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ANAESTHESIA
The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
NEWS
ISSN 0959-2962
No. 329
DECEMBER 2014
INSIDE
THIS ISSUE:
A YEAR
IN REVIEW
2013 - 2014
Managing the
psychological
impact of a fire in an
intensive care unit
Spinal surgery
in Uganda
Burnout in
anaesthetic
trainees
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Editorial Contents
Reflecting on the past year and celebrating
success are part of the festive season. Our last
Anaesthesia News of 2014 reviews what the AAGBI
has been doing; education, safety, research,
publication, representing our profession’s interests,
international collaboration, innovation and heritage
all get a mention. I’m sure you will agree that the
Association is flourishing.
From my own perspective, I have watched GAT, the trainee committee of
the AAGBI go from strength to strength. GAT has consolidated links with
Irish colleagues, taken up the cudgel on behalf of trainees and contributed
to debate on many issues, including the shape of the future anaesthetic
workforce and the impact of the European Working Time regulations.
By the second month of her presidency, Sarah Gibb, GAT Chair, had a
response from the Secretary of State for Health, by month 4 she was off
to the GMC to talk about credentialing – will she be meeting the Queen by
the end of the year? At the other end of the scale, I also had the privilege
of working with one member who was very downhearted when he came to
see me, having lost his job and been reported to the GMC. With the help
of some insightful colleagues he has worked his way back, getting well
first, checking this with the Occupational Physician, taking up a clinical
attachment and finally moving to paid work.
Mistakes are an inevitable part of the human condition. What’s important
is that we acknowledge and learn from them. This edition includes a
reflection from a trainee about a drug error, the various factors that may
have led up to it and the impact it had. Of course this trainee is not alone
– many readers will recognise the holes in the ‘Swiss cheese’ lining up as
we go about our daily work. Reflecting on my own practice this year, my
worst error was in obstetrics. I gave the usual ‘recipe’ of antibiotics but,
embarrassingly, recorded that I had given cefuroxime and metaraminol
rather than what I had actually given – cefuroxime and metronidazole. In
my defence, I did this at about 2.30am. But, of course, this is no defence
– if my brain no longer works at night the NHS should not be using it!
Two of my most valued colleagues have retired this year. One, Val Bythell,
is known to many of you, the other is my erstwhile clinical director. A quiet
man by nature, he did much to enhance the profile of anaesthesia in
the Trust and protected us from the worst excesses of corporate politics.
Val is missed for different reasons – a wonderful self-deprecating sense
of humour, an ability to cut to the chase and stupendous knowledge
and experience. Her first comment on making a drug error was ‘damn
nearly killed the patient’. The piece in this issue about the psychological
impact of a fire in an ITU points to the importance of the team and an
organisation’s culture in responding to serious events. Our team’s culture
was the richer for both of these colleagues.
The contribution from ‘Scoop’ proposes that every day should be
Monday in the NHS. There’s something in this. Paul Aylin, in his
lecture at this year’s Annual Congress, (available via learn@AAGBI http://www.learnataagbi.org) points out that people who have operations
on a Monday have better outcomes than those done on a Friday. He uses
Monday as his benchmark and looks for reasons why performance on a
Friday is poorer. There is another way of looking at this; people deliver
better care when well rested and are fresh after the weekend. So if you
are taking a few days off over the festive season remember that this will
benefit your patients as well as you.
FUJIFILM SonoSite, Inc. the SonoSite logo and other trademarks not
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of FUJIFILM SonoSite, Inc. in various jurisdictions. All other
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©2014 FUJIFILM SonoSite, Inc. All rights reserved.
The AAGBI wishes you a good festive season and a happy new year.
I better not add ‘prosperous’, pay negotiations do not bode well for
anyone in the public sector in the UK!
Nancy Redfern
Anaesthesia News December 2014 • Issue 329
03Editorial
05 President's Report
07
07 Managing the psychological
impact of a fire in an intensive care unit
10 Spinal surgery in Uganda
10
12 AAGBI: A year in review
22 Burnout in anaesthetic trainees
25 Reflections on a drug error
27 Every day is Monday for
the NHS
28 The parent and baby room
29 Your Letters
12
31 Anaesthesia Digested
32 Particles
25
27
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: [email protected]
Website: www.aagbi.org
Anaesthesia News
Chair Editorial Board: Nancy Redfern
Editors: Phil Bewley and Sally El-Ghazali (GAT), Nancy Redfern,
Richard Griffiths, Sean Tighe, Tom Woodcock, Mike Nathanson, Rachel Collis,
Upma Misra, Felicity Platt and Gerry Keenan
Address for all correspondence, advertising or submissions:
Website: www.aagbi.org/publications/anaesthesia-news
Editorial Assistant: Rona Gloag
Design: Chris Steer
AAGBI Website & Publications Officer
Telephone: 020 7631 8803
Printing: Portland Print
Copyright 2014 The Association of Anaesthetists of Great Britain and Ireland
The Association cannot be responsible for the statements or views of the contributors.
No part of this newsletter may be reproduced without prior permission.
Advertisements are accepted in good faith. Readers are reminded that
Anaesthesia News cannot be held responsible in any way for the quality
or correctness of products or services offered in advertisements.
3
PRESIDENT's
REPORT
This is your opportunity to tell us:
- what you like
ntly
re
- what you would like us to do diffe
- what you don’t like
- help shape our future strategy
It will only take a
few minutes to
complete. Please
take part and
encourage all of
your colleagues to
do the same.
Tell us how we can
do even better!
Online version will be emailed out to
all members. Paper copy available in
Anaesthesia News in the New Year.
4
I am slowly getting used to being AAGBI President, and I hope the AAGBI is also getting
used to me. There is certainly no time to be bored! Apart from an exponential increase in
email traffic and the various Council, Board, Committee and other meetings I knew I’d be
attending, I keep finding new ones I’d never heard of! I’d like to think it was my own personal
popularity, wisdom and experience that brought about so many invitations to speak and/or
dine, but even my insight is better than that.
One of the best parts of the ‘job’ is being able to say
thank you to people for remarkable achievements
either at work, volunteering for charitable activities,
acts of bravery or many other things. I never cease to
be amazed, and rather humbled, by what astonishing
and varied things anaesthetists get up to.
In October I attended Anesthesiology™ 2014 in New
Orleans. Such a contrast to the AAGBI’s meetings,
not least because there were more delegates
than we have members and with so many
simultaneous activities that the pocket guide was
more like a Eurorail timetable. The American Society
of Anesthesiologists (ASA) is pushing its new concept
of the Surgical Home, with the anaesthesiologist
taking the lead in peri-operative management of
the surgical patient. This is a fairly logical ambition
and mirrors much of the current work in the UK and
Ireland, with the focus on Enhanced Recovery and the
work of the National Emergency Laparotomy Audit
and National Hip Fracture Database. What is so very
different are the drivers for these changes. Although
safer, more effective patient care is a shared goal,
in the US influence and income are as important, if
not more so. The topic of non-physician anaesthesia
providers is a much hotter political potato in the US
than it will ever become here.
At the same meeting I was able to present the results
of NAP5, sharing the podium with Ellen O’Sullivan.
Ellen was speaking as President of the College of
Anaesthetists of Ireland and I was ‘double hatted’
as a member of Council of the Royal College of
Anaesthetists and the AAGBI. Turnout was good,
and there were very positive comments about such
impressive large-scale national audits in this and other
sessions. As the ASA focuses much more on quality,
I hope there are possibilities for future collaboration.
Certainly it was very satisfying to demonstrate to our
bigger cousins how effective the specialty can be on
this side of the Atlantic, especially when the major
organisations unite to achieve a common objective.
The next challenge for the two Colleges and
the AAGBI will be to come together to consider
the recommendations of NAP5 and how best to
implement them. I think most of us are still digesting
the results and the implications. I want to take this
opportunity to congratulate all those involved (and
there are far too many to name) on such a successful
project.
It would be easy to assume from the pages of
Anaesthesia News that cycling is the official pastime
of the AAGBI, so I thought a request from a member
for the AAGBI to support a safer cycling project
would be a ‘no brainer’. Quite the opposite, with
some Board members feeling it was not an issue on
which the AAGBI should comment. After a vigorous
debate, what swung the Board in favour of support
was the AAGBI’s role as an employer, based in
central London, which encourages its staff to cycle to
work through a cycle purchase scheme. The AAGBI
has nearly 30 staff, and it’s their efforts that underpin
everything we do for patients and members.
As is traditional, the AAGBI headquarters at 21
Portland Place will be closed between Christmas and
55 Managing the
psychological
impact of a fire in an
intensive care unit
New Year. However, we are aware that the festive season
may not be so festive for some and we were concerned
that members who needed help or support might not
be able to find it. So this year a limited online service for
urgent member matters will be provided while the office
is closed. Details will be advertised in due course.
Most of us will work some of the holiday period, but I
hope that you all get to spend as much time with your
families and friends as you want, and have some time
away from the increasing pressure of difficult times for
healthcare. I look forward to seeing many of you at
WSM London from 14–16 January and, until then, wish
you all happy holidays and best wishes for 2015.
Andrew Hartle
President, AAGBI
For the latest
news and event
information
follow @AAGBI
on Twitter
GAT ASM
ABSTRACT SUBMISSION
MANCHESTER 2015
GAT Oral and Poster Prizes
Trainee anaesthetists are invited to submit an abstract for oral
or poster presentation at the GAT ASM. The authors of the six
highest-scoring abstracts in the preliminary review will be invited
to present their work orally and will be eligible for the Oral
Presentation Prize. A cash prize will be awarded to the winner.
Case Presentation Prize
Trainees are asked to submit an abstract of an interesting case
that they have been involved in, and which has learning points
that may aid other anaesthetists in their management of similar
cases. The three best submissions as judged in the preliminary
review will be invited to present their work orally at the ASM and
the audience asked to vote for their favourite. A cash prize will
be awarded to the winner.
Poster Competition
The remaining successful authors will be invited to present a
poster. Entries will be allocated into one of the following three
categories depending on the grade of the presenting author:
Foundation Year Trainees; ACCS/Core Trainees; ST3+ Doctors.
A cash prize and a certificate will be awarded to the winner
in each category. The judges also reserve the right to award
discretionary certificates.
TRAVEL GRANTS/
IRC FUNDING
The International Relations Committee
(IRC) offers travel grants to members who
are seeking funding to work, or to deliver
educational training courses or conferences,
in low and middle-income countries.
Please note that grants will not normally be considered for
attendance at congresses or meetings of learned societies.
Exceptionally, they may be granted for extension of travel in
association with such a post or meeting. Applicants should
indicate their level of experience and expected benefits to be
gained from their visits, over and above the educational value
to the applicants themselves.
For further information and an application form
please visit our website:
http://www.aagbi.org/international/irc-fundingtravel-grants
or email [email protected]
or telephone 020 7631 1650 (option 3)
Closing date: 02 January 2015
6
Medical Students Poster Prize
Medical students are invited to submit an abstract for poster
presentation on a theme related to Anaesthesia/Pain/ITU.
A cash prize will be awarded to the winner.
CLOSING DATE FOR SUBMISSIONS: MONDAY 19 JANUARY 2015
Prize
The Anaesthesia History Prize
The Association of Anaesthetists and the History of
Anaesthesia Society will award a cash prize for an original
essay on a topic related to the history of
anaesthesia, intensive care or pain
management written by a trainee member
of the Association.
A £500 cash prize and an engraved
medal will be awarded for the best entry,
and the winner will be invited to present
their paper at the ASM.
On Tuesday 21st November 2011, just after 7pm, a fire broke out on our intensive care unit (ICU).1 An oxygen
cylinder caught fire while lying on a patient’s bed, resulting in the patient catching fire and flames spreading to
the bedding, mattress and curtains around the bed, plus the ceiling tiles and flooring. The patient was dragged
to safety while two doctors extinguished the fire; this took about five minutes and required five fire extinguishers.
Ten other ICU patients were evacuated within seven minutes of the fire starting, and a further patient (in a side
room not immediately affected) was evacuated 30 minutes later. The ICU was filled with smoke within seconds,
reducing visibility to less than a metre and making breathing very difficult. The patient on the burning bed very
sadly died five weeks later but, remarkably, no other lives were lost.
Psychological aspect – the consultant’s perspective
The vast majority of the staff working on the night of the fire suffered
a severe post-traumatic stress reaction after the event. Our clinical
psychologist attended the hospital on the night to debrief staff and
to speak to those most badly affected. While I was being treated on
the Emergency Department observation ward, he warned me I would
experience an intense and severe reaction that would make me never
want to go back into the ICU ever again - and he was absolutely right.
I suffered nightmares and flashbacks in the week after the fire and for
many months afterwards. Loud bangs, fire alarms, the smell of burning
plastic, turning on oxygen cylinders and working in the bed space on
our ICU where the fire started all made me feel sick and dizzy. Staff
were followed up by the psychology team, and the consultants and
senior nurses involved organised a number of informal meetings and
a series of email updates for those staff who had been working that
night. Most staff needed time off work, with one member of staff still
unable to work two years later. Getting psychological input at such
an early stage had an enormously beneficial effect for us all and I
feel that plans for major incidents, including ‘internal emergencies’
such as ours where inpatients and clinical staff are victims of the
emergency, should include psychologist involvement.
Patients and their families and friends on the ICU at the time of the fire
were followed up by our ICU outreach team and referred for additional
help when required.
Psychological aspect – the clinical psychologist’s perspective
For full details and to apply please go to the GAT ASM
website www.gatasm.org/content/oral-poster-prizes
If you have any additional queries, please contact the AAGBI
Secretariat on 020 7631 1650 (option 3) or email [email protected]
It is well established that the experiences of patients on ICUs can
trigger post-trauma stress symptoms, and this is likely to increase
in the future as medical practice promotes greater survival and our
patients have experiences that have, so far, been unavailable to us.
Trauma-stress is not the only psychological symptom of anxiety or
depression that can emerge but, due to the very acute and threatening
nature of the experience, it is often the most common. Similarly, the
impact on hospital staff of working with traumatised patients has also
been acknowledged.2
The acute symptoms of trauma-stress include physiological hyperarousal, intrusive (uninvited) memories of the event, flashbacks,
avoidance of anything to do with the incident and (sometimes) a
general numbing or flattening of all emotions.3 Quite quickly this level
of threat and arousal can lead to fatigue and a range of secondary
physical, emotional and behavioural difficulties. It can be difficult to
function in this state and we are more prone to making errors so it
is a significant occupational issue in the health service. Fortunately,
trauma-stress symptoms are manageable, most usually resolve, and
the risk of developing full-blown post-traumatic stress disorder is
small.
The incident on an ICU mentioned above does not relate directly to
the mainstream literature on trauma-stress in the ICU setting. It was
not about vicarious trauma for staff, nor the patients’ experience of
critical illness and treatment. Both staff and patients were caught in
a fire and were in immediate danger. The lives of patients and staff
were at extreme risk; they felt the heat of the fire, were blinded by
the smoke and struggled to breathe. Coupled with this they were
only too aware that the fire threatened the rest of the hospital. This
incident was an unambiguous critical incident. There was no need for
a debate about whether or not a staff welfare response was required,
not least because all the survivors needed to be treated and assessed
medically. It was both a full blown incident and a near miss, leaving all
those involved in an acute trauma-stress state.
As the clinical psychologist attached to the major-incident welfare
team at the Royal United Hospital (RUH), Bath, I received a call at
home from the medical director. People ringing me up to tell me that
something has happened is something I am used to but this case
was exceptional and even while driving to RUH I was in a state of
7
Fortunately, only two staff members needed observation in the
Emergency Department and the key focus was to help staff collect
their thoughts, compose themselves and get ready to go home.
There was a palpable degree of psychological ’concussion‘ among
everyone and people varied as to how much they talked and what
they focused on. Feeling dazed, shocked and a state of disbelief
were the main themes and there was a collective concern to
make sure that everyone was accounted and cared for. In these
circumstances, as a psychologist, you are only too aware that you
need to keep things simple and prepare the ground for the following
few months. How much people remember of what you say at this
point is debateable and probably minimal, but they remember how
you relate to them and that is important for all follow-up contact and
support. It felt very important to be present and composed, but not
intrusive or too pushy as people vary as to how much attention they
can tolerate in these situations.
The senior ICU staff who were not on duty during the incident
assumed a very helpful role in coordinating the welfare response
and I liaised mainly with them. We ensured we knew how everyone
was, listened to those that needed to talk and tried to make sure
that no-one was missed. You worry most about those who slip away
or appear withdrawn and that’s where it really helps to coordinate
with the senior staff who know their team. We compiled a list of
all those involved, reminded everyone of what to expect over the
coming days and offered simple advice and guidance to remember
the first principles of self-care and wellbeing. No attempt was made
to impose any structured debriefing procedures as that would have
been inappropriate and counter-productive. I was impressed at
how well-informed the staff were about psychological trauma-stress
reactions, and could see how this was having a helpful, innoculatory
effect. I’ve learned to worry about the long-term effects on senior
staff in these situations as, for them, the incident can go on for many
months and they often feel responsible for the welfare of their team.
The intensity of the incident meant that the reactions of those
involved was quite sustained and pronounced. Acute trauma-stress
in these circumstances is a very physical reaction, and there is a
real blurring between what is a physical sensation, an emotion or
8
We all vary as to how we respond to symptoms of stress and trauma.
We vary according to how comfortable we are both experiencing
symptoms of trauma-stress and asking for help. Any staff welfare
response needs to be flexible to address this diversity and observe
the right timescale, so it was helpful that the welfare team and EAP
could remain available on an ongoing basis. Formal and organised
services were put in place but, more importantly, the ICU team
organised their own informal and social meetings and initiatives to
help themselves recover from the event.
Once the immediate incident had passed and the dust had (literally)
settled it was necessary to help staff manage the return to work,
support those who kept a temporary ICU going and help support
staff over the longer term. It is important when staff return to work
that they are supernumerary for their first few shifts and that they
observe a graded return to work. Similarly, for those staff who come
in to work after the incident in a make-shift, temporary ICU, it is
important not to underestimate the impact on them and the need
to make sure they feel safe from a clinical perspective. I don’t want
to give the impression that this was a perfect process as many staff
remain affected by the incident to some degree.
26th Anaesthesia, Critical Care
and Pain Update
Val d’Isere, 2-5 February 2015
Centre de Congrés
Multidisciplinary meeting
Lectures | Workshops
Joint and Satellite sessions
Short paper competition
Guest speakers
On reflection, the ICU incident was a real education in the subjective
intensity of our reactions to threat, our capacity to endure incidents
like this and the profound protective value of preparatory education,
awareness and acceptance. The more people know about the acute
trauma-stress reaction as a normal phenomenon, the easier it will
be for them to manage and less effort will be wasted trying to resist
it, over-control it, conceal it or deny it. The first principles of good
healthy living, self-care and wellbeing are possibly more important
than any formal debriefing response.
This incident confirmed to me that good preparation and establishing
the right psychologically literate culture on a hospital unit really pays
off when something traumatic happens. If staff can make sense of
what they are going through, don’t feel the need to be defensive
about it and know the best way to care for themselves, then a
considerable number of problems can be averted. If not, then staff
retention, morale, performance and efficiency are all jeopardised.
FE Kelly
Consultant in anaesthesia and intensive care medicine
M Osborn
Consultant Macmillan clinical psychologist
Royal United Hospital, Bath
References
1.
Kelly FE, Hardy R, Hall EA et al. Fire on an intensive care unit caused by an
oxygen cylinder. Anaesthesia 2013; 68: 102–104.
2.
Davydow DS, Gifford JM, Desai SV, Needham DM, Bienvenu OJ.
Posttraumatic stress disorder in general intensive care unit survivors: a
systematic review. General Hospital Psychiatry 2008; 30: 421–34.
3.
Post-traumatic stress disorder (PTSD): The management of PTSD in adults
and children in primary and secondary care. NICE Guidelines CG26; 2005.
http://www.nice.org.uk/nicemedia/live/10966/29771/29771.pdf (accessed
28/4/2014)
www.doctorsupdates.com
education in a perfect location
doctorsupdates
The ICU at the RUH had prepared for incidents like this (to
some extent) and a project of trauma-stress awareness and
management had been running for some time in collaboration
with the Employee Assistance Programme (EAP). Similarly, in
relation to the major incident plan, a brief Trust-wide trauma-stress
awareness educational programme had been running and hospital
management were well informed of the principles involved. As a
consequence, many of the RUH ICU staff understood acute traumastress reactions, the value of a defusing process and the need to
be prepared for the psychological impact of their experience. From
my perspective, this was crucial and a huge relief as I didn’t have
to explain why I was there, what would help or what we needed to
do. We had a therapeutic alliance from the start. I was part of a
broader response too, as senior off-duty ICU staff seemed to appear
from everywhere with the intention of supporting their colleagues
and caring for patients. The senior chaplain also arrived and other
hospital managers and department heads stayed on after work to
be helpful. There was no shortage of cooperation and concern for
staff and patient welfare.
a thought. You tend to feel fatigue and hyper-arousal at the same
time, feeling both wound up and run down. It is a cliché, but still
true, that each person’s experience of a critical incident is unique
to them and this can give rise to very different reactions at times.
I think some staff were surprised at how intense their reaction was
and how long it lasted, but this is understandable given they were
primary victims, not carers or observers. Despite the diversity of
experiences it also confirmed to me that exposure matters and the
longer you were involved, the closer you were to the fire, the more
smoke you inhaled, then the stronger the primitive, physical trauma
reaction tended to be.
TM
disbelief. By the time I arrived, the ICU staff and patients were safe
and it was important to prepare the welfare response. All staff had
been checked over by the Emergency Department staff and had
been asked not to leave; they had gathered in an area which had
been set aside for them to defuse, wind down and reflect upon the
incident. It is important to guard against mania in an adrenalised
setting and ensure staff do not rush home to relax, but unwind a bit
first and then go home.
Spinal surgery in Uganda
Photograph © Dr Nur Lubis
A Skype conversation with the lead surgeon, Dr Lieberman, was
informative but lead to more questions and anxiety. He would be
taking a neurophysiologist and would be doing some procedures
that required an anterior approach, i.e. a thoracotomy. How
would I position the patient, achieve one lung ventilation, provide
anaesthesia without muscle relaxation, avoid volatiles, deal with
potential blood loss and postoperative pain relief? Being a typical
orthopaedic surgeon, Dr Lieberman could not tell me much about
the anaesthetic side of things, just that the local anaesthetists usually
coped. I spoke to my colleagues with experience in paediatric
scoliosis surgery and picked up some useful tips.
It seemed no time at all before I was at Heathrow looking for a
group of Americans. I spotted them wearing matching t-shirts
which read ‘Scoliosis Makes Me Bad to the Bones’ and was
introduced to the team consisting of five surgeons, two scrub
nurses, a neurophysiologist, an equipment rep and a medical
10 student. This was a bigger team than usual as, for the first time, the
team included two trauma surgeons and a plastic surgeon. They
came with containers full of surgical equipment and disposables
but no anaesthesia provisions. I had only brought my standard kit
consisting of a t-piece, a bougie, a permanent marker pen (to label
syringes) and a head torch (in anticipation of power cuts).
The flight to Kampala was followed by a six hour bus ride to
Mbarara where we worked for the week. We arrived at 6am and,
after freshening up, headed straight to the hospital to set up the
operating rooms and screen patients for surgery – most had
congenital scoliosis and degenerative disease as a result of TB.
Local anaesthetic team
I was pleased to meet the local anaesthetic team consisting of three
consultant anaesthetists and three trainees, some sponsored by
the AAGBI. Dr Ttendo, the head of department, was a remarkable
character who was a vital help in getting things moving and was a
fountain of knowledge. He accomplished what we struggle with in
our own hospital – a prompt morning start and a smooth patient
flow which were both critical in maximising our short time there. He
epitomised situational awareness – always appearing at the right
time, in a calm manner with a solution to whatever the problem was.
The Aestiva anaesthetic machine was something with which I
was very familiar. There was even end- tidal anaesthetic agent
monitoring which, from my previous experience, is a luxury in the
developing world. It was too good to be true – I later discovered
the end-tidal anaesthetic agent was a random number generator
probably due to calibration issues. The machine often ran out of
oxygen but a quick phone call for someone to change the manifold
over was all that was required so extra vigilance was necessary.
There was a double lumen tube but unfortunately the size was too
Being recovery nurse
My journey started when I received an email from Health Volunteer
Overseas, a US-based charity seeking an anaesthetist to go to
Uganda with a spine team for 10 days at the end of July. Recognising
this unique and rare opportunity I replied quickly, forwarding my CV
and stating my availability - then I went on the internet to research
the Uganda Spine Surgery Mission to find out more about what I
would be involved with. The Ugandan Spine Surgery Mission is a
Texas-based charity that has been doing annual trips to Uganda
for the last 10 years. I was slightly apprehensive at first as it looked
like the charity were doing complex, specialist scoliosis surgery –
not something that is bread and butter to me and they were doing
it in Uganda. I had a flashback to the last time I was in Kampala,
five years ago, attending the Anaesthesia for Developing Countries
course and visiting the main hospital to learn about halothane and
ether with a basic anaesthetic machine and limited monitoring. I have
worked in this environment before, dealing with mainly emergency
trauma patients and obstetrics, but this was different kettle of fish.
TIVA was kind of possible
Difficult airway trolley turned
into neurophysiology monitoring
station – it’s locked anyway
big for the small patients we cared for. Without a bronchial blocker,
one lung ventilation consisted of intubating the right main bronchus
with a normal endotracheal tube. Thankfully the surgeons were very
accommodating. Although there was a Montreal-like mattress and
a head cushion for prone positioning, this was often unsuitable for
the paediatric cases we dealt with so we used a lot of improvisation.
The Ugandans are generally very slim so extra padding was needed.
I was delighted to discover the availability of propofol, remifentanil
and an infusion pump but there was a caveat. I had to master the
art of making 50ml of propofol and 3mg of remifentanil last for the
duration of a 6 hour case (with some help from a volatile of course).
Imagine how much money I could save if I continued this practice in
the NHS! I was using low flows only to be told that we were running
low on soda lime and had just had a delivery of isoflurane. I needed
to preserve the CO2 absorber rather than the iso which was less
popular among the local anaesthetists who still prefer halothane as it
is more familiar and readily available.
The surgeons were impressive and blood loss was never more than
500ml from a multilevel procedure. They were modest too, crediting
the tranexamic acid for the haemostasis. Blood was available and
could be stored in a theatre fridge if needed. It was really refreshing to
have surgeons who communicate well and give accurate estimates
of surgical times. This allowed for effective planning, although there
were days when we were operating into the night, usually as a result
of unavoidable circumstances. We managed to fit in a couple of big
spine cases a day.
A particularly challenging case was a 3-year-old who had TB of the
spine and had suffered from lower limb weakness since the age of 18
months. He was scheduled for a two stage procedure starting with a
multilevel thoracic corpectomy. At induction I noted him to have poor
reserve and he would drop his saturations quickly without oxygen
supplement. The 5 hour surgery was uneventful and I decided to
The team
extubate him after some suctioning and recruitment manoeuvres.
He coped well but was again struggling with his oxygen saturation
on air. I was ready to transfer him to the ICU only to be told that
there was no portable oxygen or simple paediatric Hudson mask!
Plan B consisted of pre-oxygenating him and doing a hypoxic sprint
down the corridor to ICU with a circuit and oxygen ready on the
other end. Luckily he was fine and only needed oxygen via a nasal
cannula overnight. It never failed to amaze me how robust children
are. He was the chirpiest patient the next morning and the first to be
discharged to the ward. He had his second procedure a couple of
days later, a thoracotomy this time, and he was ventilated overnight.
One of the most important lessons I learnt on this trip was not to
make assumptions. The anaesthesia was more advanced than
I expected but I was sometimes caught out by the lack of basics.
For example, there was no post-op recovery, just a deserted ‘postanaesthesia’ room as there were no provisions for trained recovery
nurses. Another lesson was to be wary of power surges. It cost us
our X-ray C-arm on day two and the neurophysiology monitoring on
our last day. A surge protector is essential but does not always work.
I cannot emphasise enough how impressed I was with the Uganda
Spine Surgery Mission. They live up to their mission statement to
provide the best possible spine care to Ugandan patients. The
dedicated team ensured a high quality service in a challenging
setting, achieving what would be difficult to do even within the NHS.
Dr Nur Lubis
Consultant Anaesthetist, Whipps Cross Hospital
For further details:
http://www.ugandaspinesurgerymission.com
http://www.hvousa.org
11 ers
b
m
u
n
in
h
t
g
Stren
ll
21 Portland Place
Our Grade II listed building in London has attracted around
300 visitors a week and hosted numerous meetings, events
and seminars during the year.
bers at a
m
e
m
to
e
lu
a
v
g
n
ri
e
Deliv
career
l
a
n
io
ss
fe
ro
p
ir
e
th
stages in
We continue to offer office space to the World Federation
of Societies of Anaesthesiology (WFSA) and Lifebox, the
international charity of which AAGBI is a founder member.
Membership Categories
Snapshot at March 2014
Working together
with specialist societies
We are pleased to report a healthy 93% retention rate and a total of
10,681 members including 812 new members joining during
the year.
The AAGBI staff provide secretariat and event management
services for 18 specialist societies. We organised events
for the Difficult Airway Society (DAS), the Association of
Paediatric Anaesthetists of Great Britain & Ireland (APAGBI),
the Obstetric Anaesthetists’ Association (OAA) and Regional
Anaesthesia UK (RA UK), as well as seven one-day
conferences and six study days for others. There were also
upgrades to IT systems to enhance the service provided.
Progress in providing services and communicating with members
online has been a key focus this year. The website, our eNewsletters
and activity on social media offer members’ news and updates quickly
and easily.
New member benefits for the year include:
•
Discounts on UltraScan courses. This is an educational initiative
for those who want further expertise and competency in medical
ultrasound and echocardiography for clinical practice.
Mentoring sessions at AAGBI meetings with trained AAGBI
mentors. This gives delegates a confidential opportunity to
discuss career options, work-life balance, opportunities or
dilemmas.
4
1
0
2
3
1
0
2
W
E
I
V
E
R
N
I
R
A YEA
•
Total members: 10,681
ighlights
a few h
re
a
sh
e
w
re
e
h
I:
B
G
A
r for the A
a
e
y
e
iv
ss
re
g
ro
p
d
n
a
ful
success
r
e
th
o
n
a
s
a
w
4
1
0
-2
2013
Environment
drive to become
to make progress in its
The AAGBI continues
established the
friendly. Last year we
more environmentally
healthcare in
en
gre
te
mo
up to pro
Environmental Task Gro
the profession.
Council
September 2013, we
’ Meeting in Dublin in
At the Annual Members
Council members:
d
cte
ele
me three newly
were pleased to welco
Norfolk & Norwich
nsultant Anaesthetist,
• Dr Paul Barker, Co
University Hospital.
, Sunderland Royal
Consultant Anaesthetist
• Dr Upma Misra,
Hospital.
thetist, Queens
on, Consultant Anaes
• Dr Mike Nathans
tals NHS Trust.
gham University Hospi
Medical Centre, Nottin
d a 5.8 tonnes
d Place, we recycle
an
rtl
Po
21
at
e
us
In-ho
nes of CO2
to a saving of 8.0 ton
of paper. This equates
24% on the
an improvement of
and 78 trees. This is
previous year.
GAT Committee
mber at the Annual
d one new elected me
The GAT Committee ha
ford in April 2013:
General Meeting in Ox
, Hillingdon Hospital.
• Dr Emily Robson
Join the conversation
Social Media
12 More and more anaesthetists are now active in social media networks such as Twitter. It is not only a great way to keep
up with news and events in the profession, but it is also a tool for reflective learning during and after conferences. The
AAGBI connects with over 2,500 followers on Twitter; follow us and be the first to hear our news and views.
Twitter @AAGBI
Facebook AAGBI1
13 SUPPORTINGS OVERSEAS
COLLEAGUE
SAFETY
MATTERS
The AAGBI Foundation
maintains an active
programme of support for
anaesthesia worldwide,
including grants towards
educational projects in
lower resource countries,
book donations and
funding of educational
resources. This year 43
grants were awarded
towards work in 17
countries.
Last year the
AAGBI shipped
1,500 books
overseas!
r Lifebox
Fundraising fo
One of the AAGBI’s
principal activities is the
advancement of patient
care and safety in the field
of anaesthesia.
ves
Safety Initiati
National Audit Project 5 (NAP5)
The AAGBI and the Royal College of Anaesthetists have been working together
for the past two years on the 5th National Audit Project on Accidental Awareness
during General Anaesthesia (NAP5). In March 2013 an interim report of the
NAP5 findings were published in the British Journal of Anaesthesia. Over 7,000
anaesthetists were surveyed. The report attracted media coverage including BBC
News, LA Times and OnMedica.
Hip Fractures – Anaesthetic Sprint Audit of Practice.
The Anaesthetic Sprint Audit of Practice (ASAP) was commissioned by the
Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical
Audit programme. ASAP marks a successful collaboration between several
professional organisations. The NHS Hip Fracture Perioperative Network (HipPen),
British Orthopaedic Association (BOA), British Geriatrics Society (BGS), Royal
College of Physicians (RCP) and the AAGBI have worked together to explore
anaesthesia within hip fracture care using data collected by members of the HipPen.
Raising ‘dough’
for safer surgery
lobal
Anaesthesia GSurvey
Collaboration
AAGBI and Tropical Health & Education Trust (THET) teamed
up to gather and share information about anaesthetists involved
in international projects. AAGBI members shared information
about their overseas work to create an online resource that
maps UK collaboration in global anaesthesia.
In April, the AAGBI launched
the Great Anaesthesia Bake
challenging departments around
the country to show their skills in
the kitchen and raise funds for the
Lifebox Foundation. Departments
from all round the country took
up the challenge and since its
inception, the Great Anaesthesia
Bake has raised over £20,000
for Lifebox.
Gubblin’ to Dublin
In September, eight intrepid cyclists
(including the AAGBI’s President,
Honorary Secretary and Treasurer)
braved rain and gale-force winds
riding almost 400 miles from London
to AAGBI’s Annual Congress in
Dublin.
The audit showed that 44% of hip fracture patients do not receive a peri-operative
nerve block for pain relief and recommended that this type of pain relieving
anaesthetic should be offered to all hospital patients who suffer hip fracture.
e-SAFE DVD
The e-SAFE DVD was formally launched in April 2013 by HRH The Princess Royal
at the e-SAFE (Safer Anaesthesia from Education) event held at The Royal College
of Anaesthetists. The event served to highlight how the anaesthetic community are
working together to improve healthcare for under-resourced countries.
r
They raised just unde
d
an
,
ox
eb
Lif
£10,000 for
rgery
su
fer
sa
to
ted
ibu
contr
.
es
tri
un
in developing co
The DVD contains over 100 interactive e-learning sessions and an e-library with over
500 articles covering basic science and clinical anaesthesia.
14 Anaesthesia News December 2014 • Issue 329
AAGBI is proud to be a founder member of the international
charity, Lifebox. Lifebox is a not-for-profit organisation
saving lives by improving the safety and quality of surgical
care in low-resource countries by ensuring that every
operating room in the world has a pulse oximeter.
www.lifebox.org
Lifebox UK-registered charity (No. 1143018)
15 Opportunities to learn
online
and
-face
-to
face
h
ot
b
AAGBI events
In 2013-2014 the AAGBI ran a number of hugely successful
conferences, Core Topics meetings and seminars for the profession.
Annual Congress in Dublin attracted a large number of overseas
delegates and WSM London in January saw the largest delegate
numbers to date for an AAGBI conference, with 930 registered
delegates. Our major conferences are all approved for European
accreditation.
AAGBI Publications
Anaesthesia
Anaesthesia, the official journal of the AAGBI, is international in scope
and comprehensive in coverage. The journal has a very high impact
factor of 3.846 (compared to 2.958 last year) demonstrating the
relevance of articles to the anaesthesia community.
Parent and baby room facility
Parents can now bring their little ones to all our major meetings!
Lectures from the main auditorium are streamed into a separate room
so parents can catch up on CPD whilst looking after their babies in
an informal setting.
I
Learn@AAGB
Further steps to provide e-education and associated CPD services
online have been taken in converting the video platform to an online
learning zone for members; Learn@AAGBI actively supports members
with their CPD and in the revalidation process. Our comprehensive
video library now offers over 233 lectures and CPD content from our
conference and seminars. It attracts around 3,000 visits a month and
keeps revalidation simple and user-friendly.
Keeping
anaesthetists
up to date
This year the journal’s publishers, Wiley Blackwell, developed an
iPad app for the Anaesthesia making it easier for our members to
access the journal on the move. The app was downloaded 3,336
times last year.
to providing
d
te
it
m
m
o
c
is
The AAGBI
r anaesthesia
fo
s
ie
it
n
u
rt
o
p
p
o
keep up to date
professionals to sional development
s
with their profe develop and grow
to
and continues
s members.
resources for it
Anaesthesia News
85 articles were published in our popular members’ magazine
Anaesthesia News last year. We encourage our members to submit
content; it’s a great way of sharing experiences and thoughts with
fellow colleagues.
Anaesthesia Cases
Anaesthesia Cases (www.anaesthesiacases.org) is a free, online,
editorially reviewed journal of case reports in anaesthesia. Since
the launch of Anaesthesia Cases in January 2013, we have had an
increasing number of visitors from across the world. Visitor traffic
has come from countries as far as Russia, Japan, China and Saudi
Arabia.
@AAGBI
The bi-monthly enewsletter, @AAGBI, provides members with quick,
effective and convenient communication with the latest information
about the AAGBI and current issues within the profession.
Guidelines
Our Guidelines cover a wide range of clinical and non-clinical issues.
In the last year we have produced these new titles:
•
•
•
•
•
•
Immediate Post-anaesthesia Recovery 2013
GAT - Who is the Anaesthetist? 2013
Obstetric Anaesthetic Services 2013
Regional Anaesthesia and Patients with Abnormalities of
Coagulation 2013
GAT Handbook 2013
Peri-operative care of the elderly 2014
New working parties were established on:
•
•
•
•
•
Skin Asepsis for Neuraxial Block
Standards of Monitoring During Anaesthesia and Recovery
Provision of Vascular Access by Anaesthetists
Quick Reference Handbook and Guideline for the Management
of Sudden Unexpected Hypoxia or Raised Airway Pressure
Peri-operative Management of the Elective Surgical Patient with
Diabetes
Getting ideas realised
Research
opportunities
Heritage Centre
The AAGBI Heritage Centre, accredited by the Arts Council
received 976 visitors last year, an increase of 30% from the
previous year and the most successful year to date for the
Heritage Centre.
DATE (Database of Anaesthetic
Training Encounters) Project
The AAGBI wants to connect members together for peer-to-peer learning.
The pilot scheme has launched with a call for ‘hosts’ who will provide the
learning and are willing to receive fellow anaesthetists as visitors. This will
provide another way of learning and assist in revalidation.
16 The exhibition ‘Out of Our Comfort Zone: Providing Pain Relief
in a Crisis’ proved to be extremely popular. The exhibition
honoured the work of doctors, especially anaesthetists, in
treating injuries caused by wars and terrorist attacks.
“This tiny little museum is a gem”.
“If you can’t face another shop, leave the other
half for an hour’s worthwhile diversion here”.
As well as the travelling exhibitions, the BMA hosted an
exhibition celebrating the founder of the Anaesthesia
Heritage Centre,Anaesthesia
A. CharlesNews
King.
December 2014 • Issue 329
The AAGBI Foundation is one
of the UK’s largest single grant
providers for anaesthetic research.
In the past year we allocated nearly
£100,000 in research funding for
nine awards through the National
Institute for Academic Anaesthesia
(NIAA).
Abstract submission is a great
way to get research published.
boost your CV and win prizes. Last
year we had over 450 abstract
submissions for our three major
conferences.
New prizes included the medical
student’s poster prize and an
essay prize sponsored by the RSM
Section of Anaesthesia.
Promoting
innovation
The AAGBI’s annual Award
for Innovation in Anaesthesia,
Critical Care and Pain is open
to all British and Irish based
anaesthetists, intensivists
and pain specialists, with the
emphasis being on new ideas
contributing to patient safety,
high quality clinical care and
improvements in the working
environment. Last year’s
winner devised ‘SAFIRA’ Safe Injection System for
Regional Anaesthesia.
N
O
I
S
S
E
F
O
R
P
E
H
T
F
O
E
C
I
A VO
Assocation: Main sources of income
UNDERGRADUATE
ELECTIVE FUNDING
UP TO £750
Medical students in Great Britain and
Ireland are eligible to apply to the AAGBI
Foundation for funding towards a medical
student elective period taking place
between April and September 2015.
A further round of funding will be
advertised in the Spring for electives
taking place from October 2015 onwards.
Assocation: Expenditure & cost of sales
Appeal to Health
Education England
In January, members of the AAGBI Council appealed to Health
Education England (HEE) in response to Yorkshire and Humber
LETB’s decision to divert ST training posts in anaesthesia to general
practice. The AAGBI urged HEE to take immediate steps to remedy the
situation as the decision posed a significant threat to patient safety, the
delivery of an effective clinical service, and physician wellbeing.
Responding to private
healthcare investigation
For the past two years, the AAGBI has been involved in the ongoing
investigation by the Office of Fair Trading and Competition Commission
(now the Competition and Market Authority) into private healthcare in
the UK. This work has been led by the AAGBI’s Independent Practice
Committee, which called for an investigation of the restrictive conditions
placed on consultants by private medical insurers.
The Shape of Training Review
The Shape of Training Review looked at potential reforms to the
structure of postgraduate medical education and training across the
UK. The AAGBI’s Group of Anaesthetists in Training (GAT) Committee
participated actively in the review. Written evidence was submitted
followed by attendance at an oral evidence session, informed by a
survey of our membership. Several members of the committee also
participated in a workshop for doctors in training. The Shape of
Training Review’s final report “Securing the future of excellent patient
care” was published in October 2013, and GAT submitted a response
that raised questions and concerns.
Association of Anaesthetists of Great Britain & Ireland,
21 Portland Place, London, W1B 1PY
Tel: +44 (0) 20 7631 1650
18 Fax: +44 (0) 20 7631 4352
www.aagbi.org
For further information and to apply
please visit our website:
www.aagbi.org/undergraduate-awards
email [email protected]
sociation,
As a professional as
tly active
the AAGBI is constan
interests of
in representing the
ting as a
anaesthetists and ac
ion
voice for the profess
Closing date: 05 January 2015 for
consideration at the February 2015
Research & Grants Committee meeting
Foundation: Main sources of income
Anaesthesia workforce
in the Republic of Ireland
The Berwick Report
Prizes of £500, £250 and £150 will be awarded to
the best three submissions.
Foundation: Expenditure
The overall winner will receive the Wylie Medal in
memory of the late Dr W Derek Wylie, President of
the Association 1980-82.
For further information and to apply please visit our
website: www.aagbi.org/undergraduate-awards
or email [email protected]
We would like to say a huge
thank you to all our members
for their continued support!
The Wylie Medal will be awarded to the most
meritorious essay on this year’s topic related to
anaesthesia Safety in numbers written by an
undergraduate medical student at a university in
Great Britain or Ireland.
THE WYLIE MEDAL
UNDERGRADUATE
ESSAY PRIZE 2015
The AAGBI’s Irish Standing Committee released a statement on the
ongoing national workforce crisis in the Republic of Ireland. The
statement gave support and advice to anaesthetists at local, regional
and national levels in ensuring an adequate supply of appropriately
trained doctors to provide safe anaesthetic services.
The Berwick Report highlights the main problems affecting patient
safety in the NHS and makes recommendations to address them.
Professor Don Berwick, an international expert in patient safety, was
asked to carry out the review following the publication of the Francis
Report into the breakdown of care at Mid Staffordshire Hospitals.
The AAGBI released a statement welcoming the publication and
supporting its recommendations.
Preference will be given to those
applicants who can show the relevance
of their intended elective to anaesthesia,
intensive care or pain relief. Applicants
may wish to note that a key focus of
the AAGBI is support for projects in the
developing world.
Closing date:
05 January 2015
19 NOTTINGHAM
04 December 2014
DUBLIN
04 February 2015
DATES FOR
YOU R DIARY
NEWCASTLE
25 March 2015
DECEMBER 2014
End of life & intensive care
Thursday 12 February 2015
GAT: Consultant interview
EXETER
Organiser: Dr Piotr Szawarski, Slough
Tuesday 02 December 2014
Trainees
Hip fracture care
Organiser: Dr Jonathan Price, London
24 April 2015
Challenges and solutions in the care of the
obese parturient
Wednesday 03 December 2014
2 day 10 bleeding, clotting
& haemorrhage – An update
Delegates can register
for one or both days
Thursday 11 & Friday 12 December 2014
Location: De Vere West One, 9-10 Portland Place,
London W1B 1PR
Organiser: Dr Ravi Rao Baikady, London
Core.indd 1
09/09/2014 14:58
RESEARCH GRANTS
THE ASSOCIATION OF ANAESTHETISTS OF GREAT BRITAIN
& IRELAND AND ANAESTHESIA WILL BE AWARDING
RESEARCH GRANTS IN FEBRUARY 2015.
The Associations’
research aims are:
•
Patient safety
•
Innovation
•
Clinical outcomes
•
Education and training
•
Related professional
issues (e.g. standards
and guidelines, working
conditions, medico-legal
issues)
•
The environment
On this occasion the AAGBI wishes to offer particular support to
projects that address the research ideas identified by NAP5
http://www.nationalauditprojects.org.uk/NAP5report
Applications must describe how the proposed project meets the above
aims. Suitable projects may be large research studies, small clinical/
benchtop projects, idea (innovation) development, observational studies/
data collection, quality improvements or clinical audits (although the latter
are unlikely to receive AAGBI funding if they are small, ‘routine’ local audits).
Funding up to £50,000 may be sought, but applications will be judged on
‘value-for money’ as well as scientific credibility. Awards will be made via the
NIAA and, if appropriate, will be eligible for NIHR portfolio status.
For further information and to apply please visit the AAGBI website
http://www.aagbi.org/research/aagbi-research-grants
Completed application forms and supporting docs should be returned
to the NIAA secretariat [email protected]
The deadline for applications is
5pm Friday 16 January 2015
Special rate
Scottish Standing Committee open meeting
Location: Discovery Point, Discovery Quay, Dundee, DD1 4XA
Organiser: Dr Jamie MacDonald, Aberdeen
MARCH 2015
Annual update in thoracic anaesthesia
Tuesday 03 March 2015
Organiser: Prof Fang Gao & Dr Joyce Yeung, Birmingham
Ultrasound in critical care
Tuesday 16 December 2014
2 day airway update
Organiser: Dr David Ashton-Cleary, Truro
Wednesday 04 & Thursday 05 March 2015
Organisers: Drs Vassilis Athanassoglou & Mridula Rai, Oxford &
Dr Rehana Iqbal, London
JANUARY 2015
Congenital heart - Paediatric anaesthesia
Tuesday 27 January 2015
Fibreoptic & ultrasound workshops
Tuesday 10 March 2015
Organiser: Dr Raju Reddy, Birmingham
Organisers: Dr Kim Chishti, Taunton & Dr Sudheer Medakkar,
Torquay
FEBRUARY 2015
Orthopaedic anaesthesia
Ultrasound in anaesthesia
Wednesday 11 March 2015
Tuesday 03 February 2015
Organiser: Dr Jan Cernovsky, Stanmore
Organiser: Dr Andrew McEwen, Torquay
Joint AAGBI & RCoA meeting: Becoming
a consultant
Wednesday 04 February 2015
Organiser: Dr Richard Griffiths, Peterborough
Friday 27 February 2015
Organiser: Dr Neil Muchatuta, Bristol
th
Trainees
Obstetric anaesthesia – For the advanced
trainee
Thursday 19 March 2015
Organiser: Dr Lynn Fenner, Bath
Trainees
Organisers: Dr Matthew Checketts, Dundee
& Dr Sumit Gulati, Liverpool
All AAGBI seminars are priced as
listed below unless otherwise stated
All meetings & seminars are held at 21 Portland Place,
London unless otherwise stated.
£133 - AAGBI members
£88 - AAGBI trainee members
www.aagbi.org/education
£66.50 - Retired members
£260 - Non-members
Check availability and book online today
21 Burnout
seen in trainees under 30. Interestingly these levels were comparable
to other professional groups.
We invited 193 anaesthetic trainees in the East of England (EoE) School
of Anaesthesia to complete the MBI. We received 88 responses from
a wide range of grades (CT1 - ST7). For all three components the risk
fell into the average range of burnout. This compared well to other
professional groups for which data are available (Table 1). Only 4 (5%)
of the 88 trainees were categorised as being at high risk of burnout
(high burnout in all three components). On the opposite side, 16 (18%)
of trainees had a low risk of burnout overall.
in anaesthetic trainees
'Repeated failure (of the primary FRCA) has taken its toll on me emotionally and physically…
I do feel exhilarated now that I have passed it but also physically drained and low as I feel I have
abused my body with poor activity and poor eating habits.' EoE Anaesthetic Trainee
Table 1 - Burnout among professionals
Emotional
exhaustion
Depersonalisation
Personal
achievement
Human services
Professions
(n = 11,067)
20.99%
average risk
8.73%
average risk
34.58%
average risk
Medicine
(n = 1104)
22.19%
average risk
7.12%
average risk
36.53%
average risk
East of England
Anaesthetic
trainees (n = 88)
21.45%
average risk
7.3%
average risk
37.5%
average risk
Subscales
One question specifically asks individuals how frequently they
experienced burnout:
‘I feel burned out from my work’
Over 35% of trainees reported feeling burnt out at least once a week,
with 4% feeling it every day.
Burnout was not found to be clustered around any particular training
grade. Also exam re-sits did not statistically correlate with the incidence
of burnout. However we do not doubt that exams are a huge source of
stress, clearly evident from the written response of a trainee:
What is burnout?
The concept of burnout originated in the US during the 1970s.1
It described the draining of emotion that can occur in members of staff
whose occupations require frequent, client centered interactions. This
type of staff-client relationship forms the basis of any patient-doctor
relationship and is seen throughout the healthcare profession.
Many medical specialties, including anaesthetics, are involved with
complex patient groups that require significant psychological support
or care in acute stressful settings. Doctors who are frequently involved
in the care of these patients have a high risk of developing stress,
fatigue and burnout.1
Figure 1 - Example of questions from the Maslach Burnout Inventory
1. I feel
emotionally
drained from
work
0
never
1
once a
year or
less
2
once a
month
or less
3
a few
times a
month
4
once
a
week
5
a few
times a
week
6
everyday
1
once a
year or
less
2
once a
month
or less
3
a few
times a
month
4
once
a
week
5
a few
times a
week
6
everyday
What to do if an individual is identified
as having a high risk of burnout
Following our assessment, we contacted trainees and informed them
of their individual burnout risk and how this compared with the trainee
group as a whole, and with larger groups of professionals. Note that
the authors who developed the MBI state:
Within the EoE School there are the several resources available for
trainees experiencing difficulties:
• Local mentoring system. This is normally provided by the
College Tutor or Educational Supervisor.
• Those with more significant concerns can be seen by the senior
school executives (i.e. regional advisor, deputy regional advisor
etc.). They can offer additional mentoring support, time away
from the programme or transfer to an alternative hospital if
required.
• For significant problems the Dean and/or their Deputy can
be informed. This would lead to a meeting aimed at further
exploring any difficulties and trying to find a solution.
• The Deanery has funding to provide a limited number of
appointments with a clinical psychologist. The school has used
this service in the past with great success.
• Since many trainees struggle to discuss confidential personal
matters with a consultant, a trainee-trainee mentoring scheme is
an excellent alternative option. The EoE Deanery is now running
a mentor development programme for trainees and consultants.
Conclusion
Burnout is a potentially harmful syndrome that occurs in many
professionals, including doctors. We found that in the EoE, trainee
anaesthetists’ levels of burnout compared with other professional
groups. Despite only a few individuals being at high risk of burnout,
over one-third of trainees reported feeling burnout at least once a
week.
It is important to recognise that anaesthetic trainees are at risk of
burnout, particularly when multiple life events coincide (starting a
family or buying a house for example).We must be vigilant, both of
our own risk and that of our peers and be willing to engage with help
at an early stage. Anaesthetic schools should have robust systems in
place for trainees facing difficulty, including encouraging development
of peer mentoring schemes.
Acknowledgements
Dr Helen Hobbiger, Regional Advisor, EoE School of Anaesthesia,
and Ms Keeley Brundle, Administrator EoE School of Anaesthesia,
for help and assistance with the project. Also special thanks to the
EoE Anaesthetic trainees who took the time to complete the burnout
assessment.
Ben Fox
ST7, Norfolk & Norwich University Hospital
Emma Stewart
ST3, Frimley Park Hospital
‘…neither the doing (MBI) or the original numerical score should be
used for diagnostic purposes.’1
References
2.
The Maslach Burnout Inventory
Burnout amongst trainees in the
East of England School of Anaesthesia
In spite of this, we felt it was prudent to provide individuals with
information on the help available. Both the AAGBI and the BMA have a
wealth of resources for professionals who are experiencing burnout as
well as a range of other difficulties.5,6 These include links to wellbeing
schemes, counselling helplines and literature on topics ranging from
fatigue to substance misuse.
Research on burnout has led to the creation of the Maslach Burnout
Inventory (MBI).1 Now the most popular tool to assess the syndrome, it
is a questionnaire that assesses three aspects of burnout:
• Emotional exhaustion
• Depersonalisation
• Personal achievement
Despite the current NHS climate of austerity, there is limited research
assessing burnout levels in anaesthetic trainees. Recent studies in the
US and Belgium have used modified versions of the MBI and found a
high prevalence of burnout amongst trainees.3,4 In Belgium, emotional
exhaustion was seen in over 40% of anaesthetists, with the highest rate
An increasingly popular source of support can be found in mentoring;
particularly between colleagues at similar stages of training.7 This can
help doctors to face burnout and also a whole range of other difficulties.
Success with mentoring depends upon the relationship between the
mentee and the mentor. The mentee needs to be aware of what exactly
As well as a significant negative impact on an individual’s quality
of life and mental health, burnout has also been linked to impaired
cognitive performance in the workplace. It is therefore important to
assess current levels of burnout in anaesthetic trainees, identifying and
providing support to those most at risk.
22 The MBI consists of 22 questions, each scored on a Likert scale
(Figure 1).2 Nine questions relate to emotional exhaustion, five to
depersonalisation and eight concern personal achievement. For each
of the three components the scores are summed and then mapped
to a normal distribution curve based upon historic controls. The subscale scores can then be categorised into low, average and high risk of
burnout. A high degree of burnout is seen when an individual is in the
high risk range for all three sub-scales.
‘I feel burnout/frustration/lack of energy almost daily through the extra
work I have to do at work and at home for the exam. Patients are not
an issue and I really enjoy working with them. However studying for the
exam is a constant source of issues at home and at work.’
- EoE Anaesthetic Trainee
is involved in the process and open themselves up to it. The mentor
on the other hand needs to be suitably trained and use appropriate
frameworks (e.g. the GROW or Skilled Helper models). Over-ambitious
mentors with limited training can be unhelpful or even harmful.
2. I feel used
up at the
end of the
workday
0
never
1.
3.
4.
5.
6.
7.
Maslach C, Jackson SE, Leiter MP, Schaufeli WB, Schwab RL. Maslach Burnout
Inventory Manual. 3rd ed. Menlo Park, CA: Mind Garden, 1996. http://www.mindgarden.
com/products/mbi.htm (accessed 5/10/2014)
Maslach C, Jackson S, Leiter MP, Schaufeli WB, Schwab RL. Maslach Burnout Inventory:
Instruments and Scoring Guides. Menlo Park, CA: Mind Garden, 1996.
de Oliveira GS, Chang R, Fitzgeral PC, et al. The prevalence of burnout and depression
and their association with adherence to safety and practice standards: a survey of
United States anesthesiology trainees. Anesthesia and Analgesia 2013; 117: 182–93.
Nyssen AS, Hansez I, Baele P. Occupational stress and burnout in anaesthesia. British
Journal of Anaesthesia 2003; 90: 333–7.
AAGBI. Support and Wellbeing. http://www.aagbi.org/professionals/welfare (accessed
22/09/2014).
BMA. Doctors’ well-being. http://bma.org.uk/practical-support-at-work/doctors-wellbeing/about-doctors-for-doctors (accessed 22/09/2014).
AAGBI. What is Mentoring? http://www.aagbi.org/professionals/welfare/mentoring
(accessed 06/10/2014)
23 The Anaesthesia Heritage Centre invites you to a series of new exhibitions:
ANAESTHESIA
HERITAGE
CENTRE
A Silver Lining Through the Dark Clouds
Shining*: The Development of Anaesthesia
During the First World War
* A line from Keep the Home-Fires
Burning by Ivor Novello
The Anaesthesia Heritage Centre is producing a series
of four temporary exhibitions honouring the work of
the doctors who gave anaesthesia and pain relief to
wounded people during the First World War.
*
The four exhibitions, each lasting a year, will explore the
development of anaesthesia and pain relief and how the status
of anaesthesia changed during this time.
The first exhibition in 2014-2015 will look at Geoffrey Marshall
versus Henry Boyle: who really developed the Boyle machine?
Did you know that during
the First World War
s bringing back the wounded
British soldier
©IWM (Q 721) courtesy of the Imperial
War Museum
• The first specialist military anaesthetic
posts were created.
• An understanding developed of how to
anaesthetise wounded soldiers suffering
from shock.
• The Boyle anaesthetic machine was
developed which is still in use today.e
Visitor information:
The Anaesthesia Heritage Centre, AAGBI Foundation,
21 Portland Place, London W1B 1PY.
Open Monday to Friday 10am
until 4pm (last admission
3.30pm). Appointments
are recommended: email
[email protected] or phone
020 7631 8865. Admission is
free. Group visits for up to 20
people can be arranged at a
small cost per person.
Registered as a charity in England & Wales no. 293575
and in Scotland no. SC040697
Oral history interviews linking past to present
are also featured. These living histories highlight
how treating wounded people in wartime has led
to developments in pain relief and anaesthesia.
Geoffrey Marshall
Marshall’s
apparatus
Boyle’s
apparatus
Henry Boyle
Visit www.aagbi.org/heritage for further information
SAS Simulation Training
National Institute of Academic
Anaesthesia
JOINT NIAA AND RCS MEETING:
Perioperative Clinical Research:
Opportunities for surgical and
anaesthetic collaboration
or Thursday 12 March 2015
SESSIONS INCLUDE
■
Funders’ market place, HTA, EME and i4i
Exemplar initiatives from surgery and anaesthesia
Dragons’ Den: four presentations. Submit yours to
[email protected]
SPEAKERS INCLUDE
■
■
Professor Dion Morton
Professor Mike Grocott
CPD POINTS
WILL BE
AWARDED
‘Explore new collaborative research
opportunities for surgeons and anaesthetists
focusing on developments in perioperative care
and enhanced recovery.’
Book your free place now: http://bit.ly/1qH7cho
I felt absolutely devastated. It is hard to describe the feeling when I
realised I had given the wrong drug and could have harmed the patient.
I felt a mixture of fear, regret, guilt, embarrassment, disappointment
with myself and loss of self-confidence.
Factors contributing to my drug error
I spoke to and reflected with numerous people after the event,
including different consultants, my peers, friends and even my nonmedical family. Reflecting helped me to identify the contributing
factors that led to the incident.
Wednesday, 4 March 2015
at The Royal College of Surgeons of England,
35–43 Lincoln’s Inn Fields, London WC2A 3PE
■
What happened?
I was on-call over a weekend and anaesthetised a fit patient for an
emergency procedure. Intra-operatively, the surgeon asked me to
give 1.2g of co-amoxiclav. While preparing the antibiotic, the patient’s
blood pressure dropped; I picked up the diluted metaraminol, which
I had prepared previously in a 20ml syringe, and gave a small bolus
to the patient, achieving a good response. Towards the end of the
operation I realised I still hadn’t administered the antibiotic, so picked
up the 20ml syringe in the drug tray and started giving it. I realised it
wasn’t the antibiotic that I had administered but the remaining 20ml
syringe of metaraminol. I informed the ODP and the other members
of the theatre team that I had made a drug error and needed help. I
immediately increased the sevoflurane concentration to a maximum
in order to deepen anaesthesia and cause vasodilatation, and took
serial, frequent blood pressure measurements. The senior anaesthetic
registrar, who was next door, came very quickly and suggested giving
50mg boluses of propofol to control blood pressure. The maximum
blood pressure reading recorded was 198/77mmHg and I gave a
total of 300mg of propofol By the time we transferred the patient to
recovery, the patient was haemodynamically stable with a normal
saturation. After an uneventful recovery the patient was discharged
home the next day.
Shortly after the event
I documented the events clearly in the anaesthetic records.
I informed the recovery nurses and the night shift team of my error and
completed a critical incident form.
NIAA
■
Reflections
on a drug error
Venue: Centre For Clinical Practice
Chelsea and Westminster Hospital
369 Fulham Road | London | SW10 9NH
2 x one day
training
courses
Delegate registration fees: £240 per candidate
Spaces are limited. To book please contact:
[email protected]
This course is specially designed for the needs of SAS anaesthetists.
The content will be based on Anaesthesia Crisis Resource Management
(ACRM). This course aims to train anaesthetists to avoid and deal with
crisis situations. The main focus is on teamwork and human factors.
Useful practical points will also be covered. The setting is a simulated
theatre using an advanced simulation manikin with realistic physical and
physiological signs.
(CPD points applied for)
It was my first day on-call in a new and unfamiliar environment and
I understandably felt anxious. The shift started with a disagreement
with a member of staff: the theatre nurse told me off for wearing my ID
badge the wrong way! It continued with a very busy workload.
I was asked to help with a cannulation on the ward and while
performing this, I was bleeped numerous times by the theatre staff.
They wanted to know where I was and told me that they were sending
for the next patient. I explained that I had not seen the patient and
was not prepared, but they insisted on bringing the patient to theatre.
I returned without siting the cannula to assess the patient in the
waiting bay (not my normal practice), while the theatre staff looked
on impatiently. I went to an unfamiliar theatre to prepare for the
anaesthetic and had to repeatedly ask the ODP for assistance, as I
couldn’t find things that I needed.
I was torn between competing tasks, felt pressurised to do the case
quickly was frequently distracted by unnecessary bleeps and did not
have adequate breaks, I felt stressed the whole day. The incident
occurred at the end of the shift when I was tired and hungry, and in a
noisy theatre.
Conclusion
I describe myself as a dedicated, motivated and vigilant anaesthetist.
I have always had positive feedback. But, I am also human and I make
mistakes. I kept calm and acted appropriately; thankfully my patient
did not suffer an adverse outcome. I was lucky. My error could have
caused morbidity, increased the length of hospital stay and costs, or
even caused death.
Talking and reflecting helped me to cope with the event. I started to
confide in colleagues and learnt that I was not the only person to make
a mistake and learn from their experiences. It was as if I had joined a
‘drug error gang’!
I have learnt a great deal from this event about myself, and it has
definitely changed my practice. I became part of the Swiss cheese
model. I don’t want to enter the cheese tunnel again. I communicate
more with my team and my prioritisation skills have improved; that day
I wanted to be everywhere but I was nowhere. It is equally important
to stand up to nurses. It is the anaesthetist who should prioritise the
patients, not them. I realise rest periods during busy on-calls are vital;
they are necessary to be safe, no matter how many cases are booked.
Most importantly, I learnt it is vital to be open and honest to patients
and inform them of what has happened. This is a standard set by the
GMC. However difficult it may be, it is our duty.
Few, if any, anaesthetists can claim that they have never made a
drug error. Unlike most doctors, anaesthetists are responsible for
choosing, preparing and administrating drugs to patients. We should
be able to speak openly about our mistakes and encouraged to do so.
Human errors are inevitable, but their frequency and impact can be
modified. Working in a multidisciplinary team, we should all promote
a safety culture. Unfortunately, I won’t be the last professional to be
involved in a drug error.
If this happens to you...
It is important to seek help, to inform the consultant on-call and
complete a critical incident form, to reflect and learn from the event,
and to make a note of what it is you have learned. This should be in
your portfolio for discussion at your annual appraisal (and ARCP for
trainees). Making an error can be personally devastating; colleagues
are there to help – we are all only as good as our next anaesthetic.
The GMC requires doctors to provide an apology and explanation
to patients when things go wrong (Good Medical Practice para 55),
and NHS providers (the organisations) now have a statutory duty of
candour. This requires that any errors in treatment that resulted in
moderate or severe harm, or death, must be investigated and reported
to the patient, within 10 days.
25
25 Every day is
Monday for the NHS
In September 2014, the AAGBI launched Lifeboxes for Rio. A two year fundraising campaign aiming to
raise funding for 600 Lifebox pulse oximeters, one for each British athlete attending the next Olympic
and Paralympic Games in Rio de Janeiro (5 - 21 August 2016). That’s £96,000 to save thousands of lives
around the world in countries where patients are at risk of death from oxygen starvation during surgery.
By our correspondent
Scoop O’Lamine
Join the campaign and become a Lifeboxes for Rio fundraiser
The AAGBI wants to involve its members all over the UK and Ireland in the
Lifeboxes for Rio fundraising campaign. There are lots of ways to take part:
Bake, bike ride, run or walk – or devise your own fundraising concept.
www.aagbi.org/about-us/aagbi-fundraising
10
CPD
CREDITS
ANNIVERSARY MEETING:
BEYOND THE BOUNDARIES
Wednesday, 11 March and Thursday, 12 March 2015
The Mermaid, London
£415 (£315 for RCoA registered trainees)
Event organiser: Dr A Cooper
#RCoABtB
The Anniversary meeting is an annual event which
celebrates the creation of the Faculty in March
1948 and the creation of the Royal College in March
1992. The topics for the meetings change annually
and include lectures presented by national and
international speakers. This year the two-day meeting
is focussed on some of the hidden activities which we,
as a profession support.
RCoA
EVENTS
EVENT ONLINE SERVICES
[email protected] | 020 7092 1673 | www.rcoa.ac.uk/events
ANAESTHESIA NEWS
AAGBI Foundation: Registered as a charity in England & Wales no. 293575 and in Scotland no. SC040697
Lifebox: Registered as a charity in England & Wales (1143018)
Anaesthesia News now reaches
over 10,500 anaesthetists every
month and is a great way of
advertising your course, meeting,
seminar or product.
Anaesthesia News
is the official magazine
of the Association of
Anaesthetists of Great
Britain & Ireland.
CALL
NOW FOR
A MEDIA
PACK
For further information on advertising
Tel: 020 7631 8803
A dramatic new policy for the
NHS was announced recently,
following research carried out by
the Head-Bangor consultancy,
which demonstrated Monday to
be the most efficient day of work
within the NHS week.
External and, highly rewarded, Consultant Jeremy Finepoint
explained that the DoH had asked for analysis of efficiency within
NHS hospitals and also mortality rates by day of the week.
only then a small step to convince the Minster of Health that the
NHS should adopt a 7 day working week, with every day being
called Monday!'
'We found that staff worked most effectively on Mondays, with
efficiency dropping gradually over the week by Friday lunchtime.
Apart from some waiting lists, activity levels, efficiency and
safety all were lowest at the weekend.'
The DoH were originally sceptical about such a move, but a well
funded day-terminology shift trial proved the point over a 7 day
period in Cornwallop Regional Foundation Trust run by senior
Matron Matilda Thrusting. 'Just lovely – we never forgot which
day it was, although not everyone understood the concept. It
was probably just too complicated for some of our orthopaedic
surgeons who needed extra allowances to work every 6th and 7th
Mondays. But I think it has been brilliant, and there is no doubt
that we must have transformed the efficiency of our hospitals
because Professor Kube said we must have. Just think – no
more Friday slow downs or sleepy Sundays.'
The DoH pursued a full analysis of this data, consulting a number
of external statistical providers to deep dive into the fine detail
provided by Head-Bangor. A number of academic departments
also contributed to the analysis including Professor Rubix Kube
of the Daftside Community University, Dulham.
'At first I was puzzled by the data, believing only that human
factors such as tiredness and reduced staffing were the cause
of the issues described. But the more analysis I did using our
new Manyur-Bovine statistical package, the clearer it became,
following replicated transmogrified psycho-interval analysis, that
humans associate the term Monday with efficient working. It was
The DoH spokesman explained that teething problems were
being experienced with outpatient and theatre scheduling since
patients were phoning regularly to check dates 'But this is a
small price to pay to get our system in order.'
or email Chris Steer:
[email protected]
www.aagbi.org/publications
Dr Les Gemmell
Immediate Past Honorary Secretary
27 The parent and baby room
‘I am delighted to be able to tell you that your abstract has been accepted for poster presentation.’ This was
welcome news but posed a problem as the next line read: ‘the presenting author of each accepted abstract must
register for the meeting as a condition of acceptance.’ My husband is also an anaesthetic trainee and had already
registered for the meeting. I was on maternity leave and the prospect of finding childcare for our newborn son
made my attendance at the meeting seem unfeasible.
Dear Editor
The juxtaposition of Richard Griffiths cycling article with Paul Fenton's on safe
anaesthetic machines,2 reminds me of the surge in hopefulness that the Lifebox
campaign has engendered with me.
The Universal Anaesthetic Machine was excellent, as was the Glostavent. I used
the latter on patients from 3kg upwards at low flows of oxygen-concentratorderived oxygen. In my own hospital our complicated machines are withdrawn
for the service engineers if a single fault occurs. The draw-over machines are
serviceable with minimum technical help. Following Professor Mackintosh's
’Plea for Simplicity‘,3 I think the anaesthetic machine manufacturers went in the
wrong direction. It serves their budgets if we remain dependent on them for their
technological expertise. I was asked to commission a neonatal incubator in the
Gambia, a charitable donation from Europe. Sadly it was a non-starter. There was
no compressed air available. The Glostavent machine has a capacity for 8L/min of
both air and oxygen at any one time.Thanks to Paul Fenton and Robert Neighbour
(Glostavent), the patient safety advances with Lifebox monitoring can be carried
over to the administration of safer anaesthetics. We need to learn from the poor;
they have ideas that can transform and improve our professional world.
So, with our nine week old son, we had a family outing to
the GAT meeting! The parent and baby room had a speaker
system and two large screens displaying both the presentation
slides and the presenter so it was possible to follow all of the
main lectures. Although we weren’t in the main hall, we could
submit questions for the speakers via the GAT app and so we
still felt involved in the sessions.
The room was thoughtfully set up with a changing mat, baby
wipes and a selection of toys. There was even tea, coffee and
biscuits for the parents in case we didn’t make it out to the
foyer during the coffee breaks.
Dr Michael Carter
Luton and Dunstable Hospital
In addition to staying up-to-date with anaesthetic issues, there
were other benefits of the parent and baby room. The facility
was quite popular and it was great to be able to catch up with
colleagues. Perhaps one of the best things about it was how
helpful it was to be able to speak to other parents about flexible
training and childcare arrangements. The days I attended GAT
were counted as ‘keeping in touch days’ so I was paid for the
days I was there.
The Editor, Anaesthesia News at [email protected]
Please see instructions for authors on the AAGBI website
Dear Editor
1
I retired in April 2013 and cycled from Land's End to John O'Groats the next month,
sporting my red Lycra AAGBI top. I raised money for Lifebox and the International
Nepal Fellowship Medical Camps. This year I have worked in Nepal and then
the Gambia, providing anaesthesia for obstetric fistulae repairs and cleft lip &
palate surgeries. In both places the Lifebox oximeters were being used. In both
environments a Paul Fenton design-type machines were available.
We presumed the solution would be for me to ask if it would
be possible to solely attend the poster sessions. I called the
AAGBI to explain that I wouldn’t be able to attend the lectures
as I had a baby. The friendly voice on the end of the line told
me we could bring him with us as there would be a parent and
baby facility at the meeting.
'You cannot be serious'
With the end of the tennis season this summer, I have to admit I did have a
bit of a John McEnroe moment. It was during a very difficult awake fibreoptic
Intubation (AFOI), on a very anxious patient, on a Bank Holiday Monday at
2am.
A man in his thirties, with mild learning disabilities, was referred to our
hospital for an incision and drainage of a dental abscess
An AFOI was not absolutely indicated and the patient had complained of
a painful and distressing nasoendoscopy at a previous hospital. I had
planned a nasal intubation under direct laryngoscopy with a fibreoptic
scope (FOS) on standby. I was unsuccessful and woke the patient up. After
much persuasion he agreed to an AFOI. I called in the consultant.
The AFOI was extremely challenging, hindered by distorted and swollen
anatomy. As the vocal cords came into view, and I thought we were on the
home stretch, the FOS monitor went black. Not a problem, I could just look
down the scope, but there was no image there either, just pitch black.
'You cannot be serious', I thought to myself.
The ODP checked the stack. I pulled the FOS back to hang in a more
comfortable position over the vocal cords and carried on chatting to the
patient. Luckily the patient was oblivious to our predicament and chatted
away. The ODP left to get another stack. While he was away, the light and
monitor came back on. I intubated the patient and the case proceeded
uneventfully.
References
1.
2.
3.
Griffiths R. The AAGBI Harrogate Cycle Ride for Guy. Anaesthesia News 2014; 325: 7.
Fenton P. Designing and international anaesthesia machine. Anaesthesia News 2014; 325: 13–15.
Macintosh R. A plea for simplicity. British Medical Journal 1955; 2: 1054–7.
Dear Editor
We were previously completely unaware that a parent and baby
facility existed but are very grateful that it does. It enables both
anaesthetists in training and those who are fully qualified to
stay up-to-date, get valuable advice from other parents and
stay in touch with friends and colleagues without having to be
away from their children. And who knows, perhaps the little
ones are taking in some of the information too!
Fiona and Jonathan Pearson
ST4 Anaesthetists in training
Parent and Baby Room at WSM London 2015
Don’t miss out on informative lectures and networking with colleagues at WSM London 2015. The parent and baby room is a resource
room where the lectures from the conference’s main auditorium will be streamed. This will allow you to keep up to date on the
conference proceedings while looking after your children within the comfort of an informal setting.
Visit www.wsmlondon.org for further information
28 your Letters
SEND YOUR LETTERS TO:
It was a pleasure to read the paper by Matthew Down about Winston Churchill.1
The piece refers to Churchill’s hernia repair performed by the surgeon Thomas
Dunhill and states that the anaesthetist was unknown. The anaesthetist was, in
fact, Christopher Langton Hewer, the first Editor of Anaesthesia, who worked
with Dunhill at St Barthomew’s Hospital. I have seen books in the possession of
the family which are signed by Churchill and thank Hewer for looking after him.
Hewer was a brilliant clinical anaesthetist who was well used to dealing with severe
cardiovascular instability that he found on a regular basis while dealing with the
chronic uncontrolled thyrotoxicosis presented to him regularly at Barts. He and
Dunhill specialised in the procedure of ‘stealing the thyroid’ and Hewer designed
a special thyroid facemask for these operations, as Dunhill believed that tracheal
intubation increased intra-operative bleeding! Hewer had perfected his technique
and intubated these cases via the nasal route and then placed the facemask
over the tube so it was invisible to the surgeon. At the end of the case, the ODA
would calmly open the anaesthetic room door, Hewer would flick the tracheal
tube through the open door which was then promptly shut. Dunhill meanwhile was
distracted deliberately each time this occurred and it is said he never knew about
the intubation. With consummate skills such as these I believe Sir Charles Wilson’s
description of ’frequent anxious checking of the pulse‘ indicates the challenging
status problems of our profession in the eyes of certain physicians of that era.
Dunhill always respected Hewer and held him in very high regard.
Dr David Wilkinson
President, WFSA and Emeritus Consultant Anaesthetist, Boyle Department of
Anaesthesia, St Bartholomew’s Hospital, London
Reference
1.
Down M. Winston Churchill. Anaesthesia News 2014; 326: 5.
Fig 1. The stack as it should be
Fig 2. The offending equipment box
blocking the cooling fan
We later learnt that the ODP had burnt himself on the light source switch.
An equipment box had helpfully been stored behind the cooling fan for the
light source which had caused it to overheat and cut out. While the ODP was
away from the room, the light source had cooled down enough to allow us
enough time to intubate.
A lesson to us all! A memo was sent to all the theatre staff.
Manu Sharma
Anaesthetics SpR, Queen Victoria Hospital, East Grinstead
29 Digested
WORLD AIRWAY MANAGEMENT MEETING
December 2014
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a
physiological method of increasing apnoea time in patients with difficult airways
Patel A, Nouraei SAR
Early bird
rate availab
le
BOOKING NOW OPEN
FOR THE WORLD’S LARGEST
AIRWAY MEETING
12-14 NOVEMBER
www.wamm2015.com
2015
• Scientific programme • Workshops • Industry exhibition
• Poster competition • Keynote speakers • Social events
Plus, much much more!
TO MARK THE 20 ANNIVERSARY
OF THE DIFFICULT AIRWAY SOCIETY
& THE SOCIETY FOR AIRWAY MANAGEMENT
TH
JOINT MEETING OF THE DIFFICULT AIRWAY SOCIETY
& THE SOCIETY FOR AIRWAY MANAGEMENT
DUBLIN
Booking is now open for next year’s biggest world airway
management meeting in Dublin. This is a joint meeting of the
Difficult Airway Society & The Society for Airway Management.
The authors describe a novel method (THRIVE) of maintaining oxygen
saturations during intubation. In some respects this does not seem novel or
exciting, yet readers would be well advised to take a closer look at this interesting
data. First, Patel and Noraei’s patients were all difficult to intubate. For many
this had been established at previous anaesthetics. Second, all these patients
maintained oxygen saturations >90% for apnoeic periods of >10 mins. Indeed,
four of them maintained saturations of >96% for >30 mins; the longest
duration being just under 70 mins! It is difficult to conceive of any current
method in which one could maintain a patient with a difficult airway apnoeic,
while trying to secure their airway, for an hour – yet here is the data. Third – and
for many physiologically minded readers this may be the most interesting aspect
– the rate of rise of carbon dioxide was just ~0.1 kPa.min-1, much lower than
the standard 0.5 kPa.min-1 quoted in all reference texts. Indeed, it seems only
two other studies have achieved such low rates of carbon dioxide accumulation,
both using intratracheal canulae. The method used by Patel and Noraei is very
simple – a high flow, humidified oxygen delivery system applied to the nose. Just
as preoxygenation, useful in patients with difficult airways, is logically therefore
applied to all patients (since one cannot always know in advance which patient
will be difficult), it begs the question whether THRIVE (or similar techniques)
should be logically used in all patients during induction of anaesthesia.
Electroencephalogram reactivity to verbal command after dexmedetomidine,
propofol and sevoflurane induced unresponsiveness
Kaskinoro K, Maksimow A, Georgiadis S, et al.
With NAP5 having just been published, all things related to preventing accidental
awareness during anaesthesia – brain monitoring, anaesthetic mechanisms – are
rightly at the forefront of academic interest. This complex paper looks at a
parameter of the electroencephalogram (EEG), namely its ability to react to
external stimuli (in this study, up to the point when the subject is no longer
responsive to verbal stimulation). The authors found that this measure of EEG
reactivity persisted, even when subjects were no longer responsive, and also that
there were differences in the quantity measured between three different agents
(propofol, dexmedetomidine and sevoflurane). This means two things, which
practising clinicians may find difficult to accept (but many neuroscientists and
psychologists have long accepted as the norm). The first is that, even when our
patients are unresponsive to our commands, the brain is still reactive to verbal
input (and if this is the case, how do we know that our patients are actually
‘anaesthetised’?). The second is that the same macroscopic end-point at the
level of the organism (namely, in this case, unconsciousness where the subject
is unresponsive to command) can be attained in neurologically specific ways
by different anaesthetic agents. ‘Falling asleep’ with propofol is simply not the
same as with sevoflurane or dexmedetomidine. And if this is the case, how are
we able to develop a universal monitor for ‘depth of anaesthesia’ applicable to
all these agents?
Comparison of the C-Mac and Glidescope videolaryngoscopes on
patients with cervical spine disorders and immobilization
Brück S, Trautner H, Wolff A, et al.
The Difficult Airway Society published its ADEPT guidance for evaluation
of airway-related devices in 2011. High quality trials on the relevant airway
devices continue as a result of this stimulus and, in this study, Brück et al.
focus on the use of two established devices in the critical scenario of tracheal
intubation in cervical spine disorder. Reassuringly, they find that both devices are
broadly comparable, with any reported differences probably being dwarfed by
interindividual differences in practice in the real world.
The effect of needle dimensions and infusion rates on injection
pressures in regional anaesthesia needles: a bench top study.
Patil JJ, Ford S, Egeler C, Williams DJ.
Successful peripheral neural blockade requires placement of the needle tip
close to the nerve; however, breach of the epineurium and injection of local
anaesthetic intraneurally, or worse, intrafascicularly, may result in permanent
nerve damage. Both ultrasound and nerve stimulation can be unreliable and
pressure thresholds for injection constitute a third means of identifying this
potential complication. The question is then how best to measure this? In a
bench study, the authors concluded that injection rates should be no higher than
15ml.min-1 to exclude factors proximal to the needle tip as the cause for high
pressures. Very sensibly, they have translated this to mean a rate of no higher
than 0.25 ml.s-1 (which clearly helps those practitioners without immediate access
to pressure gauges) and they also suggest coupling this with both ultrasound and
electrical stimulation.
N.B. the articles referred to can be found on Early View (ePub ahead of print)
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-2044/earlyview
J. J. Pandit
Editor, Anaesthesia
31 Particles
Flint E, Cummins S, Sacker A.
Asfar P, Meziani F, Hamel JF, et al.
Patel A, Laffan M, Waheed U, Brett S.
Associations between active commuting, body
fat, and body mass index: population based,
cross sectional study in the United Kingdom.
High versus low blood-pressure target in
patients with septic shock
Randomised trials of human albumin for
adults with sepsis: systematic review and
meta-analysis with trial sequential analysis of
all-cause mortality
British Medical Journal 2014; 349: g4887
Anaesthetists are often considered to be some of the more active members
of the medical profession. Beneficial effects of physical activity on obesity
and health outcomes are well understood. Active commuting to work has
been strongly recommended by the UK National Institute for Health and Care
Excellence as a feasible way of incorporating greater levels of physical activity
into daily life.1
Studies consistently suggest that use of active commuting modes translates
into higher levels of overall individual physical activity.2-4 ‘Active commuting’
should not necessarily be limited to only walking or cycling. Research has
suggested that travelling by public transport involves significantly more exertion
than using private transport, as walking is generally required between public
transport hubs and journey origins and destinations.5 However, there is limited
research on the potential population health benefits of encouraging the use of
public transportation.
Objective
The aim of this study was to investigate the relationship between active
commuting (walking or cycling for all or part of the journey to work) and two
objective measures of obesity.
Design
A cross sectional study of data from the wave 2 Health Assessment subsample
of Understanding Society, the UK Household Longitudinal Study (UKHLS), a
large, nationally representative dataset. Commuting mode was self-reported
and categorised as three categories: private transport, public transport, and
active transport.
Participants
The analytic samples (7534 for body mass index (BMI) analysis, 7424 for
percentage body fat analysis) were drawn from the representative subsample
of wave 2 respondents of UKHLS who provided health assessment data (n =
15,777).
Main outcome measures
Body mass index and percentage body fat (measured by electrical impedance).
Results
Results from multivariate linear regression analyses suggest that, compared
with using private transport, commuting by public or active transport modes
was significantly and independently predictive of lower BMI for both men and
women.
In fully adjusted models, men who commuted via public or active modes had
BMI scores of 1.10 (95% CI 0.53 to 1.67) and 0.97 (0.40 to 1.55) points lower,
respectively, than those who used private transport. Women who commuted
via public or active modes had BMI scores of 0.72 (0.06 to 1.37) and 0.87 (0.36
to 0.87) points lower, respectively, than those using private transport. Results
for percentage body fat were similar in terms of magnitude, significance, and
direction of effects.
Conclusions
Men and women who commuted to work by active and public modes of transport
had significantly lower BMI and percentage body fat than their counterparts who
used private transport. These associations were not attenuated by adjustment
for a range of hypothesised confounding factors.
New England Journal of Medicine 2014; 370: 1583–93.
Background
Septic shock is defined as sepsis-induced hypotension despite adequate fluid
resuscitation.1 The current Surviving Sepsis Campaign Guidelines (SSCG)
recommend targeting a mean arterial pressure (MAP) of ≥ 65mmHg but
evidence for this is limited.2,3 A caveat states that a higher MAP may have a
better outcome in patients with hypertension and atherosclerosis and this is
reflected in clinical practice where higher target MAPs are frequently set.
In this study, the authors investigated whether, in patients with septic shock,
resuscitation to a high target MAP of 80-85mmHg (when compared to a low
target MAP of 65-70mmHg) affected 28 day mortality.
Methods
This government funded, 29 centre, open-label, randomised control trial
assessed 4098 patients of which 798 were eligible and underwent randomisation.
Important inclusion criteria included age ≥18 years, sufficient fluid resuscitation
and a minimum vasopressor requirement (noradrenaline was used in all but
one centre). The target MAP (high or low) was maintained for 5 days or until the
patient was weaned from vasopressors. Subsequent MAP targets were variable.
Pre-specified adverse events such as bleeding, arrhythmias and myocardial
infarction triggered a reduction in MAP target in the high group.
Results
There was no significant difference in 28 or 90 day mortality between the
high and low MAP target groups. Within a subpopulation stratified for chronic
hypertension, the high MAP target group showed a significant decrease in the
proportion of patients having a doubling of their creatinine (38.9% vs 52.0%,
p = 0.02) and requiring renal replacement therapy (RRT) (31.7% vs 42.2%, p
= 0.046). The only statistically significant difference in adverse events was a
higher incidence of atrial fibrillation in the high target MAP group (6.7% vs 2.8%,
p = 0.02).
Discussion
The SSCG target MAP of ≥ 65mmHg is a strong recommendation based on
limited evidence (grade 1c). Through a rightward shift of renal auto-regulation
curves in chronic hypertensive patients, there is a plausible physiological
justification for higher target MAPs in these patients. While less renal impairment
in this stratified population was seen in the high target MAP group, this did
not affect mortality. Due to an overestimation of expected mortality, this study
was slightly underpowered, meaning that there may be a failure to detect rarer
adverse events such as myocardial infarction.
Dr John McLenachan
CT1 Anaesthesia, Edinburgh
References
1.
2.
3.
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international
guidelines for management of severe sepsis and septic shock: 2012. Critical Care
Medicine 2013; 41: 580–637.
LeDoux D, Astiz ME, Carpati CM, Rackow EC. Effects of perfusion pressure on tissue
perfusion in septic shock. Critical Care Medicine 2000; 28: 2729–32.
Bourgoin A, Leone M, Delmas A, Garnier F, Albanèse J, Martin C. Increasing mean
arterial pressure in patients with septic shock: effects on oxygen variables and renal
function. Critical Care Medicine 2005; 33: 780–6.
Dr Jonny Price
ST6, North Central London School
References
1.
2.
3.
4.
5.
32 National Institute for Health and Care Excellence. Walking and cycling: local
measures to promote walking and cycling as forms of travel or recreation (public
health guidance 41). London: NICE, 2012. www.nice.org.uk/guidance/ph41.
Faulkner GE, Buliung RN, Flora PK, Fusco C. Active school transport, physical
activity levels and body weight of children and youth: a systematic review. Preventive
Medicine 2009; 48: 3–8.
Ogilvie D, Foster CE, Rothnie H, et al. Interventions to promote walking: systematic
review. British Medical Journal 2007; 334: 1204.
Audrey S, Procter S, Cooper AR. The contribution of walking to work to adult physical
activity levels: a cross sectional study. International Journal of Behavioral and Nutrition
and Physical Activity 2014; 11: 37.
Rissel C, Curac N, Greenaway M, Bauman A. Physical activity associated with
public transport use - a review and modelling of potential benefits. Internal Journal of
Environmental Research and Public Health 2012; 9: 2454–78.
British Medical Journal 2014; 349: g4561.
Background
The argument continues on which fluids are beneficial in the resuscitation
of sepsis, with colloids largely discredited and continuing uncertainty about
the benefits of albumin. NICE guidelines and the Surviving Sepsis Campaign
currently recommend using crystalloids for initial fluid resuscitation, with human
albumin solutions suggested for patients requiring substantial amounts of
crystalloids.1, 2 Evidence from previous RCTs is mixed, with the SAFE study3
finding a survival benefit with 4% albumin in sepsis, but this was not replicated
by the recent ALBIOS study.4
Methods
Sixteen randomised controlled trials were identified comparing albumin to
either crystalloid or colloid fluid resuscitation. A total of 4190 adults requiring
critical care were included, and classified as ‘sepsis’, ‘severe sepsis’ or ‘septic
shock’ to allow comparison between studies and subgroup analysis. Mortality
at final follow-up was the primary outcome measure. The relative risk of death
for human albumin compared to other fluids was calculated for each included
study and a pooled summary calculated.
Results
All-cause mortality was statistically similar in patients who received human
albumin solutions or control fluids (relative risk 0.94, 95% CI 0.87-1.01, p =
0.11). Subgroup analysis of disease severity and control fluid did not show
any reduced mortality with albumin, although the number of patients receiving
colloids was low. No definite signal of harm with albumin was observed.
Discussion
The meta-analysis included a large amount of new patient data, and analysed
potential bias of the studies. While it did not include the recent CRISTAL and
ongoing RASP studies, models of their potential impact did not change the
finding of no overall impact on mortality. The timing, duration and volume of
albumin administered varied considerably between studies, and the effect of
early albumin administration or secondary outcomes such as morbidity and
length of critical care stay were not examined.
While harm has not been detected from the use of albumin in sepsis, this
meta-analysis shows no impact on the high mortality. It challenges the current
recommendations on using albumin in fluid resuscitation guidelines in sepsis.
Given the high cost of albumin compared to the apparently equally effective
alternative of crystalloids, it is difficult to support the use of albumin in sepsis
on the current evidence.
Anna Roberts
ST7, Welsh School of Anaesthesia
References
1.
NICE clinical guideline 174. Intravenous fluid therapy in adults in hospital.
London: NICE, 2013. http://www.nice.org.uk/guidance/cg174/resources/
guidance-intravenous-fluid-therapy-in-adults-in-hospital-pdf (accessed
5/10/2014)
2.
Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign:
international guidelines for management of severe sepsis and septic
shock: 2012. Critical Care Medicine 2013; 41: 580–637.
3.
The SAFE Study Investigators. A comparison of albumin and saline for
fluid resuscitation in the intensive care unit. New England Journal of
Medicine 2004; 350: 2247–56.
4.
Caironi P, Tognoni G, Masson S, et al. Albumin replacement in patients
with severe sepsis or septic shock. New England Journal of Medicine
2014; 370: 1412–21.
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