aagbi cpd position statement gat oxford: submit your abstracts

NEWSANAESTHESIA

ISSN 0959-2962 No. 306

JANUARY 2013

The NewsleTTer of The

AssociATioN of ANAesTheTisTs of GreAT BriTAiN

ANd irelANd

INSIDE THIS ISSUE: AAGBI CPD

position statement

GAT Oxford: submit your abstracts now

e-learning opportunities

Anaesthesia News January 2013 • Issue 306 3

2013 Course Dates Location Organisers4–5 January Newcastle (A) Dr Ian Harper 12–13 April Bristol (A) Dr Barry Nicholls/Dr Tony Allan8–9 July Brighton(A) Dr Susanne Krone19–20 September Liverpool Dr Steve Roberts29–30 November Nottingham (A) Dr Nigel Bedforth

Faculty will vary depending on location

10% Discount for ESRA members – 15% Discount for RA-UK (FULL) members. Cost: £400 / £500 (A) including a CD with presentations and course notes. Pre-course material can be downloaded once registered on the course – including US physics, anatomy of the brachial / lumbar plexus, current articles of interest and MCQ’s. A pre course questionnaire will be sent 30 days before each course.

ProgrammeDay 1• Ultrasoundappearanceofthenerves•Machinecharacteristicsandset-up•Imagingandneedlingtechniques•Commonapproachestothebrachialplexus/upper/lowerlimb•Workshops–usingphantoms/models/cadavericprosections(A)

Day 2•Consent/trainingandimagestorage•Upper/lowerlimbtechniques•Abdominal/thoracictechniques•Cervicalplexus/spinal/epidural/painprocedures•Workshops–usingphantoms/models/cadavericprosections(A)

(A) – Anatomy based courses / with cadaveric prosections

These courses are organised by Regional Anaesthesia UK (RA-UK) in conjunction with SonoSite Ltd for training in ultrasound guided regional anaesthetic techniques. Previous experience in regional anaesthesia is essential.

For further information and to register logon to www.sonositeeducation.co.uk

UltrasoUnd gUided regional anaesthesia – beyond introdUctory

FUJIFILMSonoSite,Inc,.theSonoSitelogoandothertrademarksnotownedbythirdpartiesareregisteredandunregisteredtrademarksofFUJIFILMSonoSite,Inc.invariousjurisdictions.Allothertrademarksarethepropertyoftheirrespectiveowners.

©2012FUJIFILMSonoSite,Inc.Allrightsreserved.163310/12

2013 coUrse dates:

Introductory Ultrasound Guided Regional Anaesthesia4-5 February 13-14 May 16-17 September 25-26 November

Ultrasound Guided Venous Access 31 January 23 May 10 October

Ultrasound Guided Critical Care14 February 13 June 14 November

All courses qualify for CPD Accreditation.

Venue: SonoSite Education Centre – HitchinFor the full listing of SonoSite training and education courses, dates and to register go to:

www.sonositeeducation.co.uk

SonoSite, the world leader and specialist in hand-carried ultrasound, has teamed up with some of the leading specialists in the medical industry to design a series of courses, for both novice and experienced users, focusing on point-of-care ultrasound.

Introductory Ultrasound Guided Regional Anaesthesia The two-day introductory course is designed to teach those who have little or no experience in the use of ultrasound in their normal daily practice. The course comprises of didactic lectures on the physics of ultrasound, ultrasound anatomy and regional anaesthesia techniques. The lectures and hands-on sessions will concentrate on the brachial plexus, upper and lower limb blocks.

Ultrasound Guided Venous Access This one-day course is aimed at physicians and nurses involved with line placement and comprises didactic lectures, ultrasound of the neck, hands-on training with live models, in-vitro training in ultrasound guided puncture and demonstration of ultrasound guided central venous access. The emphasis is on jugular venous access, but femoral, subclavian and arm vein access will also be discussed.

Ultrasound Guided Critical Care This one-day course is aimed at all critical care physicians and surgeons. The programme is suitable for those who already have some basic ultrasound experience as well as those who are new to the clinical applications of focused ultrasound at the patient bedside. The course is suitable for consultant and middle grade clinicians across the spectrum of specialities (Emergency Medicine, Acute Medicine, Surgery, Paediatrics and Intensive Care Medicine for children or adults).

Fees: £375 (two-day courses) includes VAT, lunch, refreshments and course materials. £260 (one-day courses) includes VAT, lunch, refreshments and course materials.

If you have any questions or should need further information please contact: Dee Banks, SonoSite Ltd, Alexander House, 40A Wilbury Way, Hitchin Herts, SG4 0AP Tel: +44 (0) 1462 444800 Fax: +44 (0) 1462 444801 E-mail: [email protected]

UltrasoUnd training coUrses

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 2012 The Association of Anaesthetists of Great Britain and Ireland

The Association cannot be responsible for the statements or views of the contributors. No part of this newsletter may be reproduced without prior permission.

Advertisements are accepted in good faith. Readers are reminded that Anaesthesia News cannot be held responsible in any way for the quality or correctness of products or services offered in advertisements.

contents

3

Editorial

08

06

23

16

03 Editorial 05 CPD in the context of Revalidation: AAGBI position statement 2012 06 Being right-brained; medicine, reverse innovation and developing economies 08 Raleigh International 10 e-learning for anaesthetists - something for everyone 15 FRCAQ 16 Low back pain and return to work: some advice from personal experience

18 GAT ASM 2013 20 Anaesthesia Digested 23 Hip Fracture Anaesthesia Sprint Audit Project (ASAP) 25 @AAGBI recap 26 January History Quiz 27 Your Letters

28 Particles

30 Reflective Pearls

10I hope you have all enjoyed an excellent festive season and are ready to embrace the New Year. I also hope you are also braced to read this offering, my first attempt at Editing a Journal. I was excited when my colleague Ric Lawes agreed to explain to us the concept of reverse innovation, opening our minds to the fact that we can learn from health care solutions arising from challenges in less economically developed countries. Ric’s observation that Trusts are actively discouraging the use of new technologies such as smart phones while embarking on IT projects based on obsolete operating systems certainly struck a chord with Val Bythell, officially retired from Editing Anaesthesia News but still guiding us neophytes at 21 Portland Place. “We grapple with a clunky e-prescribing system on a daily basis in my Trust – designed for a different healthcare system at a time when the Millennium seemed a long way off”, said Val, and I have to say the same is happening at my home base.

I have chosen from among many excellent submissions a GAT article about e-learning opportunities. As an older anaesthetist, my mind boggles at the potential for rapid dissemination of research, ideas and opinions. I am told that conference delegates will be able to interact with lecturers in real time using Twitter, or something like it, which will add to the stage fright some of us suffer when standing before you at Congress or the Winter Scientific Meeting. (Hint, you did book for WSM 2013, didn’t you? And you have Dublin in your diary, don’t you?).

Let’s hope 2013 does not prove to be “unlucky for some”. Revalidation is upon us, and the first full year of revalidation. The biggest danger will be what the GMC call “failure to engage”. We at AAGBI are trying to find ways to make what could be a dreary and intimidating process less onerous, and maybe even productive and enjoyable. My own little contribution is the idea of Reflective Pearls? What do you think?

Happy New Year from all of us at the AAGBI

Tom woodcock

4 Anaesthesia News January 2013 • Issue 306 Anaesthesia News January 2013 • Issue 306 5

GAT PRIZES AT OXFORD 2013

GAT Oral and Poster PrizesTrainee anaesthetists are invited to submit an abstract for oral or poster presentation at the GAT ASM. The authors of the six highest-scoring abstracts in the preliminary review will be invited to present their work orally and will be eligible for the Dräger Oral Presentation Prize. A cash prize will be awarded to the winner.

The remaining successful authors will be invited to present a poster. Entries will be allocated into one of the following three categories depending on the grade of the presenting author: Foundation Year Trainees; ACCS/Core Trainees; ST3+ Doctors. A cash prize and a certificate will be awarded to the winner in each category. The judges also reserve the right to award discretionary certificates.

Case Presentation PrizeTrainees are asked to submit an abstract of an interesting case that they have been involved in, and which has learning points that may aid other anaesthetists in their management of similar cases. The three best submissions as judged in the preliminary review will be invited to present their work orally at the ASM and the audience asked to vote for their favourite. A cash prize will be awarded to the winner.

New for 2013Medical Students poster prize: Medical students are invited to submit an abstract for poster presentation on a theme related to Anaesthesia/Pain/ITU. A cash prize will be awarded to the winner.

RSM Prize, supported by the RSM Section of AnaesthesiaFurther details will be available online shortly.

All audits, whether shortlisted for oral or poster presentation, will also be eligible for the Dräger Audit Prize. Audits should demonstrate good understanding of the principle of clinical governance and evidence of completion of the audit cycle.

The Anaesthesia History PrizeThe Association of Anaesthetists and the History of Anaesthesia Society will award a cash prize for an original essay on a topic related to the history of anaesthesia, intensive care or pain management written by a trainee member of the Association.

The £1,000 cash prize and an engraved medal will be awarded for the best entry.

CLOSING DATE FOR ALL PRIZES: MONDAY 14th JANUARY 2013

Full details can be found on the GAT website www.gatasm.org/content/oral-poster-prizes

If you have any additional queries, please contact the AAGBI Secretariat on 020 7631 8807/8812 or [email protected]

Principles

The AAGBi is committed to the continuous improvement of patient care, to the ever-safer delivery of anaesthesia, critical care and pain therapy, and to the principle of lifelong learning through which individuals update, develop and enhance their clinical practice.

The AAGBi

• supports the revalidation process and endorses the approach set out in the GMC’s document ‘Good Medical Practice’ and ‘Continuing professional development: guidance for doctors’ .

• views reflective and self-directed learning as the means of linking education, appraisal and practice in a continuous cycle.

• recognises that adult learners use a variety of learning styles and ways of achieving CPD based on personal development plans and their own preferences

• considers that learning from inter-action and engagement with patients is a key aspect of continuous professional development for doctors

• endorses the GMC’s stance that revalidation is at its heart a local procedure that focuses on individuals’ practice within their own work contexts

• supports the GMC’s position that the educational content of specific learning events does not require recognition or approval by an overseeing body, but that it is for each individual and his/her appraiser to agree upon its value to the individual doctor when discussing his/her educational needs.

• believes that mapping CPD activities to standardised formats and recording CPD in a rigid, formulaic method, e.g. a points-based system, is not a necessary component for meeting the revalidation requirements set out by the GMC

• accepts that some members will wish to record their CPD activity in a points-based format in order to highlight to employers their effective use of paid, non-clinical time and study leave expenses

• recognises the work done by the RCoA in mapping the potential CPD needs of members of the profession through the CPD Matrix

• seeks to work collaboratively with the AoMRC, BMA, RCoA and other stakeholders engaged in education and learning for the profession

The AAGBi strategy for delivering education and learning based on these principles in 2012 and beyond

As the leading provider of postgraduate education in anaesthesia in the UK the AAGBi will deliver high quality and relevant cPd resources in a variety of formats and styles including seminars, major national conferences, core topics meetings, workshops and online learning to suit individual needs.

The AAGBI will quality assure its educational output by setting clearly defined learning outcomes and through rigorous evaluation that involves feedback from learners and peer review of content.

The AAGBI will offer its members online learning, CPD tools and education activities designed to deliver specific learning outcomes that map to the four domains of learning set out by the GMc (below) and, when possible, the cPd Matrix.

• Knowledge, skills and performance• Safety and quality• Communication, partnership

and teamwork Maintaining trust

The AAGBI will provide the means for members to undertake reflective learning and gather evidence of their cPd online through the website and other electronic means such as “Apps”. We will implement an easily accessible and user-friendly system that allows members to record activity and monitor progress towards successful completion of their Personal Development Plans.

The AAGBI will support members in meeting their cPd needs by ensuring that they can create electronic and paper records of not only the CPD events they attend, but also their reflections upon the learning they gain at these events, and from their interactions with patients and colleagues, which represent a part of the overall aims of revalidation defined by the GMC.

During the next few years, there will be a number of evolving systems for the recording of elements of the revalidation process developed by bodies such as the BMA, RCoA,Revalidation Support Team, other agencies in the devolved countries, and individual hospitals, Trusts and Boards The AAGBI wishes to collaborate with such bodies and complement other systems for the benefit of its members and for patients and will not seek to duplicate complex systems as they evolve. The AAGBI will therefore support members who chose to use another system, e.g. a local Trust Revalidation portfolio, by allowing them to record AAGBI activities in a way that can be included in whichever system they use.

The AAGBI is mindful of the needs of members in other roles who may welcome resources and support from the AAGBI, and the particular challenges faced by speciality doctors, by those working largely in the independent sector, the large number of doctors not on national Terms & Conditions, such as Trust Grades, Fellows and long term locums and those whose responsibilities outside work might make attendance at external CPD challenging. We will explore ways in which we may be able to support these and other user groups such as appraisers, Clinical Directors and Responsible Officers.

As ever, the AAGBi seeks to be responsive to the needs of its members, and welcomes input from members about what topics should be covered in its educational material, whether in seminars, core Topics, major national meetings or online material. Please let us have your views and comments to [email protected].

1. General Medical Council, Good Medical Practice http://www.gmc-uk.org/static/documents/content/GMP_0910.pdf (accessed 31.7.12)

2. General Medical Council, Continuing professional development: guidance for doctors http://www.gmc-uk.org/CPD_guidance_June_12.pdf_48970799.pdf (accessed 31.7.12)

CPD in the context of Revalidation: AAGBI position statement 2012

The purpose of the position statement is

• ToexplaintheAAGBI’sstancetointernalandexternalstakeholders• ToguidefutureactionsandresourcecommitmentsbytheAAGBI• TosetouttheAAGBI’sstrategicdirectioninitsservicedevelopment

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

Anaesthesia News now reaches over 10,500 anaesthetists every month and is a great way of advertising your course, meeting, seminar or product.

For further information on advertising

Tel: 020 7631 8803

Dr Les GemmellImmediate Past Honorary Secretary

21 Portland Place, London W1B 1PYT: +44 (0)20 7631 1650F: +44 (0)20 7631 4352E: [email protected]

W: www.aagbi.org

or email chris steer: [email protected]/publications

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NATIONAL SCIENTIFIC CONGRESS OF THE AUSTRALIAN SOCIETY OF ANAESTHETISTS

Australian Society of Anaesthetists

The NSC 2013 organising committee headed by Drs Mark Skacel and Paul Burt have developed a program that will appeal to a wide audience and further explore how our understanding of the basic sciences improves clinical outcomes for our patients.

Special areas of interest will include neuroscience and consciousness, fluid therapy, and outcomes for the high risk surgical patient.

Invited Speakers includeProfessor Martin Smith Queens Square LondonProfessor Colin Mackenzie University of Maryland, BaltimoreProfessor Mike Grocott University of SouthamptonProfessor Tony QuaillNewcastle University, NSW

2013

NSC AIC ADVERT 216x282.indd 1 11/8/2012 11:00:30 AM

The AAGBI’s reflective learning template will be available

at www.aagbi.org shortly


devices are prohibitive, as are the financial penalties of breaching product liabilities through re-usage. Wealthy nations can afford to adopt “use-once-throw-away” policies because they manufacture the items using cheap labour in developing economies. The amount that those workers are paid is insufficient to enable them to purchase the devices they manufacture, but they still need to resolve the problems such devices were designed to solve. Awareness of how they achieve their solutions may be mutually beneficial.6

Accessing innovative solutions depends on the dissemination of knowledge. The present model is unidirectional: developed nation to developing nation. This may be represented by, for example, multi-center; double blind controlled trials (MCDBCT) followed by peer review etc. An expensive process leading ultimately to printed matter that is no more adapted to the transportation infrastructure of developing nations than the MCDBCTs are to their finances. Not least is exclusion of less grandiose ideas, unamenable to such rigorous treatments and thus considered unworthy of publication.

To circumvent some constraints requires the removal of overzealous legal and regulatory limitations placed on innovative ideas, encouragement of innovative thinking and, most importantly, the emergence of a new inexpensive or free vehicle that would provide a platform on which ideas may be disseminated. This will require many to relinquish their vested interests - academics, politicians, big business, legislators etc. The task may look insurmountable when presented thus but some opportunities like RSS7 and YouTube8 exist already, whilst free models of traditional models also exist.9

One of the features of developing nations is a willingness to leapfrog technology. Despite the ubiquitous use of smart phones and the Internet, in the UK neither has yet been fully exploited for the dissemination of medical knowledge. Indeed some trusts actively discourage their use or embark on IT projects using obsolete operating systems. Medicine is losing out in this technology as patients use Google to research medical information (vaccination for example) and formulate their views whilst unable to distinguish between lay commentators and professional opinion. Printed journals, editorialising, proofreading, regulatory compliance have a definite function but if their complexity impedes genuine innovation additional strategies are required. The absence of peer review or editorial control over the content of such sites would not represent a hazard if new clinicians have been successfully taught how to understand creative ideas. If the next generation of doctors are not encouraged to be right-brained we will not only fail to exploit new ideas but also the value of our medical knowledge will be worth no more than commentators jottings on the internet. I would encourage all trainees to go see for themselves how exciting innovation can be and visit their sources.

dr ric lawes,Consultant Anaesthetist, Southampton

1. Reverse Innovation. Govindarajan, V, Trimble C. Harvard Business Review Press. 2012. 2. http://verneharnish.typepad.com/growthguy/2012/04/reverse-innovation-gatorades-real-

back-story-mike-maddock-favorite-paragraph.html Accessed 13/10/123. The Master and His Emissary: The Divided Brain and the Making of the Western World.

McGilchrist, I. Yale University Press. 2012.4. http://www.ted.com/talks/jill_bolte_taylor_s_powerful_stroke_of_insight.html Accessed

13/10/12.5. International Herald Tribune Tue, 09 Oct 2012 Charles Duhigg and Steve Lohr. Innovation

a casualty in tech patent wars http://www.pressdisplay.com/pressdisplay/iphone/homepage.aspx#_articlec0547561-9111-4e7e-8a0f-edc0f832a469 Accessed 13/10/12.

6. Reverse innovation Ch 10. P1427. RSS stands for “Really Simple Syndication”. It is a way to easily distribute a list of

headlines, update notices, and sometimes content to a wide number of people. It is used by computer programs that organize those headlines and notices for easy reading. http://rss.softwaregarden.com/aboutrss.html

8. YouTube provides a forum for people to connect, inform, and inspire others across the globe and acts as a distribution platform for original content creators. http://www.youtube.com/t/about_youtube

9. Budapest Open Access Initiative http://www.opensocietyfoundations.org/openaccess/read

Willingness to leapfrog technology

The way medicine is taught is analogous to the non-interchangeable functions of the cerebral hemispheres.3 The left and right cerebral hemispheres have two distinct roles. The left-brain is responsible for order, regulation, control etc. The right brain assumes the functions of creativity and imagination - the non-logical ideas that lead to inspirational discoveries. Having recovered from a stroke, Jill Bolte Taylor describes this dichotomy beautifully.4

In the UK, we are actively forgetting that some of the most inspirational discoveries in medicine have depended on a single creative observation made by an individual (penicillin, ether anaesthesia, vaccines etc.). Constraints (intentional or not) are currently placed on individuals, discouraging them from being innovative or thinking independently. For example, mandatory adherence to “clinical guidelines” obviates the need to think. We currently train our juniors to be left-brainers and to remember protocols and guidelines and log their achievements numerically. We punish those who fail in this task and impede those that dare to introduce innovative ideas. We have allowed the left brainers to dominate medicine, particularly postgraduate training. I believe it is time to reverse this imbalance and allow creative right brainers ascendency. We can relearn our creativity by paying attention to the sources of reverse innovation.

Medical device manufacturers are protected from competition by ensuring that only organisations equipped with sufficient resources (financial, legal and material) can ever introduce a new product. There is evidence of industry encouraging excessive regulation, thus excluding players other than themselves from access to markets.5 This protectionist left-brain strategy incurs real costs that are becoming prohibitive, even for the West. Protectionist strategies are not universal and numerous innovative, but unpublished ideas abound in developing economies, as anyone who has worked in these locations can attest. An example is the profligate use of non-penetrative disposable medical devices designed to be used once and then discarded. Labour costs incurred from cleaning reusable

Reverse innovation is a phrase used to describe a business strategy popularised by Vijay Govindarajan and Chris Trimble1. The idea reflects a fundamental change in direction of the flow of knowledge. Traditionally, technological and medical knowledge develops in advanced economies and then trickles down through western institutions, bolstered by funded research, before arriving in developing economies. Innovations developed to meet the needs of developing economies seldom trickle up to developed economies. It is an error to assume that this status quo is the only way knowledge can travel.2 Medicine can learn a great deal from reversal of the current situation. However, accepting this will require changes in attitude, the way medicine is taught; how knowledge is dispersed and how we view medical manufacturers.

Being right-brained; medicine, reverse innovation and developing economies

Supported by

This one day course is designed for Anaesthetist-ODP teams to teach Human Factors in Airway Management. It includes

interactive team training in “Error Avoidance” strategy, non-technical skills and their practical application in simulation

and integration with airway technical skills.

5 CPD points (1I02, 1I03, 1B02, 1C02, 2A01) applied from the Royal College of Anaesthetists

Course Fee: Consultant Anaesthetist: £225 (DAS member £200), SAS / Trainee Anaesthetist: £175 (DAS member £150),

Theatre team member: £100** This fee will be refunded if accompanied by an anesthetist from the same Trust

For application forms visit: www.anaesthetics.uk.com or www.das.uk.com

Registration Enquiries Busola Adesanya-Yusuf, Specialist Societies Manager,

Difficult Airway Society, 21 Portland Place, London, W1B 1PYEmail: [email protected] Tel: 020 7631 8816 Fax: 020 7631 4352

Wed 17th April 2013, Wed 19th June 2013, Wed 16th October 2013, Wed 18th December 2013

Venue: Clinical Sciences BuildingUniversity Hospital, Coventry CV2 2DX

‘SMART’ANAESTHESIA COURSE

20TH ANNUAL MANCHESTER

PAEDIATRIC ANAESTHESIA UPDATE

Friday 22nd March 2013 Manchester Conference Centre

Course Director: Dr Davandra Patel

PROGRAMME

Anaesthetic consideration for children with congenital

hyperinsulinaemia and diabetes

Advances in paediatric neurosurgery

Anaesthesia for children with neurological conditions

Revalidation: Paediatric anaesthesia

Review of paediatric supraglottic devices

Paediatric transfer: A DGH anaesthetists perspective

Managing anxiety in children

Course Fees £165 Doctors in training £85

All enquires should be directed to: Christine or Paula

Telephone Number: 0161 701 1263 or 701 1264

Fax: 0161 70 14875

Email: [email protected] or [email protected]

Approved for 5 CME points

20TH ANNUAL MANCHESTER

PAEDIATRIC ANAESTHESIA UPDATE

Friday 22nd March 2013 Manchester Conference Centre

Course Director: Dr Davandra Patel

PROGRAMME

Anaesthetic consideration for children with congenital

hyperinsulinaemia and diabetes

Advances in paediatric neurosurgery

Anaesthesia for children with neurological conditions

Revalidation: Paediatric anaesthesia

Review of paediatric supraglottic devices

Paediatric transfer: A DGH anaesthetists perspective

Managing anxiety in children

Course Fees £165 Doctors in training £85

All enquires should be directed to: Christine or Paula

Telephone Number: 0161 701 1263 or 701 1264

Fax: 0161 70 14875

Email: [email protected] or [email protected]

Approved for 5 CME points

Raleigh International

I had heard of Raleigh International previously, from friends and colleagues. Initially, I had reservations that I would just be an adjunct to a token ‘gap yah’. On reflection, however, I realised that I had gained a great deal from travelling and volunteering. I hope my travels have made me a more worldly and open-minded, and I hoped to encourage this development in others at a formative period in their lives.

Founded in 1978, Raleigh has projects in Costa Rica, India and Borneo and aims to develop leadership, teamworking and personal skills in ‘venturers’ aged 17-22. In addition to those on a typical gap year, subsidised places are offered to university leavers from underprivileged families and the Partnership Programme gives opportunities to those from deprived backgrounds, nominated by their social workers. Places are also given to venturers from the host country. This provides a lively mix of teams with individuals from very different backgrounds.

I went to Malaysian Borneo, where medics are required for the remote adventure phase. These consist of a week’s diving, then two weeks’ trekking in the jungle on the borders of Sabah, Sarawak and Indonesia. Medics are involved in the organisation of medical kit, casualty evacuation planning and teaching staff and venturers. At all

times there is a medic at field base for consultation by radio. I found this an advantage as I had joined the expedition after foundation training, without any previous expedition experience,. The ability to ask a peer to check treatments, look up information, or confirm judgment, when isolated in the middle of the jungle, is invaluable. It also helps when treating oneself. As cellulitis secondary to infected insect bites is common, I treated a number of cases. When faced with my own cellulitic leg in the wilderness, with evacuation hours away, the voice of a fellow medic telling me that the amputation was probably unnecessary and that I should just double the dose of flucloxacillin, was just what I needed.

On these treks, the medic usually walks at the back, encouraging the stragglers, while the other project manager leads. Once, when walking through the undergrowth, we heard a buzzing noise. One by one, those towards the back of the line ran past me and suddenly, I was being attacked by hornets. Stinging ferociously and repeatedly, they stuck in my hair as I tried to reach the adrenaline in my medical kit. The venturers dispersed wailing, into the forest. I was terrified that one would have an adverse reaction, while simultaneously trying to rid myself of the hornets (and convince myself that I wasn’t having an anaphylactic reaction). I threw a bottle of water over my head and found the others. They all coped admirably with the

intense pain. It felt as though I’d been kicked in the head. We set up camp as soon as possible and I was faced with the challenge of caring for others whilst I was incapacitated, and subsequently, when unable to get on top of their, or my, pain, caring for others when on tramadol. I remember being conscious that I was a little wobbly, and double checking everything with the field base medic to make sure it was appropriate. They, needless to say, found my conversation much more entertaining than usual.

Life in the jungle takes a bit of getting used to; carrying all food and equipment with you, tying your hammock up every night, cooking by campfire and dealing with the wildlife. Whilst on the dive island, I woke up suddenly one night and saw something move quickly over me in the darkness. My reflex was to scream and get as far away as possible, tripping over my sleeping bag and waking up the other project managers. I was first embarrassed that I’d over reacted, but when we shone a torch at the area, there was a black and yellow snake, hissing at us. We still aren’t sure what it was but the working diagnosis is a pit viper. It took two hours to get rid of it. The locals, understandably, refused to go near it (as three of us quivered on a table nearby), but it was eventually removed by the dive instructors.

Medics fulfill the dual role of expedition medic and project manager, a title which can lead to many and varied tasks. You are required to be a leader, safety supervisor, facilitator and counsellor. It is the first time that most of the venturers have had to be independent, let alone in such an environment. I enjoyed this part of the role, exercising skills which I’d forgotten I had. You need to be a confidante, referee, disciplinarian, cook, optimist, quantity surveyor, oracle hammock expert, and in my case all the emergency services. We had set up camp in an orchid sanctuary where open fires were forbidden, and so had brought a can of methylated spirit and burners with us. One venturer was cooking, when one of the burners went out. She decided to add fuel to it whilst the other burner was still alight. The can caught fire, sealing the plastic lid and pressurizing the bottle of spirits. The other project manager alerted me by yelling expletives and running in the opposite direction whilst trying to gather as many of the screaming venturers as possible. The responsibility fell to me as the doctor (apparently best placed to deal with all emergencies) to try to put out the fire, using a damp travel towel.

I would thoroughly recommend Raleigh for an introduction to expedition medicine. It seems to have been a very positive experience for the venturers in my groups. Personally, it reinforced skills that I gained during my training and reminded me that I am a rounded person who can undertake new challenges. Above all, it fulfilled the requirement – another adventure.

dr savini wijesingha,CT2 Trainee, Wessex Deanery

I have always wanted to be an expedition medic. I wanted the chance to combine my profession with adventure. So last year, I looked into ways in which I could join an expedition.

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]

w: www.aagbi.org

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.


GasCast

In 2011, a survey published in Anaesthesia [2011(66):620–631] found that 59% of anaesthetists owned an iPhone. Whilst the total number of respondents surveyed was small, only 8% of the anaesthetic workforce in England, it is not impossible to believe that this figure may be a true representation. Mobile technology plays an increasingly significant role in continuing medical education by facilitating “on-the-go” access to current knowledge. With so many excellent sources available, it is easy to suffer from information overload or academic fatigue. For this reason we set about designing an online resource for anaesthetic trainees wanting to keep their knowledge up to date, but in an accessible “anaesthesia-lite” manner. Thus GasCast was born, and is now produced as a monthly podcast that takes the form of a radio show. For the uninitiated, a podcast is a digital media file that is posted on the internet. Podcasts are a simple and powerful way to communicate a message and can be easily downloaded and played on a computer, smart phone or tablet at the listener’s convenience.

The podcast has an informal format and lasts approximately one hour, well timed for the average daily commute or laparoscopic appendicectomy. Rik Thomas currently performs anchor duties and guides the discussion through several segments, opening with our ‘Discoveries of the Month’. For the main section we each cover a particular topic, recent journal article or newly published guideline. We aim for a degree of participation from all hosts on the topic, which usually results in a fair amount of banter, and the occasional well-

informed observation. Every episode includes a brain teaser challenge and we round off with a quiz feature, appropriately named ‘Biology or Bunkum’. We have been lucky enough to meet and interview some notable anaesthetists who feature across several episodes. The theme music is of bespoke design, and is snazzy enough for the astute listener to determine that we were all born in the 70s.

Downloading GasCast is easy- through iTunes or via our website, and is entirely free. There are no pay-wall or subscription barriers to downloading, and the podcasts can be altered and redistributed by anyone, as long as the original source is credited. The first official

e-learning media for anaesthetists something for everyone

with the advent of smart phones and tablet computers, electronic educational media are more accessible to the anaesthetist than ever. This month GAT takes a closer look at some of the novel educational media that can provide you with exam revision and cMe opportunities at your convenience - that is any place any time!

GasCast episode was uploaded to the internet approximately a year ago. Since then we have achieved a near monthly podcast, despite the logistical challenges of coordinating on-call rotas, annual leave and international time differences. The podcast is checked and edited before release, although the distinct sound of a certain South African making a cup of tea does sometimes slip through.

The primary objective of our podcast is knowledge communication and translation. Each podcast is supported by our website where we link to primary sources for everything that is mentioned in the recording. We recognise that we are enthusiasts and not experts, and therefore want to ensure that anyone listening has the resources available to verify and research any of the topics we cover in greater depth. The shameless secondary objective is to have a substantial

distraction tactic at the ARCP, when asked to produce that elusive sixth DOPS. We hope that by recording our shared-learning experience, we achieve a degree of education for the listener, whilst being somewhat engaging and entertaining.

Take a listen and decide for yourself at www.gascast.co.uk

rebecca smith, Mark salmon and frank schneider ST6 St George’s Hospital

& rik ThomasST6 Barts and The Royal London

Sound revision with Dr Podcast

Feeling tired, stressed and generally rundown? Never ending on-calls and constant pressure to use every bit of free time to cram more basic sciences or clinical anaesthetics into your head? These are the familiar pre-exam circumstances in which we found ourselves back in 2007 whilst studying for our primary FRCA. Independently, we were reduced to recording ourselves drearily reading revision notes and listening back endless times. Using this “hands free” revision method, we could use our time efficiently and continue to cram more information into our barely operational brains, even when reading or note taking was not possible! Months later whilst reflecting on the experience, we both felt that this seemingly mind-numbing revision method had actually made a significant contribution to our exam success. This revelation led us to embark on a mission to create a superior audio revision resource for other anaesthetists. Much thought went into how the audio material could be presented to impart all the required knowledge at the same time as making varied and “entertaining” listening. Viva role-plays seemed the most sensible way of achieving these goals, as well as providing the listener with the invaluable insight into exactly the type of questions the examiners may ask.

The idea for Dr Podcast was formed… then the work began to accomplish it! The starting point was the syllabus for each FRCA exam. They were broken down into topics that could feasibly be covered in a podcast: 90 in total for the primary and 103 for the final. The podcasts are initially written as scripts, and then recorded as role-plays. They have 3 voices; an examiner, a candidate and an advisor who gives helpful tips on exam techniques and structuring answers. Effort is made to keep the voices as different as possible and to ensure concise contributions from each voice to prevent listener boredom! Podcast authors are trainees who have recently and successfully sat the exam at which the podcast is being aimed, they are therefore in the best position to have accurate information of the exam content. Once scripted, a consultant with up to date knowledge of the exam checks each podcast for content, accuracy and adherence to the required exam standard. Editing occurs where necessary and the final script is then professionally recorded, prior to being uploaded to the Dr Podcast website.

Achieving the ultimate podcasts was not cost neutral in terms of time, effort or the services procured to underpin the sound quality of the material. Many people have played a role in making this resource available, and to ensure the project is sustainable and progressive

we feel goodwill alone should not be relied on and therefore all contributors receive payment for their work. This in turn means that the podcasts are not free. The sets are valued to be roughly equivalent to an exam revision textbook, with the primary set of 90 podcasts costing £67.50 for 21.5 hours audio revision and the final set of 103 podcasts costing £77.25 for 26 hours. The podcasts can also be purchased individually or as smaller bundles under particular topic headings.

Following the launch of Dr Podcast in 2008 the podcasts have remained a very popular revision resource. There are now podcasts available aimed at the post-graduate exams in other specialties and many more are being produced.By popular demand, 2 books have been made available: Dr Podcast Scripts for the Primary FRCA and Dr Podcast Scripts for the Final FRCA. These are, as the name suggests, the scripts to the podcasts in print, with the advantage of having the diagrams included in the text, whereas in the podcasts diagrams are described.

The Dr Podcast material appears to be popular not only for its intended use, as an exam revision aid, but as a resource for CME or to help consultants brush up their exam knowledge for teaching purposes. There is more information available on the website www.dr-podcast.co.uk and the team are always grateful to receive feedback, questions or comments by email to [email protected].

Beccy leslie, ST6 Severn School of Anaesthesia, Director Dr Podcast

emily Johnson, ST6 Anaesthesia, West Midlands, Company Secretary Dr Podcast


Welcome to Gasclass - An online case discussion for Anaesthetists

Gasclass, which was launched in October 2011, is a weekly online case based discussion forum for use by anaesthetists of all grades. It began as an experiment using new technology in response to a perceived reduction in training opportunity and classroom time by trainees.

We attempted to think of new convenient ways in which an educational conversation could be held whilst removing some of the constraints of a traditional classroom. One such solution was the use of Twitter. This simple technology is free and widely available. Many anaesthetists are already familiar with it and it is increasingly recognised as a powerful information tool in medical education1. Importantly Twitter works across multiple platforms and is already optimised for use via a smartphone or tablet. We wondered if by using this technology we could come up with a working virtual classroom?

All cases are completely theoretical and we attempt to cover the range of sub-specialities within anaesthesia and critical care. Below is a brief description of how to get started.• Sign up for a Twitter account at www.twitter.com• By “following” the user @gasclass you will receive updates

about new cases and developments• To view the case details visit our blog page http://gasclass.

wordpress.com or simply follow the link contained in the tweet• To view the responses in a chronological order ‘search’ for

#gasclass (this is known as a hashtag and it identifies a particular conversation)

• Don’t forget to includes #gasclass in your response too (so they appear as part of the conversation)

Discussions takes place over 3-4 days and each scenario invariably ends with some form of clinical conundrum. The discussion increases in difficulty with the opening questions aimed at junior trainees, then progressing to discussion at final FRCA level and

above. A recent development has been the adding of an “expert opinion” to each week’s case summary.

A user survey showed that access was mostly via tablet or smartphone, but also by desktop PC. In using cross platform technologies we have managed to create an environment where an educational discussion can take place at a time and location that is convenient for the user. We currently have over 500 followers, showing a consistent increase since launch. Hits on our blog page each week give us an idea of class size even if visitors do not contribute to the discussion on Twitter. These peaked at over 200 unique hits per day & so far 225 people from across the world have contributed to Gasclass.

On a final note, we are happy to accept that not all will be comfortable with the idea of education via social networking and indeed this is often perceived as frivolous and time consuming. It does however allow a conversation on any topic at any time and with multiple devices. It therefore maximises time efficiency, and our experience is that once people grasp the functionality of Twitter, they begin to realise how powerful it can be. The use of hyperlinking within tweets enables quick sharing of web pages, images, documents and more all of which can easily be organised and saved for later. Gasclass encourages conversation with likeminded individuals and promotes exploration of previously undiscovered educational resources.

Martin doran, sean williamson* & ian whitehead*Speciality Trainee (ST7), Northern Deanery and Consultant Anaesthetists*, James Cook University Hospital, Middlesbrough

Reference1. Lester O, Updating College communication methods– social networking and Twitter,

Royal College of Anaesthetists Bulletin 2011;65: 28-29

e-Learning Anaesthesia

what is it?e-LA is a web-based resource designed to help UK anaesthetists to prepare for the RCoA fellowship exams and GMC revalidation. It has been around since 2008 but is still expanding. The range of information now available is vast, comprising over 750 interactive tutorials; access to a separate electronic library of 1000 journal articles; and 50 practice MCQ examinations that are automatically marked and annotated with feedback comments. The tutorials were written by College Fellows (trainees and consultants) and the entire collection has been peer-reviewed. Each session takes about 20 minutes to complete and any activity undertaken on the Learning Management System is validated by the Royal College of Anaesthetists for CPD purposes.

who is it aimed at?Initially the project was funded by the Department of Health and backed by the College to provide an online resource for trainees preparing for the Primary FRCA, but the material has been used extensively both by trainees and career grade anaesthetists.

is it any good?11,800 doctors and students have signed up to use e-LA. The system has registered 450,000 session accesses and 188,000 hours of online learning. External reviews of e-LA have been excellent. The project won Gold as ‘Best online or distance learning programme’ in the national e-Learning Age Awards beating off competition from the BBC and other commercial organisations. In 2009 the Department of Health commissioned an external peer review. The review team rated the project as ‘outstanding’ with 80-90% of users valuing the content as ‘excellent/good’.

how do i access it?Access for UK users is free of charge, but you must create your own account:1. Go to www.e-la.org.uk 2. Click on the menu item ‘Log In’3. Click on ‘Register for an account’4. Click on the purple ‘Anaesthesia’ button5. ‘Register’You will need to know your GMC number, and you will need to provide a valid NHS email address or Doctors.net email address. e-LfH (e-Learning for Health) will then provide you with a username and password.

Anaesthesia Tutorial of the Week – not just for trainees!

If you haven’t already heard of Anaesthesia Tutorial of the Week, we are a joint venture supported by the AAGBI, the World Federation of Societies of Anaesthesia (WFSA) and are endorsed by some key specialist societies including the Obstetric Anaesthetist’s Society (OAA).

The team at ATotW have been producing regular high quality offerings covering a huge subject range since 2005. Tutorials are pitched at Final FRCA level but are not solely aimed at trainees. They are written with a pragmatic eye and are designed to cover each topic in a “stand-alone” fashion. We are pleased to offer an extensive archive of over 250 past tutorials, which are available to download from the AAGBI website. In addition to the website presence, ATOTW supports international education including resource poor areas, being delivered to anaesthesia providers in over 100 countries

Over a five year cycle we aim to cover a significant proportion of the CPD subject areas required for revalidation. Why not subscribe via the mailing list ([email protected]) and receive a weekly email containing a new tutorial complete with self-assessment section. As well as being a good read, regular engagement with tutorials will make a considerable contribution to annual CPD requirements.

Under the guidance of our international editorial board, tutorials are authored by trainees, in conjunction with a consultant with an interest in the subject matter. If you are interested in contributing please contact us via the link on the ATOTW page of the AAGBI website. We periodically look to recruit reliable editors for ATOTW. If you have an interest in joining our team and have a talent for conveying complex ideas simply, we would love to hear from you. Please contact me via the ATOTW web page.

The future:We are currently developing a cross platform smart phone app as a new interface with ATOTW. Keep reading Anaesthesia News to find out when it is available.

richard hughesEditor-in-Chief

does it cost anything?No it doesn’t cost anything. e-LA is part of a wider suite of e-learning resources that have been made available free of charge by the Department of Health to all NHS employees.

i am a trainee - how might i use e-lA?e-Learning Anaesthesia was designed first and foremost around the educational needs of trainees preparing for the FRCA examination. The material within the sessions is drawn from the College curriculum and is pitched and moderated to FRCA standard by a team of editors, who are all College fellows. The sessions are grouped together into clinical modules that provide the theory underpinning clinical attachments such as critical care, paediatrics, and obstetrics. For those approaching the primary or final FRCA exams, there are specific revision sessions in ‘Module 6’ that revisit topics that are known to be important yet difficult for candidates to conceptualise. Finally, 50 sessions are arranged in the form of MCQ practice examinations. Many of the questions were provided by the College and are accompanied by feedback and explanations.

i am a consultant/sAs - how might i use e-lA?For those who have already survived training, e-LA remains a fantastic on-line resource for everyday reference and a means of providing evidence of CPD for GMC revalidation. It can be searched by keyword and many sessions are accompanied by toll-free access to over 1000 CEACCP and journal articles. The Learning Management System automatically logs access and time spent learning. This activity can then be summarised and printed as a College validated CPD report for appraisal purposes.

For more details, please go to: http://www.rcoa.ac.uk/e-learning-anaesthesia-e-la/more-information

Andy McindoeJoint Clinical Project Lead e-LA.

AnaesthesiaUK

AnaesthesiaUK.com is a medical education Web site that has been providing free training resources for anaesthesia and allied healthcare professionals for over ten years. Although the focus is on the UK Primary FRCA, UK Final FRCA and the Irish FCARCSI examinations, the site provides articles and practice questions that individuals preparing for the US Boards and European Diploma in Anaesthesiology will find helpful. The site provides independent news articles relevant to anaesthesia and medicine in general, a regularly updated list of examination and anaesthesia courses in the UK and

a list of the most popular textbooks for examination preparation. In addition to providing anaesthesia, pain, regional anaesthesia and medico-legal articles, AnaesthesiaUK provides interview preparation tips and questions and an active forum allowing our community to discuss issues around anaesthesia.

In the “Journal Alerts” section of the site one can view summaries of selected recent papers that are important to clinical practice. The “Exams” section provides resources specifically directed at FRCA and FCARCSI examination candidates, although these will be of considerable value to examination candidates anywhere in the

14 Anaesthesia News January 2013 • Issue 306

Video platforms

The AAGBI launched its video platform in 2011, and now contains an extensive archive of lectures from their conferences and seminars, as well as video material on key topics. This can be accessed via http://videoplatform.aagbi.org/. The AAGBI has recently launched a pilot project of podcasts available under the Education tab of the Associations’ website, depending on the number of downloads this resource will be expanded.

The Royal College of Anaesthetists has recently launched its own webcasting platform. This can be accessed via www.rcoa.ac.uk/webcasts. At present the topics presented are few in number, but over time this will become another valuable source of information.

EditedbyKateO’ConnorGAT Vice-Chair

Mock exam practice

There are several platforms available for this purpose, and each contains test questions in the new single best answer format. The subscriber can choose to revise in a number of formats, e.g. by subject or as timed exams. The table provides a summary of the key information for each platform.

Special Membership Offer on FRCAQ.com The AAGBi and cambridge University Press are pleased to announce an exclusive new benefit to all members. AAGBI members are entitled to significant discounts on access to the FRCAQ.com website. FRCAQ.com is an online self-testing website for both Primary and Final FRCA examinations. Now with over 4,000 questions in SBA and MTF formats, these sites allow you to tailor revision to your specific needs, as well as providing you with expanded notes and explanations as a background to each answer. Why not take a guided tour, or explore the site for longer with a free period of subscription, before taking advantage of the heavily discounted rates for 1, 2 or 4 months of access?

For the primary site:1 month sub: 30% discount, therefore the current AAGBI rate will be £14

2 month sub: 35% discount, therefore the current AAGBI rate will be £22.75

4 month sub: 40% discount, therefore the current AAGBI rate will be £36

For the final site:1 month sub: 30% discount, therefore the current AAGBI rate will be £21

2 month sub: 35% discount, therefore the current AAGBI rate will be £32.50

4 month sub: 40% discount, therefore the current AAGBI rate will be £45

Visit FRCAQ.com for a demo, or follow these links to register for a free trial and/or discounted subscription:http://www.frcaq.com/primary/jsp/trialregister.jsf

Special Subscription Rates

Special

Subscription

Rates

Visit FRCAQ.com for a demo, or follow these links to register for a free trial and/or discounted subscription:http://frcaq.com/final/trialregistration.do

As an additional benefit, AAGBI members are also now entitled to receive a discount on all Cambridge University Press print books of 30% off the retail price. To place orders and claim your discount visit www.cambridge.org/AAGBI and use the discount code AAGBI

NEW for 2013Most of the site resources are available without registration; however, registration is required if you wish to participate in the online examination section. Since the registration process requires a “GMC number,” viewers outside the UK who wish to explore this feature should register using the overseas section of the site. The examination section provides interactive questions that are marked and provided with answers. The average score for each exam is provided to help the candidate gauge their ability compared to peers. Registration also allows the option to receive targeted newsletters via email, which provide exam questions (Primary or Final FRCA) and updates regarding the site’s latest content.

AnaesthesiaUK is one of the relatively few anaesthesia sites that have been certified to meet the requirements of the “Health on the

Net” code (www.hon.ch). The AnaesthesiaUK team will be releasing a new site aimed at Intensive Care Medicine very shortly. We would like to thank trainees for their support over the years and continuing to make AnaesthesiaUK.com a continued success.

dr sumit dasConsultant Paediatric Anaesthetist, Oxford.Co-founder www.AnaesthesiaUK.com


NEUROANAESTHESIA SOCIETY OF GREAT BRITAIN AND IRELAND

www.nasgbi.org.uk

Enquiries to Emma Johnson ([email protected]) Tel: 02920 743106

Abstracts to [email protected] deadline: 1st February 2013

Back pain often starts suddenly, making you unable to move or do any activity. This acute phase sometimes settles down with rest and simple analgesics. It may recur from time to time, but for many it becomes a chronic condition. There are various treatment modalities available, but each sufferer needs individual treatment options.

For some people back pain takes time to settle down, and they need to take sick leave. They may bec unsure whether they will be able to get back to working as before. When I became a chronic back pain sufferer, I realised that it is a common problem with little guidance for the patient and very little evidence for management.. Here are some tips tor sick leave, planning and managing your return to work.

Important things to remember during sick leave are keep in touch and update your progress to your clinical director (CD), general manager, rota office, and human resources manager. Self-certification and Fit Notes from your general practitioner should be submitted promptly. It is also important to get occupational health (OH) advice at an earlier stage. Every case is different, but expect a phased return to work after a period of absence based on

• Reasons for absence• Period of absence• Experience in the speciality• Aim to achieve safe independent return to practice

When you and your GP think you are ready to go back to work, arrange to meet with your CD, general manager, human resources manager and occupational health physician or nurse. Plan your return to work, identifying things you will be happy to do and things which may be difficult during the initial period. Plan lists with consultants or senior trainees before doing solo lists. It takes the pressure off in many ways. It may be useful to have a

Low back pain and return to work:some advice from personal experience

Four out of five adults experience low back pain at some point in their life. Most cases are ‘non-specific’, ‘simple’ or ‘mechanical’ back pain. Over the years in clinical practice, we anaesthetists rarely think about our posture or movements, especially when intubating and manual handling. An injury may be responsible for back pain, but often it’s the consequence of poor posture or an awkward twisting movement, bending or a combination of these, along with inactivity which results in stiffness and poor flexibility.

workplace assessment from the Occupational Health Department to ensure that the equipment your use (e.g. chairs, work stations) are appropriate for your condition.

Returning to work can be a particularly stressful experience for senior anaesthetists. In April 2012, the Academy of Medical Royal Colleges published their return to practice guidance for all doctors returning to the same area of clinical practice following an absence for any reason.1 These recommendations have been included in the updated guidance “Returning to work after a period of absence” available via the Royal College of Anaesthetists website. It includes details on planning and preparation for absence from work, structured approach to return to work and additional resources.

Anaesthetic List Management Assessment Tool (ALMAT)

During a phased return, start with limited hours and increase them as and when you think you can. Don’t take one step forward and two steps backward. Try to be realistic about what you can achieve. Getting Anaesthetic List Management Assessment Tool (ALMAT) forms signed assists in building up your confidence and regaining competencies. Keeping a logbook is important. If possible identify a clinical supervisor or mentor who can guide and help you. Phased return can take months before you are back to your normal practice. Review by your supervisor at regular intervals to discuss progress and planning ahead are essential. Breaks during long

hours at work are essential. You may find reducing working hours during a week or midweek breaks are beneficial.Coping strategies for back pain away from work include regular exercises or fitness classes as yoga, Pilates, learning to relax during busy day, and physiotherapy. Rest is essential. This should be considered as a part of life with other routine work.

When you start back in the workplace, everything becomes a new experience. I have changed a few things permanently in my practice including taking regular breaks, sitting down intermittently, adjusting trolley heights for intubations and other practical procedures e.g. spinals. Anticipating problems is difficult. I know I will be better one day but not knowing quite when is very unsettling. Working with a chronic condition where everything is unpredictable demands a different mental approach. With time you get used to your pain, develop your comfort strategies and start to enjoy your work again. Having a positive attitude helps during this difficult period.

When you are faced with the unexpected, such as backache, which doesn’t rapidly resolve only you can understand the impact of the problem. The effect it has on you and your family physically, psychologically, socially, financially is very difficult to explain to others.

smita oswal,SAS Committee Member, AAGBI

Reference:1. Academy of Medical Royal Colleges “Return to Practice – Guidance” March

2012 http://aormc.org.uk/item/academy.html


OXFORDTHE GAt AnnuAl SciEnTific MEETing

traineeAnaesthetists

WED 03 - FRI 05 APRIL 2013

Good morning trainees, your mission, should you choose to accept it, is to book study leave for the GAT meeting in Oxford. As always, should you or any of your colleagues be caught submitting your study leave form too late, the AAGBI will disavow any knowledge of your actions. This piece of paper won’t self-destruct in five seconds, but is best put in the recycling bin!

Good luck!I am really looking forward to the GAT meeting in Oxford. The city is beautiful, the venue great, and there is a terrific scientific program lined up for you.

This year, we have:• Kepttheregistrationfeeat£195• Squeezedinmorelectures• Introducednewworkshops• Codedthetalksandworkshopstothecurriculum• IntroducedanLTFTroom(seeadjacentarticle)• Addedextrastuffthatwethinkyoushouldknowabout• Dividedthelastdayinto3parallelstreamsoflectureson: o primary exam topics o final exam topics o management topics

• How to check the anaesthetic machine correctly and examples of real critical incidents demonstrating what can go wrong when you don’t.

• What can we do to help the kidneys in sickness and in health.• Obstetric emergencies - How to deal with them and how to avoid

them.• Safe tracheostomy care.• Initial management and transfer of the head injured patient.• What anaesthetic war techniques can be introduced to NHS

practice by the non-military.• ITU papers that you should know about for FRCA and FICM.

For something a bit more light hearted, we have interactive lectures on:• So you think you know how to read an ECG.• So you think you know what you are looking at (radiology).• How not to give a presentation.• How not to get published.• How not to design a poster.

For something a bit different, we have lectures on:• How mentoring can enhance your CV.• NIAA - What is it all about?• The good, the bad and the ugly – Training and future trends in

medical employment (AAGBI/RCoA)• Addiction and trainees.

This was one of my favourite sessions at the Annual Congress. Speakers presented clinical vignettes and dilemmas and asked the audience what they would do next.

We have 4 great problems for you to think about:• A case of a tricky tracheostomy.• An obstetric dilemma.• A series of common but challenging paediatric airway cases.• An ITU dilemma.

specialist societies – we are always delighted to welcome along Spec Socs to our meetings. This year Mark Stoneham, Chairman of VASGBI, will be giving a lecture on ‘Everything you need to know about Vascular Anaesthesia in 30 minutes”, and the APA will be giving 2 talks on ‘How to manage a sick child in the DGH’ and a talk on hot topics for the Final FRCA.

The final day of the meeting will have 3 parallel streams. You are not committed to staying in one room. If something interests you in another room, feel free to float around.

Here is what we have planned:

• Driving value in anaesthesia – From quality improvement to new systems of working.

• Cock–up, conspiracy or negligence?• How to supervise a trainee, how to teach, how to reflect.• Everything you wanted to know about private practice, but were

afraid to ask.• Who manages me at work?• The structure of the NHS.• Hot topics for the consultant interview.• What is consent?

As we will have a smaller number of trainees in the 3 groups, these sessions will be lecture based but interactive, and will help you to prepare for the FRCA

• Acid base made easy• Oxygenation and oxygen transport• Cardiac mechanics• The coronary circulation• Pharmacokinetics – Key concepts• Physics Q&A’s

• Cardiac anaesthesia for the FRCA• Physiology and pharmacology of pain• How I would perform an awake fibreoptic intubation – The exam

answer• Non-obstetric surgery in pregnancy• Paediatric anaesthesia – Key topics• Applied physiology – Prone positioning ….and for both • Lung mechanics and ventilation• Basic stats: How to design a study, pass the exam and impress

your friends – Dr Steve Yentis (My first question in the Part II exam was ‘What is a t test’? Aargh! Luckily, I remembered my stats lecture from Steve who was then my SR. I cruised through what might have been the most ‘cringe worthy’ 5 minutes of my life)!

No meeting would be complete without a tongue in cheek debate. To end the meeting we have the wonderful Will Harrop Griffiths taking on the wonderful ……. Dr William Harrop Griffiths (yes you read it right the first time). ‘They’ will debate: This house believes that a sub-consultant grade is a good idea. If any of you have heard WHG speak, let alone debate against himself, I can promise you that you will leave the meeting with a smile on your face!

We have some exciting workshops lined up for you.

NeurosimulationOne Brain is a new simulation based training module developed by the Bristol team. It helps prepare trainees for their Final FRCA exam and for the complexities of Neuro-anaesthesia and transfer of a head injured patient. You will work through “The Patient Journey”, an extended scenario involving multiple candidates managing a polytrauma patient. You will assess, stabilise and resuscitate the patient before

transferring them to a neurosurgical centre where you will hand over to other candidates, who will manage the patient in the operating theatre. This extended scenario covers the key components of the initial management of the head injured patient, and neuroanaesthesia. The workshop is mapped to the curriculum, and also allows the candidates to demonstrate leadership and communication skills whilst managing a complicated patient.

The Airway workshop:This is a small group teaching opportunity with a highly experienced faculty. Stations will cover fibreoptic intubation, cricothyrotomy, video laryngoscopes, and case-based scenarios to test your problem solving and skills. This workshop is targeted at basic and intermediate level trainees but is good revision for all grades.

The Ultrasound Guided Blocks workshop:This is a hands on workshop scanning live models under the guidance of regional anaesthesia experts. Stations will cover basic ultrasound as well as upper and lower limb nerve scanning and block techniques (interscalene, supraclavicular, axillary, femoral and sciatic). This workshop is targeted at basic and intermediate level trainees.

echo workshop:This is the first echo workshop to be run at the GAT ASM, and will demonstrate how trans thoracic echocardiography skills can be integrated into the portfolio of modern critical care physicians. The Oxford Critical Care Echo Fellowship Programme will provide a workshop based around the recently introduced FICE qualification produced by collaboration of the Intensive Care Society with the British Society of Echocardiography. Using a series of workstations with models, candidates will be able to attempt real time scanning with one to one tuition coupled with focused lectures highlighting the use of echo in ICU. Topics include assessment of circulatory volume status, aetiology of shock and thoracic fluid collections.

NiAA This workshop will offer assistance to research-active (or research-interested) trainees who are looking for external reviews of their ideas, assistance with ethics applications, assistance with grant applications, or sourcing formal external academic supervision or appraisal.

There are so many prizes to be won to enhance your CV, visit www.gatasm.org/content/oral-poster-prizes for more details

So, we have an action packed meeting planned for you, brimming with education, fun and challenging issues, but watch out… the leave diary will be filling up very soon! Finally, big thanks must go to Dr Helen Tyler, Dr Caroline Wilson and Nicholas Love who have all worked tirelessly to help me put this program together.

samantha shinde, Chair Education Committee

THE GAT ASM IS BACK ON THE MAP!

lectures include:

Problem based learning (PBl)

Management for the senior trainee

Primary exam topics

final exam topics

debate

workshopsPrizes

www.gatasm.org

AnaesthesiaDigested

www.wsmlondon.org

FUTURE WSM DATES:

SCIENTIFICSESSIONS

HANDS-ONWORKSHOPS

ESSENTIALCPD

INDUSTRY EXHIBITION

CORE TOPICSSESSIONS

POSTERCOMPETITION

Conference Appcoming soon...

QEII Conference Centre, Westminster

The Association of Anaesthetists of Great Britain & Ireland

The 2013 Winter Scientific Meeting promises to be the biggest yet!Programme includes a dedicated core topics day, scientific sessions, practical workshops, keynote speakers & a poster competition

2015 14-16 January 2015

2014 15-17 January 2014

Emergency laparotomy is a high risk procedure, with highly variable outcomes. The clinical pathway is complex, and hence attempts to improve the quality of care are not straightforward. Many clinicians will be aware of how difficult it can be to improve service delivery within their hospital. This seminar will provide an overview of the quality improvement techniques that can be used to bring about improvement in the care provided to patients requiring an emergency laparotomy. The speakers are active clinicians who have been successful in implementing such initiatives. Dr Dave Murray will provide an update on the forthcoming National Emergency Laparotomy Audit. Dr Carol Peden will provide an overview of the Quality Improvement techniques that can be used to bring about improved care. Dr Andy Longmate will talk about what you can learn from reviewing

mortality in order to identify where improvement can be made. Dr Simon Varley will provide a view of the challenges of implementing care pathways for emergency laparotomy. This will be brought together with two interactive workshops that will cover:

1. The practical application of Quality Improvement techniques 2. How to design and implement care pathways within your

hospital

There will also be the opportunity for delegates to do a short presentation on any initiatives that they have implemented in their own hospitals with a view to spreading these good ideas to other Trusts. Details about how to submit your presentation will be circulated at a later date.

Quality improvement in Emergency Laparotomy Seminar26 March 2013

www.aagbi.org/education

The AAGBI is delighted to announce a new Seminar on quality improvement




LTFT Resource/parent and baby facilityAnaesthesia is one of the hospital specialties with the highest number of LTFT trainees, and has a long history of promoting support for this group. GAT and the AAGBI are planning to provide a ‘LTFT drop in resource room’ at the GAT ASM in Oxford. This will provide an informal area for those who are either already a LTFT trainee or interested in becoming one, to network with other part time trainees. The GAT LTFT trainees will be on hand to point you in the direction of useful resources to help you negotiate the nitty gritties of LTFT working and hopefully get the most out of your training time.

Last year’s GAT ASM saw at least three babies attend their first national meeting. The response to this was wholeheartedly positive from everyone at the AAGBI. If you are a parent who has a poster to present but are struggling for childcare (or no poster but just fancy a chance to attend a great meeting) then please bring yourself, your baby and your poster – all will be very welcome. The LTFT resource room will double as a parent and baby room where you and your offspring can cry, feed, chat and sleep whenever necessary!

If you are on maternity leave, then the GAT ASM is an ideal way to use of some of your ‘keeping in touch days’. You are entitled to ten of these days, and will be paid for them as long as you have them agreed retrospectively with your Trust. Over 90% of the lectures and workshops are mapped to the curriculum providing great updates in core areas of learning. Mentoring taster sessions will also be available which could be utilised to help plan an effective return to work. Information on the most up to date guidance on returning to practice will be available for all trainees who have been away from anaesthetics (including those doing research, advanced ICM etc) for any reason.

If you would like any further information about the plans for the LTFT resource/parent and baby facility at the ASM then please contact the GAT LTFT rep Sarah Gibb at [email protected]

Erb TO, von Ungern-Sternberg BS, Keller K, Frei FJ.

The effect of intravenous lidocaine on laryngeal and respiratory reflex responses in anaesthetises children

Using a very simple design, Erb and colleagues undertook a study to show that administration of 2 mg.kg-1 of intravenous lidocaine reduced the incidence of laryngospasm in children aged 25-84 months. The laryngospasm was deliberately induced by spraying the laryngeal mucosa with a small (0.25 ml) volume of sterile water. All the children were receiving sevoflurane anaesthesia administered through a laryngeal mask, and had been premedicated with midazolam. The effect was short- lived; it was present at 2 min but absent 10 min after lidocaine administration. As the authors highlight, research into laryngospasm is sparse and difficult to undertake - particularly in children. The ethical considerations are discussed in three accompanying articles (see below).

Bailey CR, Yentis SM. Small patients, big ethics

Durward A. Research in children and ethical limits: the water laryngospasm challenge

Erb TO, Frei FJ. Exploring laryngeal reflexes in anaesthetised children – the investigators’s point of view

Perruchoud AP. Exploring laryngeal reflexes in anaesthetised children – the research ethics committee’s point of view

The ethical dilemmas facing researchers, patients (and, in this case, their parents), research ethics committees, and journal editors and publishers in relation to the study of laryngospasm in children are discussed. Firstly, we (the readers) are told that this particular article underwent extensive review, particularly of the ethical issues. Durward writes that in his opinion the research is poor in any case, and that a properly conducted randomised, controlled trial would be much more beneficial and safer. Two of the authors of the original article write to support their study and its methodology. Without creating episodes of laryngospasm, their work would have been almost impossible to undertake. Finally, the chairman of the ethics committee who eventually approved the study offers an insight into the workings of his committee. In regard to the risk/benefit analysis (and subsequent decision) which the committee members were presented with, he admits that this was at least partially subjective, but that it was counterbalanced by the open and detailed discussions which took place with the researchers – including a visit to the site of the proposed research to meet them and observe their clinical practice. Undoubtedly, this work will elicit mixed responses. It has provided additional information on the prevention of laryngospasm in children. But, would you let your child participate in such a study?

Liu, C, Zhang Y, She S, Xu L, Ruan X. A randomised controlled trial of dexmedetomidine for suspension laryngoscopy

While dexmedetomidine has been available for about 1 yr in the UK, it is not yet used widely. It was, of course, released in some countries several years ago and experience there is, naturally, much greater. At present most UK anaesthetists will only have read about the agent, and articles that investigate its use are to be welcomed as clinicians decide what its role may be. Liu and colleagues have used dexmedetomidine as an adjuvant to propofol-remifentanil anaesthesia for suspension laryngoscopy. Propofol (titrated to achieve a set depth-of-anaesthesia) and remifentanil (titrated to maintain systolic blood pressure within 25% of the baseline value) requirements were reduced and extubation was achieved earlier in patients receiving dexmedetomidine 0.25, 0.5 or 1.0 µg.kg-1 15 min prior to induction, compared with placebo. Bradycardia (heart rate < 40 bpm for > 10 s) was seen in 10% of patients receiving dexmedetomidine. One criticism may be that dexmedetomidine was not compared with ß-blockers, calcium channel blockers or intravenous local anaesthetics. However, it likely that most clinicians manage such cases with rapidly titrateable agents such as propofol and remifentanil alone, so this study is certainly practical. It was conducted in healthy patients, and the effects in those with significant cardiovascular disease may be different.

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

Anaesthesia January 2013

Mike Nathanson, Editor, Anaesthesia



Dublin 08 February

Liverpool 22 February

Newcastle12 March

Cambridge 22 March

Exeter 26 April

Belfast 14 June

Manchester (2 Day) 28 & 29 June

Leeds 12 July

Nottingham 27 September

Birmingham 18 October

Glasgow 01 November

Cardiff 22 November

London (2 Day) 29 & 30 November

AAG

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013 CORE

TOPICS

www.aagbi.org/educationFor further information and prices please visit:

CoreTopics2013.indd 1 18/12/2012 09:29

Hip fractures are prevalent, and on the rise. These are common and serious injuries of the elderly, associated with high morbidity and mortality, occupying a significant proportion of hospital resources, leading to a serious financial burden to the NHS and society.1

There is a myriad of controversies surrounding best practice to make meaningful difference to the outcomes; e.g. which is better - General anaesthesia or Regional, when to treat hypotension, what should be the threshold for blood transfusion, should echocardiography be routine, should provision of level two care be routine,.... the list of questions is endless. There is a paucity of high quality evidence to help us answer these questions.2

Recruitment has consistently proven to be a serious impediment for RCTs3, e.g. FOCUS study, which was one of the largest RCTs aimed at proximal femoral fractures, could not recruit its intended 2600 patients from 47 hospitals across North America4. There is a growing feeling that for hard-to-research subjects, well-designed large-scale audits can help to discover potential links between practice and outcomes. Sprint audits are an example; these are typically run over a brief period, and are focussed on one or more specific problems.

National hip fracture database (Nhfd)

National Hip Fracture Database (NHFD) is the largest database on proximal femoral fractures in the world, growing at a rate of 5000 cases per month5. It is a rich source to feed large audits. However, at present, it contains very basic and limited anaesthetic

fields, and cannot in its current form provide information about the impact of anaesthetic interventions on outcomes.

NHS Hip Fracture Perioperative Network (HipPeN) has collaborated with the NHFD to run a “Sprint Audit” to acquire data on anaesthetic practice, in addition to the usual NHFD fields. Funding has been provided by the AAGBI in the shape of a grant through the National Institute of Academic Anaesthesia (NIAA). It is expected to obtain data on 10,000 patients over two months. It aims to explore association with 30-day mortality of co-morbidities, anaesthetic techniques and practices of management of hypotension and anaemia.

The pre-pilot phase was run in 4 hospitals, which helped to determine the anaesthetic data fields of interest. The next ‘e-pilot’ phase will have been completed in ten hospitals, by the time of these lines reaching you. The final phase will be launched in spring 2013, when all 188 of the NHFD contributing Trusts will be invited to participate.

Participating departments will be expected to have a local lead for the project, whose role will be to ensure completion of a standardised audit form (simple, mostly tick-box style, 2 sides of an A4 size sheet) for every patient with a hip fracture, by the anaesthetist responsible for that case.

Volunteer(s) will be required to collect those forms and upload, with the help of the local NHFD data inputter(s) at their hospital.

The project affords an excellent opportunity for anaesthetic trainees to undertake the collection and uploading of the audit data. Trainees could learn from participating and assisting in implementing a National audit in their hospital; at the same time it can be rewarding for their CVs / appraisals. Trainees’ active participation, under supervision of local hip fracture champions, is encouraged and will be recognised in the shape of a certificate of participation from the ASAP team.

drs Amer Majeed & richard Griffiths, Members ASAP Steering group

References:1. S.M. White, R. Griffiths. Projected incidence of proximal

femoral fracture in England: A report from the NHS Hip Fracture Anaesthesia Network (HIPFAN). Injury, 2011; 42:1230–1233

2. National Institute for Health and Clinical Excellence. The management of hip fracture in adults. (Clinical guideline CG124.) 2011. http://guidance.nice.org.uk/CG124.

3. White SM, Griffiths R, Moppett IK. Type of anaesthesia for hip fracture surgery – the problems of trial design. Anaesthesia 2012; 67: 574-8.

4. J. L. Carson, M. L. Terrin, H. Noveck, et al. Liberal or Restrictive Transfusion in High Risk Patients after Hip Surgery. N Engl J Med 2011; 365:2453-2462.

5. The National Hip Fracture Database National Report 2012. British Geriatrics Society, London

Hip Fracture Anaesthesia Sprint Audit Project (ASAP)


@AAGBI recap

The AAGBI and the History of Anaesthesia Society will award a cash prize of £1,000 to a member of the AAGBI in a training grade for an original essay of 4000-6000 words.

The topic of the essay should be related to the history of anaesthesia, intensive care, or pain management.

Submissions should be double-spaced on single sided A4 with references in the Vancouver format. Illustrations are allowed. The paper should not previously have been published.

The £1,000 prize and an engraved medal will be awarded for the best entry, and the winner will be invited to present the paper at the GAT Annual scientific Meeting in oxford, 03-05 April 2013. certificates of merit will be awarded to other entries of high standard.

A copy of the essay should be emailed to [email protected]. A confirmation email will be sent on receipt (during office hours only). closing date for submissions: 14 January 2013 Entries received after the closing date will not be accepted.

21 Portland Place venue hireTry our new menu!

21 Portland Place, the home of the AAGBI, offers a range of solutions for your meetings, committees and social events and can accommodate events from five to 55 people.

21 Portland Place has just launched a brand new menu and can offer a range of delicious breakfasts, sandwiches, salads, sushi platters, hot and cold fork buffets, desserts and beverages. There are also options for private dining.

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

The Anaesthesia History Prize 2013


ANNUAL CONGRESS19-21 Sept 2012

This year’s Annual Congress comes to one of England’s most vibrant and cosmopolitan seaside resorts.

Bournemouth has seven miles of beaches, award winning gardens and a vast variety of shops, restaurants and bars.

Bournemouth International Centre

Scientific programmeMultiple streams of lecturesDebatesHands-on workshopsIndustry exhibitionPoster and abstract presentationsCPD approvedAnnual dinner and dance

www.annualcongress.org

Lecture topics include:

BOURNEMOUTH

• National Audits (including NAP5) • The older patient • Pain management • Shared decision making in high risk surgical patient • Law and Ethics • Obstetrics • Revalidation • Papers you should know about • Wellbeing • Problem-based learning and Critical Incident case reports• Plus sessions organised by the Association of Surgeons of Great Britain and Ireland (ASGBI) and the British Geriatric Society

SAVE THE DATE! 18-20 SEPTEMBER 2013

AC-FutureLocations.indd 1 19/03/2012 10:34

Pain Less: the future of relief

The Science Museum opened a free exhibition in November, Pain Less, that explores the future of pain relief and the different ways that pain management is being developed. This exhibition has been partly funded by the AAGBI.

The exhibition (previously called ‘Senseless: Anaesthesia, Consciousness and Pain’) is the culmination of several years hard work from a dedicated team of science museum curators, anaesthetists and pain specialists. Pain Less will introduce you to the latest pain research, through personal stories, scientific discovery, fascinating objects, films and even games.

www.aagbi.org/education/events/ pain-less-future-relief

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

St Anne’s College, Woodstock Road, Oxford, OX2 6HS

•IntensiveOneWeekPrimarySyllabusLectureCourse•ParticularEmphasisonBasicSciencesandMCQPractice•FacultyofExpertClinicalandAcademicLecturers•ComprehensiveandUp-to-dateHandoutMaterial•CourseDinnerIncluded•OutstandingOxfordUniversityVenue

Registration: £600

Tobookonline, please visit www.ndcn.ox.ac.ukFor further information contactNicola Andrew T 01865 231513E [email protected]

OxfordPrimaryFRCAcourse25thFeb-1stMarch2013

“Thank you for organising this wonderful course.”– 2009

“Outstanding lectures. Overall excellent course.” – 2010


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what are/were they known or used for?

Give any eponymous name associated with pieces of equipment.

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SEND YOUR LETTERS TO:

The Editor, Anaesthesia News at [email protected]

Please see instructions for authors on the AAGBI website

Dear Editor,

When Does Anaesthetic Obligation EndAnaesthesia Training in the UK is recognised as the best in the world. When I went for a fellowship in Canada, I was told that the consultants in that hospital had never had any problem with the British trained anaesthesia trainees. Seven long years of competency based training no doubt inculcates all the necessary skills and attributes of a good clinician and physician in anaesthetists.

During years of training, a good amount of emphasis is laid on systematic approach to a patient requiring anaesthesia. Pre-operative assessment, intra-operative management and post-operative pain management is well taught. I feel that the field of anaesthesia that is under taught is the importance of post-operative visit. In a recent article in Paediatric Anaesthesia [1] it was shown that the post-operative pain management is sub-standard and teenagers and infants can have as high as 38% and 32% incidence of moderate to severe pain in hospital most of whom (44%) are surgical patients.

Understandably European Working Time Directive (EWTD) has imposed time constraints on our trainees and the trainers face the challenge of how to best utilise their time at work. All workplace based assessments are based on clinical skills and peri-operative pain management plans of the trainees. There is no importance laid on the post-operative visits where time constrains don’t even allow most caring Anaesthetic consultants to undertake such obligations.

The pain team has no doubt reduced the work load of the anaesthetists in theatre by following up post-operative patients and managing their pain appropriately. Pain team should be considered as a complementing not supplementing an anaesthetist’s obligation for a post-operative visit. Many a times not following up our own patients post-operatively makes us miss out on some feedback and some introspection into our individual practice. Hence encouraging our trainees to pay a quick visit (in the restricted time period that we have in their working hours) will help them to build up a very important aspect of their clinical practice. The enormous responsibility that trainers/consultant anaesthetists have towards our society and towards building up a safe and reliable future anaesthetist also obliges them to inculcate this important habit into them.

References:

1. Groenewald CB, Rabbitts JA, Schroeder DR, Harrison TE. Prevalence of moderate-severe pain in hospitalized children. Paediatric Anaesthesia 15th Feb 2012 DOI: 10.1111/j.1460-9592.2012.03807. x

Dr Puja Sodhi Consultant Anaesthetist, Birmingham Children’s Hospital

Dear Victor, I was sorry to read that your latest missive is your last for sometime owing to Golf Club Captaincy duties. May I congratulate you on your appointment as captain of East Sheen Golf Club . As Captain of a neighbouring golf club, may I welcome you to the Captains’ Club, which offers no benefits, lots of hard work and the opportunity for all your members to whinge at you. I hope you realise just what you have let yourself in for.

Victor, over the past few years I have enjoyed your rants which have often chimed with similar feelings of my own. I hope you won’t be driven to write similar outpourings during your two years of office. Being Captain of East Sheen Golf Club will give you a unique perspective of your Club and its members, one which I hope will be an enjoyable experience. I am sure you have sharpened your game for all the matches you will undoubtedly be required to attend albeit for lunch, the saying of Grace and making post- lunch speeches welcoming your guests and encouraging your players to victory. I am told that the annual fixture played against the Department of Stealth Golfing Society can be quite a tricky one, breaches of rules are quite frequent and there is a win at all costs philosophy. Another match that might be quite challenging will be that played against the near-by Royal Collegiate Golf Club. It is important to start the game all square and not be two down at the start and make sure they play off the correct valid handicaps.

I am a bit worried that your putting may have developed the “twitch or yips” (this is a curious condition which affects some golfers which renders them incapable of making a putting stroke and liable to propel the ball in any direction but the hole) as evidenced by the slip of your razor resulting in your loss of facial hair); I hope this is not the case. If it is it is - probably just as well you are a non-playing captain.

I plan to take time off from my Captaincy duties to give you support at your “drive in” which I understand will take place shortly.

All the best

Your friend Mashie

1. henry walter featherstone (1894 – 1967) - Featherstone was born near Birmingham. After the war Featherstone became a physician anaesthetist and was appointed Consultant Anaesthetist to the Birmingham General Hospital in 1926. As was the custom of the time, Featherstone’s work in public hospitals was voluntary, but he also built up a considerable private practice. In 1930-31, Featherstone became president of the Anaesthetic Section of the Royal Society of Medicine. Despite having his own inherited private income from business interests, he was determined to raise the status of his fellow anaesthetists. He was the main founder of the Association of Anaesthetists of Great Britain and Ireland in 1932 and became its first President. 2. eMo - Developed from the original Oxford vaporizer, the Epstein Macintosh Oxford, a compact but bulky inhaler, was designed for use in areas remote from gas cylinder supplies. It was widely used in developing countries and the armed forces. 3. Jackson ether dropper Bottle - This unusually shaped and very heavy bottle had a stopcock to control the flow, but even with the stopcock open, the bottle would not let any liquid out unless it was tilted. The bottle was considerably cheaper than the Bellamy-Gardner dropper. 4. Portex Blueline Nasotracheal Tube - One of the first pre-shaped nasal tubes. The shaped allowed connection to anaesthetic gasses away from the edge of the nose. 5. Magill laryngoscopy set - Sir Ivan Magill designed some of the first straight bladed laryngoscopes. This was one of his many contributions to the development of modern anaesthesia. 6. waters Airway - Flattened metal airway with a curved tube, to try to prevent the patient gagging. The flange prevented over-insertion. It was later modified with the addition of an anaesthetic side feed tube. 7. esmarch Mask - A modification of Skinner’s mask. The handle could be hooked through a band passing round the patient’s head so that the mask hung down over the face. 8. King George V1 ecG - In 1951 George VI, a heavy smoker, was diagnosed with lung cancer. On 23 September a pneumonectomy was performed in a specially converted room at Buckingham Palace. Anaesthetists Robert Machray and Cyril Scurr were included in the 1952 honours list. The King recovered but died on 5 February 1952. This object is on display in the Anaesthesia Museum in 21 Portland Place. 9. Boc sphygmomanometer - The sphygmometer was devised by Etienne-Jules Marey in 1860 to measure blood pressure. The first reliable sphygmomanometer was designed by Samuel Siegfried von Basch in 1880. More recent versions (sphygmomanometers) consist of a vinyl or rubber bag surrounded by a material sleeve with a gauge and pump attached with hoses. 10. laerdal Mask 2 resuscitator - In a carrying case, complete with mask, airways and oxygen reservoir tube. Used for Triservice equipment trials. 11. Nosworthy connector - One of many metal connectors designed to be used with a red rubber endotracheal tube. 12. Mitchell Needle - This needle was used like the Guest needle to give periodic doses of additional agents. It was designed to be left in place and to avoid repeated injections. The hinge on the top prevents backflow.

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Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ

Military Application of Tranexamic Acid in Trauma emergency resuscitation (MATTers) study

Archives of Surgery 2012 Feb; 147(2): 113-9

BackgroundThe CRASH-2 trial demonstrated that the anti-fibrinolytic agent Tranexamic acid (TXA) resulted in reduced mortality following civilian trauma [1]. This study was performed in civilian hospitals- some lacking modern trauma practices, some with no facility to measure coagulopathy and the mechanism of injury was mostly blunt rather than penetrating. The UK defence medical services have used TXA since 2009 as part of a massive transfusion protocol. The objectives of this study were to characterise use of TXA in combat injury and assess its effect on total blood product use, thromboembolic complications and mortality.

MethodThe study is a retrospective cohort study at a single surgical hospital at Camp Bastion, Afghanistan from January 2009 to December 2010 of consecutive patients receiving at least 1 unit packed red blood cells (PRBCs) within 24 hours of injury and a massive transfusion (MT) subgroup receiving > 10 units PRBCs. 896 admissions were identified of which 293 received TXA. Outcome measures were 24, 48 hour and 30 day mortality. Secondary end points were transfusion requirements, coagulopathy (prothrombin time >18 seconds, activated partial thromboplastin time >55 seconds), and thrombotic complications.

resultsOverall the TXA cohort had a higher injury severity score and more patients with severe extremity injury. Transfusion requirements were greater for the TXA group compared with no TXA but equivocal for the MT cohort. At 24 hours there was no difference in mortality between the TXA and no TXA group (9.6% vs 12.4%; p= 0.20). Despite being more severely injured the TXA group had lower mortality than no TXA at 48 hours (11.3% vs 18.9%; p=0.004) and overall (17.4% vs 23.9%; p=0.03). The benefit was greatest for the MT group receiving TXA compared with no TXA (overall mortality 14.4% vs 28.1%; p=0.04). For the MT cohort, TXA was also independently associated with survival (OR 7.228; 95% CI 3.016-17.322) and less coagulopathy (P=0.003). The ration of PRBC:FFP was the same for TXA or no TXA.

conclusionFollowing combat injury in actively bleeding patients, TXA used with blood component resuscitation results in improved coagulopathy and demonstrates a strong association with improved survival, most significantly in massive transfusion. It should be implemented into clinical practice for resuscitation with blood products following severe battlefield trauma with haemorrhage.

dr claire GauntST 4, St George’s School, London Deanery

References1. Shaker H, Roberts I et al; CRASH-2 Trial Collaborators. Effects of

Tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo controlled trial. Lancet. 2010; 376(9734):23-32

hypoglycaemia ad risk of death in critically ill PatientsThe NICE-SUGAR Investigators, New England Journal of Medicine, 2012, 367, p1108-1118

BackgroundIntensive control of blood glucose with insulin therapy has been one of the great controversies of the last decade in critical care medicine. Interest was originally sparked by Van den Berghe’s work in 2001 (1). Later in the decade significant doubts were raised about the safety and efficacy of intensive blood glucose control by the publication of a large (6104 patients) multicentre RCT – the NICE-SUGAR trial (2). NICE-SUGAR revealed increased mortality (27.5% v 24.9%, p=0.02) with intensive glucose control (4.5-6mmol/l) compared to a higher conventional target (<10mmol/l). The intensive glucose control group also had a higher rate of severe hypoglycaemia than the conventional group (6.8% v 0.5%, p=<0.001). This Particle looks at a new post-hoc analysis of the original NICE-SUGAR data with regard to hypoglycaemia and risk of death.

MethodsHypoglycaemia was classified as either moderate (blood sugar 2.3-3.9mmol/l) or severe (blood sugar <=2.2mmol/l). Risk factors for both moderate and severe hypoglycaemia were identified by univariate analysis then a multivariate regression model. The relationship between moderate and severe hypoglycaemia and death was examined using Cox regression and calculation of hazard ratios adjusted for treatment group, baseline characteristics, and post-randomisation factors. The authors also examined the relationships between the number of days hypoglycaemia was recorded and death; insulin treatment status at time of first hypoglycaemic episode and death; and hypoglycaemia and all cause mortality.

resultsComplete data was available for 6026 patients at 28 days, and 6022 patients at 90 days. Moderate hypoglycaemia was experienced in 45% of the study population (ie 74.2% of the intensive arm and 15.8% of the conventional arm). Severe hypoglycaemia was experienced in 3.7% of the study population (ie 6.9% of the intensive arm v 0.5% of the conventional arm). When compared with conventional blood glucose control, intensive control was identified as a risk factor for both moderate (Odds Ratio 24.19, p<0.001) and severe hypoglycaemia (Odds Ratio 16.39, p<0.001). The mortality rate in the overall study population was 26.2%. Mortality in patients who had no recorded episodes of hypoglycaemia was 23.5% compared with 28.5% in the moderate hypoglycaemia group and 35.4% in the severe hypoglycaemia group. When compared to patients with no hypoglycaemia and stratified by treatment assignment and adjusted for baseline characteristics and post randomisation factors, the Hazard Ratio (HR) for death was significantly increased in the moderate (HR 1.41, p=<0.001) and severe hypoglycaemia (HR 2.1, p<0.001) groups. The association between hypoglycaemia and death was stronger in post-operative patients but was not significantly altered by treatment group or history of diabetes at baseline. Risk of death was higher if the patient experienced moderate hypoglycaemia on >1 day (HR 1.57 V 1.28, p=0.01) and if the patient experienced their first episode of hypoglycaemia whilst not on insulin (Moderate HR 1.64 v 1.22, p=0.007; Severe HR 3.84 v 1.68, p=0.003). Hypoglycaemia was associated with increased risk of death from distributive shock (Moderate HR 2.34, p=<0.001; Severe HR 4.35, p=<0.001), and severe hypoglycaemia was associated with increased risk of death from “other” non-cardiological, non-neurological, non-respiratory causes (HR 2.98, p=0.002).

conclusionIn this study population, hypoglycaemia was associated with increased risk of death, this was more pronounced when patients experienced their first episode of hypoglycaemia whilst receiving no insulin therapy and in patients who suffered from recurrent moderate hypoglycaemia on >1 day. Although the association between hypoglycaemia and death is strong in this population, the authors state that the study design is such that it is not possible to prove a casual relationship. Suggested explanations of why hypoglycaemia is associated with death include those which describe hypoglycaemia as a marker of severe illness (ie in those patients in whom hypoglycaemia was experienced initially without insulin therapy), and also a suggestion that death may occur in part due to systemic influence of hypoglycaemia. Much of the research regarding blood glucose control in critically ill patients over the last decade has focused on avoiding hyperglycaemia, the authors suggest that clinicians also pay particular attention to avoiding hypoglycaemia.

christopher wright ST6 Intensive Care Medicine (London Deanery)

and Acute Medicine (West of Scotland Deanery)

References1. Intensive Insulin Therapy in Critically Ill Patients, Van den Berghe et al, New

England Journal of Medicine, 2001, 345, p1359-13672. Intensive Versus Conventional Glucose Control in Critically Ill Patients, The

NICE-SUGAR Study Investigators, New England Journal of Medicine, 2009, 360, p1283-1297

XigrisTM – gone but not forgottenPROWESS-SHOCK Study Group- Ranieri, V. M. et al. drotrecogin Alfa (Activated) in Adults with septic shock.New England Journal of Medicine 2012; 366(22): 2055–2064.

XigrisTM (DrotAA) was withdrawn from clinical use on 25th October 2011. The decision was taken by Eli Lilly in response to preliminary data from the PROWESS-SHOCK study, now published. This study was supported by Eli Lilly and sought to address conflicting reports of efficacy.

MethodsAdult patients meeting defined criteria for sepsis, shock and hypoperfusion were randomised centrally to 96 hours infusion of DrotAA or placebo. Primary outcome was death at 28 days. Secondary outcomes included 90 day mortality, Sequential Organ Failure Assessment (SOFA), and safety.

resultsSample size was increased to 1696 during the study as aggregate 28 day mortality was lower than the 30% used in the original power calculation. 1697 patients were recruited, primary outcome data was available for 1680, and 1666 received study treatment. 832 patients had APACHE II ≥25 .

Mortality at 28 days was 26.4% in the DrotAA group and 24.2% in the placebo group (RR 1.09, 95% CI 0.92-1.28, P=0.31). Mortality at 90 days was 34.1% in the DrotAA group and 32.7% in the placebo group (RR 1.04, 95% CI 0.90-1.19, P=0.56). No subgroup showed significant mortality differences. There was no difference in SOFA scores between groups on day 7. Bleeding events were more frequent in the DrotAA group but were mostly non-serious (RR 1.8, 95% CI 1.23-2.61, P=0.002), with no difference in serious bleeding (RR 1.25, 95% CI 0.49-3.15, P=0.81) or intracranial bleeds (RR 1.0, 95% CI 0.20-4.90, P=1.00).

conclusionsOn the basis of this study there is no apparent mortality benefit in the treatment group. However, a subsequent publication suggests there is an outcome benefit with DrotAA use within a ‘real life’ population.

Kalil, A. C., & Larosa, S. P.

effectiveness and safety of drotrecogin alfa (activated) for severe sepsis: a meta-analysis and metaregression. The Lancet Infectious Diseases 2012; 12(9): 678–686.

MethodsSystematic review and meta-analysis of studies of DrotAA in severe sepsis since 2001 recording mortality, in hospital or at 28 days. 53 publications identified, 9 controlled studies (41401 patients) and 16 single-group studies (5822 patients) included.

resultsHospital mortality across controlled randomised trials and cohorts, including PROWESS 1, ADDRESS 2 and PROWESS-SHOCK, favoured DrotAA (RR 0.852 (95% CI 0.799-0.909, P< 0.0001). For APACHE II score ≥25, RR 0.837 (95% CI 0.771-0.908, P< 0.0001).

In single-group studies (eg national registries) the mortality rate was 41.3% (95% CI 34.8-48.1). Metaregression of the effect of severity of illness on survival outcomes noted significantly lower risk of death for those who received DrotAA with increasing severity of illness.

discussionData from real life use of DrotAA demonstrates a significant reduction in risk of death, particularly in the sickest patients. Findings are in keeping with PROWESS but not PROWESS-SHOCK. The difference in findings likely lies in patient selection and study design and will doubtless be subjected to further analysis. But in the face of mixed evidence, DrotAA is, for now, off the market.

References 1. Bernard GR, Vincent JL, Laterre PF, et al, and the Recombinant human

protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344: 699–709

2. Abraham E, Laterre PF, Garg R, et al, and the Administration of Drotrecogin Alfa (Activated) in Early Stage Severe Sepsis (ADDRESS) Study Group. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med 2005; 353: 1332–41.


Keen to make a flying start I went to the NHS website helpfully named Flying Start NHS. I was hoping to examine critically the concepts of reflection in order to develop further insights into the impact that reflective practice can have on the quality of care I provide in the healthcare setting (sic), but unfortunately the exercises for modules KSF C2, S19 & S20 are estimated to take eight hours and five minutes of my time, and that’s before I have read the 128 page document and downloaded my complimentary e-copy of Chris John’s Becoming a Reflective Practitioner [2]. Now I’d normally be the last person to want to reduce such a learned text to a sound bite, but Oxford University Press have thoughtfully published a PowerPoint Presentation on their website entitled Reflective Practice - The Frameworks; it’s an Exercise for Chapter 16 of Manchester psychologist Dr Lucy Webb’s recent book on the subject [3]. The eighteenth slide reveals that John ‘uses Carper’s (1978) four patterns of knowing, aesthetics, personal ethics and empirics adding a fifth pattern ‘reflexivity’.’ Oh dear. Is there no Reflection for Dummies out there? Well, apparently there’s Schon who, in 1983, declared that ‘the Effective reflective practitioner is able to recognise and explore confusing or unique (positive or negative) events that occur during practice.’ Schon defines ‘reflection-in-action’ as my ability to think what I am doing it while

I am doing it, rather like chewing gum and walking at the same time, which one American President famously struggled with. Then there’s the Gibbs Reflective cycle, for which see Figure 1. Dr Webb seems to place more reliance on Gibbs. I got as far as Stage Two, which is to recall and explore what was going on in my head, how I was feeling when the event started, how the event made me feel, how other people made me feel, and how I felt about the outcome. Well, Dr Webb is a psychologist, but I’m afraid Feelings is one of my intellectual deficit disorders, so Gibbs is not for me. What about Driscoll’s ‘The What’ model of structured reflection? Describe the event (What?), analyse it (So What?), and propose actions (Now What?). That’s What I’m talking about, as a cool practitioner might tweet these days. Our Lords Spiritual in Westminster will approve of an example of reflection I found on the Lippincott Williams & Wilkins website which describes how the Christian practitioner consults the scriptures and uses prayer to talk to God in her analysis of an event, and why not? Then I remembered The Literary Physician, Professor Rita Charon of New York’s Columbia University, who champions Narrative Reflective Practice [4]. The ‘parallel chart’ is one of her strategies, an evolving pedagogical approach to clinical reflection, apparently. For her explanation, see box above.

Then I had an idea; I remembered from my incredibly helpful NHS management training that the Myers Briggs Extrovert asks other people for their solutions. To help those of us who face Reflection with trepidation, Anaesthesia News is calling on Members to submit examples of their own Reflections, and we are going to call them Reflective Pearls. A Pearl may be a snippet from your appraisal or your e-portfolio. It may be a thought or an idea from experience or Literature that you wish to share with us. The important thing

is that it demonstrates your reflective style, inspires, informs, and even entertains. It may be iconoclastic, it may be irreverent. It may be reassuring or it may be unsettling. It is not bound by the formal constraints of case reports or audits, and we will publish anonymously if you prefer. We will publish online, perhaps as a blog, and consider the best Reflective Pearls for publication in Anaesthesia News. With your contributions, Reflective Pearls could grow to give us a national database of critical reflection in anaesthetic practice.

Meanwhile, I am going to re-read Marcel Proust’s À la Recherche du Temps Perdu, perhaps in the original French this time, after which Professor Charon promises I’ll find myself more porous to my surroundings, to my affective states, and to what happens during the day [6]. Much like a relaxing weekend in Amsterdam, but without the uncomfortable ferry trip, what?

Tom woodcock

1. General Medical Council. Supporting Information. http://www.gmc-uk.org/Supporting_information100212.pdf_47783371.pdf

2. Flying Start England; Reflective Practice. http://www.flyingstartengland.nhs.uk/reflective-practice

3. Webb L. (eds) 2011. “Nursing: Communication Skills for Practice”. Oxford University Press. isbn: 978-0-199582-72-3

4. Charon R, Wyer P, for the NEBM Working Group. Narrative evidence based medicine. The Lancet 2008; 371: 296 - 297 or http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60156-7/fulltext

5. Charon R. Narrative Medicine: Honoring the Stories of Illness. New York: Oxford University Press, 2006.

6. Interview. Rita Charon: The Literary Physician - Proto Magazine, Massachusetts General Hospital. http://protomag.com/assets/rita-charon-

the-literary-physician

Good Medical Practice requires us to reflect on our practice and consider whether we are working to the relevant standards1, so I am going to have to learn how to write reflective notes.

Reflective Pearls...

Anaesthesia News invites you to share some of your Reflective Pearls with your colleagues, so we can all become perfect reflectors. They can be short (around 250 words, or even less if you like), or longer (up to 500 words) if you prefer, but like any pearl, small is beautiful. Our only caution is to ensure no details that could identify an individual patient are included in your Pearl. If for any reason you would prefer us to publish ‘anonymously’ or ‘pseudonymously” we will usually accept this, but our editorial staff do need to know who you are for communication purposes!

“Every day, you write in the hospital chart about

each of your patients. You know exactly what to

write there and the form in which to write it. You

write about your patient’s current complaints, the

result of the physical exam, laboratory findings,

opinions of consultants and the plan. If your

patient dying of prostate cancer reminds you of

your grandfather, who died of that disease last

summer, and each time you go into the patient’s

room you weep for your grandfather, you cannot

write that in the hospital chart. We will not let you.

And yet it has to be written somewhere. You write

it in the Parallel Chart.”5

Please email submmissions to: [email protected]

CALL FOR SUBMISSIONSRevalidation is now ‘live’ and we should all be ‘Reflecting”.

The AAGBI’s reflective learning template will be available at www.aagbi.org shortly

Attending GAT AsM not only covers your curriculum needs, as all lectures and workshops are coded to the curriculum, but gives you the opportunity to boost your cV by submitting an abstract for poster or oral presentation.

Prizes include:OralPresentationPrize•CasePresentationPrize •AuditPrize•AnaesthesiaHistoryPrize•RSMPrize


To find out more visit www.gatasm.org/content/oral-poster-prizes Closing date for all prizes: 14 January 2013



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