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Anaesthesia
The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
News
ISSN 0959-2962
No. 297 April 2012

Guest
Editorial
Contents
03 Editorial
05 President’s Report
SEE MORE.
ACHIEVE MORE.
EDGE .
06
06 Afghanaesthesia: Warfare has always
stimulated advances in medical care
12 Pask Certificate of Honour:
Members of Defence Anaesthesia
who served in Afghanistan
15 The Queen’s Honorary Surgeon
12
15 Anaesthesia Digested
16 Too little, too late?
Learn how this innovative new system can bring you
and your patients invaluable benefits.
Contact SonoSite today on 01462 444800 or email us
at ukresponse@sonosite.com
WWW.SONOSITE.COM/PRODUCTS/EDGE
Dr Bythell is away at the moment, so I am stepping into the
breach. Deciding whether and when to intervene is an integral
part of our everyday practice. This month’s article on Anaesthesia
in Afghanistan demonstrates what can be done when good teams
take joint responsibility for patient management. Meticulous attention
to detail, in which every aspect of care is reviewed and perfected,
has improved survival and quality of life for people with the most
extreme injuries. Much of this success depends on the culture of
the organisation; amongst defence medical teams the culture is one
of constant practice, improving speed, sharpening skills and getting
the right equipment to deliver what is needed. Not all of us work in
organisations with such a ‘can do’ approach. Attention to detail in the
NHS is more often centred on the purchase of cheaper disposables.
Leadership, in this situation – getting from an idea to an outcome
involves encouraging people to understand the wider picture, to
take what they see as ‘risks’, with the potential to incur the wrath of
‘management’.
16
21
19 GAT: Anaesthesia Conference Benin,
West Africa
21 The Misuse of Anaesthetic
Agents through time
23 Letter from America:
A most fascinating book!
24 Out of Programme Experience:
Life as a fellow down under
26 Particles
29 Your Letters
At last month’s AAGBI Council meeting I had the privilege of listening
to Dr Stuart White explain how he had introduced recycling of plastic
and paper theatre waste into his organisation. Hospitals can earn
good money by recycling. Despite this, he still had to work hard to
explain to hospital managers that the material was not ‘an infection
risk’, and a doctor had to sign a form stating that bags did not
contain contaminated waste. He struck a chord with me; my list this
morning produced a large bag of plastic packaging. A recent survey
showed that 94% of UK anaesthetists wanted to recycle at work. So
why don’t we?
24
The Association of Anaesthetists of Great Britain and Ireland
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Rather than encouraging innovation, the NHS culture seems to put
barriers in the way. Change comes from the top, often in the form
of service reconfigurations, and major health service reorganisation
costs millions. I’m left wondering what would happen if, instead of
pressing on with the latest set of changes, the money was spent
on developing ideas from ordinary jobbing doctors. Anaesthetists
are innovative and thoughtful people with lots of good ideas. The
article by the trainee (pages 16-17) about her granny’s hip fracture
shows just one. Perhaps growth this spring could be led by working
clinicians developing the good ideas we all have in our daily practice.
Nancy Redfern
Anaesthesia News
Editor: Val Bythell
Assistant Editors: Kate O’Connor (GAT), Nancy Redfern and Felicity Plaat
Address for all correspondence, advertising or submissions:
Email: anaenews@aagbi.org
Website: www.aagbi.org/publications/anaesthesia-news
Design: Christopher Steer
AAGBI Website & Publications Officer,
Telephone: 020 7631 8803
Email: chris@aagbi.org
Printing: Portland Print
Copyright 2011 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.
Anaesthesia News April 2012 Issue 297 3
3

The AAGBI is
now connecting
with members
through online
social networks
Facebook and
Twitter.
According to the recent membership survey,
over 70% of you use a Smartphone and over
40% of you use Facebook - so this is another
opportunity for you to keep up-to-date with
news from the industry and the AAGBI
@AAGBI
AAGBI1
©Photographer Hamish Burke/UK MOD Crown Copyright 2012
THIS MONTH’S FRONT COVER IMAGE
Soldiers board a Royal Air Force Merlin helicopter during
Operation Omid Haft in Afghanistan. Hundreds of Afghan
soldiers, supported by British and coalition forces have
taken part in a major operation in Central Helmand to clear
out insurgents from one of their last remaining strongholds.
Operation Omid Haft was planned and executed by the
Afghan National Army (ANA) partnered by International
Security Assistance Force (ISAF) troops. For several
days, Afghan Warriors battled alongside Royal Marines
and soldiers in harsh and hostile terrain where the enemy
have intimidated and threatened the Afghan population for
many years. ©Crown Copyright
An exciting opportunity:
Editor of
Anaesthesia News
Anaesthesia News is the paper
newsletter of the AAGBI, and
is circulated to over 10,000
members, at home and overseas.
A recent membership survey (2011) suggests that
98% of members read the newsletter at least several
times a year. The Editor’s post is therefore a key role
within the Association of Anaesthetists.
Key highlights and benefits for the editor include:
• The opportunity for a national leadership role for
the specialty
• Join the AAGBI Board of Directors (co-opted
member)
• Join an excellent production team
• Interact with a large number of colleagues
• Free registration for all AAGBI educational events
• Computer allowance
For a job description, person specification
and details of the recruitment process please visit:
www.aagbi.org/publications/anaesthesia-news
If you would like to chat about the post
informally please contact the current editor at:
anaenews@aagbi.org
Closing date for applications: Monday 23 April 2012
President's
Report
At the Winter Scientific Meeting in London this year I was delighted to present Pask
Certificates of Honour to Defence Anaesthetists who have served in Afghanistan. Details of
the work performed by our uniformed colleagues, and details of the citation, can be found in
different sections of this edition of Anaesthesia News, which celebrates their achievements.
The Pask Certificate is a prestigious award named after an RAF
anaesthetist, Professor Edgar Pask, who literally put his own life at
risk during the Second World War to reduce the danger faced by
aircrew baling out of aircraft at high altitude or into the sea. His
high altitude parachute descent simulations involved breathing a
hypoxic mixture of gases whilst suspended in a parachute harness,
becoming unconscious for several minutes. The other better-known
experiments were on the design of life jackets to prevent unconscious
aircrew floating face down in the water. To simulate these conditions,
Pask was anaesthetised, intubated and whilst breathing ether through
a long circuit allowed to float or sink in a swimming pool. All without
monitoring – a risky anaesthetic! Almost certainly aspiration must
have occurred as well as cooling and other unpleasant side effects.
The experiments were filmed in order to demonstrate to aircrew
the work being done on their behalf. An excellent review about the
remarkable work of Professor Pask has been published recently. 1
The Council of the AAGBI decided to award a Pask Certificate to
each anaesthetist who has served in Afghanistan in recognition of
the bravery and dedication of all those involved, from the front line
battlefield rescue, the hospital at Bastion to the return journey to UK.
The work is clearly exhausting both physically and mentally. The
trauma that we face in UK is of a much lesser degree and seldom
inflicted deliberately with such catastrophic results. The medical
expertise received by our soldiers is of the highest quality with many
of the lessons from the battlefield being translated to civilian practice.
Many of the local casualties are children who are in the wrong place
at the wrong time, or have been targeted deliberately. Tough stuff.
Many of our young soldiers who return to UK, often only a few hours
after being injured on the battlefield, face long term rehabilitation
to cope with their injuries, both physical and mental. Many of these
injuries are truly life-changing and support from our nation will need
to go on for many years.
So, when you meet a colleague coming back from Afghanistan,
remember to welcome them home, shake their hands and let them
know we appreciate them – that is the spirit and the message behind
the award. Also let’s not forget the loneliness faced by families in our
departments left at home during lengthy detachments.
The NHS and the politics of Healthcare continue unabated. At the
time of writing the Health and Social Care Bill is receiving a lot of
opposition. Of particular risk to the NHS in my view, is convenient
outsourcing to the independent sector for short term gain followed by
fragmentation of services and future increased costs to resolve the
resulting difficulties.
The BMA is due to ballot their members on industrial action on
pensions. The AAGBI responded to the pension review (see website)
and made a number of points including the fact that anaesthetists are
more likely to work part-time or to take career breaks than doctors
in many other specialties, are less likely to get Clinical Excellence
Awards and if they do, they tend to receive them later in their career.
An additional important factor when you consider your response to
the BMA ballot is whether you believe you will feel safe working in
anaesthesia until the age of 67 years? Most of my colleagues seem
to prefer to retire at 60 – 62 years of age. This is a complex debate,
especially given the pension problems in the private sector and our
increasing longevity.
By the time you receive Anaesthesia News this month, the NPSA
deadline to change to new neuraxial connectors will have passed.
Many hospitals will use the risk register while waiting for independent
testing of the new products. The new connectors will reduce risks to
patients in anaesthesia but mostly by preventing epidural infusions
or regional injections / infusions being administered intravenously.
Check the Safety section of the AAGBI website for details and up to
date information.
Trainees – check the remarkable GAT conference offer this year – 3
days of education for only £195 – see you there!
Dr Iain Wilson,
AAGBI President
1. Enever G. Edgar Pask and his physiological research – an unsung hero of World
War two. J R Army Med Corps 2011;157:8-11 http://www.ramcjournal.com/2011/
mar11/enever.pdf
Anaesthesia News April 2012 Issue 297 5

Warfare has always
stimulated advances
in medical care.
The UK armed forces have been
involved in conflict in the Middle East
and Afghanistan for over a decade
and, during this time, medical care
has seen huge changes, some of
which are applicable to civilian
trauma practice. Despite this, many
anaesthetists will be unaware of
the work of their colleagues in the
Defence Medical Service (DMS).
Typical Capability
Figure 1: Echelons of Care
Role 1 2 3 4
Primary Care. First Aid,
triage, immediate life
saving measures.
No holding or transport
capacity
The purpose of this article is to record the scope and current practice
of DMS anaesthesia in some detail. This is both a personal view, with
the limitations inherent in such, and a more general compilation of
information from a variety of sources. Any opinions expressed are my
own, and do not necessarily reflect those of any official body. Serving
members of the DMS will note that some details have been omitted
or simplified in the following descriptions. I apologise for any residual
inaccuracies.
Treatment, limited holding
capacity (

Critically unstable patients may undergo. Local slang refers to this as
“right turn resus”. This Damage Control Resuscitation (DCR) named
from the historical configuration of the operating theatre in Bastion –
a right turn from the Emergency Department. In essence, this group
of patients undergo immediate resuscitative surgery in the operating
theatre, bypassing ED. Embarking on Damage Control Resuscitation
requires confident decision making, but can be triggered the MERT, the
Emergency Department or initial surgical examination. Admission to
surgical incision times may be measured in seconds to minutes, rather
than minutes to hours as so often in civilian practice.
Operating Theatre
Camp Bastion - echelon 3
Resuscitation is thus heavily dependent on good team working
between surgeons and anaesthetists- often, two anaesthetists are
required: one to manage the anaesthetic itself, and one to achieve
vascular access, usually with one or more wide bore (Swan Sheath)
subclavian catheters and to supervise transfusion and management of
Acute Coagulopathy of Trauma using one or two Level One or Belmont
infusor systems.
Initial surgery is typically intended to control haemorrhage, with
surgical access determined by injuries. Clamshell thoracotomy,
median sternotomy and midline laparotomy are common techniques
for major vessel control. Anaesthesia for all these, including for nonanatomical
lung resection (using stapling devices) is usually feasible
with a single lumen endotracheal tube. Once haemorrhage control is
satisfactory, many patients undergo CT scanning during a surgical
pause prior to returning immediately to theatre for ongoing surgery.
Again, the proximity of CT scan to the operating room makes this a
logistically easier intervention than in most civilian hospitals.
Historically, Damage Control Surgery was abbreviated surgery, often
interpreted as shorter than one hour to prevent the onset of the bloody
vicious triad of hypothermia, coagulopathy and acidosis. Conceptually,
this may be regarded as “operating on physiology, not anatomy”
Advances in anaesthesia and the management of massive transfusion
have led to a marked reduction in the requirement for Damage
Control Resuscitation. The ability to warm fluids adequately and treat
coagulopathy aggressively allows prolonged, almost definitive, surgery
for some injuries. Examples would include triple limb amputees with
significant vascular injuries to the remaining limb. Prolonged (up to six
hours) surgery to salvage the remaining limb is now possible at initial
presentation, even if following immediately on from Damage Control
Resuscitation. This reduces residual physical deficits and improves the
potential for rehabilitation.
Massive transfusion management
Many fit young soldiers will tolerate extreme hypovolaemia, even to the
point of pulseless electrical activity states, but may recover fully once
resuscitated. Volume replacement before starting cardiac compressions
may be required. Aggressive blood and product replacement is
typically started with a ratio of red cells to FFP of 1:1. Early use of
platelets, calcium and tranexamic acid is standard, and later blood
product replacement is guided both by clinical response (resolution
of acidaemia, base deficit, tachycardia etc) and thromboelastography
using the ROTEM machine. Single limb amputations typically require
7-10 units of blood, bilateral leg amputations 12-15, and triple limb
amputations often in excess of 20 units of blood.
Given the relative difficulties with apheresis & platelet storage, military
resuscitation resorts to the emergency donor panel at times. The
emergency donor panel is a pre-selected group of donors who are
used as a source of fresh whole blood during massive transfusion.
Generally, one would consider activating the Emergency Donor Panel
at around 25-30 units transfused if non-surgical haemorrhage was an
ongoing problem.
There is active research into fibrinogen concentrates, cryopreserved
red cells, activated platelet fragments, oxygen carrying substitutes etc.
All these are driven by the logistic challenges of surgical teams working
in battle zones. As an indicator, the monthly blood use in Bastion (four
operating tables) is up to five times greater than the 800 bed tertiary
hospital I work in (20 operating theatres).
Planned surgery
Typically, soft tissue wounds are debrided at the initial resuscitative
surgery, and packed loosely with gauze dressings. After several days,
re-look surgery with additional debridement or delayed primary closure
(DPC) if appropriate is carried out. Anaesthesia for delayed primary
closure is generally straightforward- large blood loss is not common,
and spontaneous breathing, laryngeal mask anaesthesia is suitable for
many cases. If not, a typical “Afghanaesthetic” would include ketamine,
vecuronium, and morphine. Midazolam is usually given with ketamine,
although emergence phenomena are well recognised.
The number of anaesthetic staff in Camp Bastion has varied over time,
especially with increasing numbers of other nations providing medical
staff (particularly American and Danish). Generally, a 1st call, 2nd call,
3rd call, day off type of rota operates, allowing a measured response to
variable casualty numbers. Many patients require multiple operations
(see patient flow below), so even those days with few acute admissions
are often long. It is not uncommon to have in excess of 500 hours of
operating time a month, split between perhaps five anaesthetists.
Intensive Care Management
There are several distinct groups of Intensive Care patients in Camp
Bastion: UK and other ISAF (International Security Assistance Force)
military patients, typically awaiting rapid evacuation; Afghan soldiers
and adult civilians, with a longer expected length of stay; and Afghan
children with traumatic injuries.
Most UK or allied military casualties undergo evacuation and retrieval
from Afghanistan within a few hours (often casualties arrive in the UK
less than 36 hours after being wounded). The period between ICU
admission and discharge is spent correcting residual coagulopathy,
inserting epidural and nerve catheters if appropriate, identifying
missed injuries, and ensuring ongoing general care. Rapid evacuation
is preferred both for patient care and for logistical reasons (to avoid
“bed blocking”) Most of these patients, despite massive injuries, do
not develop a SIRS response or multiple organ dysfunction during their
brief ICU Stay in Camp Bastion, although this evolves more commonly
by their return to the UK.
There are some differences between therapies which are used in Camp
Bastion and those familiar to UK intensivists. Some patients with blast
lung or significant contusions or other pulmonary injuries are difficult
to ventilate and oxygenate, and separate lung ventilation via a double
lumen tube is occasionally used, or (rarely) total pneumonectomy.
Continuous renal replacement therapy is technically available,
but very rarely used. Cardiac output measurement is currently not
used, although debate about the utility of this, and of intracranial
pressure monitoring, continues. Bronchoscopes are available,
but percutaneous tracheostomy equipment is not, so surgical
tracheostomy is the intervention of choice if required.
For Afghan nationals, the medical support available locally is limited,
so many remain in Camp Bastion pending sufficient improvement
in their clinical condition to allow discharge. Thus, many of the ICU
beds are occupied by Afghans- perhaps 60% of all casualties seen
in Camp Bastion are Afghan, and around 10% of the ICU caseload
is paediatric. Burns, complex head and facial injuries, and the gamut
of penetrating traumatic wounds account for much of the caseload.
Many of the Afghan patients are poorly nourished prior to
wounding, and the catabolic stresses of severe injury often lead
to a high mortality rate, or a prolonged recovery for the survivors.
This generates a steady flow of ethical dilemmas and practical
management issues requiring senior group discussions and mature
judgement.
The current staffing of the 10 bed (14 if surge capacity required)
ICU is provided by two consultants working a 24 hour, 1:2 rota,
and around 40 nursing staff. At busy times, other anaesthetists or
medical staff can help but generally, if the intensivist is busy, so is
everyone else. In my last summer tour, the ICU in Camp Bastion
accepted as many patients each month as my 17 bed NHS Intensive
Care Unit (which has 18 medical staff and over 100 nurses).
Camp Bastion memorial
Repatriation & Rehabilitation
Currently, RAF anaesthetists lead, and form the backbone of, the
Critical Care Aeromedical Support Team (CCAST). A detailed article
on CCAST was published recently in Anaesthesia News [1].
Patient Flow
The number of patients admitted to Camp Bastion varies widely
day by day. In the winter the intensity of fighting is typically less
than in the summer months. Frequently, incidents result in multiple
rather than single casualties, and often, simultaneous incidents
generate surges in activity. Clearly, this impacts on the Emergency
Department in the initial phase, but is generally ameliorated by
calling in off duty staff (who live only a few hundred meters away).
Since almost all Camp Bastion ED admissions require surgery, a
significant amount of operating time is required following mass
casualty incidents, both for the hours afterwards, and for any
planned surgical interventions several days later. Likewise, ICU and
the wards become busy for hours to days following an incident,
aand the aeromedical support team are in great demand to move
casualties to available beds. Usually, by the time the casualties from
one incident have been treated , another incident has occurred.
It is a tribute to the exceptional organisational abilities of those in
command that the hospital always seems to simply step up a gear
to cope with whatever response is required. Even so, a three month
tour to Camp Bastion allows clinicians to experience more major
incidents than most would see in a life time of civilian practice, and
longer tours become progressively more physically and mentally
demanding.
Injury Patterns
Historically in 20th Century warfare three soldiers were wounded for
every soldier killed. Advances in protective equipment and medical
treatment have altered this ratio to around 1:9. These advances
include more heavily armoured vehicles, along with improved
helmets and body armour (including blast resistant underwear).
Not only do these save lives, but they reduce the effects of injuries
sustained.
Different conflicts produce different wounds: for example, armoured
combat results in a high number of burns (and during Afghan winters
many children are burned in domestic incidents). Well equipped
soldiers suffer proportionately fewer torso injuries than Afghan
troops, who don’t have body armour. As with previous conflicts, the
majority of the injuries seen are to the limbs.
The signature injury for the Afghan conflict over the last few years
has become the triple amputation. Generally, a casualty sustains
bilateral lower limb amputations (mostly above knee) and severe
injuries to one arm (due to carrying a rifle when triggering the
device). Usually there are less severe additional injuries to the
remaining limb. Perineal, abdominal and facial/ophthalmic injuries
are common in this patient group, and around 25% of bilateral
amputees suffer pelvic fractures. Lumbar spinal injuries are relatively
common, although cervical or high thoracic spinal fractures with
cord injuries are rare amongst survivors.
Clinical Outcomes
One scoring system in military use is the Injury Severity Score (ISS).
This score (validated in civilian practice) ranges from 0-75, where
75 is considered non survivable, and 15 is considered the threshold
8 Anaesthesia News April 2012 Issue 297 Anaesthesia News April 2012 Issue 297 9

for major trauma (since the mortality rate for ISS16 and above is 10%).
The average ISS for UK military casualties in Afghanistan is 53. The
military are currently revising ISS in part to account for a large number
of unexpected survivors, both statistically and clinically, over the last
decade.
Extreme injuries which many in civilian practice would regard as nonsurvivable
are not only survived by this military population, but the long
term functional outcomes, even if significantly physically disabled, have
been sufficiently good to justify the large amount of resource devoted to
managing them. This fit, young, and highly motivated population may
not be reflective of the general population, but are repeatedly defining
the limits of survival. This constantly raises ethical questions about the
appropriateness of some truly epic treatments such as hemipelvectomy
for triple limb amputations. In many ways, this is similar to civilian
debate around the practical limits of neonatal resuscitation.
Conclusion
Whatever one may think of the reasons for, and conduct of the wars of
the last decade, it is undeniable that the Defence Medical Service has
risen to the challenge and performed at a very high level. Lessons have
been learned about the management of victims of major trauma which
should help save lives in future.
Dr Ian Nesbitt
Consultant in Anaesthesia & Critical Care,
Freeman Hospital, Newcastle upon Tyne
Hospital - echelon 3
References:
1. GAT - The Royal Air Force Critical Care Air Support Team. Roberts
DE, Davey CMT Anaesthesia News. June 2011: 8-11.
Further reading
Military medicine is a rapidly evolving field, especially in the area of
trauma resuscitation. The information in this article is freely available
from various sources.
The website for the Journal of the Royal Army Medical Corps http://
www.ramcjournal.com/index.html allows open access to the journal,
which contains numerous articles of interest.
The Philosophical Transactions of the Royal Society (B) published in
January 2011; issue 366, also provides more details of much of the
above.
*ACoT- Acute Coagulopathy of Trauma
**ISAF International Stabilisation Afghanistan Force
***FAST- focussed Abdominal Sonography in Trauma
RCoA EVENTS 2012
RETURNING TO WORK
HOW TO SUCCEED
Date and venue:
21 June 2012 (code: D08)
Royal College of Anaesthetists, London
Registration fee:
£150 (£125 for registered trainees and affiliates)
Approved for 5 CPD credits
Event organiser:
Dr C Evans
The meeting will focus on how to manage a successful
return to work, with an exploration of responsibilities
and best practice from the employer and employee’s
prospective, and is aimed at trainees, SAS and Specialty
Doctors, Consultants, Programme Directors, Clinical
Directors and Human Resource Directorates at Deanery
and Trust level.
Please scan the code to go to the College
website for further information:
Apply: www.rcoa.ac.uk/events
Contact: 020 7092 1673 events@rcoa.ac.uk
24-25 May 2012
Ankara, Turkey
In association with the
British Ophthalmic Anaesthesia Society
• International speakers from 14 countries worldwide
• Session themes include: World Ophthalmic Anaesthesia,
Refresher lectures (both basic science and clinical practice),
Specialist Ophthalmic Anaesthesia, Risk Management,
Free Papers, Regional Anaesthesia Workshops, Challenges
and Hot Topics in Ophthalmic Anaesthesia
Congress Venue: Dedeman Ankara Hotel
For further information and registration, visit: www.wcoa2012.org
or email oyacok@wcoa2012.org or contact@wcoa2012.org
Submission of abstracts for both verbal and poster
presentations is now open. For instructions, please visit the
Congress website. Closing date for submission of abstracts:
15th March 2012.
An exciting programme of sight-seeing tours and activities for
accompanying persons is also available.
www.wcoa2012.org
AAGBI & MPS PATIENT SAFETY PRIZE
Dr Samantha Shinde, Education Committee Chair • Dr Isabeau Walker, Safety Committee Chair
Abstracts for presentation
at the AAGBI Annual Congress,
Bournemouth 2012
AAGBI
You are invited to submit an abstract for oral (free paper)
or poster presentation at the Annual Congress.
The deadline for submission is midnight on Monday 28th May 2012 and full instructions, including a template
abstract and submission form, can be found on our Annual Congress microsite: www.annualcongress.org and
on the AAGBI website www.aagbi.org/research/awards
After the deadline, a preliminary review of the abstracts received will determine which ones are accepted for
presentation at the Annual Congress in Bournemouth. Some authors will be invited to present their work orally,
under the following three categories: audits and surveys, case reports, and original research. The remaining
successful authors will be invited to present a poster.
All accepted abstracts will be published in Anaesthesia in the form of a fully referenceable online supplement.
In addition, the best ones, selected by a judging panel at the meeting, will be printed in the hard copy version of
the journal. (NB Editor-in-Chief reserves the right to refuse publication, e.g. where there are major concerns over
ethics and/or content).
Authors of the best free papers and poster(s)
will be awarded ‘Editors’ Prizes’.
If you have any queries, please contact the AAGBI Secretariat
on 020 7631 8812 or secretariat@aagbi.org
NEW
for 2012
The AAGBI and MPS would like to offer a new Patient Safety
Prize to showcase examples of improved safety in anaesthesia.
The prize is open to members of the AAGBI. The project could involve an individual, department, medical students
or allied health care professionals, provided the project lead is a member of the AAGBI.
You will need to demonstrate:
Clear aims and objectives
An innovative idea(s)
How the project was introduced and implemented
How performance was measured and benchmarked
How information about the project was disseminated
The sustainability of the project
Transferability of the project to other departments
Amount: Up to £1000 (at the discretion of the awarding Committee).
There may be more than one prize.
Awarded: At the AAGBI Annual Congress
Format of submissions: Poster presentation
In addition, the shortlisted entries will be expected to:
Make a brief oral presentation to the judges at Annual Congress
The winner will be expected to:
Make a five minute oral presentation at Annual Congress
Submit an article for Anaesthesia News
Please visit www.aagbi.org/research/awards for further details.
If you have any queries, please contact the AAGBI Secretariat
on 020 7631 8812 or secretariat@aagbi.org
The deadline
for submissions
is midnight on
Monday 28th
May 2012
We are very grateful to the AAGBI Foundation
and the Medical Protection Society for supporting this prize
SafetyPrize.indd 1 28/02/2012 08:50
Anaesthesia News April 2012 Issue 297 11

Regular and
Reserve Defence
Anaesthetists from
the Royal Navy,
the Royal Army
Medical Corps and
the Royal Air Force
have been serving
in Afghanistan since
the beginning of
the conflict there in
October 2001.
Operations in Afghanistan were commenced as a
direct result of the 11th of September 2001 attacks on
the United States. Initially a small number of Defence
Anaesthetists worked to support Special Forces during
the commencement of Operation Enduring Freedom
with forward on the spot resuscitation and critical care
evacuation. Since early 2002 they have been part of the
coalition of up to 42 Nations who have contributed to
the International Stabilisation Assistance Force (ISAF).
Consultants and later in the mission, trainees, have been
deployed to provide medical support to combat and
security operations.
© Photographer Sgt Laura Bibby, RAF UK MOD Crown Copyright 2012
Pask Certificate of Honour
Members of Defence Anaesthesia
who served in Afghanistan
and personal resolve demonstrated by those volunteers
who repeatedly return for these extremely taxing duties
on operational deployments. The stress of working daily
with critically injured young UK and Coalition Service
personnel and local civilians, including many children,
cannot be overstated. This outstanding commitment has
never faltered and has been carried out with unflagging
professionalism which should be an example to all.
is a potential lure to an ambush, but for the sake of the injured they
have not flinched from their duty. Likewise, particular consideration
is due for Royal Air Force Anaesthetists who have been deployed in
Tactical Critical Care Air Support teams. A number have undertaken
particularly hazardous missions where they have experienced constant
exposure to danger above that normally experienced when flying over
and landing in hostile territory. Tactical flying at night through mountain
passes in helicopters or fixed wing aircraft, while striving to save the
lives of critically injured service personnel, is not for the fainthearted.
Tactical and Strategic Critical Care Air Support teams have transferred
and evacuated hundreds of patients over thousands of miles. These
patients have been saved from death by the skill and resolve of their
Triservice anaesthesia and intensive care colleagues, working tirelessly
with the rest of the multidisciplinary team. Many patients have been so
critically ill, that even moving them by air or ambulance in the UK would
have been a severe challenge and perhaps not even attempted. During
these missions not a single patient has been lost and quoting Professor
Sir Keith Porter (University Hospitals Birmingham Foundation Trust)
these multiply injured patients have been delivered to critical care, in
his Trust, in better condition than patients transferred in from a few miles
away and who have had much less trauma. This speaks volumes about
the ability and dedication of Defence Anaesthetists.
This conflict has seen an unprecedented improvement in care of the war
wounded. This has been backed by continuing world class research
and development, which in many cases has been undertaken by
Defence Anaesthetists while deployed. This level of exceptional care
has led to the description of the UK led hospital in Camp Bastion, as
being the “best trauma hospital in the world”. Both the National Audit
Office and the Healthcare Commission have praised the DMS trauma
care most highly, but Defence Anaesthetists who have been part of
this trauma system deserve their own recognition for the exemplary job
they have done. This and other acknowledgments are a huge tribute
to the skill and dedication of the entire evacuation chain from point
of wounding to repatriation to the NHS. The integrity of this chain is
entirely dependent for the provision and maintenance of its links on
Defence Anaesthesia. Advances in analgesia provision throughout
the chain of care are also worthy of mention. Dedicated members of
Defence Anaesthesia have forged a comprehensive and effective
system for providing analgesia to the highest standard possible and
this work continues. Royal Air Force Defence Anaesthetist trainees
Pask Certificate of Honour Recipients 2012
have also been the backbone of advanced analgesia support to the
many thousands of war wounded who have been transferred by the
Royal Air Force Aeromedical Evacuation Service. In the UK Defence
Anaesthesia provides support to those war wounded in rehabilitation
with outreach clinics and multidisciplinary teams. Recognition must
also be extended to the families of Defence Anaesthetists, who are,
for the most part, unrecognised. Without their encouragement, support,
sacrifice and backing, many of those deploying would not have, so
readily, undertaken the missions that they have, nor would they have
felt as secure as they undertook the great challenges which faced them.
When the Association of Anaesthetists of Great Britain and Ireland
awarded the Pask Certificate for service in Iraq, the citation stated that
“It is a great tribute to Service Anaesthetists’ dedication, courage and
professionalism that they were able to produce a consistent, high quality
and enduring clinical effect in the most difficult of circumstances, in order
to treat their patients and support the overall medical effort during the
campaign”. This sentiment applies just as truly to service in Afghanistan.
It remains true that these individuals have served and continue to serve
their patients, Defence Anaesthesia, the Defence Medical Services and
their Country with loyalty, dedication and honour. It is, likewise, right that
they are recognised for that. Council of the Association of Anaesthetists
of Great Britain and Ireland takes great pride in awarding the Pask
Certificate of Honour to Defence Anaesthetists that have served in
Afghanistan.
Group Captain Neil McGuire
Pask Certificate of Honour
The Pask Award was instituted in 1977 after the Moorgate Underground
disaster of 1975 and the desire of Council to honour the gallantry of a
Registrar Anaesthestist. The award is made by Council of the AAGBI
to honour those who have rendered distinguished service, either
with gallantry in the performance of their clinical duties, in a single
meritorious act or consistently and faithfully over a long period. The
award was named after Professor E A Pask. Pask had a distinguished
career in the Royal Air Force Medical Branch as an experimental
physiologist in the Second World War. This included dangerous self
experimentation requiring considerable personal courage.
Lt Col Sue Ackerman
Surg Cdr Allister Dow
Maj David Hunt
Lt Col Paul Moor
Surg Lt Cdr Tim Scott
Many Defence Anaesthetists have seen more severe
Maj Richard Allan
Sqn Ldr Deborah Easby Surg Cdr Sam Hutchings Maj Paul Morrison
Lt Col Mark Sheridan
Surg Lt Cdr Ed Allcock
Surg Lt Cdr Amanda Edward Lt Col Mike Ingram
Lt Col Ian Nesbitt
Wg Cdr Peter Shirley
Defence Anaesthetists have been outstanding members
of the medical team, leading advances in care, which
trauma in a single day than many civilian anaesthetists will
see in an entire career, with as many as 3 major incidents
in a 24 hour period being experienced on occasions.
The level of trauma and the ensuing resuscitation
continuing long into surgery, subsequent intensive care
Wg Cdr Jon Ball
Maj Oliver Bartels
Surg Lt Cdr Dave Beard
Wg Cdr Robin Berry
Wg Cdr Kristina Birch
Surg Cdr Charlie Edwards
Sqn Ldr David Evans
Col Glynn Evans
Flt Lt George Evetts
Sqn Ldr Ian Ewington
Maj David Inwald
Col Soundararajan Jagdish
Lt Col Nick Jefferies
Capt Ami Jones
Lt Col David Kelly
Maj Tim Nicholson-Roberts
Lt Col Giles Nordmann
Lt Col Julian Olver
Maj Claire Park
Lt Col Duncan Parkhouse
Surg Cdr Ben Siggers
Sqn Ldr Charlotte Small
Gp Capt Denis Smyth
Maj Nick Tarmey
Surg Cdr Mike Tennant
Surg Cdr Dave Birt
Capt Jonathan Farmery Lt Col Iain Levack
Maj Kevin Patrick
Lt Col Rhys Thomas
have seen a great many unexpected survivors from and even into tactical and strategic evacuation has been
Gp Capt David Blake
Maj Adam Fendius
Lt Col Jason Lewis
Surg Cdr Mark Patten
Lt Col Rob Thornhill
trauma. This has heralded the lowest mortality amongst demanding in the extreme. It has often required two or
Sqn Ldr Jim Bradley
Col Jeremy Field
Maj Stephen Lewis
Wg Cdr Michael Peterson Sqn Ldr Bob Tipping
casualties in any conflict to date. Key to that has been more anaesthetists to manage up to six surgical teams
Surg Capt Steve Bree
Lt Col Mark Fox
Maj Catherine Livingstone Maj Craig Pope
Lt Col Jeff Tong
the involvement of the anaesthetist at every stage of the operating on a single patient. Transfusions of blood and
Surg Capt Andy Burgess Lt Col Scott Frazer
Lt Col David Lockey
Maj Victoria Pribul
Wg Cdr Simon Turner
evacuation chain from pre-hospital care, resuscitation, blood products of as much as 1 unit every 50 seconds
Col Richard Cantelo
Maj Claire Gaunt
Flt Lt Jemma Looker
Surg Cdr Kate Prior
Maj Caroline Walker
anaesthesia, intensive care, pain management and and 50 units of blood per hour have not been unusual.
Maj Mary Cardwell
Wg Cdr Phil Gillen
Lt Col Tim Lowes
Maj Henry Pugh
Maj Christopher Walker
aeromedical evacuation, through to command roles as When considering courage and commitment a special
Capt John Chambers
Lt Col Andy Griffiths
Surg Capt David Lunn
Lt Col James Ralph
Maj Brett Webster
Deployed Medical Directors.
mention must be made of those individuals, from all
Maj James Chinery
Lt Col Sanjay Gupta
Col Peter Mahoney
Maj Bryce Randalls
Surg Cdr Jon Wedgwood
three services, undertaking duties with the Medical
Lt Col David Clough
Flt Lt Elise Hindle
Maj Malcolm Mathew
Surg Cdr Jon Read
Sqn Ldr Joanna Wheble
Conditions at the commencement of the conflict during Emergency Response Teams (Enhanced) (MERT (E)).
Surg Cdr Dan Connor
Maj Andrew Haldane
Maj Ben Maxwell
Maj Mark Reaveley
Wg Cdr Curtis Whittle
entry operations were extremely harsh and fraught with These individuals have carried out remarkable feats
Sqn Ldr Iain Cummings Lt Col Jim Hammond
Surg Cdr Shane McCabe Maj Richard Reed
Maj Daniel Willdridge
personal danger and though the threat to personal safety
has declined over the 11 years of the conflict to this date,
it will be ever-present. Personal risk has been a constant
accompaniment over many tours of duty for some and
they deserve particular mention. Before specific groups
of resuscitation taking advanced airway techniques,
rapid sequence induction, therapeutic thoracotomy,
interosseous vascular access, blood and blood products
onto the battlefield, more often in pitching helicopters
and regularly under enemy fire. They have undertaken
Wg Cdr Phil Dalrymple
Lt Col Mark Davies
Sqn Ldr Matt Davies
Capt William Davies
Maj Rob Dawes
Capt Rachel Hawes
Lt Col Hamish Hay
Maj Clare Hayes-Bradley
Lt Col Jeremy Henning
Surg Capt David Hett
Wg Cdr Gavin McCallum
Lt Col William McFadzean
Gp Capt Neil McGuire
Lt Col James McNicholas
Surg Cdr Adrian Mellor
Flt Lt Daniel Roberts
Lt Col Matt Roberts
Surg Lt Cdr Julie Robin
Maj Jonny Round
Wg Cdr Martin Ruth
Surg Cdr Douglas Wilkinson
Sqn Ldr Stephen Wilson
Maj Kate Woods
Lt Col Tom Woolley
Maj Mark Wyldbore
Col Winston De Mello
Lt Col Ian Hicks
Lt Col Ian Mellor
Surg Cdr Mark Sair
Lt Col Adrian Hendrickse
are identified it is important to recognise the dedication mission after mission in the knowledge that everyone
Surg Cdr Barrie Dekker Maj Tim Hooper
Surg Cdr Simon Mercer Sqn Ldr Claire Sandberg
12 Anaesthesia News April 2012 Issue 297
Maj Phil Docherty
Wg Cdr Simon Hughes
Anaesthesia News April 2012 Issue 297
Maj Linzi Millar
Maj Guy Sanders
13

College of Anaesthetists
of Ireland
Irish Congress of Anaesthesia
ANNUAL MEETING 2012
THE CONVENTION CENTRE DUBLIN
25–26 MAY 2012
This two day meeting is the most prestigious and important
in the College’s academic calendar. It will feature:
• Keynote addresses from international experts
• Current issues / update sessions
• Workshops / debates
• Free papers and posters
• Excellent social programme
Further details on WWW.ANAESTHESIAIRELAND.COM
21 PORTLAND PLACE
Room Hire & Private Dining
For availability or to make a booking, please contact our Facilities Manager
on 020 7631 8809 or email john@aagbi.org
www.aagbi.org/about-us/venue-hire
KEYNOTE SPEAKERS INCLUDE:
Professor Steve Shafer, US
Professor Karen Domino, US
Professor Robert Dyer, South Africa
Professor Hugh Hemmings, UK
Professor Monty Mythen, UK
Professor Alex Sia, Singapore
Dr Steve Yentis, UK
CPD points = 12
CALL FOR ABSTRACTS
• Eligibility – Trainees, Consultants and Non-Consultants.
• “Free” means – case reports, series of cases or
clinical investigations
• The absolute time limit for receipt of applications
is Friday 27 April 2012 at 17:00 hrs.
• Abstract forms available from www.anaesthesia.ie
or email Orla Doran on odoran@coa.ie
SPECIAL DEAL:
1 day rate available
Congress Chair:
eosullivan@coa.ie
Scan with your smartphone to connect to
www.anaesthesiaireland.com
The Queen’s
Honorary Surgeon
Group Captain Neil McGuire
Defence Consultant Adviser Anaesthesia,
Pain & Critical Care
Congratulations are in order for Group
Captain Neil McGuire, who has represented
anaesthesia, critical care and pain doctors in
the defence medical services at the AAGBI
since 2007 on his appointment as Queen’s
Honorary Surgeon.
The appointment takes effect on the 1st April 2012 and was
approved by Her Majesty the Queen in late 2011. It is for a
period “at Her Majesties pleasure”, but it is normally continued
while serving in HM Forces. This is one of a small number of
Honorary Medical appointments made from the Armed Forces,
which includes Queen’s Honorary Dental Surgeons, Queen’s
Honorary Physicians and Queen’s Honorary Nursing Sisters.
The role includes duties at Royal occasions such as Investitures,
Garden Parties and State Banquets where the incumbent is a
part of the extensive medical cover which is accorded such
events. The QHS etc are always accompanied by a “registrar”,
who is either a consultant or senior trainee anaesthetist.
The holders of this appointment are distinguishable by the
fact that the uniform has Royal Cyphers (EIIR) accompanying
their shoulder rank insignias and the wearing of aiguillettes
with some uniforms (ornamental braided gold wire cord with
metal tips).
Buckingham Palace, London
Anaesthesia April 2012
Anaesthesia
Digested
Perioperative transoesophageal echocardiography: past, present & future
D.L. Greenhalgh, M.R. Patrick
An investigation into the causes of unexpected intraoperative
transoesophageal echocardiography findings
H. J. Skinner, A. Mahmoud, A. Uddin and T. Mathew
This month’s Anaesthesia contains an editorial and accompanying article
discussing trans-oesophageal echocardiography (TOE) practiced by anaesthetists.
Greenhalgh and Patrick’s excellent editorial considers how far TOE operated by
cardiac anaesthetists has developed in cardiac surgical practice and on cardiac
intensive care units.
In the space of a few years, cardiac anaesthetists have become an invaluable part
of the intra-operative care of cardiac surgical patients. The editorial discusses how
surgical or medical management is now frequently altered by the TOE findings at
operation. It goes on to consider how useful TOE has become in the management
of patients on cardiac intensive care units.
The following article by Skinner et al. is a further illustration of the significance
of TOE practiced by cardiac anaesthetists. They demonstrated a number of new
findings at time of surgery that were not recognised pre-operatively and which
changed the surgical plan in 4% of operations. This article also raises issues around
proper pre-operative informed consent for patients who may actually require an
extra or a different procedure depending on the intra-operative TOE findings.
It is a credit to our speciality to see how cardiac anaesthesia has embraced this new
technology and subsequently organised the training and competency requirements
required to perform these responsible roles for the undoubted benefit of patients.
Anaesthetists’ risk assessment of placebo nerve
block studies using the SHAM (Serious Harm and
Morbidity) scale
J. Jarman, N. Marks, C.J. Fahy, D. Costi and A. M. Cyna
The role that placebos play in clinical research involving local anaesthetic blocks
has created some controversy. This study follows a previous publication by this
group in which they described a SHAM (Serious Harm and Morbidity) scale to
assess the risk that patients are subjected to by the performance of a placebo block.
The authors reviewed a number of studies using their scale and concluded that
some studies were in contravention of the Declaration of Helsinki, which states
that ‘the patients who receive placebo or no treatment will not be subject to any
risk of serious or irreversible harm’. Some criticism and useful debate followed the
publication of this article in our correspondence section.
In this article, the authors examined the validity of their scale. They compared the
SHAM scale scores awarded by 43 anaesthetists who were given ten randomised,
controlled trials involving local anaesthetic blocks. They concluded that the
agreement was sufficient to suggest that the scale can successfully grade the
potential for complications caused by placebo blocks, and that this represented a
first step towards validation of their scoring system. I am sure this article will lead
to further debate in this area and raise the profile of this important topic.
N. Bedforth
Editor, Anaesthesia
Anaesthesia News April 2012 Issue 297 15

leaflets were more readily available in the pre-assessment clinics.
A re-audit, again of 88 patients, took place during March and April
of 2011. This demonstrated that 83% had received some written
information about their anaesthetic and 62.5% had been given the
anaesthesia information leaflet. These results fell short of the target
of 100%, but did show a significant improvement. Of the 82% of
patients seen in a pre-assessment clinic, 52 of 72 patients (72%)
felt that they had received adequate verbal information about their
imminent anaesthetic – less than previously. However, 85 out of the
total 88 patients (97%) were satisfied with the information that they
had been given. Again, all patients who had been seen in a preassessment
clinic or who had received written information about
their anaesthetic were satisfied.
in 2010. This demonstrated that through the use of an audiovisual
computer programme, patient satisfaction with the informed consent
process prior to neurosurgery improved substantially. 9 However, the
aim of improving information transfer to our patients is not solely
to improve their satisfaction. The aim is to improve information
transfer and thus create a group of well informed patients, who are
able to make autonomous decisions about their care. As well as
Gauchi’s study, others have demonstrated that the use of interactive
media improves patient knowledge and retention of information.
For example, Huang et al in Taiwan in 2009 demonstrated that the
use of an interactive multimedia device to intervene in diabetes
self-care was effective in raising the subjects’ knowledge about the
disease. 10 As well as being a point of access for more information
for all patients undergoing elective surgery, this type of medium
could also be beneficial for the minority of patients who do not wish
to receive information at that time, but whose wishes change prior
to their admission to hospital.
Too little, too late?
A study of the pre-operative information we impart to our patients
In early 2009, my grandmother underwent an elective total knee replacement at her local district general hospital.
At her pre-assessment visit she was given lots of written information about the procedure to take home and read.
A surgeon discussed the procedure with her and she was given the details of an interactive American website,
which allowed her to learn about the different stages of the procedure should she wish.... and she did.
However, she was not given any information about her anaesthetic
choices at these appointments and had concerns about what this
could entail. She therefore looked to me for this information. I
explained that practices vary between hospitals and anaesthetists,
but she found the information I was able to give reassuring. This led
me to think about the information that my patients were receiving prior
to their preoperative visit on the day of surgery. Were they too being
placed under unnecessary stress because of our communication, or
lack thereof?
The Royal College of Anaesthetists’ book Raising the Standard:
Information for patients 7 describes how best to enable information
transfer from medical professional to patient. We used this
information, along with standards suggested in the RCoA Raising the
Standard: A compendium of audit recipes – Patient information about
anaesthesia 8 to design and undertake an audit investigating what
information patients undergoing anaesthesia for elective procedures
at the Royal Devon and Exeter Hospital (RD&E) were receiving. This
initial audit, of 88 patients across a range of specialities, took place
during May and June 2009. As well as looking at the types of media
used to transfer information (information sheet, procedure booklet,
anaesthesia booklet, verbal advice), it also investigated whether the
patients were satisfied with the information that they had received. It
demonstrated that although all but one received fasting information,
only 11% of patients had been given the RD&E’s anaesthesia
information booklet. 65% had received a procedure specific
information leaflet – most of which contained some information about
the anaesthetic. 52 of 66 (79%) of patients seen in a pre-assessment
clinic felt that they had received adequate verbal information at this
time. At this time, 13 of the 88 patients (15%) surveyed were unhappy
with the quantity or quality of information that they had received. All
patients who had been seen in an anaesthetic pre-assessment clinic
or had received the anaesthetic information leaflet were satisfied.
The only dissatisfied patients were those who had not received either
of these interventions. In response to this audit, the importance of
verbal and written information transfer was explained at a succession
of pre-assessment practitioner courses. The funding for the
Graph comparing the pre-admission anaesthetic information provided to patients
undergoing elective surgery at the RD&E in 2009, compared to 2011.
The re-audit correlates with previous studies, demonstrating that
whatever format the information transfer takes, informed patients
are generally more satisfied patients. 3 It also showed that although
our department had improved its communication of information to
patients prior to their admission, it was still falling short of the RCoA
and DoH guidelines. Although the vast majority of patients were
happy with the service that we offer, some were still dissatisfied.
Most of these patients were those who felt they had access to too
little information, but a few also wanted to receive less information.
In the reference guide to consent, first published by the DoH in
2001, it is acknowledged that some patients may not wish to be
given information prior to a procedure. Both audits demonstrated
a small proportion of patients who thought that providing
anaesthetic information prior to their admission, or even prior to
their procedure was unnecessary. The guidelines recognise that
it is possible that these individuals’ wishes may change over time
and that respecting a person’s wish not to know, at the same time
as providing opportunities for access to further information is even
more important in this subset of patients. 5
Although interactive multimedia information transfer undoubtedly
confers many benefits, its disadvantages must also be recognised,
as demonstrated in a recent US based study by Zigmund-Fischer
et al. Through assessing the effect of the introduction of interactive
graphs to a computer-based information programme about the
risks of different thyroid cancer interventions, they demonstrated
that the interactivity, however visually appealing, distracted people
from understanding relevant statistical information. The intervention
group were also less likely to complete the survey. 11 In order to
encourage patient autonomy, one of the main purposes of providing
pre-operative information for our patients is to obtain informed
consent. This requires patients to understand and retain information
relating to risk. Developers of this medium would therefore need to
be aware that interactive risk presentations may create worse more
disquiet than presentations of static risk graphic formats.
In summary, we have a wide variety of patients, with a wide variety of
requirements, undergoing a wide variety of procedures, which can
be performed using an increasingly wide variety of anaesthetics.
Although it would be very difficult to encompass all of the information
required in one computer programme, providing only written and
verbal information for patients may not be enough. With the trend
towards reducing the number of face-to-face pre-assessment
meetings, conveying this information will become more problematic.
It is our duty as anaesthetists to provide the best possible service
to our patients and find ways to ensure those that want detailed
information are able to obtain this, and hence are satisfied with the
service we provide.
Dr Clare Attwood
CT2, Royal Devon and Exeter hospital
Clare is currently volunteering as an anaesthetist at Juba Teaching Hospital in
South Sudan. The AAGBI generously awarded her a travel grant to work there.
References:
1. `Patient’s Charter’, Patients Standard Care Committee Mar 1992-Sept 1993.
2. Wensing M, Jung HP, Mainz J, Olesen F, Grol R. A systematic review of the literature on
patient priorities for general practice care. Part 1: Description of the research domain.
Social Science and Medicine 1998;47:1573-88.
3. Coulter A, Fitzpatrick R. The patient’s perspective regarding appropriate healthcare. In:
The handbook of social studies in health and medicine. London: Sage, 2000:454-464
4. Coulter A. Patients’ views of the good doctor. British Medical Journal 2002;325:669-70
5. Department of Health. Reference guide to consent for examination and treatment, second
edition. DH, London 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_103643 (accessed 22/12/2011)
6. Coulter A. Choosing appropriate treatment: patient as decision-maker. In: The
Autonomous Patient. The Nuffield Trust, 2002:37
7. Royal College of Anaesthetists. Raising the Standard: Information for patients. RCoA,
London 2003 www.rcoa.ac.uk/docs/prelimscontents.pdf (accessed 22/12/2011)
8. Royal College of Anaesthetists: Raising the Standard: a compendium of audit recipes.
1.1 – Patient information about anaesthesia. RCoA, London 2006 www.rcoa.ac.uk/docs/
ARB-section1.pdf (accessed 22/12/2011)
9. Gautschi OP, Stienen MN, Hermann C, Cadosch D, Fournier JY, Hildebrandt G. Web-based
audiovisual patient information system - a study of preoperative patient information in a
neurosurgical department. Acta Neurochirurgia 2010;152(8):1337-41
10. Huang JP, Chen HH, Yeh ML. A comparison of diabetes learning with and without
interactive multimedia to improve knowledge, control, and self-care among people with
diabetes in Taiwan. Public Health Nursing 2009;26(4):317-28
11. Zikmund-Fisher BJ, Dickson M, Witteman HO. Cool but counterproductive: interactive,
web-based risk communications can backfire. Journal of Medical Internet Research
In 1992, the Patient’s Charter informed British patients that they have
the right “to be given a clear explanation of any treatment proposed,
Our hospital is working towards streamlining its pre-assessment
including any alternatives, before you decide whether you will agree
processes, which will ultimately result in fewer of the ASA I and II
to the treatment”. 1 A systematic review of the literature on patients’
patients attending a pre-admission clinic. Although these patients
priorities conducted in 1998 by the European Task Force on Patient
are the most medically fit for surgery, the audits demonstrated that
Evaluations of Practice (EUROPEP) found “patients’ involvement in
it is this patient group that are most likely to receive inadequate
decisions” and “time for care” were values patients sought in their
access to information about their anaesthetic prior to their admission
doctors that were second only to “humaneness” and “competence”. 2
to. This led us to consider: In this age of advanced technology,
Indeed, provision of information and the opportunity for patient
should we really be relying on just verbal and written information
participation feature prominently in most studies of satisfaction or
to inform our patients? My Grandma was very impressed with
dissatisfaction. 3,4 In 2001 the Department of Health (DoH) published
the service offered by the orthopaedic surgical team at her local
a reference guide to consent, stating that “in elective treatment, it
hospital. The interactive computer programme led her to feel
is not acceptable for the patient to receive no information about
empowered. Although not all octogenarians are as internet savvy
anaesthesia until their preoperative visit from the anaesthetist; at
as she, an increasing proportion of our patients are, especially the
such a late stage the patient will not be in a position genuinely to
younger ASA I and II patients. Some studies have demonstrated
make a decision about whether to proceed.” 5 These sentiments are
that patient satisfaction is improved if information is given in an
echoed in literature investigating the consent process related to
interactive format, including a study by Gautschi et al in Switzerland
16
patient autonomy. 6
leaflets was also changed to another budget and as a result the
Anaesthesia News April 2012 Issue 297 Anaesthesia News April 2012 Issue 297
2011;13(3):e60
17

Anaesthesia Conference
Benin, West Africa
My journey to Benin began shortly after I commenced working at the North Hampshire Hospital in Basingstoke.
Within the first week Dr Keith Thomson had, in his own words, ‘taken the liberty of booking my leave’ to enable
me to attend (as faculty) an Anaesthesia conference he was organising in Benin, West Africa.
The conference had been planned in partnership with Professor
Martin Chobli who runs the School of Anaesthesia in Benin, the
only school for medically trained anaesthetists in West Africa.
I have to confess I’m not sure I’d heard of Benin before; it is a
small country by African standards, covering 110 000km2, with
a population of 8.5 million and a national religion of Voodoo. I
had never been to Sub-Saharan Africa and the little I knew of the
travel within West Africa involved guarded enclaves and armoured
vehicles. But Keith said it would be fine, and so it was.
Aside from Dr Thomson there were three consultant and three
trainee faculty members. In addition, we had two interpreters: a
Canadian computer engineer and a French national anaesthetic
nurse working in Cotonou, who would prove invaluable to us
monolingual “plebs”.
We arrived late at night in Cotonou’s hot and humid airport and
were delighted upon our arrival at the Africa Mercy of Mercy
Ships Foundation to be provided with a lovely meal and pristine
accommodation. Our first wander off the ship was swelteringly
hot with the port entrenched in a shantytown smelling strongly
of the nearby fish market. An initial reaction to escape back to
the ship with its air conditioning, clean water and Western food
was thankfully short lived. I have travelled in many developing
countries over the years and this reaction surprised me; I can only
assume it was a symptom of my getting older.
We visited the stilt village of Ganvie situated within an expanse of
marshland, the likes of which I have only seen in heavy National
Geographic coffee table books. The village is serviced by a water
bus and floating markets, which we sailed past whilst enjoying the
breeze afforded by our “speed boat”.
On board the ship we took a tour of The Oak Hospital. Though
operating had ceased for the year, a few recovering maxillofacial
A river taxi
patients remained- having undergone repairs of cleft lip and palate
or removal of massive facial tumours. Not only debilitating, these
deformities may be considered a curse, resulting in ostracisation
from the community of the individual as well as their family.
Indeed, one very young patient’s strongest indication to operate
had been acceptance into the community. Despite his neurological
manifestations from which he would almost certainly die before his
1st birthday, his cleft lip and palate had been repaired with excellent
cosmetic result and he was recovering well. It was a touching sight
to witness the obvious joy of his mother now able to return and be
accepted in her community. We also met with Tony Giles and his
wife. Tony is a Maxillofacial surgeon who has worked on the ship
and in Africa for some time, performing amazing surgery on some
truly awful facial and oral tumours. They had many tales, both
devastating and inspiring from their time on the continent, and
an astonishing personal story of how this work had become their
lives. Prior to the conference we toured two local hospitals. HOMEL
(the women and children’s) Hospital was clean, well run, and
according to team members with first-hand experience, compared
favourably to hospitals in neighbouring African countries. Our visit
was co-ordinated by Dr Thomas Lokossou, the lead anaesthetist
and a formidable local driving force in the efficient running of the
hospital. Financial restraints unsurprisingly present the greatest
barrier for him. Though there was new equipment, many pieces
were not being utilized; charitable gifts for which the hospital did
not have the necessary disposables to facilitate their use. Sadly,
this is not an uncommon problem in Africa. At CNHU, the larger
University hospital in the city, each patient in the 18-bed intensive
care unit had a monitor but no ECG because of a lack of adhesive
electrodes. The medical and nursing staff were knowledgeable,
polite and informative, however, the lack of equipment resulted in
their being left rudderless with limited parameters to guide therapy.
On the evening before the conference began we visited the venue
to survey the facilities and found thankfully an air-conditioned
lecture hall. Our last minute changes proved over burdensome for
our interpreters; as the most junior members, Stuart and I e-mailed
our final drafts to students at the school of anaesthesia, crossed our
fingers and hoped nothing got lost in translation.
Heading out for the first day of the conference we loaded up the
Mercy Ship’s Land Rover with Resusci-Annie and her pals. On
arrival at the venue it was a daunting prospect to watch the lecture
theatre fill up with more than 200 people; 50 medical anaesthetists
and 150 nurse anaesthetists, mostly from Benin, though some from
further afield; Nigeria, Mali and The Republic of South Africa. The
conference opened with a lecture from Dr Thomson, detailing his
work in Africa and with Mercy ships over the years. I was surprised,
though Keith took the comment with good grace, that the first
question from the floor was a doctor questioning the longevity of
Western intervention in Africa. This is a commonly debated issue
and in some ways not a surprise at all, but made me consider it
anew in light of this man’s question.
The conference faculty
There is no doubt some truth in the idea that ‘you can’t solve a
problem like Africa’, and this may be worth preaching in the face,
for example, of the misguided donation of thousands of pounds
worth of anaesthetic machines for which no vapourisers are locally
available. However in the context of this forum, where there is an
obvious legacy of education I felt it unfair. After all we don’t often
‘change the world’ when we go to work at home in the UK; fixing one
individual’s hernia or even a coronary artery bypass truly only helps
one individual, much the same as any intervention in a developing
country. One difference with patients in the developing world is
they often have lived with their disfigurement or disability for much
longer. I suspect that this man had planned in advance to ask this
question and it was not a reflection of Keith’s opening presentation.
During my first presentation on Major Obstetric Haemorrhage, my
interpreter Vladimir surpassed all expectations with his excellent
grasp of English combined with sound anaesthetic knowledge, but
most invaluably his working knowledge of anaesthesia in Benin
and an appreciation of the resources available. We concluded he
must be the star pupil of the Benin School of Anaesthesia, and
I’m sure my presentations benefited from it! Our teaching format
was morning lectures with practical sessions in the afternoon. We
ran workshops on resuscitation (adults, children, and neonates),
airway management, and P.R.I.M.E, a teaching and discussion
forum on professionalism. Anaesthesia in Africa does not bear
a terribly high profile or status amongst the surgical community
(even less so than in the South of England), and it was obvious
that the subject matter was an unfamiliar topic for interactive
study. It was however well received with enthusiastic discussion
of topics such as the qualities of a good doctor or nurse and what
makes an effective team.
Due to a communication error we were not told until Thursday that
Friday was a national holiday, and there was no question that the
conference would continue despite this. We went on an inland
tour of Benin taking in a Portuguese Fort to hear the desperate
story of the slaves deported to Brazil in the late 1700’s and visited
the Gate of No Return, the port from which the ships departed.
The experience was interesting and very humbling. Later in the
day we enjoyed lunch on the beach and a dip in the Gulf of Guinea
to stave off the blistering heat. The final day of the conference was
attended by the minister for health, Professor Issifou Takpara who
had very recently made a significant positive change of policy
by introducing government funded Caesarean sections. At $100
(US) per procedure this was a cost previously met, or not, by the
patient and their family. The final fun took the form of an end of
conference quiz, an intense competition necessitating Stuart and
Paul being placed amongst the crowd to police the delegates. At
the end of the conference we distributed memory sticks complete
with presentations and ensured one person from each hospital
received a stick.
I think we learnt a great deal about the practice of medicine in
another part of the world with a very different system and many
different stresses to our own. We also learnt a host of new skills
regarding teaching and interacting in a learning environment with
people of a different culture and language.
There are many Medical
Schools and other
establishments in Africa for
the undergraduate teaching
of health care professionals.
There are Schools of
Anaesthesia, though less
of these. As a culture many
graduates work in rural areas
and as such postgraduate
teaching and continuing
professional development
for these individuals can
be hard to come by. The
feedback obtained told
us that our teaching had
been well received and on
appropriate subjects for
the delegates attending.
In summary we would wholly
recommend the experience of
teaching on a conference in
Sub-Saharan Africa.
Dr Emma Taylor
ST6, Wessex Deanery
Conference candidates
using a bougie to intubate
18 Anaesthesia News April 2012 Issue 297 Anaesthesia News April 2012 Issue 297 19

West of Scotland Subcommittee in Anaesthesia
ANAESTHETIC STUDY DAY:
IMPROVING PRACTICE
Thursday 17 May 2012
Venue: Kelvin Conference Centre,
West of Scotland Science Park, Glasgow
TOPICS WILL INCLUDE: -
Perioperative Diabetes – implementing the 2011 NHS Diabetes Guidelines
Indications for a pacemaker and other serious arrhythmias
The role of Anaesthesia in recovery after orthopaedic surgery
Enhanced recovery after abdominal surgery and abdominal wall blocks
Critical Incidents and Simulation
Airway management
Perioperative renal protection
REGISTRATION FEE: £75
THIS STUDY DAY CARRIES 5 CME POINTS
Application forms and further information from:
Miss Lillian Cumming
Administrative Assistant (Courses)
NHS Education for Scotland
3rd Floor, 2 Central Quay
89 Hydepark Street
Glasgow G3 8BW
Telephone: 0141 223 1504
Fax: 0141 223 1480
Email: Lillian.Cumming@nes.scot.nhs.uk
BSOA
and
Royal National Orthopaedic
Hospital Stanmore
Orthopaedic Anaesthesia Update
Thursday 10th May 2012, RNOH Stanmore
5 External CPD points applied for
Career grade; BSOA Members £50.
Non members £75. Trainees £25
BSOA Membership £15, visit www.BSOA.org.uk
An update on treatment for Sarcoma patients
DVT prophylaxis, new questions about treatment
Trauma – who cares?
New challenges of Spinal Procedures– pushing the boundaries
Legal implications of anaesthetic management for scoliosis surgery
An Update on TEG: are we using it to our best advantage?
Antifibrinolytics in modern orthopaedic anaesthetic practice
Management of spinal cord injury- what we need to know
Ultrasound guided blocks – challenges of modern practice
A paper that may change our practice
Further information please contact: RNOH Education Centre
Tel 020 8909 5326, email courses@rnoh.nhs.uk
or register via our website www.rnoh.nhs.uk/courses
Royal National Orthopaedic Hospital, Stanmore, HA7 4LP
The RNOH has good transportation connections & free car parking
AAGBI History SEMINAR
The Misuse of Anaesthetic
Agents through time
All anaesthetic agents have the potential for abuse as well as use. The abuse can be both criminal
and recreational and this seminar, timed to link-in with the current, temporary exhibition in the
Portland Place museum, explored all these aspects over the years.
The Pain Relief Foundation
A registered charity funding research and education in chronic pain
CLINICAL MANAGEMENT OF CHRONIC PAIN COURSE
5-9 NOVEMBER 2012
An advanced practical course in clinical pain management for pain specialists and trainees with
some experience of treating chronic pain. Limited to 30 participants at The Pain Relief
Foundation, Liverpool, UK
Demonstration Clinics • Practical Pain Imaging • Case presentations • Practical Pharmacology
PMPs—How to assess and treat patients • Managing common pain problems
The Pain Clinicians Role in Palliative Care • Implants for Chronic Pain • CRPS Clinic
Demonstration Theatres • Setting up and running a pain clinic & PMP • Course dinner
Contact:
FEE £850
Mrs Brenda Hall, Pain Relief Foundation, Clinical Sciences Centre, University Hospital Aintree,
Lower Lane, Liverpool L9 7AL UK. Tel +151 529 5822 or
b.hall@painrelieffoundation.org.uk
www.painrelieffoundation.org.uk
The first speaker was Alistair McKenzie
who took us back to the beginning…and
into the future. He traced the use and
abuse of drugs – from alcohol and opium
in antiquity to nitrous oxide and ether in the
19th century. Then he covered accidental
addiction in scientists and doctors, deaths
of patients under anaesthesia before the
introduction of measures to improve
safety, equipment hazards and human
error. Three aspects of the ‘dark side’ of
anaesthetic drugs were considered:
- legal (execution by lethal injection)
- illegal (suicide, murder and chemical
warfare )
- questionable (euthanasia).
In the future, anaesthesia for cloning may
present an ethical minefield.
Mark Harper then looked at the abuse
of chloroform over the years. In fact its
potential for use as an anaesthetic was
first recognised by a medical student,
Michael Cudmore Furnell, who tried it
recreationally, having been banned from
using and abusing ether. He explored
the origins and then dispelled the myth,
so popular in drama, that it could be
used to instantaneously render victims
unconscious. He then went on to describe
its role in murder, rape, auto-eroticism
and even Tintin taking in some interesting
tangents along the way.
Ann Ferguson described “Some Curare
Murders”. Of note, the Wheeldon case
was a misguided prosecution for alleged
attempted murder of the British prime
minister by curare in 1917. The Jascalevich
case involved multiple deaths of patients
at Oradell, New Jersey in 1965-66, curare
being found in exhumed bodies.
Roger Maltby investigated some
“Mysterious Deaths at Ann Arbor VA
Hospital”. These consisted of a number
of related but unexpected crash calls
to patients who had suddenly stopped
breathing. It was the courageous effort of
Dr Anne Hill in the summer of 1975 that
led to identification of pancuronium in
the urine of patients who unexpectedly
arrested in ICU. However, it was never
established who deliberately injected the
pancuronium!
The afternoon started with another talk
Anaesthesia News April 2012 Issue 297 21

AAGBI History SEMINAR
The Misuse of Anaesthetic
Agents through time
from Professor Maltby entitled ‘Things are not always what they
seem” which had the subtext of how to fake a fall from a horse.
This described a case from the US where a husband murdered
his wife when they were out riding by injecting her with Sucostrin
(succinylcholine). When she was dead, he inflicted a head injury
on her and initially managed to convince the authorities that this
was the cause of death. However, this injury was not consistent
with a fatal outcome and a drug scan revealed a chromatographic
peak overlapped by the peak of succinylcholine. Then a second
autopsy revealed an injection site.
Letter from America:
A most fascinating book!
I just read a most fascinating book, “Laughing and Crying about Anesthesia: A Memoir
of Risk and Safety”, by Gerald Zeitlin, MD (2011) (LACAA). In the spirit of full disclosure,
Dr. Zeitlin and I worked as colleagues at my hospital starting in the 1980’s, and we have
remained good friends ever since. This book describes his journey through the world of
anesthesia over a career spanning almost five decades, but it is much more than the
details of a medical career; it is a book of powerful, and sometimes difficult, emotions.
Professor Alan Dronsfield, a retired chemist (and president of the
historical section of the Royal Society of Chemistry) then gave us an
intriguing account of a propofol murder. Michelle Herndon was, by
all accounts, an extremely friendly and personable sports scientist.
Unfortunately she attracted the interest of a male ITU nurse who,
when she didn’t reciprocate his affections, administered a fatal dose
of propofol to her under the guise of helping her migraines. This
would never have been discovered were it not for the persistence
of the pathologist, Martha Burt. She noticed a tiny puncture
wound on the victim which led her to investigate more closely. The
murderer was eventually convicted on the basis of DNA from his
saliva on the needle sheath (from when he brought out the needle)
and the records from the electronic drug dispensing system
from the hospital where he worked. Next, Professor Aitkenhead
discussed the legal history of anaesthetic misuse. This led us from
the first inquest into death under anaesthesia (1847) through the
use of ether and chloroform for nefarious purposes in the 19th
century. Moving into the 20th and then 21st century he described
many Court cases of negligence, manslaughter, sexual assault and
murder involving various anaesthetic agents.
Ann Ferguson is both a retired anaesthetist and one of the judges
of the premier crime fiction prize, the Golden Dagger Awards.
She gave us a talk that encompassed the worlds of books and
medicine. She described the classes of murder seen in literature
(ranging from the usual, the unusual, the unbelievable and the
unacceptable) and the problems really good story-telling has
encountered since the advent of DNA testing in the last 20 years.
Dr. Zeitlin began his career in the UK, having attended medical
school at Oxford, training with Dr. Robert Macintosh and other British
anesthetic luminaries. He worked at the North Middlesex Hospital in
London, Whittington Hospital, Brompton Hospital, and other assorted
NHS venues. Very early in his career, after a brief (and most unpleasant)
exposure to ophthalmology, Dr. Zeitlin encountered much of what today
would be considered archaic anaesthetic practice, and unacceptable
behaviour. Iron lungs for respiratory care, spinal anesthesia without
IV access, and obstetrical hemorrhage without adequate blood bank
resources or uterotonic drugs were all common practices. Interpersonal
interactions that today would be considered unacceptable were
commonplace, and patient safety was a foreign concept. After several
years of various frustrations in the UK anaesthetic world, and urged by
colleagues and personal circumstances, Dr. Zeitlin travelled to the USA
in 1965 to work in anaesthesia in Boston, for what was ostensibly to be
a year-long stay, with every expectation of returning to the UK. However,
as we sit here today in 2012, Dr. Zeitlin has remained a Bostonian for
all these years! Did the NHS scare him away? Did the lure of American
practice keep him in USA? Or both? I think both.
quirks. But the
message is clear – UK
anesthetists are probably a bit quirkier than
those in the USA. Or is this just the biased perception
of a Brit-turned-American? Let the reader decide! And who has the
most unusual operating rooms? A comparison is made between the
windows, or lack thereof, the temperatures (usually freezing), the
induction areas, the wall colours, and more, between UK and USA
operating rooms. I will not divulge the details, but the most unusual,
peculiar operating theatre the author has ever encountered is the
neurosurgery room at the Whittington Hospital in London. Read the
book for details! Of course any American (with our traditional 7:30am
surgery start times) will be jealous of Dr. Zeitlin’s fond recollections of
a leisurely 9:00am start in the UK.
As the book draws to a close, we learn of the real emotional turmoil
resulting from this author’s career in anaesthesia – this I would call
the crying part of the book. Dr. Zeitlin is quite open about the various
medical problems that have plagued him for the last several decades,
including heart issues (a bypass, multiple stents, pacemakers, but
In Boston, Dr. Zeitlin practiced in every imaginable setting, including still going strong), and major depression (including the medical and
Mark Harper then brought us right up to
large teaching hospitals, small ambulatory surgical centers, mid-sized electrical treatment thereof) that eventually resulted in his leaving
date on the misuse of anaesthesia with an
private practice groups, and operating rooms as well as ICUs. He clinical practice. Was the depression caused by his anaesthetic career
account of the circumstances of Michael
continued his tradition of working with the best of the best in the world and the trauma he witnessed? Or was it an “incidental” finding? The
Jackson’s death and the subsequent trial of
of anaesthesia, including American luminaries such as Leroy Vandam reader is challenged to ponder some questions: Are anaesthetists
his personal physician, Conrad Murray. He
and J. Ellison Pierce, founder of the patient safety movement. LACAA particularly prone to psychiatric problems? Or are physicians with a
showed toxicology evidence that he must
describes all of these practice settings, but what permeates the book tendency toward psychiatric issues drawn to a career in anaesthesia?
have been given much more than the 25mg
and connects to the reader are the emotional aspects of this remarkable Perhaps a little of all is true, but this book will make the reader think –
of propofol that Murray claimed as well as the
career. Reading some of the cases described in the book, both during think about your practice, think about your choices in life, think about
extraordinary set-up he employed (see below
the UK portion as well as the American, one can literally feel the tension patient safety, even think about what you think about during a boring
for a way not to administer propofol). In the
and emotional angst - we’ve all been there! As in a case of bleeding case when there is nothing to think about. You will also be forced to
three months before Jackson’s death, Murray
oesophageal varices, and not knowing if the bleeding will ever stop. Or confront the signs that maybe your career should draw to a close. How
dealing with a case of massive postpartum hemorrhage, with minimal
Propofol
had ordered over 11litres of propofol! As a
do we know when it is time to retire? Are we all as observant as Dr.
resources, an inexperienced obstetrician, and watching a new mother
side-show there was the battle between the
Zeitlin to know when either medical or emotional issues are affecting
almost die in front of you. Or the feeling of utter dread as you watch a our ability to deliver proper patient care? I think many of us live in too
two expert witnesses Steven Shaffer (prosecution) and his former
patient turn blue and then black from oxygen deprivation during a difficult much of a state of denial to ponder such matters. Perhaps the author
mentor, Paul White (defence) which was as much a personal as a
intubation, today of course replaced by the horrible gut-wrenching of this book thinks too much. Perhaps we all think too much. Or maybe
legal and scientific battle in which the latter was always likely to
sound of the change of the pulse oximeter tone as the oxygen saturation we don’t think enough. Maybe we’d be better off if we all, as the kids
lose especially when confronted with the contradiction between
declines to levels incompatible with life. All of these situations are
his previously published writings and his defence of Murray. In all,
say today, chillax. In any case, this book is a fascinating exploration of
only made more difficult when dealing with totally uncooperative and
it was a fascinating and enlightening day, that was greatly enjoyed
a remarkable anaesthetic career, and provides an insightful view into
antagonistic surgeons. Much of the book compares UK and American
by everyone present.
the inner workings of our specialty. Read it!
anaesthetic practice, and in particular UK and American personalities
- this I would call the laughing part of the title. Where are the quirkiest William Camann, MD
Mark Harper, Consultant Anaesthetist, Brighton
people? Answer – it depends on your perspective, we both have our Brigham & Women’s Hospital, Boston, USA
Alistair McKenzie, Consultant Anaesthetist, Edinburgh
22 Anaesthesia News April 2012 Issue 297 Anaesthesia News April 2012 Issue 297 23

THE Out of Programme Experience:
Life as a fellow
down under
My interest in undertaking a fellowship abroad started early on in my anaesthetic training.
As a senior house officer in the West Midlands, I would listen with considerable interest
to senior registrars discussing their various plans to travel and work abroad. One such
registrar had organised a fellowship in the US. Although she turned her work and family
life upside down, I thought that doing this would be an interesting experience!
There were numerous reasons for choosing a fellowship in Melbourne,
Australia. Namely, I have a strong interest in anaesthesia for trauma,
head and neck surgery and major general surgery. The Alfred Hospital
is a tertiary referral centre, and all surgical specialties are performed
with the exception of paediatrics and obstetrics. The hospital is also
the state burns and trauma unit, as well as the state cardio-thoracic
transplantation centre. The above reasons, along with our interest to
travel to an unseen country, cemented our decision.
The General Anaesthetic Fellowship at the Alfred Hospital commenced
in February. I started work within a couple of days of flying out to
Melbourne. The first striking observation was how incredibly friendly
and down-to-earth everyone seemed to be. From the Professor of the
department to the anaesthetic secretaries, they were all warm and
inviting. I was instantly made to feel at home - which is so important
when you are thousands of miles away from your true home.
The Australian training system in not too dissimilar from ours in the UK.
Trainees were mostly from Monash University, and had undergone 5
years of medical school training, after which they did their compulsory
intern year. The subsequent one to three years could be spent in
rotations or out of training positions, after which time they apply to
commence a registrar training programme.
Compulsory anaesthetic training in Australia
is a total of 5 years; two years shorter than
the UK. Australian trainees are made
to sit both the primary and final exams
during their five year training period.
Although this is considerably shorter than the UK system, it offers
many advantages. Principally, having a shorter more intense training
programme focuses the trainees. With the advent of the EWTD and
a considerable reduction in working hours, the case numbers of UK
anaesthetists have decreased significantly. Australian trainees on the
other hand, are still working longer hours, with less mandatory ‘off’
days. The result being that anaesthetic case numbers would be roughly
on a par in the two groups.
One advantage with the structured modular training programme in the
UK is having a sense of completeness with a particular anaesthetic
sub-speciality. The requirement of maintaining a logbook is also useful,
both in the short and long term. The disadvantage of such a rigid
system means that a trainee can get particularly experienced with a
sub-speciality, and then may have no exposure to that field for another
three years.
The main difference in Australia is that whilst it lacks such structure,
trainees are expected to anaesthetise for a variety of different subspecialties
on a day to day basis. For instance vascular day one,
cardiac day two. This keeps trainees on their toes, and channels them
to giving a more academic anaesthetic whilst also allowing them to
tailor their anaesthetic. I feel that they may be at a disadvantage with
such a constant change as younger more inexperienced trainees may
not get a ‘good handle’ on each sub-speciality until later in their training.
They may also not be exposed to as wide variety of cases in each subspeciality
as the UK.
Supervision of all trainees ranging from the first year registrar to the
most senior trainees was commendable. All trainees and fellows were
doubled up with a consultant colleague for the vast majority of the
week. This was especially apparent in the first few weeks of the year.
As familiarity with the hospital environment grew, trainees were placed
on independent lists. At all times, a consultant-in-charge ‘CIC’ was
available, to discuss any challenging cases, administrative issues
or any other problems. One could argue that senior trainees were
‘over supervised’, however in most instances we were still given the
autonomy to manage our own anaesthetic.
If a trainee or fellow were placed on their own theatre lists, provision
was almost always made to have tea breaks and lunch. There were
only a handful of occasions where trainees and fellows were made to
stay late if they were not on-call.
Obviously having flexibility in the system does positively affect work-life
balance. If trainees or fellows know that they will be relieved of duties
when not on-call, they are more likely to have a better work ethic. As do
UK trainees, Australian trainees work very hard. There is a work-hard
play-hard atmosphere. Whilst it is expected they put in long hours –
and they do, 24 hour on-calls for fellows with the next day off- they
are also expected to relax and pursue extra-curricular activities during
their time off. I haven’t met such a large group of anaesthetists who
regularly participate in tri-athlons, marathons and cycling events since!
Trainees at the Alfred are also strongly encouraged to pre-operatively
assess their patients the day before. This reduces the incidence of any
surprises on the day of surgery, whilst also encouraging the trainee to
read any relevant current literature. Patients in the UK commonly arrive
the morning of an elective case thereby limiting trainees somewhat.
However, better provision could be made here in raising awareness of
theatre lists and cases in advance.
The case-mix at the Alfred Hospital was varied, ranging from highly
complex patients with multiple co-morbidities to the straightforward
patient needing an appendicectomy.
As a general fellow, I gained experience in most fields of anaesthesia
including trauma anaesthesia, anaesthesia for major general surgery
(including liver resection), vascular anaesthesia, neurosurgical
anaesthesia and anaesthesia for major ENT surgery. I also had the
opportunity of rotating to the Royal Victorian Eye and Ear Hospital for
8 weeks, where I became extremely proficient with various eye blocks.
During this time, there were also many opportunities to visit local cafes
and enjoy sitting in the numerous public gardens that Melbourne has
to offer!
In addition, I was exposed to obstetric anaesthesia at Sandringham
Hospital, a District General Hospital, where we functioned as a junior
consultant on-call. The Sandringham Hospital provides care to the
local community. However, one major contrast from the UK was our
ability to provide obstetric anaesthetic care from home! I was surprised
that despite there being multiple major teaching
hospitals in the near vicinity, some patients still opted
to deliver their babies in an environment with no
PICU or ICU facilities. The anaesthetic department
at the Alfred has a very dynamic research unit. I
had the opportunity to successfully complete a
16-week course in Peri-operative medicine there,
run in conjunction with Monash University. The
recognition that surgical patients are becoming
older with the ever increasing aged population,
more unwell and increasingly complex, has led
to more thorough pre-operative anaesthetic
management plans. Various clinical specialities
can be involved pre-operatively leading to better
patient care and outcomes. The advantage
of having pre-anaesthetic clinics means that
trouble shooting problematic patients can occur
early on and potential complications can be rectified prior to them
coming to theatres. Theoretically this could mean fewer cancellations
and more holistic care. For instance, chronic pain patients could be
identified as potentially difficult to manage peri-operatively, and could
be seen by pain anaesthetists pre-op as a result of being seen in the
pre-assessment clinic.
Anaesthetic teaching is another matter taken seriously at the Alfred
Hospital. A weekly Friday afternoon teaching session is held and
all are expected to attend. Anaesthetic Registrars and Fellows have
the opportunity of presenting clinically relevant and topical subjects.
Teaching is facilitated by a consultant anaesthetist and importance is
placed on evidence based medicine.
A mandatory tea break ensues, whereby a junior registrar is rostered
to bring in cakes for the rest of the department. This lightens the
atmosphere and facilitates camaraderie amongst trainees and
Consultants. A weekly ‘blue sheets’ follows on from the registrar
teaching. This is a less formal weekly morbidity/ mortality meeting
where relevant cases are presented by a consultant or trainee to
the rest of the department in a non-threatening manner. This weekly
‘blue-sheets’ allows for many junior trainees to listen and learn from
others without feeling judged or blamed. I think modelling this in the
UK would have many advantages and promote less of the ‘blame
culture’ which tends to occur.
Friday afternoon sessions end with a visit to the local ‘Belgian beer
garden’ where you can sit back, relax and wait for the weekend to start!
Despite only having five weeks of annual leave compared to 33 days
in the UK, there was more than enough time to travel and sightsee. We
spent many weekends visiting local attractions in Melbourne as well as
day trips around Victoria, including sampling the wineries in the Yarra
Valley. We travelled to Sydney, the Blue Mountains, Cairns, and Port
Douglas. We drove through the Great Ocean Road and visited the
Twelve Apostles. We had the chance to dive in the Great Barrier Reef
too– all with a small baby in tow! We had the opportunity of making
many new life-long friends who we will keep in touch with.
Overall, it was a tremendously enjoyable
experience – one which I would recommend
any trainee to apply for in the future.
Dr Anjalee Brahmbhatt,
ST7 Anaesthetics,
Norfolk and Norwich Hospital
Twelve Apostles, Great Ocean Road, Victoria, Australia
Great Barrier Reef
with a small baby in tow!
24 Anaesthesia News April 2012 Issue 297 Anaesthesia News April 2012 Issue 297 25

Particles
C Challand, R Struthers, J R Sneyd, PD Erasmus, N Mellor, K B Hosie, G Minto
Randomised controlled trial of intraoperative
goal-directed fluid therapy in aerobically fit and
unfit patients having major colorectal surgery
British Journal of Anaesthesia 108 (1) 53-62 (2012)
Perioperative fluid management for elective major colorectal surgery
continues to be controversial. 1 National Institute for Health and Clinical
Excellence (NICE) guidelines recommend individualised Goal-Directed
Therapy (GDT) through the optimisation of stroke volume(SV) to optimise
cardiac output and oxygen delivery, using e.g. the Oesophageal Doppler
Monitor. 2 The authors of this study set out to validate a simplified intraoperative
GDT algorithm which places emphasis on SV maximisation 3 , and
investigated whether this could reduce the surgical readiness to discharge
(RtD) time and complications, in patients with both poor and good aerobic
fitness as assessed by cardiopulmonary exercise testing (CPET).
Methods
179 patients were recruited for this double-blind randomised controlled
trial. All patients had open or laparoscopic major colorectal surgery.
Pre-operatively they were characterised as aerobically ‘fit’ based on the
results of CPET (Anaerobic Threshold AT >11.0 ml O2/kg/min) (n=123),
or ‘unfit’ (AT 8.0-10.9 ml O2/kg/min)(n=52). Patients with AT

Dear Editor
your
Warning! Concerns of a first year core trainee
GAT PRIZES AT GLASGOW 2012
GAT Oral
& Poster Prizes
Trainee anaesthetists are invited to submit an abstract Nicola for Heard oral
or poster presentation at the GAT ASM. The authors Educational of the six Events Manager
highest-scoring abstracts in the preliminary review will be invited
to present their work orally and will be eligible Direct for the Line: Draeger +44 (0) 20 7631 8805
Oral Presentation Prize. A cash prize and AAGBI medal will be
awarded to the winner. The remaining successful authors will
21 Portland Place, London W1B 1PY
be invited to present a poster. Entries will be allocated into one
of the following three categories depending on T: +44 the (0) grade 20 7631 of 1650
the presenting author: Foundation Year Doctors; F: +44 ACCS/CT1/ (0) 20 7631 4352
CT2 Doctors; ST3+ Doctors. A cash prize and E: a certificate nicolaheard@aagbi.org will
be awarded to the winner in each category. All audits, whether
shortlisted for oral or poster presentation, will w: also www.aagbi.org
be eligible
for the Draeger Audit Prize. Audits should demonstrate good
understanding of the principle of clinical governance and
evidence of completion of the audit cycle.
THE ANAESTHESIA HISTORY PRIZE
The Association of Anaesthetists and the History of Anaesthesia
Society will award a cash prize for an original essay on a topic
related to the history of anaesthesia, intensive care or pain
management written by a trainee member of the Association.
The £1,000 cash prize and an engraved
medal will be awarded for the best entry.
CLOSING DATE FOR ALL PRIZES: MONDAY 23 APRIL 2012
Full details can be found on the AAGBI website
http://www.aagbi.org/research/awards/trainee-awards
If you have any additional queries, please contact the AAGBI
Secretariat on 020 7631 8807/8812 or secretariat@aagbi.org
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TRAVEL GRANTS/IRC FUNDING
The International Relations Committee
(IRC) offers travel grants to members who
are seeking funding to work, or to deliver
educational training courses or conferences,
in low and middle-income countries.
Please note that grants will not normally be considered for
attendance at congresses or meetings of learned societies.
Exceptionally, they may be granted for extension of travel in
association with such a post or meeting. Applicants should
indicate their level of experience and expected benefits to be
gained from their visits, over and above the educational value
to the applicants themselves.
For further information and an application form
please visit our website:
http://www.aagbi.org/international/irc-fundingtravel-grants
or email secretariat@aagbi.org
or telephone 020 7631 8807
Closing date: Wednesday 13 June 2012
Letters
Dear Editor
SEND YOUR LETTERS TO:
The Editor, Anaesthesia News at
anaenews.editor@aagbi.org
Please see instructions for authors
on the AAGBI website
Anaesthesia Training: It’s a piece of cake
Frenchay Anaesthetic Department in Bristol is a popular attachment for trainees
within the South West region, with consistently high performance in national
training surveys 1,2 .The Severn Deanery expects high standards of trainees and their
CVs at completion of training often reflect this. It is therefore difficult for trainees
to stand out amongst their peers. We have hit upon a novel way of improving this
and preparing trainees for life as consultants. As part of the national drive towards
a consultant based service we introduced a departmental ‘Bake-Off” designed to
meet Departmental Daily Cake Targets and to introduce an Enhanced Recovery
Scheme for tired anaesthetists on their allocated coffee breaks. We have applied
for recognition of this activity for Cake Proficiency Development (CPD) and it will
form a significant part of Succulent Pastry Acquisition (SPA) time in the consultant
job plan.
Following the success of the consultant programme trainees are encouraged
to join a separate competition designed to be compliant with Royal College
Guidelines on Workplace Based Assessments. Initial competence is assessed
using the standard DOPS (Direct Observation of Pastry Skills) form. Progression
is confirmed with completion of mini-CAKES and final assessment is through a
Cake Based Discussion (CBD).
Following a recent sitting of the European Diploma in Intensive Care the Frenchay
Anaesthetic Departmental Bake Off received international acclaim and accolades
for its rigorous quality control. The scheme is in line with current government
policy to increase competition within the NHS, and we have been able to achieve
this without resorting to commissioning (spouse-baked) or outsourcing (shopbought)
cakes. We would strongly advise any department wishing to adopt a
similar system to also actively encourage a ‘Cycle to Work’ scheme to offset the
increased calories consumed.
Dr Abigail Lind
Specialist Trainee in ICU and Anaesthesia, Severn Deanery
Dr Jules Brown
Consultant in ICU and Anaesthesia, Frenchay Hospital, Bristol
Dr Ben Walton
Consultant in ICU and Anaesthesia, Frenchay Hospital, Bristol
1. GMC Trainee Survey 2011 Severn Deanery North Bristol NHS Trust
http://www.severndeanery.nhs.uk/deanery/quality-management/surveys/gmc-trainee-andtrainer-surveys/2011-gmc-trainee-survey/
2. Severn Deanery End of Placement Survey Results 2010. http://www.severndeanery.nhs.
uk/deanery/quality-management/surveys/deanery-end-of-placement-surveys/2010-deaneryend-of-placement-survey/
I would like to express a few concerns of my own regarding the article
“Warning!” Concerns of a first year core trainee” in February’s edition of
Anaesthesia News. The aim of the article appears to be to highlight when
to consult with a senior colleague if a clinical scenario exceeds one’s skills
or knowledge. Whilst I agree that the article may indeed illustrate this point,
I have concerns with the subsequent handling of the scenario, particularly
that the manner in which it is portrayed might suggest that this is standard
anaesthetic technique or even that it is within the remit of CT1 trainee. To
summarise the case as presented, a young elective patient with a raised BMI,
significant history of reflux and severely restricted mouth opening appears to
have been assessed by an extremely junior trainee.
An anaesthetic was then constructed using two opioids concurrently, an
induction agent which is known to increase mortality and muscle relaxant of
variable efficacy. With no mention of how the airway was maintained, a nasal
intubation was achieved despite “significant” epistaxis.
I do not believe that this in any way reflects an appropriate description of the
anaesthetic options (including awake fibreoptic intubation) which should
have been discussed by the consultant in charge of the case with the patient
preoperatively. It does not examine the possible hazards of the chosen
technique, particularly the risk of encountering a “Can’t intubate, Can’t
ventilate” scenario and the plan for managing it. I also am surprised at the
need to add further agents to an already complicated induction regimen in
order to achieve “neuroprotection”. Whilst there are many ways to provide
an anaesthetic, I do not feel that this article, which is aimed at very junior
trainees, provides a model by which they should base their practice and may
actually encourage them to undertake what would (in their hands) likely be
a hazardous non-standard technique 1 .
Your sincerely
Alastair Rose
Consultant in Anaesthesia & Intensive Care,
Pinderfields Hospital, Wakefield
(1) Difficult Airway Management. Chapter 5 “Management of the anticipated
difficult airway: without clinical upper airway obstruction”. M Popat. OUP 2009
Editor’s note: We did not intend to endorse the technique described nor
suggest that this would be a suitable case for a junior trainee except under
direct supervision of a consultant. We would encourage trainees to ask their
seniors to explain the rationale behind the techniques used especially if they
are non-standard.
Dear Editor
Vit D deficiency
It started off a year ago, when even simple procedures like intubation or
inserting central lines would cause severe back ache, and regular intensive
care ward rounds caused excessively tiredness. I initially attributed this to
general tiredness, stress, lack of rest or my erratic vegetarian diet.
But when things went from bad to worse, I consulted my GP who discovered
my vitamin D levels were 4nm/L [normal levels 50-120nm/L]. Vitamin D
deficiency may be a particular hazard and a growing problem, albeit not
discussed much. As trainees we spend time most of the time in theatres, and
with our odd shifts, we may be particularly prone to this defficiency. It is
also more common among dark skinned people, vegetarians, and pregnant
women. Vitamin D deficiency has been associated with osteoporosis,
depression, heart disease, stroke, cancer, diabetes and depressed immune
function With the incidence increasing this is a potential hazard we should
be very much aware of.
Dr R Kulkarni
ST6 Anaesthetics and ICM, RCSH
Dr Chinmayi D N
ST1 Paediatrics, East Midlands Deanery
28 Anaesthesia News April 2012 Issue 297 Anaesthesia News April 2012 Issue 297 29

13 th CORK CADAVERIC &
13 th CORK CADAVERIC &
PERIPHERAL NERVE BLOCK
PERIPHERAL
13 th CORK
COURSE
CADAVERIC
NERVE BLOCK
July 2012
&
PERIPHERAL
COURSE
NERVE
July 2012
BLOCK
Day 1: Cadaveric Course Thursday 19
COURSE July th July 2012
Day •
1: Cadaveric Course Thursday 19
Cadaveric Anatomy of Upper and Lower th July 2012
Limbs, Trunk & Neuraxis
• Cadaveric Anatomy of Upper and Lower Limbs, Trunk & Neuraxis
Volunteer Ultrasonography
Day
•
1: Cadaveric Course Thursday 19 th July 2012
Volunteer Ultrasonography
• Cadaveric Anatomy of Upper and Lower Limbs, Trunk & Neuraxis
Day • 2: Peripheral Nerve Block Course Friday 20
Volunteer Ultrasonography
th June 2012.
Day
•
2: Peripheral Nerve Block Course Friday 20
Ultrasonography of Upper and Lower Limbs, th June 2012.
Trunk and Neuraxis
• Ultrasonography of Upper and Lower Limbs, Trunk and Neuraxis
Needling Techniques on Phantoms
Day
•
2: Peripheral Nerve Block Course Friday 20 th June 2012.
Needling Techniques on Phantoms
• Ultrasonography of Upper and Lower Limbs, Trunk and Neuraxis
Department of Anatomy and ASSET Centre, University College
Cork, Department • Ireland. Needling of Anatomy Techniques and on ASSET Phantoms Centre, University College
Cork, Ireland.
Course
Department
fee: € 250
of Anatomy
per day;
and
€
ASSET
450 for
Centre,
2 days
University College
Course (10%
Cork,
discount fee:
Ireland.
€ 250 to ESRA per day; and ESA € 450 members) for 2 days
(10% discount to ESRA and ESA members)
7
Course
CME points
fee: €
per
250
day
per
awarded
day;
by
€ 450
College
for 2
of
days
Anaesthetists of Ireland
7
(10%
CME
discount
points per
to
day
ESRA
awarded
and
by
ESA
College
members)
of Anaesthetists of Ireland
Approval pending for ESRA Diploma on Regional Anaesthesia
Approval
7 CME points
pending
per
for Strictly
day
ESRA
awarded
Limited Diploma
by College
to 30 on Participants
Regional
of Anaesthetists
Anaesthesia
of Ireland
Strictly Limited to 30 Participants
Approval pending for ESRA Diploma on Regional Anaesthesia
For further information and application form, please contact:
Strictly Limited to 30 Participants
For further information Dr. Brian and application O’Donnell form, please contact:
Dr. Brian O’Donnell
Department of Anaesthesia, Cork University Hospital, Cork, Ireland
For further information and application form, please contact:
E-mail: Department corkregionalanaesthesia@gmail.com
of Anaesthesia, Cork University Hospital, Cork, Ireland
Dr. Brian O’Donnell
Tel: E-mail: +353 corkregionalanaesthesia@gmail.com
21 4922135 Fax: +353 21 4546434
Tel: +353 21 4922135 Fax: +353 21 4546434
Department of Anaesthesia, Cork University Hospital, Cork, Ireland
E-mail: corkregionalanaesthesia@gmail.com
The Association Tel: +353 21 4922135 of Anaesthetists Fax: +353 21 4546434 of Great Britain & Ireland
ANNUAL CONGRESS
BOURNEMOUTH
Bournemouth International Centre
This year’s Annual Congress comes to one of England’s
most vibrant and cosmopolitan seaside resorts.
Bournemouth has seven miles
of beaches, award winning
gardens and a vast variety of
shops, restaurants and bars.
| Multiple streams of lectures | Debates | Hands-on workshops | Industry exhibition
Poster and abstract presentations | CPD approved | Annual dinner and dance
www.annualcongress.org
Anaesthesia News
Anaesthesia News now reaches
over 10,500 anaesthetists
every month and is a great way
of advertising your course,
meeting, seminar or product.
2012
Media Pack
available
now
Anaesthesia News
is the official newsletter
of the Association of
Anaesthetists of Great
Britain & Ireland.
For further information on advertising
Tel: 020 7631 8803
or email Chris Steer:
chris@aagbi.org
www.aagbi.org/publications
Dr Les Gemmell
Immediate Past Honorary Secretary
19-21 Sept 2012
21 Portland Place, London W1B 1PY
T: +44 (0)20 7631 1650
F: +44 (0)20 7631 4352
E: les.gemmell@gmail.com
W: www.aagbi.org
Lecture topics include:
National Audits (including NAP5) • The older patient • Pain management • Shared decision making in high risk surgical patient
• Law and Ethics • Obstetrics • Revalidation • Papers you should know about • Problem-based learning and Critical Incident case reports
• Wellbeing • Plus sessions organised by the Association of Surgeons of Great Britain and Ireland (ASGBI) and the British Geriatric Society
Trainee
Anaesthetists
THE GAT Annual Scientific Meeting Wed 27th -
Fri 29th June
GLASGOW
2012
VENUE: GRAND CENTRAL HOTEL, GLASGOW
The programme has been completely redesigned and
updated with parallel scientific sessions to fulfill your
educational needs for all stages of your training.
£195 *
for a three
day meeting!
to celebrate 50 years since
the first trainee meeting
the best trainee scientific meeting of 2012!
Sessions to include:
Advanced ventilation • Depth of anaesthesia monitoring
• Airway and ultrasound • Clinical updates on core topics for exams
Workshops to include:
Interview preparation • Getting research published
• Organising a year abroad
Plus the annual keynote lectures, local and nationally renowned
speakers, competitions and a world famous social programme...
AND MUCH MUCH MORE!
Book online at www.aagbi.org
Closing date for Oral and Poster Abstracts: 23 April 2012
Trainee
Anaesthetists
Book your
study leave
NOW!
Members flat fee of
£195 for all three days *
Non members rate £300
* There will be a nominal fee for the bigger workshops