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The Newsletter
of the
Association ISSN 0959-2962 No. 369
of Anaesthetists
of Great Britain APRIL 2018
and Ireland
INSIDE
THIS ISSUE:
Join us in Dublin for
Annual Congress 2018:
Abstract submissions
now open
Reflection made simple
A tale from another
health system
Editorial
Welcome to April’s issue
Contents 03 Editorial
Non-Luer
Non-Luer Connector
Connector in accordance
in accordance with
with ISO ISO 80369-6
80369-6
of Anaesthesia News 04 Reflection made simple
! !
As the days become longer and winter is well 07 The Anaesthesia Trainee
E
NN W
E W and truly behind us thoughts turn to the GAT
ASM meeting, to be held in Glasgow in July,
and the Annual Congress, which this year is
04 Fellowship: what has it done
for me?
in Dublin’s fair city. Both should definitely be in 10 A tale from another health system
your diary. These events, along with the Winter
Scientific Meeting, are the jewels in the crown
» optimised
» optimised hub hub of the Association and are always extremely
13 Particles
» unchanged
» unchanged needle
needle design
design » comfortable
» comfortable handling
handling popular. The programmes are already looking
pretty special so please book your leave now! 14 Join us in Dublin for our
Annual Congress 2018
» improved
» improved grip grip 07
As an appraiser I often have to remind colleagues that they must include
» brilliant
» brilliant CSFCSF chamber
chamber their reflections within their appraisal folder. Older anaesthetists such as 18 Is the specialty of anaesthesia a
myself find this particularly difficult because we trained in an era where we waste of medical training?
were expected to be stoical, not to dwell on the ‘what might have been’
and to get on with our next task. This month we have a piece by Jason 20 How good a trainer are you?
Walker that makes the ‘reflection’ part of appraisal easy; simply fill in the
RegionalAnaesthesia
Regional Anaesthesia
appropriate words to complete a statement. This tongue-in-cheek piece
23 Anaesthesia Digested
is sure to help you!
10 24 Your Letters
with
with ISOISO 80369-6
80369-6 NRFit™
NRFit™ Non-Luer
Non-Luer Connectors
Connectors Every year the journal Anaesthesia appoints a trainee editor in open
competition for 12 months. In this issue we have the thoughts of Mike
Charlesworth, our current talented trainee editor, who reflects on his first 14
four months in post. I hope this will inspire trainees to apply for the next
appointment, the advertisement for which is in this month’s issue, with a
closing date of the end of May.
Patient
Patient Safety
Safety Even if you only glance occasionally at the Daily Mail you would think
that the NHS is on its knees (or worse). However, spare a thought for
Paul Fenton who was unfortunate enough to fall ill abroad, in his adopted
• ISO
• ISO 80369-6:
80369-6: newnew requirements
requirements for small
for small borebore country of retiral. His experience will leave you shocked and never For the latest
connectors
connectors in the
in the fieldfield of neuraxial
of neuraxial applications
applications
knowingly ‘dissing’ our NHS again. news and event
Michael Ward, a retired consultant from Oxford, recalls conversations information
andand peripheral
peripheral nerve
nerve blocks
blocks with his father, a pharmacist, who questioned Michael’s decision to follow @AAGBI
become an anaesthetist. Dr Ward clearly had an aptitude and affinity for on Twitter
• Reducing
• Reducing the the
risksrisks of accidental
of accidental misconnections
misconnections the specialty and shares his memories with us. I sincerely hope none of
20 24
you regret becoming an anaesthetist; after 30 years I still believe it is the
of different
of different supply
supply lineslines to different
to different access
access best decision I ever made and we at the Association are here to support
you if ever you have any doubts regarding your career choice. The Association of Anaesthetists of Great Britain and Ireland
routes
routes 21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
We all like to think we are good trainers and we all recognise a good Email: anaenews@aagbi.org
trainer when we see them in action. Mark Fairbrass devised an online Website: www.aagbi.org
questionnaire which was completed by two different cohorts of trainees.
NRFit
NRFit is a is
TM TM
a trademark
trademark of GEDSA
of GEDSA andand
is is He found consistent results that indicated some trainers were significantly
Anaesthesia News
Managing Editor: Gerry Keenan
used
used withwith
theirtheir permission.
permission. ‘better’ than others. Hopefully constructive feedback will allow those Editors: Satinder Dalay (GAT), Nancy Redfern, Rachel Collis, Craig Bailey,
Tim Meek, Mathew Patteril and Matthew Davies
underperforming trainers to ‘up’ their game. Address for all correspondence, advertising or submissions:
Email: anaenews@aagbi.org
In addition to these great articles we also have our regular and popular Website: www.aagbi.org/publications/anaesthesia-news
Anaesthesia Digested, Particles, as well as letters sent in by you. Once Editorial Assistant: Rona Gloag
again there is something for everyone this month so I really hope you Email: anaenews@aagbi.org
enjoy reading this issue of Anaesthesia News. Design: Chris Steer
AAGBI Website & Publications Officer
As always, I and the other members of the Editorial Committee would love Telephone: 020 7631 8803
Email: chris@aagbi.org
to hear from you, so please send in anything you think our members will Printing: Portland Print
find entertaining, educational or controversial, and preferably all three! All
submissions are very welcome and each is individually assessed on its Copyright 2018 The Association of Anaesthetists of Great Britain and Ireland
own merits. The Association cannot be responsible for the statements or views of the contributors.
No part of this newsletter may be reproduced without prior permission.
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Elected Member, AAGBI 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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116 2366 099 099 Anaesthesia News April 2018 • Issue 369 33
Reflection
TABLE 1 TABLE 4
• This was an excellent meeting, • and highlighted areas for advancement in
• This was a worthwhile use of my time, • and made me think about the shortfalls within
• The event was well organised, • but forced me to address the limitations in
made simple
• This activity filled a comprehensive remit, • and made me proud of what we've achieved in
• This was a good conference, • and helped me to develop a more patient-centred
• A creditworthy meeting, paradigm within
• A fantastic showcase, • but threw into sharp relief the contrasts within
• A pleasurable and productive event, • and demonstrated the deficiencies in
• A very helpful meeting, • and allowed me to appreciate the complexities of
• This opportunity was a positive one, • but left me with no illusions as to the steps needed
• A useful exercise, to improve
• This conference was valuable, • and provided a relaxed forum within which to discuss
You went to a the needs of
conference. You • and underlined the challenges facing
• and may help me address productivity within
attended most of the TABLE 2
talks, you networked, • with many opportunities to network;
• with lots of opportunity to discuss matters with the
you took notes. speakers; TABLE 5
You may even have • with a very active social media presence; • my Trust.
• my field.
enjoyed yourself. • with a nice balance of didactic teaching and open
• my department.
discussion;
• in a well-appointed venue; • my practice.
• with content that dovetailed neatly with my aspirations; • my work.
• in the best traditions of this kind of event; • my daily activities.
Six months later and you’re faced with • my specialty.
• given the subject under discussion;
that appraisal box titled ‘Reflection’. • my team.
Previously you’ve put such insights as • bearing in mind how previous events such as this have
disappointed; • my group.
‘Good meeting,’ but apparently you
need more. Last year’s ‘Educational • although the catering was a little lack-lustre; • our unit.
objectives met,’ earned you a Hard • with a good balance of clinical and non-clinical subject • my discipline.
Stare. You need something that sounds matter; • our current approach.
meaningful, but what?
• coming as it does at an exciting time in this area;
Based on previous work [1], we present
a system for producing impressive-
sounding reflections which can win over Jason Walker
TABLE 3 Consultant Anaesthetist,
the most critical of appraisers. Simply
• it fulfilled my educational needs Ysbyty Gwynedd, Bangor.
take a phrase at random from each of
Tables 1 to 5, and put them together • it validated my current practice
in order. This will give you a reflection • it helped me to consolidate my existing knowledge base
such as ‘A pleasurable and productive • it provided much material for reflection
event, with a very active social media Conflicts of interest
• it covered an interesting range of topics The author is a medical practitioner, with a need for annual
presence; it helped me to consolidate
• it led me to question my thinking appraisal. Make of that what you will.
my existing knowledge base and
• the Q and A sessions in particular were most informative
highlighted areas for advancement in Acknowledgements
my practice.’ • the presentations were of an especially high standard The author is grateful to Dr Hugh Godfrey and Dr Declan
• the speakers were appropriately challenging Maloney (Ysbyty Gwynedd) who lent their expertise to the
There are 248,832 possible reflections, • it was surprisingly stimulating tables.
which should be enough to keep you • the topics were unusually wide-ranging Reference
going. 1. Caddy J. How to say a lot and still say nothing. Today’s
• its approach was refreshing
Anaesthetist 1998; 13: 36.
4 Anaesthesia News April 2018 • Issue 369 Anaesthesia News April 2018 • Issue 369 5
Anaesthesia The Anaesthesia Trainee Fellowship:
Apply Now:
2018 Round 1 Trainee Fellowship what has it done for me?
Applications are invited for a 1-year Fellowship
NIAA Grant attached to the Journal, starting at the AAGBI
Annual Congress in September 2018.
The first round of NIAA funding for Getting a paper published is
2018 is now open to applicants.
The appointment will run concurrently with the Fellow’s usual hard-work, even for the most
anaesthetic training programme.
experienced academics and
AAGBI/Anaesthesia research grant – up to £75,000 The Fellow’s roles will include involvement in general journal business professors. My first ‘accept
available including handling submissions (but not with direct responsibility).
The Fellow must also: with revisions’ decision
The AAGBI research strategy focuses on supporting the
following key areas: • Attend the 6-monthly Editors’ away days and Editorial Board
came as a medical student
• Patient safety meetings during their term; for an article submitted
• Innovation • Attend at least one Committee on Publication Ethics forum/
• Clinical outcomes meeting;
to Anaesthesia News, and
• Education and training • Attend the AAGBI Annual Congress in September 2018, AAGBI a recent browse through
• Related professional issues (e.g. standards and guidelines, Winter Scientific Meeting in January 2019, and either the GAT
working conditions, medicolegal issues, etc) Annual Scientific Meeting in July 2018 or Annual Congress in
the corresponding issue,
• The environment
September 2019, and assist in the programmes as required. some eight years old, was
The Fellow will be answerable to and supervised by a designated
fascinating [1].
NEW
Joint AAGBI/ACTACC research grant – up to £60,000 Editor and thence the Editor-in-Chief and Editorial Board. There will be
available no payment or honorarium but reasonable travel expenses to attend
the above meetings will be met, according to usual AAGBI policy.
The AAGBI and the Association for Cardiothoracic Anaesthesia
and Critical Care (ACTACC) are jointly inviting a call for research The Fellow and Editor/Editor-in-Chief will compile a brief report at
Firstly, topics such as supervision, working hours and fatigue article. Finally, there will be significant changes at the journal in
projects up to the value of £60,000. the end of the Fellowship, to be submitted to the Editorial Board and
featured highly then as they do now, though it seems significant the coming year (watch this space!) and it has been a pleasure to
School of Anaesthesia/Deanery as appropriate.
progress has been made. Secondly, I should have read the ‘How to contribute my thoughts about these.
The AAGBI & ACTACC research strategy focuses on supporting
design a study’ article by the then newly appointed Editor-in-Chief of
the following key areas: Suitable applicants must:
Anaesthesia, Steve Yentis, somewhat sooner [2]. More on that later. So far the post has provided incredible insight into editorial decisions
• Cardiothoracic anaesthesia, cardiac intensive care and
for submitted manuscripts. Just as I would have preferred to learn
resuscitation • Be post-FRCA (or equivalent);
• Patient safety Last year in Anaesthesia News, Annemarie Docherty wrote of her the lessons from Steve’s article eight years ago [2] rather than
• Not have a substantive non-training appointment offered or
• Innovation year as Anaesthesia Trainee Fellow and invited applications for through trial and error, I am now learning through the review of many
accepted at the time of taking up the post;
• Clinical outcomes the 2017/18 post [3]. I applied, was successfully appointed, and I more manuscripts than I will ever write myself, and through peer
• Be an AAGBI member;
• Education and training have completed my first of three rotations with an editor. Matt Wiles review of my own reviews! It is difficult to become an editor without
• Have an interest in, and commitment to, advancement of the
• Related professional issues (e.g. standards and guidelines, was an obvious first choice, as he has much experience of the role experience, yet this experience is difficult to attain. Anaesthesia
specialty via the areas described in the AAGBI research strategy
working conditions, medico legal issues, etc) having previously supervised Annemarie and Kariem (Annemarie’s is one of a small number of high quality medical publications to
(http://www.aagbi.org/research);
• The environment successor). When a manuscript is sent to Matt from the Editor-in- offer this valuable experience to trainees and for that it should be
• Undertake to maintain strict confidentiality regarding all journal/
Chief (Andrew Klein), it is also sent to me for my comments and a congratulated.
AAGBI activities;
To have a chance of being successful, applications for funding decision. I receive around six submissions each month and we aim
must clearly demonstrate how the proposed project meets one to get a decision to authors within two weeks. Thus far I have helped The advert for the next Trainee Fellow features in this month’s issue
Selection will be by a panel consisting of the Editor-in-Chief, an Editor
or more of the above aims, as well as providing value for money. several authors get their work accepted for publication, and I plan of Anaesthesia News and, just as Annemarie did, I wholeheartedly
and a GAT Committee representative.
The deadline for applications is 12:00 Friday 20th April 2018 on subediting at least three accepted articles. recommend it to all interested in further understanding the research
process. Regardless, we must find someone to take over in
Decisions on these applications will be made at the NIAA grant Applications must be received via email by midnight on 31 May 2018
Peer review and subediting aside, the roles and responsibilities of September, as I will be cycling from London to Dublin with others
committee meeting in June. to anaesthesia@aagbi.org, and should consist of:
the Trainee Fellow continue to evolve. Our projects, which usually from the AAGBI and there is a good chance I may need a few
focus on aspects of publishing as supervised by one or more editors, months off to recover!
For more information and to apply visit 1. A brief (max. half-page) CV, to include your current position,
have produced some excellent outputs. My project – a review of the
www.niaa.org.uk/article.php?newsid=597 AAGBI membership number and CT date;
reporting, quality and conversion of pilot studies in the anaesthetic
2. A summary (max. 300 words) of a) how you meet the criteria; b)
literature over the last ten years – is well underway, and we hope to Mike Charlesworth
what you can bring to the Fellowship; and c) what you hope to
present some preliminary results at Annual Congress in Dublin in Trainee Fellow, Anaesthesia and ST6 Anaesthetics,
gain from it;
September. Social media is an increasingly important area where Cardiothoracic Anaesthesia and ICM, Wythenshawe
3. In your covering email, please include: i) the name and
journals can increase their impact and Anaesthesia is ahead of the Hospital, Manchester
email address of your current or immediate past Educational
game. In addition to running the Twitter and Facebook accounts,
Supervisor, who must be available to respond within a few days
myself and Andrew write a popular monthly blog to accompany
if contacted shortly after the closing date; ii) a statement that you
each issue of the journal [4]. The editors meet four times a year, References
hereby commit to informing the Editorial Office if you are offered 1. Charlesworth M. How green is your gas? Anaesthesia News 2009; 267: 22–3.
including two meetings at AAGBI conferences where our popular
or take up a non-training position between the date of application 2. Yentis SM. How to design a study. Anaesthesia News 2009; 267: 13–4.
‘How to publish a paper’ workshop is delivered. I have also, thus far,
and the beginning of the Fellowship. 3. Docherty A. A year as an editor in training. Anaesthesia News 2017: 356: 5.
contributed an editorial, several letters and a Statistically Speaking 4. https://theanaesthesiablog.wordpress.com
Anaesthesia News April 2018 • Issue 369 7
Anaesthesia Study Tour to Japan
Panel of Quality Assurance
assessors for Learn@AAGBI videos 12 – 23 September 2018
The AAGBI makes videos from its three major annual conferences (Winter Scientific Meeting in
January, GAT Annual Scientific Meeting in May/June, and Annual Congress in September), and
occasional other activities, available online on Learn@AAGBI as a powerful educational resource.
The AAGBI has a rigorous Quality Assurance process that includes on-site assessment by a
member of Council. In addition, all videos are checked and undergo further Quality Assurance
before being added to the Learn@AAGBI platform.
The Education Committee is now seeking to appoint additional members to its Quality Assurance
Panel, to assist with this process. We anticipate 1-3 videos to review per Panel member during
the few weeks following each conference, using a standardised assessment template. Training/
support will be available as appropriate/required.
We welcome applications from all sections of the membership, but Irish, international and SAS
(non-consultant non-trainee) doctors are currently under-represented on the panel.
Interested candidates must be AAGBI members and can be of any grade; they should have a
clear interest in medical education. Applications should be by email to learn@aagbi.org and
should include a brief (< 300 words) personal statement describing their suitability for the
position. Appointment to the Panel is for three years in the first instance.
For further information please contact Dr William Fawcett, Chair of the
Education Committee, via learn@aagbi.org. The closing date for applications
is 31st May 2018.
The Torii Shrine near Hiroshima
RA-UK ANNUAL SCIENTIFIC MEETING 2018
SWANSEA | UK • Travel through this fascinating country where ancient history jostles with neon modernity and Zen
serenity with heaving humanity, while gaining real insight into anaesthesia.
The • The tour is led by David Wilkinson, past President of
Preoperative the World Federation of Societies of Anaesthesiology
Association and Vice-President of the AAGBI.
• Visit a range of prestigious hospitals in Tokyo,
Hiroshima and Matsuyama, meet Japanese
ADVANCED PREOPERATIVE CARDIAC anaesthetists and visit the Kobe Japanese Museum
AND RESPIRATORY INVESTIGATIONS of Anaesthesiology.
SPEAKERS INCLUDE THURSDAY 10TH MAY STUDY DAY FOR DOCTORS • Take the bullet train from Tokyo to Hiroshima to
▌ Dr Michael Barrington 2018
visit the Peace Park, cruise across the Inland Sea to
(Melbourne, Australia)
Liberty Stadium
Updates and Workshops
17th May 2018 Matsuyama and visit the famous castle and gardens,
▌ Dr Mathias Desmet (Kortrijk, Belgium)
The National Waterfront Museum
AAGBI, 21 Portland Place, London, W1B 1PY travel via the Naoshima ‘Art Island’ to Kobe and
▌ Prof Graeme McLeod (Dundee, UK) Gala Dinner explore traditional Japan in Kyoto.
▌ Dr Kariem El-Boghdadly (London, UK) TOPICS TO INCLUDE: Respiratory Function Tests / Transthoracic
FRIDAY 11TH MAY 2018 Echocardiography / Preoperative Biomarkers / Stress • Partner programme available.
Brangwyn Hall
Echocardiograms / Interpretation of Cardio-pulmonary
TOPICS INCLUDE Scientific Conference Day
Exercise Tests / Preoperative Non-invasive Cardiac
▌ Innervation of the hip joint Output Measurement
▌ Applications of Fascia Iliaca Block
For further details and a brochure, please contact:
▌ Safety aspects All of our Study Days are at a subsidised price of
▌ Critical evaluation of Quadratus FOR MORE INFORMATION OR TO
£99 for members and £125 for non-members Tel: +44(0) 20 7223 9485 info@jonbainestours.co.uk
Lumborum Block REGISTER PLEASE CONTACT
WWW.RA-UK.ORG
▌ Using US Skills Beyond RA For full details and to book your place visit our website or call www.jonbainestours.co.uk/anaesthesia
W: WWW.PRE-OP.ORG / T: 020 7631 8896
A tale from another health system
NHS-bashing is a national pastime in the UK and it’s a popular notion that some other health systems are much better,
so I thought your readers might be interested in my own experiences as a patient in one European country. I can report
that it’s not always wonderful away from our NHS.
For more than 20 years I have had paroxysmal atrial fibrillation (AF) I woke up intubated, with my arms tied to the bed. Someone It seems as though this health system works well if you are on the
associated with a mitral valve repair done at the Royal Brompton eventually took the tube out. (That’s the second time I have woken right conveyor belt and everything goes to plan. My complications
Hospital, London, and have had ablations in both Britain and up with a tracheal tube in place and I urge my younger anaesthetic seemed to make a nuisance of me. I did not receive good care.
elsewhere. About a year ago I went to my local GP (in my west colleagues to try it for themselves sometime, before insisting on
European retirement country) with another bout of AF and he awake extubation for their patients. For the short period before The official discharge descended into farce. I was wrapped in
referred me to a cardiologist at a hospital about two hours away, a extubation it’s more memorably unpleasant than a thoracotomy sterile paper, strapped to a trolley and taken home in the back
centre of excellence. The door-to-door taxi service, provided by the incision). A doctor explained there had been some bleeding but of an ambulance, despite my telling them I had been mingling
state, guided me through the ultra-modern reception area, handing no fall in blood pressure and now it was OK. Due to non-sterile with the crowds down in the foyer drinking orange juice a few
over to the nurses on the ward – though this dated from the 1970s techniques on ICU while inserting a urinary catheter, multi-drug- hours before. The ambulance became lost so I had to undo all the
and showed it. There was no doctor around and to my surprise resistant E. coli was introduced and septicaemia developed a few wrappings to sit up and direct them. Two hours later, we arrived
I found myself at the end of a list to have coronary angiography, days later. home, the rear door was opened and I walked straight out instead
without any explanation. After a 9 hour wait, I was placed on the of being carried. The ambulance driver was outraged as I hugged
X-ray table, prepped and draped, and the doctor, meeting me for the However, having been extubated, I was sent to a distant surgical my wife: ‘He’s infectious’ he shouted, waving rubber gloves at her
first time and noting sternal wires on his screen, asked ‘Oh – have ward and knew only that it was the afternoon of the next day, I had to put on.
you had an operation?’ I told him I already had a normal angio and assorted tubes and lines and something must have gone wrong.
had been referred to him for management of my AF. Thank God for the mobile phone so I could text my wife, who talked I never heard from that hospital again (except for a 4 month routine
to my brother (also a doctor), who then contacted the cardiologist follow-up appointment) and asked my GP if he had received any
The angio was again normal and, without stents to insert, there was to find out some of what had happened. report, which he sent to me. There were no surgical notes or
no further interest from this doctor. Before discharge the next day record of the thoracic haemorrhage, transfusion, ICU stay, etc.
(still in AF), I left a note in the suggestion box recommending they Two days of postoperative AF had apparently reverted to sinus The E. coli infection had never happened; it was all business as
try ‘history – examination – investigation – diagnosis and treatment’ rhythm, yet for 4 days no cardiologist came near and there was no usual. After 2 months, I contacted the cardiologist asking about
as an excellent method of practising medicine. I got a reply some monitoring. Somewhat befuddled, I finally realised that I no longer the surgical notes which were ‘Still being typed’. It seemed as
months later acknowledging my complaint but claiming ‘there was seemed to belong to anyone. I was surgical but the surgeon thought though everything would be nonchalantly shrugged off.
no irregularity found in their billing procedure’. he had just stepped in to help a colleague and stepped back again.
He left no record of his operation. On one occasion, he passed the Later I went to see the GP for a prescription. He put his head in
By circumventing the regular channels, I did eventually receive bed on his way to see one of his own valve patients and stopped his hands and apologised on behalf of the health service. He is
a consultation with another cardiologist at a nearby world centre on the way out. close to retirement and said that in his entire medical career he
of excellence to review my AF (which had by then spontaneously The septicaemia responded to meropenem, which had to be had never come across a patient treated so badly.
reverted to sinus rhythm). He was adamant the AF would return, ‘Oh’ he said, surprised, ‘I operated on you’. given for 15 days for some reason – ‘multi-drug resistant’ being
that I needed another ablation, and should continue the amiodarone ‘Really?’, said I, ‘what for?’ equated with ‘highly contagious’ or ‘highly pathogenic’. Thus I I still have fond memories of my three admissions to the good old
(which I had never been on). ‘I drained 3 litres of blood from your chest cavity and pericardium’. was declared infectious, moved to a single room and confined Royal Brompton Hospital, even if that was 10 and 20 years ago.
‘So, I was transfused?’ was all I could think of to ask. there with barrier nursing. In fact the contamination was hospital It’s a great institution. As is, generally, our National Health Service.
This time I was first on the list but at this (also 1970s) hospital the ‘Yes, about 6 units’ he said gaily. acquired, since I had come in from the purity of the local
ablation, conducted under midazolam, went horribly wrong. A countryside. The patients’ showers were permanently out of order
rare event called ‘steam pop’ occurred; if the electrophysiologist This explained the excruciating pain in my chest for which, being in the entire hospital (blocked drains), the food was tasteless and
lingers too long in one place or tries to do too much during one unable to move and with the dressing out of sight, I had not yet inedible, so, unwashed, I sneaked past the ‘barrier’ to the café on
burn, the irrigating water is explosively vaporised by overheating at found a cause. After seeing the astonished look on my face, he beat the ground floor to eat. I met the surgeon down here as well – a
the catheter tip, like a steam bubble in a kettle. There is an audible a hasty retreat. charming man, and we chatted over a snack. He explained he
Paul Fenton
‘pop’ heard through the chest wall. Even more rarely, this bubble had diverted me from going on cardiopulmonary bypass and had
Retired Professor of Anaesthesia,
of steam can blow a hole in the atrial wall, as occurred in my case. Eventually the radial artery line was removed. I counted ten different decided on a lateral incision instead.
College of Medicine, Malawi
Tamponade rapidly ensued. Percutaneous aspiration drained half attempts at cannulation. One was well wide of the mark, somewhere
a litre but the blood continued draining, despite reversal of the over the median nerve, and worth a photo. Perhaps there had been After a second weekend, wasting away, I said I was going to walk
heparin (this much was in the hospital report), so we proceeded to no pulse at the time. Suddenly a strange realisation dawned – those out and take a taxi home unless they discharged me. This was a
theatre for an emergency thoracotomy during which 3 litres of blood multiple puncture marks spoke of a period of pandemonium during bluff, but by this time some progress was necessary. Therefore,
were drained, the myocardial hole closed, followed by overnight an episode of shock. The breezy explanation I had received in the domiciliary intravenous treatment was quickly arranged and a taxi
ventilation on ICU with 7 units of blood cells and plasma transfused. ICU had been untruthful. I was, in fact, lucky to be alive and to have ordered. The nurses were efficient, professional and pleasant.
an intact cerebrum. They said I was a good patient – having put up with it all.
10 Anaesthesia News April 2018 • Issue 369 Anaesthesia News April 2018 • Issue 369 11
Particles
Sessler DI.
Decision support alerts: importance of validation
Anesthesiology 2018; 128: 241–3.
Background
Electronic anaesthetic records are now widely used and it seems likely that in
Cooper J, McQuilten Z, Nichol A, et al. for the TRANSFUSE Investigators the near future all hospitals will have them. It is relatively easy to add decision
support functions to them, providing interpretation of the recorded variables and
Age of red cells for transfusion and outcomes in critically ill adults thus giving clinicians’ guidance about patient management. This paper looked
at an evaluation of one of these systems used in clinical practice.
New England Journal of Medicine 2017; 377: 1858–67.
Methodology
Background This paper critically appraises the evaluation of a Decision Support System,
Critically ill patients regularly receive red cell transfusions [1] during called AlertWatch and designed by Kheterpal et al. [2]. This system aims to
hospitalisation. These red cells are stored for up to 42 days or 35 days provide the clinician with advice on avoiding hypotension, limiting tidal volumes
depending on jurisdiction. At present, routine practice is for blood banks to and guiding appropriate fluid management. The investigators used two different
issue the oldest compatible red cells for transfusion. However, uncertainty control groups: one from 22 months prior to the system being available and a
exists as to whether the changes these cells undergo during storage, so-called contemporaneous one where clinicians did not use the AlertWatch system for
‘storage lesions’ affect patient outcomes. Two recent studies, the ABLE (Age advice. The chosen end-points for evaluating the system were various process
of Blood Evaluation) trial [2], and INFORM (Informing Fresh versus Old Red measures, myocardial and kidney injury, hospital length of stay and mortality.
Cell Management) trial [3] failed to show any benefit to transfusing fresher red Use of the system during the study period was left to the discretion of the
cells; however, a meta-analysis including these studies also failed to exclude treating clinician.
harm from current practice. The investigators of TRANSFUSE hypothesised
that transfusion of the freshest-available red cells would improve mortality. Results
Three main sources of bias in the study design were identified. First, time-
Methods dependent confounding, where outcomes improve over time with subtle,
This was a multi-centre, randomised, double-blind parallel-group trial unquantifiable changes in management and so attributing improved outcomes
conduced across 59 intensive care units in five countries (Australia, New to one single change, i.e. the decision support system, is unfounded. Second,
Zealand, Ireland, Finland and Saudi Arabia) between November 2012 and the Hawthorne effect, where the investigator has a vested interest in improving
December 2016. The primary outcome was 90-day all-cause mortality. Any the study outcomes and so the subject is affected by the awareness of being
adult admitted to ICU with an anticipated stay of more than 24 h who their observed. Third, regression to the mean can give a false result when the
clinical team felt needed a red cell transfusion was eligible. Participants intervention is implemented in response to a random increase in the study
were randomly allocated to receive either the freshest-available compatible outcomes that happened prior to the intervention and would have reverted to
red cells or the oldest-available compatible red cells (standard practice) baseline incidence anyway.
(note, this was 35 days in Ireland, New Zealand and Finland, and 42 days
in Australia and Saudi Arabia). The treating medical and nursing staff, Discussion
statisticians and research team were blinded to the allocations. Two staff The author comments that before and after studies are often invalid due to these
members not involved in the direct care of each patient checked the products sources of bias, but this study did include a contemporaneous control which
and concealed the collection and expiration date with opaque stickers. could have been randomised. Unfortunately, this was not done, leaving the
study open to selection bias because allocation was decided by the clinician
Results present.
Of 6363 eligible patients, 4994 were randomised and 4919 were included
in the primary analysis, with roughly equal proportions in each group. The The apparent benefit of this system was much greater when compared with
baseline characteristics of each group were similar, and the groups received the historical control, but it showed little difference when compared with the
4.1 and 4.0 units of red cells, respectively. The mean storage duration of red contemporaneous control group. This highlights how unreliable the before and
Call for nominations for the AAGBI cells was 11.8 +/- 5.3 days in the intervention group, and 22.4 +/- 7.5 days
in the control group.
after study design is. In the contemporaneous control group, there were small
improvements in process measures, but none in the outcome measures. The
lack of outcome benefit does not necessarily mean the system does not work
& AAGBI Foundation Awards In the intervention group, 90-day mortality was 24.8%, and 24.1% in the
control group (absolute risk difference 0.7% [95% CI, -1.7–3.1]; unadjusted
and the system presents physiological data in ways that may help clinicians
manage more subtle aspects of anaesthesia.
odds ratio, 1.04 [95% CI, 0.91–1.18]; p = 0.57).
Conclusion
Nominations are sought for the following awards: • The promotion of study and research into anaesthesia This paper gives an interesting appraisal of study design for evaluating a new
There was a small statistically significant increase in non-haemolytic red
and related sciences and the publication of the results cell reactions in the intervention group. Subgroup analysis showed a small clinical decision tool. Validation of a new decision support system should be
The AAGBI Award is awarded by the Board of Directors of of all such study and research. increase in mortality in the intervention group among patients with an based on robust study design and therefore randomisation would have been
the AAGBI to those who have made significant contributions • The advancement of patient care and safety in the field APACHE-III score >21.5% more appropriate. The author comments that this may have been too onerous
because of the number of patients required to demonstrate significance.
to the AAGBI, its objects and goals, or its members. The of anaesthesia and disciplines allied to anaesthesia in
award is not restricted to members of the AAGBI. The current the UK, Ireland and anywhere else in the world. Discussion
There was no benefit for critically ill adults with transfusion of the freshest- The author suggests use of an alternating intervention approach, with multiple
objectives of the AAGBI are: available red cells. There was a small increase in febrile non-haemolytic cycles of alternatively using and excluding use of the system. Changes in
• To advance and improve patient care and safety Nominations should take the form of a short description reactions with fresh red cells, but its clinical significance is uncertain. This practice over time would then be comparable during the crossover period and
in the field of anaesthesia and disciplines allied to of the nominee’s contributions (no more than one side of trial therefore supports current standard practice of transfusing the oldest the Hawthorne effect can be averaged out.
anaesthesia. A4 paper*). Self-nomination is acceptable. If you nominate compatible red cells first. This is significant, as a finding in the other direction
In summary, while decision support systems like this may intuitively seem to
• To promote and support education and research in someone else, you should gain their approval for your would put blood banks across the world under huge pressure to deliver the
freshest-available red cells to critically ill patients, with significant resource provide benefit, the guidance provided by this system only provided modest
anaesthesia, medical specialties allied to anaesthesia nomination. The closing date for nominations, which should implications. Thus it puts to rest the question over whether fresh red cells benefit, which supports the author’s assertion that they should be formally
and science relevant to anaesthesia. be sent to honsecretary@aagbi.org, is 25 May 2018. are better. tested in the same way as any other medical interventions.
• To represent, protect, support and advance the
Bence Hajdu1, Andrew Selman2
interests of its members. The AAGBI’s Honours and Awards Committee will consider Eoin Kelleher
SAT 3, University Hospital Galway, Ireland Peri-operative Medicine Fellow, 2ST6 Peri-operative Medicine Fellow, University
1
• To encourage and support worldwide co-operation nominations at its meeting on 08 June 2018, and will make College Hospital London
between anaesthetists. recommendations to the Board of Directors of the AAGBI References
and the Board of Trustees of the AAGBI Foundation, which 1. Walsh TS, Garrioch M, Maciver C, et al. Red cell requirements References
The AAGBI Foundation Award is awarded by the Board will determine the recipients of the 2018 AAGBI Awards and for intensive care units adhering to evidence-based transfusion 1. Kheterpal S, Shanks A, Tremper KK. Impact of a novel multiparameter
decision support system on intraoperative processes of care and
of Trustees of the AAGBI Foundation, the AAGBI’s charity, AAGBI Foundation Awards. The successful nominees will be guidelines. Transfusion 2004; 44: 1405–11.
2. Lacroix J, H.bert PC, Fergusson DA, et al. Age of transfused blood postoperative outcomes. Anesthesiology 2018; 128: 272–82.
to those who have made significant contributions to the informed shortly afterwards. The awards will be made at the
in critically ill adults. New England Journal of Medicine 2015; 372:
AAGBI Foundation, its objects and goals. The award is not AAGBI’s Annual Congress in Dublin (26-28 September 2018) 1410–8.
restricted to members of the AAGBI. The current objectives or at WSM London 2019 (09-11 January 2019). 3. Heddle NM, Cook RJ, Arnold DM, et al. Effect of short-term vs. long-
of the AAGBI Foundation are: term blood storage on mortality after transfusion. New England Journal
• The advancement of public education in and the * Minimum font size = 12 pt of Medicine 2016; 375: 1937–45.
promotion of those branches of medical science
concerned with anaesthesia, including its history.
Anaesthesia News
Anaesthesia News April
April 2018
2018 •• Issue
Issue 369
369 13
ANNUAL CONGRESS Join us in Dublin
for Annual Congress 2018
DUBLIN, IRELAND
26-28 Sept 2018 Convention
Centre Dublin
AAGBI’s flagship meeting for
the international anaesthesia Time to shine
community comes to Ireland There are many ways to be recognised and rewarded at Annual Congress 2018.
Abstract submission is now open
Discounted
rates for AAGBI
BOOK TODAY Have you worked on an interesting project or clinical case? This is your chance to present your findings at Annual Congress
2018. You can submit an abstract in the following categories: audit and quality improvement, case reports, original research
and survey.
members
SAS audit prize Roddie McNicol safety prize
Calling SAS anaesthetists to submit an abstract for the Showcase how you and your team have improved safety in
AAGBI SAS Audit Poster Prize. anaesthesia. The prize is open to members of the AAGBI.
Your project could involve an individual, department,
medical students or allied health care professionals,
provided the project lead is a member of the AAGBI.
The winner will receive a cash prize and will be invited to
Barema and AAGBI make a 3-minute presentation about their safety project at
Annual Congress 2018.
environment award
Remember…The winners and runners up will receive cash
Demonstrate how your project related to prizes, and all accepted abstracts will be published in an
anaesthesia, intensive care or pain management online supplement of the international journal Anaesthesia.
has had and will continue to have a measurable
beneficial effect on the environment. The winner will "Being able to publish my abstract in Anaesthesia is
receive a cash prize and a grant for further support a great accomplishment and winning the first prize
and development of the project. is the jewel in the crown".
High-profile Keynote speakers, anaesthesia topics, Dr Eid M M Hussein, SAS Anaesthetics,
South Tyneside NHS Foundation Trust
abstracts, workshops, social events and more
The deadline to submit is 23:59 on Tuesday 8 May 2018.
European Accreditation Council for Continuing Medical Education (EACCME) applied for.
www.annualcongress.org/content/abstracts
www.annualcongress.org
14 Anaesthesia News April 2018 • Issue 369 Anaesthesia
Anaesthesia News
News April
April 2018
2018 •• Issue
Issue 369
369 15
GAT
Association for
ANNUAL 04 - 06
SCIENTIFIC JULY 2018 Cardiothoracic Anaesthesia
MEETINg and Critical Care
in Scotland Annual Scientific Meeting
Location: Hilton Glasgow Joint Meeting with Congenital Cardiac Anaesthesia Network
Trainees, medical
Bristol
students and first Thursday 14th – Friday 15th June 2018
year consultants,
BOOK NOW!
www.gatasm.org
Call for nominations for the
Featherstone Professorship
Nominations are sought for the AAGBI’s 2018 Featherstone Professorship, which
is awarded to practising clinicians and scientists who have made a substantial
contribution to anaesthesia and its related subspecialties in the fields of safety,
education, research, innovation, international development, leadership, or a
combination of these.
Applications should be submitted using the application form available on the © Dave Pratt
website www.aagbi.org/about-us/awards/featherstone-professorship. The closing
date for applications, which should be sent to honsecretary@aagbi.org, is 25 May
2018.
CPET debate Pulmonary Hypertension
The AAGBI’s Honours and Awards Committee will consider nominations at its
meeting on 08 June 2018, and will make recommendations to the Board of Directors, Modern Management of Endocarditis Risk in Cardiac Surgery
which will determine the recipient of the 2018 Featherstone Professorship (if any)
at its meeting on the same date. The successful nominee will be informed shortly Paediatric Failing Heart Thoracic Update
afterwards. The award will be made at the AAGBI’s Annual Congress in Dublin
(26-28 September 2018).
Physiology in CICU Trainee Presentations
Featherstone Professorships are held for two years, during which the holder will be
Prehabilitation Using IT for Change
required to deliver a Featherstone Oration at a major AAGBI meeting.
www.actaccbristol.co.uk @ACTACCBristol
Is the specialty of anaesthesia a waste of medical training?
My father was a successful retail pharmacist, and had a shop Living away from home I still saw my parents frequently and often Fellowship exam (Fellow of the Faculty of Anaesthetists of the Royal
in High Road, Leyton, East London. In the 1960s when I was Dr Ward and his father met them on a Thursday evening, my father’s half day closing day, College of Surgeons), and got a post as Lecturer in Anaesthetics
about 15, he told me he had wanted to be a doctor, but as when he and my mother would drive to the West End to see a show and Hon Senior Registrar until December 1976. However after 18
the son of immigrants who had a corner grocery shop in the or film, and I would join them for a meal. My father was always months or so I felt that my future lay back in clinical rather than
East End of London, there was no way the family could afford asking about my courses, and what I had seen, and wanted as academic anaesthesia, and successfully applied for a post which
the fees. He settled for an apprenticeship at Timothy Whites much detail as possible so he could vicariously enjoy his youthful began at Queen Victoria’s Hospital, East Grinstead, and rotated
& Taylors, a chain of high street pharmacy shops, since ambition to some extent through me. I tried to oblige. Dad still felt after 6 months back to King’s. Finally I was appointed Consultant
taken over and merged into Boots, and then he entered the I shouldn’t decide too soon what my future should be until I had at the Nuffield Department of Anaesthetics, Oxford from July 1977
Chelsea School of Pharmacy, and qualified as a Member of seen it all, but it became clear he secretly hoped I would become until I retired in May 2007.
the Pharmaceutical Society of Great Britain. a general practitioner, as this is the field he came into contact with
most frequently and felt comfortable with. He was delighted when The day I was appointed Consultant I called my father to tell him I
Pharmacy suited my father as a close fit to being a doctor. He I told him I had turned my back on psychiatry. had been given a post at what I believed to be the most important
certainly had a bedside manner and empathy which came out anaesthetic department in the country, if not the world. He was very
when he was in the shop, and there were many patients who After the first year of clinical work, we began a rotation of specialty happy for me but I remember him saying, ‘Wonderful Michael,’
would come in to see him rather than have to face the dragon subjects, for a month at a time. When it came to anaesthesia, each then there was a pause, a beat too long, before he went on ‘What’s
receptionists and the crowded waiting rooms of the nearby student was allocated to one consultant for the entire month, and next, will you be a Professor?’
GPs’ surgeries. He had an excellent knowledge of treatment the idea was that we would trail around the individual lists with him
and had picked up enough about diagnosis so that he could or her (though then it was almost exclusively a ‘him’). If there was Looking back 40 years to that moment, I wonder whether our
generally give sound advice and find an over the counter no list, either we would be advised by our trainer to go to another profession has managed to educate the public adequately so that
remedy for most complaints. I never heard of him making a theatre or we had time to spend in the library. I was to be attached my father’s anaesthetic blind spot has been eradicated. Sadly,
bad mistake, so I suspect he was a cautious lay physician. to Dr Charles James. He had a reputation as being a very gentle though I believe it may have cleared a little, I suspect it has not
and genial person. He provided anaesthesia for several different been fully erased.
My earliest memories are of living over the shop and walking specialties on several sites, and additionally had started a very
through it on my way to school, and home again in the embryonic pain clinic. Dr James was an enthusiastic teacher and
evening. I suppose one could say I inhaled medicine from we hit it off from the onset. He was happy to chat during those
my earliest years so it was no surprise to anyone when I long tedious gynae cases on any subject that came to mind, be it
announced that I wanted to become a doctor, and it may have anaesthesia or model railways or even current affairs. I thoroughly
been that very decision that made my father admit his own, enjoyed every minute with him. He was a patient instructor who Looking back 40 years to that
unachieved, youthful ambition. I did well enough at school, was always happy to let you have a go, once he saw you knew
and my interests were tilted towards the sciences, so it fitted what needed doing, and were able to be taught. He was also a
moment, I wonder whether our
me well. The government of the time required no contribution heavy smoker, who needed to go out of theatre for a quick cigarette profession has managed to
to the medical school fees, and even gave all students a ever 30 minutes or so, leaving his anaesthetic trainees or students
grant to support them, even if the level of grant was subject in charge. We always knew where he was and he would return educate the public adequately so
to parental means testing. It was not until after my own sons immediately he was called. At the end of a month I was hooked on
went to college that the idea of parents or students making a anaesthesia. that my father’s anaesthetic blind
contribution to the fees was reintroduced, and that state has
moved forward to the sad position we are in now.
spot has been eradicated. Sadly,
Stung by his thoughts though I believe it may have
I did well enough in my A levels to take up an offer I had
received in response to my application to King’s College cleared a little, I suspect it has
Hospital Medical School, with the preclinical five terms leading When I next saw my father and told him I thought I had found what
to the 2nd MB exam being taken at King’s College London. specialty I wanted to pursue, he went quiet and then said to me, not been fully erased.
I enjoyed my time at the ‘Strand’, as we referred to KCL, but ‘Don’t you think, Michael, doing anaesthesia will be rather a waste
couldn’t wait to start clinical studies. of your medical training?’ Looking back, I was stung by his thoughts
but I suspect that this would have been a fairly common reaction
The course was very structured and exposed us in rotation at the time, with little understanding of our specialty outside the
to most, if not all, specialties. At that time there is no doubt medical profession (and sometimes inside too). Fortunately I
that surgery and medicine were the areas most of us felt did not take his words too much to heart, and as I never felt as
were the chief subjects. I remember at that very early stage drawn to any other specialty I made plans to begin my anaesthetic
of my training being attracted to psychiatry, largely I suspect training as soon as I had finished my preclinical year. I was able
because in my younger years I had really enjoyed a television to get a post as a Senior House Officer at King’s College Hospital Michael E Ward
series about a psychiatrist, who seemed to be able to achieve from July 1970. Consultant Anaesthetist (Retired), Oxford
miracles with his soft voice and demeanour alone. However,
this ambition was sadly wrecked when the first real psychiatrist I stayed at King’s for several years, becoming a Registrar there in
I came across was giving us a lecture on psychosomatic May 1971, where apart from a 6-month stint in Västerås, Sweden
illness and fell asleep at the lectern! as an underläkare, I continued until September 1973. I then had my
18 Anaesthesia News April 2018 • Issue 369 Anaesthesia News April 2018 • Issue 369 19How good a trainer are you? Figure 1. Spread of average score for each trainer 2016,
anonymised and in ascending order 21st Anaesthesia,
Critical Care and Pain Forum
Da Balaia, The Algarve
1 - 4 October 2018
Figure 2. Spread of average score for each trainer 2017,
anonymised and in ascending order
www.doctorsupdates.com
education in a perfect location®
As trainers we are asked to provide evidence of ‘teaching and
facilitating learning’ and reflect upon it; this is part of our annual
Given that the scoring was from two completely different groups of
trainees, the spread of trainer’s ratings have been very consistent
Anaesthesia Heritage
Museum in London
ANAESTHESIA
appraisal and our revalidation. It may become part of our personal over the two years, giving reassurance the results are reliable. There HERITAGE
CENTRE
development plan. We are all involved in training, be it on-call, in has been good correlation between scores for each individual over
Free
theatre, outpatients, intensive care etc. There is a lack of feedback the two years. Unfortunately, this has meant that the poorest three entry
from these areas which provide the majority of a trainee’s learning performers from 2016 were still in the bottom four places for 2017.
experiences. This indicated that simply giving a score and access to written
A unique medical
information on how to teach, along with the appraisal system
There are initiatives to provide two way feedback following a had not improved performance. This form of feedback has been science museum
teaching episode to both trainer and trainee, but none are widely well accepted, people are keen to have evidence for their annual devoted to the history
used or ready to use at this stage. Having given all our consultants appraisal to support their educational responsibilities. I discussed of anaesthesia
and Associate Specialists the option to opt out, I devised a the poor results with the poorer scoring individuals and this was and pain relief.
SurveyMonkey questionnaire to score each individual on how taken as a constructive interaction.
The GMC National Training Survey and summative assessment of
good a trainer they were. I used a star ranking, 1 star rated as
trainees gives us one measure of how a department is performing as
poor and 6 stars as excellent. The questionnaire was emailed to all A further questionnaire was carried out to collect more detailed
a group of trainers; but how we perform as individuals is more difficult
trainees and responses anonymised during collection. feedback for those who had scored poorly and had requested more
detail on their overall score following the original round. Scores
to assess. It seems appropriate that we ask the trainees themselves to
suggest what qualities a good trainer should have and be able to give
Brave Exhibition open until November 2018
Data collection was carried out for two consecutive years using
different cohorts of trainees. Each individual trainer was emailed
on credibility, approachability, communication skills, enthusiasm,
mutual respect and willingness to meet training needs were
feedback based on those qualities while we in turn assess them on an Faces
RCoA curriculum on both formative and summative formats.
their own score, the average for the whole department, and where gained. This supplemental questionnaire was done after feedback Powerful
stories of facial
they were in the ranking from top score to bottom score. The email to the trainer which may explain why the results were good and
reconstructive
included a graph showing distribution of scores, no details were did not indicate poor performance in the areas trainees considered surgery during
given on anyone else’s score to maintain confidentiality; the email important. This aspect of timing will be altered next year to make World War I
also included the RCoA Anaesthetists as Educators booklet as a the results more pertinent. Mark J Fairbrass
gold standard against which to reflect (Fig. 1). Consultant Anaesthetist, Bradford Teaching
The survey will be repeated annually in an attempt to raise training Opening hours: Monday to Friday 10am-4pm (last admission
Hospitals NHS Foundation Trust 3:30pm). Closed on Bank Holidays. Booking recommended.
Using their own score, trainers could easily see if they were an standards. It does require trainers who are open to being assessed
outlier from the graph, thus providing information for appraisal and ranked, something we may have become far removed from as *Declaration of interest: I am a clinical and Visit www.aagbi.org/heritage
and reflection. The cut off for 'poor performers' was done at two consultants and may therefore not be suitable for all departments educational supervisor
standard deviations from the mean score, although the data is not or individuals. Some may see it as criticism, which it is not – it is a
Find us at: The Anaesthesia Heritage
normally distributed it did fit nicely with the clear visual fall off point device to identify areas where individual training may be improved. Centre, AAGBI Foundation,
on both graphs and provided some justification in highlighting the The feedback has always been constructive including support on 21 Portland Place, London W1B 1PY
'poorest' performers to themselves (Fig. 2). how to improve training. Registered as a charity in England and Wales no. 293575 and in Scotland no. SC040697.
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