2014 Wylie Medal winner's essay

ISSN 0959-2962 No. 326

SEPT 2014

The NewsleTTer of The

AssociATioN of ANAesTheTisTs of GreAT BriTAiN

ANd irelANd NEWSANAESTHESIA

INSIDE THIS ISSUE: Avicenna the Anaesthetist

The Primary FRCA: trainee experiences and recent changes

Rural anaesthesia in the Transkei

Photograph: W

ellcome Library London

Anaesthesia News September 2014 • Issue 326 3

contents03 editorial 05 winston churchill 06 The Primary frcA: trainee experiences and recent changes 09 research and grants committee report 10 Avicenna the Anaesthetist

14 A successful GAT Annual scientific Meeting 17 it’s not a stethoscope, it’s a stethophone

18 wsM london 2015 Preview 20 rural anaesthesia in the Transkei 23 Anaesthesia digested 24 Your letters 28 Particles

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The Association of Anaesthetists of Great Britain and Ireland21 Portland Place, London W1B 1PYTelephone: 020 7631 1650Fax: 020 7631 4352Email: [email protected]: www.aagbi.org

Anaesthesia NewsChair Editorial Board: Nancy RedfernEditors: Nicholas Love and Caroline Wilson (GAT), Nancy Redfern, Richard Griffiths, Sean Tighe, Tom Woodcock, Mike Nathanson, Rachel Collis, Upma Misra and Felicity PlaatAddress for all correspondence, advertising or submissions: Email: [email protected]: www.aagbi.org/publications/anaesthesia-news

Editorial Assistant: Rona GloagEmail: [email protected]

Design: Chris SteerAAGBI Website & Publications Officer Telephone: 020 7631 8803Email: [email protected]: Portland Print

Copyright 2014 The Association of Anaesthetists of Great Britain and Ireland

The Association cannot be responsible for the statements or views of the contributors. No part of this newsletter may be reproduced without prior permission.

Advertisements are accepted in good faith. Readers are reminded that Anaesthesia News cannot be held responsible in any way for the quality or correctness of products or services offered in advertisements. 3

EditorialWelcome to the September edition of Anaesthesia News! I hope you have all managed to have a break over the summer and taken some well-earned time for relaxation. I am well aware that some of you may be facing stresses and challenges, be it a new job, arranging an inter-deanery transfer, preparing for an exam or caring for a loved one. Empathy and compassion are emotions most of us develop and use in our daily interactions with patients and their relatives. What surprises and bemuses me even now is why some doctors are sparing with

these emotions when dealing with a colleague in difficulty. I speak not from personal experience, I hasten to add, as I am blessed in working in a department where we stand behind and support colleagues facing personal or professional challenges.

Even the best clinician can make a mistake and find themselves the focus of a complaint or, worse still, a GMC referral. A firm handshake, an offer to make a cup of coffee or just a chat can sometimes be very comforting to this incredibly stressed individual. Remember this could happen to you sometime in your career. The GMC reported a great surge in complaints received about doctors in 2012. Of the enquiries received that year there were 8109 complaints about a doctor’s fitness to practice.

Enough of the sermon. At a recent Council meeting there was plenty of chatter about cycling to Harrogate for the Annual Congress and how people are training for it. Good luck to everyone taking part in the bike ride and to the charities they are supporting. Personally, I am petrified of cycling on the roads and I am not even on the bike! I am usually in a car behind a cyclist, going at 10 mph, watching them riding in the middle of the road in front of me. As I see a red light approaching I heave a sigh of relief, as I can easily go past him/her when it goes green again. Wait a minute…they don’t stop at all; instead they keep going through the red light! I must make myself familiar with the cyclist’s Highway Code…

On a serious note, take care when you cycle, I think a lot more can and should be done to make our roads friendlier and safer for cyclists.

In this issue there are a couple of fascinating articles on the history of anaesthesia. The Anaesthesia History Prize winner, Yasser Mustafa, was only an F2 trainee when he wrote this piece and did most of the translations himself. My colleague, Matthew Down, tells us about Winston Churchill’s anaesthetic experiences. ‘Victor Meldrew’ has a rant that some of you might empathise with! If you enjoy this, do let us know by writing to [email protected] and we might ask him to make a regular contribution. His therapist thinks that might be good for his mental health as well.

All of you are invited to the WSM in London in 2015. It’s a great meeting in a great city so book your leave now. Further details of registration fees will be available soon from http://www.wsmlondon.org/

Upma Misra

1973 05/14

2014 Course Dates Location Organisers25–26 September Liverpool Dr Steve Roberts28–29 November Nottingham (A) Dr Nigel Bedforth

Faculty will vary depending on location

10% Discount for ESRA members – 15% Discount for RA-UK (FULL) members. Cost: £400 / £500 (A) including a CD with presentations and course notes.

Pre-course material can be downloaded once registered on the course – including US physics, anatomy of the brachial / lumbar plexus, current articles of interest and MCQ’s. A pre course questionnaire will be sent 30 days before each course.

For further information and to register logon to www.sonositeeducation.co.uk

PROGRAMMEDay 1• Ultrasound a ppearance of the nerves• Machine characteristics and set-up• Imaging and needling techniques• Common approaches to the brachial plexus / upper /

lower limb• Workshops – using phantoms / models / cadaveric

prosections (A)

Day 2• Consent / training and image storage• Upper / lower limb techniques• Abdominal / thoracic techniques • Cervical plexus / spinal / epidural / pain procedures• Workshops – using phantoms / models / cadaveric

prosections (A)

(A) – Anatomy based courses / with cadaveric prosections

ULTRASOUND GUIDED REGIONAL ANAESTHESIA – BEYOND INTRODUCTORYThese courses are organised by Regional Anaesthesia UK (RA-UK) in conjunction with SonoSite Ltd for training in ultrasound guided regional anaesthetic techniques. Previous experience in regional anaesthesia is essential.

FUJIFILM SonoSite, Inc,. the SonoSite logo and other trademarks not owned by third parties are registered and unregistered trademarks of FUJIFILM SonoSite, Inc. in various jurisdictions. All other trademarks are the property of their respective owners. ©2014 FUJIFILM SonoSite, Inc. All rights reserved.

2014 COURSE DATES:Complete Ultrasound Guided Regional Anaesthesia Education (CURE)6-7 October

Ultrasound Guided Venous Access23 October

Critical Care Ultrasound - FICE Approved12 November

All courses qualify for CPD Accreditation.

Venue: SonoSite Education Centre, 240 The Village, Butterfield, Great Marlings, Luton, Bedfordshire LU2 8DL

Contact: Louise Smith Tel: +44 (0) 7593 614034 Email: [email protected]

For the full listing of SonoSite training and education courses, dates and to register go to: www.sonositeeducation.co.uk

SonoSite, the world leader and specialist in hand-carried ultrasound, has teamed up with some of the leading specialists in the medical industry to design a series of courses, for both novice and experienced users, focusing on point-of-care ultrasound.

COMPLETE ULTRASOUND GUIDED REGIONAL ANAESTHESIA EDUCATION (CURE) This two-day course is based on intensive small group hands-on training. Mini lectures complement the practical training with live model scanning and needling practice on phantoms and also features the unique “Focussed Assessment of Procedural Skills” to gauge your progress.

ULTRASOUND GUIDED VENOUS ACCESSThis one-day course is aimed at physicians and nurses involved with line placement and comprises didactic lectures, ultrasound of the neck, hands-on training with live models, in-vitro training in ultrasound guided puncture and demonstration of ultrasound guided central venous access. The emphasis is on jugular venous access, but femoral, subclavian and arm vein access will also be discussed.

CRITICAL CARE ULTRASOUNDThis one-day course is aimed at all critical care physicians and surgeons. The programme is suitable for those who already have some basic ultrasound experience as well as those who are new to the clinical applications of focused ultrasound at the patient bedside. The point of care (POC) application of ultrasound complements other POC diagnostic aids in helping clinicians provide more focused and appropriate care in a timely fashion.

Fees: £375 (two-day courses) includes VAT, lunch, refreshments and course materials. £200-£275 (one-day courses) includes VAT, lunch, refreshments and course materials.

ULTRASOUND TRAINING COURSES

Fifth National Audit Project from The Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland Accidental Awareness during General Anaesthesia

NAP5 Professional Launch Wednesday 10 September 2014

The Royal Society of Medicine, London

A full-‐day’s educational meeting, presenting the Fifth National Audit Project from The Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland. The day will present the largest ever study of Accidental Awareness during General Anaesthesia. Open to all anaesthetists and others with an interest. NAP5 Local Co-‐ordinators are especially invited to attend. The presentations will be delivered by the NAP5 Steering Panel: anaesthetists, psychologists and patient representatives Organisers: Professor Jaideep J Pandit & Professor Tim M Cook Fee: £150 CPD Credits anticipated: 5 Topics to be covered will include -‐

Overview of findings Baseline survey results Activity survey results Incidence(s) of awareness Depth of anaesthesia monitoring Patient experiences Consequences of awareness Awareness during induction, maintenance

and emergence Awareness and anaesthetic techniques -‐

TIVA, muscle relaxation etc.

Awareness and sub-‐specialties -‐ Obstetrics, Cardiac, Airway, ICU, Paediatrics etc.

Reports of awareness following sedation Depth of anaesthesia monitoring and NAP5 Medico-‐legal and consent issues The Irish experience Case presentations Question and answer session Recommendations Future steps

In his so called ‘wilderness years’ of the early 1930s, Churchill did a great deal of writing. On the 5th of January 1932 he had an article published in the Daily Mail. The subject was the accident which he had been involved in on New York’s 5th Avenue a month earlier when he was knocked down by a car. Indeed he might very easily have been killed. As it was, he suffered various contusions and had to undergo surgery at Lenox Hill Hospital. Luckily for us he gave the most beautiful and eloquent description of inhalational anaesthesia. There has never been a better portrayal of the anguished descent into gaseous oblivion. Mentally he prepared himself by imagining sitting in a chair, his back to a lovely swimming pool into which he is about to be tilted and throws himself backwards. 'Thereafter the conscious world is replaced by a vast unknowable darkness where all human truth seems explicable but is somehow beyond grasp'. Then suddenly all physical and mental pain is gone until 'without a perceptible interval' he wakes to hear reassuring words spoken.

At that time Churchill was 57 and in good physical health. When, at the age of 65, he succeeded Neville Chamberlain, there were enough concerns about his health for it to be considered necessary to appoint a private physician to be responsible for Churchill’s wellbeing. Sir Charles Wilson was engaged on the 24th of May 1940. As a result of this relationship a great deal is known about Winston Churchill’s physical condition during the war years and the decades following. In 1966, as Lord Moran, Wilson published a fascinating account of his tenure in a book entitled The Struggle for Survival. Whether its publication constituted a breach of patient confidentiality was a moot point and there was bitter debate at the time.

Churchill suffered from arterial disease – both coronary and cerebral. He might have succumbed to pneumonia complicated by heart failure and atrial fibrillation were it not for the newly discovered drug sulphonamide, prescribed to him by Wilson at Carthage, Tunisia, in 1943.

More prosaically, Churchill underwent hernia repair in 1947. Moshe Schein, a doctor resident in Wisconsin (www.docschein.com) is an authority on this fascinating episode and has gone so far as to try and obtain a copy of the medical record, but without success. The surgeon was Thomas Dunhill, a revered London general surgeon from Australia, held in high esteem by the medical establishment. After two years of wearing a truss, Churchill had finally and reluctantly accepted the need for surgery. The only correctable risk factor identified out of the great man’s numerous co-morbidities was smoking. Churchill said that he would refrain for two weeks prior to surgery if the operation could be performed, as was common practice, in his own home. In the end he was admitted to hospital and only moderated his cigar consumption. Ether (in all probability) was administered by an unknown anaesthetist, Wilson observing 'with frequent anxious checking of the pulse under the sheets'. One imagines that the anaesthetist was probably delighted when, after two hours, the procedure finally came to an end. It was not, by Dr Dunhill’s account, a straightforward herniorrhaphy.

Sir Winston Churchill’s ultimate passing, after a history of lesser strokes, is not itself without controversy. The final stroke rendered the unconscious patient incapable of feeding but enteral nutrition was rejected by the family. It was nearly two weeks later before he finally succumbed. 'I am ready to meet my maker' said Churchill once. 'Whether he is ready for the great ordeal of meeting me is another matter'.


Matthew downConsultant AnaesthetistSunderland Royal Hospital

Almost half a century ago, 90 years to the day after the death of his father (the statesman Lord Randolph Churchill), Sir Winston Churchill died on the 24th of January 1965. There will not be a great many practicing anaesthetists today who will recall that occasion with any clarity. Most were not even alive then. Churchill, while born of an American mother, is perhaps the most famous Englishman after Shakespeare, his own great hero. The World War Two legacy needs no repeating. That world which he saved is fortunate there is also another legacy - for Winston Churchill was very much a ‘man of letters’. He published more words than Charles Dickens. Never a wealthy man, he made his living largely through the publication of his books, newspaper articles, and speeches. He had a superb prose style uniquely his own. It has been described as ‘musical English’.

6 Anaesthesia News September 2014 • Issue 326 Anaesthesia News September 2014 • Issue 326 7

The examThe Primary comprises the Multiple Choice Questionnaire (MCQ), Objective Structured Clinical Examination (OSCE) and the Structured Oral Examination (SOE). Candidates must pass the MCQ prior to sitting the OSCE/SOE. Full details can be found at www.rcoa.ac.uk/examinations/overview, but major recent changes include the introduction of Single Best Answer (SBA) questions to the MCQ, in which candidates must select the best answer to the question from a list where all could be considered correct. The maximum number of attempts at the MCQ, OSCE and SOE has been increased from five to six, and a pass in the Primary is now valid towards the Final FRCA for seven years instead of ten.

Success will mostly be due to good planning and hundreds of hours of hard work over about ten months. Preparing for and sitting professional exams, while working full-time, will be much more challenging than undergraduate exams. It is important to mentally commit before picking up a book – set an early target by looking at the exam dates (www.rcoa.ac.uk/examinations/dates-fees-and-applications) and warn partners and friends in advance that you will be studying.

revisionGoals should be S.M.A.R.T.E.R: specific, Measurable, Achievable, realistic and Time-based. Continue evaluating your work and revising strategy as necessary. Tailor your revision sessions to how you best learn. One of many adult learning models classifies individuals as auditory, visual, or kinaesthetic learners. Auditory learners best remember things they’ve heard and find speaking aloud, listening to podcasts or having group discussions most effective. Visual learners learn from things they see, are good at imagining concepts and prefer images over text. Drawing diagrams or making flashcards are effective techniques for them. Kinaesthetic learners find concentrating difficult when seated, and remember things by actively doing them. They find making notes when working from a book, or moving around when memorising details useful. Regardless of learning style, individuals vary in their speed of acquiring knowledge and understanding. A suggested revision period is four to six months for the MCQ and two to three months

for the OSCE/SOE, revising for fifteen to twenty hours per week. Regarding revision as an extension of the normal working day can make completing the curriculum more manageable.

McQ Arguably, MCQ success can be achieved by doing enough practice questions, but SBAs carry heavily weighted scores and require a knowledge base beyond the pattern recognition from doing practice questions alone. Mixing book work and practice questions will develop MCQ and SOE skills.

As well as the resources in Table 1, The Royal College of Anaesthetists publishes the Guide to FRCA Examinations: The Primary, containing example questions which occasionally appear verbatim in the exam. As well as the most recent edition, which for the first time contains example SBAs (the order form can be found at www.rcoa.ac.uk/sites/default/files/EXM-Primary-Order-Form.pdf), try to get hold of the 2001 edition which contains several different example questions.

A core library should be stocked with Basic Physics and Measurement in Anaesthesia (Davis, Kenny), and Essentials of Anaesthetic Equipment (Al-Shaikh) for physics. Pharmacology for Anaesthesia and Intensive Care (Peck, Hill) is a comprehensive pharmacology text, also available as an app for mobile devices, and is structured in a way you could mimic when answering a question about a drug in the SOE. The very detailed pharmacokinetics chapter could deter beginners, but articles in the BJA’s CEACCP (ceaccp.oxfordjournals.org) can supplement knowledge in this area. Physiology is potentially the largest topic and an extremely thorough understanding of respiratory, renal and cardiovascular physiology is required. Physiology at a Glance (Ward, Linden) is a general overview text, with Respiratory Physiology: The Essentials (West) and Fundamentals of Anaesthesia (Smith) having more detailed chapters on the major systems. Anaesthesia and Intensive Care A-Z (Yentis, Hirsch) forms a general reference for quick-fire revision. Be sure to continually refer back to the curriculum to ensure you cover everything, as these texts are not exhaustive. Many other textbooks are available, and it’s worth browsing them in your hospital’s library to see which you prefer.

The Primary FRCA: trainee experiences and recent changes

soeWhile book work is fundamental to MCQ preparation, discussing theory is fundamental to the SOE. At times private revision may become quite insular and demotivating. A revision buddy can provide inspiration and support and, when it comes to OSCE/SOE preparation, prove indispensable for honing technique and learning theory. A typical SOE practice session could consist of fifteen minute mock examinations, split into five minute question slots, followed by about twenty minutes of feedback to explore learning points and discuss improvements. A graph can illustrate in seconds what would take much longer to explain verbally, so practice drawing graphs and diagrams, with labelled axes and relevant numbers included, for example from Physics, Pharmacology and Physiology for Anaesthetists: Key Concepts for the FRCA (Cross, Plunkett).

If a challenging SOE question is asked, a uniform answering style can help the candidate return to first principles instead of panicking

and immediately saying something extremely specific. ‘Define and classify’ has several benefits; defining demonstrates a good breadth of knowledge, while classifying structures the answer and lays down a good aide memoire to return to.

Before the clinical SOE, candidates have approximately ten minutes to read the scenario they will be asked about. This time can be used effectively to anticipate the questions which may be asked, including the inevitable critical incident. For example, in a paediatric emergency case, be sure to calculate estimated weight and drug doses before entering the examination hall.

SOE resources are broad, and their usefulness will vary with your learning style. The popular MasterPass books (McCombe, Wijayasiri, Patel) cover many classic SOE questions, challenging patient groups, and critical incidents. The latest DAS (www.das.uk.com), ALS/APLS (www.resus.org.uk) and AAGBI (www.aagbi.org)

The Primary frcA demands high standards of knowledge over a broad curriculum (www.rcoa.ac.uk/ccT/AnnexB). in this article we aim to share our experiences, reflections, resources and advice in approaching the challenge.

Table 1. MCQ Resources

Online – Free Website

e-learning for Anaesthesia www.e-lfh.org.uk

Anaesthesia UK www.frca.co.uk

royal college of Anaesthetists example sBAs www.rcoa.ac.uk/sites/default/files/eXM-example-PrimarysBAs.pdf and www.rcoa.ac.uk/node/7129

Online – Paid Subscription Website

frcAQ www.frcaq.com/primary/jsp/home.jsf

Pastest www.pastest.co.uk

123doc www.123doc.com/exams/primary-frca/

onexamination www.onexamination.com/exams

examdoctor www.examdoctor.co.uk

In Print Authors

single Best Answer McQs in Anaesthesia Vol 1&2 Mendonca, chaudhari

Q-Base Anaesthesia (Vols 1,4,6,7) Various


algorithms are all available free online. ‘Dr. Podcast’ tutorials (www.dr-podcast.co.uk) are often fact heavy, but useful for long commutes. Selecting two or three specific podcasts and listening to them on repeat for the week may help to absorb more details. Candidates attending the Coventry course have submitted their exam questions, which are available for anyone to view for free at www.mededcoventry.com/Courses/Anaesthesia/FRCA/Primary_FRCA_SOE_Material.aspx

osceThe trepidation of facing two examiners for half an hour can divert attention away from the more familiar OSCE format, and consequently it’s easy to under prepare for a whole exam. The pass mark is based on a total overall score, so every mark counts. Books containing OSCE-station style questions and mark schemes (for example, The Objective Structured Clinical Examination in Anaesthesia (Mendonca, Balasubramanian) can highlight the marks that could be easily missed for not asking specific questions or making specific statements. Similarly, for procedure stations a stock phrase like 'I’d perform the procedure on a patient who was appropriately consented, with a trained assistant, and using an aseptic technique. The patient must have working IV access, be monitored using AAGBI standards, and adequate resuscitation facilities must be available' can help scrape a few marks; possibly the difference between passing and failing, even without knowledge of the procedure! Concise Anatomy for Anaesthesia (Erdmann) or Anatomy for Anaesthetists (Ellis) cover the essential OSCE anatomy, or alternatively online www.nysora.com or www.neuraxiom.com cater to the curriculum well.

coursesBook early. MCQ courses take place throughout the UK, usually in the last few weeks before the exam, and focus more on consolidating

previous work rather than new knowledge acquisition, although many deaneries also run day-release lecture-based teaching courses over a number of weeks. Intensive MCQ courses last two to seven days and consist of multiple MCQs with facilitated discussion of answers. OSCE/SOE courses typically last two to three days and offer advice on exam technique and the opportunity to practice, with unfamiliar examiners, under exam conditions. Courses incorporating complete high-fidelity simulated OSCEs are beneficial, as they can be difficult to organise and staff in the workplace. A list of available courses can be found on Anaesthesia UK’s website (www.frca.co.uk/CoursesView.aspx?CatID=23).

The day of the examIt takes serious composure not to let the atmosphere get to you with candidates nervously cramming everywhere you look. No matter how bad it gets DO NOT LEAVE EARLY! A few poor stations in the OSCE, or an SOE not going well doesn’t automatically mean a fail. On our OSCE/SOE day, a candidate left early thinking their OSCE had been a disaster when they had actually comfortably passed.

AfterwardsTake some holiday after each exam - whatever the outcome a lot of hard work will have gone into the sitting and a rest is deserved.

drs Jonathan fortune and iain walker CT2, Northern School of Anaesthesia

drs chris Browell and donna KellyST3, Northern School of Anaesthesia


ReseaRch and GRants committeeRePoRt

The notable achievements this year are the increase in the number of grant rounds to four a year and the doubling of the student elective funding rounds to twice per year. All the grants rounds will be coordinated through the NIAA so that appropriate studies can apply for NIHR portfolio status for assistance with NHS costs. We have removed the division into small and large grants, allowing researchers to judge the size of requested grants for themselves. Each application will be judged on its scientific merits and its value for money. One of the biggest challenges for research grant awarding bodies is to ensure best value for money and how to quality assure the outcomes. We hope that, by removing the categories based on the size of award, this will encourage not just large randomised studies but also smaller projects aligned to our aims. For example, funding for construction of the prototype of a new piece of equipment as part of innovation, or a project to enhance patient safety.

Undertaking (and funding) research is always challenging when budgets are tight and time is increasingly constrained by service pressures. The current joint James Lind

Alliance/NIAA Anaesthesia and Perioperative Care Priority Setting Partnership project should produce a list of ten unknowns for further study – as nominated by clinicians, patients and carers. As well as being used to formulate our own research aims, we know that the larger funders take note of the outcomes of these projects when deciding the 'big questions' to be answered. This work should be complete in early 2015.

One of our main priorities for the next year is to broaden the membership of our committee; in particular, we wish to add lay representation. My own experience is that lay representation is invariably useful. We feel it would add an additional level of scrutiny and, when needed, challenge to our grant awarding processes. Any experience a lay member can bring from other organisations would be an additional bonus.

Mike NathansonChair, Research and Grants Committee

for further information visit www.aagbi.org/research

The Research and Grants Committee oversees the AAGBI's significant spend on research, as well as awarding funding for student electives, the student essay prize and other prizes. The Association's current research aims are patient safety, innovation, clinical outcomes, education and training plus professional issues (such as standards and guidelines, working conditions, medicolegal issues, etc), and the environment.

It will be only take a few minutes to complete. Please take part and encourage all of your colleagues to do the same.

Tell us how we can do even better!

We last ran a survey in 2011: the results have been acted on to ensure the AAGBI delivers the services that meet your needs:

- Last time, 86% of you said that you wanted the AAGBI to provide on-line facilities to help support your revalidation CPD - we have created Learn@AAGBI, the new online learning and CPD zone.

- You told us you valued the AAGBI’s patient safety guidelines – we continue to update our guidelines and in September 2014 will be launching the new AAGBI Guidelines App.

- 84% of you had attended an AAGBI meeting; we have provided bigger and better conferences offering top quality education with record attendance figures at Annual Congress 2013 and WSM London 2014

- 40% of you said you used Facebook – so we have developed the AAGBI Facebook page and we continue to grow our followers.

- 91% said that they thought the AAGBI membership offers value for money – we want to make sure that we are still continuing to do so...

This is your opportunity to tell us:

- what you like

- what you would like us

to do differently

- what you don’t like

- help shape our future strategy


1

Table 1

Class McGill Pain Questionnaire* Avicenna’s classification of pain

Arabic words

1 Pulsing, Throbbing, Bounding Pulsating االلضضررببااننيي

2 Jumping, Shooting

3 Stabbing, Lancinating Stabbing االلممسسققيي

4 Sharp, Cutting, Lacerating Tearing االلممففسسخخ

5 Pinching, Gnawing Pricking االلننااخخسس

6 Tugging, Cramping, Taut Stretching االلممممدددد

7 Hot, Burning

8 Itchy, Tingling Itching االلححككّااكك

9 Heavy, Dull, Aching Heavy االلثثققييلل

10 Tender, Taut Tenderness, Compressing

االلضضااغغطط

11 Tiring, Exhausting Fatigue االلإإععيياائئيي

12 Sickening, Suffocating

13 Fearful, Terrifying

14 Punishing, Cruel

15 Wretched, Blinding

16 Intense, Unbearable

17 Penetrating, Piercing Piercing االلثثااققبب

18 Numb, Squeezing Numbing االلخخددرر

19 Cold, Freezing Biting االلللااذذعع

20 Dreadful, Nagging Coarseness االلخخششنن

*Melzack R. The McGill Pain Questionnaire. Pain 1975; 1: 277–99.

include mandrake, hemlock and lettuce-seed. In addition, for each drug, he provides a wealth of information within a systematic template. Typically, he provides the drug’s definition, advice on selection, key properties, drug effects, signs of overdose and their antidotes as well as providing alternatives. Bear in mind, the following entry occupies just half a page of the entire Canon of Medicine, a textbook that spans approximately 1000 pages in its entirety.

Opium

definition: Opium is extracted from black poppy and induces sleep on smelling…and when it is heated on burning iron it turns red. selection: The variety that should be utilised is resinous with an overpowering odour. It is soft and dissolves easily in water without thickening. Avoid the yellow variety that stains water and has a faint odour for that has been adulterated with the glaucium flavum (yellow horned poppy).

Table 1

Avicenna the Anaesthetist

Perhaps to the surprise of many who consider anaesthetics a discipline forged solely after the discovery of ether in the Victorian era, and although hitherto largely lost to the annals of history, Avicenna, the great polymath, contributed much to the practice of anaesthetics. Indeed, we may question if he was one of the earliest anaesthetists to have lived. For within his five volumes of the Canon of Medicine, passages relevant to anaesthetics can be found throughout. First, he significantly advanced the theory of pain, both challenging and developing Galen’s ideas. Second, Avicenna highlights a range of taskin, analgesic agents, and mukhaddar, anaesthetic agents that can be used prior to surgery. Finally, within the Canon, he provides the first description of endotracheal intubation ever recorded and also elucidates for the first time the procedure for a tracheostomy.

The majority of the Canon of Medicine has, unfortunately, never been translated into any modern language. Of the five volumes of the Canon, only the first volume has ever been translated into English. Therefore, using original Arabic manuscripts dating back to 1593, this paper presents these intriguing insights using direct translations that highlight Avicenna’s tremendous contribution to the field of anaesthetics. These can be divided, as aforementioned, into three main areas: his development of the theory of pain, his compendium of analgesic and anaesthetic agents, and finally, his descriptions of intubation and tracheostomy.

A thousand years ago, there flourished a long and academically vibrant era in the Arab world. During this period, several scientific disciplines were pioneered: from astronomy to mathematics and from botany to medicine. Indeed, medieval medicine from the Arab world represents a tradition whose origins are multi-faceted. It marks the preservation of classical Greek and Roman medical traditions, augmented with practices from Persia, India and China, embodied in a corpus of literature that was advanced significantly by Muslim physicians. Of the latter, the oft-cited great triumvirate includes Rhazes of Persia (d. 925), Albucasis of Andalusia (d. 1013) and, arguably the most influential, Avicenna of Transoxiana (d. 1037), who wrote the five-volume, encyclopaedic al-Qanun fi’l-Tibb (The Canon of Medicine).

WINNING ESSAY OF ThE 2014 AAGBI ANd ThE hISTORY OF ANAESThESIA SOCIETY AWARdAvicenna

Abu ‘Ali al-Husain ibn ‘Abdallah ibn Sina, known as Ibn Sina or, the Latinised version of his name, Avicenna, was an 11th century Persian scholar, born c.980 CE in modern-day Uzbekistan. In his day he was widely regarded as a learned master and teacher, writing treatises on medicine and philosophy, and was highly sought after by the kings, princes and sultans of his time. Almost uniquely, he has been recognised as one of the greatest figures of intellectual history by both East and West. Kleinhenz, a European historian writes: ‘Not only did he [Avicenna] return Aristotle’s and Galen’s medical thought to the West after it had been lost for many centuries, but he also helped establish the physician as a gentleman, whose decorous behaviour admitted him to the most intimate circles of the wealthy and powerful’.1

The Canon of Medicine

Avicenna’s most famous work is the Canon of Medicine. He wrote it with the Herculean intention of distilling all extant medical knowledge and practice. The Canon was completed in 1025 and is considered to be ‘the most influential Galenic document of the Middle Ages’.2 It was translated into Latin by Gerard of Cremona (d. 1187) and formed the bedrock of medical curricula in universities across the world, from Baghdad in Iraq to Montpellier in France and Leuven in Belgium, and this lasted for over six hundred years,3 from late antiquity to the dawn of the Renaissance. A complete Latin translation appeared in 1473 and, between 1500 and 1674, some 60 editions4 of part of or the entire Canon were published in Europe for use in medical training at universities.

Theory of pain

As well as alluding to the now well-established theory of pain desensitisation to a persistent stimulus, he explains that nerves carry nociceptive pain sensations to the brain5 which itself acts as the organisational centre and subsequent source of the painful feeling experienced by the patient.

Furthermore, he elaborately categorises pain into 15 different varieties based upon causation. Whereas Galen had previously described just 4 types of pain (pulsating, weighty, stretching and tearing), Avicenna details 15 varieties of pain based upon causation. The marked similarity this classification bears to modern classifications such as the McGill Pain Questionnaire, with 20 classifications of pain, of which 13 are common to Avicenna’s list, is clear (Table 1).

On closer analysis of the descriptor classes, it can be seen that virtually all of the words that describe the sensory attributes of the painful experience, including the temporal, spatial and thermal properties (classes 1–10) as well as the miscellaneous properties (classes 17–20) are present in Avicenna’s original classification. The classes virtually absent in Avicenna’s classification are those that describe the affective and evaluative qualities of the painful experience (classes 11–16). This is unsurprising, however, as Avicenna’s classification of pain was from the outset based upon causation and aetiology, rather than the evaluative attributes. Thus, it is quite remarkable that a classification system of pain developed by Avicenna in the 11th century bears striking similarity to one that was developed almost 1000 years later and is still used by anaesthetists today.

Analgesia and anaesthesia

The second main area to which Avicenna contributed a great deal was the field of analgesic and anaesthetic treatments. The second volume of the Canon was the definitive Materia Medica for over 500 years and listed over 800 known drugs used at the time. Avicenna cites opium as the most powerful analgesic, while those less powerful

The Canon of Medicine

Avicenna

Class McGill Pain Questionnaire*

Avicenna’s classification

of pain

Arabic words

1 Pulsing, Throbbing, Bounding Pulsating

2 Jumping, Shooting

3 Stabbing, Lancinating Stabbing

4 Sharp, Cutting, Lacerating Tearing

5 Pinching, Gnawing Pricking

6 Tugging, Cramping, Taut Stretching

7 Hot, Burning

8 Itchy, Tingling Itching

9 Heavy, Dull, Aching Heavy

10 Tender, Taut Tenderness, Compressing

11 Tiring, Exhausting Fatigue



14 Punishing, Cruel



17 Penetrating, Piercing Piercing

18 Numb, Squeezing Numbing

19 Cold, Freezing Biting

20 Dreadful, Nagging Coarseness

7

Class McGill Pain Questionnaire14 Avicenna’s classification of pain Arabic words

1 Pulsing, Throbbing, Bounding Pulsating الضرباني

2 Jumping, Shooting

3 Stabbing, Lancinating Stabbing المسقي

4 Sharp, Cutting, Lacerating Tearing المفسخ

5 Pinching, Gnawing Pricking الناخس

6 Tugging, Cramping, Taut Stretching الممدد

7 Hot, Burning

8 Itchy, Tingling Itching الحّكاك

9 Heavy, Dull, Aching Heavy الثقيل

10 Tender, Taut Tenderness, Compressing الضاغط

11 Tiring, Exhausting Fatigue اإلعيائي



14 Punishing, Cruel



17 Penetrating, Piercing Piercing الثاقب

18 Numb, Squeezing Numbing الخدر

19 Cold, Freezing Biting الالذع

20 Dreadful, Nagging Coarseness الخشن

On closer analysis of the descriptor classes, it can be seen that the virtually all of the words that

describe the sensory attributes of the painful experience, including the temporal, spatial and thermal

properties (classes 1-10) as well as the miscellaneous properties (classes 17-20) are present in Avicenna’s

original classification. The classes virtually absent in Avicenna’s classification are those describe the

affective and evaluative qualities of the painful experience (classes 11-16). This is unsurprising, 7



2 Jumping, Shooting





7 Hot, Burning







14 Punishing, Cruel














2 Jumping, Shooting





7 Hot, Burning







14 Punishing, Cruel














2 Jumping, Shooting





7 Hot, Burning







14 Punishing, Cruel














2 Jumping, Shooting





7 Hot, Burning







14 Punishing, Cruel











affective and evaluative qualities of the painful experience (classes 11-16). This is unsurprising,

7



2 Jumping, Shooting





7 Hot, Burning







14 Punishing, Cruel












7



2 Jumping, Shooting





7 Hot, Burning







14 Punishing, Cruel













for a millennium across the known world. Indeed, such was its influence that Sir William Osler, in the early 20th century, described it as a ‘medical bible’ and ‘the most famous medical textbook ever written’.16 It is somewhat surprising, therefore, that only a fifth of the Canon has hitherto ever been translated into English.

The legacy left behind by Avicenna in the field of medicine is significant, and specifically in the field of anaesthetics it is evidently palpable. Having left such a great legacy in this field, the question remains as to whether we can refer to Avicenna as an ‘anaesthetist’. This essay has presented the evidence for ascribing such a title, but the answer to that question remains for the reader to decide. Regardless, his legacy lives on not only in the books of history but in several medical projects and in institutions who have honoured his scientific contributions and are today named after him, perhaps uniquely, both in the East and in the West.

Professor John Urquhart, at the Royal College of Physicians of Edinburgh was once asked ‘If the year were 1900 and you were marooned and in need of a guide for practical medicine, which book would you want by your side?’ He replied, ‘My choice was Ibn Sina [Avicenna].’17

AcknowledgementsThe author would like to thank the British Library and the Wellcome Library in London for their kind permission in allowing use of the original Arabic manuscripts of the Canon of Medicine during the research for this essay.

Yassar MustafaST1 Anaesthetics, Heart of England NHS Foundation Trust

References1. Kleinhenz C. Medieval Italy: an Encyclopedia. New York: Routledge;

2004. p84.2. Musallam B. Avicenna. Encyclopeadia Iranica3. Arabian Medicine. Encyclopaedia Britannica.4. U.S. National Library of Medicine. Catalogue of Medical

Encyclopaedias. Canon of Medicine5. Tashani OA, Johnson MI. Avicenna's concept of pain. Libyan Journal of

Medicine 2010; 5: 5253.6. Hijazi AR. Anesthesia in the works of Avicenna and anesthetic technics

during the 11th century. Annales Françaises d’Anesthèsie et de Rèanimation. 1984; 3: 76–8.

7. Ben Rejeb A, Mamissi N. Anesthesia and resuscitation in Arabo-Islamic medicine: analytic study through Ibn Sina. La Tunisie Médicale 2000; 78: 146–51.

8. Avicenna. The Canon of Medicine, Book II, p1879. Ibid, p35810. AAGBI. Pre-Operative Assessment: The Role of the Anaesthetist. 2001.

http://www.aagbi.org/sites/default/files/preoperativeass01.pdf11. Luckhaupt H, Brusis T. History of intubation. Laryngologie Rhinologie

Otologie 1986; 65: 506–10.12. Avicenna. The Canon of Medicine, Book III, part 913. Avicenna. The Canon of Medicine, Book III, p38214. Aziz E, Nathan B, McKeever J. Anesthetic and analgesic practices in

Avicenna’s Canon of Medicine. American Journal of Chinese Medicine 2000; 28: 147–51.

15. Avicenna. The Canon of Medicine, Book III, p38316. Osler W. The Evolution of Modern Medicine. Kessinger; 2004. p7117. Nasser M, Tibi A, Savage-Smith E, Ibn Sina’s Canon of Medicine: 11th

century rules for assessing the effects of drugs. Journal of the Royal Society of Medicine 2009; 102: 78–80.

Doctor taking woman's pulse. Avicenna's Canon manuscript

Nature: Cool and dry in springProperties: It is an anaesthetic and analgesic agent for use in all pains, whether ingested or applied locally. The typical oral dose is the size of a large lentil.effects:

• Tumours and warts: Stops abscesses forming. • Wounds and ulcers: Dries ulcers.• Joints: Upon mixing with egg-yolk and then heating, it dulls the

pain of gout• Organs of the head: If administered rectally, it is a hypnotic

and induces sleep. When mixed with rose oil, myrrh and saffron, it effectively treats ear pain and relieves chronic headache. However, it also decreases the cognitive ability of the mind.

• Organs of sight: Relieves eye pain but many of the ancient physicians were cautious in its use because of its negative effects on sight.

• Organs of breathing: Treats severe cough.• Organs of nutrition: Causes the relaxed stomach to contract

and promotes constipation especially if ingested without castor oil.

• Waste organs: Prevents diarrhoea and alleviates intestinal ulcers.overdose: Can kill by weakening bodily strength. The antidote is castor oil. The oral dose should not exceed two grains.Alternatives: Opium is equivalent to thrice the amount of henbane and twice the amount of mandrake.

Avicenna also suggests the use of various recipes and mixtures in order to achieve anaesthesia prior to surgery.6 Accompanying each was a detailed description of the variety of methods for administration, including oral, inhalational and rectal.7 Moreover, Avicenna demonstrates his awareness of the strength, depth and time-dependent action of anaesthesia for use in different types of operation. For example, he gives a dose of one mithqal of mandrake for 3–4 hours of general anaesthesia,8 suitable for major operations such as amputation.

Not only does the concept of providing multimodal peri-operative anaesthetic regimens continue in the world of anaesthesia today, but Avicenna – quite remarkably for his time – also alluded to another very important area in anaesthetics – minimising risk prior to administering the anaesthetic agent. This is to be achieved by taking into account the patient’s age, gender, co-morbidities, general energy, temperaments and allergies – and he emphasised that every patient is unique and what may work in one patient will not necessarily work in another ‘if even double the recommended dose’ is used.9 This is without doubt the ancient forerunner of the pre-operative assessment performed routinely and diligently by the anaesthetist today.10

intubation and tracheostomy

Avicenna is widely recognised as being the first person to have described the procedure of endotracheal intubation.11 In the chapter on the treatment of respiratory distress, stridor and suffocation,12 he describes both endotracheal intubation and also tracheostomy to a moderately practical level of detail.

Regarding intubation and tracheostomy, Avicenna explains the steps concisely and clearly. ‘There is no harm in inserting something such as a cane/reed or its like around which some cotton is wound, to clear the airway and dilate it. One might also insert a tube made from gold or silver or their like into the pharynx to assist breathing’.13

Avicenna continues to talk about the next step in airway management if this fails.14 ‘And so, if the suffocation continues, and treatments are unsuccessful, then it will be beneficial to incise the trachea. The head is extended back and the skin is gripped and stretched back

with hooks before the incision is made. The trachea is then exposed, and an incision is made in the middle between the two tracheal rings, whilst avoiding cutting the (cricoid) cartilage. The edges of the cut skin are turned outwards and stitched without damaging the underlying tissue’.15 Perhaps somewhat surprisingly, both intubation and tracheostomy have retained the same core procedural steps as described by Avicenna, as well as, of course, their crucial and often life-saving roles in medical practice.

Avicenna’s legacy

Overall, it is evident that Avicenna contributed significantly to the field of anaesthetics, whether in theorising about pain within a classical paradigm and providing classifications that have stood the test of time, providing comprehensive lists of analgesic and anaesthetic treatments or providing one of the earliest descriptions of endotracheal intubation and tracheostomy. It ought to be remembered, however, that these extracts occupy only a small portion of the entire Canon of Medicine, a book of over 1 million words that essentially crystallised the entire corpus of extant medical knowledge.

By compiling this knowledge in a systematic and organised fashion, and by using eloquent, articulate and scientifically precise language, it is understandable how the Canon of Medicine became such an unprecedented success, and formed the basis of medical curricula

Photograph: W

ellcome Library London

ADVANCE REGISTRATION ESSENTIAL Cost: £60 Cheques payable to: Westminster Medical School Research Trust Send to: Faruq Noormohamed, Department of Anaesthesia Chelsea & Westminster Hospital, 369, Fulham Road, London, SW10 9NH Tel: 0203 315 8816 email: [email protected] for further details

The Magill’s Symposium is made possible with an education grant from Smith’s Medical 4 CPD Points

23rd MAGILL SYMPOSIUM Wednesday 19th November 2014

Time: 13.00 - 18.30

ENHANCED RECOVERY: BEYOND THE GUIDELINES Chaired by Professor Masao Takata & Dr Kevin Haire Imperial College London and Chelsea & Westminster Hospital

SESSION 1: APPLIED PHYSIOLOGY

Professor Djillali Annane, Dr Nicholas Hart & Dr Richard Keays

SESSION 2: SO… HOW DO WE DO IT? Dr William J Fawcett, Mr Toby Smith & Dr Sherif Awad

MAGILL LECTURE: PATHS TO RECOVERY: FORMULATING EVIDENCE BASED GUIDELINES

Dr Philip J Devereaux (Hamilton, Canada)

ADVANCE REGISTRATION ESSENTIAL Cost: £60 Cheques payable to: Westminster Medical School Research Trust Send to: Faruq Noormohamed, Department of Anaesthesia Chelsea & Westminster Hospital, 369, Fulham Road, London, SW10 9NH Tel: 0203 315 8816 email: [email protected] for further details

The Magill’s Symposium is made possible with an education grant from Smith’s Medical 4 CPD Points

23rd MAGILL SYMPOSIUM Wednesday 19th November 2014

Time: 13.00 - 18.30

ENHANCED RECOVERY: BEYOND THE GUIDELINES Chaired by Professor Masao Takata & Dr Kevin Haire Imperial College London and Chelsea & Westminster Hospital

SESSION 1: APPLIED PHYSIOLOGY

Professor Djillali Annane, Dr Nicholas Hart & Dr Richard Keays

SESSION 2: SO… HOW DO WE DO IT? Dr William J Fawcett, Mr Toby Smith & Dr Sherif Awad

MAGILL LECTURE: PATHS TO RECOVERY: FORMULATING EVIDENCE BASED GUIDELINES

Dr Philip J Devereaux (Hamilton, Canada)

NATIONAL HONOURS

FOR ANAESTHESIA, CRITICAL CARE AND PAIN MEDICINE(MBE, OBE, CBE, KNIGHT/DAME)

Do you know someone who you believe should receive national recognition for their contribution to anaesthesia, critical care or pain medicine? Someone who has really made a difference to others’ lives, often in a quiet and unsung way, perhaps working in a voluntary capacity or for a charity linked to anaesthesia?

The AAGBI is always pleased to receive names of suitable individuals whom it can consider for nomination via the specialty’s National Honours Committee.

Please contact [email protected] for further details and guidance


physiology in addition to lectures on antibiotics and physics. The final stream covered more clinical application of the basic sciences including intensive care hot topics, cardiac output monitoring, thoracic anaesthesia, endocrine, liver and anaesthetic and surgical outcome scoring systems and risk stratification.

As at GAT 2013 there was a third stream of lectures on the Friday for senior trainees which covered various aspects of management and education. Professor Kevin Rooney gave an excellent presentation on the concepts, skills and techniques of improvement science in anaesthesia. Other lectures covered the ethics of training doctors, how to be an educator, being a new consultant, independent practice and writing business cases.

As with previous years, all of our lectures and workshops were mapped to the Royal College of Anaesthetists curriculum to allow trainees to demonstrate the areas covered during the conference, either to aid knowledge sign-offs within their deaneries or to boost portfolios for ARCPs. We also realised that the quality and content of the Annual Scientific Meeting was appropriate for continuing professional development, so we also matched it to the CPD matrix.

Professional development - posters and prizes

The poster competitions were more popular than ever with nearly 200 presented to our judging panel. With categories specifically for medical students and foundation doctors we were delighted to encourage junior trainees to present. We are grateful to all the judges for their help.

We had some great oral presentations. Dr K Stacey and Dr L Beard won the Dräger oral presentation and, with an interactive electronic voting system, the audience voted Dr K Whitehouse the winner of the Dräger oral case presentation. The audience also heard a fascinating presentation on ‘Avicenna the Anaesthetist’ by Dr Y Mustafa; winner of the Anaesthesia History prize.

After these presentations, there was an interactive audience question and answer session with a panel made up of the President of the AAGBI, Dr William Harrop-Griffths; the President of the College of Anaesthetists of Ireland, Dr Ellen O’Sullivan; Dr Tom Hannan, (BMA Junior Doctors Committee); Dr Anna Batchelor (RCoA Council member and Dean FICM); and Dr Richard Paul, the GAT chair. This session stimulated some interesting discussions and was a great opportunity for trainees to ask questions of the leaders in anaesthesia.

Support and wellbeing: LTFT and baby room, mentoring, buddying

We were delighted to welcome 11 tiny budding anaesthetists to our parent and baby room with some dads bringing along their little ones for the first time too. The lectures from the main hall were video-streamed live into the room allowing parents with children to catch up on some CPD in a relaxed environment. The room also provided

a range of resources for those planning maternity leave, returning to work, intending to change to less than full time (LTFT) training, or having difficulty with LTFT training and looking for guidance. The parent and baby room is available at all the AAGBI conferences so we look forward to meeting some more of the next generation at Annual Congress in Harrogate in September.

After an inspirational introduction to the principles of mentoring, Dr Nancy Redfern’s team of mentors was overrun with mentees for the free taster sessions. Involvement in mentoring, from both sides, is encouraged in the GMC Good Medical Practice 2013 so we hope mentoring sessions from trained mentors will be coming to a hospital near you soon.

Dr Alex Bonner led a buddying workshop based on the experiences of the North West School of Anaesthesia. Buddy systems provide new trainees with a link to a senior trainee who can relate to their daunting experiences in a new specialty and hospital.

Thank you to all those who brought baked goods to the meeting for the Lifebox cake sale; we are delighted to announce we raised over £400 in the 20 minute afternoon break.

The finale

As promised, Dr William Harrop-Griffiths and Dr David Bogod closed the meeting with a fantastic and closely contested debate: ‘Obstetric anaesthesia is more a state of mind than a subspecialty’. The audience started off fairly evenly split in their opinions, but very witty arguments from both sides resulted in a small swing in favour of the motion and victory for Dr Harrop-Griffiths.

Next year’s GAT Annual Scientific Meeting will be held from 17–19th June in Manchester. We would love to hear from you ([email protected]) with any suggestions for this meeting and look forward to seeing you there.

dr Paula Morris and dr sarah Gibb

Education - lectures, problem based learning, workshops and exam streams

The meeting kicked off with an excellent lecture series on anaesthesia in challenging patients followed by an informative research session with updates from NELA, ASAP and NAP5. A thought provoking communication lecture series covering risk and how not to get sued was a useful reminder to all that, if it’s not documented…it didn’t happen. The mentoring talk sparked a mentoring taster explosion which involved 63 delegates making the most of the free sessions available. Other lectures included the neurodevelopmental effects of anaesthesia, an interactive lecture on when to deliver the critically ill parturient and an update on obstetric anaesthesia.

This year’s Pinkerton Keynote lecture was given by Dr Hamish McLure, consultant anaesthetist and clinical director for anaesthesia at Leeds Teaching Hospitals NHS Trust. Entitled ‘Charge of the Night Brigade’ he described the human side of being a clinical director in the face of a manpower crisis when a significant number of anaesthesia training posts were removed from the Leeds Teaching Hospitals. As clinical director for 200 anaesthetists in a clinical service unit of almost 1000 staff, he described the negotiations and options available at each stage to ensure his departments continued to be staffed safely.

Dr Kevin Fong, consultant anaesthetist at University College London Hospitals and founder and associate director of the Centre for Altitude, Space and Extreme Environment Medicine, delivered this year’s excellent Wylie Keynote Lecture. A fantastic speaker, his lecture ‘Life, death and mistakes’ was thought-provoking and certainly one of the highlights of the meeting.

We heard from experts on a variety of interactive case dilemmas in the problem based learning sessions. These included cases on paediatric airway foreign body, paediatric consent, obstetric pulmonary embolus and the management of patients with ventricular assist device in situ. These sessions allowed the audience an opportunity to learn about the management options available and establish a consensus opinion for each challenging situation presented.

There was an excellent and varied choice of workshops this year which included echocardiography, ultrasound guided regional anaesthesia, difficult airways, vascular access, anaesthetising the morbidly obese patient, and organising your year abroad. These small group teaching sessions provided an ideal opportunity for the experienced workshop faculty to focus on teaching hands-on practical techniques. We are delighted to report that GAT Newcastle achieved a ‘first in show’ for style - the only place where the pork belly for the vascular access workshop came with a hand cut side salad!

The final day of the meeting continued as three parallel streams to reflect the time, money and effort of the FRCA with exam-specific streams and a third management stream. The primary and final FRCA examination lecture streams aimed to cover key aspects of the curriculum including sessions on ECGs and statistics. The primary stream covered aspects of cardiac, respiratory, renal and pain

Photograph ©Andrew Bodenham, Leeds General Infirmary

A successful GAT AnnuAl ScienTific MeeTinG

from the 11–13th June, Newcastle upon Tyne hosted the biggest ever GAT Annual scientific Meeting. with nearly 400 delegates, a large faculty and the AAGBi council, there was a fantastic atmosphere and great buzz to the conference. The formal dinner at the Assembly rooms was a superb evening with hardly a space on the dance floor. The sun even shone, welcoming everyone to the civic centre in Newcastle city centre.

Missed out on this year's GAT ASM?

Lectures available on Learn@AAGBI

www.aagbi.org/education


The Association of Anaesthetists of Great Britain and Ireland invites applications for the 2015 AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain. This prize is open to all anaesthetists, intensivists and pain specialists based in Great Britain and Ireland. The emphasis is on new ideas contributing to patient safety, high quality clinical care and improvements in the working environment. The entries will be judged by a panel of experts in respective fields.

Applicants should complete the application form that can be found on the AAGBI website www.aagbi.org/research/innovation.

The closing date for applications is Tuesday 30 September 2014.

Three prizes will be awarded and the winners will be invited to present their work and collect their prizes at the Winter Scientific Meeting in London on 16 January 2015.

The Annual AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain

www.aagbi.org/research/innovationKindly sponsored by:

The Association of Anaesthetists of Great Britain and Ireland invites applications for the 2015 AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain. This prize is open to all anaesthetists, intensivists and pain specialists based in Great Britain and Ireland. The emphasis is on new ideas contributing to patient safety, high quality clinical care and improvements in the working environment. The entries will be judged by a panel of experts in respective fields.

Applicants should complete the application form that can be found on the AAGBI website www.aagbi.org/research/innovation.

The closing date for applications is Tuesday 30 September 2014.

Three prizes will be awarded and the winners will be invited to present their work and collect their prizes at the Winter Scientific Meeting in London on 16 January 2015.

INNOVATIONAAGBI

The Annual AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain

www.aagbi.org/research/innovation Kindly sponsored by:

C

M

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CM

MY

CY

CMY

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InnovationHalf2014.pdf 1 05/06/2014 14:41

InnovationHalf2014.indd 1 14/07/2014 09:32

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It all started with policemen. They just got younger and younger; once they were respectable contemporaries; next decade they were prepubescent plods. But it’s gone on from there. Nurses look younger; so even do anaesthetic trainees - except after a night on call. Recently it’s got worse still: now chief executives look young. What’s more, they all seem to be on a Youth Training Scheme. They come to us for a few months, look around briefly, cause mayhem, and then pop off to cause chaos elsewhere.

Anyway, chief executives came to mind the other day when I heard trumpets, and bugles, and even the odd crumphorn. (It wasn’t that I was running out of my haloperidol, it all happened: honest). Our latest CE has been in post for a year or two. (Just about time to be moving on in the next rotation, you might think). Suddenly the Trust announced with great pomp that he’d been appointed. ‘But he was appointed some sorry while back’, you might retort. Not at all: it turns out he’s been on an exorbitant daily retainer, ready to jump ship at a moment’s notice. Now, hurray hurrah, he’s on board for real. That called for some celebration. So I went to congratulate him, but couldn’t help asking him what he thought of the name of one of our operating suites: the Meadowside Day Care Centre. He hesitated and gave me a gimlet eyed stare as he prepared his line of attack. ‘Ah, so you don’t approve of the Day bit. And I can well imagine that a man of your -‘, he paused and glanced at my distinguished salt and pepper bouffant - ‘a man of your seniority would find it hard to cope. But day care is the way of the future. Admission on the eve of surgery, getting medical students to examine and clerk, informing and gathering consent without a

stopwatch ticking - those are the old ways’. I didn’t retort that many patients now don’t know whether it’s hospital transport knocking or a drugs raid. Instead I observed mildly that it was the ‘care’ bit which bothered me. After all, there seems to be precious little care on show on the Meadowside. Patients stand around in the corridor discussing their most intimate details with surgeons and anaesthetists. Half of them cannot sign the consent form because they’re already holding two crutches. And if they survive the ordeal, they get sent home on snowy days without any paracetamol. Yes, even that most basic of painkillers - the one with no side effects at a reasonable dose, the one you can buy for peanuts, well our great leader has decided someone else should buy it, not him. Makes me choke on my own combination therapy: it’s halo-mepraza-lol.

It was on the Meadowside that I did a bit of teaching the other day. One of those youthful trainees asked what it was I had around my neck. It was, of course, Laennec’s great invention. I began to explain its use – auscultation, the joys of diastolic murmurs – when she exclaimed ‘Oh, so that’s a stethoscope, I’ve heard of those, but never seen one’. I didn’t want to admit I’d heard of echocardiography, but never seen one. Instead I launched into a tirade on the failure of today’s schools. How can young doctors qualify without the slightest rudiments of the classics? ‘Stethoscope? What nonsense, when did anyone ever look with one? It’s not a Stethoscope, it’s a Stethophone’.

'Victor Meldrew'


it’s not a Stethoscope, it’s a Stethophone

18 Anaesthesia News September 2014 • Issue 326 Anaesthesia News September 2014 • Issue 326 19 19 18

We have gathered a wide range of topics and speakers from the UK, Europe and further afield. It is a ’one stop shop‘ for all your continuing professional development and educational needs in 2015. As ever there will be a range of social events, including a stunning dinner dance at the world famous Savoy Hotel, to give you the chance to meet friends and make new ones from the world of anaesthesia and beyond.

With over 1000 delegates at last year’s WSM, space filled up fast, so we advise you to book your study leave and register now at the WSM London website, www.wsmlondon.org, to make sure you get your place and the workshops you want ahead of the pack.

The meeting runs from Wednesday 14th until Friday 16th January in its usual venue the QEII Conference Centre which is a mere stone’s throw from Big Ben and the Houses of Parliament in central London. There are a huge range of options for accommodation with preferential negotiated rates to suit all tastes and budgets. Please visit the WSM London website, www.wsmlondon.org, to view the hotels and rates on offer. London is an exciting and vibrant city to visit at any time of year so why not take the opportunity to come and join the fun.

So what of the programme? As promised we have put together a very varied range of topics, providing something for everyone.

We have Keynote lectures from Professor David Haslam, who is the Chair of the National Institute for Health and Care Excellence (they used to be called NICE), and the eminent neurosurgeon, Mr Henry Marsh, who published the critically acclaimed book Do No Harm – Stories of Life, Death and Brain Surgery in 2014.

The Core Topics themed day on Wednesday 14th January includes lectures on many topics such as:• 21st century peri-operative diabetic management• Left ventricular assessment – beyond the ejection fraction • Airway assessment - what works, and what doesn’t• State of the art care of the emergency laparotomy patient• State of the art peri-operative care of the older patient • Top Ten Tips to avoid making mistakes • Pre-operative fasting – what’s the big issue?• Anaesthetists as peri-operative physicians• Controversies in sedation• How and why to do awake craniotomy• Keeping up to date with resuscitation guidelines• Getting patient feedback for your appraisal• Never events - what are they and how to avoid them

The following day we have top quality sessions on topics such as: • regional anaesthesia - Reducing conversion of acute to

chronic pain after surgery (Professor Colin McCartney, Toronto, Canada); RA outreach service (Dr Calum Grant, Dundee); Block rooms – worth investing in? (Dr Nathaniel Haslam, Sunderland)

• Anaemia - Pre-optimisation more important than pre-assessment (Professor Gerrard Danjoux, Middlesbrough); Anaemia and transfusion. Restrictive or liberal? (Dr Alistair Nimmo, Edinburgh)

• haemorrhage - Haemostasis during haemorrhage - way we understand and transfusion reactions - update (Dr Paula Bolton-Maggs, Medical Director, Serious Hazards of Transfusion (SHOT), Manchester Blood Centre); Monitoring coagulopathy during major haemorrhage and optimisation of coagulopathy after major trauma (Dr Jacob Stensbelle, Copenhagen, Denmark); Major haemorrhage management - current controversies (Dr Ravi Rao Baikady, London)

• Alternative Medicine - Physiology and possible mechanism of effects of acupuncture (Dr Thomas Lundeberg, Stockholm, Sweden); Role of acupuncture in anaesthesia and pain relief - current view (Dr Jacqueline Filshie, London); Organising acupuncture services in the NHS (Mr Jonathan Hearsey, London)

• Acute Pain - Analgesia for major abdominal surgery - current opinion (Dr Anton Krige, Blackburn); Adjuvant therapies in acute pain management (Dr Jeremy Cashman, London);

Acute pain management in the opioid tolerant (Dr John John, Oswestry)

• obstetrics – Why mothers die? (Dr Steve Yentis, London; Professor Lawrence Tsen, Boston, USA; Professor Arvind Palanisamy, Boston, USA)

• Major Trauma – Professor Chris Moran, Nottingham and more speakers to be announced shortly

• AAGBI panel discussion with Dr Andrew Hartle, President, AAGBI; Dr Mark Porter, Chair of Council, British Medical Association; Dr Ellen O’Sullivan, President, College of Anaesthetists of Ireland; Dr J-P van Besouw, President, Royal College of Anaesthetists

We also have lots of workshops you can sign up to attend covering a wide range of areas of professional and clinical practice:

• ‘How to publish a paper’ led by Dr Mike Kinsella and the team from Anaesthesia

• Ultrasound in regional anaesthesia (organised by RA-UK) led by Dr Morne Wolmarans

• Paediatric emergencies led by Dr David de Beer and the team from GOSH

• TOE led by Dr Andrew Smith• GE Healthcare sponsored workshop on CPX• Mentoring sessions led by Dr Nancy Redfern and her excellent

team of trained mentors. These are free drop-in sessions and can be booked in advance or at the registration desk during the meeting. Book your place early as these sessions get booked up quickly.

• Dr Nancy Redfern will be running an interactive workshop and discussion on ‘Your working life’

On Friday, we have a session hosted by Dr Brian Jenkins, one of the editors of Anaesthesia. The theme this year is ‘Developing skills and avoiding errors’ which promises to be informative, entertaining and relevant to us all. We also have a session themed on ‘Quality improvement in peri-operative care’. We will get a sneaky preview from the Enhanced Recovery After Surgery (ERAS) Society of their new guidelines for hip and knee arthroplasty by Mr Tom Wainwright, Bournemouth; ERAS in major spinal surgery by Dr John John, Oswestry; and how the anaesthetic peri-operative physician fits into the jigsaw by Dr Mike Scott, Guildford. The latter is pertinent now that the Royal College of Anaesthetists have prepared a curriculum for the peri-operative physician. There will be interactive sessions themed on Innovation and Independent Practice and, after the Honours & Awards and Presidential Address by Dr Andrew Hartle, there will be a lively PRO/CON debate on whether resident on-call consultant anaesthetists are the future of NHS out of hours emergency cover in the UK. We will hear from Dr Simon Evans and Dr Hamish McLure with different experiences of what life is like doing regular resident on-call emergency shifts. This is a subject close to all our hearts and will be a fitting climax to WSM London 2015.

Trainees and SAS doctors – don’t forget our poster competition for your research, audit or quality improvement projects. You can also submit case report posters. The ever popular trainee lunch will again be hosted by the AAGBI Council.

There will be a huge exhibition by the anaesthetic industry so here’s your chance to see that latest bit of kit you fancy trying and then persuade your Trust to cough up for. There’s lots more going to be happening, but you will have to come along to experience the whole thing. I hope to see you in London in January.

don’t miss it!dr Matthew checkettsChair of AAGBI Education Committee

www.wsmlondon.org

PReVieW

Qeii conference centre, Westminster

The AAGBI WSM London 2015 at the Queen Elizabeth II Conference Centre in London promises to be another stunning, eclectic, contemporary and entertaining conference for anaesthetists to gather, learn, debate and network.

14-16 JanUaRY 2015

Parent & Baby Facility availableLectures from the main

auditorium are streamed into a separate room so parents can catch up on CPd whilst looking after their babies

in an informal setting

Go to www.wsmlondon.org for further information


I’d become a bit disenchanted with UK medicine during my foundation jobs, and having been lucky enough to work in a township hospital outside Pretoria as part of my medical school rotation in paediatrics, I had been so impressed by the clinical skills of the local doctors that I decided to go back and work in South Africa after F2. The hospital I chose was a 110-bed general hospital, 17km from the nearest tar road, staffed by three other foreign-trained SHOs. I was placed in charge of a general ward, i.e. all patients other than paediatric, obstetric and TB cases, and since I’d performed approximately five spinal anaesthetics on my elective two years earlier, I was also considered adequately trained to provide anaesthetic services in our basic theatre.

To UK-trained doctors, this must sound incredible, or even reckless and irresponsible. Now approaching the end of core training in anaesthesia, I shudder to think of the possible implications and complications of which I was relatively unaware at the time. However, when your patients present incredibly late (most had to travel for hours via taxi just to get to the hospital) and a transfer to the referral hospital will take around six hours, at best, in a so-called emergency ambulance (little more than a tiny white van with no oxygen, paramedics, or resuscitation equipment, and no facility for a doctor to travel with the patient), a much greater proportion of your cases become life-or-death emergencies. For around six weeks, our referral hospital went on strike so even that option was closed to us. Hence, despite limited experience, we frequently had to use what skills we had in our patients’ best interest. Road traffic accidents, stabbed chests, burn injuries and, most of all, obstetric emergencies, were extremely common and many would not have survived any significant delay. Nevertheless, as soon as it was

possible I arranged for two weeks’ intensive training in anaesthetics with the venerable and inspirational Dr Lionel Smith in Port Elizabeth, the patron saint of rural anaesthesia in the Eastern Cape, who has been responsible for training a legion of rural doctors in basic anaesthetic techniques, as well as improving facilities in their hospitals, and must thereby have been responsible for the saving of many lives.

For better or worse, our anaesthetic options were limited. We could perform spinal anaesthesia with heavy bupivacaine, or sedation with ketamine or diazepam. Now, looking back, the idea of general anaesthesia where induction options are limited to propofol or ketamine, the only volatile available is halothane, the only opiates are morphine and pethidine, and the only muscle relaxant is pancuronium, seems entirely preposterous – although, on the other hand, it would have made revising for the Primary FRCA significantly easier...

The hospital had a grand total of three LMAs, which had to be re-used, and around ten ETTs, which didn’t, but were unlikely to be replaced in a hurry if they were used. A more fundamental problem existed with our electricity and water supplies, each of which would fail intermittently, sometimes for weeks at a time. We had to perform caesareans with head torches and mobile phones as lighting when the power failed – I ended up leaving my head torch strapped to the theatre overhead lamp as a rudimentary back-up. After weeks of scrubbing up (not to mention showering and flushing toilets) with buckets of water, we eventually arranged a grant to get a rainwater-harvesting system and pump for the hospital to store water for those times when the taps went dry.

Of course, there’s no working time directive in the Transkei. I worked one weekend in four, single-handedly staffing the hospital for 72 hours while my colleagues disappeared for some much-needed down time. Some of my most memorable experiences are from those on-call weekends, feeling like the last line of defence against a rising tide of pathology from a catchment area of approximately 120,000 people. Gynaecology lists these days feel remarkably tame compared to the days where a so-called ambulance would deposit two or three unresuscitated women in the middle of the night at the hospital, with postpartum haemorrhage from retained products of conception. I would be woken by the shrill ring of our telephone – 'Molo, doc. It is OPD doc. We have three ladies bleeding and you must come now now, doc.' I’d have to pull on my clothes and run down the hill, bang on the security gates to waken the guards who would inevitably have fallen asleep after they let the ambulance out, and quickly triage and resuscitate the patients before proceeding to theatre. Here I’d ‘anaesthetise’ them (usually a quick slug of ketamine) and then have to step to the other end of the table, scrub, and do a quick D&C myself before moving on to the next. Another major problem was our almost total lack of access to laboratory investigations. When I arrived, results from a simple urea and electrolytes or full blood count tended to take around two weeks to return. This was seriously compromising our ability to deliver satisfactory care, particularly as many of our patients had (often undiagnosed) TB or HIV with concurrent anaemia, renal failure or thrombocytopaenia. After auditing the laboratory response times, and presenting the results in a few strongly-worded emails to the National Laboratory Service, I was offered Blackberry mobile devices for each doctor at the hospital with software granting us direct access

to the laboratory results system, as well as a management drive to improve processing time at our referral laboratory. Suddenly we were receiving results within two days or even, at times, a single day which radically improved the service we were able to offer to our patients.

South Africa’s rural and remote hospitals are experiencing an acute-on-chronic shortage of medical staff as their home-trained doctors prefer to work either in large population centres or emigrate abroad. Working in a rural hospital was in equal parts incredibly fun, terrifying, challenging, frustrating and intensely satisfying. There can’t be many medical jobs where you can make a difference on so many levels – I was negotiating with management and NGOs, training nurses, gaining valuable experience in anaesthetics as well as other specialties, not to mention filling in wherever I could – taking on roles such as ambulance driver, hospital cook, porter, pharmacist, occasional play therapist and even pest control (chasing goats out of theatre and cats out of the ward!)

While the hospital I worked in was too small to have a full time anaesthetist, there are many rural hospitals with full anaesthetic departments which desperately need staff to fill gaps on their rotas. I’d wholeheartedly recommend getting in touch with Africa Health Placements (www.ahp.org.za) to anyone interested in providing an essential service to a frequently neglected but often extremely grateful population, and gaining invaluable experience along the way.

stephen AlcornST4 Anaesthetics, Royal Hospital for Sick Children, Edinburgh

Rural anaesthesia in the TranskeiPerforming your first general anaesthetic, unsupervised, in a hospital with no recovery suite, let alone icU, and senior support based in a hospital 10 hours drive away, is probably not the normal entry point to a career in anaesthesia. however, there is very little that’s normal about practising medicine in a remote and rural hospital in the Transkei, in south Africa’s eastern cape.

Photograph ©Africa Health PlacementsPhotograph ©Africa Health Placements Photograph ©Stephen AlcornPhotograph ©Stephen Alcorn

Rural and remote hospitals


September 2014

Digested

N.B. the articles referred to can be found either in a print issue or on Early View (ePub ahead of print)A.E. Vercueil

Editor, Anaesthesia

How important is peri-operative hypertension?Sanders RD.

Who operates when, where and on whom? A survey of anaesthetic-surgical activity in Ireland as denominator of NAP5Jonker WR, Hanumanthiah D, Ryan T, Cook TM, Pandit JJ, O'Sullivan EP and on behalf of the NAP5 Steering Panel

A national survey (NAP5-Ireland baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in IrelandJonker WR, Hanumanthiah D, Ryan T, Cook TM, Pandit JJ, O'Sullivan EP and on behalf of the NAP5 Steering Panel of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland, and the College of Anaesthetists of Ireland

How important, indeed? It seems timely that this problem, which confronts many of us on a daily basis and yet is included in few risk scoring systems, is examined by Rob Sanders.

There is little doubt that peri-operative hypertension is common, occurring in up to 64% of people undergoing cardiac surgery. It should not just be one for the cardiac anaesthetists among us, however. Spend a bit of time in an orthopaedic theatre, and you will find that 40% of your patients having joint replacements will have the same condition. It is also widely reported to be a serious problem, resulting in increases in mortality and major morbidity across a wide range of surgical specialties. How, though, should we interpret pre-operative hypertension, and what should we do about it in theatre? Fortunately, help is at hand in this editorial, which draws attention both to what is known, and equally importantly, where we remain ignorant.

We can now begin to consider that blood pressure measured in the community may be more valuable than hypertension diagnosed on admission to hospital. Possibly more important is the pulse pressure that can be calculated from such measurements, particularly in the context of cardiac surgery, where small increases in community-measured pulse pressure dramatically increased the rates of cerebrovascular events and stroke.

And what of the various treatment options? Is there truly a benefit in peri-operative beta-blockade and, if so, how do we reconcile this with NICE guidelines that recommend angiotensin converting enzyme inhibitors or angiotensin receptor blockers as first-line treatment for those under 55 years of age? We know that these agents are associated with increased peri-operative morbidity, and will require more information on how to manage the many patients we will see who use these drugs. This is true of the intra-operative period as well, where there are real issues in inconsistency of definitions of hyper- and hypotension, which hamper our understanding of what to do about it. Perhaps we should really be concerned about tissue perfusion, and the issue of cerebral autoregulation. Near infra-red spectroscopy enables us to monitor cerebral oxygenation, regardless of blood pressure threshold, and may even stop us from using vasopressors, as by doing so we may be sacrificing perfusion for pressure and harming our patients.

We need to acknowledge that while our understanding of this topic has increased, the limitations of our knowledge are equally important. ‘Big data’ analysis may in the future be available to guide us.

The packed programme will appeal to a wide audience, exploring the theme of ‘Practice, precision and professionalism’ within the specialty.

In addition, a fantastic social programme has been scheduled to truly make the most of the Gold Coast location, with events at Movie World and Jupiter’s Casino.

Invited speakers include:

Dr Michael Barrington St Vincent’s Hospital, Melbourne Dr David Bogod Nottingham University Hospital, UK Dr Alan William Harrop-Griffiths Imperial College, UK

Practice, precision and professionalism

NATIONAL SCIENTIFIC CONGRESSGOLD COASTAUSTRALIAN SOCIETY OF ANAESTHETISTS

Improving Qualityin Day Surgery

A Joint BADS & HCUK Conference

Thursday 20 November 2014 ICO Conference Centre London

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How common is awareness during general anaesthesia in Ireland? In fact, how many general anaesthetics take place there annually, and who is giving them? Thanks to the AAGBI and the NAP5 study, the methodology of which has been reported before, clinicians and policy-makers for the first time have robust answers to these questions. These paired studies follow the publication of the initial NAP5 data for the UK last year.

There is much that is the same in the two countries, but there are also intriguing differences. The majority of anaesthesia departments in Ireland are relatively small, with a bimodal distribution of years of experience. In 2011, there were eight cases of accidental awareness reported to Irish clinicians. This incidence of one case for every 23,366 anaesthetics is broadly consistent with the UK data, and means that just one out of 37 anaesthetists will know of a new case of awareness each year, with an estimated career incidence per year of consultant practice that is almost identical to the UK estimate of one case every 36–47 years.

There are some caveats; the data applies only to public hospitals, and the independent sector in Ireland is, relatively, much larger than in the U.K, comprising some 40% of activity. The strengths and limitations of the audit itself have already been extensively debated and this relatively low incidence, strikingly lower than that seen in prospective questionnaires, means that we cannot afford to be complacent. Ireland appears to be taking the challenge seriously, and clinicians use depth of anaesthesia monitoring much more commonly than in the UK, with 80% of hospitals having access to depth of anaesthesia monitoring, and the majority of anaesthetists (62%) using it at some time as part of their practice.

We eagerly await the launch of the full findings of NAP5 on the 10th September 2014, and the detail it will provide regarding accidental awareness. We always seek to advance patient care and provide ever-safer anaesthesia, and should be mindful of the AAGBI motto, ‘in somno securitas’.


your lettersSEND YOUR LETTERS TO:

The Editor, Anaesthesia News at [email protected] see instructions for authors on the AAGBI website

dear Editor, labour pain relief oil and epidural administration

dear Editor,

I read with interest the last President’s Report1 recalling an incident of harassment/bullying of an anaesthetic trainee by a consultant surgeon. Whilst I commend the spirit in which the incident was handled, I believe there needs to be more emphasis on the support for the trainee, as well as resolution of the unprofessional behaviour.

It is well worth repeating that the support of a consultant anaesthetist for an anaesthetic trainee who has been bullied by another member of staff is vital for a successful conclusion of the episode. In my experience, far too often consultant anaesthetists shy away from standing up for their trainee colleagues, which only leads to a further sense of inadequacy in the trainee. Not only are they likely to feel that they only have themselves to blame for being bullied, but when no-one stands up for them, it compounds that feeling. It is clear that this was not the case in this instance but I would venture that this is unusual and therefore worthy of comment.

In my experience of a similar case, it was not the bullying and the resolving of the bullying that continued to upset a trainee, it was the lack of support from a consultant anaesthetist who could and should have intervened on the trainee’s behalf. There was a genuine sense of an unresolved difficulty that the trainee did not know how best to handle. An important and oft forgotten part of the whole process is feedback to the trainee after the event.

I would commend the work of the Educational Development Team who work from within the old London Deanery building. John Launer and his team have successfully worked with several London Trusts who have recognised that there has been a problem with bullying or undermining.2 This recognition has often been established following an Annual Quality (Deanery) visit or from previous GMC National Training Surveys. Occasionally, some organisations find it difficult to prevent a culture of bullying; more often than not it becomes a form of normal behaviour. It can also become systematic, from a lack of willingness by, generally speaking, senior figures, to counter it.

If Departments of Anaesthesia need help with how to deal with this type of behaviour then I would also commend the guidance produced by the said team for how to manage this type of problem.3

All of the 'crusty old codgers' amongst whom I definitely include myself, should be proud to stand up for others in the working environment and show some of the leadership that the President has demonstrated.

dr Peter Brodrick Consultant Anaesthetist, West Hertfordshire Hospitals NHS Trust

Head of the London Academy of Anaesthesia

References

1. Harrop-Griffiths W. President’s Report. Anaesthesia News 2014; 323: 5–6.

2. Support for Educational Teams.http://www.faculty.londondeanery.ac.uk/educational-team-development (accessed 29/06/14).

3. Managing Bullying, Harassment and Undermining – a guide to good practice in postgraduate medical education in London. 2013. Available from http://www.faculty.londondeanery.ac.uk/educational-team-development/managing-bullying-harassment-and-undermining (accessed 29/06/14).

EVELYN BAKER MEDAL

The Evelyn Baker award was instigated by Dr Margaret Branthwaite in 1998, dedicated to the memory of one of her former patients at the Royal Brompton Hospital. The award is made for outstanding clinical competence, recognising the ‘unsung heroes’ of clinical anaesthesia and related practice. The defining characteristics of clinical competence are deemed to be technical proficiency, consistently reliable clinical judgement and wisdom and skill in communicating with patients, their relatives and colleagues. The ability to train and enthuse trainee colleagues is seen as an integral part of communication skill, extending beyond formal teaching of academic presentation. Nominees should normally still be in clinical practice.

Dr John Cole (Sheffield) was the first winner of the Evelyn Baker medal in 1998, followed by Dr Meena Choksi (Pontypridd) in 1999, Dr Neil Schofield (Oxford) in 2000, Dr Brian Steer (Eastbourne) in 2001, Dr Mark Crosse (Southampton) in 2002, Dr Paul Monks (London) in 2003, Dr Margo Lewis (Birmingham) in 2004, Dr Douglas Turner (Leicester) in 2005, Dr Martin Coates (Plymouth) in 2006, Dr Gareth Charlton (Southampton) in 2007, Dr Neville Robinson (London) in 2008, Dr Fred Roberts (Exeter) in 2009, Dr Sudheer Medakkar (Torquay) in 2010, Dr Keith Clayton (Coventry) in 2011, Dr John Windsor (London) in 2012, and Drs Amanda Blackburn (Rotherham), Michael Donaldson (Hull), Andrew Kilner (Newcastle) and Chris Vallis (Newcastle) in 2013.

Nominations are now invited for the award, which will be presented at WSM London in January 2015. Members of the AAGBI can nominate any practising anaesthetist who is also a member of the Association. Examples of successful previous nominations are available on request. Nominations should include an indication that the nominee has broad support within their department.

The nomination, accompanied by a citation of up to 1000 words, should be sent to the Honorary Secretary at [email protected] by 17:00 on Monday 22 September 2014

AN AWARD FOR OUTSTANDING CLINICAL COMPETENCE

I would like to report two incidences of being called to administer an epidural during labour where two patients were having their lumbosacral area massaged with labour pain relief oil. One type of oil was bought online and the other one in a shop.

The contents of the oils were clary sage, jasmine, geranium, rose absolute and bergamot essential oils.

After discussion with senior colleagues, the epidurals were not administered to either patient because we were unsure of the method of skin sterilisation. The skin on the back of the first patient was peeling and the second

patient had red skin discolouration. Also, we were unsure just how much oil would be absorbed by the skin and, once inserted, whether the epidural needle would carry the oil in further.

Should we advise women in labour not to rub these oils on their backs?

dr santhosh Babu Anaesthetics, North Manchester General Hospital

dear Editor,

I thought I’d share a recent experience from a nightshift. It certainly made a change from the calls I usually receive at a district general hospital where there is no Maternity service.

‘Are you on for Anaesthetics?’ the A&E SHO asked breathlessly over the phone. ‘We need your help resuscitating a mother and baby!’

Having been staring into my mug of tea after a long nightshift, I jumped up, alarming nearby nursing staff. My previously weary, now adrenaline-pumped, limbs transferred me downstairs to the Emergency Department, where I was met by sounds of distress behind a screen. I was ushered through by a nurse to find a young woman with a baby crowning. ‘I thought she’d put on a bit of weight over Christmas!’ her mother exclaimed. As I grabbed some blankets, the A&E consultant thanked me for coming. The Broselow trolley stood at the ready but was not required as, between us, we delivered a thankfully crying bundle!

As I handed the bewildered woman her new baby, my consultant arrived and helpfully remarked ‘You never know what you might get called for when you’re on for Anaesthetics!’

dr sarah sullivan CT3 ACCS Anaesthetics, NHS Lanarkshire

for the latest news and event information follow @AAGBi on Twitter

dear Editor, Night shift illusions

Pareidolia describes the tendency to see faces in inanimate objects or configurations.

Coming towards the end of a busy night shift recently, I found myself in A&E resus, only to be confronted by a portable x-ray machine that struck me as looking remarkably like a sad robot dog (Figure 1).

A compelling explanation of this phenomenon is one of evolutionary necessity. The ability (or inability) to differentiate between friend or foe could have dire consequences to prehistoric humans. Magnetoencephalography studies have found that objects incidentally perceived as faces evoked a similar activation in the brain’s ventral fusiform cortex to that evoked by real faces, in a similar, remarkably rapid, time (165ms).1

From A&E I made my way back to the intensive care department where I was met by another x-ray machine. As the face of a cheeky robotic monkey grinned back at me (Figure 2), I must admit I reflected less on the neural pathways or evolutionary machinations; rather, I decided, it was probably time for a coffee.

dr Philip dart CT2, St Richard’s Hospital Chichester

dr radha Ganesharatnam Clinical Fellow, Royal Sussex County Hospital

Reference

1. Hadjikhani N, Kveraga K, Naik P et al. Early (N170) activation of face-specific cortex by face-like objects. Neuroreport 2009; 20: 403-7.

Figure 1 Figure 2

17th Anaesthesia, Critical Care and Pain Forum

www.doctorsupdates.com

Da Balaia, The AlgarvePortugal

29 September -2 October 2014

Aenean a magna vel pede vestibulum rhoncus. Nulla cursus orci quis tortor.

COURSE DATES

6th October 2014 13th October 2014

NOVICE ANAESTHETIST SIMULATION CRITICAL INCIDENT MANAGEMENT COURSE

This one-day practical course is aimed at anaesthetic or acute common stem

trainees in their first 6 months of anaesthetic training. The scenarios are

designed to allow participants the opportunity to manage a variety of

anaesthetic emergencies in the safety of the simulation suite.

Previous Course Feedback: “Good challenging scenarios”, “Really Friendly and

Informative ”, “Well run”, “Wish we could do this more often”

COURSE FEES

£50.00

LOCATION

Simulation Suite, PGMEC 5th floor Surgical wing

Kingston Hospital Galsworthy Road

Kingston upon Thames

For specific enquiries about the course, please contact:

Dr Deanne Cheyne Consultant Anaesthetist

[email protected] Or

Dr Sarang Puranik Consultant Anaesthetist

[email protected]

For general enquiries and bookings, please contact:

Mr Nick Wall Lead Resuscitation Officer

[email protected]

BOOK EARLY

Places limited

19th ANNUAL SCIENTIFIC MEETING Friday 7th November 2014

Nottingham Conference Centre

£2000 Prize fund

Consultant/SAS £100 BSOA Member £70 Trainee/PA £35 BSOA Member £20

www.bsoa.org.uk or www.nuh.nhs.uk/pgec

Contact: Sue on 0115 840 2608 Email: [email protected]

10 years of conflict: Lessons learnt in pain management Dr Dominic Aldington

Surgeons & Anaesthetists talking: Damage limitation & timing of polytrauma surgery

Professor Chris Moran

Anaesthesia for the bigger boned: Obesity & orthopaedic anaesthesia

Dr Nick Reynolds

Orthopaedic Enhanced Recovery: What’s new & what works?

David McDonald

Orthopaedic Enhanced Recovery: Fine tuning the process

Tom Wainwright

Comprehensive Geriatric Assessment in Orthopaedics: Panacea or Pandora’s Box

Dr Adam Gordon

Hip Fracture Anaesthesia: Art or Science Dr Iain Moppett

(Abstract closing date Wednesday 17th September)

Approved by the Royal College of Anaesthetists

for 5 CPD credits

PROGRAMME09.00 Registration and Coffee

09.30Introduction Dr Mike Boscoe, Consultant Anaesthetist, London, President, Society of Anaesthetists in Radiology

09.35

‘Safe Sedation Practice for Healthcare Procedures: Recommendations of Academy of Medical Royal Colleges’ Dr Anna-Maria Rollin, Professional Standards Advisor, Royal College of Anaesthetists

10.20 Poster presentations

11.20 Coffee

11.50

High frequency ventilation facilitates percutaneous tumour ablation Dr Mark Anderson, Consultant radiologistDr Shaun Scott, Consultant anaesthetist The Oxford Cancer Centre, Churchill Hospital, Oxford

12.30

Sedation for paediatric and adult diagnostic MRI and CT Dr Sally Wilson, Consultant Anaesthetist, The National Hospital for Neuroradiology and Neurosurgery, UCLH Foundation Trust, LondonDr Olivia Mingo, Consultant Anaesthetist, The Royal Marsden Hospital, London

13.10 Lunch

14.20 Poster competition – announcement of winner and presentation of prize

14.30Radiation: perception and risks Dr Alex Barnacle, Consultant Anaesthetist, Great Ormond Street Hospital, LondonDr Bruce Martin, Consultant Anaesthetist, UCLH Foundation Trust, London

15.15

Advances in trauma management and the use of interventional radiology Mr Tom Konig, Consultant Trauma and Vascular SurgeonDr Tim Fotheringham, Consultant RadiologistDr Nick Bunker, Consultant Anaesthetist and Intensivist, The Royal London Hospital, London

16.30 Finish

SOCIETY OF ANAESTHETISTS IN RADIOLOGY3rd Annual Scientific Meeting

Wednesday, 5th Nov 2014 09:00-16:30

ROYAL SOCIETY OF MEDICINE1, Wimpole Street, London, W1G 9LQ

Please register via www.societyofanaesthetistsinradiology.org

INAUGURAL MEETING

of the SOCIETY OF ANAESTHETISTS IN RADIOLOGY

10th NOVEMBER 2011 13:30-17:00

INSTITUTE OF CHILD HEALTH Programme:

13:30

13:3014:00 14:10 Introduction

14:10 14:30 Implantation)

14:30 14:50 Cons

14:50 15:00 Discussion

15:00 15:20 Lab

15:20 15:50 Tea

15:50

16:20Square

Recognised for 5 CPD points (RCoA)

9th West of England Anaesthesia Update Based in Chalet Hotel St Christoph Talks cover a wide range of topics

Flights available from Bristol, Gatwick and other airports nationwide All grades of Anaesthetist welcome Attractive prices

19th – 23rd January 2015 St Christoph am Arlberg (nr St Anton), Austria

www.weauconf.com [email protected]

9th West of England Anaesthesia Update

Par

ticl

es

Anaesthesia News September 2014 • Issue 326 29 28 Anaesthesia News September 2014 • Issue 326

Caironi, P., Tognoni, G., Masson, S. et al.

Albumin replacement in patients with severe sepsis or septic shock

New England Journal of Medicine 2014: 370: 1412 – 1421.

BackgroundAlbumin as a resuscitation fluid is long established within clinical practice. Its theoretical benefits include: its oncotic potential, antioxidant features, free radical scavenging and anti-inflammatory properties. However, its supporting evidence is chequered. The SAFE trial,1 via subgroup analysis, suggested that septic patients receiving albumin (compared to saline) had a small survival benefit. This was supported by work indicating that higher serum albumin benefits septic patients.

This large multicentre trial aimed to investigate the effects of albumin and crystalloid administration compared to crystalloid alone in patients with severe sepsis.

MethodsPatients with severe sepsis were recruited from Italian intensive care units (ICUs) and were randomised for fluid therapy with either 20% albumin combined with crystalloid versus crystalloid alone. Fluids were administered by goal directed therapy and, in the combined group, 200-300ml of albumin was administered to a daily serum albumin target of 30g/L for 28 days or until ICU discharge. Crystalloids were administered when clinically indicated. Primary outcome was any-cause death at 28 days with secondary outcomes being: any-cause mortality, organ dysfunction alongside length of ICU and hospital stay at 90 days.

results A total of 1810 patients were analysed. Patients receiving albumin had lower overall fluid balances compared to the control group (p<0.03 and p<0.001) although seven day cumulative fluid balance revealed no difference in volumes (3738ml and 3825ml; p=0.10). The albumin group also demonstrated lower heart rates (p=0.002) and higher mean arterial pressures (p=0.03) at seven days.

Interestingly, both groups at 28 and 90 days had a statistically insignificant difference in mortality (p=0.94 and p=0.29). Further assessment of secondary outcomes revealed statistical comparability between the two groups with organ dysfunction and length of ICU stay, although SOFA analysis revealed the albumin group had lower cardiovascular scores (p=0.03) alongside shorter times to stopping vasoactive agents (3 vs 4 days, p=0.007).

discussionThis study demonstrated that albumin use in severe sepsis is safe when combined with crystalloids, although no survival advantage is conferred at either 28 or 90 days. Additionally, albumin use confers a small but significant advantage in achieving haemodynamic parameters, reducing cardiovascular organ dysfunction and in cessation of vasoactive support. Interestingly, post-hoc analysis revealed significantly lower 90-day mortality in patients with septic shock treated with albumin, compared with the crystalloid group. This trial had limitations due to low numbers, and the possibility of under-powering because of a lower than expected 28-day mortality.

In conclusion, albumin use in sepsis is safe; however its benefit with regard to mortality remains unclear. Further study is required to confirm a possible survival benefit in patients with septic shock.

stuart deoraj Medical Student

Newcastle University

Jonathan BrandST6 Anaesthetics & Intensive Care Medicine

Northern Deanery

References 1. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline

for fluid resuscitation in the intensive care unit. New England Journal of Medicine 2004; 350: 2247–56.

Devereaux PJ, Mrkobrada M, et al.

Aspirin in patients undergoing non-cardiac surgery

New England Journal of Medicine 2014; 370: 1494-1503

BackgroundMyocardial infarction (MI) is the most common cardiovascular complication following non-cardiac surgery (NCS).1 Evidence suggests a thrombotic cause in 45% peri-operative MIs,2 however peri-operative aspirin use remains varied, even in ‘at risk’ patients.3 This study compared peri-operative aspirin to placebo, to determine its efficacy and safety in a surgical cohort.

MethodsA total of 10,010 patients scheduled for NCS and at risk of vascular complications were enrolled internationally. Subjects were grouped according to whether they already took aspirin (‘continuers’) or not (‘initiators’). Existing aspirin regimes were discontinued, on average, 7 days pre-operatively.

Participants in each cohort were randomised to peri-operative aspirin (n=4998) or placebo (n=5012). Those allocated aspirin were administered 200mg “before surgery”, followed by 100mg/day for 7 days postoperatively if continuers, or 30 days if initiators. The primary outcome at 30 days was a composite of death and non-fatal MI. Secondary composite outcomes included the primary outcome plus stroke, cardiac revascularisation or venous thromboembolism (VTE). Safety outcomes included life-threatening or major bleeding.

results Data from 99.9% enrolled patients was analysed. At 30 days, 7% aspirin and 7.1% placebo patients had suffered an MI or died (HR, aspirin, 0.99, 95% CI 0.86-1.15, p=0.92). Use of aspirin did not significantly reduce incidence of peri-operative MI; 6.2% aspirin vs 6.3% placebo patients (p=0.85), and there was no significant difference between treatments with respect to secondary outcomes, including stroke.

Major bleeding was, however, significantly more common in patients taking aspirin (4.6%) vs placebo (3.8%) (HR, aspirin, 1.23, 95% CI 1.01-1.49, p=0.04); 78.3% of which occurred at the surgical site. Post-hoc analysis demonstrated that bleeding risk associated with aspirin diminished in significance from day 8 postoperatively (p>0.29).

discussionThis study revealed no significant benefit of peri-operative aspirin in preventing death or MI, whether it was newly prescribed or continued and, instead, demonstrated that aspirin significantly increases bleeding risk in the first 8 days postoperatively.

It is possible that no appreciable benefit on MI incidence was achieved because aspirin’s pro-haemorrhagic effects balance its anti-thrombotic properties, or because the primary aetiology of peri-operative MI is non-thrombotic.

Notably, patients who received a bare metal or drug eluting coronary stent within 6 weeks and 1 year, respectively, of surgery were excluded from the research, so efficacy in these very high-risk patients cannot be ruled out.

In summary, this trial provides convincing evidence that withholding aspirin peri-operatively is safe, if patients have alternative VTE prophylaxis and meet certain coronary intervention criteria.

Katherine BrownMedical student, Newcastle University

References1. Botto F, Alonso-Coello P, Chan MT, et al., Myocardial injury after

noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology 2014; 120: 564–78.

2. Gualandro DM, Campos CA, Calderaro D, et al., Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: frequent and dangerous. Atherosclerosis 2012; 222: 191–5.

3. Alcock RF, Naoum C, Aliprandi-Costa B, Hills GS, Brieger DB. The peri-operative management of anti-platelet therapy in elective, non-cardiac surgery. International Journal of Cardiology 2013; 167: 374–7.

Kim F., Nichol G., Maynard C., et al

effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest. A randomized clinical trial

JAMA 2014; 311: 45-52

introductionThis study aimed to establish whether prehospital cooling improved survival and neurological recovery after VF and non-VF arrest, and any associated adverse effects from cooling. Cold i.v. fluids achieve therapeutic hypothermia more rapidly compared to surface cooling devices and early cooling in laboratory studies has suggested further outcome advances.1

MethodsInclusion criteria included return of spontaneous circulation (ROSC), tracheal intubation, i.v. access, oesophageal thermometer and unconsciousness. Exclusion criteria included traumatic cardiac arrest, age <18 years, obeying commands and temperature <34oC. Prehospital cardiac arrest patients were randomised to standard care or intervention; where 2 litres of 4oC normal saline was infused through an 18G cannula at 300mmHg, and i.v. pancuronium and diazepam were given. Intervention was commenced after ROSC with a target temperature <34oC. Both groups received standard hospital care: therapeutic hypothermia for up to 24 hours by surface or intravenous cooling methods. The medical staff involved in patient care were not blinded, however study data collectors were.

ResultsThe study enrolled 1364 patients over five years. There was no significant difference in survival to hospital discharge or neurological recovery between intervention and standard care groups for VF or non-VF. Patients in the intervention group had significantly higher rates of rearrest, diuretic and radiographic evidence of pulmonary oedema. They also had significantly lower SpO2, PaO2 and pH values. Hyperglycaemia levels were significantly higher in the control group.

discussionThe results from this large, well-designed, randomised control trial provide an opportunity to reflect on the current practice of out of hospital cardiac arrest patients. • The use of cold i.v. fluids is a practical and effective method for rapid

prehospital cooling compared to standard care alone (p<0.001). However, it has detrimental effects for VF and non-VF rhythms with no survival or neurological benefit.

• Surface cooling to 32-34oC for 12-24 hours has shown improved survival and neurological outcome in VF arrest.2,3

• Therapeutic hypothermia has not demonstrated outcome benefits in non-shockable rhythms, only increased length of ICU stay.3

dr Jennifer daviesST5 AnaesthesiaMersey Deanery

References1. Bernard SA, Smith K, Cameron P, et al. Induction of therapeutic

hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation 2010; 122: 737–742.

2. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurological outcome after cardiac arrest. New England Journal of Medicine 2002; 346: 549–556.

3. Vaahersalo J, Hiltunen P, Tiainen M, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in Finnish intensive care units: the FINNRESUSCI study. Intensive Care Medicine 2013; 39: 826–837.

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2014 Wylie Medal winner's essay

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