anaesthesia points west

ANAESTHESIA POINTS WEST
WINTER
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THE SOCIETY OF ANAESTHETISTS OF THE SOUTH WESTERN REGION
PRESIDENT: DRR. M. WELLER Frenchay
\rICE PRESIDENT: DRR.
J.
ELTRINGHAM Gloucestershire Royal
PRESIDENT-ELECT: DRR. W. JOHNSON UBHT
HOLDER
HONORARY TREASIIRER: DR P. RITCHIE
COMMITTEE: DR J. CARTER
DR J. PURDAY
DR S. COURTMAN
DR E. HOSKING
EDITORIAL COMMITTEE: DRP. McATEER
DR N. WILLIAMS
Mrs D. FOSTER
HONORARY SECRETARY: D. K.
Southmead
Cheltenham
(Past llonorary Secretary) Frenchay
Royal Devon and Exeter
(Trainee Representative) South West School
(Trainee Representative) Bristol School
(Editor) Royal United Bath
(Assistant Editor) Gloucestershire Royal
(Secretary to Editor) Royal United Bath
ANAESTHESIA POINTS
WEST
CONTENTS
Winter,2001
Vol.34 No.2
Page
Editorial I
J
Editorial2 / Future Meetings
4
Citations for Honorary Memberships
the Society
News of the West
Examination Successes and Honours
Spring Meeting of the Society
of
5
10
2t
Kathryn Holder
22
John Carter
Robin Weller
Emma Hosking
Ruth Taylor
) Peter Young
Tim Cook
Limericks of Barcelona edited by
Annual Trainees Meeting of the Society
Anaesthesia for Electro-Convulsive
Therapy in Late-Trimester Pregaancy
An Anaesthetist's Dilemma
\
Nick Brown
Aileen K Adams
Tessa Whitton
At the Receiving End
.A Herpetic Weekend in California
"Anustheshuh!" - Revisited
Another Young Man Goes West
GP Anaesthetists: Doers or Dodos
Anaesthesia for Paediatric Cardiac
Surgery with Profound Hypothermia
Can I Have Another Assistant Please?
Pay up, pay up and play the game
Book Reviews - Awareness During
-
30
32
36
38
40
42
Ed Morris
Martin Coates
45
48
John S. Zorab
Spencer
Goodman
Clare Stapleton
Ruth
50
Neville
52
Anesthesia
-
28
Conducting Research in
Anaesthesia and Intensive
Care Medicine
Board Stiff Too - Preparing
for Anesthesia Orals
Rob
- Low Flow Anaesthesia
- Practical Fibreoptic
Sneyd
54
55
Anne Thornberry
56
Jan Baum
Jean Waters
51
David Gabbott
59
Roger Seagger
60
James Pittman
62
64
58
Intubation
-
Resuscitation in Pregnancy
A Practical Approach
The New Pickwick Papers
(The Diary of a Gas-been)
Pittrnan on Plonk
Correspondence - Letter to Editor
Poem
Crossword
Cartoon
-
\
J Anonymous spellchecker
Robin Weller
Robin Forward
Brian Perriss
Kathy Smith
Notice to Contributors
@2001 The Society of Anaesthetists of the South Westem Region
65
67
68
69
Editorial - L
'Doublethink means
the power of holding two contradictory beliefs
in one's mind simultaneously, and accepting both of them."
George Orwell 1903-50
As Winter 2001 approaches it would not be difficult
to be consumed by the current intemational sense of
"Eve of Destruction" gloom - 2lst century style. The
images of that infamous dae. September l lth, when
thousands of innocent people were massacred during
the daily round of ibeir routine office lives, shocked
the global TV vieu.ing public to its foundations. In
the phenomenally horrific- but spectacular and truly
televisual, blizing of those tu-in towers in New York
our world changed too: it $'as an irony that they were
hit by American planes. filled with American
passengers, although hijacked by dedicated suicidal
enemies of all things Anerican. Not all who died in
New York were Aneri€rr. of course, and some may
even have harborred rm-American ideas (for all we
know). New York fire-fighters were the immediate
symbolic heroes: their bravery and fortitude
deservedly receir-ine u-orld*'ide recognition. An
urgent and appropriate response to this unparalleled
attack was vital- Clearly friends had to rally round!
The culprit was identified promptly and our Prime
Minister was the first all)'of the USA to respond. So
now we are engaged in a just and unavoidable" war
against international terrorism; bombs and food
parcels rain on Afghanistan; anthrax is killing
innocent American postal sorkers (George Doubya
is, no doubt, on -cipro-): u-orld nade has collapsed
(or at least wobbled); los of jobs in aviation and
other industries bave b€en lost all over the western
world, and there is still escalating violence in the
Middle East. It does not soem hyperbolic to state that
sensational and sinister forces have been unleashed
upon an uncertain s-orld-
In this context, it seems elmost indecent to allow
ow thoughts to dwell on relatively minel issus5, sush
as the continued worsening inadequacies of the
National Health Service, as the workaday
anaesthetist goes on with her or his daily routine. No
beds; therefore mid u'eek elective lists cancelled;
therefore extra waiting lis initiatives performed by
some consultants, at premium rates, during the week,
and at weekends often rvhile emergency cases stack
up. Horrendous gaps in the trainee on call ranks,
brought about by the two-pronged effect ofreduced
junior hours and Calmanised training, are covered
by consultants "acting down", for a variety of
locally negotiated arrangements. Sometimes these
extracurricular consultant activities run
simultaneously!
In some Trusts, a knee jerk reaction to accept the
recommendation of vested interest groups such as
MDA to discard anaesthetic circuits labelled, by
them, "for single use only" after each patient - even
when airway filters had been used - has wasted
thousands of pounds in a couple of months. However,
common sense will soon prevail on this one issue
alone, thanks to ordinary anaesthetists reporting their
views in sufficient numbers through bodies such as
the AAGBI and the RCA. Of course the fact that
manufacturers realised that they would not be able to
keep up with the newly created demand may have
been a more significant factor! Who knows what will
be the next unexpected event to change our lives?
So let us be cheered by some good news. There
seems to be a hopeful new peace agenda in Northern
Ireland (at the time of writing, at least!). Perhaps this
is one benef,rcial result of the anti-terrorist backlash
following September l lth. Also, when all is said and
done, the average NHS anaesthetist can only begin to
imagine the hardships encountered in the daily
routine of an Afghan farmer in Winter 2001. For us,
patients still appear as interesting and rewarding as
ever; colleagues, however beleaguered,
as
comradely; and trainees as bright, innovative and
optimistic as ever. This would be a very good day to
introduce one of the representatives of the up and
coming generation of SASWR members. In the
following editorial Simon Courtman outlines the
steps he has taken on our behalf to set up a website
for the society. So here's to our future, whatever it
holds!
Tricia McAteel
Editorial - 2
Into the Web: www.saswr.co.uk
"If the CIA and the Chinese government can't control the Internet,
what chance do a couple ofblokes on Tottenham Court Road have."
- Advertising
I have always considered myself a quite sporty
and
sociable individual, so the acquisition of the position of
Society Webmaster, or anorak, has been troubling me.
With the relentless quick march of information technology,
anyone who used to play with a ZX8l and has a
willingness to regularly waste a few hours tinkering on a
desktop PC, can suddenly find himself or herself in my
position.
There can be few, except the most stubbom ostrich, who
have not had experience of the Intemet and its millions of
web pages. The Intemet was conceived in the 1960s as part
of an American military strategy to
establish
communication across the world in the event of a nuclear
war. The Internet is a worldwide network of computers
(estimated to be in excess of 50 million) that share one
language and are able to communicate with each other. In
the last decade, the Internet has continued to grow
exponentially with the number of websites currently
estimated at 500 million, and increasing by 20 million
pages a month. The potential uses of the Internet as a mode
of communication are widespread. E-mailing has become
an integral part of our daily lives. Shopping and banking
on the Internet are increasingly common uses. A
refrigerator that orders food from Tescos for you was
recently displayed at the Ideal homes exhibition. Medicine
has also found an increasing number of uses for this
technology e.g. Medline, discussion forums, societies,
joumals, and exam revision. It is relatively simple to have
the table of contents of any medical joumal sent to yow PC
each month. Most large centres have their own websites
providing information about hospitals and departments for
both patients and professionals. Similarly most Colleges
and societies are represented and provide easy rapid access
to information for members.
Therefore it became apparent that a society with the
stature of SASWR should take the step (if somewhat
murky) and throw itself into the web. Now I have noticed
Standards Commission
that when one starts discussing how to build a website at a
dinner party, there is a very rapid glazing ofeyes followed
by a stampede to the bathroom from where sobbing noises
emanate. The truth is, the technical process of placing a
website on the worldwide web, is a lot simpler than most
people realise. You simply rent some web space (similar to
renting office space) on a big computer, integrated with the
Internel and fill it with your information. The diffrcult part
is knowing what i-nformation to put on the website. Ideally
this should be relevant, concise, up-to-date and easily
accessible. lndividuals surhng the Intemet have an average
attention span of 5 seconds per web page visited
emphasinng the need for clarity and conciseness.
With these thoughts in mind, we have constructed a
*-ebsite for the socieq'- It is a simple site conveying the
information mos useful to both existing members as well
as to non-members risiting the site to leam more. It is still
in is infancy and uill continue to evolve as it becomes
clear s'hat indisiduals s'ant from such a site- We are
currently in the process ef iasluding the joumal on the site
and possibll'a links page although these seem to be
el'eryntere. This is a continual leaming process for me as
well and the simplest tasks can become the greatest
obstacles- The greatest challenge so far, surprisingly, has
been making the site visible to search engines e.g. Yahoo,
Excite, Google which is remarkably tricky without
spending a fair sum of money.
There will undoubtedly be a few teething problems so
please forgive the odd inaccuracy which I will always
blame on a virus or dodgy software on your computer. In
the mean time, the site can be found directly on
www.saswr.co.uk.
most welcome and
All your thoughts and comments are
I will do my best to respond to them
and integrate requests into the site where appropriate.
Simon Courtman, SpR in Anaesthesia
([email protected] - it's a long story)
Future Meetings of the Society
Autumn Meeting 2001
Bristol
2kd
and 24th November 2001
Spring Meeting 2002
lTth and lSth May 2002
Exeter
Autumn Meeting 2002
22nd and 23rd November 2002
Bath
Honorary Life Memberships to
The Society of Anaesthetists of the
South Western Region
At the most recent
SASIAR committee meeting
it was decided to confer the highest award of
the Society on three
individuals who have in their dffirent ways served the speciality of Anaesthesia, particularly in the South
Western Region x'ith great distinction. Each has held SASWR Presidential Office and served the socieQ
diligently and lo1,all1, over many years. There follows brief citations from close colleagues to these three eminent
persons. Thq,are: Geoffrey l4/inspear Burton, Cedric Prys-Roberts and John Stanley Mornington Zorab.
Geoffrey Winspear Burton
Dr Geoffrey W. Burton was born in Yorkshire
between the wars. He was educated in his home
county and was an honours BSc student at the
University of Leeds before proceeding to his
medical studies at the same university. He graduated
from Leeds in 1950 and obtained his first postgraduate degree, the D Obst RCOG 18 months later.
He was then conscripted into the army under the
national service regulations at the time and was
quickly sent overseas. Between 1951 and 1953, he
served in Vienna, Graz and Trieste. While in Vienna
his specialty of obstetrics apparently, as far as the
afiny was concerned, also made him a surgeon and
"pox doctor". The latter activity involved the
prescription ofthe new antibiotic, penicillin, to cure
the results of the liberality of distribution of sexual
favours, common among many armed forces.
However, Geoffrey's patients didn't get better! On
making enquiries he discovered that the plot of The
Third Man was based entirely on reality. The
patients weren't getting better because the
G e offr
ey
Wins p
e
ar
B ur
ton
antibiotics were being stolen for the 'black market'.
He managed to escape from Trieste just hours before
the Yugoslav borders closed in 1953. He drove
himself to freedom. Most of us would feel that
freedom itself was sufficient, but Geoffrey in his
inimitable style, drove himself across the border and
then sold the car.
Geoffrey has always been totally dedicated to the
profession, and particularly to Anaesthesia. No
matter how late one left the hospital, Geoffrey
always left later. Mind you, he always telephoned
you, to let you know that he had changed your
treatment during the intervening time. His
dedication
it was that
and Intensive Care
set up Paediatric Anaesthesia
in the Bristol Children's
Hospital. For many years he, together with Dr Derek
Faulkner and Dr Jack O'Higgins, shouldered the
burdens of both these activities. It meant further
extended periods in the hospital, late night
departures seemed to be a way of life that suited
Geoffrey and he thrived on it. It was interesting to
note when one was involved in the Children's
Hospital Anaesthetic Services, that Geoffrey was not
really an early moming person. Although he would
always outstay you, you could easily get into the
hospital before him in the moming. It didn't do any
good of course because he would just come along
later and change the treatment plan anyway.
Geoffrey has an unvarying habit
of self
deprecation which is belied by his achievements.
His assertions that he "can't cope" become quite
reassuring when one gets to know him better. They
are, like his other bon mots, a sign that all is well.
It's when he isn't talking about "his things dropping
down" that one needs to worry about an actual or
potential problem threatening the even tenor of
anaesthetic life in theatre.
Geoffrey has a great love of Anaesthetic societies
and associations. He really is a clubable chap. He
founded the Bristol Anaesthetic Club and has been
an active member of the Society of Anaesthetists of
the South-Western Region since his arrival in Bristol
in
1959. He has been the assistant editor
of
Anaesthesia Points West and the Society's Honorary
Treasurer as well as being elected President in 1980.
His other love is the Section of Anaesthesia at the
Royal Society of Medicine. He has been a member
of that Council and its President and he is now
an
His other great London commitment was to our
College. His time as an examiner began in 1976
when he was elected as an examiner for the
Diploma in Anaesthesia. He became Chairman of
the DA examiners between 1980 and 1982 and then
the examination system changed. A transitional
period ensued when the DA was subsumed into the
new three part fellowship of the then Faculty of
Anaesthetists of the Royal College of Surgeons.
Geoffrey with his great experience and auditing
capacity was re-elected
the part
in 1983 as an examiner for
I examination. He continued with this
examination for the next 12 years. During that time,
he audited both the examiners and the exam itself.
His "statistics" became increasingly complex but in
fact they predated most medical attempts to audit
anything. During the early part of his stint as an
examiner, Geoffrey had a habit of using dubious
hotel chains whose only virtue it seemed to one who
shared Geoffrey's recommendations, was that they
were remarkably cheap. Fortunately his affection for
the Royal Society of Medicine made it a fairly easy
matter to talk him out of the lower end of the
commercial world and into the Domus of the RSM.
Sharing those episodes of examining was actually
rather like having a holiday in London. There was
only one job to do so it could be done really well.
The evenings always had an opportunity for good
food, good fellowship and an occasional visit to a
concert or the theatre. Geoffrey's skills at social
arrangement were to the fore once again. His
performances in restaurants were impressive. Indeed
on one notable occasion he made such an
impression that one of the waiters became
incredibly fond of him almost at hrst sight!
Geoffrey Budon has been an excellent colleague
providing unfailing support and wise advice when
necessary and also setting an example ofdedication
to his profession. His anaesthetic skills were never
less than impressive and he was always ready to
introduce new methods, techniques and drugs into
his practice once he was satisfied of their virtues
and advantages for his patients. I have an enofinous
admiration and affection for him. I thank him for the
invaluable help which he gave me and
I
would
Honorary Member of the Section. He hates missing
the regular monthly section meetings and, even
though not in office, still arranges post academic
meeting dinners in the Royal Society of Medicine
Dining Room. Geoffrey's dinners are well attended
recommend his example to any younger anaesthetist
who cares for the quality of his practice.
Forhrnately he has a gift for getting out of the RSM
just in time to get to Paddington and catch the last
sensible train back to Bristol.
Trevor Thomas
and closely monitored by the man himself.
6
It is entirely appropriate that we should accord
our colleague Geoffrey Winspear Burton honorary
membership of the Society that he has supported
unflaggingly for over 40 years.
Cedric Prys-Roberts
(perversely) made modern anaesthesia so safe as to
threaten its academic future. In doing so he helped
to illuminate the biology as well as the therapy of
tetanus, hypertension and cardiovascular disease and
one of his many active retirement interests is in the
biology of phaeochromocfoma.
To his heavy involvement in discovery, Cedric
added a deep commitment to dissemination
of
knowledge and best practice. He travelled widely to
honour countless invitations to visiting lectureships
and professorships at congresses and refresher
courses as well as to examinerships for higher
degrees. He has in turn been honoured by life
memberships and fellowships in Colleges and
Learned Societies of Anaesthesia and
An(a)esthesiology at almost all points of the globe.
He has been on the editorial boards of the British
Journal of Anaesthesia, Anaesthesia and Analgesia,
European Journal of Anaesthesiology and the
Journal of Clinical monitoring, as well as being
founding editor-in-chief of Current Opinion in
Anaesthesiology.
Cedric was part of a generation of anaesthetists
(academic and NHS) who had to carve out an
Cedric Prys-Roberts has been one of the most
recognisable features of the Anaesthetic landscape
for more than three decades- He has affected the
personal anaesthetic experience of countless
anaesthetists nationally and internationally, but
identity for Anaesthesia, which they did as much by
force of personality as by intellectual acumen. The
establishment of the Royal College of Anaesthetists
was a milestone. Cedric was its third President, after
sterling service on its council and several of its
advisory committees. He conhibuted in many other
ways to the establishment and maintenance of
national standards in practice and postgraduate
particularly in the South West of England.
training. He was active at various times in the
Cedric Prys-Roberts
Educated at Dulwich College
and
St Bartholemeu-'s Hospital Medical College, he
graduated from the University of London in 1959,
progressing to FFARCS in 1964. The first of his 140
original papers came in 1966, at the dawn of the
golden age of Academic Anaesthesia. Over the next
three decades, classical physiology of the
respiratory, cardior.ascular and autonomlc nervous
system were incorporated into everyday clinical
practice along with an increased understanding of
the pharmacokinetics and pharmacodynamics of
inhalational and inffavenous anaesthesia. This all led
to the implementation of minimum standards of
monitoring for anaesthesia and intensive care.
Whether from his lectureship in Leeds, readership in
Oxford, or professorships in San Diego and Bristol,
Cedric has stamped his particular mark on each and
every one of these developments, which have
councils of the Association of Anaesthetists and the
Royal College ofSurgeons ofEngland, the senate of
the European College of Anaesthesiology, the
Academy of the Royal Medical Colleges, the
General Medical Council and the Standing
Committee on Postgraduate Medical Education.
But, though Cedric walked the corridors of power,
he was at least as happy to be teaching an SHO or
medical sfudent one-to-one in theatre. When he was
"at home" (rather more often than is alleged), his
clinical commitments were top priority. He was
meticulous in every detail of his clinical practice,
and very clear on exactly why things should be done
'Just so". A trainee's list with The Professor was
something that needed ample notice and a great deal
of preparation but Cedric's aura of authority often
denied him the pleasure of no-holds-barred verbal
contest. As bef,rts a true figurehead, he led from the
front in many aspects of everyday practice. We in
Bristol were emboldened to follow where many
tread such as in the use ofepidural
opioid infusions on the general surgical wards. The
"Professorial mixture" is still to be found in daily
use throughout the South Western Region though
the results achieved by ordinary mortals may not
angels feared to
always stand comparison with Cedric's!
Even a limited knowledge of the man behind the
I was first aware of
walking a foot or so to the left. Cedric is a keen and
knowledgeable bird-watcher, though his twitching is
reserved for when some poor unfortunate waxes
Iyrical about "bolus" injections or the "mean arterial
blood pressure" (whatever that means). His
accomplishments as a trumpeter are also something
to be experienced, whether he is playing Purcell in
Strasbourg or Bristol Cathedral or jamming with the
band
in the Assembly Rooms at Bath. His
Cedric in the late 1960s as the strong silent presence
improvisation on piano with Burnell Brown is a
touching fronticespiece to their "International
behind Alex Crampton-Smith. He never seemed to
speak unless he had something important to say.
Practice of Anaesthesia".
Success at Cedric's level does not come without
image has been a privilege.
it was bound to be
important. He is a real and metaphorical
mountaineer, aiming for the top in everything he
attempts and occasionally creating the illusion of
recklessness. I experienced a moment of heightened
anxiety when, during one of his famous
Thus, whenever he spoke,
unstinting family support. This has clearly been
forthcoming, particularly from Linda. Equally,
Cedric enjoys reciprocating and derives obvious
satisfaction from the many successes of his children
and grandchildren. There cannot be many daughters
who can relish working for father as Kate patently
Departmental Walks and notwithstanding his
did during Cedric's last two years in post. But
imposing figure, he insisted on demonstrating that
retirement is payback time. Cedric's a soft touch for
baby-sitting!-
he could
still hurdle a metre-high fence as
effortlessly as in his youth. Like the others, I found
it more comfortable to
Andy Black
negotiate the fence by
John Stanley Mornington Zorab
To describe the career of such a distinguished
anaesthetist as John Zorab in 500 or 600 words is
a formidable challenge. It could all too easily
become a catalogue of achievements, clinical,
administrative, and political, so that those of you
who don't know John would recognise somebody
who's clearly had an outstanding career, but not the
man so many of us love and admire.
Let me start at the beginning with a fact few
people know. John's father registered his birth, with
his second name as Charles. His mother didn't like
it, and got her way, (of course), at the christening
when he became Stanley. As for Mornington!
After Cheltenham College, he spent a slightly
prolonged time at Guys, the highlight of which must
have been passing his mother
John Stanley Mornington Zorab
off
as Princess
Christine of Schleswig-Holstein at a hospital rugby
match and getting the RFU and Guys dignitaries to
grovel appropriately.
His anaesthetic career led, via East Grinstead and
Southampton, Copenhagen and several visits to
Queens Square, to a consultant post at Frenchay in
1966. Despite all that follows, Frenchay has
benefited hugely from John's appointment. He
started with the ITU; his leaving achievement was
the HDU. The Postgraduate Centre has the Lecture
Theatre named after him. The Anaesthetic
Europe came first, where he was made Hon.
Department has been led and cajoled by his example
and his enthusiasm to achieve far more than would
Secretary of the European Regional Section of the
have been possible without him. He has an
extraordinary ability to bring out the best in people,
to recopise talents they may not have realised they
had. He proved not only a great lateral thinker -
regularly finding solutions to insoluble problems but
has an ability to explain anything and everything so
clearly. New hospital developments call in JZ.
Problems with ENT? Who can solve it? JZI Why?
He'd read up the background and know more about
it than any of them! Director of Surgery - who else
could control this gang of prima donnas but JZ, and
this fact recognised by the surgeons who asked for
him.
Frenchay can never really repay John for what he
has done for
it, but at least it could give him
Emeritus status when he retired, the first to get it.
There are so many points to pic\ up from the big
world outside. There was the RSM)where we had a
regular Bristol group for supper after the lecture. Sir
Ivan Magill and Sir Robert Macintosh both had
John, and Tony Makepeace, to thank for the area
John arranged, with the right wiring, for the deaf.
Then the Faculty, and then College, where John was
on the Board and an Examiner. But it was as an
Association man I knew him better. Council
Member and Hon. Secretary, meeting organiser
extraordinaire, initiator of the International
Relations Committee. He served for 23 years - a
period matched only by his mate Peter Baskett and
(perhaps) one or two of the Scottish mafia. But
while these national posts would have been enough
for most ordinary mortals, John was soaring up the
international ladder too.
WFSA. This led on to his election to the WFSA
Executive Committee in 1918, and then Secretary
General in 1984. This covered a phenomenally
successful European Congress in London in 1982.
The climax of his international career came in 1988
when John was made President of the WFSA, only
the second UK President. Not a bad achievement for
a consultant from a smallish hospital on the northern
fringes of BristoM am not sure how many Honorary
Memberships John holds, but it was 6 in 1992, and
must now be well into double figures, just a sign of
the recognition he is held in around the world.
Now you may wonder what John has done since
he retired. He is still travelling to the World
Congresses. He is .deep into anaes-thetic history,
preserving memories and videos for us and our
successors. He is still writing! His opinion you will
find in anaesthetic and general journals. And all this
despite a pretty horrendous series of experiences
with some of our surgical and medical colleagues.
It is absolutely right that the Society of
Anaesthetists of the South Western Region
acknowledges one of its most distinguished
members with Honorary Membership. Indeed, we
probably should have done so long ago. His
achievements are outstanding. But despite them all,
he has remained the modest, approachable, social
chap, bursting with life and ideas, who we are all
proud to know but, much more, are delighted to
have as a friend.
Robin Weller
President
News of the West
This is where you are kept up to date on all the news and gossip from each department in the South Western
region (andfrom our member in "exile" in New Zealand). The name of the correspondent appears at the end of
each contribution and he/she is also the SASWR LINKMAN for that department. Anyone wishing to find out
more about SASI4/R or wishing to join should search out the local linhnan who will readily supply details and
application forms. In addition to other benefits, members receive the twice yearly editions of APW FREE!
Barnstaple
Welcome first to Huw Williams, his wife and
newly born son who joined us in September. Huw
and subsidise their employer by paying for the
privilege of parking at work!
is our eleventh consultant appointment and we still
need numbers twelve and thirteen to bring us up to
complement - quite where we are going to put
them is debatable as so far no extension to our
office accommodation has been sanctioned. We
rather fancy adding another storey to our present
offices, perhaps complete with roof garden, patio,
jactzzi and bar but so far there are no
developments. For now I shall continue to resist
all attempts to get me on e-mail until such time as
I have a desk of my own at least.
Two SHOs have left us, Chris Baird and James
Banfield and we wish them well. In their places
we are please to greet Simon Chapman and
Richard Parry, both of whom we hope will enjoy
their stay with us.
The highlight of our social calendar so far this
year has been a charabanc trip to the Eden Project,
which Pat Ward brilliantly organised complete
with pub lunch - thanks again Pat. A bike ride is
in the offing, weather permitting.
Other news of note should include Tony
Laycock's continuing love affair with the rota and
organising the department. Seriously Tony "you're doing very well" - less than a year to go!
And
I
shouldn't forget the associate specialist (my
wife), Ruth Whittle, who tried to set fire to the
rotameter block of an anaesthetic machine. This
was tracked down to a defective rectifier in the
oxygen analyser - said to be fizzing and too hot to
handle. The potential consequences of "sparks"
and oxygen did not escape the razor sharp
Dr Whittle and it took several bubbles both outside
(bath) and in (champagne) to restore equanimity
that evening.
So, I think enough for now,
I'm off to do battle
over the introduction of car parking charges. It
must be the last recourse of a destitute and
bankrupt NHS to ask its workers to take a pay cut
l0
Nick O'Donovan
Bath
I would like to start, in best Oscar fashion,
by thanking my predecessor Patrick Magee
who managed not only to write this news update but
also be departmental Chairman, European examiner
and University lecturer, at least. Your new
correspondent has almost no other responsibilities,
so nobody else to blame if this is profoundly
lacklustre.
Bath has been a very busy place of late, mainly on
the domestic front. We have had four weddings (no,
happily none ofthe other) but sadly no cake tasting
contests. Nicky Morgan became Nicky Weale, Sara
Gabriel became Sara Keeley, Sally-Ann Ryder has
tied the knot and Paul Hersch married Liz, a local
GP. I think it's the Spa water myself. We have also
-tcen fabulously fecund (if I am allowed to say so),
with two sets of twins. Anna Hallett and Ahilan
have both become proud parents of twosomes, and
Hannah Blanshard and Rachel Awan have both had
boys. Nobody is convincing me that's nothing to do
with the Spa water. On a more serious front, boys,
we beat the surgeons (again) at cricket. Happily,
without Bob Marjot's 'special techniques'. We are
also embroiled in a departmental
tennis
championship organised by Lesley Jordan which
will shortly culminate in a final (for the players) and
a strawberry tea (for the spectators). In fact, we only
had a departmental jolly a few weeks ago, courtesy
of Boehringer Ingelheim and ably organised by
Bruce McCormick. Somebody let Alex Mayor
choose the wine, which came out of one of the
departmental budgets, and we'll be making the
payments for some little time. In the end, we
combined senseless pleasure with Emma Hosking's
house-moving celebrations.
On a more work-related front, Bath has expanded
its empire to Westbury, where we anaesthetise for an
almost-weekly day of local anaesthetic cataract
surgery. This is inexplicably popular amongst the
department, perhaps because of the 'away day'
sensation it engenders. Back in the RUH, we have
had Kim Carter's triumph over the FRCA primary
(and subsequent Cheshire cat impersonation). Steve
Laver has become our first ITU staff anaesthetist,
and few people have been more gratefully received
into any post than he. ITU continues to be
perpetually over-full and simply unable to keep up
with the ever greater demand.
Our glamorous image has recently
been
strengthened by the arrival of two visiting overseas
anaesthetist observers (who will doubtless have
moved on by the time that you read this). Irina
Kosheleva has come over from St Petersburg and
Sabita Sreevalsan from Bombay, via Swindon where
her husband is a surgical registrar. We also have
Eleni Soilemezi, a Greek SHO, with us for the next
year. We very much enjoy the new perspectives
brought by our colleagues from abroad.
Trainee movements are, as always, hard to keep
up with. We have lost Chalam to South Thames and
Nadeem Ahmed to Canterbury. Stella Mclaughlin
briefly returned from Australia, only to join the
South West (Bristol) rotation and move to
Southmead. Christopher Baird has arrived from
Barnstaple and David Whitelock is passing through
on his way to the rotation. So no shortage of new
blood. Most recent news, Pete Ford has married
Lucinda and, courtesy ofBin Laden, spent a couple
of days of their honeymoon grounded in a motel
during an unscheduled halt in their journey to New
Mexico. CONGRATULATIONS to them and also
to Rachael Kelly and Katy Congreve who have
passed Primary FRCA!
Must go now and practice a few double faults for
the tennis championship
Monica Baird
Cheltenham
Most remarkable news from Cheltenham in the last
few months has been the transformation of our
absurdly small shoebox of a department. It involved
a month's building work, temporary rehousing in a
pink sauna, and much hard work by our secretaries,
Wendy and Betty, and ow chief, David 'Little Red
Shoes' Goodrum. The grand opening was looked
forward to with enonnous anticipation and, yippee,
we all had what we had always wanted .
a
gloriously refurbished but only very slightly larger
shoebox. Hurrahl (Only a temporary solution to the
housing problem though, we are assured.)
New (relatively) permanent arrivals have all made
contributions to the smooth running of the
department: Sunny 'The Retreat' Karadia and Ted
'And your real name?' Rees (consultants), Sean
'The patients love him' Santos, Bob 'The patients
love him even more' Cross, Rahq 'Mr Cool' Arsany
(staff grades) as well as Olly Parmar and Amelia
Sale (research fellows). Several trainees have
fought/scrapped/worked very hard to leap over one
or other of the College's hurdles over the last year:
Sudha Bechan (primary), Mike Richards Jnr and
Judith Stedeford (final) - well done to them.
Such is the physical size of our accommodation
that no one can be let in without letting someone
leave first. And so sadly we had to say goodbye to
many 'good eggs', notably Ruth Taylor, whose new
tutorial timetable we will be slavishly adhering to
for years to come, as well as a never-ending string of
South African locums.
The last year has seen a number of notable
recoveries from serious CNS pathology: cervical
stenosis requiring decompression (Mike Richards
Snr), bacterial meningitis (Bill Brampton), and
hangover-of-the-year (anonymous female SHO aft er
summer winetasting party). All required time off
work but eventually made it back into circulation.
Regrettably there were ugly scenes when Bill
Brampton deserted his Audit Coordinator post to
become Clinical Tutor. Rumours about fisticuffs in
the car park were unfounded, but such was the
clamour to take over this coveted responsibility that
no less than three consultants now share this crucial
task.
When the heir to the throne (no, different throne,
David) knocked himself out playing polo and spent
the night before Granny's birthday on the private
ward, fortunately the department's services were not
called upon. However, when he had a head CT,
much respect was shown in neither laughing at the
jokes about taping back his ears to fit in the scanner
nor questioning what exactly in his head they were
looking for.
Good news for next years drug budget - we now
have a highly talented dan"e.-c.tri-hyp-trotherapist in
our midst in the form of Tony Burlingham's new
wife, Annie, who has been charged with keeping the
old rascal in step as well as reducing our propofol
expenditure.
Speaking of dancing, it seems to have been the
activity of the last year. Our Australian registrar,
Justine Lowe, found luurrrvvv on the salsa dance
floor, and one of the (female) PRHOs was also a
regular attender with her new consultant eye surgeon
boyfriend. This latter Latin lover also made
a
1l
distinguished start by introducing herself to the
department at the now traditional 'Retreat' Xmas
party in a dress so Hurleyesque that it required
prolonged and close inspection (I am told by Chris
Mather) to work out whether it really was an item of
clothing at all or merely an apparition- The cabaret
that night (ably written and organised by Juliet
Learner and Adam Skinner) succeeded in its goal of
being both truly awful and appropriately humiliating
to the majority of the department who took part.
Can't wait for this year's Xmas party . . .
Ted Rees
Well,
I write part of this column to say goodbye- I
have been Points West reporter from Cheltenham for
over 8 years now and it is time for changeFollowing my illness, and thanks to everyone who
has supported me in some way or other, I feel it is
time to step down. Ted Rees has offered to step into
the breach and improve the literary style of the news
though the interest will still be up to the 'goings on'
in the department! I am also standing down as
college tutor, which I have held for the same length
of time. I am pleased to say that I have a really
enthusiastic replacement in Jon Francis and I know
that the Trainees are as equally enthusiastic about
him! I wish him luck as the paperwork that
surrounds the training goes on increasing. I shall
miss the post greatly but fully intend to be active in
teaching.
Just to say that I do have news of one Cheltenham
'Old Boy' - Basil Ateleanu (known fondly as 'Basil
the Beast'). Basil came to us directly from Romania
and his wish was to pass the FRCA. He has done
that and completes his full training shortly in
Cardiff. He tells me that he is going to marry his
long time partner Paola in the Autumn. We wish
himwell.
I will leave the rest to Ted.
Best wishes to everyone
seemed to find his way there! Ed has joined us from
Southampton
to us!
-
who are probably still not talking
Keith and Cathy Allman have a new son Jake,
Andy and Jan Morris have a new son Leo (he must
vote Labour) and Colin and Teg Berry have a new
40 foot boat! Colin has just asked if I'd like to help
sail her round to Falmouth - the forecast is Force 8
to 9 (nothing to a trans world sailor) but I'11 stick to
the Med thanks Colin!
Just passed Fred Roberts in the corridor - he was
looking very bleak - might have something to do
with the England v Holland football last night what is it about Northem men and football!
There has been the usual change around in staff.
Louise Barrett has left as SHO and gone to
Cambridge as an SpR and Natasha Clark has started
as a new SHO. Vijaya Nathan has moved to the
Children's hospital and Lesley Thompson has
started with us after 3 years in the Antarctic. Or
should I say under as she's heavily into scuba diving
- sounds a bit cold to me!
Emma Hartsilver has bought a house in Topsham
and regails us with talk of failed floor sanders when she is not organising the training of Iveta
Jacob, our new PRHO in anaesthetics and ICU,
Mark Daugherty is known by every estate agent
in SW England as he moves up the coast. This is
despite his anaesthetic colleagues in Plymouth
feeling they should buy his house as they had 'lived'
all his various renovations over the past 3 years.
Most of the discussion this Summer has revolved
around who's going to do the non-elective nonemergency work at the weekends? This has caused
rounds of endless emails and evening meetings, with
all the various on call rotas being thrown into the
melting pot. After much discussion we seem to be
down to extra payment for lists on Saturday - but I
won't hold my breath!
Well, I must go and find my sun tan cream, as I
join the summer exodus of depleted anaesthetic
departments!
Mike Richards
Jon Purday
Exeter
My nettle rash has finally settled down. The
anaesthetic summer barbeque was at 'The Turf - a
pub only reached by sailing, cycling or a long walk.
Unfortunately cycling along a narrow tow path, in
the dark with no lights, after more than a few pints
of 6X, does have it's downside! There was a good
turnout and everyone seemed to make it home! Even
Ed Hammond, our latest consultant appointment,
t2
Frenchay
The steady growth of the Frenchay Anaesthetic
Department continues with our latest four new
consultants now all in post. They may even have
some work to do if lists stop being cancelled due to
the Summer bed crisis, which has imperceptibly
taken over from the Winter bed crisis. It seemed
Iike a good idea at the time to open two wards as
"term time" wards, staffed by nurses with school
age children and then close the wards during school
holidays. All part of the "back to work" ethic.
Unfortunatelv. q-e do not have term time operating
theatres. surgeons and anaesthetists, although with
tbe amount of extra holiday being generated by
consultants -acting down" on the on-call rota, this
mignt be an option to investigate.
Our senior colleague, David Cochrane, is
counting the days to the big six-o and retirement.
He has already cleared his desk and vacated his
office to make way for the new appointees. He now
has a card table in the comer of the office I share
q.ith our Clinical Director, Robin Weller, and I keep
expecting to come and find the two of them playing
bridge with our secretaries Lynne and Kathy.
David has planned his last few months very
carefully time to get his carpal tunnels
decompressed so that he can concentrate fully on
his golf swing. He and Brenda recently holidayed in
Peru where they both felt the earth move, despite
being in single beds. Apart from experiencing an
earthquake, David has also returned with the
Peruvian drip, although he hasn't said exactly
which part of him is dripping!
Frank Walters has also been travelling, he
recently visited Doris Salem in Tanzania (at least
that's what it sounded like). Frank andLizzie
graciously allowed their beautiful garden to be used
for the much belated Anaesthetic Department New
Year Party, which was held in late June in a
It was an excellent evening with music
marquee.
provided by a band which inspired
enthusiastic dancing. Seeing the difficulty
members of
some
some
the Department were having with the
sloping dance floor, Debbie Harris and Alison
Cloote decided that the tables were a safer bet and
started a ctne for table dancing. From where I was
sitting, I could see that Jenny Eaton was just in the
process of climbing up onto her table as well when
unfortunately the music stopped. In the spirit of a
new form of entertainment at each successive
anaesthetic party,
I look forward to lap dancing
soon.
Other entertainment was provided by our
Chairman, Michael Milne, who gave an excellent
resume of the Department's activities over the
previous year, whilst roving from table to table. No
doubt he felt he would be a harder target to hit
should anyone take offence. We were also delighted
to welcome Sally Wilton once again who presented
Bruce McCormick with the Wilton Award for
services above and beyond the call ofduty.
The holiday season is upon us once again and
some are taking a leaf out of the Dutch Prime
Minister's book and holidaying in the UK. Judith
Dunnet has just returned from Slapton Sands and is
about to go glacier skiing in Les Deux Alps in
August. Robin Weller has managed to fit in a visit
to Cornwall in between holidays in Cyprus and is
soon off to the States. He is in dire need of a
holiday having been granddaughter-sitting for what
seems like aeons. Now that he has stopped doing
on-call, he didn't even have the excuse to come into
the hospital at weekends or evenings. Clare
Stapleton, one ofour new consultants, is holidaying
in Devon having just bought a house in Redland.
She sprained her ankle on a recent jog through the
woods and thought that her toes had turned black,
but then realised it was just her nail varnish. On the
matrimonial front, Debbie Harris has made an
honest man of Mike Taylor; they married in
September at the Mansion House and honeymooned
in Rome (without James Rogers). One of our SpRs,
Karine Zander, got married to her Valentine in
France; and our Advanced Intensive Care Medicine
trainee, Yvonne Marney, is marrying another one of
our current SpRs, Matt Oram, in October. Plans are
also in hand for David Lockey's forthcoming
marriage to Kate in Tuscany. David has inherited
the largest desk in the Department so we are
expecting big things from him. There are also two
more births to report, a girl for Juliet Learner, one
of our SpRs, who has gone on maternity leave just
before accrediting, much to Alex Manara's dismay
as Programme Director (although why should he
care as he is handing over the post to A N Other as
soon as the Dean makes an appointment). The other
baby is to Ed (Tory Boy) Monis who has exercised
his right to paternity leave. I daresay he will also try
to become a flexible trainee, as the current pay
scales encourage everyone to train part time. He, at
least, has a bona fide reason.
As I write this, we are under threat of losing all
our paediatric services from Frenchay; in fact if the
new Children's Hospital were bigger, I am sure
they would already have gone there. Best place for
them! Or am I becoming ever more cynical? I fail to
see why we are twisting ourselves inside out and
jumping through hoops set up by various paediatric
interest groups trying to set up a paediatric HDU
which will need its own team of middle grade and
specialist consultant cover when the City already
has a PICU. It is not even an anaesthetic problem as
the current problem has been caused by the
Paediatric College threatening to withdraw
recognition for SHO training. The sooner we have a
new single site built for North Bristol NHS Trust, or
preferably for the whole of Bristol, the better.
Back to the holiday scene (never far from my
l3
mind), and the Mediterranean remains very popular,
with both our secretaries Lynne and Kathy going to
the same Greek island - Levkas - but at different
times, of course. We couldn't possibly manage
without both of them, even if we were able to clone
our locum secretary, Frederica, (now there's a
thought!). Peter Simpson went on a cycling tour of
Italy and has returned with a very distinctive walk,
despite a chamois gusset and a gel-hlled saddle.
Janine Mendham had a three-week break in the
USA, and has since completed the Bristol halfmarathon, along with Richard Dell, Claire Jewkes,
Clare Stapleton, Bruce McCormick and Maggie's
husband Steve. Steve is also running in the New
York marathon and has already started on "cipro" in
preparation! Tom Main, one of our SHOs, also a
runner in the Bristol half-marathon has recently
completed the Dublin marathon. Amber Young took
time off from running the paediatric HDU services
singlehanded for a holiday in Bermuda and your
correspondent went sailing in Turkey. Regular
readers of this column will know that it is unusual
for me not to injure myself on holiday and, tme to
form, on day one, a fluky wind and a following sea
resulted in a hand injury when an accidental gybe
caused my hand to be smashed against a winch by
the mainsheet. Not wishing to spend the rest of the
holiday in plaster, I managed to avoid Turkish
hospitals and strapped it up until I returned to the
UK. Other travellers include Frank Walters, who is
currently away on an unpaid sabbatical. What a pity
that NHS Trusts are not enlightened enough to
allow us all to have paid sabbaticals every l0 years
or so. It might even encourage some consultants to
work beyond the age of 60.
I am delighted to report that I have joined Kate
Bullen on the Council of the Association and thank
you to anyone reading this who voted for me. I have
been trying for the past 16 years to drop my all day
Friday neuro lists and, as Association business is
conducted in London on Fridays, I have now
succeeded. This does, of course, mean that I will
still be home late! I have also been told that our
Department has had a continuous presence on the
Association Council for well over 30 years. Not bad
for a little village hospital. In closing, another
achievement to report is that our Staff Doctor,
Caroline Easterbrooke, has qualified as a lifeguard
and is rumoured to be auditioning for the next series
of Balrvatch.
John Carter
Gloucester
Summer over, everyone has returned from their
t4
holidays and the children are back at school.
Normality, depending on which way you look at it,
has retumed to the department. Great news is that
our new secretary, Tina Bazeley, is settling in really
well. Our three new Staff Grade doctors, Ian
Godfiey, Shanta Nair and Dr Wahed, are all in post
which has temporarily solved our juniors on-call
rota problems. Despite heavy work commitments
our trainees have surpassed themselves with exam
results. Ken McGrattan, Nilesh Chauhan and Wilson
Thomas all passed the Primary exam, while Mohsen
Khalil, Amanda Porter and John Walton were all
successful in the Final FRCA. Congratulations to all.
We were all pleased to have Vanessa Helliwell
return to us as a senior SpR, having trained her as a
novice SHO in Gloucester. Now she's telling us
what to do! Other new comers on the Bristol SpR
rotation include Guy Bayley, Jonathan Garstang and
Amanda Porter. Amanda is married to the new
Consultant Dermatologist in Gloucester so we hope
to see more of her in the future as I gather she's off
to Frenchay soon.
New SHO's are Mike Eales, Ivan Ramos and
Sarah Richards, who's a surgical trainee. Sarah's
hrst list included witnessing a failed intubation in a
bleeding tonsil that was a Jehovah's Witness with a
Hb of 5. The patient survived due to great efforts by
the Anaesthetic, Surgical and ICU staff. We just
have to reassure Sarah that most cases are much
easier to manage. Talking of bleeding tonsils, we
have had 11 cases in the last month. We're not sure
if this is due to the waiting list initiatives or the new
disposable sets. I always knew there was a good
reason for not doing ENT lists.
The trainees who have left us include Simon
Lewis, John Walton and Thys deBeer, all to other
places on the rotation, they were all excellent and
will be missed. Nilesh Chauhan, our SHO with the
wild hair, has left after a great night out in
Cheltenham.
One of our new Consultants, Sarah Bakewell, got
married at the beginning of September and is now
enjoying an exotic honeymoon on safari. Sarah
apparently had a "hen" weekend, which featured
assorted Ann Summer's goods including a rather
racy,lacy, red and black bra and panties. There are
photographs of Sarah wearing these, which have
been included in guidelines for new staff, under
"dress code". Copies can be provided for a small
fee! And she seemed like such a nice girl at the
interview. Ian Crabb and wife Nina have produced
baby number 2, Henry. Congratulations and no
doubt many sleepless nights go to them. No one else
in the department is admitting to anything and as far
as
I knos.
the Paddy Clarke casting couch hasn't
been rs€d so rmtil next time, farewell.
Belinda Pryle
Hlmoutt
Yet anofrer seasonal change tells us that it's time for
P\mouth's update for the region. A state of flux -
me could describe it as . . . not of course implying
anv lavatorial humour, but lots of chopping and
changlng and periods of not quite knowing what's
happening next! Nothing new to those used to the
NHS I suppose but all the same, of late, the
department have taken their fair share ofknocks.
Peter Taylor finally hung up his laryngoscope
earlier in the year after a career in Plymouth and can
now be seen on the golfcourse 7 days a week during
daylight hours (nothing new there then!) - and such
n-as his legacy as Clinical Director that he drove our
popular business manager, Claire Dascombe to leave
tre country to set up a new hospital in the middle
east leaving us searching for new volunteers. Since
then the Trust has deigned to give us temporary
business managers making it difficult for them to get
snrck in with the work. Sharon Kowalski, our latest,
dares to come down from the safe haven of cardiac
theatres to join us and appears to be holding her
own. What of her boss then? John Lytle stepped into
Peter's shoes taking over as CD not realising the
smouldering barrel of gunpowder that he was taking
on, but has unfortunately been offfor health reasons
of late. Imagine the scene - the call for volunteers to
help out
-
consultants diving for cover
in all
directions to avoid the draft . . . and from the dawn
mist in the clearing, like a knight in shining annour
appeared . . . Chris Andrews, ready to take up the
baton. Not content with bailing out at the top
(medical director) a while back, he has agreed to act
as caretaker CD until John can retum.
Entering this fluctuating department, apart from
what appears to be an endless stream ofnewjuniors
who have just got their photo on the board when it's
time to move on, have been Mark Sair joining the
Intensive Care Team and Andy Porter as Herbie
Balmer's replacement, Herbie having relinquished
his final eye list in May. Sarah Ford already working
here as a locum, moved sideways into a permanent
slot then celebrated on the ski slopes to the tune of
snapping ACLs and is only just back on her feet
properly following surgery. All this was too much
for Sophia Wrigley who runs the rotas and
she
developed appendicitis to get out of the fray, but is
now back in the fold once more. Adrian Dashfield,
soon-to-be ex-RN colleague, flushed with his recent
MD success finally jumped ship (keelhauling to be
arranged locally), when he heard about Bob
Hodgson's impending retirement and has
successfully gained a well earned place in the
department. Bob leaves in October to pursue his
love of botany and any connection with growing
strange plants and working in the pain clinic, I'm
sure, is purely coincidental. Mark Daugherty also
left the department in moving his job to Exeter
(more keelhauling!) and can be seen most days
evading radar traps commuting back and forth
awaiting the sale of their house near Plymouth.
Other notable temporary escapees from the
department include Chris Andrews and Liz Rawlings
who disappeared to Sri Lanka for what seemed a
very long time (with respective partners I might add)
- watching cricket ostensibly but inwardly digesting
most pathogenic bacteria by all accounts. Further
afreld the e-mails and postcards most likely to cause
stress in the department come from Pete Davies who
is "working very hard" in New Zealand on a one
year sabbatical. Our hearts go out to him - all that
beach time and walking etc . . . good on'im! We
hope it IS only temporary - last person that did this
was Chris Nixon - and he's the one who got Pete
this trip having stayed out there to work himselfl
On the academic front Rob Sneyd as Associate
Dean to the new Medical School is in charge of the
Plymouth aspects of the job, and somehow manages
to squeeze in countless meetings promoting the
cause with his other duties, whilst also finding time
to terrorise people in Plymouth Sound at the helm of
his new go-fast RS600 dinghy. His latest venture
saw him take part in the Fastnet race (not in the
dinghy) with an unlikely crew made up of GPs,
Obstetricians and Plastic Surgeons - a potential
nightmare scenario - but who gained a very
creditable place in their group. Jeremy Langton has
been appointed Director of Research and
Development within the Trust to add to his other
duties of head of Academic Anaesthesia in Derriford
now that Rob is tied up with the Deans job.
Our military colleagues although predominantly
RN fly a Tri-Service flag. All 3 services are now
well in evidence and disappear from time to time on
various jaunts. Andy Burgess has been to Kosovo
once more and Sierra Leone at short notice, Steve
Bree recently returned from the latter, just in time
for Dave Birt to disappear to an aircraft carrier.
Charley Johnston following recent promotion to
Captain has just relinquished his title of Hospital
Commander for the military side of Derriford, and
becomes Tri-Service advisor in Anaesthesia whilst
Andy B has picked up the chalice of Clinical
Director of main theatres in Derriford.
l5
Finally the harvest festival round up of offspring,
where once again the Plymouth brethren have
excelled. Bouncing baby girls to Drs Simon
Courtman (Ava), John Ingham (Freya), Steve Bree
(Alice), and . . . stopress, Jenny Benton (tbc), with
Ian Christie adding to the family with a baby boy
Congratulations to all ofthem and to Pete Ford and
Ciara Ambrose who are both getting married this
month although not to each other.
(Alexander). And all in a days work . . .
common problem seems to be people unplugging
our anaesthetic machines in the middle of a case.
We have thought of a number of solutions such as
covers to lock the plugs in place or red plugs, but
Steve Robinson has come up with the ultimate
deterrent. Simply take the back off the plug: they
won't do it more than once!
I'm afraid I'll have to write about the summer
barbecue next time as it's not happening until after
this report is due. So, with best wishes for a long,
Andy Burgess
Southmead
We've had quite a quiet spring and summer at
Southmead, principally because there have been
very few beds into which to admit patients.
I understand that we have fared slightly
better than Frenchay and the BRI so we'll comfort
ourselves with that thought. Our new holding bay
However,
has opened in main theatres but has not been a
conspicuous success so far because, surprise,
surprise, there aren't really enough staff to run it.
Work has frnally started on the new g)mae theatres
which will be next to the delivery suite and will
bring all women's health onto one site. This is only
about a year (or is it 9 years?) behind schedule and
is due to be completed next July; so watch this space.
Half the consultant body disappeared
to
Barcelona in May but I won't tell you any more
about that as you can read all the sordid details in
Kathryn Holder's report. Chris Johnson has kept up
the Southmead tradition of injuries by getting his
foot caught in a rabbit hole whilst orienteering and
breaking his leg. In fact, rabbits seem to be a bit of
a recurring theme
for our department. Jill, our
secretary, slipped and broke her leg whilst rushing
over wet grass to feed the family rabbit and Fiona
McVey broke her ankle whilst doing bunny hops at
the gym! I'm very worried as my next-door
neighbours have just got a rabbit and have told me
I'll have to look after it whilst they are away on
holiday. Iain Dunnett has been getting ready for
retirement by doing ATLS and APLS courses and
working for the government in Cyprus. He tells us
that this is so he can go and work in the Falklands
but it seems obvious to me he's being groomed for
some sort of 007 role.
Our junior staff have been very successful with
their careers of late. Simon Lewis and Pete Ford left
us to go to SpR jobs in Gloucester and Bath
respectively whilst Rachel Johns has gone to a LAS
post in Torbay. Matt Thomas has gone to Australia
for a year and Pushpa Nathan has gone slightly less
far afield to Frenchay. Tom Main and Sarah Pickard
have both passed the Primary FRCA and Richard
Haddon was successful in the Final.
16
Critical incident reporting is very big in our
department now and aside from the usual mayhem
with dextrose and insulin infusions the most
hot, indian summer I'll say goodbye from
Southmead.
Fiona Donald
Taumarunui
Your correspondent, having missed the last issue
altogether, is cutting it a bit fine for this deadline as
well. However, instead of the usual last-minute fax,
I will be able to hand this bulletin in person to your
editor when I meet her at the Association meeting in
Belfast later this week.
Since the last news from Taumarunui, we have
been through the experience of"credentialling" - an
exercise largely wished upon us by management. It
was ill-thought out and poorly scheduled, and
managed to demonstrate the communication skills of
an oyster allied with the amicability of a rhinocerous
with toothache. Suffice it to say that one of the two
interviewers was - for reasons which remain
obscure to us - a pathologist, and that Nick, with
100 miles to travel to the interview in Hamilton, was
glen 231+ hours notice of it. The capability of
organising a certain function in a brewery does
rather come to mind.
The outcome of this doubtless fairly expensive
process is that we are to have yet another review,
which is tentatively scheduled for October. It had
been planned for September, but even our lords and
masters could comprehend that holding it while half
the department was on the other side of the planet
might have its drawbacks. Probably by the time the
spring issue rolls around we will be on to the audit
ofthe review ofthe credentialling. . .
To a more trivial line of thought. Has anybody
else noticed how diffrcult it is these days to identifz
the sex of a small child? Hair length and style is no
guide - a little boy on our dental list recently was
sporting quite fetching pigtails - and most of them
arrive wearhg rnisex trackpants and sweatshirts, or
shorts and T-shirts according to season. A Barbie
doll sweashirt is fairly unlikely to have a little boy
inside it, but the logo of the World Wrestling
Federation does not mean the occupant isn't a girl.
As for the names, they're no help at all. I yearn for
the relative certainties of Mary or John, and I can
even cope with a reasonable proportion of the Maori
names, although I sometimes stumble on the
pronounciation. But what guess would you like to
make at to the sex of the following?
Brin
Shairone
Kiel
Lyshahrn
Niko
Shavaugn
Devon
Trayden
Brodie
Shalako
Casey
and his quiet efficiency is very welcome. Also in the
welcome stakes is Jane Calder who joined us from
Yeovil to replace Joe Silsby, Joe and Sally Silsby
have gone to continue their third world experience
in Nepal for six months, and loaned their house to
Phillipa 'flipper' Seal so that she can bash the books
whilst the Silsby's absorb the Himalayan
atmosphere.
Congratulations go to Samar Al Rawi who passed
the Primary FRCA at the first attempt - when she
outgrows our department we will have to lose her
which will be a great loss to us.
The surgical block at Musgrove remains the
subject of debate as to its future - and its location to date we have gained a 3 bedded high dependency
unit, ostensibly run by surgeons (. . . in your
For the record, they are all boys except for the last
two; and the last one is the Kiwi version of a name
more usually spelt "Siobhan". Believe me, it does
nothing for the doctor - patient relationship when
you smile benevolently at long-haired Brodie and
say "How has she been just lately!", only to have
mother retort coldly "It's a he!" And don't advise
me to check the label in the notes, because that isn't
always right either.
I close with our best wishes for Christmas and the
New Year.
Best Regards.
dreams!) This is a superb facility for intermediate
care of surgical patients and the patients don't want
to leave at the end oftheir stay there !
I submit this bulletin from Joanne's office (our
department secretary and 'gas master') as the view
from her window is being obliterated by a shanty
town built outside
-
portacabin for the Research and
Development mob
I
I
am told
-I
am
just glad
am not the site planning ofhcer! (More especially
as Joe Silsby keeps sending her e-mails describing
the views from his various abodes in the Himalayas!)
Tim Zilkha
Torbay
Heather Cosh
Taunton
Once again we keep up the tradition of Taunton
being a late entrant! Apologies
offering.
-
here is our
I begin this report with the news of
them mums and dads undertaking recreational
activities, frankly, best left to the children.
the
appointment of Geer Hubregtse as our l6th
Consultant from December 2001 who will be
providing a broad range of anaesthetic duties so
willingly surrendered by the rest of us - doubtless
with his characteristic enthusiasm. I really did feel
for the estate agents knowing that he would try to
complete all the administration in moving from
Totnes in under 24 hours - what it is to have patient
colleagues.
Talking of patience
Despite recent difficulties with limited access to the
countryside,Torbay seems to have had a busy
summer tourist season. There has been the usual
flow of holiday-makers into the hospital, some of
-
we welcome Bronwyn
Webster from Brisbane who has toppled off the top
of the training scheme back home in Oz so is fully
fledged and bolstering our SpR ranks for six months.
With her flair for facing issues head on we have
already enjoyed considerable entertainment.
Matt Oldman joined us recently as Senior SpR
The Department is further enhanced by the
appointment of two new Consultant colleagues in
the form of Andre Varvinski and John Carlisle,
increasing our number to 22. Both are already
familiar with Torbay, with John's presence in
theatre made obvious by his motorcycle leathers
exoskeleton in the changing rooms.
The Pain Management Clinic is on a roll under
the wings of Judith Norman and Douglas Natusch;
refurbishment of the so-called Chapel corridor
rooms will offer improved accommodation. A fulltime Pain Clinic secretary, Annie Hasnip, has taken
up her appointment, and a new study day "The
Successful Return to Work with Back Pain" has been
organised. For more details contact Judith or Douglas.
The Critical Care Unit is up to ten beds and down
I"o zero staff coffee rooms, the existing facility
t7
currently being transformed into a future operating
SHOs Richard Bensa and Mark Danielsen are now
GP registrars in Cornwall. Debbie Eaton is spending
time in Paediatrics in Bath. David Simcock has
returned to the Solent to spend time as an SHO in
Follow-up Clinic for long-stay patients from CCU is
established; this gives patients the opportunity to
consult with an Intensivist, CCU nurse and Clinical
Intensive Care. Suzie Ryan has moved back to
theatre. I think I
heard the words coffee and
Portacabin mentioned in the same sentence. The
Outreach Project is now running 24 hours, and a
Psychologist.
We welcome Dr Lorraine Alderson to the
Department, and congratulate her (and husband
David, a recently appointed Consultant ENT
surgeon), on the arrival of their son. Lorraine has
been standing in as a locum Registrar.
Roger Tackley continues his commitment with
setting up Electronic Patient Records (EPR) for the
Shires (most of Devon, Somerset and Bath), a
seemingly thankless job involving spending money
on equipment and systems, and talking to other
Regions to ensure compatibility. We are depending
on Roger to come up trumps so that we can work
from home.
Ian Norley
Truro
It has been a good sunny summer for a change and
the visitors returned in great numbers. The acute
services have been stretched but have held up well.
It finally took the August bank holiday to earn us a
Scotland to continue her anaesthetic training. She is
sorely missed in the Juniors' mess for the sterling
work she did as the BMA junior POWAR. Fiona
Martin has moved across to Medicine for six
months. However, Alistair Martin has rejoined the
department after the 18 month medicine module of
his rotating post, and hasn't stopped grinning with
delight yet. Mike Parris has passed his MRCP and
kept up our record. So far all our SHOs rotating
through the medical acute specialities rotation have
collected the MRCP. Phil Cowlishaw has taken up
the ITU SHO post and Grant Pienaar has come back
onto the general Rota. Ronelle Mouton is about the
only Trainee who has not moved this summer.
Dr Prabu has joined us as an experienced SHO from
India and is already a valued member of our team.
Charlie Brown has returned from six months of
Medicine in New Zealand and is now learning the
gentle art of Obstetric Anaesthesia. Rob Daniel
joined us from South Africa for three months and
has now headed off to the Carribean to work for
& O. Louelle Botha is helping us as a locum SHO
and keeping our South African numbers up. We
P
there is no sign ofthe buildings for them yet.
welcome Drs Elliott and Cronje as our new rotating
SHOs starting their anaesthetic training.
On the exam front congratulations to Tasneem Ali
on passing the final fellowship exam, and best
wishes to our SHOs sitting Part 1 this Autumn.
We are two down on the Consultant numbers. Roz
Harrison has been unwell, but we hope to see her
back with us soon. Lars Jakt fractured his Tib and
Fib. He stayed in hospital for three days after his
ORIF then rushed home before the armies of eager
We have had a great turnover of staff. We have
not appointed any new consultants for a change, but
speedy and uneventful recovery.
negative headline for prolonged waits upon trolleys.
The Autumn promises excitement. The Trust
publishes a public consultation document outlining
the options for the rational development of acute
services across our three Hospital sites. Somebody is
bound to be disappointed! We are also waiting with
baited breath for some new building activity at
Treliske. Medical students are coming soon but
we are interviewing next month. Our congratulations
to Pauline Mitchell who has been promoted to
Associate Specialist. Among our Specialist
registrars, Tasneem Ali, Alison Moore and Simon
Courtman have returned to Plymouth. Geoff Watson
helped us as a locum Consultant and has now left to
take up his Consultant Post in Winchester. In their
place we welcome David Brown, Lynn Margetts,
Sam Banks and Andy Lee, who now has a training
number. Our ITU SHO Julian Berry has also gained
a training number. We have welcomed Siva Manyan
Staphyllococci could get at him. We wish him
a
The summer yacht race was held in rough
conditions with gusts reaching force 7 at times. The
course was shortened. Two boats chose discretion as
the better option and retired. Not so our orthopaedic
colleague, who,
filled with competetive
zeal,
declined to reef his main and forfeited his mast. Line
honours went to Paul Upton this time. Nevertheless
Paul and Noreen Griffiths hosted a lively after-race-
back to the department as a Staff Grade. She
party, in spite of the fact that their yacht is cruising
Portugal this year.
Make the most of the brief respite before the onset
of winter pressures.
replaces Sarah Taylor who has moved to Scotland to
complete her General practice training. Among the
Bill Harvey
l8
Best wishes
UBHT
Six months on and the usual head scratching as I
r*'onder what if anything has changed in UBHT?
Sometimes it seems that hospital life in central
Bristol is fairly humdrum compared to the rest of
Plenty of turnover, as ever, among the medical
staff, with five new consultant appointments to
report this time. Becky Aspinall, John Hadfield,
Daniela Smith and Jon Williams are all familiar
names, though we also welcome Claudia Paolini
who is joining us from Southampton as our new
thoracic anaesthetist. At trainee level, newcomers
the opening of the new Children's Hospital spring
to mind. Perhaps life here is not quite so dull after all.
The Kennedy report has actually had little recent
effect on things here, since in common with most
other hospitals, the cultural changes suggested in
the report have been enacted some years ago.
from outside the region include Matthew Molyneux
from not so exotic Swindon, Filip Beernaert from
bit more exotic Belgium, Christina Diaz Navarro
from Spain (well via Cardiff), Jonathan Garstang
the region. But then the culmination of the
paediatric cardiac surgical inquiry, not to mention
Nonetheless its publication marks the end of a
chapter, so that hopefully we can now concentrate
on looking forward with less need to look back.
The opening of the Children's Hospital,
coincidentally at about the same time as the report
was published, should indeed help us to do that.
It is still early days for the new hospital, so we
still in the early stages of reacquainting
are
ourselves with our long lost paediatric colleagues
who are now only just down the corridor (and a
flight of stairs as well in actual fact). Perhaps the
rest of us should hold some sort of welcoming
party for them? Still, there seems to be no lack of
integration on the extracurricular front, with
significant contingents of both paediatric and nonpaediatric anaesthetists entering this year's Bristol
half marathon. Indeed this is (or was, by the time
you read this) the largest entry of 'marathoneers',
or in Chris Monk's case, marathonears (whoops . . .
oh well, at least now I'11 get to find out whether he
actually reads this or not!), since the heady days of
Craig Cox, way back in the twentieth century.
A special mention also for those who dropped
out from the half marathon during training (you
know who you are AC and AC - and neither of
them your correspondent I hasten to add - been
there, done that, got the knee injury thank you),
with Anita Cox dropping out not just from the half
marathon but also the department. A major change
for us, although since she's now working in PICU
in the Children's Hospital it's not as if she's
actually gone far . . . only just down that corridor in
fact. Plus, as she remains allocator of our waiting
list initiatives there's probably not much danger of
her losing touch with the rest of us!! The office, in
fact, has seen almost as many comings and goings
as the registrars with Jane (Everett) going, Jane
(Mcl.ean) returning, and Amie and Linda (but not
Lyn) coming and then going. All very confusing
but some stability fortunately in the shapes of Mary
and Lyn.
(previously working in Australia) and Lesley
Thompson from Antartica (well perhaps not
originally!). Not to mention our PRHOs from
incredibly exotic Bristol, Amelia Pickard, Lesley
Ward and James Harding. Tessa Whitton has
retumed from what was obviously avery good year
in Seattle, but obviously with an avowed intention
to make up for the lack of good ol' British beer 'n'
curry nights out there!
Five consultants in and two consultants out, with
Simon Howell and Martin Schuster Bruce leaving
for Leeds and Bournemouth respectively. Richard
Protheroe got an ICU job in Manchester and Colin
Yeoman and Mark Bechter have both left for jobs
in industry and to buy cars which will no doubt
make the rest of us jealous. Krishna Moorthy got
onto the West Midlands training rotation, whereas
Lesley Archer has gone to try her hand at
radiology.
A good summer for Guru Hosdurga, Raymond
St Hill, Matt Taylor and Karine Zander who have
all had that swagger that comes from recently
passing frnal FRCA. In fact a clean sweep for the
department, so we all had a bit of a swagger for a
while. Tim Lovell in fact had a double swagger
(now there's a thought!) since he also managed to
pass the American Transoesophageal Echocardiography
exam in
April. Other people swaggering (I'm going
to do this one to death I'm afraid!) in
the
department were our new parents (well none of
them new parents actually, but you know what I
mean) Gary Gutteridge (Charlotte), Jill Homewood
(James) and Jane Mclean (Nerys), though in the
case of the female members of the trio perhaps
swaggering might not be quite the correct
terminology. Finally, there were congratulations to
the newlywedded Karine Zander (another one with
a double swagger therefore) who married
Valentine, and also to Mike Taylor who of course
married Debbie and who, at the time of writing, is
still on honeymoon, so I don't know whether he's
doing any swaggering or not, though somehow I
suspect that he might be (amongst other things).
t9
That's all folks - next issue's exciting report,
with Steve Linter about to complete his term as
clinical director, will be the first of the new Nevin
regime - don't miss itl
Alan Cohen
the Grand Pier, there's the Royal Pier and then . .
there's Lord Archer".
'
John Dixon
Yeovil
Well what has been happening in Yeovil? Quite
a
lot
actually, first of all a slapped wrist for the
Weston-super-Mare
bi remembered as the year of the reviews
. . . first there was participation in the Avon Strategic
correspondent who forgot to send a report for the last
journal, I'm sure you were all mortally wounded.
The department has grown, since our last report.
Commission is looking at theatre efftciency' Thus far
CHI seems to have performed the best in that they
We have appointed 2 new Consultants, one a
2001 will
Review, then a visit by CHI and now the Audit
ke
repo
month. They a
conclusion that,
have already
preliminary
d
a
last
the
zed
trusts, we are performing remarkably well with the
minimal resources made available to us. As for the
Avon Strategic Review we wonder after nine months
if it will ever be published.
Whatever changes might occur as a consequence
of the above reviews life otherwise goes on. The new
extension ofthe hospital has been topped out and we
are actively discussing the changes to the surgical
floor
which
beds and an
such as the d
both some extra
various facilities
ning nine months
above it is rare for us to report a birth so were
delighted to learn earlier this summer of the safe
arrival of a son, Ioin, for Ruxandra and Radu Mihai'
Alison and Andy Smith hosted a fine barbecue to say
farewell to both Ruxandra and Neil Muchatata who
have moved on to Bristol, and also to Rachel
Rowlands who stayed with us for just six months
before pursuing her chosen career in paediatrics' We
welcome Laura Taylor, Louise Mcloskey and Hugo
Wellesley who are already making their mark on the
to the subject of CHI, the clinical
- who came from a seaside town driver on arrival here how many piers
there are at Weston-super-Mare. "It depends",
replied the cabbie: "it's either two or three - there's
20
replacement post and the other an expansion. Our
two new recruits are Dr Matthew Wootton who had
been kicking his heels in Cheltenham and Jo Kerr
who came to us from Merseyside. Yes Jo is of the
female persuasion and so the last bastion of all male
Consultants has fallen. Another Matthew is also
gracing our corridors, Matthew Cornish our new
Staff Grade - welcome.
Yeovil is becoming a department to reckon with in
terms of exam passes, Chris Bryant and Hanne
Sinding both passed their final fellowships
-
congrats. Chris has since left us but we still have the
benefits ofHanne.
One of our senior SHOs Jason Klein passed his
membership and now has secured an SpR position in
A&E, and last but not least Bill, one of our
anaesthetic nurses, outscored the 18 year olds in his
A level Archeology.
On the service side everybody continues to keep
the Trusts head above water, we continue to work as
a team and usually it is quite entertaining.
One notable loss to the department has been Jackie
our manager, she is missed but has been ably
replaced by Lisa Spencer who has settled in very
well - she wears lovely blouses!. Elaine keeps us all
in line and Debbie lights up the office.
So all in all a good 6 months. I haven't lost to
Chris Elsworth at squash or tennis for ages and Rob
and Roger were members of the victorious team that
blitzed Taunton at golf. Long may it continue.
Tim Scull
Examination Successes and Honours
BRISTOL SCHOOL OF ANAESTHESIA
FRCA
Chris Bryant
David Earl
Richard Haddon
Guru Hosdurga
Mohsen Khalil
Amanda Porter
Mike Richards
Steven Sale
Hanne Sinding
Judith Stedeford
Raymond St.
Hill
Matt Taylor
Jonathon Walton
Karine Zandet
FFARCSI
PrimaryFRCA
Mohsen Khalil
Sudha Bechan
Cheltenham
Kim Carter
Bath
Nilesh Chauhan
Katherine Congreve
Jill Dale
Gloucester
Rachael Kelly
Tom Main
Sarah Pickard
Wilson Thomas
MRCP
Jason
Klein
Bath
Bath
Bath
Southmead
Southmead
Gloucester
Yeovil
SOUTH WEST SCHOOL OF ANAESTHESIA
FRCA
PrimaryFRCA
Tasneem Ali
Sqdn Ldr K. Birch
Al Rawi
P. Sice
Taunton
Exeter
Exeter
Exeter
Plymouth
S. Barrington-Blackman
Plymouth
Mike Parris
Truro
Samar
Louise Barrett
Sarah Hodges
Jan Hanousek
Primary FFARCSI
If onyone who should
have had an examination success or any olher honour acknowledged and who has nol
been included - sorry! I can only publish the names sent to me by each department's
SASWR linkman and college tutor.
21
Anaesthesia Points West Vol. 34 No. 2
Meeting Report
Spring Meeting of the Society of Anaesthetists
of the South Western Region
May 8th - l2th200l
TAPAS AND
ACADEMIAIN BARCELONA
Dr Kathryn Holder and Dr John Carter
A select group, consisting of the usual suspects,
travelled out in advance of the main body. This
"Presidential Party" had the onerous task of
finding as many Tapas bars and restaurants as
possible to recommend to those coming later. The
main body arrived on the Tuesday by a variety of
routes, mainly involving aircraft, although some
by car. One couple, Andrew and Patsy Diamond,
came by boat and train, and then left before the
meeting began!
Dr Robin Weller, Mr J. Clos,
The Lord Mayor of Barcelona,
Prof. Antonio Montero and The Vice President
the ltalian Society
of
The Society held its Spring 2001 meeting from the
Sth to the l2th May in the city of Barcelona as a
combined meeting with the Catalan Society of
Anaesthethetists, known in full as the Societat
Even before the first social event, the fun had
started. In fact, even before people had left the
airport at Barcelona, one handbag and one coat
had to be reclaimed, having been left on the
aircraft. Robert and Ursula Johnson's suitcase was
more of a challenge. It was eight hours before that
finally showed up at the hotel, but its owners
remained calm - probably looking for an excuse to
have to find replacement items in the enticing
shops ofBarcelona!
The two hotels used by the Society, the AC
Diplomatic and the Hotel Montblanc were both
Catalana d'Anestesiologia Reanimacio i
Terapeutica del Dolor. The Meeting attracted the
largest attendance of any overseas meeting, with
over 100 members and partners, drawn no doubt
by the brilliant academic programme, although
holding the meeting in the most visited of
European cities may have contributed to its
popularity. The Catalan Society had very kindly
honoured us by moving their Meeting, usually
held in March, to accommodate the later date of
our Spring Meeting. The attraction of al fresco
dining in the late spring sunshine and keeping the
President's wife, Tricia Weller's suntan topped-up
were obvious advantages of a May fixture, and the
city made famous by Picasso, Gaudi and the 1992
Olympics was a venue not to be missed.
22
The Presidents of our Two Societies:
Prof. Antonio Montero and Dr Robin Weller
n-ithin a short stroll of the pedestrianised shopping
area
of La Rambla. and on the first evening,
3\'en'one sathered at the Hotel AC Diplomatic for
qelcome cocktails and tapas. Some of the
members of the Catalan Society came along as
rell. and it s'as especially good to greet Professor
-{ntonio Montero, President of the Catalan
Society, and Dr Juan Castano, the Hon. Secretary.
The local champagne, cava, soon had people in the
parq' mood so when the food and drink finished in
rhe hotel, the Society hit the restaurants of
Barcelona at the traditional local evening meal
time of 2200 hours. Already the anaesthetists of
the rvest were adapting to Barcelona time.
Recoveringfrom another night ofpole dancing
\Iontserrat and Sitges
Bv Wednesday morning when the first day trip
rras scheduled, we had already 'lost' two members
of the par1y. Apparently something to do with not
until 7am although most would agree
that Jon Hadfield had earned a lie-in, having
beaten off two would-be muggers. The second
mugger climbed into Jon's taxi, but fled at the
rsords "Oy, Pedro, get off! " (or words to that
effect - whether he delivered them in English or
Catalan is unclear), followed by a hefty shove.
\\ho was mugging whom you might ask!
So, minus Jon and Judith Nolan, the party of
about 60 boarded the coach which wound its way
up a very windy road to Montserrat. Several green
taces looked relieved to have arrived and be
allou'ed to wander around the monastery, touch
the black Madonna, listen to the choirboys of the
Escolania and take the funicular up the Mount St
_eetting home
Joan to greater scenery and fresh air.
The coach took us on to the restaurant of Can
Paradis for a leisurely lunch at 2pm. Delicious
Les Shutt celebrates his birthday with
a
few fi,iends
tapas was followed by attempts to drink sherry
from a porro. This conical glass flask with a spout
allows the drinker to be at the receiving end of an
arc of alcohol, whilst the pourer tips it out from
some distance away. Only Mike Inman had arms
long enough to allow him to be both pourer and
consumer! Having dallied so long over lunch there
was not much time for a look at the gardens before
our first day trip ended with a visit to Sitges, a
lovely Catalan seaside town that looked its best in
the sunshine and was great for a post prandial
stroll after an obligatory siesta on the coach. In
spite of Robin Weller publicising the permitted
nude bathing, nobody was spotted taking
advantage ofit.
Codorniu and Barcelona
The South Western anaesthetists could not have
been in Penedes, the home of cava, without
checking the product out, so on Thursday morning
we travelled to Cavas Codorniu. Behind the
impressive wrought iron gates stood buildings
(very artistically decorated with broken bottle
glass) housing the equipment and cellars needed
for cava production. The cellars extend over a
distance of 20 kms and contain 30 million bottles
of cava. The tour involved a little train ride around
the extensive cellars. Great fun! The swaying of
the trucks and the gasps of the passengers at the
back as they sashayed round right-angled bends,
almost brushing rows of dusty bottles put Alton
Towers in the shade. Who says we are all still
children at heart? There was just enough time to
taste the Brut cava before being shown into the
shop, full of very reasonably priced cava and very
difficult to resist. Basil and Ruth Hudson
staggered out of the shop with cases and cases of
z)
Next it was the Sagrada Familia, Gaudi's great
unfinished cathedral which will apparently not be
completed until 2050 because of the way the
funding has to be raised. Those with strong legs
climbed the tower and then had jelly legs for the
next half hour. Others wandered around the
facades depicting the Sacred Family and the
Passion, and the columns and scaffolding inside
the cathedral shell.
Mila is one of Gaudi's houses on the
of call.
This amazing house is without straight lines
Casa
Passieg de Gracia and was our final port
Peter Baskett demonstrates how to keep
Jon Hadfield quiet with open-drop sherry
cava - it was then that their wisdom in driving to
the meeting became apparent. It is interesting to
note that in the UK cava is looked upon as a
cheap {rzz. Sometimes it is, but there is also lots of
excellent vintage cava, as good as champagne, but
far cheaper. (Personal communication R. Weller).
After another relaxed lunch (this time snails
were on the menu) at Can Cordata it was time to
anywhere (because he didn't believe in them) and
contains some of the furniture he designed as well.
The roof of the house defies description, and
whether seen from street level or from the roof
access is a testament to Gaudi's remarkable ideas.
Whilst the Society was taking the tourist route,
their President, Dr Robin Weller, set them a task
to exercise their minds, and hopefully keep them
awake between cava tastings, long lunches and
tapas bars. The task was a limerick competition.
The President read out the completed entries over
the coach's tannoy system, with only very few
needing censorship, and the best of the bunch are
see Modernistic and Gothic Barcelona. After
printed elsewhere in this journal.
passing through the Olympic area and a brief visit
to the 1992 Olympic Stadium, we started at the
gothic cathedral. Our excelient tour guides divided
Academic Meeting
On Friday morning there was an early pickup from
us into 2 groups and told us interesting details
about every aspect of the building. They showed
us the choir stalls decorated with shields from
every king in Europe, put there after an important
gathering a long time ago, and the cloisters floored
with the gravestones of those who could afford to
rest there.
the hotels to take us to the Medical College of
Barcelona for our joint meeting with the Catalan
society. Assuming the coach driver would know
where he was taking us, no-one paid much
attention to his driving, that is until we drove past
the same red BMW in a garage twice and it
became obvious he did not know the route.
Fortunately, we managed to arrive in time for the
Presidents of the two Societies, Prof Antonio
Montero and Dr Robin Weller, to open the
meetlng.
It immediately became obvious that the
simultaneous translation was of extremely high
standard. The few who could speak both Spanish
and English, ie David Cochrane and Debbie
Harris, were very impressed that even difficult
phrases and medical tems were not missed. Quite
a talent being able to talk and listen in different
languages at the same time - some of us do not
seem to be able to manage to talk and listen in one
language!.
Another night in Barcelona another Tapas Bar
24
The first session was about 'Perioperative
medicine' chaired by Dr Frances Forrest and Prof
Carmen Gomar. Two of the Catalan speakers,
Dr Fernando Escolano and Dr Jorge Castillo told
us u-hat the Catalan anaesthetists are doing about
preoperative assessment and what work they
undertake outside theatres, before Dr David
Gabbon updated us on anaphylaxis and Dr Jon
Hadfield told us about his experience with
outreach and emergency medical teams in
-\ustralia and their potential in the UK.
-{fter a short break while the Catalans listened
to free papers and during which our Society
members nipped to Parc Guell or had a long street
cafd coffee or in some cases a mid-morning
aperitif. it was time for lunch, the usual long
Spanish lunch with wine to ease us into the
afternoon's work. This started with a slightly
unusual session chaired by Dr Kathryn Holder and
Dr Juan Castano where the topics of training and
*affing problems in anaesthesia were outlined and
Another night in Barcelona- another Tapas Bar
with lunch in between. It sounded as though it
went well apart from the attempted snatch of Sally
ro give an account of training in the UK, whilst
Ritchie's handbag. Hero Roger Eaton literally
sprang into action, giving chase and rescuing the
bag from the rather surprised thief who was all of
12 years old. As if that wasn't enough action, as
the party left the Picasso museum there was a
n-ith scarcely more warning, Robin Weller gave an
sudden, unexpected downpour and the group had
impromptu talk on staffing problems. There was
plenty of audience participation, and the British
anaesthetists were delighted to hear that over the
age of 43 you are not allowed to be resident on
call in Catalonia!
The final session on Friday was chaired by
Dr Claire Jewkes and Dr Tomas Gracia. The
subject was 'Intensive Care Medicine' and talks
s'ere given on Catalan experience with hepatic
resection by Dr Inma Camprubi and non-invasive
tentilatory support by Dr Lucia Garcia. Dr Jas
an impromptu 'wet T-shirt' competition which was
then comparisons made between the two countries.
To his apparent surprise, and allegedly with little
u-arning, John Carter was summoned to the stage
Soar covered the
difficult subject of'Not for
especially enjoyed by Henry Rollin on his first
overseas visit with the Society, ever youthful at
nearly ninety.
Joint Societies Dinner
On Friday evening the Catalan and South West
groups held a joint society dinner at the La
Galerna restaurant in the Olympic Port area.
Trainees and consultants, Catalan and British, we
all dined on several courses bf delicious seafood
resuscitation orders', initially with the microphone
positioned halfway down his throat. Once the
loudspeakers had recovered from the excessive
feedback he was followed by Dr Andy Mclndoe
s'ho ended with his presentation on simulators. In
spite of being renamed after that famous tennis
star McEnroe, and a slight hiccough with the
computer, he showed some very high tech
demonstrations of the new simulator centre plans
in Bristol.
Partners' Programme
\\:hile the academic programme was taking place
on Friday, about l8 partners went to the Parc
Guell (Gaudi's park with Hansel and Gretal
houses at the entrance), and the Picasso museum
The Presidents'wives and Honorary Secretary
(who is that man with the striped tie?)
25
and dessert with a fine selection of wines under a
huge white tent. Dr Robin Weller proposed a toast
to the King of Spain, and Prof Antonio Montero
responded by proposing a toast to the Queen of
England(sic). There then followed a toast to Basil
Hudson, whose birthday it was that day, and our
Society gave the officers of the Catalan Society
some momentos of Bristol Blue glassware.
Speeches ofthanks were given by both Presidents,
and Dr Weller has to be remembered for thanking
the 'not so small' Hon. Secretary, Kathryn Holder
for her hard work in organising the meeting. By
prior arrangement, the immediate past Hon Sec,
John Carter, had offered to pay the bill for the
evening for later reimbursement by the Society.
Something to do with collecting air-miles on his
gold card. Unfortunately the restaurant bounced
his card, and to complete his humiliation, Jon
Hadfield stepped in with his platinum card and
saved the day.
The walk to the coach taking us home was the
final highlight. It meant passing a good number of
bars with loud music blaring and girls dancing on
the bars clinging to poles. This caused some
interest especially when it was pointed out that
some of the 'girls' were not what they seemed!
And those that were wore very little! Needless to
say not all the members of our party were able to
resist the temptation of joining in. Anyway, having
left Jon Purday and Emma Hosking auditioning as
pole dancers, a small group including the Carters
and Hadfield(s) were seen attempting to get into
Professor Robert Sneyd then told us about
'Propofol and paediatric anaesthesia' and Dr Jon
Purday, looking very good considering his new
night job as a pole dancer, gave the results of a
recent audit carried out on what types ofpaediatric
surgery and anaesthesia are being done in the
various hospitals of the south west region. This
provoked some lively discussion before we were
treated to an extra presentation on research into
the spinal action of sevoflurane from Dr Matute.
Several of the British partners joined the
audience for the Closing Lecture. We were
privileged to hear the Lord Mayor of Barcelona,
Mr J Clos, talking about Barcelona, past and
present. Obviously a past master of brinkmanship,
he was observed by the welcoming committee
putting his tie on as he rushed from his car into the
lobby! He trained both as an anaesthetist and a
public health physician before becoming involved
in politics, which to his great delight, in front of a
part-British audience, enabled him to jokingly
refer to the similarity between himself and John
Snow. He gave a fascinating account of the history
of Barcelona, without reliance on notes or visual
aids, occasionally speaking in English to make a
parlicular point. Our President, Dr Robin Weller,
had a briefopportunity to respond at the end ofthe
Mayor's lecture and mentioned, to much
the casino for nothing, but eventually everybody
ended up at the AC Diplomatic Hotel bar.
(Everybody that is except Jon Purday.) Now
although Barcelona does not come alive until after
l0pm, for some reason the hotel bar shut every
night at lam regardless of how many drinkers
were there. Fortunately, we remembered the cava
that we had all bought that morning at the visit to
the cellars, and by the early hours of the morning
the bar started to resemble the inside of a bottle
bank.
Saturday
The Catalan society started early with free papers
which meant that the South West anaesthetists
could have a lie-in ready for the Paediatric session.
Drs Elizabeth Hansen and Dr Nicola Williams
chaired an interesting session with talks on
regional anaesthesia by Dr Pintanel, and
intraoperative management by Dr Silvia Lopez.
26
S h oo bee-
Doo bee-
Doo,
B ee-
Doo bee- Doto be e,
Doobee-Doobee-Doo.
Eat your heart out, ol' Blue Eyes
more of us arrived, so the waiters moved the
boundaries of the restaurant area by moving the
troughs containing a mobile hedge - you could not
do that in an inside restaurant! There was even a
street busker to entertain us, although Virginia
Penning-Rowsell's attempt to persuade him to
play "Happy Birthday to you" in honour of Les
Shutt's birthday, must have lost something in the
translation, as it sounded exactly like everything
else that he played. All in glorious weather and a
wonderful atmosphere. A great end to our visit to
Barcelona.
To end this report thanks are due to Kate Prys-
Roberts for her valuable assistance in the
organisation and travel arrangements, to the
Stevie Robinson demonstrates how Barcelona F.C.
should have intercepted the high cross
wonderful Spanish conference and tour organiser,
merriment from the locals, that on a previous visit
to Barcelona he had bought a most appropriate
souvenir - a Barcelona Football Club umbrella!
^{fter the academic meeting was closed, everyone
s'as invited for cava in the foyer of the medical
college.
The final event of our Barcelona visitjust had to
be tapas. The Ciudad Condal restaurant was very
near to the hotels and very popular with the locals.
We soon found out why. On the Saturday evening
77 of us sat down under a white awning over
a
large pavement area and were treated to delicious
tapas and cakes on white table cloths. As more and
Nuria, who really looked after all of us so well and
had so much enthusiasm at all stages of organising
and running the meeting; all the speakers,
for coming to the meeting
and behaving themselves; and of course the
Catalan Anaesthetists, especially Prof Antonio
Montero, for making us feel so very welcome in
their beautiful city. Needless to say, we would
love to have a return meeting of the two Societies
in the South West in the not too distant future. We
all arrived back in the UK feeling a little more
European than we left - oh, and the Johnson's
suitcase went astray on the aircraft home as well!
members and partners
2',1
Anaesthesia Points West Vol. 34 No. 2
Article
Limericks of Barcelona
Lightty Edited by Robin Weller
In a completely vain attempt to keep the assembled company awake after lunch on the bus, after a Cava tasting
and a visit to Montserrat, the President challenged members to produce limericks. The only requirement was that
they should include the word Barcelona. As a sop to the rhymesters, the word Barca (with a hard "c"), was
allowed. Apize, though promised, was not forthcoming. Since no mention was made that some, or any, would
be published, and permission has not been granted, the authors have not been credited with their work. When
you read them, you might agree that this is a wise decision. However, a list of them all does appear, and I leave
it to you to guess who is responsible for which.
There was a young lady of Spain
Who got on the bus, not the train.
"I will phone you
When we're in Barcelona;
I'll not tell this story again!"
She said,
There was a supporter of Barca
Who was a remarkable farter.
He could fart anything,
from God Save the King,
28
An anaesthetist in Barcelona
Asked a geneticist to clone her.
He made far too many
So they sold for a penny
Which offended the original owner.
A senorita from Barcelona
Spent most of her life as a loner.
She promenaded in style,
to Beethoven's Moonlight Sonata.
Never walked up the aisle,
And rejected all offers to own her.
My loves, said the big girl from Barca
Are tattooed on my breasts as a marker.
A young lady from fair Barcelona
offavours sex-u-al is a donor.
On the right is a bear
called Pooh, and I fear
On the left is an otter called Tarka
To sample her charms
end up in her arms
No problem at all - simply phone 'er.
There once was a gas girl of Barca
Whose motives could not have been darker.
Her foul depredations
froze intemational relations
When she asked a Spaniard to f-farc her.
A young man from old Barcelona
whose name was put down as a donor
Got knifed in a fracas
Went head over tapas,
But a donor's no good with a stoma.
El presidente del Sociedad
Was seen to try very hard
While in Barcelon . . .
. . . a, to direct the porron
At his wife's pharyngeal localidad
There was a young stripper called Ramona
who performed her act in Barcelona.
To fumulfuous applause
She took offher drawers
And eamed her a few bob for her owner.
Ald
Barcelona in Spring should be hot
but this year it really was not
So Weller's the boy
To make you enjoy
Whatever the weather you've got
Champagne and Cava, the same
Codorniu, the fabulous name
Raventos the man
Who had the grand plan
Then went on to invent halothane
(alright, no Barcelona, but allowed in as an exception!)
Embarrassed Authors, in alphabetical order:
Peter Baskett, Brenda Cochrane, Stephen Coniam, Mike Hills, John Little, Ian Norley, Brian Perriss,
Cedric Prys-Roberts, Anna-Maria Rollin (and Henry), Les Shutt and Robin Weller.
29
Anaesthesia Points West Vol. 34 No. 2
Meeting Report
Annual Trainee Meeting of the Society of
Anaesthetists of the South Western Region
Woodbury Park, Exeter
13th - l4th July 2001
Emma Hosking, SASWR Trainee Representative
Bristol School
For the second year running we held the trainees'
meeting at Woodbury Park Hotel and Golf Club on
the outskirts of Exeter. After lunch on Friday we
started the meeting with an update from Dr John
Carter about training, appraisal and portfolios. It
seems that the future is bright for those of us who
accredit in the next few years and we may be able
to pick and choose our jobs. Unfortunately they
are all likely to involve resident
on-ca11,
supernumerary SHOs and a ban on private work.
So we're off to Australia, if that's all right! Prof
Sneyd then told us the latest news on the Peninsula
Medical School. The proposed curriculum looks
slightly different to the ones we all remember.
Somehow we don't think that the students of the
Naughties will resent not having six hours of
biochemistry a week in their first year.
After tea Dr Tim Craft challenged everyone to
think about what they really wanted from their
lives (and consultant careers). Obviously the
answers were resident on-call, supernumerary
SHOs and no private work . . . or perhaps not. He
to think about all the
implications when making your choices and the
stressed the need
benefits of working with flexible, responsive,
dynamic colleagues. Apparently living costs in
Bath are so high you have to go without socks
yourself in order to clothe your children. Dr Steve
Linter, one of our local CHI members
(www.chi.nhs.uk) then spoke about clinical
governance in an action-packed presentation. He
agreed with Dr Craft that sabbaticals for
consultants are a good thing and plugged a new
society: Anaesthetists in Management. The second
UK meeting is happening early next year in
30
Bristol, and anaesthetists of all grades are
welcome. A similar outfit already exists in the US.
Dr Mike Inman finished the afternoon session
with a highly entertaining and reflective account
of his career. We heard about medicine above and
below decks, in deserts and jungle, and an
anaesthetic travel club that involved trips to
Middlesbrough, Leeds, Portsmouth and Cardiff.
There were even a few tips on managing money.
With the academic programme over for the day
we all went for a swim in the leisure complex an
excellent way to prepare for the evening. Robin
Weller had kindly agreed to run a "Guess The
Wine" competition. Simon Courtman and I had
thought this might be a bit ambitious given that we
can only just tell what is red and what is white.
However, some of our colleagues were very
impressive, able to distinguish Sauvignon from
Chardonnay with no problems at all. It was a
pleasure to have Robin, Neville and Sally
Goodman, and Mike Inman join us for dinner.
With so many social animals in one place it was a
late evening in the bar (see www.saswr.co.uk). It's
good to know that some recently appointed
consultants have such fond memories of the
trainee meetings that they can't stay away.
The numbers on Saturday morning were slightly
less than Friday. Once again on-call commitments
prevented several people from staying on. We
enjoyed Neville's talk on how
to give
a
presentation. Not a man to pull any punches, it
was always going to be tough for Andy Pittaway
and Jonathan Paddle to follow on. Would they
have remembered not to mix their serif and sanserif fonts? However, they rose to the challenge
beautifully, despite Woodbury Park's best efforts
to sabotage the projection of 35mm slides.
Traveller's stories are an essential part of any
Southwest meeting, and we were entertained by
tales of ice, penguins, sun and military coups from
Antarctica and Fiji.
In total there were 23 trainees ranging from
SHOs in their first six months of training, to the
more 'mature' specialist registrars. The meeting
remains a unique opportunity for trainees
throughout the region to meet up. We are grateful to
the SASWR committee for their continued support-
3l
Anaesthesia Points West VoL 34 No. 2
Case
Report
Anaesthesia for Electro-Convulsive Therapy
in Last-Trimester Pregnancy
R. Taylor, Specialist Registrar in Anaesthesia, Department of Anaesthesia,
Cheltenham General llospital, Cheltenham, Glos. GL53 7AN, UK
P. N. Young, Consultant Anaesthetist, Department of Anaesthesia,
Cheltenham General Ilospital, Cheltenham, Glos. GL53 7AN, UK
Summary
We present a case where electro-conl'ulsive therapy
was felt to be indicated in a female patient at the
beginning of the third trimester of pregnancy. The
ffeatment proved to be both effective for the mother
and safe for the fetus. The method of anaesthesia
used and a survey ofthe literature on this subject are
using concurrent electroencephalogram monitors
(EEG). This has become more popular now that
seizures are regularly 'modified' by the use of
muscle relaxants.
Like pharmacological methods of treating
fit produced by ECT enhances
central adrenergic tone. It achieves this by activating
depression, the
presented.
central noradrenergic systems.
Keywords: Psychiatry : Electro-convulsive Therapy,
Anaesthesia, General: Obs tetric : Pregnancy.
serotonin reuptake in the brain.
Introduction
Electro-con'vulsive therapy (ECT) was initially used
for schizophrenia in the l930sr, though it was not
long before its benefits for depression were
identified. It was not until 1945 however, that the
French introduced the use of anaesthesia for ECT,
'L'electroche sous narcose'2, with the subsequent
introduction of muscle relaxants to reduce the
incidence of fractures and dislocations occurring
during the fits. During ECT an alternating electrical
current of 30-45J is passed across the skull over
0.5-1.5 seconds. After a latent period of 2-3 seconds
a bilateral grand mal convulsion should follow, with
a tonic phase of3-5 seconds and then a clonic phase
of 30-50 seconds. It is the seizure that provides the
therapy, and its duration is critical to the responser.
Seizures of less than 30 seconds duration have little
clinical benefit, whilst prolonged seizures cause
increased memory loss and post-ictal confusion. It is
possible to accurately measure the extent of the ht
*Footnote : Address
for correspondence:
E-mail : peter.young@egnhst. org. uk
32
increasing
dopaminergic receptor sensitivity and reducing
Electro-convulsive therapy (ECT) is a treatment
that has undeniable benefits in some forms of
depression, particularly when other treatments have
failed. It is normal to provide general anaesthesia for
this. The technique of anaesthesia is fairly standard,
and the physiological changes occurring with the
anaesthesia and therapy in the majority of patients
are well understood. We were recently consulted by
a Consultant Psychiatrist who wished to prescribe
ECT for a patient in the 28th week of pregnancy for
whom drug therapy was proving ineffective.
Although the feasibility of ECT in pregnancy is well
documented in the literature, we have found only
sketchy references to the practicalities ofanaesthesia
for this procedure.
Case Report
The patient was a 4l-year old Community
Psychiatric Nurse who had been an in-patient for 4
weeks in the psychiatnc unit. She had been admitted
at 24 weeks gestation in her second pregnancy with
severe depression showing psychotic features. She
was otherwise fit and well. A previous pregnancy,
l5
years before, had resulted in an elective
Caesarean Section at term under general anaesthesia
in another hospital. She gave a history ofprolonged
neuromuscular blockage following this operation.
Our initial concern about the possibility of
succinylcholine apnoea in this patient was allayed
when notes from the other hospital made it clear that
the problem was the result of 6mg of pancwonium
being used for a short operation. Subsequent to the
birth of her first child she developed a puerperal
psychosis, which had responded to pharmacological
treatment.
On this admission she had shown transient
improvement on imipramine, but had then regressed
and was now voicing suicidal thoughts. The
Consultant Psychiatrist felt that venlafaxine was
indicated, but the manufacturer was adamant that
this could not be regarded as safe in pregnancy. He
therefore felt that ECT was indicated, and contacted
the Consultant Anaesthetist with responsibility for
ECT to ask about the feasibility and safety of this.
During this discussion it was agreed that ECT was
indeed indicated in view of the suicidal tendencies
displayed even in view of the apparent risks of the
procedure to both mother and fetus. Also, when not
suicidal the patient was showing great concern about
her ability to care for the baby after delivery because
of her mental state. Further consultation with a
Consultant Obstetrician made it apparent that there
was a risk of placental abruption or of premature
delivery associated with ECT if wide swings in the
arterial pressure or pulse were allowed to occur, it
was therefore considered that the treatment should
take place in the base hospital and not in the
psychiatric unit some I mile (1.6 Km) distant. We
also arranged for midwifery staff to be in attendance
in order that fetal monitoring could be undertaken.
The patient was seen by the Consultant
Anaesthetist 3 days before the day of the first
planned ECT. She presented as profoundly
ofinsight into her
illness, and she was desperate for something to be
depressed but
with a
great degree
to alleviate her state. The risks to her and the
fetus of the anaesthesia and treatment were fully
done
commenced and run through in the approximate
45 minutes it took to complete the procedure. She
was connected to both full noninvasive anaesthetic
monitoring and to a cardiotocography (CTG)
monitor; a midwife was in attendance to observe
this. After l0 minutes of a normal CTG trace had
been observed, an uncomplicated rapid sequence
induction was performed using preoxygenation,
alfentanil 0.75m9, propofol l00mg
and
suxamethonium l00mg. Intubation was easy, with a
good view of the glottis. The arterial pressure
readings were then altered from a 3 to a I minute
cycle and a tooth guard was inserted. The psychiatrist
then delivered the ECT, monitoring the duration of
the fit with the aid of an electro-encephalogram,
which showed it to be adequate.
Throughout the procedure she was easy to
ventilate and remained cardiovascularly stable. She
was ventilated with 100% oxygen with saturations
above 98% throughout. Preinduction arterial
pressnre and pulse were 110167 and 100 bpm sinus
rhythm. Immediately after induction her arterial
to 95156, and after the shock she
had a 4 second period of asystole after which her
heart rate returned to 92 bpm sinus rhyhm. This was
pressure dropped
followed by a mild hypertensive reaction with
arterial pressures of 158192, 134182 and l19168 in
sequential minutes; the hearl rate remained between
89 and 109 during this event. The fetal heart rate
slowed by about l0 bpm after the propofol was
given, but otherwise remained normal. On
emergence from the anaesthetic she was extubated
in the left lateral position and recovered in the usual
manner. At the second and subsequent treatments
3mg of ephedrine were given at induction, and this
prevented the slight fall of arterial pressure noticed
at the first treatment.
In total our patient required two sets of treatment
sessions of ECT in each. All
anaesthetics were given either by consultant
with 9 and 4
anaesthetists or an associate specialist, or by a senior
trainee under direct consultant supervision. For each
session the same anaesthetic technique, with minor
explained, and she agreed that the treatment should
variations as mentioned, was used, with similar
go ahead. Ranitidine
results. She was eventually delivered at 39 weeks
gestation by elective caesarean section under a
15Omg
by mouth
was
prescribed for the evening before and the day ofthe
planned treatment. On the day of the procedure she
arrived, fasted, in the anaesthetic room and was
given 30mls of 0.3M sodium citrate by mouth; she
was then positioned supine with a left wedge of 15",
a 2.0mm outside diameter cannula was placed in a
vein in her left arm and a I litre bag of 0.9% saline
spinal anaesthetic. The operation was uncomplicated
and she had a healthy baby boy who was observed
on the neonatal unit for signs of drug withdrawal but
did not require any treatrnent. The mother was stared
on venlafaxine 8 days post partum after which she
was discharged into the care of the psychiatrists.
JJ
Discussion
Depression in pregnancy is detrimental not only to
the mother, but to the fetus as well. Depressed
patients are often malnourished, may indulge in
alcohol, cigarettes or substance abuse, are more
prone to infections and their illness may lead to
disruption of the family unit, often with aggressive
behaviouro. Prompt, safe and effective treatment is
therefore essential. There are obvious concerns
regarding the use of drugs during pregnancy. Cyclic
antidepressants and the newer noradrenergic
serotonergic reuptake inhibitors have been
associated with higher rates of fetal abnormalities,
though causation has not been proven. Lithium is
well known to be teratogenic. There are conflicting
reports on their effect on the fetus ofanxiolltics, but
they are well documented to cause withdrawal
symptoms in the neonates. Uncertainty about the
effects of many psychotropic drug and the risks of
continued illness increase the attractiveness of ECT
in these patients.
As with any therapy it is important to be aware of
possible effects on the pregnancy and the effects of
the pregnancy on the treatment. Animal studies have
shown6 that seizure threshold is decreased by
oestrogens and alkalosis whilst progesterones will
raise it. Although the effects are thought to be the
same in humans there is great individual variation
and the clinical significance of this phenomenon is
unknown. Until the late 1940s pregnancy was
thought to be a contraindication to ECT, as there
was concern about miscarriage and teratogenicity.
In fact up until 1982, in some states of the USA, it
was illegal for epileptics to marry due to concern
about the mother fitting whilst pregnantT. In 1994
Dr Miller, a psychiatrist from Chicago performed a
retrospective study looking at cases of ECT in
pregnancy'. She identihed a total of300 case repods
from 1942 to 1991. As with most retrospective
studies there were problems with inaccurate
recording of data. For the majority, 219 (73o/o) itwas
unclear during which trimester they received their
treatment, there was a wide variation in the number
(l to 35) and type of treatments given and in the
follow up of the infants (2 months to 19 years).
However, this still represents the largest study to
date. She identifred the following 9 major potential
risks in 28 patients: transient benign fetal
arrhythmias, mild vaginal bleeding (with one minor
abruption), self limiting uterine contraction, non
specific abdominal pain and one case of
insignificant neonatal respiratory distress. None of
34
these has adverse effects on the pregnancy or infant.
Premature labour occurred in 4 patients, though not
immediately after ECT so the relevance is uncertain.
There were 5 cases of miscarriage, one of which was
related to an accident though even including this
case the incidence (1 .6%) is far less than the
reported national incidence (20%). There were 3
reports of still birth and neonatal death; one was a
child born with congenital pulmonary cysts who
died of pneumonia shortly after birth, another
mother had had ECT 7 months prior to delivery and
the last woman had eight insulin coma therapies
after her ECT which resulted in marked weight loss
and vomiting. There were 5 cases of congenital
abnormalities but no set pattern of abnormality to
suggest causation and again the rate is lower than
the national average of3%".
There is no direct evidence that ECT is
detrimental to pregnancy and the Royal College of
Psychiatrists state that it can be, 'prescribed with
confidence in the second and third trimesters of
pregnancy' but that little is known of its effects in
the first trimestere. Obvious concerns for our patient
were prevention of aspiration, maintaining placental
oxygen delivery and avoidance of hypertensive
surges, which could result in abruption or premature
delivery.
Assessment
of our patient's airway gave
no
indication that there would be complications and
after routine prophylaxis against acid aspiration, a
rapid sequence induction was performed with grade
I laryngoscopy. To maintain placental oxygen
delivery she was ventilated using 100% oxygen,
maintaining saturations above 98Yo at all times, and
kept on a left lateral tilt to prevent aortocaval
compression. We used
a larger dose of
succinylcholine (100mg) than we would normally in
an attempt to provide optimal intubation conditions,
this making EEG monitoring of the fit duration
essential.
Our technique was further modihed in an attempt
to minimise the cardiovascular changes that would
normally occur with ECT and intubation. ECT
stimulates both the peripheral autonomic and neuroendocrine systems'n. There is a parasympathetic sympathetic response early in the procedure, which
is repeated but to a lesser degree during the clonic
phase. Typically the parasympathetic stimulation
occurs immediately after the shock, with a brief
period of brady-arrhythmias including asystole often
associated with hypotension. This is followed by
sympathetic stimulation causing tachy-arrhythmias,
hypertension, increased myocardial and cerebral
oxygen consumption and increased intra cerebral,
ocular and gastric pressures. To obtund the laryngeal
response to intubation we used 0.75mg of alfentanil
at induction and to prevent the hypotensive and
bradycardic responses, both to induction and the
ECT, we gave an infusion of 1 litre normal saline
and a 3mg bolus of ephedrine, immediately prior to
the shock. This resulted in good stability of the
circulation. The variations in her arterial pressure
were minimal with an initial drop to 92o/o (103/56)
a transient rise to
142% (158192) for less than 1 minute. She however,
experienced a transient 4 second period of asystole.
The use of anti muscarinics has been suggested in an
ofher pre induction recording and
attempt to prevent this occurringrr, with
glycopyronium being the drug of choice due to its
fetal/maternal ratio of only 0.13. In our experience
any brady-arrhythmia caused by ECT has been selflimiting and this would not be part of our routine
practice in anaesthetising patients for ECT.
However, at one treatment 200mcg of
glycopyronium were given in an affempt to prevent
the brief period of asystole; it was effective in this
respect, but gave rise to a considerable fetal
bradycardia, and this was not thereafter repeated.
Since we were also concemed about the effects of
hypotension on placental flow we elected to use
ephedrine after the first treatment. We felt that the
brief asystole was acceptable, especially in the
knowledge that the fetal heart rate remained entirely
normal. Although she did experience a hypertensive
surge this was too brief to commence any treatment,
though had this been prolonged we would have
considered using a bolus of either propofol or
hydralazine.
The neuro-endocrine changes with ECT include;
raised catecholamine, ACTH and cortisol levels with
increased secretion
of glucagon, prolactin',
vasopressin and, perhaps more worrying for us'
oxytocinon which could start premature labour"'''.
There is no known means of abating this response
but forhrnately this did not cause any problems.
Interestingly the fetal heart rate showed no
significant signs of parasympathetic or sympathetic
stimulation with any of the sessions, except when
glycopyronium was given. American authorities
have recommended the use of complicated fetal
monitoring in these cases. i.e. twice weekly
'biophysical profiles' with weekly Doppler studies
of the umbilical arteryl'3. However, the Royal
College of Psychiatrists state that there is no
evidence that this improves outcome.
Conclusion
ECT is essentially a safe and effective treatment for
depression in pregnancy. It is essential that there is
good communication between the anaesthetist, the
obstetrician and the psychiatrist handling the case.
As ever, consent is vital and the anaesthetist must be
aware of the physiological changes of both the
pregnancy on the patient and those that will occur
from the ECT and alter their
management
accordingly to minimise any risk to both mother and
child. We would also add that the treatment
presented a considerable organisational challenge' as
it required fitting the case into normal theatre
emergency time, and also the attendance of six
professionals from four different disciplines. The
organisation of all this fell, naturally, on the
anaesthetic department.
References
l. Simpson KH, Lynch L.
Anaesthesia and electro-convulsive
therapy (ECT). lnaesthesia 1998, 53: 615-617 2. Lassner J. Anaesthesia for ECT. Anaesthesia, 1998; 53:
1228-123'.7.
3.
Electro-convulsive Therapy. In: Yentis SM, Hirsch NP,
Smith GB, Anaesthesia A to Z Bttterworth Heinmann,
4.
Walker R, Swartz CM. Electro-conlulsive Therapy During
1995:1 55-6.
High-Risk Pregnancy. General Hospital Psychiatry, 1994'
16:.
348-352.
5. Hassner LA. Pregnancy and Psychiatric Drugs' Hospital and
Community Psychiatry, 1985; 85: 817-818.
6.
Krumholz A. Epilepsy in pregnancy in, Neurological
Disorders of Pregnancy. Ed Goldstein PJ, Stern BJ. Mout
Kisco, NY, Futura 1992.
7. The Legal rights of persons with Epilepsy. 5th ed. Landover
Md Epilepsy Foundation of America, 1985.
8. Miller L. Use of Electro-conr,ulsive Therapy during Pregnancy.
Hospital and Community Psychiatry 1994, 45: 444-450 9.
Lock T. ECT and Obstetrics.
In
The Royal College
of
Psychiatry ICT handbook. 1995; 1 : 22-23.
10. Electro-conl'ulsive Therapy. ln: Anaesthesia Cucchiara RF,
Miller ED, Reves JG, Roizen MF, Savarese JJ Fourth edition.
11.
Churchill Livingston 1994; 2269-227 3.
Walker R, Swartz CM. Electro-convulsive Therapy During
High Risk Pregnancy. General Hospital Psychiatry, 1994; 16:
348-53.
12.
Salvin BL. Electro-convulsive Therapy Anesthesiology'
13.
American Psychiatric Association Task Force on Electro-
198'7; 67:367-385.
convulsive Therapy. The practice of electro-convulsive
therapy: recommendations for treatment, training and
privileging. Washington DC: American Psychiatric
Association, 1990: 7 2-3.
35
Anaesthesia Points West VoL 34 No. 2
Case Report
An Anaesthetist's Dilemma
What would you do?
-
T. M. Cook" Consultant, Royal United Hospital, Bath
N. Barlow, SIIO, Royal United Hospital, Bath
A 54 year old man was refened by the physicians to
the surgical team for repair of a tender umbilical
hernia He had been admitted four days earlier with
shortness of breath and haemoptysis after an
alcoholic binge. He had a long history of alcohol
abuse leading to hepatic cirrhosis and portal
hypertension, complicated by oesophageal and
gastric varices. These conditions had led to multiple
hospital admissions. He also had ischaemic heart
disease, atrial frbrillation, asthma and emphysema.
His normal exercise tolerance was 50 yards. Regular
medications included spironolactone, frusemide and
thiamin. Admission findings included increased
jaundice, ascites and a large pleural effusion. Six
litres of pleural aspirate was drained over four days.
On the fourth day he developed abdominal pain and
swelling. He was not vomiting and continued to pass
wind.
On examination he was jaundiced, malnourished
with abdominal distension and gross signs of ascites.
Chest auscultation revealed large persisting pleural
that he would be unlikely to respond to resuscitation
in the case of sudden collapse. The surgeons
believed the hernia contained omentum, but no
bowel, and that the bowel was not obstructed. The
high risk nature of surgery was discussed with the
patient and surgeons.
Problems were as follows
r with acute on chronic liver disease the risks
associated with any form of anaesthesia and
r
abdominal surgery were life-threatening'
the surgical condition was incompletely defined
and the extent of surgery could not be defined
until the operation was underway. At best
surgery would simply be body wall repair, at worst
it might involve resection of necrotic bowel
r admission to intensive care would
be
inappropriate as any organ failure would be
r
unlikely to be reversible
post-operative analgesia would be problematic as
non-steroidals were contra-indicated and
response to opioids could be unpredictable.
effusions and prolonged expiratory time with
wheeze. He looked clinically dehydrated but was
peripherally warm and vasodilated. He was
markedly anxious. He had an obvious umbilical
swelling that was inflamed, discoloured, bruised and
tender.
I
r
I
I
Options for anaesthesia were
general
regional
local
decline to provide anaesthesia as risk too high.
Investigations showed Na l3l mmol.l-r, K 3.5
mmol.lr, Urea 2.3 mmol.l-' on admission rising to
6.5 mmol.l' on the day of surgery. Urine output was
<500 ml in previous 24 hours. This was considered
to perhaps represent hepatorenal syndrome. Other
blood results included bilirubin 240 pmol.l-r,
Alkaline phosphatase 215 U.|, ALT 27 U.lr,
albumin 30 g.li. Hb 11.8 g.dt', MCV ll3 fl, Wcc
8.9 xlOe.lr, pl 133 xl0e.l-r, INR 1.9, KCCT 4l s,
hypotensionn-'. Abdominal surgery itself induces
Ereater and longer lasting effects on hepatic blood
flow than anaesthesia6. Behaviour of anaesthetic
agents is altered by hepatic dysfunction and includes
D-dimers 1033.
resistance to muscle relaxants and increased
His condition was discussed with his attending
physicians and surgeons.
36
It was already
considered
General anaesthesia with volatile or intravenous
agents is associated with reduction in hepatic blood
flow'r. This is worsened by mechanical ventilation,
alteration in carbon dioxide tension
and
sensitivity to opioids with reduced elimination
rates8'e.
Regional anaesthesia reduces hepatic blood
flow in proportion to falls in blood pressure'o.
Regional anaesthesia may be contra-indicated
because of prolonged prothrombin time and
qualitative alteration in platelet function. Renal
failure was a considerable risk with general or
regional anaesthesia and renal failure associated
with hepatic disease has a particularly high
mortality". Local anaesthesia would be possible for
body surface surgery but would be inadequate for
viscus surgery. The mortality associated with major
surgery/anaesthesia with severe hepatic impairment
(prothrombin time prolonged >4 s beyond normal,
albumin < 30 gl dl, ascites present and poor
nutritional state) is above 40o/o and may reach
800/or2''3.
This patient had all these features.
Regional anaesthesia was chosen and the
treatment plan as follows. Surgery should be the
minimal necessary. Intra-abdominal surgery should
be avoided unless absolutely necessary. Anaesthesia
should be managed to maintain normoxia and
prevent hypotension. Spontaneous ventilation should
be maintained to preserve liver blood flow. General
He was nursed for 12 hours in a high dependency
unit. Epidural analgesia with bupivacaine 0.1%o was
continued for 48 hours and the catheter removed
after repeat infusion of FFP. There were no
neurological sequelae. He had 24 hours of mild
confusion (encephalopathy grade 2) post
operatively. Renal and liver function changed
minimally post-operatively: urine output was
maintained, urea peaked at 8.5 and albumin fell to
27 but other hepatic indices improved. He made a
slow but steady recovery, which was complicated by
recurrence of pleural effusion, hyponatraemia,
hyperkalaemia, poor oral intake and depression but
was discharged home after six weeks with no
complications.
References
1. Arahna GV, Greenlee GV. Intraabdominal surgery in patients
with advanced cirrhosis. Archives of Surgery 1986; l2l:.
77 4-8O
2 Goldfarb G, Debaene B, Ang ET et al. Hepatic blood flow in
humans during isoflurane-NrO and halothane N2O
3
anaesthesia. lnesthesia and Analgesia 1990;71: 349-53.
Thomson IA, Fitch W, Hughes RL et al. Effects of certain
IV
of
anaesthetics on liver blood flow and hepatic oxygen
prolonged post-operative respiratory failure,
worsened hepatic function with encephalopathy and
need for intensive care would be increased. We
4 Brendeberg CE, Paskanik A, Fromm D. Portal
inappropriate.
5
anaesthesia to be avoided as the lii<elihood
considered admission to intensive care
consumption in the greyhound
1986; 58: 69-80.
Combined spinal anaesthesia (CSE) was chosen
to minimise the risk of failure of regional
6
anaesthesia and allow profound blockade, which
was both titratable and able to be prolonged for post-
7
operative analgesia. A needle through needle
technique was used to minimise passage of needles
into the spinal canal. Arterial and central venous
pressures were monitored invasively.
Fresh frozen plasma (FFP) and vitamin K were
given to correct coagulopathy but INR remained 1.7.
CSE was performed with 1.6 ml of bupivacaine
plain and a block to T5 developed. Hypotension did
not occur (the patient was already vasodilated). No
vasoconstrictors were needed. One litre of colloid
and 700 ml of crystalloid brought his CVP to
10cmH2O. Conscious sedation was provided by a
target controlled infusion of propofol titrated against
effect. Surgery was performed through a small
transverse incision. The hernia contained necrotic
bowel and obstruction was evident. A short section
of small bowel was resected and anastamosed.
Surgery was well tolerated. At the end of surgery the
patient vomited copiously but easily protected his
airway.
.
British Journal of Anaesthesia
haemodynamics in dogs during mechanical ventilation with
positive end expiratory pressure. Surgery 1981 ; 90: 817 -22.
Cooperman LH, Warden JC, Price HL. Splanchnic circulation
during nitrous oxide anaesthesia and hypocapnia in normal
man. Anesthesiologt 1968; 29: 254-8.
Gelman S. Disturbances in hepatic blood flow during surgery
and anesthesia. ,4 rchives of Surgery 1976; 111: 881-3.
Doi R, Inoue K, Kogire M, et al. Simultaneous measurement
of hepatic arterial and portal venous flows by transit time
untrasonic volume flowmetry. Surgery, Gynaecology and
Obstetrics 1988; 167: 65-9.
8 Duvaldestin F, Agoston S, Henzel D et al. Pancuronium
pharmacokinetics in patients with liver cirrhosis. Brilisft
9
Journal of Anaesthesia 1978; 50: 1 l3 1-6.
Strunin L. Effects of anaesthetics and drugs on liver function.
ll7
lll-l/'l ll15 In International
Practice of anaesthesia.
Editors Prys Roberts C, Brown BR. Butterworth-Heinemann,
Oxford, UK 199610 Kennedy W, Everett G, Cogg L et al. Simultaneous systemic
and hepatic and haemodynamic measurements during high
epidural anaesthesia in normal patients. Anesthesia and
Analgesia 1971; 50: 1069-'77.
11 Brown BR. Risk assessment for anaesthesia in patients with
liver disease. In International Practice of anaesthesia. Editors
Prys Roberts C, Brown BR. Butterworth-Heinemann, Oxford,
UK 1996 pp rl73/l-1/73/9.
12 Childs CG. The liver and portal hypertension. In Major
problems in Clinical Surgery edited by Childs CG. Vol I
Philadelphia WB Saunders 1963.
13 Pugh RNH, Murray-Lyon IM, Dawson JL, Pietroni M,
Williams R. Transection of the oesophagus for bleeding
vaices. British Journal of Surgery 1973; 60: 646.
37
Anaesthesia Points West VoL 34 No. 2
Article
At the Receiving End
Aileen K. Adams, Emeritus Consultant Anaesthetist, Addenbrooke's Hospital, Cambridge
I was prompted to submit this article after reading
about some of the nasty complications that can
follow peribulbar anaesthesia. I was glad not to
have read them until after I had had my cataracts
removed. These operations are so commonplace
that an account ofpersonal experience might seem
unnecessary, but I have been struck by the attitude
of medical and non-ophthalmic surgical colleagues
whose reaction has often been "I would be
terrified of having an eye operation under local".
This is in contrast to anaesthetists, who need no
reassurance of the effectiveness of local analgesia
and lay patients, who take it in their stride.
However, anaesthetists might like to know more
about what it is like at the receiving end.
When I started anaesthesia, cataracts were done
under local analgesia using facial and retrobulbar
nerve blocks, not without the occasional serious
complication. Improved instruments and the use of
the microscope resulted in more complex and
longer operations, so many surgeons turned to
general anaesthesia, once we had shown we could
produce the right conditions. I spent much time on
this myself investigating the effects of general
anaesthetic agents and techniques on the eye,
indeed I was invited to dine out on this topic many
times.
After fifteen years of retirement from clinical
practice, it became my turn. With only momentary
misgivings, I opted for local. My anaesthetist said
I could eat and drink beforehand what and when I
liked, showing confidence in his skills. "No
- is that all right?"
"Yes of course, whatever you usually do is all
right with me". It was fine, the Elgar cello
concerto knocks any pharmacological
premedication into a cocked hat and I was pleased
that my anaesthetist, like Dr Francis', followed the
late Dr Alfred Lee's dictum of always having
intravenous access assured. Both the block and the
premed and a peribulbar block
38
it was just a
it" and I did. The visual
surgery were completely painless,
matter of "relax and enjoy
effects of phacoemulsification were fascinating, a
continuously-changing kaleidoscope of blues,
greens, silver, with occasional flashes of red, black
and yellow. I have never gone swimming under an
iceberg at sunset, but I imagine it might look
something like this. Occasionally the surgeon's
face appeared as if in a fuzzy green photographic
negative. He likes to chat when operating and we
found a common interest in Nepal and mountain
walking. I was quite sorry to hear "I've almost
finished".
Postoperatively BBC Radio 3 provided my
beloved Papa Haydn, with "The Seasons" live
from Eisenstadt in Austria, with a trip in the
interval to the EsterhazaPalace in Hungary. I had
visited both some years ago when researching the
relationship between Mrs John Hunter and Haydn.
I could visualise the magnificent Haydnsaal with
the orchestra - the largest Haydn ever used crowded along with the chorus onto its small
stage, with the horns for the hunters' chorus
sounding from the gallery. It brought back vivid
memories of a Hunterian lecture and the first
of "The Creation " to Anne Hunter's
libretto in the Festival Hall in 1993'z. Any
performance
diffrculty in getting off to sleep was nothing to do
with the sugery but everything to do with being
hyped up - as the late Anthony Storr reminds us,
listening to music is always intensely arousing'.
The block was slow to wear off and it was not
until 3am that I awoke in moderate pain, but this
was quickly relieved with paracetamol.
Waiting a few weeks for the second operation
was a bit tiresome, because binocular vision is not
much improved when the two eyes are doing
different things. A different anaesthetist looked in,
said he'd be around but that the surgeon would do
the block, nor did he bother with intravenous
said'Just a sub-conjunctival
injection this time - more limited, you can tell me
which you like best afterwards". Both block and
operation, as before, were painless. The lack of
akinesia was not a problem to either of us. The
access. The surgeon
microscope light was at first blindingly bright,
striking straight through to my occipital cortex
where it seemed to intensify, but this passed off
quickly. The effect of the lens emulsification was
quite different, pure white cumulus-like clouds
gently moving against a beautiful blue sky, with
the microscope lights providing a double sun.
Conversation this time was about the anatomy of
the eye and whether it was the Greeks or the Arabs
who first discovered that the lens was not spherical
and was not in the centre of the globe. The block
wore off much more quickly, just as I finished my
supper, but as before the discomfort was easily
relieved. On balance I preferred this more limited
and shorter-lasting effect that gets you back to
As I had so obviously enjoyed the experience,
my surgeon afterwards asked me to write an
account of it so he could give it to his more
nervous patients to read! Was there nothing
unpleasant about it? Well, some of the eye drops
sting a bit and putting them in yourself is
inconvenient.
It should
be recorded that the end-result is
superb, never did the flowers look more colourful,
distance vision without glasses is clear and sharp
and I can drive at night again with confidence.
What I need now is new ears and fortunately there
are technicians working on this problem too.
References
1. Francis JG. Correspond.ence, Anaesthesia Points W'est,
2000;33: 122.
2. Adams AK. I am happy in a wife. Hunterian Bicentenary
3
Commemorative Meeting, 1993, Royal College of Surgeons
of England, London. 32-37.
Storr A. Music and the Mind. 1992, HarperCollins, London.
normal more quickly.
39
Anaesthesia Points West Vol. 34 No. 2
Article
A Herpetic Weekend in California
*Tessa Whitton, SpR in Anaesthesia,
Bristol
In March of this year I left the rainswept wilds of
Seattie, where I was working in the University of
Washington Pain Centre, on a year's "Out of
Programme Experience", and flew south to the balmy
shores of southern California to attend the Fourth
International Conference on Varicella, Herpes Zoster
and Post-Herpetic Neuralgia, held in La Jolla. My trip
was funded by the contribution of the Feneley
Travelling Fellowship which was generously awarded
to me by the SASWR, and for which I was extremely
grateful.
The conference was organised by the Varicella
Zoster Virus Research Foundation, and aimed to cover
the latest developments in Varicella Zoster Virus
(VZV) research. The main topics covered were cunent
experience with and future potential of vaccines to
prevent varicella and zoster, and advances in our
understanding and treatment of zoster pain and postHerpetic Neuralgia (PHI$. Genomics, transcriptional
control and surface expression fascinating as they are,
my interest is in post-herpetic neuralgia and zosterassociated pain, and this was the main reason for my
attendance.
Prior to leaving for Seattle, I had been carrying out
a longitudinal study on vibration sense as a predictor
for PHN, under the supervision of Dr Bob Johnson at
the BRI Pain Clinic. Dr Johnson was fully involved
with the conference, both as co-chair for the clinical
session and as a prograrnme committee member, so
it
provided an opportunity for me to catch up with him
(plus he knew absolutely everybody there so was an
invaluable source of information and contacts!). The
session on clinical and treatment aspects was
excellent, covering the pathogenesis of zoster*Footnote:
Dr
Whitton was the recipient of The
Feneley Travelling Fellowship and here records the
trip for which this was awarded.
40
associated pain, new models of pain measurement and
evaluation, pain mechanisms of acute herpetic pain,
and recent advances in treatments for pHN. This
session was expertly chaired by Bob Johnson and was
followed by another excellent session on
epidemiology of both varicella and zoster. The
evening's entertainment was a dinner at Scripps
Marine Research Centre, preceded by a tour around
Ihe amazing aquarium there. Day two commenced
with another well-presented session on prevention and
vaccine development; then it was time for the clever
scientists to talk about basic science. I coped for a
while but lost the plot somewhere between
glycoprotein gH and single nucleotide
polymorphisms, and was forced to nip off for a swim
in the gorgeous pool. After lunch a comprehensive
plenary session ended the conference and it was offto
the airport for a flight back up to the land ofStarbucks
and Microsoft.
Intemational conferences such as this are ,not to be
missed' opportunities for a number of reasons. If you
are involved in research on any topic, whether basic
science-based or clinical, there will usually be
someone else somewhere in the world doing
something, if not similar, then related in some way.
Such a conference, particular$ one on a well-defined
topic, provides a great opporhrnity to make contacts
vide a starting
Meetings like
'fits in' to the
big picture. The number of specialties and disciplines
involved in research into any disease is huge: in this
case anaesthesia, pain medicine and management,
paediatric s, dermatology, immunology, geriatric s,
infectious disease, virology and public health, not to
mention basic sciences. Lastly, most conferences are
held in gorgeous places; this was no exception. La
Jolla is on a spectacular part of the southern
Californian coast, all windswept beaches and palm
trees, so despite a busy schedule there, I still went
home feeling like I'd had a holiday! The Feneley
Travelling Fellowship is available every year; all
tainees may apply to be considered for it. This year, I
was the only person to apply (thanks to the prompting
of on-the-ball SASWR trainee representative,
EmmaHosking).
I'll finish with a lesson in Californian etiquette.
When at yow pre-conference 'meet and greet' sushi
buffet, you will lose both yor.r cool and poise if, like
me, you mistake a bowl of wasabi (HOT Japanese
horseradish sauce) for guacamole, fill your face with a
huge mouthful of it and have to run squealing like a
pig to the ladies in full view of the assembled
grandees. Nil points for star quality.
4l
Anaesthesia Points West Vol. 34 No. 2
Article
o'Anustheshuh! ))
- Revisited
Another Young Man Goes West
Ed Morris, SpR in Anaesthesia, Bristol School
I hadn't
realised quite how many of the South
West's consultants had followed the well-trodden
path to Ann Arbor until I started telling people about
the year out I had arranged for myself there, as a
Visiting Instructor at the University of Michigan. I
was inundated with the names of people to look out
for and things to say to them (and indeed people to
watch out for and things not to say) by everyone I
met who had been there. It was the strong tradition
of British Anaesthesia at the U of M that had made
the trip there relatively easy to arrange and, once I
had arrived, relatively easy to settle into. Several
senior registrars from this region who went to the
USA never came back and send their regards to
those who might remember them - Allan Brown,
Prema Dorje and Gaury Adikhari to name but three.
We arrived in April to a glorious spring along
with another five rotating SpRs and their families,
which made settling in a lot easier. There is a
tradition ofhanding on property leases and vehicles
from year to year and we struck gold with the house,
a lovely condominium set in lakeland with wildlife
in abundance. Ann Arbor is a beautiful l9th century
university town which gives way at its edges to
rolling countryside and the River Huron - which
considering it is only 20 or so miles from Detroit,
the murder capital of the USA, is remarkable.
Family thus installed, I ventured to the hospital and
my first experience of American medicine.
The University of Michigan Health Care System
is the second biggest employer in Ann Arbor after
the University and is a tertiary referral centre for a
large proportion of Michigan. Its size is impressive the staff car parks alone stretch for a mile alongside
the road approaching
it.
The Department of
Anesthesiology boasts 60 attending staff, over 50
residents, a similar number of Nurse Anesthetists
(CRNAs), and around a dozen rotating British
"Visiting Instructors" at any one time. Across all
42
sites there are around fifty operating theatres
(I never managed to count them all with any degree
ofcertainty) and around 350 operations per day.
The pattern of work was very different. Each day
I was assigned two or three operating rooms, each of
which had either a resident or a CRNA staffing it.
My r61e was to rubber stamp the plan for anaesthesia
for each case, be present for induction
and
emergence and (in the case of a resident) to stay and
teach for a while until called to another room to do
something else. Only for the most difficult cases
could I be freed up to remain with the patient all the
way through but in general the CRNAs were quite
able to work unsupervised - some of them
humblingly so - and the residents were delighted
that 'the Brits' were sometimes prepared to stand
outside in the corridor while they induced
anaesthesia alone. I firmly believe that one of the
strengths of my training in Anaesthesia has been the
distant supervision that our system permits for a
proportion of the time. An American senior resident
can accredit as an attending anesthesiologist, and go
into independent practice in the middle of nowhere,
without ever having intubated a patient
unsupervised.
About 70% of operations are performed as day
cases at the U of M, many of them plastic,
laparoscopic and orthopaedic surgical procedures
that in the U.K.would be assumed to require
admission to hospital; for example local flaps for
melanomas, laparoscopic cholecystectomy, and
anterior cruciate ligament repair. The acceptance by
the public of this - and the consequent virtual
guarantee of an operation at a stated time - means
that patients and their families plan care for after
discharge, which may include a four hour drive
home, or a stay in a local motel. Often in the UK, I
realised, we keep patients in hospital for no reason
other than to provide pain relief, and as the shortage
of beds and nurses to staff them continues to swell
the waiting lists a move towards more day-case
work seems inevitable. It was impressive to see how
anaesthetic and analgesic techniques had been
modified to compensate for early discharge, intraarticular infusions of bupivacaine using prefilled
automatic systems were very popular, as were large
water filled "cold-packs", wrapped around the knee
and connected by hoses to a portable refrigeration
unit. Nevertheless, I sometimes felt uneasy as I
waited at the entrance for my lift home each evening
watching that day's patients being levered into cars
by relatives, clutching their Nurofen and Tylex,
waving bravely at me.
The surgery itself was slower on average than that
in the UK, but there may be good reason for this.
Blood donation is perceived to be such a risk in the
USA (HIV is still transmitted in 1 in 50,000 units
there, and hepatitis C much more frequently) that
haemostatis is obsessive, and it was usual to record a
blood loss of only 50 or 100 ml for a bowel
resection, or 300 ml for a hip replacement. Slower
surgery brings with it a number of challenges,
including temperature control (a Bair hugger was
used for every case), prolonged recovery (although
this didn't seem to affect discharge times), and
choice of technique - try devising a dose of spinal
anaesthetic to outlast a 3 hour hip replacement.
Many patients were obese - Michigan is America's
second fattest state
-
and my record for the year was
a lady weighing 550 pounds (250 kg) for
a
hysterectomy. I learned two things about obesity.
Firstly, if you have the infrastructure - beds that sit a
patient up at ninety degrees, operating tables that
accommodate trunk-like arms and legs - a lot of the
stress ofanaesthetising these patients is taken away.
Secondly, if all other airway variables - Mallampati
score, thyromental distance, lower jaw protrusion,
neck movement - are normal, then obesity itself
does not seem to predict an airway problem. I do
have a vague memory of someone from this region
publishing work demonstrating that obesity is an
independent predictor of diffrcult intubation, and can
only suggest that in Michigan obesity tends to be
respected by a wide variety of other doctors to a
system where surgeons unequivocally rule the roost
and Alaesthesia to some degree has been relegated
to an airway management specialty. "My patients
don't get epidurals", "You won't need an arteial
line for this", "I want you to use propofol for this
case", or "You're not putting my patient on her side
with a laryngeal mask" were comments to which
one became almost immune, and
perhaps
understandably are part of a system where often a
nurse anaesthetist (to whom the American surgeon
feels a natural superionty) is the only representative
of the department in the room for much of the time.
Slightly more irritating was the orthopaedic surgeon
who offered to have a go at a spinal after I had spent
ten minutes at a particularly arthritic back, and the
first-year surgical resident who suggested that I
might intubate more quickly
if I
levered the
laryngoscope blade rather than lifting it!
But people are people, and comments like the one
above do not reflect a poor opinion
of one's
professional skills, as has been suggested in the past,
but rather a culfure in which the cleverest and most
ambitious doctors become surgeons and are trained
to take ultimate responsibility for their patients and
to question everything that is done to
them.
Reputations are earned over a period of time, and
after a few months it was clear that the slightly more
artistic style of Anaesthesia practised by the British
contingent was recognised and appreciated by the
surgeons. I became friendly with many of them indeed some have visited - and the chance to try
new things in a "can do" atmosphere was
challenging. One young attending surgeon and I set
out to see if we could reduce hospital stay after
parathyroidectomy by using a laryngeal mask
(answer: no, because you spend so long supporting
the airway despite the LMA that your fingers
inevitably appear in the wound, necessitating
interminable washouts and a longer course of
antibiotics). A gynaecological colleague had started
doing partially-awake laparoscopies to try to map
areas of endometriosis for diathermy, and we
achieved about a 50%o success rate using intermittent
body-wide and the result of too much good food,
whereas in this country it is often truncal and the
propofol and large doses of midazolam. In such an
environment it is difficult to maintain a "them and
result of too much bad food.
Much has been written about the relationship
between American surgeons and their anaesthetists
(the so-called "anustheshuhl" phenomenon) and it
was hard, initially, to move from a system where
us" culture, and I suspect that those who believe that
to be the case haven't scratched deeply enough
anaesthetic opinion is frequently sought and
below the surface.
Teaching, both in and out of theatre, was a large
part of the job. American residents have only three
years in which to learn the specialty before
43
accrediting, although many then spend a Fellowship
year in a particular field. They do tend to focus on
the "doing" rather than the "thinking" bits of
anaesthesia, but their enthusiasm is infectious and
their desire to master every practical procedure
today rather than tomorrow is impressive, if a little
ambitious. I can now sympathise fully with my owrl
teachers, who over the years have had to sit and
watch me make multiple attempts at - well,
everything. A year of doing only the "difficult
ones" has probably improved me, although it still
feels strange to do a case and put all the lines in
myself now I am back in the UK. At least here I
have an anaesthetic assistant to smile
sympathetically if I have difficulty - there are no
ODPs in America.
Away from work we had a great time exploring a
very small proportion of an enormous country. We
visited the Great Lakes and the wild Upper
Peninsula of Michigan, took a trip to Niagara Falls,
spent an expenses paid week in New York under the
guise of delegates at the New York State Assembly
of Anesthesiologists, and had a fortnight in Florida
just before the tourists arrived. I managed to get
down to Tennessee to the wedding of Southmead's
44
- a splendid Deep South affair, in beautiful
weather - and, just like Harrison Ford in Witness,
we mingled with the Amish in Indiana, althouch we
can't prove it because they wouldn't let us take any
pictures. And although the working days started
early and finished late, the relatively light on-call
meant that I could spend evenings and weekends
watching my daughter growing up and learning to
Jas Soar
talk in that way that only American kindergarten
children can.
My year in Michigan gave me the opportunity not
only to observe a health care system very different
from that in the UK, but also to look at the NHS
through different eyes on my return. I realise now
that I am not simply an NHS employee who happens
to be a doctor, but a doctor who works for the NHS.
I now have a perspective on what we do well and
what we do badly. I believe I may be better prepared
for some of the changes that will face the NHS in
the future. I am immensely grateful to those
colleagues who encouraged me to spend a yeat
abroad, particularly those who suggested the USA,
and I shall be doing some encouraging of my own in
the very near future.
Anaesthesia Points West Vol. 34 No. 2
Article
GP Anaesthetists: Doers or Dodos?
Martin Coates, Consultant in Anaesthesia and Regional Advisor in Anaesthesia, Derriford
They say that: "There's nothing new under the sun",
"What goes around comes around", and "History
repeats itself'. These aphorisms seem to reflect my
personal interest and involvement with GPs who
also practice Anaesthesia which seems to have
followed a cycle of about 30 years.
In recent years, my colleagues and I in Plymouth
have run a bi-annual 4-day Refresher Course for GP
Anaesthetists which has attracted participants from
far-flung corners of the U.K. and occasionally, from
far-flung corners of Australia! Due to increased
popular demand (probably because CME and
revalidation are now high on the agenda), we are
However, at the time I felt woefully under-trained to
take on such a challenging and multi-talented
diagnostic and caring r6le. At least in hospital there
was always someone more senior to "pass the buck"
to, or seek advice from. I decided to try different
things at SHO level, but always had general practice
at the back of my mind.
I
was an SHO in the
Professorial Obstetric unit at Southmead and loved it
- so exciting, full of challenges and very rewarding,
if a little scary at times - and then returned to Bath
as a Casualty Offlrcer to learn the tricks of the hade
from the renowned Roger Snook.
appears that there are plenty
of GPs out there who
are still "passing the gas", and want to be kept up
to date.
During this period, events occurred which
indirectly influenced my ultimate career decisions:
firstly, I came into more contact with anaesthetists
and what ahappy, helpful, enthusiastic, "can-do"
bunch they were. They also seemed so multi-
The wider issue of whether GPs (or indeed,
Clinical Assistants) are appropriate people to be
providing anaesthetic services these days has long
been contentious, with many Consultants and
talented, knowledgeable and unflappable in a crisis
that I decided to give anaesthetics a try, but before
taking up my first post in Bath, I paid the bills with
several weeks of General Practice locums. I entered
indeed, the Royal College of Anaesthetists regarding
them as an historical anachronism, but I will return
to that later.
The reason for my interest in the subject is that
bolstered by my time in Obstetrics and Casualty,
believing that I could probably deal with most
now planning to run the course annually, so
about 30 years ago,
I
it
had every intention of
becoming a GP/Anaesthetist/Obstetrician! This was
back in the Dark Ages when halothane and
thiopentone ruled supreme, when monitoring
consisted of a regular peep at the pupil, a finger on
the pulse and the occasional use of an
oscillotonometer: and when "Om. and Scop" was
the standard premedication - the halcyon days
before Bain circuits (1971), Manley ventilators and
temperature compensated vaporisers: and aeons
before computers, propofol, T.I.V.A., cerebral
function monitors and clinical governance!
When I qualified as a doctor, I had little idea of
which path my career would follow, but during my
house jobs, I gradually began to lean towards
general practice (tweed suits, a nice country house
and the Dr Finlay image seemed quite attractive).
General Practice with increased confidence
things, but I was soon rendered completely
inadequate by a desolate, weeping and agonised
coal-miner from Radstock (that's how long ago it
was!) who had multiple complaints, none of which
resulted in any abnormal clinical signs that I could
elicit after a prolonged and detailed examination.
Psychology not being my strongest point, I told
him I could hnd nothing wrong with him, which was
clearly the wrong thing to say, as he completely
broke down in tears and appeared inconsolable. In
desperation and embarrassment, I was inspired by
the memory of an article I had read literally the day
before in that wonderful rag "World Medicine"
(R.I.P. and much missed!) A very similar scenario in
the mythical Slagthorpe had resulted in a diagnosis
of "ergophrenia" ("work on the mind") so I duly
signed my weeping miner off with just such a
diagnosis, and then spent the next few weeks
45
wondering when the agents of the DHSS would
appear on my doorstep and haul me off to explain
"ergophrenia" to the G.M.C. I'm relieved to tell you,
nothing ever happened, and I hope the sad miner had
a good rest.
In the early, very enjoyable months of my
anaesthetic career, I still harboured visions of a
comfortable GP career with interesting sessions in
perhaps Obstetrics, Casualty and Anaesthetics in the
local D.G.H. to add spice to life. However, two
further episodes which were at the time quite
stressful (but are now historically amusing) poured
significant volumes of cold water on my enthusiasm
for General Practice.
I was doing a locum for a highly regarded private
GP in Bath who had gone off on his annual trek in
the Himalayas and left me in sole charge of his
practice. I questioned his sanity later!
Over the first few days, I got used to paying social
(rather than professional) visits to his devoted
clientele in very posh houses, and very interesting it
all was, usually culminating in the offer of a glass of
dry sherry and a generous cheque!
All seemed well until one day I was asked to visit
an eminent octogenarian spinster who had colicky
abdominal pain, distension and complete
constipation. I examined this elegant, elderly lady on
her sofa in her chintz-curtained lounge and found
that she had all the signs and symptoms of faecal
impaction. I asked her equally upperclass sister for a
bowl of warm, soapy water, some towels and a large
dessert spoon. These were instantly provided and I
spent the next half hour delicately extricating rock-
hard faecoliths from the patient's rectum with
a
silver spoon which was definitely not E.P.N.S.! The
whole scenario was bizarre - gilded furniture, velvet
upholstery, exquisite decor and the most appalling
smell. However, the result was excellent and I was
rewarded with a generous cheque, much gratitude
and the obligatory glass of sherry which I really
couldn't face - a stiff whisky was what was
required!
The second episode was on the "other side of the
tracks" in every way. Surprisingly, there were (and
may still be) some quite deprived areas in Bath, the
Jewel of Georgian Britain. Late one night, I was
called to see a sick infant with a chest problem and
duly arrived just before midnight. When I eventually
gained entry to this rather squalid abode, I was taken
into the "lounge" which was occupied by a mixed
group of adults and children of all ages in one corner
avidly watching a loud T.V. programme and clearly
46
not the slightest bit interested in my presence. The
opposite corner of the room was occupied by a pile
of coal which was clearly used by the family cats as
a "convenience". Once again, the smell was
appalling but I managed to examine the grey,
listless, pyrexial and tachypnoeic 2 year old who
was presented to me.
I had just decided that whatever the actual
diagnosis was, this child was sufficiently ill to
warrant immediate hospital admission, when all the
lights went out and the T.V. fell silent. There was a
brief period of stunned silence, then out of the
darkness one bright spark enquired "Hey Doc, have
you got two-bob for the meter? Luckily I was able to
oblige, the child went off to hospital and I departed
back to my bed without so much as a "thank you,'.
These two episodes, coupled with my own
feelings of inadequacy, put a signihcant damper on
my idealistic and enthusiastic dreams of being a
country GP with sessions in Obstetrics and
Anaesthetics. The final nail in the coffin was the
decision of the anaesthetic department in Bath to
stop providing any anaesthetic services in any of the
peripheral community hospitals but to concentrate
their efforls within Bath itself.
So gradually, surgery in Warminster and Frome
faded away as did the opportunity for Gps to
provide an anaesthetic service in those distant
outposts, as supervisory support was not
forthcoming. I am sure that this was probably a wise
stance to take at the time, but I still remember with
great affection and enjoyment the many trips out to
Warminster with Ken Lloyd-Williams in his Rover
3500: it was a genuine adventure for an SHO to be
given the opportunity to work with an eminent
Consultant Surgeon and enjoy each other's
All things must pass. So what to do? - I
was thoroughly enjoying Anaesthesia - the
company.
challenges, the variety and the exposure to so many
other aspects of medical and surgical specialisation,
but my future was still unclear in my head. I
considered many options, dithered with the prospect
of becoming an Obstetrician, or even something
more cerebral like an Orthopaedic surgeon. In the
midst of this uncertainty the offer of a post in the
Bahamas suddenly occurred: supported by an
adventurous, supportive and "gung-ho" wife, it took
us about 5 seconds to decide to go!
On arrival I was offered a Registrar post
in either
Obstetrics or Anaesthetics and picked the latter
(thank God!), because it confirmed my love of
Anaesthesia with its infinite variety and involvement
and as an added bonus, the rewards of a little private
practice allowed us the luxury of a ski-boat.
It was a delightful four years, both professionally
and socially and to this day we have friends and
colleagues world wide. This period was followed by
a 6 months Anaesthesia residency in Calgary (with
an initial aim of taking the Canadian Fellowship) but
at the time the FFARCS was still the more valuable
qualification, so I contacted Torry Baxter at the BRI
and he thankfully absorbed me back into his empire
with an SHO post at Southmead. The primary and
final fellowship were duly passed (the former with
great difficulty and hard work) and I was appointed
Senior Registrar in Bristol in 1978. During the next
4 hugely enjoyable years (rotating through
Gloucester, Cheltenham, Bath, Southmead, the BRI
and Charlottesville) I and many other colleagues
occasionally lined our wallets by lucrative locums in
Holland and Sweden and also learned an awful lot
about other health care systems and anaesthetic
provision. By the way, whatever happened to Peter
Hutton, Griselda Cooper, Paul Cartwright, John
Ballance and the rest?
In more recent years I have been fortunate enough
to work in and visit other countries and it is these
varied experiences over the last 30 years that leads
me back to the controversial theme that I alluded to
in my opening paragraphs.
On the one hand there are many who firmly
believe that ALL anaesthetic services should be
provided by highly qualified and trained specialists
in a superbly equipped environment i.e. consultant
based, supported by N.C.C.G.s suitably supervised.
In an ideal world, this view is clearly entirely
sensible since we all know that there is no such
thing as an anaesthetic without risk (despite what
some surgeons still believe!) However, as we are all
increasingly aware, the N.H.S. is not an ideal world
and the Government are looking at ways of reducing
the work-load on hospital doctors by various means:
two examples of this are the increasing use of
suitably trained nursing staff taking on roles
previously performed by doctors, and also trying to
get GPs to do more minor procedures in the
community thereby reducing referrals to hospitals.
In Anaesthesia, whether we agree with it or not,
there are still many GPs who provide anaesthetic
services both in community hospitals and in
D.G.H.s. It is only a small proportion of total workload but
if
their contribution was terminated across
the country, the added burden on the hospitals would
become even more troublesome.
In my travels I have seen several different
systems of anaesthetic provision such as nurse anaesthetists and junior medical officers without
higher qualifications. If not properly supervised,
these practitioners can and do get into trouble, but if
supervision, protocols, patient-selection and case-
mix are suitably applied, they can provide
an
invaluable service.
I personally believe that we can continue to use
GP anaesthetists in our system provided the right
support and supervision are available. C.M.E and
C.P.D. are essential and that is what our own
refresher course in Plymouth is all about. It is also
essential that GP anaesthetists are made responsible
to the Clinical Director in the local D.G.H., that they
should do some of their sessions in the main hospital
so that their skills and competencies can be regularly
reviewed, and Consultants should do regular lists in
the Community hospitals to ensure that the
equipment, monitoring, recovery facilities and
support staff are of an acceptable standard. In these
circumstances (excepting the occasional dental chair
disasters over the past few years) I do not know of
any evidence that GP anaesthetists cause any greater
morbidity or mortality than occurs in hospital
practice.
After all, on the basis of recent national scandals
and disasters, the holding of a higher degree, the
C.C.S.T. and Consultant status is no guarantee of
high standards ofcare. One could also argue that the
ability of some GPs to maintain and develop their
skills in airway management, i.v. cannulation and
resuscitation techniques is an additional benefit to
the community in the early management of cardiac
arrest, drug overdoses, head injuries and trauma.
In the medium to long term, it is highly probable
that GP Anaesthetists will become an extinct species
because with the demise of the Diploma in
Anaesthetics and the more structured training
programmes both in General Practice and in
Anaesthesia, it is difficult to envisage where the next
generation of GPs who are also competent in
Anaesthesia will come from. The minimum
requirement of 2 clinical sessions per week is also
difficult to achieve for busy GPs and the poor
remuneration deters all but the most enthusiastic.
In the meantime at the risk of being burnt at the
stake by the R.C.A. for my heretical views, I believe
GP-Anaesthetists are worthy of our support, at least
until we reach that high quality utopia when their
services are no longer required.
We live in hope but don't hold your breath!
47
Anaesthesia Points West Vol. 34 No. 2
Article
Anaesthesia for Paediatric Cardiac Surgery
with Profound Hypothermia
John S. M. Zorab, Consultant Anaesthetist Emeritus, Frenchay
The recent Report on the problems of paediatric
cardiac surgery in Bristol has prompted me to reflect
on a technique in use, (the so-called Drew
Technique) when
I was a Senior Registrar
Westminster Hospital, London.
My involvement was in
196415 and
at the
I
was
fortunate in having Dr Cyril Scurr as my supervising
consultant. At that time, the South West Regional
Board were contemplating opening a second open
heart unit at Frenchay Hospital. The senior cardiothoracic surgeon was Mr Ronald Belsey and Mr
Gerald Keen had recently been appointed. Gerald
Keen and I were both at the Westminster Hospital
and there is little doubt that one of the factors in my
being appointed as consultant anaesthetist to
Frenchay Hospital was because there was an
intention for the "Drew Technique", with which
Keen and I were familiar, to be used at Frenchay.
Indeed, the new thoracic theatres had been designed
with this in mind.The use of hypothermia in cardiac
a problem since the circulation was maintained by
the extra-corporeal circulation. Thus temperatures
could be, and were lowered to l5oC and below. At
this temperature, total cessation of the circulation for
up to one hour could be achieved without brain
damage. During the period of circulatory arrest, the
patient was in a state of suspended animation and
the ECG and EEG were completely inactive.
Touching the skin of a patient cooled to I 5 oC had an
uncanny feel. Quite simply, the patient felt dead. Re-
warming, using the extra-corporeal circulation
presented no particular problems other than those of
a distorted acid-base balance. Various techniques
were used to combat this including the use of
bicarbonate and CO2. Anaesthesia presented no
particular problems other than those common to
anaesthetising
tiny babies. Drugs such as
thiopentone, opiates and inhalational vapours were
kept to an absolute minimum although generous
doses of tubocurarine were used. Monitoring was
surgery down to temperatures of 30'C was well
established but only allowed a period of circulatory
arrest of eight minutes. Lower temperatures could
not be used because of the risk of ventricular
fibrillation which usually occurs at 29oC. Cardiopulmonary bypass was one solution to this problem
but this also had disadvantages - particularly in
relation to extra-corporeal oxygenation. These
disadvantages were overcome by Drew and his
colleagues by using the technique of profound
hypothermia. In this technique, the left femoral and
pulmonary arteries were cannulated, allowing for a
purely cardiac bypass whilst the patient's lungs
could still be used for oxygenation, thereby
obviating problems related to extra-corporeal
oxygenation. The extra-corporeal circulation was
passed through a heat exchanger and this allowed
the patient's temperature to be lowered, and
subsequently raised, very much more quickly than
could be achieved by surface cooling and surface
re-warming. Ventriculation fibrillation was no longer
48
Fig.
I
rather less sophisticated then than it is now.
Pre-operatively an Ellab thermometer with multiple
probes was used and a continuous pen-recorder
The Drew technique in its original form did not
survive since later developments in heart-lung
machines largely overcame the early problems of
displayed the ECG. Blood pressure recordings were
made with an indirect system but were of little value
except during the early and late stages. Sophisticated
extra-corporeal oxygenation. They were, however,
interesting days and, although the results were very
commendable, I have no doubt that there was some
mortality but this technique proved its worth at the
time. It saved the lives of many babies who would
otherwise have died and bought time for further
developments in this taxing field to be made.
I am grateful to Dr Cyril Scurr and to Mr Gerald
paediatric ventilors did not exist and artifical
ventilation with 100% oxygen, using a Starling
Pump (Fig. 1) was used throughout the hypothermic
phase. Since no intensive care unit was available,
the patients were nursed post-operatively in a side
room with the junior anaesthetist (me!) remaining at
the patient's bedside for many hours (often
for their assistance in the preparation of this
briefpaper.
Keen
ovemight), doing repeated blood gas analyses, using
the old Astrup machine so that each analysis took
about 20 minutes.
49
Anaesthesia Points West Vol. 34 No. 2
Article
Can I Have Another Assistant Please?
Dr Ruth Spencer, SpR in Anaesthesia, Bristol School
Do you carry a rabbit's foot to work? Do you avoid
walking under ladders before a day on call? Has
clinical governance honed your risk management to
the extent that you now work in a nice, controlled
and calm environment? Lucky you! I suspect that
for most of us there are actually still some days
where we feel singled out by the gods for
particularly harsh treatment and seem to be falling
foul of any reasonable laws of probability.
Up until 10pm, August lst 2001 had already been
an above average rotten day involving the messy
death of a young road accident victim. I was
consequently not feeling at my most cheerful when
we came to deal with the fall out from that incident,
taking to theatre an l8 year old motor-cyclist who
had crashed in the tailback resulting from the first
accident. He was accompanied by his very calm,
sensible mother, but he had broken several bones
and generally de-gloved bits of him that would have
been better off gloved. All was progressing in a
straightforward manner until regrettably the
anaesthetic assistant, rather than the patient, took a
furn for the worse. There's probably never a good
time to go into fast atrial fibrillation at 180/min, but
just prior to assisting with a general anaesthetic is a
bit inconvenient all round. The calm and helpful
mother sat quietly with her son while the now
sweaty and breathless anaesthetic assistant was
bundled into recovery, attached to a monitor and
given some aspirin and GTN for her central chest
pain. Having secured a coronary care unit bed, we
duly dispatched assistant number I to the medics
and began phoning round all other anaesthetic
assistants at home to try and find cover at this late
hour. Having gone through all the "not at home"
candidates plus all the "at home but not sober"
confessions (surprisingly large number), we
eventually acquired anaesthetic assistant number 2,
who came in speedily and with good grace. The
operation was completed uneventfully and everyone
went off to bed at 2:30am.
At 3:30am the urgent call to casualty came and
we arrived to find an impressively severed neck.
50
The victim had gone through two veins, two arterres
and reassuringly exposed his cricothyroid membrane
to an extent that we could have cannulated it quite
easily should the need have arisen. His haemoglobin
was already down to S.5gldl and short of putting a
tourniquet round his neck (a practice generally
frowned upon I believe) a trip to theatre seemed
inevitable. The most bemusing aspect of the thing
was that he was being comforted by the same calm
and helpful mother who had been with the
motorcyclist mentioned earlier, although to be fair,
she was starting to look a bit frayed at the edges by
now. It transpired that this latest victim of events
was her partner, who whilst waiting up at home for
news of the road accident had inadvisedly walked
downstairs in his slippers carrying a brandy glass.
He had slipped on the bottom step, landed on the
glass and inflicted considerable damage to himself,
the carpet, the wallpaper and several soft
fumishings.
Like most trainees, my heart always sinks when
there's a crash caesarian section and now, with the
sense of timing so necessary for really good
comedy, the inevitable occurred. Assistant number 2
disappeared with speed from theatre at a time when
his presence would have proved helpful and the
emergency assistant (number 3), sleeping in the
hospital was called with haste. Unfortunately no
assistant appeared. The phone to her room rang and
rang but to no avail, her mobile tumed out to have a
flat battery and yelling outside the window proved
equally unrewarding.
It was later discovered that a
visitor to the hospital had slept in that room and a
"do not disturb" bar had been placed on the phone
that prevented it from ringing. Security officers were
summoned to break in and although they appeared
clutching an enormous bunch of keys, in the true
spirit of the evening, I probably don't need to tell
you which set was missing.
Unbelievably, we took to the phones again, this
time to explain that the usually very reliable
assistant number 3 was now missing in action,
presumed alive, but swallowed up by what was
turning out to be some sofi of Bermuda Triangle for
anaesthetic help. By now it was 4:3Oam and a
second emergency caesarian section forced us to
phone the same colleagues whom we had called six
hours earlier, in the hope that one of them had
sobered up sufficiently to grace us with their
reverted to sinus rhythm spontaneously but I half
wish I had anaesthetized her as well, since it would
presence.
thinking that you'd rather not be standing next to me
during a violent lightening storm, I can only think of
two major learning points. Firstly, if you do not
want to be called in when you are not on duty, it is
Assistant number 4 expressed some trepidation at
joining what was apparently a jinxed workforce and
reminded me that anaesthetic assistants have not yet
joined the list of single use only disposable items.
We were finally able to proceed, receiving no
complaints from the calm and helpful mother, still at
her post, who clearly now believed that it was
normal to arrive in the anaesthetic room and then
wait for half an hour. When we finally finished at
6:00am, the only thing remaining on the emergency
list was the planned cardioversion of assistant
number 1. She went on to do the decent thing and
have made a rather elegant end to an unusual
evenlng.
I
believe that most publications are supposed to
be of educational value but apart from perhaps
important to be over the limit almost as soon as you
reach home and secondly, if you must walk
downstairs carrying alcohol, it is best to choose
footwear with a slightly better grip than slippers.
Beyond that, I think this story, like many medical
tales serves only one really useful purpose, namely
that of amusing others. I hope it has at least done
that!
5l
Anaesthesia Points West VoL 34 No. 2
Article
Pay up, pay up, and play the game
Neville Goodman, Consultant in Anaesthesia, Southmead Hospital
There used to be a board game called CareersrM,
committees, got substantial amounts of money. As a
made by Waddingtons. Players progressed around
the board collecting money, fame and happiness. We
system
played
comrption, but manageable. It needed changing.
The Discretionary Points system has exchanged
one bad system for another bad system. Depending
on point of view, the new system may or may not be
it as children, on family holidays in North
Wales on those rare days when the sun did not shine.
What made the game interesting was that the rules
did not define the combination of money, fame and
happiness needed for victory. Before the first dice
was thrown, players wrote down their victory
combinations. These combinations totalled 60
points, but players could go for 20 each of money,
fame and happiness, or they could just plump for 60
fame, or for anything between. Once chosen, players
could not change their options no matter what their
fortunes in the game.
Consultants play a similar game every year except
that it's for real, the points are judged and added up
by one's colleagues, and superannuable salary
increases are the reward. We are about to embark on
the 2002 round of Discretionary Points.
When there was just the merit award system,
awards were decided by committees more or less
remote from consultants' working hospitals. There
were gross injustices, but most doctors knew that
publications, committee work, and being known to
the great and good through one's work were helpful.
Any list of the chosen contained some who should
not have been there, and missed some who should,
but in general most doctors acknowledged that merit
awards went more or less to the right people. The
merit awards' grave flaw was that the basic way
consultants achieved them was by not doing the job
they had been appointed to: a C for being well
known locally, a B for being well known nationally,
and an A for being well known intemationally (A+
for intergalactically?) meant that these doctors were
likely to spend a lot of time away from their clinical
it was to varying
degrees opaque,
demonstrably and objectively unfair, liable to
It is bad in different ways from the old
system. Discretionary Points are completely
transparent, less objectively but nevertheless still
unfair, devoid of any comrption, but unmanageable.
There are still feelings of injustice and of being
ignored, but the focus of those feelings has moved
better.
from the remote committees to one's own consultant
colleagues, which is far more divisive.
When I look at my colleagues, there are some
who work harder and do more than others. I could
perhaps grade them on a four-point scale: excellent,
good, ordinary, less than ordinary. I could not grade
them, as the Discretionary Points scheme asks, on a
five to seven-point scale, for each of ten criteria,
every year. To compound the complexity,
consultants are eligible eventually for eight Points.
How can anyone, or any group, claim to judge one
doctor's (self-proclaimed)'Professional Excellence'
against another doctor's 'Publications in last 3
years', each on the same and presumed equivalent
scale of up to seven? How do doctors score for the
criterion 'Progress achieving NHS priorities' if their
specialty has not been given governmental favour?
To add to the confusion, consultants last year filled
in questionnaires for eligibility for 'intensity
payments'. These are derisory when compared with
discretionary points, but nonetheless they are
payment for extra clinical work. As these internally
inconsistent and illogical methods of increasing
salary take hold, what objection can be raised to
posts, which is only possible in well staffed
hospitals where others can stand in for the clinical
performance-related, even fee-for-service,
duties. Not only that, but doctors in less well staffed
hospitals were often carrying a \arger clinical load.
Beyond discretionary points, the merit awards still
lurk. B, A and A+ are there for the real high-flyers,
however that be interpreted. Some of them indeed
work very hard. But are they working harder, are
For this they got no reward, while their luckier
colleagues, with time to write papers and sit on
52
remuneration?
they worth more, than an overworked consultant in
an understaffed department, working with too many
patients and too few beds, having to cope with
contracting trainee hours and increasing public
expectation?
The whole thing is reminiscent of the oft repeated
story about the driver who stops in the middle of the
countryside somewhere and asks the way to a distant
town. After a moment's thought and sucking-in of
breath, the passer-by says, "If I were you, I wouldn't
start from here." Consultant pay is a mess, and when
sorted out, large sections ofthe consultant workforce
will be upset, the particular section depending on the
particular solution. There are governmental
proposals for revamping the Discretionary Points
and Merit Award schemes, which can be found at a
website whose name includes the word
clinicalexcellenceawards. The revamped scheme is,
in its efforts to be fair to everyone, open in its
considerations, and favoured by the government,
even more convoluted than the present ones.
The only schemes of performance-related pay that
work properly are those that are self-financing, i.e.
those that apply to salesmen. No one can then feel
aggrieved, because they can simply be told to go out
and sell more, by which means they will earn more.
All
other forms of performance-related pay risk
demotivating those who do not get reward. In the
2001 round of Discretionary Points, the 40 or so
consultant anaesthetists employed by North Bristol
NHS Trust got precisely one Point between them.
But three of the criteria are so engineered that
service specialties are disadvantaged compared with
continuing care specialties. And what does the
criterion'Professional Excellence' mean anyway?
The basic difficulty is summed up in the question:
who is the better runer - the 100 metre sprinter, or
the marathon runner? It is the way of the world that
sprinters are likely to make more money; it doesn't
make them better, but it does make them richer and
more famous. There is a moral to this, which I
hesitate to draw.
One thing is certain: never has the governmental
goal been closer ofcontrolling consultants through a
contract tightly linking their pay to manageriallyjudged performance. Without strong leadership and
a united profession, the next few medical scandals
(and they will come, do not doubt it) will give the
necessary public lever to the achievement of that
goal.
In Careerstt, the game was almost always won by
someone who went for 20 each of money, fame and
happiness. If there is a moral to that, I don't know
what it is.
53
Anaesthesia Points lMest Vol. 34 No. 2
Book Reviews
Awareness During Anesthesia
Author: M. M. Ghoneim Publisher: Butterworth Heinemann 2001
Price: f,40 ISBN: 0750672013
This is the first published text-book devoted entirely
to the subject of memory and awareness during
anaesthesia. The author is exhemely well known, an
active writer and researcher, and would be
considered by many to be an authority in this field.
The 180 page book sets out to define the terms
used in memory and awareness research and to
present to the reader a summary of knowledge
gained so far, in each ofthe related topics. The first
two chapters on awareness during anaesthesia and
implicit memory are written by the author and
certainly achieve this aim. The following chapters
are written by experts in each individual field of
research. All are well known and have published
widely. There is considerable overlap between the
topics covered, and there is therefore a degree of
repetition. However this only aids in providing the
reader with a good understanding ofthe subject, and
an up to date knowledge of relevant research. All the
chapters are well set out and easy to read.
Researchers in the field of memory and awareness
come from many different scientific backgrounds,
54
including anaesthetists, psychologists
and
neurophysiologists. The emphases in each chapter
are therefore different. Not every chapter will be as
interesting to anaesthetists as they may be to
workers in other scientific disciplines.
The summary chapter on awareness is concise and
informative and is of great relevance to our
specialty, as are the chapters on monitoring the
depth of anaesthesia, the psychological
consequences of memory during anaesthesia and the
medicolegal consequences of awareness with recall.
Only those with a particular interest in the field will
read this book cover to cover but it would be a
valuable book to have in any anaesthetic department
library. Reading of at least some of the chapters will
keep all general anaesthetists informed about a
fascinating area of science and may inspire future
interest and research.
Clare Stapleton
Consultant Anaesthetist
Frenchay Hospital
Anaesthesia Points West VoL 34 No. 2
Book Reviews
Conducting Research in Anaesthesia and
Intensive Care Medicine
Authors: A. M. Zbinden and D. Thomson Publisher: Butterworth Heinemann
Price:f45
Research touches everybody who trains and
practices in medicine. We may be principal
investigator, research collaborator, unwilling
minion, volunteer or even patient but we can't get
away from it. Research is therefore everybody's
business and it is reasonable that training and
appointment committees take some note of whether
an individual has developed their understanding of
research with or without some evidence (using the
form of publications) of their progress. Certainly, a
familiarity with the process is a minimum. This
book offers a series of essays addressing relevant
topics and includes contributions from well-known
and less well-known chapter authors from Europe
and the United States. Unusually for a transatlantic
collaboration it includes a meaningful number of
mainland European contributors.
Zbinden and Thomson have done well to achieve
such a distinguished collection. A high proportion
are fairly well-known in their individual fields and
this comes across. These people know what they are
talking about and how to communicate it.
All multi-authored texts risk an element of
overlap or redundancy and sometimes this is
construed as a problem. A more constructive
approach is to enjoy alternative viewpoints on key
topics. In general, where there is overlap it is in
things that are important and some points bear
repetition. Certainly it doesn't seem to be a problem
in this book. The chapter authors write with
enthusiasm and the editors have allowed them to
explore at depth their particular interests. Inevitably
therefore coverage of topics within the book is
uneven but this isn't a problem, rather it gives us a
set of fascinating chapters of which many have been
written with real passion. In here you will find
everything from details of using Xenopu eggs for
gene expression through to programme macros in
Excel spreadsheets. By giving the authors scope to
ISBN:075064544){
flavour of the excitement of research and the
amazing variety of things that people get up to.
Textbooks are often dry stuff and it's a real
challenge to produce one that is 'a good read'.
Much of this book is absolutely fascinating and
gives real insight into daily activities of active
researchers. As such, it should help convey to the
inexperienced some feeling for the rewards of
research enquiry.
Individual chapters take us through the whole
of
the research process starting with literature
searching through funding and ethics to the design
and conduct of clinical trials. Ethical considerations
for volunteers and animals are well addressed and
put in their proper context. We get advice on
statistical analysis, preparation for publication
including the use of English and advanced word
processing features. Having done the writing, we are
then told how to get it published and how to present
it at scientific meetings. Technical chapters pick out
commonly used measurement techniques and give
detailed and useful advice in a very practical way.
There are plenty of good details here, which I would
have appreciated at an earlier stage and I might then
have avoided a lot of time wasting mistakes in my
own career. Overall, pretfy much everything that is
important is picked up.
Reviewers often include a recommendation that
libraries should stock a particular tome. I would go a
little further and encourage people to buy this book
for themselves. It is a good one to dip into and it is
also interesting enough to sustain periods ofstraight
reading on a train or plane journey.
I really like this book. It is very well put together
and does an excellent job of communication.
Rob Sneyd
Associate Dean and Professor of Anaesthesia
Peninsula Medical School, Plymouth
expand on their pet subjects, the reader gets a real
55
Anaesthesia Points West Vol. 34 No. 2
Book Reviews
Board Stiff Too
Preparing for Anesthesia Orals
2nd Edition
Authors: Christopher J. Gallagher, Steven E. Hill, David A. Lubarsky
Heinemann Cost: f32.50 ISBN: 0750671572
Publisher: Butterworth
This is an A4 size paperback and is about an inch
thick, so it is not a light weight tome to carry about
for light reading and yet in a way that is exactly
what I would like to be able to do with it. This is a
guidebook designed to help those studying for the
oral part of the American Board exams. As such it is
aimed at experienced anaesthetists such as those
studying for ow Final Fellowship.
The book is divided into three sections. The first,
entitled "Driving School" describes the content and
strucfure of the exam, who is present, what the aims
and objectives of the exam are, tips on how to
perform, how the scoring system works etc.
Obviously a considerable amount of this is not
relevant to the British Fellowship exams, but there
are some extremely valuable observations,
particularly about how to obtain the knowledge and
prepare for the exam, that are transferable to the UK,
similar to the clinical scenarios that UK trainees face
in the Final Fellowship, but one or two of the
cardiac and neuro-surgical cases are considerably
more complex, reflecting the fact that the American
Board exams are taken at the end of training.
The basic principle of the management of the
scenarios is transferable but there are differences in
anaesthetic management, e.g. Propofol is not
mentioned and the suggested induction for several
cases is "Fentanyl, midazolam and pancuronium".
My personal view is that the structwed approach is
very valuable and the American management is very
interesting, but to benefit from this section the UK
trainee would need to have the knowledge and
experience to be able to adapt the answers to UK
practice.
The authors' style is light hearted, amusing and
non-threatening. It is defrnitely not concise and to
of wisdom that I think any trainee sitting vivas will
the point, but is packed full of words of wisdom
liberally illustrated with stories. It is a pity that it is
such a big, heavy book because it would be nice to
be able to carry this around and dip into it in quiet
moments. I would not recommend it to trainees just
before the exam, because filtering through the
anecdotes to find the wisdom may well engender
panic. Perhaps the best time to read it would be
to 1l
appreciate. The chapters are concise ranging from 4
pages long, so it is easy to read a whole chapter
in a short lunch break and then mull it over all aftemoon!
The third section, "Test Track", is the largest part
to read the stories and ask consultants how they
would manage similar scenarios in the UK. I would
suggest it might also be a book that a trainee should
of the book and includes numerous examination
scenarios. The layout of the questions is the
annotate, so that they can find that word of wisdom
again, when needed, nearer the exam!
if you have time to sift through the anecdotes.
Part two, entitled "Mechanic's Manual", works
through the systems discussing common problems
that furn up in the exams and how to manage them,
pit falls that examinees fall into and systems to help
avoid them. This section is not comprehensive and
cannot be used as a textbook, but does include gems
immediately after Primary, when trainees have time
scenario, a suggested outline, a systematic approach
to identifying the problems, the kind of questions
Anne Thornberry
that the examiners may ask and the authors' views
on the correct answers. The basic principles are
Consultant Anaesthetist
Gloucestershire Royal Hospital
56
Anaesthesia Points West Vol. 34 No. 2
Book Reviews
Low Flow Anaesthesia
Author: Jan Baum Publisher: Butterworth Heinemann
Price:345
This is a 300 page hardback book on the theory,
history and practice of low flow, minimal flow and
closed system anaesthesia.
My first impressions were unfavourable. The
contents guide at the front of the book stretched to
7 pages and is subdivided into four tiers of bullet
points. To add to this daunting and unfriendly first
impression the first page of the first chapter included
ISBN:0750646721
on Deutsch Mark savings to be made by employing
these techniques.
If a trainee or consultant colleague were to quiz
me on a text to fui1her their knowledge of low flow
anaesthesia I might direct them to chapters 5, 6 and
10. These three chapters alone would probably be
more than enough to quench their thirst for low flow
knowledge.
under the heading "Classification of breathing
The comment on the back cover of the book
systems according to underlying technical concepts"
claiming that this was an essential purchase for the
the
recommendation given by E. A. Ernest, the ISO
norm 4135, being identical to the draft of a common
trainee and experienced anaesthetist was a little over
zealous. The next line stating that it will serve as a
the paragraph 'In accordance with
European norm prEN ISO 4135 . . .'
This book is an English translation of a German
text. It has obviously been written to chronicle the
scientific and historic processes involved with low
flow anaesthesia and all the equipment involved in
its use. Although this subject would never classifr as
light reading, I felt there was sad lack of humour and
'readability'. There was no colour, no highlighting
of key points and there were still frequent comments
for medical engineers and
technicians is probably true, but also serves as a
reminder as to why you should never go for a drink
with a medical technician.
In summary I could not recommend this book
reference book
to you.
Robin Cooper
Consultant Anaesthetist
Gloucester Royal Hospital
57
Anaesthesia Points West Vol. 34 No. 2
Book Reviews
Practical Fibreoptic Intubation
Author:
MansukhPopat
Price:f30
Publisher: Butterworth-Heinemann
ISBN:0750644966
This would be an excellent addition to any
anaesthetist's bookshelf. It is written in a clear and
easy style, which allows it to be read straight
through, whilst being in the form of a practical
manual, which can be dipped into for relevant
information as required. It is comprehensive,
informative and well laid out into clear sections with
easy to find practical suggestions. Clear diagrams
and photography make the factual content very
straightforward to follow. It is a book, which will
hold the interest of both the novice fibreoptic
operator and the experienced trainer, being
comprehensive enough to stimulate and inform both
parties.
Equipment, maintenance, forms of anaesthesia,
techniques and case scenarios are all covered in this
well-written book and I suspect that the answer to
58
any question related to fibreoptic intubation could be
found within its covers, both quickly and easily. The
text is well referenced and allows further study and a
greater depth of information if required. Although
the author will often state his preferred technique or
piece of equipment, he presents a balanced view of
all the possibilities and gives the reader enough
information to steer his/her own path.
It is a book which I consider to be a useful tool
for all anaesthetists and which would stand very
well, as a reference volume in a deparlmental library
and on an individual anaesthetist's desk.
Jean Waters
Consultant Anaesthetist
Gloucestershire Royal Hospital
Anaesthesia Points West Vol. 34 No. 2
Book Reviews
Resuscitation in Pregnancy
A Practical Approach
-
Authors: Philip Jevon and Margaret Rary
Publisher: BFM Books for Midwives by Butterworth-Heinemann
Price: f,14.99 ISBN 0750644575
This is a handy pocket sized book, written by a
Resuscitation Training Officer and a Community
Midwife, both of whom are well known in the
resuscitation arena. The book is primarily aimed at
Midwives and General Practitioners and is an
attempt to give guidance on resuscitation for the
pregnant mother.
There are good initial chapters on the Conhdential
Enquiry into Matemal Deaths and the physiology of
bo
The
on resuscitation
pregnancy,
background.
a
rs
C,
basic and advanced life support with obvious
reference to the pregnant mother. There is then an
isolated chapter on treatment of anaphylaxis, which
is well written and relevant to all pregnant mothers.
However, there are no other chapters on other highly
relevant conditions which may cause maternal
collapse, namely the fitting mother, the bleeding
mother, the mother who may collapse through
amniotic fluid or thrombotic emboli, or the mother
who has an inadvertent total spinal from an epidural
top-up. These are all conditions that midwives
should be able to recognise and manage during the
initial resuscitation period. It is a shame that the
authors have not included additional chapters on
and central venous pressure monitors on the delivery
suite and guidance on this would have been useful.
In conclusion, this is a well-written and wellreferenced source for resuscitating the collapsed
mother in pregnancy. It is a useful guide for
Midwives and General Practitioners but does not
contain enough information for Obstetricians and
Anaesthetists in training regarding other common
causes of matemal collaPse.
David Gabbott
Consultant Anaesthetist
Gloucestershire Royal Hospital
59
Anaesthesia Points West Vol. 34 No. 2
Article
THE NEWPICKWICKPAPERS
(The Diary of a Gas-been)
Roger Seagger
Well, in the absence of major revolt from the
readership of "Points West" the Editor has allowed
me another chance to fill a page with ravings from
the retirement home.Those of you brave enough to
have read the Spring Ravings may recall that in one
item I concealed the name of a surgical colleague by
inserting asterisks for most letters. You will, I am
sure be greatly amused to know when using the
"spellcheck" it commented that as Mr B**'(**n was
not in its accepted vocabulary I should substitute
Baboon!
Try it yourself if you doubt it!
Since the last diary entries I have been in touch
with two other members of
"pensioners
anonymous", both of whom are anything but retired
or even retiring! During Salcombe regatta week
Captain Ed Galizia decided to put to sea once again,
and after making record time for the trip round from
Cawsand, was soon on a prime mooring below the
Sailing Club in Salcombe Estuary. On arrival he
'phoned to invite Sue and I to dine aboard. We were
duly collected from the pontoon and taken aboard
"Oracle". Soon Galizia sized Gs and Ts had been
dispensed, as we relaxed on deck in the pleasant
evening sunshine. Suddenly a look of sheer panic
came over Ed's face. Fifty metres away and at full
speed was several hundred tons
of "Salcombe
Crabber" Ed was convinced we were doomed, but at
the last second the crabber changed course passing
within feet of Ed's maritime pride and joy. Before
we were able to relax again a deluge of water filled
balloons were bursting everywhere. We had become
unwitting and very wet victims of Regatta Week
humour. Fortunately the saloon was wafin and dry,
and Berenice's Thai curry just the fare to follow a
drenching, but I'm still not convinced that this was
not Ed's idea ofa pre-dinner cabaret!
The rest of the evening aboard "Oracle" remains a
little hazy although I cannot imagine why. With Ed
spinning his nautical yams about an encounter with
a chap called Richard Lenz, in Falmouth, together
60
with two other guys Jonathan Walker and Jack
Daniels. I believe Ed told me that they were
I am sure he was confused. Perhaps
still in shock after the attack ofthe Crabbers!
"rafting", but
The other pensioner to make the diary pages this
issue is Alistair Fuge. He related that one of his
recent trips to a "Tribunal" in Newcastle had been
threatened by a rail-strike. After having been
authorised to go by air C.A.F. duly booked his ticket
. . . Minutes after take-off, coffee had been served,
when the cabin intercom burst into life to inform
passengers of various details of travel and to tell
them they were in the safe hands of Captain Tim
Tuckey. Seizing the opportunityAlistair presented
his compliments to the flight deck and was duly
invited to sit in the spare seat up front for the
approach to Newcastle. Feeling extremely envious I
asked Alistair what it was like."Oh!" said Alistair as
only he can,"marginally easier than getting to grips
with the new Datex machines!"
Meanwhile another term at my woodwork class
has proved a challenge to both carpentry skills
and rusting medical knowledge. The first occasion,
followed the collapse of a burly, middle-aged
motorcyclist out in the shop. Unfortunately I had
failed to clear my bench, and make good my escape
in time, and felt guilty at the thought of walking out
on Tutor Jack and the first aider. So I stayed and
after a quick history, and a 'phone call to his G.P.
Mr Kawasaki was delivered to Bradford-on-Avon
surgery for an E.C.G. This was thought to warrant
hospital admission such was his gratitude the
Kawasaki Kid discharged himself from the R.U.H.
next day! Think I will stick to woodwork!
The second consultation involved Sid, the senior
student from bench two. During the coffee break Sid
told me all about his painful right hip, and the
increasing stiffness in the knee and ankle of the
same leg. Trying to appear sympathetic without
getting too involved I told Sid "That's old age Sid.
Nothing more!" "That's B*x**cks Doctor", retorted
Sid. "The left leg is fine and it is the same age as the
right!"
I am pleased to say that since my last ravings we
have enjoyed another holiday. This time foresaking
a chance to practise some newly acquired Italian
phrases, to dust and practise the very rusty
schoolboy French, on a "walking holiday" (an
oxymoron if ever there was) in the Luberon Valley.
This was an unqualified success, with both liver and
legs returning apparently undamaged, although
neither have been seriously tested since returning
home. The walking was gentle with few steep
inclines, the late September weather amazing and
some very reasonable local wines at ridiculous
prices distracted us from some of the very strange
things the French expected us to eat!
We did however, return enriched by one charming
French custom
company had urged us to be aware of the "Country
Code", which, as in Britain, required us to "damage
nothing" and "clear away all rubbish". Our walk on
the last day passed through a particularly pretfy and
well-kept village. So you can imagine how strange it
seemed to see that instead of clearing away the dog
excreta, the locals placed a pebble on each pile! On
reaching the town square where many examples
could be seen,I approached a local resident watching
the "boules" and asked about this quirky habit.
"Ze explanation ees simple monsieur,we learn
from ze Breeteesh zat we should leave no turd
unstoned!"
Well after that I'd better beat a hasty retreat
pausing only to say that today "spellcheck" informs
me that Alistair Fuge is really Alligator Fugue.
There is nothing left to say!
. . . In the brochure our holiday
6l
Anaesthesia Points
llest Vol.
34 No. 2
Article
Pittman on Plonk
Not A Patch on Australia
Californians are weird
or so the East Coast
Americans think and there is aready explanation for
this. As the early settlers moved west all the freaks,
criminals and religious nuts were constantly moved
on until they finally reached the ocean. Welcome to
the 'Golden State' where pets have psychiatrists,
most women have their own silicone valley and
where murder rarely has a motive. So what is good
that the vintner contributed at least 75%o of the grape
juice whereas "made and bottled by" may mean that
as little as l0o/o came from that vintner. 'Reserve',
'Special Reserve' and 'Vintner's Reserve' have no
special meaning, but be reassured that if it says
"California" on the label 100% of the grapes were
Californian grown. Yippee! The reason for this
about California? You live in constant fear of
earthquakes, there are huge power shortages and
house prices are a joke. Of course the attracfion has
to be the near perfect climate that accompanies the
Californian wine can be a problem. Unless you
know the producer, the label gives you little idea of
what you are getting until you open the bottle and
taste it.
As California is such an enorrnous wine region I
will focus on one area. Napa Valley, being the most
famous, is the obvious choice. Lying just northeast
of San Francisco, Napa consists of 8 AVAs (plus the
Carneros AVA, which it shares with Sonoma). Napa
is famous for its white Chardonnay wine, the taste of
which is described as having a mixture of apricot,
pineapple and citrus. With an alcohol content of
l3Yo or more I am sure this depends on how much
you've drunk. Sauvignon Blanc (also called Fume
Blanc) is said to be the next best of the white wine
varieties. In the red wine look for Napa's Cabernet
Sauvignon, arguably California's best red. Merlots
flourishing and well-promoted wine industry.
Everything is big in the US and if Califomia were
a country it would be the world's 4th largest wine
producer after Italy, Spain and France. In true
Californian style they would have you believe that
they invented the production of wine. I saw a notice
at a Napa vineyard claiming Jesus had to have been
a Californian; He never cut his hair, walked around
barefoot and turned water into wine. Californian
wine production actually started in the l9th century
when early pioneers planted grapes from their native
European countries but it was not until the 1970s
that wine production really became established.
The lack of tradition seems to mean fewer rules (a
common theme in California) and this is an
important issue for the potential buyer. The US
legislates that California be divided into AVAs
(approved viticulture areas) and this is usually
written on the bottle label. However, unlike the
French 'appellation controllee' AVAs exert no
influence on which varieties are planted or the
annual yields per acre. AVAs control, less tightly
the concept that "what is advertised on the label is
what is in the bottle". Subsequently quantity, and
not quality, may lead the agenda of producers. Wine
displaying a grape variety on the label has only to be
made from 75Vo of that grape, and an advertised
AVA infers only that 85% of the wine comes from
that region. "Produced and bottled by" guarantees
62
tedious account is it explains why buying
are also very popular and the surprise local specialty
is Zinfandel, which can be very good. Both of these
have less tannin than the Cabernet Sauvignon. The
tasting note for a $40 bottle of Napa Zinfandel was
surprising.
It recommended it
was best with
Mexican Fajitas. Nothing beats re-fried beans and
chili sauce to culture your taste buds. Finally the
rose wine, White Zinfandel, has come into fashion
as a light fruity summer wine. 'Blush' is very
San Francisco!
Touring several Napa vineyards revealed that the
US vintners are trying to use technology to increase
productivity and taste. They are experimenting with
different configurations of trellising the vines so that
more of the grapes are "in the zone" (in the sun)
during the day. This, they claim, can improve the
potential complexity of the taste of the grape juice.
They are not adverse to a little genetic
experimentation and graft vines onto all sorts of
rootstocks. Importantly, one of the vineyards we
visited was trying hard to make production more
organic. They had stopped spraying with pesticides
and put land aside for an insectary. It was claimed
this encouraged a natural balance ofpredaceous and
crop damaging insects to exist in the vineyard and
reduces crop damage. All very Jurassic park but a
nice idea.
Fast facts
o
The higher the elevation of the vineyard, the
'
'
'
afford to taste them. The following Napa producers
seem popular and are recommended by various
experts. Beringer, Robert Mondavi, St Supery,
Franciscan Oakville Estate, Pine Ridge, Rutherford
Hill
superior the quality of the wine. The Napa AVAs
Grove, Sterling and William
Trouchard and Ravenswood are popular producers
from the Carneros AVA. Remember that Mumm
Napa Valley winery makes a good sparkling wine
Napa still has problems with the aphid
Phylloxera despite introducing resistant
rootstocks.
The early morning cool air that blows north from
San Francisco produces conditions in Napa that
permits the growth of Botrytis, Look for the term
'late harvest' on the labels of these sweet wines.
Wineries.
via the "Methode Champenoise" called 'Cuvee
Napa'. As the characteristically bottled Cordon
Negro tastes very similar, we have nicked named the
Spanish Cava 'Mumm in the gimp suit'.
Napa area for the production of Cabernet
Top tips
Despite Californian wine being on the expensive
side, it maybe worth buying a couple of cases and
keeping them safe. When that San Andrea fault
finally hits force l0 on the Richter scale we can say
goodbye to the California wine industry. The wines
will become highly collectable (I suppose even those
of Ernst and Julio Gallo will be wanted by some
collectors) and your cases will become a nice little
eamer. After a tip like this I must disclose that I am
independent of any financial organisations and
Sauvignons.
regularly loose money on the stock market!
Advertising is a big part of the Califomian wine
industry so beware of the eye-catching labels on
the front of second-rate wine. Although not
related, we were amused to see a Napa restaurant
advertising the freshest pickled oysters in town!
'
I think Californian wines are over priced. In the US
it is difficult to buy a Napa wine for less than $15
and at the lower end of the market they do not
compare for value with the Australian equivalents.
In the UK, Californian wines maybe easier on your
pocket but as I have already alluded to, it is diffrcult
to predict what is good unless you really know the
producer. At the higher end I am sure that some
Napa wines rival the best but I regretfully cannot
of Spring Mountain, Howell Mountain and
Mount Veeder are generally superior to the
valley floor AVAs of Rutherford and Oakville.
'
Best buys
The Carneros AVA at the base of the Napa
Valley is famous for the Pinot Noir grape.
The Stag Leap AVA of Napa is the premium
63
Correspondence
The Editor would like to have published the
communication received from a correspondent
concerning two "typos" in the book review section
of the last edition of APW shortly after it was
circulated. Unfortunately this keen individual made
it difficult to thank him or her for the interest shown
because of the method chosen to contact the editorial
team!
So to our anonymous reader in Wales (the
envelope bore a Welsh postmark, and a second-class
stamp), thank you for tearing out two pages of the
journal and encircling the words 'Judicial" and
"memoir". Your suggested alternatives were
'Judicious" and m6moire"; probably correct in each
instance. It grieves me to think of a torn journal, but
if it was your own . .
Oh, by the way could I offer you a post as
.
Yet again I must congratulate James on an excellent
article, this time about Catalonia and Barcelona. I
cannot, naturally or unnaturally, comment on the
Ramblas queens! He has managed to include every
item of fact and opinion that matters! Just in case
anybody asked me about Pened6s, cava or anything
else, I had dredged out ofvarious books all I thought
I might need to know, and had it discreetly written
out. However, I was left in peace, mostly. I now
know why. APW was delivered just before we all
left for Spain, and everybody, having read James'
article, knew it all already. Thank you James.
In addition, I can only but admire, and support,
his choice of best buys. We came home with one top
of the range cava from Codorniu, two bottles from
the Torres range, and a vintage Juve y Camps cava.
Also one leather jacket (female), one suit
Honorary Proof-reader?
Tricia McAteer, Editor
P.S. Ifour mysterious keen-eyed
reader, or anyone
else, spots the deliberate mistake(s) in this edition of
APW, please send a photocopy of the offending
page(s), (rather than tearing out the original one),
with corrections. There may be an editorial prize(s)!
64
Pittman on Plonk
(female), three pairs of shoes (female), one handbag
(female of course), one plate, two books etc. Well
one does, doesn't one!
Robin Weller
Itinerant Anaesthetist and Wine Enthusiast
Poem
FROM WHERE
I'M SITTING
When I was six, my parents said
that I cut worms in half,
watching each end wriggle,
wondering which bit was head
which tail.
Grandfather, on father's side,
had been a doctor, done everything,
prison doctor, force fed suffragettes,
medicine, surgery on cataracts . . .
Lived like a 1or4
spent time out in Antigua,
black servants - that sort of thing,
tennis parties on the lawn,
until the weakness in his hand
set in,
that was his racket hand. He died young,
muscles wasted with Progressive Atrophy
(me still a babe in arms).
The only words he ever said to me 'Fine boy'.
I had to be a doctor. At St Thomas's
where grandfather had trained, Prof. Davies
held up a Gray's Anatomy, 'Learn this'
So
he said, 'cover to cover . . .'
I never did,
did to my knowledge.
Dissection days, four students to a body,
fullof the irreverence of youth.
2nd MB, some gone after the contest,
last vacation, heading west
as no one else
65
on my motorbike to pick blackcurrants.
Long light evenings through small roads,
lush with the hedgerows of Gloucestershire,
girl on the pillion.
Then summer gone.
Back at St Thomas'S, the ward rounds,
waiting in that grand enormous hall,
like some great Roman temple,
for our consultant while marble busts
stared back at us.
The final metamorphosis into consultant.
You spread your wings. Days pass and seasons.
Those you work with, trust you with their lives.
Good friends and cool clear reason.
We do our best.
But as Bob Dylan sai{ the times are changing.
Post-Shipman and hospital scandals, the old order
tumbles, pillars crumble, the Tsar is dead.
Dogs of the revolution snap at our legs.
See how it spreads,
comrade to comrade. When the revolutionaries
askZhivago 'Are you the doctor who writes poetry?',
the rabble all around him, he simply replies yes'.
It's the need inside that drives us,
nothing more, or less.
Robin Forward
66
Crossword
Dr B. W. Perriss
Clues Across
7. Spend one's early years with young thug. (9)
8. Conductor told to continue innings. (5)
10. I'm
I
1.
crazy about two illegal drugs. (8)
Fruit that is two feet long? (6)
12. Theory that is nearly perfect. (4)
13. My French circle criticize train supporter. (8)
15. Pair willing to revolt. OK? (7)
17. Strengthen support. (7)
20. Goodbye to good food. (8)
22. Note the back of the school. (4)
25. Getrid of CID underwear. (6)
26. Girlrings gallery for a comment. (8)
27. Greek innkeeper one can see through! (5)
28. Pilot with a pomographic photo. (9)
Clues Down
l.
Shake a Swiss vessel. (5)
Arranged to be in the first three in the race. (6)
2.
3. Dispatch friend to become sailors chum, (8)
4. Get up and put on a uniform. (7)
5. Utility where anaesthetic is successful. (8)
6. This Summer use the pari-mutuel. (9)
9. Sleep up on the bridge. (4)
14. Power of fixed number found in analog
arithmatic. (9)
16. Prior becomes worried. It's a sham! (8)
18. Ring Rowing Club about evergreen shrub. (8)
19. Adaptable and quietly responsible. (7)
2l.
What one does with different teas. (4)
23. Commotion made by a bowler? (6)
24. The time for a second wash. (5)
Solution to Crossword in
SUMMER 2001 Anaesthesia Points West
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68
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l.
Notice to Contributors
Please type all articles, including news items, obituaries and reviews on white A4 paper with margins of at
least 2.5 cm andthroughoutuse double spacing of lines. One copy shouldbe retained. Articles should also be
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Submission of articles to Anaesthesia Points West implies transfer of copyright to the Society of Anaesthetists
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Editor
Dr P. McAteer
Department of Anaesthesia
Royal United Hospital
BATH BAI 3NG. 01225 825057
e-mail: [email protected]
Editor
Foster
Secretary to
Mrs Delia
Department of
Anaesthesia
Hospital
BATH BAI 3NG
Tel:01225 825057
Royal United
E-mail address for articles etc.
-
Assistant Editor
Dr N. Williams
Department of Anaesthesia
Gloucestershire Royal Hospital
Gloucester
GLI 3NN
Tel:01452 394812
GLOS
[email protected]
69