gat in brighton - aagbi her well in her consultant post in stoke. gat asm brighton 2007 doing so...

Anaesthesia News October 2007 Issue 243 �

The Newsletter of the Association of Anaesthetists of Great Britain and Ireland. ISSN 0959-2962

21 Portland Place, London W1B 1PY, Tel: 020 7631 1650, Fax: 020 7631 4352, Email: [email protected], Website: www.aagbi.org

AnaesthesiaNews No. 243 October 2007

GAT in Brighton

Core Topics Meetings – AAGBI goes regional

Opting in or opting out of organ donation

� Anaesthesia News October 2007 Issue 243

Contents

03 GAT ASM Brighton 2007

07 President’s Report

09 Editorial

11 Council News & Announcements

13 Wylie Prize Essay

17 Seminars

21 Committee Focus: International Relations Committee

22 Clinical Excellence Awards – the deadline for English awards is looming!

24 ruOK4CME@AAGBI?

27 The History Page

30 Naked Gasman

33 Welfare Dilemma

36 Dr Ruxton

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 NewsEditor: Hilary AitkenAssistant Editors: Iain Wilson, Mike Wee and Val BythellAdvertising: Claire Elliott

Design: Amanda McCormickPips Design, Telephone: 01604 642263Printing: C.O.S Printers PTE Ltd – SingaporeEmail: [email protected]

Copyright 2007 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.

This year has brought with it some very uncertain times for all doctors, especially trainees. MMC has changed the way a number of specialties view training. MTAS and all that has followed has stressed the profession almost to its limits, leaving well qualified doctors without posts, some journeying overseas to find employment, and those lucky enough to secure a training post unsure what the future holds. Bearing this in mind the GAT committee are delighted to report an excellent turn out to the GAT ASM – this year held in not-so-sunny Brighton.

The broad theme was risk, risk management and ethics, with specific areas of clinical practice also covered. Whilst risk may not arouse a burning passion in some, it is vitally important to anaesthetic practice, and our specialty has led the field in ensuring best practice.

The first session provided a lively and informative start to the meeting with discussion ranging from patient-focused issues (the living will for example), to broader public health issues. A second session on Thursday morning complemented this and went on to explore further the ways in which one can reduce risk and learn from errors, not just in anaesthetic practice but as doctors and throughout daily life and work.

The Pinkerton Lecture delivered by Professor James Reason clarified and brought together a lot of the topics that had already been presented, and touched upon other areas of error management…it’s never a single individual’s error when something goes wrong, even though you’re likely to spend a lot of time blaming yourself. Incident reporting is not about pointing the finger, it’s about finding the often multiple reasons for system failure. I never thought I would be spouting so much ‘management talk’. Thank you Professor Reason for a very balanced lecture - who would have thought error management could be so engaging?

The Wylie lecture continued on a somewhat similar vein. The title was ‘The impact of law on medicine – help or hindrance?” I suspect a lot of you feel it is more hindrance than help, and I waited to see how Dr Branthwaite would fare entering the lions’ den as a doctor turned lawyer. Dr Branthwaite spoke effortlessly, without aid, for an hour on the Friday morning, and the audience was spellbound – no mean feat considering the ball had been the night before. Most if not all of us were converted to the benefit of the law in difficult circumstances. It is not hostile to the profession; it merely seeks to do what is right and fair, and by

GAT ASM Brighton 2007



with her paper entitled “Aprotinin use during cardiac surgery: friend or foe?”. The runner up was Dr Lee Riddell (What is a successful epidural?) and third place was taken by Dr Sagadai (Effects of diamorphine and diluents on baricity when added to hyperbaric bupivacaine).

57 posters were shortlisted for presentation and after much deliberation the winners were announced as Drs R Ramaiah and W Lum Hee in first place, Drs KP Patel, K Tatham and N Patel in second place and Dr T Mane and J Easby in third place, with a special commendation for Dr A Combeer.

For the first time ever there were two winners in joint first place for the Abbott history prize, which meant slightly shorter presentations from Dr T Dawes on ‘Michael Tunstall and the development of Entonox’, and Dr B McGrath on ‘The history of one lung anaesthesia and the double lumen tube’.

While planning the ASM, Dr Meadows and Dr Hunt met with Professors Crockard and Heard to discuss GAT concerns regarding MMC, and were delighted to secure Professor Heard as a speaker for the trainee conference. Clearly matters changed and Professor Heard withdrew from the meeting. Dr Venn, Regional Advisor for the South Thames School of Anaesthesia and chair of the STC, agreed at short notice to fill this slot and managed to summarise the preceding year’s debacle for trainees and trainers alike in a concise, humorous and understandable presentation.

The AGM followed with Drs Hunt, Malligere and Freddy standing down from committee. Dr Hunt handed over the Chair of GAT committee to Dr Chris Meadows, Dr Paul Johnston was elected as Vice Chair, and Dr Felicity Howard was accepted as Honorary Secretary Elect. The Committee offered their thanks to Dr Hunt for her tireless work in difficult times for trainees and wished her well in her consultant post in Stoke.

GAT ASM BRIGHTON 2007

doing so offer guidance. That said it did highlight how imprecise we as medics are with our use of language and encourage even greater practice of defensive medicine.

The first day continued in a more clinical fashion, considering blood and then critical care. Rationing in the NHS is affecting us all, and blood is an expensive product that is not without risk. The three talks combined to give an understanding of when, how and why not to use blood. The session on critical care focused on three areas – burns, optimisation of patients in theatre (or “don’t give too much fluid”) and how and who to ventilate non-invasively.

The Friday morning slot soothed beer-sodden brains with practical and entertaining talks about alternative anaesthesia. The practical looked at working overseas, either in the developed world or with a Non-Government Organisation. There seems to be something for everyone, and many trainees are considering this as an option. There is a lot of planning for either option but as a volunteer, once the paperwork is sorted, you’re off and you’re it!

The entertaining session gave us a whistle stop tour of a day in the life of the London Zoo anaesthetist, and we saw the biggest red rubber tube! Dr Whitaker suggested using a fibreoptic scope and hopefully helped the vet with his problem of how to intubate an anteater – an estimated 1metre to the larynx through a very small mouth… makes you think about our difficult intubations!

Presenting at the GAT ASM either in the registrar’s prize or Abbott history prize, or submitting a poster to the audit competition is an excellent way to gain points on your job applications. This seems to have been borne out as we had record numbers apply to enter both competitions this year, and the standard was again very high.

Out of the six short listed presentations for the registrar’s prize we would like to offer congratulations to the winner, Dr A Binks

Dr Binks is presented with the Registrar’s Prize

The outgoing GAT chairman, Sara Hunt, receives a gift from her

successor, Chris Meadows


Dr Hunt gave a verbal report of committee activities throughout the year and urged delegates to reply to the Tooke report on-line. (For an update on the Tooke enquiry go to http://www.aagbi.org/gat.htm and follow the link.) She also welcomed our newly elected members to committee – Drs R Broomhead, M Shankar Hari, and A Ward.

Four workshops were run as parallel sessions during the scientific programme and proved very popular. Three out of the four took place at the Corn Exchange itself, while delegates were taken to the simulation centre for the paediatric emergencies workshop. The workshops are designed to offer small group teaching and ‘hands on practice’ in a non-threatening environment. This year we covered oesophageal Doppler monitoring, ultrasound guided regional anaesthesia and difficult airways.

The social programme at GAT is always something to look forward to. This year the original plan was fish and chips on the pier, followed by fair ground rides… we managed the first but wind and rain put paid to the rollercoaster, so we made do with karaoke and beers. Who would have known what a singing talent we have in our new Chairman: I think he did every third turn, but the outgoing Chair matched him with her rendition of Dolly Parton’s “Nine to Five”, with the Portland Place staff on backing vocals. However, there were actually some very talented singers!

Thursday night was the annual dinner at the Brighton race course….a masquerade ball, with everyone joining in: some more than others, yet they still managed to put in appearance on the Friday morning - you know who you are. Dr Whitaker closed one of our best yet GATs on Friday and delegates made their way home.

GAT is the only national UK conference for anaesthetic trainees. It is an environment in which to learn, meet other trainees from around the country, find out what is going on, and let your hair down. The scientific programme tries to be broad and include both clinical and non-clinical topics in order to appeal to as wide an audience as possible. The success of the conference is not only down to its organisation but also to the delegates that attend. We are currently planning the next GAT, which will be in Liverpool 2008, City of Culture. Book your study leave and join us.

Finally, the GAT committee would like to thank Dr Neville Hutchinson, Dr Rick Kennedy and the events team at the Association of Anaesthetists for all their hard work in organising and running the Brighton GAT ASM.

See you next year!

Jane SturgessHonorary Secretary, GAT committee

The interpretation of “Masked Ball” allowed plenty of scope


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In August a cross-party group of MPs launched a scathing attack on government management of the civil service saying that no department, including the Department of Health, is currently “fit for purpose”. The Public Administration Select Committee says departmental capability reviews paint a bleak picture of performance (1). The Department of Health scored only slightly better than the Home Office but with “serious concerns” about leadership, and strategy was an “area of urgent development”. High-profile failures mentioned include the Rural (non) Payments Agency and the MTAS fiasco over recruitment of junior doctors. They have called for a new National Performance Office to oversee and audit civil service management.

As mentioned in previous reports I believe the NPSA concept of “Purchasing for Safety” should now be a key process in our work. When acquiring new drugs and equipment it sets down the cultural basis for making these decisions and justifies any increase in the cost of purchasing if not offset by savings in the improved patient outcome overall. Spending money transparently in this way at the clinical front line on direct patient care should never even be questioned whilst billions of the taxpayers’ money is squandered on management consultants, Information Technology, Independent Sector Treatment Centres, Private Finance Initiatives etc, with no monitoring or evidence of their worth, let alone value for money.

The need to involve clinicians in management has long been called for, but with limited success. That is not surprising with two often inherently different agendas. Surely it is now time to

refocus on such potential cooperation or alternatively call for some management engagement in clinical areas and concerns. It frequently seems to be forgotten that clinical work and the doctor-patient interface is the core business of health care and that is where the effort and resources should be concentrated with everything else working its way back from the patients’ side to the boardroom and Whitehall. There are good managers but the others need to understand practice at the coalface and how their management training and skills can be used to support the doctors and nurses delivering patient care.

An ultramodern concept for excellence in service organisations (e.g. some airlines) is to look after the staff and make sure they're happy. After doing that you don't need to concentrate much on the customers as they get looked after automatically every step of the way - even in ways that the old Modernisation Agency would never have documented. When I suggested this as an ultramodern management concept this was opposed on the basis that it was common sense. The reverse is certainly true - you never get great service from unhappy staff.

In August the first Chinese language edition of Anaesthesia was published. This is a quarterly journal put together by the Chinese editorial board, led by Professor Liu. They select and translate articles from three consecutive editions of the main journal that they feel will most valuable to Chinese anaesthetists. To launch this exciting venture and meet and thank the enthusiastic Editorial Board I visited Beijing in July together with Editor-in-Chief David Bogod, Honorary Secretary William Harrop- Griffiths and Editor

President’s ReportOctober 2007


Mike Nathanson. We were also invited to speak at a China - UK Anaesthesia Symposium organised jointly by the Chinese Society of Anaesthetists and Beijing Society of Anaesthetists. In my address to the 1700-strong audience I invited any Chinese anaesthetist visiting London to drop into 21 Portland Place have a look at the museum and a cup of tea. There are 60,000 anaesthetists nationally and we look forward to inviting their representatives to one of our meetings in the future.

The Tooke Inquiry is now underway and interested parties have submitted their written comments - 4600 of them apparently. The number of submissions tells the inquiry board something important before they even start to read them. The MTAS review group chaired by Academy of Royal Medical Colleges vice-chair Neil Douglas has now produced a report which blamed the system for 'the biggest crisis within the medical profession in a generation'. The Douglas review is dated 12 July, but was not published until 3 August - a week after Parliament rose for the summer recess. There was no DoH press release for the report and it was only published on the Modernising Medical Careers website (2).

One effect of this debacle has actually been to unite the medical profession and cause a number of organisations, colleges and associations to all talk to each other much more frequently than usual and develop some common threads - long may it continue.

Most organisations’ Tooke Inquiry responses are available on their websites (as is the AAGBI’s) and there is a lot of similarity, particularly hope for more flexibility. Such is the concern and importance attached to a satisfactory outcome to all this that the Tooke Inquiry itself will be reviewed by the Health Select Committee in the autumn. Watch this space, but keep looking after the patients.

Whatever the outcome of this catastrophe in medical training, anaesthetists will still be required and with this mind and the continuing need to recruit high-quality candidates into the specialty, GAT have revised their document ‘Your Career in Anaesthesia’. This third edition is aimed primarily at informing medical students and doctors in their first years of training. Great efforts have been made over years by the AAGBI, the RCoA and others to make a career in anaesthesia attractive. Parity of pay for NHS work is definitely not the least of these and it must never be thrown away. A recent letter I received from an anaesthetist in Africa reminded us of the stark truth of what happens to recruitment and retention when this is not the case. An unintended consequence of the relative abundance of money for HIV is that it severely compromises the provision of anaesthesia and other services. In the UK this autumn as Trusts

and PCTs attempt to meet the government's 18 week target, more NHS work in non-contracted hours on both Trust premises and in the Independent Sector will be offered. In various parts of the country this NHS work is already being carried out on a parity basis so please ask the NHS body funding the work in your area for parity as well. Always maintain clinical standards and transparency and do not throw the parity principle away. No anaesthetist should volunteer for this NHS work on any other basis. The world looks to British Anaesthesia.

David Whitaker

References1.www.parliament.uk/parliamentary_committees/public_administration_select_committee/pasc0607pn48.cfm2. http://www.mmc.nhs.uk/download_files/final%20reportx.pdf

Undergraduate Elective FundingUp to £750

All medical students in the UK who have successfully completed two years of clinical medical training are eligible to apply to the Association of Anaesthetists of

Great Britain and Ireland for funding towards a medical student elective period.

Preference will be given to those applicants who can show that their intended elective has an anaesthetic,

intensive care or pain relief interest.

For further information and an application form please visit our website: www.aagbi.org

or email [email protected] or telephone Chloë Smith on 020 7631 8807

Closing date 11th January 2008


The NHS in the early years relied on the “implicit compact” between government, the medical profession and the public1. Ham and Alberti suggested that the compact allowed medicine “to be largely self regulating, with both government and the public ceding to the profession the responsibility to control standards and assure quality through the GMC and royal colleges.” This “implicit compact” has long disappeared.

When Richard Smith, then editor of the BMJ, wrote an editorial in the wake of the Bristol Inquiry; the title was indicative of his impression of how this would effect the medical profession: “All changed, changed utterly”.2 The article ends with a stark warning: “Failure of doctors' organisations to implement much better mechanisms for ensuring high quality of care may lead to the micromanagement of doctors that is routine in the United States.” Subsequent scandals, such as organ retention in Alder Hey and the conviction of the mass murderer Dr. Shipman, have in many doctors’ minds propelled the profession to Smith’s conclusion.

The NHS is now undergoing far-reaching and radical reform. New incentives are being introduced to improve performance, in particular through supply side reforms – greater consumer choice, competition between providers, greater use of non-NHS providers – all underpinned by a new system of paying hospitals, Payment by Results (PbR). In addition to these mostly target driven reforms there are also modernisation changes of medical education and regulation. By and large these reforms occur in silos of non-communicating activity; the end result being potential jeopardy to patient safety. The continuing implementation of the modernisation agenda of target driven reforms often clashes with a safe patient journey.

As the effect of the MTAS chaos unfolds, the next radical change to be implemented will be the recommendations following the recent White Paper “Trust, assurance and safety – the regulation of health professionals in the 21st century”. The AAGBI has responded at length to this White Paper and was pleased to note some of the CMO’s proposals had been modified in response to suggestions from the AAGBI and other professional bodies. Revalidation will definitely occur and it is vitally important that we as a profession play the leading role in the methodology and implementation of revalidation. The mistakes and de-stabilising effects of MTAS must not be repeated in the implementation of revalidation.

The history of revalidation provides pointers to the direction it may take and shows the influence of society’s response to the repeated medical scandals and adverse media coverage. The Joint Committee on Good Practice (JCGP) was set up in response to the changing quality agenda and revalidation in particular and is a joint venture between the AAGBI and the RCoA. The third edition of the “Good Practice Guide” maps out the development of revalidation, a process which started in anaesthesia in 1997. A Working Party developed a modus operandi, setting out the first edition of the “Good Practice Guide” and developed into the JCGP. The original remit was:• to collate current agreed guidelines and standards which

specify good practice.• to consider how these guidelines and standards could be

applied at individual departmental and national level to ensure patient safety.

• to offer guidance on the identification and management of poorly performing anaesthetists.

The JCGP has responded over the years to the increased demand

Guest Editorial

THERE MAY BE TROUBLE AHEAD…

�0 Anaesthesia News October 2007 Issue 243

for improved quality and society’s expression of doubts about the ability of the medical profession to set standards and provide rigorous regulation. In the third edition the JCGP stressed the importance of reinforcement of the regulatory process. Now that the White Paper has set out the road map for regulation it is imperative that the AAGBI and RCoA provide a workable, fair, but thorough process. Only by strong medical leadership can a repeat of the MTAS disaster be avoided.

I believe some of the burning issues are:1. The cost - and who will bear its burden. A DoH document

reveals the expected costs of the revalidation process3. The current cost of the regulatory process of £77.7m is estimated to rise to £155.9m; of the extra £78.2m, £18m will come from doctors on top of the current GMC subscriptions. There are some positive aspects to this cost burden - some monies are allocated to the Colleges to develop standards, and sums are set aside for remedial action following failure to revalidate. These figures do not contain any consideration of the cost of the time of the doctors concerned. Will trusts take an altruistic attitude to time taken for revalidation? Vigorous job planning will be necessary to ensure a fair allocation of time to this process.

2. Appraisal as presently designed cannot be expected to undertake the multiple tasks of detecting poor practice, quality assuring practice, ensuring compliance with contractual obligations, improving practice and facilitating continuing professional development. Revalidation should not be based solely on appraisal. Some of the suggestions such as knowledge testing and use of simulators would require a new infrastructure which conjures up doctors travelling around the country to approved centres either to test or be tested, which adds a sort of MTAS feel to the situation. There must be careful planning of these forms of testing. A generic approach is unlikely to work; different specialities and doctors in different age groups will need individualised methods of testing, although some generic themes such as communication skills are applicable to all.

3. There are concerns that the Colleges will be setting standards, assessing competence and judging outcome. This may fundamentally change the nature of members’ and fellows’ relationship to the College. Consultant membership would become associated with the assessment process. The College would essentially change from being a representative body for anaesthetists to being their regulator. The AAGBI has offered as “a truly representative professional body” to act as a guarantor that the process is fair and appropriate.

4. The changes required need to be fully piloted and adequate time allowed to consult with the medical profession about the results of the pilots. Patricia Hewitt stated in the Parliamentary debate in February 2007 on the White Paper: “The introduction of a new appraisal and revalidation

system covering all health professionals in the UK needs to be piloted thoroughly, managed carefully and phased in over time to ensure that it works well, that it works fairly and that it enables employers and commissioners to put in place the capacity and capability needed to make it work well.” The Government’s track record for adequate time for introduction of new initiatives is not good, and equally poor is its track record in consultation with the profession on pilot studies. Will this implementation be any smoother?

The emerging revalidation process a few years ago was stalled by the Shipman Inquiry. Following this inquiry, led by Dame Janet Smith, the UK Government set up two reviews of the regulation of healthcare professions. Dame Janet was highly critical of the appraisal process and of the GMC. Only a small minority of doctors have competence or performance falling below acceptable standards. Many in the medical profession have doubts whether the new changes would have prevented Shipman. The suggested format of revalidation is targeted at individuals: doctors, especially anaesthetists, work in multidisciplinary teams. Revalidation has to encompass team work; the outcome is dependant on all members of the team. 360° appraisal, whilst a useful tool, does not give an adequate picture of the outcome of the multidisciplinary team. This has serious implications for anaesthetists both in revalidation and in performance management.

There are other concerns with the White Paper, not least the change to the standard of proof in alleged negligence, but it is an opportunity to provide a revalidation process fit for purpose and designed by the medical profession. Post-MTAS there is bound to be suspicion in the minds of doctors, so openness and good communication are essential to help allay fears of the new process. Smith’s editorial used a quotation from Yeats as its title: “All changed, changed utterly” to dramatically highlight the changes that would have to happen for the medical profession to regain patients’ confidence. The quotation finishes “A terrible beauty is born;4” the hope is that the “terrible beauty” is not a risk averse, over-regulated profession unwilling to advance its skills and care for the seriously ill.

Les GemmellHonorary Secretary Elect, AAGBI

REFERENCES:1. Ham C., Alberti, K., The medical profession, the public, and

the government BMJ 2002; 324:838-842.2. Smith, J., All changed, changed utterly. BMJ 1998;316:1917-

1918. 3. Provisional costing estimates for recommendations made in

Good doctors, safer patients. DoH.4. Yeats, W., B., Easter 1916, www.yeats-sligo.com

Anaesthesia News October 2007 Issue 243 ��

COUNCILNews & Announcements

The AAGBI decided that it was necessary to provide guidance on “do

no attempt resuscitation” (DNAR) orders in the perioperative period.

This was highlighted as a problem in an editorial in Anaesthesia

[Anaesthesia, 2006, 61, pages 625–627]. The authors highlighted the

ethical and legal issues surrounding the suspension, or not, of DNAR

orders during surgery.

The Working Party has met and wishes to seek views from AAGBI

members. The editorial and a scenario for comment have been posted

on the AAGBI web site. Members are asked to send their comments to

the Working Party Chairman, Dr. Les Gemmell [email protected].

DNAR in the Perioperative Period - A New AAGBI Working Party

New Exhibition in the Anaesthesia Heritage CentreA new temporary exhibition has opened in the Anaesthesia Museum in the Association’s headquarters at 21 Portland Place.

The year 2007 marks 75 years since the foundation of the Association of Anaesthetists of Great Britain and Ireland. The strapline chosen to mark this is “75 years promoting patient safety” and our temporary display in the museum area this year is also on the theme of safety. This display celebrates British contributions to safety in anaesthesia and the work of the Association of Anaesthetists of Great Britain and Ireland.

Amongst the items displayed are early inhalers, gas cylinders, anaesthetic record cards, scavenging valves, the laryngeal mask airway, and the works of John Snow who realized very early on the need to measure the amount of anaesthetic administered.

Please come and visit our exhibition next time you are in London.

Trish Willis and Iris MillisHeritage Centre Staff

Farewell to John and RoddieRoddie MacNicol (L) and John Carter have recently stepped down from AAGBI Council, having accumulated 14 years’ service between them. Roddie has recently retired and will be spending more time in France (where he has a house) and Australia (where he has a grandchild). John remains in harness in Bristol! Both have contributed much, and will be missed. Thanks are due to both for their work over the years.

The new exhibition is opened by AAGBI President David Whitaker, seen here with Trish Willis, Heritage and Estates Manager

�� Anaesthesia News October 2007 Issue 243

This year Jon Griffin, a final year medical student at Leeds University, won the Wylie medal for the best essay submitted by an undergraduate on a topic relating to anaesthesia. An abridged version is printed below.

A 32 year old man lies in an intensive care bed having been admitted the night before. A ventilator and intravenous inotropes are keeping him alive. He is brain dead. The rest of his body however remains in a fully functioning state. Twenty miles away another man is awaiting a heart transplant. Our patient is a perfect tissue and blood type match. There is a problem: he is not on the organ donation register and has never discussed donation with his wife. She is understandably distraught and is in no state to make a decision about what should happen to her husband’s organs. How do the doctors determine whether or not it is appropriate to take his organs?

This scenario often occurs in an intensive care setting. There are of course protocols and agreed methods of obtaining consent for the removal and transplantation of organs, but in 2003 six thousand people were awaiting transplants and although there are ten million people on the UK donation register1, many patients will die on the waiting list. Consent is the pivotal ethical concept when procuring organs. The last decade has seen a division in thinking about consent among different countries. In the UK and America the patient’s consent, in the form of a donor card or their relatives’ consent is needed. France, Austria and

Belgium work on a principle of ‘presumed consent’. This means that it is presumed that the patient consents to the removal and use of their organs unless they stipulate otherwise in life. With the introduction of the presumed consent system in these countries approximately ten years ago, there was an immediate increase in available organs2. In Belgium the number of kidneys available for transplantation increased by 114 percent over the ensuing five years3. Many ethical issues are highlighted, not least consent and respect for patient autonomy. The concept of justice is also important as we must consider the wider reaching effects that organ donation has on society. Usually the opinions of the potential donor’s relatives are sought and this can often be the casting vote in deciding whether or not to use the organs. This article discusses the concept of opting in and opting out of organ transplantation and explores how ethically viable each system is.

AutonomyPhilosophers have debated the characteristics that someone must posses to qualify as a person. There are five popular characteristics to personhood:

• Being human. • Intelligence. • Moral conscience. • Having interests. • Potentiality.

Wylie Prize EssayOpting in and opting out, who should choose?



A brain dead patient may be argued to possess none of these characteristics and therefore logically should not be considered a person. Superficially, it might appear that the principle of autonomy, or indeed any other biomedical principle, does not apply to our patient. With regard to organ donation autonomy relates intrinsically to the ability to consent. The dead patient has no autonomy and therefore no right to consent or refuse the donation of his organs. Following this argument through it becomes apparent that another party must have authority over what happens to the patient’s organs. One might assume that the doctors’ decision is final or perhaps that the decision whether or not to donate might be influenced by the family. Either way the end result is the same. The patient is dead and therefore their organs can be donated.

It is not this simple however. Let us assume the patient was on the organ donation register. This means he has expressed the wish to have his organs removed and transplanted after his death. Although being dead he no longer has autonomy, his autonomy before death must be respected - ‘retrospective autonomy’, if you will. This view questions the idea that a brain dead patient does not have moral conscience as they had moral conscience in life, which is now informing treatment after death. The other side of this argument is less clear-cut. If a patient was not on the organ register this does not necessarily mean they were opposed to their organs being used for transplantation. If the patient’s family give permission for the organs to be used, it will be on the assumption that the family knew the donor well enough to make this decision on their behalf. This may not be the case. Death is a taboo subject and people do not like to talk about what happens if they die prematurely or what should happen to their organs. The principle of retrospective autonomy suggests that if a patient has made their wishes clear, their organs should be used irrespective of the family’s views.

So how does a presumed consent system impact on a patient’s autonomy? The strongest argument against opt-out protocols is that a patient no longer has a choice about what will happen to their organs after death. Autonomy underpins consent and choice and so to disregard choice would violate accepted bioethical principles. During life, autonomy is central to giving people identity. It allows somebody to have control of their life and seek the best possible outcomes from situations by making choices. This ability to make choice and consent reinforces a sense of self-ownership which makes a person an autonomous individual. Choice is significant in medical and healthcare decisions, as the outcomes involve something being done to one’s body. By this argument should we force patients to donate their organs if they express no wishes during life?

I argue that we are not violating their autonomy. By telling patients that their organs will be used to benefit others unless they express an opinion otherwise, we may in fact force them into thinking about the difficult decision about organ donation in a deeper sense. I think this enhances their autonomy as they would have to find out about organ donation and make a decision in a ‘negative’ (not donating) direction. By being forced to think about donation the patient will be more informed and as noted previously, information is paramount when empowering a patient with autonomy. Given that 70% of British adults are willing to donate their organs4, it would appear that apathy and lack of education are stopping people from joining the organ donation register, not a lack of desire to donate.

JusticeIn the field of medical ethics justice is synonymous with fairness. In the area of organ transplantation there are two parties we must treat fairly: the donor, and society. I believe that society is the more important group here. To treat them fairly we must find a way to make up the shortfall in available organs. Under the principle of justice, presumed consent is ethically viable if we take a utilitarian stance - ie ensuring the greatest good for the greatest number. By utilitarian principles everyone would consent to having their organs used as they would want an

John Griffin receives the Wylie Medal from David Whitaker.


organ to be available if they ever needed one. It is this concept of reciprocal care that makes society seek the greatest good for itself with regards to healthcare decisions. This is illustrated the allocation of resources within the NHS. The conditions that cause the most detriment to society (cancer, heart disease, hypertension) receive the most funding. By extrapolation it is obvious that a presumed consent system offers a greater benefit than an explicit consent system. Therefore society is treated justly and is presumed consent is ethically viable.

When analysing utilitarian decisions one can class the decisions as either ‘good’ (helps the greatest number) or ‘bad’ (actively hinders the greatest number). We’ve seen that presumed consent for organ donation helps the greatest number and is therefore a good utilitarian decision. Extrapolating from this, an opt-in system is a bad utilitarian decision as it actively denies patients the organs they may need to live. Going back to our definitions of personhood we see that belonging to a moral community is part of being a person. If by not allowing your organs to be used another person dies, surely you are not behaving in the best interests of the moral community. Considering so many people do not have opinions either way about organ donation, we must assume they would want to do what was morally right – donate their organs. A presumed consent system would allow people to take this morally right action by default. It allows them to act in the best interests of the moral community.

SummaryAn opt-out system is one of the many initiatives currently being investigated by the BMA as a way of closing the gap between supply and demand of transplanted organs5. Persuading the general public to endorse and participate in such a scheme would be difficult. In a post-Alder Hey world, the use of organs without consent will be cause concern as society will feel their right to freedom of choice has been abused. However, recently there has been an increase in political interest regarding presumed consent implying there is now fertile ground for debate and discussion surrounding opt-out legislation6. Many health professionals in the United States agree with the principle of presumed consent but recognise that, in a country with arguably some of the toughest views on liberty and choice, it would be impossible to implement an opt-out system7.

It is also important to remember that consent is not a simple matter of opting in or opting out. Consent is a wide spectrum of choice ranging from a decision made entirely by the patient to one made exclusively by healthcare professionals. In the middle of this spectrum is the mandated choice system. This involves individuals deciding at a predetermined time (for example when

renewing a driver’s licence) whether or not they wish to donate. Mandated choice does not violate autonomy in the same way that some argue a presumed consent system does, rather it informs the public and allows them to make a decision from this prompt.

Is a presumed consent system ethically viable?From the arguments presented I take the stance that it is. There is a strong argument for presumed consent infringing on autonomy as society is forced into donating their organs unless they specify otherwise. From a different perspective, the opt-in system forces society not to donate their organs unless they seek out a way of consenting before death. An opt-out system also removes stress from the family at the time of death as they do not have to think about what their loved one would have wanted and this makes the grieving process easier. From a utilitarian point of view we’ve seen that presumed consent increases the number of available organs and therefore offers the greatest good for the greatest number. If the human race really is as altruistic as it claims to be surely everyone would want to help as many people as possible after their body is no longer useful to them.

For presumed consent to be instigated effectively and ethically a well-designed awareness and education program would have to be developed. As with so many ethical disputes in medicine, lack of education and information is partly responsible. If the pros and cons of such a system were presented in a fair and effective way I think presumed consent for organ donation could be accepted by society.

Dr Jon GriffinFoundation Year 1 Doctor St James University Hospital, Leeds

For details of entry to this year’s Wylie Prize competition, see advert on page 25

References1 http://www.doh.gov.uk2 http://news.bbc.co.uk ‘Doctors reconsider transplant stance’, 19983 British Medical Association Medical Ethics Committee. Organ donation in the 21st Century: Time for a consolidated approach. BMA, 20004 Kings Fund Institute. A question of give and take: improving the supply of donor organs for transplantation. London: Kings Fund Institute, 1994:39–40.5 See reference 36 http://news.bbc.co.uk ‘New calls for organ donor opt-out’, 20077 Ethics in transplantation. Berry P.H. Texas Medicine’s symposium on current issues in medical ethics, February 1997

RESEARCH FELLOWSHIPApplications are invited for a

Research Fellowship tenable for up to 2 years

Further information and application forms are available from the Association website:

www.aagbi.org

or Chloë Smith, Association of Anaesthetists of Great Britain and Ireland, Direct Line: 020 7631 8807, or email:

[email protected]

Closing date for applications: 12 October 2007

Association Educational Awards are only open to members of the Association of Anaesthetists of Great Britain and Ireland

SAS Audit and Research Prize

The Association of Anaesthetists of Great Britain and Ireland (AAGBI) invites applications for the SAS Research and Audit prize. This is exclusively for SAS doctors to encourage them

to undertake research and audit. Entries will be judged by the Research Committee of the AAGBI. All SAS doctors who are

members of the AAGBI are eligible to apply for the prize.

An audit project should be carried out under the supervision of a consultant and have been approved by the Trust. A

research project should also be supervised by a consultant and approved by the local ethical committee and Trust.

Applicants should submit a summary of their audit or research of no more than 1000 words, 3 figures and 3 tables. It should

be presented in the style of the journal Anaesthesia.

The winning entrant will have an opportunity to present their work at a national scientific meeting held by AAGBI. Other

entrants may be asked to display a poster at the same meeting (as judged by the Research Committee of the AAGBI).

Please email entries along with full contact details of the author to [email protected]

If you have any additional enquiries, please contact Chloë Smith on 020 7631 8807.

THE CLOSING DATE FOR ENTRIES IS 11TH JANUARY 2008

21-23 NovemberPortsmouth Guildhall, Portsmouth, UK

One day of hands on workshopsincluding “mock” trial of an airway disaster

Two days of plenary lectures, presentations and debate

For further details please visit:www.dasportsmouth2007.org

Drinks reception at Spinnaker Tower

Annual Gala Dinner



Seminars at 21 Portland PlaceEducation for Anaesthetists is a prime objective of the Association of Anaesthetists. To this end it organises a programme of highly popular seminars.

Seminars are held at the Association of Anaesthetists' headquarters, 21 Portland Place, London, W1B 1PY.

We aim to time seminars so that it is possible for those attending to travel to and from the venue on the day of the meeting, without the need to stay overnight.

A hot lunch and refreshments are included in the cost of the seminar.

How to book a seminar For availability, to look at programmes and download individual application forms please see the website at www.aagbi.org. Alternatively you can complete and send the generic application form enclosed in this section (please photocopy to apply for more than one seminar).

Unfortunately we are unable to reserve places or accept telephone bookings.

Cancellation PolicyAll cancellations must be received in writing. Written cancellations received more than two weeks before the seminar will be subject to an administration charge of £20. Delegates cancelling after this date will be liable to pay the full seminar price unless the Association considers there to be exceptional circumstances that would warrant a refund.

Waiting ListIf we receive applications and the seminar is fully subscribed, your payment will not be processed and you will automatically be placed on the waiting list. Should a place become available through cancellation, we will contact those on the waiting list on a first come – first served basis. When a repeat seminar date is fixed, we will write to all members on the waiting list before we advertise the seminar generally.

To be placed on the waiting list, please e-mail Gemma Williams, Events Administrator [email protected] Tel 020 7631 8804.

Please note that you cannot attend an Association seminar if you have not applied in advance. Health and Safety codes dictate we are unable to admit anyone who arrives on the day without prior arrangement.


Seminars Calendar

Please note that some of the SEMINARS LISTED have been previously advertised and may already be fully booked – please check our website for

availability: www.aagbi.org

GAT: THE CONSULTANT INTERVIEW

Wednesday 10 October 2007 Organiser: Dr M Parris, London

• Criteria for a good CV• Preliminaries to the interview• How to be number one choice at an

interview• Practice interviews - with a selection

panel followed by debriefing and analysis• Hot topics and interview skills workshop

ULTRASOUND FOR ANAESTHETISTS

VASCULAR ACCESS & ICUMonday 15 October 2007 Organisers: Dr N Moore & Dr A Gaur, Leicester

• Ultrasound - basics• Vascular anatomy and techniques• Sono anatomy and sono techniques re

vascular access • Ultrasound in ICU• Ultrasound scan on volunteers• Hands-on experience on phantoms

AAGBI HISTORY OF ANAESTHESIA SEMINAR

THEME: MILITARY ANAESTHESIA

Tuesday 16 October 2007 Organisers: Dr A G McKenzie,

Edinburgh Dr C N Adams, Suffolk

• Military anaesthesia before World War I• Anaesthesia in World War I• Military anaesthesia in World War II• Film footage of anaesthetic practice in the

two World Wars• Military anaesthesia in the aftermath of World

War II and beyond• Anaesthesia in the Gulf Wars

MMC UPDATE – LATEST NEWS AND VIEWS

Tuesday 23 October 2007 Organiser: Dr V Bythell,

Newcastle upon Tyne

• New structure of training• Best practice in recruitment and selection• Practical exercises in recruitment• Changes to the training curriculum,

assessments and examinations• Who is going to do the work?• Manpower & discussion

NEUROANAESTHESIA & NEUROCRITICAL CARE

RECENT ADVANCESThursday 25 October 2007 Organisers: Dr E J da Silva,

Birmingham & Dr J Sturgess, Cambridge

• Awake craniotomy – anaesthetic input• Depth of anaesthesia – recent advances• TIVA – drugs and new equipment• Interventional neuro-radiology

– (Thrombosis in coiling/ Ca2+ blockage infusions)

• Radiology input into neurotrauma and critical care

• Optimising conditions for brain recovery in intensive care

DIFFICULT AIRWAYSWednesday 31 October 2007

Organisers: Dr M Stacey & Dr T Turley, Penarth

• Prediction of the difficult airway• Anaesthetising the airway• Practical awake fibreoptic intubation• Management of the difficult airway in

children• Difficult intubation in adults• Failed intubation in obstetrics• Extubation

MANAGEMENT & FINANCE SEMINAR

Thursday 1 November 2007 Organisers: Dr R Alladi, Lancashire

& Dr M Martin, London

• What do you really need to know about management? Overview

• Difficult colleagues – issues and some solutions

• Life outside anaesthetics • How to rally support and make your

voice heard • Maximising your benefit from the NHS

Pension • Tax efficient savings • Property – important information that

you may not know • Wills, intestacy and simple Inheritance

tax solutions

SEMINAR AT THE ROYAL COLLEGE OF PHYSICIANS

ULTRASOUND GUIDED

REGIONAL ANAESTHESIA - INTRODUCTION OF ULTRASOUND INTO CLINICAL PRACTICE

Monday 12 November 2007Organiser: Ultrasound interest group

RAGBI / AAGBI

Sponsored by:

• Introduction - application and limitation of ultrasound

• Anatomy - ‘You only see what you know’– the importance of anatomy in clinical ultrasound

• The perfect block!! - Upper limb• Peripheral nerve stimulation – ‘dead and

buried’ or ‘alive and kicking’• Ultrasound – the evidence• Abdominal blocks – an alternative to

epidurals• How to introduce ultrasound into

clinical practice, training & assessment of competency

AWARENESS AND DEPTH OF ANAESTHESIA

Wednesday 14 November 2007 Organiser; Dr J Andrzejowski,

Sheffield

• A sceptic’s guide to depth of anaesthesia• KIS(S): The isolated forearm technique• Neurophysiology of depth monitoring

made simple• Bispectral index (BIS) monitoring• Learning in your sleep? The

psychological impact of awareness• Beyond the BIS - best of the rest?• Medicolegal aspects of intraoperative

awareness


LUNG ISOLATION AND ONE LUNG VENTILATION

PLEASE NOTE NEW VENUE: ROYAL INSTITUTE OF BRITISH ARCHITECTS

Tuesday 20 November 2007 Organiser: Dr D Duthie, Leeds

Delegates will have a day consisting of 1/2 lectures and 1/2 workshops.

Lectures:Physiology of one-lung ventilationLung isolation and one-lung ventilation in clinical practiceComplications of lung isolation

Workshops:1. Robertshaw double lumen tubes and clinical confirmation of lung

isolation 2. Bronchocath double lumen tubes and fibreoptic correct positioning 3. Arndt and Cohen blockers 4. Univent tubes 5. Rigid bronchoscopy

Seminars at Portland PlaceNEW SATELLITE INDUSTRY SEMINAR ORGANISED BY

FANNIN HEALTHCARE

ADVANCES IN SINGLE USE LARYNGOSCOPESIncludes hands on Practical Sessions

Wednesday 21st November 2007

• The Development of a Single Use, Single Piece, Fully Disposable Laryngoscope. Including Practical Demonstration.

• An Anaesthetists Experience with the Yeescope in an Adult and Paediatric Practice. The Development of the AirtraQ Optical Laryngoscope.

• Practical look at the AirtraQ Disposible Optical Laryngoscope For more information and availability, see website

www.aagbi.org or email: [email protected]

We regret that we cannot accept telephone bookings.

ANAESTHETISTS AND THE LAW Wednesday 28 November 2007Organiser: Dr S Yentis, London

Part I – How it works & what it means• The courts and their structure• The different types of law• Lawyers and legal referencesPart II – How you might encounter it:• Prosecution under various Acts• Assault, battery, negligence, manslaughter & murder• The GMC• Keeping out of trouble

PAEDIATRICS SEMINAR Thursday 29 November 2007

Organiser: Dr B Bingham, London

• What's new in resuscitation/airway management?• Clinical dilemmas on the day of surgery • Paediatric sedation • Managing the "difficult child"• Optimal analgesia for paediatric day case surgery • Minimizing PONV in children • Optimal peri-operative fluids in children

BLEEDING, CLOTTING AND HAEMORRHAGE - AN UPDATE

PLEASE NOTE NEW VENUE: THE ROYAL SOCIETY OF MEDICINE

Tuesday 4 December 2007 Organiser: Dr R Rao Baikady, London

Supported by an unrestricted educational grant from Novo Nordisk Please note fixed rate for all attendees: £120

Open to all Anaesthetists, Intensivists and Haematologists.

• 'Normal haemostasis: current models'• The complex nature of coagulopathy in massive bleeding in

trauma/surgery• “Monitoring coagulation during haemorrhage to optimize the

haemostatic intervention”• Can we avoid blood transfusion?• Massive bleeding in trauma/surgery: hematological management• Antiplatelet therapy – pre, intra and post operative implications• Interesting Case discussion: 1. Bleeding Trauma Patient 2. Leukemia patient with neutropenia and thrombocytopenia 3. Post cardiac surgery bleeding

RESUSCITATIONTuesday 11 December 2007 Organiser: Dr J Nolan, Bath

• Mouth-to-mouth ventilation is redundant• Defibrillation – state of the art• Airway management for CPR - above or beyond the larynx?• Controversies in advanced life support• Life support courses - do we need them?• Post resuscitation care

Joint meeting run by the AAGBI and NSUKI to be held at 21 Portland Place. Please note fee for AAGBI & NSUKI members £120 (retired

members £60)

AN INTRODUCTION TO SPINAL CORD STIMULATION

Wednesday 30 January 2008 Organiser: J M J Valentine, Norwich

• Physiological basis of SCS and its clinical relevance• Clinical indications for SCS & how to select the right patients • Patient information and consent • Percutaneous systems & trial stimulation • Surgical leads & basic surgical skills• Complications: how to avoid them & how to manage them• Data collection and maintaining best practice• SCS programming skills

Joint meeting run by the AAGBI and NSUKI to be held at 21 Portland Place. Please note fee for AAGBI & NSUKI members £120 (retired

members £60)

AN INTRODUCTION TO INTRATHECAL DRUG DELIVERY

Thursday 31 January 2008 Organiser: Dr F Luscombe, Plymouth

• An overview and indications for Intrathecal Drug Delivery• Management of Severe Spasm with ITDD• Management of Cancer Pain with ITDD• Management of Chronic non malignant pain with ITDD• Organisation and setting up a service• When to use ITDD and when to use SCS


Booking a Seminar

To book a place on a seminar, please complete this form and return to: Gemma Williams, Events Administrator, Association of Anaesthetists, 21 Portland Place, London, W1B 1PY Tel 020 7631 8804, Email [email protected] or fax to: 020 7631 4352. For availability, see website www.aagbi.org or telephone 020 7631 8862/8834. We regret that we cannot accept telephone bookings.

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Association Seminars: you choose them, we run them

By the time you read this I will have handed over the reins of the International Relations Committee (IRC) to Professor Chandra Kumar, as I am no longer an elected, but a co-opted member of Council. International work is an important aspect of the AAGBI’s activities, and one of the areas in which many of our members take a keen interest – as evinced by the outstanding support for the Overseas Anaesthesia Fund since it was launched two years ago. It has been an honour and privilege to be involved in this work for the last couple of years.

The Association is pleased to announce that the third “Anaesthesia Resource” CD-rom has been agreed and hopefully will be launched at the World Congress in Cape Town next July. This is a joint initiative with the World Federation of Societies of Anaesthesia (WFSA) – while AAGBI funds these CDs, Mike Dobson of WFSA does all the legwork, securing agreement from various organisations to use material included in the CDs, and organising costings and production. These are distributed free to anaesthetists in developing countries. Most hospitals in the developing world have access to a computer, but internet access appears to be more patchy, so the CDs are an ideal way of cramming a lot of material onto a lightweight medium, minimising shipping charges. The new CD will contain, among other things, a complete reproduction of “Anaesthesia” for 2005-06, “Update in Anaesthesia”, the journal produced specifically for anaesthetists in the developing world, and parts of the “Oxford Handbook of Anaesthesia”. Thanks are due to all the copyright holders who made this possible. Over 10,000 copies of CDs 1&2 have been distributed already, and we regularly receive feedback about how well these are appreciated.

One of the things I have been developing, particularly in the last year, is a bit of what might be termed IRC “housework” (no sexist comments please). IRC started as a small informal committee with a small budget for overseas projects, but over the years this has changed. I felt it was time to review some of the committee processes, especially with regard to funding applications. If you wish to obtain funding from the AAGBI’s research committee, whether you are in your first year in anaesthetics or the President

of AAGBI, you must fill in a detailed form and submit it to be considered in competition with all the other funding applications. IRC has traditionally been less formal than that, so much less detailed proposals have been considered. A new form, adapted from the research grant application form, has been produced for all applicants to complete. Along with this, there will be a slight change in emphasis – in the past, AAGBI tended to seek out projects to fund, using the extensive network of IRC contacts. I am sure many members did not realise that IRC funds existed for overseas projects, although the travel grants, which account for about one third of IRC funds disbursed every year, attract many applications. So in future, IRC funding will be advertised on the website, and in Anaesthesia News, just as research funding is at the moment. The downside is there is now a complicated form for applicants to fill in! However, as IRC funding is disbursed from AAGBI’s Education and Research budget, which is a registered charity, it is only right and proper that the paperwork relating to this funding is detailed and properly documented.

Another housekeeping issue I have been examining is the structure of the committee itself, as part of a larger process of committee structure reform being undertaken by AAGBI. The committee is in the process of being streamlined, which means we will be saying farewell to several members who are extremely long- serving. Thanks are due to all of these individuals and the experience they have brought to the IRC committee meetings. Apart from anything else, they will be missed for their ability to spell remote foreign cities most of us have never heard of – one of the light diversions of IRC meetings is the approval of the minutes to see which foreign outpost the chairman has managed to mis-spell this time!

I am sure the International Relations Committee will go from strength to strength under its new chairman. It has been hard work but rewarding, (as well as great fun) and I wish Chandra success as he takes the committee forward.

Hilary AitkenFormer Chairman

International Relations Committee

International Relations Committee

COMMITTEE FOCUS


Since the 2003 national contracts produced changes to the Clinical Excellence Award scheme (differences apply in Scotland and Wales) the Association has taken a great interest in its implementation and treatment of anaesthetists. Data are available showing that anaesthetists receive less than the average number of awards in all schemes. Meetings have taken place to try and improve the situation, but it is thought that 53% of anaesthetists did not submit any CEA form last year.

83% of trusts in England have the closing date for the employer based schemes between November and April, so the majority of English anaesthetists should now be preparing their CEA form for the next round of the employer-based scheme. The trust closing dates may be co-ordinated nationally in future to link in better with a national CEA scheme.

While this information is specifically for the English scheme, it is hoped the recommendations can be useful to anaesthetists participating in other schemes. Articles outlining the situation in Scotland, Wales and Northern Ireland will feature in future editions of Anaesthesia News.

Recommendations

1. Every anaesthetist should see the PowerPoint presentation on Clinical Excellence Awards. This was produced jointly by the Association and the Royal College in June and distributed to all the AAGBI Linkman and College Tutors earlier this year.

2. All consultant anaesthetists should fill in and submit a CEA form every year. No one has ever got an award without submitting a form. Only consider missing a year if you were successful recently, but take the opportunity to update the form, which will remind when you come to apply in subsequent years.

3. New consultants after 12 months’ appointment become eligible (in England) and so they should complete a CEA form.

4. Before completing a form every anaesthetist should read and strictly follow the current instructions on the CEA website. Studying these instructions will also identify areas of extra activity that individuals can develop in future to include in their forms in subsequent years and increase their chances of success.

5. Reviewing and completing a CEA form should become a familiar annual event (like appraisal) for every consultant anaesthetist.

6. Every Department of anaesthesia should read the ACCEA national guidelines for the implementation of the Employer Based Awards scheme (levels 1 to 9) in their local trust and see that they are carried out in 2007. Departments of anaesthesia, ideally through their Local Negotiating Committee (LNC) should insist that their trust complies.

7. A senior consultant anaesthetist familiar with the process should be identified in each department to help others with queries about completing and submitting the CEA forms.

Under the new scheme, as a Specialist Society the AAGBI makes nominations for National Clinical Excellence Awards. The nominations committee, which includes lay representation and a non award holder, uses a recognised scoring systemand follows the appropriate guidelines on the ACCEA and Association websites. Anyone wishing AAGBI support in this way should read these guidelines and email their completed form to the Association at [email protected] by 15th November 2007.

David WhitakerPresident AAGBI

Clinical Excellence Awards – the deadline for English

awards is looming!


SecretaryProf Ezzat Aziz

Faculty of MedicineCairo University

Cairo Egyptezzataziz2002@

hotmail.com

Scientific ChairmanProf Chandra Kumar

James Cook University HospitalMiddlesbrough, UKchandra.kumar@

stees.nhs.uk

PresidentProf Chris Dodds

James Cook University HospitalMiddlesbrough, UK

2nd World Congress of Ophthalmic Anaesthesia

28th-29th February 2008Cairo, Egypt

Organised in association withBritish Ophthalmic Anaesthesia Society

Correspondence and informationOrganising office in-charge: ICOM

Tel/Fax: +2034204849 +2034249072 Cellular: +20101224849 +20122480206

Email: [email protected]

Visit our website for registration form, full details of CPD approved scientific programme, social and

other programmes

www.wcoa2008.com


Well it seems a good idea to ask you! Within AAGBI we have a large membership and the Association aims to provide a comprehensive postgraduate programme with something for everyone. We currently offer several different formats which vary in size, duration and degree of specialisation.

Our major meetings (Annual Congress, WSM London and GAT) are multi-day events with parallel sessions, international speakers, sessions by Specialist Societies, workshops, eponymous lectures and a solid social programme.

The long-running seminar series offers an opportunity to concentrate on a single topic in a smaller group with plenty of time for discussion and excellent opportunities for networking and the development of individual special interests.

CME days are run every year in conjunction with the Royal College of Anaesthetists and provide a popular multi-track London based event.

Finally, we provide a variety of special one-day meetings for Linkmen, Clinical Directors and on individual special subjects, sometimes in conjunction with other bodies.

As anaesthetists our working environment is changing with increased production pressure in the NHS making it harder for clinicians to get away from the workplace, whilst restrictions to study leave funding make it essential that meetings demonstrate value for money whilst keeping travel costs to a minimum.

With annual appraisal a reality and revalidation (recertification?) on the horizon we all need to maintain and develop our knowledge in core areas relevant to our clinical practice.

Core Topics The idea of a set of “core topics” with which every anaesthetist should be familiar has been developing over a number of years. An initial list was produced by Mike Harmer, and this is currently under revision. Hopefully, with proper consultation we can agree a set of core topics which can then provide a framework against which individual clinicians can demonstrate that their CME addresses a proper breadth of general topics in addition to their subspecialty interests. To support this process AAGBI is rolling out a new educational series - “Core Topics”. We will provide a series of one–day meetings delivered regionally by a mixture of regional and national speakers. Subjects will cover core areas of general relevance and be at postgraduate level.

The format of the day will be a series of 30-minute presentations with plenty of time for questions. Typically the last session of the day will include an “Open House” session hosted by an

ruOK4CME@AAGBI?



AAGBI council member allowing engagement between our members and the heart of the Association and providing a channel for dissemination of AAGBI plans and strategy whilst allowing members to feed back their concerns and aspirations for representation and action.

We will offer five regional core topic days in 2008 (see list). My aim is that these should be high quality meetings with a consistent standard, good speakers and presented in suitable venues with a decent lunch! Have a look at the programme for 2008 and put some dates in your diary!

7 February 2008 - Cardiff - City Hall – Council representative Les Gemmell, local representative Paul Clyburn28 April 2008 – Exeter - Sandy Park Conference Centre – Council and local representative: Iain Wilson19 June 2008 - Manchester University – Council and local representative: Ramana Alladi1 October 2008 - Edinburgh – Royal College of Physicians – Council and local representative: Neil Mackenzie

10 December 2008 – Birmingham - Austin Court – Council and local representative: Ranjit Verma

We are always on the look out for new lecturers and interesting subjects. If you would like to contribute to our programmes (in any of the formats mentioned at the top of this article) then do let us know.

So ruOK4CME@AAGBI? If you have comments, feedback, praise, brickbats or ideas please share them with us by emailing [email protected]

Robert Sneyd

TRAVEL GRANT The Travel Grant is aimed at those undertaking

visits in Great Britain and Ireland or overseas which include teaching, research, or study.

GRANTS UP TO £1,000

RULESThere is no deadline for the submission of entries and theoretically there is no limit to the number of travel grants that may be awarded. However, grants will not be considered for the purpose of taking up a post abroad, nor 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. Candidates should indicate the expected benefits to be gained from their visits, over and above the educational value to the applicants themselves.

For further information and an application formplease visit our website: www.aagbi.org

or email [email protected] telephone 020 7631 8807.

Application forms should be forwarded [email protected]

THE WYLIE MEDALUNDERGRADUATE PRIZE 2008

The Wylie Medal will be awarded to the most meritorious essay concerning anaesthesia or associated clinical practice written by an undergraduate medical student at a university

in Great Britain or Ireland.

Prizes of £300, £150 and £50 will be awarded to the best three submissions.

The overall winner will receive the Wylie Medal in memory of the late Dr W Derek Wylie, President of the Association

1980-82.

For further information and an application form please visit our website: www.aagbi.org

or email [email protected] or telephone Chloë Smith on 020 7631 8807

Closing date 11th January 2008

British Association Of Indian Anaesthetists

6th Annual Meeting, Saturday 27th October 2007The Marriott

Forest of Arden Hotel & Country ClubWARWICKSHIRE

The scientific programme will include lectures and discussions from Dr. Judith Hulf, President of the RCOA, Drs. Julian Bion, Gordon Lyons, Bhaskar

Tandon, Devendra Patel, Ian Smith, Nick Sutcliffe, Roop Kishen, Professors Rajinder Mirakhur, Chandra Kumar, Ravi Mahajan, and other eminent speakers.

The meeting is open to all anaesthetists.Anaesthetists in training presenting papers are

eligible for prizes. The deadline for abstract submission is 15th October 2007.

CME 5 Points

Chief Guest: Prof. M. Ravishankar, JIPMER Pondicherry

For further details, contact the Organising SecretaryDr G. Raghuraman

Consultant AnaesthetistBirmingham Heartlands Hospital

Tel: 07780 611969E-mail: [email protected]

Website: www.baoia.org

South West Regional Anaesthesia Course

5th & 6th November 2007 Royal Devon & Exeter Hospital, Exeter

• Upperandlowerlimbperipheralblocks • Ultrasound • Novelblockse.g.T.A.P • Videolinkedlivedemonstrations • Lecturesandworkshops • Aimedatanaesthetistsintraining

Cost:£160(£200after5thOct)Registerearly–strictlylimitedto

40participants

Fordetails&applicationformsvisit:www.sowra.org.uk

[email protected]

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The History Page

‘Just a little Whiff of Gas’;

a partial history of UK dental chair anaesthesia.

General anaesthesia (GA) in general dental practice (GDP) stopped in December 2001, 10 years after the Poswillo Report (1) and unlamented by the majority of doctors and dentists. So-called ‘chair dentals’ generated many reports from groups and working parties and much controversy. Two months after publication of Poswillo in October 1991, the British Dental Journal (BDJ) had ‘A Personal View’: General Anaesthesia, Sedation and Resuscitation in Dentistry (2) by David Watson James OBE, a general dental practitioner, former member of the GDC and various other important dental bodies. The header: ‘In the eyes of the public there is a traditional link between general anaesthesia and dental practice. After 150 years’ experience, the link may be broken by the Government’s acceptance of the Poswillo Report and its major recommendations’ typified the attitude of many in the dental profession to general anaesthesia.

Dentists frequently used to remind anaesthetists that a dentist, James Robinson, gave the first GA in England, but forget he stopped after a few months, handed over to John Snow and returned to trying to improve the standards and practice of dentistry. Watson James’s statement was plain wrong; the public had no idea of a ‘traditional link between general anaesthesia and dental practice’. If one asks patients preoperatively whether they’ve ever had an anaesthetic; they may answer ‘No’ but if they’d had any teeth out? ‘Ooh, yes, I had gas at the dentist’s’. In the eyes of the public ‘a little whiff of gas’ was linked with dental practice. So the ‘150 years of experience’ had little effect on a technique virtually unchanged since the days of Wells and Colton in 1844.

T. W. Evans, an American dentist in Paris, introduced chair dental GAs into Britain. In 1868 he came to the Langham Hotel, a stone’s throw from the present AAGBI HQ, and demonstrated Colton’s method. It spread rapidly as doctors, dentists and lay

people took up the method. Nitrous oxide became popular for extractions because ether was difficult and chloroform was dangerous. Both Joseph Clover and the dentist Alfred Coleman used nasal masks and designed mouth gags - essential for rapid dental extraction. In London by the mid 1870s, nitrous oxide was liquefied in cylinders, which were widely available. It wasn’t until 1892 that Hewitt published the results of the first clinical investigation and urged mixing with oxygen, advocated by Andrews of Chicago in 1868. Hewitt designed a portable machine in 1887 (by then Colton claimed he had given 150,000 nitrous oxide GAs with no fatalities). Many dentists and doctors persisted with 100% nitrous oxide into the late 20th century despite McKesson’s intermittent flow machine in 1910 (and the Walton in 1925) and modern volatile agents. Rivalry between dentists and doctors about who were the best anaesthetists was always present. In 1899, Marston, a dentist, said because they did more, dentists were better, but he objected to operator/anaesthetists. It wasn’t until 1983, however, that the single operator/anaesthetist was outlawed by the GDC after a second patient died while the dentist was on bail for manslaughter from a previous death.

Why did the practice of ‘chair’ GAs survive so long in Britain when it died out or was never practised in other countries? Dentistry has always been a separate profession but not until Parliament introduced regulation and registration in 1921, was it properly supervised. Before this many dentists trained by apprenticeship, like medical training in the early 19th century. One major reason dentists didn’t ‘let go’ of GAs in GDP was money. In 1935 the National Insurance fee was ½ guinea per GA (52½p) but London County Council (well known for its good medical and dental services) paid 1 guinea (£1.05) - perhaps £50 in today’s money. No wonder the Mayfair Gas Company – Ivan Magill and other London anaesthetists - did a lot of dental GAs.



From the beginning of the NHS, dentists were paid fees for item of service for all their work. Given the appalling state of British teeth consequent on the highest sugar consumption per head in the world, poor preventive dentistry and fierce resistance to fluoridation, extraction of teeth was a major part of dentists’ work and so a large source of income. It was also quicker to extract teeth under general rather than local anaesthesia, especially in children, and many adults preferred to be ‘asleep’.

In 1958 Victor Goldman published ‘Deaths under anaesthesia in the dental surgery’ (3) in the British Dental Journal (BDJ), a review of general anaesthesia in dental practice at that time. It was the first modern attempt to count GAs and deaths in GDP in the UK. He quoted Dental Estimate Board (DEB) numbers of 6.68 million dental GAs in England & Wales for 1952-55. He added another million GAs for hospital, school clinic and private patients. During those four years, the Registrar-General had had reports of 56 deaths in ambulant dental patients, giving a 1: 137,500 mortality rate.

Drummond-Jackson of the Society for the Advancement of Anaesthesia in Dentistry (SAAD) wrote to the BDJ (4) quoting from the Registrar General’s Official Statistics of 1949-1957: 125 deaths associated with dental anaesthesia, most of which occurred in hospital and stating: ‘It was doubtful if one of the 125 [deaths]...was caused by a dentist’. Further correspondence exploded including some amusing letters from Mike Coplans. There seemed to be little insight at that time by dentists about medical problems facing anaesthetists, such as managing inpatients having dental clearances before cardiac surgery, or recognition that some patients died in hospital having collapsed in a dental surgery.

Two years later in Edinburgh, Goldman read a paper: Halothane in the dental surgery. The BDJ published it with ensuing discussion in October (5). It updated his 1952-55 figures. (Table 1)

TABLE 1. Dental cases under General Anaesthesia 1952-58

NHS cases 12,447,140

School Dental Service 4,549,769

Additional cases (estimated) 4,900,000

Approximate total for seven years 21,896,909 The number of NHS cases for 1952-58 (12,447,140) is almost the same as figures supplied to the author in the 1990s by the Dental Practice Board (DPB) (12,508,730); both cover only England and Wales.

The next survey of GDP GAs was by Dinsdale & Dixon in 1976 (6), which omitted GAs in UK dental schools. The author

collected these and also obtained the GA figures for England and Wales back to the start of the NHS from the DPB, plus the numbers of GAs in Scottish dental practice back to 1968, and compiled the graph (figure 1). The lower line of the graph shows DPB numbers for GA fees paid in England & Wales only. These were extrapolated using Goldman’s figures in 1960 and the dental school GAs to show on the upper line an estimate of the total GAs for Great Britain (ie not including Northern Ireland). An approximation of more than 1.75 million by a Ministry Sub-Committee 1965 is marked u and Dinsdale & Dixon’s 1976 survey l (neither include Scottish or dental school GAs).

Figure 1 – see text for explanation

The numbers of deaths are from the Registrar General, from papers by Coplans and Curson and for the last decade of the century from ‘A Conscious Decision’ (9). It was in the latter publication that the practice of GA in dental surgeries was put to rest even though the death rate over 50 years has been less than 1:235,000, which compares favourably with GA mortality in other surgical specialities.

Adrian PadfieldSheffield References 1. General Anaesthesia, Sedation and Resuscitation in Dentistry.

Report of an expert working party. Department of Health, October 1991. (The Poswillo Report)

2. Watson James D. General Anaesthesia, Sedation and Resuscitation in Dentistry. Br Dent J 1991 170 345-7.

3. Goldman V. Deaths under Anaesthesia in the Dental Surgery. Br Dent J 1958 105 160-163

4. Drummond-Jackson SL. Letter ‘Deaths under Anaesthesia’. Br Dent J 1958 105 230

5. Goldman V. Halothane in the dental surgery. Br Dent J 1960 109 259-63

6. Dinsdale RCW. & Dixon RA Anaesthetic services for dental patients Br Dent J 1978 144 271-279

7. Coplans MP & Curson I Deaths associated with dentistry Br Dent J 1982 153 357-362

8. Coplans MP & Curson I Deaths associated with dentistry and dental disease Anaesthesia 1993 48 435-438

9. A Conscious Decision. A review of the use of general anaesthesia and conscious sedation in primary dental care. Department of Health, July 2000


THE FINAL FRCA EXAMINATION

THE S.A.Q. PAPERProspective Examination Candidates Are Invited

To Join

A Writer’s ClubMembership of the Club will Expose You to the Intricacies of the Short

Answer Paper

As a Member of the Club, You will have a Number and not a Name.

You will be Expected To Address under Examination ConditionsOne Twelve Question Paper per Week

You will also be expected To Set Questions & To Mark Answers

Through such Intimate Involvement with The Short Answer Challenge, You will become that much more Fit for Victory & Able to Triumph

CLUB NUMBER ONE Opens on May 1st

Registrations will Close June 30th

The Opening PaperWill be Dispensed the First Friday following Registration

Submission will be Expected the following Friday

Fee for Membership until Successful £200*

For Registration Forms & Club Rules:[email protected]

*Cheques to be Dated 30 days after Date of Registration thus affording Members the opportunity to withdraw if disappointed.

“In The Discipline Lies the Reward”

Well, August 1st has come and gone and the NHS did not go

into complete meltdown as some had predicted. What a pity

– if it had we might have been spared yet another review to

reform the failing NHS. This time it will presumably be based

on the review of healthcare in the capital (“Healthcare for

London – a framework for action”) by that nice Mr Darcy from

Pride and Prejudice. Somebody told me it had been written by

Darth Vader, or maybe it is just that everyone who gets involved

with NHS management seems to end up on the “Dark Side”.

No doubt it will be piloted in some unsuspecting provincial

region before being applied to London. Apparently the plan is

to increase the number of specialist hospitals, keep fewer major

hospitals, develop more treatment centres for simple surgery,

and some local hospitals for all but the major stuff. Polyclinics

would be created by amalgamating GP surgeries where some

consultants will be based; and more care, such as childbirth,

rehabilitation and terminal care, would be delivered at home.

The driving force behind this is the information that more

Londoners are dissatisfied with the NHS than the rest of the

country – really? Perhaps Mr Darcy should get out into the

country a bit more! - And your life expectancy is decreased if

you watch EastEnders (at least I think that was what it said.)

So, new plan for the NHS, new Minister of Health – isn’t he a

darling? I wonder how long he’ll last! Interesting to note that

we have had the same chancellor for 10 years, and I recall that

his first action was to remove responsibility for inflation from

political control and give it to the Bank of England; perhaps

now that he is our Prime Minister, he might consider that if

political control was removed from the NHS, the average in-

post life expectancy of a Minister of Health would increase from

the current nine months.

Whilst the MTAS fiasco may not have resulted in total gridlock of

the NHS, this was only due to the responsible action taken in many

Trusts and departments in cancelling clinics, operating sessions

and in some cases consultant leave, to ensure that predictable

gaps were covered by consultants and trainees already in post.

Patients did not die but many were inconvenienced; not to

mention the effect on those trainees caught in the middle of it.

Many had virtually no notice of where their next post would be,

holidays had to be cancelled and career plans radically altered.

There has also been the establishment of a brand new type of

post - the “Hewitt” post. This is a post with no association with

training, no prospects, is used to keep someone in post who

could not be placed anywhere else, and keep rotas workable.

Easy to see where the name came from! It is hard to believe

that anyone in the DoH has the overall picture of what happens

in the acute specialties. We have increased the number of

medical students and trawled developing countries for doctors

(which they could ill afford to lose), in order to catch up with

reductions in junior doctors’ hours and the planned expansion

of consultant posts; and then suddenly someone has decided to

reduce the number of training posts and shorten the length of

training and that we do not need so many consultants after all.

Hello! We still have far fewer doctors per head of population

than most other developed countries. The notion that MMC

will be the holy grail of postgraduate training has resulted

TheSummerof 007

Naked Gasman


in disappointment and hardship for many junior doctors. I

know of a married foreign medical couple who have had to

accept training posts at opposite ends of the country, with the

consequence that their young child has been sent back overseas

to be brought up by grandparents until the family can be together

again. Hardly surprising that the publication of the damning

report of the MTAS review group, which described MTAS as “the

biggest crisis within the medical profession in a generation”,

was delayed by the Government until after Parliament had risen

for the summer recess.

Meanwhile, Independent Treatment Centres (ITCs), staffed

by European doctors, are creaming off ASA 1 and 2 patients

thereby removing training opportunities from our surgical and

anaesthetic trainees and leaving NHS hospitals to cope with the

more difficult cases which are obviously going to cost more to

treat so the hospital is constantly struggling financially. It is not

surprising that hospital managers are refusing to replace retiring

consultants with substantive appointments, as no-one seems to

know from one year to the next how many patients they will

have to treat and how much money they will have to do so.

I have heard that one ITC has employed nurse anaesthetists

(rather than anaesthetists) from Poland and Sweden – just as

well they are only doing the straightforward cases.

Anyway, whilst all this was going on, yours truly has been hors

de combat. Ignoring the edict that over a certain age nobody

should go up a ladder unless their livelihood depends on it, I

managed to take a tumble whilst indulging in a spot of do-it-

yourself, and catching my leg in the ladder as I fell, I sustained

a fractured ankle. For logistic reasons I ended up not at my own

hospital, but at a neighbouring one, where I was offered the

last available orthopaedic bed and a place on the trauma list

the following morning. Remembering that when my daughter

had fractured her ankle she had been moved between two

hospitals in my own Trust and spent all night on a trolley in

A&E, I graciously accepted the offer. I recently anaesthetised

two retired doctors who were consecutive patients on an

operating list. They queried everything that both the surgeon

and I discussed with them. I used to wonder if such patients

in a restaurant insisted on discussing how a meal was cooked

and suggesting alternative ingredients with the chef, (come to

think of it, one of my friends has severe gluten intolerance, and

he does just that!) In contrast, my attitude during my recent

experience of surgery was to feel totally relaxed and confident in

the abilities of both my anaesthetist and surgeon – after all, this

is our profession, we must have confidence in our colleagues

or something is seriously wrong! I was slightly miffed when my

anaesthetist explained that he thought a spinal would be a bad

idea as AT MY AGE there was a risk of postoperative retention.

I was still reeling from this slight when the surgeon arrived and

introduced himself with the axiom:

“It is the business of the wealthy man

to give employment to the artisan”

A trifle smug, I thought, in the circumstances? No, it was a

surgeon’s idea of friendly banter! If I’d had my wits about me I

would have pointed out that the original quote from the poem

by Hilaire Belloc applied to Lord Finchley being struck dead

whilst changing a light bulb, and was rather unpleasant as

it says “And serve him right!” I pondered this as I lay on the

last available orthopaedic bed waiting to be called to theatre.

“Wealthy man” – well yes, my non-medical friends all believe

that poor doctors are in the same group as the tooth fairy and

Father Christmas: figments of the imagination; and following

the new contracts for consultants and GPs, we are now the

“haves” and the “have yachts”. But who is “the artisan”? Is it the

workman who would have been up the ladder instead of me, or

is it the bone-mender?

HELP FOR DOCTORS WITH DIFFICULTIESThe AAGBI supports the Doctors for Doctors scheme run by the BMA which provides 24 hour access to help

(www.bma.org.uk/doctorsfordoctors).

To access this scheme call 0845 920 0169 and ask for contact details for a doctor-advisor*. A number of these advisors are anaesthetists, and if you wish, you can speak to a colleague in the specialty.

If for any reason this does not address your problem, call the AAGBI during office hours on 0207 631 1650 or email [email protected] and you will be put in contact with an appropriate advisor.

*The doctor advisor scheme is not a 24 hour service


DERBY ANAESTHETIC ACADEMYFOURTH DERBY UPPER LIMB

REGIONAL ANAESTHESIA MEETING

Thursday 29th November 2007Derbyshire Royal Infirmary

The program is dedicated to upper limb regional anaesthesia with an emphasis on practical, hands-on Ultrasound training and experience for those looking to increase confidence in performing regional blockade

Course Organisers: Dr Adrian Searle, Dr Zahid Sheikh

CME approved 5 points

Application forms and more information from:Course secretary Mrs. Shirley Goddard

[email protected]. 01332 347141 Ext 2174

Derbyshire Royal Infirmary, London Road, Derby, DE1 2QY


A 35 year old doctor’s registration was suspended for two years by the GMC for substance abuse and prescription fraud. She was on a holiday flight abroad when a passenger became ill with pleuritic chest pain. When the cabin crew asked if there were any doctors on board, no-one responded.

Dilemma: Should she help and what may be the consequences?

1. She was no longer a registered practitioner - should she treat the patient?

2. Would she be penalised by the GMC since she has broken the rules of suspension by doing clinical work?

3. If she treated the patient would there be any consequences if she made a wrong diagnosis?

4. If she did not treat the patient would she be liable if someone found out she was a qualified doctor and failed to give assistance?

5. Would she be covered by the MDU legal representation who acted for her during her court appearances?

Answers: 1. Would she be penalised by the GMC since she has broken the rules of suspension by providing clinical care?

Good Medical Practice 2006, the Good Clinical Care Section Page 11, Para. 11 states: ‘ In an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence, and the availability of other options for care. This applies to registered & practising doctors. The GMC did advise however that they would extremely unlikely to take any action as the doctor acted with good intentions suspended or not.

2. She was no longer a registered practitioner - should she treat the patient?

The GMC advised:a. it would depend on why the doctor was suspended b. that a risk assessment should be made as to how serious

the situation appeared to be before intervening. (one could argue that this would be difficult without it being obvious that you are a doctor!).

c. The doctor should tell the patient/people at the scene that they are suspended, before embarking on any treatment.

3. If she treated the patient would there be any consequences if she made a wrong diagnosis?

Continuing an occasional series of dilemmas submitted by the AAGBI Welfare committee. The doctor featured in this article has given permission for details of this episode to be published.

WELFARE DILEMMA

Damned if you do?...


WELFARE DILEMMA


In theory, yes, she could be sued for harm on a civil rather than malpractice basis. A suspended doctor is regarded in the same way as a member of the general public and therefore only covered by the civil Good Samaritan Act.Unless she did something extremely unconventional or wrong, legal action is highly unlikely given that there was no-one else on board capable of managing the situation.

4. Would she be covered by the MDU legal representation who acted for her during her court appearances for fraud etc?

No - suspension does not allow retention of a defence body membership.

Any legal consequences of this scenario would be classed as civil and not medical malpractice. Defence bodies do however defend doctors who were paying their subscription at the time of their drink driving offence, fraud etc prior to suspension.

On the other hand, registered doctors paying full defence premiums are covered under the Good Samaritan Act anywhere in the world, and would be defended by their defence body.

In some states in the USA, doctors with long term recovery from addiction are even offered reduced defence premiums as they are considered safer than colleagues who may be under the weather from the night before!

It is not uncommon for us to witness emergencies outside our usual place of work and some situations may be indeed be beyond our level of competence. Before readers are frightened off helping at 32,000 feet, this scenario demonstrates a situation where acting with good intentions and the clinical need for care outweighed the theoretical legal implications. A doctor could be criticised for not helping in these circumstances.

The author (not currently suspended!) recently attended an accident in the Australian bush, where a passenger was trapped in a car which had careered off the freeway. One arm was trapped and inaccessible; paramedics had arrived, but could not find a vein on the small visible part of the other arm. The author was able to insert a Venflon successfully. Fluids and analgesia were able to be given before the helicopter arrived and the patient was finally cut out of the car and airlifted to hospital. Even though not registered with the New South Wales (NSW) Medical Board, the UK MDU policy would cover

claims for this type of Good Samaritan act anywhere in the world and the situation also complies with the ‘Good Medical Practice’ GMC document …. In an emergency, wherever it arises , you must offer assistance. (see above).

In summary, if the suspended doctor acted with good intentions and within her own competence, then her actions would/should not be held against her, whether registration is current or suspended.

Ruth MayallWelfare Committee, AAGBI

Acknowledgements: Blake Dobson, GMC Manchester, Yvonne Bradbury, GMC, and Dr Michael Wilkes, ex-Chairman BMA Ethics Committee all assisted with advice during the writing of this article.


Final FRCA Viva Weekend CourseInstituted2004

Course#714.00 Friday 30th November – 16.00 Sunday 2nd December

Candidates(June2007)wereinvitedtoscorethus:-

1=WasteofTime&Money-5=Excellent-AverageScore-4.59

Comments June 2007 “Very well coordinated course.”

“Good preparation for unusual questions.” “Best organized course I’ve ever been to.”

“Great exposure to viva material, thank you.” “Learned how to behave under pressure.”

“Thanks to everyone including John* for making it an enjoyable course. ” “Amazing toilets, kept clean even on Saturday and Sunday.”

“Good selection of cases.” “Good overall, very tiring but well worth it. “Question booklets were of high quality. ”

“As always, well organized and totally enjoyable. ” “Tremendous amount of revision”

“Best course I have ever attended.”

*The Director has no idea as to who ‘John’ was or as to what he did to make the weekend so enjoyable for the candidate submitting this comment. (All feedback comments are submitted anonymously)

Important NoteThecoursewillonly beofvaluetothosecandidateswhosurvivetheSAQ/MCQhurdleandwhohavebeeninvitedtoLondonfortheOralExamination.ThuscandidateswillneedtoproducetheirRCACandidateRegistrationNumber

The Course Programme

Friday14.00 Reception Master Class Viva Practice 20.00 Close

Saturday07.30 Breakfast 08.00 Viva Practice 20.00 Close

Sunday07.30 Breakfast 08.00 Viva Practice 16.00 Close

Aintree Hospitals - £250Breakfast – Lunch – Refreshments – Sweets - Water

Further Details & Application Form – msoa.org.uk

Dr Ruxton has not been silent recently; indeed his ire has been such on several subjects that greater powers have protected you, gentle reader, from his rants. But he has a couple of other matters that have got him in a lather which only sharing with you will exorcise.

He is glad, even grateful, to the AAGBI for recent guidelines on managing the obese, and to Professor Chambers for his chairmanship of the guidelines committee. But if measuring the weight and height of patients “is a good start”, as the Prof is quoted to say, then we are lost. How many patients on your wards already have their weight and height entered on the anaesthesia record form when you do your preoperative assessment round? Rhetorical as ever, Dr R will tell you – none.

The pre-operative assessment nurse may have asked them to step onto the scales, but that is usually fully clothed and the scales are calibrated in stones and pounds. Once, in a previous life, Dr Ruxton knew his doses in scruples per stone, but none of the drugs with which he was familiar in that format are still in use, and perforce he has converted to the Napoleonic, or Metric System for everything he uses now.

Why is it when the theatre is equipped, Dr R is proud to say, with a laser display board and a microsonic coffee machine, that the wards are still weighing patients in a system of measurement that is a criminal offence when selling bananas? And to his knowledge, there are no height scales on the wards or the pre-operative assessment clinic. So we are using drugs that are given in micrograms per kilogram, or infused by an algorithm that demands kilograms and centimetres when those parameters are either measured by outdated equipment, in alien units, or we ask the patient. You might as well phone a friend or go fifty-fifty if you want an accurate anaesthetic. And as for weighing a two hundred kilogram patient, we have no scales that will go higher than twenty stone, and the patient can’t stand up anyway.

On another matter, for arrogant orthopaedic omniscience, the surgeons of that ilk are victorious again. On opening the limb of a patient who had recovered from the open reduction and internal fixation of a complex fracture, but who now complained of discomfort and requested that the metalwork be removed, they were nonplussed to find that none of their screwdrivers fitted. That the patient had originally been treated on the other side of the world, and that the screw heads were just white blobs on the x-rays taken here had not fazed them one bit.

“They looked like AO screws!” they complained, like naughty children who “didn’t mean to set the cat on fire!”

They shrugged their shoulders, and spoke of getting the patient back in for another go, but were rather shocked when Dr Ruxton told them that this patient was staying asleep until all possible alternatives had been exhausted. That interesting and complex bit of external fixation that was next could wait and he would LOVE to cancel the bunion that yet again was on the end of the list. What could we do?

The hospital works department has a collection of ordinary, Phillips, crosscut, Starr, Torx, Snake Eye, Pin Hexagon and Resistorx screwdrivers, and some Allen keys. Surely one of those will fit?

“But this hospital has no CSSD, Dr Ruxton. We get all our sterile trays from the infirmary.”

How long to sterilise them? “Three hours.”Could there be any kit at the infirmary that might fit? “Well, these screws look like those in the Extra Special

Hand Set.”You’re sure, you thought these looked like AO screws? “Yes, they might fit.”

OK, might is better than another anaesthetic and another operation. Ask the infirmary theatre to get that up here. Blue-light police car – the Bobbies love a mercy dash. “ I’m sorry Dr Ruxton, they already called for a taxi.”Let me talk to Sister at the infirmary. A taxi will take an hour – I’ve been here before.But did the infirmary theatre phone answer? It did not, for ten minutes. “Hello, Dr Ruxton? Yes, I’ve just given the taxi driver the

pack. He left two minutes ago.”

And it did take nearly an hour for the taxi to arrive, and the special screwdrivers did not fit. So his patient must return again for another anaesthetic and another operation. And Dr Ruxton will not anaesthetise another such patient. This is an absolute contraindication to general anaesthesia, unless the surgeon has contacted his colleague who put it in. Doesn’t matter if they were on the other side of the world, or the Trust next door.

“Not done here” means won’t be anaesthetised here, unless we know what we are doing.

Dr Ruxton on weight and waiting

gat in brighton - aagbi her well in her consultant post in stoke. gat asm brighton 2007 doing so...

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