ANews December Web.pdf

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NEWS ANAESTHESIA ISSN 0959-2962 No. 317 DECEMBER 2013 THE NEWSLETTER OF THE ASSOCIATION OF ANAESTHETISTS OF GREAT BRITAIN AND IRELAND INSIDE THIS ISSUE: Postcode lottery in anaesthetic training The history of the specialty of Anaesthesia in the UK Learn@AAGBI A YEAR IN REVIEW 2012-2013

Transcript of ANews December Web.pdf

Page 1: ANews December Web.pdf

NEWSANAESTHESIA

ISSN 0959-2962 No. 317

DECEMBER 2013

The NewsleTTer of The

AssociATioN of ANAesTheTisTs of GreAT BriTAiN

ANd irelANd

INSIDE THIS ISSUE:

Postcode lottery in anaesthetic training

The history of the specialty of Anaesthesia in the UK

Learn@AAGBI

A YEAR IN REVIEW2012-2013

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Anaesthesia News December 2013 • Issue 317 3

contents

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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: Kate O’Connor, Nicholas Love and Caroline Wilson (GAT), Nancy Redfern, Val Bythell, Richard Griffiths, Sean Tighe, Tom Woodcock, Mike Nathanson, Rachel Collis and Upma MisraAddress for all correspondence, advertising or submissions: Email: [email protected]: www.aagbi.org/publications/anaesthesia-news

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

Copyright 2013 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.

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Editorial

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03 Editorial

04 President’s Report 05 Trainees… what can the NIAA do for you?

06 FRCA viva revision – the Skype is the limit 08 8th IHSA, Sydney, 2013 09 The Great Anaesthesia Bake

10 AAGBI: A year in review

18 Postcode lottery in anaesthetic training

20 The history of the specialty of Anaesthesia in the UK

22 Annual Congress review

24 Learn@AAGBI

27 The development of a block room

29 Your Letters

31 Anaesthesia Digested

32 Particles

34 If you’re going to San Francisco...

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retrospective: Goodbye and thanks for all the flowers

In this edition we publish our annual review, and some editor’s highlights from Annual Congress in Dublin. Looking further back, the history boys (and girls) have been busy, and the reproduction of a paper describing the birth of our College and Association makes interesting reading.

The phrase ‘..of necessity, large numbers of routine aneasthesia and most of the emergency anaesthesia in hospitals must be administered by interns’ reflects the reality of the NHS that I joined in 1981, and we still have some way to go before consultant-delivered care is anything but a pipe-dream. Indeed, some of you may still regard it as a nightmare.

Like Iain Wilson, who wrote last month’s editorial, I am looking back on my career in anaesthesia and at the AAGBI - I will be leaving the specialty soon and left the AAGBI at Annual Congress in September. I would second Iain’s feelings about the AAGBI having been a great organisation to work with, as has the wider NHS. Despite all the negative press, the care we give to patients undergoing surgery today is so much better than it was thirty years ago, at the start of my career. Having said that, I suspect that there may be some giant leaps in our understanding in the fairly near future that will help us to improve outcomes to an extent that we have hardly dreamt of to date. That was certainly the message I heard listening to Daniel Sessler at Annual Congress in September - read more on that subject in the report from Dublin.

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Anaesthesia News December 2013 • Issue 317 5

Editorial continued UndergradUate

elective FUndingUp to £750UndergradUate elective FUnding

Up to £750

Medical students in the UK and Ireland are eligible to apply to the Association of Anaesthetists of Great Britain and Ireland for funding towards a medical student elective period.

Preference will be given to those applicants who can show the relevance of their intended elective to anaesthesia, intensive care or pain relief.

for further information and an application form please visit our website: www.aagbi.org/undergraduate-awards or email [email protected] or telephone 020 7631 8807

Closing date: 06 January 2014

The Wylie Medal will be awarded to the most meritorious essay on this year’s topic related to anaesthesia Something old, something new, something borrowed, something blue written by an undergraduate medical student at a university in Great Britain or Ireland.

Prizes of £500, £250 and £150 will be awarded to the best three submissions.

The overall winner will receive the Wylie Medal in memory of the late Dr W Derek Wylie, President of the Association 1980-82.

for further information and an application form please visit our website: www.aagbi.org/undergraduate-awards or email [email protected] or telephone 020 7631 8807

Closing date: 06 January 2014

tHe WYlie MedalUndergradUate

priZe 2014

• A new NHS Consultant Contract that recognises that there are some hospital specialties that provide a lot of complex and acute care out-of-hours, and that the best way to reward consultants in these specialties, and to make sure that high-quality medical graduates continue to embark on careers in these key medical specialties, is to pay them properly for working at unsocial and non-family-friendly times, even if this means paying anaesthetists, intensivists, obstetricians, surgeons and A&E doctors quite a lot more than doctors who are almost exclusively clinic-based during weekdays.

• A totally new reward system to replace the current Clinical Excellence Award scheme that is fair to all specialties and does not lead to the inequitable situation in which the self-same, clinic-based doctors who stay in their beds all night, every night end up with four times as many local and national awards than genuinely clinical excellent specialties such anaesthesia and A&E medicine.

• A system of training in hospital specialties that does not keep changing every other year in response to political pressures, that appreciates that trainees are hard-working and dedicated professionals, that “generalists” in anaesthesia are in reality highly specialised, and that an ever-shorter training period means even less clinical experience.

• A pension scheme for doctors that is not downgraded at every politically convenient opportunity.

• Hospital managers who are motivated to put patient safety well ahead of “cost improvement” in any list of priorities.

• Senior NHS leaders with unbesmirched reputations who value the work of healthcare professionals and put patient safety first.

• A Government that does not view doctors as soft political targets for repeated financial attacks but values them as being at the very heart of healthcare, and worthy of just reward for a lifetime of commitment.

• A healthcare system that understands that the safety of surgical patients is best served by promoting and supporting

teamwork in the operating theatre rather than adding layer upon layer of top-down, mandatory dictats that only serve to overcomplicate patient care and foster a blame culture.

• Surgeons who respect and value the theatre team rather than interpreting a “team-based approach” as an opportunity to shout at the whole team rather than at individuals.

• A non-Luer spinal and epidural needle connector design that is based on ISO standards, has been appropriately bench-tested and then clinically trialled, and is introduced in a logical and systematic way.

• An effective solution to the workforce problems in the Republic of Ireland that means that all those completing their training in anaesthesia will wish to stay in Ireland rather than leave for countries in which they view consultant anaesthetists as being more valued, better rewarded and less overworked.

• Massive donations to the Lifebox Foundation that will allow it to put a pulse oximeter in every one of the 75,000 operating theatres in the world in which patients are treated without this literally vital form of physiological monitoring.

• A Ducati Multistrada 1200 S Granturismo.

I do realise that giving me all of the above for Christmas will be a bit of a tall order so, if you can only grant one of these wishes, I think I will opt for the Ducati Multistrada. Meanwhile, the AAGBI is working on its New Year’s Resolution, which is likely to bear a strong resemblance to last year’s: to continue to advance safety, education and research in anaesthesia and its related subspecialties.

Happy Christmas!william harrop-GriffithsAAGBI President

president's RepoRt

Dear Santa,Having been an exceptionally good boy in the last year, I think it only reasonable to send you a list of Christmas wishes that is a little more challenging than usual. I would therefore be most grateful if you would consider placing the following in my stocking, which you will find nailed to the desk in the President’s Office at 21 Portland Place on 25th December 2013:

Anaesthesia News December 2013 • Issue 317 5

A younger colleague recently asked me to pass on a few tips. He felt I must have learned something that would be helpful to him over the years. I was initially flummoxed, but have returned to the question from time to time. Looking at a couple of nascent ‘glossies’ (Fatigue and Occupational Health – both strongly recommended reads – they should be published early in the New Year), and reflecting on my own career, I have three ‘top tips’; not things that I think I have done well, but that I ought to have done better:

‘Have lunch’ is pretty much my No 1 tip. Really, I skipped an awful lot of meals and ate an awful lot of KitKats, and I am not sure I really did anyone any favours in doing so. We need to stay healthy to be able to do a good job.

At the risk of sounding corny, and in the light of my recent experiences as a patient, I would have to say that my No 2 tip is ‘listen to patients’. I mean this in a slightly broader sense than just listening to their responses to your questions – go a bit further and cultivate empathy.

Last, but not least, make an effort to understand yourself better at an early stage of your career. I did some of this work in the course of learning to mentor others, but I could have done with some of the self-knowledge I gained in that way earlier. There are other ways of doing this, and different kinds of knowledge. ANTS training will give some insight into areas that we all find challenging clinically – I think it is still the case that most of us learn that we too can err (for example by making a drug error) the hard way, in the clinical forum. It doesn’t need to be that way - simulation can help us to learn these lessons about our behavior.

My husband (also an anaesthetist – Phil Bayly) has two tips: Say ‘yes’ to opportunities - you’ll be surprised what you can do; and put as much money as you can into an equity (not cash) ISA every year so that you can retire when you want to. This latter advice comes with the warning that Phil is an anaesthetist not a financial adviser….

Last but not least, my newly-retired outstanding colleague Ian Warnell offers this: ‘Take a sabbatical. You won’t miss anything’.

I feel these tips are enough from me – you are extraordinary people and you do extraordinary things every day. Keep up the good work and look after yourselves as well as your patients! Have an excellent Christmas and a safe, happy and productive 2014.

Val Bythell

PS; we haven’t included a Christmas quiz, but you could pursue the historical theme and tackle the History of Anaesthesia Society’s online quiz at http://www.histansoc.org.uk/2012-quiz.html

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6 Anaesthesia News December 2013 • Issue 317 Anaesthesia News December 2013 • Issue 317 7

How long do you delay cardiac surgery if your patient is on Clopidogrel?

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eleanor carterSpecialty Trainee in AnaesthesiaEast of England

The NIAA trainee strategySupporting the training and development of trainee anaesthetists has been a core value of the NIAA since its inception and is emphasised in the 2012-2017 strategic plan3. There is a lack of formal academic posts in anaesthesia, with only seven of the advertised 268 academic clinical fellow (ACF) posts for 2013 being in the specialty4. However, many anaesthesia trainees in standard clinical training programmes are engaged in research and the NIAA activities aim to support the development of all trainees (Figure 1). The NIAA Academic Trainee Coordinator is Dr Ramani Moonesinghe assisted by two trainee representatives, Dr Robert Saunders and Dr Eleanor Carter.

Researcher and trainee databasesThe NIAA holds a database of research-active individuals, both senior anaesthetists and trainees, that is accessible via its website. Trainees can join the database and search for other individuals working in their area of interest for networking opportunities and to identify potential research supervisors. The NIAA has also asked research-active trainees to log their details with the Institute and provide a brief summary of their current research. This information will be used to build a complete picture of the level of research participation by trainees and to publish a report on their activities.

Trainee resourcesThe NIAA website has a section specifically for trainees with useful information for those considering a career in academic anaesthesia. In addition, there are links to articles on routes into research and other online resources such as e-learning for health research training modules. NIAA Board members have also contributed information on research training to the GAT Handbook. The aim is to expand the online resources to further assist with research training.

Training coursesThe NIAA research week earlier this year brought together research courses from the BJA, Anaesthetic Research Society and NIAA Health Services Research Centre. The aim was to facilitate access to research training for anaesthetists and allow participants to attend multiple research events if desired. The NIAA also recently hosted an Introduction to Research course for trainees in association with the London Deanery. The intention is to introduce similar courses throughout the UK, to enable anaesthesia trainees to access research training early in their careers.

Trainee representationThe NIAA has an academic trainee coordinator and two trainee representatives who attend and contribute to NIAA Board, providing a

voice for trainees in the organisation. The NIAA also intends to support high quality trainee research networks, such as the South West Anaesthetic Research Matrix (SWARM) and is holding its first National Trainee Research Federation meeting later this year.

Provision of funding informationThe NIAA coordinates grants, awards and fellowships offered by its founding and other funding partners. Full information regarding current opportunities, eligibility criteria and application processes are available via the NIAA website. Trainees are eligible to apply for many of these grants and should check the funding pages regularly if they are looking to fund a research project.

SummaryA core value of the NIAA is to support the training and development of the next generation of academic anaesthetists. Current activities include provision of written and online resources, organisation of training courses and trainee representation. The future aims are to expand and develop these activities resulting in high quality research exposure for all trainees ensuring a bright future for academic anaesthesia.

figure 1Summary of the NIAA trainee activities

References1. Pandit JJ. A National Strategy for Academic Anaesthesia. The Royal College of

Anaesthetists; 2005 [accessed 23 Feb 2013]. Available from: http://www.niaa.org.uk/article.php?newsid=20

2. www.niaa.org.uk3. Mahajan RP. National Institute of Academic Anaesthesia Strategic Plan 2012-

2017; 2012 [accessed 2 Aug 2013]. Available from: http://www.niaa.org.uk/article.php?newsid=20

4. Carter E. Academic anaesthesia for trainees. Anaesthesia News 2013; 310: 20-2.

What is the NIAA?The National institute of Academic Anaesthesia (NiAA) was established in March 2008 as a response to the crisis in academic anaesthesia identified by the 2005 Pandit report1. its aims include improving patient care by promoting the translation of research findings into clinical practice, facilitating high profile, influential research, and supporting training and continuing professional education in academia2.

Trainees…what can the NiAA do for you?

There are many barriers to organising regular, structured, face-to-face revision for the structured oral examination (SOE) components of the FRCA examination, and anyone who has sat the examination will remember the intense frustration of spending valuable revision time arranging viva practice only for it to be cut short by extraneous factors. Candidates must contend with colliding EWTD shift-patterns, geographical dispersion across large deaneries and placement in departments with no other trainees sitting the examination.

We observed many of these obstacles during revision for the Primary FRCA and decided to use new technology to maximise opportunities for viva practice for the Final SOE by using Skype, a free online video conferencing tool, to connect to each other for practice.

Resources available to assist candidates revising for the FRCA examinations traditionally take the form of large and comprehensive textbooks supplemented by smaller revision-style texts, continuing education articles, and written question banks specific to particular examination sub-sections. In the past ten years these resources are increasingly complemented by use of online question banks, smart-phone applications and revision courses of significant cost but variable quality.

For the SOE sub-part to the Primary and Final examination candidates typically revise in small groups in their spare time and with local consultants during working hours, squeezed into lunch breaks or lists

with ‘big cases’. Enthusiastic consultants who are cognizant of the current SOE formats are an extremely valuable but surprisingly scarce resource. Even if your hospital possesses such consultants, on-the-job viva practice is often far from ideal with interruptions, delays and cancellations inevitable as you compete for your consultant’s attention with normal service provision.

Although based at different hospitals, and deaneries, we used Skype to viva in pairs or small groups from our own homes. Skype video calls gave us face-to-face practice that replicated the ‘across the desk’ atmosphere of a real viva, and we experienced no problems with connectivity or bandwidth on our domestic broadband connections. Group work was done without video, as this is a feature requiring paid subscription. The virtual nature of our viva’ing saved hours of time traveling to work or each other’s houses and the history log kept us informed of how many hours work we put in. By working in an informal network of five candidates there always seemed to be another person available to practice, and we each performed approximately 70 hours of viva’ing on Skype in the weeks before the examination. There is also a great convenience viva’ing from home, with textbooks, the internet and most importantly the kettle all at your fingertips.

For a small monthly subscription Skype users can upgrade to use multi-video conference calls and though we did not use this feature the benefits for group work are obvious. This subscription upgrade also allows a ‘shared desktop’ function, with evident advantage for Primary candidates who need to reproduce appropriate diagrams as part of their basic science explanations.

Skype viva’ing formed a significant part of our revision strategies alongside more conventional revision tools like consultant viva’ing, courses, and of course lots and lots of reading. We would heartily recommend its use to prospective candidates at either SOE examination.

drs david hewson, Nikhail Balani and James wight, ST4, Guy’s and St Thomas’ NHS Foundation Trust

dr Alexa curtis, ST4, Brighton and Sussex University Hospitals NHS Trust

Editor’s note: This is clearly an idea whose time has come; a number of you have submitted similar stories. There are several other similar technologies that would achieve the same ends.

frcA viva revision – the Skype is the limit*

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Monday 10th June was the day when the covert bakers of wythenshawe hospital Anaesthetic department came out of the cake baking closet and answered the call to arms (or aprons), from the Association – the day of the ‘Great Anaesthesia Bake’ in aid of ‘lifebox’ was upon them and it was time to step up to the plate and show what they were made of: and step up they did, with admirable results!

Not all patients respond to Clopidogrel

in the same way…

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1. Di Dedda et al. Eur J Cardiothorac Sur 2013. 2. Ann Thorac Surg. 2012 Nov;94(5):1761-81 3. Ann Thorac Surg 2011;91:123–30 4. Anesthesiology 2012; 117:531– 47

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When faced with organising any event like this, the first impulse for most is to mentally envisage the hurdles that would have to be jumped in order to make it happen: the next impulse is to yawn, turn the page and move onto the next article. Thankfully Sarah Wheatly, an Anaesthetic Consultant at Wythenshawe Hospital, resisted those impulses and made it happen.

Once the Trust Mandarins had been sweet talked into agreeing to the enterprise (which was no small feat in itself), there came the small matter of whipping up the enthusiasm of colleagues to whip up some eggs in aid of an admirable cause. Despite numerous assurances of good intentions and promises of support, there was always the worry that none of the produce would actually materialise and the whole thing would flop like a sagging soufflé.

In the event, these concerns were unfounded. By 8am on the allotted morning, Cake Mission Control was established in the

Education Centre where projected ‘footfall’ would be optimum (thanks for specialist insight from Alan Sugar et al). By 9am the several Anaesthetic volunteers (including the vice-President of the RCOA) who had offered their services for the day were inundated with cakes of every variety and nationality, ranging from Polish Yeast Cake to Anzac Cookies. We even had a ‘Pulse Oximeter’ Cake, complete with wave-form and saturation reading that was put up for raffle to great effect. Contributions and support came from every grade of Anaesthetist in the department, from the most junior through to the immediate Ex-President of the RCOA (or possibly his wife!).

Two Theatre Drugs trolleys were commandeered for the day and converted into cake dispensing trolleys, groaning with delicious fayre: these were then dispatched to every corner of the Hospital – nowhere was safe: even a Trust Board meeting was interrupted for a Charity Cake Bake Break (with excellent feedback from all concerned)!

The whole day was a tremendous success on many levels: morale boosting, team building, bridge building with other departments, positive PR for the department and, above all, great fun!

…and the final and most important result? Over £1000 raised for LifeBox to provide not just Pulse Oximeters where the need is greatest, but also an essential training package in how to use an Oximeter safely and effectively:

I would hope that The Great Anaesthetic Bake will become a regular event, and that any Departments that have considered getting involved just get on and do it! It’s a sure recipe for a guaranteed great experience in aid of a truly worthwhile cause!! Adam dobson,Consultant Anaesthetist, UHSM

The Great Anaesthesia Bake

The delegates from the northern hemisphere had to adjust to a temperature of 40 degrees Celsius, but this was soon accomplished with the aid of local cold beverages, which came in strange measures: ‘schooner’, ‘middy’ and ‘jug’.

There were over 150 delegates from at least 12 countries. The History of Anaesthesia Society (UK) was well represented with 14 delegates (delivering a total of 14 lectures), including the President, Dr Anne Florence.

More than 90 presentations were delivered; a particularly memorable presentation was the first French educational video on muscle relaxants, which was quite shocking. It demonstrated not only the rabbit head drop test, but administration of muscle relaxant to a human volunteer without general anaesthesia! Notable events were the Young Historians’ essay competition (12 presentations) and an anaesthetic history book-signing/ sale from international authors. Alistair McKenzie represented the AAGBI in this regard. There was also a workshop on the value of reinstating the history of anaesthesia into the anaesthesia training curriculum – with a resolution to set

up a website on this topic. The highlight of the non-academic program was a dinner cruise round Sydney Harbour. During this, the winner of the Young Historians’ essay competition, Dr Martin Graves was awarded the Gwen Wilson Prize for his paper on the role of the Australian anaesthetist in World War I.

At the closing ceremony the organising committee (for the Australian Society of Anaesthetists, the Australian & New Zealand College of Anaesthetists and the New Zealand Society of Anaesthetists) were congratulated for a tremendous meeting. They had convinced the delegates of the theme of the symposium “History matters!” Finally the successful bid for hosting the next (9th) ISHA 2017 was announced, so make a diary note now: 9th IHSA meeting, Boston, 2017

Boston of course was where the first public demonstration of general anaesthesia (with ether) took place on 16 October 1846.

Alistair McKenzieConsultant Anaesthetist, EdinburghHon Archivist, AAGBI

8th IHSA, Sydney, 2013

Closing ceremony: Dr David Wilkinson thanks Co-Chair Prof Ross Holland.

since 1982 an international symposium on the history of Anaesthesia has been held approximately every four years. The venues for the first seven were successively rotterdam, london, Atlanta, hamburg, santiago de compostela, cambridge and crete. These symposia have generated a huge archival record on the development of anaesthesia, analgesia and intensive care worldwide. The eighth ishA was held in sydney, Australia from 22 to 26 January 2013 – providing an opportunity for expansion of previous research, new topics and exchange of ideas.

Welcome reception: organizer Dr Michael Cooper (extreme left) is thanked by 3 delegates who attended the first ISHA in 1982: (L to R) Prof J Severinghaus (USA), Dr Jean Horton (UK) and Dr J Rupreht (The Netherlands).

Fig. 2: Sydney Harbour Cruise: (L to R) Dr J Wilkinson (UK), Dr W Stratling (UK) and Dr M van Wijhe (The Netherlands).

Presentation of Gwen Wilson Prize: (L to R) Dr W Stratling, Dr G Kantianis, Dr Christine Ball (Organizer), Dr M Cooper, Dr M Graves, Prof J Severinghaus.

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COUNCIL At the Annual Members’ Meeting in Bournemouth in September 2012, we were pleased to welcome three newly elected council members: • Dr Rachel Collis, Consultant Anaesthetist, University

Hospital of Wales• Dr Matthew Checketts, Consultant Anaesthetist, Ninewells

Hospital• Dr Roshan Fernando, Consultant Anaesthetist, University

College London HospitalsAt the AMM in Dublin, in September 2013, we were again pleased to welcome:• Dr Upma Misra• Dr Paul Barker• Dr Mike Nathanson

TRAINEES’ COMMITTEEThe GAT Committee was joined by four new elected members at the Annual General Meeting in Glasgow in June 2012:• Dr Ben Fox, Addenbrookes Hospital,• Dr Claire Gillan, Lothian University Hospitals NHS Trust• Dr Jonathan Price, Royal Free Hospital• Dr Elaine Yip, Forth Valley Royal Hospitaland at AGM in Oxford 2013:• Dr Emily Robson, ST6, London

A YEAR IN REVIEW 2012 -2013

strengtH BY association

SPECIALIST SOCIETIES The AAGBI staff provide secretariat and event services for 20 specialist societies, the largest being DAS, APA and OAA. Eight one-day conferences and five study days were organised for specialist societies, together with upgrades to IT systems to enhance the service provided.

@aagbi

Social Media Our Facebook and Twitter accounts have been extremely popular and we are now connecting with our members and new audiences through these interactive means. We have over 1600 followers on Twitter.

Join us on Twitter @aagbi or Facebook aagbi1

Trainees Ordinary Overseas Retired Honorary

Membership categoriessnapshot of March 2013

Total members 10,592

21 PORTLAND PLACE Our Grade II listed building in London has attacted around 300 visitors a week and hosted numerous meetings, events and seminars during the year.

We continue to offer office space to the World Federation of Societies of Anaethesiology (WFSA) and Lifebox, the international charity of which AAGBI is a founder member.

The year 2012-13 was another successful and eventful one: here we share a few highlights.

we are pleased to report a healthy 93% retention rate and a total of nearly 10,600 members including 723 new members joining during the year.

The enhancement of membership services is a key focus. New services launched this year were: AAGBI Core Topics in Anaesthesia 2012 and the online case reports site Anaesthesia Cases launched in 2013. Additionally, we now offer an exclusive discount for members wishing to purchase the frAcQ online exam resource from cambridge University Press.

ENVIRONMENT The AAGBI continues to make progress in its drive to become more environmentally friendly, for example using more energy efficient lighting and encouraging recycling where possible. Clinical guidelines and other publications are available for download from the website and limited print runs to reduce the environmental impact

in the last year we recycled

a total of 9,330 kg of paper,

making a co2 saving of

13,060 kg – that’s equivalent

to 126 trees saved!

DELIVERING VALUE TO

MEMBERS AT ALL STAGES IN

THEIR PROfESSIONAL CAREER

Submit a case report today www.anaesthesiacases.org

From 1st October 2013 case reports can no longer be

submitted directly to Anaesthesia. The Anaesthesia

Cases website is hosted by the AAGBI and may be

reached here www.anaesthesiacases.org. Case

reports will be considered for publication online at

the Anaesthesia Cases website, and a proportion will

be passed to Anaesthesia for possible publication in

the Journal. Those not published by Anaesthesia will

be passed back to Anaesthesia Cases for publication

there. Once published online (or in the Journal for

those accepted there), reports cannot be submitted

for publication elsewhere.

Following the successful launch of Anaesthesia

Cases earlier this year, the new website will

become the sole route for submission of case

reports to either Anaesthesia or Anaesthesia

Cases from 1st October 2013.

www.anaesthesiacases.org is the new way to submit your

case report to Anaesthesia

AnaesthesiaCasesA5.indd 130/08/2013 13:13

Anaesthesia Cases

neW tHis Year

www.anaesthesiacases.org

www.aagbi.org

MEMBERSHIP SAFETY edUcationRESEARCH PROFESSIONALS NEWSPUBLICATIONS INTERNATIONAL

AAGBI

tHe ASSoCIAtIoN oF ANAeStHetIStS oF GReAt BRItAIN & IReLAND

A YEAR IN REVIEW2012-2013

Anaesthesia News December 2013 • Issue 317 11 10 Anaesthesia News December 2013 • Issue 317

Full details are at www.aagbi.org/about-us/

council/aagbi-board-directors

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“These young men and women are the new face of anaesthesia in Uganda. The more we can improve our numbers, the more we can develop our speciality. We are noticing better outcomes all the time”Dr Stephen Ttendo, Head of Department at Mbarara University Hospital, Uganda

sUpporting colleagUes overseas

The AAGBI Foundation maintains an active programme of support for anaesthesia worldwide, including grants towards educational projects in lower resource countries, book donations and funding of educational resources. This year 37 grants were awarded towards work in 17 countries.

saFetYMatters

One of the AAGBI’s principal activities is the advancement of patient care and safety in the field of anaesthesia. Over the last year the AAGBI’s Safety and Standards Committees have worked with like-minded organisations, industry and governments to advise and act on safety matters that affect anaesthetists and their patients.

The Overseas Anaesthesia Fund (OAF) enables individuals and organisations to donate directly to AAGBI programmes that support training and promote safer anaesthesia in developing countries.

• Nearly 100 regular donors generated a total of £50,000 last year.

Important Safety Initiatives

Neuraxial connectorsIn February 2013, AAGBI, RCoA, OAA, RA-UK, APA, and RCoA Faculty of Pain Medicine and Patient Liaison Group released an updated statement to advise hospitals and support clinicians in the NHS in the process of introducing non-Luer connectors for neuraxial and regional anaesthesia. The AAGBI is represented on the External Reference Group established to support the safe implementation of new devices. We would like to hear of your experiences with the new non-Luer needles. Please e-mail us at [email protected].

AAGBI and the Safe Anaesthesia Liaison Group (SALG)The AAGBI works with SALG to promote learning from incident reporting. It has two networks (with a total of 800 individuals) that disseminate information and provide valuable feedback. It publishes quarterly Patient Safety Updates to highlight reported safety incidents, the latest one relates to fire safety on intensive care and in theatre.

National Audit Project 5 (NAP5)NAP5 was launched by the AAGBI and RCoA in June 2012 to investigate accidental awareness during general anaesthesia in the UK and Ireland. All four Chief Medical Officers endorsed the work. Cases continue to be sent in and the results will be published in Anaesthesia and the BJA. Several follow-up projects are planned.

Assistance for the Anaesthetist statementThe AAGBI released a supporting statement on assistance for the anaesthetists in September 2012 to supplement the existing Anaesthesia Team 3 guideline.

National Essential Anaesthetic Drug List (NEADL)The WHO defines national essential medicines as ‘those that satisfy the priority healthcare needs of the population’. The AAGBI canvassed the views of delegates attending the WSM 2013 meeting on essential anaesthetic drugs and produced the first version of NEADL. At this year’s Annual Congress we will conduct another consultation with members.

Checking Anaesthetic Equipment (checklist)The machine checklist published in June 2012 to complement the Checking Anaesthetic Equipment safety guideline will be tailored to suit the machines of a variety of manufacturers.

AAGBI is proud to be a founder member of the international charity, Lifebox. Lifebox is a not-for-profit organisation saving lives by improving the safety and quality of surgical care in low-resource countries by ensuring that every operating room in the world has a pulse oximeter.

www.lifebox.orgLifebox UK-registered charity (No. 1143018)

Overseas Anaesthesia fund

Uganda fellowship Scheme

• Now in its seventh year, 23 doctors are currently being supported in training.

• Joint funding support is provided by RCoA, OAA, DAS and WAS.

Anaesthesia News December 2013 • Issue 317 13 12 Anaesthesia News December 2013 • Issue 317

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Education: face to face and online

The AAGBI is committed to providing opportunities for anaesthesia professionals to keep up to date with their professional development and continues to develop new resources for its members.

“An excellent CME resource

allowing members the

opportunity to catch up on

Association meetings from

the comfort of home!”

Dr Chris Gornall, Consultant Anaesthetist

Heritage Centre

The Arts Council accredited AAGBI Heritage Centre hosted nearly 750 visitors in London and at events around the country.

The exhibition A Blessing in Disguise proved to be extremely popular and was extended for an additional six months. Our dedicated team of hardworking and enthusiastic heritage volunteers were joined by two new volunteers and we have developed a new internship programme this year.

AAGBI Publications

AnaesthesiaAnaesthesia is the official journal of the AAGBI, published by Wiley Blackwell, and is international in scope and comprehensive in coverage. The journal has a very high impact factor of 2.958 demonstrating the relevance of articles to the anaesthesia community.

Anaesthesia NewsAnaesthesia News reaches over 10,500 anaesthetists every month and submitting content is a great way of sharing your experiences and information with fellow members.

98% of our members read Anaesthesia News regularly with the favourite content being feature articles and letters to the editor.

GuidelinesOur guidelines cover a wide range of clinical and non-clinical issues. In the last year we have produced these new titles:

• Checking Anaesthetic Equipment 2012 published June 2012.• Checklist for Anaesthetic Equipment 2012 A4 sheet published

June 2012.• Management of Proximal Femoral Fractures 2011 published

June 2012.• Immediate Post-anaesthesia Recovery 2013

Web-Published March 2013. Hard copy published August 2013• Obstetric Anaesthetic Services 2013 published August 2013• GAT - Who is the Anaesthetist 2013 published July 2013• Regional Anaesthesia and Patients with Abnormalities of

Coagulation. Web-published August 2013 (http://onlinelibrary.wiley.com/doi/10.1111/anae.12359/full)

Keeping tHe proFession Up-to-date

New working parties were established on• Best practice in pre-operative hypertension for elective

surgery, avoiding cancellation on the day of operation – joint with the British Hypertension society

• Care of the Older Surgical Patient• Out of Hours Operating• Peri-operative Management of the Morbidly Obese Patient

– joint with SOBA• Preventing iatrogenic hypoglycaemic brain injury caused

by sample contamination of blood drawn from arterial lines • Preventing iatrogenic hypoglycaemic brain injury caused

by sample contamination of blood drawn from arterial lines

Video Platform and e-education

Development of e education and online learning for CPD is a key priority. Our online video platform now offers over 200 lectures and CPD content from our conference and seminars. It attracts, on average, over 900 views a month The AAGBI is working to incorporate the video platform into a CPD zone which will allow users to record CPD for appraisal and revalidation purposes.

@AAGBI and www.aagbi.org

The bi-weekly enewsletter, @AAGBI, provides members with quick, effective and convenient communication with the latest information about the AAGBI and current issues within the profession.

The average opening rate continues to be 30 - 40%. In addition, we sent out 40 individual e-flyers which had an opening rate of 42%.

AAGBI online

Research opportunities

The AAGBI Foundation is one of the UK’s largest single grant providers for anaesthetic research.

In the past year we allocated nearly £130,000 in for research funding through the National Institute for Academic Anaesthesia (NIAA) and in addition provided funding towards the fifth National Audit Project (NAP5) on awareness during surgery.

Through the NIAA, the AAGBI now has a portfolio of 34 funded research projects

getting neW ideas realisedPromoting innovation

The AAGBI launched its annual award for innovation in anaesthesia, critical care and pain in 2011. The award is open to all British and Irish based anaesthetists, intensivists and pain specialists, with the emphasis being on new ideas contributing to patient safety, high quality clinical care and improvements in the working environment. The judges are a distinguished panel of experts in their field. The prize is awarded at the Winter Scientific Meeting in January.

opportUnites to learn

Conferences and seminars

Greater numbers of educational events were provided for the profession in the form of three national conferences: GAT, AC 2012 and WSM London 2013.

Attracting 1,800 delegates, significantly more than previous years. WSM London in January 2013 was the largest ever attendance at 848 delegates. 2251 delegates attended our seminar programme throughout the year and our regional core topics programmes attracted almost 1200 delegates.

15 14 Anaesthesia News December 2013 • Issue 317

feedback from a tour group visitor:

“It was all very positive, one of the best visits

and we have visited many places! The subject

was interesting and relevant, the timings were

just right and above all, your speakers were

superb. They were knowledgeable, engaging

and with just the right amount of humour.

They were happy to answer all questions and

you all made us feel very welcome.”

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16 Anaesthesia News December 2013 • Issue 317

25th Anaesthesia, Critical Care & Pain Update

Val d’IsereCentre de Congrés27-30 January, 2014

www.doctorsupdates.com

Over the year, the Association has supported members with the Revalidation process and has published a position statement on CPD, actively liaising with the General Medical Council (GMC).

The AAGBI has also responded to the Office of Fair Trading and Competition Commission investigations of private healthcare and contributed to the Department of Health consultations on training, manpower planning and the future consultant role.

a voice For tHe proFession

As a professional association, the AAGBI is constantly active in representing the interests of anaesthetists and acting as a voice for the profession.

AAGBI Foundation - Summary of financial statement - Finance Overview 2012-2013

Association of Anaesthetists of Great Britain and Ireland - Finance Overview 2012-2013

Total AAGBI expenditure for 2012-2013 = £2,712,000

Total AAGBI income for 2012-2013 = £2,804,000

Total AAGBI Foundation income for 2012-2013 = £2,760,000

Total AAGBI Foundation expenditure for 2012-2013 = £2,453,000

Dr Sean Tighe, Chairman of the AAGBI’s

Independent Practice Committee

We would like to say a huge

thank you to all our members

for their continued support!

View the full financial statements and annual reports online:www.aagbi.org/publications/annual-report

Association of Anaesthetists of Great Britain & Ireland, 21 Portland Place, London, W1B 1PY

Tel: +44 (0) 20 7631 1650 Fax: +44 (0) 20 7631 4352 Email: [email protected] www.aagbi.org

AAGBI – Where our income came from

AAGBI – How we used our income

AAGBI Foundation - Where our income came from

AAGBI Foundation – How we used our income

School of Medicine

PRIMARY  FRCA  OSCE/VIVA  COURSE  

 

 

This  is  a  1  or  2  day  course  devoted  to  intensive  VIVA  &  OSCE  preparation,   individual  appraisal,   and  small  group  tutorials  directed  by  experienced  teachers  and  examiners.  Candidates  can  register  for  1  day  or  both  days  depending  on  requirements.  TO  REGISTER  PLEASE  EMAIL  YOUR  DETAILS  TO  

[email protected]  OR  CONTACT  FRCA  COURSE  ADMINISTRATOR  SAN  THORPE  ON    

0116  258  5735.        

DATE:     THURSDAY  16th  &  FRIDAY  17th  JANUARY  2014  

VENUE:   Clinical  Education  Centre,  Leicester  Royal  Infirmary  

FEE:                                  Thursday        OSCE                                £140.00    Friday                SOE/VIVA                  £140.00  Thursday  &  Friday:                          £260.00    Lunch/refreshments  and  car  parking  (if  required)  included  Please  Note:  Accommodation  is  NOT  included  

   

School of Medicine

PRIMARY  FRCA  OSCE/VIVA  COURSE  

 

 

This  is  a  1  or  2  day  course  devoted  to  intensive  VIVA  &  OSCE  preparation,   individual  appraisal,   and  small  group  tutorials  directed  by  experienced  teachers  and  examiners.  Candidates  can  register  for  1  day  or  both  days  depending  on  requirements.  TO  REGISTER  PLEASE  EMAIL  YOUR  DETAILS  TO  

[email protected]  OR  CONTACT  FRCA  COURSE  ADMINISTRATOR  SAN  THORPE  ON    

0116  258  5735.        

DATE:     THURSDAY  16th  &  FRIDAY  17th  JANUARY  2014  

VENUE:   Clinical  Education  Centre,  Leicester  Royal  Infirmary  

FEE:                                  Thursday        OSCE                                £140.00    Friday                SOE/VIVA                  £140.00  Thursday  &  Friday:                          £260.00    Lunch/refreshments  and  car  parking  (if  required)  included  Please  Note:  Accommodation  is  NOT  included  

   

DAY ONE: ■ Session 1: Welcome and course

introduction

■ Session 2: Learning and teaching

■ Session 3: Feedback: the fuel to drive performance

■ Session 4: Workplace teaching: planning

DAY TWO: ■ Session 5: Workplace teaching:

skills teaching

■ Session 6: Workplace assessment

■ Session 7: Practice teaching

■ Session 8: Wrap up

AEa

EVENT ONLINE SERVICESEVENT ONLINE SERVICES

CPD Matrix Codes: 1H01, 1H02, 2H01 and 2H02

ANAESTHETISTSAS EDUCATORS: TEACHING AND TRAINING IN THE WORKPLACE

Date and venue:24–25 February 2014RCoA, London(code: C84)

Registration fee:£425 (£320 for RCoA registered trainees and affiliates)

Event organisers:Dr S Williamson

Follow @rcoa_events

/royalcollegeofanaesthetists

Apply: www.rcoa.ac.uk/eventsContact: 020 7092 1673 [email protected]

an-december.indd 2 04/10/2013 14:58

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18 Anaesthesia News December 2013 • Issue 317 Anaesthesia News December 2013 • Issue 317 19

Postcode lottery in anaesthetic training

Figure 1

Figure 1 shows the ICM start date month relative to the size of hospital, and highlights some issues:

Figure two breaks this down dependent on whether a dedicated obstetric block was provided. From our limited numbers, the provision of a dedicated obstetric training block (including OOH) would be beneficial for accrual of experience.

Following trainee feedback and evidence obtained at the ARCP, we undertook a survey of core trainees that highlighted inconsistencies in the delivery of training and experience within Wessex Deanery. We focused on ICM training, the IAC, out-of-hours (OOH) anaesthesia and obstetrics.

Following permission from the Associate Dean for Quality Management, all CT1 and 2’s were invited to participate in the survey via email. 58 trainees were invited; 33 replied.

Intensive Care Medicine

As part of “Basic Anaesthetic Training”1, ICM should occur after gaining of the IAC. The curriculum defines learning outcomes to be achieved during this module, including those associated with airway management.1 The importance of adequate airway training in relation to ICM was highlighted in NAP4, with a lack of training a contributory factor in 58% of reported events.2

Trainees had cited issues with ICM timing, and the impact they felt this had on training. We enquired about the timing of their ICM module.

1. 5 of the 6 trainees undertaking ICM in month one felt this was detrimental to their training. Potentially they may not accrue adequate experience in the complexities of airway management in the critically ill, with the frequent combination of airway abnormalities, hypoxaemia and cardiovascular instability.

2. ICM forms part of “Basic Anaesthetic Training” in the curriculum, therefore is undertaking ICM in month one against the curriculum guidance?

3. Trainees that started their ICM module immediately after their IAC (month 4, all smaller DGH) felt they had inadequate time to consolidate their anaesthetic and airway skills.

Inadequate training was noted by NAP4 to be a contributory factor in many incidents2. Without their IAC, trainees are not expected to perform airway management on ICU patients unsupervised. ICM is more suited for trainees to consolidate their airway skills. The authors feel this would best be achieved following a period practising anaesthesia. The next ICM module will be in ST3, and trainees will perform airway management on critically ill patients under distant supervision. If they are inexperienced, is this adequate both for training and more importantly, patient safety?

The authors feel the curriculum should be more prescriptive as to the timing of the ICM module, and that it should follow six months of anaesthetic training. Whilst evidence for this recommendation is lacking, it is prudent to allow a period of consolidation of newly acquired skills. However, rota obligations often means in smaller DGH’s trainees rotate to ICM before this time (10 of 20 prior to month 6).

Initial Assessment of Competency

The IAC is a requirement prior to trainees anaesthetising without direct supervision. It is prescriptive for learning outcomes and assessments.

In Wessex, training during the IAC varies. We questioned how supervision was organised. 17 of 31 trainees had a core group of supervising consultants; all found this useful. 10 of the 14 trainees who didn’t have a core group felt this would have been beneficial.

From these results trainees find a core group of mentoring consultants beneficial. Benefits include monitoring of progress, provision of consistent feedback and identification of the trainee in trouble. Those trainees not attaining skills, as highlighted in a recent audit3, such as endotracheal intubation and facemask anaesthesia, will be identified early. It is well established that inadequate supervision can contribute to stress and has a negative impact on learning in doctors4.

Trainers also benefit4. Consistent observations by regular supervisors enable fair and reliable assessments over a period of time.

Out of Hours Anaesthesia

OOH anaesthesia offers many training opportunities, with trainees often providing anaesthesia with distant supervision. Anecdotally trainees experience in OOH anaesthesia varies widely.

The opportunity to perform OOH anaesthesia varied with training location. 31 of 32 respondents had performed OOH anaesthesia. In three of seven hospitals trainees were allocated to cover ICU OOH (one dependent on the year of training), thus limiting the opportunity to conduct OOH anaesthesia. Worryingly one CT2 had not performed any OOH anaesthesia.

Training location therefore has an impact in the amount of OOH anaesthesia trainees will be exposed to. Most, though not all, trainees in Wessex will rotate to the larger DGHs/university hospital, and will have the opportunity to perform OOH anaesthesia. For some of the CT2s, most of this experience is in obstetrics. Is a lack of previous experience in OOH anaesthesia acceptable for these trainees when starting on the obstetric rota?

Obstetric Anaesthesia

Concerns have been highlighted both nationally 5 and locally (by trainers and trainees) as to whether CT2s are achieving an adequate caseload prior to appointment to both the obstetric on call rota and to ST3 posts.

The main aims of basic obstetric training are to become competent in essential obstetric anaesthetic skills, and obtain the IAC in obstetric anaesthesia (IACOA). The curriculum does not stipulate how obstetric training is delivered, but suggests an obstetric block is beneficial1. We surveyed trainees with, or undertaking, the IACOA (n=26) regarding how their obstetric training was delivered.

All trainees at larger hospitals had a dedicated obstetric block and practised OOH obstetric anaesthesia. Only one of four smaller hospitals provided a dedicated obstetric block, and of 9 respondents in smaller DGH’s, 6 had other commitments that prevented them from gaining experience in OOH obstetric anaesthesia.

To see if trainees were accruing enough obstetric experience, a predetermined caseload (100 cases, 50 epidurals, extrapolated from the college audit standard for airway experience during the IAC6) was stipulated. Trainees were asked whether they felt they would achieve this by the end of CT2.

One solution to the problem encountered by trainees at smaller DGH’s would be to provide obstetric training as a dedicated block in the larger hospitals. However this would lead to inevitable manpower issues at the smaller DGH’s for both daytime theatre lists and out of hours shifts.

summary

A postcode lottery does exist in basic anaesthetic training, and we have shown areas of training in our Deanery that may need improvement.

We have highlighted potential solutions to the issues we have identified:• undertaking ICM after month 6 of training,• CT1s providing OOH cover for emergency theatres with local

supervision,• a dedicated group of consultants for continuity of supervision

during the IAC,• a dedicated obstetric training block for CT2 trainees.

We recognise this is the ideal training programme and realistically would be difficult to achieve in most hospitals. Undesirable consequences include:

• rota gaps, and difficulty providing daytime list cover, especially if resident OOH consultant cover is introduced

• a further shift in balance between in hours versus out of hours caseload by higher trainees (previously noted following the implementation of the European Working Time Regulation7).

Concerns with regards to the adequacies of training are not unique to our region, and have been previously highlighted in the 2012 and 2013 GMC National Training Survey. 8% of CT1s and 15% of CT2s were neutral or not very confident that their current post will help them acquire the competencies they need at that particular stage of training.8

dr Patrick TapleyAnaesthetic Registrar, North Shore Hospital, New Zealand

dr Kathy TorlotAnaesthetic Consultant, Portsmouth Hospitals NHS Trust

References

1. Royal College of Anaesthetists. Curriculum for a CCT in Anaesthetics. http://www.rcoa.ac.uk/document-store/curriculum-cct-anaesthetics-2010

2. The Royal College of Anaesthetists and The Difficult Airway Society. 4thNational Audit Project: Major Complications of Airway Management in the UK. March 2011. http://www.rcoa.ac.uk/nap4

3. Blandford C. Do novice anaesthetic trainees receive enough training in airway management skills? A five-year data collection from a district general hospital. Anaesthesia News June 2012; 299: 20-21

4. Greaves JD et al. Watching anaesthetists work: using the professional judgement of consultants to assess the developing clinical competence of trainees. Br J Anaesth 2000; 84: 525-33

5. Paul RG et al. The effect of the European Working Time Directive on anaesthetic working patterns and training. Anaesthesia 2012, 67, 951-956

6. Whymark C. Airway management training for novice anaesthetists. Raising the standard: a compendium of audit recipes, 2012. http://www.rcoa.ac.uk/system/files/CSQ-ARB2012-SEC13.pdf

7. McIndoe AK. Modern anaesthesia training: is it good enough? Br J Anaesth 2012;109(1):16-20

8. National Training Survey. General Medical Council. http://www.gmc-uk.org/education/national_summary_reports.asp

The first two years of anaesthetic training lay the foundations on which future practice is based. The “Basis of Anaesthetic Practice”1, provides a comprehensive introduction to the principles and practices involved in anaesthetic care, with the achievement of the initial Assessment of competency (iAc) the endpoint. The next 21 months (“Basic Anaesthetic Training”1) provides exposure to different subspecialties, with expected competencies documented in the curriculum.1 whilst there is no prescriptive order in which training should be delivered, the intensive care Medicine unit of training (icM) should be delivered in a dedicated three-month block.1

Figure 2

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20 Anaesthesia News December 2013 • Issue 317 Anaesthesia News December 2013 • Issue 317 21

Since the RCoA’s launch of a new video made to celebrate the 65th anniversary of the NHS in July this year, the AAGBI has received a number of queries about the history of the specialty of Anaesthesia. In the video1, Dr Peter Venn says that: “the specialty of Anaesthesia is widely regarded as being the same age” (as the NHS itself), implying that the creation of the Faculty of Anaesthetists of the Royal College of Surgeons, later to become the College of Anaesthetists (in 1988) and later still the Royal College of Anaesthetists, marked the start of the specialty of Anaesthesia in the UK. As some of the historical experts we consulted seemed not fully to agree with this assertion, we sought some more objective evidence about the origins of our specialty. We believe that we have found a good and accurate contemporary description in an article published in Anesthesia & Analgesia in 1949. The article is based on a talk given by Dr Henry Featherstone, founder of the AAGBI, to a meeting of the International Anesthesia Research Society in October 1948, a very short time after the creation of both the NHS and the Faculty of Anaesthetists. It seems to tell a rather different story in which the Section of Anaesthesia of the Royal Society of Medicine and the AAGBI worked with the then President of the Royal College of Surgeons, Sir Alfred (later Lord) Webb-Johnson to promote the creation of the Faculty. The first Dean of the Faculty was Dr Archibald Marston (Dean 1948 – 1952) who had shortly before this demitted office as President of the AAGBI (1944 – 1947). We reproduce this article in full with the permission of Anesthesia & Analgesia. We hope you will enjoy it.

“History Boy”

1. https://www.rcoa.ac.uk/news-and-bulletin/rcoa-news-and-statements/65-years-of-anaesthesia-the-nhs

Royal College of Surgeons England - FeatherstoneThe Faculty of Anesthetists of the Royal College

of Surgeons of England.*(A Note on Its Origin and Purpose)

H. W. Featherstone, O.B.E., M.A., M.D., LL.D., F.F.A.R.C.S. Eng., D.A., F.I.C.A., J.P., Birmingham, EnglandUniversity Lecturer in Anesthetics, Birmingham University,

Senior Anesthetist, United Birmingham Hospitals

HERE ARE TWO ASPECTS of anesthesia which I should like to discuss: first, the organization and status of the specialty of anesthesia, with special reference to the chain of events which has led to the formation of the Faculty of Anaesthesia and second, in a later paper, the teaching of anesthetics. Although these two

problems have of course affected anesthetists on this side of the Atlantic very closely, and indeed have received most important attention from the International Anesthesia Research Society and other bodies of anesthetists in this continent, nevertheless I hope you will find it instructive to receive an exposition from the point of view of British anesthetists.

In the course of the development of the specialty of anesthesia in the United Kingdom, we have evolved the Section of Anaesthetics of the Royal Society of Mediche-which was inaugurated about forty years ago, when the Royal Society of Medicine absorbed the former Society of Anaesthetists-then the Association of Anaesthetists of Great Britain and Ireland, and, during the past few months, the Faculty of Anaesthetists of the Royal College of Surgeons of England. In addition, since the War, the British Medical Association has established the anesthetists’ group, membership of w’hich is limited to doctors w’ho are interested primarily in anesthesia. Its function is to represent anesthetists within the British Medical Association.

There are also several more or less local societies or associations of anesthetists in different parts of the British Isles. The three principal bodies, however, which deal with the specialty of anesthesia in the United Kingdom are those which I mentioned first: the Section of Anaesthetics, the Association of Anaesthetists, and the Faculty of Anaesthetists. These three are in close cooperation, and members of each are on the Coun.cils of the other two. It should be clearly understood that each organization deals with a different aspect of anesthesia, and a description of the origin and function of each will show how the three bodies are able to strengthen the position of the specialty in a remarkable manner, and that the newly formed Faculty of Anaesthetists is a body which offers the possbbilities of a brilliant future.

The Section of Anaesthesia of the Royal Society of Medicine is concerned entirely with the point of view of science and research in anesthetics. The Section provides the forum where British anesthetists describe their work and their views. Moreover, during the War, many anesthetists from Carada, the United States and other allied countries took a much valued part in discussions of the Section at the House of the Royal Society of Medicine in Wimpole Street. Dr. Ronald Jarman is now President of the Section.

Eighteen years ago, in 1930, when I was President of the Section, the Section was the only “central” organization of anesthetists which they could join, but we found that the strict limitation of its powers, solely to study and research, rendered the Secticn unable to perform other functions which were becoming more and more urgent.

In the sixteen years after the beginning of War I, surgery and anesthesia had undergone important advances. The operations of routine surgery had become standardized, many more elaborate procedures were being carried out, and surgical team work had become everyday practice.A skilled anesthetist was regarded as an essential member of the team.

Drugs and technique provided better and safer anesthesia, but they demanded the ripe experience and sound training of specialists. In order to provide this large and increasing service of anesthetists, it was evident that considerable numbers of practitioners would be required. But although the demand was obvious, the conditions for the workers had been shown by the experiences of many senior and skilled anesthetists to be financially unreliable, and the status of those who had undertaken the special study and practice of anesthesiology often depended far more upon their personality, and on the success in private practice of the surgeons with whom they worked, than upon their skill and industry. The large voluntary hospitals, where at that time most of the operative surgery was performed, offered no salaries for visiting anesthetists (and indeed for the most part, at that time, they preferred to attend on an honorary basis), but the pool of remunerative work in private practice was not large enough to meet the needs of all the workers whom the anesthesia service required.

It was clear that the status of specialists in anesthesia urgently needed a hallmark or test to indicate that they had attained a proper standard of training and skill; they also required an autonomous body of their own through which their views could be collected and represented in negrtiations with outside bodies, such as departments of the Government, universities, examining bodies and hospital authorities.

I discussed the problem with the senior anesthetists of the British teaching hospitals, with the result that in 1932 we founded the Associalion of Anaesthetists of Great Britain and Ireland Thanks to the enthusiastic cooperation of most of those who have specialized in the subject, the Association has achieved remarkable success. The Diploma in Anaesthetics soon came into being through the ready response of the Royal College of Surgeons of England to our suggestions, and the diploma has proved to be of the greatest value in establishing the specialty. During the War, not only did the enhanced position of anesthetists receive confirmation in the Services through the appointment of specialists and graded specialists on conditions similar to those of other departments of medicine, but the diploma was of particular value in assessing the capabilities of candidates for these posts.

From another angle the diploma was very useful. Of necessity large numbers of routine anesthesia and most of the emergency anesthesia in hospitals must be administered by interns. Formerly, the interns who administered these anesthesias knew little of the subject. But in recent years a candidate for the diploma should have held a post as resident anesthetist at an approved hospital, and in consequence more of these posts have been created, with resulting improvement in the standard of anesthesia in routine and emergency surgery.

Our specialty naturally follows the changes, not only of the technique of surgery, but also of the type and organization of the hospitals in which it is practiced. In England until twenty years ago, most operative surgery was performed in the main voluntary hospitals, either attached to medical schools or situated in the larger cities and towns. The Poor Law Infirmaries with many beds were used almost entirely for the chronic sick, but in 1928, by Act of Parliament, the Infirmaries came under the Minister of Health and they were then gradually improved both in medical staffs and in equipment, so that just before the War many were already offering a standard of surgical work of a high order. This process has been expedited during the past ten years with the result that many more posts for skilled anesthetists have been provided. Accordingly the Association has altered its rules of membership. Formerly nearly all specialists in anesthesia were on the staff of teaching hospitals and membership was limited to these; but in order to meet the new developments membership is now on a broader basis and the more senior members are eligible for election as Fellows.

Since the War, we have been preparing for a National Health Service

which is to provide, among many other things, a complete hospital service available for every individual in England, Scotland and Wales. As a corollary of this vast change nearly all hospital consultants and specialists are tecoming part-time or whole-time salaried officers of the Service. The grading of salaries is a problem of lively interest to all of them. But it was pointed out that if all the specialists were to be treated on a similar grading of salary, they should offer similar skill and should have undergone training and examination tests of equally high order. Although perhaps each specialty is different - some are more interesting, some more strenuous, some more difficult, and some more sought after than others - nevertheless, this principle carries much weight. Accordingly, it was decided that not only should the standard of the Diploma in Anaesthesia be raised, but that the examination should be taken in two parts instead of at one sitting. In addition to anesthesia and analgesia the syllabus was extended to include physiology, pharmacology, clinical pathology, anatomy, clinical medicine and surgery in so far as they have application to anesthesia.

This step brought the problems connected with training, particu-larly in its theoretical aspects, into serious prominence. It became evident that since the Royal College of Surgeons of England granted the Diploma, it was most desirable that anesthetists should be able to collaborate as far as possible with that body in arranging the lines of instruction. Already, Brigadier Ashley Daly (the Consulting Anesthetist to the Army) when he was President of the Association, had secured their interest and help and they had provided accommodation and secretarial assistance in the College buildings. I feel I must mention in parenthesis that, until this arrangement was made, most of the office work had been provided free of charge by Dr. Mennell, who was treasurer for ten jears. preaitlent for rhree years and my own most helpful comrade in the early adventures. An important further move was now possible, because under the far-seeing guidance of its distinguished President, Lord Webb-Johnson of Stoke-on-Trent, the College was proceeding forward from the granting of diplomas in many departments of medicine and surgery to the establishment of faculties in those branches of surgical science and practice for which they were desired.

The Faculty of Dental Surgery had already been formed when, less than twelve months ago, Dr. Marston, who had already performed splendid services for anesthetists while he was secretary and afterwards president of the Association. took the lead in arranging for the institution of the Faculty of Anaesthetists. In this project he had the keen and unanimous support of the other officers, fellows and members of the Association.

The Faculty of Anaesthetists is controlled by a Board of Faculty of which Dr. Marston is the Dean. The Faculty is part of the organization of the Royal College of Surgeons, but it is given as free a hand as possible. The Board comprises, in addition to ex-officio representatives of the Council of the College, twenty-one diplomate in anesthesia who have been selected from among the leading anesthetists of the country. All who hold the Diploma in Anesthetics are eligible for election to membership, and by special selection from among the members, Fellows of the Faculty are elected.

The Faculty has now entered upon its principal duties and for postgraduate students has arranged a comprehensive course of three months’ duration which will include lectures, demonstrations and tutorials. A (library committee looks after the special needs of anesthetists. The Section of Anaesthetics fosters scientific discussion and research in anesthesia ; the Association is the independent deliberative body which represents anesthetists, and the new Faculty will provide for the training of anesthetists.

It appears to be a source of strength that anesthetists should possess vigorous sections in the Royal Society of Medicine, in the British Medical Association and in the Royal College of Surgeons.*Presented before the Twenty-Third Annual Congress of Anesthetists, Joint Session of the Internatonal Anesthesia Research Society and the International Collcge

of Anesthetists, Montreal, Canada, Octoher 18~21, 1948.

Dr Henry Featherstone

The history of the specialtyof Anaesthesia in the UK

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22 Anaesthesia News December 2013 • Issue 317 Anaesthesia News December 2013 • Issue 317 23

Annual congress really was an excellent affair this year. i found myself relatively free to attend the talks and workshops that i was really interested in, and to browse the posters without having to judge, speak or undertake other duties. Then there was the social side – particularly splendid. i really enjoyed seeing so many old friends from far-flung places (There was even the odd kilted highlander…). You really can’t do all that online.

With some difficulty, Nancy and I have selected one ‘top talk’ each for special mention. You will be able to see these (and many other) talks on the AAGBI’s video platform soon (via learn@aagbi).

I have chosen Dan Sessler’s talk for special mention, because it seems to me that he has done more work that has directly changed my clinical practice than any other single figure during my clinical career, and that the breadth and simplicity of his insights are totally inspiring.

long term perioperative outcomes Prof Dan Sessler, Cleveland, USA

i have made a précis of the top points as i understood them:In his opening spiel (which was protracted due to technical issues with his slides, perhaps fortunately, as he made some excellent off-the-cuff observations) Sessler observed that we are beginning to understand that the interventions and choices we make as anaesthetists can influence patient outcomes (such as survival) years down the line. The days of lamely complaining that it is hard to make our contribution seem important when all we have to measure in terms of outcomes are PONV, sore throat and so on are emphatically over.

Perioperative Myocardial infarction (Mi): ‘Prognosis defines diagnosis’This is back on the table. Referring to the VISION study (JAMA 2012), which is a preliminary publication of results relating to the first 15,000 patients in this massive study, he informed us that in all patients over 45y of age, undergoing any non-cardiac inpatient surgery, the incidence of perioperative MI is 9%, of which 80% are silent. Mortality is the same for silent vs symptomatic MIs, and mortality of perioperative MIs remains about double that of MIs presenting as such to A&E.

Raised (above the level of undetectable) fourth generation troponin plasma levels (TnT) during the first three post-op days predict 30 day mortality (the greater the peak level, the greater the mortality). He emphasised that the current clinical guidelines (Thygeson, Circulation 2012) about diagnosing MI use specific, arbitrarily determined cut-off points for biochemical markers of MI (90% of the population) which are unrelated to patient outcomes. He argued that this is the wrong way round, and that ‘prognosis defines diagnosis’ works better as a paradigm. There is no information yet (trials in progress) about options for reducing the incidence. He opined that MAP matters (vide infra) and that there is a threshold effect at a MAP of 55mmHg – he felt it was likely that the aetiology of perioperative MIs lay in the myocardial supply-demand equation, in contrast to non-perioperative, where the aetiology is different. Nevertheless, he said (low dose) aspirin is very effective for primary prevention and initial management of MI, and that we should give this if in doubt.

what should we do now?Avoid/treat MAPs less than 55, measure TnT postoperatively more frequently especially in high risk patients, give aspirin if in doubt. Keep our eyes open for more trials reporting data.

Perioperative blood transfusionMore harmful than we thought. A RCT is in progress, but the immunosuppressive effects may be particularly harmful, extending beyond cancer recurrence. We should limit transfusions and keep an eye on the literature. I didn’t catch his references…

The ‘triple low’.

Sessler’s own research addresses this (Sessler, Anesthesiology, 2012)

Low MAC (less than 0.8)Low MAP (less than 75)Low BIS (less than 45)

Any one, sustained for more than 15 mins in total during an anaesthetic predicts increased length of stay.‘Triple low’ predicts 4 x mortality, ‘double low’ (any combo) predicts 2 x mortality.Cause/effect relationship is unknown; a big trial is in progress to see whether interventions directed at correcting low values improve outcomes.

What should we do now? Hard to know. My personal view is that it is unlikely to be harmful to try and avoid a triple low – though one could argue that there might be an increased risk of awareness. Watch out for more trials reporting on the effects of interventions.

Val Bythell

John Snow LectureThe road to PerditionDr Rhona Mahony, Dublin, Ireland

I have chosen the John snow lecture, given by Dr Rhona Mahony. For me, this provided a fascinating insight into events and beliefs that surround the very different attitudes the UK and Ireland has had to women’s health and childbirth. Dr Rhona Mahony is an obstetrician, Master at the National Maternity Hospital, Dublin, the first woman appointed to this role since its foundation in 1894. With 9,000 deliveries per year, one-in-eight of all Irish children are delivered in the hospital.

She chose as her title ‘The Road to Perdition’ and gave a well researched and moving account of the role of women in Ireland over the last 100 years and of attitudes to childbirth and the rights of the mother and fetus. The description of Dublin’s abject poverty, overcrowding, maternal mortality from pre-eclampsia, haemorrhage and infection, coupled with high perinatal mortality, would have been true of many Edwardian cities. The effect the 1914-18 war had on women, liberating them to work outside the home as nurses and in other roles, was not unique to Ireland. But the next 50 years were remarkably different on the two sides of the Irish Sea. There were no roaring twenties. Women were compulsorily retired as soon as they married, they couldn’t take the civil service exams or serve on juries. Many of those who found themselves pregnant out of wedlock were incarcerated in the now infamous Magdalene laundries. For some, the only option seemed to be infanticide; until 1952 there were no arrangements for formal adoption.

Underpinning what now seems an archaic attitude was Ireland’s desire to be a pure society. In pursuit of this aim, seemingly useful innovations such as a free antenatal care package and free healthcare for children were opposed, lest Catholic women went to protestant doctors who might discuss contraception and sex education. Termination of pregnancy was illegal and in 1935 use or distribution of contraception was made a criminal offence. It has only been since the 1990s that people spoke openly about sexual abuse in Catholic institutions, repression and its impact on peoples’ lives.

History shapes our culture. Dr Mahony gave a straightforward and dispassionate explanation of events and the beliefs that underpinned them. For me this was both captivating and disturbing. Hearing this account has made me look at people like Mary Robinson and our own Ellen O’Sullivan, President of the College of Anaesthesia of Ireland in a new light. See what you think.

Nancy redfern

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24 Anaesthesia News December 2013 • Issue 317 Anaesthesia News December 2013 • Issue 317 25

Learn@AAGBI New!Learn@AAGBI was launched at Annual Congress in Dublin in September this year, and already many of you have used this site to record your many and varied CPD activities.

Learn@AAGBI is the equivalent of your ‘bottom drawer”, a place to store your reflective notes on a variety of activites, and a vehicle to access our video platform. This platform has over 250 videos, and once you have watched a video, the system will produce a CPD certificate for you, which automatically populates your CPD area.

As WSM is round the corner and we are expecting >1000 attendees, I thought I would give those of you who haven’t used Learn@AAGBI before a few top tips:

Step 1: Go to www.aagbi.org

Step 2: Click on Education and Meetings

Step 3: Click on Learn@AAGBI, in all its pink glory!

Here you will find written instructions on what to do, a video of me reminding you what to do (!), 6 topical talks and most importantly the log in area at the top right hand corner. That’s the easy part!

Step 4: Click on ‘log in’

You will now have to remember where you put your AAGBI membership card, or look on the front of your unopened Anaesthesia journal for your membership number on the address label. If you have forgotten your password, just click the appropriate buttons and your password will be sent to you within seconds. This ONLY works if you have registered your correct email address with us. If in doubt email [email protected] or call 0207 631 8801/8866. When using the system for the first time, you will be asked to enter your name and surname.

Once logged in, this is the first thing that you see:

This is your entry point for for your own CPD area and for the AAGBI video platform.

1. THE AAGBI VIDEO PLATFORMThis is an ever growing resource of videos from our conferences, seminars and interviews. You search videos by:• List of Categories (e.g. Airway Management, Burns)• AAGBI Conference (e.g. AC 2013) or Seminar• One of the 4 GMC Domains ((Knowledge, skills and performance/

Safety and quality/Communication, partnership and teamwork/Maintaining trust

• Primary/Final/Pre Consultant interviews content

When you choose a video, you will see which GMC domain and CPD code is covered. I have chosen to watch the video ‘Detecting research fraud’ by John Carlisle.

You will be provided with information about the author and a short summary of the video and the length of the video. When you have seen the video, click on the words at the bottom of the page which state ‘Finish video to access the reflective learning form’ and start filling in your reflective form. The feedback form will automatically contain the title of the video and the meeting at which it was presented. You can reflect and save the form as a draft which you can modify later or submit the form which cannot be modified further.

Once you have submitted this form, you will be provided with a CPD certificate.

2. MY CPD AREAIf you click onto the ‘my CPD area’, you can see how your CPD is progressing.

• You can view all your CPD content from any time length on the screen or hide it to show current activity

• You can download all selected reflection and CPD certificates • You can click on ‘Register a reflective activity at the top of the

page. This is really useful as it allows you to reflect on any meeting, journal club, departmental meeting, M and M, critical incident, quality improvement activity etc. and store it in your CPD area. You can register this activity anytime, but it is particularly good if, like me, you like to reflect whilst or as soon after an event as possible,

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Anaesthesia News December 2013 • Issue 317 27

The Development of a Block Room

fig

ure

2

Block rooms are increasingly being used and developed in the UK having been successfully used in North America and scandinavia. in this article we review our experience of setting up and working in a block room at the sunderland royal hospital.

The patient centered benefits of regional anaesthesia are well known. Indeed regional anaesthesia is advocated by the department of health document Delivering Enhanced Recovery1, by the PROSPECT group for total knee replacements2 and by the UK Hand Surgery Report3):

“3.15 Anaesthetic support should include facilities for regional anaesthesia by brachial plexus block, which is the optimum mode of anaesthesia for many hand trauma cases. It provides excellent postoperative analgesia and avoids the risk of disruption of repairs during a restless recovery from general anaesthesia.”

A commonly quoted disadvantage of regional anaesthesia is its perceived effect on patient throughput. Regional anaesthetic techniques require a significant time for administration and onset of effective anaesthesia, with a high degree of skill and expertise required to use modern ultrasound guided techniques. The use of a block room takes away some of the time pressure for the anaesthetist, and provides as relaxed environment where the patient can await surgery.

Concepts

Patients, in most hospitals, move through the operating suite in a linear fashion, starting at reception and ending in the recovery room in a series of sequential steps. One case is competed before the next can begin and periods of time that could be used for operating are left unused.

A major advantage of using a block room to administer regional anaesthesia, is that the block can be performed, and established whilst a case is currently on going: so called ‘parallel processing’. Regional anaesthesia is commenced, in a dedicated block area, within the theatre suite, while the previous case is still taking place. The patient is monitored, in a dedicated ‘cooking area’, until the operating theatre is vacated. Then they are moved into the prepared theatre with very minimal downtime and surgery commenced seamlessly. Time can be built in for any change of anaesthesia plan e.g. rescue blocks, and importantly teaching time can be accommodated whilst operating continues. Procedures such as tourniquet application, patient positioning and the timely administration of antibiotics may also be performed.

Parallel processing removes the large variability of time needed for anaesthesia. This changes the rate-limiting step of patient throughput to that of theatre preparation. This is shorter and less variable than that of anaesthesia, the result being a gain of operative time within a theatre session available for additional cases.

One of the criticisms of parallel processing is the cost of employing extra staff to run a block room system. A major advantage of this system of working, however, is its ability to increase efficiency and generate additional income. This potential for additional income generation outweighs the modest increase in staffing costs. This is especially the case if, as in Sunderland, the anaesthetic cover can be removed from upper-limb orthopaedic lists, with patients on these lists receiving regaional anaesthesia in the newly created block room.

As can be seen in figure 2, in theory it may be possible to perform additional cases without overrunning a theatre list. But does this work in practice? We ran a pilot over a 5-day period in early 2010, servicing two primary lists and an effort was made to service other lists as required. This

fig

ure

1

in order not to add it to the growing list of ‘things I need to do’! The key is to put as much information about the activity you are recording in the title area, as this is what flags up on your CPD page e.g. Lecture on Rotem, by Dr Tim Hooper, Frenchay 18.07.13.

My Learn@AAGBI logo is now bookmarked on my iPad and iphone ready for me to reflect at a moments notice.

All of my educational activities and learning relevant to all 4 of the GMC domains can be recorded, reflected on, and will then automatically populate my CPD area.

All that leaves me to do is to just download it all into my Trust appraisal e-portfolio whenever I want to. Easy peasy…. and this is just Phase 1, wait till you see what we have planned for Phase 2 in 2014!

when you next have an opportunity, try learn@AAGBi (www.aagbi.org/education), it will make appraisal, revalidation, reflecting and learning more interesting, fun and make you think you are an incredibly organised person…… at least that’s my New Years’ resolution, hopefully it should last until 15th January for the beginning of wsM 2014!

dr samantha shindeHonorary Secretary Elect

For further information and an application formplease visit our website:

http://www.aagbi.org/international/irc-fundingtravel-grantsor email [email protected]

or telephone 020 7631 8807

Closing date: 01 March 2013

TRAVEL GRANTS/IRC FUNDINGents Manager

+44 (0) 20 7631 8805

ortland Place, London W1B 1PY

[email protected]

The International Relations Committee (IRC) offers travel grants to individuals who are seeking funding to work, or to deliver educational training courses or conferences, in low resource countries.

Closing date: 04 October 2013

Please note that the grant application forms were revised in April 2013 and only these updated forms will be accepted. Grants will not normally be considered for attendance at congresses or meetings of learned societies. Exceptionally, they may be granted for extension of travel in association with such a post or meeting. Applicants should indicate their level of experience and expected benefits to be gained from their visits, over and above the educational value to the applicants themselves.

Closing date: 13 December 2013

Programme includes:Challenging airwaysThe airway in ICU & the Emergency DepartmentAirway management in remote & rural locationsTraining in airway managementFront of neck access

Speakers include:Anil Patel, London Mark Stacey, CardiffDavid Ray, EdinburghSuzie Thomson, EMRS

When: Friday 7th March 2014, 09:00-17:00Where: Royal College of Physicians of Edinburgh, 9, Queen Street, Edinburgh.Fee: £120 (£100 if booked before 8th January)

£60 reduced rate for traineesLimited places for non-medical staff - £30

Abstracts encouraged: see online. Closing date 31st January Best abstract and best oral presentation -

£150 prizeApply: Online at www.scottishairwaygroup.co.uk

Scottish Airway GroupAnnual Meeting 2014

Edinburgh

5 CPD points applied for

Feedback from 2013…very enjoyable meeting, with thought provoking speakers…came away feeling inspired...excellent meeting…best meeting I have been to in ages...excellent value for money...excellent meeting clarifying a few controversial issues and generating new ones...thought-provoking and relevant.

Photograph used under a Creative Commons licence

Delegate rate fixed since 2011!

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28 Anaesthesia News December 2013 • Issue 317 Anaesthesia News December 2013 • Issue 317 29

your lettersSEND YOUR LETTERS TO:

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

Dear Editor,A reinforced message

We would like to report an incident involving a reinforced endotracheal tube that was used for a rapid sequence induction for an emergency category one neurosurgical craniotomy. A reinforced tube was chosen as per the norm in our establishment for neurosurgical cases for their resistance to kinking. All equipment was checked prior to induction including checking the inflation of the endotracheal tube’s cuff.

Anaesthesia was induced and a grade IIb view was gained on direct laryngoscopy. A bougie was placed uneventfully into the trachea and whilst trying to railroad the reinforced ET tube over the bougie it became evident that the tube would not advance even before entering the mouth. Closer inspection showed that the reinforced tube was irreversibly compressed just above the cuff not allowing the passage of the small diameter Frova bougie. The tube was quickly discarded and replaced by another reinforced endotracheal tube, anaesthesia was maintained and the case proceeded without any ill effects.

On further detailed inspection of the discarded tube there was no obvious external damage to it or packaging and it wasn’t immediately evident unless a ‘dent’ was specifically looked for (Fig 1). We postulate that at some time the tube had been clamped or crushed somehow – which is surprising as the metallic inner is meant to protect from kinking.

There have been previous case reports highlighting that even reinforced tubes are prone to damage especially by biting during emergence, however we would like to raise awareness of this as a pre-induction problem and also underline how important it is to check the endotracheal tube fully and not just the inflation of the cuff. Revisiting the AAGBI equipment check it is clear that a part of the guideline is pre-operative airway equipment check (which was done). However the guideline does specifically state that airway equipment should be available in all appropriate sizes and ‘have been checked for patency”3. This was clearly not done here and had a bougie not been required, the ETT would have been placed unknowingly and could have given rise to a potentially problematic ventilation intra-op and increased ventilation pressures with no evident cause.

This has certainly reinforced that looking down the endotracheal tube or checking its patency via the ventilation tubing (as we commonly do with the HME filters) is something to do pre-operatively alongside the other checks. We do acknowledge that had we opted to insert a stylet to stiffen the tube, we may have identified the problem earlier – pre insertion. However the use of a stylet isn’t always warranted and shouldn’t replace the full checking of endotracheal tubes.

l. Bowen, ST6 Anaesthetics, University Hospital Wales, Cardiff

s. rees, Consultant Anaesthetist. University Hospital Wales, Cardiff

References:

1. Malhotra D., Rafiq M., Qazi S., Gupta S.D. (2007). Ventilatory Obstruction with Spiral Embedded Tube – Are they as safe? Indian Journal of Anaesthesia. 51 (5):432-33

2. Brusco L, Weissman C. (1993). Pharyngeal obstruction of a reinforced orotracheal tube. Anesth Analg. 76:653-4.

3. Hartle A., Anderson E., Bythell V., Gemmell L., Jones H., McIvor D., Pattinson A., Sim P. and Walker I. (2012) AAGBI Safety Guideline. Checking Anaesthetic Equipment. Page 12.

Dear Editor,We refer to the AABGI patient safety alert1 issued in November 2012, and your article in the April edition of Anaesthesia News2 regarding a fire on an intensive care unit which was caused by an oxygen cylinder.

We would like to report an incident regarding an oxygen cylinder which occurred in our hospital, whilst transporting a ventilated intensive care patient to the CT scanner. The oxygen cylinder had been laid on the bottom of the patient’s bed, and whilst the bed was being turned around a corner, the end of the bed was accidentally hit against the frame of a door. During this, the top of the oxygen cylinder was also knocked, causing damage to the cylinder neck and valve. The oxygen cylinder began to leak very noticeably and loudly and the Oxylog portable ventilator stopped ventilating. The patient was ventilated via self-inflating bag on room air, the oxygen cylinder turned off and the patient returned quickly to the intensive care unit. The patient did not come to any harm.

We strongly support the AAGBI suggested practice regarding the use of appropriately designed oxygen cylinder holders, and keeping the cylinder upright rather than lying the cylinder on the bed or trolley next to the patient, to avoid potential damage to the oxygen cylinder during transfers, as occurred in our case; and in the case of an ignition2,3 to minimise its impact.

shilpa Patel & edward Todman,

Anaesthetic Specialty Trainees 7, National Hospital for Neurology and Neurosurgery, London

References

1. Safe handling of oxygen cylinders. AAGBI safety committee. November 2012

2. Kelly F, McDonald J. Fire on intensive care caused by an oxygen cylinder. Anaesthesia News 2013; 309: 8-9

3. Kelly FE, Hardy R, Hall EA, McDonald J, Turner M, Rivers J, Jones H, Nolan JP, Cook TM, Henrys P. Fire on an intensive care unit caused by an oxygen cylinder. Anaesthesia 2013; 68:102-104

pilot demonstrated a reduction in ‘down time’ from 410 to 300 minutes (a reduction of 27%) whilst the time in theatre remained constant (1127 vs. 1134 minutes). We repeated this for three weeks, servicing additional theatres and we were able to demonstrate time savings, on average, of 123 minutes per day. Potentially this time could be used to undertake an extra case.

constructing a business plan

A business case was constructed based on this time saving of 123 minutes per day. Trust data indicated that our average income per orthopaedic case was £2207 (once prosthetic and staffing costs had been taken into account). Initially the block room was to run 3 days a week. With this information we formulated three levels of productivity outcomes, dependent upon the amount of extra cases performed. The worst-case scenario was one extra case per week, the intermediate case was one extra case per day and our best-case scenario was one extra case per list (3 lists) per day. These would give the projected additional annual incomes outlined in table 1.

Table 1

level Projected increase in annual income (£)

Worst 114,764

Intermediate 344,292

Best 1,012,876

Test run to wider practice

A typical block room day now involves servicing both standard orthopaedic lists and hand lists. In the morning the block room team consisting of a consultant anaesthetist, a trainee anaesthetist (often the regional anaesthesia fellow) and the block room ODP gather all the lists for the operating suite. They identify cases that may potentially require blocks and will then discuss these cases with the anaesthetist responsible for that list. It is not unusual in a single day for the block room team to perform well over 15 blocks for a variety of procedures, encompassing neuroaxial blockade, popliteal sciatic nerve blocks, femoral nerve blocks, axillary, interscalene and ankle blocks.

The block room team has to co-ordinate with the various theatres as to when they are likely to require their next patient blocking and, as with so many aspects of anaesthesia, for this to work effective communication is key.

have we achieved what we set out to?

In 2010 the average number of cases performed per session was 2.08. By 2011 it had risen to 3.10 cases per session rising still further to 3.58 per session by the end of 2012. This equates to 3 extra cases per day being performed since the block room was introduced. But does this just mean we’re working longer and harder rather than smarter?

We looked at start and finish times for our theatre lists, with a late finish being a finish > 30minutes from the scheduled finish time, we found that since the introduction of the block room, and in spite of not starting earlier (and increasing number of cases performed as above), we are finishing lists earlier. The number of early finishes rose from 26.4% to 38.9% over the period, giving extra for further improvements in productivity.

other benefits

Are there any benefits other than the increased productivity of theatres? From an educational point of view the trainees who are allocated to the block room get to see a wide range of blocks performed on a regular basis, enabling a more rapid attainment and better retention of both knowledge and skills in ultrasound guided regional anaesthesia.

Further to this, it allows for a greater utilization of the skill mix available along the theatre corridor. Previously it may have been difficult to provide all patients who may have benefited from regional anaesthesia with the specific technique they required. In the block room system of working an anaesthetist with a specific interest in regional anaesthesia is available to all patients and provides an easy point of contact for colleagues requiring assistance.

97% of our patients report no pain in recovery, and we have high patient satisfaction levels with 100% of patients recently surveyed following axillary brachial plexus blocks being either satisfied or very satisfied with the block (as measured on a 5 point likert scale).

Review of our processes for awake hand surgery has lead to new protocols allowing these patients to bypass recovery and go straight back to our day-case unit, freeing up space and staff within the recovery room.

But is it all positive?

What about the anaesthetists looking after the patients who receive anaesthesia from th eblock room staff? There certainly is the possibility of deskilling the non-block room anaesthetists. However, the presence of a block room has increased the profile of regional anaesthesia within the department and increased the total number of regional blocks performed. Colleagues with a regional interest have the opportunity to cover block room sessions and also continue to perform their own blocks, especially at busy times and when use of the block room will not lead directly to increased efficiency. There are obvious advantages in the system for the occasional orthopaedic anaesthetist.

future developments

Currently the block room works out of an anaesthetic room for a decommissioned theatre. The block room has been so successful that a purpose built block room is being created in a more suitable location that will further enhance the flow of patients through theatres.

conclusions

The Sunderland block room experience has been a positive one, for patients, consultants, trainees and the trust. It has improved the quality of service provided to patients and leaves them with high levels of satisfaction. It has improved the quality of regional anaesthesia training and we have been able to demonstrate a significant improvement in theatre productivity and efficiency. We hope to continue to develop the block room service and believe that the block room system of working may be a useful model for other NHS trusts.

ian Baxter, Nathaniel haslam and Andrew Morrison Consultant anaesthetists, Sunderland

References1. Delivering Enhanced Recovery: Helping patients get better sooner after

surgery. Department of Health, product 200977, pg 20. 2. PROSPECT (Procedure Specific Postoperative Pain Management)

Recommendations for Total Knee Arthroplasty (2007).Available from http://www.postoppain.org/frameset.htm (last accessed 16/5/13)

3. Hand Surgery in the UK Manpower, resources, standards and training. The British Society for Surgery of the Hand. Pg 14.

Anaesthesia News is the official newsletter of the Association of Anaesthetists of Great Britain & ireland.

Anaesthesia News now reaches over 10,500 anaesthetists every month and is a great way of advertising your course, meeting, seminar or product.

For further information on advertising

Tel: 020 7631 8803

Dr Les GemmellImmediate Past Honorary Secretary

21 Portland Place, London W1B 1PYT: +44 (0)20 7631 1650F: +44 (0)20 7631 4352E: [email protected]

W: www.aagbi.org

or email chris steer: [email protected]/publications

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Anaesthesia News December 2013 • Issue 317 31

December 2013

Digested

Articles on: Multidisciplinary peri-operative care; Pre-operative assessment/risk stratification; Frailty; Legal/ethical aspects of care; Analgesia; National research strategies; Emergency surgery; and General management of elderly patients.

www.anaesthesia-journal.org

Due

out in the

New Year

New supplement: ‘Anaesthesia for the Elderly’ – advance notice.

T. Heidegger, D. Saal and M. Nüblin

Patient satisfaction with anaesthesia – Part 1: Satisfaction as part of outcome – and what satisfies patients

M. Nübling, D. Saal and T. Heidegger

Patient satisfaction with anaesthesia – Part 2: Construction and quality assessment of questionnaires

E. McGrady

Patient feedback and anaesthetists: what are patients assessing and why?

J J Pandit, Editor, Anaesthesia

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

One of the elements now required for revalidation is patient feedback. At best, the additional workload required is often regarded as a nuisance, especially if the tools are not validated. At worst, the outcomes of any feedback can be misleading. One of the pertinent questions is: “what is the patient feeding back on, in the case of anaesthesia?” There are clear dangers that, in cases where the primary dissatisfaction is with surgical outcomes, the anaesthetist who has delivered a high-quality, pain- and nausea-free experience will nonetheless be tarred with the same negative brush as surgical or other colleagues. Equally giving a ‘terrible’ (to our own high standards) anaesthetic (with apparently traumatic airway management, multiple attempts at venous access, poor blood pressure control, abandoned epidural replaced with IV opiates, etc) can still leave the patient (unaware of any difficulties) entirely contented, with a pain free and excellent outcome and positive feedback.

In the November issue of the journal, two articles by Heidegger’s group analysed ‘patient satisfaction’

in relation to anaesthesia in some detail and the work provides resource material for anyone wishing to study and develop this important topic. Further, McGrady’s accompanying editorial offered some very helpful and pragmatic advice for those colleagues facing the perhaps daunting task of collecting patient feedback. She makes the helpful point that the emphasis really is on communication, and outlines how forms might be distributed and collected. There is one small aspect which, in my ignorance, I did not previously know; namely that the distribution of forms to patients should be ‘random’. This is surprising because nobody really knows what ‘random’ means, or how to achieve it (e.g. even the proper ‘randomness’ of a randomised controlled trial is often hotly debated). Pragmatic alternatives might be ‘universal’ (especially where response rates are low), or ‘consecutive’ or ‘representative’. What will almost inevitably be near to random is whether or not the patient actually completes the form.

2014 Course Dates Location Organisers10–11 January Newcastle (A) Dr Ian Harper / Dr Nat Haslam 11–12 April Bristol (A) Dr Tony Allan / Dr Barry Nicholls14–15 July Brighton (A) Dr Susanne Krone / Dr Ali Diba25–26 September Liverpool Dr Steve Roberts / Dr Raj Naveen28–29 November Nottingham (A) Dr Nigel Bedforth / Dr James French

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.

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

These courses are organised by Regional Anaesthesia UK (RA-UK) in conjunction with FUJIFILM SonoSite Ltd for training in ultrasound guided regional anaesthetic techniques. Previous experience in regional anaesthesia is essential.

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

©2013 FUJIFILM SonoSite, Inc. All rights reserved. 1839 10/13

ULTRASOUND GUIDED REGIONAL ANAESTHESIA – BEYOND INTRODUCTORY

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Anaesthesia News December 2013 • Issue 317 33

Adelson PD, Wisniewski SR, Beca J et. al. for the Paediatric Traumatic Brain Injury Consortium.

comparison of hypothermia and Normothermia after severe Traumatic Brain injury in children (cool Kids): A Phase 3 randomised control TrialThe Lancet 2013; 12: 546-53

introductionSevere traumatic brain injury (TBI) remains a leading cause of paediatric death and permanent disability around the world. Evidence from previous trials investigating the role of therapeutic hypothermia in TBI in children has been conflicting1,2,3. Following a phase 2 trial showing reduced mortality using hypothermia in children after severe TBI2, the authors aimed to assess whether therapeutic hypothermia (32–33°C) with slow rewarming over 48-72 hours improved mortality at 3 months. MethodsThis randomised controlled, multi centred, multinational trial was conducted in the USA, Australia and New Zealand. Children, aged 0-17, were enrolled within 6 hours of injury and were included if they had sustained a non-penetrating head injury, a GCS of 3-8 and a motor score of less than 6 following resuscitation. Randomisation was via a web-based assignment algorithm and investigators who assessed outcome were masked to treatment allocation. Patients were managed in conjunction with a standardised, two-tiered head injury management protocol.

The primary outcome measure was mortality at three months post-injury. Secondary outcome measures were global function at 3 months post-injury (using the Glasgow Outcome Score - Extended Paediatrics) and occurrence of adverse events. Based on a previous randomised controlled study2, the authors planned to recruit 340 children. This would allow detection of a 10% difference in mortality with 80% power.

results77 patients (39 in the hypothermia group, 38 in the normothermia group) were recruited into the study between November 2007 and Feb 2011. An interim data analysis on these patients led the authors to terminate the study early on the grounds of futility. The mortality rates at 3 months were 6/39 (15%) in the hypothermia group vs. 2/38 (5%) in the normothermia group. Poor outcomes did not differ between groups and there was no between group difference in the occurrence of adverse events.

discussionThe authors conclude that hypothermia for 48hrs with slow rewarming does not reduce mortality or improve global functional outcome after paediatric severe TBI. However, the study only recruited 77 of the projected 340 patients required to show a statistical difference. The study was terminated at this point as an interim futility analysis showed that there was less than 20% chance of confirming the primary hypothesis. This futility analysis was performed due to slow accrual of patients into the study and due to safety concerns from another randomised controlled trial, which showed that hypothermia in children with TBI might be associated with worse outcome1. The authors highlight several of the difficulties of performing studies in this field and the need for further studies to define the role of hypothermia in TBI in children.

fiona Yau ST6, London Deanery

Tajinere fregene Research Fellow, London Deanery

References1. Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia therapy after

traumatic brain injury in children. New England Journal of Medicine 2008; 358: 2447-56

2. Adelson PD, Ragheb J, Kanev P, et al. Phase 2 clinical trial of moderate hypothermia after severe traumatic brain injury in children. Neurosurgery 2005; 56: 740-54

3. Biswas AK, Bruce DA, Sklar FH, Bokovoy JL, Sommerauer JF. Treatment of acute traumatic brain injury in children with moderate hypothermia improves intracranial hypertension. Critical Care Medicine 2002; 30: 2742-51

Futier et al, for the IMPROVE study group

A Trial of intraoperative low-Tidal-Volume Ventilation in Abdominal surgeryNEJM 2013; 369: 428-437

introductionLung protection ventilation utilising low tidal volumes and positive end expiratory pressure (PEEP) is considered best practice in critically ill patients1. Its role in general anaesthesia for major surgery is unknown. This patient group includes 230 million patients worldwide2. Large cohort studies have shown that 20-30% of this group is intermediate to high risk for postoperative pulmonary complications.

MethodsThis was a multicentred, double blinded, parallel-group trial. Patients were randomised to either lung protective ventilation (LPV) or non- protective ventilation (NPV)3,4. Inclusion criteria were age >40 years old, elective major abdominal surgery, duration >2 hours, preoperative risk index for pulmonary complications of >2. Exclusions included emergencies, recently unwell and obese subjects.

Protective ventilation included tidal volumes of 6-8ml/kg (predicted), PEEP of 6-8cmH2O, recruitment (30cmH2O for 30s every 30 minutes), and plateau pressures of <30cmH2O. Non-protective ventilation included tidal volumes of 10-12ml/kg (predicted) with no PEEP or recruitment.

Primary outcome was a composite of major pulmonary and extra-pulmonary complications at 7 days post surgery. Secondary outcomes were followed up to 30 days.

results Over 18 months 400 patients were randomised. There were no differences in groups in type and duration of surgery, epidural use or fluid use. Primary outcomes occurred in 10.5% in the LPV group versus 27.5% in the NPV group (RR: 0.40; 95% CI, 0.24-0.68, P=0.001). Within 7 post-operative days 5.0% of the LPV group required non-invasive ventilation or intubation for respiratory failure compared to 17% assigned to NPV (RR, 0.29; CI, 0.14-0.61; P=0.001). Length of hospital stay was shorter among patients receiving LPV compared to NPV (mean difference -2.45 days; 95% CI, -4.17 to -0.72; P=0.006).

discussionAccording to this study LPV resulted in a 69% reduction in the number of patients requiring ventilator support within 7 days of surgery. The observed rate of postoperative complications was higher than predicted. This may have been due to exclusion of patients with a low risk of complications. They suggest that this improvement is due to reduction in ventilator-associated lung injury. The tidal volumes in the NPV group were 10-12 ml/kg, which was felt to be standard practice. Important study limitations include the failure to standardise fluid administration; although administration was similar in the two groups.

James dayST6 Oxford Deanery

References1. The Acute Respiratory Distress Syndrome Network. Ventilation with lower

tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New England Journal of Medicine 2000; 342: 1301-8

2. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372: 139-44

3. Bendixen HH, Hedley-Whyte J, Laver MB. Impaired oxygenation in surgical patients during general anesthesia with con- trolled ventilation: a concept of atelectasis. New England Journal of Medicine 1963; 269: 991-6

4. Jaber S, Coisel Y, Chanques G, et al. A multicentre observational study of intraoperative ventilatory management during general anaesthesia: tidal volumes and relation to body weight. Anaesthesia 2012; 67: 999-1008

Ashton-Cleary DT

is thoracic ultrasound a viable alternative to conventional imaging in the critical care setting?British Journal of Anaesthesia 2013 111 (2): 152-60.

introductionThoracic ultrasound in the past has been dismissed as a useful investigation, but with renewed enthusiasm in its uses, opinion is changing. This review examined relevant studies between 1995 and 2012, focusing on four common conditions that require repeated imaging to diagnose and monitor treatment.

review Pleural effusion: Using computed tomography (CT) as the reference standard, several studies demonstrate the superior ability and reliability of critical care ultrasonography (CCUS) to detect pleural effusions over chest x-ray (CXR).1 Of more clinical relevance is the identification of effusion characteristics. Evidence is heterogenous but suggestive that useful estimations of effusion volume may be derived.2 Further work is required to identify one single, simple method of volume estimation that would validate current evidence.

Consolidation & atelectasis: Distinguishing between alveolar oedema, interstitial oedema and consolidation on CXR is difficult. From alveolar consolidation studies, Lichtenstein and colleagues show that CCUS can provide an accurate lung assessment by combining four ultrasound features. This was with comparable diagnostic performance to CT.3 However many subsequent studies by other groups failed to reproduce such findings.

Extravascular lung water: There may be an emerging role for ultrasound here, however evidence is conflicting. CCUS may enable differentiation between pneumonia and pulmonary oedema through specific ultrasound features. It performs well at identifying cardiogenic pulmonary oedema, compared to echocardiography and functional cardiac testing.3 More research is required to support the role of ultrasound in this area.

Pneumothorax: CCUS is considered valuable in detecting pneumothorax. Diagnosis is defined by an absence of B-lines, lung sliding and the presence of A-lines. If lung movement is likely to be absent, A-lines themselves can be used to differentiate between diagnoses. The largest study of critical care pneumothoraces excluded ventilated patients due to reduced ultrasound sensitivity – an anomaly not mentioned in other studies.4 In general, CCUS outperformed CXR in diagnosis and monitoring, with CT used as the reference standard.3

discussionThe four reviewed conditions have a varying evidence base to support the role of thoracic ultrasound. Overall CCUS appears to approach the quality of CT and surpasses that of CXR. CCUS can potentially save time and provide cost savings, however the difficulty for implementation is that of training. Guidance is available regarding necessary core competencies, however the accreditation of CCUS is still largely undecided.

emma MclaughlinST3 Anaesthesia and Intensive Care Medicine

South-East Scotland Deanery

References1. Lichtenstein D, Goldstein I, Mourgeon E, et al. Comparative diagnostic

performance of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anaesthesiology 2004; 100: 9-15.

2. Roch A, Bojan M, Michelet P, et al. Usefulness of ultrasonography in predicting pleural effusions > 500ml in patients receiving mechanical ventilation. Chest 2005; 127: 224-32.

3. Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008; 134: 117-25.

4. Galbois A, Ait-Oufella H, Baudel JL, et al. Pleural ultrasound compared with chest radiographic detection of pneumothorax resolution after drainage. Chest 2010; 138: 648-55.

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34 Anaesthesia News December 2013 • Issue 317

Delegates at the Lifebox workshop

If you’re going to

San Francisco...

With a packed multi stream programme starting at 7.30 am on many days, finding your way to the right session at the right time was often challenging. Highlights included:

• Dr Jane Fitch taking up her role as new ASA president, only the second woman to hold this office in the organisation’s history. Dr Fitch is professor and chair of the Department of Anesthesiology at the University of Oklahoma Health Sciences Centre in Oklahoma City.

• The launch of ASA’s public affairs campaign ‘When seconds count’ promoting the role of anaesthetists. http://www.asahq.org/whensecondscount.aspx

• A debate on the death penalty linked to ASA action to persuade policy makers not to use anaesthetics for executions. ASA successfully lobbied the State Governor of Missouri to stop possible use of Propofol for this purpose, so averting the threat to anaesthetic treatment from this move.

• Lifebox fundraising and workshop. • Patient Safety as the theme of the conference with Hollywood actor Dennis Quaid

taking part by video in a plenary session on the Chasing Zero Project promoting safety and quality.

An important discussion on drug shortages took place at a World Federation of Societies of Anaesthesiologists (WFSA) session – where the ongoing work by AAGBI on the national essential anaesthetics drug list (NEADL) was a focus and joint action by the Association, WFSA and European Society of Anaesthesiologists was agreed as a follow up.

As always at such events, there are many opportunities for networking with colleagues and a meeting was held between CEO’s of national societies for information sharing as well as a lunch for Presidents of member organisations from around the world.

Karin PappenheimExecutive Director, AAGBI

As the 1967 song by Scott McKenzie goes, be sure to wear some flowers in your hair. And, although there are still many flower children and hippies to be seen in the city, this was not actually the dress code for the American Society of Anesthesiologists (ASA) annual meeting in San Francisco where the AAGBI was represented by our President William Harrop Griffiths, Vice President Isabeau Walker and Executive Director Karin Pappenheim. There were also around 130 UK delegates amongst the 15,000 anaesthetists, industry reps and others attending this major five day event in October.

34 Anaesthesia News December 2013 • Issue 317

www.asahq.org/whensecondscount.aspx

AAGBI Vice President and Lifebox board member, Dr Isabeau Walker presents an oximeter to Elizabeth Ogboli Nwasor from Nigeria

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MEMBERS EARLY BOOKING RATE ENDS 17 DEC