Less than full time: Boldly going where not many men have gone

NEWSANAESTHESIA

ISSN 0959-2962 No. 309

APRIL 2013

The NewsleTTer of The

AssociATioN of ANAesTheTisTs of GreAT BriTAiN

ANd irelANd

INSIDE THIS ISSUE: Fire on intensive care caused by an oxygen cylinder

Anaesthetic confusion on the delivery suite

Trainee survey on workforce planning

2 Anaesthesia News April 2013 • Issue 309 Anaesthesia News April 2013 • Issue 309 3

03 Editorial 05 President’s report

07 The AAGBI and Clinical Excellence Awards (CEAs) 08 Fire on intensive care caused by an oxygen cylinder 10 Anaesthesia Digested 11 Trainee service lead: Management experience for trainees in the Birmingham School of Anaesthesia 13 Making our events greener 14 Anaesthetic confusion on the delivery suite 16 WSM London review 18 From WSM with love 19 Less-than-full-time 22 Your letters

24 Particles

26 RCoA/GAT trainee survey on workforce planning

31 Education committee report 33 New for 2013! Anaesthesia Cases 35 @AAGBI Recap

contents

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08

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76,999 TO GO.

TODAY, TENS OF THOUSANDS OF OPERATING ROOMS DON’T HAVE A PULSE OXIMETER.

And without a pulse oximeter, millions of lives are put at risk. That’s why scores of hospitals, medical organizations and private donors are taking a stand against unsafe surgery. They’re making contributions to send a pulse oximeter to an operating room in need. And they’re ensuring that all patients have access to the care they deserve.

77,000 ISN’T A SMALL NUMBER. BUT IT’S NOT AN IMPOSSIBLE ONE. TOGETHER, WE’LL MAKE IT ZERO.

Visit www.lifebox.org/makeitzero to become part of the mission. © 2012 Lifebox Foundation. Registered as a charity in England and Wales (1143018).

Saving lives through safer surgery

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The Association of Anaesthetists of Great Britain and Ireland21 Portland Place, London W1B 1PYTelephone: 020 7631 1650Fax: 020 7631 4352Email: [email protected]: www.aagbi.org

Anaesthesia NewsChair Editorial Board: Felicity Plaat Editors: Kate O’Connor (GAT), Val Bythell, Richard Griffiths, Nancy Redfern, Sean Tighe, Iain Wilson and Tom WoodcockAddress for all correspondence, advertising or submissions: Email: [email protected]: www.aagbi.org/publications/anaesthesia-news

Design: Christopher SteerAAGBI Website & Publications Officer Telephone: 020 7631 8803Email: [email protected]: Portland Print

Copyright 2013 The Association of Anaesthetists of Great Britain and Ireland

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3

Editorial

I write this looking out over snow-covered fields, hoping that by the time it arrives on your doorstep spring will be in the air.

I read the description of the fire with a combination of horror and admiration. I must admit that I complete my mandatory fire safety training, secretly thinking that if I was faced with a real fire I’d read the label on the extinguisher to see how to use it. Clearly this wouldn’t work in practice; finding the extinguisher would be challenge enough with visibility of less than a metre and acrid smoke would make my eyes water. The article and pictures bring into stark focus the difference between training and the real thing. Advice from the Department of Health to leave the fire to the professionals, evacuate the area and shut the doors, didn’t seem to be the best plan. Instead it was the quick thinking of two trainees who put the fire out that prevented a much worse situation. Involving the clinical psychologist on the day of the fire to discuss events with the staff, was very helpful and something the writers suggest we should include in any major incident plan.

But it’s not just fire fighting where trainees come into their own; other contributions show resourcefulness in other aspects of practice. One presents a guide to the confusing abbreviations used in the labour ward, for those new to obstetric anaesthetic practice. Others have increased their involvement in departmental management, introducing a Trainee Service Lead to improve trainees’ input into the management team and prevent trainee issues taking a back seat. A new flexible trainee reflects on finding himself as the only male, and suggests that in future there will be greater male participation in childcare, and increasing demands for flexible work patterns. The GAT/ RCoA trainee committee survey outlines the views of trainees on the changes being proposed to consultants’ jobs. Essentially the Centre for Workforce Intelligence predicts an oversupply of anaesthetists and have recommended cutting our numbers in favour of more GPs. Not good news, either for our trainees or for our future patients.

76,999 TO GO.

TODAY, TENS OF THOUSANDS OF OPERATING ROOMS DON’T HAVE A PULSE OXIMETER.

And without a pulse oximeter, millions of lives are put at risk. That’s why scores of hospitals, medical organizations and private donors are taking a stand against unsafe surgery. They’re making contributions to send a pulse oximeter to an operating room in need. And they’re ensuring that all patients have access to the care they deserve.

77,000 ISN’T A SMALL NUMBER. BUT IT’S NOT AN IMPOSSIBLE ONE. TOGETHER, WE’LL MAKE IT ZERO.

Visit www.lifebox.org/makeitzero to become part of the mission. © 2012 Lifebox Foundation. Registered as a charity in England and Wales (1143018).


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14


AAGBI COUNCIL ELECTIONS 2013

Nominations are now invited from members of the Association wishing to stand for election.

Further information and nomination forms are available from Gemma Campbell on 020 7631 8855, [email protected] or can be downloaded from the AAGBI website www.aagbi.org/about-us/council

Closing date – Friday 12 April 2013

CALL FOR NOMINATIONS

Back in December 2012, the Doctors’ and Dentists’ Remuneration Body (DDRB) report on the future of Clinical Excellence Awards (CEAs) was published1. To those lucky possessors of CEAs, it made dismal reading, for its proposals included decreases in the absolute value of CEAs, the termination of their pensionable status, and the potential gift of more power in the awarding of CEAs or their next incarnations to managers. Perhaps more significantly, it proposed the creation of the post of Principal Consultant, a senior position attracting a salary of around £120,000 that could be awarded to up to 10% of existing consultants who are “experienced, high-performing... undertaking larger roles in terms of service delivery, expertise or leadership”. If this grade is created, can we have confidence that it will be filled by those who truly deserve it? Our experience with the distribution of CEAs in recent years suggests that the answer may well be “no”, so those charged with creating the processes by which these posts are awarded should exercise great caution lest they end up creating a system aimed at rewarding excellence that simply propagates the historical injustices of its predecessors. Let me justify these statements by analysing the results of the current CEA system.

In the table below, I have calculated the relative numbers of national CEAs given to consultants in the major hospital specialties, expressing them as a ratio of the number awarded to the number that each specialty would get if CEAs were awarded pro rata, i.e. 16% of NHS consultants are anaesthetists; if they were given 16% of the awards, their ratio would be 1.0. In 2008 and in 2011, and in almost every year in living memory, anaesthetists have come out worst in any such league table. In the last pre-credit-crunch award round in 2008, there were 576 national awards. This has been decreased to about half of this number in the last four years. The effect of this decrease has been to increase the degree of iniquity. In 2008, physicians were three times more likely to get an award than anaesthetists. In 2011, they were six times more likely.

The leaders of our specialty have for many years engaged with those responsible for the awards systems in an attempt to persuade them that the application forms and assessment processes best suit the large, bed-owning specialties. We have repeatedly been told that the procedures are “robust and objective”3, and that those anaesthetists who apply for national awards have an excellent chance of getting them. However, this belies the truth that proportionately far fewer anaesthetists apply for awards than any other specialty, and one reason for this is that far fewer anaesthetists are in a position to apply for national awards than their colleagues in other specialties, for the local award systems that feed the national system give anaesthetists fewer awards. If you download the latest lists of consultants holding both local and national awards (the “Nominal Rolls”4), you will find that although there are only 25% more physicians than anaesthetists in the NHS, the number of physicians who hold local awards is 65% more than anaesthetists. Perhaps more importantly, the physicians who hold local awards have more points than the anaesthetists. The ACCEA’s own data3 show that your chances of getting a Bronze National Award are much better if you have a level 5 – 8 local award than if you have a level 1 – 4 award. Thirty-five per cent of those physicians who hold local awards are in this key “5 – 8 national launchpad” area, whereas only 24% of anaesthetists are so favoured.

What do I conclude from all these data? First of all, let me make it quite clear that I am not suggesting that physicians and surgeons are deviously manipulating the ACCEA system to benefit themselves and grind the anaesthetists down. These two specialties simply find themselves the leading beneficiaries of a system that has developed organically over decades and, as such, they are highly unlikely to make significant change to a system that has given them such advantages in terms of both status and financial reward – this is wholly understandable if not wholly admirable. We may sometimes feel that our medical and surgical colleagues do not hold us in high regard, but I have yet to meet one who held on to this view when they or their loved ones were in need of our professional services. However, these data do clearly suggest that the system is biased. Notwithstanding the ACCEA’s insistence that the process is “fair and equitable”, it is clear that a system that claims that one group of NHS clinicians is six times as clinically excellent as another group of their peers is likely to have fundamental flaws. The ACCEA makes great efforts to follow its award trends in terms of gender and ethnicity, but seems to ignore the fact that those hospital specialties that receive fewer awards are increasingly those that are the most feminised and those that are blessed with the highest proportions of ethnic minorities and overseas graduates.

President's RepoRt

On excellence and Principal Consultants

The AAGBI are connected with anaesthetists, industry and public through online social networks Facebook and Twitter.

@AAGBI AAGBI1 Table: 2008 and 2011 National Clinical Excellence Awards Ratio for major hospital specialties: if awards were distributed pro rata, the ratio for all specialties would be 1.0 (exact methods of calculation given in footnote)2,3.

1

President’s Report

On excellence and Principal Consultants Back in December 2012, the Doctors’ and Dentists’ Remuneration Body (DDRB) report on the future of Clinical Excellence Awards (CEAs) was published [1]. To those lucky possessors of CEAs, it made dismal reading, for its proposals included decreases in the absolute value of CEAs, the termination of their pensionable status, and the potential gift of more power in the awarding of CEAs or their next incarnations to managers. Perhaps more significantly, it proposed the creation of the post of Principal Consultant, a senior position attracting a salary of around £120,000 that could be awarded to up to 10% of existing consultants who are “experienced, high-‐performing... undertaking larger roles in terms of service delivery, expertise or leadership”. If this grade is created, can we have confidence that it will be filled by those who truly deserve it? Our experience with the distribution of CEAs in recent years suggests that the answer may well be “no”, so those charged with creating the processes by which these posts are awarded should exercise great caution lest they end up creating a system aimed at rewarding excellence that simply propagates the historical injustices of its predecessors. Let me justify these statements by analysing the results of the current CEA system. In the table below, I have calculated the relative numbers of national CEAs given to consultants in the major hospital specialties, expressing them as a ratio of the number awarded to the number that each specialty would get if CEAs were awarded pro rata, i.e. 16% of NHS consultants are anaesthetists; if they were given 16% of the awards, their ratio would be 1.0. In 2008 and in 2011, and in almost every year in living memory, anaesthetists have come out worst in any such league table. In the last pre-‐credit-‐crunch award round in 2008, there were 576 national awards. This has been decreased to about half of this number in the last four years. The effect of this decrease has been to increase the degree of iniquity. In 2008, physicians were three times more likely to get an award than anaesthetists. In 2011, they were six times more likely. Specialty 2008 CEA Ratio

(Total awards = 576) 2011 CEA Ratio (Total awards = 316)

Medicine 1.42 2.22 Surgery 1.25 1.24 Paediatrics 0.88 1.23 Pathology 1.20 1.14 Radiology 0.67 0.60 Psychiatry 0.65 0.45 Anaesthesia 0.43 0.37 Table: 2008 and 2011 National Clinical Excellence Awards Ratio for major hospital specialties: if awards were distributed pro rata, the ratio for all specialties would be 1.0 (exact methods of calculation given in footnote) [2,3].

The leaders of our specialty have for many years engaged with those responsible for the awards systems in an attempt to persuade them that the application forms and assessment processes best suit the large, bed-‐owning specialties. We have repeatedly been told that the procedures are

The President outlines the proposals made in the Doctors’ and Dentists’ Remuneration Body (DDRB) report on the future of Clinical Excellence Awards, pointing out the inequities of the current system and raising serious concerns about the idea of a management appointed grade of Principal Consultant. Whatever our views are of the system as a whole, he is clear that he will work hard on our behalf to make sure that any new system is fair.

Strong national leadership will certainly be appreciated in my department. A downhearted coffee room discussion on this topic was only trumped by rumours that the Trust was about to remove 100 places from the car park. The medical student doing her 6 week option in anaesthesia looked on with amazement as news spread round the theatre suite and the mood grew darker. She had been contemplating a career in anaesthesia, and still naively thought consultants and senior trainees might earn an element of respect. 3 days’ notice that we would have to park over a mile away didn’t seem to demonstrate this to her, and my rather weak attempt to give a positive spin by remarking on the solidarity amongst the anaesthetists, surgeons and theatre nurses in objecting to this, probably won’t do the trick. Personally I’ve given up the fight. My son has bought me a folding bike on Ebay and I’ll park on the street fairly near the hospital and cycle the rest of the way. I’m not relishing the prospect – I’m as fit as a South American sloth with a body that was never built for a bike. But with spring in the air perhaps I’ll change my mind – Principal Cyclist - now that is something to reward!

dr Nancy redfern

6 Anaesthesia News April 2013 • Issue 309

The AAGBi and clinical excellence Awards (ceAs) The Advisory Committee on Clinical Excellence Awards (ACCEA) issued a statement in November 20121 that indicated that the 2012 round of national awards would be complete by the end of February 2013, and that there may be a 2013 round to follow this. If things were uncertain at that time, they were made even more uncertain when the delayed Doctors’ and Dentists’ Remuneration Body (DDRB) report was published in December 20122. The sweeping changes recommended in this report will take some time to negotiate, alter and implement, so – at the time I write this in January 2013 – it is difficult to foresee exactly what will happen to local and national CEAs in 2013 and beyond. However, our best current guess is this:

• It is highly likely that there will be a 2013 national award renewal process.

• For the first time, it will be possible for citations to accompany applications for national award renewal.

• It is possible that there will be a 2013 round for new national awards, for which citations will form part of the process as usual.

• If a new award round takes place, it may do so at short notice, with only a month or two between its announcement and the closing date for applications. The guidance from the ACCEA quotes a possible launch in March 2013, with a closing date of June, but this is uncertain.

our current advice is as follows:

• If you are scheduled for a national award renewal (four years since your original award) or if you wish to submit an application for a new award, please prepare your application as soon as possible. Forms are available online1.

• The AAGBI will accept submissions from members for consideration for a citation and will announce its process on the website: www.aagbi.org and via our e-newsletter. The lead time for publication will not allow us to announce the process in Anaesthesia News, so please keep an eye on the website and newsletter.

• Members should also keep an eye on www.rcoa.ac.uk, as the College will use its website to announce its process as a nominating body.

Meanwhile, the AAGBI is engaging with the Departments of Health and the DDRB, and will continue to promote the interests of anaesthetists, intensivists and pain specialists. The current CEA system does not favour the award of CEAs to many AAGBI members that deserve them, and we will do what we can to make the current system fairer, and to make sure that any system that replaces it has equity built into it from the start.

If you have any questions about the AAGBI and CEAs, please email [email protected].

dr william harrop-GriffithsPresident

References1. http://www.dh.gov.uk/health/2012/11/clinical-excellence/

2. http://www.dh.gov.uk/health/2012/12/ddrb-report/

Anaesthesia News is the official newsletter of the Association of Anaesthetists of Great Britain & ireland.

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Call now for a media

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Whatever the merits or injustices of the current ACCEA system, the clear role of those leading our specialty is to do what they can to make sure that any system that emerges from the DDRB report is equitable. This is particularly true for the processes underpinning the promotion to any new grade such as that of Principal Consultant. Although there have been arguments in the past that awarding CEAs on a pro rata basis would steer the system away from one that focuses purely on clinical excellence, it is my personal view that the time is now right to insist that excellence awards and Principal Consultant posts be awarded to specialties on a pro rata basis. We comprise 16% of NHS consultants and our contribution to the work of the NHS is no less than that of any of our consultant colleagues in other specialties. We must be prepared to argue this case and, if necessary, to fight for what is fair.

I will leave you with three final comments. Firstly, there are those that have said that in the past, the leaders of professional medical organisations have been a little hesitant in their criticism of merit award and clinical excellence systems in part because they were past and potential future beneficiaries of these systems. I hope that by writing this article it will be clear that I am prepared to put my head well above the parapet in order to argue for equity. Secondly, I am well aware that many AAGBI members do not work in the English NHS, and that their own award systems, if any, are very different. The AAGBI will do what it can promote the interests of all our members. Finally, I know well that many AAGBI members have no interest whatsoever in the CEA system, and that some think it to be an obsession of a small group of senior clinicians. Further, it can be argued that if the whole CEA system were swept away in an instant and never replaced, the specialty that would suffer the least would be our own. Although my personal view is that some form of system should be retained if it can be made just and equitable, it may well be that the only awards system that is fair to all is no system at all. However, if, as seems likely, there is some form of Principal Consultant grade created in the NHS, the selection processes that underpin it must be constructed so as to be fair to all specialties. The AAGBI will do what it can to make this a reality.

dr william harrop-Griffiths, President

References1. http://www.dh.gov.uk/health/2012/12/ddrb-supplementary-

evidence/ 2. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/

PublicationsPolicyAndGuidance/DH_092419 3. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/

AnnualReports/DH_132860 4. http://www.dh.gov.uk/health/2013/01/nom-roll-jan-13/

Methods of calculation of figures in table:

A. Proportion of consultants in each specialty taken from the numbers of those eligible for Bronze Awards, page 20 of [3].B. “Major specialty” defined as one that has >5% of total NHS consultants.C. Total number of awards given in 2008 and 2011 rounds taken from [2] and [3].D. Total numbers of awards for each specialty in 2008 and 2011 taken from page 5 [2] and page 12 [3].E. The CEA Ratio is that of the number of awards given per specialty (D) to the number expected if awards were made pro rata, i.e. D/A*C.

Final FRCA Examination Intensive Preparation Course

The University Hospitals Bristol SAQ/MCQ/SBA

Preparation Course

Monday 8th to Friday 12th July 2013

This five day course includes sessions on examination technique, applied basic science, ITU, pain management,

hot topics and practical subjects.

Also mock examinations and performance analysis. Conducted by national and local experts

at Engineersʼ House, Clifton Down, Bristol

For further details, please contact: Jane McLean

Department of Anaesthesia Bristol Royal Infirmary

Marlborough Street, Bristol BS2 8HW

Telephone: 0117 342 3801 (direct line) e-mail: [email protected]

Website: www. bristolfinalfrca.com

Course Directors: Dr Kathryn Jackson FRCA, Dr Neil Muchatuta FRCA

Includes: Welcome dinner and course meal All lunches plus coffees and teas Digital copy of all lectures

£475

Early Bird Discount! £425 if booked before 6th May 2013

2013

Final FRCA Examination Intensive Preparation Course

The University Hospitals Bristol SAQ/MCQ/SBA

Preparation Course

Monday 8th to Friday 12th July 2013

This five day course includes sessions on examination technique, applied basic science, ITU, pain management,

hot topics and practical subjects.

Also mock examinations and performance analysis. Conducted by national and local experts

at Engineersʼ House, Clifton Down, Bristol

For further details, please contact: Jane McLean

Department of Anaesthesia Bristol Royal Infirmary

Marlborough Street, Bristol BS2 8HW

Telephone: 0117 342 3801 (direct line) e-mail: [email protected]

Website: www. bristolfinalfrca.com

Course Directors: Dr Kathryn Jackson FRCA, Dr Neil Muchatuta FRCA

Includes: Welcome dinner and course meal All lunches plus coffees and teas Digital copy of all lectures

£475

Early Bird Discount! £425 if booked before 6th May 2013

2013

Abstracts for presentation at the AAGBI Annual CongressDublin 2013

You are invited to submit an abstract for oral (free paper) or poster presentation at the Annual Congress. The deadline for submission is midnight on Monday 10 June 2013 and full instructions can be found on our Annual Congress microsite: www.annualcongress.org and on the AAGBI website: www.aagbi.org/education/events/abstract-submission-deadlines/annual-congress-abstract-submissions

After the deadline, a preliminary review of the abstracts received will determine which ones are accepted for presentation at the Annual Congress in Dublin. Some authors will be invited to present their work orally, under the following three categories: audits and surveys, case reports, and original research. The remaining successful authors will be invited to present a poster.

All accepted abstracts will be published in Anaesthesia in the form of a fully referenceable online supplement (NB Editor-in-Chief reserves the right to refuse publication, e.g. where there are major concerns over ethics and/or content).

Authors of the best free papers and poster(s) will be awarded ‘Editors’ Prizes’.

If you have any queries, please contact the AAGBI secretariat on 020 7631 8807 or [email protected]

CALL FOR ABSTRACTS


on the use of fire extinguishers, but at present it is not clear as to exactly who should receive this training and who should not.

Finally, we were extremely fortunate that the clinical psychologist attached to our ICU came into the hospital on the night of the ICU fire to debrief staff and to speak to those most severely affected. Many of the staff working that night have had a severe post traumatic stress reaction, and have been receiving help from him and his team over the past year. We feel that getting such input at such an early stage had an enormous beneficial effect, and that including such psychologist input in major incident planning should always be considered.

Whilst all hospitals already have a comprehensive policy for major incidents, such plans are not entirely applicable to an ‘internal emergency’ such as ours, where in-patients and clinical staff are victims of the emergency. Therefore, we hope that our suggestions might contribute to a more robust approach to this kind of scenario more widely in the NHS.

fiona KellyConsultant in anaesthesia and intensive care medicineRoyal United Hospital, Bath

James McdonaldST3 emergency medicineGreat Western Hospital, Swindon

References1. Kelly FE, Hardy R, Hall EA. Fire on an intensive care unit caused by

an oxygen cylinder. Anaesthesia 2013; 68, 102-104.2. Firecode: Fire Safety in the NHS. Health Technical Memorandum.

Department Of Health. 2007 (Part C: textiles and furnishings.)3. The Regulatory Reform (Fire Safety) Order 2005. HM Government.

Table 1: Suggested best practices when setting up and administering medical gases.

1. set up the cylinder for patient use before placing it close to the patient

The most likely time for an ignition to occur is either when the valve is initially turned on or when a flow is selected. Hence the advice is to:

a. connect the tubing and oxygen delivery device to the cylinder;b. slowly open the cylinder valve;c. select the prescribed flow rate;d. if required, check the gas is flowing;e. fit the oxygen delivery device to the patient.

2. Place the cylinder in an appropriately designed holder

Where possible, cylinders should be placed in holders designed to be fitted, ideally, to the bottom of the bed (or to the back of wheelchairs). The position of the holder needs to take account of how close the cylinder is to the patient. The holder should ideally keep the cylinder upright so that if there is an ignition its impact would be minimised.

Although cylinder holders and brackets are available, a suitable design is dependent on the specific bed or wheelchair being used. As the NHS uses many different types of hospital beds and trolleys, there is no single design that can be used in all situations and this remains an issue to be resolved. BOC Ltd are currently working with bed, trolley and wheelchair manufacturers to develop suitable cylinder supports.

3. Avoid placing the cylinder on the bed next to the patient if at all possible; use extra care when there is no option but to place the cylinder on the bed

There are times when there is no option but to place the cylinder on the bed or stretcher. If this is the only option, setting up and turning on the cylinder before putting the cylinder on to the bed will minimise the potential risk of injury to the patient.

The fire was put out by two doctors, using five fire extinguishers. The patient on the bed suffered burns to her lower legs but no other patient suffered ill effects. However, one member of staff was admitted overnight and another was kept in hospital for six hours with smoke inhalation injury. The Health and Safety Executive (HSE) investigation is on-going and their final report is awaited at the time of writing.

Following this fire, BOC has released recommendations on the use of oxygen cylinders (table 1) and these have been endorsed in a statement by the Association of Anaesthetists of Great Britain and Ireland (AAGBI).

The ICU staff involved have drawn up a list of issues that we are addressing in Bath and which could be considered by other ICUs and theatre suites. We should emphasise that the HSE investigation is still in progress and is likely to make recommendations of its own; however, this incident has many implications for patient safety and, in our view, a discussion at this stage is helpful. We have improved the way we carry out fire training for our ICU staff. Fire safety training for all staff in our Trust occurs at induction and thereafter every two years. We were fortunate that the consultant in charge at the time of the incident had undergone a personalised fire training session on the ICU when starting her consultant post; in addition, two new nurses, who were working their first ICU shift that evening, had been shown the ICU fire call points and fire extinguishers earlier that day. In addition to the Trust standard fire training, all our ICU junior doctors receive a ‘fire tour’ as part of their induction, all medical and senior nursing staff can locate and operate the oxygen shut off valves and our Trust fire

training officer carries out regular fire training sessions in-situ on the ICU. We have always had a policy of showing agency nurses fire call points and fire extinguishers at the start of their shift.

icU fire evacuation policy

We have rewritten (and tested) our ICU fire evacuation policy following the fire. The main changes are that we now plan to evacuate ICU patients to the Emergency Department (ED), rather than the medical admissions unit, and our plans take into account that staff may be injured themselves and so cannot be relied upon to care for ICU patients. The ED has multiple monitors, a number of transport ventilators and staff who regularly care for sick patients, often in significant numbers.The ED also has the ability to divert ambulances, giving it more flexibility than a hospital ward. We have installed a dedicated telephone line between ICU and ED to facilitate communication in an emergency, and are in the process of rewriting our theatre evacuation policy.

Our fire alarms and the fire control panel in switchboard have been upgraded to make it easier for switchboard staff to see where a fire call point is activated and to speed up communication with the fire and rescue services. We are considering a text-based system for calling in medical staff in the event of a major incident, rather than relying on switchboard to call doctors individually.

New ICUs are designed with multiple side rooms and/or small bays of patients, which would be better at preventing the spread of a fire than our large open plan ICU. Indeed, during our fire, one patient remained safely ventilated in a side room throughout the incident. We are aware of one new ICU which

is being built with water sprinkler systems and multiple corridors providing alternative exit options (personal communication, D Holland, North Bristol NHS Trust), although specialists reviewing our fire feel that a sprinkler system would not have had an effect on a fire caused by an oxygen cylinder as in our case (personal communication, P Henrys, BOC.) We were fortunate that our ICU is on the ground floor, enabling us to evacuate our patients to the service road outside. Due to the fact that visibility was so poor, many staff involved have asked whether we should install illuminated fire exit signs. All our ICU mattresses, bedding, curtains and flooring meet NHS standards (Ref 2) for fire retardant materials; however, this standard is tested with a match or small fire, rather than an oxygen-related fire, and some have asked whether there should be stricter NHS fire retardant standards for ICU equipment and materials.

It is not common in the UK for medical staff to be trained in the operation of a fire extinguisher; we understand that this is also true in industry (personal communication, D McIvor, MHRA.) The Department of Health recommends that staff leave fire fighting to those who are experienced in the use of extinguishers, as described in The Regulatory Reform (Fire Safety) Order 2005 (ref 3). Their advice is to leave the fire, evacuate the area, shut the doors and await the fire and rescue service. If we had followed this advice, the whole ICU and possibly the entire surgical block would have caught fire; had this happened it is likely that there would have been numerous fatalities. In our opinion, there should be a national debate on whether ICU staff (and other frontline hospital staff) should be trained in the use of fire extinguishers. Our Trust fire officer is happy to train ICU and theatre staff

caused by an oxygen cylinder

on the 21st November 2011, a fire occurred on our intensive care Unit (icU) at the royal United hospital, Bath.

An oxygen cylinder, laid on a patient’s bed to provide oxygen to her whilst she was being transferred to another

hospital, was turned on and then caught fire1. her mattress and bedding immediately ignited, rapidly followed by the

curtains around her bed, the flooring and ceiling tiles. within seconds the icU filled with thick, black, acrid smoke;

visibility was reduced to less than a metre and breathing became extremely difficult. The patient on the burning bed

was pulled to safety by two nurses and ten of the eleven icU patients were evacuated within seven minutes. The

eleventh patient, ventilated in a side room, was not immediately affected and was evacuated ten minutes later.


Trainee Service Lead: Management Experience for Trainees in the Birmingham School of Anaesthesia

In a large busy teaching hospital it is unfortunately possible that trainee issues sometimes take a back seat. To prevent this, and to increase trainees’ input into the management team, the role of Trainee Service Lead (TSL) has recently been introduced in our anaesthetic department. In this article, we describe the role, discuss its benefits and give our personal experience of it.

Over recent years our department has been working hard to balance the training and education needs of the trainees with the service requirements of the department. To help facilitate this, the role of Trainee Service Lead was introduced in February 2011. It was initially an expansion of the “Admin SpR” role which was previously given to a senior trainee who needed some management experience. It is now is appointed to a senior trainee (ST5+) at our hospital for 6 months or more in a competitive application process, including interview.

Since its inception, the role of TSL has been developed and expanded. At present, the multiple roles of the TSL include:1. Writing the on call rota which links on

call duties and daytime modules.

2. Liaising with the College Tutors, Management and Administration teams to ensure that training needs of the trainees are being met via an ongoing “Time in Module” audit.

3. Running a regular Trainee Forum and feeding back issues as appropriate.

4. Attending management meetings as Trainee Representative.

5. Developing and maintaining a Trainee Handbook.

6. Completing a Management Project.

One day per week is allocated to the role, and Workplace Based Assessments have been developed to allow completion of a Management Module to reflect the educational value of the post.

We have found that there are many

advantages of this role, both for the department as a whole and for the individual trainee appointed.

Departmental advantages

1. Improved training and education for traineesIn order to optimise the educational value of on calls, the first TSL restructured the on call rota allocations to match a trainee’s on call commitments to their daytime training module. This has maximised trainee’s exposure to all aspects of the curriculum of the module they are completing and has also enabled the completion of modules in 2 months, rather than 3 months (excluding intensive care). Compulsory modules are therefore completed more quickly, allowing trainees to spend more time in

Anaesthesia April 2013

Anaesthesia Digested J. J. Pandit, T. M. Cook, W. R. Jonker and E. O’Sullivan.

A national survey of anaesthetists (NAP5 baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in the UK

This is the first publication from the NAP5 group tasked with examining accidental awareness during general anaesthesia, and describes the largest national survey conducted to date. It is also historic in that it is the first joint publication between Anaesthesia and the British Journal of Anaesthesia, reflecting its unique and vital importance as viewed by the AAGBI and the Royal College of Anaesthetists. Every single hospital in the UK contributed, and the experience of 7125 anaesthetists (82% of the total number of consultants and non-consultant career grades) in a single year (2011) is brought out.

What is fascinating is that, despite the comprehensiveness of this survey in terms of numbers of anaesthetists quizzed and the inclusion of every NHS hospital, only 153 cases of accidental awareness were reported, which equates to an incidence of about 1 in 15,000. This implies that the rate of accidental awareness, in the UK and in the year 2011 at least, is much lower than previously suggested from the literature. Only 46 cases of accidental awareness were reported during surgery itself, the rest occurring before surgery started or after its conclusion, and the authors confirmed that patients who experienced accidental awareness during surgery were considerably more likely to go on to register a complaint.

Why the incidence of accidental awareness should be so low is a matter of conjecture. However, it appears we can rule out a major contribution from specific monitors of depth of consciousness, as routine use was reported by less than 2% of anaesthetists. The authors speculate on whether UK patients may be especially resistant to accidental awareness by virtue of being particularly sensitive to anaesthetic agents or by nature of their psychological response to the experience. The low incidence may also be due to missing some cases that were not reported to anaesthetists, or were reported to anaesthetists not responding to this survey, but this also appears to be unlikely. An alternative explanation may be an evolution in anaesthetic practice since other published studies reporting a higher incidence were carried out.

Whatever the explanation for the very low incidence of accidental awareness reported by the NAP5 team in this survey, there is no doubt that we should all read their study closely, and we look forward to the publication of their prospective study of the causes and effects of a large number of cases of accidental awareness during general anaesthesia currently in progress.

A. Stewart, R. Katznelson, N. Kraeva, J. Carroll, T. Pickworth, V. Rao and G. Djaiani.

Genetic variation and cognitive dysfunction one year after cardiac surgery

Genetic make-up and how it affects outcome after surgery or indeed anaesthesia per se is an interesting and rapidly evolving topic. A number of studies have suggested that adverse neurological outcomes, including delirium and cognitive dysfunction leading to distressing and hugely important effects such as memory loss or change in personality, may be related to both genetic and environmental (surgery and anaesthesia) causes; indeed some authors have suggested that such events may be most significantly associated with the disease process leading to the surgery itself and may not be more common than in patients not undergoing surgery and/or anaesthesia.

However, Stewart et al in this current article describe a reasonably strong association between cognitive dysfunction after cardiac surgery and the platelet glycoprotein III-a gene and a combination of this and the apolipoprotein-e4 gene. This means that perhaps these genes affect neurological outcome because of their association with thrombotic events and systemic atherosclerosis respectively, and if such an association is confirmed in larger prospective trials, we may in future be able to identify patients at greatest risk of neurological deterioration by means of a blood test. There is even a possibility such a test could be relatively quick and inexpensive (compared to now anyway), and if so, this would allow better risk stratification, more complete consenting and perhaps (the holy grail) even targeted treatment for at-risk patients.

Andrew A. Klein, Editor, Anaesthesia

N.B. the articles referred to can be found in either the latest issue or on Early View (ePub ahead of print)


In August’s Anaesthesia News, we launched our Environmental Policy Statement outlining our commitment to provide services in a way that ensures a safe and healthy workplace that minimises our environmental impact. This includes taking a more environmentally friendly approach to educational events. We run over 70 events a year and we are already taking steps to reduce our carbon footprint whether in-house at 21 Portland Place or externally.

we have:• Encouraged greater use of online booking;• Reduced paper advertising and increased electronic formats;• Printed materials on Forest Stewardship Council (FSC) accredited paper

www.fsc-uk.org;• Stopped producing the pocket guide (its content is now incorporated into the Event

Application).

we plan to:• Gain online feedback from delegates and exhibitors;• Stop producing a USB memory stick which reduces carbon costs from shipping and

material used (the USB’s content is now incorporated into the Event Application);• Switch to electronic badging and using electronic materials where we can rather than

shipping materials to event venues.

we are considering:• Installing water coolers instead of using bottled water.• Enforcing a zero-waste policy so that exhibitors take home all their waste .• Offering a ‘green exhibitor award’ or charging exhibitors a fee for excessive waste to

encourage good practice.• Encouraging delegates to car share, use public transport or sign-up to a city bike

scheme. • Reducing building energy by making sure that lights and machinery are switched off

when not being used.

We realise that this is just the start, and as an organisation, it is important that the AAGBI is committed to reducing its carbon footprint.

Nicole Bates,Marketing and Communications Manager, AAGBI

Making our events

greenerThe AAGBi’s environmental impact and approach to sustainability is central to our organisational practice. our website contains a hub of information for anaesthetists concerned about reducing the environmental impact of their clinical practice (www.aagbi.org/about-us/environment). however, we want to play our part in making sure that green anaesthesia goes beyond the operating theatre.

areas of their choosing. By limiting the number of trainees per module at any one time, it also ensures that trainees are more evenly spread across theatres and fewer moves out of module are needed. The only disadvantage of this is that writing the rota is even more of a challenge!

The daytime allocation of trainees to appropriate lists is also audited. The weekly rota is reviewed and the number of training lists each trainee has been allocated to and their number of supervised sessions is recorded: the “Time in Module” audit. Should a trainee need to be moved out of module to assist with service provision, the audit is used to determine who is most appropriate to move. This helps to ensure that all trainees are treated fairly and are given equal time in training lists. The audit data is summarised at regular intervals so that any trainees who have spent excessive time out of module or who have fallen below the recommended levels of direct supervision1 can be highlighted.

Finally, to improve the departmental educational programme, the role of Trainee Education Lead has recently been proposed and is being trialled. This role is for a post fellowship trainee with an interest in teaching and medical education. It provides a link between the consultants who are involved in teaching and allows for coordination of various teaching programmes. So far it has improved the weekly whole-department teaching programme and the CME opportunities for consultants.

2. Increased departmental awareness of trainee issues We have improved this by introducing specific, regular meetings at which trainees can raise any concerns or issues they have: the Trainee Forum. This is supported by the consultants who ensure trainees can be released from their lists to attend. There are also regular meetings to feed back issues arising at this meeting with the College Tutors, Management Team and Consultant body which allow time for discussion.

3. Trainee input into departmental management teamThe advantages of doctors and managers working together from early in their careers are being increasingly recognised. Trainees rotating through different hospitals have the benefit of exposure to many different systems and are often well placed to put forward suggestions of how departmental improvements can be made. By introducing a more formal link

in our department between junior doctors and the management team this allows us to work together with managers, rather than in parallel. This extends beyond the TSL and the management project that they complete. By improving communication channels, information about and access to the management team, any interested trainee can get involved. The establishment of the Trainee Education Lead role is an example of how this has been put into practice.

Individual advantages

1. Practical management experience Being Trainee Service Lead is an excellent opportunity for trainees in our School of Anaesthesia to gain management experience alongside clinical work, which is often difficult as a registrar. Trainees get a better understanding of the roles of and demands on the departmental management team earlier in their careers. Communication and negotiation skills are developed which are especially important for the representative aspect of the role. The completion of a management project allows the trainee to develop an interest in a particular area and to contribute to improving how the department functions.

2. Competitive application process This is good practice for senior trainees approaching the end of their training and a consultant interview. The recruitment process is coordinated by the out-going TSL and we have found that there is as much to be learnt by interviewing as being interviewed.

Personal experience

We are the most recent TSLs to have completed the role. We are LTFT trainees and were appointed to the post jointly in January 2012. It was the first time the role had been shared by two LTFT trainees and there were some reservations about how it might work. Most of the tasks were completed jointly but there were some that it was helpful for one of us to take the lead on. We split the allocated time between us but also made sure we had a regular “management” session together to make sure we were both fully informed about everything going on. Simple things like a shared folder for documents and a specific email address to which we both had access were helpful. The feedback at the end of the 6 months was very encouraging and one of us was appointed as a consultant in the department during the time in post.

The role was incredibly hard work and did spill over the allocated time. At times it could be frustrating, partly from trying to track down the information we needed and often because it changed at short notice.

It was also very rewarding. In the past, trainees have often felt a bit lost when rotating through our hospital and we worked hard to try to prevent this. Our management projects were both trainee focussed: one looked at ensuring that out of hours work was fairly and appropriately distributed amongst the different trainee on call rotas, and the second concentrated on how and from whom trainees should summon assistance in various clinical situations.

We came to appreciate and value the roles of the management and administration teams and understand some of the pressures on their time and resources. We also learnt very quickly that you cannot please everyone all of the time.

In SummaryCreation of the Trainee Service Lead role is not “rocket science”. Nor is it overly demanding on resources. The lessons learnt may seem obvious and predictable, however the role does acknowledge the value that trainees can be to the management team in a department and also allow trainees to take some responsibility for their education and training. In our department it has been a positive step forward. On a wider scale it is hoped that the development of the TSL role not only benefits our department, but also any department in which the former TSLs work in the future, either as a trainee or consultant.

dr emma Plunkett, SpRdr Kerry cullis, Consultant Anaesthetistdr Katie clift, Deputy Clinical Service Lead for Anaesthesia

Queen Elizabeth Hospitals Birmingham

AcknowledgementsWe would like to acknowledge the work of the Trainee Service Leads who were appointed before us, Nick Parry, Annabelle Whapples and Ruth Francis, as well as Katie Clift for creating the role and management module and mentoring us all.

references1. Curriculum for a CCT in Anaesthetics (2010),

RCoA. Edition 2, August 2010, Updated June 2012.

Anaesthesia News April 2013 • Issue 309 15

Anaesthetic Confusion on the Delivery Suite

At handovers, questioning looks are frequently exchanged between the anaesthetic team members, supplemented by whispered questions to clarify what a previously unheard or forgotten acronym or abbreviation means. We have composed a short scenario to highlight just how many of these acronyms are in use, and how bemusing handovers can get, particularly to the new ST1/2 setting out on their first obstetric placement.

You look dazed as you gaze at the D/S board at the SBAR handover…. There are women suffering with PGP or who have SROMed and PPROMed, several who have just been transferred from MLU or OAU, stepped up from MLC as they need IOL or an ARM. Some, having torn up their carefully discussed birth plans are asking for an EFL, (if you’re lucky there’ll be an ODP to help).

There are complications; women needing Abx for GBS, high BMIs, poorly controlled BMs in women with GDM, those with high BP either PIH or at risk of PET needing bloods to check for HELLP or AFLP and a CSU for PCR.

If they’ve had a previous SVD then all should be OK but if VBAC is planned (TOS/TOL to some), or if there is CPD or FGM they may need a LSCS.

The unborn babies themselves may be problematic, they may have IUGR, FM, or AFI and require close CTG monitoring for FHR or FSE if there are trace problems or “decels”, these may be an early sign of APH. There could then be a need to check a FBS to determine the need for cat1 or cat 2 C/S. There may even be DCDA twins, triplets or quads following IVF. NNU may need to be informed.

TOF, LSCS or ERPC under CSE, GA, SAB or Epi top-up may result in PPH. This in turn will require assessment of EBL and serial FBCs and coags and potentially a t/f of RBCs/ PRCs, FFP and cryo.

After those most awaited three letters, DEL, appear, the problems still may not be over, a trip to theatre may be needed for MROP!

Sadly alongside the nervous, expectant parents there may also be those admitted with an IUD, potentially requiring a PCA.

Discussion

Of the 300 words in the paragraphs above, 63 are abbreviations! This passage may be somewhat contrived, but we believe it is not too far from the reality of what a labour ward handover can sound like.

Abbreviations are widely used in medicine to make handover sheets or notes concise and save time. It has been highlighted that abbreviation can lead to serious morbidity and mortality, especially in prescribing1, 2.

Other work has shown how ambiguous abbreviations can be. An audit published in 20083 showed that only 14-20% of abbreviations used were standardised (medical dictionary). In addition there were multiple or alternative meanings for up to 12% of abbreviations used. Interpretation of abbreviations by staff is also poor; only 56% of junior/middle grade doctors correctly interpreted the abbreviations in an audit, and in a survey of gastroenterologists4 only 37% of abbreviations were correctly interpreted by doctors of all grades.

We hope this short article will be of use, reassuring trainees new to obstetrics that it is not uncommon to be baffled by the abbreviations commonly found on labour ward. We encourage them to seek clarity when in doubt, and seek to remind everyone of the potential pitfalls of abbreviations. The glossary of the terms may help anaesthetists, less familiar with ‘labour ward speak’ .

s. Gill, ST7 AnaestheticsT. west, ST4 Anaesthetics

References1. Dean B, Schachter M,Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002; 359(9315):1373–8.2. http://www.health.vic.gov.au/qum/downloads/acsqhc_recomendations.pdf Accessed Oct 20123. Sheppard JE, Weidner LCE, Zakai S, et al. Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping. Arch Dis Child 2008;93:204–6.4. Parakh P, Hindy P, Frutcher G. Are we speaking the same language?: Acronyms in Gastroenterology. American Journal of Gastroenterology 2011; 106: 8-9

Glossary

Afi Amniotic fluid index (indication of volume of amniotic fluid based on ultrasound)AflP Acute fatty liver of pregnancy APGAr Assessment of health of newborn. Devised by Dr Virginia ApgarAPh Ante-partum haemorrhageArM Artificial rupture of membranesBMs Blood glucose; Boehringer Mannheim company that produced first test stripsBMi Body mass index cat1 Category 1 caesarean section- immediate threat to life of mother or fetuscat 2 Category 2 caesarean section- no immediate threat but at riskcPd Cephalo-pelvic disproportion c/s Caesarean sectioncse Combined spinal-epidural cTG CardiotocogramdcdA Di-chorionic, di-amniotic twins“decels” Decelerationsdel Delivered (on our unit frequently DE denotes baby delivered, with the L added only once placenta is deliveredd/s Delivery suiteeBl Estimated Blood Lossefl Epidural for LabourerPc Evacuation of retained products of conception, also “Evac” (see also MROP)fBs Fetal Blood SamplefGM Female genital mutilationfhr Fetal Heart ratefM Fetal monitoring/Fetal medicinefse Fetal scalp electrode GBs Group B streptococcusGdM Gestational diabetes mellitus

hellP Hypertension, elevated liver enzymes, low plateletsiol Induction of labouriUd Intrauterine deathiUGr Intrauterine growth retardationiVf/ icsi In-vitro fertilisation/ Intracytoplasmic sperm injectionlscs Lower segment caesarean section Mlc Midwifery led careMlU Midwifery led unitMToP Medical Termination of pregnancyNNU Neonatal unitoAU Obstetric assessment unitodP Operating department practitionerPcr Protein creatinine ratioPeT Pre eclamptic toxaemiaPGP Pelvic girdle pain (previously SPD)Pih Pregnancy induced hypertensionPPh Post partum haemorrhage PProM Prolonged premature rupture of membranes ProM Premature rupture of membranessAB Sub arachnoid blocksBAr Situation, Background, Assessment, RecommendationscBU Special care baby unitsPd Symphysis pubis dysfunctionsroM Spontaneous rupture of membranessVd Spontaneous vaginal delivery T/f Transfer or transfusionTof Trial of Forceps or Tracheo oesophageal fistula or Tetralogy of FallotTol Trial of Labour (see also VBAC)Tos Trial of scar (see also VBAC)VBAc Vaginal birth after caesarean section

having started a new post in August, in a new hospital, in a new labour ward, with a number of junior anaesthetists new to obstetric anaesthetic practice, we became acutely conscious of just how confusing the profusion of abbreviations and acronyms used at handover and more generally on the labour ward can be. Many are widely used but some seem to be specific to individual units.

→→

©Illustration by Gemma Gill


The Wednesday Core Topics day can be a bit of a struggle for me as I arrive in London early in the morning after an overnight flight. Fortunately, there was plenty to keep me interested and awake, and there is always coffee available during the breaks. I particularly enjoyed Professor Elliott’s lecture on Tracheal Transplants – not only did he describe his exciting developments in the field but he heavily emphasised the value of teamwork in providing health care. I had to check the programme to confirm he really is a surgeon!

Thursday brought a session on ageing – of great personal interest to many anaesthetists, including myself. Dr Jagger’s work encouraged us that it may be worth living beyond 85 after all. Another session was on morbid obesity - less of a personal issue perhaps, but an ever-increasing problem in everyone’s field of practice and I picked up a few practical tips. Later in the day Dr. Zideman shared his Olympic experience with us. Having been lucky enough to have my own Olympic experience and watch Great Britain win an Olympic gold medal at Eton Dorney, it was fascinating to learn about all the behind the scenes preparations. As a specialty, we particularly recognize the need to be ready for every eventuality.

On Friday there were noticeably fewer delegates, ostensibly because of the heavy snow rather than following the dinner at the Savoy the previous evening. Those of us who fought our way through a very pretty London to get there were treated to an excellent Anaesthesia Journal session. Alicia Dennis had travelled even further than me to get there, John Carlisle deterred us all from faking research by showing how easily he can find us out and Steve Yentis stepped in to replace a speaker stymied by the snow storm. The resulting discussion of a controversial research article was of particular interest to me as Chair of my hospital’s Ethics Committee.

One of the real highlights of the meeting for me was the GE Healthcare Lecture, given that day by Mr. Nigel Edwards of the King’s Fund. He is an engaging speaker and I found it fascinating that so many of the issues and concerns he raised regarding the future of the NHS are the same as those facing Bermuda’s health care system, despite the many differences in the way we actually provide our services.

The AAGBI was offering free mentoring sessions to members during conference hours so I availed myself of the opportunity. I wasn’t quite sure what to expect – or whether I would really find it useful – but by the end of the session I felt my mentor had helped me to organise my thoughts around my particular question, and given me a number of suggestions as to how I might move forward. I will definitely be seeking a follow up session and would highly recommend the service.

Why on earth would anyone travel over 3000 miles from Bermuda to London in January every year?

Not for the weather obviously, and not, as my colleagues suspect, to do some post-Christmas shopping, but to attend the annual AAGBI WSM of course. This was my fourth visit and it has now become a regular fixture on my calendar.

Many of the lectures will soon be available on the AAGBI video platform so I’m sure more than a few of you are wondering why anyone would bother to attend in person any more. The WSM is about far more than just the lectures. There are opportunities to ask questions of experts – in public or behind the scenes during the coffee and lunch breaks. It is a chance to catch up with old friends and colleagues, and perhaps to make some new ones. I went to my first WSM five years ago to meet my old chum Jim Carter, who worked with me in Bermuda twenty years ago. This year I bumped into Peter Wallace in the lift – now retired, he gave me my first job in Anaesthesia in Glasgow well over twenty years ago. The venue is excellent – perhaps not the most comfortable seating but you are supposed to be awake for most of the day. It is a spectacular location in the heart of Westminster, within walking distance of most of London’s most famous landmarks. The lunch is always worth staying around for and the biscuits (arguably the best means to rate a conference) are both delicious and plentiful. The Industry Exhibition is an opportunity to see and sometimes even to try out the latest equipment. I find reps become very enthusiastic when I tell them where I work and always offer to come and set everything up in person for me. I spotted a new piece of equipment this year – a very natty AAGBI cycling top.

I have already booked my study leave for 15-17 January 2014. Have you?

dr elaine campbell FRCA

Consultant Anaesthetist, King Edward VII Memorial Hospital, Bermuda


Shortly before I started LTFT training in February 2012, I attended a London Deanery ‘LTFT training workshop’. The workshop laid to rest my unease and anxieties about the details of training LTFT, and generally reassured me, but for one thing: I was the only man there. I found myself thinking ‘Ah well, of course childcare is still largely a maternal concern’ and other not-very-enlightened things largely informed by the gender stereotyping I’ve had drummed into me from an early age. And then I thought, ‘Hang on – I’m in a room full of ambitious professionals, in 21st century London, where gender equality reigns supreme – what’s going on?’

It seems, however, that this gender imbalance is widespread. The RCoA website reports that, based on deanery figures from 2011, 8.5% of all Anaesthetic trainees are LTFT, and that 95% of those are women.1 Within the North East London School of Anaesthesia, there are 14 LTFT trainees, of whom only two (one of which is me) are men. Is this because the perceived advantages of LTFT training – most frequently cited as having more time to care for children (or other family members), pursue outside interests, and striking a better ‘work-life balance’ – are more appealing to female trainees than male ones? Or do the disadvantages – principally earning less, and extending the duration of training – impact more significantly on male anaesthetic trainees?

I believe there are two reasons. First, men are more likely to be the main breadwinners than their female partners. The 10.5% pay gap2 that persists between men and women, despite the supposed equality of opportunity in the 21st century workplace, has rightly garnered much recent media attention. This discrepancy obviously doesn’t apply within Anaesthesia (or other branches of medicine) – for all its faults, the NHS does at least pay men and women in equivalent posts equal salaries. However, men in general are more likely to be the primary earners in their households, and therefore more reluctant to sacrifice a proportion of their salary by reducing their working hours.

Gender Roles

Second, gender roles are still deeply engrained in our society. Many mothers of young children consider childcare their main priority (which I would suggest many fathers do not), while many men see their main role as providing for the family’s material needs. Do I sound like a caveman? Perhaps, but the circumstances that have afforded me the luxury of going LTFT are, I think, the exception rather than the rule. I am able to train LTFT because my wife earns more than I do (hence losing 20% of my salary has a relatively minor impact on our family finances), and because she’s prepared to forego childcare and work 5 days a week instead.

Whatever the underlying reasons, the preponderance of female LTFT trainees clearly has implications for workforce planning. LTFT consultant posts are still a rarity: at the time of writing, bmjcareers.com has 16 adverts for consultant anaesthetist posts, of

which only one mentions the possibility of part time working. However, LTFT training has seen significant growth among Anaesthetic trainees in recent years, which implies a likely increase in future demand for LTFT consultant posts. Moreover, creating more LTFT consultant posts (as suggested by Dr Hunningher) could provide a means to fill the imminent void of consultant vacancies for new CCT holders, and Anaesthetics – as an inherently shift-based specialty – is particularly amenable to flexible working patterns.

While the precise details of flexible working at consultant level may vary, the question remains of whether LTFT consultant contracts would prove equally attractive to both male and female CCT holders. Some men might jump at the opportunity: after 7 years or more of full-time training, the prospect of having more time to devote to family / fishing / the golf course (delete as appropriate) will appeal to those yearning for a better work-life balance. Others may be strongly averse to accepting a salary reduction – arising when financial outgoings such as mortgage payments and childcare may be most acute – and the perceived loss of status as primary family breadwinner. Perhaps surprisingly, the Centre for Workforce Intelligence’s ‘Shape of the Medical Workforce’, published earlier this year, has little to say about the role of LTFT consultants in the future NHS workforce. They acknowledge that ‘the percentage of female consultants has increased’, and will continue to do so; however, they imply that LTFT consultant posts are likely to remain a rarity, asserting that ‘trainees who train flexibly often choose to work as a full-time consultant’ [sic]3. No figures are provided to support this claim, and given the growth in LTFT training, it seems premature to conclude that most LTFT trainees will choose to work full-time as consultants. Meanwhile, none of their seven scenarios for the future of the medical workforce makes provision for increasing numbers of LTFT consultants.

The future make-up of the UK’s Anaesthetic consultant workforce is fraught with uncertainties, but I believe we can reasonably expect it to reflect three clear trends throughout the western world: namely greater female participation in the workforce, greater male participation in childcare, and increasing demand for flexible work patterns. Other countries have long encouraged the male of the species to look beyond the traditional role of working to provide for the family: Sweden, for example, has offered 480 days of paid ‘shared parental leave’ for each child since 1974. The Coalition government’s proposal for mothers and fathers to be able to share a year’s maternity leave (due to take effect in 2015) is clearly a step in the same direction. Anaesthetics as a specialty is well-placed to embrace this zeitgeist, but it can only do so if men and women alike are open to the benefits that flexible working can offer.

oliver Boney, Dr ST4 Anaesthetics, Barts and the London School of Anaesthesia

1. http://www.rcoa.ac.uk/training-anaesthesia/less-fulltime-training-ltft2. http://www.homeoffice.gov.uk/equalities/women/women-work/3. http://www.cfwi.org.uk/publications/leaders-report-shape-of-the-

medical-workforce

In the November issue of Anaesthesia News, Dr Hunningher

proposed a radical vision of flexible consultant work patterns

as a potential solution to the looming shortage of consultant posts for trained anaesthetists.

But will men and women embrace flexible working with

equal enthusiasm?

Snow nearly stopped play but all of our speakers got to the meeting on time! A huge thank you to them and to all the delegates, who not only made the effort to trudge through central London to get to the QEII Centre, but who also had to face the challenges of the homeward journey. I know that lots of you had to spend the night in London, cadging favours and floorspace from friends, and even some of our speakers from snowy climates struggled to get home!

Over 850 delegates attended WSM of whom 110 were trainees. 104 people signed up for workshops and 80 posters were judged. Delegates flew in from Bermuda, Australia, South Africa, NZ, UAE, Kenya, USA and Uganda. A truly global audience matched by a global mix of speakers!

The Event app has gone from strength to strength. Over 1400 people downloaded the WSM Event app and nearly 300 of you accessed the WSM programme via your computer. We have yet more exciting developments for the app and on line portal to make Revalidation even easier for you. Look out for these changes at the Annual Congress in Dublin.

The highlights of the meeting for me were the 3 keynote speakers:• Prof Martin Elliott gave a truly inspirational lecture about

tracheal transplants• David Zideman’s passionate talk about his Olympic

experience made us want to relive the summer of the games all over again, and

• Nigel Edwards gave a brilliant talk about leadership development and health policy

I normally write my reflective notes as I listen to the lectures, but for these 3 keynote speeches, I just sat back and enjoyed the wonderful content and delivery styles.

All 3 of these lectures have been fast tracked for the video platform, as well as Dave Murray’s lecture on the National Emergency Laparotomy Audit and Tom Pierce’s thought provoking talk on anaesthesia and the environment. We have also fast tracked the BATS (British Anaesthetic Trauma Society) and quality improvement lectures for those of you that missed these sessions because of the snow. Please visit http://videoplatform.aagbi.org.

WSM was our biggest conference ever but I have a feeling that the Annual Congress in Dublin will be even bigger. If the city itself doesn’t entice you to come along, then a combination of a crazy cycle ride, pints of Guinness, and a really interesting programme surely will!

dr samantha shinde,Chair of the Education Committee

From WSM with love…

For further information and an application formplease visit our website:

http://www.aagbi.org/international/irc-fundingtravel-grantsor email [email protected]

or telephone 020 7631 8807

Closing date: 01 March 2013

TRAVEL GRANTS/IRC FUNDING

Nicola HeardEducational Events Manager

Direct Line: +44 (0) 20 7631 8805

21 Portland Place, London W1B 1PY

T: +44 (0) 20 7631 1650

F: +44 (0) 20 7631 4352

E: [email protected]

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The International Relations Committee (IRC) offers travel grants to members who are seeking funding to work, or to deliver educational training courses or conferences, in low and middle-income countries.

Please note that grants will not normally be considered for attendance at congresses or meetings of learned societies. Exceptionally, they may be granted for extension of travel in association with such a post or meeting. Applicants should indicate their level of experience and expected benefits to be gained from their visits, over and above the educational value to the applicants themselves.

Closing date: 28 May 2013

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Design that matters.”

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The Association of Anaesthetists of Great Britain & Ireland

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Dear Editor,

Protective eyewear in green light laser prostatectomy and its effects on the colouring of syringe drug labels.One laser that has gained widespread utilization during the last 5 years is the high-powered potassium-titanyl-phosphate (KTP) laser for the treatment of symptomatic benign prostatic hypertrophy. This laser system is coined “greenlight photoselective vaporization of the prostate (PVP)” and is commercially marketed and manufactured as GreenLight-PV® and Greenlight HPS® (American Medical Systems, Minnetonka, Minnesota).

The KTP laser beam is fully transmitted through aqueous irrigant and is preferentially absorbed by the oxygenated haemoglobin present in prostatic tissue. This mechanism delivers the energy to simultaneously cause fragmentation of prostatic tissue and coagulation of blood. The end result is associated with a more favourable risk profile compared to transurethral resection of the prostate (TURP), including reductions in bleeding, capsular perforation and elimination of TURP syndrome.1

However, as with many lasers the operator and theatre staff are required to wear eye protection during the procedure to negate the potential effects of aberrant laser radiation. The KTP laser beam produces light at a wavelength of 532 nm, which falls within the visible spectrum and is perceived as green. The recommended eye protection filters out green light, rendering the visual field in a red glow. This has important implications for the colouring of syringe drug labels used in theatres. Labels that include green within their colour will change colour when seen through the protective glasses. The most striking example is that for the colours of neuromuscular blocking drugs, hypnotics, anticholinergic agents and local anaesthetics labels. Figures 1 and 2 show that under the rosy-coloured visual field, the red neuromuscular blocking drugs label and the orange hypnotics label become a bright orange. The green anticholinergics label appears a dull grey whereas the grey local anaesthetics label changes to purple.

Figure 1 Appearance of syringe drug labels pre-protective eyewear

Figure 2 Appearance of syringe drug labels post-protective eyewear

We used a graphics editing software (Adobe Photoshop®) that filters out green light to examine the colours of syringe drug labels published on the Association of Anaesthetists of Great Britain and Ireland website (Figure 3) and noted comparable changes (Figure 4).

Figure 3 Appearance of syringe drug labels from AAGBI website

Figure 4 Appearance of syringe drug labels from AAGBI website post-green light filter using Adobe Photoshop®

Whilst the potential clinical consequences of these colour changes can be quietly contemplated in routine theatre work, there is much more room for error under pressure in an emergency situation.2 We recommend that anaesthetists who work in such theatres be aware of the colour distortion that protective eyewear presents, when used in green light laser procedures.

K.s. Ang, CT2 Anaesthetics, Department of Anaesthesia, Western General Hospital, Edinburgh

d. duncan, Consultant Anaesthetist, Department of Anaesthesia, Western General Hospital, Edinburgh

References:

1. American Medical Systems, Inc. Clinical Outcome Comparison of GreenLight KTP-532 Laser (80W) Prostatectomy versus Transurethral Resection of the Prostate (TURP), 2008. http://www.amsgreenlight.com/documents/GreenLight_GLvsTURP_whitepaper.pdf [accessed 20.06.2012]

2. JP. Coles, DK. Menon. A reply. Anaesthesia 1999, 54(1): 100

Dear Editor,

in the i of the beholder.It has come to our attention (preparing for spinal anaesthetics) that the label applied directly to the sterile vial of heavy 0.5% Bupivacaine (‘Heavy Marcain’ manufactured by AstraZeneca UK) carries a mistake – and this has been the case for some time.

Figure 1 – An i for detail. Heavy Bupivacaine vial with missing vowel

Having noticed this anomaly on prior batches in another trust Dr Winterbottom contacted AstraZeneca UK who were unaware of the mistake and passed on the information to their Regulatory Affairs department. They have responded to confirm that the labels are in the process of being changed and, depending on stock turnover, will display the correct spelling in new batches from now on. Until then, we invite you to continue playing i-spy.

dr Toby winterbottom, CT1 Trainee Anaesthetist, St. Richard’s Hospital, Chichester

dr Mark Bentley, Consultant Anaesthetist, St. Richard’s Hospital, Chichester

©Photograph by Dr Mark Bentley

Dear Editor,

we would like to bring to your attention a complication regarding tourniquet release after lower limb arthroplasty.A 22 year old woman with significant juvenile rheumatoid arthritis was scheduled for a bilateral knee replacement. Preoperative blood tests, ECHO, CXR, and ECG were within normal limits.

She had an uneventful induction with propofol and fentanyl while her airway was secured with a Proseal LMA and anaesthesia was maintained with Sevoflurane in an oxygen/nitrous oxide mix. Surgery commenced on the right knee with a tourniquet pressure of 300 mmHg. She had two Litres of 0.9% Normal Saline as maintenance IV fluid. Total tourniquet time was 64 minutes. Then, 3-5 minutes following tourniquet release, the oxygen saturations became 78% on 0.5 Fi02, with sudden onset tachycardia of 140/min and a blood pressure of 180/100 mmHg. Given her sudden clinical deterioration she was intubated (grade 3 Laryngoscopy with evidence of pink frothy sputum) and ventilated with 100 % oxygen and PEEP of 5 cm of H2O. The three lead ECG showed multiple ventricular ectopics. A chest x ray obtained in theatre demonstrated acute pulmonary oedema. Twenty milligrams of intravenous furosemide was given with good diuresis. Once oxygen saturations improved, the trachea was extubated in theatre without any complications. The procedure was completed and the contra-lateral knee replacement was abandoned with the patient being admitted to our High Dependency Unit (HDU). Her stay in HDU was uncomplicated; she maintained saturations of 96% on 2L of Oxygen. Post- operative blood tests were normal with a negative twelve hour Troponin T. The patient was transferred to the ward the following day and was discharged after the fifth day.

Acute pulmonary oedema can be either cardiogenic or non-cardiogenic with cardiogenic pulmonary oedema being the commonest. In this case, we have, by the process of exclusion, proposed a diagnosis of non-cardiogenic pulmonary oedema (NCPE). Additionally, we postulate that pathogenesis is due to an Acute Lung Injury (ALI) secondary to the ischemic reperfusion (IRI) injury whereby the release of inflammatory mediators follows the tourniquet release. The exact pathophysiology is not understood, but aberrant activation of neutrophil mediated injury is thought to play a central role.1

At present there is no clinically effective intervention for this condition other than supportive care but ongoing research on the use of propofol and N-acetyl cysteine is promising.2,3 Our group is currently undertaking a systematic review to determine the magnitude of attenuation of this IRI via different anaesthetic modes. Currently, there is no general consensus regarding which type of anaesthetic technique (TIVA vs. volatile for example) can best protect patients from this complication.

References:

1. JP Dillon, AJ Laing, RA Cahill, GC O’Brien, JT Street, JH Wang, A McGuinness, HP Remmond. Activated Protein C attenuates acute ischaemia reperfusion injury in skeletal muscle. Journal of Orthopaedic Research 2005; Nov 23(6):1454-1459.

2. R Turan, H Yagmadur, M Kavutcu, B Dikmen. Propofol and tourniquet induced ischemia reperfusion injury in lower extremity operations. European Journal of Anaesthesiology 2007; 23:185-189.

3. F Saricaoglu, D Dal, AE Salman, OA Atay, MN Doral, MA Salman, K Kilinc, U Aypar. Effect of low-dose N-acetyl-cysteine infusion on tourniquet-induced ischaemia-reperfusion injury in arthroscopic knee surgery. Acta Anaesthesiologica Scandinavica 2005 July; 49(6):847-851.

dr saibal Ganguly, ST5 Anaesthesia, Department of Anaesthesia, Pinderfield General Hospital, West Yorkshire

dr Michael charlesworth, CT1 Anaesthesia, Department of Anaesthesia, Pinderfield General Hospital, West Yorkshire

BackgroundThere is often a reluctance to admit to ICU patients who develop critical illness on the background of haematological malignancy due to an assumed poor prognosis. A prospective UK study indicated that 7% of all patients admitted to hospital with a haematological malignancy develop a critical illness; although around 1.5% of general adult ICU admissions have a haematological malignancy.¹ Recent advances in chemotherapy, haematopoietic stem cell transplantation and critical care have led to better outcomes for these patients. However, some of these radical treatments may themselves increase the risk of developing a critical illness. This study evaluates the mortality rates within ICU, in-hospital and within 6 months in patients admitted to the Royal Marsden cancer unit ICU, and attempts to identify potential predictors for in-hospital mortality.

MethodThis was a single centre cohort study conducted over a 5 year period. Data was collected on all patients admitted to the ICU from October 2004 to September 2009, with haematological malignancy as a primary or concurrent co-morbidity. Variables collected included patient characteristics, type of haematological malignancy, reason for admission, APACHE scores, number of organ failures, type of organ support received and laboratory values. These patients were followed up for a period of 6 months from the point of ICU admission. Data were statistically analysed using computer software and factors predictive for in-hospital mortality were identified.

resultsOne hundred and ninety nine patients with haematological malignancies were admitted to ICU in the 5 year period. ICU, in-hospital and 6 month mortalities were 67/199 (33.7%), 91/199 (45.7%) and 118/199 (59.3%) respectively. The most common cause for ICU admission was respiratory failure (33.7%) and 51.9% patients required invasive mechanical ventilation. Cardiovascular support with vasopressors was required by 51.5% patients.

Multivariate analysis indicated that invasive mechanical ventilation (OR 3.03 95% CI 1.22-6.90) and ≥ 2 organ failures (OR 5.62, 95% CI 2.3-13.7) were independent predictors of in-hospital mortality.

Other predictive factors of in-hospital mortality identified with univariate analysis included in-hospital time before ICU admission of greater than 6 days (P=0.02), renal replacement therapy (P<0.001), use of vasopressors (P<0.001), inotropes (P=0.01), invasive fungal infection (P=0.04), graft vs host disease (P=0.007), platelets<20 x109L-¹(P=0.03), and bilirubin >32µmol L-¹(P<0.001). Other factors that were found not to be predictive of in-hospital mortality included duration of ICU stay >5 days (P=0.25), post-haematopoeitic stem cell transplant (P=0.19), type of haematological malignancy (P=0.41), age (P=0.51) and neutropenia (P=0.06).

discussionThis study raises a number of interesting discussion points. It identifies some factors which may be helpful in predicting which patients may benefit from ICU admission and raises the question of where these patients are best managed. It also challenges the notion that patients with haematological malignancies have poorer outcomes than the average ICU patient population.

Factors which may predict outcomes in ICU patients is an important question and has been the subject of many prior studies. Factors such as multi-organ failure, invasive mechanical ventilation, prolonged hospital stay prior to ICU admission and inotropic support were all identified in prior larger studies as factors predicting ICU mortality. Other factors previously identified as being predictive of ICU mortality which were not deemed important in the current study included severe sepsis, increasing age, haematological diagnosis (Hodgkin’s lymphoma), haematopoietic stem cell transplant and a low GCS.1,2,3

The perception that patients with haematological malignancy admitted to ICU’s carry a high mortality rate is challenged in this study. The average ICU mortality rate of admissions to general adult ICUs varies from 20% to 80% according to case mix and referral patterns with average figures of 25%4. According to this study, average ICU mortality of a patient admitted with a haematological malignancy is 33.7%. In comparison to other patient groups such as those admitted post cardiac arrest (where mortality rates can be as high as 80%), these mortality rates may be considered favourable.

This study also raises the pertinent question of whether patient outcomes may be improved if this complex group of patients were managed in specialist cancer ICUs. Whilst crude mortality rates are difficult to compare across different studies, the ICU mortality at this specialist cancer unit was lower than previous figures collected through ICNARC data (43%) and Scottish ICS Audit Group data (39%). This may be a reflection of the increased caseload; in this study the percentage of patients with haematological malignancy admitted to ICU was 5.9% as opposed to 1.5-1.6% in national data collected for admission to general ICUs. It is now widely accepted that treatment in specialist centres confers a survival benefit; NICE recommends specialist conditions be managed in such centres, for example neurosurgical centres in the case of head injury. It would follow that the same may be true for cancer patients where multi-disciplinary expertise can be provided in dedicated cancer ICUs.

Anna PetsasST4 Anaesthesia, Oxford Deanery

References1. Gordon AC, Oakervee HE, Kaya B et al. Incidence and outcome of

critical illness amongst hospitalised patients with haematological malignancy: a prospective observational study and intensive care unit based care. Anaesthesia 2005; 60: 340-347

2. Hampshire P, Welch C, McCrossan L et al. Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database. Critical Care 2009; 13: R137

3. Cuthbertson BH, Rajalingam Y, Harrison S and McKirdy F. The outcome of haematological malignancy in Scottish Intensive Care Units. J Intensive Care Society 2008; 9: 135-40 Bird et al. Outcomes and prognostic factors in patients with haematological malignancy admitted to a specialist cancer intensive care unit: a 5 year study. BJA 2012; 108(3): 452-459

4. Council of the Intensive Care Society. Critical Insight. An Intensive Care Society introduction to UK adult critical care services. http://www.ics.ac.uk/professional/critical_insight_.Published in 2003.

Bird GT, Farguhar-Smith P, Wigmore T, Potter M and Gruber PC.

outcomes and prognostic factors in patients with haematological malignancy admitted to a specialist cancer intensive care unit: a 5 year study British Journal of Anaesthesia 108 (3): 452-9 (2012)

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Kittur ND, McMullen KM, Russo AJ and Ruhl L.

long-Term effect of infection Prevention Practices and case Mix on cesarean surgical site infections.

Obstetrics & Gynecology: August 2012 :120(2),246–251

Giving prophylactic antibiotics up to 1 hour before cesarean incision, instead of after umbilical cord clamping, reduced surgical site infections by 48% according to a 96-month retrospective cohort study by Kittur et al, This study included 8668 women who underwent caesarean delivery from January 2003 to December 2010 in a US tertiary-care hospital.

During the study period, several infection control measures were either changed or implemented at the hospital, and the authors examined their effect on infection rates. In January 2004, the hospital instituted a policy directing antibiotic administration to change from after umbilical cord clamping to within 60 minutes before caesarean incision, and the anaesthetist assumed responsibility for antibiotic administration.

Dr. Kittur and colleagues used time series analysis to estimate whether any of these developments had any effect on surgical site infection rates after they adjusted for underlying secular trends in patient mix. Of the 8668 women who had caesarean deliveries, 303 (3.5%; 95% CI 3.1-3.9%) developed surgical site infections. Implementation of the prophylactic antibiotics policy resulted in a 48% reduction in surgical site infections (Δ = −5.4 surgical site infections/100 cesarean deliveries; P < .001).

In a univariate analysis, the researchers found a significant association between the incidence of surgical site infection and white race, age 35 years or older, BMI of 35 kg/m2 or greater, the antibiotic prophylaxis policy, and the artificial nails policy. However, multivariate analysis showed that the antibiotic prophylaxis policy was the only factor that had a significant association with surgical site infection rates. The policy banning artificial nails in surgical staff and the streamlining of operating room cleaning and disinfection processes did not affect surgical site infection rates.

“Our results support the administration of prophylactic antibiotics before incision in patients undergoing caesarean delivery. Future research should aim at understanding adherence to this policy and best practices for delivering prophylactic antibiotics in a timely manner in both routine and emergency obstetric situations,” the authors write.

In 2011, the American College of Obstetricians and Gynecologists recommended a similar change in practice, with antibiotics to be delivered in the 60 minutes before incision. In UK hospitals there is a trend toward the adoption of an early administration policy for prophylactic antibiotics, but it needs to be a team effort from both the obstetricians and anaesthetists to get this simple but potentially lifesaving intervention correct.

dr Anand JayaramanST6 Northern School of Anaesthesia


RCoA/GAT Trainee Survey on Workforce Planning

The Department of Health (DH) workforce strategy document ‘A High Quality Workforce’1 recommended the establishment of the Centre for Workforce Intelligence (CfWI in 2010, as the “national workforce planning and development resource for the health and social care system”2.

In February 2012, the CfWI published “Shape of the Medical Workforce: Starting the debate on the future consultant workforce”3. Arising from their previous 2011 report “Shape of the Medical Workforce: informing medical specialty training numbers”4, the CfWI suggested that to meet future medical needs, intake to General Practice would need to be increased to the detriment of trainee numbers in hospital-based specialties. This reduction, along with changes in service delivery and utilisation, would impact on the future consultant workforce.

Due to the length of medical training the future consultants of 2020 are already in their final years of medical school or early years of postgraduate training. Decisions therefore need to be taken years in advance to avoid over or undersupply. The 2012 report outlined, using data obtained from mathematical modelling, the likely outcome of 7 scenarios upon the consultant workforce. These are outlined below:

These models incorporated existing workforce data (e.g. Office for National Statistics, NHS Information Centre for Health and Social Care) to generate a supply and demand model for the consultant workforce as a whole. Different scenarios, generated after a consultation exercise with major health service stakeholders, were then applied to the model.

The projected results for scenario 1 suggest that if no changes occur in recruitment or consultant working practices, there will be an increase in the consultant headcount by 60% to over 60,000 doctors by 2020. This represents an oversupply of trained doctors against the projected demand. These projections are worrying for trainees looking to join the consultant workforce in the next decade.

Table reproduced from Van Besouw JP. Anaesthesia News, Sept 2012

A joint survey by GAT and the Royal College of Anaesthetists Trainee Committee

The Presidents of the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) have responded to the report with concerns over the validity of some of the tabled scenarios5,6. All scenarios, if enacted, are likely to affect current trainees more than our senior colleagues. GAT and the RCoA trainee committees therefore conducted a membership survey both to gauge trainee and junior consultant opinion about these potential changes, and to raise awareness of the report’s potential implications.

This article aims to highlight the main survey results. The full survey report can be downloaded at www.aagbi.org/professionals/trainees

A survey of current trainees and those who received their CCT within five years of the survey date, was conducted over a 3 week period (26th October to 16th November 2012). 2165 individuals took part with 1796 complete responses obtained. Of those respondents who supplied their grade there were: 1741 trainees, 325 consultants and 94 were made up of locum consultants, specialty doctors and fellows.

Responses to the questions:

1. What are our memberships views on the seven ‘modelled’ scenarios?

The seven scenarios were ranked in order of acceptability. 1906 complete responses were submitted. Free text comments revealed that some trainees thought all the options were unacceptable. Despite evidence that maintaining the status quo (scenario 1) will become unfeasible, it was the most popular option (mean ranking 2.81) whilst the implementation of a graded career structure (scenario 7) was the least popular (mean ranking 5.98) (figure 2).

Figure 2: Mean ranking of CfWI scenarios based on all responses (lower number represents higher ranking).

Potential models for the future workforce configuration Scenario Overview Scenario 1 Business as usual No changes are made to the current patterns of

recruitment and deployment of trainees and doctors. Trends continue as at present

Scenario 2 Shift to General Practice There is a shift from hospital specialty training posts to General Practice to achieve a target 50:50 ratio

Scenario 3 Change in retirement age Retirement fixed at 60 years of age Scenario 4 Set level of demand The size of the consultant workforce is set using the

Royal College demand criteria Scenario 5 Training consolidation period A consolidation period is introduced during CCT Scenario 6 Consultant-‐present service Employers move to a service where a consultant is

in the vicinity at all times with accountability and responsibility for patient outcomes

Scenario 7 Graded career structure A multi-‐level career structure is introduced with recognises different levels of expertise, competence and intensity of work

Scenario 1 - Business as usual

Scenario 4 - Set level of demand

Scenario 3 - Change in retirement age

Scenario 6 - Consultant-present service

Scenario 5 - Training consolidation period

Scenario 2 - Shift to General Practice

Scenario 7 - Graded career structure


2. Which potential ramifications of the scenarios would be considered acceptable?

In addition to the ranking exercise, all trainees were asked how willing they would be to accept the changes necessary for the CfWI scenarios to be implemented. These ranged from changing speciality to reducing the national medical school intake.

The most obviously unpopular options were:• Changing specialty (Statement 1,CfWI Scenario 2) with 1451 (91% of respondents) scoring as disagree or strongly disagree• Formation of a tiered consultant grade (Statement 6, CfWI Scenario 7) with 1270 (80 %) scoring as disagree or strongly disagree

Only one option was universally popular – reducing the numbers at medical school (Statement 7). The Shape of Training review7, currently being conducted, will specifically look at the transition from undergraduate to foundation doctor. This question canvassed opinion on whether workforce planning in medicine should begin at an undergraduate level. 1264 trainees (80%) agreed or strongly agreed that this concept was a potential solution to the problem of excess trained doctors.

3. Which of the proposed alterations to consultant practices would our membership consider acceptable?

We asked respondents to rank the acceptability of some alternative ways of working at consultant level beyond the current New Consultant Contract (2003)8. Creating resident on-call sessions ranked the highest for acceptability (mean 1.72), whilst altering the consultant job plan to have neither pay nor career progression ranked lowest (mean 4.83 and 4.59 respectively).

The CfWI state that it is unlikely that the status quo of transition from trainee to consultant will be maintained, and that compromises will have to be made by current and future trainees. We presented six examples of compromise and asked respondents to rank which ones they considered most or least acceptable. These included changing sub-speciality, changing location and taking up a non-consultant post for varying time periods:

37% indicated they would be willing to work within a different anaesthetic subspecialty (choosing either “strongly agree” or “agree”) and 36% would relocate within the UK. 1475 out of 1866 (79%) responded that if a graded consultant structure were to be introduced (scenario 7), they would consider emigration or leaving the NHS (either “agree” or “strongly agree”).

60% of respondents would accept a time-limited non-consultant post with good prospects of a consultant post afterwards, however 2/3 (64%) disagreed with taking up a time-limited non-consultant post where the options for advancement were unclear and 72% rated taking up a permanent non-consultant post as unacceptable (“disagree” or “strongly disagree”).

conclusion:

Trainee and newly appointed consultant anaesthetists are concerned about future employment. Despite the evidence put forward by the CfWI for the need for change the main scenarios put forward (4-7) were deemed unpalatable by the majority of survey respondents. “Business as usual” was considered to be the most acceptable solution, despite the potential for a slowing of the previous decades’ consultant workforce expansion. The second most popular choice was to “set the level of demand” by using Royal College guidelines. The high ranking of this choice is difficult to understand, but may be due to the report stressing it would “find solutions for current trainees”3. However, scenario 4 details the deployment of trainees in alternative service delivery models, such as using excess trainees in a “trained doctor-delivered service”; in other words, trainees becoming permanent non-consultant career grades. Setting the retirement age at 60 was considered the third most acceptable choice; however, this is unlikely under current employment law.

The worrying scenario is naturally number 7. The graded career structure has the potential to irreparably damage the medical service. Over generations, junior doctors have worked diligently through long, anti-social hours in order to progress to the consultant grade, where respect and a salary commensurate with their standing were expected. ‘Grading’ consultants, whereby those newly appointed would no longer be able to achieve the same position as those of longer standing, has to be considered as potentially damaging. Firstly, trainee satisfaction may take a significant hit, and as the survey has shown, nearly three-quarters of trainees have said they would consider emigrating if scenario 7 were enacted. Secondly, it would serve to split the consultant workforce into factions, reducing cohesion and the teamwork so often espoused for optimum patient care. Creating tiers of seniority runs a risk of removing the unified consultant voice that has often called for reason in the face of NHS political changes. The most acceptable compromise to respondents in altering the way they would practice in the future was opting for a consultant-delivered service with resident on-call sessions.

With the joint review on medical and dental school intakes having been published in November 2012 by the Department of Health and the Higher Education Funding Council9 and the Shape of Training Review’s interim report due in April of this year, it seems appropriate to include alterations to medical student numbers as a possible choice. If the future workforce planning concerns of the medical profession could be mitigated to some extent by reducing medical school intake rather than creating a breed of unemployed expert professionals, trained at the tax-payers’ expense, then this should be considered as an option. 80% of respondents agreed or strongly agreed with this position. It should be noted that these are possibilities put forward by a single, non-medical organisation and scenario 7 may not actually come to fruition. However, with the NHS Efficiency Challenge calling for significant cost-savings, it is unlikely that the medical profession will escape unscathed.

dr richard Paul, GAT Chair (elect)

References:1. Department of Health. A High Quality Workforce: NHS Next Stage Review; 2008: 1–56. 2. WCL. Department of Health: Procurement of Centre for Workforce Intelligence; 2010 [accessed 4 Feb 2013]. Available from: http://www.w-c-l.com/Articles/ 191717/

WCL/How_we_can/Case_studies/Department_of_Health.aspx3. Centre for Workforce Intelligence. Shape of the Medical Workforce: starting the debate on the future of the consultant workforce; 2012 [accessed 4 Feb 2013]. Available

from: http://www.cfwi.org.uk/publications/leaders-report-shape-of-the-medical-workforce4. Centre for Workforce Intelligence. Shape of the medical workforce: informing medical specialty training numbers; 2011 [accessed 4 Feb 2013]. Available from: http://

www.cfwi.org.uk/publications/medical-shape-2011. 5. Van Besouw JP. Workforce planning: the issues. Anaesthesia News. 2012; 302: 9–10. 6. Harrop-Griffiths W. Is a consultant-delivered anaesthesia service feasible or desirable? British Journal of Anaesthesia. 2012; 109: 4–7. 7. Shape of Training Review. Call for ideas and evidence; 2012 [accessed 4 Feb 2013]. Available from: http://www.shapeoftraining.co.uk/static/documents/content/

Call_for_ideas_and_evidence_pub_0001.pdf_50395402.pdf8. National Audit Office. Pay Modernisation: A New Contract for NHS Consultants in England. London: The Stationary Office; 2007: 1-9.9. Department of Health. The Health and Education National Strategic Exchange (HENSE): Review of Medical and Dental School Intakes in England. Available at: https://

www.wp.dh.gov.uk/publications/files/2012/12/medical-and-dental-school-intakes.pdf [accessed 10/02/13]

Figure 3: Respondents acceptance of CfWI proposals (n = 1585). = strongly agree, = agree, = no opinion, = disagree, = strongly disagree.

Figure 4: Alternatives to current consultant working practices. Mean ranking by respondents (1 = most acceptable, 6 = least acceptable) (n=1866)

Consultant resident-on-call sessions

Reduced SPA time compared to established consultants (e.g. 9:1 or 10:0)

On-call commitment disparity between consultants in same department

Pay disparity between consultants on the same rota

No career progression (from A to C)

No pay progression

Change to GP Change to avoid unemployment

Enforced retirement

Perioid out of training

Reduce NTNs Tiered ConsultantGrade

Reduce MedicalSchool intake

1400

1200

1000

800

600

400

200

0

dr Katy Nicholson,RCoA Trainee Committee member


what were our three biggest achievements in the last year?

• Achieving the highest ever attendance, for any of our conferences, at WSM 2013, and doubling the number of trainees attending the GAT meeting in Glasgow. This achievement, as well as our Core Topics and Seminars programme, firmly places us as the major player in Education for Anaesthetists in the UK and Ireland.

• Launching the Event app and on line portal for our Conferences.

• Restructuring the GAT meeting so that there is educational content for every trainee of every grade, and fixing the price of the meeting at £195 for 3 years.

what current challenges are we facing?

• Dispelling the myths about Revalidation and supporting the GMC’s 4 domains in all of our Educational activities

• Providing value for money in this time of Economic gloom

• Gaining recognition from hospitals, that the work done by our members in delivering the GMC’s 4 domains at our meetings, whilst not of direct benefit to the Trust, supports the Revalidation process.

what are our priorities for the coming year?

• My priority is the development for our new Education platform project. This will bring together, via a single sign on login, the wide range of our AAGBI CPD content: video/slides, videos/audio lectures, GASCAST podcasts, ATOTW and more. In addition we plan to create a repository for all of your reflective learning whether it be from AAGBI meetings, critical incidents, or departmental lectures, and will be done via an app or an on line portal. This will be the equivalent of your ‘bottom drawer’ for revalidation paperwork, but in a neat little repository on line, ready to fling into whatever revalidation portfolio your Trust decides is flavour of the month!

dr samantha shinde Chair of the Education Committee

Education Committee

LATESTREPORT

The Education Committee is responsible for the educational strategy of the AAGBI. Educational events include Seminars, regional Core Topics meetings, and the annual Winter Scientific Meeting (WSM) London and Annual Congress, details of which can be viewed at www.aagbi.org/education.

A major focus of the Education Committee is to develop online learning for all. In addition to podcasts and the Anaesthesia Tutorial of the Week, we have an online video platform (http://videoplatform.aagbi.org), where you can view lectures from seminars and major meetings online. With the prospect of revalidation we know that there will be greater demand for CPD. At the same time, we realise the increasing difficulty in getting time away from work and hospitals decreasing financial support for study leave. We hope we can help with your learning requirements from the comfort of your own homes!

21 PORTLAND PLACE

Room Hire & Private Dining

www.aagbi.org/about-us/venue-hire

for availability or to make a booking, please contact our facilities Manager on 020 7631 8809 or email [email protected]

We are very grateful to the AAGBI Foundation and the Medical Protection Society for supporting this prize

AAGBI & MPS PATIENT SAFETY PRIZEThe AAGBI and MPS would like to offer a Patient Safety Prize to showcase examples of improved safety in anaesthesia.The prize is open to members of the AAGBI. The project could involve an individual, department, medical students or allied health care professionals, provided the project lead is a member of the AAGBI. Applicants may like to consider projects based on themes identified in SALG patient safety updates.

You will need to demonstrate:

Clear aims and objectives An innovative idea(s) How the project was introduced and implemented How performance was measured and benchmarked How information about the project was disseminated The sustainability of the project Transferability of the project to other departments

Amount: Up to £500 (at the discretion of the awarding Committee). There may be more than one prize.Awarded: At the AAGBI Annual CongressFormat of submissions: Poster presentation

In addition, the shortlisted entries will be expected to: Make a brief oral presentation to the judges at Annual Congress

The winner will be expected to: Make a five minute oral presentation at Annual Congress Submit an article for Anaesthesia News

Please visit www.aagbi.org/research/awards for further details.If you have any queries, please contact the AAGBI Secretariat on 020 7631 8807 or [email protected]

The deadline for submissions is midnight on Monday 10 June 2013


The surgical impact of obesity

Dr Euan ShearerDr Claire NightingaleDr Mike Margarson

Sleep apnoea – the hidden killer?

Dr Mike MargarsonDr Claire NightingaleDr John Cousins

Pre-operative assessment to reduce risk

Dr Will Fox Dr Nick KennedyDr Euan Shearer

Airways and ventilation

Dr Will Fox Dr Nick KennedyDr Mike Margarson

Anaesthetic systems management to reduce risk

Dr Claire NightingaleDr Euan ShearerDr Nick Kennedy Dr Mike Margarson

BOOKBOOKONLINEONLINEBOOKONLINE

CPD STUDY DAY:ANAESTHESIA FOR THE MORBIDLY OBESE PATIENT

Date and venue:17 April 2013RCoA, London

Registration fee:£195 (£150 for registered trainees and affiliates)

Event organiser:Dr N Kennedy

Follow @rcoa_events

Apply: www.rcoa.ac.uk/eventsContact: 020 7092 1673 [email protected]

an-advert.indd 2 04/02/2013 10:06

Case reports remain an important route to publicise difficult or interesting cases. They are not just the first port of call for trainees wanting their first publication, some of the most interesting cases in medicine were first published as case reports – just think of Christiaan Barnard in 1967, or Denborough reporting the malignant hyperthermia for the first time in 1962.

The AAGBI recently launched Anaesthesia Cases, a new free service for members.

This is a new educational resource of case reports to allow rapid publication of interesting, informative, or notable cases in anaesthesia, critical care and pain.

The web-based submission, publication and search functions will allow users to both submit and access reports through computers, tablets and smartphones at all times. If you are faced with a tricky case and want to see how others have managed the same situation you will be just a few clicks away.

The site is linked to the journal Anaesthesia and all submissions will undergo careful review and editing. Reports that are particularly noteworthy will be published by the journal. Other reports, providing they are not duplicates, spam, or libellous (!), will be published online. Each report will have a unique URL that can be used if the report needs to be referenced.

Searches will include all case reports published on the site and those published in Anaesthesia since 2012.

The site editor is Mike Nathanson and the assistant editors are Serene Chang and Judith Dinsmore.

www.anaesthesiacases.org

Anaesthesia Cases is an online, editorially-reviewed, journal of case reports in anaesthesia, pain medicine and intensive care.

Users are able to submit and search case reports – a brilliant resource for trainees and consultants!

Submit a case report today www.anaesthesiacases.org

Anaesthesia Cases

NEW for 2013!

ENDURA ROAD JERSEYAAGBI

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MEN’S WOMEN’S

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Payment can be made via PayPal to: [email protected] or by cheque made payable to: Richard Griffiths

Please allow up to 12 weeks for your shirt to be delivered.

Please mail cheques with a completed order form to:Dr Richard Griffiths, Michaelmas House, First Drift, Wothorpe, Stamford, Lincolnshire, PE9 3JL

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@AAGBI recap

Latest safety updates

View the latest safety updates and Medical Device Alerts on the AAGBI website.

www.aagbi.org/safety/incidents-and-alerts

@AAGBI

For breaking news and event information follow @AAGBI on Twitter

WSM videos now available!

Lectures from WSM 2013 are now available on the video platform

• Keynotes by Prof Martin Elliott speaking on Tracheal transplants and Mr Nigel Edwards on Rethinking the hospital – how are hospitals dealing with threats and changes facing them.

• Talks on The National Emergency Laparotomy Audit - What you need to know and the Environment and Anaesthesia - Can we do better? Plus, latest updates on Safety; Quality improvements and Trauma.

There is also a video of the talk by Dr David Zideman, clinical lead for the Emergency Medical Services, London Organising Committee of the Olympic and Paralympic Games.

Visit the video platform now!

http://videoplatform.aagbi.org

Irish Congress of AnaesthesiaA N N U A L M E E T I N G 2 0 1 3

This two day meeting is the most prestigious and important in the College’s academic calendar. It will feature:

• Key-note addresses from international experts• Current issues / update sessions• Workshops / simulator sessions• Free papers and posters• Excellent social programme

Further details on WWW.ANAESTHESIA.IE

CALL FOR ABSTRACTS

• Eligibility – Anaesthetists in Training OR Fellows of the College of Anaesthetists of Ireland (in good standing) – Consultants and Non-Consultants.

• “Free” means – case reports, series of cases or clinical investigations

• The absolute time limit for receipt of applications is Friday 29 March 2013 at 17:00 hrs.

• Abstract forms available from www.anaesthesia.ieWWW.ANAESTHESIA. IE

Further details on

THE CONVENTION CENTRE DUBLIN, 17 - 18 MAY 2013

Key-note speakers include:

Lee Fleisher, US

Lukas Kirchmair, Austria

Manoj Karmaker, Hong Kong

Manfred Greher, Austria

Rupert Pearse, UK

Annual Congress Dublin 2013

Following a successful Annual Congress in 2012, we’re swapping the beaches of Bournemouth and hopping across the Irish sea to Dublin. Annual Congress is taking place between 18-20 September, right in the heart of this fantastic city in the Convention Centre, which overlooks the River Liffey.

Full details on the programme and how to book your place is available on our website. www.annualcongress.org

The AAGBI responds to the Mid Staffordshire public inquiry Following on from the tragic events at Mid Staffordshire NHS Foundation Trust, the AAGBI has issued its response to the Francis report. We are asking anaesthetists to raise any patient safety concerns and continue in their role as patient advocates. We are calling on every healthcare professional to think about the following: “Would you want this sort of care for your family?” You can read the full statement on our website.

www.aagbi.org/www.aagbi.org/news/latest-news

St George’s Day

Anaesthesia Forum

Tuesday 2pm, 23rd April 2013

at St George’s Healthcare NHS Trust Blackshaw Road, London SW17 0QT

Lecture Theatre F, 1st Floor Grosvenor Wing

To celebrate the work of

Prof George Hall (on his retirement)

The following will contribute to the programme:

Dr J-P van Besouw Dr Joan Desborough Dr Judith Dinsmore Dr William Fawcett Prof Mike Grounds Prof Jennifer Hunter

Dr Phil Newman Dr Grainne Nicholson Dr Barbara Philips Dr Heidi Robertshaw Dr Neville Robinson Prof Peter Salmon

For more details please call Department of Anaesthesia St George’s Hospital, tel. 0208 725 0051/3317

or email [email protected]

16th Anaesthesia, Critical Care and Pain Forum

Da Balaia, The AlgarvePortugal

31 September - 3 October 2013

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Less than full time: Boldly going where not many men have gone