2015 Spring

the society of anaesthetists of the south western region
news of
the west
eXecutiVe
MonKey
escaPes froM BristoL
research institute
Incorporating
Anaesthesia Points West
spring 2015
ASA classification
revised
Following a nasty case of Manthrax in North Bristol,
it was decided to revise the ASA classification with
the addition of a sixth level. ASA 6 is to be defined
as ‘Too poorly to fulfil private practice commitments’.
Such cases are often associated with perversely
heightened levels of job satisfaction and financial
well-being in close colleagues of the afflicted
person.
In related news, the ‘Monarch of the Glen’ is said to
be on the mend, although nursing a residual deficit
in his balance.
Wine Writer On Wagon
The long-serving wine writer to APW is reported
as saying he felt ‘pretty good’ whilst on the
wagon during Dry January, but feels much better
now it’s all over. His wine recommendation in
this edition is: ‘Just drink it’.
Mystery
surrounds
the
whereabouts of Dr. Chris
‘Monkey Man’ Monk following a
party to celebrate his retirement
from United Hospitals Bristol.
At the event, held in the
appropriately named M Shed,
Dr. Monk was presented with a
Platinum Banana in recognition
of his dedication to teaching
and research over a long
career. Reported sightings in
New Zealand and Hawaii and,
more recently, near the Downs
in Bristol, suggest he may be
running low on bananas.
Hunt for lost Editorial team
increasingly desperate
-see inside
the society of anaesthetists of the south western region
President
Dr Chris Monk
UHBristol
Dr Robert Sneyd
Plymouth Hospitals
Honorary Secretary
Dr James Pittman
Exeter
Honorary Treasurer
Dr Ed Morris
Southmead
Dr Mark Pauling
Dr Ben Gupta
South West School
Bristol School
Dr Richard Dell
Editor,
Southmead
Kate Prys-Roberts
UHBristol
Dr Ben Howes
UHBristol
President – Elect
Trainee Representatives
Editorial Committee
Administrator
Website Manager
www.saswr.org
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anaesthesia Points west
Contents
Vol 48 No 1
spring 2015
Page
Editorial
Richard Dell
3
Future meetings of the Society
5
Presidential Profile
Ed Morris
6
News of the West
Linkmen of the Region
9
Autumn Scientific Meeting report
James Pittman
25
Intersurgical Trainee Prize Winning
Presentation
Rebecca Leslie, Rowan
Hardy, Paul Hersch and
Fiona Kelly
30
SASWR Poster Prize Winner
Melanie McDonald, Genevieve O’Farrell, Fiona Kelly
32
Lectures and the Communication Revolution
Neville Goodman
34
Anaesthetics and Critical Care
Retrieval in the Outback
Peter Valentine
36
A PhD Late in Life
Patrick Magee
41
Ulna Tidal Volume Ruler, Red Tape
and Origami.
Jon Rivers and Jules
Brown
44
Examination successes and honours
The Wine Column -
Hello, my name is Tom
Poem – White Moments
46
Tom Perris
47
Robin Forward
49
Ross Davis Adventure Bursary
Crossword
50
Brian Perriss
51
Prizes and bursaries
52
Notice to Contributors
53
2
Editorial
Abstinence makes the heart grow fonder
Welcome to the Spring edition of
Anaesthesia Points West. Regular readers
will notice that the format changes little from
issue to issue, at least since the front cover
went downmarket in a blatant attempt to
engage with a younger readership. So it
was fascinating to be given a box of old
APWs by Robin Weller, a former President
of the society and also ex-editor of APW.
The box included the very first edition,
from October 1968, when the journal
was sustained financially by commercial
advertising, hence the advert for ‘Tubarine’
(entries on a postcard) and an advert for a
Barnet Mark 3 ventilator, which is about the
size of a Bentley. God only knows how big
the Mark 1 was; I expect you had to lie in it.
I’d like to be able to tell you who the first
editor was, but it seems back then people
were known by only their initials, and so I
can only say that it was J.F.P (it’s a bit like
that bit in Harry Potter when Regulas Black
leaves only his initials on the scrap of paper
in the fake locket). Likewise, News of the
West was written by one person, a P.J.F.B.
although I actually know who that was, and
it was entirely fitting he wrote News of the
West as he generated most of the news
and gossip himself, back in the day.
Strangely enough, the issues being
discussed in APW Volume 1 were
awareness under anaesthesia, and
excitement at the prospect of the
forthcoming scientific meeting of the
Society in Plymouth, which, by happy
coincidence, is exactly where we find
ourselves now. Plus ca change!
The Society dinner at the Plymouth
meeting is to be held in the Officer’s
Mess of the Commando Forces, a place
few civilians ever have access to. Once
this became known in the Southmead
anaesthetic department, there was an
unseemly rush from some of the females,
most of whom were old enough to know
better, to bag the few remaining leave
slots in the departmental diary. To save
any disappointment, I don’t think there are
going to be many marines at the dinner,
and you can’t hide out there for ever.
One change for this edition is that there
are no wine recommendations from the
resident wine-writer, Tom Perris, due to
his joining many others and having a ‘Dry
January’. Very commendable, but I’m
sure P.J.F.B. would have had something
memorable to say on the subject. I did
actually try Dry January myself, but was
forced to give up after two days due to
a combination of circumstances which,
happily, I can no longer recall. Anyway, if
one is serious about cutting down, there’s
always next January.
Elsewhere in this edtion, Neville Goodman
espouses on the etiquette of using
electrical devices during lectures, and
Peter Valentine is highly entertaining
writing about his adventures as a flying
doctor, amongst other posts he held in
Australia. Peter sent a ton of photos,
although sadly there wasn’t space for all
of them.
Patrick Magee, from Bath, has written
an illuminating article on how to embark
on a PhD course later in life, and James
Pittman provides an account of the highly
successful Autumn meeting in Bristol, and
3
quite rightly draws attention to unnecessary
audiovisual malfunctions.
Jon Rivers
and Jules Brown provide an entertaining
insight into their difficulties dealing with
research bureaucracy.
There is also all the news (and probably
none of the gossip) from around the region
in News of The West, with an account of a
particularly lively ‘Strictly’ style Christmas
party in Exeter. Be warned, there are
rumours that the Exeter Massive are
mobilizing for the SASWR meeting in Bath
in December, so book early. A great band
will be playing too, apparently.
I would draw the attention of any trainees
4
reading to the Ross Davis Adventure
Bursary page towards the back of APW,
as the funding for this will soon cease. It
is a fantastic opportunity for a trainee with
itchy feet to fund a year working abroad,
although it’s not implausible that they
might come back with some other part of
their anatomy itching.
Many thanks to regular contributors Robin
Forward and Brian Perriss, who provide
the poem and crossword respectively.
See you in Plymouth.
Richard Dell
Future Meetings of the Society
spring 2015
Plymouth
14-15th May
Autumn 2015
Bath
3-4th December
spring 2016
18-21st May
Overseas Meeting
Destination to be announced shortly
5
Portrait of the President
Dr. Chris Monk
The most remarkable thing about Chris
Monk’s retirement party in January was not
the superb view over Bristol’s harbourside
from the top floor of the M-Shed, nor the
enthusiastic performance by SASWR’s
resident band the Dell Stars, nor even the
witty presentation made that evening by his
fellow anaesthetists. The most remarkable
thing was the sheer range of colleagues
from every sphere of his professional
life who had come to wish him well. In
addition to anaesthetic colleagues there
were trainees past and present, nurses
from theatres and the wards, cardiac
technicians, ODPs, a large number of
health service managers including the
current chief executive of University
Hospital Bristol, and Chris’s wife Charlotte
and adult children.
This guest list gives an insight into this
year’s President: a popular and admired
clinician, a valued and supportive
colleague, a sought after and respected
trainer, a highly regarded medical manager,
and a devoted family man.
Chris was born in London but spent most
of his formative years on either side of
the Pennines, ending up at Manchester
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University in the early 1970s. I would dearly
love to be able to produce a photograph of
him in a kaftan with a Zapata moustache
but sadly the only reference he makes to
his college years is that he ‘rowed a bit,
and walked in the Lakes and Snowdon’.
Digging a bit more deeply reveals that
having been encouraged to join the rowing
team by the Dean in view of his height, he
was then told unceremoniously to stop after
narrowly failing his pharmacology exam –
an injustice which he still feels keenly. His
wife Charlotte, whom he had met initially
in the sixth form, reappeared on the scene
during his third year at college and has
been at his side ever since.
Chris’s training reflected both his academic
ability and his sense of adventure. He
gained his early anaesthetic experience
in Manchester, including his first taste of
cardiac anaesthesia; he also spent some
time in general medicine and an extended
holiday as a GP in Regina, Saskatchewan.
Rural Canada, or perhaps general practice,
failed to lure him away from anaesthesia
and he returned to Manchester as a
registrar, winning the final fellowship prize
in January 1983.
On the back of this academic success
Chris applied successfully to the South
West Senior Registrar rotation, spending
time in both Plymouth and Bristol among
colleagues who are well known both
within SASWR and within anaesthesia
nationally. As lecturer to Cedric PrysRoberts he published and lectured on
propofol infusions, blood pressure control
and organ perfusion, swapping posts
with Peter Hutton, Griselda Cooper, and
our own Neville Goodman. As necessity
demanded even then he presented much
of this work to SASWR in the hope of
gaining a consultant post in the region – an
ambition which, after a further 18 months
in North America in Charlottesville and San
Francisco, he realised with his appointment
to the BRI in January 1989 as an adult and
paediatric cardiac anaesthetist. This was
despite his involvement in the infamous
‘bread roll fight’ at his first SASWR dinner
at Redwood Lodge - Chris has always
worked hard and played hard (of which
more later) in the best tradition of our
profession, and his wry sense of humour
has enhanced many a meeting and social
event.
Chris’s ability as an organiser, manager, and
diplomat was soon recognised by his new
department and he took on (or was pushed
into) a host of roles in the BRI department
during a time of much transition for both
the hospital and the NHS as a whole. As
lead cardiac anaesthetist from 1990-96
and CD for anaesthesia from 1993-95 he
oversaw reorganisation and rebuilding at
the BRI, including the design of the Hey
Groves theatres in which so many of us
worked and trained. Colleagues from the
time talk of ‘his ability to get things done’,
and his ‘immense diplomacy’ as well as
the respect he earned from his clinical
abilities. These skills came into their own
when the problems of paediatric cardiac
outcomes at the BRI were highlighted in
the mid 1990s. Chris, along with many
of his colleagues, gave evidence to the
enquiry and then set about playing his part
in rebuilding the department in the wake of
that difficult time.
By now his talents had been recognised
by those further up the organisation and
within the region and Chris was appointed
Associate Medical Director for planning and
strategy in 1996. This enabled him to play
his part in developing the new Children’s
Hospital (1998) and the new Bristol Heart
Institute (2008) and finally, as head of the
Division of Medicine (2005-11) the New
Building at the BRI to replace the old
building which dated from 1735. Whenever
I saw Chris during this period he was
either going to or coming from a meeting
to persuade one group or another to see
his (invariably reasonable) point of view
– anything from talking to councillors and
strategists about regional healthcare plans
to persuading the residents of Kingsdown
to let the new hospital have a helicopter
landing pad. His legacy in reordering the
healthcare of central Bristol is a huge one
– and all the more remarkable because he
kept up a busy clinical practice and on-call
contribution through all the time he was
involved in management.
Chris continued to travel as a consultant,
lecturing for the WFSA in Moscow,
Paraguay, the West Indies and Archangel,
and helping Gianni Angelini establish
the first cardiac unit in Trinidad. And he
combined his interest in teaching with
his organisational ability to help set up
and become chairman of the Brunel ODP
training school which ran from 1997 for ten
years and produced dozens of ODPs for
Bristol before being merged with Oxford
Brooks University in 2007.
It seems that for Chris the phrase ‘if you
want something doing, ask a busy man’
could have been invented, but away from
work Chris has found time to pursue a
variety of hobbies, including running and
cycling (he recently cycled from Bristol to
Paris to raise funds for a hospital charity),
snow boarding and skiing, and tending
a garden with an ornamental fish pond
(who knew?!) in Bristol’s suburbs. His
7
children Katie and Ric, a solicitor and
architect respectively, are in the process
of providing Chris and Charlotte with a
brood of grandchildren and his aim to walk
some of the coast to coast walks over the
next few years will no doubt attract some
enthusiastic followers.
Chris has been an enthusiastic supporter
of SASWR throughout his time in the South
West. A regular fixture at meetings at home
and abroad, we were delighted when he
took on the role of Honorary Secretary
six years ago. His term of office was
8
not without excitement – a volcanic ash
cloud threatened to cancel the overseas
meeting to Rome which he organised
and a visit to Bristol by the Queen forced
a last-minute change of venue in 2012 –
but Chris dealt with both events with his
typical good humour and organisational
flair. His presidency of SASWR is a natural
progression for a colleague who has spent
his career delivering, supporting, and
improving anaesthesia and healthcare in
the South West of England.
Ed Morris
News of the West
This is where you are kept up-to-date on all the news and gossip from each
department in the South Western region. The name of the correspondent appears
at the end of each contribution and he/she is also the SASWR LINKPERSON for
that department. Anyone wishing to find out about more about SASWR, or wishing
to join, should search out the local link person, who will readily supply details and an
application form. In addition to other benefits, each member will receive the twiceyearly edition of APW- free!
Barnstaple
So we are top fourth in the country when
it comes to staff satisfaction and this
naturally translates into good patient
care. The Chief is very pleased, but there
is still work to be done! Not so says our
GMC trainee feedback! Does this just
mean that senior substantive staff, are
not working hard enough and the trainees
are bearing the brunt! Or is it that North
Devon is a well-kept secret where people
rub benignly along, much like the New
Zealanders,
happily
geographically
isolated and a few generations behind
the modern rat race. Our trainees on the
other hand seem reluctant to venture
into town. Perhaps they fear the Cyclops
on Butchers Row or the monsters in the
nightclubs here at the end of the earth.
According to a reliable source it wasn’t long
ago that Barnstaple only had one high street
supermarket and everyone knew each other.
Now we are surrounded by supermarkets,
a couple more in planning, there are three
bridges over the Taw, and plans to make
the link road into a dual carriage way! Still
not as frantic as Bristol though and a great
place to raise the kids, anyone tempted?
The skips have gone thereby depriving
me of a free source of parts for kids go
carts and a welcome distraction on the
way to the car park. What has emerged
in its place is a swanky new state of the
art chemotherapy unit, complete with
feature gardens, Astroturf lawns and moss
covered rooftops.
The intensive care unit is still in need of a
major facelift and we need more beds or
we won’t be making the right impact on the
EPOCH trial. Recovery is still home to a
couple of ITU hopefuls most nights, and
things don’t look like letting up in the near
future. How about a swanky moss covered
unit!
Whatever the case may be, we have
been fortunate to have had a great deal
of interest in our latest round of jobs. So
we can welcome (in no particular order)
David Beer, Caroline Cheeseman, Balasz
Ittzes and Lucy Miller into the fold. Lucy
and David have yet to hit the ground, but
Caroline arrived February in the early
stages of pregnancy and promptly fell
victim to a proper bout of pneumonia.
Balasz Bartos is doing a chronic pain locum
consultant job until Lucy arrives and Rubina
Mohamed will be sadly leaving us after a
very productive three years as chronic pain
lead. Nigel Hollister has already passed on
the responsibility for organizing the M&M
schedule to Nick Love, soon to be followed
by audit and quality improvement. Simon
Hebard is trying to drag us into the 21st
century by restructuring and resourcing
9
the preassessment clinics and braving a
bit of abuse from the Jeremy Clarksons of
our department.
We will be introducing an electronic patient
record over the next couple of years and
even some of the skeptics seem impressed!
No doubt we will have everything in place
just in time for a major cyber assault on the
NHS network.
Ruth Whittle has set a date for her
retirement do, as has Tony Laycock
(his first). The department is becoming
unrecognizable from the one I joined 13
years ago and I am beginning to feel like I
should be wiser.
On the trainee front we have had a couple
of exam successes for James Bickley and
Eleanore Quinn. who will be leaving in
August, James to work for world cup rugby
and Eleanore to an ST3 job, hopefully of
her choosing! David Robertshaw is getting
married sometime soon, and will that mean
that he doesn’t have to commute to Oxford
quite as much? Mark Brown or rather
“Skidmarks Brown” managed to hit 70 in
his souped up Seat Ibiza down the road
to the petrol station. In his eagerness to
get his girl a valentine’s gift, he sadly flew
past a squad car on the way. Credit to him
and his powers of persuasion he didn’t end
up walking back up the hill, bottle of wine
and cheap chocolates in hand. Martin Paul
puts in an occasional appearance filling
the staff car park with his friend of OPEC
motor home. Laura Squire and professor
Christian Mertes spend most of their time
on the unit these days, usually together
as yours truly didn’t put them on opposite
sides of the rota.
On the middle grade front, Chrisiane
Schub has decided to head back to the
world of chronic intensive care in Germany
where they regularly raise the nearly
10
dead! (patients with hypoxic brain damage
waking up three months after the event!!!).
When is it right and fitting to declare the
game over? We wish her well.
As usual other news is scant but Tony
has been off gallivanting around the world
again posing with yet another pin up, this
time from deepest darkest Vietnam!
‘Look, no hands!’
On a more somber note, Henry Bastiaenen’s
wife Sue passed away at the end of March
after she was diagnosed with a brain
tumour. Patrick Brighton also passed away
this summer on the Intensive care unit he
once worked in, following a brief illness.
Staff fondly remember him leaning out of
the office window, fag in hand or irreverently
wandering off to the maternity unit for an
urgent C section, spinal needle and loaded
syringe in his pocket.
Guy Rousseau
Bath
It was with great sadness that we
learned of the intended retirement of
Elspeth Alexander. Elspeth has been the
departmental ‘sergeant at arms’ for the past
more years than I care to remember. She
has been brilliant at cajoling, coercing and
coordinating all of us, to ensure the smooth
running of the department of anaesthesia,
pain management and intensive care
medicine at the Royal United Hospital.
It was incredibly reassuring to know that
all one needed to do was phone Elspeth,
begin your tale of woe and she would
take over, finishing your sentence for you,
sorting out whatever was troubling you
and hanging up before you’d finished or
managed to say ‘thank you’.
Occasionally, she even fixed issues you
never even realised you had!
Whatever the problem, Elspeth always put
the patients first. She tirelessly rejigged
the rota, covering unexpected sickness,
early maternity leave, unpredictable
paternity leave, forgotten study leave and
last minute annual leave to ensure that we
covered the lists and that the anaesthesia
road show carried on. We will all miss her
and wish her well with her future life. I hope
we will be able to cope without her.
As one era ends, so a new one begins.
We are extremely pleased to welcome
Melanie Macdonald, Justine Barnett, Rob
Axe and Ian Kerslake to the department as
consultant colleagues.
I recently asked them all what was the one
question they hoped would not come up in
their consultant interviews. Ian Kerslake
replied immediately with “what do you do
to de-stress at the weekend” and given his
penchant for cross dressing as Princess
Leia, I’m not surprised.
I would love to see the look on Commander
Goodwin’s face when Ian fronts up in
a flowing white robe and starts barking
orders at him!
There goes that particular fantasy…
Our only hope would be the Princess might
entice some Jedi Nights to use the force to
find us some extra hospital beds.
One of the downsides to having young blood
join the department is that it moves the
rest of us old dogs further up the seniority
ladder. I’ve long given up challenging the
young ‘uns to tests of physical strength,
but was really distressed to see just how
fresh faced our new recruits are!
Rob in SPA mode
11
Although, by the look of Rob Axe in this
photo, he may have used up all his energy
getting through the competitive interview
process! I rather hope he is well rested by
the time he starts and we can all benefit
from his youthful vitality and maybe even
get out for the odd cycle ride or two.
Too cool for school
I wondered why Justine Barnett was
protecting her eyes. Clearly the shining
light that is Dr Carol Peden, now Professor
Carol Peden (again) is brighter than ever.
Well done Carol on your new Chair.
Also well done to all the trainees who have
also recently excelled in their exams: Paul
Watson, Sarah Steynberg, Ed Miles and
Mark Everleigh.
After many years of sufferance, Jenny
Tuckey has finally accepted that Professor
Tim Cook and Dr Jeff Handel are not and
will never be, house trained. She has
therefore taken the bold step of vacating
‘the swamp’ and moving into an office with
Drs Goodwin, Coupe, Souter and Gold.
I am unnerved at the thought of Tim and
Jeff left unsupervised in their little den and
envious of Drs Goodwin, Coupe, Souter
and Gold who have definitely benefitted
from the transfer.
Malcolm Thornton
12
Exeter
We have survived the winter, if not the
winter pressures. Cunningly, our Trust
has avoided much of the attention of the
local press, by inventing a new state of
emergency, known as ‘pre black’. If only
the other trusts in the Peninsula had been
so colour literate, they might have avoided
a nightly feature on Spotlight. As it is, we
have had medical patients taking over the
world, and the surgical wards, with very
little hope of managing any real operating
for days at a time, and now that there is
a slight improvement in the bed state, ITU
has reached such a state of full to bursting
that they are threatening to over flow into
the rest of the hospital thus blocking the
remaining beds. I am tempted to stop even
attempting to write a rota, and just ask
everybody to meet in the coffee room at
8am each morning, to match up the work
and the workers. I might even be able to
delegate and have a day off. We have
survived another round of job planning,
which has possibly alienated the remaining
few who weren’t alienated in the last round,
and now we are doing even more for even
less.
We have welcomed a few new babies into
the department. Congratulations to Megan
on the birth of Max, who was born during
the 48 hours between going on maternity
leave, and a good luck send off. Tim Tufnell
Barrett has had a baby, and Mark Ridgeway
welcomed baby Harriet right at the end of
his obstetrics on call shift. (I like a baby
who recognises the in importance of not
disrupting the on call rota). Rich Wassall
is expecting baby number two imminently.
Best wishes also to Catherine Dore, and a
couple of others who for now must remain
nameless, as I am possibly the only person
who knows (the rota-writer trumps even
family). No weddings this time.
Welcome also to James Simpson, to join
Alex Mills, Cathryn Matthews and Graham
Simpson as the ‘the new guys’.
The Christmas party was held at the
Clarence again this year, after a couple of
years testing out the Thistle. The highlight
of the evening was the Strictly competition,
where several couples, mainly comprising
an unwilling trainee and an over eager
consultant, took to the floor.
‘Seven!’
The dance likened to one of Harry Pugh’s
blocks – very theatrical, took ages, but
limbs still flailing everywhere at the end,
will stay with me for while.
‘I can still move my arms’
Elven safety rules ignored
Richard Wassall, a former ballroom
champion from his university days, put
in hours of time and effort, to create the
illusion that all the couples had at least
heard their music before. John Saddler,
AKA Len, did his judging homework, and
produced some memorable lines.
All in all, the effort involved, the glitter,
and the amount of bare flesh made for a
memorable evening. The attached photos
hardly do it justice.
Well, that’s about it for now. It just remains
to wish David Conn good luck during the
next few months.
Pippa Dix
13
Gloucester
The Spring news from Gloucester comes
from a sparkling hospital – the Care Quality
Commission has recently paid us a visit!
The hospital has been transformed by a
major spring clean – corridors repainted,
new floors laid, posters removed and even
Gloucestershire highways have filled in the
potholes in preparation for their visit. The
transformation is amazing we nearly look
as new as Southmead Hospital.
With summer fast approaching Tom Perris
and Steve Twigg are currently in fierce
competition for ‘the biggest loser’. Not only
are they starving themselves but they are
also training hard on their bikes for the
Dragon ride with several Bristol colleagues
– I don’t want to alarm the Southmead
contingent but I think you may struggle to
keep up with the new super light, super fit
Gloucester boys !
Judith Stedeford has taken over from
Sarah Bakewell as college tutor. Not
easy footsteps to follow in as Sarah did a
fantastic job however I am sure that Judith
will rise to the challenge and be equally
dedicated to our trainees. Judith starts
her new role with a great group of trainees
in place. One of biggest success stories
is our first ever neurosurgical ‘poach’ –
David Cronin previously a neurosurgical
registrar has seen the light and now has
successfully attained an anaesthetic job.
We are delighted to welcome him into our
speciality.
We have a couple of trainees due to tie the
knot this summer – Sarah Hoskins is getting
married in August and Janaid Fukuta in
June. Kath Rosendale will shortly be going
on maternity leave and Tim Cominos and
his wife Sharon are expecting their first
baby. We wish them all well at this exciting
time in their lives.
14
We have had news from Kat Shelly in
Australia – she is currently working for
MedSTAR and having a fantastic time and
enjoying life. She plans to return the UK
this August.
Finally, those of you interested in Jazz
will be delighted to hear that ‘Mango
Jam’ ( Gabbott, Twigg and Phelps) have
been invited to play at the Cheltenham
Jazz Festival at the end of this month so
please come and join us for this musical
extravaganza !
Claire Gleeson
Plymouth
To all those who have been waiting for
it, here is a long awaited fashion tip. The
season’s new colour is black and all the
hospitals across the Southwest seem to
be joining us in the latest trend. Not all
however, are equally enthusiastic about
displaying their true colours with some
being rather more coy about it and trying to
accessorise (disguise?) their true situation
with flashes of grey, red and even green in
an attempt to confuse the editors of Vogue.
Fortunately, Richard Struthers continues
to guide us through these difficult seasonal
changes and provide the advice and
humour necessary to prevent any fashion
mis-haps and too much excitement from
the latest trends.
This combined with the ongoing deluge of
medical patients into the hospital and the
subsequent ongoing bed crisis has led
to nostalgic reminiscences by those old
enough (mainly Pete Glew) to remember
the good old days. This was when we
came to work, and promptly anaesthetised
the patients on the list in the same order
and went home with a feeling of having
achieved something.
The season’s colour coupled with the lack
of UV light has led to some bad cases of
SAD.
Patient undergoing UV therapy for SAD.
The cognitive effects can be surprisingly
debilitating
Having kept us all going with her exuberant
daily and then hourly countdown to her
retirement, Anna Johnson has headed
off for the first of several well-deserved
post-retirement holidays. She should be
commended for her adjustment to using
big syringes again and for surviving
intact her return to anaesthetising adults.
Unfortunately, there was no dissuading her
from leaving Derriford on the auspicious
day of Friday 13th February. The growing
excitement in her voice was all-apparent
as the final days and then hours ticked
by. It is noticeably quieter already and her
bright, smiling demeanour is already being
missed. It is reassuring to know that there
will be a suitable number of leaving parties
to celebrate the contribution that she has
made to the department and anaesthesia
in Plymouth over the years.
Fortunately, we have had three new
permanent appointments to the department
with Ruth Treadgold, Kim Chishti and
Robert Tonko all taking up substantive
posts in November. They are greatly
appreciated and are being put to use
improving the efficiency of the orthopaedic
‘green’ lists once the sets have finally been
laid up!
There have been some more celebrations
with congratulations to Matt Jenkins,
Matt Boyd and David Radley who have
all successfully passed the Primary,
and to Rebecca Pugsley, Robert Goss,
Johannes Retief and David Levy who have
successfully navigated their way through
the Final.
There has only been one wedding amongst
the young singles and we wish Vicky Lewis
and her husband the very best for their
future together. It has also been a quiet time
for staff on labour ward. Congratulations to
Dave Adams on the birth of his daughter.
After some deliberation and a number of
names starting with ‘C’ they have elected
to call her Charlotte. Dave looks a little
more tired, and denies that it has anything
to do with vintage champagne. Life is just
a bit busier.
The Christmas party was in January and
proved even more popular than usual with
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a late change in venue to accompany the
marauding hoards, some of whom were
descending from Dartmoor for the first time
in many years. These brave souls left the
frozen wastes and ventured deep into the
verdant South Hams for an evening of fine
wine, food and conversation. The balmy
conditions made for a thirsty evening and
enthusiastic socializing. Many thanks
again to Sam for organising a wonderful
evening, even if she did miss the end of
the party.
The dancing was somewhat hampered by
the DJ not appearing but various iPhones
were forced into action and with some
amusing playlists and staccato selections
the fun continued. Matt Ward protested
that half the music on his phone is nothing
to do with him and he has no idea who
put it there. Even this didn’t stop the
customary excessive shape creation with
some astounding new combinations from
the ever-inventive Gary Minto. His next
public performance will be at the SASWR
Spring meeting – it’s worth the conference
fee on it’s own.
The most-newly weds had a flash back to
their courtship as Vicky Lewis recreated
her own version of Cinderella. Kicking off
her shoes for the dancing, only one of
them reappeared before she disappeared
off into the night with her Prince Charming
following on behind, clutching a very
important and functional Cath Kidston bag.
Spring is coming and a feeling of
euphoria is starting to be felt amongst the
department. The departmental business
case is getting clearer, job planning is
going to be completed on time, and the
general election won’t result in a whole
new raft of changes and targets. Must be
those March hares.
Matt Hill
16
Southmead
So, we’ve been nearly a year in the
magnificent new building and it would be
fair to say that there is still some work to
do to get things just as all would want. It
would be very easy to write a long list of
woe and misery but that would not give the
correct impression anymore and so I won’t.
Truth be told there are still things that are
a cause of immense frustration but we are
now on an upward trajectory and there is
more than a glimmer of light at the end
of the tunnel. As a department we have
made huge strides, often in a leadership
capacity, towards sorting out the issues
that have beset the hospital. That has not
gone unnoticed the corridors of power and
there are a few amongst us who apparently
have “managerial potential”. Let’s hope
that isn’t too serious a threat and we
can be left alone to get on with the jobs
we really enjoy. The elective orthopeadic
theatres have been most under the cosh
since the move and even there laughter
has reportedly been heard and I’m not
talking only of the hysterical variety. We
still have a way to go but I (and I’m not
alone) are beginning to feel that this place
can actually be great.
Having spent the last few years steering
us through choppy waters, Maggie
Gregory and Nia Griffith have handed over
the departmental chair’s reins to James
Nickells. How he will fill both pairs of shoes
is anyone’s guess but his appointment
has had unanimous support from within
the department (and not along the lines
of - would a volunteer take one step
forward, cue everyone else taking one
step back). He has already taken the first
tentative steps up the corridor of power
including a “conscious uncoupling” from
Rhys Davies by refusing to share a desk
with him anymore. The reason given was
that from his new desk no one could read
his confidential emails, but we all know
he had been looking for a way out of the
relationship for some time. One of James’
many strengths is his love of organisation
(usually involving an Excel spreadsheet or
two somewhere along the way) and he is
rubbing his hands with glee at the thought
of one spreadsheet to rule us all. However
the phrases “herding eels” and “putting
cats in a bag” both spring to mind.
The rota writers (Jill Homewood, Claire
Fouque, Jane Olday and Caroline Oliver)
all still make the seemingly impossible
happen by staffing all required lists. Leave
is being booked with every increasing
foresight, with a colleague recently
confiding that he is considering booking
future summer holiday leave along the
lines of a “hopeful life expectancy”.
After years of loyal and dedicated service,
including a spell as Departmental Lead
David Holland has hung up his substantive
NHS laryngoscope. There will never be
another who can give a quicker anaesthetic
with fewer drugs nor write a more minimal
anaesthetic chart.
Never one to miss out on a chance to have
some fun he has come back on a part time
basis and, like all recent retirees, looks in
even ruder health.
Our military workforce have all remained
safe and healthy though both are not
relishing the idea of a trip to Sierra Leone to
battle ebola. There has been some gentle
teasing that this is essentially an offshore
cruise in the sun but none of the civilian
contingent have been seen offering their
services at the local TA recruitment centre.
At NBT we have always been a department
that has contained those who do straight
anaesthetics and those who do both
anaesthetics and ICM or anaesthetics and
pain. We now also have two colleagues
(David Campbell and Matt Thomas) who
practice solely the ICM dark arts. We are
lucky as a group to have such a wide range
of practice and expertise and we will, in
time, be more the richer for it.
We have made some excellent recent new
consultant appointments with Anna Davey,
Alia Darweish and Paddy Morgan already
at the coalface with more to follow. There
are now 85 substantive anaesthetic and
critical care appointments at NBT making
us quite a force to be reckoned with. With
a projected lifespan of 20 years-ish as
a consultant / associate specialist that
means that there will be the need for some
forward planning so trainees take note!
On the social side there has been the usual
sporting exploits, injuries and outrageous
global travel experience. Leave around
the upcoming Rugby World Cup is already
fully booked and there is now an excellent
social scene involving the newly reformed
Wine Society and the newly formed
Frenchay Pie Club. Both are open to all
and both involve the imbibing of alcohol.
The latter, as the name suggests, also
involves the eating of pies and because our
departmental lead is involved has a large
number of rules, policies and customs.
Our trainees are universally excellent and
have, on occasion born the brunt of the
recent upheavals. They are (mostly) still
smiling and we all thank them for bearing
17
with us. However as I said at the beginning
of the article the future is now looking a
great deal brighter.
Ben Walton
Swindon
‘Am I on-call to-night? Didn’t realise’. ‘Feel
free to cope,’ I say to my already sleepy
SHO and Registrar as I retire to my motor
for the gentle drive home. I listen to some
‘hauntingly beautiful’ music on Classic
FM. Only a garish display of blue lights
as an ambulance thunders past on its
way to Cheltenham General with another
hot aneurysm disturbs, briefly, my inner
Karma. What a blessing, and step forward,
these Vascular and Trauma centres are.
We seem to be losing our Associate
Specialists. Is it because on-calls have
become so boring?
Robert Vach left in December after seven
years. Returning to his hometown of Brno
in the Czech Republic where he was at
Medical School. Robert tells me he came
to the UK with his girlfriend, now wife, ‘for
fun’. He claims that he has ‘acquired a
lot of wisdom’ at GWH. Hmmm. Dr & Mrs
Vach are taking the precaution of taking
a year travelling before he re-boards his
hamster wheel.
Marislav Chiabaca has also been with
us for seven years. He must have been
captured at the same recruiting drive.
He took a sabbatical for five months last
year . . . to enrol in a German language
(medical) course. He is back, but sadly we
have not been able to contain him. He is
off to Freiburg in the summer to be ‘nearer
home’.
Susana Zambrano has been with us since
the good old PMH days. She has taken
advantage of the relative political thaw and
gone home to Cuba to spend time with her
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ageing mother. We’ll see her back in the
spring. . . hopefully.
Readers must be getting the impression
that your scribe is the only one left. Don’t
switch off the lights. Let’s talk arrivals:
Like our Drager anaesthetic machines,
Robbie Pongratz is very German. A
proper German too - from Bavaria. After
graduating from Munich, he came to
Swindon as a houseman, ‘To improve his
English and augment the CV’, and just in
time to see PMH demolished. Robbie so
fell in love with the Magic Roundabout that
he vowed to spend his life in Swindon.
Bavarian cuckoo clocks and the Alps are
soo overrated. Originally on a surgical
rotation, he was converted from darkness
into light during his ICU attachment by our
local evangelist, Gary Baigel. Robbie was
here as a registrar in 2011, and has been a
consultant since December 2013.
Your scribe has problems with James
Andrew. Like knowing left from right, it’s not
a thalamic response, he has to think about
it: is it James, or is it Andrew? We’ll call
him JA. JA is our Holy Grail appointment –
a real-live pain specialist. James qualified
from Birmingham in 2002. His anaesthetic
training was in the Midlands, topping out
with a Pain Management fellowship in
Melbourne. Claim to fame: appeared in
a production at the National theatre aged
twelve (sorry, no photo). Usual anaesthetic
hobbies: cycling (summer only), running.
New interest in DIY since moving to his own
place: JA’s girlfriend reports a few ‘practice’
drill holes around the new shelving unit.
Mala Greamspet qualified in Madras and
did all her anaesthetic training in India
before deciding, with her husband (a
shrink), to come to the UK. Rumors of the
glory of Swindon’s architecture, culture
and Outlet Village were rife in Madras . . so
why not? Mala came as a Clinical Fellow
in 2007. She then re-did her anaesthetic
training: SPr-dom in the Severn Deanery,
the UK exams, jumps through various
hoops, loops, traps & sacks; and was
finally appointed here last year. Interests:
cooking, films, currently hooked on the
‘British Sewing Bee’ on TV. Also just moved
house, so currently a renewed interest in
‘interior decoration’. Mala’s husband does
the DIY.
Your scribe could go on: we have also
been joined by Jahan Hashmi, Gemma
Talling and Vandhna Sood as Associate
Specialists; and Ed Scarth and Mark Yates
as Locum Consultants. There isn’t room
for a salvete for all. Maybe the next edition.
And now the department casualty list:
Jill Dale ruptured her ACL skiing. The usual
story: binding failure followed by sickening
ripping noise. Jill is now sporting a leg
brace that I think may have been acquired
at the auction of old ‘Terminator’ props.
Repair is scheduled in a couple of weeks.
Julian Stone, sadly, registers a couple of
notches up the Beaufort scale. Cycling to
his parents’ home he remembers flying
over the roof of a car. Lying on the road
and relieved to find himself alive, he lifted
his right leg and was somewhat alarmed to
see his foot hanging from a mangled tibia
– that’s when the pain kicked in. Next, he
was on his way to the JR in a helicopter.
As one would expect, recovery has been
slow. A few ops later, to leg and shoulder,
including a free flap; he is on the road to
recovery, though not back at work yet.
Congratulations to Zoe Ridgway, currently
on maternity leave, on the safe delivery of
a baby boy (at last). Sorry, don’t know his
name; and congratulations to Lizzie James,
Shelley Barnes and Inthu Kangesan on
passing Primary. Well done all.
Lastly, a message to our Cheltenham
colleagues on behalf of the entire
Anaesthetic Department at GWH: we really
are very sorry about Swindon’s vascular
tsunami. There you are, your scribe
hopes he has done enough to prevent any
Swindonians ‘accidentally’ falling from the
balcony at this autumn’s SASWR meeting
And finally, your scribe passed his English
O level in 1973 at grade 6 – the lowest pass
grade. He is quite sure there are better
qualified candidates for the post of Swindon’s
SASWR reporter; so he is going to hand over
his quill to a new, as yet unidentified, hack.
So watch this space. Goodbye.
Doug Smith
Taunton
Mike Davies
It’s been a period of ups and downs for
Taunton. Sadly our major news was the
sudden unexpected and unexplained death
of one of our Consultants, Mike Davies on
January 9th. Mike joined our department
in 2010. He was a totally larger than life
character, always smiling and always the
first person to reply to the “can you swap
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on call” email. In the, what now seems like
short time that he was with the department
he became chairman of our Senior Hospital
Medical Staff committee where he worked
tirelessly to protect our interests and work
collaboratively with those around us. He
also set up a training programme and
competency assessment for two of our
ODP’s to become ophthalmic practitioners,
a system that now works really well with
fantastic results. For several years he ran
an after work “exam clinic” for all of our
trainees. He was legendary for bringing
in his George Forman grill on weekend
on calls and making bacon butties for the
whole theatre department which needless
to say made him a supremely popular chap.
He has countless other achievements in
the years he was with us and leaves a
big void in the department. Mike leaves
behind his wife Vicky who is due to give
birth to their daughter in May, and two sons
Jack (7) and Freddie (5).
The ups for us came from Stuart Collins
marrying his long term partner Lorraine
Ayres (Abbvie rep in the South West) – a
surprise announcement in January with
a promise of a big party to follow in the
summer. Congratulations to them both.
We also congratulated Dr Julie Lewis and
her partner Duncan on the birth of their
second child, Joseph in September. We
are now in the unusual position of being
pregnancy free amongst our permanent
staff (I think?!) In the trust we said goodbye
to our chief executive of seven years (Jo
Cubbon) and hello to our new chief exec,
a former GP, Dr Sam Burrell. She has
arrived with much enthusiasm and ideas
for new initiatives. We are confirmed as
the trust to take over Weston Hospital and
continue to await what that means to us
in ‘real life’.We have been lucky enough to
20
welcome some fantastic new staff grades
into our midst – Dr Ilinka Dragusin, Marius
Vaida and Dr Nelum. This has relaxed the
extremely tight rota system and brought
the possibility of coffee breaks and at least
one toilet break a day back into the realms
of possibility. We bade a very fond farewell
to Dr Jonathon Alper who has taken early
retirement through ill health. He has
served in our department for over 10 years
and we were very sorry to see him go.
In final news from Taunton, our consultant
cloning programme seems to be going well.
Drs Tim Zilkha and Rurai Moulding
I think we might restrict this to certain
members though, there are certain
members of our staff (myself included)
where one is definitely enough!
Helen Hopwood
Torbay
So here we are again! The last six months
has flown by and all too soon it is time for
me to regale you again with my fascinating
and witty insights into the world of Torbay
and its anaesthetic department.
With this in mind, the Christmas party
seems an appropriate place to start. This
year saw several changes which I think
were key to the copious amounts of alcohol
consumed and the resulting tomfoolery.
First the night chosen was a Friday (unlike
the ‘school night’ of the previous year);
second we had a live band playing- and a
good one- which included one of our own
general surgeons, Steve Mitchell; third and
perhaps most importantly, we were joined
this year by the ICU nurses. Need I say
more. Things never quite reached the
crescendo of the now infamous yacht club
do of 2011 mainly I think because Nuala
was driving this year. Nevertheless, we
saw a variety of styles and competence
on the dance floor with the traditional ‘Dad
dancing’ style perhaps best epitomised
by messrs Tod Guest, Jon Ingham and
Richard Hughes. I have asked around
for photos to include but no one has
been forthcoming….evidence itself of a
good night perhaps?! Sarah-Jane is now
stepping down as social secretary, so we
will have to wait and see what direction the
Christmas party takes this year. Moving
swiftly on…
Although not as comprehensive as the
traditional August changeover, we have
had some turnover in trainees. At registrar
level we bade a fond farewell to Suzy
Baldwin. We wish her well in the challenges
that lie ahead in Derriford. In her place
we have welcomed back Daniel Quemby
for his period of grace as well as Louise
Cossey at ST3 level. In addition, Susan
Cummins has returned from maternity
leave and Jan Mamurekli is working part
time as a trust grade.
If your maths is as good as mine, you will
realise that this represents a net influx of
trainees- a happy position for us to be in.
Yes, times are good in the department at
the moment. We are enjoying a rich bounty
of trainees- most of them CT2s or abovewhich has resulted in a full rota and the
slightly perverse situation where trainees
are complaining they are not getting
enough solo list experience!
At consultant level, Richard Eve and Ben
Ivory have both now officially started
as ICU consultants with Tom Clark due
to arrive in a month. We also have one
(potentially two) further ICU appointments
to make after interviews next month which
will complete a remarkable influx of ‘new
blood’ into the ICU directorate.
Steve Stamatakis is still here as a locumalthough not in a strictly literal sense given
that he is currently on paternity leave after
the birth of his first born. Congratulations
by the way to Steve and his wife Amy on
this. We are still waiting to hear the name
of the little girl in question but wish them
well in this new chapter in their lives. On
the subject of new arrivals, I must also
congratulate David Hay and his wife on
the birth of their baby boy Alexander.
David has been having an extremely busy
year what with a wedding, new baby and
primary FRCA to contend with! Fran Smith
has also recently joined the locum ranks
here. I believe Fran has worked here in the
past as an SHO but that was so long ago
most of us can’t remember- welcome Fran!
In a previous column (Spring 2014) I wrote
a few paragraphs on the retirement of Kerri
Jones. However, Kerri didn’t actually leave
us completely at that point, and over the
21
past year she has continued with some
clinical and non-clinical work. Suffice to
say, Kerri has now completely retired and
we enjoyed both an informal lunchtime get
together with her, as well as a lovely dinner
(with speeches) at the Orestone Manor.
I will not repeat Kerri’s achievements
again here (space would not permit!) but
she has been a standout member of this
department for many years and will be
sorely missed.
Finally, in other news I am pleased to
announce that our department quiz team
‘Volatile Agents’ are once again taking
the Universally Challenged hospital quiz
competition by storm with a comprehensive
victory over Haematology to reach the
quarter finals. It hardly seems like two
years since I was last writing about this,
but this University challenge style quiz
is once again proving to be an excellent
fundraiser for Comic Relief.
So well done to the team of Jane
Montgomery, Jeremy Ackers, Dan Quemby
and yours truly. We’ve yet to hear if Jodie
is going to name an unchanged team for
the next round. Based on current form, my
place could certainly be in jeopardy!
Until next time, have a good spring and
summer everyone (when it finally arrives!).
andrew Mcewen
Truro
“Ahoy” our dear English colleagues, for
we are coming. We are, of course, right
there in front of your very eyes every
Sunday evening. It states it is based upon
historical novels but ‘tis not true, ‘tis more
like a docu-soap of our daily life here in
Cornwall. In the Royal Poldark Hospital,
our anaesthetic department is a veritable
feast of frilly shirts and heaving bosoms,
and that’s just the men. Meanwhile we
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Demelzas keep the pasties coming thick
and fast in our corseted frocks, constantly
scanning the treeless horizon, ever hopeful
for another glimpse of our Mr Poldark.
Amidst this drama, we also have news.
Our trainees have done very well lately and
passed their exams. Megan Thomas, Kelly
Mackey, Gareth Meredith, Anna Ratcliffe,
Kat Mulcahy, Geoff Wigmore and last but
not least Dave Baglow have passed the
Primary. Our fabulous Nicola Pilkington
passed her Final FRCA before moving on
to Derriford.
Terry Skinner is coming to an end of his
time as our Clinical Director. He has been
at the helm through interesting times and
has stepped up to include Surgery within
his remit. We thank him for his extremely
hard work, consistency, fairness and
decisiveness. It appears that he has
maintained his sanity thus far, I also think
he has managed to retain some sense of
humour in the face of adversity, which a
lesser person may not have.
Within the trust, we are still with an interim
Chief Executive. A friend of mine from
another specialty commented this week
that she has come to realise that ‘interim
manager’ is code for ‘someone with special
training (in herding cats) to sort you all out’.
We are really pleased to welcome some
new(ish) faces. Nila Cota, Claire Preedy
and Ben Warwick have joined us as
substantive Consultants. Helen King has
finished her training and we are lucky
to have her stay on with us as a Locum
Consultant. We welcome all of them.
Other new arrivals include babies of
course. Simon George has returned to us
as a new Dad, I think he’s planning on his
little one getting out on a board fairly soon
so as not to totally waste his days off. Chris
Pritchett is following in Roger’s footsteps
with a fourth, days off a very distant
memory for him now. Barney Scrace has a
brand new baby, as of February, hopefully
being in ICU is giving him some time at
home with his new family.
A select few made it to the Alps for some
study leave. Sally Nash tells us her
luggage was lost en route. So she must
have looked pretty special on the slopes;
in Aunty Kate’s pants, someone else’s
contact lenses and Nick Boyd’s thermals.
Hmm, “lost luggage”...what goes on tour
Sally...
Looking forwards, there are plans afoot
for a beach day in June. Hopefully the sun
will shine and the competitive spirit will
be strong for our ‘any craft will do; races.
Either way, I’m sure fun will be had and
hopefully it will give me something to talk
about next time.
Cheers, an’ gone.
Georgia Brooker
United Hospitals Bristol
The most significant event of the winter
has to be the retirement party of our
current SASWR President, Dr Chris Monk.
Attended by all sorts of hospital-folk, there
was no doubt about how much Chris means
to us standing in our community. A state
of ‘advanced refreshment’ was inevitably
attained by many attendees, resulting in
some impressive ballroom dancing from
couple Matt Molyneaux and Dr Monk
himself. Chris is currently lapping up the
antipodean sunshine, having missed out
on pension ‘reform’.
In February, the ever-intrepid general
anaesthetists group went off to the rarefied
climes of the Black Mountains for a bit of
winter team bonding.
Braving frostbite, avalanches and severe
runny noses, we took on a long wintry
mountain walk in deep snow. Of course, this
earned us the right to consume excessive
rations whilst making merry round the
stove in our bunk house accommodation.
An unseen risk of sharing space and hip
flasks with your colleagues is the risk of
transmission of pathogens - several of the
party ended up off work with a ‘nasty’ virus.
Nothing to see here.
‘I am just going outside and may be some
time’
It’s appointments time again, it’s hard
to believe how many bodies we seem to
need to keep this ship sailing. The next
round of bright young things are waiting in
23
the slaves quarters, readying themselves
to enter the gladiatorial arena that is Trust
HQ. ITU have recently appointed Adrian
Clarke and have also poached ‘versatile’
Sarah Sanders from the general team.
Faithful trainee Ben Gibbison has returned
from Papworth as a consultant in cardiac
anaesthesia, but is currently in his natural
habitat climbing mountains. Also joining the
cardiac team is Amit Ranjan, who trained
in Sheffield and begun work at exactly the
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same time as his wife delivered a baby what a trouper!
Intensive care has finally moved into the
new ward block. There was something
homely and cosy about the old unit - the
new one feels shiny and high tech, but
you need GPS to find your way from one
end to the other. Hope still springs eternal
for some sort of staff eating facility. Man
cannot anaesthetise on crisps alone.
Ben Howes
Anaesthesia Points West Vol 48 No 1
Meeting Report
The Society of Anaesthetists of the South Western Region
Autumn Scientific Meeting, 2014
Bristol MShed
Dr James Pittman, Honorary Secretary, SASWR
The Society of Anaesthetists of the South
Western Region (SASWR) reconvened at
the Bristol MShed in November 2014 for
another excellent meeting. On this occasion
the thanks must go to the North Bristol
Hospital department who enthusiastically
organised the meeting and put together a
very high calibre of academic programme.
The MShed is a classy venue and the
large number of delegates at this meeting,
matching the attendance at SASWR’s 2013
MShed event , suggests it works for us.
Bristol is now such an attractive city: it is
always a pleasure to come back for a few
days.
The meeting was opened after the
SASWR Annual General Meeting. The
AGM had been conducted slightly earlier
on the Thursday morning so that it did
not impinge on registration. The SASWR
committee feel that the AGM should not
run concurrent to registration, as arriving
delegates are not sure whether it is part of
the meeting or whether they should attend.
This will remain the format for the future.
The AGM has historically been the
moment when the presidential role is
formally passed on to the president elect.
This process now happens at the start of
the academic meeting, in front of a much
bigger audience! The outgoing President,
Dr Chris Johnson, addressed the audience
and started by announcing his award of the
SASWR president’s prize posthumously to
Dr Guy Jordan. The tragic death of this
colleague had been a defining feature of
his presidential term and he was delighted
that the Society could give the prize as a
financial contribution to the Jordan families
chosen charity. Dr Johnson then calmly
passed the presidential baton on to the
new president, Dr Chris Monk. It was clear
from his resume of Dr Monks professional
career that the society is in experienced
hands. There is no doubt that SASWR
has a very popular local president and his
recent role as Hon. Secretary gives him a
very close understanding of SASWR and
its strategic goals. Dr Monk welcomed the
society members and guests.
Dr’s Johnson and Monk: the presidential
handover
The first session was chaired by one of
the co-organisers, Dr Sarah Martindale.
Dr Fiona Donald, the oldest (and yet still
so youthful) obstetric anaesthetist in NBT,
then gave us her very useful top tips on
what to do on the labour ward.
25
The ever youthful Dr. Fiona Donald
Saline or air, sitting or lying, but how about
some advice on working with the midwives!
The next two lectures then covered aspects
of the very topical subject of anaesthetists
being Perioperative Physicians. Professor
Ashley Cooper opened our minds to the
importance of even moderate exercise and
illness. We are becoming more and more
sedentary and relatively small amounts of
gentle exercise can make a real difference
to our health. This led beautifully into
Dr Claire Dowse and Frances Forrest’s
update on pre-operative assessment and
pre-habilitation. It seems clear that there is
lots that can be done in the pre-operative
period to improve patients recovery after
surgery and at the moment we are only just
beginning to recognise this unmet need.
You would not expect to run a marathon
without training, so why should you pitch
up for your joint replacement surgery
26
without trying to be in ‘optimal’ condition.
Research in anaesthesia is once again
gaining momentum and SASWR was
fortunate to have four leading individuals
lecturing at our meeting. Dr Tom Clark
and Dr Chris Newell updated us all on the
immensely impressive trainee led research
networks. The Southwest has led the way
in the development of these groups and
SWARM and STAR are providing the
templates for a national development of
this idea. Congratulations to these and
other individuals for their vision, skills and
organisational abilities in moving this all
forward and let us make sure we continue
to support the trainees in undertaking their
research projects. Dr Ramini Mooneshinge
from University College Hospital set the
national scene with a ‘where we were and
where we are going’ review of academic
anaesthesia. Anaesthesia is a problem
area with 72% of trainees having no
experience of research. More research
fellow posts need to be developed and
the research activity broadened into the
provinces rather than being so London
centric. Dr Gary Minto, Plymouths leading
researcher, then gave a very good critical
account of anaesthetic research, good and
bad, and an update on some important
recent ‘practice modifying’ anaesthetic
studies.
The trainee Intersurgical prize session
followed next. Drs Weber and Everson
presented their work on arterial line irrigation
fluid and showed that although heparinised
saline was more expensive it was better
than normal saline at maintaining arterial
line patency and performance. Dr Loosely
then spoke on behalf of the STAR group
and their involvement in the International
Surgical Outcomes Study (ISOS) study.
Dr Barratt was the next trainee to present
and he spoke about post discharge
nausea and vomiting. There is a higher
incidence of this than you would imagine
and the APFEL score is a useful screening
tool to detect those at risk. Finally, Dr
Leslie showed the audience her video on
paediatric anaesthesia that helps children
prepare for their operative experience.
Despite no sound, the film wowed the
audience and more importantly the judges
with the result that she was awarded the
SASWR Intersurgical 1st Prize. Dr Barratt
came a commendable second.
The Humphrey Davey lecture was given
by Lt Commander Rees Thomas. His
lecture was on Erythropoietin: how it has
been illegally used in the world of Cycling
and now how it may revolutionise the
management of trauma and critical illness.
It appears that its beneficial physiological
effects are not only on the increased
production of red blood cells but probably
more significantly in the enhanced efficient
use of oxygen at a mitochondrial level.
Rebecca Leslie receiving the Intersurgical
Prize from Chris Monk
The Humphrey Davey lecturer, Lt
Commander Rees Thomas, receives his
SASWR Bristol blue glass bowel from the
President as a thank you.
Intersurgical 2nd prize winner: Dr Barratt
plus President
The Society’s dinner was held that night at
the Bristol Zoo. There was a good turnout
of people across the generations, including
a very welcome number of trainees. The
usual fun evening was had by all and
finished off with some enthusiastic middle
aged dancing. But we do it so well!
Friday morning was kicked off by Dr
Matt Thomas. He eloquently covered the
important topic of Sepsis and the latest
evidence to help the anaesthetist manage
the septic patient in the operating room.
There are many unanswered questions
but is now difficult to defend the protocol
27
delivered use of goal directed fluid therapy
and we probably need to use antibiotic
infusions rather than boluses. We were
next treated to a hugely entertaining lecture
by local cardiologist, Dr Philip Boreham.
He whistled through ECG analysis
and interpretation for the anaesthetist
making this subject both interesting and
surprisingly entertaining. Dr Adam Whittle
also gave us an excellent update on
respiratory medicine. This speciality was
somewhat in decline over the last decade,
but the increase in mesothelioma and
the explosion of patients with obstructive
sleep apnoea (OSA) have led
to its
resurgence. OSA is obviously an important
consideration for the Anaesthetist and this
was well covered.
The next lecture was given by a ‘great’ of
Anaesthesia. Professor Hutton, previous
President of the RCOA, spoke to us on the
‘Aging anaesthetist.’
Senior anaesthetists: Professor Peter
Hutton and Dr Chris Monk
He covered not only the rapidly increasing
numbers of elderly people in society and
the consequences of aging upon these
patients and society but also the relevance
both personnel and professional to the
28
ageing anaesthetist.
His lecture had
huge relevance to many in the audience!
The future does not look that optimistic.
The number of people in retirement gets
closer and closer to the number in work:
public sector pensions look unaffordable.
The aging theme was carried on by Dr
Andrew Seven, who had come down from
Lancaster, to tell us about the complex
world of cognitive dysfunction in our
surgical patients. There are approximately
¼ million anaesthetics given to patients
with dementia each year and we have
little knowledge of how we should best
manage these anaesthetics. Avoiding
anti-muscarinic drugs seems clear. Dr
Antony Carey rounded this session off
with a practical and financially defensible
explanation of how to set up and run a list
of awake patients having day case upper
limb surgery. He demonstrated an increase
in throughput, lowered costs and improved
patient satisfaction.
The final session was a double header
between the architect of the new NBH
Brunel Building and the clinician who
ended up trying to make it practically
work. Mr Chris Green gave a very honest
account of how you design a hospital
building within a contained site and inside
the restraints of our planning laws. Dr
Chris Thompson then talked us through
how you make the architecturally beautiful
building work to deliver the highly complex
process of health care. No one would have
expected it to be easy and it was true to
form. All things considered the build and
movement of services has happened and
the hospital has kept running. Well done to
all those who have been part of this huge
change and if you are in Bristol do go and
have a look around.
thanks to the organising committee of Dr’s
Kay Spooner, Ronnelle Mouton and Sarah
Martindale and to the ever efficient Kate
Prys-Roberts who does so much of the
unseen administration for these meetings.
Mr Chris Green and Dr Chris Thompson:
There were never any doubts it would
work!
The meeting was then closed by Dr Monk.
The meeting had run very well except for
the antiquated MShed computer projector
system. This needs an upgrade! My
The organisers: Dr’s Ronelle Mouton, Kay
Spooner and Sarah Martindale
29
Intersurgical Prize Winning Presentation
Two locally produced short films to improve satisfaction
with paediatric anaesthesia
r Leslie1, R Hardy2, P Hersch2, F Kelly2
1 ST7 Severn Deanery, 2 Consultant Department of Anaesthesia,
Royal United Hospital, Bath
Introduction
Going to theatre is a stressful experience
for children. Evidence shows preoperative
preparation minimises distress for the child.
Studies have also shown benefit to relevant
‘play preparation’ prior to anaesthesia
[1], interactive preoperative education
computer package [2] and distraction with
hand held video games [3]. In addition,
viewing a preoperative educational video
about paediatric anaesthesia has been
shown to facilitate preoperative preparation
and lessen parental anxiety [4,5]. Despite
this, standard practice routinely uses only
booklets or photographs in this process.
We felt that a well-produced film would be
an appropriate way for children to visualise
their theatre experience.
Method
We conducted a survey of parents to
see how well they thought their child was
prepared for their anaesthetic and if they
thought a short film would be beneficial.
We then created two short films, one for
under 8 year olds, and one for over 8 year
olds, to show the whole patient journey
from paediatric ward to discharge. This
film was made available online prior to
admission and on the ward. We then
conducted a follow-up survey.
Results
We surveyed 20 parents prior to releasing
30
our anaesthetic film.
9/14 (64%)
received written information prior to
elective admission. 19/20 (95%) saw an
anaesthetist prior to going to theatre and
18/20 (90%) felt the anaesthetist gave an
adequate explanation of the anaesthetic.
16/20 (80%) saw a play specialist and 4/20
(20%) were shown photos pre-operatively.
After producing our films we surveyed 36
parents of children who viewed our film as
part of their anaesthetic preparation. 15/36
(42%) viewed the film at home and 34/36
(94%) viewed it in hospital. 36/36 (100%)
children and 36/36 (100%) parents found
the film helpful. 36/36 (100%) children and
parents felt the film helped them know
what to expect, 36/36 (100%) felt the film
made the child feel more relaxed and
36/36 (100%) would recommend it.
Discussion and Conclusion
Despite initial parental doubt the results
of our survey show that both parents and
children found the films helpful. As they
were filmed on our children’s ward and in
our theatre suite with our own staff, they
truly allow the children to visualise what
they will experience. 100% of parents we
surveyed felt the films helped alleviate
their child’s anxiety.
We would recommend all paediatric
anaesthetic departments consider producing
a short film for their patients to watch to help
prepare them for their anaesthetic.
References
1. Cassady JF et al. Anaesth Analg. 1999;
88(2): 246-50.
2. McEwan A et al. Paediatr Anaesth. 2007;
17(6): 534-539.
3. Patel A et al. Pediatr Anaesth. 2006;16:1019–
26
4. Cassady JF et al. Anaesth Analg. 1999;
88(2): 246-50.
5. McEwan A et al. Paediatr Anaesth. 2007;
17(6): 534-539.
31
Autumn SASWR Meeting Poster Prize Winner
Tea Trolley Difficult Airway Training: A Novel Approach
M McDonald, G O’Farrell, FE Kelly
Royal United Hospital Bath
The fourth National Audit Project (NAP4)
demonstrated that problems with tracheal
intubation remain a major cause of airway
related morbidity and mortality [1]. In
a significant number of cases this was
due to delay or failure of rescue airway
techniques. To address this issue, NAP4
recommends regular training in rescue
airway techniques and guidelines [2].
In clinical practice difficult airway skills
are called upon relatively infrequently,
therefore
without
regular
training,
competence in these essential skills can
decline. Increasing pressures on time
and study leave allowances can make
it difficult to attend regular courses and
workshops. To tackle this patient safety
issue we have designed a novel method of
practical airway training, which is brought
to members of our department during their
standard working day.
Materials and methods
A theatre trolley was laid out with airway
manikins and airway rescue technique
equipment, a pot of tea, and homemake
cakes. This trolley was taken to each
anaesthetic room in the theatre complex.
Training was run by 2 anaesthetists; the
‘relief anaesthetist’ took over the care of the
patient in theatre, allowing the anaesthetist
working in that theatre to attend a 15 minute
one-to-one difficult airway training session
in the anaesthetic room run by the ‘training
anaesthetist’. Three sessions were run
32
over a period of 8 weeks. A different topic
was covered in each session: 1. Front of
neck emergency airway access: needle,
seldinger and surgical cricothyroidotomy.
2. Asleep fibreoptic intubation, using a
supraglottic airway as a conduit. 3. Awake
fibreoptic intubation. All participants
completed anonymous feedback using
a Likert scale to rate their confidence in
airway rescue techniques before and after
training.
Results
Thirty participants completed the ‘tea
trolley’ training programme, including
trainees, clinical fellows, consultants and
operating department practitioners. One
hundred percent of participants completed
feedback.
Graph to show feedback results from ‘Tea Trolley’ Training Sessions
Conclusions
The difficult airway ‘tea trolley’ is a simple,
efficient and successful approach to
difficult airway skills training. There was
overwhelming participant support for
the training method. It requires minimal
manpower to run and minimal time
commitment from participants. All training
occurs within normal working hours at
no additional cost to the department. We
believe that it is a sustainable model, which
is 100% transferable to other anaesthetic
departments. It is also transferable to other
areas within the hospital; a ‘managing
sepsis in obstetric patients’ tea trolley
has delivered 4 teaching sessions with
similar success. Tea trolley difficult airway
teaching in our hospital is now repeated
on a regular basis so that each topic is
covered approximately every 6 months.
References
1. Cook TM, Woodall N, Frerk C (2011) Major
complications of airway management in the
UK: results of the 4th National Audit Project
of the Royal College of Anaesthetists and the
Difficult Airway Society.BJA:106; 617-31.
2. Wong DT, Prabhu AJ, Coloma M et al.
(2003) What is the minimum training required
for successful cricothyroidotomy?: A study in
mannequins. Anaesthesiology; 98:349-353
33
Lectures and the Communication Revolution
or
Taking the tablets
Dr Neville W Goodman
Retired Consultant, Southmead Hospital
We have become pretty good with mobile
phones during lectures. Even without
a formal request from the chair before
lectures start, to hear a mobile ring during
a lecture is now unusual, and likely to
provoke disapproving stares. But the
communication revolution has moved on.
First laptops became easily small enough
to carry about and use in lectures, even
sitting on an uncomfortable armless plastic
chair: and now there is the tablet.
The tablet is a marvel of the modern age.
Tablets are ubiquitous and absurdly easy
to use. They are a great way of taking
notes in lectures. Typing – unlike on many
laptops – is almost silent, so doesn’t disturb
one’s neighbours. If the lecturer mentions
a particular study, or says something that
sounds contrary, you can rapidly check the
internet for that awkward question later.
But there is a downside.
Before writing on a topic, one should always
check for previous work. So I did. The
most common pages were titled, “Etiquette
in the lecture room”, or something similar.
Here is a selection from those pages – with
bolding and capitals as they appeared.
“It is also extremely rude if you surf the
web or check your email during class…”
“DO NOT TEXT IN CLASS. Not only is it
rude and disrespectful to me and to your
34
fellow students but…”
“…it is certainly not fine… to be seen
sending e-mails… during lectures…”
“It is also very distracting to the [lecturer]
to observe that students are more
interested… than they are in the class
discussion… In case you are unaware,
these behaviors are rude…”
“…don’t… surf the internet. First, by not
paying attention to the [lecturer], you’re
showing… disrespect. Second, surfing the
web during class can also distract your
classmates sitting behind you.”
So it’s not just me. Using an electronic
device during a lecture for anything not
connected with the lecture is rude and
distracting. (I do not count a quick check of
one’s phone because it buzzed; or a short
– but I mean short – text reply.) Would you,
unless you wished to let the lecturer know
that they were boring, sit reading a novel?
My browsing turned up websites aimed at
undergraduates, and they were all from
the US. I’m sure there are UK websites
giving similar advice, but I doubt there are
websites giving advice to doctors attending
lectures for CPD. I would have hoped that
such people didn’t need such advice.
If one person thinks it reasonable to
ignore the lecturer, why not two, or three
– or everybody? Would anyone think it
satisfactory for a lecturer to be talking to
a whole lecture theatre of people swiping
and typing away, occasionally looking up
to see what’s being projected?
I did turn up one formal published paper on
the subject [1]. It was a survey of attitudes
to the use of communication devices
in lectures. Most students realised the
use to be disturbing – but still thought it
acceptable: a clear example of selfishness
or cognitive dissonance. Or perhaps
just immaturity: older students – and,
unsurprisingly, instructors – thought the
use illegitimate. In their summing up, the
authors wrote, ‘Surfing the web… in the
presence of face-to-face communicators is
‘disconfirming’. Disconfirmation has to do
with acts that say to your listener and those
around you that, “I don’t care, you are not
important, what you are saying is not worth
listening to or I have more important things
to do than being here with you.”
In postgraduate medical lectures, the
offenders tend to be the more senior in
the audience, who may indeed have more
important things to do: in which case
they should do them outside the lecture
theatre. And leave their CPD attendance
certificates at the reception desk.
1 Hammer R, Ronen M, Sharon A et al.
Mobile culture in college lectures: instructors’
and students’ perspectives. Interdisciplinary
Journal of E-Learning and Learning Objects
(IJELLO) 2010; 6: 293 – 304.
35
Anaesthetics and Critical Care Retrieval in the Outback
Dr Peter Valentine
ST3 Anaesthetics Trainee
Royal Cornwall Hospitals, Truro
Many of my friends had gone to Australia to
work following foundation training. The East
coast – Sydney and the infamous North
Shore were particularly popular as was Perth.
But for me the only place I wanted to work –
undeniably inspired by “Flying Doctors” and
“ Crocodile Dundee” from the 80s – was
Darwin, Australia. And The Outback.
blocks amidst endless conversation about
local “fushin’” spots. And then, as if it
was nothing unusual – “ Don’t forget your
gloves mate, this one’s got Leprosy!” he
said casually. Seriously? I thought I was in
Australia!
Stepping out of the cool air-conditioned
airport in Darwin in January, I was
immediately hit by the heat and humidity.
I was instantly soaked as the saturated air
condensed on my cool skin. By the time I
got the car carrying my heavy bags I was
a mess. It was 35 degrees and felt like 42
with the humidity in the 90% region.
Soon though, airconditioning on maximum
in the car, I was struck by the incredible
scenery of Darwin. Parrots and egrets
filled the trees and the sky was dominated
by soaring black kites and sea eagles.
I went to the hospital, where I would be
living briefly and was delighted to find a
fantastic outdoor swimming pool! Too good
to be true? Nope. This was Australia.
Soon enough came my first day of
Anaesthetics at the Royal Darwin Hopsital.
An enthusiastic Kiwi consultant greated
me - “ Do you like fushin’ ” to which the only
possible answer was “yes”. We proceeded
to the first case on the Cataracts list, with
my Consultant teaching me Peribulbar
36
Gas induction using Goldmann vapourisers
As time went on I got the hang of things.
Flexibility and choosing your battles was
the name of the game.
Sixty per cent of the hospital patients were
indigenous Australians. Unfortunately the
hospital, which had been rebuilt since the
original was flattened by Cyclone Tracy
on Christmas Day 1974, was not built with
these very sociable people in mind. It is tall
– eight floors and very well air conditioned,
neither of which are very natural for them.
It was common to find patients wheeled
out into the much more pleasant tropical
sun and humidity, to warm up and socialise
in their hospital beds.
recorded incidence of acute rheumatic
fever in the world and consequently
rheumatic heart disease is relatively
common with an incidence of around 1%
affecting all ages.
The Northern Territories (NT) is also home
to an unusual gram negative bacteria,
Burkholderia mallei, which lives in the
soil and causes Meilioidosis. A condition
which seemed to be able to form abcesses
anywhere in the human body.
People in Darwin are double hard. Even the
white Australians. I once had a 40 year old
patient drive for 36 hours with appendicitis,
stop at a hotel (“The Humpty Doo”) eat 2
steaks despite the pain – which suddenly
got better at some point in the night – and
present to ED the following morning with
sepsis from a perforated appendix.
Children also suffered from malnutrition,
scabies and lung disease from campfire
smoke inhalation. Bronchospasm and
laryngospasm were not uncommon events
during general anaesthesia.
There is pus everywhere – emergency
lists don’t stop at night as the back log
would never be caught up with. Now a
few abcesses here and there sounds
pretty mundane – however, the indigenous
people particularly have wide ranging
problems that mean a significant proportion
of even twenty year olds might be ASA 3 or
4. This provides many a challenging case
at 4 o’clock in the morning. I gained lots of
experience at regional techniques.
Health problems amongst the local
population included complications of
type 2 diabetes such as end stage renal
failure at 20-30 years old, and peripheral
neuropathies severe enough to mask third
degree burns to the feet sustained as a
result of walking barefoot on hot tarmac
without realising! COPD and alcoholic liver
disease were also highly prevalent.
The Northern Territory has the highest
Trauma was also common. Dangerously
boring long straight roads would lead to
inattention on the road and the giant 200
tonne Road Trains and a speed limit of
130km/h were a recipe for disaster.
Crocodile snake bites were also common
although, in all honesty, not often requiring
anaesthetic input.
There was also lots of trauma from
assault. The concept of ‘payback’ was
rife amongst the indigenous Australians
who would present with various machete
wounds and very commonly bilateral jaw
fractures from thrown punches. These
would typically present late with trismus
and abscess formation and be the basis for
a Wednesday fractured mandible list and,
for me, practice at fibreoptic intubations.
The humidity causes other problems too –
lighting fires becomes difficult and it was
very common for people to present with
severe burns to their ankles after lighting
fires using petrol– “Boots on or off?”, my
37
consultant would ask in reference to the
extent of the burns.
But it wasn’t all work.
Typical pastimes would be drinking at the
local watering hole – the Beachfront – with
views across a turquoise bay and orange
cliffs.
Sunset over the boat ramp
In the wet season this would be completely
cut off by flood waters which would bring
with them huge saltwater crocodiles in
their hundreds. With the receding waters
in the dry season, the park rangers would
gradually catch and evict these terrifying
creatures and slowly open up the main
spots. Traps would remain throughout the
dry season though and swimmers would
have to make up their own minds how
brave they were! – local bogans would
have their picture taken standing on the
crocodile traps! The local paper, The NT
News, was constantly full of stories of
crocodile attacks.
Having become accustomed to Darwin
healthcare, climate and its hostile wildlife,
I then began my position as a critical care
retrieval registrar with Careflight.
‘Throb’ - the cities best club featuring
a midnight show… performed by
transsexuals. As in “that Sheila’s a bloke!”
With days off there were a number of
spectacular national parks to visit. Hiking
through dense forest tracks to emerge at
incredible crystal clear rivers, billabongs
and escarpments.
Flight to East Timor
Twin Falls with crocodile trap
38
It began with an intense two week training
programme, which included ATLS- like
training – territory style – involving
practicing chest drain insertion and
thyrocotomy on goat carcasses – which
were kindly donated from a friend of a friend
of the course instructor. It also consisted of
the exciting HUET (Helicopter Underwater
Escape Training) course.
Once fully trained up, we were set to go. Work
consisted of repatriation from anywhere
in the NT (area) and also internationally,
typically from Bali, East Timor, Papua New
Guinea, Thailand etc. We would then fly to
a tertiary centre in Australia such as those
in Perth, Adelaide, Sydney or Melbourne
before returning the following day.
Inside a Beech King air ambulance
The job was as demanding as it was varied
and we used all modes of transport from
twin propeller King Air aircraft, to Lear Jets,
to “ Troopies” ( 4X4) to helicopters.
Washing the car Oz style
At the end of the week we often all met up
hear what each of us had been involved
with. There were always some fascinating
stories. Be it a bloke bitten by a snake
out in the bush and then on examination
finding its severed head still latched on to
the patient’s leg! Or a helicopter rescue
for an unstable patient on the beach and
racing against the 8 metre tides and the
lethal wildlife it would rapidly bring.
I attended a road train accident. The
hundred tonne behemoth had overturned
and spilt its load of cattle all over the road.
We arrived to this mayhem by helicopter
and had to assess the driver for injuries.
Road train wreck
Meanwhile the local police had to shoot
the poor injured animals with a rifle –
obviously not used to such a task we had
to keep reminding him not to point the rifle
in our direction when pulling the trigger!
The indigenous Australian locals stood
patiently on the roadside, sharpening their
knives and anticipating a free porterhouse!
It is a wild country, the cabin temperature on
the runway could hit 60 degrees centigrade
whilst the tarmac outside actually bubbled.
Massive tropical storms would provide
spectacular lightning shows out of the
aircraft window, though the theatre seat
might be a little bumpy at times as the
planes tended to plunge hundreds of feet
in seconds over the flooded crocodile
infested wetlands below.
39
Lightning over Darwin
In all, my year in Darwin was a fascinating,
challenging and unforgettable experience.
I learned so much, from peribulbar blocks
and fibreoptic intubations to managing
40
labouring women with rheumatic heart
disease and double lumen intubations for
VATS to treat empyemas. I learned to work
independently, often at altitude in planes,
and in foreign countries with critically
unwell patients and satellite phone
communications And, best of all I now
know how to get out of sinking helicopter
and rescue my buddy!
I would fully recommend either post to
anyone looking for a slightly different
Australian experience!
A PhD Late in Life
Patrick Magee
Bath
Having been a consultant in anaesthesia
at RUH Bath for thirteen years, and in the
absence of any specific roles on which
to focus my skills, I decided to pursue
an academic interest. I had started life
as a biomedical engineer, and I wanted
to undertake some research into the
mechanical function of the low flow circle
breathing system, as used by all of us in
anaesthesia, with a view to improving its
rather primitive design. I had first become
interested in this subject as an SHO in 1983
at Westminster Hospital, where Professor
Cyril Conway had done a lot of research
into the function of circle systems prior to
his death in 1985, building on the work of
Mushin, Galloon, Mapleson and others in
earlier decades. I was also interested in
the role of such breathing systems in other
activities, such aerospace, diving, firefighting and mountaineering.
With two of my RUH colleagues supporting
my application, I registered for a part
time PhD in the Mechanical Engineering
Department of the University of Bath in
November 2005, with a thesis entitled
‘Mathematical Modelling of Low Flow
Breathing Systems for Use in Extreme
Environments’. My chosen supervisor,
Dr Derek Tilley, had already written the
Fortran software, for a contract with the
Admiralty, to model the thermodynamic
behaviour of breathing systems used
by military divers. Given the immediate
availability of this mathematical model, it
would have been neglectful not to use it to
study anaesthetic systems as well. I spent
at least a year getting used to using the
mathematical model, and another three
years using it to model the function of the
standard circle system and the coaxial
circle system. I used a 50% oxygen in
nitrous oxide mixture for the gas model as
a surrogate for all such anaesthetic gas
models, since I anticipated doing a clinical
trial as well, using volunteers breathing
entonox. Modelling of different systems
was repeated using newer iterations of the
software, thanks to Dr Tilley’s expertise. In
subsequent models I altered the geometry
of the system to determine whether
this would alter its function The results
revealed that the gas pathways within the
circle system were not as I expected, and
certainly varied a great deal depending
largely on the fresh gas flow and to a
lesser extent on the system geometry.
In particular, the modelling revealed that
some of us prematurely reduce the fresh
gas flow before either adequate nitrogen
excretion or adequate volatile anaesthesia
is achieved. As expected, making the
tubing shorter and narrower enhanced the
responsiveness of the system to changes
in gas concentrations in the standard
system; what was more surprising was
that this occurred without significant
increase in resistance to gas flow or in
the work of breathing, which means we
can considerably reduce the volume of
the system without any loss of function.
Altering the geometry of a coaxial system
had less effect on function than expected.
41
I then spent the next two years modelling
a (coaxial) circle system using a venturi
device and no unidirectional valves in
the system, testing how it would function,
and altering aspects of its geometry.
Further work is required to determine the
efficacy and safety of such a system. A
venturi needs adequate fresh gas flow to
function, otherwise it stalls and the gas
concentrations received by the patient are
unpredictable; the function of the venturi,
and the degree of gas entrainment by the
venturi are also highly dependent on the
geometry of the neighbouring structures.
In the meantime I was devoting less and
less time to the research due to my role
as a full time clinical consultant, with
less time available for such personal
developmental activity. In 2011 I was
required to present myself for a viva to
justify continuation of the work beyond the
initially designated MPhil level towards
PhD status. Furthermore, I had taken so
long to do this work that Dr Tilley, the only
expert on the modelling software in the
University, retired. Dr Roger Ngwompo
took over as supervisor and organised a
total of eighteen months of ‘suspension’
for me. This sounds punitive, but merely
stops the clock on elapsed time (and fees
payment) when progress is delayed, and
is actually rather a useful mechanism
when one is unable to devote adequate
time to the research. However, both
supervisors had in the meantime decided
that the engineering model required
some clinical validation data. The thesis
was therefore now entitled ‘Mathematical
Modelling and Clinical Testing of Low
Flow Circle Breathing Systems’ and I
arranged to undertake a small clinical trial.
I determined to recruit local anaesthetic
42
colleagues, as non-naïve participants,
to breathe entonox gas through a mask
from standard adult, paediatric and coaxial
circle breathing systems at three fresh gas
flow rates, using my own hospital as the
venue to enhance familiarity and safety.
In 2012 the Frenchay ethics committee
gave me a bit of a run around, expressing
concern that I might coerce colleagues into
participating in the trial, or that entonox
breathing might be harmful. However, by
the second appearance at the committee
some months later I managed to convince
them otherwise, I agreed to recruit more
widely, and the trial proceeded after
local approval from the RUH. Most of
the nineteen participants enjoyed the
experience of breathing entonox through
a tight fitting mask, those under thirty
years of age regarding it as ‘better than a
Saturday night’, while for those over forty
the experience was more of a physiological
challenge. In just two participants was it
necessary to modify or terminate the trial
due to brief loss of consciousness and
airway management issues, and only one
participant had significant nausea and
vomiting. Lower than expected (but not
hazardous) inspired oxygen concentrations
were demonstrated at low fresh gas flows
in inadequately denitrognated systems
in some robust male participants. I was
touched by the generosity and courage
of my colleagues and family who offered
themselves for this trial. In general there
was good agreement between the clinical
trial results and the mathematical model,
though with better agreement for some
breathing systems and at some fresh gas
flows than others.
It was only when I retired from full time
NHS practice in 2013 that I was able to
give the project more of the time and
effort it deserved in order to complete it.
This was done, and my thesis written up
by early 2014. My viva took place a few
months later, with an engineer, Dr Nigel
Johnston from University of Bath, and an
anaesthetist (chosen by me), Professor
Neil Soni from Chelsea and Westminster
Hospital, as my examiners. As an
examiner myself in the primary FRCA
exam, I can safely assert that the two hour
viva was the most difficult exam to which I
have ever exposed myself! I am pleased
to say that the outcome was successful,
but I was obliged to undertake a number
of changes to my thesis, euphemistically
termed ‘corrections’ but actually involving
a significant amount of additional work. I
also had to undertake an online test set by
University of Bath on plagiarism avoidance,
(with a pass mark of 85%!) before I was
allowed to graduate.
Acquiring a PhD in late life while working
as a NHS consultant took a long time,
far too long really; it was primarily for my
own benefit and did not further my clinical
career, although it is an appropriate thing for
me to have done as a biomedical engineer.
However I am glad I did it, and it was heartwarming to have so many people helping
me to succeed. But these achievements
become harder with advancing years! I
was particularly sad that my supervisor,
Derek Tilley died last month, well before
his time, and before we had had a chance
to celebrate my success together.
43
Ulna Tidal Volume Ruler, Red Tape and Origami
Jon Rivers and Jules Brown
Intensive Care Unit, Southmead Hospital
Despite 15 years since ARDS net was
published compliance with low tidal volume
ventilation is limited. Lack of a known ideal
body weight makes it harder to select
the correct tidal volume and measuring
recumbent
patients
is
surprisingly
inaccurate. Patients have been known to
wake during measurement, concerned
that they are being fitted for a coffin. The
length of the ulna bone correlates well with
height and hence ideal body weight. We
designed a simple printable paper ruler
calibrated in tidal volume (ml) to allow tidal
volume to be rapidly estimated from ulna
length. We set out to prove it works, initially
in healthy volunteers. Back in the day, this
would have been a perfect trainee study,
ideally completed from idea to submission
within a couple of days. No patients, no
paperwork, no funding.
Our plan was to measure standing height
and ulna length (wrist to elbow) in a hundred
of our colleagues, carefully selected from
a random sample (ICU coffee room). We
did a modified power calculation: 101 to
small, 102 feasible, 103 unrealistic. We risk
assessed it: the most likely danger would
be accidentally punching oneself in the
face when putting hand across chest.
We initially contacted the Journal of the
Intensive Care Society to see if they would
require ethical approval for our study. The
Editor was very helpful and suggested we
either needed a ‘Sponsor’ or agreement
from our Research Ethical Committee
(REC) to waive requirement for ethical
approval. We made the fatal error of
44
approaching both.
Our hospital Research and Innovation
(R & I) were contacted with the naïve
impression that they existed to facilitate
Research and Innovation. Sadly, their role
seems to be to generate as much red tape
as possible, in the shape of the ‘Integrated
Research Application Process’, or IRAS.
This is how the email conversation went;
Them: Have you obtained MHRA approval?
Us: It’s not a medical device.
Them: Yes it is.
Us: It’s just origami.
Them: No it isn’t. You need to resolve your
intellectual property issues.
Us: What issues, this is the sole idea of
one author (JR).
Them: No it’s not, we own all intellectual
property rights. Where is your protocol?
Us: We don’t need one.
Them: Yes you do. We are concerned
about confidentiality.
Us: There is nothing to be concerned
about.
Them: Where will you store information?
Us: On a secure hospital PC.
Them: Where will you store your written
consent forms?
Us: What consent forms?
Them: You need written consent to
participate.
Us: Why?
Them: You might coerce your staff.
(Perhaps they had heard about the
infamous registrar coercion episode from
the RUH experiments on triple H (Hooper’s
Humerous Humerus). See APWs passim.
Us: Have you seen Ben Walton?
Luckily we received an email from our
REC waiving the need for ethical approval
allowing us to wave goodbye to R&I.
We set out our high tech equipment in the
ICU coffee room and managed to coerce
100 ICU staff to be measured up. We were
fortunate no weights were required as a
previous cricoid pressure study by Tracey
Clayton was hampered by reluctance to
stand on scales. Data was collected on our
data collection tool (sheet of paper) over
the next few ICU shifts.
Deciding between correlation and Bland
Altman plots lead to lively non-expert
discussion, with the latter selected.
We were pleasantly surprised that our
article was accepted by the Journal of the
Intensive Care Society. We like our paper
to be referred to as ‘the Rivers paper’.
Without breaking any copyright issues the
headline figure is that using our ruler would
achieve a tidal volume between 5.1 and
6.3 ml/kg in 95% of cases.
We think this is clinically acceptable and
our ruler is certainly easy to use. It can be
downloaded as a PDF from the Severn
Trainees Anaesthetic Group (STAR)
website. For free.
We think R&I are still poring over upper limb
anatomy trying to identify the difference
between the IRAS and the elbow.
45
Examination Successes and Honours
Primary FRCA
Dave Baglow
Shelley Barnes
James Bickley
Matt Boyd
Kerensa Chapman
Sean Edwards
Mark Everleigh
Lizzie James
Matt Jenkins
Inthu Kangesan
Lorrie Kidd
Kelly Mackey
Gareth Meredith
Ed Miles
Kat Mulcahy
Eleanore Quinn
David Radley
Anna Ratcliffe
Sarah Steynberg
Megan Thomas
Paul Watson
Geoff Wigmore
final frca
Robert Goss
David Levy
Nicola Pilkington
Rebecca Pugsley
Johannes Retief
Tom Teare
ficM
Marcin Pachucki
Emma Riley
Society of Anaesthetists of the South Western Region Prizes
Intersurgical Prize
Rebecca Leslie, Rowan Hardy, Paul Hersch, Fiona Kelly
Poster Prize Autumn 2014
Melanie McDonald, Genevieve O’Farrell, Fiona Kelly
Miscellaneous examinations
Ph. D University of Bath
Dr. Patrick Magee
Thesis: Mathematical Modelling and Clinical Testing of Low Flow
Breathing Systems
Please accept the apologies of the editorial team if your success has not been mentioned above. We can only
print the names supplied to us by the college tutors and linkmen from around the region
46
Anaesthesia Points West Vol 48 No 1
Article
The Wine Column
Tom Perris
Hello, my name is Tom and I’m Not an Alcoholic, after all
This edition of the wine column is born in
unusual circumstances because, contrary
to my standard practice of conspicuous
indulgence in fine wine, I have recently
completed a self-imposed period of
abstinence. Yes, I did Dry January; the
longest period I have gone without alcohol
since I was about seventeen years old.
‘Why?’ is the obvious question. Why would
I voluntarily deprive myself of something
that has become an integral part of much
that I find pleasurable in life? A beer at
the rugby, a glass of wine with dinner, a
Scotch on a Sunday evening to round off
the weekend. All wonderfully enjoyable,
and I think that is the answer, right there.
After a series of excellent but inebriated
Christmas events, I felt that I was looking
forward to the next one with a disconcerting
degree of enthusiasm when it was obvious
that I would certainly have benefitted
from a quiet night in with a cup of tea. I’d
thought about doing a dry period before
but, frankly, couldn’t face it. And that was
starting to worry me. A brief examination
of the referrals to our critical care service
revealed a series of people who have
made, and continued to make unwise
lifestyle choices and I certainly didn’t want
to be one of them. Also, my clothes were
getting progressively snugger and if I got
any fatter, I’d be scanning the internet for
“plus” sizes. Something had to be done.
So, after the usual anticlimactic staying up
late watching Jools and slurring a Robbie
Burns poem to each other, I stopped
drinking for a month. Almost. One minor
lapse on visiting my old university flatmate
who was getting divorced. I tried it on PG
Tips, but after a couple of hours, it just
wouldn’t do the job. Other than that I was
on the wagon and my body was truly a
temple of temperance.
And it was surprisingly easy at first. I just
didn’t drink alcohol and enjoyed the slightly
sanctimonious feeling that went with my
new-found sobriety. Going to the pub –
no problem. I’ll just have an orange juice,
thanks. Even the SICWoE meeting wasn’t
too bad. No, the real test was after a week
on call when, like Pavlov’s mongrel, I’d be
salivating all the way home at the prospect
of a large and well-deserved glass of wine
from the better quality end of the cellar.
That was the toughest but, as my wife
kindly pointed out, “it’s only a habit. Get
over it! “Thanks Dearest.
The people who kindly send you
motivational texts and emails throughout
January if you take the pledge claim
all sorts of benefits for abstinence from
weight loss to higher energy levels. Did it
work? Well, yes and no. I did lose weight,
quite a lot in fact but then I kept having to
go to the gym to distract from my cravings.
Did I have more energy? No, not really, but
I probably did sleep better and certainly
woke up fresher without a hangover which
was certainly good. Did I save money?
Yes, but then I spend a lot on wine usually,
and it was less embarrassing putting the
recycling out too!
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Did I enjoy it? Not even a little bit. It was
tedious in the extreme and contrary to my
every basic instinct. I don’t like depriving
myself at all, but it did get easier as I
gradually undermined those bad habits. I
realised that I don’t have to have glass of
wine when the kids are in bed and I did get
more stuff done in the evenings instead of
sitting in front of the telly with a drink.
And am I healthier? Well probably a bit,
but it’s arguable. The evidence for health
benefits from wine are well known and
have been claimed for almost 4500 years.
Certainly moderate drinkers seem to live
longer (and possibly happier) lives than
both heavy and non-drinkers. Where the
bottom of that particular mortality curve
lies, is debateable. It depends on age,
sex, genetics, diet and probably a dozen
other factors but is somewhere around
the 10-15 units a week level according
to most studies. But since all the studies
are self- reported and everyone tells fibs
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about what they really drink, it’s hard to
get an exact figure. What is for certain is
that prolonged heavy consumption is bad
for you (duh!) and drinking nothing at all is
missing out on some likely benefits. These
would appear to be linked to the pigments
contained in the skins of grapes (red and
white, but since red wine spends more time
macerating with its skins for colour and
flavour during fermentation, its levels of
resveratrol, the chief beneficial substance
are higher). So, drinking red wine appears
to be good for you. You could just eat the
grapes instead, but it’s not as fun!
So apologies for the self-indulgent
reflection piece. Not my usual style and
not to be repeated but I’m confident that
having realigned my drinking behaviour, I
can go on enjoying slightly less wine for
many more years. I promise I’ll write about
it next time.
Enjoy! (Sensibly)
Anaesthesia Points West Vol 48 No 1
Poem
White Moments
Engraved on our Sundial, the legend
‘let others tell of storms and showers’
it states on a metal plate ,
‘only count the sunlit hours’.
Where did all those blue skies go?
You’d glimpse them through
a theatre window, wistfully.
In that corridor you knew.
Surrounding the sundial
a host of snowdrops,
like gentle theatre nurses,
waiting while time stops.
Meanwhile, in the darkness
of my wardrobe, time has stopped
for my cherished theatre clogs,
white as those snowdrops.
They bow their heads
in some sort of supplication.
The sky is grey; no sun today.
The surgeon postpones the operation.
Robin Forward
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CROSSWORD
Brian Perriss
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Clues Across
7
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1. Unusual but bloody. (4)
3. Be against any kind of stagnation. (10)
8. American novelist wears knitted cape. (6)
9. Still seeing label grandma put in sleeves of suit. (8)
10. Moral becomes confused after novel begins as usual. (6)
11. In charge of one in an internal organ is ceremonial. (8)
12. Object around hotel needs trimming. (8)
14. Take Enid out to eat. (4)
16. A study of this seaport. (4)
18. Northern theatre produces plays that are not square.(3,5)
20. Bending a wire in Germany. (8)
21. Ann, you’ll say that every year. (6)
22. Climb round church but event turns sour. (8)
23. Spacecraft for twins? (6)
24. White house in Africa? Ask Humphrey. (10)
25. Holds animals discovered in Africa gene pool. (4)
Clues Down
1. Sent in a plant when ill. (8)
2. Set a time apart for judge. (8)
3. Heavenly swimmer? (9)
4. Exercise on two rings at noon and win silver coin. (7)
5. This is about departure in progress. (2,5)
6. Created mentally. (8
7. Utter “La tot” confusedly. (5)
13. Complaint that could be painful to face. (9)
15. Anonymous but strangely less mean. (8)
16. Taking Cyanamid leaves one without strength. (8)
17. Carpenters items for cosmetic use. (4,4)
18. Its often stopped with a raised hand. (7)
19. Correct measure in order to get straight. (7)
20. Coin that Francis is leaving. (5)
Solution to Crossword of Autumn 2014 APW
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51
Prizes and Bursaries
Details of all prizes, rules, and entry deadlines can be found at www.saswr.org
There are several bursaries and prizes available to members of SASWR:
The SASWR Intersurgical Trainee Prizes
Two prizes, of £750 and £250 respectively, are awarded annually at the November Scientific
Meeting of the society. Entries of up to 2000 words maximum in the form of an essay or
short paper on any topic related to anaesthesia, intensive care or pain medicine should be
submitted electronically to the Honorary Secretary of the Society ([email protected]), by
30th September each year.
The three best entries will be presented orally at the SASWR meeting in November, and the
prize awarded at that meeting. Any entrants who do not make the shortlist will be invited
to enter the poster prize at the meeting. Please note that you must be registered for the
meeting in order to present your work, and you may not enter both this and the poster prize.
SASWR Poster Prize
The Spring and Autumn scientific meetings will have a poster prize of £250 awarded to
the best poster presentation. To enter, submit your work as an abstract or poster to the
Honorary Secretary ([email protected]) by 30th September each year for the Autumn
meeting and 31st March for the Spring meeting. You will need to be registered for the
meeting and be able to present your poster to the judges during coffee.
The Ross Davis Adventure Bursary
Annual awards totaling £1000 in memory of Dr Ross Davis, are presented by his family
and friends, to trainees of ST3 or above from the Wessex, Peninsula or Bristol deaneries
to support ‘exciting endeavours in anaesthesia’. Further information can be found at
www.rosswindsurf.co.uk and applications should be directed to the Honorary Secretary
of SASWR ([email protected]) by 1st May each year. The successful applicant will be
invited to accept their award at the following November meeting of the society, although the
award may be released before then!
The Feneley Travelling Fellowship
This cash bursary is awarded to any member of the society to support a ‘mission abroad’.
Applications, to the Honorary Secretary of SASWR ([email protected]), are welcomed
throughout the year.
52
Notice to Contributors
All articles should be sent by email to the editor (see below for address). Scientific articles
should be prepared in accordance with uniform requirements for manuscripts submitted to
biomedical journals (British Medical Journal 1994; 308: 39-42) i.e. as used by Anaesthesia.
Please ensure that references are complete and correctly punctuated in the required style.
The approved abbreviations will be used for journal titles. Photographs should be sent as
separate attachments.
The deadline for submissions is usually 10 weeks before the next meeting of the society.
Submission of articles to Anaesthesia Points West implies transfer of copyright to the Society
of Anaesthetists of the South Western Region. If an article has been previously published
elsewhere, permission to use the material should be sought from the editors of that journal
before submission to Anaesthesia Points West. Submissions will be acknowledged on
receipt and notice of acceptance/rejection/need for corrections will be sent as promptly as
possible.
Editor
Assistant editor
Dr Richard Dell
Department of Anaesthesia
Brunel Building, Southmead Hospital
Southmead Road
Bristol
BS10 5NB
0117 414 5114
[email protected]
[email protected]
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