1,

with others in the field, and encouragement our endeavours. However, conventional or drop us an email at THE PERIOPERATIVE MEDICINE for cross-specialty collaboration. Didactic training rarely offers the opportunity or [email protected] for and interactive sessions are delivered by experience to prepare for large-scale event more information a number of nationally renowned and planning, and so resilience and persistence ROADSHOW: RUNNING A local POM specialists. Topics covered are needed. include intraoperative fluid management An enthusiastic and receptive group of with haemodynamic simulation, enhanced individuals is vital to assure success, with recovery, perioperative anaemia, NATIONAL EVENT the Roadshows allowing local teams cardiopulmonary exercise testing, frailty, to be involved in and part of their local and the Perioperative Quality Improvement events planning. Roles such as booking Programme. It has been prospectively venues, arranging speakers, advertising, awarded CPD points through the RCoA. and administrative duties were completed Roadshow success as a team. The use of instant messaging and online document sharing allowed Dr Anas Zyada, TRIPOM Roadshow Lead At the time of going to press, the first two most of the planning to be done despite Dr Nicole Greenshields, TRIPOM Committee, Events Team Roadshows have taken place in Swansea geographical separation, with regular and Brighton in October and December Dr Sam Moore, TRIPOM Committee, Events Team instructions and updates to the local teams. 2018 respectively. These were attended by doctors in training of all disciplines, specialty Despite the hard work and dedication In 2018, TRIPOM (Trainees with an Interest in Perioperative Medicine) launched doctors, consultants, medical students, and needed to make the Roadshow a multidisciplinary team members. Events will success, there is no doubting the sense its national Perioperative Medicine Roadshow, an educational programme also be taking place in Stoke and Oxford in of accomplishment and satisfaction it aiming to bring perioperative medicine to all training deaneries in the UK. February and April 2019. brings, especially when considering that it has been undertaken alongside clinical A total of 149 people enrolled for the anaesthetic training. TRIPOM is an international society, TRIPOM therefore decided to create up their time, we are able to provide a first two Roadshows, with 85 per cent based in the UK, providing access to a mobile perioperative conference – quality POM educational resource free stating afterwards that learning from the Join us! free educational resources, events, the Roadshow – with the purpose of of charge for attendees. day will directly influence their clinical and opportunities for publications in making POM education more easily TRIPOM is free to join (all welcome), and The Roadshow visits each training practice. We are grateful for the qualitative perioperative medicine. Established available to doctors in training from provides a number of free resources via the deanery in the UK (one every two feedback from candidates, which has been in 2016, it is run by and for doctors all regions. With an educational grant website www.tripom.org. These include: months), offering a free POM education overwhelmingly positive: in training. It is a multidisciplinary from Edwards Life Sciences and the ■ day mapped to the curriculum, a chance ■ details of fellowships in perioperative collaborative of perioperative medicine generosity of our speakers in giving ‘Excellent range of cross-specialty for POM-interested doctors to network medicine enthusiasts with regional leads in each speakers’ ■■ Perioperative Medicine in a Nutshell training deanery in the UK. Figure 1 Job titles of Roadshow attendees ‘Leaving feeling very energised re POM’ – a series of short articles on key ‘A fantastic event’ Why the need for a national topics that are published in the British Journal of Hospital Medicine, written by 18% 11% The Roadshow will be travelling to Bristol Perioperative Medicine Foundation year TRIPOM members Roadshow? on the 3 June 2019, and free places can 3% CT/ST 1/2/3 be booked online: http://bit.ly/2Eu0eLa ■■ Perioperative Medicine Tutorial of Perioperative medicine (POM) is a core Pending further funding, TRIPOM will the Month (POMTOM) – longer curriculum topic in anaesthetic training, ST 3/4 continue the Roadshow into the latter articles on interesting topics within as well as a mandatory element of both 36% half of 2019. perioperative medicine, accompanied surgical and medical training. However, 23% ST 5/6 by self-test MCQ’s. most national perioperative medicine Consultant Reflections on running large courses and conferences with nationally We are running a breakout session at the reputed speakers are based in London, SAS events Anaesthesia conference, 20–22 May 2019 which, with limited study leave and What is needed to set up a national event? (www.rcoa.ac.uk/anaesthesia), and an 13% Other budget, can make it difficult for those in Resilience, proactivity and organisation! educationally focused day at the TRIPOM As anaesthetists we are high achievers, Annual Congress held at the British training to attend. 45% and therefore naturally feel the need Museum on 3 July 2019 (https://ebpom. to maintain the highest standards in all org/TRIPOM-2019).

antibiotic used for prophylaxis in place of Figure 1 Map of the TRNs throughout the UK. Details of the TRNs can be found on Dr Laura Carrick penicillin for penicillin-allergic patients. the RAFT website (www.raftrainees.com/member-research-networks.html). RAFT Secretary, Patients over 18 years of age undergoing ST6 East Midlands Deanery elective surgery were recruited, with demographic and baseline data collected. Follow-up was required for those patients who had a specific beta- lactam and/or opioid allergy label, and looked at whether they had received beta-lactam or opioid medication at any RAFT AND THE POWER point and if any unexpected or adverse event had occured. Anaesthetists working on the designated study days were also asked to complete a drug OF CITIZEN SCIENCE allergy knowledge and attitudes survey. On behalf of the RAFT committee and Trainee Research Network This data collection occurred over three study days. Since the first trainee research network (TRN) was established in 2012, DALES has become the largest-ever consenting anaesthetic study in the beyond anaesthesia, with cross-specialty national studies, which have all utilised engagement with research by anaesthetists in training has grown to the extent UK, with recruitment across England, projects linking anaesthesia with collaboration to generate huge data sets, Northern Ireland, Scotland and Wales. that there are now 18 regional and 3 subspecialty TRNs – paediatrics (PATRN), orthopaedic and general surgical TRNs. with the idea that such large numbers 1,500 local investigators at 214 sites pain (PAINTRAIN), and military (TriSTAR). provide high-quality information. This recruited 2,100 patients and 5,000 A number of the TRNs have led is the underlying principle of citizen anaesthetists. As an NIHR portfolio study educational meetings within their regions, The TRNs provide all anaesthetists in RAFT has, to date, led three national the Elderly), and most recently DALES science, and the success of the NAPs this large-scale recruitment translated providing relevant knowledge and training with the opportunity to engage projects: COMS (Cardiac Output (Drug Allergy Labels in the Elective and RAFT projects clearly demonstrates into significant financial gain in the form promoting research within anaesthesia. in audit, quality improvement, and Monitor Study – looking at the Surgical population). Each project has the power this has, as well as being of accruals for each site. The project Through this and through project research projects. Harnessing the power availability of cardiac output monitors been chosen, developed and led by something that is within everyone’s reach. was also the first to utilise realtime of collaboration, the Research and and the impact of NICE guidance anaesthetists in training, with each activity, more anaesthetists in training secure data uploading online using Audit Federation of Trainees (RAFT)1 is and Commissioning for Quality and project relevant, topical, and aiming to than ever are completing their Good The achievements of the TRNs, both REDcap software on such a large scale, an umbrella organisation that links the Innovation (CQUIN) payment schemes), achieve something meaningful for both Clinical Practice training. For many, individually and collectively through demonstrating the feasibility of such a TRNs together. iHYPE (Intraoperative Hypotension in patients and anaesthetists. their involvement with their TRN has RAFT, have developed research system and the digital potential for future proved to be educational with the added education and activity by anaesthetists large multicentre trials. Study results are benefit of meeting many of the Annex G in training to a new high level which has Local DALES data collection team members DALES expected to be shared and published requirements, and, significantly, this work resulted in recognition by the RCoA, the The 2018 DALES study aimed to explore later in 2019. is now receiving recognition by deaneries, AAGBI and the NIAA. This is all thanks the prevalence of allergy labelling and with the work recognised at ARCPs. to the hard work and sheer excellence of assess the knowledge and attitudes Impact for anaesthetists in the anaesthetists involved. of anaesthetists towards this. Drug training Traditionally the focus has been on allergies are of particular relevance to research quality and randomised A recent survey of TRN activity has References anaesthetists, as patients can present controlled trials (RCTs), but with such revealed that all the TRNs have taken 1 RAFT (www.raftrainees.com/). with a wide range of allergies; however work often appearing to be distant part in at least one NIHR portfolio 2 Harper NJN et al. Anaesthesia, Surgery it is commonly accepted that many from normal everyday clinical practice study, proving that the aim to facilitate and Life-Threatening Allergic Reactions: of these are reported incorrectly. and not easily within reach for most. Management and outcomes in the easy access to research for all is being Consequently the patient may receive However, it is increasingly recognised 6th National Audit Project (NAP6). Br J achieved. Many of the TRNs are also Anaesthesia, 2018. 121(1):172-188. alternative medications which potentially that RCTs are not the only way in which running locally developed regional could lead to harm. This is exemplified 3 National Audit Projects. NIAA. meaningful research can be conducted. (www.nationalauditprojects.org.uk). 2 multicentre projects, and collaborative by the recent results of NAP6 which This is exemplified by both the National projects between TRNs have flourished. highlighted a 17-fold increase in the Audit Projects (NAPs)3 and RAFT’s Further, collaborations have extended risk of anaphylaxis with teicoplanin, an

anaemia and setting up intravenous iron Figure 2 Map showing global locations of course students services, how POM can improve care in Key: emergency paediatric surgery, and an Number GLOBAL REACH OF THE introduction to the Perioperative Quality of joiners Improvement Programme. The course also has a Spanish translation available to PERIOPERATIVE MEDICINE ‘MOOC’ improve its global accessibility. This is the first free and open access course on POM that is available to Dr Katie Samuel all members of the MDT, and in all Perioperative Medicine in Action Lead Educator, countries of the world. It has broken ST7, Bristol School of Anaesthesia boundaries in both reach and popularity. We are beyond proud that its quality and innovation has been recognised with formal endorsement from the Royal Why perioperative medicine? College of Anaesthetists, the World Federation of Anaesthesiologists, the High-risk surgical patients are at significant risk of perioperative complications and of students, and globally available. A and higher POM curriculum modules – Colombian Anaesthetic Society, and MOOC in POM was therefore exactly great for helping sign-offs! death, and a call to make changes to care provision to improve their outcomes the International Board of Perioperative the platform needed to disseminate 1,2 Medicine. has been made globally. Perioperative medicine (POM) is the practice of high-quality, free POM education Achieving excellence multidisciplinary and integrated medical care that aims to optimise the clinical around the world. Through a competitive To date, the course has been accessed If you are interested in taking the pathway of these patients by providing a clear care structure from the moment process, a grant from University College by more than 16,000 people in 140 course, then simply visit London was secured, and a space on the countries. The majority of these are www.futurelearn.com/courses/ 3 the patient is considered for surgery until they have fully recovered. MOOC platform, Futurelearn, acquired. UK-based anaesthetists, but all members perioperative-medicine, create a profile, of the MDT are represented, as well and sign up for free. The next courses Since its first inclusion in the training to become a mainstay of anaesthetic staff (doctors, nurses, pharmacists, The ‘Perioperative Medicine in Action’ as individuals from both high- and start on 1 July and 4 November 2019 – curriculum in 2015, supported by the training and service development. physiotherapists) to learn more about course was created, with definition of low-income countries. The course has we look forward to ‘seeing’ you there! RCoA vision document ‘The Pathway to There is also significant interest from how POM can improve patient the course content beginning with a been commended for its global reach, 3 review of the current evidence base better surgical care’, POM has evolved all levels and specialties of healthcare outcomes. While there are courses in A huge thank you and recognition to the for POM, as well as seeking examples popularity (200,000 learning steps POM available, they all involve a not- work of Dr Abigail Whiteman (current lead of outstanding perioperative care to completed and 16,000 forum posts Figure 1 Topics covered by ‘Perioperative medicine in action’ course insignificant enrolment fee, and are not educator and course initiation), encourage learning from excellence. The made), high completion rate, and high openly available to all members of the Dr Phil Sherrard (previous lead educator Week 1 The surgical epidiemic course structure was divided into four learner-retention index (0.475). team. and course initiation), POM UCL team, ■■ Defining the high-risk surgical patient and the need to change the way we care weeks (see Figure 1). for them. Qualitative analysis of post-course the RCoA, and all other contributors for We wanted therefore to create a free, ■■ An introduction to perioperative medicine and RCoA vision for improved Delivery is in a number of short survey comments showed that learners their input and support. accessible online course on POM perioperative care. steps that take around 15 minutes to thoughtTitle of theimage course was of ‘very high that was available and relevant to all ■■ New perioperative medicine pathways. complete, and uses a variety of media quality’, ‘beneﬁcial to the MDT’, and References members of the multidisciplinary team Week 2 Risk assessment and shared decision making – review articles, videos with experts, ‘an outstanding innovative mode 1 The International Surgical Outcomes Study (MDT), no matter where in the world Group. Global patient outcomes after elective ■■ The role of risk assessment tools, including CPET and risk scoring systems. and polls for you to voice opinions of education’. The course has had they were based. surgery: prospective cohort study in 27 low-, ■■ Shared decision making; what it is, why it is so important and how to achieve it. and hear others from around the universally positive feedback from middle- and high-income countries. British world. Contributions from more than learners, with 84 per cent reporting that Journal of Anaesthesia 2016;117:601–609. Week 3 Protocols in surgical care Why a MOOC? ■■ The principles of enhanced recovery. 50 POM experts representing more it will directly ‘improve their patient care’. 2 Pearse RM et al. Mortality after surgery Online education has evolved from in Europe: a 7 day cohort study. Lancet ■■ Professional and patient engagement with protocols. than 30 institutions around the world simple e-learning to something In such a fast-moving specialty, our 2012;380(9847):1059–1065. ■ are included, and social learning is ■ Protocols in care of the emergency surgical patient. 3 The Royal College of Anaesthetists. substantial enough to harness encouraged in the course’s forums. The main challenge has been to ensure that Perioperative medicine: the pathway to Week 4 An age old problem each course run is up to date with the international education. The ultimate course was launched in 2016, and is run better surgical care. 2015 (www.rcoa.ac.uk/ ■■ The unique perioperative problems of the elderly. configuration of this is the Massive Open over a four-week period, three times latest evidence-based interventions, periopmed/vision-document) ■■ How to improve perioperative care of the elderly. Online Course (MOOC). This is, exactly a year. It takes roughly 2–3 hours per and incorporates improvements in 4 Grocott MPW, Pearse RM. Perioperative ■■ The current economic climiate and how perioperative medicine is the value as the name suggests, hosted online, week to complete, and covers all of the response to learner feedback. Examples medicine: the future of anaesthesia? British proposition. Journal of Anaesthesia 2012:108(5):723–726. free to users, unlimited in the number clinical topics from basic, intermediate include new sections on perioperative

Dr Danny Wong Trainee Lead, SNAP-2

Reflections on SNAP-2 and collaborative research successes in the UK Where has all the time gone? As I sit down and write this article, almost three years have passed since I first embarked on my time out of training to work on the second Sprint National Anaesthesia Project (SNAP-2), which many readers will no doubt have come across at some point in the last couple of years. Now, as I am preparing to return to training, it is a good time to take stock of what the project has achieved.

In the spring of 2017, frontline anaesthetists planning to ensure the NHS can continue success has led to substantial international led by doctors in training in many late in the training cycle. In contrast, postoperative critical care provision for all over the NHS participated in data to deliver quality care to patients in the interest, with many colleagues around other countries as well. the FRCA exams are midway through patients undergoing surgery, and also for collection for SNAP-2, and since then we perioperative period. Source data from the world asking how we manage it and ■■ Strong membership links with training for anaesthetists, and there what it revealed about the enthusiasm and have published the first peer-reviewed the second paper in particular is playing a whether our research delivery model and through the Royal College of is acknowledgment that our long energy for delivering research that sits on article from the study in the British Journal central role in the intensive and critical care would work in their local contexts. I have Anaesthetists and the Association of clinical careers benefit from the diverse the frontline of the NHS. Long may the of Anaesthesia (BJA). This generated workstream for the Getting It Right First written elsewhere5 about the factors that I Anaesthetists: anaesthetists in the UK experiences acquired post-fellowship. latter continue! 2 Therefore, we are all encouraged to be significant public interest, with more than Time (GIRFT) programme. think have been crucial to the delivery of have an active social and professional involved in local, regional and national References 2,900 collaborators across the UK listed collaborative multicentre research, but I engagement with the College and The success of SNAP-2 is entirely the projects to develop skills which will 1 Wong DJN et al. Cancelled operations: a on PubMed as collaborators.1 That work, would like to reiterate them here: the Association. The strong sense of result of frontline contributions from ultimately benefit patient care. 7-day cohort study of planned adult inpatient describing the scale and reasons for anaesthetic community means that the surgery in 245 UK National Health Service working anaesthetists across the NHS, ■■ Trainee research networks: there are members of both organisations are I would like to take this opportunity to hospitals. British Journal of Anaesthesia surgical cancellations in the UK, was picked both consultants and anaesthetists in now more than 20 trainee research often very motivated in participating (advanced online access) DOI: https://doi. up by all the major newspapers in the training, who provide high-quality data networks spread out across various personally thank all the anaesthetists in the activities of the group, and org/10.1016/j.bja.2018.07.002). UK and reported by many regional BBC alongside the provision of high-quality regions in the UK, coordinated by who have taken an interest in SNAP-2, this principle of community runs 2 Getting It Right First Time: intensive radio stations. A second paper has also patient care, often in the midst of the Research and Audit Federation and also thank them for their continued and critical care workstream. (https:// all the way through in maintaining been accepted by the BJA, and this also significant difficulties as the NHS faces of Trainees (RAFT).6 The networks involvement in the National Audit Projects gettingitrightfirsttime.co.uk/clinical-work- clinical standards, and fostering future stream/intensive-and-critical-care). includes data contributed by collaborators austerity together with increased service provide different regions of the (NAPs) and SNAPs. More papers are anaesthetists through education 3 iHypE: Intraoperative hypotension in elder in Australasia from their iteration of SNAP- demands. The UK anaesthetic research UK with a way of coordinating planned from SNAP-2, and manuscripts and training, as well as improving people. (www.i-hype.org). 2 Down Under, which describes and are currently being prepared to provide community now has a proven record research activities, and facilitate 4 DALES: Drug Allergy Labels in the Elective knowledge through research. answers to some of the other research compares the critical care and high-acuity of producing high-quality, impactful the delivery of larger projects that Surgical population. (www.raftrainees.com/ facilities available to postoperative patients research projects such as the National involve multiple hospitals. They are ■■ Post-fellowship training: for many questions which SNAP-2 was designed project-summary.html). in the UK, Australia and New Zealand. Audit Projects and SNAPs, and other a powerful resource for crowd- other medical specialties, technical around. SNAP-2 has been an extremely 5 SNAP-2 and training research networks. Findings from both these papers are likely projects like iHypE3 and DALES4 led by sourcing data, and are now serving education is the focus of specialty informative study both for its findings The Gas 2018;21:9. to contribute significantly to future service anaesthetists in training. Our collective as a model for research initiatives training, and fellowship exams come about the structure and processes of 6 (www.raftrainees.com).

20 | | 21 Bulletin | Issue 115 | May 2019

with leadership, such as intelligence, toughness, determination and vision, are required for success, they are insufficient on their own. Truly effective leaders are Growing in emotional also distinguished by a high degree of emotional intelligence, which includes: resilience requires that

■■ self-awareness – knowing yourself and your own resources, instincts and we work towards greater actions ■■ self-regulation – managing your own self-knowledge state, impulses and reactions

■■ motivation – emotions and drivers that help towards achieving goals induction. Resources to make your life or career. More information on ■■ empathy – awareness of others’ #CoffeeandaGas a big success can be this can be found at: www.aagbi.org/ feelings, needs and concerns found at: www.aagbi.org/professionals/ professionals/welfare/mentoring/aagbi- mentoring-scheme ■■ social skills – ability to interact with welfare/coffee-and-gas others and get the desirable response Another project led by doctors in training Dr Sally El-Ghazali Essentially, strong emotional intelligence which promotes emotional intelligence Although some of these schemes outline Chair, Association of Anaesthetists and resilience helps us deal with is the #KnockItOut campaign. This is help to promote resilience and emotional Trainee Committee adversity and failure without finding a joint venture between the RCoA and intelligence, it is important that these ourselves stuck in a rut. Growing in AAGBI, utilising the work done by the should not be used in isolation. Providing someone with the skills and the support emotional resilience requires that we British Orthopaedic Trainee Association. to deal with stressful situations will only work towards greater self-knowledge. It It focuses on the importance of a positive go so far, and may give the perception is important, for example, that we learn workplace culture that is free from that if someone is struggling they are to identify how we react in emotional bullying, harassment and undermining not ‘resilient’ enough. Therefore, while situations; becoming aware of how we behaviours. The initiative highlights it is important to help people develop react when stressed helps us gain better the negative behaviours within an GROWING RESILIENCE AND their emotional intelligence, this needs to control over those reactions. environment, and empowers individuals be done in conjunction with improving to speak up if they experience or witness the environmental factors that may be Training and development unacceptable behaviours. EMOTIONAL INTELLIGENCE contributing and mitigating their impact. Teaching and training in emotional Resilience is described as the capacity to maintain wellbeing, cope with working intelligence and wellbeing support have There are many schemes run by the grown hugely in the last few years. The Association of Anaesthetists and the under pressure, and the ability to bounce back from setbacks effectively. Association of Anaesthetists Trainee Association of Anaesthetists Trainee Committee have helped to develop Committee that can help develop There has been increasing interest in need support, as without this they may of others, for self-motivation, and for and introduce the #CoffeeandaGas and nurture emotional intelligence. resilience and resilience education, feel not only overwhelmed but also managing emotions well individually and initiative. This is a wellbeing project One such project is the Association both within medical schools and the professionally unfulfilled. in relationships. Understanding the root in which we encourage anaesthetists of Anaesthetists’ national mentoring anaesthesia training programme. cause of our emotions and how to use The natural progression for some, in training, consultants and all theatre scheme. This was set up to allow However, there appears to be selective them can help us effectively identify who therefore, seems to be to turn towards the members to spend time with a trained criticism of this concept, as some feel we are and how we interact with others. staff to take time out of a busy working concept of emotional intelligence rather mentor in their region to help establish that it does not matter how ‘resilient’ an day to come together and have a than resilience. While resilience forms an Emotional Intelligence became a their values and goals, and to explore individual is if they are not working in a chat! Conversations are important to important component of it, emotional popular subject to explore in the 1990s what will help or hinder them in making culture of wellness. Most importantly, help us share our experiences and intelligence encompasses much more after the publication of the psychologist changes. It enables mentees to achieve just because someone is labelled as reduce stress levels. It has been a great than this. It is defined as the ability to Daniel Goleman’s work. He found that ‘resilient’, it does not mean they do not success, with some departments running something they care about and bring recognise our own feelings and those while the qualities traditionally associated this regularly or during departmental about a positive change in their personal

Professor Mike Bennett Project Lead on behalf of the Faculty of Pain Medicine Cancer Pain Forum

In 2016, the FPM published core for clinicians and commissioners. This in relation to meeting the needs of standards for pain-management services, is timely because of the importance patients with cancer and other life- including those for cancer pain, which to the public of pain associated with limiting diseases. Closer integration were adopted into the CQC inspection life-limiting disease, the evidence of of these specialties can result in more framework from 2017. However, there under-treatment or poor access to care, comprehensive pain assessment and has been no supporting guidance for the need to show evidence of better a wider range of Level 3 and Level NHS trusts or existing pain-management, pain management in CQC inspections, 4 services for patients, comprising oncology and palliative-care services and the need to meet updated pharmacological, interventional, on how an integrated service might commissioning requirements for Highly rehabilitative, and psychological be configured, how it might be Specialist Pain Management Services. approaches. Although this will certainly commissioned, and what activities it benefit patients with more complex pain The framework describes four levels should undertake. syndromes, it might also help those with of service provision, and is designed less complex pain but who require more This new, recently published particularly to inform and stimulate skilful balancing of analgesic medicines guidance led by FPM collates delivery of Level 3 services in secondary or access to other interventions. existing publications into a pain care (Table 1). This is likely to have service specification or framework the greatest impact with least cost

Table 1 Four levels of service provision

Level Healthcare Group Assessment Intervention Faculty of Pain Medicine (FPM) 1 All healthcare professionals Recognition of pain Effective information-giving and compassionate support Screening for pain Referral to oncology or palliative-care professional Initiation of conventional analgesia 2 All oncology and palliative-care Assessment of pain Management and titration of conventional analgesia Framework to improve pain physicians and advanced practitioners Diagnosis of pain disorder Support for self-management Referral to specialist pain management as required services for patients with cancer 3 Linked palliative care and specialist pain Diagnosis of complex pain Management of complex analgesic combinations, including management in secondary-care settings syndromes high-dose opioids Consultant in pain medicine jointly Interventional procedures of varying complexity depending working with consultant in palliative on local skills and resources and other life-limiting diseases medicine, both with accredited training Support for self-management in pain management in cancer and other Referral to adult highly specialist pain management as life-limiting diseases required across the UK Access via referral from primary or secondary care professionals The Faculty of Pain Medicine has led guidance that will encourage closer 4 Adult highly specialist pain Diagnosis of complex pain Interventional procedures not available at local Level 3 and working between pain-medicine, palliative-medicine and oncology management in tertiary care settings syndromes including some more complex procedures (eg, implanted professionals to benefit patients with pain from cancer and other life-limiting Specialist services across the UK with intrathecal drug delivery systems, cordotomy, and other consultant teams in pain medicine and neurolytic procedures) diseases. This is a collaboration with the Association for Palliative Medicine, palliative medicine Rehabilitative programmes the Association of Cancer Physicians and the Faculty of Clinical Oncology. Access only via referral from Level 3 Managing distress or other behaviours suggestive of services complex drug dependence

Chris Kennedy RCoA CPD and Revalidation Co-ordinator

Revalidation for anaesthetists What you need to know about CPD in the Lifelong Learning

Faculty of Intensive Care Medicine (FICM) platform Work is progressing to incorporate CPD functionality into the Lifelong FICM curriculum update Learning platform. This major project commenced in March Medical Practice. There will be a more migrated into the Lifelong Learning 2019, although the features that are intuitive way for recording CPD skills, platform. However both systems will run being developed had been informed and it will be possible to add ‘realtime’ in parallel for 12 months from launch Dr Tom Gallacher by a number of previous stakeholder reflections while attending a CPD- to assist users in downloading their Chair, FICM Training Assessment and Quality Committee engagement activities, including a survey approved event. CPD Learners will also documents, which in many cases will be of users of the existing CPD Online have full access to the Logbook. A PDF just the CPD activity report. Diary, an information day for existing report of the CPD Learner’s completed and potential new CPD Assessors, and CPD activities plus reflections will We hope you will enjoy using the responses to Bulletin updates on this work. continue to be available to evidence this Lifelong Learning platform with added supporting information requirement. CPD functionality, and for any further The Faculty of Intensive Care Medicine has had its Purpose Statement accepted While all members are strongly advised information about it please contact by the General Medical Council with some minor conditions, and is now to check the Lifelong Learning FAQs on Your user accounts [email protected]. the College website at www.rcoa.ac.uk/ pushing ahead with the full curriculum rewrite to comply with the new standards If you are a current user of the CPD node/28166, we would also draw your Online Diary, you will be emailed when set out in Excellence by design: standards for postgraduate curricula. attention to the following key information the Lifelong Learning about this important work. platform is ready for use. The curriculum working group has now trainers alike. In addition, we have a partner specialties’ new curricula. This This will be sent to the email drafted the 14 proposed intensive care major role in the rewriting of the Acute will also facilitate the transfer of acquired A fully joined-up Lifelong address that you currently medicine (ICM) High Level Learning Care Common Stem curriculum, advising competencies between specialties Learning platform have in the CPD Online Outcomes (HiLLOs) mapped from the and liaising with partner colleges should a doctor decide to change their Launched in August 2018, the Lifelong Diary. Anaesthetists in existing ICM syllabus. Although we to ensure that the ICM component career plans and train in a different but Learning platform currently comprises training using the Lifelong are required to rewrite the curriculum provides the necessary elements related specialty. the anaesthetists in training e-Portfolio Learning platform will to comply with the new standards, required by doctors going on to pursue These have been constructive meetings, and clinical Logbook. The integration of receive a prompt via the there has been no change in the a career in anaesthesia, medicine and and the new HiLLOs in medicine and CPD functionality will deliver a seamless system when they are skills and competencies required to emergency medicine as well as ICM. anaesthesia have now been agreed and experience, supporting members eligible to use CPD features. become a specialist in ICM. Therefore, We have collaborated with the Royal will be submitted to the GMC when we throughout their careers and helping the challenge is to ensure that all College of Anaesthetists and the Royal submit our final proposed curriculum meet their needs for revalidation. components of the current curriculum Information in the College of Physicians to agree the to the latter’s curriculum advisory group are included in the rewritten curriculum current CPD Diary anaesthesia and medicine modules for approval. We intend to do this in the while at the same time reducing the System enhancements As has been the case with in the new curriculum to ensure they early part of 2020. burden of assessment – a change which The system enhancements will allow the e-Portfolio, historic meet the requirements of the respective will be much welcomed by trainees and CPD Learners to link activities and events records from the CPD to the ‘Domains’ in the GMC’s Good Online Diary will not be

SAS and Specialty Doctors RESILIENCE

Dr Lucy Williams RCoA SAS Member of Council, Great Western Hospital, Swindon

The bamboo that bends is stronger than the oak that breaks. Japanese proverb

Much has been written about medical burnout in the last few years, and there has been a burgeoning of resilience training and workshops in response. What is this all about and how might it involve you? actually looks at life in its widest sense. anaesthetist. One of the joys of theatre be more specific staff wellbeing services. Burnout can result in exhaustion, facilities, but you don’t have much compassion. Doctors generally set A balance must be achieved between working is building relationships with These are often not well publicised within depersonalisation, cynicism and feelings control over this. themselves high standards, and can be work, personal, and family life. Where that other professionals, especially operating hospitals, so ask. You may prefer to look of uselessness at work1. Fatigue from shift very self-critical. None of us is perfect, balance lies can vary through life and will department practitioners and anaesthetic outside work using formal channels such working and poor sleep can be a major Most resilience workshops focus on and learning to accept that is a step on be very individual, but you are the only nurses. They can be hugely supportive as your GP or local ‘talking therapies’. contributor. The College, Association steps we can take as individuals to the way to improved mental wellbeing. person who can identify when things are and many a heart-to-heart takes place at Resilience is not an all or nothing and FICM have been working hard to protect ourselves from the potential We cannot care well for others if we do not right. Is it temporary or do you need the head-end during long cases. concept. It is about more than your understand this better with a series of harm of our work. In the south west, the not look after ourselves. It can be difficult to make some adjustments? The RCoA Being kind to others makes us happier. mental health – it encompasses a much fatigue surveys. As I write, the SAS survey deanery has run sessions specifically to leave work behind at the end of the SAS survey of anaesthetists showed that a If you feel your workplace is not kind wider spectrum of wellbeing and coping is live and I hope that you will contribute. for SAS doctors, and these have been day, but try to commit to engaging with significant proportion choose SAS grades 5 and supportive, be the change you strategies for life, with all its ups and You can find educational material on the well received. Participants really valued family and valued activities when you for a better work–life balance. want to see. Give your colleague a tea downs. There is always somewhere to Association website.2 the safe space in which to share and arrive home. You also need to eat and Identifying what is important to you break if your list has finished early, buy turn if you need support. reflect on experiences. They were often drink when working – make the time!3 can help in making sensible decisions someone a coffee, bake a cake (I see The infamous NHS winter pressures surprised to find that their feelings were about work–life balance. Sometimes you a food theme emerging here!). Saying References now seem to last most of the year, and shared by others across all specialties. Understanding oneself means you can may be at a bit of a decision point, and thank you is hugely important, and it 1 Burnout among doctors. BMJ 2017;358.doi: all staff in healthcare have to deal with Look for similar opportunities near you, identify areas that need nurturing and unsure of the direction to take. Coaching can irritate when people fail to thank us. (https://doi.org/10.1136/bmj.j3360). emotionally demanding work. What can as well as sessions at national events. developing. There are many self-help or mentoring can assist. In training to do Niceness is catching and poor behaviour 2 Fatigue education resources. AoA, FICM, you do to protect yourself from potential books. A popular one is The 7 habits of RCoA (www.aagbi.org/professionals/ 4 has negative effects on all those burnout? Hopefully your employer is A fundamental concept in developing highly effective people, which is not just either of these, you learn more about wellbeing/fatigue/fatigue-resources). around, including observers not directly providing appropriate rest and catering resilience is that of self-care and self- about being more effective at work, but yourself than anything else. Look for a 3 Looking after ourselves at work: the colleague doing the training – they will involved. You may not be able to change importance of being hydrated and fed want people to practise on. Alternatively, the behaviour of others, but you can 4 BMJ 2019;364. doi: (https://doi.org/10.1136/ check with your post graduate education absolutely change your response to it. bmj.l528). lead or SAS tutor for advice. There may 5 Stephen R Covey: The 7 habits of highly Sometimes life is tough, and talking effective people. Free Press, 1989. be a formal hospital system in place of can help to get things in perspective. We cannot care well for others if we do not which you were unaware. 6 SAS Anaesthetists: securing the workforce. Hopefully, you have a trusted colleague RCoA 2017 (bit.ly/RCoA-SAS). look after ourselves Good relationships reinforce personal or family member. If you feel isolated, resilience. An SAS anaesthetist can there are other options. You can access spend a lot of time working as a solo occupational health services, or there may

Patient Perspective How are your stress levels?

Carol Pellowe Chair, RCoA Lay Committee

Problems with mental health and stress appear to be this season’s colours. They are raised in our papers, in our television programmes, and on the radio. Are we all turning into snowflakes, or are we being overwhelmed by forces beyond our control? In a world of increasing uncertainty (and the unmentionable B word!) we seem to have plenty to worry about. Some may think we have always had worries, so why is this different now?

Some of it may be due to the way we work do I feel? Where’s my thinking going?’ One and live. Bit by bit we have eroded our face- means of grounding oneself is the ‘5-4-3-2-1’ to-face social contacts, and the key means exercise, which involves thinking of five things of communication is increasingly by social you can see, four things you can hear, three media. For example, the loss of the ‘firm’ in things you can feel, two you can smell, and hospital medicine and new ways of working one you can taste. That should bring you to may give a better experience, but does it offer the here and now. Additionally, try to avoid good support to F1 and F2 doctors? Do they using social media first thing on waking, as a feel part of a ‘family’ or just tossed upon the negative response can alter your day. waters? Adam Kay, author of ‘This is Going to I often hear retired people comment on how Hurt’, noted on Radio 4 that a crisis number busy they are to the point that they do not was prominently displayed in the dressing know how they had time to work! I find this room of the London theatre where his show odd because the point of being retired is that was being performed. He wondered why you can choose how to spend your time, and there was no such thing in the NHS? I know if you are that busy, well you opted to be so. the College has support mechanisms and Is our work ethic so well entrenched that we resources, but do we really advertise them cannot live without it? We like to be useful extensively? and help where we can. However, we all need Stress can be useful. It’s the impetus to get some time out for ourselves, whether it’s five things done, like writing this at the eleventh minutes on the bed, reading for pleasure, hour! However, in excess our state of listening to music or phoning a friend. Let us wellbeing deteriorates. One suggestion is try and be kinder to one another and, more a daily check of oneself. Ask yourself: ‘How importantly, to ourselves.

Anaesthesia Clinical Services Accreditation (ACSA) THE TRAINEE ROLE IN ACHIEVING ACSA Dr Tom Munford, Dr Seetal Aggarwal and Dr Thomas Fletcher ST7 Anaesthetic Trainees, Nottingham University Hospitals NHS Trust

More than half of departments across the UK are working towards ACSA. From previous articles, it is clear that collective will is required to engage in a process that can take several years of preparation. This article differs from others as we look specifically at how we, as a group of higher trainees, were able to help and influence Nottingham University Hospitals NHS Trust (NUH) in their desire to gain accreditation.

Why get trainees involved? review and audit, the process provides about NHS management structures, and ACSA aims to assess and review the an excellent opportunity to engage with this improved our understanding of the systems worked. The availability tremendous pride in presenting our Summary management at both departmental and hurdles that have to be jumped to bring provision of anaesthetic services in all of Wi-Fi, especially in a Victorian department to the visiting ACSA Being involved in our department’s trust level, enabling positive change quality improvement initiatives to fruition. locations across a trust. Trainees are era hospital building, was shown review team. Being a large and dual- ACSA bid as trainee representatives for future trainees rotating through the continuum throughout 24-hour to have implications with regard to site tertiary centre, it was impossible has been hard work, yet it was an our trust. From a trainee point of view, What were our roles? anaesthetic care, and are involved in the consultant–trainee communication in to be aware of all the incredible enjoyable and extremely productive majority, if not all, of the areas where it provides invaluable experience in Initially we focused on the trainee areas, remote sites. This led to the building projects, services and processes task. The process has increased our anaesthetic services are required. For quality improvement and management, conducting surveys on supervision, ease of a business case for IT services to that are in place to improve patient understanding of the management this reason, we are uniquely placed to especially for those in advanced of access to consultant advice, and improve coverage within the trust. care within our trust; ACSA has structure of our department, and give an overview. Additionally, there training or approaching CCT. Being support in solo training lists. We looked allowed us to bring all of these to the helped us build the skills to enable us As the process evolved, we analysed are a number of trainee domains within actively involved with many stages of at rest facilities for on-calls and at forefront and showcase them. The to become effective and productive complex patient pathways, including the ACSA standards. Through peer a department’s ACSA bid reveals a lot how well the on-call bleep and phone process provided reassurance to the future consultant colleagues. We those for patients with obstructive department in terms of the service we would encourage other trainees to sleep apnoea and for the follow-up of currently provide, but also gave us get involved in their departments’ patients with complex postoperative a determination to act on standards bids; it may surprise you how much needs. NUH is a dual-site tertiary that still require attention. As higher you will learn and get out of it! All that major trauma centre. Collecting trainees, we are involved in the remains is for us to complete the last Trainees are the continuum throughout demographic data on the number majority of the clinical activities that few remaining standards, and then of cases anaesthetists are involved take place in our trust. However, from hopefully achieve accreditation and with and on staffing levels was an 24-hour anaesthetic care, and are involved a departmental perspective, there receive our plaque! incredibly complicated task that gave were still many things happening us all a greater understanding of the that we were not aware of. It was eye in the majority, if not all, of the areas where medical-data-recording systems used opening and interesting to meet key within our trust. people in the management structure anaesthetic services are required. who had previously just been names What did we learn? at inductions. Building on these Having been involved with the relationships played an important role process for a year, our team took in implementing change.

While each project delivers a new system or way of working, it is the completion of each integrated workstream which generates the the real value

the provision of online exams. The interest: College efficiency and security. perioperative experience if you like, that team have done a great job of defining In the past, for example, a research is the workstream creating value as a the need and working with potential document may have gone to 10 people whole. As we move into the latter part of suppliers, which has resulted in them as an email attachment for consultation, the programme we are starting to see this identifying two good candidates for with Research team staff then having workstream value being realised as more this area. The team and TSP members to collate 10 sets of comments and than the sum of each project’s parts. will now put the two finalists through amendments, and then circulate I mentioned the Document Collaboration Aaron Woods their paces via a hands-on systems- the amended document again for project, and this is one of about seven RCoA Technology Strategy Programme development workshop with both. another round of 10 sets of comments projects that make up the ‘Infrastructure’ Director and amendments, etc. Now a single In the area of Training, Exams and document can be shared from its online workstream. By the time you read this the Events, I am pleased to reflect on the location, and people can collaborate on workstream will be complete. So far it has delivered Unified Comms (the new phone Technology Strategy Programme (TSP) Events team’s achievement in going it and see the changes as they are added live with their new EventsForce booking – much more efficient. In the past those and conference system), cloud-based platform. Not only does this give a 10 people may have left various versions email, Documentation Collaboration, much more modern and much easier of this document saved locally on their College network improvements, and Technology Strategy Programme user experience for our members, it also new security tools. The last piece of home or work devices, but now there is offers real reductions in the time and just one copy stored on a platform with the puzzle is a suite of new servers at update complexity the team have historically the strongest data-protection standards Churchill House. Together as a package had to contend with in running the old – much more secure. these changes have transformed how events-booking system. Having proven we store information, communicate with In the January Bulletin, Michael King (Digital Project Manager) and myself the value of the new platform, I’m I want to move on now from individual each other, work remotely, collaborate, focused on the two big remaining projects on the programme: the new pleased to report that the Exams team projects to workstreams. The Technology stay secure against ever increasing will also be moving to EventsForce for Strategy Programme is made up of 32 cyber threats, and ensure our business website and the new membership management system. This time I will give their bookings in the summer. separate projects grouped into seven operations are protected. you a round-up of how the other projects are going, and do a bit of reflection workstreams, and while each project Another project to report on is delivers a new system or way of working, Admittedly these changes will be felt on what has recently been achieved. ‘Document Collaboration’, which went it is the completion of each integrated mostly by staff and those members live in December 2018. This is the workstream that generates the real value. with College roles, but they are solidly I’m delighted to report that work on the results. Adding CPD will complete Logbook aspect of Lifelong Learning work College’s new system for sharing of Think about the individual roles health supporting one of your organisation’s adding CPD functions to the Lifelong the trio of functions the application offers, offline for when you have no Wi-Fi signal. and collaboration on documents with professionals play when, for example, current five strategic aims: ‘Resourcing Learning platform began in January. The and really deliver on the ‘Lifelong’ aspect multiple external people, sometimes a person needs surgery: the GP, the the Future of Anaesthesia’. The next At the other end of the Lifelong timeline, Training team have an intense two-month of the platform. Read more about these in realtime. Now, this may not sound nurse, the porter, the anaesthetist, the big area of workstream value to arrive, development phase, during which they exciting changes on page 27 with Chris I can report rapid progress by the as transformative as, for example, a surgeon, the GP again – these are the however, will be all about the member will be working with our supplier and ‘Mr CPD’ Kennedy’s update. Lastly, I’m Exams team on their work to find a new new member portal, but it does solidly projects. But the overall experience experience: the coming together of the College members to define how the pleased to report that, at the time of system that not only manages their address two areas where you as a and life improvement for the patient new website, member portal, single sign- system will work, to build it, and to test writing, work has begun on making the exams administration but also offers subs. paying member should have an through them acting together – the on, offline working, and CPD. I can’t wait!

Professor Jaideep J Pandit RCoA Council Member and Consultant Anaesthetist, DROP A DAY’S WORK – AND Oxford University Hospitals LOSE NO PAY? Body, recently presented to Parliament by the same, despite hundreds of hours of of heavily taxed extra sessions, to the the prime minister herself.6 Calculations, extra work, at ~£140K as it was before. end of their days. Some readers will in On (not) meeting workforce challenges based on civil servants and the armed They might as well have played golf. fact enjoy this work so much that they forces, apply to all public sector workers, are prepared literally, to work for nothing. From a different angle, someone who is including doctors. in anaesthetic departments already anywhere within this ‘death zone’ Other readers will take professional The ‘income death zone’ is wide: gross might realise a strong incentive to drop an advice and seek various ways out of the salary ~£105K–£165K, across which net entire day’s work (or more, depending on zone. Some, by declining additional income stays constant. Thus someone exactly where they sit within the zone) and NHS work or some, by actively dropping who earns about £105K through a mix find they lose not a penny in take-home NHS sessions and enjoying the free of base income and clinical excellence pay. They are then – literally from their time released. Since income from awards, and who chooses to devote, perspective – being paid to play golf. private practice can also land one in the say, two programmed activities (PAs) ‘death zone’, the attraction of invoicing First, how many anaesthetists does it take to change a light bulb? to additional NHS work, and perhaps Conclusions via a limited company but not drawing diligently works annually in 20 extra NHS planners hope that, despite Figure income, may appeal to others. Leaving In theory, no anaesthetic department should ever be short-staffed, because weekend waiting-list initiatives, will 1 emanating directly from government, the NHS pension scheme, as explained accurate estimations of staffing requirements are well-established in standard take their total salary to say ~£140K. most readers will continue to disbelieve elsewhere,2 will allow others to break The graph shows they need not have free (ie, the green and red areas in Figure 1 the realities and remain in the ‘death texts on operating-room management. bothered. Their take-home pay remains zone’, passively working in the ignorance 1 then become net income). None of these options help meet the NHS For small departments, individual under-staffs and seeks to make existing instead on private practice (and/or, staffing shortfall, which was the initial details can be collected, but for large staff work harder for the same pay. This anaesthetists in training may be removed Figure 1 UK government analysis of pension/tax changes on income. If there was focus of this article. departments, median estimates work can be achieved by some or all of: from the department). So the aggregate no tax, as gross income rises (y-axis) then take home pay (x-axis) would follow the equally well. First, assess the median ■■ reducing the supporting professional effect may be that little or no extra work solid black line. However, the sum of tax (grey), pension contributions (green) and References direct-care component (DCC) within job activity (SPA) allocations in job plans results and staffing shortfalls remain. annual allowance charge (red) reduce the gross towards the take-home pay (blue). 1 Pandit JJ. Practical operating theatre plans (separately for consultants and SAS in various ways The ‘income death zone’ is the range of gross salary ~£105K and ~£165K where management. Cambridge University Press. doctors). Then estimate leave entitlements 2019. ISBN 978-1-316-64683-0. ■■ reducing or abolishing DCC time for Second: understanding the there is no increase in take-home pay despite a very large rise in gross income. (factoring in an amount for sick leave) 2 Pandit JJ et al. Why are there local shortfalls in perioperative care ‘income death zone’ anaesthesia consultant staffing? A case study and allow for everyone to take their leave of operational workforce planning. J Health ■■ curtailing or abolishing preoperative It may be too much to hope for mature over the year while having sufficient Org Management 2010;24:4-21. assessment clinics and pain-service approaches to job planning and workforce staff present. Then, assess the average 3 Green A et al. An analysis of the delivery of contribution of anaesthetists in training rounds calculations. Yet there is a latent, stronger anaesthetic training sessions in the United to service. Downloadable tools make ■■ curtailing annual leave by increased force at work limiting our ability to solve Kingdom. Anaesthesia 2017;72:1327-1333. calculations simple.1 Consistently it is found bureaucracy, requiring leave to be staffing shortfalls. Detailed analysis has 4 Pandit JJ. Potentially adverse and unintended consequences of income taxation changes taken at fixed times, and abolishing already explained how government tax that for a single operating theatre running in the 2009 Budget for NHS service delivery. and pension changes logically mean that two sessions per day five days a week, the carry-over of leave across years Anaesthesia News 2010;272:26. fewer anaesthetists will offer spare capacity magic number ‘to change the lightbulb’ ■■ restricting study leave funding 5 Pandit JJ. Pensions, tax and the anaesthetist: 4,5 is approximately 2.2 full-time equivalents to the NHS. Yet my lectures on this have significant implications for workforce ■■ abolishing professional leave (proportionately higher for more sessions been met with disbelief. Yes what I say planning. Anaesthesia 2016;71:883-891. ■■ maximising trainee service in per day or more days per week). makes sense, but how can government 6 40th Annual report on senior salaries, 2018 3 exchange for training. policy ever actively disincentivise NHS (Report No.89). Read M (Chair). Review Body on Senior Salaries 2018. Why then, are staffing shortfalls so In response, individuals affected may work? Figure 1 will therefore induce, for (http://bit.ly/2TlLqqp). common?1,2 The bottom line is that trusts use the appeals process or tribunals, some, a Damascene conversion. It does simply cannot afford this magic number. or actively reduce working hours, or not originate from a lone crackpot (like Instead, the NHS generally knowingly become disengaged and concentrate me), but from the Senior Salaries Review

Professor Abdul Lalkhen Dr Stuart Dolling Consultant in Anaesthesia and Consultant Anaesthetist, Pain Medicine, Salford Royal Salford Royal NHS NHS Foundation Trust Foundation Trust

Dr Fiona Martin, ST7 Anaesthetist, Northwest School of Anaesthesia FEEDBACK: GOOGLE FORMS AND QR CODES The system for obtaining anonymised feedback from trainees regarding their educational experience with consultants on training lists, which uses a Google form linked to a QR code, was brought to us by Dr Fiona Martin. The Google form uses specific domains to evaluate the quality of the trainee’s educational it mandatory for the trainee to present from the QR code system is delivered culture of the department. Our their QR code to the consultant at the on a monthly basis to the educational experience has been that the volume experience. A trainee can access the form by scanning the consultant’s unique end of the educational experience, supervisor as an Excel spreadsheet or of QR code feedback obtained is an QR code (QR Code 1), and this leads to the form at https://bit.ly/2SL7sPA. although the consultant will have a list of in graphical form, to be discussed with indicator of performance. Trainees in all trainees and their QR codes in order the trainee at their regular educational difficulty avoid using the system, and We have configured the same system with their personal QR code. We have experience has been that consultants to facilitate remote feedback. supervisory meeting. sometimes the popular trainee who for the trainee to obtain feedback had feedback that the trainees find tend to feed back on aspects of the gets on with everyone also avoids the The College tutors are responsible for We had some teething problems with system. The system therefore facilitates on their performance following any the system of providing profiles of the trainee’s personality, which is often the administration of the system. We the use of the QR code system, as the remote monitoring of progress of educational interaction with a consultant consultants in electronic format useful in influenced by the personal interaction assemble the profiles given to us by consultants had become accustomed trainees by the College tutors. We have (theatre or the emergency department). easing the potential discomfort of being between the consultant and a trainee, the trainees into a single document, to the form that had been sent around found that the feedback has allowed Each trainee is given a QR code at the a new trainee in a large department. rather than providing feedback on the produce the QR codes, and circulate at the end of a placement. The uptake us to more effectively assess trainees in start of their placement. They are also trainee’s ability to self-regulate or on Our department consists of more than the document amongst the consultants. of the QR code system was initially low, difficulty, and to implement educational asked to submit a profile of themselves their task performance. The purpose of 70 consultants, and we often have more Each trainee has an educational but has increased as the system has interventions in a specific and timely which includes details of their current feedback is often forgotten – it is not than 30 trainees circulating within the supervisor, and the feedback generated embedded itself into the educational fashion. training level, their direction of travel to make people feel better, it is to help department at any point in time. Thus from a career perspective, and their them do better. there is a low probability of a trainee QR Code 1 QR Code 2 preferred learning style. The profiles of interacting with the same consultant on all the trainees are then circulated to The Google form that we have devised more than one occasion, and this makes the consultants. The QR code for the and which can be found at: https:// it more important to collect feedback in individual trainee appears next to their bit.ly/2RFb74n is populated by the a contemporaneous, objective fashion, picture in the profile document. We consultant at the end of an educational rather than to rely on the consultant’s have in addition provided the trainees experience. It has specific domains subjective memory when it comes to the with profiles of the consultants in the related to aspects essential for trainee end of the placement. department. The profile has the details progression, including tasks such as of the consultant’s special interests, their Consultant feedback is mandatory airway skills, and also domains related preferred teaching style, their contact with regards to Completion of Units to self-regulation, such as situational details, and a picture of the consultant of Training forms. Historically, our awareness (QR Code 2) . We have made Scan the QR code or use the link below Scan the QR code or use the link below https://bit.ly/2SL7sPA https://bit.ly/2RFb74n

Dr David J Wilkinson CAN YOU IMPROVE THE WORLD? Past President WFSA, Trustee WFSA UK

charity health sector. In subsequent years Dr Luz Marina Sotelo completed the Luz comments that the ‘patient will the number of office staff has grown CLASA-WFSA Pain Management be the biggest beneficiary as they will as they try to take on the administrative Fellowship in Buenos Aires, Argentina, from receive better attention and gain a better functions previously carried out by 21 May to 31 July 2018. She wrote that ‘[in] quality of life’. consultant anaesthetists. the operating room we observed how the different procedures were performed As a long-term supporter of the Fellowship The Fellowship programme is one of in pain management with the help of programme and donator to ‘Fund a Fellow’, many activities of this ‘new’ WFSA (all ultrasound and fluoroscopy for a better I would like to ask you to donate towards activity can be seen on www.wfsahq. approach of interventionism. We learned this programme. This can be done as an org), but it can only be maintained by how we should prepare a patient from the individual or as a department. It can be donations. The Fellowship Training preoperative stage to the whole procedure a ‘one-off’ or an annual donation, all of Programme is delivered at no cost to the by means of protocols and algorithms which can benefit from Gift Aid as you fellow and is run by local volunteers. All already established in each hospital’. are donating to a UK Charity (WFSA UK), of the money raised for the Fellowship which in turn supports WFSA. If you go to programme goes to the travel and living Of the many skills and the knowledge the WFSA website then you can follow the expenses of the fellow. that Luz gained during her fellowship, simple instructions to donate: go to she notes that she is now able to perform https://wfsahq.charitycheckout.co.uk/#!/ The Fellowship programme works well. acute and chronic pain-management and fill in the form. Individual anaesthetists are trained in protocols, leading to improved care for a geographically ‘nearby’ university her patients. Following her fellowship, At present, four times as many people hospital and then return home to Luz returned to Peru and prepared a die every year from conditions that could work and teach and spread their new conference to replicate the activities be treated by surgery and anaesthesia as In 1955, the World Federation of Societies of Anaesthesiologists (WFSA) was knowledge. The WFSA now has 52 she did during her fellowship, which die from HIV, malaria and tuberculosis set up at the end of the first World Congress of Anaesthesiologists (WCA). fellowships as shown in Figure 1. benefited a further 20 to 30 assistant combined. Please do something to help anaesthesiologists and 25 specialty WFSA change this; tell other people Over the next 60 years the WFSA has grown to cover almost every country The recently published experiences of about this unacceptable situation and one such fellow is shown here: anaesthesiology residents. and to hold WCAs every four years. donate to change it.

Anaesthesia has made huge leaps forward since the mid- Basic anaesthesia and surgery have long been regarded as Figure 1 Fellowship 1950s. There is now safer and more sophisticated apparatus expensive luxuries by less affluent countries, but in 2015 the Training Programmes for the delivery of anaesthesia; drugs have improved in quality; World Bank published the 3rd Edition of Disease Control and safety, and education and training are at an all-time high. Priorities which showed things from a different point of view. But these developments are mainly limited to the affluent They concluded that for every $1 invested in safe surgery and world, and in the less affluent world patients lack even the most anaesthesia there was a $10 return as those judged as sick and basic opportunities to experience safe anaesthesia and surgery a drain on the economy returned to work. for life-changing procedures. The WFSA has sought to improve anaesthesia provision The Lancet Commission on Global Surgery reported in April around the world since its inception. It has published books 2015, and highlighted the fact that in a world population of and manuals, it has provided lecturers to many countries, and seven billion, five billion were unable to receive safe surgical or has encouraged meetings and communication. Now specific anaesthesia support for three fundamental surgical procedures. Training Centres have been set up where anaesthetists go These procedures were the treatment of a compound to learn relevant techniques that they can take home and long-bone fracture, a laparotomy, and the management of then teach locally – this became the Fellowship programme. obstructed labour. These were staggering results and remain Changes increased from 2012 onwards when the organisation totally unacceptable. appointed a highly qualified Chief Executive Officer, Julian Gore-Booth, who had a long track record of working in the

The College offers training opportunities for anaesthetists from low-income and lower- middle-income countries via the Medical Training Initiative

revealed that patients with long-lasting educational opportunities. The Fellowship References pain experience a multitude of negative exam was established in 2012; it covers 1 Niv D, Devor M. Chronic pain as a disease in attitudes and distrust from healthcare both practical and clinical knowledge its own right. Pain Pract 2004;4(3):179–181. providers, colleagues, families and and knowledge of relevant sciences, and 2 Jackson T, Stabile V, McQueen K. The global aquaintances.7 has the aim of enhancing the practice burden of chronic pain. Newsletter of the American Society of Anaesthesiologists of pain medicine in the UK. The Faculty Inadequate chronic-pain management 2014;78:24–27. has submitted a draft document to the 3 Turk DC, Wilson HD, Cahana A. may be related to the inherent GMC for consideration of piloting pain Dr Victor Mendis Treatment of non-cancer pain. Lancet challenges of treating chronic pain, medicine as one of its first credentials. 2011;377(9784):2226–2235. RCoA Medical Training Initiative Lead, insufficient consideration given to 4 Dahlhamer J et al. Prevalence of chronic Pain Medicine common co-morbidities, concerns about While enthusiasm for pain education pain and high-impact chronic pain among dependence, and addiction. But, more and clinical training in developing adults. United States, 2016. Centers for Disease Control and Prevention. Morbidity importantly, it can be due to lack of countries has grown, restrictions by and Mortality Weekly Report September 14, training for chronic pain management governments and health administrations 2018. Weekly/vol.67/No.36. in medical school and residency have represented a significant barrier. 5 Reid KJ et al. Epidemiology of chronic non- programmes, and a lack of educational The Royal College of Anaesthetists cancer pain in Europe: narrative review of PAIN MEDICINE TRAINING resources. Consequently it is unsurprising offers training opportunities for prevalence, pain treatments and pain impact. Curr Med Res Opin 2011; 27(2): 449–462. that providers report low satisfaction and anaesthetists from low-income and 10.1185/03007995.2010.545813. Reaching out to the developing world lack of confidence in treating chronic lower-middle-income countries via 6 Breivik H et al. Survey of chronic pain in pain.6 Despite the high prevalence the Medical Training Initiative (MTI). Europe: prevalence, impact on daily life, and Understanding pain has been one of the oldest challenges in the history of and public health burden of pain, pain The scheme provides a route for high- treatment. Eur J Pain 2006; 10(4):287–333. education is considered a non-essential quality international medical graduates 10.1016/j.ejpain.2005.06.009. medicine. The European Federation of the International Association for the part of undergraduate medical education to obtain sponsorship for their GMC 7 Hollingshead NA et al. Examining influential factors in providers’ chronic pain treatment 8 Study of Pain (IASP) declared that chronic and recurrent pain is a specific across Europe. registration and also sponsorship for decisions: a comparison of physicians and a Tier 5 visa, which will allow them to medical students. BMC Medical Education healthcare problem and a disease in its own right. Postgraduate specialist pain training undertake a training placement in a UK 2015;15:164, (https//doi.org/10.1186/s12909- 015-0441-z). in the UK takes place within the hospital for a maximum period of 24 8 Briggs EV et al. Current pain education According to a 2014 global study on the and affecting a patient’s level of activity.³ average of 40 per cent of pain sufferers anaesthetic curriculum, and consists months. There are many opportunities within undergraduate medical studies across global burden of chronic pain, at least Primary care settings in Asia, Africa, were not satisfied with the effect of the of two mandatory modules (basic for pain medicine under this scheme, Europe: advancing the provision of pain and intermediate) and two optional 10 per cent of the world’s population is Europe, and the Americas had patients treatment they were receiving for their and the Faculty of Pain Medicine would education and learning study. BMJ Open affected by a chronic pain condition, and reporting persistent-pain prevalence of long-lasting pain. Around 31 per cent of modules (higher and advanced). Strongly encourage interested trainees to apply. 2015;5:e006984. committed trainees embarking on a every year, an additional 1 in 10 people 10 to 25 per cent. Consistent estimates of respondents had achieved pain control Further information can be found on the chronic-pain prevalence in the US range career in pain medicine undertake an develops chronic pain.² Chronic pain is within six months from the time when College website at bit.ly/RCoAMTI19. from 11 to 40 per cent, and prevalence of advanced year, and usually spend this a disabling condition, and, as reported they first experienced pain, but almost 20 per cent has been noted in Europe.4,5,6 in a single tertiary pain centre, or in a by Turk et al, affects every aspect of a as many (28 per cent) had been in number of units each offering different patient’s life, contributing to a loss of A survey of chronic pain in Europe pain for five years before they received both physical and emotional function conducted in 2004 concluded that an effective treatment. The survey also

Dr Maria Chereshneva RCoA Quality Improvement Fellow

Quality improvement book - recipes for success The 3rd edition of Raising the standard: a compendium of audit recipes better known as the ‘Audit recipe book’ was published back in 2012.1 The last edition sought to bridge the gap between audit and quality improvement (QI) and to provide practical guidance on how to use QI to act on audit findings. Since the last edition, there is much greater awareness of implementation and quality improvement science both within the specialty and healthcare as a whole, but many of us still have limited experience of ‘real-life’ practices of improvement. methodologies and skills; however, The forthcoming edition of the QI examples of change, and encourage better skills and knowledge alone recipe book will provide a resource to anaesthetists to look at their own When the topic of QI comes up, Royal Colleges through their Quality NHS as a whole depend on us for the do not always equal improvement. support the QI agenda in anaesthetic department/hospital practices and inevitably some will still ask ‘what should improvement training for better outcomes delivery of safe, reliable and effective QI is about having the attitude, skills departments and to encourage teaching, inspire them to lead that change. For I do and how do I do it?’ There are many document.2,3 This recognition is also care. The initial approach to improving and will to make things better. The training and continued professional anaesthetists in training this is will allow reasons why we should all learn how to reflected within the RCoA strategy – that care within the healthcare systems was to Health Foundation’s – The habits of development in QI. The book covers them to become intimately involved in do improvement work and understand good quality QI learning and delivery focus on reducing errors and audit. Both an improver, emphasises that if we a wide range of subject areas in shaping hospital systems and lead to lifelong adoption of QI methodology the basic QI tools. Quality improvement needs to be actively supported. error reduction and audit are essential are to make meaningful and lasting anaesthesia and perioperative medicine, while in the long run improving patient provides us with the means to influence but we need to take further steps to improvements, we should adopt a as well as wider issues affecting our The modern NHS requires improved experience, outcomes and their own the environment in which we practise, make sustained changes in behaviour. number of QI ‘habits’, such as being practice. Inclusion of ‘real-life’ examples efficiency and effectiveness, despite job satisfaction. to tackle waste, harm and unwarranted In order to make viable and long-term empathetic, optimistic and a team will describe different approaches limited resources and on the background variation in our system. In addition the improvements we need to transform the 4 and enable the user to put content of an ageing population with increasingly player. Only when we change our References: need to improve delivery of person- systems that we work in. behaviours, will QI be the ‘norm’. We all into practice. Experts and specialist complex health needs. It is we, the 1 Raising the standard: a compendium of audit centred care is a core value for all health societies contributing to this edition frontline staff who deliver care every day So what do we need in order to know that getting people to change can recipes for continuous quality improvement in professionals. This is specifically reflected have identified important themes facing anaesthesia (3rd Edition). RCoA 2012 and understand these challenges, who improve? There is an enormous be very complex but seemingly small by the GMC in their Generic Professional us now and also in the longer term. We (www.rcoa.ac.uk/node/8622). need to make the improvement of care amount of information out there behavioural changes can have a ripple Capabilities Framework for training and are confident that this will be a good 2 Generic Professional capabilities framework. a core daily activity. Our patients and on improvement science, different effect in healthcare. As anaesthetists, supported by the Academy of Medical starting point for all to improve the GMC. 2017. (bit.ly/2XFewA9). we have always been early adaptors patient journey and outcomes. Each 3 Quality Improvement- training for better of various innovations and forerunners outcomes. AOMRC 2016 (bit.ly/2XHayY7). recipe is mapped onto curriculum, CPD in initiating changes, advocating for 4 Lucas B, Nacer H. The habits of an improver: matrix and ACSA standards to allow improved patient experience and safety. Thinking about learning for improvement in departments to focus on particular health care. The Health Foundation. 2015. So make a point of starting – find QI is about having the attitude, skills and standards and ultimately facilitate ISBN: 978-1-906461-67-6 (bit.ly/2XDxF5K). something that you want to improve, delivery of GPAS and entry into ACSA. will to make things better start with some easy wins and keep going. Don’t let what you can’t change Finally, the anticipation is that this put you off doing things that you can. resource will provide meaningful

Eight of the 58 patients did Patients who proceeded to surgery post CCU MDT at the proposed date Dr Simon Trundle Dr Ramanathan Kasivisvanathan not have surgery before the ST7 in Anaesthetics, Head of Anaesthesia and proposed date. 2 Perioperative Medicine, 3 Perioperative Fellow, Outcomes for the 20 patients that Survived The Royal London and The Royal Marsden NHS the CCU MDT did not recommend Died within 30 days Royal Marsden Hospital Foundation Trust for surgery are shown below. It is to 45 be noted that three out of the four Died within 90 days patients who were declined surgery at RMH and who subsequently had surgery at another institution THE MULTIDISCIPLINARY TEAM IN ACTION: died within 90 days of surgery. The remaining patient left hospital after Not recommended for surgery by CCU MDT applying perioperative medicine to three months. Financial impact 4 Alternative oncological treatments We involved the RMH’s costing the high-risk surgical cancer patient No further care at the 10 team and a health economist to 6 Royal Marsden Hospital look at the financial impact of the Surgery at diﬀerent hospital As a specialist cancer centre, the Royal Marsden Hospital (RMH) undertakes CCU MDT. The cost of care for patients going through the CCU approximately 4,000 major to major/complex surgical procedures per MDT and not proceeding with year, and patient selection and optimisation is a key factor for a successful surgery (undergoing alternative non-surgical oncological care at outcome. At RMH we have looked at cancer patients presenting for major RMH), was compared with the cost Table 1: The financial impact of the high risk surgical patient CCU MDT surgery over a four-year period, and we have seen a significant increase in of matched patients having the Median (IQR) savings to trust age, frailty, and co-morbidity.1 same surgical procedure at RMH from a historical dataset plus the Calculation of the proposed savings by the CCU High £18,342 Risk Patient MDT for every patient going through the cost of the CCU MDT. The cost of Quite often these are palliative/end- Personnel involved to surgery. The CCU MDT also enables process and not having surgery (undergoing alternative (£7,342 – £25,490) the CCU MDT was estimated at of-life patients presenting for surgery discussion and exploration of curative non-surgical oncological care) The High Risk Surgical Patient CCU 0.25 sessions of direct clinic care to aid symptom management and versus palliative goals in the context of the MDT at the Royal Marsden Hospital is for five consultants and two hours improve quality of life. Increasingly patient’s wishes, expectations, and quality led by five or six critical care physicians, of Band 7 health professionals’ time patients are being referred to us who of life. with discussion and input from various for 42 weeks per year (Table 1). have been turned down by other Conclusion Reference specialties that are vital to delivering care centres, typically because of the This patient-centred approach and The development of the CCU MDT 1 R. Kasivisvanathan et al. High risk multi- to these patients. These include surgeons, The overall estimation of cost is shared decision-making are key factors in for high-risk surgical cancer patients disciplinary process for major cancer surgery. complexity of their cases. likely to underestimate the actual BJA 2016;117:623–625. physiotherapists, occupational therapists, determining an objective risk assessment is one of the first of its kind in the UK, savings because matched patients This group will therefore have an increased dieticians, clinical nurse specialists, and and risk prediction. The overall outcome and has allowed us to develop a robust were not objectively identified as risk of requiring significant organ support, our senior critical care nursing teams. of the CCU MDT process allows us to perioperative decision-making process high-risk in the calculation and of long term functional disability, and of facilitate more informed decision-making for those high-risk patients considered for The MDT approach in decision-making had fewer complications, thus mortality. Surgery in this patient population and patient consent. cancer surgery. This process has been vital in high-risk cancer surgery enables more costing less. The inference from requires significant resources during the to ensure patients have the right surgery at effective communication between team the calculation was that the CCU perioperative period. The application of Patient outcomes the right time and in the right place, and is members, allowing the identification of MDT’s decision was the cause of perioperative medicine to this group is Of the 78 patients referred to the likely to have resulted in financial benefit. potential problems by bringing together the patient not having surgery. vital, and from our experience the process CCU MDT between 2016 and 2018, a the full knowledge of each professional. of shared decision-making is integral to decision to proceed with surgery was During this process any potential areas for ensure these patients get the very best recommended in 58 cases. outcomes. This has led to the development optimisation are highlighted preoperatively. of our High Risk Surgical Patient Critical The most appropriate mode of surgery Fifty patients proceeded to surgery Care Unit Multidisciplinary Team Meeting is discussed (for example’ robotic versus having the originally listed procedure (CCU MDT). open surgery), and also alternative options as planned.

Dr Sarah Ramsay Ewelina Kolaczek RCoA Council Member and RCoA Membership Engagement I have referred most of my residents to others like myself to improve and, in turn, Chair of the RCoA Scottish Board and Marketing Assistant courses at the College to motivate them help improve others. towards higher education and training. The meeting was important in allowing the Regrettably, almost all doors are closed, as College to participate in the vision that the there are almost no openings for further members and fellows have for its future training or even post-training fellowships. and its growth. It was a long journey from Amman to Dundee RCoA Membership It is essential that similar meetings continue London, to Edinburgh, and finally to to occur, allowing members and fellows Dundee, where I walked in to lively to bestow valuable thought and advice. Dr M Al-Husein discussions. Engagement Focus Group: The College must continue to build on this Chairman of the Examination Committee Throughout the discussions between relationship with its members. The Council November 2018 of the Jordan Board in all groups, two main ideas came to the members do not necessarily accurately Anaesthesia forefront: all individuals within all groups represent the views of all members at all were there solely for the best interest of times. the College, and the anticipation that the The College is committed to improving the way we engage with you, I think the College needs to, and is now College is losing valuable opportunities willing to, open avenues for doctors from our fellows and members. As part of this commitment, the Membership for progression. outside the UK to refine their education Engagement team invited all fellows and members to join us in Dundee Throughout my journey to Dundee I and training. The benefit here has proven in November 2018 for a Membership Engagement Focus Group. We continuously questioned the purpose of to be twofold – not only do the doctors my trip and my role in the meetings and at gain prestige and expertise, but also the had already facilitated a number of focus groups in London last year and the College. Ultimately, I have come to see College itself shifts into the international internationally via Skype, and wanted to expand this opportunity for fellows that, just like all participants at the focus community and becomes part of a groups, I too want to continue the legacy larger institutional movement, one that is and members who live in other areas of the UK. of the College in shaping and guiding respected worldwide.

Chaired by RCoA Council Member and Chair of the RCoA Scottish Board, Dr Sarah Ramsay, the focus group was a structured, yet open, space for attendees to share their views and concerns, as well as to let us know what they value and would like to see As I near the end of my training, I have finally The mix of grades, geographical base, more of. This was a chance to shape the College’s priorities and improve our services. Together with the feedback we get from moved away from the ‘exam fear’ associated subspecialties and different career stages our all-membership survey, the qualititive information and insight we obtain from focus groups is invaluable in understanding and with attending the College and its events. made for an interesting discussion, and determining how the College can better serve its membership. important issues raised included support in Below are reflections from three of our fellows and members who attended the group. When I discovered that a Members’ focus revalidation, interaction with international group was being held in my very own members, and locations and content of city, Dundee, I was excited to attend and Working in Scotland, I’ve always felt a bit of meetings often felt to be prohibitive meetings and training. contribute to the discussion. distant from the College. Rather naively, to attendance. It was clear that video- It was a fantastic opportunity to gain I assumed it would be mainly Scottish linked or web-based meetings would be As a higher trainee I felt it important insight into the issues affecting consultants consultants at the meeting. However, a popular development. We all felt that to raise the issue of engaging post- Dr Kate Arrow and to voice ideas for trainee engagement. people attended from all over the UK and recent innovations such as the monthly FRCA Anaesthetists in training. Ideas ST6 Anaesthesia, Tayside beyond, and it was incredibly enlightening President’s Newsletter were positive and included practical support for consultant School of Anaesthesia, to hear the challenges others face. helped us feel more involved in College interviews, involvement in RCoA projects Scotland life. However, the lack of opportunity to give trainee/clinical perspective, exam The agenda was broad and optimistic, with to take up roles within the College was observation, and opportunities for RCoA- the opportunity to discuss our perceptions discussed at some length, especially the To join the Membership Dr Christina Beecroft endorsed improvement work. of the College and how the College challenges and restrictions that face those Engagement Panel Consultant Anaesthetist, represents, leads and communicates with who wish to be examiners. While we discussed the issue of ‘London- Ninewells Hospital, visit our website at: us. Support with revalidation is clearly an centricity’, the arrival of a Member all the Dundee important issue for us all and something I really enjoyed the meeting and would way from Jordan soon made our London bit.ly/RCoAMEP the College needs to address. Study leave encourage others to attend similar events. travels seem relatively trivial! was another common theme, with the cost

48 | Bulletin | Issue 115 | May 2019

optimisation, structured risk assessment, the shared decision-making communication with patients and model. Medical assessment Dr Ahmed Gilani family (including limitations in treatment includes objective risk ST6 Anaesthetics, and resuscitation status), and medical assessment, frailty testing, Sandwell and West Birmingham NHS Trust management aimed at expediting early preoperative exercise testing, surgery with continued postoperative and preoperative optimisation care enabling rapid rehabilitation. This of conditions such as anaemia, role also includes participation in the diabetes and frailty. Objective multidisciplinary team round and carrying risk scoring and collaborative Dr Melani Sahni, ST5 Anaesthetics, Sandwell and West Birmingham NHS Trust out a structured postoperative ward round decision-making with the patient Dr Subash Sivasubramaniam, Consultant Anaesthetist, Sandwell and West Birmingham NHS Trust for all high-risk patients. and surgical team are done routinely. A designated Level 1 There was no additional funding area, consisting of four beds, is required for the new post: previously reserved for high-risk general Enhancing perioperative two anaesthetists were allocated to surgical patients requiring trauma theatres during the morning postoperative continuous session; the reallocation of the second monitoring, complex medical care: a novel model anaesthetist allowed for the creation of decision-making, and close the perioperative anaesthetist. nursing care. The initiation in 2015 of the RCoA’s drive for perioperative care services has We have an ongoing data-collection Patients in this area are for elective major colorectal patients led to new pathways to ensure optimal perioperative care. We recognised process which provides continuous reviewed daily by the perioperative from 9.4 days (2017) to 8.1 days (2018), that patients who have complex medical problems were finding themselves feedback on our perioperative process and anaesthetist, the general surgical and better day-one Bauer patient outcomes, enabling us to identify areas for consultant on call for the week, the satisfaction scores compared to the being looked after by a multitude of different members of the surgical team quality improvement. Our locally collected pain team, nursing staff (including national average. and ‘single-organ specialists’, leading to a lack of holistic care and support. data demonstrates improvements in critical care outreach), nutrition teams, We hope that with the simple process of outcomes such as reduced postoperative and physiotherapists. This occurs via a standardisation of care we can continue We would like to share our experience orthopaedic surgery. This includes two timetable for all seven days in a week. complications, improved pain scores, formal structured multidisciplinary ward to significantly improve outcomes, and with our novel model of the dedicated roles – the ‘trauma anaesthetist’ and an The perioperative anaesthetist for the reduced cancellation rates, and reduced round which addresses all aspects of ultimately to improve quality of care ‘perioperative anaesthetist’ at Sandwell additional ‘perioperative anaesthetist’. week, who is primarily based on the ward, rates of serious untoward incidents in hip- perioperative care, including enhanced for surgical patients throughout their and West Birmingham Hospitals, which provides perioperative care in partnership fracture patients. recovery using the ‘PREPARE’ model of The trauma anaesthetist for the week perioperative experience. has led to considerable and demonstrable with the orthogeriatricians and the care (Physiology optimisation, Remove provides care for the full theatre The latest National Hip Fracture improvement in care and outcomes. wider surgical team. This involves pre- Database (NHFD) report for our trust catheters and drains, Emotional support, References: Pain and Physiotherapy, Activities, Ready The ‘perioperative anaesthetist for the demonstrates significant improvements 1 Falls and Fragility Fracture Audit Programme 1 for discharge, and Eat). This is aimed at week’ does a morning session (primarily Figure 1 Improvement in anaesthesia indices since the standardisation of care for in several aspects of perioperative care. (FFFAP): National Hip Fracture Database expediting early patient recovery and (NHFD) Extended Report 2014, 2015, based in the ward) on all five days of hip-fracture patients1 Figure 1 demonstrates the improvement rehabilitation. 2016, 2017. (www.nhfd.co.uk/charts/ the week, and has two primary roles – in anaesthesia indices since the overall?opendocument&org=SAN) perioperative care of high-risk trauma standardisation of care. Financially, we Building upon the lessons learnt from (last accessed 15/10/2018). patients and perioperative care of were able to demonstrate the project to the trauma service, we adopted the 2 Perioperative Quality improvement programme: Annual Report 2018. general surgery patients. It is the same be cost neutral to the trust. ‘Plan, Do, Study and Act’ (PDSA) (https://pqip.org.uk/pages/ar2018) anaesthetist who does all five days in the model to provide quality improvement (last accessed 15/10/2018). week to ensure continuity of care. Role 2: perioperative ward in the standardisation of care and rounds perioperative outcomes for our complex Role 1: trauma perioperative The first step of our perioperative surgical patients requiring elective and role programme begins during the pre- emergency surgery. The latest series In 2015, we standardised the practice assessment clinic visit, when patients of Perioperative Quality Improvement for the perioperative management of are triaged for their potential enhanced Programme (PQIP) reports for our trust patients receiving hip-fracture care, and perioperative needs. Nurse-led pre- have shown significant improvements in we provide a seven-day, consultant-led assessment clinics are augmented by three various standards since the introduction theatre service for acute trauma and dedicated consulant-led pre-assessment of our perioperative model.2 Examples clinics a week. These clinics are run on include a reduction in the length of stay

Professor Bryn Baxendale PERIOPERATIVE JOURNAL WATCH Chair, RCoA Simulation Dr Katie Samuel, Bristol School of Anaesthesia; Dr Jon Whitby and Dr Karthikeyan Selvaraju, Dr Marie Nixon Perioperative Medicine Fellows, University College London Hospitals Working Group and RCoA Clinical Quality Advisor Consultant Anaesthetist, Perioperative Journal Watch is written by TRIPOM (trainees with an interest in perioperative Nottingham University medicine – www.tripom.org), and is a brief distillation of recent important papers and articles Hospitals NHS Trust on perioperative medicine from across the spectrum of medical publications.

Long-term impact of What is the effect Preoperative systemic Relationship between crystalloid versus colloid of perioperative inflammation and preoperative anti- Simulation and multiprofessional solutions on renal intravenous iron therapy perioperative myocardial depressant and anti- function and disability- in patients undergoing injury: prospective anxiety medications and crisis resource management (CRM) free survival after major non-elective surgery? A observational postoperative hospital abdominal surgery systematic review with multicentre cohort study length of stay This paper represents analysis meta-analysis and trial of patients undergoing An ever growing proportion team training of one-year follow-up data sequential analysis non-cardiac surgery. of patients are taking anti- from a previous Belgian Perioperative anaemia Inflammatory response depressant and anti-anxiety double-blinded trial comparing pathways usually focus on is a known contributor medications at the time The College promotes multiprofessional team training through the Guidelines goal-directed fluid therapy elective procedures; this to myocardial injury, and of surgery, with potential using crystalloid (Plasmalyte) meta-analysis sought to assess Neutrophil Lymphocyte ratio impact on postoperative pain for Provision of Anaesthetic Services (GPAS) and Anaesthesia Clinical Services and colloid (hydroxyethyl management, altered coping the effect of intravenous iron (NLR) is a readily available starch). The safety of starch mechanisms, and medication- Accreditation (ACSA). NHS England also emphasises team training and preoperatively in anaemic measure of inflammatory solutions is controversial, with related issues. This retrospective patients having emergency response. This prospective educating staff in Human Factors within its National Safety Standards for some intensive care studies analysis of administrative surgery. study aimed to elucidate Invasive Procedures (NatSSIPs) framework (2015). However, we know little suggesting nephrotoxicity, any association between a data aimed to examine although surgical studies have Three randomised control trials pre-existing inflammatory the relationship between about the quality, quantity or outcomes of team training that is undertaken shown no ill effect. (RCTs) with 605 patients were response and perioperative preoperative medication use myocardial injury. NLR and and length of stay. within different hospital settings. Patients undergoing major included in the meta-analysis. high-sensitivity troponin T abdominal surgery received No effect on infection rates, Data from more than 48,000 (hsTnT) levels were measured Hence, following publication of the 1 Enhanced team briefing – a daily interactions with other teams to maintenance crystalloid time to resolution of anaemia, patients undergoing non- in 1,652 patients over the age RCoA Simulation Strategy (see RCoA mental and verbal five-minute demonstrate safety-critical system therapy, along with either or transfusion requirement cardiac surgery between of 45 undergoing non-cardiac Bulletin, March 2019), the Clinical rehearsal for teams to talk/walk resilience – conducted 6–12 colloid or crystalloid boluses was shown. There was also January 2011 and December surgery on the first three Quality Directorate has prioritised a through their response to relevant monthly according to team and delivered in a goal-directed no difference in length of stay, 2014 was examined. Patients postoperative days. work programme to pilot and establish critical situations, prompted by service needs. manner by a closed-loop 60-day mortality, or quality-of- taking either anti-depressant a national quality-assured approach to predesigned reference action cards automated system. life scores. There was significant or anti-anxiety medications Evidence of implementation might multiprofessional CRM team training that also signpost relevant evidence- association between had an increased length of include individual logs (reviewable at Follow-up of the 160 patients The authors suggest relevant to anaesthetic practice and based team skills and behaviours. myocardial injury and raised stay compared to those who appraisal) and a department/trust systems showed no difference in renal that further large RCTs perioperative care. This will focus on NLR preoperatively [OR: were not (incidence-rate ratio 2 Rapid system stress tests – monthly function at one year, with are needed to detect a regular in-situ rehearsal of team-based safety audit. Peer review of safety-systems 2.56 (1.92-3.41); P<0.0001]. 1.04 (p<0.01) and 1.1 (p<0.01) coordinated 15–20 minute in-situ lower disability scores and difference in transfusion skills and drills for infrequent, difficult or testing would enable dissemination They therefore concluded respectively). team exercises with peer-led higher disability-free survival requirement, as these studies of good practice and demonstrate that preoperative NLR is challenging situations that may result in observation and micro-debriefing, in the colloid group. This is Though this study does not responsiveness to national safety alerts or were underpowered for this independently associated with patient harm if not performed optimally designed to provide assurance on likely to relate to lower rates prove causal correlation, changes in standards of practice. outcome. Variability in dosing perioperative myocardial injury, in practice. the readiness of local systems and of 30-day postoperative it suggests these patients regimes and inclusion of and that chronic systemic team responsiveness to specific complications seen in the may require greater holistic Within any department there are multiple If you are interested in helping to design, only hip fracture and kidney inflammation may contribute critical situations. colloid group in the original attention in both the pre- and teams, in different areas, working pilot and evaluate these interventions, transplant patients limits the to the development of publication. postoperative periods. in different circumstances, and this 3 Full immersion safety-system please email: [email protected]. generalisability of results. perioperative myocardial injury. programme needs to be adaptable to tests – in depth, planned testing of Joosten A et al. Anesthesiology Vashishta R, Kendale Shah A et al. Perioperative Ackland GL et al. Br J Anaesth local context and resources. A three- existing or new systems, processes, 2019;130:227–236 SM. Anesth Analg Medicine 2018; 7:30 2019;122(2):180-187 tiered model is being considered – environments, care pathways and http://bit.ly/2XCVgTU 2019;128(2):248-255 http://bit.ly/2XFKIUf http://bit.ly/2XCVxpU http://bit.ly/2XUOLfp

Dr David Wilkinson Retired Consultant Anaesthetist, Barts Healthcare NHS Trust, London AS WE WERE... Gardeners and herbalists: the first anaesthesiologists? Most anaesthesia historians define the beginning of modern anaesthesia as the moment when William Morton gave ether anaesthesia in the Massachusetts General Hospital on 16 October 1846. But in fact, anaesthesia had been created many times for many hundreds of years before this. The problem lies in trying to produce absolute scientific proof for events hundreds or thousands of years ago. Seishu Hanaoka – picture courtesy of Professor Akitomo Matsuki, Hakodate, Japan

Opium has been available for use Ayurvedic medicine as an analgesic) and other alkaloids, including hyoscyamine, seed-ball groups with combinations like suggestions have been made about Manuscripts across Europe and the work for at least 6,000 years. Seeds of cloves (which contain eugenol and were atropine and scopolamine. many medieval recipes and, in nearby cannabis, opium, datura, and various done in Japan indicate that forms of Papaver somniferum have been found advocated for the relief of toothache). rooms, fragments of sawn bone! So, other alkaloid containing plants. herbal anaesthesia were regularly created Combinations of all these herbs and in Neolithic burial sites in Spain. The Willow trees contain salicylates, and their for many, many centuries it is likely that Hanoaka spent more than 30 years for many centuries prior to the ‘accepted plants have been used over the centuries Egyptian civilisation created a wealth products were used by the Sumerian and monastic orders housed the first of our experimenting on his wife and mother- dates’ for the introduction of our specialty. to produce an unconscious state. The of medical papyri in which obscure Assyrian civilisations. Aspirin was derived profession, and utilised products from in-law, using a variety of combinations It is likely that more and more information major problems encountered with their recipes defy modern pharmacological from meadowsweet by Bayer following their extensive herbal gardens to create of datura to create unconsciousness, will come to light on these matters use were firstly, the lack of reproducibility rationalisation. However, they did use an idea put forward by Felix Hoffman. states (anaesthesia!) which permitted and eventually perfected a combination as the translation and digitalisation of with different levels of alkaloids found Blue Lotus flowers which, when steeped Lettuce was regarded as a useful sedative, surgical treatment. he called ‘mafutsusan’. This contained manuscripts and books from Arabic, in the same species, and then secondly in wine for some time, created a sedative and Beatrix Potter, who herself had a six plant extracts: datura, aconitum, Indian and Chinese sources continue. the proximity of therapeutic and toxic Seishu Hanoaka (1760–1835) in Japan effect from the alkaloids, like nuciferan huge herbal garden at her house in two forms of angelica, cnidium, and threshold! In one of the Cambridge had been made aware of the work of the References and aporphine, that were released. Ambleside and actively collected plants arisaema. After intensive research he Chinese physician, Hua Tuo (c140–208), for medicinal use during World War University Libraries there is an illuminated created a mixture which had a standard 1 Syndics of Cambridge University Library (MS who had experimented with a herbal Mandrake root was a popular ingredient One, highlighted this in The tale of the manuscript entitled ‘How to make a drink effect, and on 13 October 1804 he Dd.6.29, f79r-v). drink called ‘mafeisan’ – literally ‘cannabis in sedative recipes from the time of flopsy bunnies who ate too much of Mr that men call dwale to make a man sleep produced anaesthesia for the removal 2 Matsuki A. Seishu Hanoaka and his medicine. boil powder’. This, he had apparently Hirosaki University Press, 2011. the Greeks right through the Middle McGregor’s produce and were captured whilst men cut him’.1 This drink contains of a breast carcinoma.2 This was the used to create an anaesthetic state, but Ages. Dioscorides described the use of by him while sleeping off the effects! a mixture of hemlock, mandrake, first confirmed anaesthetic in modern the exact constituents remain unclear mandrake to produce an unconscious Hemlock was said to have been used by lettuce and opium in wine, and times. Hanoaka went on to teach his as all his writings are thought to have state, and the plant does contain alkaloids Socrates to hasten his death. It contains presumably it worked. Those performing method to numerous other surgeons in been destroyed after his execution in like scopolamine. Other plants used the very potent alkaloids, conhydrine archaeological pharmaceutical research Japan, and this was the accepted form of 208. There has been much debate to relieve pain include turmeric (which and coniine, the latter being a powerful in the old medieval hospital at Soutra anaesthesia until information about ether about what mafeisan included, and contains curcumin and was popular in respiratory depressant. Henbane contains Aisle in the Scottish Borders have found and chloroform reached Japan.

LETTERS TO THE EDITOR If you would like to submit a letter to the editor please email [email protected]

Dr David Bogod

Dear Editor, Dear Editor, Dear Editor, Dear Editor, Letters page, RCoA Bulletin: a pedant writes, and As We Were: ‘Chair dental GAs’: the last blood sport in As We Were: ‘Chair dental GAs’: the last blood sport in As We Were: ‘Chair dental GAs’: the last blood gets it wrong anaesthesia, or the last art form in anaesthesia? anaesthesia, or the last art form in anaesthesia? sport in anaesthesia, or the last art form in (RCoA Bulletin;113:62) (RCoA Bulletin;113:56-57) (RCoA Bulletin;113:56-57) anaesthesia? (RCoA Bulletin;113:56-57) Dr Smith, in the last issue, describes herself as a ‘medant’, Inhaling 100% N2O is still possible Dr Adrian Padfield asks whether the final ending of the in having a low tolerance for poor medical English, administration of general anaesthesia in dental surgeries in 2001 Articles on the history of anaesthesia are always to be The operator could deliver 100% nitrous oxide to the patient and particularly for badly-spelled medical terms. was one hundred years too late. If so, it was not for want of warmly welcomed. Consequently I read with great interest with the Walton Five dental anaesthetic machine pictured in Dr Unfortunately, in her letter she has misspelled the word trying by anaesthetists. In the extract below, taken from an article and pleasure Dr Adrian Padfield’s eloquent essay on Adrian Padfield’s ‘Chair Dental GA’ article (Bulletin 113:56-57), as melaena as malaena (sic). Schadenfreudelicious! in the Lancet in 1911, Dr Frederic Hewitt mentions his failure to ‘Chair Dental’ GA’s, a subject on which he is an authority. could the contemporary McKesson (Figures 1 and 2). Non-dental persuade the British Dental Association to support the restriction I too used to struggle with this one, until I noticed that Nevertheless I feel compelled to remove the rose tinted anaesthetic machines could deliver 100% well into the early of anaesthetic administration to doctors: the ‘mel’ in melaena shares the same root as the ‘mel’ in spectacles of nostalgia just for a moment. 2000s, when a child with seizures was mistakenly given N2O melanin – from the Greek for ‘black’, or so google just instead of oxygen in an Accident and Emergency department In May, 1909, Sir Donald MacAlister, in his presidential address In 1959 no less a figure than Victor Goldman while told me. and died. This expedited new machines with linked oxygen/ to the General Medical Council, drew special attention to the at Eastman Dental Hospital espoused his 4th breath 1 I expect there will be correspondence in your next issue N2O flowmeters delivering a maximum 75% N2O. The illegal subject of anaesthetics, and reported that practically all the technique as follows. The patient inhales 100% nitrous

correcting some error in this letter. recreational use of 100% N2O continues. The contents of an examining bodies for medical qualifications had now given effect oxide until asleep and deeply cyanotic, and then air is to the recommendations of the Council in regard to instruction in Yours in anticipation, 8 gram N2O whipped cream maker cartridge is released into given every 4th breath for 2 to 3 minutes. To avoid the a balloon (a circuit un-alphabeticised by Professor Mapleson), anaesthetics. In the same month a committee was appointed by the damaging effects of cerebral hypoxia it is recommended, in John Glen inhaled with rebreathing and a breath-hold.2,3 To measure the Council ‘to consider the proposals for legislation on the subject of Dr Goldman’s words, that oxygen be judiciously added for Consultant in ICM, amount of gas produced, a manufactured-for-purpose aluminium anaesthetics which have been or may hereafter be put forward.’ longer procedures or ‘if there is an increase in respiratory North Wales ‘cracker’ pierced a N2O cartridge (Figure 3) to release gas inside a rate indicating marked hypoxaemia’. One assumes this was Whilst the-question was thus receiving adequate consideration at sealed anaesthetic reservoir bag. By counting the number of times a popular method through the 1960’s and beyond. It was the-hands of the dominant educational authority it began seriously I thank Dr Glen profusely for correcting my egregious a 60ml syringe was filled and evacuated when emptying the bag, not until 1973 that the Synopsis of Anaesthesia, by then to attract the attention of the British Dental Association. At the annual misspelling. The error had gone unnoticed not only by a volume of 3.67 litres N2O was measured. in it’s 7th Edition, began to advise caution against the use meeting of this association at Birmingham the present writer laid me, but also several fellow pedants, including the Editor of a technique which by then had earnt nitrous oxide the William FS Sellers before that association various arguments in favour of the principle himself! A reminder of the etymology is most welcome. chilling soubriquet of the Black Gas. Locum Anaesthetist of placing all, general anesthetics, including nitrous oxide, in the I shall be found hanging my head in shame (and buying hands of registered medical men, and local anaesthetics in the hands In skilled hands that no long term harm was done to the drinks) at the next Medants Anonymous meeting. References of registered medical and dental practitioners. It is to be regretted, children’s developing brains as teeth were whipped out Dr Emma-Jane Smith 1 Saunders DI, Meek I. Almost 30% of anaesthetic machines in UK do not however, that these proposals, in spite of the fact that they had the in record time is not doubted. But what of the single ST5 Anaesthetics & Intensive Care Medicine, have an anti-hypoxia device. BMJ 2001:323(7313):629. support of Mr CS Tomes, Mr William Hern, Mr Russell Barrett, Mr A handed dentist administering their own anaesthetics? A Lewisham and Greenwich NHS Trust 2 Acharya A, Basnett I, Gutteridge C, Noyce A. Laughter isn’t always the best Hopewell-Smith, and a few other leading dentists, did not commend uniquely British eccentricity, chair dental anaesthesia was medicine. BMJ 2018;363:4579-4580 doi:10.1136/bmj.k4579. themselves to the dental profession as a whole. A resolution was, in never exported, as Dr Padfield points out, and perhaps 3 Sellers WFS. Misuse of anaesthetic gases. Anaesthesia 2016: 71:1140-1143 fact, passed almost unanimously protesting ‘against any legislation doi:10.111/anae.13551. that is just as well. which would make it illegal for registered dentists to administer anaesthetics for dental operations.’ It was contended that any such Yours sincerely legislation would not be ‘in the best interests of the public.’ Matthew Down Consultant Anaesthetist, Sunderland Royal Hospital Reference Reference 1 Hewitt FW. The position of the present reform movement in Anaesthetics. Lancet 3 June 1911; 1486-1488. 1 M Down. Nitrous Oxide. The good, the bad (and the ugly). Anaesthesia News 2016;344: 14-16. David Hatch Figure 1 Figure 2 Figure 3 Emeritus Professor of Anaesthesia, 1999 Hewitt Lecturer, RCoA

LETTERS TO THE EDITOR OBSTETRICS ON-CALL If you would like to submit a letter to the editor please email [email protected] Dr Reena Ellis ST3 Anaesthetist, East Midlands

Dr David Bogod My Pain is Your Pain Dear Editor, Dear Editor, Until the Shiny Point is dulled. Anaesthetic Soapbox #1 “No, I don’t want 2 ml of b****y fentanyl!” Anaesthetic Soapbox #1 “No, I don’t want 2 ml of eased by sodium blockade (RCoA Bulletin;113:40-41) b****y fentanyl!” which softens the edges (RCoA Bulletin;113:40-41) soaring you onwards towards a scalpel delivery I applaud Dr Harrop-Griffith’s endeavours the ritual as a whole. I’d encourage our onto it, you are knowingly performing Tell me, what’s a Normal Delivery? to encourage critical and reflective colleagues to reflect on this point which a ritual that may have some value to I would like to compliment Dr Harrop-Griffiths’s in his excellent Each unique but each alone thinking of our practices, yet I feel the is what I believe Dr Harrop-Griffith was you but poses no substantive threat to and (thought) provoking Soapbox article. You journey on, piece has a muddied overall message. I attempting to convey. either the rugby ball or the aeroplane. I noted an interesting error in the article’s accompanying image, Every path takes you forward feel the trainee at the end of the session Yours faithfully, I suspect that many of those who give may be somewhat confused when some fentanyl immediately before induction however... towards the rainbow’s end. Dr Ahmed Gilani of their answers to justify their use of are not aware that what they are doing is ST6 Anaesthetics, Birmingham The cannula in the image, a safety version of the BD Venflon is Oxytocin Driven fentanyl as part of induction are riposted a ritual. If you really need to inject 2 ml being used with the sharp stylet needle still in it. Not only does You suddenly arrive then reformatted as ‘caveats’. Reference of something as a ritual at the start of an this bypass the sharps safety system for which it is designed, but pain forgotten and dismissed. 1 Elliot C. Slow Cures and Bad Philosophers: anaesthetic, may I suggest saline? The wording of ‘purposeless ritual’ I expect whatever is injected via the port will leak from the open Essays on Wittgenstein, Medicine, and But not for us. strikes me the most. ‘Ritualisation’ in Bioethics. Duke University Press: 2001. Kind regards, end (perhaps just as well if it is fentanyl...) medical practice is acknowledged in William Harrop-Griffiths For our role lies at the end of a syringe. phenomenological medical philosophy.1 I am sure this is not a technique that Dr Harrop-Griffiths would We create a new experience, Dear sir I estimate that about 75 per cent of A ritual ‘orientates’ a person to what is PS recommend to his trainees. changing more than just one life, obstetric anaesthetic practice is ritual of important to them (a form of value-based I am grateful to Dr Gilani for his interest but at what Cost? some sort, but that will be the subject of Will the next Anaesthetic Soapbox article be accompanied by medicine); a ritual gives an ‘order’ of in my Soapbox article; I agree with much another in this series of Soapbox articles. an image demonstrating a cannula being used in the correct How closely do we consider the impact events to follow, as if numbered. Such of what he says about rituals in medicine. way, as well as avoiding the back of the hand? of how we impart our skills? ordering is most useful when events can I teach the trainees who are unfortunate Dear Editor, The endless pressures of screaming wear thin be uncertain, dangerous or stressful. enough to find themselves in theatre with Maybe I too am getting overly pedantic as I progress through me that there are three reasons to do in the deafening darkness at 3am. Rituals promote solidarity, usually by Letter to the Editor: Airway the years?! things during an anaesthetic and that they bringing a ‘team’ together, creating a Training Can you retain your ability all start with the letter ‘R’: Yours faithfully, certain ‘power’. Take the example of (RCoA Bulletin;113:60) to empathise, resuscitation – the ‘team’ works in an ■■ if it is Recommended in guidance Dr James French Anthony Rubin is absolutely correct when you’ve reach this frayed end? ‘order’ in a seemingly uncertain and from a body competent to provide Consultant Anaesthetist and Anaesthetic Equipment Lead, when it comes to airway training; the stressful situation to ‘orientate’ towards a such guidance Nottingham No time to consider gum elastic bougie and blind nasal desired outcome. No time left to reflect ■■ if it is Rational and is based on both intubation are both (literally) life Dr French was not the only eagle-eyed reader to spot this. They’re calling again The fact that fentanyl is commonly used logic and a knowledge of the relevant savers. I can reassure him that the Enquiries reveal that this photo comes from a series hosted at induction is, I believe, owed toward physiology, pharmacology, anatomy, etc technique of blind nasal intubation by someone who we have decided to refer to as ‘a highly rush and run it fulfilling a part of a ‘purposeful’ ritual ■■ if it is a Ritual. is far from dead, and is in regular when used correctly during induction respected senior consultant’, who is holding the propofol be quick and fast and good and kind The important aspect of the last of the use by this craniofacial anaesthetist; that is reproducible and likely to reinforce syringe. The good news is that no patient was harmed in the and be sure, to come back tomorrow three Rs is that (a) we must be aware that it has got me out of a tight spot on the ‘pharmacological tic’ described. This process, as the ‘cannulated’ hand (actually the hand onto which for some more what we are doing is a ritual and (b) the many occasions. Mind you, I was is why it becomes a ritual. The shared the cut cannula has been taped) is that of the photographer. as when you find yourself ritual should not have the capacity to taught the technique by a master: experiences of ODAs, trainees, trainers, This still doesn’t explain the apparent presence of the needle on the other side harm the patient in any way. If you dance Dr Rubin himself! and patients makes it endure as part of inside the cannula which, despite the editor’s Poirot-like you’ll be grateful around before taking a rugby place- our culture and rites. But, like rituals, when doggedness, remains a mystery. kick like Jonny Wilkinson or you touch Bernard Norman for the golden glide meaning is lost ‘purposeless’ ensues. the side of an aeroplane before getting Consultant Anaesthetist Dr David Bogod of that Sodium Blockade. Fentanyl’s incorrect use undermines Editor

Research, Education and Travel Grants

The National Institute of Academic To apply by the Royal College of Anaesthetists Maurice P Hudson Prize doctor in training who is the principal publication, since 1 August 2018, please Anaesthesia (NIAA) has several small Please visit www.niaa.org.uk/RCoA- or its associated Faculties, other related Dr Maurice Hudson was a consultant author of the best paper relating to submit your article along with a copy grants funded by the Royal College Small-Grants to view the assessment organisations and specialist societies. anaesthetist in London, took the DA in the management of acutely ill patients of your curriculum vitae and a covering of Anaesthetists for the purpose of criteria and download a copy of the The lecture is commemorated by the 1936, was awarded the FFARCS in 1948 published, or accepted for publication, in letter by email to the NIAA Co-ordinator supporting research, education or travel application form, which must be emailed presentation of a certificate. and had a particular interest in dental a peer-reviewed journal. at the address below by 5.00pm on connected with the study of anaesthesia. to the NIAA Co-ordinator at the address anaesthesia. The Hudson Harness was Friday 6 September 2019. A prize of Applications for Macintosh You can read about previously successful Priority will be given to educational below. The deadline for applications is one of his innovations. £500 is available. Professorships are open to fellows Maurice P Hudson Prize applicants by projects, the presentation of original 5.00pm on Friday 6 September 2019. work or the provision of education to and members of the Royal College of The late Dr Maurice Hudson’s daughter visiting the NIAA website here: Please note that only one article may be developing countries. Macintosh Professorship Anaesthetists and other clinicians and generously donated money to the www.niaa.org.uk/RCoA-Maurice-P- submitted per applicant. scientists involved in anaesthesia, critical Hudson-Prize-Winners#pt The Royal College of Anaesthetists has College in memory of her father for an Applications are invited for the following care and pain management within the Applications for the above grants, established a number of initiatives to annual prize for the best paper on his funds: United Kingdom. Applications will be To apply awards and prizes should be sent to the foster research in anaesthesia, critical favourite subject – resuscitation. considered by the Board of the National If you are an anaesthetic or intensive NIAA Co-ordinator, Ms Pamela Hines, Ernest Leach Research Fund care and pain management. Their aim is Institute of Academic Anaesthesia and The criteria for this prize have now been care doctor in training and the principal by email to: [email protected] This fund was established in June 2011 to to encourage experienced researchers expert external advisers. Depending extended and the prize will be awarded author of an article as outlined above be utilised for the purposes of research. as well as those who are in the early on the quality of applications, the to the anaesthetic or intensive care and published, or accepted for stages of developing a research Value up to £2,500 review panel reserves the right to award portfolio. Macintosh Professorships a Professorship to more than one Sargant Fund are aimed at established clinical or candidate in any given year. For education and research purposes. laboratory researchers who are already performing at a high level. Their purpose CALL FOR PROPOSALS FOR SNAP3 Value up to £2,500 The College welcomes nominations for is to recognise and disseminate the work this award from national and/or specialist The Royal College of Anaesthetists requests those wishing to suggest a topic Belfast Fund of the award holders and facilitate their societies in anaesthesia within the UK. If for the 3rd Sprint National Anaesthesia Project of the Royal College of progress in the academic world. Anaesthetists to contact [email protected] To fund grants for educational purposes. successful, the title of the Professorship will reflect a joint award from the College Value up to £600 Recipients of the award will have a As a guide we suggest the topic should: and nominating body. national or international reputation in ■■ be important to patients Eligibility their field. Their curriculum vitae will You can read about previously awarded ■■ be important to anaesthetists All RCoA fellows and members in good be consistent with an individual who Macintosh Professorships by visiting the standing, and registered anaesthetists ■■ be currently incompletely studied in incidence or nature is performing at, or is on the cusp of, NIAA website here: www.niaa.org.uk/ in training, are eligible to apply for the ■■ be a short observational clinical research study professorial level through research, RCoA-Macintosh-Professorship#pt above grants. We regret that applications innovation, and leadership. Those who ■■ recruit a large number of patients from as many NHS hospitals as possible in a short period of time for funding towards registration for show equivalent excellence in teaching To apply ■■ engage ‘grass-roots’ anaesthetists, particularly trainees, in delivering the studies. higher degrees or College course fees and education will also be eligible for Please submit a synopsis of your will not be considered. Topics that may potentially involve collaboration with other specialties and/or international collaboration in the award. proposed lecture, along with your SNAP3 are encouraged, though this is not essential. You can read about previous successfully curriculum vitae and covering letter by Macintosh Professorships are awarded funded projects by visiting the NIAA email to the NIAA Co-ordinator at the Closing date: 9.00am, Friday 31 May 2019 for one year (normally the College website here: www.niaa.org.uk/RCoA- address below by 5.00pm on Friday 6 academic year). Recipients are required, Small-Research-Education-and-Travel- September 2019. within that time or soon after, to give a Grants keynote lecture at a meeting organised

NIAA Research Grants: 2018 Round 2

On Wednesday 5 December, the NIAA Grants Committee met to consider the second round of applications for 2018 on behalf of the Association of Anaesthetists and Anaesthesia, the British Journal of Anaesthesia, the Royal College of Anaesthetists, and the College of Anaesthetists of Ireland.

The committee considered 32 applications over five categories for a requested sum of £1,599,632 and made a total of 12 awards over four categories to a value of £665,073. Success rate: 36 per cent.

A list of the successful applicants are in the following table and abstracts can be viewed online here: bit.ly/NIAARound22018. Minutes of the grant committee meeting can be viewed here: www.niaa.org.uk/NIAA-Grant-Committee-Minutes#pt

Association of Anaesthetists/Anaesthesia Research Grants

Dr Reema Ayyash Investigating the associations between patient reported outcomes and preoperative frailty in £40,000 patients with operable, potentially curative, colorectal cancer: an observational study

Dr Sara-Catrin Cook Improving outcomes for frail patients undergoing elective colorectal cancer surgery £17,479

Dr Sara-Catrin Cook The Videolaryngoscope Airway Database App Project £4,882

Dr Louise Savic Teicoplanin Anaphylaxis: Development of a diagnostic pathway, and elucidation of the underlying £20,000 allergic mechanism

BJA/RCoA Project Grants

Dr Tristan Bekinschtein How are neural mechanisms underpinning touch-evoked pain modulated by sensory expectation £54,272 and cognition in individuals with Complex Regional Pain Syndrome

Prof Philip Hopkins Transcriptional and functional changes underpinning acute and chronic mitochondrial £25,663 dysfunction in human and murine malignant hyperthermia

Prof David Lambert Use of novel fluorescent probes to examine MOP/NOP interaction: studies with Cebranopadol £59,829 and AT-121 as mixed agonists

BJA/RCoA Non-Clinical PhD Studentships

Dr Andrew Conway Morris Mapping and manipulating the human neutrophil response to staphylococcus aureus £99,342

Prof Helen Galley & Interactions between melatonin and endogenous opioid peptide release £89,426 Dr Heather Wilson

Dr Sian Henson Characterisation of metabolic dysfunction and altered T cell migration in lymphopaenic £92,481 perioperative individuals

Dr Manu Shankar-Hari Studying immune trajectory to determine optimal timing for immunomodulation in sepsis patients: £89,331 Scientific cohort study

BJA/RCoA History PhD Studentship

Dr Stephanie Snow The History of the First 100 Years of the BJA £72,368

Mersey Dr C Gerrard (Whiston Hospital) in APPOINTMENT OF FELLOWS TO CONSULTANT AND SIMILAR succession to Dr J Slee POSTS *Dr S Griffiths (The Walton Centre for The College congratulates the following fellows on their consultant appointments: Neurology and Neurosurgery Dr Suzanne Bell, Princess Alexandra Hospital, Harlow South West Dr Julia Bowditch, Salisbury NHS Foundation Trust Peninsula Dr Marika Chandler, Royal Devon and Exeter Hospital Dr N Campbell (Musgrove Park Dr Helen Doherty, Freeman Hospital, Newcastle upon Tyne Hospital) in succession to Dr M Dr John-Oliver Dunn University Hospital Southampton NHS Foundation Trust Khakhar Dr Soumitra Ghosh, Oxford University Hospitals NHS Trust

Severn Dr Nadeam Mujtaba, University Hospital Southampton NHS Foundation Trust Dr A Clarke (Bristol Royal Infirmary) Dr Jonathan Paige, University Hospital Coventry and Warwickshire Dr N Harvey Dr Benjamin Plumb, Musgrove Park, Taunton Dr Ilyas Qazi, University Hospitals Birmingham NHS Foundation Trust Yorkshire and the Humber South Yorkshire Dr R Bhosale (Doncaster Hospital) in succession to Dr M B Balasa DEATHS With regret, we record the death of those listed below. Dr B Edwards (Northern General Hospital) in succession to Dr A Nair Dr John Alexander, County Antrim Dr Narendar Kumar Mathur Dr Jack William Brooks, Colwyn Bay Dr John Roylance, Birmingham NEW TO THE COLLEGE Wessex Dr Thomas Victor Campkin, Southampton Dr Eileen Patricia Sapsford, Romsey Dr S Radauceanu (Queen Alexandra Dr Keith William Dodd, Edinburgh Dr Poornima Sreekumar, Newport Hospital) in succession to Dr M The following appointments/re-appointments were approved Dr Paul Andrew Holder, Aberdeen Professor John Andrew Thornton, Jackson (re-appointments marked with an asterisk). Dr John Roland Lewis, Shropshire Abergavenny Please submit obituaries of no more than 500 words, with a photo if desired, of fellows, members or trainees to: [email protected]. All obituaries received will be published Deputy Regional Advisers Scotland East Midlands on the College website (www.rcoa.ac.uk/obituaries). Anaesthesia South East Scotland *Dr A Kathirgamanathan (Kings Mill Northern Dr O Daly (Royal Infirmary of Edinburgh) Hospital) Dr I Whitehead as Deputy Regional in succession to Dr S Thompson London CONSULTATIONS Adviser for the Northern Region West of Scotland South East The following is a list of consultations which the College has responded to in the last two months. Those published on the Dr V J Vallance (Hairmyres Hospital) in Dr H Thomas (Guy’s and St Thomas’) Wessex College website via our Responses to Consultations area (bit.ly/rcoa-consultations) are marked with an asterisk. succession to Dr J Duffty in succession to Dr M Sicinski Dr M Jackson as Deputy Regional Adviser for Wessex in succession to *Dr S Smith (Royal Glasgow Infirmary) Imperial Originator Consultation Dr E Costar Acting tutor at Charing Dr J Chambers England NHS Improvement/NHS England Implementing the NHS Long Term Plan – Proposals for possible change to legislation Cross Hospital, covering for Dr N Stranix College Tutors East of England & Bart’s and the Nursing & Midwifery Council Standards of Proficiency for Midwives & Pre-Registration Midwifery Programmes London Oxford Wales Dr M May (Basildon University Hospital) Dr C Walker (Milton Keynes University National Data Guardian National Data Guardian for Health and Social Care: a consultation about priorities Dr M D L Williams (Prince Charles in succession to Dr V Shenoy Hospital) in succession to Dr A D Kalla Hospital) in succession to Dr J Butler British Orthopaedic Association The care of the older or frail orthopaedic trauma patient

Dr M Roberts (University Hospital of East of England North West National Institute for Health and CG190 Intrapartum care for healthy women and babies Wales) in succession to Dr J Hall Dr S Grover (Lister Hospital) in Dr M Anderson (University Hospital Care Excellence succession to Dr M Simpson of Morecombe Bay NHS Trust) in Northern Ireland succession to Dr C Coldwell Royal College of Obstetricians Green-top Good Practice Paper no.16: Good Practice for Supporting the Family and Dr G Bostock (Ipswich Hospital) in Dr G McClune (Ulster Hospital) in and Gynaecologists Staff Following a Maternal Death succession to Dr H Boyce succession to Dr D T Lee

64 | | 65 Bulletin | Issue 115 | May 2019

A Career in Anaesthesia FPM 12th Annual Meeting JULY 9 October 2019 29 November 2019 EVENTS CALENDAR RCoA, London RCoA, London Final FRCA Revision Course Further information about all 1–5 July 2019 UK Training in Emergency of our events can be found on RCoA, London Airway Management (TEAM) DECEMBER our website. 28–29 October 2019 Winter Symposium RCoA, London www.rcoa.ac.uk/events SEPTEMBER % 10–11 December 2019 [email protected] RCoA, London @RCoANews FPM Exam Tutorial NOVEMBER 2 September 2019 RCoA London UK Training in Emergency JANUARY 2020 Airway Management (TEAM) FPM Study Day: Musculoskeletal Primary FRCA Revision Course Presentation of Diplomates 7–8 November 2019 MAY JUNE System Examination for Diagnosing 14–17 January 2020 6 September 2019 Royal Infirmary of Edinburgh Pain Problems Central Hall, London RCoA, London Regional Anaesthesia Masterclass Introduction to Leadership and 12 June 2019 Anaesthetists as Educators: 4 June 2019 GASagain (Giving Anaesthesia % Management: The Essentials RCoA, London Advanced Airway Workshop % Teaching and Training in the RCoA, London Safely Again) 2–3 May 2019 24 September 2019 Workplace Airway Management: Training FICM Annual Meeting: End of Life 15 January 2020 RCoA, London RCoA, London 14–15 November 2019 % the Trainer Matters! Bradford Royal Infirmary RCoA, London Anaesthetists as Educators: 6 June 2019 13 June 2019 Updates in Anaesthesia, Critical % Final FRCA Revision Course % Anaesthetists’ Non-Technical RCoA, London RCoA, London Care and Pain Management Anaesthetists as Educators: 20–24 January 2020 Skills (ANTS) 24–26 September 2019 % Anaesthetists’ Non-Technical Skills UK Training in Emergency Airway RCoA, London 7 May 2019 Updates in Anaesthesia, RCoA, London (ANTS) Management (TEAM) RCoA, London % Critical Care and Pain 22 November 2019 10–11 June 2019 Developing World Anaesthesia Management RCoA, London Solihull Hospital 30 September 2019 ANAESTHESIA 2019 17–19 June 2019 RCoA, London % 20–22 May 2019 Anaesthetists as Educators: Mercure Hotel, Bristol etc.venues St Paul’s, London % An Introduction www.rcoa.ac.uk/anaesthesia 11 June 2019 UK Training in Emergency Airway OCTOBER RCoA, London Management (TEAM) 20–21 June 2019 Anaesthetists as Educators: Royal United Hospital, Bath % An Introduction UPDATES IN ANAESTHESIA, CRITICAL 1 October 2019 CPD Study Day – Hull RCoA, London CARE AND PAIN MANAGEMENT % 21 June 2019 Double Tree by Hilton, Hull Anaesthetists as Educators: 17–19 JUNE 2019 | BRISTOL % Simulation Unplugged Primary FRCA Revision Course 2 October 2019 24–27 June 2019 RCoA, London RCoA, London Leadership and Management: Airway Workshop Leading and Managing Change % 20–22 May | etc.venues | St Paul’s, London 25 June 2019 7 October 2019 RCoA, London RCoA, London

GASagain (Giving Anaesthesia Ultrasound Workshop SOLD OUT IN 2018 Safely Again) % 8 October 2019 Don’t miss out, book now: 26 June 2019 RCoA, London Royal Bournemouth Hospital www.rcoa.ac.uk/anaesthesia View the full programme online now

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.

ANAESTHETISTS CPD STUDY AS EDUCATORS DAYS

CPD approved CPD credits 5 % %

21 June 2019 | DoubleTree by Hilton, Hull Our series of Anaesthetists as Educators events support clinical educators in delivering high quality training and REGIONAL ANAESTHESIA Hear about best anaesthetic practice, maintain your education in the workplace. Participation in the courses competence and earn CPD points to aid revalidation at provides supporting evidence towards the GMC approval MASTERCLASS our CPD study days. Join us in Hull for discussion on a process for trainers. broad range of engaging topics including:

■ CPD ■ processed EEG monitoring credits 5 % An Introduction ■■ anaesthesia for patients with cardiac disease undergoing AIRWAY RCoA, London 11 June 2019 | RCoA, London 4 June 2019 | non-cardiac surgery 1 October 2019 | RCoA, London ■■ enhanced maternal care Join us as we explore the use of Regional Anaesthesia at WORKSHOPS Provides an overview of postgraduate medical education ■ our first RCoA masterclass. Study the pros and cons of ■ the paediatric difficult airway – The Vortex approach in anaesthesia. This highly interactive course is suitable safely using Regional Anaesthesia, by looking at the past, ■■ psychology for patients at high risk of post-operative pain for doctors with no previous training in teaching or the present and the future, including an in depth look at ■■ guidance on communication, consent and giving medical education. CPD professional opinions approved the latest research. Watch live interactive demonstrations % where you can learn top tips from the experts on blocks for ■■ dealing with difficult patients Teaching and Training in the Workplace shoulder and chest surgery. ■■ perioperative management of the bleeding patient Airway Management: Training the Trainer 14–15 November 2019 | RCoA, London Intended for doctors with some experience of teaching and 6 June 2019 | RCoA, London supervising trainees, this course looks at the education and Discover how to deliver effective airway courses and teaching assessment of trainee anaesthetists and raises awareness of EXAM REVISION A CAREER IN for multidisciplinary teams, in a cost effective manner. some of the key concepts associated with education. ANAESTHESIA Airway Workshop COURSES 25 June 2019 | RCoA, London Anaesthetists’ Non-Technical Skills (ANTS) Learn core technical and non- technical airway skills 7 May 2019 | RCoA, London including awake tracheal intubation and front of neck 22 November 2019 | RCoA, London Primary FRCA Revision Course access. Appropriate for all grades. For those wishing to increase their understanding of how 24–27 June 2019 | RCoA, London 9 October 2019 | RCoA, London behavioural aspects of performance contribute to patient 14–17 January 2020 | RCoA, London UK Training in Emergency Airway Are you a medical student or foundation year doctor and Management (TEAM) safety. Learn about the concepts and vocabulary used to Final FRCA Revision Course considering a career in anaesthesia? The RCoA is holding a 10–11 June 2019 | Solihull Hospital formulate a personal strategy using the ANTS framework. 1–5 July 2019 | RCoA, London half-day information session for those who want to find out 20–24 January 2020 | RCoA, London 20–21 June 2019 | Royal United Hospital, Bath more about the specialty. This day will focus on the general Simulation Unplugged 28–29 October 2019 | RCoA, London aspects of a career in anaesthesia, providing an insight into 7–8 November 2019 | Royal Infirmary of Edinburgh 2 October 2019 | RCoA, London Offering a combination of learning methods, including lectures, small life as a trainee and consultant anaesthetist. There will be For those developing their knowledge and skills in A two day simulator-based course designed to teach the group tutorials and practice MCQ, opportunities to ask questions throughout the day. delivering educational simulation. This course is designed knowledge, skills and attitudes required to safely manage the SBA and SAQ papers, these revision Sessions will include: to debunk the myths and get back to the nuts and bolts of airway in an emergency situation outside the operating theatre. courses will inspire confidence and what you and your learners need. ■■ life as an anaesthetic trainee ensure trainees are well prepared Advanced Airway Workshop ■■ intensive care medicine for the Primary and Final FRCA written 24 September 2019 | RCoA, London ■■ pre-hospital medicine examinations. These intensive courses An extension of our Airway Workshop series, in this ■■ ACCS anaesthetics cover the topics candidates typically workshop you will enhance and refine your existing ■■ recruitment and application processes have most difficulty with. specialised airway skills. Aimed at senior trainees, airway Full programmes available online ■■ the future of anaesthesia and the skills required. leads and anaesthetic consultants.

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

CPD credits 15

#RCoAUpdates

UPDATES IN ANAESTHESIA, CRITICAL CARE AND PAIN MANAGEMENT 17–19 June 2019 | Mercure Holland House Hotel and Spa, Bristol 24–26 September 2019 | RCoA, London

Stay ahead of the curve and join us for three days of new ideas in anaesthesia, critical care and pain management. Discover new developments on the horizon from today’s thought leaders and learn how best to combat the growing issues you will face in your anaesthetic practice.

Programmes include: Bristol London

■■ anaesthesia at extremes of body weight ■■ muscle wasting in the critically ill patient

■■ perioperative care and dementia ■■ intubating the unstable cervical spine

■■ how to start a QI project ■■ long term outcomes following ICU

■■ consent in anaesthesia ■■ awake tracheal intubation guidelines

■■ decision making in airway management ■■ ICU in the 21st century: current challenges in the UK.

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