July 2003 Inside this issue - The Royal College of … 2003 BULLETIN 20 THE ROYAL COLLEGE OF ANAESTHETISTS Inside this issue TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Aspects

July 2003

BULLETIN 20

THE ROYALCOLLEGE OFANAESTHETISTS

Inside this issueTRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA

Aspects of Myocardial physiology (Part 1)

Hawks, doves and vivas; plus ça change ...?

Anaesthesia in Ethiopia

Anaesthesia in Blantyre, Malawi

AN OUTSIDER LOOKING INTO ANAESTHESIA ...

Ars Longa, Vita Brevis – v – The singer not the song

The Obstetric Anaesthetists Association andInformation for Mothers

Consultant job descriptions

Formula for establishing sessional shortfallon accreditation visits

CORRESPONDENCE

Casey WF, Nunez J, Wilson AM

THE ROYALCOLLEGE OFANAESTHETISTS48/49 Russell Square London WC1B 4JY tel ++44(0)20 7813 1900 fax ++(0)20 7813 1876website www.rcoa.ac.uk email [email protected]

President Dr P J Simpson Vice-Presidents Dr D M Justins & Dr D A Saunders

Editorial Board Paul Cartwright Chris Heneghan Mandie Kelly (Editorial Officer)Gavin Kenny Jeremy Langton Rajinder Mirakhur Jane Pateman Anna-Maria Rollin(Editor) Peter Simpson

Inside Bulletin 20971 – President’s Statement

974 – GUEST EDITORIALThe new College Electronic Logbook – Progress and future development

976 – Non-consultant career grades

977 – TRAINEES’ TOPICSBook Review: ‘Managing Obstetric emergencies and Trauma’The Examinations Directorate

980 – Hawks, doves and vivas; plus ça change ...?

984 – Anaesthesia in Ethiopia

986 – TRAINEES’ FORUM: PREPARING FOR THE PRIMARY FRCAAspects of myocardial physiology (Part 1)

991 – Education Programme (July 2003 to June 2004)

999 – AN OUTSIDER LOOKING INTO ANAESTHESIA ...Ars Longa, Vita Brevis – v – The singer not the song

1001 – The Obstetric Anaesthetists Association and Information for Mothers

1003 – How was it for you?

1006 – Anaesthesia in Blantyre, Malawi

1008 – Consultant job descriptions – Musings of a Regional Adviser

1011 – Formula for establishing sessional shortfall on accreditation visits

1012 – Report of meetings of Council (February to May)

1016 – Correspondence

1017 – Notices

The views and opinions expressed in the Bulletin are solely thoseof the individual authors, and do not necessarily represent the viewof The Royal College of Anaesthetists

© 2003 Bulletin of The Royal College ofAnaesthetistsAll Rights Reserved. No part of thispublication may be reproduced, stored in aretrieval system, or transmitted in any formor by any other means, electronic,mechanical, photocopying, recording, orotherwise, without prior permission, inwriting, of The Royal College ofAnaesthetists.

Fellows, Members and trainees are asked tosend notification of their changes of addressdirect to: Miss Karen Slater, MembershipOfficer, at The Royal College of Anaesthetiststel 020 7813 1900 fax 020 7580 6325email [email protected].

Articles for submission, together with anydeclaration of interest, should be sent viaemail (preferred option) to:[email protected], or by post (accompaniedby an electronic version on disk, preferablywritten in any version of Microsoft Word), to:Mrs Mandie Kelly, Editorial Officer, The RoyalCollege of Anaesthetists. All contributionswill receive an acknowledgement. The Editorreserves the right to edit articles for reasonsof space or clarity.

The Royal College of Anaesthetists isgrateful for the contribution to theproduction of this publication by:

I’m learning fast! Presidents have to

meet deadlines and these are not

necessarily of their own choosing. Presidents-elect are not

exempt from this, and shortly after being elected at March

Council, both Anna-Maria Rollin, our Bulletin Editor and

Mandie Kelly, our Editorial Officer, gently but firmly told me

when my first President’s statement was due – before I even

take up the role in June. In fact, thinking back, I remember

Peter Hutton writing about being in a similar position three

years ago. His statements have always made excellent

reading; pithy, witty and no-holds barred (well almost!). My

style may be something more akin to Alastair Cooke’s ‘Letter

from America’, but you will have to judge for yourselves.

The other major lesson I have learnt very rapidly is that

there is no such thing as ‘off the record’, when one is a

College President, elect or otherwise. People seem to listen

to whatever you say, or at least they politely look as though

they do. They may believe it or disagree with it, but seldom

show it and one is left from time to time with considerable

self-doubt. As a result, one becomes quite an expert in ‘body

language’. Rather like the examination candidate who gives

an answer in such a convincing way that, although it is 180o

out of phase and wrong, and you are sure you are right, you

begin to doubt yourself and your years of learning and

experience. The main message for me has been that

everything one says or does is fair game and all is admissible,

quotable and attributable, so for those who know me well, I

am not really meaning to appear cagey or secretive, but just

trying to avoid putting my foot in it.

Our outgoing President – Peter HuttonMajor changes have been achieved during Peter’s term of

office as President, for which we all owe him enormous debt.

He has been a true leader of our College and the speciality

and it has been an education and privilege to work alongside

him, as a Vice-President, with Graham Smith and Doug

Justins, during the past two years. He has given his time and

energy selflessly to the College and the Academy and has

enhanced the importance and significance of anaesthesia,

critical care and pain management, not only within the

medical profession, but also within Government and the

Department of Health (DoH). We are now seen as key to the

delivery of critical care services across the NHS, and also as a

specialty which is prepared to look sensibly at how these

services can be delivered in the future. This is emphasised in

the latest strategic document from the Department of Health

‘Keeping the NHS Local’, in which anaesthesia and critical

care services are acknowledged as fundamental to the

running of acute hospitals, however big or small.

It would be all too easy, as a President, to simply try and

‘keep all the balls in the air’, but this is certainly not Peter’s

style. How many of you noticed, not long after he was

elected, the new College image, clearly stating the modern

environment in which we work? This was emphasised in

what has become our strap line ‘Educating, Training and

Setting Standards in Anaesthesia, Critical care and Pain

Management’, together with ‘The RCOA: Advancing Patient

Care and Promoting Safety’. Such statements may appear

somewhat trite to us, but they have had a significant impact

amongst those to whom we offer our services and expertise.

By emphasising professional standards, training and the

quality of patient care as the cornerstones of our activities

and practice, we have clearly stated that patients and our

professional integrity are the fundamental concerns of our

College. We have so far escaped producing a College

mission statement, but who knows? Things will change

inevitably in response to developments in healthcare and

service delivery, but I believe that the place of anaesthesia,

critical care and pain management is now well established

and our role is to ensure this by sustaining and seeking to

further improve the excellence of training, professional

development and the quality of the service that we provide.

Peter was always determined to make College Fellowship

and Membership inclusive and to ensure that all those

involved with the delivery of anaesthetic services in the UK

had an appropriate link with the College. The introduction

of the new style Membership and Associate categories has

proved extremely popular, as has the Retired Fellows Club.

Accreditation in the future – The PMETBThe Postgraduate Medical Education and Training Board

(PMETB) legislation has now been through both the

English and Scottish Parliaments and the House of Lords.

Although it may seem remote from our everyday work, this

combination of the Specialist Training Authority (STA) and

the Joint Committee for Training in General Practice

(JCTGP) had the potential, in its initial versions, to alter

completely the way in which the training of doctors was

regulated and approved prior to entry on to the Specialist

Register. Peter Hutton, as Chairman of the Academy of

Medical Royal Colleges (AoMRC) spent many hours of

effort on behalf of all specialities to ensure that their

activities, and those of their training committees, continued

to remain central to the whole process. Some of you might

Bulletin 20 The Royal College of Anaesthetists July 2003 971

From the President’s OfficeOff the record? You must be joking!

remember the initial documents describing the role of the

proposed Medical Education Standards Board (MESB),

which spoke about ‘training doctors to work in today’s

NHS’, under the direct control of the Secretary of State. To

the credit both of the Academy and Government, and

related, in large part, to Peter’s efforts, a sensible and

workable solution has been found which will be to the

benefit of all. This was cemented by the joint signing of a

Memorandum of Agreement between the parties, which

endorses the formation and working of the PMETB and the

ways in which the Colleges and Government, through the

Department of Health, can work together in the future.

A new home for our College?Peter has also vigorously pursued our target of achieving

new College premises to enhance the facilities available to

everyone. This has never been about simply re-providing

the office accommodation, but rather, has been aimed at

establishing an educational and training facility for the

benefit and use of the whole breadth of our speciality,

including a lecture theatre, seminar rooms and appropriate

skills training facilities. To maximise the opportunities

which such a facility would offer, I believe that it is crucial

for us to work together with other Societies and

organisations within anaesthesia and in particular the

Association, to achieve this aim. It would be senseless to

provide facilities which remained underused, while other

anaesthetic organisations rented accommodation in other

parts of London.

Our search, led by Peter and Kevin Storey and utilising

external professional advice, has involved looking at and

considering over 70 buildings, together with all the

constraints of listing, freehold/leasehold and frankly

whether we can afford it – to which, like buying a private

house, the answer is almost always no! We are also acutely

aware of the legacy which we will leave to future generations

of anaesthetists, not only in terms of capital investment but

also in running costs. With the dramatic recent falls in

commercial property prices in London, purchasing a

suitable freehold property seems an ideal long-term

proposition and investment, but we will continue to ride the

emotional roller coaster until the right one emerges.

The GMC electionsThe process of being elected to any position is not

something which most of us relish and, as I write this, a

number of our colleagues have been deeply involved in the

elections for the ‘new’ General Medical Council. The

constituency for this is of course now regionally based, but

more importantly, the number of available medical seats on

the new GMC Council is vastly reduced, making the

election of a balance between general practice and hospital

specialities all the more important. Indeed there are so

many groupings, both professional and personal, that there

will be many who feel disenfranchised and un-represented

and it will be a major task for Sir Graeme Catto and his

colleagues to address these anxieties, particularly now, with

revalidation just around the corner. He is certainly someone

with whom the College finds it easy to work and we would

hope to continue our good relationship with the GMC in

the future. We have been exceedingly fortunate to have

Professor David Hatch as Chairman of the GMC’s

Committee on Professional Performance and at the same

time working as an advisor to our Professional Standards

directorate over the past three years, but David did not stand

for election to GMC Council this time.

So much for the past. What plans do we have for the

future and will you be seeing radical changes at the College,

new initiatives and controversial advice? Those who know

me well, will tell you no, and my main aims will be to build

upon the excellent foundations and developments which

my predecessors have laid down. I am very fortunate to

have two good and hard working friends, Doug Justins and

David Saunders as Vice-Presidents and a wonderful team at

the College, both on Council and on the permanent staff,

led by Kevin Storey, our College Secretary and our

Directors, David Bowman and Emilia Lightfoot. I am sad

that Emilia is leaving just as I begin, but we wish her well

and welcome our newly appointed Director of Professional

Standards, Charles McLaughlan, who joined us in June. I

have also just heard that, sadly, Trisha Bernays has decided

to retire from her role as Personal Assistant to the President

to coincide with Peter Hutton demitting office. As someone

who has worked with five Presidents over the past 14 years,

she deserves a big ‘thank you’ on behalf of us all. I will be

sad not to have the opportunity to work with her too, and

apprehensive over the potential loss of such a vast wealth of

‘corporate memory’. Nevertheless, I feel sure that, with her

interests and energy, retirement promises to be exciting and

we look forward to regular contact with her in the future.

The futureSo what would I like and hope to see? Certainly to work

more closely with the Association in those areas where our

activities and responsibilities overlap and therefore, where

we all stand to gain. After all, like most anaesthetists, I am a

Fellow of the College and a Member of the Association.

Equally, there are specific responsibilities, which our two

organisations do not have in common and it is better and

appropriate for these to remain separate. I would also like

to find ways of encouraging and representing anaesthetists

in the new clinical excellence award system and to get away

972 Bulletin 20 The Royal College of Anaesthetists July 2003

from the mad rush in the weeks around Christmas each

year. Since our CVs don’t suddenly change dramatically on

1 November, I believe that we could present ourselves better

and write more informed citations and letters of support, if

time were not so critical. Anaesthetists have a heavy clinical

workload and the citations, as much as the CV, must be used

to emphasise excellence in this area of our work. It is also

important to draw attention to the breadth of our speciality

by supporting colleagues with distinct major commitments

to intensive care medicine and pain management.

I am also keen to see a logical single critical incident

reporting system, linked through the Trust systems to the

National Patient Safety Agency (NPSA). I have been

discussing this with NPSA and CHI in conjunction with

John Carter, Chair of the Association’s Safety Committee

and while a single electronic system is ultimately desirable,

anaesthetists need something to be developed and approved

in the near future which will also provide feedback for use

at Trust and departmental level. So, watch this space!

August 2004 – book your annual leave now!Although August 2004 and the introduction of the first

European Working Time Directive (EWTD) target of 56

hours for junior doctors may seem a long way off, I would

sincerely urge you to think about how the impact will be

addressed in your individual hospital situation. If you are

waiting for some magical recipe to appear, or to be told not to

worry, I’m afraid that you will be disappointed. While the

Department of Health will say that it is promoting and

piloting several potential solutions, none of these will come

close to maintaining the current level of service provision by

August 2004. New ways of working and the involvement of

non-medical roles in anaesthesia, critical care and pain

management may be possible in some Trusts, but the truth is

that, for most of us, we will have to address the problem

utilising the existing workforce and provide our own solution.

I am sure that it is vital for every Department to discuss and

formulate realistic plans for its own situation, remembering

that the EWTD applies to us all, career grades and trainees

alike, so that either some on-call services will be reduced or

rationalised, or elective work and therefore waiting lists will

suffer. It is actually an opportunity for us all to reorganise our

working patterns and the balance of our professional and

private lives and if we view it as such, in a positive way, the

results may not be nearly as bad as we imagine.

I am sure that some Trusts have already made provision

and this could well be a blueprint for others, who can then

also achieve the necessary goals. We do need to work with

our managerial colleagues to achieve the best solution for

our individual circumstances and of course, for patients.

Although the EWTD is part of health and safety legislation,

by preventing fatigue and lack of sleep amongst doctors it

will inevitably be of significant benefit to the quality of

patient care. There will be many who find that sustaining

the current levels of anaesthetic service is impossible. I

believe that it is crucial for managers to be informed of what

will and will not be possible at an early stage, so that they are

in no doubt of what is required and what will be the result.

While I realise that the likely response is that they do not

have a solution either, it is crucial that we work with them

and patients to try and solve the problems or at least

prioritise the services which can be delivered. If nothing is

said, we as anaesthetists will be the scapegoats in 2004 when

things grind to a halt, whereas flagging it up at an early

stage, in documented correspondence, warns of the

consequences and allows sensible planning, hopefully

without confrontation.

Finally, at this point, while Peter Hutton would probably

have offered an erudite quotation from Virgil, I will use

something more modern. In trying to encapsulate what I

believe my new role should be, I was reminded of the

inimitable and satirical humour of Michael Flanders and

Donald Swann. To paraphrase one of their pithy

introductions, while Government appears intent on

maintaining the thin veneer of comforting illusion and cosy

half truth, my and the College’s job, as I see it, is to strip it

away again!

Peter Simpson


Data from logbooks are required from all trainees for the

RITA process leading to the award of a CCST.

Electronic logbooks are used already by over 90% of

trainees to store and analyse their anaesthetic experience

and it has been agreed that the College should support their

use. The present electronic hand held system in common

use was developed by members of the Society for

Computing and Technology in Anaesthesia. It was based on

the Psion Organiser but that will be discontinued by the

manufacturer and a replacement system must be made

available to trainees.

In addition, problems had arisen in the past because

trainees had assumed that the College IT department would

provide support although the Psion systems had been

produced by groups outside the College. The decision was

made to develop the new electronic logbook within the

College structure and a working group was established to

determine the optimum way to progress.

Handheld solutionThe working group considered that the optimum solution was

for data collection to be undertaken using a hand held device.

Two major types are available which are based on different

operating systems. The Palm Pilot has its own proprietary

operating system and is available in several different devices.

Microsoft Pocket PC is the alternative operating system and

is also available for several devices. It is not clear which of

these two forms, if either, will dominate the market in the

immediate future and the group agreed that support should

be provided for both. The handheld device would have no

analysis function and all analysis and reporting would be

undertaken by uploading the data into a PC-based system.

Desktop based solutionThe group agreed that the FileMaker Pro system which had

been developed by Dr Andy McIndoe and Dr Ed Hammond

met all the necessary criteria for the analysis and reporting

operations. This system has been in widespread use and has

proved to be reliable and effective. Data output in standard

formats is possible from the desktop system should

individuals wish to transfer data to other analysis and

reporting packages. Data will be able to be entered either by

downloading the information from one of the supported

hand held devices or directly into the PC using the keyboard.

College supportOne of the major aims was to provide support for users

based on the College IT department. It has been agreed that

the College IT staff will provide the first line support for the

electronic logbooks and would pass the users’ enquiries to

the developers of the software for further advice if required.

The developers are involved in the working group and all

have agreed to provide this essential support to the College.

Feasibility studiesSeveral database programmes were evaluated for use in the

hand held devices but only one, HandBase, could be used

with the two different operating systems. The disadvantage

of this is that the relevant software must be downloaded

from the Internet and the full version will cost each trainee

who wishes to use the hand held system about $30 to

purchase on-line. This database programme then allows the

College software to be run and data to be entered using

either of the two hand held devices.

DistributionThe new electronic logbook system will be available either

from the College web site or on the CD-ROM which will

also contain the updated versions of the College training

documents. The software package will contain both the

Palm Pilot and Pocket PC versions of the hand held software,

the PC system to enter and to analyse the data, and help files

to explain how to load the software on to the hand held

devices and how to use the system.

Operation of the systemThe new electronic logbook system has been designed in a

similar manner to the Psion system where ‘drop down’

menus are used as much as possible to simplify and speed

up data entry. It was not possible to produce a system which

would allow direct transfer of the data from the HandBase

programme directly into the PC database. Where a hand

held device is used for data entry, the information must be

transferred to the PC for storage and analysis following the

instructions provided.

ReportsA wide variety of tabular and graphical reports are available

from the PC analysis system which should be helpful to


Guest EditorialThe new College Electronic LogbookProgress and future developments

trainees. Examination of various College documents revealed

that a range of different terms had been used for items such

as the level of supervision, anaesthetic categories and

definition of ‘out of hours’. These have now been clarified to

a common list of items which are used throughout the

training documents, the data entry systems and the final

reports. A report is now available on the desktop system

which would be used for the RITA process.

Data protection actThere has been considerable discussion about the influence

of this Act on the use of an electronic logbook to record

trainee experience and whether or not each trainee must

register their system. The major problem is that there is no

established case law and therefore no precedent to provide

us with definitive guidance on the correct way to proceed.

The UK Data Protection Act states that:

‘Personal data means data which relate to a living individual

who can be identified – (a) from these data, or (b) from these

data and other information which is in the possession of, or is

likely to come into the possession of, the data controller …’.

The GMC Confidentiality Guidance (glossary) defines

anonymised data as:

‘Data from which the patient cannot be identified by the

recipient of the information. The name, address and full post

code must be removed together with any other information

which, in conjunction with other data held by or disclosed to

the recipient, could identify the patient’.

NHS numbers or other unique numbers may be included

only if recipients of the data do not have access to the ‘key’

to trace the identity of the patient using this number.

It therefore seems clear that if the patient hospital

number were to be included in the data collected by the

trainees, then no one who would have access to the

electronic logbook data would be able to ascertain the

identity of the patient in question, since they would not have

access to the relevant ‘key’ referred to in the GMC guidance.

On that basis, no data protection issues should arise under

the Data Protection Act since neither the trainee nor anyone

who would have access to the trainee log will be dealing with

‘personal data’ as defined under the Data Protection Act.

One option to avoid any complications arising from the

Data Protection Act, may be not to take any data outside the

hospital environment and simply keep all the information

within the anaesthetic department on the department’s

desktop. If the hospital number or the patient’s date of birth

is not recorded, then this would be an alternative strategy, in

which case, it would be important to use one’s own

individual case numbering system, with the ‘key’ kept

completely separately from the main logbook data files.

Future developmentsWe will continue our efforts to provide trainees with

suitable systems for recording their experience gained in

critical care and pain medicine. In addition, we intend to

produce systems which would assist both trainees and

consultants with collection of material for their portfolios to

assist with the revalidation process.

The possibility of extending the use of the electronic

system to produce training reports at a department level is

an attractive option which we intend to explore.

ConclusionWe hope that the new electronic systems will provide

trainees with a logbook which is simple to use and can assist

them by providing an accurate record of their training

experience. As the real duration of training is decreased, it

is absolutely vital that we make the best use of all the time

which is available and an accurate and detailed record of

experience is one of the major tools to achieve this aim.

Gavin KennyGlasgow Royal Infirmary


Our futureThe Department of Health has concluded its review of the

Non Consultant Career Grades and is about to publish a

consultation document. I’ve had a sneak preview and it

looks like we’re being taken very seriously and that the

Department is keen to improve our grades and to make

further training for those who wish it a realistic possibility.

The BMA is about to publish its proposal for a ‘single spine’

which would have two tiers, with entry to each tier having

clear criteria. Both documents should be available well

before the Bulletin goes to press and I’d be grateful for any

comments.

MeetingsThe April NCCG Review Day was a great success.

Dr Graham Arthurs once again put together a varied,

interesting and challenging timetable. There was something

for everyone and the main complaint was that the meeting

was too short. We all went away having learnt something.

The NCCG Day on 16 October will have both clinical and

political themes – we want to explore the possibilities for the

future and to present updates on rapidly developing aspects

of our practice.

For the first time, this meeting will be held jointly with

the Association of Anaesthetists – an exciting new venture

which will really give the meeting some political clout! I

hope you can come.

The Royal College of The Association of AnaesthetistsAnaesthetists of Great Britain and Ireland

Autumn NCCG Day16 October 2003 (code: C63)at the Royal College of Anaesthetists,London WC1

Topics will include:

● The future for SAS doctors.

● Who represents the group, where andwhat are the issues?

● Acute vascular emergencies.

● New airway devices.

● Trauma anaesthesia.

● Transfer of critically ill patients.

Registration fee: £175Approved for CEPD purposes


Non-consultant career gradesDr C Rowlands, Chairman, NCCG Committeeemail [email protected]

TRAINEES’ TOPICS Editor Dr M J Garfield, The Ipswich Hospital, Suffolk


Book Review

Managing Obstetric Emergenciesand TraumaThe MOET Course ManualEdited by R Johanson, C Cox, K Grady and C HowellRCOG Press, London, 2003.ISBN 1 900364 70 0, 314 pages.

This clear and concise book is the core text for the Managing Obstetric Emergenciesand Trauma (MOET) course, but it is also available as an independent text. This bookis aimed at obstetricians, midwives, accident and emergency doctors andanaesthetists. It is divided into six colour coded sections- Introduction,Resuscitation, Trauma and Other Emergencies, Obstetric Emergencies, Triage andTransfer and Bibliography.

The ‘Introduction’ section introduces the structured approach, that is, the A, B, C,D, E approach to managing the seriously ill and injured patient. This is a recurrenttheme throughout the book as is the need for early interaction between

obstetricians, anaesthetists, midwives and paediatricians. The ‘Resuscitation’ sectioncovers basic and advanced life support, the importance of early defibrillation and the adaptations ofCPR in the pregnant patient. Chapters on amniotic fluid and pulmonary embolism are verycomprehensive and interesting.

The chapter on ‘Airway Management and Ventilation’ offers a very basic overview for non-anaesthetists. As an anaesthetist, I feel a number of points have been glossed over. Illustrationsand photographs associated with this chapter lack explanations attached to them, and non-anaesthetists may have difficulty interpreting the relevance. The ‘Trauma and Other Emergencies’section encompasses a wide range of topics, and provides a structured method for assessing andmanaging patients with any type of injury that may be encountered. The first three sections formjust over half of this book and mirror the Advanced Life Support and Advanced Trauma and LifeSupport manuals.

The fourth section ‘Obstetric Emergencies’ offers an extensive review of the assessment andmanagement of conditions associated with pregnancy. The chapters on pre-eclampsia, eclampsiaand obstetric haemorrhage are very informative. Not all of the obstetric chapters are directlyrelevant to anaesthetists and their practice, for example, shoulder dystocia and destructiveoperations. These make interesting reading but are not essential topics for the anaesthetist to learnabout. The ‘Triage and Transfer’ section explores the need to prioritise patients and the systematicapproach advocated for prioritisation.

The book is well referenced, up to date, easy to read and provides suggestions for further reading.Each chapter has an easy to follow layout with a key point summary, flow chart, objectives andrelevant learning material. The flowchart appears at the start of the chapter. Personally, I wouldprefer it at the end of the chapter so the material read is further reinforced.

In summary, I feel this is a useful compendium of management plans for trainee anaesthetists andconsultant obstetric anaesthetists to read, but it does not offer any new or different knowledge thatis not already available from obstetric anaesthetic textbooks.

Dr C E WalkerAnaesthetic Specialist Registrar, Birmingham Women’s Hospital, UK.email [email protected]

Please send articles forsubmission, togetherwith any declaration ofinterest, to the Editor ofTrainees’ Topics,Dr Mark Garfield, viaemail (preferred option)to: [email protected], or by post(accompanied by anelectronic version ondisk, preferablywritten in any versionof Microsoft Word),to: Department ofAnaesthetics, TheIpswich Hospital, HeathRoad, Ipswich, SuffolkIP4 5PD.

The Editor reserves theright to edit articles forreasons of space orclarity.

The staff of four administers five examinations per year,

three sittings of the Primary FRCA and two of the Final

FRCA. From a departmental aspect, there are three phases

to each sitting:

1 Pre-exam – applications/bookings/question setting.

2 Exam – administering MCQ/SAQ, vivas and OSCEs.

3 Post exam – results, audits and quality assurance.

The procedure starts on the opening date for applications

and this is usually the catalyst for a number of telephone

queries regarding eligibility. The basic eligibility rules

require applicants to:

1 be eligible for registration with the GMC, either full

or limited

2 be registered with the College as a trainee or exempt

from registration, not being in a training post in the UK

at the time of sitting the exam

3 have completed the period of approved training

required for each part of the exam.

Examinations Regulations provide detailed information on

all aspects of the examination including the definition of

‘approved training’, eligibility, exemptions, application and

withdrawal procedures, failure/guidance and representations/

appeals. They are available on the College website or from the

Examinations Department and, to avoid misunderstandings

and delays in the processing of applications, are recommended

reading for both applicants and College Tutors.

The Examinations’ Calendar is available from the

department or from the Examinations pages of the website

(www.rcoa.ac.uk/examinations) and gives all the key dates

for each exam. In order to allow plenty of time to resolve

discrepancies, which may arise in an application, before the

closing date, we recommend submitting it as early as

possible and this is particularly relevant if it is the first

attempt. Applications are frequently received with notes to

the effect: ‘awaiting registration with College’ or

‘documentary evidence to follow shortly’. To ensure a

trouble free booking for the exam, plan ahead, have the

required information ready before submitting the

application, complete the form in accordance with the

instructions and get it in early!

On receipt, the application is checked to ensure the

candidate is eligible and has, where required, included all

necessary supporting documentation. Once the checks have

been satisfactorily completed the applicant is booked in for

the exam. Acknowledgement of receipt is sent only if the

pre-printed card or a stamped addressed envelope is

included with the application. The next communication the

candidate can expect is the admission notice for the written

exams. This will provide all the necessary information

including location of the examination centre of their choice,

timings, candidate reference number etc. and is normally

despatched two to three weeks but no later than ten days

before the exam date.

On completion of the written exams, the papers are

returned to the College for marking as follows:

Multiple choice questions (MCQs)Answer sheets are scanned through a computerised, optical

reader, which marks the paper automatically. The system is

extremely accurate (provided candidates complete their

answer sheets according to the instructions). Notwith-

standing this, there is still a series of manual checks and

audits carried as a quality control measure. The MCQ core

group will then meet to conduct the banding, usually

around the middle of the week following the exam.

Short answer questions (SAQs)Examiner pairings for the Vivas will have been determined

and each pair will be allocated a certain number of papers to

mark individually. For each candidate, one examiner will

mark paper A and the other paper B. In addition one

candidate’s paper will be selected as an audit paper and is

sent to every examiner. The examiners then meet on cross

marking day; usually about two weeks after the exam-

ination, for discussion within the pairs to arrive at an agreed

combined mark for each complete paper.

The department is always inundated with calls,

sometimes as early as the day after the exam, asking when

the results will be out. In order not to prolong the agony, we

now publish the names of successful candidates on the

examination pages of the College website the day after

results are known. The formal letter of notification of

success or failure then follows. As a ‘rule of thumb’, the

results will usually be finalised about seven working days

after the Primary MCQ and two weeks after the Final

MCQ/SAQ. Whilst understanding the candidates are keen


The Examinations DirectorateMr J McCormick, Examinations Manager


to know results, dealing with the many calls we receive on

the matter does delay the process and we would ask that,

rather than calling, they periodically check the website.

The next stage is the most challenging from an

organisational and logistics standpoint. Those candidates

invited to the OSCE/Vivas are allocated to specific days and

time slots for each element of the exam. Whilst it cannot be

guaranteed, individual requests from candidates for specific

days will, where possible, be accommodated. In the case of

the Final vivas, care is also taken to ensure examiners are not

assigned to candidates whose SAQ paper they marked. Viva

questions change six times daily and OSCE questions twice

daily. To support this, stores must be ordered, the

appropriate equipment identified and serviced, artefacts

checked, actors and support staff booked. Accommodation

and catering for examiners is also confirmed. The whole

process is planned with the precision of a military

operation, but things don’t always go to plan, the actor

delayed on the tube or the machine damaged by an over-

enthusiastic candidate. For this type of incident we have

alternative questions standing by, which can run on the

equipment and personnel immediately available, hopefully

keeping the delays to a minimum and the exam on track.

Following the exams the department despatches written

confirmation of results to every candidate and, where

necessary, provides dates and venues for guidance to ensure

those requiring it can attend in time to be eligible for the

next exam. Whilst we make every effort to ensure there are

sufficient sessions, availability of examiners and venues is

not infinite and, at times, demand for places at some

sessions is high. The message for candidates is if you require

guidance, book as soon as possible and do try to attend at

the venue nearest to your place of work.

Key statistics are compiled after each exam for analysis by

the audit working party. These statistics include a variety of

permutations of data on overall pass rates, gender, area of

qualification, previous attempts, allocation of marks for

each component and a cumulative table of marks awarded

by each examiner. Individual question performance is also

recorded and, together with any comments received from the

examiner, the results are forwarded to the appropriate

working groups for analysis and, where necessary, refinement.

By the time this process has been completed the

applications for the next exam are rolling in and we are

ready to start all over again.

In between exams, the department is involved in a variety

of supporting activities such as:

● guidance

● plenary meetings

● overseas exams – liaison with the local examining

authorities and nominated visiting RCA examiners

● new examiner elections

● representations and appeals

● production of the Examinations Calendar and

Regulations

● servicing the various working parties and committees

● maintenance and updating of question banks

● responding to general enquiries.

Examination fees are frequently perceived as being excessive

however, the reality is somewhat different. The 2001–2002

annual report shows the income generated through

examination fees was £825,000 against an expenditure of

£849,000, a deficit of around 3%. The fees for 2002–2003

were accordingly increased by 3%. Whilst the fee is clearly a

significant sum, it is realistic and accurately reflects the

department’s commitment and success in getting value for

money without compromising on quality. It also acts as an

added incentive for candidates to ensure they succeed at

their first attempt!



The author of a rejected manuscript received a letter from

Sir Thomas Lewis, first editor of Clinical Science, saying

‘This contains something that is both new and original …

however, what is new is not original and what is original is

not new’. Is this sentiment also relevant to the changes in

viva examinations over more than 130 years? The article

Behind the Scenes at the Final Exam1 referred to the final-

Final ‘FRCA’ exam at Queen Square in 1983 (the term

‘FRCA’ includes FFARCS, FCA and FRCA). At the post-final

party, John Lambert, the Examinations Secretary of the

Royal College of Surgeons with long associations with the

Faculty of Anaesthetists, read a parody of the exam entitled

‘The Spider and the Poulterer, a Yarn of the Spun’ written in

1904 by TC Dent,2 a surgical examiner. It was a shock to

realise that there was little new or original in contemporary

dilemmas about hawks and doves, passing or failing too

many candidates, the tedium of being an examiner and

whether some questions were too obscure. Recently, Peter

Thompson, a former ‘FRCA’ examiner from Cardiff, showed

us a similar exam parody called ‘The Vulture and the

Husbandman’ written by AC Hilton in 1872.3 We

reproduce, below, Hilton’s and Dent's parodies where it is

obvious that Dent had imitated Hilton and Hilton himself

was influenced by Lewis Carroll who, in the same year,

published ‘The Walrus and the Carpenter’ in Through the

Looking Glass.

Undoubtedly there are some changes. The surgical viva

at the RCS in 1894 (Figure 1) shows bored examiners in

dark clothes, a splendid fireplace, antique clock, pictures,

Figure 1 Detail from FRCS viva at Lincoln’s Inn Fields 1894This painting by Henry Jamyn Brooks is in the Webb Johnson Halland is reproduced by kind permission of the President and Council,Royal College of Surgeons of England

Figure 2 Final FRCA at Queen Square,1983

busts and statues; the furnishings almost unchanged at

Lincoln’s Inn Fields to this day. Contrast this with Figure 2,

the spartan ‘Fencing School’ at Queen Square in 1983.

‘FRCA’ examiners in white coats (one nodding, one in shirt

sleeves and two tables with only one examiner at each) no

statues or paintings, and, shock horror, a tennis racket, an

observer, at least two female candidates.

Arthur Clement Hilton (1851–1877)Despite his early death aged 26 years, Hilton is described as a

pre-eminent composer of parody in verse. Hilton obtained

his degree from Cambridge in 1872 and became curate of St

Clement and St Mary in Sandwich but died unexpectedly a

few years later. Undergraduate examinations were a popular

theme at the time and one of Hilton’s lasting achievements is

a parody of Bret Harte’s Heathen Chinee.4 Hilton’s The

Heathen Pass-ee is about his personal tips for examinations.

On the cuff of his shirt

He had managed to get

What he hoped had been dirt,

But which proved, I regret,

To be notes on the rise of the Drama,

A question invariably set.

In the crown of his cap

Were the Furies and Fates.

And a delicate map

Of the Dorian States,

And we found in his palms which were hollow

What are frequent in palms – that is dates.


Hawks, doves and vivas; plus ça change…? Professor J G Jones and Dr J S M Zorab*, formerly Examiners and *Chairman of the finalFinal ‘FRCA’ at Queen Square

The Spider and the PoultererT’was afternoon and yet it seemed As if the sun were down;The streets were up, the fog was thickThe mud was black and brown And this was odd you know,Because it was in London Town.

The Spider and the PoultererWere walking near the Strand:They groaned, like anything, to think Of what they had in hand.‘If this were only Friday week’,They said, ‘it would be grand.’

‘With papers marked a 9 or 8 Under our system new,Do you suppose’ said Section X,‘That more will wriggle through?’‘I doubt it much’ said Section V,‘We'll see’ said Section U.

And Section I just heaved a sighAnd sadly shook his head,He gravely feared that any changeWould make things worse instead Tho’ Section Y thought otherwise And so did Section Z.

‘Now, let the candidates come up’,The Sections did beseech ‘And let us hear if they know allThe things we love to teach:Ten minutes is the time prescribed For us to give to each’.

Obedient to the raucous call,In line the numbers fell;And some were neat and some were not,And some looked far from well;Few deemed their lot quite Heavenly;Some thought it simply Hell.

‘Our tips’, they said, ‘we’ve clean forgotWe scarce know what we're at,We feel as if down in our bootsOur hearts go pit-a-pat’‘Be seated, pray,’ said Section J,And, thereupon, they sat.

‘The time has come’, said Section X‘To talk on many points,On cataracts – and gangrenes rare –And nerve supply to joints –And what a rump-fed runyon doesWhen he – or she – aroynts’.

The Vulture and the HusbandmanThe rain was raining cheerfully,As if it had been May;The Senate House appeared insideUnusually gay;And this was strange because it wasA Viva Voce day.

The men were sitting sulkily,Their paper work was done They wanted much to go away To ride or row or run;‘It’s very rude,’ they said, ‘to keep Us here, and spoil our fun’

The papers they had finished lay In piles of blue and white.They answered everything they could,And wrote with all their might,But though they wrote it all by rote,They did not write it right.

The Vulture and the Husbandman Beside these piles did stand,They wept like anything to seeThe work they had in hand,‘If this were only finished up’,Said they, ‘it would be grand!’

‘If seven D’s or seven C’sWe give to all the crowd,Do you suppose, the Vulture said,That we could get them ploughed?’‘I think so’ said the Husbandman,‘But pray don't talk so loud’.

‘Oh undergraduates, come up,’The Vulture did beseech,‘And let us see if you can learn As well as we can teach;We cannot do with more than two To have a word with each’.

Two undergraduates came upAnd slowly took a seat,They knit their brows, and bit their thumbsAs if they found them sweetAnd this was odd because you knowThumbs are not good to eat.

‘The time has come,’ the Vulture said,‘To talk of many things,Of Accidence and Adjectives,And names of Jewish Kings.How many notes a sackbut has,And whether shawms have strings’.


Thomas Clinton Dent (1850–1912)Dent was a remarkable man who became a distinguished senior surgeon at his medical school, St George’ s Hospital. On

his own initiative he went to the Boer war as a correspondent for the British Medical Journal. He became such a famous

climber and President of The Alpine Club that few realised that he was also a surgeon. He was an expert photographer, art

collector, conversationalist and writer. His many publications included articles on mountaineering, insanity following

surgical operations, the wounded in the Transvaal War and surgery of the heart.

Hawks and dovesThe Vulture and Husbandman seem to be Hawk and Dove

respectively. The Vulture is so hawkish that he takes over all

the questioning while the Husbandman, worrying about

failing too many candidates (he fails them anyway), receives

a tearful and hypocritical wink from his companion. The

names, Spider and Poulterer, have hawkish implications and

seem to have been cloned into pairs of hawks at every other

table (section). All their candidates also fail.

Contemplating the examContemporary examiners may groan at the thought of

fighting London’s traffic jams, the underground or

clambering up the stairs of Russell Square Station and enjoy

neither the ghastly winter weather nor London’s enervating

summer humidity. The sinister Spider and Poulterer

contemplate the exam on a dark and foggy day in the Strand

whereas the Vulture and Husbandman enjoy a rainy day in

May although their exam hall (probably the Senate house in

Cambridge) was ‘unusually gay’. The latter was a sharp

contrast to the frightening atmosphere of the Queen Square

‘Fencing School’ and, later, the Gestapo-like Headquarters at

Bonham Carter House. Before the exam, the Vulture and

Husbandman were sitting sulkily and really wanted to get

away (all male examiners then) whereas the Spider and

Poulterer groaned when they thought about what they had

in hand. Both sets of examiners in our parodies have the

written papers ready before the oral but the Spider and

Poulterer’s group have a new marking system which is a

cause of some concern for their colleagues. The latter was


‘Please sir’, the undergraduates said,

Turning a little blue,

We did not know that was the sort

Of thing we had to do

‘We thank you much’, the Vulture said,

‘Send up another two’.

Two more came up, and then two more;

And more. And more, and more;

And some looked upwards at the roof,

Some down to the floor,

But none were any wiser than

The pair that went before.

‘I weep for you’, the Vulture said,

‘I deeply sympathise!’

With sobs and tears he gave them all

D's of the largest size

While at the Husbandman he winked

One of his streaming eyes.

‘I think’ observed the Husbandman,

‘We're getting on too quick

Are we not putting down the D's

A little bit too thick?’

The Vulture said with much disgust

‘Their answers make me sick’.

‘Now, undergraduates’, he cried,

‘Our fun is nearly done,

Will anybody else come up?’

But answer came there none;

And this was scarcely odd, because

They’d ploughed them every one.

AC Hilton, 1872.

‘Great Scott!’ the candidate remarked,

And turned from green to blue,

‘The crammer said we'd never have

That sort of thing to do –’

‘We thank you much!’ said Section X

And put him down a 2.

Some simple questions 9-0-2

Completely seemed to floor;

When shown an obvious Mandible,

He called it Lower Jaw.

And 9-0-3 was just as bad,

Still worse was 9-0-4.

A melanotic growth he missed,

Though black as river barge –

A hydrocoele he failed to spot –

He’d tap a hernia large –

He’d treat a plump lipoma with

Pot:lod: c Hydrarg:

‘We feel for you’ said Section Y,

‘We deeply sympathise.’

But all the Tables marked him down

Noughts of the largest size:

And then, for various reasons, asked

Him questions on the eyes.

It may be right, but still it seems

They cannot do the trick;

A bare pass mark is all they get

Unless they’re smart and quick,

Well, really now said Section Y

It is a leetle thick.

‘Now Gentlemen, unto your names

Pray answer when I call’ –

For sole response a dismal wail

Rose echoing round the hall –

And this was scarcely odd because

They’d plucked them one and all.

TC Dent, 1904.


echoed by a change in the marking system in the final ‘FRCA’

after the move from Queen Square which was associated

with nearly all the candidates failing and much heart

searching behind the scenes.

Failure, the ultimate accoladeThe names Husbandman and Poulterer are interesting in

relation to the outcome of the exam. The Poulterer and his

colleagues ‘pluck’ all their candidates. Dating from 1713,

pluck is British university slang for a fail, possibly from the

convention that one could veto a candidate for a degree at

Oxford by tugging (plucking) on the sleeve of a proctor’s

gown during the degree ceremony. This cruel punishment,

occurring very late in the day, is on a par with the lethal

ONE mark used in the RCA exam to fail a candidate at the

final call over. The Husbandman, skilled at tillage, although

the silent partner in this exam, is nevertheless equally deadly

and he ‘ploughs’ all the candidates. The term plough dates

from 1853, and became a substitution for pluck.

Examiners’ pet questionsThe modern FRCA examination candidate may be spared

the torture of having to handle the bizarre questions that

were familiar to us when we were examiners in the 1980’s.

One FRCA examiner used to show a chest X-ray showing a

large thymoma in the right lower lung field. This fooled

even the physician examiner who facetiously diagnosed

‘Two hearts’. Nevertheless it was our experience that these

questions were used only for candidates who were so

outstanding that the examiners were interested in exploring

the boundaries of knowledge rather than pompous ‘one-

upmanship’. The latter however has a long history. In

Hilton’s verse eight, a candidate is asked the corker, ‘How

many notes has a sackbut’ (an old instrument with a slide

like a trombone so, as many notes as you like). Another

question was, ‘Does a shawm have strings?’ (no, it’s a wind

instrument). Dent’s verse eight has far worse. ‘Rumpfed

runyon’ is neither rumpy pumpy nor Damon Runyon

whose reputation as a writer in 1904 still lay in the future.

Who knows about ‘Aroynts’?

Plus ça change, plus c’est la même chose?Some aspects of today’s exam, for example, the Objective

Structured Clinical Examination (OSCE), are new and

original. Other aspects are unchanged over more than 50 years.

Contemporary candidates may feel reassured by the more

structured orals of today’s FRCA but there is still much truth

in the words of Charles Colton (1790–1832), i.e. ‘Examinations

are formidable, even to the best prepared, for even the

greatest fool may ask more than the wisest man can answer’.

AcknowledgementsWe thank Ms Tina Craig, Librarian of the Royal College of

Surgeons of England for help with references, Professor

John Lumley, Editor of the Annals of the Royal College of

Surgeons for permission to reproduce Dent’s parody, the

Department of English (University of Toronto) and the

University of Toronto Press, 1998, for Hilton’s ‘The Vulture

and the Husbandman’.

References

1 Jones JG. Behind the scenes at the final exam. Roy Col Anaes

Bulletin 2002;14:670–672.

2 Dent TC. The Spider and the Poulterer, a Yarn of the Spun.

Roy Col of Surg Eng Annals 1954;15:348.

3 Hilton AC. The Vulture and the husbandman. Faber Book of

Comic Verse, 1942. Faber and Faber, London, Boston.

4 Hilton AC. The Heathen Chinee. Faber Book of Comic Verse,

1942. Faber and Faber, London, Boston.

One day I found a note from Professor G Smith asking if

anyone wanted to teach anaesthetics in Ethiopia. This

seemed ideal as I am interested in teaching and I’ve wanted

to go to Ethiopia for ages. The Professor of Paedatrics in

Leicester, Professor Mike Silverman, had set up a link with

Gondar College of Medical Sciences (GCMS). A new two-

and-a-half year degree course in anaesthetics for nurses was

to start and ITU was to be established.

IntroductionEthiopia – population of 64 million (50% under 16 years),

is one of the poorest countries in the world; per capita

income of $120 US/year. There is a high and rising rate of

HIV infection, 15% in Gondar. There are 20 physician

anaesthetists, (a two year postgraduate programme is run at

Black Lion Hospital, Addis Ababa). Ten of these practise in

Addis – where it is possible to treble the government

hospital salary. There are 120 nurse anaesthetists also

trained at Black Lion Hospital – the only Ethiopian

anaesthetic training centre. There are locally trained

personnel who give anaesthetics.

Gondar is in the north east of Ethiopia in the highlands,

at a height of 2,100 m. A former capital city, it has beautiful

palaces and royal buildings. The Italians added a 1930s style

city centre. The anaesthetic department at GCMS consisted

of two doctors (Drs Mamo and Workneh), one nurse

anaesthetist and two locally trained nurses. There were ten

nurses on the course, all with at least two years experience

post qualification. GCMS is a tertiary referral hospital of 350

beds with paediatrics, orthopaedics, maternity, gynaecology,

general medicine, surgery and A&E. It is on a tree filled

campus 3 km from the town, housed in 1930’s buildings. My

time in Gondar was taken as an OOPE (out of program

experience). It was easy to organise after filling in a few

forms. I soon was at Heathrow with two huge bags, one full

of text books from colleagues in Leicester.

Daily work activitiesThe anaesthetic department had been joined by Dr Jo who

was with VSO (Volunteer Service Overseas). She had arrived

two weeks earlier for a year’s stay. It was fantastic to have a

like minded person to work with. First we did a stock take of

the department’s equipment and reorganised the cupboard.

The cupboard is of fundamental importance as in it are kept

all manner of items just in case. However, you rarely do use

them as you never know when you might really need them!!

Figure 1 Gondar wards – orthopaedic and paediatric

Figure 2 Admissions Unit – a typical call: cerebral malaria

We found all types of goodies – six LMAs, a Hudson mask

and trachy tubes. Dr Mamo was amazed at how many drugs

I had brought. In fact I’d found them-in another cupboard!

There was a reorganising of the supplies. We gave some

adrenaline to maternity as they had an arrest and had no

adrenaline. In fact there was no resuscitation equipment, so

an AMBU Bag appeared in the delivery room.

There were three theatres in the theatre complex, which

was separate from the wards so patients walked to theatres

and changed in the hall. The patients sat on a bench and had

their IV lines sited. Each patient had a bag with fluids,

surgical gloves for the surgical team and an intravenous

cannula. In theatres there was one Boyle’s type machine and

a Drager machine. The monitoring, often temperamental,

consisted of ECG, attached to the skin with K-Y jelly and

tape, portable pulse oxymeter and automated blood

pressure, or nothing if there was a power cut – a frequent

occurrence. The standard anaesthetic was a spinal with 5

mls of 2% lignocaine and adrenaline, or 100 mg of ketamine,

100 mg of suxamethonium and an endotracheal tube (ETT).

Recycling is the norm, with all suction catheters, ETTs, spinal

needles cleaned. The spinal needles were often so blunt that

they would not go through the skin; you pushed hard! There


Anaesthesia in EthiopiaDr Sally-Ann Nortcliffe, Department of Anaesthesia and Critical Care, Leicester Royal Infirmaryemail [email protected]

was no post operative analgesia apart from IM NSAIDS and

they were rarely used.

The lists were very varied with burr holes, cleft lip and

amputations on the same list. Patients often waited till their

symptoms were extreme and so the size of the goitres and

ovarian masses was amazing. The 15 kg ovarian tumour was

taken to pathology in a wheel barrow. Ruptured uterus was

common (30/year) and women died as there was often no

blood, or not enough. The sick patients showed great

resilience and would survive after a night on a bag of

dopamine. The patients could not afford to go home and

return so they waited in hospital – the average pre operative

stay was 14 days. The theatre staff were all very friendly and

many of them spoke good English. Recovery was used as an

HDU and we helped look after these patients. This was made

interesting as there were no fluid balance/drug charts. If the

relatives did not buy the antibiotics then the patients did not

get them. The monitoring in recovery consisted of one blood

pressure cuff and the loan of a pulse oxymeter from theatre-

if available and working. There was no piped oxygen nor

regulator for the oxygen cylinder and so an interesting

arrangement of an iv giving set and elastoplast replaced the

regulator for the sickest patients only. The cylinders did not

last long. They came from Addis – two days by road.

Non-anaesthetic activitiesLife in Gondar required a few adjustments as the calendar is

seven years behind the UK, the year starts in September and

has 13 months. The time is measured in two 12 hour cycles

starting at 6.00 am. I was known as Dr Sally, family names

are not used. The altitude meant I was short of breath but

after a month I was back to running up hills. We often went

walking and exploring. The poverty was all too obvious as

we walked by people’s houses.

GCMS was host to the national public health conference

and I was allowed to attend. It was very interesting and I

learnt a lot about tropical medicine, particularly HIV/AIDS.

The size of the problem is huge and increasing. There is a lot

of stigma and misinformation. It is a common belief that

HIV is sent by the USA, who put the virus inside condoms

and then encourage their use. I did a lecture on infection

control for my students, their first one as nurses. I was asked

if you could get HIV from boiled sweets from America. I was

gratified to see that the enthusiasm for cleaning the

laryngoscope after use improved dramatically after this

lecture. There was another conference on the use of anti-

retroviral therapy and it was interesting that a sizable group

of the Ethiopian doctors felt that this was a waste of money

and that these patients should be left to die. It was through

this conference that I arranged a visit to Mekele hospital

where they are hoping to set up a school of anaesthesia but

have no physicians to run it – any volunteers?

Figure 3 A&E Admissions Unit – patients slept on the ground untila bed was available. Trees were very handy for drip stands

What did I achieve in my three months?I taught the nurse anesthetists by formal lectures, theatre

supervision, ward teaching and interactive seminars. All

teaching is in English. I lectured the medical students. We

drafted drug and fluid balance charts and drew up guidelines

on pre-operative investigations. In HDU we looked after the

patients and taught the interns. We drew up simple

guidelines on nursing care in HDU. We demonstrated

manual handling techniques, i.e. do not pull the patient by

one wrist and ankle! We ran five resuscitation sessions, made

boxes of equipment for theatres and delivery suite and a

portable box for emergencies on the wards. Guidelines for

neonatal resuscitation were posted in theatre and delivery

suite. A campaign to ensure all patients came to theatre with

four clean syringes showed a 94% success at two weeks. On

my arrival the same four syringes were used for several lists

of patients. We talked to the theatre staff about infection

control and I bought sharps boxes for theatres and recovery.

Advice on the correct management of sharps injuries was

given. I learnt how to use sux infusions and gallamine. ICU

had only just been built and as there were no nurses or

equipment, I could not help set up the unit.

I did two audits. I showed that the rate of spinal

anaesthesia for LSCS had increased after the arrival of the

two physician anaesthetists from 11% to 70%. I looked at

the 50% increase in neonatal deaths last year. The

emergency of known risk factors (e.g. twins) in a

department with no delivery protocols and many junior

doctors suggests that protocols could improve outcome.

My time in Gondar was interesting and challenging.

Teaching the students was great fun and rewarding. The

NHS seems marvellous by comparison.

AcknowledgementsI would like to thank The Royal College of Anaesthetists for

their generous sponsorship of myself and Dr Jo Haidon.

Dr Andrew Hall, consultant anaesthetist, kindly provided

technical support.

Gondar are keen to have visiting teachers – why not try it?


TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Editor Dr J A Langton, Derriford Hospital, Plymouth


IntroductionThis is the first of two articles covering aspects of myocardial

physiology which are important to candidates preparing for

the Primary FRCA.

Cardiac action potentialsAction potentials (APs) are sequential changes in

transmembrane potential that occur as a result of activity of

ion channels, this results in the propagation of electrical

impulses in excitable cells. The heart has a multicellular

structure but behaves like a syncytium because the

individual muscle cells communicate with their neighbours

through gap junctions which provide low resistance

pathways for easy movement of action potentials between

cells. The cardiac action potential is much longer than those

of nerve or skeletal muscle (~250 ms compared with ~ 1–3

ms). This is due to a prolonged plateau phase caused by

calcium ions in cardiac muscle. Two types of action

potential occur in the heart:

Figure 1 The Purkinje fibre action potential

1 The fast response – found in heart muscle and Purkinje

fibres (Figure 1). The resting membrane potential of

cardiac muscle and Purkinje fibres is ~-90mV (interior

negative to exterior). An AP is initiated when the

membrane is depolarised to a threshold potential (~-

65mV). The initial depolarisation originates from

transmission from an adjacent cell via gap junctions.

Phase 0 – Rapid depolarisation –the inward current

caused by opening of fast Na+ channels becomes large

enough to overcome the outward current through K+

channels resulting in a very rapid upstroke. T-type

(transient) Ca2+ channels open at negative membrane

potentials of -70mV to –40mV causing Ca2+ influx.

Phase 1 – Early incomplete repolarisation – due to

inactivation of fast Na+ channels and efflux of K+ ions.

Phase 2 – Plateau phase – a period of slow decay mainly

due to Ca2+ entering the cell via L-type (L=long

lasting) Ca2+ channels which are activated slowly when

the membrane potential is more positive than ~ -35mV.

There is also slow closure/inactivation of some of the

Na+ channels. Reduced K+ outward current continues.

Calcium entry during the plateau is essential for

contraction; blockers of L-type Ca2+ channels (e.g.

verapamil) reduce force of contraction.

Phase 3 – Rapid repolarisation – Ca2+ influx declines

and the K+ outward current becomes dominant, with

an increased rate of repolarisation

Phase 4 – Electrical diastole – resting membrane

potential is restored.

Figure 2 The Sinoatrial node action potentials

2 The slow response (Figure 2) – found in pacemaker

tissues; for example Sinoatrial and Atrioventricular

nodes. These cells spontaneously depolarise and are

said to have automaticity.

Phases 1 and 2 are absent. There is no depolarisation

plateau.

Phase 4 – Pacemaker potential – The cells have an

unstable resting membrane potential during phase 4;

they gradually depolarise from ~-60mV to a threshold

of ~-40mV due to a slow continuous influx of Na+ ions

Aspects of myocardial physiology (Part 1)Dr A M Campbell, Clinical Fellow in Cardiothoracic Anaesthesia and Dr J A Hulf, Consultant CardiothoracicAnaesthetist, The Heart Hospital/University College Hospitals, London


and a decreased efflux of K+ ions. A Ca2+ current due

to the opening of T-type (transient) Ca2+ channels

completes the pacemaker potential.

Phase 0 – Depolarisation – when the membrane

potential reaches threshold potential fast (L-type)

calcium channels open, causing Ca2+ influx and an AP

is generated.

Phase 3 – Repolarisation – due to efflux of K+.

Noradrenaline and adrenaline (mediated via β1-

receptors) increase the slope of phase 4 by increasing

Ca2+ influx, therefore increasing the heart rate. Ca2+

influx also increases the force of contraction.

Acetylcholine (mediated via M2 receptors) decreases the

slope of phase 4 by increasing K+ efflux and causing

hyperpolarisation (increased negativity within the cells).

This makes the conduction tissue much less excitable so

it takes longer to spontaneously reach the threshold

level. This results in a decrease in heart rate. The

intrinsic rate of the SA node is 100 beats/minute

however, vagal tone decreases this to ~70 beats/min.

Refractory periods During the absolute refractory period (ARP) (Figure 1) the

cardiac cell is totally inexcitable. During the following

relative refractory period (RRP) there is gradual recovery of

TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Aspects of myocardial physiology (Part 1) Campbell AM, Hulf JA

Figure 3 Events of the cardiac cycle Re-printed from: Guyton AC, Textbook of Medical Physiology,8th edition, © 1991 with permission from Elsevier.

excitability. A supramaximal stimulus can elicit an AP in the

RRP. This AP, however, has a slower rate of depolarisation, a

lower amplitude and shorter duration than normal and,

therefore, the contraction produced is weaker. Peak muscle

tension occurs just before the end of the ARP and the

muscle is halfway through its relaxation phase by the end of

the RRP The long refractory period protects the ventricles

from too rapid a re-excitation which would impair their

ability to relax long enough to refill sufficiently with blood.

Unlike skeletal muscle, two contractions cannot summate

and a fused tetanic contraction cannot occur.

The Cardiac Cycle The cardiac cycle refers to the relationships between

electrical, mechanical (pressure and volume) and valvular

events occurring during one complete heartbeat.

Passive filling (early diastole)The atria and ventricles are relaxed, ventricular pressure is

zero. The atrioventricular (AV) valves are open and the

semilunar valves are closed. Blood flows from the great veins

into the atria and ventricles (from a higher pressure to a

lower pressure.) About 80% of ventricular filling occurs

during this phase.

Atrial contraction (late diastole)A wave of depolarisation beginning at the sinoatrial (SA)

node, spreads across both atria, and reaches the AV node –

the P wave of the ECG. The atria contract and atrial

pressures increase producing the a wave of the central

venous pressure trace. Blood continues to flow into the

ventricles and ventricular pressure increases slightly. The

atrial contribution to ventricular filling increases as heart

rate increases, as diastole shortens and there is less time for

diastolic filling. Ventricular volume is greatest at the end of

diastole. End-diastolic volume (EDV)= volume of blood in

the ventricle at the end of diastole. Arterial pressure is at its

lowest at this stage of the cycle.

Isovolumetric ventricular contraction (early systole)The action potential is conducted through the AV node,

down the bundle of His, across both ventricles and

ventricular depolarisation occurs – the QRS complex of the

ECG. Ventricular contraction causes a sharp rise in

ventricular pressure, and the AV valves close (first heart

sound) once this exceeds atrial pressure, preventing

backflow into the atria. Ventricular pressure increases

dramatically with no change in ventricular volume. During

this initial phase of ventricular contraction pressure is less

than in the pulmonary artery and aorta, so the outflow

valves remain closed – the ventricular volume does not

change. The increasing pressure causes the AV valves to bulge

into the atria, resulting in a small atrial pressure wave – the c

wave of the central venous pressure trace.

Ejection (systole)The semilunar valves open as ventricular pressure exceeds

aortic blood pressure. Approximately two thirds of the

blood in the ventricles is ejected into the arteries. Flow into

the arteries is initially very rapid (rapid ejection phase),

but subsequently decreases (reduced ejection phase).

Stroke volume (SV) = volume of blood ejected from each

ventricle in a single beat.

Ejection fraction = SV/EDV. Arterial blood pressure rises

to its highest point – systolic blood pressure. During the last

two thirds of systole before the AV valves open again, atrial

pressure rises as a result of filling from the veins – the v wave

of the central venous pressure trace. Active contraction

ceases during the second half of ejection, and the ventricular

muscle repolarises – the T wave of the ECG. Ventricular

pressure during the reduced ejection phase is slightly less

than in the artery, but blood continues to flow out of the

ventricle because of momentum. Eventually the flow briefly

reverses, causing closure of the outflow valve and a small

increase in aortic pressure, the dicrotic notch.

Figure 4a Left ventricular pressure-volume loop Figure 4b The pressure-volume loop is affected by the contractilityshowing left ventricular volume and pressure and compliance of the ventricle, and factors that alter refilling orchanges during a single heart cycle in a normal ejection (e.g. CVP, afterload)adult at rest



Figure 4a re-printed from: Smith JJ, Kampine JP, Circulatory Physiology – The Essentials,3rd edition, with permission from Lippincott, Williams and Wilkins.

Figure 4b re-printed from: Aaronson PI, Ward PT, The Cardiovascular System at a Glance,1st edition with permission from Blackwell Publishing Ltd.

Isovolumetric relaxation (early diastole)The ventricles relax and ventricular pressure falls below

arterial blood pressure. This causes the semilunar valves to

close – the second heart sound. The ventricular pressure

falls with no change in ventricular volume. When

ventricular pressure falls below atrial pressure, the AV valves

open and the cycle begins again.

X descent of CVP trace – results from atrial relaxation and

downward displacement of the tricuspid valve during

ventricular systole.

Y descent of CVP trace – due to atrial emptying as the

tricuspid valve opens and blood enters the ventricle.

The pressure volume loopThis represents the events of the cardiac cycle. The cardiac

cycle proceeds in an anticlockwise direction. (A) End

diastole, (B) aortic valve opening (C) Aortic valve closure,

(D) mitral valve opening. EDV and end systolic volume

(ESV) are represented by points A and C respectively. The

area closed by the loop represents the stroke work (since

work = pressure x volume). The pressure-volume curve in

diastole is initially quite flat, indicating that large increases

in volume can be accommodated by only small increases in

pressure. However, the ventricle becomes less distensible

with greater filling, as evidenced by the sharp rise of the

diastolic curve at large intraventricular volumes.

Coronary circulationThe heart is supplied by the right and left coronary arteries.

They arise separately from the aortic sinus at the origin of the

ascending aorta, behind the right and left cusps of the aortic

valve. The right coronary artery (RCA) runs forward

between the pulmonary trunk and right atrium, to the AV

sulcus. As it descends to the lower margin of the heart, it

divides into posterior descending (interventricular) and right

marginal branches. The left coronary artery (LCA) runs

behind the pulmonary trunk and forward between it and the

left atrium. It divides into the

circumflex, left marginal and anterior

descending branches. There are

anastomoses between the left and right

marginal branches, and the anterior and

posterior descending branches, but

these are not enough to maintain

perfusion if one side of the coronary

circulation is acutely occluded. The

LCA supplies mainly the left ventricle

and septum and left atrium. The RCA


supplies mainly the right ventricle and right atrium, SA node

(in 60%) and AV node (in 80%). The ‘dominant’ supply to

the heart is usually determined by the artery that forms the

posterior descending and supplies the major arterial supply

to the posterior inferior wall of the LV and to the AV node.

The RCA is dominant in 70% of individuals, the LCA is

dominant in another 20% and the flow delivered by each

main artery is approximately equal in the remaining 10%.

Venous drainageVenous drainage is mainly via the coronary sinus and

anterior cardiac vein which both empty into the right

atrium. Some venous blood empties directly via the

Thebesian veins and small venules into all heart chambers.

Venous blood entering the left side of the heart will cause a

small reduction in the O2 content of systemic arterial blood.

Control of the coronary circulationThe heart at rest receives about 5% of the cardiac output.

Coronary blood flow is ~250ml/min. O2 extraction by the

myocardium at rest is very high (65%) compared to other

tissues (35%). Therefore, the myocardium cannot

compensate for reductions in blood flow by extracting more

oxygen from haemoglobin. Any increases in myocardial O2

demand must be met by an increase in coronary blood flow.

The three main factors influencing coronary flow are:

1 Mechanical, mainly external compression

and perfusion pressure.

2 Metabolic.

3 Neural.


Figure 5 Coronary arteries


Coronary artery compression and blood flowCoronary blood flow is unique in that there is interruption

of flow during systole (mechanical compression of vessels

by myocardial contraction). Coronary blood flow occurs

predominantly during diastole when cardiac muscle relaxes

and no longer obstructs blood flow through ventricular

vessels. Conversely, right coronary arterial flow rate is

highest during systole, because the aortic pressure driving

flow increases more during systole (from 80 to 120mmHg)

than the right ventricular pressure which opposes flow

(from 0 to 25 mmHg). As about 80% of the total coronary

arterial flow occurs during diastole, a pressure around aortic

diastolic pressure becomes the primary determinant of the

pressure gradient for coronary flow. CPP=arterial diastolic

pressure – LVEDP. Increases in heart rate that shorten

diastolic time for coronary blood flow are likely to increase

oxygen consumption more than elevations in blood

pressure, which are likely to offset increased oxygen

demands by enhanced pressure-dependent coronary blood

flow. The myocardium regulates its own blood flow

(autoregulation) closely between perfusion pressures of 50

and 150 mmHg. Beyond this range, blood flow becomes

increasingly pressure-dependent. This autoregulation is due

to a combination of myogenic and metabolic mechanisms.

Metabolic factorsThe close relationship between coronary blood flow and

myocardial O2 consumption indicates that one or more of

the products of metabolism cause coronary vasodilation.

Hypoxia and adenosine are potent coronary vasodilators.

Other factors suspected of playing this role include ↑PCO2,

H+, K+, lactate and prostaglandins. Under normal

conditions, changes in blood flow are entirely due to

variations in coronary artery tone (resistance) in response

to metabolic demand.

Neural factorsThe coronary arterioles contain α1-adrenergic receptors,

which mediate vasoconstriction, and β2-adrenergic

receptors which mediate vasodilation. Sympathetic

stimulation generally increases myocardial blood flow

because of an increase in metabolic demand and a

predominance of β2-activation.

Further reading

Guyton, AC. Textbook of Medical Physiology, 10th edition.

Philadelphia. WB Saunders Company.

Smith JJ, Kampine JP et al. Circulatory Physiology – The Essentials,

3rd edition, Baltimore. Williams and Wilkins.

Berne RM, Levy MN. Cardiovascular Physiology, 8th edition,

Missouri. Mosby.

Levick JR. An Introduction to Cardiovascular Physiology, Oxford.

Butterworth-Heinemann Ltd.


THE ROYAL COLLEGE OF ANAESTHETISTS

EDUCATIONPROGRAMME

Please note that unless indicated otherwise, lunch is included in the registraion fee.

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E – PLEASE PULL OUT AND KEEP

Bulletin 20 Education Programme from July 2003 to June 2004 991

Basic Sciences Course forPrimary FRCA 7–18 July 2003 (code: C12)Clore Management Centre, London WC1This course is intended to complement study forthe primary examination and consists of twoweeks of full time lectures on those aspects ofphysiology, pharmacology and statistics that areof relevance to anaesthetists. Lectures will takeplace between 0900 and 1630 Monday to Friday.Tutorials will also be held during the course andeach participant will be entitled to attend fourtutorials. A separate application form isavailable from the Courses and MeetingsDepartment. Please do not use the genericapplication form. Registration fee: £530(excludes lunch).

Symposium on Safe Sedation Practice23 September 2003 (code: C79)The Royal College of Physicians and Surgeonsof Glasgow, Vincent Street, Glasgow G2A joint meeting between the RCA and RCPSGlasgow. Registration fee: £100

Final FRCA Course8–26 September 2003 (code: A79)Clore Management Centre, London WC1This course is intended for those studying forthe Final FRCA Examination and consists ofthree weeks of full time lectures onanaesthesia, intensive care and pain relief. Thelectures run throughout the day between 09.00and 17.00. Tutorials will also be held during thecourse and each participant will be entitled toattend one week of tutorials from 16.45–18.00at the College. A separate application form forthis course is available from the Courses andMeetings Department. Please do not use thegeneric application form. Registration fee: £680(excludes lunch).

How to Teach – Teaching Methods1–2 October 2003 (code: A37)St Anne’s College, OxfordAn intensive two day workshop for consultantsand senior SpRs. Please note this workshop haslimited places. Registration fee: £400.

NCCG Autumn Meeting16 October 2003 (code: C63)The Royal College of Anaesthetists, London WC1Registration fee: £175.

Meeting for Newly AppointedConsultants17 October 2003 (code: C40)The Royal College of Anaesthetists, London WC1Registration fee: £180.

Progress in Anaesthesia, CriticalCare and Pain21 October 2003 (code: D09)Education Centre, James Cook UniversityHospital, MiddlesbroughSpeakers will be a mixture of local and regionalexperts together with support from one or moremembers of the College Council. The timing ofthe meeting will allow anaesthetists fromacross the North of England and the East coastto reach Middlesbrough in ample time for thestart. Registration fee: £180.

Course on Current Topics in Anaesthesia27–31 October 2003 (code: C11)The Royal College of Anaesthetists, WC1Consisting of lectures and discussion, it isintended as both a refresher course and updateon the latest techniques for consultants andNCCGs. Registration fee: £500.

Emergencies in Anaesthetic Practice29 October 2003Malone House, BelfastHeld jointly with the College of Anaesthetists,RCSI. Further details on page 994.

College SymposiumHigh Quality Anaesthesia –Best practice6–7 November 2003 (code: B05)Institution of Electrical Engineers, LondonIn addition to the two day programme, there isan opportunity to meet with colleagues andfriends at an informal reception on the eveningof 6 November. Registration fee: £330 (traineesregistered with the College: £260).

CME Day8 November 2003 (code: A76)Institution of Electrical Engineers, LondonA joint meeting with the AAGBI.Registration fee: £180.

RCA and BJA ResearchMethodology Meeting13 November 2003 (code: C43)The Royal College of Anaesthetists, WC1See details on page 996. Registration fee: £100.

Christmas Lecture 200316 December 2003The Royal College of Anaesthetists, WC1Aimed at School leavers and other sixth formersconsidering a career in medicine and associatedsubjects. Further details to follow.

Basic Sciences Course for thePrimary FRCA12–23 January 2004Clore Management Centre, London WC1This course is intended to complement study forthe primary examination and consists of twoweeks of full time lectures on those aspects ofphysiology, pharmacology and statistics that areof relevance to anaesthetists. Lectures will takeplace between 0900 and 1630 Monday to Friday.Tutorials will also be held during the course andeach participant will be entitled to attend fourtutorials. A separate application form isavailable from the Courses and MeetingsDepartment. Please do not use the genericapplication form. Registration fee to be advised.

How to Teach – Teaching Methods4–5 February 2004The Cavendish Hotel, Eastbournean intensive two day workshop for consultantsand senior SpRs. This workshop has limitedplaces. Registration fee to be advised.

Final FRCA Course16 February to 5 March 2004Clore Management Centre, London WC1This course is intended for those studying for theFinal FRCA Examination and consists of threeweeks of full time lectures on anaesthesia,intensive care and pain relief. The lectures runthroughout the day between 09.00 and 17.00.Tutorials will also be held during the course andeach participant will be entitled to attend oneweek of tutorials from 16.45–18.00 at the College.A separate application form for this course isavailable from the Courses and MeetingsDepartment. Please do not use the genericapplication form. Registration fee to be advised.

College Anniversary MeetingAnaesthesia and Organ Failure17–18 March 2004Institution of Electrical Engineers, LondonFurther details to follow.Registration fee to be advised.

Anaesthetic EmergenciesA Core Topic Day25 March 2004Venue to be confirmed in GlasgowA one-day meeting covering core topics onanaesthetic emergencies such as crisismanagement, cardiac arrest, failed intubationand anaphylaxis. Registration fee to beadvised.

Review Day for NCCG Anaesthetists29 March 2004The Royal College of Anaesthetists, LondonThis is a clinical study day for NCCGs such asstaff grades, associate specialists and thosedoing a significant number of clinical assistantsessions who would like to update theirknowledge on common areas of practice. Theseminar is designed to allow time fordiscussion and group work around a number ofanaesthetic and resuscitation scenarios. Thosewho have not had a recent opportunity toreview anaesthetic practice are particularlywelcome. Registration fee to be advised.

Airway Day – A Core Topic Day7 April 2004Royal College of Obstetricians andGynaecologists, Regent’s Park, LondonA one-day meeting covering core topics such asfailed ventilation, new airway equipment, theshared airway and pre-operative airwayevaluation. Registration fee to be advised.

Diplomates Day 20045 May 2004Venue to be advisedA ceremony of presentation of diplomates forthose doctors who passed their Final exam inJune 2003 and December 2003. Attendancewill be by invitation only. Further details willbe posted in February/March 2004.

How to Teach – An Introduction toTeaching for SpRs27 May 2004The Royal College of Anaesthetists, LondonA meeting designed to introduce post-FRCASpRs to the skills that are required tofacilitate effective teaching and training.Registration fee to be advised.

NCCGs as Teachers8 June 2004The Royal College of Anaesthetists, LondonA meeting for NCCGs interested in increasingtheir involvement in teaching anaesthetictrainees. Registration fee to be advised.

Course on Current Topics inAnaesthesia7–11 June 2004Venue to be advised in ManchesterConsisting of lectures and discussion, it isintended as both a refresher course and updateon the latest techniques for consultants andNCCGs. Registration fee to be advised.

Training Paramedic Trainers16 June 2004The Royal College of Anaesthetists, LondonFurther details to follow.

Intensive Care Meeting17–18 June 2004Institution of Electrical Engineers, LondonFurther details to follow.

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992 Bulletin 20 Education Programme from July 2003 to June 2004

All meetings have CEPD approval onthe basis of five points for a full dayand three points for half a day.

Retired Fellows continuing tosubscribe to the College are entitledto attend meetings at half price.

Please complete the genericapplication form or contact theCourses and Meetings Department atthe College for further information:

The Courses and MeetingsDepartmentTraining and ExaminationsDirectorateThe Royal College of Anaesthetists48/49 Russell SquareLondon WC1B 4JY

switchboard 020 7813 1900ansaphone 020 7813 1888fax 020 7636 8280email [email protected]

Please note that newmeetings and updatedprogrammes are availableon the College website(www.rcoa.ac.uk/courses)

Basic Science Course for thePrimary FRCA7–18 July 2003 (code: C12)at the Clore Managemment Centre, 25–27 Torrington Square,London WC1

This course is intended to help those studying for the Primary Examinationsand consists of two weeks of full-time lectures on anaesthetics and thoseaspects of physiology, pharmacology, statistics and measurement that are ofinterest to anaesthetists. Lectures will take place between 09.00 and 16.30Monday to Friday. Tutorials will be held between 14.00 and 17.00 on two daysduring the first week of the course.

The course will be held in the Lecture Theatre at the Centre, which is a fiveminute walk from the College. The tutorials will be held at College in RussellSquare, London WC1. Trainees wishing to apply for admission to the courseare strongly advised to apply as soon as possible as places are strictly limited.

Please contact the Courses and Meetings Department for an application form.

Registration fee: £530

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How to Teach – TeachingMethods Workshop1–2 October 2003 (code: A37)at St Anne’s College, Oxford OX2There are limited places for this workshop.

An intensive two day workshop for consultants, NCCG’sand post-Fellowship SpRs about the teaching techniquesthat are useful for anaesthetists who plan and participatein education programmes for medical students,anaesthetic trainees and consultants.

Delegates will learn how to extend their repertoire ofteaching techniques both in theatre and in the classroom.There will be an emphasis on the skills of planning,teaching and giving feedback. The workshop will includelectures and discussion groups and there will be anopportunity for participants to be videoed making a shortpresentation and to discuss their style with aprofessional actor.

One night’s accommodation at St Anne’s College,lunch/refreshments and dinner on the first evening of theWorkshop are all included in the registration fee.


Final FRCA Course8–26 September 2003 (code: A79)at the Clore Management Centre, 25–27 TorringtonSquare, London WC1

This course is intended to help those studying for the FinalFRCA Examinations and consists of three weeks of full-timelectures on anaesthesia, intensive care and pain relief. Thelectures run throughout the day between 09.00 and 17.00,Monday to Friday. Tutorials will also be held during thecourse and each participant will be entitled to attend oneweek of tutorials from 16.45–18.00 at the College.

Those wishing to apply for admission to the course arestrongly advised to apply as soon as possible as placesare strictly limited.

Registration fee: £680 (excludes lunch)Please contact the Courses and Meetings Departmentfor an application form (please do not use the genericapplication form). Meeting for Newly Appointed

Consultants17 October 2003 (code: C40)at The Royal College of Anaesthetists, WC1


● Who and how to supervise.

● Theatre teaching.

● Appraisal and assessment of trainees.

● Examinations, examining and observing.

● Relationships with the Postgraduate Dean.

● How to be an achiever.

● How to survive.


Forthcoming AirwayWorkshops 2004The College is intending to run three Airway Workshops inthe following cities during 2004:

Cardiff London Glasgow

These workshops have limited numbers and will focus onclinical scenarios, group discussion and practical skills.Please see future issues for further details.

Joint meeting with the Association of Anaesthetistsof Great Britain and Ireland

Autumn NCCG Day16 October 2003 (code: C63)at the Royal College of Anaesthetists, London WC1


● The future for SAS doctors.

● Who represents the group, where and what arethe issues?

● Acute vascular emergencies.

● New airway devices.

● Trauma anaesthesia.

● Transfer of critically ill patients.


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The Royal College of The College of Anaesthetists, RoyalAnaesthetists College of Surgeons of Ireland

Core Topic DayEmergencies in AnaestheticPractice29 October 2003at Malone House, Belfast

Topics to include:

● Perioperative arrhythmias.● Cardiac arrest.● Acute cardiac failure.● Head Injuries; immediate management and treatment.● Anaphylaxis; diagnosis and management.● Failed intubation/aids to difficult intubation.● Paediatric trauma and training.

The Northern Ireland Society Open Forum Meeting will beheld following this at 18:00–19:00 hrs.

Registration fee to be advisedApproved for CEPD purposes

Course on Current Topicsin Anaesthesia 27–31 October 2003 (code: C11)at The Royal College of Anaesthetists, WC1

This course consists of a week of lectures, each of which isfollowed by ample time for discussion. It is intended for doctorsengaged in clinical anaesthesia (i.e. consultant, specialist grade ortheir overseas equivalent) who feel that they may benefit from arefresher course in the latest techniques. Places will not beallocated to anaesthetists in training. The programme will covertopics under the following headings:

● Scientific foundations of anaesthesia and their clinicalimplications.

● Advances in anaesthesia, intensive care and pain.● Local and regional anaesthetic techniques.● Anaesthetic equipment and monitoring.● Postoperative care.

Registration fee: £500 Approved for CEPD purposes

Progress in Anaesthesia,Critical Care and PainA Core Topic Regional Day21 October 2003 (code: D09)at The Education Centre, James Cook UniversityHospital, Middlesbrough

10.00 Registration and coffee

10.25 Welcome – Dr P G P Lawler, Middlesbrough

Morning SessionChair: Professor C Dodds, James Cook UniversityHospital10.30 Progress in the management of sepsis

Dr A M Batchelor, Royal Victoria Infirmary,

Newcastle

11.05 Progress in pre-assessmentDr W Scott, Derby City General Hospital

11.40 Standards of acceptable anaesthetic practiceDr A J Mortimer, Wythenshawe Hospital

12.15 Discussion

12.45 Lunch

Afternoon SessionChair: Dr P G P Lawler, James Cook UniversityHospital13.45 Progress in airway management

Dr D P Cartwright, Derby City General Hospital

14.20 Progress in pain management in childrenDr M Tremlett, James Cook University Hospital

14. 55 Discussion

15.10 Tea

15.35 Progress in the management of acuterespiratory failureDr S Baudouin, Royal Victoria Infirmary,

Newcastle

16.10 Progress in management of cardiac arrestMr K Han, Middlesbrough General Hospital

16.45 Discussion

17.00 Round up and FinishDr P G P Lawler, Professor C Dodds


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Thursday, 6 NovemberSession 1 – Anaesthetic technique – Best practice10.00–10.25 Total intravenous anaesthesia

Professor G Kenny, Glasgow Royal Infirmary

10.25–10.50 Inhalational anaesthesiaDr G Nunn, The General Infirmary at Leeds

10.50–11.15 Regional anaesthesiaDr N Denny, Queen Elizabeth Hospital, Kings

Lynn

11.15–11.25 Discussion and coffee

Session 2 – Education and individual performance –Best practice11.50–12.15 CPD and maintaining best practice

Sir John Lilleyman, Royal London Hospital

12.15–12.40 Monitoring performance; assessment andappraisalDr K Myerson, Eastbourne District General

Hospital

12.40–13.05 Education; service v training; time v competencyDr D Greaves, Royal Victoria Infirmary,

Newcastle upon Tyne

13.05–14.15 Discussion and lunch

Session 3 – Pain management – Best practice14.20–14.55 Neuraxial techniques for post-operative pain

Professor H Breivik, Rikshospitalet, Oslo

14.55–15.20 Opioids for chronic non-cancer painDr P Collins, Taunton and Somerset Hospital

15.20–15.45 Epidural steroid injections- low back and leg painof spinal originDr E Walsh, Southmead Hospital, Bristol

15.45–16.30 Discussion and tea

Session 4 – Quality control and healthcare management –Best practice16.35–17.00 Learning from NCEPOD

Dr A Gray, Norfolk and Norwich University

Hospital

17.00–17.25 Clinical governance in anaesthesiaDr S O’Kelly, The Great Western Hospital,

Swindon

17.25–17.50 Skill-mix and new working practicesDr J Moore, Department of Health

17.50–18.00 Discussion and Reception for all delegates

Friday, 7 NovemberSession 5 – Anaesthetic drugs – Best practice09.10–09.35 Fluid and electrolytes

Professor M Mythen, Institute of Child Health,

London

09.35–10.00 Drugs for haemodynamic controlDr R Feneck, St Thomas’ Hospital, London

10.00–10.25 Safety and side effects of COX2 inhibitors andother NSAIDs Professor H McQuay, Churchill Hospital,

Oxford

10.25–11.00 Discussion and coffee

Session 6 – Risk management – Best practice11.05–11.30 Developing Effective guidelines

TO BE CONFIRMED

11.30–11.55 Consent for anaesthesiaDr D Bogod, Nottingham City Hospital

11.55–12.30 Errors in healthcare: the study of safetyProfessor C Vincent, St Mary’s Hospital,

London

12.30–13.45 Discussion and lunch

Session 7 – Hickman Eponymous Professor of Anaesthesia13.50–14.30 Safer central venous access – A pivotal role for

anaesthetistsDr A Bodenham, Leeds General Infirmary

14.30–14.55 Tea

Session 8 – Paediatrics – Best practice15.00–15.25 Paediatric and neonatal resuscitation

Professor A Wolf, Bristol Royal Infirmary

15.25–15.50 Sedation for babies and childrenDr M Sury, Great Ormond Street, London

15.50–16.15 Transfer of the sick childDr P Crean, The Royal Belfast Hospital for Sick

Children

16.15–16.30 Discussion and close

Registration fee: £330(£260 for trainees registered with the College)Approved for CEPD purposes

Autumn Symposium 2003High Quality Anaesthesia – Best Practice6–7 November 2003 (code: B05)at the Institution of Electrical Engineers, Savoy Place, London WC2

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The Royal College of The Association of AnaesthetistsAnaesthetists of Great Britain and Ireland

Continuing MedicalEducation DaySaturday, 8 November 2003 (code: A76)at the Institution of Electrical Engineers, Savoy Place,London WC2

Topics to include:

● Stabilising the critically ill child (DGH point of view).

● Consent and risk.

● Anaesthesia for maxillofacial surgery.

● Acute pain team.

● Sick obstetric patient.

● Arrhythmias.

● Anaesthesia in the elderly.

● Lung pathology in anaesthesia.

● Airway management equipment.

● Low flow in anaesthesia.

● Anaesthesia for vascular surgery.

● Inotropes in anaesthesia – what can I use next.

● Burns.

● Critical incident management.

● Anaesthesia and major trauma – The first hour inhospital.

● Issues/developments of orthopaedic anaesthesia.

● Anaesthesia for the sick laparotomy.

● Dealing with difficult colleagues.

Registration fee £180Approved for CEPD purposes

The Royal College of Anaesthetists andThe British Journal of Anaesthesia

Research MethodologyMeeting13 November 2003 (code: C43)at the Royal College of Anaesthetists, WC1

This meeting is designed to introduce participants to theway in which good research should be conducted andpresented. It will be useful for anaesthetists of any gradewho are already involved in research or about to embarkon a research project. Post FRCA Specialist Registrarsand Lecturers will find this meeting to be particularlyappropriate to their needs since knowledge of researchmethodology is one of the non-clinical topics which forman important part of Post FRCA training. Even if actualresearch is not undertaken it is considered essential fortrainees to acquire an understanding of researchmethodology so that they are able to critically appraiseresearch reports in the literature.

The presentations will be given by experiencedanaesthetists who possess an extensive knowledge of allthe issues related to research. There will be groupsessions in which participants will be able to work onexercises provided by the faculty members. The number ofdelegates at the meeting will be restricted to ensure thateveryone is able to participate in the small group work.

The teaching sessions will address the following topics:

● Developing a research idea.

● Study design.

● Project management.

● Analysis, presentation and interpretation of data.

● Dissemination of results.

Group sessions will allow participants to:

● Provide criticism of a published research paper.

● Design a clinical trial.

● Detect common pitfalls in analysis andinterpretation of data.


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COURSES AND MEETINGSBooking proceduresA generic application form for all events, except FRCA courses, iscontained in every edition of the Bulletin. This is also available todownload from the College website (www.rcoa.ac.uk/courses).

Application forms for the Final FRCA course and Basic Sciencescourse for the Primary FRCA are available separately from theCourses and Meetings Department.

Once a course or meeting and the relevant fee have been publicised,bookings on the generic application form will be accepted at anytime. The appropriate fee must be paid at the time that the bookingis made (bookings will not be accepted for events that do not show afee). If your Hospital/Trust is paying your registration fee, pleasepass the completed application form to the relevant person forforwarding with payment.

To ensure that bookings are processed correctly, it is essential thatthe booking form shows the code number, title and date of the eventbeing booked, e.g. C81 – How to Teach: Small group teaching 20June 2002.

All courses and meetings are open to all grades of anaesthetist(unless specifically stated otherwise). Bookings will be accepted ona first come first served basis. When a course or meeting is full thiswill be publicised on the College website. For several weeks beforemajor meetings, details of vacancies will be available on the Coursesand Meetings Department ansaphone.

Fees and cancellations

Payment for all College courses and meetings can be made bySterling cheque, payable to ‘The Royal College of Anaesthetists’,Switch, or Credit Card (Mastercard/Visa/Delta).

Notice of cancellations must be given in writing to the Courses andMeetings Department at the Royal College of Anaesthetists at leastten working days before the course or meeting commences in orderto qualify for a refund. All refunds are made at the discretion ofThe Royal College of Anaesthetists and are subject to a £25administration fee. Delegates cancelling after this date will NOTbe entitled to a refund unless the Royal College of Anaesthetistsconsiders there to be exceptional circumstances that wouldwarrant a refund.

Accommodation

Local hotel information will be sent to you on receipt of yourapplication.

Application forms

Completed generic application forms should be returned to the:Courses and Meetings Department, Training and ExaminationsDirectorate, The Royal College of Anaesthetists, 48/49 RussellSquare, London WC1B 4JY switchboard 020 7813 1900ansaphone 020 7813 1888 fax 020 7636 8280email [email protected]

The British Journal ofAnaesthesia Symposium26 February 2004The Recovery Period9.00–10.00 Registration, coffee and trade exhibition

10.00 Session 1 – Chairman, Professor J M Hunter10.00–10.30 Influence of anaesthetic and analgesic techniques

on outcomeProfessor F Bonnet (Paris)

10.30–11.00 Recent advances in postoperative pain therapyProfessor I Power (Edinburgh)

11.00–11.30 Advances in the treatment of PONVProfessor D J Rowbotham (Leicester)

11.30–12.15 Guest LectureThe future of the speciality of anaesthesia in thetwenty-first centuryProfessor R D Miller (San Francisco)

12.15–13.30 Buffet lunch and trade exhibition

13.30 Session 2 – Chairman, Professor C S Reilly13.30–14.00 Postoperative myocardial infarction – aetiology and

preventionProfessor H Priebe (Freiburg)

14.00–14.30 Chronic pain after surgeryProfessor H Kehlet (Copenhagen)

14.30–15.00 Cognitive and psychological changes in thepostoperative periodDr C D Hanning (Leicester)

15.00–15.30 Tea and trade exhibition

15.30 Session 3 – Chairman, Professor G M Hall15.30–16.00 Fluid therapy and renal dysfunction in the

postoperative periodProfessor J W Sear (Oxford)

16.00–16.30 The role of extended HDU and outreach ICUDr D Goldhill (London)

16.30–17.00 Injuries associated with anaesthesia – a globalperspectiveProfessor A R Aitkenhead (Nottingham)

Registration fee: £120

The meeting will be held at the Hanover International Hotel andClub, Hinckley. For further information, please contact ChristineGethins, University Department of Anaesthesia, Critical Care andPain Management, Leicester Royal Infirmary, Leicester LE1 5WWtel 0116 258 5291 email [email protected]

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Courses and Meetings Department, The Royal College of Anaesthetists, 48/49 Russell Square, London WC1B 4JYSwitchboard 020 7813 1900 ansaphone 020 7813 1888 fax 020 7636 8280 email [email protected]



The distinction between society’s attitudes towards the art

of medicine and the therapist has transformed over my

professional lifetime of 30 years. We used to suppose that

life was nasty, brutish and short, whilst medicine was

unreliable, uncomfortable and often ineffective. As a result

we deferred to our own doctors who we persuaded ourselves

were cleverer than their colleagues, in the hope that their

individual skills would in some way beat the odds for us.

I remember hearing London Coroners in the 1970s

explaining to relatives that it did sometimes happen that

patients died whilst undergoing anaesthesia in circumstances

that could not be explained by the anaesthetist or the

pathologist. This did not imply that anyone was at fault. One

simply had to accept that there were risks associated with

uncomplicated anaesthesia and death was one of them.

At the time I suppose we must have been mid way

through the process in which mortality from anaesthesia

has fallen from 1 in 1000 general anaesthetics when I was

born to 1 in 240,000 today. The circumstances surrounding

this change are many and varied. They include the abolition

of the custom whereby an SHO in their second month in the

specialty would assess and anaesthetise a high risk patient

with whom they did not share a language. Then the annual

reports of the Medical Defence Organisation and the

Confidential Inquiry into Maternal Mortality made it clear

that the inhalation of stomach contents was a constant risk

associated with obstetric anaesthesia.

Today most of that has changed. The art of anaesthesia

is reliable, effective and comparatively safe. However, the

consequence is not that patients are grateful for having

escaped a danger which they have already forgotten or

regard as a part of history. The consequence is rather that

they demand perfection. They used to be grateful to wake

up at all after surgery and attributed survival to the

exceptional skill of their doctor. Now if they wake up with

scoline pains they are likely to suppose that the doctor has

delivered a sub-standard service.

In a strange way as the art has become better, respect for

the artist has declined. My clients deliver a far better service

than they achieved 20 years ago, but the 999 who do well are

less grateful for having received what they regard as their

due, and the one who has been unfortunate feels betrayed. I

know that my clients are doing better than they did before

but it is far harder to defend them. Because the profession

Ars Longa, Vita Brevis – v– The singer not the songMr Bertie Leigh, Senior Partner, Hempsons Solicitors, London

ON THE OUTSIDE LOOKING IN ...

has managed to minimise risk, anaesthesia is in the vanguard

of a series of associated developments in medicine.

The existence of the individual practitioner has become

much less attractive. The patient who has received their due

is not grateful to the doctor who has brought them safely

through an operation. The individual doctor has to

maintain the standards of their art to a far higher standard

to be an acceptable member of the profession. It is much

harder for a singer of uncertain ear to survive in a top

quality choir.

There is a third component which has cut across the

doctor/patient relationship sometimes with disastrous

consequences. The administration of the NHS kept off the

pitch of medicine as much as possible until the Griffiths

Report of 1985, with its dazzling apercu that if Florence

Nightingale were walking the wards of the NHS tonight she

would be trying to find out who was in charge. Doctors and

patients were then left to get on with things as best they could.

The intervention of management in taking control of both the

art and the practitioner serves to de-personalise the service.

Then one consulted a doctor who was made available by the

National Health Service which took little interest in what he

actually did. Today clinical governance means that the doctor

delivers a service which is defined by management. The

patient makes use of that Service. If the patient does not like

the treatment the complaint lies against the Service.

There are considerable advantages in this model. I do not

want an enthusiast who will fight for my life in the fashion of

an AJ Cronin hero, if I can have a modest doctor who can help

me through an illness without a crisis by following predictable

rules. The doctor who is a protocol-driven part of a service

becomes anonymous and may even appear to drop out of the

equation altogether. Just as I do not want a beautiful pre-war

Aston Martin which keeps on breaking down if I can have a

reliable but dull modern car. At a similar end point, the car is

replaced by a nameless means of transport.

Real life is what happens to me when I am not ill and I

would rather not be the subject of someone else’s heroism if

I can avoid the need. Furthermore the service I want from

my doctor should be objectively defined and consistent

wherever I happen to be when I fall ill. It should not be

whatever one idiosyncratic doctor thinks is good for me.

Clinical freedom must defer to evidence-based medicine.

This litany is familiar stuff. Yet there is a baby in that bath

water somewhere. I may not want great medicine if I can

enjoy the banality of the good health I take for granted, but

when good health deserts me an anonymous Service,

however well organised will have to be delivered by someone.

When I am ill I will develop a close relationship with my

therapist. If I need surgery I will be wholly dependent upon

the anaesthetist who has taken over the function of several

body systems I have controlled without understanding

throughout my life. Just as patients do better in the hands of

doctors who are nice to them, there is good evidence that the

intensity of the therapeutic relationship is valuable.

Medicine may now be too important to be left to the doctors,

but it cannot survive without them. We are in danger of

constructing a system which is so unsatisfying for the

individual practitioner that we may be forced to function

with inadequate numbers of doctors because they simply do

not like the job. Nobody can deliver perfection consistently,

and until we replace our mortal and unpredictable bodies

with more reliable pieces of machinery we need the intuitive

and humane qualities of the therapist. At the same time as we

demand ever more predictable and rule-governed doctors,

we are flocking to complementary therapists as never before.

Society is entitled to demand that its members are treated

with understanding and perception by the medical

profession. Unless society is a little more understanding and

perceptive about the needs of doctors, we will create a role

which cannot be cast.

Finally, this perception must come primarily from the

profession: unless you explain that the demands being made

are unrealistic, the rest of society will not understand. You

must explain that the daily stresses are such that more of the

best of you find premature retirement attractive every year;

that those who take their place have a fraction of their

experience because of the combined effect of Calman and

shorter hours, so that the training is getting ever shorter

whilst the demands are ever higher. Only you can explain

that the gulf between what the public wants and what it can

expect grows wider every year.


Criteria for awardingEponymous CollegeProfessorshipsThe College has established a number of initiatives tofoster research in anaesthesia, critical care and painmanagement. The aim is to encourage the researchers toexpand their horizons beyond normal clinical activities.Important among these are the eponymous CollegeProfessorships.

In 1995 Council agreed that the College should award upto four eponymous College Professorships per annum,comparable to the Hunterian Professorships awarded bythe Royal College of Surgeons. The names of Davy,Hickman and Snow were approved for the eponyms.Appropriate, alternative eponyms can be used byagreement with the College.

The purpose of these College Professorships is toencourage the presentation and dissemination of highquality research in clinical topics or basic science subjectsapplied to anaesthesia, critical care and pain management.The College Professorships awarded thus far haveundoubtedly conveyed a sense of prestige and honour tothe recipients.

College Professorships are held for one year (the Collegeacademic year). The eponymous Professors are required,within that time or soon after, to give a lecture on thesubject of their research, either at the College, or atanother suitable venue, in the presence of an audienceincluding College Officers and a quorum of Councilmembers. Such a lecture can, for instance, be given at amajor College meeting or as part of the proceedings ofanother relevant organisation. The lecture iscommemorated by the presentation of an illuminatedcertificate, together with an honorarium.

Applications for eponymous College Professorships areopen to Fellows and Members of the College, togetherwith clinicians and clinical scientists involved inanaesthesia, critical care and pain management within theUnited Kingdom. Applications will be considered by apanel nominated by Council, and including members ofCouncil and expert external advisers.

The next advertisement inviting applications forEponymous Professorships will be published in the March2004 edition of the Bulletin.


The Royal College of Anaesthetists and the Association of

Anaesthetists of Great Britain and Ireland (AAGBI) have

recently published ‘Raising the Standard: Information for

Patients’. The working party involved in this project

consulted widely and surveyed all UK anaesthetic

departments before reviewing the available patient

information materials. During this review, input was

invited from the specialist anaesthetic societies, including

the Obstetric Anaesthetists’ Association (OAA).

Challenges to the obstetric anaesthetist

Obstetric anaesthetists are usually caring for fit healthy

women who are awake for labour and delivery, rather than

patients having surgery. The obstetric anaesthetist may be

presented at short notice with a distressed and sedated

woman requesting epidural analgesia or with a category 1

caesarean section requiring emergency anaesthesia where the

lives of the woman and/or fetus are at risk. This challenges

the ability of the anaesthetist to provide the woman with

adequate information before an anaesthetic procedure; for

this reason it is essential to be able to present clear relevant

information to mothers about analgesia and anaesthesia.

Information and women

Research has also shown that despite the influence of pain

or analgesic drugs, women would like to be informed and

are capable of recalling risks.1,2 Women are bombarded with

information from relatives, friends, magazines, books, the

Internet as well as antenatal classes in the community or

hospital. This can sometimes lead to confusion. The

National Birthday Trust (NBT) survey3 found that among

those women attending antenatal classes, 54% attended a

health centre, 38% a hospital and 8% National Childbirth

Trust (NCT) classes. Midwives were considered important

sources of information both antenatally and during the

birthing process, followed by the obstetrician and

anaesthetist. Women expecting their first babies cannot tell

how they will cope with labour. They have been found not

so much to underestimate the pain of labour as to

overestimate their ability to cope with it.

Obstetric anaesthetists must endeavour to impart clear

information directly to women at various stages of

pregnancy and labour and also need to participate in the

education of midwives and obstetricians.4 The NBT survey

also showed that women wanted to know what pain relief

methods were available locally; it was a great source of

dissatisfaction if a particular method of analgesia that they

had expected was not available. Too much information can

be a source of confusion particularly if it contains

contradictions. Well-intentioned relatives, friends and

those participating in antenatal classes may paint a certain

picture of the labour and delivery but the reality is that it

ain’t over until the fat baby screams!

Role of the OAA

The OAA has made patient information a priority over

many years. In 1994, a video entitled ‘Coping with labour

pain’ was produced for Poole Maternity Unit for local use.

The video featured interviews with mothers who recounted

their own experiences with the various methods of pain

relief, accompanied by brief descriptions of the various

methods. The success of the video was attributed to the

‘patient friendly’ and non-patronising way it was presented;

the use of clear language and images and the fact that it was

short. The video was endorsed by both the National

Childbirth Trust (NCT) and the Association for the

Improvement of Maternity Services (AIMS).

In an effort to provide clear, concise and evidence based

information, the committee of the OAA adapted the Poole

video and endorsed its use among members nationally. To

complement the pain relief video, a working group was

formed with Dr M Bryson as chair to produce an

accompanying booklet. The first edition of the OAA pain

relief booklet entitled ‘Pain relief in labour’ was produced in

1997 and the second edition in 2001. To date over 300,000

copies of the booklets have been sold nationally. The pain

relief booklet and several translations can be downloaded from

the OAA website (www.oaa-anaes.ac.uk). All the translators

are volunteers and always included a lay representative to

ensure that the patient friendly flavour of the booklet is

preserved. The Web site has links with other sources of

patient information. Both the pain relief video and booklet

were appraised by the newly formed Centre for Health

Information Quality5 (CHiQ) in 2001 and awarded their

Triangle Mark seal of approval. The ChiQ use recognised

tools to assess the quality of health information in

conjunction with its own checklist.

The Obstetric Anaesthetists’ Association (OAA)and Information for MothersDr M Wee, Honorary Secretary, OAA and Dr A E May, Consultant Anaesthetist, Leicester Royal Infirmary


The OAA Information for Mothers Sub-committeeLater, the multidisciplinary Information for Mothers sub-

committee (IFMS) was formed to include wider

representation from the Royal College of Midwives, AIMS,

patients and their representatives. This allowed multi-

disciplinary discussion to take place on a wide range of

issues of common interest. The IFMS acted as a link and

exchange of ideas with various organisations as well as a

vehicle for producing multidisciplinary information media.

In 2001 the OAA committee gave approval for the

production of a video and booklet on caesarean sections.

These were entitled ‘Your anaesthetic for Caesarean section’

and ‘Caesarean section: your choice of anaesthesia’ to

distinguish the video from the booklet. The main emphasis

was on the anaesthetic choices as well as post-operative

analgesia, and the advantages and disadvantages were

described. The ChiQ awarded both the OAA caesarean

section video and booklet its Triangle Mark seal of approval

in 2003. All the OAA videos and booklets can be obtained

from the OAA Secretariat (email secretariat@oaa-

anaes.ac.uk). Other areas of information development and

research include the use of epidural information cards and

pain relief algorithms during labour.

The excellent work that had been undertaken by the OAA

is recognised by the Royal College of Anaesthetists and the

AAGBI; hence obstetric anaesthesia was not included in the

project ‘Raising the Standard: Information for Patients’. The

IFMS was concerned with this omission. The Royal College

of Anaesthetists has therefore put in a link from the patient

information section of the website to the OAA Information for

Mothers section of the OAA website (www.oaa-anaes.ac.uk).

References

1 Pattee C, Ballantyn M, Milne B. Epidural analgesia for labour

and delivery: informed consent issues. Can J Anaesth

1997;44:9,918–923.

2 Affleck PJ, Waisel DB, Cusick JM et al. Recall of risks following

labor epidural analgesia. J Clin Anesth 1998;10:141–144.

3 Chamberlain G, Wraight A, Steer P (eds). Pain and its relief in

childbirth:the results of a national survey conducted by the

National Birthday Trust. Edinburgh: Churchill Livingstone, 1993.

4 Brooks H, Sullivan WJ. The importance of patient autonomy

at birth. Int J Obstet Anaesth 2002;11:196–203.

5 Centre for Health Information Quality. The Help for Health

Trust, Highcroft, Romsey Road, Winchester SO22 5DH

(www.chiq.org).

Fellows of 50 yearsstandingThe College would like to congratulate the following whowere granted the Fellowship on 15 May 1953 and havetherefore been Fellows of the College for 50 years:

Ablett, John James LloydBrown, Allan ScrimgeourBryce-Smith, RogerCarnegie, David MichaelChristie, AlbertClynick, Francis EdwardEastwood, Arthur BrianEnderby, George Edward HaleEnglish, Ian Charles WoolrychGilchrist, EdithGlazer, PhilipGrigor, Kenneth CarkHargreaves, John BennettHawkins, Gordon FrankHeadley, Seton Robert TristramHind, Alan WheeltonHolmes, FrankHorton, John Anthony GuyHowat, Douglas Donald CurrieLawrence, Reginald CharlesMackenzie, AlistairMason, Stanley ArthurMountford, Laurence OliverRendell-Baker, LeslieRoberts, Barbara CecilyRoberts, HildaRobson, Sir GordonScurr, Cyril FrederickCrampton-Smith, AlexSpence-Sales, DorothyStride, Sydney Donald KelseyTaylor, JohnYoung, Douglas Steele


An eclectic group

Idon’t really know of a suitable collective noun for a group

of anaesthetists: many have been suggested and I initially

thought that borrowing from the military might seem an

option, but platoon or squad lacks the requisite ring: flight

sounds even less appropriate. I would like to suggest that a

group of anaesthetists be termed an Eclectic.

The 50 strong department I have worked in for the last five

years in Riyadh is staffed by such a group: an eclectic

selection of men and women drawn from Europe, North and

South America, Australia, South Africa, Syria via Germany,

Egypt, the Subcontinent and Saudi Arabia, a melange of

medical globalisation. The department has two basic

divisions: those who work in the cardiovascular unit and

those who don’t. Much of the cardiac surgical load is neonatal.

Whilst employing several staff members who are certified

super specialist anaesthetists in their own countries of

origin, non-cardiac staff members take on all comers

regardless of age or pathology, both electively and

emergently. By eschewing the nightly roll call for a parade

of sub-specialist staff – neuro, obstetric, paediatric, etc and

persisting with the concept of a generalist in anaesthesia the

hospital both cuts costs and on-call commitment

substantially. It also demands a sharpness of performance.

Were one to meet some members of the department on a

dusky evening most might appear as battered cynics:

physically battered by the hours of late running lists and by

nights on-call, intellectually battered by the unceasing

demands of management to increase output whilst being

denied additional resources and emotionally bereft by a slew

of family failures. One colleague with four children

attended a single parent – teacher evening and two summer

sports days from a total of 52 child school years; but he did

attend two university graduations, the first, so he told me,

because he had a new Sony eight video camera to try out.

Despite their cynicism most arrive early for the day’s work.

All are sober and ‘clean’. They curse when the digital clock

plinks past the release hour but always hang on for the extra

time. All bitterly resent being ill themselves. One man worked

with a below knee walking plaster wearing an image

intensifier elasticised plastic condom over his foot ‘for

sterility’. Another member of the department insisted that his

wife push him in a wheel chair from ward to ward to review

patients pre-operatively whilst he was dying from an occult

carcinoma. If I remember correctly it was his third wife.

What are the driving forces that have propelled Russians

with Finnish passports and outdoor Southern Hemisphere

sports lovers to reach a common end point? What have been

the life changing events that have parachuted them all – in

some cases more than once – into the aridity of a desert city

which, when most of them were children, was little more

than a huddled collection of mud houses sealed from the

world by guarded walls? The petro-dollar is in their pockets

now but it had not even been printed in childhood.

Disparate motivations

The simple answer, to quote the patrician Harold

Macmillan, is ‘Events, dear boy, events’. It’s relatively easy to

understand why a man would leave the Communism of a

bankrupt Russia, the street violence of Cape Town or

Johannesburg and Robert Mugabe’s imploding Zimbabwe

to seek a more open or less threatening environment for his

family. Straightforward salary scales account for the

Egyptian and Sub-continental members. The cocaine

fuelled nationwide anarchy in Columbia is intolerable.

Taxation has been the reason for the Danes and Swedes,

leavened with not a little distaste for political correctness, to

pack away their skis and skates and exchange snow for sand.

A consultant anaesthetist in a large district general hospital

in Sweden might find £2,250 in his net monthly wage packet

whilst over the suspension bridge spanning the entrance to

the Baltic his Danish colleague has better beer but even less

disposable income. European socialism is not reflected at all

well in salary scales.

These are benign explicable reasons, easily enunciated

and instantly understood, but more interesting are the

reasons which coalesced to inspire this disparate group to

select anaesthesia for their medical career. In most cases the

choice was multifactorial, involving personal choices as

much as a single – minded focus on a defined career path to

a consultant appointment within the speciality. If there is a

specific anaesthetic personality type then psychometric

testing should be able to pick it up in medical school. Much

literature exists to measure stress in doctors,1 in the ICU in

particular. Mal-adaptive coping strategies are equally doc-

umented, but not so entry criteria.

How was it for you?Dr R J Knight, The Royal Devon and Exeter Hospital, Exeter


A pregnant wife was reluctant to move the 3,000 and more

miles from Vancouver to Newfoundland which would have

allowed her husband to move a rung up the surgical ladder.

He quickly sought out the first available slot in his hospital

and has been slotted away ever since. Has anyone reviewed

the role played by pregnancy in the choice of a career within

medicine? Now, with more than half of all medical school

graduates being female, perhaps the time has come?

One man so enjoyed his golf – the best of his life, he

inevitably affirms – that he stayed as senior resident for far

too long and passed the qualifying Board examination

almost by mistake on a frozen December day. Not

surprisingly he became the first member of his consortium

to own a mobile phone but with the current stock market

doldrums he intends to hang on to his on-call phone rather

than hang it up.

Another Canadian gave up general practice when he

discovered that he could no longer tolerate the midnight

mindlessness of coughs, colds, and spotty holes in a small

city where mosquitoes in summer were as big as B52s. An

anaesthetic residency in Toronto was the route back to

music and sanity . Anaesthetic manpower in the UK has

consistently been inadequate, the slave of so many

ministerial misjudgements. Consequently it was at one

point seen as a short cut to a hospital consultancy and to the

status that position once enjoyed. Little better can be said of

the US residency matching schemes in recent years: many

US physicians feel that the current HMO system is a failure.

These may seem eccentric – or eclectic – reasons for

committing one’s life’s work to a discipline which thirty five

years ago was emerging from the control of men who had

seen action in the Field Surgical Teams and Dressing

Stations of WWII and who were eternally grateful to

Imperial Chemical Industries for releasing halothane a

decade after demobilisation . The ease with which electro-

physiologically monitored neurosurgery is performed today

under TIVA would impress, even amaze, this generation

weaned as it was on ether.

Is the present discomfort sensed within the anaesthesia

world in part due to the general perception that anaesthesia

is so very safe? Or is it that the anaesthesia community,

fragmented as it is by surgical affiliations – neuro, cardio,

obstetric, paediatric – and now spending 50% of the

working week elsewhere other than an operating theatre,

feels exploited by all and respected by none?

The swinging sixtiesIn the 1960s, in the UK, the speciality, via the Blease

Pulmoflator and phenoperidine, was nurturing intensive

care into a life sustaining environment and was soon to

beget acute and chronic pain services. The bugbear of so

many non fee-for-service systems, the obstetric epidural,

crept back into the anaesthetic vocabulary a little later in the

early 1970s and planted the seed which metamorphosed

into the obstetric anaesthetist of today

Today, intensivists control ICUs other than in the UK

where a ‘special interest’ only is required. Pain specialists are

seldom seen beneath the revealing light of the scialytic lamp

in the operating theatre. They prefer the pixel powered half

light of the imaging machine or the discrete candlepower of

the private consulting room where electro-acupuncture for

weight loss is munificent.

The obstetric epidural, however, remains, but how to

explain the risks, benefits and options of an epidural

injection to a young primigravida at 3:30 am remains as

much of a mystery as a bugbear. Her antenatal notes may

carry a signed declaration of her avowed intent not to have

an epidural but this, it seems, is insufficient to keep the

pager from howling at 3:15 am when the lady moves from

push to shove and changes her mind.2 The patient’s

competence is all.

SoapNotwithstanding the 24-hour satellite TV channels

dispensing medicated soap and a web site and support

group for every known disease, plus the same for many

spurious entities, the medical knowledge base of some

consumers – or is it clients? – remains singularly worrisome.

In which year the Casualty Department was born again as

The Emergency Room (ER) escapes me: it may have been an

unconscious national effort to exorcise lingering memories

of WWII and bombing raids. Today’s euphemism for war

wounded casualties is of course ‘collateral damage’. The

metamorphosis to ER may perhaps have been a

governmental spin doctor’s attempt to recruit more staff to

become trolleyologists (one who treats patients on a trolley)

or it may have something to do with junior surgical trainees

skirting around Colles fractures.

The transplanted discipline of Emergency Medicine,

some of whose early recruits were also defectors from

general practice, inspired by their Chairman Mao booklets,

ACLS and ATLS, sweeps up the detritus of traffic accidents.

The ER crew do their thing before passing the patient with

central line, arterial line and intubated to the theatre team:

and therein lies the rub as evidenced by recent

correspondence.3 Is the airway to be managed by the ER

Doc or by an anaesthetist? Perhaps only a court case will be

able to decide the better choice?

If, as seems currently likely, George Clooney and his team

assume responsibility for trauma airway management, does

this diminish the role of anaesthesia in any meaningful way?

But who now will sit, possibly uninsured, in the body of an


ambulance to transport an intubated patient in search of an

ICU bed or to the Regional Neurosurgical Centre? I doubt if

this role fits in with the trolleyologist’s scheme of things.

The winds of changeAs the NHS is slowly shifted towards the American model

with the PFI and self insurance, the fee-for-service

compensation deal may well come with it. An MBA thinks

in terms of a 24-hour day/seven day week. This translates

into a new theatre paradigm: like any industrial production

line, it becomes available 24x7x365= 8,760 hours per

annum. The British Medical Association calculates that

most UK anaesthetists work a nominal 49 hour week x 48

weeks = 2,352 hours pa (the average US anesthesiologist

works 3,500 hours).4 Clearly there is room for change, not

least in a PFI CEO’s vision. He knows only too well that 75%

of total health expenditure is to be found in monthly salary

cheques and that salaries in the UK health system are

constrained by fixed employment rules and pay scales as

once were another smaller group of government employees,

the fire brigades.

Given a fee-for-service compensation package, who then

will sit in the transport ambulance or travel to the roadside

site of motorised carnage in a rescue vehicle? Will the UK

eventually licence nurse anaesthetists?5 The current split

between MDs and CRNAs in the US is light-years beyond

bitterness. One reads of the developing role of the

perioperative physician: where or what will be the end point

for this creature?

So then, how was it for you? In this department 25% of

the staff is aged over 60 and another 25% between 55 and

60. The youngest member, one of several Danes, is in his

mid forties. In the eldest group there exist more than 300

man years of international anaesthetic experience spread

over all five continents and taking in a range of professional

environments from the military, world class US university

centres to working single handed for two years in mission

hospitals deep in the developing world: an eclectic mix.

Living with change, clinical and administrative, life long

learning, garnering CME hours, and revalidation have all

been accommodated by these long toothed warriors. They

are systematically following guidelines. They carry a loaded

PDA in their shirt pocket and stroll the pathways of a

clinical Elysium. They are masters of search engines, Pub

Med and MS PowerPoint, these for departmental, national

and international presentations.

But as they don their ‘scrub suit’, known in this hospital

as ‘the combat kit’ and enter the jousting lists, one wonders

if they have enjoyed it all: and would they do it again?

Would their wives let them do it again? No-one I spoke to

had ever seen a dermatologist in a hospital after 6:00 pm

unless he was attending a cocktail party in the Board Room.

References

1 Coomber S et al. Stress in UK intensive care unit doctors. Br J

Anaes 2002 89;6:873–881.

2 Heneghan C. Letters. Today’s Anaesthetist 2002 17;4:115.

3 Sweeting CJ, Dow AC. Anaesthesia 2002 57:1217.

4 Lema MJ. Editorial. ASA Newsletter Vol.66;No.3:March 2002.

5 Ballance J. Anaesthesia News No.186;January 2003:3.

AS WE WERE ...‘As the art of giving anaesthetics has advanced fromthose crude efforts when, assisted by a strong porteror efficient straps, the administrator drenched astruggling patient with ether vapour from anunwashed felt cone, to the practice of today … so theprofessional status has improved of those who devotethemselves entirely to the practice of anaesthetics. Itis true that even today the general public is largelyunaware of the responsibilities of the anaesthetist orof the extent to which the success of surgery maydepend upon his competence. … As showing thestate of affairs at present in London, it may bementioned that there are twenty-seven specialists attwelve teaching hospitals … and at ten of thehospitals anaesthetists are represented on thecommittee of the hospital or medical school. … It isgratifying that England may fairly be said to haveshown the way to the proper recognition of theanaesthetist …’

ReferenceBlomfield J. Anaesthetics in Practice and Theory.London, Heinemann, 1922:12–13.

David ZuckHistory of Anaesthesia Society


Malawi comprises a narrow strip of land about

119,000sq Km in area wedged between Mozambique,

Zambia and Tanzania. It has a population of approximately

ten million. Malawi was ranked 169th out of 179 countries

in a recent WHO health standards survey. The infant

mortality rate is 134/1000 live births (UK rate is 6/1000) and

average life expectancy, which is falling sharply, is between 35

and 40 years. Health problems are largely related to poverty

and malnutrition, immune compromise (HIV/AIDS), and

infectious diseases (malaria, TB, diarrhoeal illnesses, pelvic

inflammatory disease and pulmonary infections). Trauma

and obstetric complications also contribute to the workload

in all healthcare facilities.

In theory there is a three tiered health system. Health

centres and dispensaries provide primary care. Secondary

care is delivered by community and district hospitals. The

central hospitals in Blantyre, Zomba, Lilongwe and Mzuzu are

tertiary referral and training centres. In practice district and

central hospitals also provide a great deal of primary health care.

Around 30% of rural health care is provided by church charitable

organisations. In urban areas private health clinics provide

mainly ambulatory diagnostic, curative, and referral services.

Countrywide shortages of qualified staff, basic equipment and

drugs hamper service delivery. Insufficient and delayed

investment in infrastructure further exacerbates this problem.

The government of Malawi has developed a health sector

reform programme. Through decentralization of

management, collaboration and integration, resource

mobilization, improved efficiency and community health

prioritisation it hopes to revitalise health services.

The College of Medicine of Malawi (COM)COM was established in 1989 as part of the University of

Malawi and is under the control of the Ministry of

Education. Queen Elizabeth Central Hospital (QECH)

serves as its teaching hospital. Training of Malawian

physicians started in 1991 and initially took place abroad. In

1999 the first class of home-grown students graduated from

the College. The MBBS training programme is now well

established and internationally recognised. The College is

situated in a purpose built complex close to QECH. Guided

by five year plans, it aims to improve the standard and

breadth of training at all levels and promotes research activity

and support of other training institutions. A programme to

develop structured and recognised postgraduate training for

doctors is currently in progress.

Financial restraints and the shortage of qualified staff

hamper the work of the College. Clinical training oppor-

tunities are restricted by the facilities available at QECH.

The College is an equal opportunities employer. In the

face of equal academic performance it operates a gender-

preference policy to balance staff opportunities.

Queen Elizabeth Central Hospital (QECH)QECH with over 1000 beds is the largest hospital in Malawi.

Its wards are overcrowded (over 100% bed occupancy) and

it is subject to the countrywide problems described earlier.

Under the proposed health sector reforms it is expected that

QECH will gain independent status under the management

of a Board. It is not yet clear how this autonomy will take

shape. The hospital accommodates clinical and academic

departments of anaesthesia and intensive care, internal

medicine, surgery (general, burns, paediatric, dental,

orthopaedic and ophthalmic), paediatrics, obstetrics and

gynaecology. In all these departments community health is

at the basis of the medical training. QECH also

accommodates training institutes for nurses and clinical

officers. All clinical specialties offer internships to junior

doctors and clinical officers and training placements for

nurses. There are opportunities for overseas elective

medical students. In some departments (e.g. anaesthesia

and orthopaedics) training of specialist clinical officers and

development of curriculae is part of the daily work. In

anaesthesia this is carried out by the Malawi School of

Anaesthesia. Medical specialists paid by the Netherlands

government supervise these programmes.

The Netherlands government supportand the Dutch Exit StrategyThe Netherlands government has a long-standing

relationship with Malawi assisting in the improvement of

health service provision. During the last few years Technical

Assistance (TA) has been targeted at the College of Medicine

and QECH. With Netherlands support the COM currently

employs nine consultant-level medical specialists. There is

provision also for employing up to two junior specialists in

each department. Research activity and community and

reproductive health training programmes in the district are

supported (e.g. a medical student community-training

programme in the Mangoche district).

A change in the Netherlands government development

cooperation policy has left Malawi no longer eligible to

Anaesthesia in Blantyre, MalawiDr H Haisma, Head, Department of Anaesthesia, Blantyre, Malawi


receive bilateral assistance. A three year support

programme (The Dutch Exit Strategy 2001–2004) aims to

prepare the College and hospital for this withdrawal.

Assistance for sustainable projects has been a priority in

anticipation of the phasing out of technical assistance. The

Dutch Exit Strategy may, if necessary, be extended beyond

2004 for a maximum of two years. Support given to the

College of Medicine aims to increase the number and

quality of Malawi trained doctors and medical specialists.

The goal is to achieve greater self-reliance in training

undergraduate and postgraduate staff. For historical

reasons this is concentrated in the specialties of anaesthesia,

internal medicine, obstetrics, gynaecology and surgery.

Greater self-reliance would allow the withdrawal of

Netherlands technical and material assistance within three

to five years.

The Malawi School of Anaesthesia and theDepartment of AnaesthesiaProfessor Paul Fenton founded the Malawi School of

Anaesthesia in 1988. It is based in QECH (Director: Mr

Cyril Goddia) and in Lilongwe Central Hospital (Director:

Dr Reintraut Burmeister). Its intake includes general

clinical officers, medical assistants and nurses. Through an

intensive 18 month course the school produces anaesthetic

clinical officers.

Two senior clinical specialists (intensivists), two junior

clinical specialists, a registrar, nine anaesthetic clinical

officers (ACOs), 13 trainee anaesthetic clinical officers

(TACOs), three patient attendants and a secretary are

currently working in the Department.

The clinical commitment is principally to the nine

operating theatres (in four different locations within

QECH), the recovery room, the intensive care unit, the

maternity unit and the adult and paediatric admissions

units. Two ACOs (one on site, the other on call from home),

three TACO's and a consultant on-call provide the night

service for theatres and ICU.

There currently exists a vacancy for:

A (Senior) Lecturer in the Department of Anaesthesia

of the College of Medicine.

Position available from 1 July 2003 (or as soon as possible):

Job descriptionQualifications required: Anaesthetist with FRCA

or equivalent.

Duties

● To perform academic and clinical duties with the

College of Medicine, Department of Anaesthesia and

Malawi School of Anaesthesia.

● To assist in the fulfilment of all the following

commitments of the Department:

1 Provision of a supervised, competent and safe 24-hour

clinical anaesthetic service to all departments.

2 The training of anaesthetic clinical officers in The

Malawi School of Anaesthesia.

3 The teaching of clinical officers, medical assistants,

medical students, postgraduate physicians, district

health staff, and nurses. Classroom and bedside

teaching, workshops and clinical meetings deliver this.

4 The development of a course curriculum for the

postgraduate M.Med in Anaesthesia.

5 Curriculum development for anaesthetic clinical officer

and intensive care nurse training.

6 The development of evidence-based protocols for

practice in post-operative care and the intensive care

unit.

7 The initiation, administration and supervision of

research activity.

8 Structured supervision of all of the above.

● To provide on-call cover to junior colleagues.

Details

The working day usually starts at 07:40 with a handover

meeting. The night's work is discussed and the day's pre-

operative assessments are presented. Operating lists run from

08:15 to 17:00. During term-time there is a morning lecture

and afternoon discussion group attended by the TACOs.

TACOs attend theatres for teaching when not in class. A

formal ward round on the intensive care starts at 10:30. The

consultant on-call duty runs from Friday to Thursday. This is

followed by a long weekend off (Friday–Sunday).

Conditions of service

The candidate will serve a one year contract with the

College of Medicine in Blantyre, Malawi starting July 2003.

The College will provide local salary, air ticket,

accommodation allowance and administrative support to

obtain Temporary Employment Permit. The candidate will

be appointed as senior lecturer provided that publications

and teaching experience are adequate. The appointee will

receive a supplement of $1000 US (lecturer) or $2000 US

(senior lecturer) in a UK bank account. The Dutch Exit

Strategy, through the College, provides this supplement.

Applications should be addressed to: Professor R I

Broadhead, Principal COM, Private Bag 360, Chichiri,

Blantyre, Malawi. A copy should be sent to: Dr H J Haisma,

Head, Department of Anaesthesia, Private Bag 360, Chichiri,

Blantyre, Malawi email [email protected]


Over the last four years as Regional Adviser (RA) I have

had the opportunity to review a large number of

consultant job descriptions. At first I often sought the

advice of my immediate predecessor, principally about the

content of the weekly job plan. Further, I asked my fellow

RAs for written guidance and well remember the response

from a then senior RA, and now Council member. He

suggested that written guidance would be difficult to

provide and that, as RAs, we were ‘advisers’ and that clinical

directors tended to listen to the advice given – at the time

this did not seem very helpful, but four years on I

understand his drift completely!

Why do consultant job descriptions have to be approved

by the RA? The Good Practice Guidance on appointment of

consultants1 states that ‘the RA … must be given an

opportunity to comment on the draft job description and

selection criteria. This is to ensure that the post contains a

proper balance of clinical, academic, research and

managerial activities and that there are sufficient facilities to

enable these activities to be performed’. How should these

be addressed in 2003? I offer a number of personal views.

The job descriptionIndividual departments prepare a job description and person

specification after taking account of the service needs of the

Trust and the future demands of the post. I believe that it is

important that they include as much information as possible

about the post and the hospital, to inform prospective

applicants. I suggest that there should be a succinct profile of

the hospital (including the range of medical services

provided) and the department. Descriptions of the core

services relevant to the specialty, for example the critical care

and obstetric services, add to the profile. Further

information about any sub-specialty area relevant to the post

should be included to demonstrate that appropriate facilities

are available (e.g. information about secretarial help,

multidisciplinary support, theatre, out-patient and in-patient

facilities for pain management). The weekly clinical

commitment should be clearly identified in the ‘job plan’

along with a person specification. Finally, the Trust should

include a general information pack covering terms and

conditions of service and other relevant local information.

The job planThis, I believe as a RA, is the single most important element

of the job description. Further, it is seen as the way ahead

by both the Department of Health and the British Medical

Association (BMA), according to the Chairman of the

BMA’s Central Consultants and Specialists Committee.2 I

believe it is essential that it reflects the type of work an

individual clinician is expected to undertake and over the

last four years my views on the nature and content of the

weekly job plan have changed considerably.

Job plans divide the basic working week into ten half-day

sessions, consisting of a mix of ‘fixed’ and ‘non-fixed’

sessions. I do not intend to consider the contractual issues

further, concentrating instead on the content of the working

week. The current contractual arrangements are well

reviewed in the Association of Anaesthetists publication

Guidance on Contracts and Workload for Consultant

Anaesthetists 1997.3

Fixed sessionsThese refer to the clinical component; job plans can vary

greatly both within departments and between Trusts.

Overall the clinical content should provide a satisfactory

professional mix of sessions, as well as allow necessary core

skills to be maintained. Care needs to be taken when

developing a new job plan – most specialist registrars

indicate that a mix of interesting clinical sessions is the most

important consideration. A collection of unpopular

sessions may constitute a thoroughly unattractive job plan –

do not be surprised if there are no takers!

Traditionally all fixed theatre sessions were identified

with designated surgeons. Whilst this should still be the

case for the majority of fixed sessions (to ensure

professional satisfaction), it has become increasingly

obvious over the last four years that departments need

flexibility both for the individual to maintain core skills, and

the department to provide flexibility. As a result, many job

plans now have a core ‘fixed’ clinical component (identified

sessions), with one or two identified ‘fixed flexible’ sessions

(fixed in time, but variable in content) as well.

Consultant job descriptions– Musings of a Regional AdviserDr A A Tomlinson, Regional Adviser for West Midlands, North Staffordshire Hospital, Stoke-on-Trent


Fixed flexible sessions for maintenance of core skills

The majority of job descriptions include responsibility for

the provision of out of hours emergency cover. Clinical

governance, I believe, demands that consultants retain core

skills for the areas for which they have out of hours

responsibilities. Thus, if the on call rota includes out of

hours cover for the intensive care unit (ICU) it is important

that those without routine day time sessions in intensive care

spend time, on a regular basis, maintaining core skills in this

area of practice. Similarly, a consultant anaesthetist with an

interest in intensive care should maintain familiarity with the

obstetric unit, if this forms part of their out of hours

responsibilities. It is my view that the same goes for out of

hours cover of paediatric emergencies.4 Thus, the district

general hospital (DGH) consultant has to retain a far broader

breadth of skills than the consultant with responsibility for a

single subspecialty area within a larger hospital. How many

sessions per week are required to maintain core skills? This

question was put to the Training Committee after a RA

received a job plan consisting of four sessions in ICU and two

fixed flexible theatre sessions. The general view was that two

theatre sessions per week would be sufficient, provided the

clinical content of the lists was appropriate.

Fixed flexible sessions for cover of leave

Clinical directors may find it helpful to seek approval for

fixed flexible sessions in all consultant job plans, to provide

the flexibility needed to cover annual, study and professional

leave. Trainee members of a department are no longer able

to provide such cover to any great degree for a variety of

reasons. It has been suggested that for every consultant

member of a department, there is the need for at least 1.5

fixed flexible sessions per week to provide such cover over a

year.5 The difficulty clinical directors might have, is

persuading local purchasers that they must fund additional

consultant posts without obtaining a perceived increase in

throughput (although in reality there will be an increased

throughput, as the additional consultant input will ensure

the clinical work is undertaken and not cancelled).

Special interests

Many job plans include an ‘interest’ often to provide a range

of clinical activity that will be seen as attractive to the post

holder. Such ‘interests’ tend to vary considerably, depending

upon the size and needs of an individual hospital. Some job

plans, particularly in major subspecialty areas, will be

almost exclusively devoted to that area of practice (e.g.

cardiothoracic anaesthesia, neuroanaesthesia and paediatric

anaesthesia in a specialist centre). In my experience, DGH

posts often include a special interest (e.g. obstetrics, critical

care medicine and paediatric anaesthesia), where the job

plans typically include two sessions for the ‘interest’, with

the rest a mixture depending upon the needs of the

department. How many sessions are required to be a

designated specialist? This is debatable and probably does

not matter greatly. In the DGH setting, I now believe that

only the identified ‘lead’ clinician needs more than one

session in the specialty area – the remaining sessions should

be distributed amongst the remaining consultants within

the department who have out of hours responsibility for

these specialties.

Job plans with an interest in critical care

In my region, I ensure that these job plans receive the

approval of RA for intensive care medicine, as well. These

posts fall (broadly) into two groups:

● Posts in hospitals with large critical care areas.

Continuity of care over several days by one consultant is

preferred in most such hospitals. The increasingly

onerous nature of the work (particularly out of hours)

is being recognised in many departments by an

increased sessional allocation for the days covering

critical care, with a ‘lighter’ theatre commitment in the

non-critical care component of the job plan – such job

plans frequently have a rolling weekly programme,

reflecting different intensities of work over several

weeks, making such posts more attractive.

● Posts including cover of smaller critical care areas. Such

posts usually have two or at the most three, sessions

allocated to critical care. The approach taken in this

region has been to seek continuity of care, by

encouraging departments to work flexibly allowing one

consultant to take responsibility for critical care for at

least 24 hours at a time, or longer if at all possible. As a

result, it is preferable for these sessions to be linked

together in the job plan.

Job plans with an interest in pain management

It is my impression these are more attractive if there are at

least three sessions devoted to this area of practice: it is also

crucial that such posts have sufficient secretarial, and other

essential, support. In future, there should be input of the

Regional Adviser in Pain Management.

Non-fixed sessionsIt is my belief that non-fixed sessions on the weekly job plan

should be left blank, although there should be an

accompanying statement, noting that they provide flexible

time recognition for all the other duties consultants undertake

in the course of the working week. These include pre- and

post-operative visiting, on call, audit, teaching, research and

management. Increasingly, the number of sessions allocated


to pre- and post-operative visiting may vary depending upon

the content of the job plan. Equally, out of hours emergency

duties are increasing in many hospitals and such clinical

commitments should be recognised.

Some job descriptions now include specific reference to

candidates indicating which area of non-clinical activity

they would wish to become involved in (and the resources

that may be needed). In this way, the clinical director, the

Trust and the successful applicant are aware of their

responsibilities for making correct use of these non-fixed

sessions. If an individual consultant does not wish to get

involved in the wider activities of the department or other

aspects of health care at local, regional or national level,

then it would seem more than reasonable for them to be

expected to undertake a greater clinical workload.

Person specificationCare should be taken when developing a person

specification. It is important that the essential criteria are

carefully considered: it is quite possible to exclude all

applicants by including a series of demanding essential

criteria. Equally, some person specifications are so vague

that it becomes impossible to exclude any applicants from

the short-list. If a department wishes for specific qualities in

an applicant, these must be part of the essential criteria, but

be careful not to exclude those candidates you hope may

apply! The person specification should determine who is

short-listed – it is for the interview panel to decide finally

whether any, or all, of the short-listed candidates are, or are

not, suitable for the post.

ConclusionJob descriptions should give a clear indication of the duties

of the post, as well as providing as much relevant

information as possible about the Trust and the

department. Once advertised, this should not be changed;

any subsequent changes may contravene equal

opportunities legislation and must be discussed fully with

the local Human Resources Department and RA.

Job plans are the basis on which a consultant’s working

week is structured. They should be designed in a way that

allows the individual to maintain core skills, whilst

providing a stimulating and satisfying professional working

life. I suggest that, in general, the usual seven fixed session

job plan with an ‘interest’ should contain three to four

general sessions, one to two sessions in the specialty area

and two fixed flexible sessions. This should ensure a

satisfying professional clinical component, whilst providing

some flexibility to the department and the Trust.

More senior members should also be prepared to amend

their job plans accordingly – this should ensure that new job

plans continue to include attractive sessions.

The non-fixed sessions should recognise the extra non-

clinical work that an individual consultant undertakes – some

will require more than the normal three sessions to carry

out such duties, whilst a few may require less if they do not

undertake any other professional activities outside the clinical

area, or have a weekly clinical commitment that is not perceived

to require significant additional time for pre- and post-operative

visiting. I anticipate increasing pressure on consultants to

demonstrate that such time is being used appropriately.

FinallyThe views expressed are my own and do not necessarily

reflect those of the College Council. Further, all may change

if time sensitive contracts are accepted and introduced.

References

1 The National Health Service (Appointment of Consultants)

Regulations 1996. Good Practice Guidance. NHSE.

2 DoH gives managers training to locally implement contract.

Hospital Doctor 24 April 2003, Page 4.

3 Guidance on Contracts and Workload for Consultant

Anaesthetists 1997. Assn of Anaes of Gr Brit and Ire, June 1997.

4 Tomlinson A. Anaesthetists and the care of the critically ill

child (Editorial). Anaesthesia 2003;58:309–311.

5 Simpson PJ. Formula for establishing sessional shortfall on

accreditation visits. Roy Coll of Anaes Bulletin 2003;20:1011.

As consultant numbers increase and the consultant to

trainee ratio also increases, the old fashioned view that

trainees cover consultant absences is no longer tenable. A

failure to acknowledge or address this has resulted in major

shortfalls in anaesthetic staffing in some hospitals, with

serious adverse effects on training. This is a suggested way

of establishing the magnitude of the shortfall, to inform

discussions with Trust management and the College.

Establish current situationNumber of consultants.

Number of NCCG’s and other career grade staff.

Number of FIXED sessions each contributes, including

sessions in ITU, acute pain, chronic pain, obstetrics,

NCEPOD lists, etc. Also include total number of FIXED

FLEXIBLE sessions currently available in the Department

to cover leave.

You should not normally include true on-call sessions (as

opposed to trauma and NCEPOD) since these are flexible

sessions, which are covered prospectively by others on the

rota, under the current contract.

Establish number of fixed sessions which have no career

grade staff attached to them and are therefore regularly

undertaken by trainees.

Establish number of fixed sessions in a full-time anaesthetic

contract in that hospital and Region. Normally seven, but

some do six (plus one for early starts and late finishes).

CalculationsConsultants are entitled to six weeks annual leave, two

weeks study leave and on average need two weeks of

professional leave (management meetings, training,

lecturing and education, regional and national duties, etc),

i.e. they are away for ten weeks per year and therefore only

available for 42 weeks per year.

Thus ten weeks per consultant need covering by another

career grade member of staff, preferably another consultant,

i.e. 70 sessions.

If every consultant had one FIXED FLEXIBLE session to

cover colleagues’ absences, this would provide 42 sessions

per year. {Some would argue that the number of fixed

sessions per consultant needing cover would fall to 60 (6 x

10 weeks), but this is not actually true, since their flexible

commitment also needs covering}. This means that for

every consultant’s planned absences, at a one flexible session

per consultant contract rate, 1.67 colleagues (70/42) are

need to cover leave or, put another way, every full time

consultant actually needs at least 1.5 FIXED FLEXIBLE

sessions, or every other one needs at least two.

Transposed into most departments which have some

flexible provision, this means that all new appointments should

have at least two fixed flexible and only five fixed sessions.

The same rules obviously apply to NCCGs who are

fulfilling fixed commitments and whose planned absences

are the same. It could be argued that they do not need

professional leave so that their sessional absence is 56 (8 x

7), but some of course undertake eight or more fixed

sessions. Obviously they too should have fixed flexible

sessions unless their absences are to be covered by

consultants, rather than NCCG colleagues.

Other considerationsSince five or six fixed sessions equates with a new career

grade member of staff ’s salary, there is no excuse for any

department to have more than four or five fixed sessions

which are undertaken by trainees

These calculations take no account of covering long-term

absences due to sickness, suspensions and Clinical Director,

Medical Director and other Trust based managerial duties,

which should be covered by locums but which are frequently

not. Furthermore the situation is often made worse by

consultant retirements and resignations and a temporary or

permanent failure to recruit to fill the vacancy.

New consultant and NCCG contractsAlthough these calculations are based on the current

consultant contract, they are directly transposable to any

new contract. If a fixed session is four hours, then every

full-time Consultant and NCCG needs to have at least six

and probably seven to eight hours of FIXED FLEXIBLE

time built into his or her contract.


Formula for establishing sessionalshortfall on accreditation visitsDr P J Simpson, President

The College would like to congratulate

Professor T Cecil Gray (above left with

Dr Peter Wallace, President of the

AAGBI), a Past Dean of the Faculty of

Anaesthetists, who celebtrated his 90th

Birthday recently. Professor Gray was

Guest of Honour at the 55th Anniversary

Dinner which was held at the Institute of

Electrical Engineers in London on

Wednesday, 19 March. He was presented

with the Sir Ivan Magill Gold Medal from

the Association of Anaesthetists. The

medal was instituted in 1988 to

commemorate the centenary of the birth

of the pioneer anaesthetist Sir Ivan Magill,

and is awarded for uniquely outstanding

innovative contributions to the specialty

of anaesthesia.

At the same dinner, Mr Mark

Haywood, Managing Director of Abbott

Laboratories, and Mr Robert Spencer,

Finance Director of Datex-Ohmeda,

accepted the award of the Humphry Davy

Prize on behalf of their respective

companies. The prize was awarded in

recognition of the contribution each

company has made to the work of the

College and clinical anaesthesia. This is

the first time the College has recognised

industrial partners in this way.

NorthernDr L edmondson, Wansbeck Hospital,Ashington (Acting Tutor from 1 March 2003 forsix months covering the College Tutor’sabsence on maternity leave)

YorkshireDr T R Riad Henein, Dewsbury District Hospital(in succession to Dr O Maher)

North Thames (West)Dr A Wijetunge, Central Middlesex Hospital(in succession to Dr R A Griffin)

North Thames (Central)Dr R C Khiroya, Chase Farm Hospital, Enfield(in succession to Dr B F Munro)

Mersey*Dr B D Weldon, University Hospital, Aintree

South Trent*Dr N D Platt, Grantham and District Hospital

Wales*Dr A Valijan, Ysbyty Gwynedd, Bangor(second term extended by 12 months)*Dr W C Edmondson, Wrexham MaelorHospital

West MidlandsDr T J McLeod, Birmingham HeartlandsHospital (in succession to Dr J M James)

In addition to those names listed in the

May 2003 Bulletin for the meeting of

Council held on Wednesday, 19 February

2003, the following was approved for the

Diploma of Fellow of the College

(University of primary medical

qualification in brackets):

Nilmini Wijesuriya (Vinnitsa Medical Institute)

At a meeting of Council on Tuesday, 18

March 2003, Professor J A W Wildsmith

(Dundee), Dr A J Mortimer (Manchester),

Dr K R Myerson (East Sussex),

Dr J D Greaves (Newcastle upon Tyne)

and Dr S C Glover (South Yorkshire) were

admitted to Council following the

Election on Wednesday, 5 March 2003.

Dr P J Simpson (Bristol) was elected

President for 2003–2004, Dr D M Justins

(London) was elected Senior Vice-

President for 2003–2004, and

Dr D A Saunders (Southampton) was

elected JuniorVice-President for

2003–2004. Dr J E Charlton (Newcastle

upon Tyne) and Professor N Franks

(London) were awarded the College Gold

Medal. Dr L Bardosi (Liverpool), Dr J R

Darling (Belfast), Dr C F Heidelmeyer

(Bristol) were admitted to the Fellowship

ad eundem.

The following were appointed Regional

Advisers:

North WestDr D M Nolan, Wythenshawe Hospital,Manchester

West MidlandsDr A F Malins, Queen Elizabeth Hospital,Birmingham

The following were appointed/re-

appointed College Tutors (re-

appointments are marked with an asterisk):

AngliaDr F D Spears, Luton and Dunstable Hospital,(in succession to Dr A J Twigley)

Report of meetings of Council


Mr Mark Haywood

Mr Robert Spencer

Dr J Edmond Charlton

Throughout his career Ed Charlton has

worked tirelessly to promote good practice,

to protect the welfare of patients and, very

importantly, to protect the status of

anaesthetists. Two of his greatest

contributions have been to regional

anaesthesia and pain management. Ed

learnt about these in Seattle during a

golden era for regional anaesthesia, and at

the time when pain management was

emerging as a sub-specialty. After his

return from the USA he established pain

management in Newcastle upon Tyne and

bounded onto the national stage.

He served with distinction as a Council

Member, and then as President, of the Pain

Society during a period when the Society

metamorphosed into a vibrant, multi-

professional organisation. He was a

distinguished secretary of the International

Association for the Study of Pain. It is

impossible to overstate the value of his

contributions to the College’s Pain

Management Committee. He was a

distinguished Honorary Secretary of the

Association of Anaesthetists and, whilst

Editor of Anaesthesia News, battled hard to

obtain a rightful place for anaesthesia and

pain management in the medical and

political firmaments. His critical abilities

have been employed to advantage in many

other editorial activities but most especially

for the journal Pain.

He has been a splendid ambassador for

British anaesthesia and pain management.

Ed has achieved all this armed with a

deeply seated mistrust of bombast and

humbug. With his subdued and

understated style he has prevailed because

of hard work, common sense and reasoned

arguments. The College Gold Medal is

awarded to distinguished Fellows of the

College or scientists working in the field of

anaesthesia. Ed Charlton is indeed such a

distinguished Fellow.

Dr D M Justins

Professor Nick Franks

Professor Nick Franks graduated with a

degree in Physics and joined Maurice

Wilkins at King's College London where he

completed his PhD in 1975. His PhD work

using X-ray and neutron diffraction to

study membrane structure laid the

foundations for his work on anaesthetic

mechanisms.

This has shown that the traditional

view, that general anaesthetics acted by

perturbing the structure of neuronal cell

membranes, was incorrect. His work has

led to the generally accepted view that

general anaesthetics act by directly and

selectively binding to a small number of

protein targets in the central nervous

system. He is one of the world's leading

authorities on the mechanisms of

anaesthetic action and has received grants

from both the UK Medical Research

Council and the US National Institutes of

Health. He is currently Professor of

Biophysics and Anaesthetics at Imperial

College, holds joint appointments in the

Departments of Biological Sciences and

Anaesthetics, and is Head of Biophysics at

the Blackett Laboratory.

Professor Nick Franks has a long list of

published work to his credit and has a truly

international reputation. His research and

insight have led to fundamental changes in

our understanding of the mechanisms of

anaesthesia.

Professor G N C Kenny


At a meeting of Council on Wednesday,

21 May 2003, the following Regional

Adviser was re-appointed:

Nottingham and East Midlands*Dr B Riley, University Hospital, Nottingham

The following Deputy Regional

Adviser was appointed:

North Thames (East)Dr K J Wark, Barts and The London NHS Trust

The following Regional Advisers in

Pain Management were appointed:

Leicester and South TrentProfessor D J Rowbotham, Leicester RoyalInfirmary

North Thames (West)Dr A C Rice, Chelsea and WestminsterHospital

The following College Tutors were

appointed/re-appointed (re-appointments

marked with an asterisk):

Yorkshire*Dr G Reah, Calderdale Royal Hospital, Halifax

North Thames (Central)Dr A I H Khalil, King George Hospital,Goodmayes (in succession to Dr D G Martin)*Dr I A Walker, The Hospital for Sick Children,Great Ormond Street

WessexDr D P Murray, Salisbury District Hospital(in succession to Dr K N Duggal)Dr D G C Quick, Dorset County Hospital,Dorchester (in succession to Dr A J Wilson)

South Thames (West)Dr B J Liban, St George’s Hospital (insuccession to Dr G M Farnsworth)

Nottingham and Mid TrentDr K J Girling, University Hospital, Nottingham(in succession to Dr A M Norris)*Dr B T Langham, Southern Derbyshire AcuteHospitals NHS Trust

WalesDr V M O’Keeffe, Glan Clwyd District GeneralHospital, Rhyl (in succession to Dr A C LFraser)

At a meeting of Council on Wednesday,

9 April 2003, the following Regional


MerseyDr A R Bowhay, Royal Liverpool Children’sHospital

The following Deputy Regional


South East ScotlandDr C H Young, Royal Hospital for Sick Children,Edinburgh

The following Regional Advisors in

Pain Management were appointed:

NorthernDr J H Hughes, The James Cook UniversityHospital, Middlesbrough

North Thames (West)Dr A C Rice, Chelsea and WestminsterHospital

Sheffield and North TrentDr D Graham, Doncaster Royal Infirmary

The following College Tutors were

appointed/re-appointed (re-

appointments marked with an asterisk):

NorthernDr G A Lear, Sunderland City Hospitals (insuccession to Dr J H Carter)

North WesternDr T A Oldham, Royal Lancaster Infirmary (insuccession to Dr C B W Till)*Dr V Gadiyar, Fairfield General Hospital, Bury

South Thames (East)*Dr J A R Pook, Lewisham Hospital*Dr A Martin, Bromley Hospital*Dr R C Leech, Maidstone Hospital

The following were recommended to

the Specialist Training Authority for the

award of a Certificate of Completion

of Specialist Training having

satisfactorily completed the full period

of higher specialist training in

anaesthesia:

OxfordDr Gary David Baigel

Dr Alexandra Sian Bullough

Dr Felicia Nwanne Umerah

Dr Venkatraman Hariharan

Dr Julian Kurt Berlet

TrentDr Mark Jeffrey Ehlers

Dr John Paul Harris

Dr Anthea Catherine Pinder

Dr Ivan Llewellyn Marples

Dr Ashraf Fakhry Farid

Dr Michael Richard Wild

Dr Rebecca Victoria Martin

Dr Cindy Horst

Dr Pamela Judith Wake

North Thames (West)Dr Simon Geoffrey Clarke

Dr Matthew Bruce Hacking

Dr James Gilbert

Dr Malcolm Paul Gunning

Dr Ian Appleby

Dr Peter David Alexander

Dr Amer Mehmood Qureshi

Dr Kathleen Hempenstall

Dr Mark David Esler

North Thames (Central)Dr Alexander Jack Duncan Parry-Jones

Dr Maxim Daniel William Nicholls

Dr Murali Thavasothy

Dr Anthony Michael Roche

Dr Sally Jane Harrison

Dr Premila Arunasalam

North Thames (East)Dr Marie Clare Sheppey

Dr Hassan Jabbar Shaikh

Dr Ian Mcgovern


South Thames (West)Dr Keith Ian Mitchell

Dr Joanne Louise Norman

Dr Jonathan Warwick Redman

Dr Wisam Ali

South EasternDr Magnus Fraser Dunsire

Dr Michael William Frost

Dr Emma Louise Alcock

Dr Fiona Dawne Chadwick

Dr Suparna Das

Dr Vadim Iakimov

Dr Sadik Kunnath Kodakat

Dr John Alexander Prickett

Dr Fiona Jane Baldwin

Dr Werner Friedrich Hauf

South WesternDr Jonathan James Paddle

Dr Tracey Jane Clayton

Dr Anthony John Matthews

Dr Robyn Mary Harry

Dr Mark Richard Pyke

Dr Peter Nigel Brook

WessexDr Rachel Anne Haden

Dr William Robert Garrett

Dr Michael Thomas Williams

North WesternDr Claudia Shiren Rebmann

Dr Justin Andrew Turner

Dr James Alexander Kenningham

Dr Zulfiqar Ali Sadiq

Dr Kamran Abbas

Dr Isma Razzaq

Dr Peter Ruther

Dr Simon Richard Scothern

MerseyDr Lawrence Anthony Mccrossan

Dr Maria Enyuia Araba Akrofi

Dr Helen Alexandra Binns

Dr Jonas Appiah-Ankam

Dr Scott Alexander David Miller

Dr Jonathan Barry Kendall

Dr Richard John Dodd

West MidlandsDr Shelly-Ann Jurai

Dr Sujatha Chari

Dr Thomas Michael Perris

Dr Jeremy Simon Thomas

Dr Julian Paul Chilvers

NorthernDr Claire Susan Mcgregor

Dr Emilio Jose Garcia

YorkshireDr Zahid Rafique

WalesDr Susan Ann Jeffs

South East ScotlandDr Philip Neal

Dr Samantha Jane Moultrie

Dr Lindsay Donaldson

West of ScotlandDr Valerie Lochhead

Dr Kevin Stephen Canavan-Holliday

Northern IrelandDr Aideen Anne Marie Keaney

Tri-ServicesDr James Kelvin Ralph

Dr Paul Richard Hughes

Dr Duncan Anthony Francis Parkhouse

Dr Samuel Pambakian

Dr Martin Joseph Ruth

Dr Michael Keith Peterson


Examination papersMadam, – I noted the history questions in

the first DA examination paper with

interest (Bulletin 19, May 2003).

Shortly after becoming a consultant in

1970 I wrote to Anaesthesia making the

point that it was time for a scientifically-

based specialty to give up the historical

questions, of which the latest was: ‘Give an

account of the history of endotracheal

intubation’. I proposed that one could

demonstrate a knowledge of scientific

anaesthesia by answering: ‘Give an

account of how the difficulties and

problems of endotracheal intubation have

influenced its development’ without, as I

put it: ‘Remembering useless names and

dates’. I was not prepared for the result.

The editor, Dr Bryce-Smith passed it to

the Chairman of the Examiners who

replied in a vituperative way, slating me

for criticising: ‘The hard-working body of

examiners, who work only for the

profession, and who are unable to reply

publicly to criticism’. He said that it was

known that ‘some candidates do not

bother to learn history, rather relying on

their ability to answer the other questions’.

In fact, this had been my technique. He

demanded that I withdraw my letter.

How different from today when so many

details of the examination are made

public, and have been defended openly.

Bryce-Smith, one of the greatest ‘names’ in

anaesthesia, treated me most politely, and

sent a copy to the Dean, Cyril Scurr, who

wrote congratulating me on my re-

working of the question. Unfortunately

the Chairman of the Examiners died

during our correspondence, but the

history questions ceased almost

immediately.

A Murray Wilson, retired Consultant,Sheffield

President’s StatementMadam, – I have enjoyed Professor

Hutton's statements. They show a man of

wide and deep culture who can easily

quote from history and literature and who

show us the context within society in

which the medical profession and our

specialty lives and develops.

I doubt, however, that part of his last

statement (Bulletin 19, May 2003) will

impress many of the clinicians in the

NHS. By publishing figure 1 about the

salary distribution in the UK I don't know

if Professor Hutton is trying to shame us

for earning close to the top of the scale or

suggesting that we should be happy with

what we earn if we compare ourselves

with the rest of the British population.

It is difficult to accept that other

professions of similar degree (i.e. lawyers)

earn easily more than we do. This is the

context where we should compare our

salaries. Our long training years, long

working hours, the amount of stress

involved when lives are in our hands and

the huge responsibility that we have all the

time do not seem to be recognised enough.

So the ‘myth of medicine that we are

underpaid for what we do’ is not a myth,

it is a reality and, on a light note, I include

these contributions from doctors.net.uk

that may illustrate the point:

GP notices his plumber is driving a Porsche.

‘I can’t afford a Porsche on my earnings’

grumbles the doctor. ‘Neither could I’ says

the plumber, ‘when I was a GP.’

‘I was chatting to one of my mates (a

plumber) at my local pub this lunchtime.

He’s on-call for the weekend: £50 call-out

fee then £75 per hour or part hour worked

plus parts. He reckons he’ll get nine to ten

calls. Nice work if one can get it. So this

Sunday he’ll earn at least £1,200.’

‘The self-employed electrician rewiring my

house turns over £120,000-a year-profit.’

J Nunez, Consultant, Huddersfield

Breaking bad news andgiving informationMadam, – I hope that the excellent article

by Dr C Heaven (Bulletin 19, May 2003) is

widely read and the advice it contains put

into practice. I feel, however, that in an

attempt to be concise yet comprehensive,

a few important points concerning

breaking bad news that I learned during

my time as a Macmillan Consultant in

palliative medicine have been omitted.

Before starting to give bad news, it is

imperative to confirm the identity of the

person or persons to whom you are

talking and to clarify their relationship

with the patient. Likewise, you should

ensure that they know who you are and

what your role is or has been in the

management of the patient. I also believe

it is very useful for the bringer of bad

news to be accompanied, if possible, by a

member of the nursing staff who has been

involved in the patient’s care. Not only can

they fill in practical details of the patient’s

treatment, of which you may not have

been aware, but they can also help comfort

the relatives if they become emotional.

It is well recognised that when a lot of

new information is given, especially to a

distressed person, only a limited amount

is retained. As well as inviting further

questions at the end of an interview, it

was always my practice to tell the relative

that I was sure other questions might

come to mind after they had left and to

invite them to contact me or the nurse

again. We would be happy to answer any

further questions or go over anything that

wasn’t clear.

Finally, in these litigious times, it

would be wise to record who said what

and to whom.

WF Casey, Consultant, Gloucester

CorrespondencePlease make your views known to us via email (preferred option) to: [email protected], or by post accompanied by an electronicversion on floppy PC disk, preferably written in Microsoft Word (any version), to: The Editor, c/o Mrs Mandie Kelly, Editorial Officer,The Royal College of Anaesthetists, 48/49 Russell Square, London WC1B 4JY. Please include your full name, grade and address.All contributions will receive an acknowledgement. The Editor reserves the right to edit letters for reasons of space or clarity.


The Mersey SchoolAnaesthesia and Perioperative Medicine‘If you feed the children with a spoon, they will never learn to use the chopsticks’


Final FRCA (Booker)Course6–10 October 2003 and 13–17 October 200319–23 April 2004 and 26–30 April 2004

Two weeks of SAQ practice and analysis,MCQ practice and analysis andlectures/tutorials.

Candidates may register for both weeks or foreither one of the two weeks. Places arelimited to 30 people.

SAQ Weekend Course12–14 September 2003

Master classes in style and technique.Supervised practice and analysis. Pleasenote that places are limited.

Mersey SelectiveCourse29 September to 3 October 200316–20 February 2004

A five-day course of lectures and tutorialsdesigned to cover some of the more esotericaspects of the Primary Basic Sciences notadequately explained in the standard texts.(Trainees are advised to consider this coursetwo to three months ahead of the MCQ paper).

Basic ObstetricAnaesthesia Course11 November 2003

A one-day course on the Practice and Theoryof Obstetrical Anaesthesia specificallydesigned for SHOs as an introduction toMaternity Unit responsibilities.

Primary Prep Course –(OSCE/Orals)10–26 September 2003 (waiting list only)16–23 January 20047–14 May 2004

A seven-day course of Master Classes, OSCEand Viva Practice, available only to traineeswho have been successful in the precedingMCQ paper.

(Failure to ‘get a viva’ will guarantee a placeon the following course if required).

Primary Prep Course –(MSQ17–22 August 2003 (waiting list only)23–28 November 200328 March to 2 April 2004

A six-day course of intensive MCQ analysisintended only for candidates within weeks ofsitting the Primary FRCA Examination.

For further details and applicationforms, please see our websitewww.msoa.org.uk

Journals wantedThe Horst-Stoeckel Museum in the University of Bonnis seeking to complete its collection of Britishanaesthetic journals. In order to do so it requires thefollowing issues:

British Journal of AnaesthesiaVol.68 (1992) to Vol.89 (2002)Vol.88 (2002) nos 1–5Vol.89 (2002) no 1Vol.90 (2003) nos 2–3

AnaesthesiaVol.1 (1945) to 28 (1973)Vol.38 (1983) and Vol.39 (1984)Vol.47 (1992) to 53 (1998)

Any readers or departments in a position to assist arerequested to contact Professor G Smith, UniversityDepartment of Anaesthesia, Critical Care and PainManagement, Leicester Royal Infirmary, Leicestertel 0116 2585291 email [email protected]

Examinerships 2004–2005The College invites applications for vacancies forexaminerships in the academic year 2004–2005.Examiners will normally be recruited to the Primaryexamination in the first instance, although applicantsare invited to indicate an interest in the Finalexamination on the application form.

Precise numbers of vacancies are not known at thetime of going to press but we envisage approximately12 vacancies.

Applicants should normally be Fellows of the College,in a consultant post or equivalent for at least sevenyears and a visitor to at least one FRCA examinationwithin five years of applying.

Application forms and information for applicants maybe obtained from Ms Victoria Lloyd, Training andExaminations Directorate by tel 020 7908 7319,email [email protected] or via the Examinationspages on the College website(www.rcoa.ac.uk/examinations).

The closing date for receipt of completedapplication forms is Friday, 31 October 2003.

Election to the ScottishBoard 2003There are no retiring members from theScottish Board in 2003 and there willtherefore be no election. However, threevacancies will arise on the Board next yearand a notice will appear in the July 2004Bulletin giving further details.


The Association ofAnaesthetists of GreatBrtain and IrelandGAT Annual Scientific Meeting17–19 September 2003, Bristol University

More detailed information on this and other meetings canbe obtained from the Association of Anaesthetists of GreatBritain and Ireland, 21 Portland Place, London WC1B 1PYtel 020 7631 1650 fax 020 7631 4352email [email protected] website www.aagbi.org

Bristol Medical SimulationCentreForthcoming courses for 20038–9 July – Two-day Paediatric Anaesthesia Critical Incidents, foroccasional paediatric anaesthetists (£275)

5 September – Medical Emergencies Course, for SpRs andconsultants in emergency medicine, ITU and anaesthesia (£200)

9 October – Low-Flow Anaesthesia Course, for anaesthetists (£150)

14 October – NCCG Critical Incidents Day, for non-consultant careergrade anaesthetists (£150)

16–17 October – Transport for the Critically Ill Course,for all grades (£275)

21 October – Paediatric Anaesthesia Critical Incident Day, foroccasional paediatric anaesthetists (£160)

22–23 October, Team Training for Critical Incidents, for nurses andclinicians (£270)

Fees include coffee, tea, biscuits and lunch. All coursesapproved for 5 CEPD points (one day) and 8 points (two days)

For further information, please contact: Mr A Jones, CentreManager, The Bristol Medical Simulation Centre, UBHT EducationCentre, Level 5, Upper Maudlin Street, Bristol BS2 8AEtel 0117 342 0108 email [email protected] http://simulationuk.com

PANGPain and Nociception Group

Goes North!Regional anaesthesia – what’s new?Friday, 14 November 2003The Conference Centre, UMIST, Manchester

● Pharmacology of local anaesthetics.● Combined regional techniques.● The brachial plexus – common blocks.● Useful lower limb blocks.● Regional techniques in children.● Nerve injury – complications.● Obstetrics – specific requirements.● Local anaesthesia for the eye.

Registration fee: £150 (trainees: £100)Concessionary rates available.

Further information is available from: Mrs S Welham,PANG Administrator, 7 Dover Road, Sandwich, KentCT13 0BL tel/fax 01304 612520 mobile 07801 930370website www.pangmeetings.com

Approved for CEPD purposes

Everything you wanted to knowabout being a Consultant butwere afraid to ask!Establishing and Developing as a Consultant20–21 November 2003The National Liberal Club, Whitehall Place, London SW1(PGEA Approved) 9 CEPD points(PGEA Approved) 9 CEPD points

This is a two-day seminar intended for consultants and senior SpRs,and is based on the format of previous successful meetings. Thetopics addressed cover much of the non-medical knowledge usefulfor consultant life, and often difficult to find. Subjects coveredinclude contracts and negotiation, NHS and hospital politics, medicalprotection and dealing with complaints, discretionary points, and anextensive guide to starting in and developing private practice.Within a unique venue there will be ample opportunity for questions,debate and one to one discussion.

For the full programme and on-line booking, please visit:www.everythingyouwantedtoknow.co.uk

Registration fee includes all refreshments, post meeting drinks andflight on The London Eye. Two days: £300. One day: £250. There isa 25% reduction for doctors in training.

You can contact us as follows: TowMed Courses, c/o SimoneSeychell, Department of Anaesthesia, Chelsea and WestminsterHospital, London SW10 9NH tel 020 8237 2763 fax 020 8746 8801email [email protected].


Appointment of Members, AssociateMembers and Associate FellowsThe College would like to congratulate the following who have been admitted:

MembersMarch 2003Dr Qussay Abdul H Al-MitwallyDr Shafquat Ali Shah

April 2003Dr Iftikhar Ali KhawajaDr Subramaniam Prakasha

May 2003Dr Mumtaz Begum HanidDr Periketi DayakarDr Anoob Mohamed PakkarDr Asma Ghazali

Associate MembersMarch 2003Dr Irfan Mazhar QureshDr Gehad George Elias Homsey

April 2003Dr William John KentDr Deivanayagam SankarDr Monisola O Adeyemi

Associate FellowsApril 2003Dr Nicholas Bruce ScottDr Edwin Ameuda Djabatey

May 2003Dr Kanchan Valli RatnamDr Zorica Jankovic

Appointment of Fellows toconsultant and similarpostsThe College would like to congratulate the following Fellowson their consultant appointments:

Dr Muthiah K Balasubramanian, Barnet General Hospital

Dr Fiona J Baldwin, Royal Sussex County Hospital, Brighton

Dr Surmed M Fadheel, Basildon and Thurrock NHS Trust,Essex

Dr Sleeba P Jacob, Scarborough Hospital

Dr Nicholas Levy, West Suffolk Hospital, Bury St Edmunds

Dr Lawrence A McCrossan, Royal Liverpool UniversityHospital

DeathsThe College regretfullyrecords the deaths of thefollowing Fellows:

Dr Allan Fisher,Beersheba, Israel

Dr Raymond Miller, NewYork, USA

Dr Thomas B H Strain,Birmingham

The Royal College of Anaesthetists48/49 48/49 Russell Square

London WC1B 4JYtel 020 7813 1900fax 020 7813 1876

email [email protected] www.rcoa.ac.uk

College SecretaryMr Kevin Storey

Deputy College Secretary andTraining and Examinations

DirectorMr David Bowman

Professional StandardsDirector

Mr Charlie McLaughlan

Examinations ManagerMr John McCormick

020 7908 7336

IT ManagerMr Richard Cooke

Courses and MeetingsMr Amit Kotecha020 7908 7347

Miss Chantelle Edward020 7908 7325

ansaphone 020 7813 1888fax 020 7636 8280

email [email protected]

Educational approval forSchools and hospitals

Ms Claudia Lally020 7908 7339

Individual TraineesMrs Gaynor Wybrow

020 7908 7341

Membership ServicesMiss Karen Slater

020 7908 7324

Subscriptions020 7908 7329


Documents

July 2003 Inside this issue - The Royal College of … 2003 BULLETIN 20 THE ROYAL COLLEGE OF ANAESTHETISTS Inside this issue TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Aspects