No.32, Dec 2010 - Association of Surgeons of Great Britain and Ireland

Transcription

Association
of Surgeons
Great
Britain•and
Ireland32, DecemberNumber
Association of Surgeons
of Great
Britainofand
Ireland
Number
2010 28, December 2009
EDITORIAL
On the first day of Christmas,
my true love sent to me
A partridge in a pear tree.
… and a merry Christmas and a Happy New Year from the
Association of Surgeons of Great Britain and Ireland ….. or is it?
We are in the process of great change to our long loved profession
of Surgery. Our budgets are being cut, we are asked to produce
more for less, our hours are restricted, but not as much as our pay,
and we are being WATCHED. Yes, “Big Brother” is out there
Ladies and Gentleman and he can take many shapes or forms.
Take the week 22nd to 28th November 2010 as an example. On the
Wednesday, the Guardian published an article entitled “NHS heart
surgeons ‘lead Europe’ with a 25% lower mortality rate”. Hurray I
hear you say, but wait! Heart surgeons results are collected, audited
and published and are available for public scrutiny. “UK cardiac
surgeons are very proud that they publish the most comprehensive
cardiac surgery data in Europe” quotes David Taggart, President of
the Society for Cardiothoracic Surgery. But, we are not cardiac
surgeons and we are not publishing our results! The Guardian
states that “other specialties are far behind heart surgeons in data
collection” and that, my friends, includes us! Indeed, a separate
Guardian investigation earlier in the year found that “data
collection by vascular surgeons was variable around the UK, as
were patient death rates”. In addition, they noted that “some
disciplines collected little or no data”!
How can we allow this to happen in 2010? The Guardian will
return to look at the Vascular Surgeons (and you!) and will have
access to all of our data, utilising the Freedom of Information Act.
You are all exposed to external audit, and it is essential that your
“house is in order”. Each one of us needs to contribute to National
Specialty Databases and set up Quality Improvement Programmes
(QUIP) within our disciplines before we are named and shamed! To
this end, I have asked David Mitchell, Audit and Quality
Improvement Lead for the Vascular Society to write in this
Newsletter about the Society’s approach to this concern.
That Sunday 28th November, the Observer published its leading
article entitled “Exposed: Hospitals that shame the NHS”. I quote:
“19 hospitals have high death rates; NHS failing patients’ on
critical care”. The article refers, in fact, to the Dr Foster Hospital
guide 2010 (http://www.drfosterhealth.co.uk/docs/hospitalguide-2010.pdf) which publishes Hospital Standardised Mortality
Ratios (HSMRs) for NHS hospitals. Were you named and shamed?
Was the guide accurate? If not, do you have your own data to
support your practice? Remember, newspapers like headlines and
most headlines are BAD! We need to collect data, audit our
practice, adopt QUIPs and improve our service to patients urgently
in 2011. Are you all QUIPing? Do you need to QUIP? Your views
will, as usual, be gratefully received at: [email protected]
On the second day of Christmas,
Two turtle doves,
And a partridge in a pear tree.
Turtle doves symbolise teenage deaths from knife crime over the
Festive Season. Within the UK, teenage knife crime is rapidly
rising. To this end, ASGBI and its charity, The Surgical Foundation,
hosted the first joint surgical/police conference in London on
Monday 15th November 2010. The aim was to improve cooperation and effectiveness of harm prevention and crime reduction
associated with knives. This highly successful venture resulted in
several areas of agreement which will form the basis of an ASGBI
consensus document on knife injuries to be published in early 2011.
The conclusions included the following statements of intent:
• Surgeons should get involved in early years peer group education
programmes.
• Data sharing between emergency departments and community
crime reduction partnerships must become standard practice in
every hospital in the UK.
• Restrictions in the access to alcohol are supported; evidence
suggests that this would have a dramatic effect on violent
behavior in the young.
• The development of regional trauma networks, supported by
accredited training programmes and courses that include the
management of violent injuries, is encouraged.
• ASGBI strongly recommends that all general surgeons involved
in the treatment of trauma should attend one of these accredited
training programmes.
• Surgeons should be trained to appreciate the forensic requirements
of the criminal justice system by preserving evidence.
The conference was widely reported in the media, and we do hope
that you will all become involved in local initiatives to reduce knife
crime in your regions of the UK.
On the third day of Christmas,
Three French hens,
Two turtle doves,
And a partridge in a pear tree.
Finally, may I inform you that the Stage 2 Application for
Specialty Status for Vascular Surgery has been submitted for
approval. If successful, “National Selection” to ST3 training in the
new specialty may begin as early as summer 2012, with the first
tranche of CCTs being awarded in 2018. Clearly the separation of
Vascular from General Surgery will have profound effect to the
provision of emergency surgical services, and this will require
significant forward planning in the years ahead. Vascular reviews
are occurring in most regions already, but if you are not yet
prepared for change, you will need to discuss your situation on a
local basis. There is no one plan which will suit all centres, and the
decision for networks or centralisation will be a local agreement.
At the ASGBI 2011 International Surgical Congress to be held
in Bournemouth from 11th to 13th May 2011, we have organised a
symposium entitled: “Specialty Status for Vascular Surgery:
Implications for the General Surgeon?” Please do come and
participate. Tell us of your concerns and local problems with this
radical change to the provision of Vascular Services within the
UK. Also, please write to me at [email protected] with any
local issues you may wish to share, and I will publish your
letters in the March 2011 Newsletter.
On the twelfth day of Christmas,
Twelve drummers drumming …
And a partridge in a pear tree!
I have no more gifts for you except of course the gift of
succession. The advertisement for a new Honorary
Editorial Secretary is within the pages of this
Newsletter . I wish all of those interested good
luck and much joy if successful; it is indeed a
worthwhile and extremely rewarding job!
Have a peaceful ‘Twelve days
of Christmas’ and a happy
and prosperous New Year.
Mike Wyatt
Honorary Editorial Secretary
IS THE GENERAL SURGERY
CCT FIT FOR PURPOSE?
2
Number 32, December 2010
NEWSLETTER
Association of Surgeons of Great Britain and Ireland
William Allum
Chair, SAC in General Surgery
Introduction
The last ten years have seen a series of significant
changes in surgical training. We now have a
comprehensive, on-line, interactive curriculum,
which has defined knowledge and clinical and
technical skills. This has also carefully documented
- for the first time - the professional attributes of a
good surgeon as well as the appropriate approaches
for clinical judgment in daily practice. The Junior
Doctors New Deal and the European Working Time
Regulations (EWTR) have radically modified
working time. This has created considerable
disquiet, but has also highlighted the need to
consider novel approaches to training and learning
with emphasis on work place based assessments,
self-directed learning and simulation. The training
environment has been modified by the changes in
service culture with emphasis on targets and
contracting of work to agencies outside the NHS.
These have all challenged the traditional
apprenticeship model of surgical training. Many are
concerned that, on completion of surgical training, a
trainee may not be fully equipped to meet the
demands of the modern NHS. In such a debate, it is
important to understand the current requirements
and regulations for training, how these are provided
and how they fit into the current service, as well as
looking in to the future to identify how and where
improvements can be made.
Requirements for the General Surgery CCT
The requirements and the regulations are defined
in the ‘Gold Guide’ [1]. The Certificate of
Completion of Training (CCT) qualifies the trainee
for entry to the Specialist Register of the GMC
and, hence, the ability to apply for a consultant or
equivalent post in the NHS. Award of the CCT is
subject to the successful attainment of the required
competencies as defined in an approved
curriculum. A CCT can only be awarded to a
doctor who has been allocated a National Training
Number (NTN) by competitive entry to an
approved training programme. The programme
should provide specialty training covering the
entirety of the relevant curriculum. A trainee with a
NTN is required to register with the relevant
Deanery and is encouraged to enroll with the
relevant College or Faculty for support in the
process of application for award of the CCT. On
completion of training the Surgical Royal Colleges
recommend the trainee to the GMC for entry to the
Specialist Register. The process of application is
overseen by the Joint Committee on Surgical
Training and, in practice, by the appropriate SAC.
The application includes details of all training
appointments since qualification with an up to date
CV, confirmation from the Deanery that the
training programme has been satisfactorily
completed, a completed RITA G or ARCP 6 form,
with reference to passing the Intercollegiate
examination, and a final report from the Training
Programme Director (TPD). Currently in general
surgery, unlike some surgical specialties, a
validated logbook is not required. It is expected
that the logbook will have been continually and
progressively reviewed throughout the RITA and
ARCP processes.
Content required for a CCT application
General Surgery specialty training comprises core
surgical training with competitive entry into higher
surgical training. The programmes are designed to
provide experience in the generality of general
surgery and experience in a chosen subspecialty as
defined in the ISCP curriculum [2]. Currently, there
are two groups of trainees; those appointed before
the introduction of the ISCP (Calman type), and
those appointed after. The duration of higher
surgical training for both groups is six years,
although the Calman trainees have been eligible for
recognition of one year of research as part of the
six years. Exposure to emergency general surgery
is expected throughout training, although
emergency experience in the chosen subspecialty is
accepted for the final year if appropriate.
The curriculum has defined the Scope and Practice
of General Surgery at CCT as competence to
manage an unselected emergency surgical “take”
and development of an interest in one of the subspecialties of general surgery. Progression through
the programme is guided by the syllabus which
describes the basic, intermediate and advanced
aspects of knowledge, clinical skills and technical
expertise. In order to complete a programme,
satisfactory progress is assessed by either the RITA
or the ARCP process. These processes take into
account assessments undertaken in the work place
of clinical and technical competences as well as of
professional behaviour and clinical judgment. Such
regular review allows identification of areas of
deficiency and their correction by appropriate
targeting of training and allocation to appropriate
training posts and opportunities. Particular
reference is made of logbook experience which is
essential for a craft specialty. The preferred format
for satisfactory progress is for the trainee to
undertake as much surgery as possible in a
supervised setting, rather than spending prolonged
time assisting or operating unsupervised. The work
place based assessments are complimented by the
assessments in the Intercollegiate examination.
This currently is undertaken after completion of a
minimum of four years of higher surgical training
and requires approval of satisfactory progress by
the TPD. The exam comprises aspects of elective
and emergency general surgery with critical care as
well as special interests assessed in both written
(multiple choice paper) and oral sections. The final
report of the TPD should not identify any specific
issues, as the nature of the annual or more frequent
review process should have ensured satisfactory
progress by the end of training.
Does training deliver the content of a CCT
application?
The ISCP 2010 curriculum has evolved into its
current comprehensive form based on previous
iterations written by the SAC, which reflected the
design of training from the time of primary FRCS
and Clinical in Surgery in General FRCS to the
development of the Intercollegiate exam. Most would
accept that the current curriculum covers the required
body of knowledge as well as describing the
progression of skills and experience and the
development of the professionalism and clinical
judgment expected of a consultant. It is
acknowledged that, in some specialised areas, it is not
possible to achieve full competence. The development
of fellowships, either before or after the award of the
CCT, reflects the need for such specialist experience,
The financial constraints of the service, together
with the emphasis on productivity, have also affected
training. The target culture has created a tension
between completing operating lists for the service
and allowing unpressurised time for training. The
development of contractual arrangements with both
Independent Treatment Centres and the private
sector has limited opportunities, particularly for
basic surgical procedures. A concern from Iain
Anderson’s recent survey of Emergency General
Surgery [5] was the relatively limited availability of
CEPOD theatres for general surgery emergencies
implying that the limited “productivity” of an
The introduction and the implementation of the
ISCP were dependent on new approaches to
training, and this specifically required faculty
development. Traditionally, the apprenticeship
model was based on the ‘what and how’ of surgery
and the ability to know how to and, equally, when
not to, was experiential. The ISCP provides
challenges to these approaches and the emphasis
on work place based assessments has had some
teething problems. Jonathon Beard’s well argued
article in the July 2010 ASGBI Newsletter [7]
identifies many areas where new approaches can
overcome the changes in the learning environment.
However, these and the developments implicit in
the use of simulation require investment both in
terms of human and financial resources and of
time. Evolving attitudes to the definition of “work”
within EWTR should allow appropriate time
allowance and incentive for trainees to progress
their experience by self-directed learning.
Measurement of the effectiveness of training is
difficult. The majority of trainees entering higher
surgical training are eventually awarded a CCT.
Some will have had periods of targeted training or
had their time for training extended as a result of
issues identified at the annual review. The only
objective evidence is the success rate in the
Intercollegiate examination, a test of knowledge.
Figures for the 2009/2010 diets of the exam show
that, for those trainees in recognised training
programmes, 77% passed the first section (MCQ)
of whom 85% were sitting for the first time and
83% passed the second section (orals and clinicals)
of whom 91% were sitting for the first time. The
forthcoming developments in sub-specialty
recognition will allow identification of what is
required as well as highlighting how these
requirements can be achieved and in what
environment. It is for these reasons that the planned
changes to the Intercollegiate exam will ensure
appropriate assessment both in the generality of
general surgery including critical care and in the
proffered sub-specialty. The timing of the general
There have been significant changes, which have
affected the ability of training units to meet these
standards. These were highlighted in Professor
Michael Eraut’s report [3] on the introduction of the
ISCP. The EWTR and the Junior Doctors’ New
Deal have reduced time available for training. It is
no longer possible to train to a standard of
competence across the spectrum of general surgery,
as many of us did. However, the demands of the
service actually no longer require such a breadth of
skills. Nevertheless, there are many examples of
comparisons of logbooks between current and
previous cohorts of trainees showing significant
reductions in practical operating experience. The
PMETB survey [4] of the effect of EWTR
implementation in 2009 highlighted that surgical
specialties had the lowest rate of compliant rotas
(66.7% compared to an overall of 78.5%), the
lowest attitude rating of acceptability (52.1%
compared to an overall of 70.7%) and the lowest
level of agreement that trainee needs have been
met (31.5% compared with 67.4%).
These and other similar influences need to be resisted
by engagement with our managerial colleagues to
ensure training and service provision are on an equal
level. The development of a training contract would
allow the respective responsibilities of the training
unit, the trainers and the trainees to be defined to
ensure the necessary opportunities are readily
available to the required standards. A review of the
relationship between local providers of training and
those responsible for the standards would be timely.
The externality provided by the previous SAC visits
process not only enabled advocacy of the standards,
but also identified areas of good practice as well as
areas where improvements were required.
Modification and regeneration of this process by, for
example, using existing trainer and trainee structured
questionnaire information would facilitate qualitative
improvements and consistency in training. In their
recent report The Future of Surgical Training ASIT
[6] have highlighted the limitations of training within
the modern NHS and have stressed the
responsibilities of all involved, identifying in
particular the onus on Trusts, not only in terms of
human resource but also financial, to ensure adequate
and appropriate incentive for high quality training.
NEWSLETTER
The quality of specialty training programmes
should reflect best practice and, indeed, there should
be an appropriate link between good service
provision and good training experience. The GMC
is responsible for quality assessment with the
Deaneries responsible for quality management of
the provider units. This has been evolving as the
Schools of Surgery have developed over the last
five years. However, the standards expected of
general surgical training are a professional issue
and the responsibility of the SAC. In 2003, the SAC
set objective standards against which a training unit
should be assessed. This included staffing and firm
structure, hospital facilities and working
arrangements and an educational environment to
support trainees both in terms of supervision and
educational opportunities. These standards formed
the basis of the previous approach to training unit
evaluation including regular and triggered visits.
Currently, the JCST is developing recommendations
for a variety of quality measures which include both
generic and specialty specific standards. In fact, in
general surgery, much of what was documented in
2003 still pertains, although there have been
reductions in caseload volumes.
emergency theatre has led to its use for more costeffective elective work.
but also raises limitations within existing programmes
to deliver the entirety of the syllabus. The popularity
of these fellowships among trainees can be
interpreted as a desire to develop a competitive CV,
but may also reflect an appreciation that current
training does not allow accumulation of the
confidence to start consultant practice, which
additional time will provide. Comparison with US
and Australian residency programmes shows the
benefits which fellowships can confer.
3
component is likely to be after four years of higher
surgical training with the sub-specialty component
two years later. It is still envisaged that clinical and
technical competence to CCT level will only be
achieved by a total of six years of higher surgical
training, irrespective of sub-specialty or even
general interest.
What is the required end product of Training?
There are currently approximately 1,800
Consultants in General Surgery in the UK. The
actual numbers with sub-specialty interests is not
known, although the membership numbers at
consultant level for the sub-specialty associations
suggests, as a rough guide, the proportions with
respective interests:
NEWSLETTER
The fact that the vast majority complete higher
surgical training and are awarded a CCT, suggests
that the selection process, the development of ISCP
defined competences and the acquisition of required
knowledge during the training programme are fit for
purpose. However, is that the correct end product?
ASGBI
AUGIS
ACP
ALS
ABS
BAETS
Transplant
Vascular
2270
390
600
334
435
200
140
460
As part of the recent application to the GMC for
sub-specialty recognition, Peter Lamont analysed
the consultant posts advertised in the BMJ online
in May 2009. There were 16 vacancies:
General Surgeon
General & Upper GI
General & Colorectal
General and Breast
Colorectal (laparoscopic)
Upper GI (intestinal failure)
Vascular
General and Oncology (sarcoma)
Renal Transplant
0
2
2
4
2
1
2
1
2
All specified a sub-specialty interest and
participation in emergency surgery was optional/not
required for three of the four breast posts. Neither
of the two vascular posts, nor the two transplant
posts, included involvement in the emergency
general surgery rota, as they would take part in a
separate vascular or transplant rota. By contrast, the
ASGBI survey of Emergency General Surgery [5]
confirmed that 75% of respondents had a regular
commitment to acute general surgery on-call.
The recent White Paper Equity and Excellence:
Liberating the NHS [8] has highlighted the
provision of local care. It remains to be seen how
this will affect service configuration, but the
emphasis on commissioning by primary care is
likely to focus on local hospital surgery. There will
need to be a balance with sub-specialisation, as
patient demand is an important driver for subspecialty treatment. It became apparent during the
recent application to the GMC for sub-specialty
recognition, that there is central concern that overemphasis on sub-specialisation could be to the
detriment of the provision of emergency care. This
was strongly countered by assurance that the
evolving sub-specialty curricula will ensure the
commitment to general surgery throughout higher
4
surgical training, particularly for acute and
emergency patients, as well as defining the subspecialty skills. This will, however, have manpower
implications. Once vascular surgery becomes a
separate specialty and many consultants with a
breast sub-specialty interest withdraw from the
acute rota, the consultant workforce will need to be
sufficient to provide the acute service and have
acceptable and appropriate working conditions.
Manpower numbers will need to be defined with
regard to the sub-specialties to prevent trainees
selecting areas of interest where there are likely to
be very few vacancies. Although Peter Lamont’s
survey showed little call for general surgery, the
White Paper initiatives suggest a need for the
general surgeon with a gastrointestinal interest.
Indeed, this is consistent with the joint statement
from AUGIS, ACPGBI and ALS in 2006 [9] in
which the specialist gastrointestinal surgeon was
defined, providing a general gastrointestinal
portfolio having completed two years each of upper
GI and colorectal surgery training.
Conclusions
The current CCT is awarded after successful
completion of the training programme which
provides the necessary skills defined in the ISCP
curriculum. In keeping with other aspects of
professional development, the CCT should be
considered part of an evolving process, the
evolution being defined by the demands of the
modern NHS. It does provide a surgeon at the end
of training with the skills upon which to build as
their consultant career develops including both
emergency general surgery and sub-specialty
interest. However, training must be able to respond
to changes in the NHS and must be carefully and
continually reviewed. There is an imperative for all
involved in training to ensure that the right
environment is in place to enable us to provide the
highest quality training opportunities to ensure that
the CCT holder of the future is fit for purpose.
References
[1] A Reference Guide for Postgraduate Specialty
Training in the UK - The Gold Guide Fourth
edition, 2010
[2] Intercollegiate Surgical Curriculum Programme 2010
www.iscp.ac.uk
[3] PMETB and the European Working Time Directive
PMETB, September 2009
www.gmc-uk.org
[4] Evaluation of the Introduction of the Intercollegiate
Surgical Curriculum Programme
Eraut M, 2009
[5] Emergency Surgery Survey
Anderson I, Krysztopik R and Cripps N
ASGBI Newsletter, No 31, September 2010: 12-15
[6] The Future of Surgical Training: A Position Statement
Association of Surgeons in Training, 2010
[7] Can UK surgical trainees achieve competence in
procedural skills within the current working time
restrictions?
Beard J D
ASGBI Newsletter, No 30, July 2010: 2-5
[8] Equity and Excellence: Liberating the NHS
Department of Health, 2010
[9] Specialist Gastrointestinal Surgical Training
ACPGBI, AUGIS and ALS
ASGBI Newsletter, No 14, June 2006: 8-10
Bill Allum is to be congratulated for this
comprehensive and succinct analysis of where we
currently stand with training in General Surgery.
The problems faced in service delivery of upper
gastrointestinal surgical practice are complex but
not insurmountable and are summarised thus:
• Upper GI has evolved further into three distinct
service driven sub-specialties over the last
decade:
• Oesophago-gastric cancer surgery.
• Complex (predominantly cancer and
transplant) hepato-pancreato-biliary surgery.
• Complex benign UGI surgery (largely driven
by the demand for bariatric procedures).
• These developments over the last ten years have
not, until now, been matched by appropriate
evolution of both the training curriculum and
syllabus, nor by the final accreditation
examination.
• External pressures beyond the control of the
profession that make calculations of future UGI
consultant numbers difficult to predict in the
years ahead:
• Future role of the ISTCs and NHS
reimbursement for routine procedures within
the remit of the UGI surgeon (elective
cholecystectomy, anti-reflux surgery,
abdominal wall hernia surgery).
• The impact of developments in chemotherapy
on the role of the surgeon in the management
of UGI cancer patients (the reduction in the
use of surgery for oesophago-gastric cancers
versus the increase in the use of surgery for
patients with liver metastases).
• The threat to bariatric practices from ‘Big
Pharma’ where the magic pill to cure satiety
is now the number one area of drug
development globally (members of the
Association will be relieved to know that
male impotence remains the number two area
of development, while cancer lags at number
five!). Those of us of over a certain age will
remember vividly the overnight impact of the
introduction of H2 antagonists for peptic ulcer
disease on the use of elective vagotomy in the
mid nineteen seventies.
AUGIS ( and its constituent groups: BOMSS,
GBIHPBA and the OG surgical group) has, for
some time now, recognised the challenges posed
by these developments, particularly within the
training requirements for often complex surgical
procedures within all three areas of our practice.
Even before the very welcome changes to subspecialty status within General Surgery now
being taken through the GMC, we have been
instrumental in establishing post-CCT
fellowships in all three of our elective sub-
The other perennial problem remains the delivery
of emergency General Surgery. The separation of
vascular (outside General Surgery) and
transplant (remaining within General Surgery)
surgery is welcome, and reflects the
sophistication of twenty first century surgical
practice. What remains is predominantly acute
gastrointestinal disease and trauma. It is,
therefore, appropriate that the demand to deliver
such services, with ever increasing expectations
on outcomes (especially with possible moves to
centralise trauma services) should not fall on
surgeons with a major interest in breast disease.
This effectively means that this service will
continue to be delivered, for the foreseeable
future, by members of AUGIS and the
Association of Coloproctology. This reality
means that the new curricula and syllabus has to
reflect necessary skills and competencies in both
UGI and Coloproctology training programmes to
reflect these demands. As Bill says above, much
of this experience in emergency surgery can be
achieved in years 1-4 of specialist surgical
training before sub-specialty training, but will
need to be reiterated by continuing exposure to
emergency surgery in the subsequent subspecialist years of training through to CCT.
The way ahead
AUGIS is committed to the development of upper
GI Surgery as a recognised sub-specialty within
General Surgery. The changes currently being taken
through the GMC by the remaining five (Upper GI,
Coloproctology, Breast, Transplantation and
Endocrine) sub-specialties of General Surgery
(following the recent departure of Vascular
Surgery) do not alter the fact that the CCT remains
within General Surgery. What these changes do
achieve is to enable trainees to focus their final
years of training in dedicated and accredited
training units within their chosen sub-specialty
discipline, in the knowledge that this training will
be intense and allow them to maximise their
training opportunities within the restrictions of the
EWTR and finite training programmes.
Furthermore, it will finally offer future employers
the opportunity to appoint consultants in the
knowledge that the appointment actually does
‘what it says on the tin’. However, we will need to
continue to refine the training programmes to
reflect the realities of the further sub-specialisation
that has already occurred, and horizon scan for the
known challenges outlined above, while remaining
vigilant for the unknown challenges that will
inevitably confront the profession during the
financially troubled times of the decade ahead.
Graeme Poston
President, Association of Upper
Gastrointestinal Surgeons of Great Britain and
Ireland (AUGIS)
NEWSLETTER
COMMENTARY ONE
specialty areas of interest (funded centrally,
locally or externally from industry). These posts
remain popular, competitive and over-subscribed,
but I am concerned that, as we move into tighter
fiscal times, such funding may become more
difficult to achieve in the future. Indeed, AUGIS
with the English Department of Health, has now
produced a position paper (view at
www.augis.org) on the structure, centre volume
and surgeon volume necessary for the delivery of
upper GI cancer surgery services, which we hope
will give better guidance to future manpower
demand in our sub-specialty.
COMMENTARIES
5
COMMENTARY TWO
Mark Lansdown
SAC member with specialist interests in
Endocrine and Breast Surgery
NEWSLETTER
Yes, the CCT in General Surgery is fit for
purpose, but the processes for ensuring that
trainees holding a CCT are fit for purpose is
another matter. This may seem contradictory, but
developing a curriculum and standards for the
competencies required to take a place on the
specialist register is a lot easier than putting in
place a comprehensive training programme which
ensures that a trainee only progresses when those
competencies have been achieved.
We have developed a competency-based curriculum
which has been shoe-horned into the constraints of
the EWTR and an expectation that the CCT will be
achieved in six years of higher surgical training.
Many have voiced their concerns about the massive
reduction in hands-on experience that trainees now
get in the operating theatre compared with 10 or 20
years ago. But this is not just because of the
EWTR. Other factors include pressure from
managers to get as many patients through a list as
possible, and the need to achieve the highest
possible operative success rates in an increasingly
transparent and competitive world.
Nevertheless, I believe it is possible to train the
majority of our trainees in six years if they have
access to training of sufficient quality. As a
trainee and newly appointed consultant I was
often struck by how much longer operations took
in North America compared with my experience
of surgery here in the UK (just look at the
literature on laparoscopic procedures to see how
long cholecystectomy usually takes there); and
how few procedures an American trainee
performed before being “licensed”. Later, I had
the opportunity of observing surgical training at a
specialist centre in New York. As far as I could
tell, every case was a training case and the trainer
took time to help the trainee with every step of the
procedure, ensuring that the operation was
performed to the same standard as if they had
done it themselves. Now I understood how an
American trainee could become proficient at an
operation with exposure to so few cases. I recently
heard of a trainee whose RITA form stated that
they needed more operative experience. During
that attachment the trainee had assisted at more
than 30 cases of a particular procedure, but had
only been allowed to perform the procedure twice
under supervision! They were signed off ready for
the next stage of training. You cannot have it both
ways – either provide training, or tackle in the
appropriate way the issue of a trainee who should
not be allowed to progress. Perhaps the trainer was
worried about outcomes. It appears (in
cardiovascular surgery at least) that publication of
surgeon-specific data leads to a reduction in the
COMMENTARY THREE
Wyn Lewis
The traditional British Surgical apprenticeship,
which had evolved over more than 200 years, and
was arguably once the envy of the world, has
6
number of cases deemed suitable for trainees to
perform. In fact, evidence that outcomes are as
good in training cases as those performed by
consultants is accumulating.
High-quality training takes time, and much of that
time is the trainer’s time whether in theatre,
helping with simulated training or giving feedback.
It also conflicts with the target-driven environment
that most of us have to work in and the lack of a
surgical assistant to hold the retractors while we
hold the trainee’s hand. When will managers
recognise that we must be allowed this time and
resource? Perhaps they would listen if there was a
sufficient uplift to the HRG (Healthcare Resource
Groups) paid for a procedure during which
training took place. I do not think they are
listening to the Deaneries or the SAC.
I contend that there has been insufficient pressure
on our employers to allow us to train, and too
little re-education and training of trainers to
ensure that trainees are thoroughly scrutinised as
they progress towards their place on the specialist
register and their ticket to applying for consultant
posts. Within each Deanery there are some
training posts that are more fit for purpose than
others, and there are hawks and doves when it
comes to filling in trainees’ assessment forms.
Comparing the situation now with my experiences
of sitting on training committees 10 years ago, I
would say this has not changed and a minority of
trainees are being signed off ready for the next
stage of training when they should not be. The
difference now with shortened training is how
little time there is to get the trainee back on track
when the deficiencies are recognised – assuming
they are. When deficiencies (perhaps a better term
is “lack of progress”) are recognised, I am
surprised at how many trainees contest a decision
that they would benefit from targeted training or
perhaps an extra six months or a year before being
signed off for independent practice. Perhaps they
are mindful of all those cases spent holding a
retractor when they could have been performing
the procedure under supervision!
In conclusion, I believe the solutions to ensuring
that trainees with a CCT are fit for purpose are
threefold:
1 Trainers need more support to understand the
modern curriculum and how to ensure that an
individual trainee has reached the required
standard to progress to the next stage of
training.
2 Trainers must be given the time and resources
to train properly.
3 The SAC and schools of surgery must be
allowed by PMETB/GMC and our employers to
re-invigorate training and quality assurance.
Then I think we will produce CCT holders to be
proud of.
during the course of the last fifteen years been
systematically dismantled. The culprits and usual
suspects are well known and stem from a
workplace target driven culture allied to health
and safety legislative dogma. The contemporary
Certificate of Completion of Training has adapted
The purpose of a generic Certificate of
Completion of Training (CCT) is to comfirm
satisfactory completion of a United Kingdom
training programme, which has commenced from
the start of the prospectively approved programme
or equivalent, and makes a doctor eligible for
inclusion on the General Medical Council’s
Specialist or General Practitioner Register. To
deliver an assessment of this competency within a
limited time frame inevitably means a degree of
counting of index procedures performed, together
with an assessment of an individual’s position on
the global general surgical learning curve.
Nevertheless, this should be limited to certain
specific, agreed and proven key outcomes. With
regard to General Surgery the counting of
competencies begins at an early stage, with the
requirements for competitive entry into higher
surgical training, and then continues with the aid
of log books, regional RITA and ARCP processes,
culminating in an Intercollegiate FRCS
examination, both in general surgery and a subspecialty. More recently, sub-specialist fellowships
have been developed in addition to the above to
increase logbook numbers of specialist operative
procedures and further enhance trainees’ multi
disciplinary experience. This is of particular
In conclusion, with the contemporary trend for
increasing sub-specialisation, general surgery has
perhaps foregone much of its traditional romance,
glory and breadth. Nevertheless, it remains a very
competitive, demanding but rewarding specialty in
which to practice. The contemporary CCT is
indeed evolving and the planned modifications to
the intercollegiate exit examination are moving in
tandem. Plans to assess general surgery and
critical care competencies at ST 5/6 level, with the
option to proceed to a subsequent specialist
qualification after a further two years experience,
seem both sensible and workable. Finally, large
professional organisations such as the NHS are,
by their very nature, continually in a state of flux
and continuous change. The most recent
Government white paper relating to the NHS in
England; Equity and Excellence: Liberating the
NHS; is explicit in its aims to provide local care
with an emphasis on commissioning of services
by primary care. Such change is not, obviously, in
keeping with increasing surgical subspecialisation which risks being at odds with
locally delivered emergency care, and will
undoubtedly drive local manpower planning. The
CCT of the future decade will, as ever, need to
adapt if it is to remain fit for purpose.
COMMENTARY FOUR
by Bill Allum in his leading article. All of the
uncertainties and difficulties implied by the curse
are certainly present.
Neville Jamieson
Head of School of Surgery, East of England
Deanery
“May you live in interesting times” usually
described as a Chinese curse/blessing and
attributed to Confucius is, in fact, more likely to
have been first coined in the USA in the early part
of the 20th century. Nonetheless, it does
accurately describe the present situation outlined
“Not everything that counts can be counted and
not everything that can be counted counts.”
The potential weaknesses of the system currently
evolving lie in the local or regional assessments of
on the job practical competencies, and it will be the
remit of the regional Schools of Surgery to address
this potential pit fall. Moreover, the forthcoming
developments in sub-specialty recognition, with a
separate vascular SAC high on the agenda, must to
some extent be viewed as experimental. While the
advantages are clear in terms of large
multidisciplinary teams, high quality outcomes and
enhanced training opportunities in large regional
centres of excellence; this scenario may not be in
the interest of rural and other relatively smaller
district general hospitals, proving local care and
services to populations of circa 120,000, and often
seeking to attract general surgeons with diverse
skills and abilities.
NEWSLETTER
In the greater context, western general surgical
pos graduate training (Australia, New Zealand,
Canada, United States) consists of a five to seven
year residency leading to eligibility for a
Professional College Fellowship or American
Board of Surgery Certification respectively, which
is also required for hospital operating privileges in
the USA. In the United Kingdom, there are clear
similarities, with the caveat that the last decade
has witnessed the emergence of multiple
workplace targets, which has had a particular
affect on the way that medical care and training is
delivered. The above has also been heavily
influenced by European Working Time legislation,
which may, at first glance, seem to have
theoretical advantages, but nevertheless also
carries inherent risks. It is said that Albert
Einstein had the following quote hung high on the
wall behind his office desk at Princeton
University, which is a poignant summation of the
present state of target culture:
importance within focused areas such as
oncoplastic and laparoscopic surgery, where indepth experience is more challenging, associated
with longer and, by definition, shallower learning
curves, and therefore more challenging to achieve.
While this latter development may be a reflection
of the beneficial experience reported from
Australian and the United States, it may also
simply reflect a practical manifestation of
competition for Consultant appointments.
and evolved in tandem with the above, and
William Allum’s article is a well-timed and erudite
summary of the present position.
Bill has described well the current situation and
the difficulties seen with the impact of the EWTR
and New Deal on delivery of training using the
traditional apprenticeship system which was the
mainstay of surgical training. The old, broad
based, general surgical training is disappearing
and being replaced by more focussed sets of skills
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NEWSLETTER
aimed at specialty specific skills. Overall
experience in the trainees log book can be
inspected by RITA and ARCP panels and has
certainly decreased with shorter hours, although
this can be mitigated by focussed training and
emphasis on achieving relevant competencies
without excessive commitment to repetitive routine
service tasks. Although we do emphasise that
training is competency based, it is interesting to
see that some specialties where a wide range of
operative skills are required are using indicative
log books reflecting the experience gained in
training by a cohort of newly appointed
consultants to gauge the progress of trainees
currently in training.
General surgery still exists as a title which we all
recognise and even as a sub-specialty in the
existing Intercollegiate exam in general surgery
– but not in the adverts section of the BMJ as
pointed out by Peter Lamont. Trainees now
aspire to be colorectal surgeons, breast surgeons,
oesophago-gastric surgeons, endocrine surgeons,
etc and seek training and experience to match the
jobs which do exist. These various subspecialties are likely shortly to be accepted
formally as separate sub-specialties and vascular
is close to separating completely with a separate
SAC, separate training programme and a new
career structure of its own. These changes have
come rapidly and we have adapted training to
match, although new changes are constantly
appearing and, as Bill points out, it is essential
that the training system remains under constant
review to allow it to adapt and evolve in
response to the rapidly changing requirements of
the health service. We have an online curriculum,
which has been recently updated, and have
changed the emphasis of the training
programmes to give more sub-specialty training.
COMMENTARY FIVE
Mike Bradburn
Head of School of Surgery, Northern Deanery
Bill Allum has comprehensively outlined the
external influences on surgical training and the
changes these have caused over the last 15 years
or so. The restriction of hours, the introduction of
targets and the tension between service and
training have all conspired to affect the training
opportunities available to a trainee. He rightly
points out that the newly qualified surgeon is a
different animal to that of 20 years ago, but the
job itself has changed, and most of us are now
subspecialists to a greater or lesser degree. The
most telling figure is Peter Lamont’s analysis of
consultant vacancies in May 2009. There were no
adverts for pure general surgeons, and the adverts
for three of the four breast surgeons allowed an
opt-out from the on-call (general surgery); the
vascular and transplant posts had no on-call
component at all. General surgery is coming to
mean participation in the emergency on-call rota,
and this is increasingly becoming the province of
the upper and lower GI surgeons. Despite this, we
make all trainees sit examinations and achieve a
The Intercollegiate Board Examination is
undergoing huge changes to reflect the need to
provide and test a training in general emergency
surgery followed by a defined sub-specialty
specific exam.
Fellowships have developed in all areas of
surgery, and many trainees who have completed
their CCT will now add a further period of
fellowship to their training. Many of these
fellowship posts were designed to meet specific
training needs not available at the time in
conventional training programmes such as
oncoplastic fellowships for breast trainees,
laparoscopic fellowships for colorectal trainees
and endovascular fellowships for vascular
trainees. The need for some of these will
become less as these techniques are more widely
adopted and applied in all units in the standard
training programmes. However, they also serve a
second purpose, allowing further experience,
polish and competitive edge to advanced
trainees in an increasingly difficult job market.
In some cases, they exist in the first instance
primarily to allow units to function within the
EWTR with their educational role being
secondary and, indeed, by diluting experience
for the standard NTN bearing trainees may be
counter-productive in this regard.
Meanwhile, there is an increasing emphasis on
consultant delivered services which will see
further changes in the jobs on offer to the new
CCT holder and the prospect of reductions in
training budgets and numbers of trainees with
increasing emphasis on their training requirements
and less on their availability to help with service.
The health service has changed enormously in
recent years but more change is on the way –
interesting times indeed!
CCT in general surgery, an experience it is
unlikely the breast, vascular and transplant
surgeons will ever use. These changes are now
upon us, but the examination and certification
system is still catching up.
Vascular surgery is likely to split as a separate
subspecialty in the near future. Trainees will be
awarded a CCT, but not with general surgical
competencies, and their exposure to upper and
lower GI surgery - “general surgery” - will be
much reduced from current requirements.
Transplant and breast surgery have not yet taken
this step, but may do so in the future and would,
consequently, seek their own CCTs.
The current CCT is an adequate level of
certification; it confirms that new consultants
have the necessary skills to develop their future
practice. Medical indemnity malpractice claims
for newly appointed consultants would not
suggest that we are training unsafe surgeons. We
should, however, award this to trainees who will
practice in the generality of emergency surgery
and allow more tailored training and certification
to those subspecialties already breaking away
from the fold.
This is a difficult question to answer, as there are
inevitably two sides to any story. However, we are
all aware of patients subjected to surgery when
they may well have been better off without an
operation. Getting the best results for our patients
requires careful consideration of the risks and
benefits of any procedure and a careful discussion
with the patient, their families and carers. It is also
important to recognise that it takes a team of
surgeons, anaesthetists and nurses to perform an
operation and the agreement of the patient to go
forward to surgery.
Avoiding poor outcomes requires a team practised
and skilled in the procedure required. In higher
volume hospitals with good outcomes, patient
factors are most important in determining
outcomes. Teams need to be able to recognise the
high risk patient and have time to explain those
risks, finding out what the patient wants. This
forms the core of the new government strategy “no
decision about me, without me” [1]. The time spent
on assessment and consultation may avoid the
distress of complications and death that could have
been avoided by deferring risky surgery. It is no
longer acceptable to say that the patient had to have
any given operation, as many elderly patients will
elect for conservative management once the risks
and benefits of major surgery are fully discussed.
Improving quality requires recognition that there is a
problem, or that outcomes or service quality could be
improved. If accompanied by a change in behaviour
to ensure that all members of the team and the
patient are fully involved in decision making, then
improvement is much easier to achieve.
One of the major issues facing vascular surgeons in
the UK in 2008 was that our reported mortality for
open Abdominal Aortic Aneurysm (AAA) repair
compared badly to the rest of Europe [2]. These poor
outcomes mirrored those reported from NCEPOD
[3] and The Vascular Anaesthesia Society of Great
Britain and Ireland [4], suggesting that there were
problems with the quality of care we offer our
patients. Our response has been to approve a quality
One of the key features of any QIP is robust
measurement to ensure that the programme is
heading in the right direction. QI methodology is
somewhat different from standard clinical research
methodology in employing small tests of change to
determine progress. The randomised clinical trial
is not a traditional feature of QI programmes, as
the time taken to implement change by this route
is often lengthy.
Another central focus of QIPs is implementation
and embedding of change in clinical culture. A
good example of this is hand washing after patient
contact in the NHS. This was combined with a
focus on “naked below the elbow”. It was this
latter part of the programme that irritated many
clinicians who complained of a lack of evidence
base. This, in part, missed the point of the QIP
which was to change attitudes to hand hygiene.
Changing the dress code focussed minds on
washing and clean hands around patient contact.
Combined with regular audits of hand washing
behaviour (measurement), the culture in the NHS
has been shifted to one that focuses on clean hands
for patient contact.
Similar approaches questioning the use of central
venous catheters has seen MRSA rates fall in
many NHS hospitals. This was achieved without
the use of RCTs. The data collection method was
to provide running totals of MRSA rates within
hospitals, the so-called “run chart”. This allowed
all clinicians to see how they were progressing
from month to month. The effect was to heighten
awareness of the MRSA problem and to see steady
and sustained falls in bacteraemia rates.
Introduction
At the first patient focus group meeting I attended,
one of the patients told the story of his uncle
George. George had heart failure and was in
hospital being treated for it. He had very limited
exercise tolerance. Whilst in the ward, he had a
number of tests and was found to have a large
abdominal aortic aneurysm. He was referred to,
and seen by, a vascular surgeon who told him he
needed an operation to fix it. His family was not
involved in this discussion, and were of the view
that George was not fit enough to survive major
surgery. Following the operation, he had a stormy
course with repeated lapses into heart failure.
About a week after the operation he died on the
ward. The question that the patient in the group
wanted answered was “How do we stop surgeons
operating on patients like Uncle George?”
Aims of quality improvement programmes
(general)
Vascular surgery is not alone in facing challenges
provided by better audit and greater scrutiny of
clinical outcomes. The desire to improve outcomes
is common throughout medicine, and any committed
clinician will agree that quality improvement is a
worthwhile activity. The Vascular Society submitted,
and was awarded a grant by the Health Foundation
to undertake a quality improvement programme
(QIP) for AAA surgery. There were many applicants
for these grants with varied aims from reducing
needle sharing in drug addicts to improving neonatal
care. The common theme was a desire to improve
the care offered to patients. The funding enabled us
to appoint a project management team to co-ordinate
and deliver our QIP [6].
NEWSLETTER
David Mitchell, Audit and Quality Improvement
Lead for the Vascular Society
improvement framework as a Society, in 2009, with
the aim of halving the 30 day mortality rate
following elective AAA repair [5].
QUALITY IMPROVEMENT
PROGRAMMES IN
VASCULAR SURGERY:
WHAT, WHY AND HOW?
Such techniques have been subjected to formal
assessment showing that providing regular data
feedback can drive quality improvement on its own
[7]. What is important is that there are clear,
achievable, goals for each QIP and that the
clinicians involved understand the steps required to
reach those goals. Regular monitoring will allow
the direction of the programme to be varied, if
needed, to maintain progress towards the QI goal.
Why do this in Vascular Surgery?
A significant part of vascular surgery deals with
sick elderly patients presenting with arterial
disease. The presentations of severe limb ischemia,
cerebro-vascular ischemia and abdominal aortic
9
NEWSLETTER
pathologies are often accompanied by underling
arteriopathy in the heart, kidney and intestine.
Such patients face high risks of death and
complications from surgery. Discussion with older
patients often focuses on a fear of disability and
death from interventions. The role of a QIP is to
identify areas where change in process or outcome
(or both) is desirable. The programme brings
together the evidence available and fashions a
pathway of care that will minimise the risks
associated with surgery. Once a pathway of care is
agreed, the next step is to implement it and to
monitor the effects of implementation on
outcomes. This requires a period of measurement
before, during and after introducing changes.
For vascular surgery in the UK, the most obvious
need for change is to improve mortality rates after
elective AAA repair. The introduction of the
National Abdominal Aortic Aneurysm Screening
Programme (NAAASP) is another important
stimulus to change, as the benefits of screening are
only seen if surgery for AAA can be delivered with
a low mortality [8]. Our first step was to articulate a
quality improvement framework (QIF). This set out
a clear goal of reducing the death rate by 50%, from
the current level to 3.5% by 2013. The QIF then
described the processes by which this would be
achieved and the necessary organisational structures
to underpin it. Once designed, it was published and
circulated to the membership of the Vascular
Society of Great Britain and Ireland (VSGBI) with
a questionnaire asking for feedback. There was
strong support from within the VSGBI, and the QIF
was formally adopted at our annual meeting in
November 2009. The VSGBI also had strong
support from our sister organisations, the Vascular
Anaesthesia Society of GB & I, the British Society
for Interventional Radiology and the Society of
Vascular Nurses. It is this support that forms one of
the cornerstones of our programme. The other is
having significant patient input to the project.
Finally, the grant we received provided us with
access to healthcare consultants and experts in QI
methodology. Their input has proven very important
to maintaining focus and momentum in the project.
How the QI programme works
* Organisation of teams
There are a number of key steps that follow
agreement to embark upon a QIP. Firstly, the
programme requires significant time input from
the core team and a wider team of healthcare
professionals. To deliver change, everyone
involved in providing care to the patient has to
become involved. The QIP has to become part of
the “how” for all team members and also for all
clinicians delivering care to patients.
Funding to support the work is important as it
allows the core team to devote time to the project.
Our first steps involved securing grant monies.
Once achieved, we appointed a team to run the
programme. We have a full-time project manager,
an audit assistant and part-time PA support. The
next task was to produce a project plan that
described how our quality improvement framework
(our aspirations) would be translated into clinical
practice. This was organised through a stakeholder
day at the Royal College of Surgeons of England.
We had input from surgeons, anaesthetists,
radiologists, nurses, cardiovascular networks,
10
public health and patients. This ensured that the
plan was focussed on all aspects of care delivery.
The project plan is a living document and has
needed updating as we progress. The plan allows
us to focus on a number of workstreams that drive
the programme. The two initial workstreams focus
on patient involvement and data collection.
A project that covers the whole UK cannot be
delivered centrally, so our first step was to create a
regional network to allow us to spread
information. Significant time was also spent
ensuring that we can contact clinicians and clinical
governance leads in all UK NHS Trusts, both to
provide data and information and to receive
feedback on the project. We continue to work on
developing contacts with commissioners and
cardio-vascular network leads.
* Patient involvement
Setting up patient groups was also organised on a
regional basis, using local leadership. This has
proved to be a very empowering process for both
patients and clinicians. Under the guidance of the
focus groups, we have improved our patient
information sheets and provided (for the first time)
written information about what to expect in the
recovery phase after discharge from hospital. Our
original (evidence based) information sheets were
heavily criticised for being too defensive and
focussing excessively on what could go wrong. We
were concerned that we might fail to warn of the
risks of surgery, but were encouraged to produce
leaflets that provide information on assessment
and care delivery in a more positive tone. These
are now available for surgeons to use.
The patient groups are focussed on ensuring
consistency in clinical behaviour and have strongly
supported the introduction of a “safe for surgery”
checklist, formal anaesthetic assessment prior to
admission and more detailed discussion with the
patient about their concerns prior to deciding on
intervention. They also supported our view that all
centres offering AAA intervention must be able to
provide both open and endovascular repair, and
must offer patients a choice when they are suitable
for either method of intervention. The patient
groups are now established in England, Scotland
and Wales and we see them as powerful
influencing groups for developing QIPs in other
areas of vascular surgery in the future. They
provide a regular reality check on our plans and
the progress of the project.
* Data collection and reporting
Data on AAA repair is collected by vascular
surgeons on our national vascular database (NVD).
This is a web-based tool located on the secure
NHS server. It collects data about indications for
surgery, pre-operative fitness, the conduct of the
operation (both open and endovascular) and about
anaesthesia. Data on post-operative care,
complications and outcomes are also routinely
collected. The database contains a search facility
that can highlight incomplete records. It also
provides a reporting tool giving outcome analysis
by unit, and surgeon for all of our national index
procedures (AAA, carotid intervention, lower limb
bypass and amputation).
Data entry is voluntary, and has been inconsistent
with wide variation in data entry rates between
* Measurement of process and outcome
Part of any QIP is to describe the processes that
are needed to bring about change. For our QIP the
focus is on three key areas involved in delivering
high quality care. The first is to describe the
process of pre-operative care. We believe that
improving pre-operative optimisation of patient
fitness and improving selection will enhance
patient safety. To enable measurement of the
processes involved in delivering care, we have
created care bundles. These are a group of
practices which, when performed together, make a
process consistent. Consistency of performance
can be measured against the number of times that
the full care bundle is implemented. The preoperative care bundle states that:
• Elective anaesthesia to be provided by an
anaesthetist with a regular elective practice in
vascular anaesthesia.
• All patients to be operated upon by vascular
surgeons and, for EVAR, by interventional
specialists experienced in the techniques involved.
• The operating theatre must be properly equipped
for AAA procedures including cell salvage auto
re-transfusion.
• There must be rapid access to transfusion &
haemostatic agents EVAR must be performed in
a sterile environment.
Challenges
* Clinician Engagement
A plan can only succeed if implemented in clinical
practice. This requires clinicians involved in care
delivery to adopt it. We all lead busy lives and face
many challenges in daily practice with continual
change being pushed at us. The AAA QIP is just
one of many such challenges. Seeking engagement
from clinicians requires the core team to have a
clear message and a plan that can be understood
and embedded into everyday practice. Clinicians
need to feel that the plan and care pathway will
work for them on a personal level. It requires time
and effort to spread the word about our project.
Seeking engagement works best if done at a
personal face-to-face level. Although we have
created a website for the project, this serves
mainly as a repository of information and evidence
that can be accessed by all clinicians and patients.
* Measurement and feedback
To engage clinicians, we have visited both regional
and national meetings of surgeons, anaesthetists
and radiologists. Part of the process is to provide
feedback on the progress of the project and part to
seek engagement through encouraging regional
action planning days. The core team works with a
local organiser to arrange the meeting and provides
some essential funding through our grant monies.
The day focuses on developing a local plan and the
core team then provide significant input in
translating those plans into useable documents. We
also provide assistance to those clinicians involved
from the outset to help to cascade the regional plan
throughout all hospitals in each region.
* Patient pathway
It is difficult to bring about change by data
reporting alone. We believe that it is important to
describe how improved care will be achieved. The
method we have chosen is to develop a pathway of
care for a patient that describes the journey from
the out-patient consultation, through admission and
surgery to return home. The approach adopted has
been to develop this in one region using a multidisciplinary team. We are using the North East of
England to initiate the process and develop a
pathway. This forms a core part of our regional
approach, using what we term “Regional Action
Plans”. The idea is that the pathway will be
developed and publicised. It will describe the key
steps in assessment and care delivery and contain
documentation relevant to the pathway. This can
then be taken and adapted to local needs by other
regions in the country ensuring a consistent
approach to care delivery. We anticipate that the
pathway will be ready for dissemination in the
spring of 2011 when we have a number of regional
action planning days arranged. This approach
avoids the need to start from scratch in each region,
and helps to clarify the steps required from each
unit to meet national standards for care delivery.
We have also created a bundle for the facilities that
need to be provided in order to undertake surgery
safely. The components of this bundle are:
NEWSLETTER
Figure 1. Regional data comparison of Hospital Episode
Statistics (HES) contribution and National Vascular
Database (NVD) contribution for April to June 2010
• All patients will undergo formal pre-admission
anaesthetic assessment.
• All patients being considered for intervention
will be assess by CT angiography for suitability
for open and endovascular repair.
• Patients will be assessed through a multidisciplinary team that will comprise a surgeon,
radiologist and anaesthetist as a minimum.
• All patients will be offered a choice of Open
Repair or EVAR if suitable.
surgeons and NHS Trusts. Part of our QIP has been
to provide feedback to surgeons and Trusts about
data entry (see Figure 1). To provide a stronger
focus, the VSGBI is now setting quality standards
for data entry to try and achieve a consistently high
quality of data. This will allow us to monitor
progress against our mortality goals with greater
confidence. There is interest from commissioners in
using these standards as part of the commissioning
process for vascular surgery. Current evidence
suggests that providing data feedback has stimulated
a fall in the mortality rates following elective AAA
repair in the UK in the last two years.
A second challenge is to provide enough feedback
to show that the project is progressing and that the
efforts being made to change practice are
achieving their aims. Measurement can take many
forms, and having national data returns provides a
significant part of this. Delivering local
measurement against care bundles may require a
varied approach. One method that can help to keep
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12
* Embedding change
Changing processes is not accomplished until those
processes are embedded in the culture of care. At
that point, the new (better) process replaces the old
process. Providing the tools to do this and support
for change is important as is demonstrating that
change is working and producing the improvement
sought by the project. However, embedding those
changes may require more push than laying these
things in front of clinicians. Using the influence of
commissioners to commission clear national
quality standards can be a vital step in getting
change to take hold. This is why an important part
of the project team activity is to seek the support of
key figures in local cardiovascular networks,
commissioning bodies, Royal Colleges and the
Department of Health.
NEWSLETTER
measurement active is to perform short repeated
snapshot audits of defined steps in the pathway.
This allows sampling of activity at regular
intervals and plotting of trends. This may help to
both demonstrate progress and to embed change
within the culture of an organisation.
The future
Delivering a quality improvement programme is a
learning process for the whole Vascular Society
and its partner organisations. We intend to use this
experience to drive quality improvement
throughout our speciality. We already run a carotid
intervention audit with the Royal College of
Physicians and we are focussing more and more
on trying to deliver against national targets for
intervention after stroke or transient ischemic
attack. Through two rounds of the audit we have
seen improvement in reducing delays to treatment.
Lower limb amputation for vascular disease is
associated with poor outcomes and a high mortality
rate in the UK. We have developed a QIF for
amputation which should be approved by the VSGBI
by the time this Newsletter is published. This will
inform our national pathway for amputation, seeking
to raise the standards of care that we offer to some
of our most vulnerable patients.
Conclusions
Quality improvement is a worthwhile activity for
all clinicians to engage in. Self reflection and redesigning processes of care to improve patient
safety in surgery should be part of everyday
clinical practice. When combined with robust
measurement and audit, it can empower healthcare
providers to embed new standards of care into
routine clinical practice. Whilst it is challenging to
individuals to admit that a service could be
improved, the process of delivering improved
quality can provide a focus and stimulus to daily
practice that re-invigorates clinical teams. Coupled
with improving outcomes for our patients this can
generate high levels of professional satisfaction.
References
[1] Equity and excellence: Liberating the NHS. The
Stationery Office 2010
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalas
sets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf
[2] Gibbons C et al: 2008.
http://www.esvs.org/files/About_the_Society/ESVS_VAS
CUNET_REPORT_2008_BW.pdf
[3] Abdominal Aortic Aneurysm: A service in need of surgery?
http://www.ncepod.org.uk/2005report2/index.html
[4] In-hospital mortality from abdominal aortic surgery in
Great Britain and Ireland: Vascular Anaesthesia Society
audit. Bayly PJ, Matthews JN, Dobson PM, Price ML,
Thomas DG. Br J Surg 2001, 88(5): 687 – 692
[5] Framework for improving the results of elective AAA
repair, Dec 2009
http://www.vascularsociety.org.uk/library/qualityimprovement.html
[6] Abdominal Aortic Aneurysm Quality Improvement
Programme. www.aaaqip.com
[7] Campbell D A, Englesbe M J, Kubus J J, Phillips L R,
Shanley C J, Velanovich V, Lloyd L R and Hutton M C
Accelerating the pace of surgical quality improvement: the
power of hospital collaboration. Arch Surg 2010
Oct;145(10):985-91.
[8] Ashton H A, Buxton M J, Day N E, Kim L G, Marteau T M,
Scott R A, Thompson S G and Walker N M.
The Multicentre Aneurysm Screening Study (MASS) into
the effect of abdominal aortic aneurysm screening on
mortality in men: a randomised controlled trial. Lancet
2002 Nov 16; 360(9345):1531-9.
GENERAL SURGERY: ST3
NATIONAL SELECTION ENGLAND AND WALES
History
Prior to 2007, Deaneries advertised vacancies on
their training programmes as they arose.
Applicants were shortlisted, based on their CV or
application forms, and generally underwent a
single panel interview lasting 15 to 20 minutes.
There was little or no standardisation of eligibility
requirements, and interview design and technique
varied widely. Applicants’ interview performances
were discussed by the panel before a ranking was
agreed introducing the risk that dominant panel
members could sway others’ opinions.
NEWSLETTER
Gareth Griffiths, Chair of Selection Group
Bill Allum, Chair SAC in General Surgery
Peter Lamont, Past Chair SAC
The widely derided Medical Training Application
Service (MTAS) was introduced in 2007 as part of
the Modernising Medical Careers (MMC)
reforms. These changes included the introduction
of run-through training in which trainees were
required to select their specialty/ies of choice
during their 2nd Foundation Year and compete for
entry into training in those specialties. Trainees
who had already received some
training/experience at the old Senior House
Officer level also applied, but for higher levels of
training. The application and interview process
was the same, however, for all levels. Difficulties
arose from the application form which had many
questions requiring free text answers and from the
interview process which, in being formulaic and
highly structured, prevented in-depth questioning.
These issues were then compounded by capacity
and security issues with the computer system.
Following the collapse of MTAS, selection
reverted back to the Deaneries with each
developing their own process, guided by what by
then had become the national person
specifications.
Rationale
Selection processes are better now than before
MTAS in that they are based on a standardised
person specification and many include a selection
centre approach in which a longer interview (often
30 minutes) involves interaction with two or three
different pairs of interviewers. Selection centres
give a more reliable outcome than a single panel
and a greater number of stations gives even
greater reliability.
However, there are still drawbacks to the current
system. Standards are inevitably applied
differently around the country. Popular
programmes attract the best applicants, but may
not have sufficient posts to accommodate them all
leaving the possibility that good trainees may not
be accepted onto any training programme. There
is the risk that local applicants may be favoured
over others, leading to potential unfairness.
Applicants correctly apply to a number of
Deaneries (728 applicants made over 4,000
applications for general surgery at ST3 in 2010),
but this increases the cost of the process, both in
financial terms and in lost time for patient care, as
14
trainees attend several interviews and Consultants
spend more time interviewing than is strictly
necessary. Trainees and Deaneries face difficulties
when offers are made, as trainees may prefer to
wait to see if they get a better offer. This can lead
to offers being declined or trainees withdrawing
from posts they previously accepted. In addition
to the administrative difficulties this causes, it can
result in poorer applicants being offered a post in
one Deanery while better applicants get no offers
from other Deaneries. Clearly, improvements can
be made.
National Selection Pilot Studies
Against this background, the Specialty Advisory
Committee (SAC) in General Surgery was asked, in
2008, to recommend how best to select trainees for
specialty training at ST3 level. A pilot study was
funded by the Department of Health and led by Mr
Peter Lamont, then Chair of the SAC. The principle
aims were to establish how best to ensure fairness
for all applicants and to develop a process which
selected the best trainees and placed them in their
highest possible preferred Deanery. While a single
selection centre panel interviewing all applicants
might achieve this, such a process would clearly be
impossible to organise given the numbers involved.
The aims of the study were, therefore, to establish
whether multiple panels could reliably select the
best applicants and to develop a robust selection
methodology which assessed the characteristics
considered important for general surgery training,
as based on the person specification.
The results of the first year of this pilot were
presented at the ASGBI International Surgical
Congress in April 2010, and published in the
Association’s Newsletter. A paper describing the
outcome of the full pilot is soon to be submitted
for publication. In the first year of the pilot, two
separate teams of assessors each assessed the
same cohort of volunteer applicants to see if
similar interview scores would be obtained. In the
second year, the selection methodology was used
“live” in three Deaneries for their ST3 selection to
see if the results from the first year were
repeatable on a larger scale.
Station 1
Portfolio
Station 2
Clinical and Managerial
Scenarios and Academic
Station 3
Leadership and Teamworking
Scenarios
Station 4
Technical Skills and Audit
Presentation
Station 5
Communication Skills
Table 1: Description of the domains assessed at each
of five stations
Stations were designed to each specifically assess
different characteristics (see Table1) and a global
rating score format was used to assign scores (see
Figure 1). In this system, which has been shown
to be reliable and valid in a number of different
assessment settings, the important components of
the characteristic under question are separated
into four or five fields each of which has a five
point descriptive scale guiding which score (from
1 to 5) should be applied.
4
5
Safety features
no safety features
beyond standard seat
belts
driver and passenger
air bags only, anti lock
brakes, pre-tensioned
seat belts with antisubmarining
multiple front and side
air bags, ABS with
power assist brakes,
pre-tensioned seat belts
with anti-submarining,
electronic stability
control, speed/lane
wandering alerts
Economy
known poor resale
value, high fuel
consumption/CO2
output, high servicing
costs (all quantified)
moderate resale value,
moderate fuel
consumption/CO2
output, moderate
servicing costs (all
quantified)
good resale value,
good fuel
consumption/CO2
output, good servicing
costs (all quantified)
documented history of
poor reliability,
warranty limited to 1
year and mileage and
does cover important
features
average reliability,
warranty period 1-3
years covering most
features
documented good
reliability, warranty
period over 3 years
covering all important
features
0-60 in <20 seconds
30-60 in <15 seconds
0-60 in <15 seconds
30-60 in <10 seconds
0-60 in <10 seconds
30-60 in <7 seconds
Reliability/
warranty
Performance
Figure 1: Example Global Rating Score scheme as applied to assessing the quality of a new car
In brief, inter- and intra-team reliability was good
to excellent when two different teams of
interviewers assessed the same applicants, even
though there was a learning effect for the second
of these two interviews. This reliability was
confirmed in the second year of the study.
Internal consistency was appropriate in both years
and was consistent with the fact that the selection
centre was designed to assess different
characteristics. By far the greatest variability in
scores arose from applicant related factors in both
years of the pilot.
A statistical tool known as Rasch analysis was also
assessed. This assumes there is bias in all the factors
which influence a score except one – the applicant.
Through an extension of linear regression, the bias
is then removed and a “fair” score calculated from
the “observed” score. In the second year of the
pilot, had this technique been used, then very few
successful applicants (as selected on the observed
score) would have fallen below the appointable
score, although more (as selected on the fair score)
would have had their scores increased so bringing
them into the appointable range.
Plan for 2011
The Training Programme Directors and the Heads
of School have agreed that a national selection
process should be recommended to the Department
of Health adopting the same format as the
Selection Pilot. Arrangements are now being made
to implement this, and a core group comprising
Programme Directors and members of the SAC has
been established to oversee the process.
It has been decided that no short-listing will be
used for the first year of this process for two
reasons. First, there is evidence from the 2010
selection process across the UK that short-listing
scoring is unreliable. Secondly, the pilot study did
not assess short-listing and further work is
required before it can be relied upon. It is
intended to carry out a study to examine how
short-listing may be improved as part of the 2011
selection, although it will not contribute to the
actual selection process.
The question of how to enable fair competition
between those who just meet the essential entry
criteria (ie, those completing Core Training) and
those with more experience, has exercised a
number of specialties over the last few years. A
variety of methods have been devised in an attempt
to address this issue and active consideration is
currently being given as to how this will be handled
for general surgery for 2011. More information on
this will be available in the near future.
Rather than attempting to run several selection
centre panels in each of three or four different
geographical locations, as was the original
intention, it has been decided for ease of
administration to hold all interviews in London.
The London Deanery is the Lead Deanery for
General Surgery and would be responsible for
administering national selection however it was
designed. Although all interviews will take place
in London, the membership of the panels of
assessors will be representative of the whole
country. The selection methodology will be the
same as that developed in the Pilot Study, and the
whole process will be subject to quality assurance
and statistical analysis. Rasch analysis will not be
used to assign scores for actual selection, but will
be studied further to see what effect it would have
if it were used.
3
NEWSLETTER
2
1
The basic process will run as follows:
• Advert placed by London Deanery in February
on behalf of all Deaneries.
• London Deanery host national on line portal of
application.
• Applicants complete the national application form.
15
NEWSLETTER
• Applicant preferences for deaneries captured at
application stage. Applicants will be able to
rank their choice of all participating deaneries
and indicate if they do not wish to be
considered for any regions. There will not be an
opportunity for applicants to change this after
submission of their application.
• Preferences will be blinded from interviewers.
• Long-listing will be based on immigration
status, Fitness to Practice, language and the
essential criteria from the person specifications.
• Any candidates who do not meet basic
eligibility requirements or essential criteria will
be removed from the process at this stage.
• All eligible applicants invited to a national
selection centre hosted in London.
• Interviews will take place between 4th and 15th
April 2011 using the nationally agreed scoring
methodology.
• Panel made up of members from all deaneries
to ensure equitable representation across
regions.
• There will be a national minimum score
required for appointment.
• Scores will be collated at the end of the
interviews to form a national ranking.
• Offers will be managed by London Deanery.
• In rank order, successful applicants will be
offered a deanery programme based on
applicant preferences collected at the
application stage (eg, top candidate gets first
choice and so on).
• If a first choice deanery is unavailable as all the
slots have been taken by higher ranked
candidates, applicants will be allocated to their
second choice deanery and so on until all slots
are filled or the limit of appointable candidates
is reached (whichever comes first).
• If an applicant does not score high enough to
be allocated to any of the deaneries they have
preferenced (eg, all the slots have been taken
by higher ranking candidates) then no offer will
be made.
• If there are sufficient posts to be filled later on
in the year, a second recruitment round will be
held in the autumn.
Summary
National selection for general surgery at ST3 level
is being introduced after a careful pilot study of
interview methodology and process design. It is
being introduced so that applicants are assessed
by a fairer and more standardised process. It is
aimed at ensuring that the best applicants are
selected from all over the country and that they
get their highest possible choice of Deanery
location based on their ranking. It should make
the offers and acceptance process clearer and
easier for both applicants and Deaneries and will
be more efficient in terms of overall time taken
and cost over a regional model.
Timetable
Applications open
Closing date
Interviews
7th February 2011
4th March 2011
4th to 15th April 2011
SIR BERNARD RIBEIRO
APPOINTED AS A LIFE PEER
The Association is delighted to report that Sir
Bernard Ribeiro has been appointed a Life
Peer. Lord Ribeiro was the Honorary
Secretary of ASGBI from 1991 to 1996 and
President of the Association in 1999-2000,
when he held the ‘Millennium’ Annual
Scientific Meeting in Cardiff. Amongst
Bernie’s many achievements for the
Association were the evolution of the Link
Surgeon network, the development of the
Overseas Surgical Fellowship Group (now the
ASGBI International Committee) and the
inauguration of the annual Helen Rollason
Memorial Lecture at the International
Surgical Congress.
Bernie was appointed as a Consultant
Surgeon at the Basildon Hospital in 1979
where he served until his retirement in 2008.
During a distinguished career, Bernie has
made many major contributions to surgery at
a local, regional and national level, and was
President of the Royal College of Surgeons of
England from 2005 to 2008.
16
This raises the question of whether academic
pathways should be ‘decoupled’, as has been
the case for most surgical specialties with
some exceptions (for example neurosurgery).
This would limit potential complacency
amongst academic trainees and allow for
appropriate competition for academic ST3 at
the core-to-specialty training transition point.
Furthermore, should clinical lectureships
remain open to all NTN holders who hold a
higher degree and the other essential and
desirable attributes, or should they be offered
exclusively to those who are ACFs with an
NTN(A)? Similar considerations, as regards
how well the ACFs have used the
opportunities afforded to them by the
academic pathway, need to be made and
compare this with how productive a nonacademic NTN holder would be in a clinical
lecturer post. Predicting productivity in a post,
and hence the selection to academic surgical
training in general, is fraught with difficulty.
This difficulty with standardising academic
success is magnified when one considers that
academia has a number of guises including
science, education, management and
leadership. Factors such as publications, grant
generation, collaborations, presentations,
departmental cost-savings and student
achievement of learning outcomes may not be
equally applicable to each of these ‘academic’
disciplines. It is likely that each such
discipline will require its own entry criteria
and competencies/performance indicators.
An additional consideration is whether
selection should be local or national. National
selection would facilitate the appointment of
the best candidates to posts, particularly at a
time when NTNs and NTN(A)s are limited.
Also to be addressed is the mechanism by
which surgical trainees are attracted to
academic training. This may be achieved by
confronting some of what are currently
considered to be deterrents to academic
surgical life and why 9% of clinical academics
are surgeons, compared to 37% being
physicians [1]. Unfortunately, at present less
than 2% of the UK’s medical research funding
is applied to surgically-based research projects
– the Royal College of Surgeons of England
has stated “a desperate need to redress this
balance” [2].
Junior academic surgical trainees may be
deterred by ‘unbanded’ academic blocks in
their training, coupled with a requirement to
attain their clinical competencies in less time
than non-academic colleagues. As surgery is,
arguably, more experience-dependent than
other medical specialties, some say that
research comes at the cost of clinical
development, with academic surgical trainees
‘deskilling’ whist in research posts.
More senior surgical academics may
experience job vulnerability, with pressure
from the employing universities to publish
papers in high impact factor journals and
generate research grant income. During
challenging economic times, there are often
redundancies among academic staff.
Furthermore, surgical academics may have
less time for private practice and other
activities which generate additional income
(such as medico-legal work). This may be
offset in some instances by commercial
consultancy work and, although less
commonly, lucrative patents and intellectual
property.
There are a number of challenges relating to
the recruitment of surgical trainees to an
academic ST3 appointment. A good starting
point would be overall number of these posts,
particularly outside London. This is
confounded by the fact that a proportion of
these posts are earmarked for surgical
academic core trainees/fellows (ACF), who are
still appointed to run-through programmes.
These trainees, upon completing their clinical
and academic competencies and successfully
negotiating their annual review of competence
progression (ARCP), would pass into these
ACF posts at ST3 level. The opportunity,
therefore, for non-ACF core trainees to obtain
ST3 ACFs is attenuated.
NEWSLETTER
Alun H Davies
However, clinical lecturer posts may be
better suited to a particular individual:
perhaps s/he has worked in the department,
set up a project, is already undertaking or
supervising work in a department, has
expertise in a technique which is desired by
the department. Such may not be addressed
by national selection process where the
‘best’ candidates are chosen centrally and
then ‘distributed’ to units according to
selection rank and candidate choice rank, i.e.
national selection may lead to a ‘mismatch’
of candidates to posts.
THE PROBLEMS OF
RECRUITING TO ACADEMIC
ST3
References
[1]. Margerison, C.M.,
Clinical Academic Staffing Levels in UK Medical
and Dental Schools
2007, Medical Schools Council (previously The
Council of Heads of Medical Schools) and the
Council of Heads and Deans of Dental Schools.
[2]. Research Department, RCS England
Surgical Research Report 2010-2011. Investing in
research to improve patient welfare,.
J. Hackett, Editor. 2009.
17
LAPAROSCOPIC SURGERY: A
TRIUMPH OF TECHNOLOGY
OVER COMMON SENSE?
John MacFie
18
NEWSLETTER
“Every age has its sources of wisdom, those to
whom we turn for a little light in the abiding
darkness: the oracle at Delphi intoxicated by
volcanic gases; shadowy priests whispering
behind the grille; or ascetics and gurus in their
mountain fastnesses.”
So wrote Julian Sheather recently in the British
Medical Journal [1]. This was a preface to a
comment on a recently published book entitled
Wrong: Why experts keep failing us and how to
know when not to trust them by David Freedman
[2]. I would strongly recommend this text to all who
claim to practice evidence-based medicine. It turns
out that, even when focusing on research published
in the most prestigious of medical journals, two out
of three studies are likely to be unreliable.
Freedman states that the rate could be higher, but no
one has tried to refute more than half the rest and
yet the findings of many of these studies appear
daily in the media as the nearest thing we have to
health gospel. As we are all well aware, career
researchers are under enormous pressure to get their
research published. These journals are more
interested in positive than negative findings. There
is undoubtedly pressure on researchers to come up
with findings that support a study’s hypothesis
rather than refute it, resulting in so-called
publication bias. And there are, of course, many
other sources of contemporary scientific error.
These include the effect of commercial sponsors,
the perils of peer review, the habit of assuming
causes when there are only correlations and the
failure to publish negative findings. Could this have
happened with laparoscopic surgery and particularly
laparoscopic colorectal surgery? The last decade or
so has seen an explosion in publications related to
laparoscopic surgery. Invariably, these papers
purport to show that laparoscopic surgery is
associated with enormous benefits.
of hospital stay for these studies, it is rapidly apparent
that laparoscopic surgery was associated with shorter
durations of hospital stay, but these are far in excess
of what we would now consider the norm after open
surgery conducted using the principles of enhanced
recovery. We have previously suggested that, if ERAS
principles are adopted and rigorously applied, it is
difficult to demonstrate additional advantages for the
use of the laparoscope [3].
Admittedly, there is relatively little controlled data
comparing laparoscopic vs. open colorectal surgery
within an ERAS setting (see Table 1). A recent
meta analysis reported two randomised controlled
studies and three controlled trials which suggested
a more favourable, but non-significant, benefit for
laparoscopic procedures in terms of length of stay,
re-admission rates and morbidity [4 to 9]. However,
these studies have several methodological
limitations: the sample size was small, different
colonic surgical procedures were carried out in the
same data analysis and outcome parameters varied
between the studies. There are recent reports of
laparoscopic surgery conducted within an ERAS
setting, but these are largely case series conducted
without a control group.
Table 1 Studies included in this review:
Considering that laparoscopic colorectal surgery has
been practised for over twenty years, is routine in
many units and has recently been endorsed by NICE,
it really is surprising that there is so little robust data
supporting its use. This is not to doubt that
laparoscopic colonic surgery is safe, feasible in the
majority of patients and oncologically sound when
performed in expert hands. Further, there is no doubt
that it is aesthetically satisfying, and all of us will be
aware of anecdotal reports of patients undergoing
extensive surgery with the laparoscope who return to
work within hours of their surgery apparently
completely well. But, as they say, anecdote is the
lowest form of science. I know lots of anaesthetists
who rely upon anecdote to judge us surgeons. Almost
to a man (or woman) they regard laparoscopic surgery
as a means by which straightforward operations that
used to be done quickly now take hours and inevitably
involve vast quantities of disposable kit.
This table originally appeared in:
S Khan, M Gatt and J MacFie
Enhanced recovery programmes and colorectal surgery: Does
the laparoscope confer additional advantages?
Colorectal Disease 2009; 11; 902-908
and is reproduced here with the kind permission of Blackwell
Publishing.
The definitive version of the paper is available at:
http://onlinelibrary.wiley.com
The main pillar upon which laparoscopic surgery is
based (assuming equivalence in oncological safety,
etc) is that it is associated with improved outcomes
inferring more rapid recovery and reduced lengths of
hospital stay. Many of the early trials did suggest this
but, arguably, are open to the criticism that their
comparator was open surgery using old-fashioned
perioperative care. If one looks at average durations
Notwithstanding any benefits for the laparoscopic
over the conventional approach, no one would
dispute that there are some drawbacks to the
laparoscopic approach. These include a prolonged
learning curve, prolonged operating times and
higher initial costs. No one would doubt the
learning curve issue. Few would challenge the
prolonged operating times, at least for complex
There is no question that we need to encourage
Lapco and other training modalities to ensure that
surgeons are comfortable with these new techniques.
It is, however, debatable whether or not we should
support recent NICE guidelines which recommend
that patients who require elective left or right
hemicolectomy should be offered laparoscopic
resections and that failure to be able to provide this
service should necessitate the patient being
transferred elsewhere. No wonder surgeons feel
anxious to adopt these techniques. There is no doubt
in my mind that one consequence of NICE’s
recommendations is that surgeons feel under pressure
to complete procedures laparoscopically. This, in my
view, is not justified on the basis of available
evidence. This, I would emphasise, is not saying that
those who are competent to perform laparoscopic
procedures safely and expeditiously should not do so,
We need more information before deciding that the
laparoscope is an essential component of every
abdominal operation rather than a valuable part of
the colorectal surgeon’s armamentarium. Many
colorectal surgeons will be aware of the La-FA
study which is an on-going multicentre randomised,
controlled trial comparing laparoscopic with open
surgery using ERAS principles [11]. This study will
be adequately powered and may provide definitive
results. Until then, or until other good prospective
data is published, we should be cautious about
adopting surgical techniques which are not
evidence-based.
Footnote
I am grateful to Mr Nick Markham for the title.
References
[1]
Sheather J
The sybil is faulty
BMJ 2010; 341: c4471
[2]
Freedman D
Wrong: why experts keep failing us and how to know when
not to trust them
Little Brown and Company, London, New York 2010
[3]
Khan S, Gatt M and MacFie J
Enhanced recovery programmes and colorectal surgery: does
the laparoscope confer additional advantages?
Colorectal Dis 2009; 11: 902-8
[4]
Vlug M S, Wind J, van der Zaag E, Ubbink D T, Cense H
A and Bemelman W A
Systematic review of laparoscopic vs open colonic surgery
within an enhanced recovery programme
Colorectal Dis 209: 11(4): 335-43
[5]
Basse L, Jakobsen D H, Bardram L, Billesbolle P, Lund C,
Mogensen T, et al.
Functional recovery after open versus laparoscopic colonic
resection: A randomised, blinded study
Ann Surg 205; 241(3): 416-23
[6]
King P M, Blazeby J M, Ewings P, Franks P J, Longman
R J, Kendrick A H, et al.
Randomised clinical trial comparing laparoscopic and open
surgery for colorectal cancer within an enhanced recovery
programme
Br J Surg 2006: 93(3): 300-8
[7]
Polle S W, Wind J, Fuhring J W, Hofland J, Gouma D J
and Bemelman W A
Implementation of a fast-track perioperative care program:
What are the difficulties?
Dig Surg 2007; 24(6): 441-9
[8]
MacKay G, Ihedioha U, McConnachie A, Serpell M,
Molloy R G and O’Dwyer P J
Laparoscopic colonic resection in fast-track patients does not
enhance short-term recovery after elective surgery
Colorectal Dis 2007; 9(4): 368-72
[9]
Junghans T, Raue W, Haase O, Neudecker J, Schwenk W
Value of laparoscopic surgery in elective colorectal surgery
with ‘fast-track’-rehabilitation
Zentralbl Chir 2006; 131(4): 298-303
The survey is published in this Newsletter. The
findings are disturbing: of over 500 surgeons who
responded no less than 78% were aware of a case
of serious iatrogenic injury in the previous 12
months (note, the survey asked for information
about all laparoscopic procedures, not just
colorectal). I am well aware of the fact that many
have criticised this survey on the grounds that it is
not a prospective randomised trial, that it is not
evidence-based, that it does not compare results to
a controlled group using open surgery and that it is
prone to the criticism of double reporting. I would
remind these critics, however, that a survey is a
survey and does not claim to be anything else. Its
purpose is simply to raise awareness of a
potentially important problem and thereby
encourage appropriate investigation. This survey
should be seen as a wake-up call to those that
inappropriately pursue laparoscopic procedures or
slavishly persist with the laparoscopic approach for
hours in the mistaken belief that this is in the
patients’ best interests.
I do recognise that some surgeons are capable of
performing all their colorectal resections without
significant morbidity and that clearly these surgeons
are masters of the laparoscopic art. This, however, is
not a reason to coerce other surgeons to adopt these
techniques, particularly when the evidence of
benefit remains inconclusive.
NEWSLETTER
More important than these drawbacks to
laparoscopic colorectal surgery is the recognition
that iatrogenic complications may occur. Some
months ago, the NPSA issued a patient safety notice
appertaining to iatrogenic injury occurring in
association with laparoscopic surgery (all
laparoscopic injury, not just colorectal procedures)
[10]. The NPSA, as part of their investigation into
this topic, invited a number of surgeons to a
meeting to discuss the issue. These surgeons
included myself, representing ASGBI, Derek
Fawcett, President of the FSSA and the then
President of BAUS, and Mike Parker, Council
Member of RCS England and President, at the time,
of ALS. All were agreed that adequate training was
essential to minimise risks of iatrogenic injury and
that the true incidence of such injuries was not
known. This was the catalyst to embark upon a
survey, which was an attempt to determine the
magnitude, if any, of the problem.
simply that the jury is still out as to whether this
provides tangible benefits to patient outcomes if
compared to open surgery conducted using modern
perioperative care.
cases. It is remarkable, however, how little
discussion there has been in the literature about the
cost-effectiveness of laparoscopic colorectal surgery.
The difference in the comparative costs of disposals
is enormous. Yet these differences are justified by
surgeons on the grounds that they are offset by
reduced lengths of stay or morbidity. Our political
and managerial masters and mistresses have, so far,
accepted this without challenge. Hence, the
laparoscopic bandwagon rolls on unimpeded much
to the delight of industry.
[10] Laparoscopic surgery:
Failure to recognise post-operative deterioration
NPSA Rapid Response Report NPSA/2010/RRR016
[11] Wind J, Hofland J, Preckel B, Hollmann M W, Bossuyt P
M M, Gouma DJ et al.
Perioperative strategy in colonic surgery:
LAparoscopy and/or FAst track multimodal management
versus standard care (LAFA trial)
BMC Surg 2006; 6: 16
19
ASGBI SURVEY: INJURIES
ASSOCIATED WITH
LAPAROSCOPIC SURGERY
Nicholas Markham
ASGBI Director of Informatics
NEWSLETTER
Introduction
The veritable explosion in laparoscopic surgery
has, arguably, been one of the most significant
developments in surgery over the last 50 years.
From the early nineties, it mushroomed to become
almost as commonplace in an operating theatre
complex as are sutures and blades.
Like all surgery, there are potential complications,
risks and traps for the unwary. Long thin
instruments, often attached to diathermy, have a
huge potential for causing inadvertent damage,
especially when one considers that about 80% of
the instrument’s length is out sight of the operator
as it is being used. Added to that, an even more
difficult and potentially disastrous scenario can
unfold as the operator tries to gain first entry into
the abdominal cavity, whether that be by an ultrathin Verres needle, completely blindly, or by using
an optical port with tissue-separating blades. Even
‘open’ insertion of the first port can be difficult
and hazardous at times.
Many have expressed concerns about reports of
inadvertent injuries sustained either at first-entry
or during the procedure itself. An analysis of the
true incidence of such adverse events, taken across
the country, would be a difficult exercise; however,
a survey of surgeons should give us an idea of just
how significant, or not, the issue might be.
As a result, the National Patient Safety
Association, through ASGBI, conducted an on-line
survey, in which surgeons were asked to state how
many serious injuries they had seen in the previous
year (whether or not they had actually been
personally involved) and to say what were the
outcomes in terms of morbidity and mortality.
Serious injury, as defined by the survey, would not
include, for instance, the troublesome bleeding that
can beset all surgeons from time to time, but
incidences where serious inadvertent damage,
however produced, had occurred. We present the
results below.
Summary
• Over 500 surgeons from the UK and Ireland
responded to the survey.
• 95% were either Consultants or SpRs, over half
of whom had been qualified for more than 10
years.
• Furthermore, 93% had themselves undergone
formal laparoscopic training and ? were
performing more than 5 laparoscopic
procedures a week. On the whole, therefore, the
respondents were experienced surgeons.
• 75% had witnessed a serious injury at some
time in their career.
• 3 people said they had seen two such events in
the previous week.
• 22% had seen a vascular injury in the previous
year.
20
• 50% had seen a visceral injury in the previous year.
• Most injuries (about 2/3) were seen in either
biliary or colonic surgery, with over 20% in what
was classified as ‘other’ surgery. One suspects
this referred to gynaecological procedures.
• In nearly half the incidents, no adverse harm
resulted as the injury was recognised and dealt
with immediately and appropriately.
• In about 20% the result was ‘nothing more’ than
a delayed discharge.
• Death was the ultimate outcome of serious
injury in 7.5% (although the figures for ‘death’
are different in Figures 16 and 17, as in the
latter the number is only 5%).
Comment
These are not reports from those who one might
imagine have a natural opposition to laparoscopic
surgery, but rather from self-evident enthusiasts.
That said, there was one person who reported
having seen between 6-10 serious vascular injuries
over the preceding year and another one (perhaps
the same?) who said they had seen between 16-20
visceral injuries in the same period. One is
tempted to surmise that this was either a tertiary
referral surgeon to whom all these injuries would
have been referred, or else that the department of
surgery in that hospital needs an urgent visit.
So what should we conclude? How reliable or
representative are the results? Could it be, for
instance, that more than one surgeon is reporting
the same incidents? Whatever else, the outcome of
the survey needs to be viewed in the light of the
fact that I would estimate that well over a hundred
thousand laparoscopic procedures would be
performed each year in the UK and Ireland.
Some serious injuries (about half in this survey)
are recognised immediately, dealt with
appropriately and little deficit accrues. However,
that does not lessen the importance of the
message that we must strive rigorously to reduce
the incidence of serious injury. Others (20% in
this survey) are dealt with and a delay in
discharge results, but probably nothing worse.
There is a group (5% here) where the consequent
morbidity is highly significant and where the
patient ultimately dies.
Every surgical operation caries risks – no matter
who does it, where it is done or how carefully it is
performed. We all need constant reminders of the
fact that all surgery has the potential to be
dangerous for all patients. There is ample
evidence to support the belief that laparoscopic
surgery ‘ups the ante’ in this regard, although
equally, many having laparoscopic procedures fare
considerably better as a result of having them
performed in this way.
What I believe this survey should do, is remind us
of our responsibility to ensure that we are as well
trained and as careful and meticulous in our
surgery as we possibly can be. Each and every
case where serious injury occurs should be
reported to a central database so that surgeons can
gauge their performance against their peers and
those who are ‘outliers’ can be identified and the
correct course of action (whatever that may be – it
is outside the scope of this report) taken.
NEWSLETTER
ASGBI SURVEY: SUMMARY OF RESULTS
21
NEWSLETTER
COMMENTARIES
COMMENTARY ONE
Mark Coleman, National Clinical Lead, Lapco
Mike Parker, President ACPGBI
“Cnut set his throne by the sea shore and
commanded the tide to halt and not wet his feet
and robes; but the tide failed to stop”. According
to Henry, Cnut leapt backwards and said “Let all
men know how empty and worthless is the power
of kings, for there is none worthy of the name, but
He whom heaven, earth, and sea obey by eternal
laws.” He then hung his gold crown on a crucifix,
and never wore it again.
Laparoscopic surgery is here to stay for the simple
reason that it has been shown to be as safe, and,
moreover, preferred by patients compared to the
standard open approach [1, 2, 3, 4, 5]. The reduction
in length of hospital stay after laparoscopic
colorectal surgery is more than mere anecdote,
and with the dissemination of enhanced recovery
programmes across the UK, this will undoubtedly
become more widespread [6, 7].
All surgeons would do well to remember that it is
our responsibility to offer, as part of the process
of obtaining informed consent, all approaches to a
procedure that have been demonstrated to be safe
and effective by appropriate scientific study
within our health care system [8]. Therefore, both
22
open and laparoscopic surgery should be
mentioned, regardless of the surgeon’s preferred
approach. This is the assessment made by NICE
and we should stand by that decision.
If a procedure, such as laparoscopic colorectal
surgery, represents a challenge to surgeons
without laparoscopic skills, it is necessary to offer
them a safe and effective means to obtain the
required skills. Lapco, the Department of Health’s
National Training Programme in laparoscopic
colorectal surgery for England offers such an
opportunity [9]. Within Lapco, the proficiency
gain curve, with direct mentoring by expert
laparoscopic colorectal surgeons, is as little as 2425 colectomies, which can be achieved in less
than six months and, therefore, refutes the
suggestion of a ‘prolonged learning curve’ [10].
The Survey mentioned in Professor MacFie’s
article related to all types of laparoscopic surgery
and, therefore, includes non-general surgical
specialities such as urology and gynaecology.
Several major scientific flaws were apparent
including: double reporting; retrospective; no
denominator; and no attempt to determine the
risks of open surgery.
It is not acceptable for Professor MacFie to simply
acknowledge in his article that the survey was
badly flawed but then go on to refer to it as a
“wake up call”. A survey, if correctly designed
Professor MacFie is correct; more data are always
required. Perhaps he would accept that no new
surgical techniques have been more rigorously
studied than laparoscopic colorectal surgery. We
now have long-term data from a number of
international multicentre prospective RCTs which
prove the improved outcomes without the
sacrifice of safety or oncological outcome. We
have no need to fall back on anecdote; we have
the evidence [1, 2, 3, 4, 5]. Even now, there is
evidence that points to major variation in
outcomes from open surgery – hernia recurrence
rates, permanent stoma rates for colorectal
surgery and, perhaps worst of all, wide variation
on cancer outcomes [11]. Where is the evidence
that TME was introduced on the back of a RCT?
The current move towards prone extralevator
APER has no RCT. Should Professor MacFie not
consider that these matters are considered as well
as laparoscopic surgery?
It is worth dwelling on the LAFA trial, work
presented at ESCP, Sorrento, September 2010 [12,
13]. In this RCT, four hundred and twenty seven
patients were randomised into four groups:
laparoscopic surgery and fast track (enhanced
recovery) post op care, laparoscopic and standard
care, open and fast track, and open and standard.
Those patients undergoing laparoscopic surgery
within fast track performed significantly better than
those who underwent open surgery with fast track
(5 days vs 7 days, p=0.001). This counters
Professor MacFie’s suggestion that the rigorous
application of ERAS principles to open surgery
would be as good. Furthermore, the study assessed
cost in the broader context of operative, hospital
stay, out-patient attendance, operation time and
complications, and no difference in cost between
the patients who underwent either operative
approach was found. It is not the only evidence
References
[1] Guillou P J, Quirke P, Thorpe H, et al.
Short-term endpoints of conventional versus
laparoscopic-assisted surgery in patients with colorectal
cancer (MRC CLASICC trial): multicentre, randomised
controlled trial.
Lancet 2005; 365(9472):1718-26
[2] Nelson H, Sargent D, Wieand H S, et al for the
Clinical Outcomes of Surgical Therapy Study Group.
A comparison of laparoscopically assisted and open
colectomy for colon cancer.
N Engl J Med 2004;350(20):2050-9
[3] Buunen M, Veldkamp R, Hop W C, et al.
Survival after laparoscopic surgery versus open surgery
for colon cancer: long-term outcome of a randomised
clinical trial.
Lancet Oncol 2009; 10(1):44-52
[4] Veldkamp R, Kuhry E, Hop W C, et al.
Laparoscopic surgery versus open surgery for colon
cancer: short-term outcomes of a randomised trial.
Lancet Oncol 2005;6(7):477-84
[5] Dunker M, Bemelman W, Slors J, et al.
Functional outcome, quality of life, body image, and
cosmesis in patients after laparoscopic-assisted and
conventional restorative proctocolectomy.
Dis Colon Rectum 2001;44 (12):1800-7
[6] Levy B F, Scott M J, Fawcett W J and Rockall T A.
23-hour-stay laparoscopic colectomy.
Dis Colon Rectum 2009;52(7):1239-43
[7] Delaney C P.
Outcome of discharge within 24 to 72 hours after
laparoscopic colorectal surgery.
Dis Colon Rectum 2008;51(2):181-5
[8] www.gmcuk.org/static/documents/content/
Consent_0510.pdf
[9] www.lapco.nhs.uk
There is substantial good quality peer-reviewed
evidence that suggests laparoscopic surgery is as
safe as open surgery and consistently offers
patients advantages, particularly in terms of post
operative outcome. The trauma and sequelae of
open surgery should not be underestimated: the
increase in short-term complications such as
infection and dehiscence; the increased incidence
of incisional hernia formation; the long-term
additional morbidity and cost of adhesions
including reduced fertility.
Cnut saw the inevitable coming, and was wise
enough to relent. It is high time that Professor
MacFie saw the world from a patient’s perspective
- not through the eyes of surgeons entrenched in the
world of the open surgery of the last century. The
Oracle at Delphi was known to enter a trance-like
state, produced by the gaseous effluent from a
volcanic hole in the ground, prior to the issuance of
her prophesies. Perhaps those stuck in the ways of
open surgery should wake up and smell the freshly
brewed coffee of key hole surgery. They might find
that it is actually quite tasty!
NEWSLETTER
We now have good evidence that laparoscopic
colorectal surgery is being introduced safely
through the Lapco programme. The conversion
rate within the mentorship programme is 4.2%,
the hospital stay is a median of 5 days, and the
anastomotic leak rate is 1.8% [11]. There is a
challenge to make sure clinical quality is
maintained post sign-off from the programme
which we are addressing.
confirming that laparoscopic surgery is no more
expensive than open surgery, which again is
contrary to Professor MacFie’s commentary [14, 15].
and carefully constructed, can determine trends
and provide useful and pertinent data. This survey,
however, does none of these things and remains a
poor representation of the current state of
knowledge regarding laparoscopic surgery and
should be interpreted with great caution for fear
of making erroneous claims.
[10] Miskovic D, Wyles S M, Parvaiz A, et al.
Outcomes of the National Training Programme in
Presented as free paper, ALSGBI, Nottingham, Nov 2010
[11] NBOCAP 2009
[12] Wind J, Hofland J, Preckel B, et al.
Perioperative strategy in colonic surgery; Laparoscopy
and/or Fast track multimodal management versus
standard care (LAFA trial).
BMC Surg 2006;6:16
[13] Bartels Colorectal Dis 2010;12(S3):
[14] Norwood M G, Stephens J H and Hewett P J.
The nursing and financial implications of laparoscopic
colorectal surgery: data from a randomised controlled trial.
Colorectal Dis 2010 Oct. Epub
[15] Dobson M W, Geisler D, Fazio V, et al.
Minimially invasive surgical wound infections:
laparoscopic surgery decreases morbidity of surgical site
infections and decreases the cost of wound care.
Colorectal Dis 2010 Apr. Epub
23
COMMENTARY TWO
Professor MacFie raises some controversial yet valid
concerns regarding the safety of universal adoption
of laparoscopic colorectal surgery in the UK. Despite
the many years of evaluation (more than any other
laparoscopic procedure) prior to its introduction, it
remained the technique of choice in less than 25% of
all major colorectal procedures performed during
2009 in the UK. As John points out, few would argue
that laparoscopic colorectal surgery is safe and
effective in expert hands, the difficulty faced in the
UK has been the relative lack of surgeons
experienced in these techniques. This may be due, in
some part, to the guidance issued by NICE in
December 2000 recommending laparoscopic
colorectal surgery only within the confines of an
RCT. It was suggested that the remainder of patients
should undergo “ordinary” surgery!
NEWSLETTER
Alan Horgan
National Clinical Lead, Enhanced Recovery
Partnership Programme
We were then faced with the dilemma that the
major trials in the US and UK showed a favourable
short-term outcome (admittedly minor) in those
patients who had undergone laparoscopic
procedures. It should be remembered that the
surgical procedures undertaken in both of these
trials were carried out by surgeons, the majority of
whom were in the relatively early phase of their
laparoscopic colorectal surgical experience. Indeed,
some had done as few as 20 laparoscopic colorectal
procedures. Despite this, no increase in
postoperative complications was identified and no
long-term adverse oncological issues were
demonstrated. This would suggest that laparoscopic
colorectal surgery can be performed safely by
surgeons even when they are at the relatively early
stages of their experience. In support, a study from
The Cleveland Clinic looked at their laparoscopic
colorectal experience over 12 years and 900 patients
between 1991 and 2003. The group showed a
reduction in operative time and conversion rates
with increasing experience. More importantly,
postoperative complications and readmission rates
remained unchanged throughout the series, and
were not dependent on operator experience.
I accept that the recent NPSA survey uncovered
78% of respondents who could recall an iatrogenic
COMMENTARY THREE
Graham Layer
I suspect the Editor asked me to write a brief
commentary on John MacFie’s controversial article
because I have written a little about laparoscopy in the
past and now work in a Department of Surgery which
must be one of the leading centres of laparoscopic
surgery in the United Kingdom and, indeed, abroad –
but these days, of course, I confine myself to the
breast and have not even seen the new operation of
endoscopic mastectomy and endoscopic breast
reconstruction. However, I was one of the founder
members of the British Surgical Stapling Group and
the Society for Minimally Invasive General Surgery
way back in the 1990’s, so I have seen this
extraordinary evolution of surgery occur in parallel
with extremely impressive technological advances in
instrumentation, digital imaging and optics.
24
surgical injury associated with laparoscopic surgery
over the previous 12 months; I strongly suspect that
if asked the same question regarding open surgical
procedures, the figure would be similar (or higher).
Never before has any laparoscopic procedure been
subject to such rigorous scrutiny before gaining
acceptance. Certainly the same cannot be said for
laparoscopic Cholecystectomy which was, as most
Hepatobiliary Surgeons will attest, associated with
unacceptable levels of iatrogenic injury. None of us
would wish to repeat the same lessons learned
during that particular learning curve, but few would
argue that the end product was a major step forward
in surgical innovation and technology. The formation
of LapCo, with the on-going support of the Cancer
Action Team, has gone a long way to ensuring that
these lessons are not revisited. The lifting of the
NICE Guidance (TAG105) waiver has certainly
caused concern that surgeons throughout the UK
will subject their patients to laparoscopic surgery for
treatment of colorectal cancer without the requisite
experience and expertise. It is likely, however, that it
will be recommended that surgeons have achieved a
certain level of experience prior to 2006 or have been
“signed off ” by the National Training Programme
before they can proceed independently.
My enthusiasm for “Enhanced Recovery”
Programmes approaches that of Prof MacFie
(although not for as many years). I entirely agree
with his sentiment that successful Programmes can
be achieved without the use of laparoscopic
colorectal surgery. It is also true that the large
National and International randomised trials
looking at laparoscopic colorectal surgery were
conducted outside the confines of an Enhanced
Recovery Programme. The same can be said,
however, about most, if not all, other elements of
the Enhanced Recovery Programme. This does not
mean that each individual component does not
have a valid contribution to make to the complete
“package”. I remain confident that the LaFa Trial
will show a benefit associated with the use of
laparoscopic surgery compared with open surgery
even within the confines of an Enhanced Recovery
Programme. Until then, when asked, I will continue
to respond that laparoscopic colorectal surgery is a
desirable, but not essential, component of a
successful Enhanced Recovery Programme for
patients undergoing Colorectal Surgery.
I came in to general surgery from gynaecology,
where I was familiar with the rigid laparoscope for
both diagnostic and therapeutic pelvic procedures –
without television cameras and screens. I was also
involved in the early birth of laparoscopic
cholecystectomy and, indeed, remember trying to
use a flexible choledochoscope through a port to
image the interior of the common bile duct. So
times have moved on and, although John’s leader is
contentious, I have been incredibly impressed with
the results of complex laparoscopic general and
gynaecological surgery over the years and are
fortunate enough to see, walking around our short
stay wards, those patients who have had colorectal
resections and are up and running to go home
comfortably and safely very soon after their
surgery. My colleagues are very skilled at
performing these procedures and clearly that is one
of the secrets of successful laparoscopic surgery.
Michael Rhodes
President, Association of Laparoscopic Surgeons
It is a great pleasure to be invited to comment upon
the article “Laparoscopic Surgery: a triumph of
technology over common sense” by John MacFie.
John refreshingly reiterates our need to have
evidence for what we do, and also highlights the
speed with which the landscape in which we
operate changes. The rapid accumulation of
evidence about Enhanced Recovery has been
generated in parallel with the randomised trials on
laparoscopic colorectal surgery. These sorts of
parallel developments are not infrequent. It is
hardly surprising that trials of laparoscopic verses
open colorectal surgery, within the enhanced
recovery environment, are few and relatively underpowered. It seems a trifle harsh, therefore, to label
laparoscopic surgery as “a triumph of technology
over common sense”!!
First, let us lay one myth to rest, the lack of an
evidence base for laparoscopic surgery. A cursory
search on the international Medline databases
reveals 451 prospective randomised trials
comparing laparoscopic surgery with older open
techniques. I would venture to suggest that there
are very few other aspects of surgery that have
been subject to such rigorous examination. In my
own area, as an Upper GI surgeon, could
somebody tell me the evidence base for Whipples
resection in pancreatic cancer? Or, perhaps, the
evidence for total oesophagectomy in Barrett’s
oesophagus with severe dysplasia? Where is the
evidence to say that surgery is superior to radical
radio/chemotherapy in carcinoma of the pancreas,
or newer endoscopic techniques for severe
dysplasia in Barrett’s? There is none. Yet, for most
laparoscopic therapies, there have been several
reasonable randomised trials.
Then, of course, we come to the ASGBI
questionnaire about iatrogenic injuries from
laparoscopic trocars and the related report from
the NPSA on failure to recognise deterioration
after laparoscopic surgery. I am sure the findings
that 78% of 500 surgeons were “aware of serious
iatrogenic injury after laparoscopic surgery in
the last 12 months” is accurate. But STOP!!!
First, if there is a serious iatrogenic injury in the
average hospital with 6-8 general surgeons, is
nobody “aware” of it, or everybody. I would
venture to suggest, after over 15 years as a
consultant in a hospital which now has 20 general
surgeons, that EVERYBODY is eventually “aware”
of it, thus the case for serious over-reporting is
clear for the ASGBI questionnaire. Second, a very
amateur academic like myself must ask, what is
the denominator? There are over 100,000
laparoscopic procedures per annum in the UK
according to HESS data. Thus, if we assume that
78% of 500 surgeons were “aware” of an
iatrogenic injury in the previous 12 months, and
that very few hospitals have less than 6 general
surgeons, then there are 390 surgeons aware and
being generous this may represent 65 incidents
(the NPSA had somewhat less than this reported
for the equivalent year I seem to recall). Thus, we
have 65/100,000 injuries, 0.065%. That seems fair.
Yes, we all wish that surgery was without
complications, but this seems about right.
COMMENTARY FOUR
So, overall, I am an enthusiast for Surgical
Darwinism and enjoy the evolution of surgical
innovation and techniques which benefit our patients
in a plethora of ways: be they enhanced recovery,
cosmesis, oncologic safety and an overall better
outcome. I have yet to be convinced that trying to
perform these complex procedures through single
operating ports is a correct way forward, and have
fears that this simply might give rise to longer
procedures and iatrogenic disasters, but cannot
support that with fact. I am reliably informed that
three dimensional laparoscopic surgery is the next
thing for the future and is here to stay and I can
certainly see the argument that, for some surgeons,
this will help and improve their laparoscopic skills
with which some fortunate surgeons have been born
and others struggle to make the mark. What must be
recognised is that those surgeons who themselves
have insight into realising that they do not have the
appropriate and necessary neural connections to
perform safe laparoscopic surgery, or do not
improve with further education and training, that
they should recognise these facts and contribute to
all the other facets there are of our fascinating
profession. More festive food for thought!
NEWSLETTER
There is a parallel in the breast field when, after the
successful ALMANAC Trial was performed, a
proctored programme of instruction, validation and
audit of the technique of sentinel lymph node biopsy
in breast cancer was introduced. This was known as
NEW START and was a joint venture of the Royal
College of Surgeons of England, Cardiff University
and The Department of Health and, for the first time,
educated surgeons both systematically in the
theoretical principles and in the practical tasks and
skills that were required to perform the safe
oncological procedure of sentinel lymph node biopsy
which would be of benefit to the patient and not put
them at risk of inappropriate axillary staging which
would lead to the incorrect clinical management.
NEW START has been a huge success, and it is my
experience as a founder instructor with this scheme
that influences my views on the uptake of
laparoscopic surgery and I, therefore, mirror John
MacFie’s thoughts on these aspects of the
introduction of new techniques. Patients’ safety has
to come first and then financial benefits can be
considered, be it shorter length of stay despite more
expensive equipment, etc.
The exponential take up of laparoscopic
cholecystectomy without a formal training
programme ended up with damaged biliary
anatomy and hence the importance of particular
mentoring in the advent of laparoscopic colorectal
surgery and in training our new generations of
surgeons. I am somewhat alarmed, on occasions, by
very junior surgeons insisting on performing
laparoscopic appendicectomy and this rings clinical
governance alarm bells as consultants, when
working with, or covering more junior surgeons. It
is essential to know the capabilities of the operating
surgeon to be certain of safe surgery.
Now, before concluding, I must ask a somewhat
mischievous question about the ASGBI and NPSA
25
reports. What if we substituted in the question
about surgeons being “aware” the following
possibilities:
1. Retraction of a colostomy needing revision.
2. Dehiscence of a laparotomy.
3. Leak from a routine right hemicolectomy.
COMMENTARY FIVE
Bruce Campbell
NEWSLETTER
Dare I suggest the 78% affirmative response from the
ASGBI survey is likely to be the same for these
questions? Does this mean that Hartman’s procedures,
laparotomies and open right hemicolectomies should
be highlighted as no longer safe - of course not! All
surgery has complications, which we strive to keep to
an absolute minimum. To do so, we need rigorous and
John McFie rightly suggests that the plural of
anecdote is not evidence, but then uses the results
of a survey to suggest that serious iatrogenic
injury after laparoscopic colorectal is common.
Serious events often become well known in the
specialist community, and so there must be quite
some uncertainty about how many of these were
duplicated in the survey. It is true that
observational data are particularly powerful for
flagging up adverse events, but their validity does
depend on some certainty that events are reported
only once.
COMMENTARY SIX
Iain Anderson
Professor MacFie’s challenging article brings to the
fore several issues of current debate around
laparoscopic surgery, colorectal in particular. For
the questions of learning curve, longer surgery and
doubt about benefit, we have been here before,
most notably with laparoscopic cholecystectomy.
Are there lessons learned that can be transferred,
and where might the common sense come in?
Whatever the initial problems and lack of
randomised evidence, there is no doubt now that
lap chole is better - better view, better recovery - a
great success story. I doubt any of us would opt for
an open cholecystectomy now. Some pressure to
change and improve is healthy but if ill judged it
can put patients at risk. Is Professor MacFie’s
article undue provocation or a timely reminder?
Mini-lap cholecystectomy was briefly touted as an
equivalent, but was characterised by a poor view
and lots of pulling. Some of the same arguments
can apply to inexpert laparoscopic colorectal
surgery. Is a lap-assisted right hemicolectomy any
advantage? Non-believers argue that the operation
can be done through a short transverse cut anyway
– but either type of procedure can risk the surgeon
resorting to excessive pulling or other poor
techniques in order to prove a point. Pulling
viscera and mesenteric pedicles out through
slightly too small holes with a cry of “Voila!” by
either technique will come unstuck for the
individual patient at some point. Left
hemicolectomy and rectal resection pose different
questions, some technical, which probably need to
be addressed separately.
26
comprehensive training which needs considerably
more hours actually performing surgery than our
current shortened training allows for. We also need
accurate and dispassionate data collection. The ALS,
along with its fellow associations AUGIS and
BOMSS, has established the National Bariatric
Surgery Database for just this reason, and is also
seeking to establish clear data about other
laparoscopic procedures. The job of the Associations
is to make it clear that surgeons wish to do all they
can to reduce complications, but also to inform the
public that ALL surgery carries complications. I
suspect, on the basis of evidence, those from many
laparoscopic procedures may well be less than those
from the equivalent open surgery.
The future of laparoscopic surgery will be driven
by a balance between the demands and
expectations of patients, and how much society is
prepared to pay for the increased costs of
equipment, operating time and surgeons. The
demand for decreasingly invasive surgery, done to a
very high standard, is universal in developed
countries. It is hard to imagine that the period from
the late 1800s to the early 2000s will not be seen in
medical history books as the age of open surgery.
The appeal of tiny and less painful incisions is just
too attractive for the march of laparoscopic surgery
to be halted. What is needed is a very high standard
of training and practice, together with the
maturation of really effective and safe techniques.
When the advocates and detractors of laparoscopic
colorectal surgery are closely matched and hence
each at risk of stating their case slightly too
stridently, where can we turn in the current
definitive evidence dearth? Our specialist nurse
colleagues are often a good source of objective
comment and common sense - certainly mine are,
and maybe they have it right. They tell me that some
cases seem to do very well with laparoscopic, others
are no different to open. Maybe we don’t understand
all the factors, but some lap patients recover far
better than open patients ever will. Whether that
difference is cost-effective is another question.
What about injuries then? Professor MacFie is
right in that most of us have seen them, but maybe
there are different subgroups being lumped
together here. The initial years of lap chole were
troubled by a high rate of biliary injury, some of
which may have been contributed to by marked
inexperience or by surgeons’ persevering with
difficult cases. Lapco is a laudable attempt to
prevent a repetition of the former, but common
sense is needed to avoid the latter. Pressure to
succeed can influence decision making and we
need to guard against a repeat.
Other injuries, especially vascular, still come from
port entry and may be almost totally avoidable by a
cut down technique as has been long-known.
Unfortunately, it can be very difficult in the larger
patient. Should sharp entry be banned, or is a tiny
incidence of catastrophic injury acceptable? If the
latter, should it be on the consent form given the
consequences? Is optically guided port entry the
happy medium or neither one thing or the other?
Objective data or guidelines may be overdue.
more than offset by the reduced length of stay and
reduced need for blood and medications. Other
benefits are also becoming apparent: reduced fluid
and electrolyte disturbances, reduced blood loss,
earlier mobilisation and reduced need for
analgesics. These are all likely to account for the
reduced complications and mortality after
laparoscopic surgery. Just as laparoscopic
cholecystectomy was originally considered by
some to be an expensive waste of time, so it is with
Adam Widdison
There is no doubt that Professor John MacFie, Vice
President of ASGBI and an eminent colorectal
surgeon, eloquently voices the opinions of many in
his thought-provoking article. In the interests of
promoting a healthy debate, I would contend that
laparoscopic surgery is not a triumph of technology
over common sense, rather, the triumph of common
sense over the straightjacket of the doctrine of
evidence based medicine. There is no doubt that
laparoscopic surgery has been widely adopted
despite the absence of robust evidence to prove its
efficacy. However, if the rules of evidence-based
medicine had been applied to laparoscopic surgery,
then surgery would have been set back 10 years.
The growth in the application of laparoscopic
techniques to surgery has occurred because the
benefits are so obvious that patients want it. It has
nothing to do with commercial interests or hiding
trials with negative results. It is a clear example of
common sense prevailing; evidence has to catch up.
Laparoscopic surgery has led to a different spectrum
of complications compared with open surgery.
Furthermore, they present in different ways and at
different times after the surgery. Iatrogenic injury
occurs with all types of surgery and is more likely
during the learning curve, when a new technique is
introduced or when an operation is performed
infrequently. However, the complications are the
same whether the operation is performed open or
laparoscopically. There is, however, increasing
evidence that the rate of complications is reduced
after laparoscopic surgery and it is likely that late
complications such as adhesions and incisional
herniae are also going to be reduced. Indeed, one of
the successes of laparoscopic surgery is that it is
memorable when a complication occurs!
Within 10 years of Phillipe Mouret (1987) reporting
the first video laparoscopic cholecystectomy, most
general surgeons were routinely doing the
operation. The widespread uptake of laparoscopic
cholecystectomy heralded an era of rampant
innovation. Laparoscopic techniques were tried
everywhere, and sometimes with disastrous results.
In the early years, the UK colorectal fraternity was
concerned that laparoscopic surgery would
compromise cancer resection margins and cause
port site metastases. It is of note that the evidence
for this was confined to animal studies, case reports
and anecdotes. Another 10 years were to pass
before this fear was disproved and the safety of
laparoscopic colorectal surgery accepted. As a
consequence, laparoscopic colorectal surgery only
really started outside clinical trials in the UK about
5 years ago. This was a tipping point similar in
importance to the laparoscopic cholecystectomy
revolution. Technology allowed the change, but did
not drive it. Technological advances in high-energy
devices and staplers have made laparoscopic
colorectal surgery easier, but have not caused the
phenomenal growth. In reality, the converse is true:
progress in laparoscopic surgery has been
handicapped by the lack of technological advances.
For example, there is a long overdue need for
laparoscopic stapling devices to be improved.
Laparoscopic surgery has now come of age. It is no
longer just the domain of benign upper GI surgeons
but also of colorectal surgeons, gynaecologists and
urologists. In recent years, the balance between open
and laparoscopic surgery has shifted. Elective
abdominal operations are increasingly being
undertaken laparoscopically. Elective open
abdominal surgery is in the minority in many
centres. In the last decade, more and more
laparoscopic surgeons have gained the confidence
and experience to train others. Trainees are
increasingly exposed to laparoscopic surgery and are
being trained in laparoscopic techniques, often to the
exclusion of their open surgical experience. Many
laparoscopic techniques are transferrable so trainees
are developing generic skills. Teaching is easier to
undertake laparoscopically compared to open
surgery because, not only is the operating site visible
to all, but it is easier to demonstrate how to use the
equipment and to show subtleties of technique.
Video’s can be reviewed to learn method and
technique and to assess progress. Current surgical
trainees must become excellent laparoscopic
surgeons to prepare themselves for the future.
At the present time, laparoscopic colorectal
operations take slightly longer than the equivalent
open operation. However, the anaesthetic time is
reduced so that the overall theatre time is now less
for some laparoscopic colectomies than it takes to
do an equivalent open operation. It is likely the
procedure time will continue to improve in the
same way it did with cholecystectomies. There is
little data comparing cost, and it is widely assumed
that laparoscopic surgery is more expensive than
open surgery. However, with similar theatre
utilisation times, the extra cost in disposables is
All these changes have occurred because
improvements in the patients’ experience have been
so great that they are apparent to patients, relatives,
friends, healthcare professionals and surgeons
alike. Patients do talk to one another, and word of
mouth is driving patient expectations irrespective
of the evidence base. There remains a serious
ethical issue about whether a development such as
the introduction of laparoscopic surgery with
manifest advantages to patients should be withheld
until unequivocal evidence is available. Common
sense says it should not.
COMMENTARY SEVEN
NEWSLETTER
With that, I would agree. Standards, yes but
recognise excessive pressure may be
counterproductive. Let’s take the good bits and
develop steadily.
The learning curve remains a weakness of complex
laparoscopic surgery. I think Professor MacFie is
calling for stepwise advancement of technique but
without undue pressure applied to those learning.
27
TRAINEE FOCUS
90th Anniversary Bursaries
In partnership with ASiT, and generously sponsored by STRYKER, the Association
has been able to is award six 90th Anniversary Trainee Bursaries during 2010. These
Bursaries are to the value of approximately £1,000 each, and the purpose is to enable
aspiring young consultants (within two years of appointment) and senior registrars
(within three years of CCT) to extend their training by attending a course of their
choice held at The Royal College of Surgeons of England in the prestigious Raven
Department of Education.
To be considered for one of the 90th Anniversary Bursaries, candidates were invited to
write a short paper (maximum 1,000 words) on “The future of laparoscopic surgery single incision versus less traumatic instrumentation”
One of the winning entries is reproduced below.
THE FUTURE OF
LAPAROSCOPIC SURGERY:
SINGLE INCISION VERSUS
LESS TRAUMATIC
INSTRUMENTATION
Martyn Evans
Year 6 Specialist Registrar, All Wales Higher
Surgical Training Scheme
The explosion in the use of laparoscopic
surgery in the last twenty years must be viewed
as one of the major developments in the art of
surgery. In my short career in surgery, spanning
only ten years, I have observed first hand how
the number of procedures performed
laparoscopically has mushroomed, with
minimally invasive approaches now considered
the standard of care for many conditions. The
impetus for this growth has been the enhanced
recovery observed, with twenty-four hour stay
for laparoscopic cholecystectomy and three-day
28
stays for laparoscopic colectomy now the norm,
rather than the exception. Whilst hospital stay is
important, for patients it is the impressive
reduction in post-operative pain and early
comfortable ambulation that must be viewed as
the greatest success of laparoscopic surgery. In
the last five years, single port laparoscopic
surgical (SPLS) procedures are being reported
with an ever-increasing regularity. Are we
therefore about to embark on another chapter in
surgical history, whereby SPLS makes as bigger
contribution as the introduction of conventional
less traumatic laparoscopic surgery twenty
years ago?
SPLS was developed in an effort to further
reduce the surgical trauma compared to
“traditional” laparoscopic surgery (TLS). There
are many commercially available systems, but
all share a single port which is larger than
“traditional” laparoscopic ports. The
fundamental idea of SPLS is to have all
The safety of SPLS for cholecystectomy has
never been addressed in a randomised trial,
however, a recent review analysed the published
data to date [1]. They showed that, although
feasible, data on safety was lacking. It was
noted that it was more difficult to achieve the
“critical view of safety” of Calot’s triangle with
SPLS than TLS. The overall biliary
complication rate was 0.7%, although what
these injuries were was poorly documented.
Currently SPLS is generally being attempted by
surgeons who are “good” laparoscopic surgeons,
who are likely to have a lower than average
biliary complication rate with TLS. A concern
with the widespread adoption of SPLS must be
as surgeons with less laparoscopic skill attempt
the technique it is likely that complications will
increase. This, of course, was one of the major
concerns when TLS cholecystectomy was
popularised and one must be careful not to let
skepticism halt surgical development. Another
concern about SPLS is that the larger incision
necessary may increase risk of incisional hernia
compared to TLS port incision. At present, there
are insufficient data to confirm or refute this
concern but there are several reported cases [2,
3]. Thus, early data suggest that SPLS is
feasible, but that more data is required to
confirm its safety.
SPLS therefore appears feasible and maybe
associated with improved cosmesis when
compared to TLS, but at present is significantly
more expensive. However, questions remain
about its safety. When considering the present
data on SPLS, there are some other factors that
should be considered: the data maybe skewed by
early adopters being more technically able than
the average surgeon, consequently as more
surgeons perform SPLS the complication rate
may increase. Alternatively, it may be that
currently available data underplays the benefits
of SPLS, as it is representative of surgeons on
their “learning curve”; with technical refinement
greater benefits maybe realised. For the patient,
a choice exists between possible improved
cosmesis and greater risk of complication, the
importance of each which will vary between
individuals. For healthcare providers, at the
present time, the benefits do not appear great
enough to justify the risk. Then again, this is
what was said about laparoscopic
cholecystectomy twenty years ago. It may be
that, in twenty years, SPLS is as commonplace
as conventional less traumatic laparoscopic
surgery is today. Ultimately, is SPLS the future at present the jury is still out.
TRAINEE FOCUS
Safety and Feasibility of SPLS
The successful use of SPLS has been reported
for a myriad of different operations across
specialties. In General Surgery, large numbers
cholecystectomies, and appendicentomies are
reported. The largest amount of published data
using SPLS pertains to cholecystectomy, which
interestingly was the procedure that is credited
with popularisation of TLS. A recent review
reported accumulated data on 895 patients that
established the feasibility of SPLS
cholecystectomy, with a conversion rate of 2%
[1]. It is probably reasonable to assume that, if
cholecystectomy is feasible, then other
intermediate level surgical procedures are also
achievable. More complex TLS for upper and
lower GI procedures are now common place,
whilst the number of reported SPLS complex
procedures are fewer early reports suggest they
are also feasible.
Outcomes and cost effectiveness of SPLS
Length of stay (LOS) is one surgical outcome
that interests patients, surgeons and healthcare
managers alike. The biggest success of TLS
was the dramatic improvement in LOS. At
present, LOS after SPLS is equivalent to that
after TLS. It is difficult to envisage that this
situation will change even as SPLS is used for
complex surgical procedures. This is because,
generally, it is not the trauma related to
abdominal access that limits LOS following
TLS, but the patients’ response to the actual
intra-abdominal procedure. When considering
surgery for malignancy, there are insufficient
data to draw any conclusion about the
oncologogical adequacy of SPLS. One area
where SPLS may be beneficial is in postoperative cosmesis; SPLS is usually performed
through the umbilicus, meaning that the
mature scar often can shrink to a point that the
scar is almost invisible. When cost is
considered, at present SPLS is unequivocally
more expensive [1].
laparoscopic working ports entering the
abdominal wall through the same incision,
allowing a camera and two operating
instruments. The challenges for the surgeon
performing SPLS surgery are those of loss of
triangulation and available ports with which to
create tension to facilitate dissection.
Consequently, at present SPLS remains a
procedure being performed by the minimally
invasive enthusiast. Should SPLS be adopted
into the mainstream surgical armamentarium?
When assessing any new surgical intervention or
technique, the important questions that must be
answered concern whether it is safe, feasible,
with acceptable outcomes of surgery and is it
cost-effective?
References
[1] Allemann P, Schafer M and Demartines N
Critical appraisal of single port access
cholecystectomy
Br J Surg. 2010 Oct;97 (10): 1476-81
[2] Romanelli J R, Roshek T B, Lynn D C and
Earle D B
Single-port laparoscopic cholecystectomy: initial
experience
Surg Endosc. 2010 Jun; 24(6): 1374-9
[3] O’Gorman T, MacDonald N, Mould T, Cutner A,
Hurley R and Olaitan A
Total laparoscopic hysterectomy in morbidly obese
women with endometrial cancer anaesthetic and
surgical complications
Eur J Gynaecol Oncol. 2009; 30 (2): 171-3
29
PUBLICATION
MALPRACTICE AND FRAUD
FOR SURGEONS
Introduction
Publication malpractice and publication fraud are
major challenges to the integrity of the world’s
professional and scientific literature. Regrettably,
some of those who perpetrate it are members of
the medical profession. From time to time, a
journal editor is faced with quite outrageous
examples of deceit and fraud. Some examples are
headed off at the pass, but others undoubtedly slip
through an imperfect professional net, sometimes
to be detected many years later.
NEWSLETTER
David A Rew
Medical Chair, SCOPUS Content Selection
Advisory Board
Council Member, Committee on Publication
Ethics (COPE)
In this article, I consider the range of publication
fraud; the reasons why it is not a victimless crime;
the means by which it is increasingly being
detected; and the consequences for the
perpetrators, from the perspectives of the Editor
of a peer reviewed surgical journal with a broad
international authorship.
The motives for publication fraud
Publication fraud may be viewed as the deliberate
misrepresentation of research accomplishments
and findings to advance a research programme, to
secure sources of funding, or quite simply for
personal professional advancement at least effort
and to disguise personal inadequacies.
Professional career success and public
recognition are significantly influenced by
publication records and published work.
Academic institutions place great store on the
publication productivity of their staff, and a
whole industry of citation metrics exists to
measure and quantity academic output. There is,
thus, great pressure on individuals to publish.
The damaging professional myth of “publish or
perish” is bandied about, where volume of
publications is perceived to equate with
intellectual energy and professional
effectiveness. In truth, publication quantity is no
substitute for quality. The double Biochemistry
Nobel Prize laureate Fred Sanger at the
University of Cambridge was quoted as saying
that he rarely published, and then only every
eight years or so. His infrequent publications
each had considerable impact.
The international medical scientific literature has
been accumulating over many centuries, and at an
increasing rate as the technologies of print and
information distribution change. It contains a
small number of world and life changing papers
and books; many very good and important papers
and books; and a mass of papers and books of
lesser interest which are rarely, if ever. cited.
In order to get noticed, it becomes more and more
difficult to find original angles and to make an
impact. For the gifted few, publication success
30
flows easily. For the grafting many, small and
original contributions come with time and effort.
For a number of individuals without such talent or
commitment, plagiarism (copying) of the work of
others may appear as an easier route to
recognition than personal graft.
Why does dishonesty in publication really matter?
Medical science flourishes on trust. The world’s
journal repository is vast, and there are many
places in which to lodge and lose suspect science.
However, if plagiarism and malpractice are
allowed to flourish, the scientific literature
becomes progressively contaminated and
overburdened with unreliable and untrustworthy
work, and the public reputation of the profession
sinks and stinks.
Misleading, unvalidated and dishonest work can
lead to inappropriate actions in medical practice
which can misdirect huge resources and, at worst,
can lead to death. At best, they waste professional
effort, time and resources in unravelling and
cross-checking the work of others. Your
colleagues and collaborators, your unit, your
hospital, your university, your corporation or even
your country may suffer serious professional and
reputational damage which may take years of
restoration. For example, the reputation of the
South Korean scientific community was seriously
undermined in late 2005 by the revelation than an
entire stem cell research programme, under the
direction of Professor Hwang Woo-Suk at the
Korean National University, was built on wholly
fictional and dishonest data. Woo-Suk had
become a national hero on the basis of fraudulent
work which had given him two papers in Science
in 2004 and 2005 on the creation of human
embryonic stem cells by cloning.
Definitions and the scope of Malpractice
Publication malpractice can range from minor,
inadvertent and forgivable errors to wilful fraud
which might be judged as criminal intent. At the
heart of malpractice is plagiarism, which is the
copying and passing off of the work of others as
one’s own without recognition or attribution. The
act of copying in itself is not wrong. Indeed, the
entire basis of citation would be undermined if
selective quotation were outlawed. The key moral
obligation is to make appropriate reference to the
work of others, rather than to conceal the origins.
High standards of study design, departmental,
institutional and Ethical Oversight of all work
coming out of a department often help eliminate
publication misconduct at source, and help
eliminate the following forms of mild to serious
publication malpractice:
Deliberate deception: The World Association of
Medical Editors, WAME, sets out the following
definition on its website: “Deception may be
deliberate, by reckless disregard of possible
consequences, or by ignorance. Since the
underlying goal of misconduct is to deliberately
deceive others as to the truth, the journal’s
preliminary investigation of potential misconduct
must take into account not only the particular act
or omission, but also the apparent intention (as
best it can be determined) of the person involved”.
Salami Slicing: This is another form of multiple
publication, which unnecessarily inflates the
literature. It takes a body of work which could be
covered in a single paper, and divides it up into as
many component parts as possible. It is difficult
to address if the components are sent to different
journals, but the practice becomes very evident
over time on the citation indices. The most
outrageously entertaining example of this practice
which I have seen was when we received a
seemingly well written paper some years ago at
the EJSO on the expression of a particular protein
in a modest cohort of lung cancers which was
accepted. We then received eight further papers in
short order from the same group reporting the
same series of tumours, in each case with a
different protein. It became obvious that they were
simply working through the results of a single
micro-array analysis which could, and should,
have been written up in one paper. We rejected the
entire cohort of papers with a recommendation
that they should be rewritten into one paper.
Near-duplicate publication: This is a variant on
salami slicing, in which the same material or
series is used repeatedly with minor changes. For
example, through republishing, on an annual
basis, the same case series with marginal
additional short-term follow up information. The
repeat publication of the same or related results
artificially inflates both the author’s publication
record and the general literature.
Reverse salami slicing or jigsaw reconstruction:
I have recently adjudicated on three papers
submitted to the EJSO which fraud detection
software demonstrated to be re-assemblies of
Misappropriation of the ideas of others: An
important aspect of scholarly activity is the
exchange of ideas among colleagues. Authors can
acquire novel ideas from others during the process
of reviewing grant applications and manuscripts.
Violation of accepted research practices:
Serious deviation from accepted practices in
proposing or carrying out research, improper
manipulation of experiments to obtain biased
results, deceptive statistical or analytical
manipulations, or improper reporting of results.
Material failure to comply with legislative and
regulatory requirements affecting research:
Including, but not limited to, violations of
applicable local regulations and law involving the
use of funds, care of animals, human subjects,
investigational drugs, recombinant products, new
devices, or radioactive, biologic, or chemical
materials.
Inappropriate behaviour in relation to
misconduct: This includes unfounded or
knowingly false accusations of misconduct, failure
to report known or suspected misconduct,
withholding or destruction of information relevant
to a claim of misconduct and retaliation against
persons involved in the allegation or investigation.
Data fabrication: This is the act of creating data
to fit the purposes of the paper and its authors.
This may range from small quantities of data to
complete a series, to the fraudulent creation of
entire papers from scratch. Forensic statistical
analysis will often reveal such frauds, as the
intricacies and variability of true raw data can be
difficult to replicate in synthetic data.
Duplicate publication: This practice is
widespread and sometimes unintentional. It
commonly arises where work in a local language
paper is resubmitted to an English language
journal to reach a wider audience. Moves towards
the English language as the standard medium of
international scientific communication, combined
with the much greater transparency for all papers
on the Internet, should reduce the need for dual
publication on language grounds alone. A variant
on this process is simultaneous submission,
which is the concurrent submission of the same
manuscript to multiple journals. This wastes the
time of editors and publishers who may invest
considerable resources in assessing the manuscript,
and it may lead to duplicate publication.
Improprieties of authorship: Improper
assignment of credit, such as excluding others,
misrepresentation of the same material as original
in more than one publication, inclusion of
individuals as authors who have not made a
definite contribution to the work published; or
submission of multi-authored publications without
the concurrence of all authors.
NEWSLETTER
Self-plagiarism: This refers the practice of an
author using portions of their previous writings on
the same topic in another of their publications,
without specifically citing it formally in quotes.
component papers. This would be a seemingly
clever and putatively undetectable fraud but for
the power of text comparison systems.
One example of such deliberate fraud which came
to our notice at the EJSO involved the precise
replication and re-submission of a paper on nasojejunal feeding under new surgical authorship
which had appeared 10 years previously in a
journal which had subsequently folded. The
perpetrators, who clearly thought that their fraud
would have no chance of detection, had not
reckoned with the powers of observation and
memory of one astute reviewer.
Responsibilities in countering malpractice
These lie squarely with those perpetrating the
fraud. Nevertheless, education about those marginal
aspects of misconduct where genuine confusion
might arise, combined with awareness of the power
of modern fraud detection systems, should help
reduce fraud to a minimum. Notwithstanding
protestations of innocence and ignorance from the
perpetrators, major fraud is as obvious as the
elephant in the room when you see it.
WAME states that “Journals should have a clear
policy on handling concerns or allegations about
misconduct, which can arise regarding authors,
reviewers, editors, and others. Journals do not
have the resources or the authority to conduct a
formal judicial inquiry or arrive at a formal
conclusion regarding misconduct. That process is
the role of the individual’s employer, university,
31
Publication fraud detection systems
Editors, reviewers and readers cannot be expected
to spot wilful and devious misdemeanours in the
publication process, and examples in my own
experience have usually come to light by
extraordinary coincidence. In one of our cases, a
reviewer spotted his own work in a manuscript
submitted for review. This role of luck suggests
that many more examples go undetected. Some
malpractice can be detected in advance of
publication by simple checks on the authors and
on the related literature using PubMed or other
citation systems. This can be very helpful in
identifying duplicate and near-duplicate
publication and salami slicing.
NEWSLETTER
granting agency, or regulatory body. However,
journals do have a responsibility to help protect
the integrity of the public scientific record by
sharing reasonable concerns with authorities who
can conduct such an investigation.”
Automated plagiarism detection systems
Sophisticated software and text comparison
systems are now under development for the
detection of publication fraud. One only needs to
consider the functionality of search engines such
as Google, which can trawl and compare huge
quantities of data almost instantaneously, to
realise the potential of computer systems in this
role. Some of these systems have evolved from
academic plagiarism detection systems. For
example:
Turnitin ™ is a plagiarism detection service
which was originally developed for academic and
undergraduate use. Students submit their papers
electronically to the system, which compares the
content of those papers to over a billion other
papers and documents. Turnitin highlights any
similarities and supplies an annotated document
showing both the student’s paper and the original
source. This document is called the Originality
Report. Turnitin uses three continually updated
content bases, which trawl billions of pages of
web content; hundreds of millions of pages of
proprietary content from subscription-based
publications, books, newspapers, magazines and
scholarly journals; and 100 million+ student
papers previously submitted to Turnitin in over 30
languages.
CrossRef TM is the official Digital Object
Identifier (DOI) registration agency for scholarly
and professional publications. It was established
in 2000 as an independent, non-profit membership
association and the citation-linking backbone for
online publications and the navigation of
electronic journals across digital internet
platforms provided by individual publishers, using
open-standards technology.
CrossCheck TM is a database system which has
grown from work between CrossRef and
iParadigms, a developer of plagiarism screening
systems, using the iThenticate TM tool for
checking documents against the database.
Publishers’ content is trawled in much the same
way that a search engine indexes full text. The
system then produces a “similarity report” which
32
shows the percentage of the document that
matches other content in the database, where that
content comes from, and the matching content
itself. Publishers can then check new manuscripts
against the database and, optionally, the wider
internet. By integrating systems such as
CrossCheck with electronic submission systems
for manuscripts, it will be possible in due course
to undertake “up front” plagiarism checking very
early in the manuscript acceptance process.
The Déjà vu TM Plagiarism Detection System is
an academic project developed at the University
of Texas Southwestern Medical Center for the
detection of plagiarism and covert multiple
publications of the same data. The developers
report that, in 2002, an anonymous survey of
3,247 US biomedical researchers asking them to
admit to questionable behaviour revealed that
4.7% admitted to repeated publication of the same
results and 1.4% to plagiarism. In general, the
problem of duplication of scientific articles has
largely been ignored by the publishers and
database curators. Extrapolation of the results of
an anonymous survey to the Medline database of
more than 17 million citations predicts some
800,000 such cases on Medline. In recent work,
Deja Vu searched a subset of 62,000+ Medline
abstracts. 421 potential duplicates were found and
further investigated. Three of these papers which
were referred to us at the EJSO were found to be
almost identical “jigsaw” reconstructs of related
papers by other authors, which we subsequently
decided to retract formally from the literature.
Extrapolating to the subset of Medline records
that have abstracts (8.7 million), this would
correspond to roughly 117,500 duplicates with the
same authors.
Simultaneous submission: The Déjà vu database
also contains many pairs of highly similar
abstracts with overlapping authors that appear in
the same month, all apparently acts of
simultaneous submission to multiple journals. In
general, duplicates are often published in less
prominent journals with lower impact factors to
minimise the odds of detection. As increasing
numbers of journals and publishers put their back
catalogues on line and up for checking by tools
such as déjà vu, so it is both possible and likely
that more such cases will come to light. The Déjà
vu team cite various contributing factors to such
publication fraud, in that:
a. There is considerable international confusion
over acceptable publishing behavior.
b. There is a perception that there is a high
likelihood of escaping detection.
c. There is a lack of clear standards for what level
of text and figure re-use is appropriate.
Automated text-matching systems must, and will,
ultimately become a ubiquitous aspect of the
publication process. There will be automatic
crosschecking of submitted manuscripts against
all published work. The costs of detection arising
from participation in unethical duplication
practices will progressively become such as to be
unacceptable to all but the most desperate (or
most skillfully fraudulent) practitioners.
• Acknowledge their error and offer to correct it
by withdrawing the paper, introducing
appropriate references, or issuing a letter or
note of formal clarification if their manuscript
is already in print.
• Deny all knowledge of the source papers.
• Become agitated and abusive in
communications or threaten legal action, which
responses are often an indication of guilt.
Sanctions against publication fraud
1. Notifying the fraudster’s institution
Where the institution of affiliation of the fraudsters
is known, the notice of concern and the evidence
for it should be directed to the Head of the
institution. At this point, things become murky,
because many institutions do not want such
problems brought to public attention. They may fail
to reply and/or decide to bury the matter locally.
The response varies considerably from institution to
institution and from country to country in the
absence of clear guidance, recognised international
law and directives on publication fraud. A reputable
institution or university will generally take such
allegations seriously, request the evidence and take
public and visible action to address the issue and
deal with the problem, or refer the fraudster to an
appropriate regulatory body for further action.
There are, as yet, no explicit obligations or powers
for Editors and publishers to take the matter to
professional regulatory bodies; to take the case to
advisory bodies such as the Committee on
Publication Ethics (COPE); or to take matters to
the Police and Criminal investigation authorities
in the relevant jurisdiction (although the police
may subsequently become involved). Publicity in
the media may force public attention to the matter,
as has ultimately been the case in all of the
documented major scientific frauds. In going
public, the complainants must be confident in
their grounds, and have taken sound legal advice
in advance.
2. The formal retraction notice
If the responses from the perpetrators and the
relevant institutions are unsatisfactory; if there is
evidence of plagiarism beyond reasonable doubt
and coincidence, and if informal approaches have
failed to resolve the issue, then a formal retraction
notice can be issued by the recipient journal.
Retraction is a formal process which places the
Future developments in dealing with
publication fraud
The work of well intentioned editors and
publishers in combating publication fraud in all of
its forms is currently constrained by the lack of a
consistent international approach to the issues,
and even recognition of the problem from one
jurisdiction to another. The work of institutions
such as COPE, WAME and the Déjà vu team have
done much to develop the evidence base, from
which further developments will come. We can
look forward to the creation of a body of law; a
common regulatory approach across international
boundaries; a formal and objective classification
of publication fraud, and an Internet “hall of
shame” database of publication misdemeanors and
their perpetrators which is accessible to all
editors, publishers, reviewers and readers. Now
that so many publishers have recognised the
problem, and that the subject is under discussion
at a high level in various organisations and bodies,
it is likely that such a formal international
framework will ultimately be put in place.
In conclusion, case experience demonstrates that
publication malpractice in its various forms is
commonplace, and that surgeons are, from time to
time, involved in serious forms of publication
fraud. Awareness of the problem and of the potent
systems now available for the detection and
notification of such transgressions should reduce
inadvertent misconduct. It should help banish
thoughts of publication misconduct from the
minds of all but those most willfully set upon
such foolhardy actions, and in full knowledge of
their potential consequences.
• Refuse to respond.
3. The personal consequences of fraud detection
Publication fraudsters can, and do, escape detection
and sanction. However, the personal consequences
of being named and shamed as a publication
fraudster can be profound, with loss of professional
license, status and reputation, and even criminal
sanctions in the most rigorous jurisdictions, such as
the UK. The General Medical Council takes
matters of plagiarism very seriously, and has
recently set severe precedents in proven cases.
NEWSLETTER
Once the editors, publishers and their legal teams
have looked at the material and decided on
common sense grounds that there is prima facie
case of plagiarism, the case must be put in writing
to the perpetrator, who in turn may:
event and the suspect paper in the public domain.
The US National Library of Medicine makes a
clear statement of general application on the
issues of retraction and partial retraction, which
can be accessed at
www.nlm.nih.gov/pubs/factsheets/errata.html
Partial Retractions of erroneous data may also be
published.
Actions on suspicion of plagiarism
Wise editors and publishers proceed with caution
when made aware of alleged fraud and plagiarism,
both because of the laws of libel and because the
consequences can be career changing for those
who commit plagiarism or who are accused on it.
Checking can be a time-consuming process, and
the evidence must be very strong, as no deliberate
fraudster can or will safely admit to the fraud.
Editors must develop a sensitive approach and a
thick skin during investigations.
Selected References and web links
UK Office for Research Integrity ORI publication
Analysis of Institutional Policies for Responding
to Allegations of Scientific Misconduct:
http//ori.dhhs.gov/html/polanal2.htm
http//ori.dhhs.gov/html/publications/studies.asp
CrossCheck and CrossRef:
www.crossref.org/crosscheck.html
and
www.crossref.org/03libraries/index.html
M Errami and H Garner
A tale of two citations
Nature (2008), 451, 397-399
33
Cavendish
Medical
CAN PIIGS FLY?
This useful acronym - PIIGS - is thought to
have first appeared in 2009 to describe the
European nations (Portugal, Italy, Ireland,
Greece and Spain) whose governments had
overextended themselves in the years of
plenty and would now need to follow a crash
diet or face serious financial indigestion.
Sure enough, in May 2010 a Euro 110
billion loan facility was extended to the
Greek government to help control their cost
of borrowing on the international financial
markets and ensure that all of their
liabilities could be met in full. This was the
culmination of a number of months of
jittery share prices, volatile currencies and
last-minute political wrangling between the
Greek government, the EU and the IMF.
Prior to the loan being agreed, it was even
whispered that the Euro might not survive
as a currency unless decisive action was
taken and quickly.
Following the Greek crisis, a relative period
of calm descended. In addition to the initial
“bailout” and austerity budget, this calm
was attributed to the apparent success of
“stress testing” the loan books and financial
standing of all the major European banks,
an exercise deemed necessary to get any
further bad news out in the open. Being
able to raise new debt, along with new
taxes, is integral to the ability of any
government to function, as this cashflow is
required to pay public sector wages and
effectively ensures the lights are not
switched off prematurely.
The problems faced by Ireland and the other
PIIGS in the single currency are presumed
understood – in a crisis you cannot devalue
your currency at the expense of others to
increase competitiveness and stimulate your
own economy.
When Ireland’s cost of borrowing over 10
years rose above 8.5% and kept rising, it
seemed evident that they would require
external assistance or risk running out of
money and not being able to meet existing
liabilities in full. If existing borrowers had
been faced with “taking a haircut,” or not
being paid back their loans in full, then
who would be willing to lend? The only
alternative would surely have been for
Ireland to quit the Euro, an option with
unthinkable consequences.
34
The UK Coalition Government appears to be
united in the firm belief that a similar
sovereign debt crisis could arise in the UK
without some very strict medicine. Just how
strict this medicine should be is the subject
of fierce debate, although less direct action
than has been seen in France and Greece to
date. The slogan that “we are all in this
together” is a catchy one and goes some
way to limiting the pain when the axe falls
in our own back yard. Fairness is a word
that seems to be frequently deployed, but is
less easy to define in practice.
There have been many changes over the last
three years that affect Surgeons in the UK
and Ireland in particular, not including
whatever efficiency savings have already
been accounted for in your own unit or
hospital.
We have seen a gradual increase in the tax
burden for UK “higher earners.” The entry
point for a higher earner is understood to
be £100,000 gross per annum and includes
earnings, bank interest, dividends, rental
income, etc. This is the point above which
your annual tax free personal allowance, the
first £6,475 that you would otherwise have
received free of tax, is lost, resulting in a
60% tax charge.
Planning tip:
If your total income is less than £130,000
per annum you can regain your tax free
personal allowance by making a gross lump
sum pension contribution. This attracts full
tax relief, mitigates the 60% tax and your
personal allowance is maintained.
Whether or not you think that it is fair to
continue to tax those adjudged to have
“the broadest shoulders” the most, it seems
that this is the stated intent of the
government taxation policy.
From April 2011 it is proposed that a new
maximum “annual pension allowance” of
£50,000 will be introduced. This measure is
designed to raise £4 billion in revenue for
the Treasury in the tax year 2011 / 2012.
In order to calculate an annual allowance
we need to know how much the nominal
value of your NHS pension benefits have
increased over 12 months to gauge whether
this is more than £50,000. If so, any
“excess” will be added to your other income
and taxed accordingly (at 40% or even
50%). This can lead to a nasty tax charge,
potentially running into the thousands, for
those caught unawares.
The trigger for a tax charge in almost all
cases is an increase in pensionable pay. This
is typically the award of a CEA, taking up a
management position or reaching the next
increment of the new consultant contract.
For those with particularly high pensionable
pay, an additional year’s service in the NHS
pension can be enough.
Example calculation:
38/80 X £109,696 (penultimate increment
plus CEA level 5) = £52,105 X16 + £156,316
(£989,996) X CPI 3.1% = £1,020,685
39/80 X £135,930 (final increment plus CEA
level 9) = £66,265 X 16 + £198,797 =
£1,259,037
from the NHS or when accessing personal
pensions or AVCs.
Although one should never consider doing
anything for tax reasons alone, the two
changes highlighted above inevitably refocus
the minds of those close to normal
retirement age who may have the
opportunity of taking pension benefits
before any changes are introduced.
Excess is (£1,259,037 - £1,020,685) =
£238,352 (less £50,000 annual allowance) =
£188,352
As we have said before, at a time when taxes
are on the increase and interest rates are
low, it becomes ever more important to use
the allowances available on an annual basis
to shelter savings and investments from
unnecessary tax.
At this point if you have any unused
allowance from the previous three tax years
you can discount this, otherwise £188,352 is
liable to income tax at 40% and 50% (a
liability of £92,769!)
The current ISA rules state that up to
£10,200 can be sheltered in this tax year;
this is increasing to £10,680 from April 2011.
The allowance also extends to your partner
and other family members.
The alternative proposal is that this tax can
be paid through a reduction in your eventual
pension benefits at retirement.
Bearing in mind the usual disclaimer that
past performance is no guarantee of future
returns stock markets have performed well
in 2010 with returns of close to 10% in
some cases.
I must stress that the legislation remains in
draft form only and is subject to revision,
however, this is our understanding from the
examples provided by HMRC.
To add insult to injury, a further proposal
has been advanced to restrict total tax
relievable pension savings to £1.5 million
from April 2012. For those who have
followed the “Lifetime Allowance” (LTA)
saga closely since its introduction in April
2006 this may come as a surprise.
Current legislation allows an individual to
retire with accumulated savings of up to
£1.8 million in Superannuation and private
pensions. Any excess above £1.8million will
be taxed at 55%!
To reach £1.8 million, an individual usually
needed a CEA, 38 to 40 years service in the
NHS pension with Added Years and a
personal pension.
Superannuation
38/40 X £150,000 = £71,250 X 23
= £1,638,750
Personal pension fund
Standard Life £350,000
Total value: £1,988,750
Excess above LTA in March 2012: £188,750
LTA tax charge in March 2012: £103,812
Excess above LTA above LTA in May 2012:
£488,750
LTA tax charge in May 2012: £268,812
If you are willing to accept risk, historical
evidence suggests that you can still expect
that you will be rewarded with a higher
long-term return. This is particularly
important when inflation is taken into
consideration. Whether we are using the
government’s preferred CPI (consumer prices
index) or the more traditionally understood
RPI (retail prices index) we need a return in
excess of 3.1% just to break even. This is
particularly hard when headline savings rates
are poor, unless funds are tied up for years
and with any interest being taxed.
If you wish to discuss any of the changes
discussed above you can contact Simon
Bruce in confidence at 0207 636 7006 or
[email protected]
May we take this opportunity to wish all
Members, Fellows and staff of the ASGBI a
very happy Christmas break and a healthy
and successful New Year.
This article is not and should not be treated as
financial or investment advice.
Cavendish Medical is regulated and authorised
by the FSA as an independent financial
planning practice.
The firm is also a Professional Partner of the ASGBI.
Cavendish Medical Ltd is registered in England and
Wales, registration number 05448773.
Representing an increase in tax of 156%
over two months!
Pensions are only tested against the LTA
when you draw benefits either by retiring
experience the difference
35
“WHAT A MESSY THING IT IS
TO KILL A MAN”
Pierce A Grace
Sentence of Death
At the Central Criminal Court at the Old Bailey
on the 22nd of October 1910, Lord Chief Justice
Baron Alverstone asked the prisoner before him if
he had anything to say before passing sentence on
him. The prisoner replied: “I still protest my
innocence”. The judge donned his black cap and
sentenced the man “to be taken hence to a lawful
prison, and from thence to a place of execution,
and that you there be hanged by the neck until you
are dead, and that your body be buried in the
precincts of the prison. And may the Lord have
mercy on your soul”.
NEWSLETTER
Put this in any liquid thing you will
And drink it off, and if you had the strength
Of twenty men, it would dispatch you straight.
Romeo & Juliet, Act V, Scene 1
Hawley Harvey Crippen
Lord Chief Justice Alverstone
The prisoner appealed his sentence to the Court of
Criminal Appeal, which upheld the sentence on
5th of November. A Petition for Clemency was
submitted to, and rejected by, the Liberal
Government’s Home Secretary, Winston Churchill,
and the execution was carried out as ordered at
Pentonville Prison on November 23rd 1910. The
man who was hanged was an American, Dr
Hawley Harvey Crippen, and the crime for which
he was convicted was the murder of his wife Cora
who had disappeared without trace from their
home, 39 Hilldrop Crescent, on the 31st of
January 1910. Her dismembered remains were
found under the coal cellar of the house. The case
was a sensation in 1910 and it would become one
of the most famous and controversial murder trials
of the 20th century.
Training in Homeopathy
Henry Harvey Crippen was born in 1862 in
Coldwater, Michigan, the only child of Myron
38
Augustus Crippen (1827-1910), a storekeeper, and
his wife Andresse Skinner (d. 1909). In 1884,
Crippen qualified from the Cleveland
Homeopathic Medical College, which had been
founded in 1850 as the Western College of
Homeopathy, the second such institution in
America. Crippen stated at his trial that he had
“not been through a practical course of surgery
but a theoretical course”. Abraham Flexnor, in his
famous (and scathing) report on medical
education in the US, commented about the
Cleveland Homeopathic School that: “it was weak
and uneven; beyond ordinary dissection and
elementary chemistry, they offer little else.
Equipment for pathology and bacteriology is
meager”. Flexnor concluded that: “the
organization of medical education in this country
(i.e. USA) has hitherto been such as…to obscure
in the minds of the public any discrimination
between the well-trained physician and the
physician who has had no adequate training
whatsoever”. It would appear that Dr Crippen was
one of the all too numerous latter.
Marriage and remarriage
In November 1887, Crippen married Charlotte
Bell, a student nurse who had emigrated from
Dublin. United States immigration records show
that a Charlotte Bell aged seven years entered the
US from Ireland in June 1866, and this may have
been the Charlotte that married Crippen. They
moved to San Diego where Charlotte gave birth to
a son, Otto, in 1888. Crippen then worked as eye
and ear specialist in Salt Lake City where, in
January 1892, Charlotte collapsed and died of
apoplexy just as she was due to give birth again.
Otto was sent to his grandparents in California
while Hawley headed back to New York where he
worked as an assistant to Dr Geoffrey of
Brooklyn. Within a year he had met and married
in Jersey City the 17-year-old Cora Turner whose
real name was Kunigunde Mackomatzki of
Russian/German extraction.
Cora had ambitions to be an opera singer and
Crippen paid for music lessons for her. Shortly
after they were married, Cora’s sister noticed that
Cora had a recent scar on her abdomen but she
‘Dr’ James Munyon
In the late 1890s, Crippen started to work for the
famous and very rich ‘Dr’ James M Munyon.
Munyon had been a publisher for a while but
found homeopathy more profitable especially the
production of patent medicines, which consisted
mostly of sugar and alcohol. A specialty of the
company was “Munyon’s Homeopathic Home
Remedies Cabinet”, which consisted of a tin box
with 10 drawers, each of which contained the cure
for a specific problem, e.g. cold remedies in
Drawer 5, general debility in Drawer 7 etc. The
contents of the drawers included pills, powders or
phials of liquid. In spite of his claim that “no
punishment is too severe for those who deceive the
sick”, Munyon made a fortune out of doing just
that. Crippen eventually became a general
manager and advisory physician to Munyon’s
company and he and Cora came to London around
1898; he, to manage Munyon’s London office,
she, to pursue a music hall stage career, having
given up the idea of becoming an opera singer.
Crippen said that Cora was “always rather hasty
in her temper”. She took to the stage as Belle
Ellmore and was not a success.
An Affair
Around 1902, Crippen went back to America
leaving Cora in London for several months on her
own and when he returned he found that she was
having an affair with Bruce Miller, a music hall
artist; she told Crippen that she did not care for him
anymore and did not wish to be familiar with him.
According to Crippen’s testimony, Cora picked
quarrels with him over trivial incidents and that she
would frequently get into great rages, and threaten
to leave him. Ironically, Munyon eventually fired
him because he was spending too much time
promoting Belle’s stage career rather than
promoting Munyon’s business. However, he seems
to have worked with the company until 1909.
Douret’s Institute for the Deaf
In 1903, Crippen got a job working for Douret’s
Institute for the Deaf in London. This was another
dodgy enterprise, this time claiming to cure
deafness by the application of plasters behind the
Ethel Le Neve
Douret’s Institute was significant for Crippen
because there he met the 18-year old Ethel Le
Neve who became his secretary and had, like
Cora, changed her name; she was born Ethel
Clara Neave in Norfolk in 1883. Ethel was
everything Cora was not. She was gentle, retiring
and sympathetic, and she and Crippen got on very
well together. By 1906 they had become lovers
and she appears to have had a miscarriage in
1909. Crippen told her that Cora was going to
leave him and, as soon as that happened, he was
going to divorce Cora and marry Ethel.
39 Hilldrop Crescent
In September 1905, Crippen and Cora moved into a
large house, 39 Hilldrop Crescent, Camden Road,
North London at an annual rent of £52-10s-0d.
Cora Crippen (Belle Elmore)
NEWSLETTER
ears. A report in the British Medical Journal in
1904 about another employee of the Douret
Institute, Dr H N Dakhyl, stated: “Possibly this
gentleman may possess all the talents, which his
alleged foreign degrees denote, but, of course, he
is not a qualified medical practitioner, and he
happens to be the late ‘ physician’ to the notorious
Drouet Institute for the Deaf. In other words, he is
a quack of the rankest species”.
could not say whether this was due to an operation
or not. At his trial Crippen said that Cora had had
an “ovariotomy” about this time.
39 Hilldrop Crescent
39
NEWSLETTER
Cora became involved with the Music Hall Ladies
Guild which was a charity devoted to looking
after artists’ wives and children. They had an
office in Albion House, New Oxford Street, in the
same building as Crippen’s office. The Crippens
continued to live together, harmoniously as far as
their acquaintances could tell, and Hawley started
a new venture called ‘The Yale Tooth Specialist’
with a dentist named Gilbert Rylance. Their
friends seemed to know nothing of the family
turmoil and described Hawley as “a kind-hearted
and good-tempered man”. On 31st January 1910
the Crippen’s had a ‘pot luck’ dinner at home with
friends from the Music Hall Ladies Guild, Paul
and Clara Martinetti. Mrs Martinetti stated that:
“After dinner we went upstairs to the parlour on
the first floor and had a game of whist. I and my
husband left the house at about 1.30 in the
morning. We spent a pleasant evening, and there
was no quarrel of any sort. Mrs. Crippen came to
the top of the steps and wished me good-bye. She
was in quite good health. I never saw her again
after that night”.
Cora Disappears
Nobody ever saw her again. Cora simply
disappeared. Crippen told the Martinettis that she
had gone urgently to America, to California, and
that he had received a letter saying that she was
very ill with double pleuro-pneumonia. However,
Crippen turned up at the Music Hall Benevelont
Fund Ball accompanied by Ethel Le Neve on
February 20th. The observant or suspicious Mrs
Martinetti noticed that Ethel was wearing on her
bodice “a brooch similar to one I had seen Mrs
Crippen wearing”. On the 24th of March, Crippen
gave the news that his wife had died in California
and that she was to be cremated. He placed a
notice of her death in the weekly theatrical affairs
newspaper The Era which appeared on the 26th
of March 1910. Crippen and Ethel went to Dieppe
for a week and, on his return, he told his partner,
Gilbert Rylance, that he had married Miss Le
Neve. In March 1910, Ethel moved into 39
Hilldrop Crescent, and Crippen arranged for a
French maid to help her.
Music Hall Ladies Guild’s Suspicions
The Music Hall Ladies Guild members were,
however, unconvinced by Crippen’s explanations
regarding the death of his wife. On June 30th
John Nash, husband and manager to music hall
artist, Lil Hawthorne, called to Scotland Yard and
made a statement regarding their suspicions about
Cora’s disappearance to Superintendant Frank
Froest of the Criminal Investigation Department.
Froest asked Detective Inspector Walter Dew to
investigate. On the 8th of July Dew went to 39
Hilldrop Crescent and met Miss Le Neve. Crippen
was at his office in Albion House, so Dew and
Ethel went there together to talk to him. Dew said
that neither Cora’s friends nor the police were
satisfied with what he had told them as to his
wife’s disappearance, to which Crippen replied: “I
suppose I had better tell the truth”.
Avoid Scandal
Crippen then made a statement outlining his early
life and subsequent marriage to Cora. He stated
that, after the Martinettis had left on the 31st of
January, “his wife abused him and said she would
40
not stand it any longer; she would leave him next
day and he would not hear of her again”. To avoid
a scandal, he had put it about that she had gone to
America and then died but this was not true. He
believed that she was alive and had gone to
Chicago with Bruce Miller. All three of them then
returned to 39 Hilldrop Crescent where Dew
looked over the house. He seemed satisfied and
said to Crippen: “Of course, I shall have to find
Mrs Crippen to clear this matter up”. Crippen
agreed and offered to place an advertisement in
various American newspapers.
Inspector Dew finds a body (or parts of it)
Dew returned on the 11th of July, but Crippen and
Ethel were nowhere to be found. He began a more
thorough search of the house and, on the 13th, he
probed the cellar floor with a poker; “at one place
I found that the poker went rather easily in between
the crevices, and I got a few bricks up. I then got a
spade and dug the clay immediately beneath the
bricks. After digging about four spadesfull down,
that is, about nine inches below, I came across
what appeared to be human remains”. They were
human and were wrapped in pyjamas. A warrant
was issued immediately for the arrest of Hawley
Harvey Crippen and Ethel Le Neve for the murder
of Cora Crippen (Belle Ellmore). Inspector Dew
was entrusted with its execution.
Hue and Cry
The police issued a dramatic bulletin on the 15th
of July 1910:
MURDER AND MUTILATION.
Portraits, Description and Specimen of
Handwriting of
HAWLEY HARVEY CRIPPEN,
alias Peter Crippen, alias Franckel; and
ETHEL CLARA LE NEVE,
alias Mrs. Crippen, and Neave.
Wanted for the Murder of CORA CRIPPEN,
otherwise Belle Elmore: Kunagunde
Mackamotzki: Marsangar and Turner,
on, or about, 2nd February last.
The bulletin was distributed widely to newspapers
in England, Europe and North America and a
reward of £250 was offered. Mr William Thorne
MP asked in the House of Commons how the
police had allowed Dr Crippen to slip through
their fingers.
The Inquest
An inquest was held at the Islington Coroners
Court into the cause of death of the remains found
under the cellar of 39 Hilldrop Crescent. Mr
Nash, whose suspicions had led to the discovery
of the remains, gave evidence. He was familiar
with San Francisco, and said that Dr Crippen
became very nervous when he (Nash) asked him
where exactly in California his wife had died, or
what the name of the crematorium was, or what
certificates were issued in relation to the death.
This had prompted Nash to go to the police.
Inspector Dew described how he found a mass of
human flesh under the cellar floor but no head or
bones whatsoever. “It seems as if someone had
carved the flesh to pieces”. There was also a
quantity of lime and some hair. The police
surgeon Dr Thomas Marshall said that it was not
SS Montrose
The World Watches
As the SS Montrose made its way across the
Atlantic the world was treated to a day-by-day
account of the on board activities of Crippen and
Miss Le Neve; what they ate, what books they read
and how often they strolled the deck; the fact that
Ethel’s suit and hat did not fit very well. Crew
members surreptitiously took photographs of them
on board, which would be reproduced later.
The arrest in Canada was a media circus. On the
31st of July 1910, Dew went on board the SS
Marconigrams
Using the new wireless technology that had been
installed on his ship, Kendall sent the following
message (Marconigram) to Scotland Yard: “HAVE
STRONG SUSPICIONS THAT CRIPPEN LONDON CELLAR MURDERER AND
ACCOMPLICE ARE AMONG SALOON
PASSENGERS”. In response, Scotland Yard sent
by wireless a fuller description of the fugitives,
which confirmed Kendall’s suspicions. Inspector
Dew was dispatched to Canada on The Laurentic,
a faster liner than the SS Montrose so that he
would be in place to arrest Crippen and Le Neve
when they arrived.
NEWSLETTER
Captain Kendall’s Suspicions
While the inquest continued, the police were
searching for Dr Crippen and Ethel Le Neve. One
of people who read of the murder and the
disappearance of Crippen and ‘his typist’ in the
newspapers was Henry Kendall, captain of the
Canadian Pacific Steamship Company’s 5431-ton
cargo ship, SS Montrose, bound for Quebec out
of Antwerp.
newspaper photos. What he saw convinced him
that that Robinson and his ‘son’ were in fact
Crippen and Ethel Le Neve disguised as a boy.
possible to state on anatomical grounds the sex of
the flesh saying that: “the man had evidently
endeavoured to remove every evidence of sex”.
William Long, a dental mechanic, told of buying a
suit of clothes and hat at Crippen’s request and
then receiving a letter in which Crippen asked him
to wind up his household affairs, including paying
the rent for the previous quarter. Mr Augustus
Pepper, a consulting surgeon to St Mary’s
Hospital, gave evidence that he believed the
remains to be those of a human adult and that the
dissection “must have been done by someone with
anatomical knowledge”. There was a surgical scar
on the abdominal tissue but the sex was not
discernable. Dr William Wilcox, senior scientific
analyst to the Home Office, described his
extensive chemical analysis of the remains and
how he had found considerable amounts of the
alkaloid, hyocine, in the tissues, which was the
cause of death. The coroner’s jury returned a
verdict stating that the remains were those of Cora
Crippen, that death was by poisoning by hyocine,
and accused Dr Crippen of the willful murder of
his wife.
Captain Henry George Kendall
Among the passengers on Kendall’s ship were
John Philo Robinson, merchant, aged 55 and his
son, John C Robinson, aged 16. Captain Kendall
noticed this strange father and son who held hands
frequently and he observed that the father had
shaved off a moustache recently and had marks on
his nose from wearing spectacles. Kendall used
bits of cardboard to block out Miss Le Neve’s hair
and he chalked out Crippen’s moustache from the
Crippen and Le Neve on board ship
41
42
Ethel is Acquitted
Ethel Le Neve was tried a few days later, the
charge being an accessory after the fact and a
fugitive to justice. However, she was defended by
the brilliant F E Smith, the future Lord
Birkenhead, who would eventually hold all the
important law offices of England (Solicitor
General, Attorney General and Lord Chancellor).
Smith painted a picture of Ethel as an innocent
young woman merely following the instructions of
her lover. She was described as a “gentle
inoffensive girl”. Her trial lasted all of one day
and it took the jury only 12 minutes to acquit her
of all charges.
Inspector Dew arrests Crippen
NEWSLETTER
Montrose disguised as a pilot and arrested
Crippen with the words: “Good afternoon, Dr
Crippen”. Crippen told Dew that Ethel “knows
nothing about it; I never told her anything.” Dew
and his prisoners returned to England in August
and both were formally charged at Bow Street; he
with the willful murder of Cora Crippen, and she:
“that she did feloniously receive, comfort,
harbour, assist, and maintain him” (ie. Crippen).
The Trial
On the basis of the coroner’s verdict, Crippen was
brought to trial on the 18th October 1910. A
famous barrister, Richard C Muir, KC, led the
prosecution team while Alfred Tobin, KC
defended him - rather poorly. But for the
pigheadedness of his solicitor, Crippen might have
had Edward Marshall Hall defend him. Marshall
Hall was the most famous defence counsel of his
day, but Alfred Newton, the solicitor, had a row
with Marshall Hall’s clerk regarding the fee,
resulting in Tobin getting the brief. The evidence
presented at the trial was a rerun of that presented
to the coroner. The defence was that the remains
under the cellar floor were there when Crippen
moved into 39 Hilldrop Crescent. The prosecution
showed clearly that the pyjamas in which the
remains were wrapped were made after that date the label contained the words “Jones Brothers,
Limited”. Jones Brothers became a limited
company in 1906, one year after Crippen moved
into the house.
Medical Expert Witnesses
A considerable number of medical experts were
quizzed about the scar on the torso and whether it
was a surgical scar or not. Dr Bernard Spilsbury,
who would become a very famous forensic
pathologist, offered to bring his microscope into
court to show that the scar on the torso was in the
lower midline and was consistent with a surgical
scar for an oopherectomy. Dr Wilcox repeated his
evidence that death was due to poisoning by
hyocine. It emerged that Crippen had purchased
five grains (325mg) of the drug from Lewis &
Burroughs, a London chemist, on 10 January
1910 and had signed the Poison’s Register. He
claimed that he had seen a dilute solution of
hyocine being used as a drug to subdue violent
psychiatric patients at the Bethlehem Hospital
(Bedlam) a few years earlier and that he had used
it to make up small tablets. The medical evidence
convinced the jury after a mere 27 minutes of
deliberation that Crippen was guilty.
Dr Crippen and Miss Le Neve in court
Epilogue
Ethel visited Crippen every day in prison. Before
his execution, Crippen wrote that Ethel was
innocent of any crime save that of yielding to the
dictates of her heart and he prayed that God would
protect her and allow him to join her in eternity.
On the day of Crippen’s execution Ethel changed
her last name to Nelson and went to Canada. She
later moved back to England and married an
accountant named Stanley Smith who never knew
his wife’s previous notoriety. She died in Croydon
in 1967 at the age of 85. Captain Kendall
collected the £250 reward money but was almost
drowned when, in 1914, his ship SS Empress of
Ireland was destroyed off Father Point, close to
where Crippen had been arrested. Chief Inspector
Dew retired from the police force, having
successfully sued several newspapers for libel for
comments about his conduct of the Crippen case.
He set up a private detective agency and became a
crime expert for the press. He died in 1947. Sir
Bernard Spilsbury became the most famous
pathologist of the age and gave evidence in
numerous murder trials. He committed suicide in
his laboratory in London aged 70 in 1947. The
Further Reading
Hitchcock A
In films murders are always very clean. I show how
difficult it is and what a messy thing it is to kill a
man
Hitchcock Quotes
Available at:
http://www.hitchcockwiki.com/wiki/Hitchcock_Quot
es accessed 22-06-2010
Murder Case Magazine 9
The Mild Mannered Murderer. Dr Crippen, The London
Doctor who killed for the woman he loved
Marshall Cavendish Partworks Ltd, Tarrytown, NJ. 1990
Encyclopaedia of Cleveland History
Available at: http://ech.cwru.edu/echcgi/article.pl?id=CHH1 accessed 12-06-2010
Hawley Harvey Crippen.
The Proceedings of the Old Bailey. t19101011-74.
Available at:
http://www.oldbaileyonline.org/browse.jsp?id=t1910
1011-74&div=t19101011-74&terms=crippen
accessed 12-06-2010
Flexnor A.
Medical Education in the United States and Canada.
A repost to The Caregie Foundation for the
Advancement of Teaching.
Available at:
http://www.carnegiefoundation.org/sites/default/files/
elibrary/Carnegie_Flexner_Report.pdf p 159-160
accessed 12-06-2010
Charlotte Bell
The Battery Conservancy, 2009
Available at: http://www.castlegarden.org/index.php
accessed 13-06-2010
Medico-Legal.
Brit Med J 1910, 2: p1372-1383 (29th Oct 1910)
Medico-Legal and Medico-Ethical
Brit Med J 1904, 2 p 359 (13th Aug 1904)
Dr Munyon Dies in Florida
The New York Times, March 11th 1918. Available at:
http://query.nytimes.com/mem/archivefree/pdf?res=990DE3D61538EE32A25752C1A9659
C946996D6CF accessed 21-06-2010
Ethel Clara Le Neve.
The Proceedings of the Old Bailey t19101011-75
Available at
http://www.oldbaileyonline.org/browse.jsp?id=t1910
1011-75&div=t1910101175&terms=Le|Neve#highlight accessed 21-06-2010
Technology then and now
Lastly, the case had caught the public imagination
because the wireless telegraph was able to provide
a day-by-day voyeuristic account of the hunt
across the Atlantic. Given the extraordinary press
coverage, it is doubtful that Crippen could ever
have a fair trial. In 2007, Dr David Foran, a
forensic scientist at Michigan State University,
caused a sensation when he revealed that
mitochondrial DNA isolated from one of
Spilsbury’s slides, which had been carefully
preserved in London, did not match the living
female relatives of Cora Crippen. This evidence
demonstrated that the human remains under the
cellar floor could not have been Cora’s. Dr Foran’s
team then went on to state that the body parts
were not only not Mrs Crippen they were not even
female. The mystery remains as to who was under
the floor of 39 Hilldrop Crescent and, if Dr Foran
is right, how did he get there. Should Hawley
Harvey Crippen be pardoned and what happened
to Cora?
Fido M
Crippen Hawley Harvey, Murderer (1862-1910)
Oxford Dictionary of National Biography. Available
at:
http://www.oxforddnb.com.proxy.lib.ul.ie/view/articl
e/39420 accessed 21-06-2010
NEWSLETTER
Why?
The Crippen case is notable. Why would an
intending murderer openly purchase a rare poison
and sign for it in the Poison’s Register? Why
would he dismember the body? – the whole point
of poisoning is to make it look as though the
victim died naturally. Why place the torso and
organs under the cellar floor, why not dispose of
them with the head, bones and limbs, which were
never found? Was Crippen capable of
dismembering the body with the surgical precision
attested to by the medical experts? Why did he
run away and why did he use such a poor disguise
for Ethel? In the absence of an identifiable body,
the prosecution’s case rested on proving from the
abdominal scar that the remains were Cora
Crippen’s. These remains contained a lethal
quantity of hyocine, a drug Crippen had bought.
However, it was impossible to say for certain in
1910 that the remains were definitely those of
Cora Crippen. A more robust defence might have
had the charge reduced to manslaughter at the
most. The Lord Chief Justice, in summing up,
advised the jury that they “must give the benefit of
any doubt to the prisoner”. It would seem, 100
years later, that the evidence was not beyond
reasonable doubt.
Clough B
Dr Crippen, The most infamous murderer in AngloAmerican relations.
Available at: http://www.drcrippen.co.uk/ accessed
11-06-2010.
Luftwaffe destroyed 39 Hilldrop Crescent during
the London blitz, and the SS Montrose broke her
moorings and was wrecked off Dover in 1914.
Hilldrop Crescent Case
The Irish Times (1874-1920) Sept 27, 1910.
ProQuest Historical Newspapers The Irish Times
(1859-2000) pg 9A
English Early J. Technology, Modernity, and ‘The
Little Man’: Crippen’s Capture by Wireless.
Victorian Studies, Vol. 39, No. 3 (Spring, 1996), pp.
309-337 Available at
http://www.jstor.org/stable/3829449 accessed 16-062010
Foran D.
Executed in error
Available at
http://www.pbs.org/wnet/secrets/features/executedin-error/david-foran/204/ accessed 21-06-2010
43
OPERATION TELIC IRAQ
2003-2009: A SURGICAL
PROFESSIONAL
RETROSPECTIVE
David A Rew
Tommy (Atkins)
Rudyard Kipling (1865-1936)
MILITARY SURGERY
For it’s Tommy this, an’ Tommy that, an’
“Chuck him out, the brute!”
But it’s “Saviour of ‘is country” when the guns
begin to shoot;
An’ it’s Tommy this, an’ Tommy that, an’
anything you please;
An’ Tommy ain’t a bloomin’ fool - you bet that
Tommy sees!
Painting: The defence of CIMIC House by 1st Bn
Princess of Wales Royal Regiment, Al Amarrah, 2004:
Oil on Canvas by David Rowlands, reproduced by kind
permission of the Artist
The troops have come home. The official
documents are locked away in the Army’s
Corporate Memory Vaults. The doors are
closed on Operation Telic, a campaign in
Southern Iraq which outlasted the Second
World War, running for six years, from March
2003 to April 2009. 179 UK service personnel
who died and 1,000 or more who were seriously
injured in Iraq bore witnesses to a brutal new
phase of warfare, in which the suicide bomber
was pushed to the fore, and the Internet
propagandised the work of the belligerents in
gruesome fashion.
Operation Telic will not be judged a military or
a political success. The Iraq campaign, which
was conducted against the popular mood on the
basis of very suspect evidence, will become
synonymous with the inner workings of the late
Blair government. These were dissected in
genteel but effective fashion during 2010 by the
Chilcott Inquiry.
Operation Telic nevertheless spawned at least
one remarkable story which should not be
overlooked in the Great Yawn of History.
Collectively, our Military Medical Services, in
which surgeons played a significant role, have
overseen a transformation in the care of
casualties from the point of wounding to longterm rehabilitation and advanced prosthetics;
and in the management of the most extreme
44
injuries which are at, and have previously been
beyond, the boundary of survivability. This
experience has also transformed casualty care
in the campaign in Afghanistan, which has yet
to stand the judgement of history in the round.
More importantly, it has helped, at last, to
bring about the long-overdue modernisation of
the NHS Trauma Service, a process in which
military doctors, fresh from overseas
battlefields, have also played a very
significant role.
As a junior Surgeon Taken Up From Trade in
March 1991, I stood among the burning
oilfields in Northern Kuwait after a race across
Southern Iraq in front of the Big Guns with the
Field Surgical Team attached to 4th UK
Armoured Brigade. Exactly 12 years later, as a
Consultant Surgical Reservist with 202 Field
Hospital (TA) in Northern Kuwait, I stood on
the same ground observing the launch of
Operation Telic 1. A junior doctor, observing
the frenetic military activity around us,
commented that “we had never done anything
like this before”.
In fact, not only had we done it only 12 years
earlier, but much of our equipment and
procedures would have caused no discomfort or
surprises to our predecessors at El Alamein and
in the North African Desert from 1940-1943,
about which the late Mr Bernard Williams
FRCS had tutored me in his retirement.
I therefore resolved to seek to improve the
medical corporate memory of Operation Telic.
We held a study day in Kuwait in early May
2003, and subsequently I cajoled colleagues
across the Forces to write down their stories and
empty their digital cameras in a higher cause.
The upshot was the e-book Blood Heat and
Dust, which covered the Entry Campaign, Op
Telic 1, from March to June 2003. The book
was contemporaneous and richly illustrated
with imagery and personal vignettes, and some
1,500 copies were taken up by the MoD for
onward distribution. The book remains directly,
fully and freely available as a download on the
Internet at: www.pangrafix.com/bhd
That account left many professional themes
open ended. Events in Iraq ran for much of the
decade in parallel with events in Afghanistan,
which causes even more confusion and
distortion in the personal and collective
memory. The end of Operations in Iraq in the
Spring of 2009 thus provided the opportunity
and the stimulus to wholly revise Blood Heat
and Dust in a Second Edition. The draft of this
book is now broadly complete with such
additional material as I have been able to
secure, and under official scrutiny prior to
intended publication in 2011. Relevant material
has also been published in 2010 by Penguin
Viking in the book Medic by John Nichol and
Tony Rennell.
Specifically, in respect of surgeons, the
Definitive Surgical Trauma Skills (DSTS)
Course at the Royal College of Surgeons of
England, and more recently the Military
Operational Surgical Trauma (MOST) Course,
have been invaluable in developing skills,
insight and experience in a workforce for whom
injuries of the type seen in Iraq had never been
met in civilian practice in the UK.
As the insurgency gathered steam through 2004
and 2005, UK forces withdrew progressively
towards Basra, and by mid 2007 the situation in
the outposts in Basra itself became untenable.
Insurgent tactics, including improvised
explosive devices, ambushes and suicide
bombings were progressively refined, severely
restricting the intended efforts at “nation
building”. Conventional forces were withdrawn
to the Contingency Operating Base at Basra
Airport, where they were under regular and
heavy mortar and missile fire through late 2007
and into 2008. The field hospital at the COB
itself was frequently hit during this time, and a
number of injuries were sustained by staff.
The unheralded Operation Charge of the
Knights by the Iraqi Army in March 2008
effectively routed the insurgency in Basra,
allowing the remaining 4,000 or so UK forces
personnel to draw down and extract peacefully
by April 2009, along with the remaining
medical support units and hospital squadron.
As the casualty rate rose, Iraq taught us much
about surgical trauma, and obliged the
relearning of old lessons from past military
ventures into Mesopotamia. An Iraqi military
doctor told us in 2003 how Basra had been
regarded as a punishment posting in Saddam’s
Army, and as the thermometer passed 50deg C
in May and dust devils tore through the hospital
tentage, we understood why.
The medical and surgical lessons of
Operation Telic
What were the key areas of transformation in
Trauma care through Operation Telic? In terms
of the individual and collective preparation of
From the front line, advances in the training,
deployment and equipping of individual
soldiers and of combat medics, with much
improved body armour, tourniquets, chest seals
and clotting accelerators, combined with a
move almost universally to rapid helicopter
transit, saw the delivery of “unexpected
survivors” of the immediate blast injuries. This
created substantial clinical pressures for the
trauma teams and for the supply of blood and
blood products.
At field hospital level, Operation Telic 1 saw us
enter Iraq with “Cold War” scales of
equipment, in old tentage for which thermal,
dust and environmental controls were
impossible despite sterling ‘Make and Mend’
efforts; with the old collapsible, air portable
rigid McVicar operating tables; and without CT
scanners, digital imagery, or specialist
paediatric equipment. Teamworking among
multidisciplinary professionals has been
elevated to new levels, and reserve and regular
personnel have integrated seamlessly.
Fortunately, preparatory work during the Balkan
campaigns of the late 1990s had allowed our
anaesthetic colleagues to make considerable
advances in preparing Field ITUs, with
appropriate and ruggedised equipment. In later
phases of Op Telic, all of the material
deficiencies were addressed, other than for the
continued use of tentage, albeit that the working
accommodation was “much improved”. From
this experience, lessons were learned which led
to the commissioning of the remarkable Camp
Bastion hospital in Helmand in 2008 in a
prefabricated special to purpose building.
Operation Telic 1, the overwhelming military
“entry” by UK forces into Southern Iraq, was
conducted by some 45,000 UK troops, with
remarkably few deaths. This was despite
adverse publicity about equipment, as for
example the local shortage of body armour for
some forward troops. A political decision was
made to draw down this force by more than a
half by the end of Op Telic 1, and by half again
over the next two years, such that, at the height
of the insurgency in 2006-2007, a light brigade
of some 7,000 troops, of whom many were not
in the “fighting arms”, were holding the ring
against a major uprising within a population of
two million Iraqis around Basra.
MILITARY SURGERY
medics for deployment, considerable advances
were made in training programmes and in
predeployment hospital exercises, such that by
the end of Operation Telic, all deploying
medical units were subject to rigorous
assessment and governance oversight, along
with feedback of practical experience into the
trauma management drills and procedures. The
National Field Hospital Trainer at Towthorpe
near York has proved invaluable in this process.
The military events in Southern Iraq selfevidently created the framework upon which
many medical advances were built. They
paralleled the experience of US forces
elsewhere in the country, but US casualties
were an order of magnitude higher than ours,
with more than 4,000 operational deaths. Our
medical lessons drew heavily on this tragedy of
trauma, and on the parallel suffering of large
numbers of Iraqi combatants and civilians.
Expansion of the Critical Care Aeromedical
Strategic Transfer teams allowed large numbers
of ventilated, stabilised casualties to be returned
rapidly and safely to the UK, where care was
progressively consolidated through East
Midlands Airport to Selly Oak Hospital in
45
This led to the next challenge, which was one
of adaptation of a now largely civilianised NHS
hospital resource to military needs, following
the closure of most of the UK’s remaining
military hospitals through the 1990s. The early
overload of Selly Oak with complex military
casualties; the admixing of these casualties with
civilian patients and a number of resulting
problems led to critical internal MoD reports
and to adverse media coverage. This pressure,
in turn, produced a substantial improvement in
capacity and form of care for military casualties
and a drive for improved facilities in the new
Queen Elizabeth Hospital in Birmingham,
opened in 2010.
MILITARY SURGERY
Birmingham, where the Royal Centre for
Defence Medicine was collocated.
The next level of care to come under pressure
and scrutiny was the military rehabilitation
service. This was focussed upon RAF Headley
Court Rehabilitation Centre, which was in
danger of becoming overloaded both with the
volume and complexity of its workload in its
peacetime configuration. Whereas, in the past,
single limb trauma has been the norm there,
double and even triple amputee survivors were
now posing major challenges for
rehabilitation and prosthetic design. An
improved national rehabilitation service was
put in place with 12 regional centres, so that
Iraq casualties with their particular and
unique needs did not become a lost tribe,
drifting alone and poorly understood through
civilian health facilities.
On the academic and governance side, the
collection and analysis of trauma data and
injury causation has been rigorously
systematised by colleagues at the RCDM,
whose work has been rightly recognised in the
National Honours. Weekly conference calls
between the deployed trauma teams in Iraq,
Afghanistan and the UK leads allowed the rapid
dissemination of lessons and experience across
theatres and in feedback to the deployed teams.
Wars in Peace throw up huge psychological
problems for service personnel cast adrift in a
seemingly uncaring civilian world, as the
Vietnam Veteran experience in the US and that
of the “Afghanisti” in Russia have shown us.
We now have much better understanding and
collective sympathy for the problems and
casualties of post traumatic stress. Much work
has been done in psychological Trauma Risk
Management (TRIM) debriefings in the field,
homeward bound decompression (in Cyprus)
and in long-term support. Programmes such as
“Battle Back” and “Toe in the Water” have
provided teamworking and physical challenges
for the badly injured, while continued
employment in the Forces for all but the most
severely injured has provided a breathing space
for individuals to re-align their lives.
46
One remarkable pointer to the discontinuity
between overt public antipathy to the politicians
for their responsibility for events in Iraq, and
public support for the troops themselves has
been the remarkable boom in charitable giving,
both to the established service charities, and to
new start-ups. Most remarkably, Help for
Heroes has raised some £50,000,000+ in five
years from a standing start.
It is very difficult fully to appreciate the
courage and loyalty of the young service
personnel, men and women, soldiers and
medics who went out on patrol or on convoy
duties in the hellish alleys of Al Amarrah, Az
Zubayr, Umm Qasr or Basra city; or who sat
through mortar fire onto tented wards and
operating theatres during the dark days of
Operation Telic; and who lost life and limb
for what was progressively seen at home to
be a lost political cause, but which remained
a matter of intense personal, subunit,
regimental and military honour and pride on
the ground. In crude numerical and historical
military terms, deaths and casualties were
relatively light across the breadth of
Operation Telic. The advances in trauma care
which were forced by events upon our
clinical teams in Iraq and in the UK, helped
to ensure that significant numbers of service
personnel and Iraqi nationals survived
injuries from which they might otherwise
have died. Many lessons were learned, for
which we owe the casualties a great debt, and
our duty is now to ensure that these lessons
will endure.
For many years to come, the long-term
casualties of the Iraq Campaign of 2003-2009
will continue to trickle through the nation’s
hospitals. The passage of the years will increase
the wear and tear on broken bodies, and the
exhaustion of daily activities without limbs or
orientating senses will increase. Some of these
people may pass though your own hands. Their
care will remain our moral duty and obligation
for at least another generation. They will not
ask your sympathy, but they will deserve your
understanding and respect for what they have
sacrificed in the Heat and Dust of Iraq.
Painting: 1 Close Support Medical Regiment at Bridge
4, Basra, 2003. Oil on Canvas by David Rowlands,
reproduced by kind permission of the Artist
The Management
of Knife Injuries
CONSENSUS CONFERENCE
Sponsored by The Surgical Foundation and the Metropolitan Police
Monday 15th November 2010 saw 114 delegates, from
across surgery, law enforcement and social work, attend
the Association’s Consensus Conference on improving
co-operation and effectiveness of harm prevention and
crime reduction associated with knives. The event, which
was held in partnership with The Surgical Foundation
and the Metropolitan Police Service, received extremely
positive feedback, a good deal of national media
coverage and resulted in the following joint statement,
laying out the major areas of agreement:
Sharing of data and public health measures:
• Data sharing between emergency departments and
community crime reduction partnerships must
become standard practice in every hospital in the
UK. ASGBI commits to encouraging surgeons to
work to set this up in their local hospitals.
• ASGBI and the Metropolitan Police are of the
opinion that we should go further on the quality and
nature of data shared. Fears over patient anonymity
are inhibiting the ability to properly target services
for some hospitals. Non-anonymised data sharing
between public services for violent injuries would
support approaches to safeguarding children and
adults. This would require ratification by the General
Medical Council.
• ASGBI would support the restrictions on access to
alcohol. The evidence suggests that this would have
a dramatic effect on violent behaviour in the young.
Surgical training:
• ASGBI and The Surgical Foundation endorse the
development of regional trauma networks – these
must be supported by accredited training
programmes and courses that include the
management of violent injuries.
KEY PRINCIPLES
Background:
• Tackling violence needs close co-operation with
police and other partners across the public, private
and voluntary sectors. There is a need for all public
services to work together more cohesively to break
down barriers and tackle violence in the community
and the role of the extended family requires support.
• ASGBI strongly recommends that all general
surgeons involved in the treatment of trauma should
attend one of these accredited training programmes.
• Surgeons should be trained to appreciate forensic
requirements of the criminal justice system by
preserving evidence.
• There is a need for long-term policy focusing on
prevention – the best evidence for prevention lies in
targeting children before they become involved in
violence as either victims or offenders.
• Police enforcement activity is crucial, but cannot be
a long-term solution and is often not a deterrent for
this group.
Extending education programmes:
• Surgeons should get involved in early years peer
group education programmes involving schools,
youth organisations and local police forces.
• More needs to be done to link up new local
violence campaign/support groups and agencies to
work collaboratively with existing organisations and
pre-existing infrastructure.
A detailed Consensus Statement supporting, and
expanding on, the above Key Principles will be
published by the Association in the New Year.
ENDOVASCULAR
FELLOWSHIP 2009: PERTH,
WESTERN AUSTRALIA
Background
Similar to the majority of today’s vascular trainees,
I became increasingly concerned as I headed into
the latter stages of my surgical training regarding
my limited experience and opportunity in
endovascular intervention. Simply performing
EVAR cut-downs and consenting our patients for
peripheral intervention that radiological colleagues
would ultimately perform had grown tiresome. I
therefore decided early that I needed to leave the
UK for a dedicated period of time in order to
obtain the required endovascular training that, in
my opinion, needed to be surgeon-delivered.
NEWSLETTER
Philip Davey
Perth City and Swan River
SCGH) promising to keep me in mind for any
future appointments. Undeterred, I remained
positive and, after having successfully negotiated
the inter-collegiate exam in February 2008, I
decided to make further contact with all three
units, giving SCGH priority. I emailed the lead
clinician (CV attached) asking specifically if he
would have any objection to a subsequent
telephone call from me to discuss a possible
fellowship further. This approach prompted an
immediate positive email response and, four
weeks later, I was appointed following an
informal telephone interview.
It was always my intention to count this fellowship
as training within my higher surgical training
programme and, immediately after successful
appointment, I began the now compulsory process
for prospective approval with the Deanery, SAC
and PMETB. While this procedure wasn’t
complicated, it did have the potential to be quite
time-consuming so one should bear this in mind if
planning a similar strategy. Temporary registration
with both the WA medical board and Royal
Australasian College of Surgeons was mandatory
and relatively straightforward. Although several
visa options were feasible, I opted for a type 442
sponsored occupational trainee temporary visa. A
distinct advantage of this visa class was the ability
to claim financial remuneration for assisting in the
private sector. Full medical examinations were
required for all people included on the visa (wife
and children) with compulsory HIV, Hepatitis B &
C testing for me.
Selection, Planning & Application
Having decided to apply for an endovascular
fellowship abroad, I was only ever really
interested in securing a position in Perth, Western
Australia (WA). The region’s pedigree in the
worldwide endovascular arena remains
undisputed, and the reports I sought regarding the
high quality of training delivered were very
attractive. The added advantages of no language
barrier, a healthcare system similar to the UK,
good quality of life, climate and an agreeable
family left me with little decision to make
regarding our planned destination for 2009.
Consequently, in early 2007, I made direct contact
(letter and CV) with the Heads of Department of
all three tertiary vascular units in Western
Australia. The initial
response was slightly
disappointing, a
single email from one
unit (Sir Charles
Gairdner Hospital,
Sir Charles Gairdner Hospital
CVIL (Cardio-Vascular Invasive Laboratory) at Sir Charles Gairdner
Hospital. Note the absence of interventional radiologists and the
resident anaesthetic equipment for EVAR
Although I didn’t manage to secure any corporate
sponsorship for the fellowship, it is always worth
a try through your local reps. I was, however,
successful in securing a £5000 Endovascular
travel grant (two available annually) from The
Circulation Foundation which was obviously
gratefully received. There are several other travel
grant and bursary schemes open for application
and these should all be considered during the
planning stage of the fellowship.
48
Vascular Services in Western Australia
The entire state-wide population of Western
Australia (approximately 2.25 million) is served
by the three vascular units centrally located in the
metropolitan Perth region. Royal Perth Hospital
(RPH) is historically the core of Perth vascular
services that housed much of the Cook endograft
development by Michael Lawrence-Brown and
David Hartley. In truth, it has now probably been
surpassed by SCGH for both elective open and
endovascular activity. The differing case-mix
between RPH and SCGH results mainly from two
factors. Firstly, RPH remains the major trauma
centre for the state and, for this reason, tends to
generate a heavier emergency workload. Secondly,
unlike SCGH, the vascular unit continues to
provide all renal access services at RPH. The
other main centre providing a comprehensive
vascular service is Fremantle Hospital (FH). It is
probably quieter at FH with perhaps slightly less
enthusiasm on endovascular management than
exists at both SCGH/RPH.
Relationships between the departments of SCGH,
RPH and FH are generally very good. The
monthly WAVES group meeting (Western
Australian Vascular and Endovascular Surgeons)
serves to both co-ordinate WA vascular services
and is a regular forum for group/individual
discussion and debate. Contrary to the trainees
who are hospital-based, the on-call commitment
for consultants is state-wide (1 in 12/13) and this
frequently involves operating remote from their
base hospital at the other two sites.
More rural WA vascular services remain limited.
Visiting centrally-based surgeons do provide outpatient clinics in Broome, Geraldton, Bunbury
and Albany, but these usually only occur on a
monthly basis. For all vascular emergencies, and
An Office with a view
Outlook from the SCGH Vascular department office towards King’s
Park with City of Perth on horizon
Facilities for open and endovascular surgery at
SCGH were enviable. In addition to the dedicated
vascular operating theatre (with DSA-capable
high-specification mobile image intensifier), there
was capacity for angiosuite intervention in both
main X-Ray and a Vascular-specified catheter
laboratory that was shared with cardiology (CVIL:
cardio-vascular invasive laboratory). As one
would expect, the former were policed by the
interventional radiologists, but the latter CVIL
sessions were for exclusive use by the vascular
surgeons and, hence, it was where the majority of
the endovascular work was performed. In practice,
it was only the complex EVARs (e.g. fenestrated
(FEVAR), iliac branched devices) that were done
in X-Ray in a team approach with IR. Similarly,
the vascular team worked well with the resident
cardiology/cardiothoracic team in the management
of both acute and chronic thoracic aortic
pathology. Contrary to the UK, standard EVAR
and TEVAR were largely done independently by
the surgical team in the cathlab with full
anaesthetic support. Approximately 85% of AAAs
were repaired at SCGH by EVAR, with an
established protocol for endovascular management
of ruptured AAA (eEVAR). Routine peripheral
work included iliac, femero-popliteal and tibial
interventions (angioplasty/stenting) as well as
mesenteric and renal artery procedures.
NEWSLETTER
The SCGH Endovascular Fellowship
The Vascular department at Sir Charles Gairdner
Hospital comprised five Consultants (4 part-time,
1 full-time), the Fellow, a local junior registrar and
two Interns (F1 equivalents). In the extended team
there was a dedicated vascular sonographer,
vascular nurse specialist and the expected allied
healthcare specialities. The Unit was combined
with the Cardiology ward at SCGH, consisting of
24 in-patient beds with adequate HDU/ITU
support where appropriate. Patients for
interventional procedures typically utilised the
dedicated short-stay unit for day-case and
overnight stay beds.
those patients requiring elective in-patient care,
transfer to one of the three centres in Perth is
necessary. Consequently, many acute admissions
may have to travel a significant distance in order
to receive definitive care, often with very
advanced pathology.
A typical weekly timetable of activity for the
Fellow is shown below:
Clinical responsibilities of the fellowship included
involvement in the vascular outpatient clinics
(consultant-led, ulcer and surveillance), leading
49
NEWSLETTER
the multi-disciplinary grand rounds, audit,
theatre/cathlab bookings and the general day-today management of the unit. Furthermore, I was
expected be directly involved in teaching junior
medical staff, students and nursing staff, and
participate in a variety of in-hospital education
sessions. We also arranged the weekly unit
Consultant rounds and combined unit radiology
meetings. The out of hours on-call commitment
was 1 in 3 non-resident, the rota shared with both
the junior registrar and a third-nightly contribution
from the General Surgical trainee. The vascular
fellow had no reciprocal commitment, however, to
General Surgery. In order to maximise the
endovascular experience, the fellow was
encouraged to assist in appropriate cases within
the private sector assuming adequate in-house
cover was in-place at SCGH.
Living in Perth
Situated on the banks of the picturesque Swan
River, Perth is one of the most modern, cleanest
and safest cities in the world. The city has all one
would expect of a major urban centre with
excellent shopping, restaurants and nightlife.
Despite being one of the most isolated cities in
the world, it is well-served by road, rail and air
links regionally, nationally and internationally.
In twelve months I was involved in over 600
emergency and elective cases with the salient
procedure numbers shown in tabular format below
(P-performed independently; S-performed
supervised; A-assisted). Unsurprisingly, in over
90% EVAR cases the Cook Zenith device was
used. Other devices deployed were the Medtronic
Endurant and Gore Excluder. Note that an
appreciable volume of work continues to be
conventional open surgery and also the refreshing
paucity of varicose veins.
Our Campervan adventure up in Northern WA
The ‘rig’ at Monkey Mia (above) & Sunset at Coral Bay (below)
Table 1: EVAR experience
Table 2: Catheter Intervention
Table 3: Open Surgery
There was ample opportunity to attend the
monthly state-wide vascular trainee education
sessions and the weekly Cook Endovascular
planning meetings, where worldwide complex
aortic and thoracic endograft repairs were
discussed and planned by a multidisciplinary team
of Vascular Surgeons, Interventional Radiologists
and Cook Planners.
The SCGH fellowship employment contract is
typically for a 12-month period, commencing each
January. The basic 38-hour weekly salary is far
better than the UK (approximately A$110,000)
50
and overtime, on-calls and call-backs are added
pro-rata following monthly submission of claim
forms. One should also pay attention the
advantageous salary-packaging schemes
established for the public sector workforce. As a
temporary resident, tax is paid as an Australian
with additional automatic pay contributions to a
superannuation plan that can be reclaimed
following permanent departure from the country.
SCGH itself is centrally located opposite Kings
Park within the affluent suburb of Nedlands. Having
had our children accepted, in advance, into one of
the local public primary schools, we opted to stay
nearer the coast in City Beach. We certainly did not
regret it. Average rental costs in WA are expensive
and the market is notoriously fierce, irrespective of
location. That said, the cost of living was roughly
equivalent to the UK: high-priced groceries and
water offset by cheaper fuel and utility bills.
The hot, dry climate in WA lends itself to a
lifestyle that is essentially outdoor. In addition to
the countless beaches, there is the Swan River to
enjoy for all manner of water-based activities.
Away from the coast, there is the beautiful
countryside of the Swan Valley and Perth Hills.
There were excellent park facilities to enjoy a
barbeque at throughout WA, none more so than
the world-renowned Kings Park. Other favourite
daytrip locations included the port of Fremantle,
Rottnest Island, Mandurah and Hillary’s Boat
Harbour for the children. Weekends were often
spent some three hours south of Perth in the
Margaret River area either exploring caves, winetasting or simply relaxing on the white sanded
beaches coasting the Indian Ocean.
essentially delivered by interventional radiologists.
Despite the undisputed credibility of many of
these latter programmes, the advantages of a more
contemporary and seamless training fellowship
are clear.
Rural attractions of Western Australia
Kalbarri (above) & The Pinnacles National Park (below)
Smith’s Beach, Yallingup (Margaret River). One of our favourite
weekend locations
The Future: Home and Down Under
The SCGH fellowship certainly fulfilled all my
prior expectations regarding surgeon-led
endovascular training. Although similar UK-based
training opportunities currently remain elusive,
this should improve over time as an increasing
number of true ‘vascular & endovascular
surgeons’ continue to be appointed at home. In the
interim, vascular trainees will have to decide
whether they are willing to travel or apply for
positions where endovascular training is
Conclusion
The SCGH fellowship is to be strongly
recommended, and has been one of the best
experiences of my professional career to date.
There is little doubt in my mind that the surgeondelivered endovascular training I received would
be difficult to better anywhere in the world. As
with all these oversees appointments, the main
piece of advice I’d give would be to plan well in
advance and research the fellowship extremely
carefully before committing. Unfortunately of
late, I have been made aware of a few Australian
endovascular fellowships that aren’t all that they
claim to be. Assuming that you do manage to get
a position in a similar set-up to SCGH, however,
you’ll be well set.
The anxiety for current UK trainees regarding
Australasian endovascular fellowships is that their
availability may soon become extremely limited.
Many native vascular trainees are beginning to
exercise their right to take up a supplemental year
of supervised experience at the end of their
training, prior to taking up a Consultant post. In
effect, this would reduce the number of
fellowships available for oversees trainees who
may end up having to look elsewhere such as
North America or mainland Europe.
NEWSLETTER
Floreat Beach - our local haunt. Only 5 minutes walk from City
Beach and typically as busy as is seen
One of the highlights of our entire year was a
family adventure we took in a hired six-berth
campervan up to Northern WA. During the
2200km round-trip to the unspoilt Ningaloo Reef
at Coral Bay for some diving, we took in the eerie
moonscape of the Pinnacles, Kalbarri and also
Monkey Mia where we were lucky enough to be
chosen to hand-feed the famous local dolphins.
Good on ya!
Acknowledgement
The Circulation Foundation for financial support
with a £5000 Endovascular Travel Grant.
51
A LETTER FROM MALAWI
It would not
have won any
prizes, or even
troubled the
scorers at the
City & Guilds
examinations –
we would
probably have
been sent away
with a large flea in our ear and told to go back
to page 1 of the manual – but, as we stood
before the wall we had built, there was an
unquestionable sense of pride and achievement
to be had. This was, when all was said and
done, the product of our own sweat and toil
and stood proudly against the African sky,
warts and all.
A LETTER FROM...
Nicholas Markham
The mission of the CharChar Trust is to help
end a legacy of poverty, not by telling Africa
how to meet the challenges many of us can
hardly grasp, but by helping Africans to find
their own solutions and determine their own
futures by providing them with the materials
they need to read and write, communicate,
teach and learn through English or their own
local languages.
As summer holidays go, this was about as
different as it gets. Sun, but no sun loungers;
filling fare but no gourmet. What had made a
Devon family opt for something so different?
Almost a year before, we had listened with a
deep sense of shock to the story of a British
family - a 10? year old girl and her parents - on
a walking safari in Zimbabwe. What had made
the elephant institute its lethal charge was
unclear - a perceived threat to its calf perhaps but after it was over, a grief stricken father was
left to try to find some meaning in his life, in
ruins without his wife and daughter.
Determined to honour their memory, he set up
a charity, the Char-Char Trust, to provide
educational facilities for African children - not
by giving money, but by practical action in the
building of schools and provision of books and
educational opportunities. Two thirds of
African children have no access to formal
education. Intensely moved by the story perhaps there was a chance to make a
contribution, do something practical and learn
some valuable lessons?
As it happened, a school in Suffolk (Culford)
assemble a party of sixth formers each summer
to go to Malawi to do just that, and contact with
them established that an extra two teenagers
52
and their
parents
would not
perhaps
destabilise
the
dynamics
too much. In
truth, in
accepting
that we join, they were taking a big risk that the
essentially unknown outsiders would not disrupt
the party.
And so it was that we touched down at
Lilongwe airport in Malawi one Saturday
afternoon in July, not quite sure of what exactly
to expect. A four-hour coach ride south to
Blantyre brought the first glimpses of Africa,
its people and the extraordinary scenery.
Coffin-makers manufacturing their wares and
selling them beside the road, alongside others
with foodstuffs of every description from piles
of maize to colourful fruits. Others with vast
arrays of old tyres presumably restored to some
sort of usefulness - whole communities seem to
exist by the roadside living their days in what
appeared to be a somewhat fruitless existence.
The greeting from the Culford school group
(who had arrived a few days before us) was
warm and genuine - each party finally able to
begin to answer the question of whether the mix
would work or not. For our parts, we did not
need to give it a second thought - this was an
exceptional collection of 16 children and their
five teachers, focused on the tasks that lay
ahead and eager to maximise every experience
this opportunity would give them.
The work was hard but it never seemed so.
Dried mud was
excavated and mixed
liberally with water
drawn from a nearby
(and often not so
nearby) well. Mixing,
not with tools, but with feet until a gooey mess
could be scooped by hands into wooden moulds
and then turned out onto the scorched earth to
dry out in shapes that were supposed to be
brick-like. We got better at it I like to think - as
with so many other tasks with which we were
completely unfamiliar - as time went on.
Dried mud makes
brick-like
structures (even in
our hands) but
will largely
disintegrate in the
rains unless they
are fired. The rural African version of the kiln
is a pile of bricks about two metres cubed with
spaces underneath the bottom two rows in
Once the
bricks had
been fired
(and for us,
this meant
using ‘one I
made
earlier’ as
the ones we
had created
would be weeks away from being ready) they
had to be transported to the site where they
would be used. No 3-ton HGV solution here –
just form a couple of lines of people and pass
the bricks, one at a time, along the lines until
the pile at the distant site had been recreated
some 100 metres away. Singing as the ‘pass the
parcel’ exercise continued somehow made the
whole experience so much more pleasurable,
even if we struggled to get the tunes right,
never mind the words. And still they smiled
with those big infectious grins.
A LETTER FROM...
What nobody (except perhaps Andy) had
expected, was the site and the cacophony of
sound that greeted us as we arrived. Seemingly,
the whole village had assembled - upwards of
100 men women and children, dancing and
singing and waving their welcome to the work
party. Through the dust clouds that their
enthusiasm had generated it became very clear
that their faces were as radiant as their minimal
clothing was threadbare. Such images remain
clearly imprinted on the soul - such happiness
despite such abject poverty. And just yesterday,
I found myself - just briefly - moaning that the
price of balsamic vinegar had risen again in
Tesco’s. One lesson, almost learnt.
which a fire
would be lit,
to burn for
days until
the heat had
filtered
through to
the top and
hardened all
the bricks.
Simple, yet seemingly remarkably efficient.
This was one of many examples where
necessity was able to prove the mother of
invention in the African bush.
We all stayed in an international school in
Blantyre (where Andy, the party leader, had
taught for several years before returning to the
UK to teach in Culford). Each day we would all
depart in the school bus for an hour’s journey
down some very bumpy tracks (let’s be honest,
more craters than divots) out into the depths of
the African bush to one of the four building
projects financed by the Char-Char trust or the
Methodist Relief and Development Fund.
Bit by bit, the walls of the classroom we were
building rose up. Somewhat wonky it may have
looked – we blamed the misshapen bricks – but
local folk were on hand to correct our mistakes
and realign and reposition where necessary.
Water had to be brought from the wells by
bucket – deftly carried on the head – and the
sand and cement mixed together in the correct
amounts to create mortar. Teams were assigned
to each of the tasks and would rotate regularly
to ensure that all the experiences could be
shared together.
Three days spent visiting an orphanage some
50 miles further south presented a different
53
A LETTER FROM...
54
sort of challenge. A handful
of unpaid volunteers looked
after about 100 orphans in
conditions that left most of
the party reeling in disbelief.
Children between the ages
of one and eighteen,
deprived of their parents
through the ravages of
HIV/AIDS, malaria or other causes, lived
together in a commune that was seemingly
devoid of all but the most basic of life’s needs.
Water and scraps of food were evident, but not
much else. Two
rooms – probably
about 6m square,
housed the boys and
the girls. That meant
50 in each room, yet
what bunk beds there
were would only
have catered for about a
third of them – the rest
would lie on the floor.
Most of the bunk beds
were broken and
essentially useless. Any
mattresses were so
dilapidated, filthy and flearidden that the bare floor
was probably a better
option anyway. Even
understanding the
importance of protection
against malaria - maybe
they didn’t, it was hard to know – had not
resulted in more that a couple of nets between
all of them. Their one communal building –
where they would eat and have some
semblance of teaching – had been rendered
useless when its roof had been blown off in a
recent storm, the same storm that had
destroyed their chicken hut and most of the
chickens with it. As we toured the premises
some of the party became visibly distraught
and the sense of utter helplessness was
universal. Yet even ‘though what we succeeded
in doing was barely a scratch on the surface,
after two days of making makeshift repairs to
the bunks, painting the walls, hanging
mosquito nets over each of the refurbished
beds and general cleaning, the consensus was
that we had really
done something
useful. And once
again the welcome
we were afforded
and the goodbyes
each day (and
especially when
we left for the last time) were a cacophony of
singing, music (improvised instruments testing
the very boundaries of ingenuity) and gleeful
noise that completely defied the desperate
nature of their plight. Yet again, we had a
reminder that ‘those who have nothing seem to
be the most tranquil’ and a more humbling
message would be hard to find.
Whilst it was true that much of what we saw
made us feel sad, there were so many things
that produced real joy and fulfilment. Africa is
stunningly beautiful and the expression ‘Malawi
is the warm heart of Africa’ is palpably true.
The landscape – especially when viewed as the
sun sets – can be stunning, and the people who
live there have a rich warmness to them which
completely belies their situation. The
camaraderie we enjoyed with the students and
staff from Culford School was remarkably
fulfilling and we made friendships that will last
a long time. We were truly impressed with them
and the energy and commitment they put into
the project. We are so grateful to them for
allowing us share their adventure and only hope
that they felt we had made something of a
positive contribution.
What now? Experience of life in Malawi has
resulted in an understanding of the need to
prioritise resources into education for the longterm benefit of its people. The work of the
Char-Char Trust focuses on such goals and we
would hope to be involved in other ways in the
future to support them. A re-evaluation of
personal priorities and objectives began before
we had even returned. To have experienced
what we did as a family was immensely
valuable and produced a measure of consensus
in many areas that otherwise might be
unobtainable between combatative teenage girls
and their stubborn parents. A couple of weeks
on the beach next summer will not be on the
menu, whatever else we decide.
New initiative for UK medical students launched
The UKMSA is a new student-doctor
collaboration, which aims to unite
over 40,000 medical students across
the UK and provide them with the
resources they need to maximise
their experience of university.
Fifth-year medical student Mahiben
Maruthappu is the founding
President of UKMSA, the United
Kingdom Medical Students’
Association, which also involves a
number of other professors, senior
clinicians, researchers and students.
Honorary Chairman is Lord
Walton of Detchant, a significant
figure in British medicine, being
the only person to have been
President of the British Medical
Association, the Royal Society of
Medicine and the General Medical
Council during his career.
“This is the first time medical
students across the UK have been
linked in this way to share
experiences and resources, wherever
they are studying,” explains
Mahiben. “We aim to provide free
resources to students nationwide,
including careers and examination
advice, information on research
opportunities, competitions and
prizes, grants, discounts on medical
books and equipment, podcasts and
an online forum. There are currently
a vast number of medically related
societies out there and the
opportunity to create and facilitate
links between them would have
significant benefits for students.”
The UKMSA will be holding its
inaugural International Medical
Student Conference on Wednesday
May 11th 2011 and the event is
kindly being hosted by the ASGBI
2011 International Surgical
Congress. Thus, as well as over
1500 surgeons attending the ASGBI
Congress, we hope to additionally
welcome over 300 medical students
to the UKMSA Conference at the
Bournemouth International Centre.
It is hoped that this will be one of
the largest and most prestigious
single-day medical student
conferences in Europe.
“We are delighted to be affiliated
with an organisation as impressive
and influential as the ASGBI,” says
Myura Nagendran, a fourth year
medical student and Vice-President
of the UKMSA. “Our annual
conference will be a fantastic
opportunity to bring medical students
together for networking and debate,
as well as giving them a chance to
present their scientific work through
posters. We feel strongly that it will
also facilitate productive dialogue
with students for the ASGBI, a
society keen to engage all levels of
medical professionals with an
interest in surgery.”
The student committee is guided
by an Executive Trustee Board of
which Professor Shervanthi
Homer-Vanniasinkam, a surgeon
with a significant interest in medical
student affairs, is a member. She
remarked that “…the UKMSA seeks
to provide medical students with a
forum to both interact, and further
their aspirations in medicine. In the
short time I have been associated
with the organisation, I have been
particularly impressed by their vision,
and the diligence with which they
pursue their goals. I would like to
take this opportunity to wish them
every success in their future
endeavours.”
Professor Robin Williamson, a
former President of ASGBI, had this
to say: “I remain closely involved with
the teaching of surgery and anatomy,
so it is a pleasure to be an Executive
Trustee of UKMSA. I am delighted
about the new affiliation with ASGBI,
an association with an Association
that is close to my heart.”
Guided by the vast experience of
the executive trustees which also
include such influential clinicians
and surgeons as Professor Sir
Graeme Catto, Professor Michael
Baum and Professor Christopher
Bulstrode, the student team hopes
to expand the UKMSA into the
premier go-to website and
umbrella organisation for UK
medical students seeking
information and support.
The organisation is currently
recruiting representatives across
medical schools nationwide. For
more information please visit
www.ukmsa.org or contact the
Vice-President Myura Nagendran
on:
[email protected]
THE SECRET LIFE OF …
Chris Imray
After climbing through
the night, the red glow
of dawn gradually
began to fill in the
eastern sky over the
vast Himalayas.
Nearby, the shadows of
Lhotse (8,516m) and
Makalu (8,462m) could
almost be felt and, over
150 miles away, Kanchenjunga (8,586m) was
silhouetted by the growing red, golden tinge that
was the horizon. At these altitudes, the horizon
dips perceptibly due to the gentle curvature of the
earth. With each breathless step, we had climbed
inexorably upwards until eventually we crested the
South Summit of Everest. An Xtreme dream was
about to be realised.
THE SECRET LIFE OF...
Caudwell Xtreme
Everest Medical
Research Expedition
Cho Oyu 2006
I first met Mike Grocott as a fellow ‘diplomat’ on the
UK Diploma in Mountain Medicine Course in 2003.
Mike had a plan which had seemed so ambitious as
to be verging on the foolhardy. He proposed a
medical research expedition to climb Everest. In
preparation, he organised an expedition to the sixth
highest mountain in the world, Cho Oyu (8,201m),
the aim to test both equipment and climbers at
extreme altitude. One of the pre-requisites for
inclusion in the Everest summit climbing team was
an uneventful prior ascent of an 8,000m summit.
On the summit of Cho Oyu (8,201m) with Everest and Lhotse
25 miles to the east
carry to the road-head. From there, it was a day by
jeep to the Tibetan/Nepalese border. As a result, I
thought I had lost out on any serious chance of
climbing the mountain. However, I managed to
catch up the others and summit with them. On the
return journey, Mike asked me to join the Xtreme
Everest Expedition. The difficult conversation with
my wife went along the lines “Darling, you know I
said I always wanted to climb an 8000m peak, well
there is just one more mountain...”
Everest 2007
The expedition was four years in the planning and
is the largest medical research expedition ever
undertaken. There were 200 participants, 22 tons
of equipment and the total cost was approximately
£2,000,000. The complex science programme
investigated the adaptation of the human body as
it acclimatises to extreme altitude, using the
shortage of oxygen as a possible model for
patients in intensive care units. The expedition
subsequently featured in BBC 2’s science
programme Horizon ‘Doctors in the death zone’.
Two months before the expedition left for Nepal,
the entire team underwent a week of baseline
testing. This was also the final opportunity to test
equipment before shipping it to Nepal.
Arrival in Nepal
After a somewhat fraught journey from the UK,
we arrived in Kathamndu. Our base, the Summit
Hotel, has wonderful walled gardens which act as
a haven of peace from the frantic hustle and bustle
of the streets of Kathmandu. We wandered around
this enigmatic city, visiting old haunts, finding
last bits of equipment and getting to know the rest
of the climbing group and our sherpa team. I
certainly felt a degree of nervousness as we
completed our preparations.
We flew from Kathmandu in a tiny propeller
driven plane getting incredible views of the
Himalayan chain. Lukla (2,860m) airstrip is
angled upwards at 15-20 degrees, which means
not only that it is the runway unfeasibly short, but
also that the pilot has only one attempt to get the
approach correct. At the ‘airport’ we were greeted
by a chaotic crowd of porters, sherpas, yak drivers
and lodge owners, each vying for potential
business. Trekking out of the village, the pace of
life slowed. On a typical day, one would walk for
a couple of hours on steep narrow mountain paths,
crossing swaying suspension bridges high above
the roaring Dudh Kosi, and then take tea at a
lodge, before moving on again.
I had started climbing as a teenager and, in the
following 30 years, had been lucky enough to have
climbed all over the world. For me, Cho Oyu
would be a quantum leap in altitude, and a
challenge which I felt at the time would probably
be beyond me, however this would be a once in a
lifetime opportunity and I managed to persuade
my wife to let me have to have just one crack at an
8000m peak.
Whilst climbing Cho Oyu, a climber from another
team had a stroke and we discussed at length who
should accompany the casualty to the border. The
next morning, with twelve Tibetan porters, I set off
with the patient across the glacier on a six-hour
56
Everest from Namche Hill (3,400m)
Khumbu Icefall and Western Cwm
The route climbs rapidly through some of the
most sensational ice landscape in the world. It
tackles the vertical seracs and the gaping
crevasses head on, using a combination of fixed
ropes and rickety aluminum ladder bridges
(using up to four tied together). In some ways,
the route is a sociable place as one meets friends
and climbers from other expeditions, but speed
is the essence for safety, since it reduces the
time spent in this exquisitely beautiful, but
hostile and potentially dangerous, environment.
Our strategy was to acclimatise elsewhere on
safer ground, so that we could move through the
icefall more quickly.
On the ladders in the icefall (6100m)
Lhotse Face
Coffee, tea or French onion soup?’ Was the
question Sundeep asked me, as we settled into
Camp 3, perched halfway up the Lhotse Face at
about 7,100m. The Face is a 1,500m (4,500ft) ice
and snow slope angled at between 40-50 degrees.
Our campsite (!) was a narrow strip of horizontal
space and had been carved out of the steep ice and
snow slope by our sherpas. On the one side blocks
had been cut out of the slope, and on the other the
blocks had been used to build up a ramp to give a
six foot wide horizontal terrace to place our tent.
The intention had been to spend the night at over
7,000m as part of the acclimatisation process. It was
a couple of hours before sunset, and we were just
settling down to a brew and the slow process of
melting snow in order to rehydrate ourselves, when a
crackle came over the VHF radio. The weather
forecast predicted a storm which threatened 2030cms of snow. The Lhotse Face is no place to be in
a snowstorm in particular because of the risk of
avalanche. The options were to sit the possible storm
out, and hope that the forecast was wrong so
completing our acclimatisation sojourn, or to pack
up rapidly and descend the fixed ropes and try to get
back to the safety of Camp 2 before dark. A rapid
conversation took place, and with safety paramount,
we packed up and abseiled down the fixed ropes,
getting into Camp 2 just as it was getting dark.
To begin with, the food seemed good, but over
time and with limited access to fresh food it
became increasingly dull. At times I felt I was
being forced to live out the Monty Python‘spam’
sketch with spam fritters, spam pizzas, and even
spam curry! Appetite suppression and weight loss
at altitude [1] are recognised phenomena and I
dropped from 80kg to 66kg during the expedition.
Basecamp
After ten days trekking, we arrived in Basecamp
(5,300m). This bleak and desolate spot on the
Khumbu Glacier was to be our home for the next
three months. The Khumbu Icefall dominates
Basecamp like no other glacier I know. Basecamp
is actually placed on the glacier itself and is on
the move in two ways all the time. Firstly, it is
melting fast and rocks and tents are left high and
dry as the surrounding ice melts giving the
impression of the tide going out. Secondly, the
entire camp is slowly on the move down the valley
and, every so often, there are pistol shot noises as
the ice readjusts its position.
On the long haul up to Namche Bazaar (3,800m),
we turned a corner and caught our first glimpse of
Mount Everest with a three mile plume of snow
generated by the jet stream. At 29,035 feet
(8,850m), every child learns that this is the
highest mountain in the world. It has been formed
by the up thrusting of land as two continental
plates collide, and is continuing to grow in height.
In 1856, the mountain was named after Sir George
Everest, the Surveyor General of India from 1830
to 1843, and was first climbed by Edmund Hilary
and Norgay Tenzing on May 29th 1953, just in
time for Queen Elizabeth II’s coronation.
We descended to Dingboche (4,280m) for a week
to eat, enjoying a menu of chicken burgers, yak
sizzlers and delicious Khumbu potatoes. Every
meal ended with at least one deep fried Mars bar.
Psychologically, leaving the relative ‘comfort’ and
safety of the yak herder’s village and returning to
the mountain was very difficult.
Crossing a crevasse in the Khumbu Icefall (6,200m)
Death Zone
All too soon, it was time to turn around and head
back up the mountain through the precarious
57
Khumbu Icefall, the immense and very hot
Western Cwm, up the steep and treacherous
Lhotse Face, through the Yellow Band, across the
Geneva Spur and finally up to the South Col
(7,980m). On first arrival, the South Col had a
deceptively benign appearance. In the sun and
without any wind, it was warm enough for T
shirts. It was only later, when the sun set and the
wind picked up, that we began to appreciate the
true harshness of the place. Temperatures
plummeted to as low as -35°C, and with oxygen
levels 1/3 of those found at sea level, we began to
appreciate what was meant by the term the ‘death
zone’ [2]. At this altitude, the body is deteriorating
all the time, and life is unsustainable for any
prolonged length of time. Without oxygen, even
simple tasks such as brushing ones teeth took on
gargantuan proportions, and it was necessary to
rest in order to complete the task.
Evening light on the South Col (7,950m)
Most teams arrive at the South Col in the early
afternoon, they then spend a few hours
rehydrating and sleeping before setting off on
their summit attempt somewhere between 9.00pm
and midnight. Our plan was different; we had the
most ambitious range of scientific experiments
ever undertaken at this altitude to undertake in the
world’s highest ‘laboratory’. We spent a day
setting up equipment, followed by two days of
experiments ranging from transcranial Doppler
cerebral perfusion studies to VO2 maximal bicycle
exercise tests [3]. At rest, and off supplemental
oxygen, our blood arterial oxygen saturations
were between 48-56%, and with exercise these
levels dropped further, understandably our bodies
were deteriorating continuously. In total, we spent
five nights on the South Col - we believe this is
the longest anyone has ever spent there.
Cardiopulmonary exercise testing and transcranial Doppler
measurements on the South Col (7,950m)
Whilst on the South Col, we became involved in
one of the highest rescues ever undertaken. A 22
year old woman with cerebral oedema, or brain
58
swelling, was found alone and unconscious at
8,500m by an American guide Dave Hahn. He
spent 30 minutes giving her his oxygen and, as
she began to rouse, he radioed down to the South
Col asking for assistance. We spent three hours
stabilising her in a tent, before a team of climbers
and sherpas began the long carry/lower down
through the Yellow Band and Lhotse Face to
Camp 3, arriving after dark. A second team spent
the night resuscitating her before she was lowered
the rest of the way down the Lhotse Face to Camp
2. She was finally carried through the Icefall to
Basecamp 5,300m (the altitude ceiling for
helicopters rescues) and flown to Kathmandu. She
has subsequently lost a couple of toes and the tip
of her thumb from frostbite [4], but has otherwise
has made a complete recovery.
Summit attempt
Ten sherpas and five climbers had set off from the
South Col (7,980m) at 9.30 pm on 22nd May. In a
bitterly cold wind, we had crossed the South Col
Glacier, and steep climbing had led to the 40°
Triangular Face. The spindrift driven by the strong
winds had filled in the previous steps, so breaking
trail was hard work. We arrived at the Balcony in
good time and took a short break, but a
combination of the cold, the dark and the wind
meant it was better to be moving. The cold clear
starlight night silhouetted the South Ridge, which
lead through a loose rocky section up towards the
South Summit. The head-torches of our party
twinkled above us as we tackled the steep rock.
Approaching the South Summit (8,690m)
After climbing through the night, the red glow of
dawn finally and gradually began to fill in the
eastern sky over the vast Himalayas. Nearby, the
shadows of Lhotse (8,516m) and Makalu (8,462m)
could almost be felt and 150 miles away
Kanchenjunga (8,586m), was silhouetted by the
growing red and golden tinge of the horizon. At
these altitudes, the horizon dips perceptibly with
the gentle curvature of the earth. With each
breathless step, we had climbed inexorably upwards
until eventually we crested the South Summit. An
Xtreme dream was about to be realized.
Between the South Summit and the Hillary Step,
there is a switchback ridge made up of huge
surreal whipped meringue cornices which
overhang both the Kangshung Face to the East and
the South West Face to the West. There was a
strong blustery cross wind and, with drops of over
8,000 feet on either side, clearly this was no place
to fall. The route twists and turns along a knife
edge ridge to reach the Hilary Step. This short
steep segment was adorned with a mass of rope,
mostly old and tatty, but there was at least one in
reasonable condition. Having surmounted the Step,
a further 200-300m of relatively flat ground led to
the summit of Everest, the highest point on earth.
arterial blood oxygen levels. Four of us underwent
femoral arterial stabs at 8,400m on the descent,
and a sherpa ‘ran’ these down to Camp 2 at
6,400m for analysis. This descent took us two
days, but Pasang managed it in two hours - with
time for tea at the South Col!
References
[1] Imray C H E, Wright A, Subudhi A and Roach R
Acute mountain sickness: pathophysiology,
prevention, and treatment.
Prog Cardiovasc Dis. 2010;52 (6): 467-84
[2] Firth P G, Zheng H, Windsor J S, Sutherland A I,
Imray C H E, Moore G W, Semple J L, Roach R C
and Salisbury R A
Mortality on Mount Everest, 1921-2006:
descriptive study.
British Medical Journal. 2008; 337: a2654. doi:
10.1136/bmj.a2654
[3] Wilson M H, Newman S and Imray C H E
The cerebral effects of ascent to high altitudes.
Lancet Neurology. 2009; 8 (2): 175-91.
[4] Imray C H E, Grieve A, Dhillon S, the Caudwell
Xtreme Everest Research Group
Cold damage to the extremities: Frostbite and nonfreezing cold injuries.
Postgraduate Medical Journal 2009; 85:481-488
At last it was possible to
climb no higher. There was
a mass of prayer flags
fluttering in the bitterly cold
and strong wind. It was so
cold that we spent the
shortest possible time on
Final few feet to the
the
summit. Initially, there
summit
was an enormous feeling of
elation shared with Mike,
Sundeep, Dan and Nigel, and huge thanks to Tashi,
the sherpa, who had shadowed me for the entire
climb. Then a few private moments were taken to
contemplate the effort and commitment required to
get to the highest point on earth. There was also
time to remember the support and prayers of those
nearest and dearest, and then it was time to leave
before the penetrating cold and hypoxia endangered
a safe return, focusing on each and every step of
the return journey.
View from the South Summit (8,690m) towards the Hilary
Step and summit (8,850m)
Conclusions
The mountain was climbed, everyone returned
home safely, and great friendships were forged.
Judged by conventional criteria, Mike Grocott has
lead one of the most successful Everest
expeditions ever. On the research side, tantalising
initial insights into the pathophysiology of
hypoxic ‘healthy’ individuals and the critically ill
are beginning to emerge. However, perhaps the
most remarkable aspect of the expedition were the
incredible sherpas. With enormous good grace
and humour, they performed amazing physical
feats often in a very dangerous environment and
under extreme hypoxia. Surely their genetic and
physiological adaptation offers the most obvious
line of research in trying to understand to the
response of humans to extreme hypoxia?
‘‘In four samples taken at 8400 m (27,559 ft) - at
which altitude the barometric pressure was 272
mm Hg (36.3 kPa) - the mean PaO2 in subjects
breathing ambient air was 24.6 mm Hg (3.28
kPa), with a range of 19.1 to 29.5 mm Hg (2.55 to
3.93 kPa). The mean PaCO2 was 13.3 mm Hg
(1.77 kPa), with a range of 10.3 to 15.7 mm Hg
(1.37 to 2.09 kPa).’’ [5]
[5] Grocott M P, Martin D S, Levett D Z, McMorrow
R, Windsor J, Montgomery H E; Caudwell Xtreme
Everest Research Group
Arterial blood gases and oxygen content in climbers
on Mount Everest.
NEJM. 2009; 360(2):140-9.
Amongst the summit prayer flags (8,850m)
Results
Although much data is still in the process of being
analysed, there are some interesting and
potentially important messages emerging from the
preliminary data [5]. Perhaps the most notable
being Mike Grocott’s paper in the NEJM on
arterial blood gases and oxygen content in
climbers on Mount Everest. It demonstrated that
individuals appear to be able to function
reasonable normally (!) with exceptionally low
Acknowledgements
The expedition was supported by John Caudwell,
BOC Medical, Eli Lilly, the London Clinic, Smiths
Medical, Deltex Medical, the Rolex Foundation,
the Association of Anaesthetists of Great Britain
and Ireland, the United Kingdom Intensive Care
Foundation, and the Sir Halley Stewart Trust.
Caudwell Xtreme Everest is coordinated by the
Centre for Altitude, Space, and Extreme
Environment Medicine, University College
London. http://www.case-medicine.co.uk/
59
WHEN VENUS CAME TO THE
AID OF AESCULAPIUS,
SURGERY TOOK ON A
WHOLE NEW DIMENSION
In 1890, Dr William Stewart Halstead,
surgeon-in-chief and later professor of
surgery at the newly opened Johns Hopkins
University Hospital in Baltimore, USA
wanted to find a solution to his chief nurse
(and fiancée) Caroline Hampton’s severe
dermatitis caused by contact with the carbolic
acid they routinely used at the time to
sterilise their hands.
CORPORATE PATRONS
Few would have thought that the very first
surgical glove to be produced using rubber
would have been born out of a love affair
between a surgeon and his assistant. But that
is precisely what happened.
Halstead approached the Goodyear Rubber
Company to see if it was possible to make a
pair of thin rubber gloves that could be dipped
in carbolic acid without compromising its
ability to perform well during surgical
procedures and ensure adequate protection for
the hands. And the result was the world’s first
rubber operating glove.
The process involved in manufacturing
surgical gloves has come a long way since the
early days of this innovative frequent use,
multi-procedural, glove that was pioneered by
Halstead more than a century ago. Today,
latex surgical gloves undergo a multi-stage
process to ensure ease of donning, grip,
sensitivity, fit and the comfort characteristics
required in the modern surgical environment.
But before they reach hospital theatres, surgical
gloves must undertake a comprehensive and
often demanding journey which starts
thousands of miles away at the
very source of the
manufacturing process Southeast Asia.
Tapping into
resources
Southeast Asia
is the centre of
rubber activity
and home to the largest number of rubber
plantations in the world, with the three
biggest producers (Malaysia, Thailand and
Indonesia) accounting for 72 per cent of
global natural rubber production.
While the sourcing of raw materials such as
oil or natural gas employ sophisticated
technology, tapping a rubber tree to extract its
latex remains an antiquated, manual process
that has remained relatively unchanged since
the days of the Olmec’s in Mexico around
1,000BC, with each tree capable of producing
liquid latex for around 25 years.
Starting the manufacturing process
Before the latex leaves the plantation, it needs
to undergo a process of centrifugation to
reduce the level of water content within the
latex from between 70 and 80 per cent to 30
per cent. Once this has been done, it is
transported to the factory where modern
technology comes into play and man and
machine work in tandem to convert the latex
into favourable surgical glove material. Now
the manufacturing process really begins. At
this stage, the latex must be formulated with
chemical compounds to ensure the end
product has sufficient tensile strength, and
anti-oxidants added to improve the shelf-life
of the finished product.
The next step takes the glove formers (or
moulds) through a series of stages of
‘dipping’ to achieve the desired elasticity and
thickness (controlled by the amount of time
spent in the latex) of the glove before
subjecting it to a leaching process which
removes all the excess residual chemicals and
proteins from the surface of the latex itself.
But the cleansing process does not end there.
Having been shaped and given their glove-like
aesthetic by the formers, the gloves are then
placed in a tumbler where they will be doused
and chlorinated in a chlorine water or
hypochlorite-hydrochloric acid mixture. This
serves to harden the surface and optimise
performance of the glove in wet and dry
60
Quality control
Whilst the factory conducts a series of
rigorous tests prior to shipping, sometimes
the freight can take a month or longer to
reach the UK from Southeast Asia, by which
time the gloves properties can be altered. To
ensure that Biotex GL and Synthesis’
surgical gloves exceed all existing UK and
European regulatory requirements, Polyco
will re-test the gloves at point of distribution
in the UK to ensure the products perform
above the industry standard.
Formed in 1979, the company pioneered the
concept of tailoring products to match the
needs of our customers. And, through
continual investment in research and product
development combined with a reputation for
innovation, quality and exceptional levels of
customer service, BM Polyco has set the
standard for an industry that is constantly
under pressure to meet and respond to the
increasing demands of the modern
healthcare sector.
Dr Halstead is heralded as the father of
American surgery and is credited as being the
first surgeon to use rubber gloves in the
operating theatre. Ironically, the very hand he
wanted to protect he was soon to take in
marriage in a move that many of the
Halstead’s peers regarded as “Venus coming
to the aid of Aesculapius” – although it is not
clear if the gloves had anything to do with it.
Sterilisation
With the coating, rinsing and drying process
complete, the surgical gloves are ready for
testing and sterilisation using gamma
irradiation. Gamma rays penetrate the sealed
packaging and kill any living organisms
inside. This irradiation process is conducted
remotely as gamma radiation would also kill
any person within close proximity.
British company, world-class reputation
BM Polyco is the largest British-owned
manufacturer and provider of hand and arm
protection in Europe, and the first surgical
glove manufacturer in the UK to be
approved as Corporate Patron of the
Association of Surgeons of Great Britain
and Ireland, in recognition of their
technically advanced Biotex GL surgical
glove.
CORPORATE PATRONS
Because the medical profession is moving
away from powdered latex gloves in light of
latex allergy concerns, surgical gloves such as
Biotex GL and Synthesis by Polyco have
polymer coatings on the inside which reduce
the amount of friction between wet skin and
the gloves allowing them to be damp and
intra op donned with greater ease than their
uncoated counterparts. This further reduces
incidences of hand fatigue as a consequence
of prolonged surgical glove use.
conditions (grip), coat the exterior and remove
the stickiness which impedes smooth donning.
61
After three very successful years in post, Mike Wyatt is demitting office,
at the conclusion of his term, at the Association’s AGM in May 2011.
ASGBI now seeks, therefore, to appoint a successor as
HONORARY EDITORIAL SECRETARY
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NEWSLETTER
A Job Description is available, via the ASGBI website, at:
www.asgbi.org.uk/appointments
Appointment to this post will be by competitive interview, and applications, in the form
of a covering letter and a brief CV, should be received by the closing date of
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Applications should be emailed, in confidence, to:
The Association produces a professional portfolio of publications including a quarterly Newsletter, frequent
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of Issues in Professional Practice booklets. The Honorary Editorial Secretary assumes responsibility for the
Association’s publications and takes an active part in the management and strategic direction of ASGBI. The post is
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63
MASSIVE UPPER
GASTROINTESTINAL
HAEMORRHAGE FROM THE
CYSTIC ARTERY: A RARE
COMPLICATION OF
DUODENAL ULCERATION
66
CASE STUDIES
D A Lees, D W Borowski, S Filson, S M Griffin
and J Shenfine
Northern Deanery and Royal Victoria
Infirmary, Newcastle upon Tyne
Summary
A 56 year old man with a history of alcohol excess
presented with refractory upper gastrointestinal
bleeding from an anterior duodenal ulcer. This was
initially managed with endoscopic injection
therapy. Subsequent haemorrhagic shock
necessitated emergency laparotomy during which
it was discovered that the cystic artery had been
eroded by the previously noted ulcer. Ligation of
the bleeding vessel was curative and the patient
made a full recovery. Erosion of the cystic artery
secondary to duodenal ulceration is a rare cause of
upper gastrointestinal haemorrhage, but should be
considered in cases of refractory bleeding from an
anterior duodenal ulcer as this is difficult to
manage endoscopically, whereas urgent
laparotomy could be life-saving.
Case Presentation: Part One
A 56 year old male was admitted as emergency at
21.35 hrs with a 24 hour history of a mixture of
melaena and fresh red rectal bleeding on a
background of dyspeptic symptoms for the
previous week, chronic alcohol dependency and
long-term non-steroidal treatment for polyarthritis.
Initially, the patient was haemodynamically stable
with a haemoglobin count of 11g/dL, normal
clotting profile, urea of 8.2mmol/L and creatinine
of 59µmol/L. However, at 05.00 hrs (7? hours post
admission), the patient experienced further fresh
red rectal bleeding and became haemodynalically
unstable with a decreased level of consciousness
(GCS 14-13/15, BP 70/50mmHg, pulse 150 bpm,
respiratory rate 30/minute). A repeat haemoglobin
count was now 4.5g/dL, urea 7.0mmol/L, and
creatinine 56µmol/L. The patient was resuscitated
and stabilised with intravenous colloid, 6 units of
packed red cells and 2 units of fresh frozen
plasma. Urgent upper gastro-intestinal endoscopy
demonstrated an anterior ulcer with no active
bleeding. Nevertheless, the ulcer was injected with
1:10000 adrenaline and this was thought to be
successful. An intravenous bolus of 80mg
Omeprazole was given and an 8mg/hr infusion
commenced. Post transfusion haemoglobin was
measured at 9.7g/dL. Despite this, at 16.00 hrs
(18? hours post admission and 11 hours after his
last bleed), a further episode of bright red rectal
bleeding occurred with haemodynamic instability
(GCS 12/15, BP 70/50: increasing to 92/61mmHg
with 1L colloid, pulse 123bpm, respiratory rate
26/minute) requiring further 4 units of packed red
blood cells. Haemoglobin had again dropped to
7.9g/dL, urea 4.6mmol/L and creatinine 65µmol/L.
Blood gasses were recorded as pH 7.402, pCO2
5.19, pO2 37.13, act HCO3 23.7, base excess -1.0,
glucose 6.8, lactate 2.96, O2 saturation 99.7%.
1. What has happened to the epidemiology of
upper gastrointestinal bleeding since the
advent of proton pump inhibitors (PPIs) and
endoscopic therapies?
The development of histamine H2-receptor
antagonists, proton pump inhibitors and
Helicobacter pylori eradication therapy has greatly
improved the management of peptic ulcer disease
and it was assumed that this would reduce the
incidence of ulcer-associated upper gastrointestinal
bleeding. Although an association with a reduced
re-bleeding and surgery has been demonstrated, the
incidence (1500-3000 per 100 000 population per
year) and overall mortality (1 in 13 overall, but 1
in 5 in people using ulcerogenic drugs) [1] remains
unchanged. The widespread use of non-steroidal
anti-inflammatory drugs, aspirin and clopidogrel
increases the risk of ulcer development by 5 to 8
times [2 to 4], estimated to be responsible for 24%
of the overall incidence [5]. Whilst proton pump
inhibitors are effective for the management of nonbleeding ulcers, their exact role in the management
of bleeding ulcers is controversial and unclear [6].
2. What are the most common causes of acute
upper gastrointestinal bleeding?
• Duodenal or gastric ulcer.
• Oesophageal or gastric varicies.
• Mallory-Weis tear.
• Oesophagitis/gastritis.
• Neoplasm.
• Angiodysplasia.
3. What scoring systems can be used to predict
mortality and morbidly and the risk of rebleeding?
When selecting patients with upper GI bleed for
intervention, the endoscopic appearances (Forrest
classification) is often used as a tool for
stratifying patient’s mortality and re-bleeding risk
[9]. Similarly, the Rockall and Blatchford scoring
systems have their place, but all systems
essentially ‘quantify’ common sense, it is no
surprise that patients with ‘spurting haemorrhage’
have a high re-bleeding rate nor that patients with
shock, major associated co-morbidity, cancer and
organ failure have a high mortality rate (see
Tables 1 to 3).
4. What are the endoscopic
therapeutic options?
The management of acute upper gastrointestinal
bleeding (UGIB) has been revolutionised by
endoscopy with the risk of re-bleeding reduced
from 50-80% to as low as 10% with combination
techniques. Endoscopic intervention for UGIB
reduces the risk of re-bleeding or continued
bleeding, the need for surgery, the transfusion
requirement and total length of hospital stay.
Endoscopic therapeutic options include:
1. Injection therapy (dilute epinephrine or
sclerosants).
2. Ablative therapy (thermocoagulation,
electrocoagulation, Argon plasma coagulation,
cryotherapy, photocoagulation, dual therapy
devices: electrocautery with needle injection,
electrocautery with mechanical therapy).
3. Mechanical therapy (haemoclips, suture/snare
devices or band ligation).
Therapeutic modalities reduce the risk of rebleeding in patients with peptic ulcer disease with
stigmata of recent haemorrhage to about 20%.
However, studies now support combination of
therapies, such as epinephrine injection (see
Figure 1) followed by an ablative or mechanical
therapy. A re-bleeding rate of only 4% was
demonstrated in patients
treated with a combination
of epinephrine and
haemoclip therapy
compared to 21% for those
receiving epinephrine
injection alone (n= 105)
[11]. This data is supported
by randomised controlled
Figure 1: Injection of
trial evidence [12].
Epinephrine
5. Do PPIs make any difference?
A Cochrane review in 2006 of 24 randomised
controlled trials (n=4373) demonstrated the
superior efficacy of PPIs compared to H2-receptor
antagonists or placebo. PPI treatment significantly
reduced re-bleeding (odds ratio (OR) 0.49; 0.37 to
0.65), surgical interventions (OR 0.61; 0.48 to
0.78) and further endoscopic haemostatic
treatment (OR 0.32; 0.20 to 0.51) at a confidence
interval of 95%. There was no evidence of PPI’s
reducing all-cause mortality, however, a
significant reduction was demonstrated when the
analysis was restricted to patients with high-risk
endoscopic findings of active bleeding or a nonbleeding visible vessel [13].
Figure 2: View of ulcer during laparotomy
Table 3: Forrest Classification [10]
CASE STUDIES
Table 2: Blatchford Scoring System[8]
Score <4 predicts resolution without intervention
Score >5 indicates intervention required
The gentleman was brought into theatre suite
and, despite being stable during transfer, whilst
in the anaesthetic room he became unstable. The
patient was transferred immediately to theatre
and an emergency upper midline laparotomy was
performed. There was no free blood in the
peritoneum but the anterior duodenum was
closely applied to the neck of the gallbladder.
This was pinched off to reveal a 15mm anterior
duodenal ulcer which had eroded into the
gallbladder neck and the cystic artery, which was
the source of the ongoing blood loss (see Figure
2). The cystic artery was ligated and divided,
with no apparent loss of viability of the
gallbladder. Due to the patient’s instability, the
decision was made to preserve the gallbladder
assuming sufficient collateral blood supply. The
duodenal ulcer was closed with an omental
(Graham) patch repair. After 24 hour stay on the
Intensive Care Unit, the patient was transferred
to ward-level care and made an uneventful
recovery. He was discharged 12 days postoperatively and reviewed as out-patient at six
weeks with no further symptoms.
Table 1: The Rockall Scoring System[7]
A score of less than 3 indicates a good recovery
A score >8 indicates a high risk of mortality
Case Presentation: Part Two
Aggressive resuscitation was commenced with
high flow oxygen, colloid and packed red blood
cells. A further 7 units of packed red blood cells
were given. Outreach services and the Intensive
Care Unit were notified and attended the ward to
assist with resuscitation. The on-call upper
gastrointestinal surgical consultant made the
decision to proceed immediately to theatre. The
plan was to re-endoscope in theatre under
general anaesthetic as the previous endoscopist
had struggled to maintain a clear view of the
anterior duodenum.
6. When should an operative approach be
considered?
Non-variceal bleeding that continues despite
endoscopy requires surgical intervention. Repeat
endoscopy can confirm ongoing bleeding and a
further attempt made at achieving haemostasis.
Clinical judgement, local experience and expertise
dictate subsequent management. For the majority,
a policy of close observation with the decision to
proceed to laparotomy if bleeding occurs for a
second time. However, the patient’s age, comorbidities and high risk endoscopic findings
may demonstrate that a semi-urgent surgical
intervention may prove to be in the patients’ best
interests [14].
67
7. Should we have removed the gallbladder?
CASE STUDIES
The gallbladder was placed at a significant risk of
ischaemia and infarction as the cystic artery is an
end vessel and cholecystectomy should have been
strongly considered at the time of laparotomy.
Furthermore, if gallstones had been present this
would further strengthen the case for removal.
However, cholecystectomy was not done in the case
described as there was no evidence of gallstones at
the time of surgery and the gallbladder was well
perfused with a collateral blood supply.
8. What are the learning points from this case?
• When presented with a refractive upper
gastrointestinal haemorrhage unresponsive to
initial endoscopic therapy, laparotomy should
not be delayed.
• It is common to assume that an ‘anterior’
duodenal bleed is simply an endoscopic error
but other causes such as cystic artery erosion
should be considered as, although this is not
common, endoscopic access to the bleeding
point is not easily achieved and early surgery
may be indicated.
• Angiography would delineate the source of
bleeding and allow embolisation, but this may
result in gallbladder infarction. Definitive
treatment should not be delayed if radiological
embolisation is not to be undertaken, thereby
placing an already compromised patient at
further risk of mortality.
References
[1] Zittel TT, Jehle EC, Becker HD.
Surgical management of peptic ulcer disease today indication, technique and outcome. Langenbecks Archives
of Surgery 2000;385(2):84-96.
[4] Henry D, Dobson A, Turner C.
Variability in the risk of major gastrointestinal complications
from non-aspirin non-steroidal anti-inflammatory drugs.
Gastroenterology 1993;105(4):1078-1088.
[5] Kurata JH, Nogawa AN.
Meta-analysis of risk factors for peptic ulcer Nonsteroidal antiinflammatory drugs, Helicobacter pylori,
and smoking.
Journal of Clinical Gastroenterology 1997;24(1):2-17.
[6] Leontiadis GI, Sharma VK, Howden CW.
Systematic review and meta-analysis of proton pump
inhibitor therapy in peptic ulcer bleeding
British Medical Journal 2005; 330(7491):568.
[7] Rockall TA, Logan RF, Devlin HB, Northfield TC.
Risk assessment after acute upper gastrointestinal
haemorrhage.
Gut 1996; 3:316-321.
[8] Blatchford O, Murray WR, Blatchford M.
A risk score to predict need for treatment for uppergastrointestinal haemorrhage.
The Lancet 2000; Oct 14(356):1318-1321.
[9] Heldwein W, Schreiner J, Pedrazzoli J, Lehnert P.
Is the Forrest classification a useful tool for planning
endoscopic therapy of bleeding peptic ulcers?
Endoscopy 1989;21(6):258-262.
[10] Forrest JA, Finlayson ND, Shearman DJ.
Endoscopy in gastrointestinal bleeding.
The Lancet 1974;17:394-397.
[11] Lo CC, al. e.
Comparison of hemostatic efficacy for epinephrine
injection alone and injection combined with hemoclip
therapy in treating high-risk bleeding ulcers.
Gastrointestinal Endoscopy 2006;63:767-773.
[12] Chung SS, al e.
Randomised comparison between adrenaline injection
alone and adrenaline injection plus heat probe treatment
for actively bleeding ulcers.
British Medical Journal 1997;314:1307-1311.
[2] Svanes C, Ovrebo K, Soreide O.
Ulcer bleeding and perforation: non-steroidal antiinflammatory drugs or Helicobacter pylori.
Scand J Gastroenterol Suppl 1996;220:128-31.
[13] Leontiadis GI, Sharma VK, Howden CW.
Proton pump inhibitor treatment for acute peptic ulcer
bleeding.
Cochrane Database of Systematic Reviews 2006 (Issue
(1):CD002094.).
[3] Garcia Rodriguez LA, Jick H.
Risk of upper gastrointestinal bleeding and perforation
associated with individual non-steroidal antiinflammatory drugs. Lancet (North American Edition)
1994;343(8900):769-772.
[14] Palmer KR.
Non-variceal upper gastrointestinal haemorrhage:
guidelines.
Gut 2002;51:iv1-iv6
TOTAL MIDLINE ECTOPIC
THYROID
N N Basu, D F Sallomi and P H Rowe
Eastbourne District General Hospital
aspiration cytology of the mass was inconclusive.
An isotope scan confirmed that all of the patient’s
active thyroid tissue was contained in this region
(see Figure 2).
Clinical Presentation
A fifty-one year old gentleman presented
with a painless lump in the upper midline
of his neck (see Figure 1). This mass had
been slowly increasing in size over many
years. The patient’s primary concern was
cosmesis. There were no systemic
symptoms. Clinical examination revealed
a three-centimetre tumour readily visible
in the anterior midline of the neck,
immediately below the hyoid bone. No
cervical lymphadenopathy was present.
Blood tests, including thyroid function,
were normal. An ultrasound scan of the
neck suggested a multinodular centrally
elevated thyroid gland. Fine needle
68
Figure 1: Solitary lump in the midline of the upper neck – below the
hyoid bone.
Question?
What is the differential diagnosis of a midline
neck mass?
Answer
More common in children. Differential in all age
groups include: thyroglossal duct cysts, sebaceous
cysts, dermoid cysts, lymph nodes, lipomas,
neoplasms and ectopic thyroid tissue[1].
Question?
What is the embryological origin of the thyroid
gland and its relationship to pathology?
Answer
The thyroid develops from a midline endodermal
proliferation between the tuberuclum impar and the
hypobranchial eminence in the fourth week of fetal
life. This subsequently descends anteriorly and
remains attached to the foramen caecum by a
tubular stalk, the thyroglossal duct [2]. The
Question?
What is the main complication of ectopic thyroid
tissue?
Answer
Malignant transformation has been reported in
ectopic thyroid tissue. All common types of
thyroid malignancy have been seen, the majority
of tumours being papillary in nature. It is not
known whether ectopic thyroid tissue is more
likely to undergo malignant transformation.
Studies suggest that ectopic thyroid tissue does
not pose a threat to children, but carcinoma has
developed in older patients. Current
recommendations are removal of ectopic thyroid
tissue after the age of thirty years because of the
risks in later life. The case reported here would
support this recommendation.
Histological analysis confirmed a multinodular
thyroid containing a large cellular lesion, which
was mixed solid and follicular in architecture.
This area showed considerable pleomorphism,
was non-encapsulated and showed no definite
vascular invasion. The nuclei did not show the
features of a papillary carcinoma, and in some
areas the nucleoli were prominent in otherwise
generally round open nuclei. Local invasion was
present in some areas. The conclusion was that of
a low-grade microinvasive follicular carcinoma,
probably related to its origin in developmentally
abnormal thyroid.
CASE STUDIES
Question?
What is thyroid ectopia?
Answer
It is defined as any functioning
tissue not located anterior or lateral
to the second, third or fourth
tracheal rings. This tissue may be
Figure 2: Anterior planar image of a Technetium-99m thyroid uptake scan which present at any position along the
demonstrates a large rounded focus of increased uptake high within the neck.
course of the descent of the
This is in the midline below the level of the submandibular gland. A note is made thyroglossal duct. Ninety percent of
of the marker representing the level of the suprasternal notch.
cases occur at the foramen caecum,
known as a lingual thyroid, and is
The patient proceeded to Sistrunk’s operation and
more prevalent in females (78%)
[3]. Total thyroid ectopia is rare, accounting for
at the time of surgery it was obvious that the
thyroid gland was absent from its normal
1:6,000 cases of thyroid pathology. Total midline
anatomical position. The postoperative course was
ectopic thyroid has been reported in patients of all
unremarkable and he was discharged on thyroid
ages, but the majority of cases in the literature
replacement therapy.
apply to patients under the age of thirty [4].
thyroglossal duct becomes bilobed
and reaches its final position
(anterior to the upper trachea and
below the thyroid cartilage) by the
seventh week of embryological life.
The hyoid bone develops from the
second and third branchial arches
laterally and fuses in the midline in
close association with the
thyroglossal duct. Thyroglossal cysts
occur when the duct fails to fuse
correctly or where epithelial cells
may persist at any level during its
course. The attachment to the
foramen caecum accounts for the
clinical sign of protrusion of midline
swelling on protrusion of tongue –
pathognomic for thyroglossal cysts.
References
[1] Damiano A, Glickman A B, Rubin J S and Cohen A F
Ectopic thyroid tissue presenting as a midline neck mass
Int J Paediatric Otorhinolaryngology 1996. 34:141-48
[2] Al-Dousary S
Current management of thyroglossal duct remenant
J Otolaryngology. 1997 26(4):259-265
[3] Okstad S, Mair I W S, Sundsford J A, EIde T J and
Nordrum I
Ectopic thyroid tissue in the head and neck
J Otolaryngology. 1986 15(1):52-55.
[4] Gibson J R and Noblett H R
Suprahyoid median ectopic thyroid
Aust Paediatric J 1977. 13:49-52.
69
CONFIDENTIAL REPORTING SYSTEM IN SURGERY
70
This issue of Feedback contains cases which, once again, highlight the need for appropriate preoperative checks. The problem of lack of familiarity with new equipment is a perennial cause for concern.
Always ensure that you know how the equipment you intend to use works, that the necessary
components are present and functional and that you’ve practised using the new equipment BEFORE
encountering your patient.
We are grateful to the clinicians who have provided the material for these reports. The on-line reporting
form is on our website www.coress.org.uk which also includes all previous Feedback Reports.
Published contributions will be acknowledged by a “Certificate of Contribution” which may be included
in the contributor’s record of continuing professional development.
FLAMING (N)ECK
An elderly patient was admitted for day case surgery to
excise a lipoma from the back of her neck under local
anaesthesia. The patient was placed prone, the
operation site was cleaned with an alcohol-based skin
preparation and draped. The patient was given mild
sedation and oxygen through nasal cannulae. It appears
that the disinfectant solution had collected in the
patient’s hair because, when diathermy was applied to
cauterise a small wound edge bleeding point, the
patient’s head was suddenly engulfed in flames. The fire
was rapidly extinguished but left small burns to one ear
and loss of a large portion of hair.
Reporter’s Comments:
Several factors contributed to this incident. A flammable
skin preparation was used and the presence of residual
alcohol after cleaning went unrecognised. Accumulation of
oxygen from the nasal cannulae beneath the drapes may
have acted as an accelerant. The diathermy spark acted
as an ignition source. Always be vigilant to the risk of
surgical fires, particularly when operating on head or neck
or in areas where a skin preparation solution may pool.
CORESS Comments:
All alcohol preparations are flammable. Even lower
concentrations of alcohol containing solution (eg.
(Ref: 96)
povidone-iodine containing 30% alcohol) carry a
moderate flammability risk with a documented flash
point of 34°C [1].
There should be no hazard if alcoholic preparations are
used correctly:
• The amount used should be adequate to keep the site
wet for the recommended time.
• Sufficient time must be allowed for alcohol-based skin
preparations to dry thoroughly before commencing
the procedure, to ensure that all combustible
ingredients have evaporated.
• The preparation should be allowed to evaporate
completely before electrocautery, diathermy or laser
instruments are switched on.
• Pooling of excess liquid below the patient, or in cavities
or bodily contours, should not be allowed to occur.
Reference
[1] Recommendations for Surgical Skin Antisepsis in
Operating Theatres. Centre for Healthcare Related
Infection Surveillance & Prevention (CHRISP),
Queensland Health, August 2009
http://www.health.qld.gov.au/chrisp/resources/rec_prac_skinprep.pdf
CONSECUTIVE CHOLECYSTECTOMIES?
A middle-aged female patient was referred to the
outpatient clinic with a history of intermittent right upper
quadrant pain and the report of an ultrasound scan,
performed at a local community hospital, which
described a contracted gallbladder with multiple
gallstones. She gave a past history of appendicectomy
and laparoscopic hernia repair, both performed more
than 10 years previously. She was booked for elective
laparoscopic cholecystectomy and seen in the preassessment clinic which elicited the same history of
previous surgical procedures.
On the morning of her surgery, she underwent
informed consent for laparoscopic cholecystectomy
when the procedure to remove her gall bladder was
explained to her. At laparoscopy, adhesions around the
gallbladder fossa were found and, when these were
taken down, she was found to have no gallbladder. A
second opinion was sought from a hepatobiliary
surgeon, who confirmed the findings. After surgery, a
frank discussion took place with the patient and it
transpired that the patient had previously had “an
operation on her gallstones”, but thought that she still
had a gallbladder.
(Ref: 99)
She made an uncomplicated recovery and went home.
A critical incident form was completed.
An incomplete past medical history was obtained from
this patient, perhaps because of her lack of
understanding of previous treatment, and this was
compounded by an erroneous ultrasound report,
leading to inappropriate surgery.
CORESS Comments:
An ultrasound is best interpreted as a dynamic
investigation. Without the scan itself, many surgeons
would accept a report from an ultrasonographer known
to them. However, an ultrasound scan is relatively
cheap and easy to repeat. Surgeons should maintain a
high index of suspicion and a repeat scan should have
been undertaken pre-operatively in any circumstances
of doubt. A check of the date of the ultrasound report
was essential since the reported scan may have
preceded the patient’s previous surgery. Finally, if the
patient had been given a copy of the discharge
summary following previous surgery, this might have
helped to resolve her (and the surgeon’s) confusion
about past procedures.
MISSING KIT MISHAP
(Ref: 95)
This occurred pre-WHO checks which, if then in
existence, might have saved the day. Always ask the rep
to bring TWO of everything – there is always the
possibility of stapler failure, dropping the handle on the
floor, de-sterilisation, etc.
CORESS Comments:
This case is one of several, recently received by
CORESS, in which operative delays have occurred
because vital equipment was missing. ALWAYS check,
yourself, that the correct equipment is present, that the
parts match and can be assembled and, preferably, that
a spare is available. Particularly when using new
equipment, make sure you are familiar with its operation
and assembly of component parts. If possible, practice
using the equipment in a simulated setting first.
TRACHEOSTOMY CONFUSION
A tracheostomised patient, with no available previous medical
records, was admitted requiring urgent abdominal surgery.
The patient was only able to give a limited verbal history to
the on-call anaesthetists. The patient was handed over to a
new on-call team before surgery, and a trainee re-assessed
the patient in the anaesthetic room. On hearing the patient
speak, the doctor assumed the upper airway was patent and
pre-oxygenation was attempted via a face mask. It became
rapidly apparent there was no oropharyngeal communication
with the trachea, and that the patient had a tracheostomy
tube sitting in an end-tracheal stoma, with an indwelling
tracheo-oesophageal valve permitting speech. Anaesthesia
and ventilation were delivered via the tracheostomy, and the
rest of the procedure was undertaken uneventfully.
With improving outcomes from chemo and radiotherapy
and organ preserving surgery, patients with
laryngectomies are seen less frequently. Tracheostomy
care is increasingly delivered by specialist nurses and,
(Ref: 97)
as a result, junior doctors gain little experience in
tracheostomy management.
CORESS Comments:
Some tracheostomised patients may still have a patent
upper airway, permitting delivery of gases, and
occasionally intubation, but this must never be assumed.
Most laryngectomy patients will have a visible permanent
stoma in the neck, but some wear a bib, external oneway valve, or retain a tube to prevent stomal closure.
Many laryngectomy patients have indwelling tracheooesophageal valves allowing them to produce oral
speech, therefore the ability of the patient to speak must
not be taken as a sign of upper airway patency.
This case highlights, once again, the importance of good
handover communications, appropriate use of preoperative checks. CPR training should include the care of
tracheostomised patients, and all doctors should be aware
of the principles of safe management for such patients.
URETHRAL BALLOON INFLATION DURING URINARY
CATHETERISATION
An elderly male with known prostate cancer, in addition to
colonic cancer with liver metastases, developed urinary
retention and was referred to hospital where a Foundation
Year 1 doctor performed urethral catheterisation.
Catheterisation was painful and the balloon of the catheter
was inflated although no back flow of urine was obtained.
The doctor left the ward with instructions to contact her in
2 hours time if no urine had passed. After two hours, no
urine had passed and the patient began passing frank
blood and clots. The catheter balloon had been inflated in
his prostatic urethra causing trauma. Urological assistance
was obtained and the catheter inserted into his bladder
with drainage of urine prior to inflating the balloon.
The next day the patient had passed 2500ml of frank
haematuria, and the bleeding continued. The patient had
abnormal clotting secondary to his liver metastases. After
consultation with the haematologist, the patient was
treated with fresh frozen plasma 15ml/kg and vitamin K
10mg IV for 3 days. Following this, the haematuria
ceased and the patient was discharged to palliative care.
CONFIDENTIAL REPORTING SYSTEM IN SURGERY
I was performing a laparoscopic gastric bypass on a
male patient with a BMI of 54, and had arranged with a
surgical instrument company representative to try out a
new circular stapling head for gastro-enteric
anastomosis. Everything was going smoothly and I had
placed the new circular stapling head, when I asked the
representative for the laparoscopic handle portion of the
stapler to complete the anastomosis. A silence ensued,
the rep went pale, and I felt that trickle of perspiration
between the shoulder blades when she told me she had
only brought the standard handle, which did not match
the head. I waited in vain whilst efforts were made to
obtain another handle, but eventually converted to a
hand-sewn anastomosis. A post-operative leak occurred
(inevitably) and the patient developed a wound infection,
but survived. Eventually, to his satisfaction (and his
surgeon’s relief!), he began to lose weight.
(Ref: 100)
The admitting doctor continued to catheterise the patient
despite the procedure being painful, and did not seek
help. The catheter balloon was inflated before flash back
of urine was seen, causing trauma in the prostatic
urethra. Despite the patient being in painful urinary
retention, the doctor left the patient, before seeing any
urine to drain from the catheter.
CORESS Comments:
Prostatic disease may render catheterisation difficult.
However, in the event of significant pain or difficulty
introducing a urinary catheter, attempts at
catheterisation should cease and expert help should be
obtained. Care should always be taken to avoid inflating
the catheter balloon unless this is in the bladder. Failure
to pass urine via the catheter, in a patient with urinary
retention, should have alerted the practitioner in this
case to the fact that the catheter was inappropriately
sited. Always measure and document residual urine
volumes ensuring that the output fits the clinical picture.
FINALLY …….
The Medicines and Healthcare products Regulatory Agency (MHRA) receives many reports of incidents involving
infusion pumps. These incidents are of concern, as many result in patient harm or death, primarily from over-infusions.
MHRA have recently released a revised Device Bulletin on Infusion Systems which can be found at:
http://www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON007321
This publication has been updated to take into account changes in devices and practices, as well as information
gained from the investigation of adverse incidents and current trends in the use of infusion systems.
CORESS is an independent Registered Charity (number: 1134175) and a company, limited by guarantee, incorporated in England and Wales (number: 6935638).
CORESS is grateful to ASGBI for publishing this feedback.
71
THE BACK PAGE
To celebrate the end of the Association’s 90th Anniversary year, we
are pleased to enclose a complimentary limited-edition drinks coaster
with this edition of the Newsletter. We hope that this will be a
colourful and useful addition to your desk!
The Association’s Executive Board, Council and
Staff extend their seasonal greetings, and very best
wishes for the New Year, to all our readers!
35-43 Lincoln’s Inn Fields, London, WC2A 3PE
Tel: 020 7973 0300 Fax: 020 7430 9235
www.asgbi.org.uk
A Company limited by guarantee, registered in England 06783090
Printed on
recycled paper
72
The opinions expressed in this Newsletter are those of the individual authors,
and do not necessarily reflect the policy of the Association of Surgeons of Great Britain and Ireland

No.32, Dec 2010 - Association of Surgeons of Great Britain and Ireland

Transcription

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