Volume 7 Number 2 July 2006 - JICS - The Intensive Care Society

The Journal of the Intensive Care Society 

Volume 7 

Number 2 

July 2006 

Price £15 

● Lessons Learned From The London Bombings 

● Organ Donation - Time For A Rethink? 

● The ACUTE Initiative 

● Best Interests - Who Decides? 

This issue is supported by 

an educational grant from 

Lilly Critical Care 

● Tight Glycaemic Control 

● Pericardial Tamponade

Journal produced by The Intensive Care Society. 

29B Montague Street, London, WC1B 5BW. 

Tel: 020 7291 0690 Fax: 020 7580 0689 Website: www.ics.ac.uk 

Editor: Dr. Bruce Taylor, Consultant in Intensive Care and Anaesthesia. 

Department Of Critical Care Medicine, Queen Alexandra Hospital, Cosham, Portsmouth, Hampshire PO6 3LY. 

Email: bruce.taylor@porthosp.nhs.uk 

Editorial Assistant: Jemma Regan Email: jemma@ics.ac.uk

Volume 7 Number 2 

Editorial 3 

Contents 

Editorial / President’s Report 

03 Editorial B Taylor 

04 President’s Report A Batchelor 

Meetings Reports 

06 Annual Spring Meeting Report T Jackson 

09 Annual Spring Meeting Exhibition Report M Moore 

10 Poster Presentation Winner 

11 SKINT Workshop D Goldhill 

Research & Development Update 

12 Tracman Update L Morgan 

Surveys & Audits 

13 Designated Consultants for the Inter-Hospital G Allen, P Farling 

Transfer of Patients with Brain Injury – a survey of B A Mullan 

practice among neurosurgical units in the UK and Ireland 

16 Tight Glycaemic Control in Scottish ICUs E S Jack, M J E Neil 

19 An Audit of Hypoglycaemia in Critical Care A N Thomas 

E M Boxall 

G Sabbagh 

J Eddleston 

T Dunne, A Stevens, 

P Murphy 

Original Articles 

23 Best Interests -Who Decides? C Danbury 

25 The Point of Death J Radcliffe Richards 

27 Pakistan Earthquake A Charters 

29 Not Left to Your Own Devices S Ludgate 

30 Diagnosis and Management of PVL-associated C Day 

Staphylococcal Infections 

32 Reflections on the clinical learning points from the PJ Shirley, M Thavasothy 

Royal London Hospital Intensive Care Unit D McAuley, D Kennedy 

following July 7th 2005 terrorist attacks 

G Mandersloot 

V Verma, M Healy 

35 Cardiac Tamponade Following Insertion of An R Davis, M B Walker 

Implantable Defibrillator 

37 Bedside Ultrasound of Pleural Effusions by UK D Y Ellis 

Intensivists; How Much Training Do we Need? R M Grounds 

A Rhodes 

38 Update on the ACUTE initiative G Perkins 

40 Lemmingaid - Kafka and the Clinical Director Wood & Trees 

(Metamorphosis) 

CATmaker Reviews 

42 Rescue Angioplasty vs Repeat Thrombolysis in A Gershlick 

Acute MI? 

44 Furosemide and albumin improve oxygenation in D MacNair 

a small group of patients with Acute Lung Injury B H Cuthbertson 

46 Corticosteroids in late ARDS K Steinberg 

48 Non-invasive ventilation in patients with acute J L Moran 

cardiogenic pulmonary oedema: a meta-analysis 

Manpower 

50 Manpower Census R Kishen 

Correspondence 

51 Aussie Training – a Perspective from Down-Under S Blakeley 

52 National Critical Incidents Reporting Scheme J Mitchell 

52 National Critical Incidents Reporting Scheme A N Thomas 

53 Guidelines for clearing suspected spinal injury in E Thomas 

unconscious patients 

Miscellaneous 

55 Industry Members 60 Secretariat Report 

56 Council Members 62 Meetings Diary 

58 Advertising and Sponsorship Rate Card 

JICS Editorial Board 

Bruce Taylor (Editor) 

Jemma Regan (Editorial Assistant) 

Carl Waldmann 

David Goldhill 

CAT reviews; 

Chris Cairns 

Brian Cuthbertson 

Sheena Hubble 

The Editor writes 

It is with great sadness that we heard of the recent death of another 

popular and highly respected colleague. We hope to include a tribute 

to Fiona Clarke in the next edition – which will be the second time in 

just over a year that that we have reflected on the death of a young, 

talented intensivist who, for reasons that remain enigmatic, chose to 

end their own life. Such a devastating loss causes us to stop and 

think; the common characteristic in both instances seems to be that 

even close colleagues didn’t see it coming – which inevitably leads us 

all to think about our own colleagues, and whether we should have 

concerns about their (and perhaps even our own) wellbeing. 

It also at least raises the question of whether we are as resilient about 

the effects of the job that we do as we might like to think we are. You 

don’t choose a career in intensive care unless you enjoy a challenge, 

and the unpredictably of the work that goes with the territory. 

However, an integral part of the work also includes difficult decisions, 

and the management of situations that can be both harrowing and 

distressing for all involved. Asking colleagues how they cope with 

such challenges produces responses ranging between ‘I don’t do 

stress’ from some of the more outwardly robust, to that of a capable 

and enthusiastic SpR trainee who decided not to pursue their 

preferred career because they felt unable to handle the emotional 

pressures that come with the job. Most of us probably fit somewhere 

between these extremes, and have developed our own strategies for 

coping with the ups and downs of our everyday work; there will be few 

of us who have not accumulated a private, personal collection of 

memories that will always remain with us. 

When we spend so much of our time caring for patients who are 

critically ill because of accidents, bad luck or complications, do we 

really walk away as unscathed as we would like to believe? I suspect 

not. Most colleagues (if persuaded to discuss this largely ‘no go’ 

area) admit to having rather distorted perspectives about things 

like accident risks, family health and life expectancy, and many 

acknowledge that these do affect their worries about everyday 

activities. It seems that we cope in different ways – from fastidious 

fitness training to music-making, skiing to scuba diving. It also seems 

clear that the peer support from working in a cohesive team plays an 

important part in attenuating the effects of difficult days. Within the 

‘bell curve’ distribution of personalities, it is perhaps inevitable that 

there will be some who will be at the vulnerable end, and we can only 

speculate on what influences the development of depressive illness 

that leads them to end their life – but it seems clear that we should all 

do everything that we can to identify colleagues who may be at risk, 

and to help them in any way that we can. 

Two articles in this edition provide us with retrospective commentary 

on other, tragic unexpected events, with an analysis of the clinical 

lessons learned from the July London bombings and of the huge 

practical difficulties that had to be tackled by volunteers in the 

aftermath of the Pakistan Earthquake. Those of you who attended 

the excellent Gilston Lecture at the Spring Meeting will have been 

impressed by the science that underpins the concept of intensive 

insulin therapy, and two articles are included which focus on its 

implementation and potential complications in intensive care practice. 

Also included is an analysis of the implications of the latest legal ruling 

in the Baby MB case, a thought-provoking perspective on organ 

donation, updates on PVL staphylococcal infection, the ACUTE 

initiative, and medical device malfunction. And for those of you who 

may be considering taking on the role of Clinical Director, Wood and 

Trees offer some advice that you may wish to consider! 

B Taylor 

bruce.taylor@porthosp.nhs.uk 

The Journal of the Intensive Care Society


4 

Report 

President’s Report 

President - 

Anna Batchelor 

It’s hard to believe that a year has gone by already. 

This is a great job and I am really enjoying it, but 

it’s hard work! I am writing this in a hotel room in 

London, having got the 0718 train this morning 

from Newcastle and attended the Critical Care 

Stakeholders forum (CCSF) meeting, after which 

I had tea and a “catch up” with Keith Young from 

the Department of Health and Jane Eddleston, 

the Department advisor for Critical Care. When 

ensconced in my room (I am rapidly becoming an 

expert on the hotels of Bloomsbury) I did about 2 

hours of electronic “paper work” and dealing with 

emails before getting down to writing this report. 

Tomorrow I am having breakfast with Kathy Rowan 

from ICNARC, followed at 1030 by chairing the 

Education and Competence group for the assistant 

critical care practitioners’ stream of New Ways of 

Working in Critical Care, and late afternoon hoping 

to make the Royal College of Anaesthetists Critical 

Care Committee. With luck and a following wind I 

will get the 1700 train and be home about 2015 just 

in time to put my baby to bed. I will have to miss the 

Royal College of Physicians Critical Care Committee 

meeting tomorrow morning unless I can clone myself 

before then. Cloning would actually be very useful 

because if I had stayed in Newcastle today I would 

have done a 0900 to 2100 day in theatre which of 

course has been left to my colleagues back at the 

ranch. Last week had just 1 day away and next 

week is similar, but the following one I am away 4 

days. The representation work increases year on 

year, a reflection of the value placed on the Society’s 

advocatory role for Critical Care clinicians. You 

could ask why more is not done on email, but 

sometimes meeting face to face just gets the job 

done quicker and sometimes interesting things 

happen at meetings - but more of that later. 

Saxon Ridley has now left Council and Jane Harper 

has been elected to fill my former place. I am 

particularly pleased that I have replaced by another 

woman - for some reason very few stand for 

election. I am sure Jane will be a useful addition 

to the Society and as Chair of the Network Medical 

Leads will bring the strands back together which I 

hope will lead to a stronger force for Critical Care. 

At the CCSF today we heard that several networks 

are struggling to find funding and some have just 

ceased to be. This is a great pity as networking is 

something intensivists do well and the benefits are 

there for commissioners to see if only they would 

take the trouble to look. I very much hope that the 

combined efforts of the Society, the Medical Leads 

and the CCSF may be able to help these networks 

get back up and running. 

The Spring meeting in Harrogate went well, and we 

still have the Focus meeting on Transplantation, the 

Trainees’ Meeting and State of the Art to come. This 

year we are also introducing some small seminars in 

the new College on Clinical Excellence Awards, 

Education and Management, so look out for those 

too. We are very aware that access to study leave 

may be less generous than previously and that you 

need good value from the meetings you do attend, 

so I hope the Society can deliver this. 

The National Burn Care Review is coming to a 

conclusion and Specialised Commissioners are 

working with providers to fit their local service into 

the Centre/Unit/Facility model. I was concerned to 

see that there were apparently less beds for burns 

critical care in the Jan 06 KH03a compared to Jan 

05, and we must guard against the possibility of 

having less provision for burn critical care at the end 

of this review than we had at the beginning. I would 

be keen to hear of any problems colleagues have 

experienced. 

The New Ways of Working Programme continues 

and the Advanced Critical Care Practitioner 

Education and Competence Framework which is 

currently going through the Government ‘Gateway’ 

should be available in both hard copy and 

electronically very soon. I hope you will look at it 

and feed back. I strongly believe we need to look 

towards practitioners who are appropriately trained 

and supervised helping us with the service delivery 

gap which will be left by Modernising Medical 

Careers and the EWTD. As with many things with 

the DH, there is of course no money to continue the 

programme and fund second wave pilots. I hope the 

framework is strong enough to enable the production 

of a high quality transferable practitioner workforce. 

Having completed that we are now working on the 

Assistant Practitioner documentation and this should 

be available in the late summer. 

We are hoping that NICE will be able to take on 

“The Care of the Unexpectedly Acutely Ill Patient 

in Hospital” as a fast track programme. The initial 

vibes are good and we await ministerial approval. 

NICE are a powerful body whose edicts must be 

followed. Unfortunately we cannot tell them what to 

put in their guidance but we hope that the results of 

the NCEPOD report along with the considerable 

amount of expertise now available will result in a 

process that leads to benefits for patients. 




Report continued 5 

The Critical Care Contingency Planning Group 

continues to work on the complicated issues that 

may arise from an unexpected sudden increase in 

demand for intensive care beds, and is due to 

produce the first draft guidance in the near future. 

The group wishes it to be clear that this should be 

regarded as ‘work in progress’ and that feedback 

and suggestions for future amendments will be 

welcomed and encouraged. 

Professor David Menon continues to do excellent 

work representing the specialty concerning the 

Human Tissue Act, Mental Capacity Act, the Clinical 

Trials Directive, and the Data Protection Act. These 

are very complex documents and I am grateful to 

David for his diligence and expertise in guiding us 

through these issues. 

At the beginning I said sometimes meetings can be 

interesting... ...last week’s away day proved to be 

very unexpectedly so. You may have heard of Skills 

for Health, a Sector Skills Council for Health - one 

of 27 such projects covering the whole UK economy 

(that’s plumbers, electricians and just about 

everyone with the possible exception of politicians). 

This body have been in existence for some time, 

writing competences (sic) for all health care workers 

including doctors. It was clear at the meeting that 

many people had just woken up to the existence of 

this organisation and they were not too impressed 

with the product. You may wish to look at the 

website http://www.skillsforhealth.org.uk/. I would 

be very grateful for feedback which I can add to that 

I have already provided. For those of you who 

cannot face this I will just tell you there are 92 

competences for Emergency Urgent and Scheduled 

Care, of which giving an anaesthetic is one and 

taking a blood sample is another. Quite why out 

of only 92, removing organs deserves a whole 

competency I will leave you to guess. 

So that’s it, a few days in the life of the ICS 

President, till the next issue TTFN. 

A Batchelor 




6 

Meeting Report 

Harrogate ICS Spring Meeting 

2006 Report 

T Jackson 

Harrogate was once again chosen to host the 

Spring ICS meeting this year. Having enjoyed the 

successful SKINT meeting, delegates gathered amid 

the decidedly changeable weather for the two day 

conference. A packed programme boasted parallel 

sessions with such diverse themes as trauma and 

climate change (ironic in the context of the change 

of weather from Monday to Tuesday!) and promised 

an array of expert speakers. 

The Harrogate International Centre has developed 

since the last ICS meeting, with the addition a year 

ago of the Queens Suite adding to the flexible 

conference facilities. The first session here centred 

on trauma, starting with Prof Monty Mythen’s 

presentation of the pitfalls in evidence for volume 

resuscitation strategies based on certain well-quoted 

trials. The general consensus was carried into the 

questions, namely that minimal resuscitation should 

not be mistakenly interpreted as under-resuscitation. 

Prof Pete Giannoudis developed a comprehensive 

journey through the genetic basis of trauma 

responses, from the history of trauma management 

strategies to the future expectations of genetic 

markers of inflammatory responses. The session 

was concluded with a poignant reminder of the 

recent London terrorist bombs from Dr Hugh 

Montgomery, with the chilling message that many 

of our colleagues in the capital knew a terrorist 

attack was a certainty, and the place that drills and 

preparation played in the response to those attacks. 

Having watched the events unfold in the media that 

day, as many of us will remember, it was fascinating 

to hear first hand experience of the dynamics of 

casualty flows and intensive care activity at such a 

testing time. 

The parallel session in the main auditorium 

concerned outreach issues, with presentations on 

the lack of evidence for efficacy of outreach in the 

light of the antipodean MERIT study, the spectrum 

of musculoskeletal dysfunction in the ICU setting 

and some potential avenues for impacting on these 

difficult conditions, and discussion of the commonly 

applied ‘track and trigger’ scoring systems applied 

to patients at risk of critical illness. 

The refreshment break provided the first 

opportunity to view the range of industry exhibitors, 

although there was some debate as to who would 

pluck up courage to visit the rectal tube vendors 

with confidence! 

The second session of the day fell to a choice of 

matters nephrological or scanning the horizon for 

areas of forthcoming impact on the critical care 

world. The former, began with a talk from Dr 

Andrew Davenport concerning the haemodynamic 

instability associated with renal replacement therapy. 

There were some useful insights into methods of 

minimising this potentially serious complication. 

Dr Andy Lewington from Leeds spoke on the 

interplay between nephrologists and intensivists in 

the management of the critically ill patient with renal 

failure, although it was clear that not all shared his 

experience of joint care. Following on from this was 

Prof Didier Payen from Paris presenting his work on 

whether early renal replacement has any impact on 

the progression of organ dysfunction in sepsis. 

On the background of various theories why 

haemofiltration might be effective was clear 

evidence to the contrary, however he ended by 

suggesting that high-volume filtration may offer 

some as yet unproven benefit. 

Lunch was followed by an intriguing look at how 

climate change may affect the spectrum of infectious 

diseases presenting to UK ICUs. This was put into 

context by a talk from Prof Ken Carslaw from Leeds 

University’s school of Earth and Environment, 

detailing how the evidence for global warming has 

developed over the years, and predictions of how 

our impact on the climate is likely to progress. With 

increasing coverage of this field in the media, it was 

interesting to hear expert opinion on a politically ‘hot’ 

topic. Following this, Dr Philip Stanley presented 

illustrative cases of diseases associated with foreign 

travel which may already necessitate ICU admission 

in a small group of individuals, a theme which was 




Meeting Report continued 7 

developed by Prof Jon Cohen, who discussed 

reasons why infectious diseases with which we are 

unfamiliar may become more commonplace in the 

face of a climate more associated with North African 

countries. He used the examples of West Nile virus 

and Hantavirus to illustrate how climate change can 

have a direct impact on disease presentation. 

The highlight of the afternoon was the Gilston 

Lecture, where Prof Greet Van den Berghe 

presented a very comprehensive account of her 

compelling research into glycaemic control in 

intensive care. 

There was a noticeable paucity of delegates at the 

pre-conference coffee on day two. I’m not sure if 

this was related to over-indulgence at the dinner 

dance the night before, or to casualties of the 

fun-run earlier that morning. 

The Fun Run - raring to go...! 

Day two promised further interesting topics, and I 

began to wish I could clone myself and attend both 

parallel sessions. The aspects of training and 

revalidation were received well, particularly in the 

current climate of modernising medical careers 

and contract issues. However, I elected to join the 

neurosciences session. Dr Peter Andrews 

presented an overview of potential advances in 

neurocritical care, including the disappointing results 

of several important trials, suggesting alternative 

ways of assessing outcome to improve the yield of 

trials in the future. He also concentrated on the role 

of decompressive craniectomy in the management of 

traumatic brain injury, and ended with outlines of 

agents which may show some promise, including 

statins which are being assessed for use in 

vasospasm related to subarachnoid haemorrhage. 

Professor Carl Hendrik Nordstrom presented the 

theory and practice of the Lund approach to 

managing traumatic brain injury, which differs 

from the standard North American teaching on 

maintenance of cerebral perfusion pressure. He 

described the protocol for manipulating capillary 

hydrostatic pressure, including the use of metoprolol 

and clonidine accepting cerebral perfusion pressures 

down to 50mmHg. It was clear from the lively 

discussion which was initiated (but sadly not 

concluded due to time constraints) that neither Lund 

nor North American approaches suit all brain-injured 

patients. The session was completed by Dr Steve 

Wilson with a round-up of the evidence base (or lack 

thereof) for various elements of the management 

of traumatic brain injury. The most compelling 

evidence seemed to be from the TARN database 

study suggesting significant reduction in mortality in 

patients managed in a neurosurgical centre, 

although Dr Wilson presented some obvious 

caveats. 

Next, I attended the session on trainee issues. 

This caught my eye largely for the echo talk, and 

didn’t disappoint. It was heartening to hear Dr 

Robert Orme talk of his quest to become trained in 

echocardiography, although this personal account 

also reinforced what I and many colleagues have 

found, which is that it isn’t easy to acquire the 

necessary exposure to train and then remain 

validated in such techniques. Dr Orme also 

imparted some useful resources for anyone 

interested in achieving echo competence. This 

was followed by an interesting presentation by Mrs 

Carole Boulanger detailing her metamorphosis from 

experienced intensive care sister to advanced critical 

care practitioner. It is clear both from her talk and 

some of the questions that there is some unease at 

the origin of these new roles from various quarters, 

but as manpower issues become more prevalent, 

ACCPs may well become more commonplace. 

Delegates assemble in the lecture area 




8 

Meeting Report continued 

There then followed a pair of lunchtime symposia. 

I was surprised that nobody seemed to adopt the 

Latin derivation of this term (a drinking party) and 

instead we all tucked into our packed lunches with 

as little rustling as possible, so as to hear the 

industry sponsored presentations. The Queen’s 

Suite auditorium hosted two presentations regarding 

remifentanil based sedation regimes. Firstly, Dr Atul 

Kapila described the experience in Reading of the 

introduction of a sedation protocol and subsequent 

audit cycles, highlighting the issues surrounding 

education for the nursing staff. This was followed by 

Dr Wolfram Wilhelm from Lunen in Germany, who 

presented his unit’s experience of more widespread 

use of remifentanil in ICU. In the parallel lunchtime 

session Dr Duncan Wyncoll summarised the results 

of the XPRESS study, an investigation into the 

administration of Activated Protein C with or without 

heparin. 

into the breach at very short notice, describing the 

‘Lo-Trach’ endotracheal tube and its role in 

minimising the impact of ventilator associated 

pneumonia, for which he presented a compelling 

argument. Following this, Prof Van den Berghe 

again took to the platform to reprise her glycaemic 

control research, this time including discussion of 

some of the studies which have disagreed with her 

work, and answering some of the criticisms that 

have been levelled at it. Finally, Dr Sapsford also 

returned, to discuss the myths and developments in 

arrhythmia management, centring on various rhythm 

disturbances and the emerging role of 

radiofrequency ablation techniques to provide more 

long-term relief. Of more relevance to critical care 

were his discussion of atrial fibrillation and the 

evolution of the rate versus rhythm control debate, 

which currently favours the former (probably!). 

The meeting was a resounding success with some 

very stimulating presentations from a wide range of 

nationally and internationally renowned speakers. 

Thanks must go to Prof Mark Bellamy and Ms Judith 

Thornton for their work in developing the programme 

and also for the hard work put in by the ICS 

secretariat and meetings committee. Here’s to a 

repeat performance next year at Bournemouth! 

As usual, the poster presentations attracted lots of interest 

After lunch, there were parallel sessions on 

cardiology and IT in critical care. The cardiology 

session began with Echoardiography in ICU 

presented by Dr Sean Bennett with a 

complementary view to Dr Orme earlier; he 

presented several clinical examples of how echo 

diagnosis can affect ICU management. The second 

presentation was from Dr Rob Sapsford regarding 

the management of acute coronary syndromes, 

and brought together some of the changes in 

nomenclature and investigations which have evolved 

over the last few years. Rounding off the session 

was a presentation by Prof Alistair Hall on 

biomarkers of coronary disease, introducing the 

markers which can further refine the management of 

patients presenting with acute coronary syndromes, 

and the future for multi-marker profiling. 

The final session of the day centred on myths 

and new developments in critical care. Dr Duncan 

Wyncoll performed magnificently having stepped 





Exhibition Report 

M Moore 

Harrogate International Centre held this year’s 

Spring 2006 Conference on 22 nd - 24 th May, which 

included the Skills for Intensivists Workshops and 

the Annual Spring 2006 Meeting, successfully filling 

the trade hall with 49 exhibitors with a mixture of 

Corporate, Company and non industry members. 

After hours of build up, constructing the stands for 

the exhibition, we finally produced a trade hall with 

some amazing purpose built stands. AstraZenca’s 

stand was one of the impressive designs that 

appeared very appealing to the delegates with 

interactive technology and a modernised style. 

Although the weather was clearly not on our side 

throughout, delegates still arrived first thing to attend 

this year’s event. Everything ran smoothly as 

delegates weaved through the whole venue covering 

the exhibition hall and both main sessions. 

Tuesday evening mellowed down to the sound of 

Jazz at our Annual Dinner and Dance accompanied 

by appetising food and drink and a lively atmosphere 

on the dance floor. 

It was a bright and early start on Wednesday 

morning for those who took part in the Intensive 

Care Foundation Fun Run around the muddy fields 

of Harrogate. There was just enough time for a 

quick change, then it was back to the Centre for the 

final day of educational and research sessions. 

The ICS would like to thank all exhibitors and 

sponsors for contributing to this event and their 

continuing support throughout the years. We greatly 

appreciate the involvement from our Industry 

Members and look forward to welcoming new 

associates to our Corporate and Company 

Membership Schemes. 

Thank you to the following exhibitors: 

Abbott Point of Care 

Anmedic UK Ltd 

Arrow International UK Ltd 

AstraZeneca UK Ltd 

B. Braun Medical Ltd 

Beaver Medical 

BOC Medical Plc 

Cardiac Services 

Codan Ltd 

ConvaTec Ltd 

Cook UK 

Delta Surgical Ltd 

DOT Medical 

Dräger Medical UK Ltd 

Edwards Lifesciences Ltd 

Eli Lilly & Co Ltd 

Eumedica Pharmaceuticals 

Fresenius Kabi Ltd 

Fresenius Medical Care 

Fukuda Denshi UK 

Gambro Hospal Ltd 

GE Healthcare 

Gilead Sciences Ltd 

GlaxoSmithKline Ltd 

Henleys Medical Supplies Ltd 

IMPACT 

Inspiration Healthcare Ltd 

Johnson & Johnson Wound Management 

Kapitex Healthcare Ltd 

Lidco Ltd 

Maquet Ltd 

Norvartis Medical Nutrition 

Novo Nordisk Ltd 

Pfizer Ltd 

Pulsion Medical 

Respironics UK Ltd 

Roche Diagnostics Ltd 

SLE Ltd 

Smiths Medical 

SonoSite Ltd 

Spacelabs Medical UK Ltd 

Teleflex Medical Systems Ltd 

The CESAR Trial 

TracMan Trial 

Trumpf Medical Systems Ltd 

Viasys Healthcare 

Vital Signs Ltd 

Wisepress Ltd 

Zeneus Pharma Ltd 

M Moore 

Events & Marketing Administrator 




10 

Meeting Report continued 

Spring 2006 Clinical Practice Poster Presentation Winner 

Congratulations to: 

Dr Rachid Berair and Dr Michael Lim 

Audit on physician prescription of sedation scores in mechanically ventilated patients 

Spring 2006 Research Poster Presentation Winner 

Congratulations to: 

Dr Elaine Harrison, Dr Samuel Pambakian, Dr Justin Woods and Dr William Fellingham 

Comparison between pulmonary artery catheter and Vigileo – FloTrac 

The Intensive Care Society 

Annual Spring 2006 Meeting 

Delegate Badge Prize Draw Winner 

Congratulations to Dr Paul Knight from 

Calderdale Royal Hospital, whose badge was 

drawn out to receive the £25 book token. 

We thank all those delegates who return their 

badges at the end of each conference. 

This ensures the badge holders are re-used at 

future events and helps to keep costs down. 





SKINT - Skills for Intensivist Workshops 

D Goldhill 

The workshops have now been running for two 

years and have all been held in conjunction with 

one of the ICS meetings. The equipment-based 

workshops are designed to be practical hands-on 

sessions providing an opportunity to work with a 

range of equipment and to get first-hand advice 

from experts. 

The ultrasound-guided vascular access workshop 

At the recent conference in Harrogate four 

workshops were held. They were; 

1. Advanced ventilation: 

This year the workshops was expanded and 

started in the morning and ran until late afternoon. 

Topics covered included non-invasive ventilation, 

COPD/asthma, automated weaning, prone 

entilation, lung recruitment and oscillation. There 

was the opportunity to work with machines from 

Drager, Respironics. Maquet, Viasys and GE. 

2. Percutaneous tracheostomy: 

This popular workshop was based around 

Cook and Portex kits with key lectures and 

demonstrations using models, bronchoscopes 

and the tracheostomy kits themselves. 

The workshops took place on Monday 23 rd May, 

the day before the main conference. Most places 

were taken and feedback from all of them has been 

excellent. As well as these workshops, Intracranial 

Pressure Monitoring has been run several times. 

Future planned workshops are on Non-invasive 

Cardiac Output Monitoring and Echocardiography. 

Their success is due to three things. Firstly the 

enthusiasm and hard work of individuals who 

devised and organised the individual workshops. 

For Ventilation this was Peter Macnaughton, for 

Percutaneous Tracheostomy Alf Shearer, for 

Ultrasound Andy 

Bodenham, for Intracranial 

Pressure Monitoring Carl 

Waldmann and for the 

PBL Monty Mythen. 

These individuals have 

been joined by a team of 

helpers who have freely 

given of their time and 

expertise for little reward. 

The percutaneous 

tracheostomy workshop 

The final element in the 

package is the support 

of industry who have 

supplied the equipment 

and educational materials. 

These workshops are a superb opportunity to learn 

or revise some essential skills, and to play with the 

necessary toys. They will be run again. If you want 

to help with any of the current workshops, or if you 

have ideas for workshops you would like to run, 

please contact the ICS. 

D Goldhill 

SKINT_Meister 

3. Ultrasound-guided vascular access: 

This workshop has been run on several previous 

occasions. ‘Phantoms’ and volunteers allowed 

the participants to get excellent training in 

ultrasound anatomy, needle visualisation and 

techniques for vascular access. The session 

ended with an introduction to echocardiography. 

4. Problem-based clinical scenarios (PBL): 

This was a new innovation consisting of an 

interesting review of current sepsis treatment 

options followed by an interactive discussion of 

three case presentations. This was a marvellous 

opportunity to learn from experts about their 

approach to real clinical cases. 




12 

Research & Development Update 

TracMan: Tracheostomy 

Management in Critical Care 

Update 

Dear All, 

Over 60 Intensive Care Units (ICUs) around the UK are now collaborating in the TracMan Trial with a total of 

335 patients recruited (at 25 May). Terrific effort from the ICS community we think! 

Our top recruiting ICUs January to April 2006 are: 

Month 

Jan 06 

Feb 06 

Mar 06 

Apr 06 

Hospital and Lead Consultant/Nurse 

Whiston Hospital, Prescot (Dr R MacMillan) 

Southampton General Hospital (Dr T Woodcock & Mrs K de 

Courcy-Golder) 

Joint top recruiters: 

Derriford Hospital, Plymouth (Dr P D Macnaughton & Mrs N Donlin) 

St Thomas Hospital, London (Dr D Wyncoll & Mr T Sherry) 

Southampton (Dr T Woodcock & Mrs K de Courcy-Golder) 

Derriford Hospital, Plymouth (Dr P D Macnaughton & Mrs N Donlin) 

Our thanks go to these and all our collaborators for their efforts and enthusiasm! We are well on our way to 

addressing the important question concerning the timing of tracheostomy. 

If your ICU is not currently involved in TracMan and you would like to know more, please do not hesitate to 

contact me on Tel: 01865 857627, email: Lesley.morgan@nda.ox.ac.uk. 

Look forward to hearing from you! 

L Morgan 

TracMan Trial Manager 




Surveys & Audits 13 

Designated Consultants for the Inter-Hospital Transfer of 

Patients with Brain Injury: A Survey of Practice Among 

Neurosurgical Units in the UK and Ireland 

G Allen, P Farling, B A Mullan 

Summary 

In 1996 the Association of Anaesthetists of 

Great Britain and Ireland, in conjunction with the 

Neuroanaesthesia Society, produced a set of 

recommendations for the inter-hospital transfer of 

brain injured patients. Ten years on we surveyed 

neurosurgical units in the UK and Ireland to assess 

their compliance with the recommendations. Thirty 

three out of a possible 36 units participated in the 

survey, which revealed that a significant proportion 

of neurosurgical units still do not have a consultant 

with overall responsibility for standards relating to 

transfer. The presence of such a person would 

appear to facilitate audit and training and improve 

patient safety. Importantly, the infrastructure to 

support the role of the designated consultant is 

currently inadequate. 

Introduction 

In the UK moderate and severe head injuries 

have a yearly incidence of 15 per 100,000 of the 

population 1 . It has been estimated that 11,000 

inter-hospital transfers of critically ill patients may 

occur in a year 2 . Approximately 10% of these 

may be for isolated head injuries 3 . In 1996 the 

Association of Anaesthetists of Great Britain 

and Ireland (AAGBI), in conjunction with the 

Neuroanaesthesia Society, produced 

recommendations for the safe transfer of patients 

with brain injury 4 . An audit of the ability of UK 

hospitals to implement these recommendations 

was published in 1999 5 . It showed that many 

hospitals had responded to the guidelines and were 

attempting to implement them. However, it also 

concluded that designated consultants, with 

responsibility for overseeing the conduct of transfers 

and staff training, were not readily identifiable. It is 

now 10 years since the publication of the initial 

recommendations. A revised, up-to-date set, are 

due to be published this year. We therefore felt that 

it would be timely to undertake a survey of the 

neurosurgical units in the UK and Ireland to assess 

their current compliance with the appointment of 

lead clinicians responsible for inter-hospital 

transfers. The units also provided information on 

the education, training and audit activities related to 

neuro-transfers, and the local infrastructure in place 

to support these activities. 

Methods 

There are 36 neurosurgical units in the UK and 

Ireland (Table 1). The Neuroanaesthesia Society 

of Great Britain and Ireland (NASGBI) has a 

representative in each of these units. This 

representative was contacted and asked if they 

would participate in a telephone questionnaire 

survey at a time which was convenient. The 

representative could delegate the questionnaire 

to a more appropriate consultant if applicable. 

A single investigator (GA) collected all the data. 

As Northern Ireland has a well-established regional 

critical care transport service, we also surveyed the 

district general hospitals (DGHs) in Northern Ireland 

with a functioning Emergency Department. The lead 

clinicians in the Departments of Anaesthesia at 

these hospitals were identified and their participation 

requested. A separate questionnaire was developed 

for the DGHs. 

Results 

Thirty three of the 36 neurosurgical units participated 

in the survey. Failure to achieve a 100% response 

rate was due to our inability to contact the 

appropriate NASGBI representative for that unit 

and to identify a suitable substitute. 

Seventeen units (52 %) had a designated consultant 

with overall responsibility for the inter-hospital 

transfer of head injured patients. Only 3 of these 

units (18 %) had this activity recognised in the 

consultant’s job plan. No units were able to identify 

specific budget allowances for the role of the 

designated consultant. Units involved in regional 

critical care transfer services did have separate 

funding arrangements for these activities. Three 

adult units (Table 1) are currently involved in the 

retrieval of head injured patients. In all cases this 

was by way of a general transfer service for the 

critically ill, which would on occasion transport 

head injured patients if the acuity of the situation 

permitted. 

A total of 16 units (49 %) were participating in formal 

education and training of junior medical staff 

involved in the transfer of head injured patients: 13 

of the 17 units (76 %) with a designated consultant, 

and 3 of the 16 units (19 %) without a designated 

consultant. Audit was performed at 27 units (82 %): 

13 of these units were regularly auditing transfers 

and 14 were auditing occasionally. All units with a 

designated consultant performed audit, whereas only 

10 of the 16 units without a designated consultant 

undertook audit (63%). 

Of the DGHs surveyed, 7 out of 11 hospitals 

participated in the survey (64% response rate). 

Only 1 of the hospitals (14 %) had a designated 

consultant. 2 hospitals audited their transfers (29%). 

All senior house officers in the Northern Ireland 




14 

Surveys & Audits continued 

School of Anaesthesia receive formal lectures on 

inter-hospital transfer and on the management of 

head injured patients. The transfers were normally 

performed by consultants in 1 hospital (14 %), by 

senior house officers in 2 hospitals (29 %) and by 

specialist registrars in the remaining 4 hospitals (57 

%). On occasions all 7 hospitals had used the 

regional general critical care transfer service to 

transport acute head injuries. The decision to use 

the service or not was taken by the neurosurgeon 

on-call, and was determined by the perceived 

urgency of the situation. All 7 hospitals felt that 

regular formal feedback form the receiving 

neurosurgical unit would be helpful. 

Discussion 

Trauma services in the UK and Ireland are 

organised regionally. Therefore patients with brain 

injury who require definitive treatment may have to 

be transferred from a receiving hospital to a 

neurosurgical unit. Many studies have shown that 

such transfers may be poorly conducted and hence 

patients may be exposed to secondary insults 6,7 . 

These insults include raised intracranial pressure, 

hypotension, hypoxia, hypercapnea, hyperpyrexia 

and hyperglycaemia. The risk of secondary brain 

damage can be reduced if the transfer is of high 

quality and based on sound principles. In 1996 

the AAGBI and the NASGBI published a set of 

recommendations for the safe transfer of patients 

with acute head injuries to neurosurgical units 4 . 

One of the recommendations was that there should 

be designated consultants in the referring hospitals 

and the neurosurgical units with overall responsibility 

for transfers. It was envisaged that this individual 

would have an important role in the clinical 

management of transfers, the education and 

training of nursing and medical staff, and in 

auditing the quality of inter-hospital transfers. 

The recommendations also stated that trusts should 

recognise that appropriate time and funding is 

required to support these activities. Our survey 

has revealed that almost 10 years on from the 

publication of the recommendations a significant 

proportion of neurosurgical units still do not have a 

designated consultant. The figures were even more 

disappointing for the acute DGHs in Northern 

Ireland. In those units that could identify a 

designated consultant, it would appear that little 

recognition or support for the activity is being 

provided by the healthcare trusts. This situation 

is untenable for the future. Without adequate 

resources it is extremely difficult to have a good 

quality service. The activities of the designated 

consultants involve a substantial time commitment 

and should be reflected in their job plans. 

A survey by Knowles et al in 1999 5 revealed that 

many referring hospitals in the UK thought that the 

formation of transfer teams to transport severe 

head injuries would have some merit. Currently 

only 3 adult units are involved in the retrieval of 

head injured patients. However, they are all general 

transfer services for the critically ill and are not 

specific for neurotrauma. Given the clinical urgency 

of some brain injury transfers, even if it were 

possible to establish specific neuro-transfer teams, 

there would still be occasions where the referring 

hospital would have to undertake the transfer 

themselves. Transfer teams cannot absolve 

DGHs of all their transfer responsibilities. Indeed, 

education and training would become even more 

important for these hospitals if the frequency with 

which they performed inter-hospital transfers was 

reduced. 

Conclusions 

Many neurosurgical units, and possibly many 

peripheral hospitals, do not yet have a designated 

consultant with overall responsibility for the transfer 

of patients with brain injuries. Our results suggest 

that the presence of this consultant facilitates 

education, training and audit, all of which are 

crucial to improving the standards of transfer. The 

infrastructure to support the designated consultant 

is currently poor, with few units recognizing the role 

in the consultant’s job plan. Urgent attention is 

required to rectify this situation and future healthcare 

planners need to be made aware of the necessary 

resource implications. 

G Allen a , P Farling b , BA Mullan b 

a. Specialist Registrar 

b. Consultant, Department of Anaesthesia & 

Intensive Care Medicine, The Royal Group of 

Hospitals, Grosvenor Road, Belfast, BT12 6BA. 

References 

1. Jennett B, MacMillan R. Epidemiology of head injury. Br Med J 

(Clin Res Ed). 1981;10: 101-4. 

2. Intensive care society. Guidelines for transport of the critically ill 

adult. ICS 1997. 

3. McGinn GH, MacKenzie RE, Donelly JA, Smith EA, Runcie 

CJ.Interhospital transfer of the critically ill trauma patient: the 

potential role of a specialist transport team in a trauma system. 

J Accid Emerg Med. 1996;13:90-2. 

4. Jenkinson JL, Saunders DA, Wallace PGM, et al. 

Recommendations for the transfer of patients with acute head 

injuries to neurosurgical units. AAGBI. 1996 

5. Knowles PR, Bryden DC, Kishen R, Gwinutt CL. Meeting the 

standards for interhospital transfer of adults with severe brain 

injury in the United Kingdom. Anaesthesia 1999; 54: 280 – 283. 

6. Gentleman D, Jennett B. Hazards of inter hospital transfer of 

comatose head-injured patients. Lancet 1981; 2: 853 – 855. 

7. Vyvyan HAL, Kee S & Bristow A. A survey of secondary 

transfers of head injured patients in the south of England. 

Anaesthesia 1991; 46: 728-731. 




Surveys & Audits continued 15 

Table 1 

List of neurotrauma centers in the UK and Ireland. 

* Units with general critical care transfer services which occasionally transfer acute head injuries 

Aberdeen Dublin * Nottingham 

Atkinson Morley Dundee Oldchurch 

Barts & The London Edinburgh Oxford 

Belfast * Glasgow * Plymouth 

Birmingham Haywards Heath Preston 

Birmingham Child Hull Queen Square 

Bristol Kings Royal Free 

Cambridge Leeds Sheffield 

Cardiff Liverpool Southampton 

Charing Cross Manchester Stoke 

Cork Middlesbrough Swansea 

Coventry Newcastle Great Ormond St 




16 


Tight Glycaemic Control in Scottish 

Intensive Care Units 

E S Jack, M J E Neil 

Abstract 

Recent work has shown a mortality benefit in 

critically ill patients when hyperglycaemia is 

prevented. We performed a telephone survey of 

all ICUs in Scotland to identify methods of glucose 

control, their ability to achieve target ranges, and 

any related audit processes. In 23 of 26 adult ICUs 

blood glucose is controlled by formalised insulin 

protocols, mostly (19/26) similar to that described by 

Van Den Berghe. Few units are auditing the quality 

of this inexpensive and effective intervention. 

Keywords: Insulin; normoglycaemia; critical illness 

Figure 1: Methods of controlling normoglycaemia 

Introduction 

It has long been recognised that hyperglycaemia is 

associated with increased mortality in a variety of 

critical illnesses, e.g. acute myocardial infarction 1 , 

stroke 2 and trauma 3 . Recent evidence has shown 

a mortality benefit in general intensive care patients 

by using insulin protocols to gain and maintain tight 

normoglycaemia 4,5 . 

Aims 

Our three primary aims were to establish: 

1. The methods of controlling blood glucose in use in 

Scottish ICUs. 

2. The blood glucose target ranges set by individual 

units. 

3. Whether target blood glucose levels are achieved 

and the audit processes used to measure this. 

ICU units 

Beds 

Rigid Protocol 19 145 

Individual approach 4 25 

Sliding scale 3 16 

Target Ranges 

There is a considerable variation in the target range 

adopted by units. Of 23 units (91.4% beds) using a 

target range (rigid protocol or individualised system) 

the majority [19 units, 134 beds (78.8%)] set a 

lower limit of



Figure 3: ‘Tightness’ targeted 

Range (mmol.l -1 ) Number of units Beds 

1.5 –1.9 4 26 

2 – 2.4 8 60 

2.5 – 2.9 4 47 

3 – 3.4 3 16 

3.5 – 3.9 3 17 

4 1 4 

Audit of control 

Only 5 out of 26 (19%) units were aware of recent or 

ongoing audit of glycaemic control. All of these were 

units that had instigated a rigid protocol of control. 

Figure 4: Audit or survey of degree of control 

The remaining units had no observational study 

done within the previous 12 months, or if one had 

been performed its results had not been published 

within that unit. 

Discussion 

General intensive care has seen some significant 

advances over the recent past, including the first 

large scale randomised controlled trials involving 

the sickest of patients. This research has led the 

adoption of interventions proven to reduce 

mortality and morbidity, e.g. ARDSnet protocol for 

ventilation in acute respiratory distress syndrome 6 , 

recombinant activated protein C for sepsis 7 , low 

dose corticosteroids for inotrope-dependent 

sepsis-related circulatory failure 8 , and maintenance 

of tight control of normoglycaemia with insulin 4 . 

Many of these have been integrated in the 

international ‘Surviving Sepsis Campaign’ 9 . The 

acceptance and implementation of this evidence by 

the majority (23/26, 91.4% of beds) of Scottish units 

is encouraging. The absence of published evidence 

on the benefits of a rigid protocol versus an 

individualised daily scale limits conclusions about 

the decision to favour differing methods of glucose 

control. 

Target Ranges 

The wide variety of ranges of glucose concentration 

reported to be beneficial to patients is reflected in 

Scottish critical care practice. There are significant 

variations in both the absolute limits set and the 

‘tightness’ of the range, often arising as a result of 

alterations made during implementation of protocols. 

Although these variations restrict comparison of the 

degree of control, the fact that 4 units set tolerance 

ranges of less than 2mmol.l -1 between upper and 

lower limits suggests that very tight control of 

acceptable glucose levels is practicable. Resistance 

to using tight limits has centred on the possibility of 

overt hypoglycaemia, but with good implementation 

this would seem avoidable. 

Audit 

In the absence of reliable audit of the 

implementation of this intervention, and only a 

minority of units (5 out of 26) appearing to 

disseminate information on results, concern must 

exist about overall achievement of tight glycaemic 

control. Although medical students, trainees or 

nurses may have indeed been diligently collecting 

data and performing small scale surveys, without the 

dissemination of such information to the wider staff 

progress is inevitably limited. It is the responsibility 

of all units to audit how well they are achieving their 

target levels (no matter which range they are using), 

and to keep all involved workers informed about the 

results, so that they can attempt to constantly 

improve. Our survey suggested that only one unit 

re-audited levels of control on a month-to-month 

basis; their control levels were up to 80% of all 




18 


glucose results being within their set range (a very 

tight range of only 1.7mmol.l -1 ). Only 5 of the 26 

units had recollection of a survey/audit being 

completed within the previous12 months, with 

control levels ranging from 55% to 85%. This would 

seem to indicate scope for further improvements in 

achieving targets, and that very tight ranges can be 

applied in a general intensive care unit. 

Conclusions 

Most ICUs (23 of 26, 91.4% of beds) in Scotland 

use formalised approaches to maintaining 

normoglycaemia, with only 3 units (8.6% of beds) 

having no formal control mechanism. Discrepancies 

were identified in the definitions of normoglycaemia 

as well as the tolerance range (i.e. between 1.5 & 

4mmol.l -1 ) accepted. Although there is scope for 

improving the audit of glycaemic control within 

Scottish ICUs, the practice of tight control has to be 

seen in the wider context of overall intensive care. 

E S Jack a , M J E Neil b 

a. SpR Intensive Care Unit, Victoria Infirmary, 

Glasgow. G42 9TY. 0141 201 5320 

correspondence to ewanwendy@supanet.com 

b. SpR Department of Anaesthesia, Ninewells 

Hospital, Dundee. 01382 60111 

References 

1. Malmberg K, Ryden L, Hamsten A, et al. Effects of insulin 

treatment on cause-specific one-year mortality and morbidity 

in diabetic patients with acute myocardial infarction. DIGAMI 

(Diabetes Insulin-Glucose in Acute Myocardial Infarction) Study 

Group. Eur Heart J 1996; 17: 1337–1344 

2. Scott, J. F.; Gray, C. S.; O'Connell, J. E.; Alberti, K. G. M. M. 

Glucose and insulin therapy in acute stroke; why delay further? 

Qjm 1998; 91: 511-515 

3. Laird AM. Miller PR. Kilgo PD. Meredith JW. Chang MC. 

Relationship of early hyperglycemia to mortality in trauma 

patients. J Trauma-Injury Infection & Critical Care 2004; 56: 

1058-62. 

4. Van den Berghe, G; Wouters, P; Weekers, F et al. Intensive 

Insulin Therapy in Critically Ill Patients. NEJM 2001. 345: 

1359-1367. 

5. Cariou, A; Vinsonneau, C; Dhainaut, J-F. Adjunctive therapies in 

sepsis: An evidence-based review. CCM 2004; 32: S562-S570. 

6. The Acute Respiratory Distress Syndrome Network: Ventilation 

with lower tidal volumes as compared with traditional tidal 

volumes for acute lung injury and the acute respiratory distress 

syndrome. N Engl J Med 2000; 342: 1301-1308. 

7. Bernard GR, Vincent JL, Laterre PF, et al: Efficacy and safety 

of recombinant human activated protein C for severe sepsis. N 

Engl J Med 2001; 344: 699–709 

8. Annane D. Sebille V. Charpentier C. et al. Effect of treatment 

with low doses of hydrocortisone and fludrocortisone on 

mortality in patients with septic shock. JAMA 2002; 288(7): 

862-71. 

9. http://www.survivingsepsis.org/ 





An Audit and Review of Hypoglycaemia 

in Critical Care 

A N Thomas, E M Boxall, G Sabbagh, Dr J 

Eddleston, T Dunne, A Stevens, P Murphy 

Summary 

The incidence of hypoglycaemia during critical 

illness was audited by asking staff across a critical 

care network to complete pre-printed forms attached 

to glucose vials used to treat this complication. 

Twenty eight episodes were identified in 2764 

patient days, with a median blood glucose 2.3 

mmol.l -1 , (range 1.3 to 4.0 mmol.l -1 ). A more 

complete record of the circumstances associated 

with hypoglycaemia was obtained than from 

reviewing 22 unstructured critical incident reports. 

The importance of maintaining calorie intake and 

monitoring night time glucose were identified as 

potentially preventative measures in 76 

hypoglycaemic episodes. A risk register was 

produced to provide recommendations on how such 

events can be avoided. Details of the database and 

pre-printed forms can be found on the ICS website 1 . 

Key Words 

Glucose, hypoglycaemia, insulin, intensive care, 

adverse events, critical incident, glucometer. 

Tight control of blood glucose has been shown to 

improve survival and reduce morbidity in critical 

illness 2 . Intensive insulin protocols are, however, 

associated with the risk of hypoglycaemia 2,3,4 . 

This paper describes a structured method of auditing 

hypoglycaemia and reviews the circumstances 

associated with hypoglycaemic episodes. A 

literature review revealed other potential situations 

where hypoglycaemia may occur; these situations 

are described and strategies to minimise these risks 

are discussed. 

Methods 

The study was part of a wider investigation into 

intravenous drug administration in critical care, 

conducted with local research ethics committee 

approval across the Greater Manchester critical care 

network. Pre-printed forms (available on the ICS 

web site 1 ) requesting details of hypoglycaemic 

episodes were attached to vials of strong glucose 

solution used in their treatment. Staff accessing 

these vials to treat hypoglycaemia completed the 

forms and placed them in their unit’s critical incident 

box. The data was entered into an Access database 

(Microsoft Access, Microsoft inc. Seattle USA). The 

study was conducted for a 4-week period in units 

across the network at times staggered between the 

start of February and mid April 2005. To obtain a 

larger sample of hypoglycaemic episodes than would 

be found in such a short audit period, critical incident 

forms in one ICU were hand-searched to identify all 

hypoglycaemic episodes reported from August 2002 

until January 2005. For similar reasons, a second 

unit also prospectively reviewed their observation 

charts during March 2004 to identify all episodes 

where the blood glucose fell below 3.0 mmol.l -1 . 

We therefore collected episodes of hypoglycaemia 

by prospective audit using pre-printed forms, by 

retrospective review of critical incidents, and by 

review of observation charts. The information from 

all of the episodes identified using these 3 methods 

were then entered on an SPSS spreadsheet (SPSS 

for Windows 11.4. SPSS inc. Chicago Il) for 

subsequent analysis. 

Results 

A total of 76 hypoglycaemic episodes were 

identified, 28 from completed pre-printed from the 

glucose vials, 26 from the retrospective review of 

critical incidents and 22 from the prospective chart 

review. The median blood hypoglycaemic level 

recorded using the pre-printed forms was 2.3 mmol.l 

-1 

(range 1.3 to 4.0 mmol.l -1 ). Reports were 

received from 8 intensive care units with a median of 

3 per unit (range 1 to 6). These units had a total of 

97 beds open at the time with an occupancy rate of 

95%, so the 28 episodes occurred in approximately 

2764 bed days. All of the units were using tight 

glucose control protocols (target range 4.0 to 8.0 

mmol.l -1 ). The median hypoglycaemic level for the 

single unit retrospective record review was 2.1 

mmol.l -1 (range 1.1 – 3.9 mmol.l -1 ). 

To increase the sample size and facilitate 

identification of factors associated with 

hypoglycaemia we included results from previous 

hypoglycaemia critical incidents and a retrospective 

chart review with the main audit from the glucose 

bottle forms (76 episodes in total). From within this 

combined record the median hypoglycaemic level at 

the time of recording was 2.5 mmol.l -1 (range 1.1-4.0 

mmol.l -1 ). The median blood glucose concentration 

recorded before the episode of hypoglycaemia was 

5.4 mmol.l -1 (range 2.4 – 13 mmol.l -1 ) in the 60 

incidents where this information was available. 

The median time between this reading and the 

hypoglycaemic episode was 3 hours (range 1 to 6 

hours) in the 39 records where this could be 




20 


calculated. Of the 32 records where it was 

recorded, 25 had been receiving insulin for less than 

24 hours and 17 for more than 24 hours. In the 

63 records where the time of hypoglycaemia was 

recorded, 35 were reported between 21:00 and 

07:00, 17 were reported between 07:00 and 14:00 

and 11 were reported between 14:00 and 21:00. In 

3 of 10 patients who were not receiving insulin at the 

time of the incident other conditions were known to 

have caused hypoglycaemia. In the 44 patients 

where the insulin dose was recorded the median 

dose was 3 units/hr (range 1 to 14 units/hr) at the 

time of hypoglycaemia. The method of glucose 

measurement was recorded in 50 patients; in 31 

glucose was measured using a blood gas analyser, 

20 by glucometer (both methods used in 1 case). 

One glucometer reading was checked by laboratory 

measurement. Where the information was recorded, 

28 of 71 patients had experienced interruptions to 

their calorie intake in the previous two hours, and 

14 of 50 patients were receiving steroids. 

Using the old reported critical incidents it was 

not possible to establish the time between 

measurements or the method of measurement for 

any of the incidents. The measurement intervals 

could, however, be established in 18 of 28 episodes 

reported using the pre-printed forms, all of which 

reported the measurement method. Insulin dosage 

was not recorded in 12 of 22 of the old unstructured 

forms but was in all of the pre-printed forms. 

Older critical incident forms failed to document the 

important observation that the patient’s calorie intake 

had not been altered, and none reported on a 

patient’s steroid medication. The record of 

information required to describe the circumstances 

of each episode was therefore more complete when 

the pre-printed forms were used. 

Discussion 

A number of advantages arise from the use of 

pre-printed forms adhered to glucose vials to collect 

information on hypoglycaemic episodes. Firstly, 

a more comprehensive representation of the 

circumstances of hypoglycaemia is established 

than was previously possible by reviewing free text 

reports, where important details of the circumstances 

around the hypoglycaemic episode may be omitted. 

Secondly, a clear reminder is provided to report the 

incident and it is possible to track the use of all 

glucose vials and associated clinical indications to 

establish the completeness of the record. Thirdly, it 

highlights for review incidents where glucose was 

administered when glucose levels exceeded 3.0 

mmol/l -1 , which are not normally associated with 

symptoms of hypoglycaemia 5 . Finally the form 

fields can be matched to a prewritten database to 

allow easy incident recording and analysis. 

The method described does have some 

disadvantages. Firstly, completed forms had to be 

reliably returned. Although relatively simple in units 

with “critical incident boxes”, for those with electronic 

records there may be nowhere to put the forms. 

This could be resolved by replacing forms with 

prompts to enter required information into an 

electronic incident report, or by providing envelopes 

for the forms to be sent to an allocated individual 

who could enter them onto the database. 

Alternatively, staff could enter information directly 

onto the database, but we avoided this request as it 

would have increased workload and would also have 

required additional training and computer access. 

The system described is relatively simple to run and 

could be widely adapted across many ICUs so that, 

over time, it would produce a clear picture of the 

circumstances leading to hypoglycaemia and the 

processes required to reduce these episodes. 

None of the incidents reported in this study resulted 

in any demonstrable long-term harm to patients, in 

keeping with studies describing the implementation 

of tight glycaemic control 2,3,4 . Hypoglycaemia is, 

however, a potentially devastating side effect of 

insulin use and has been associated with many 

deaths and considerable disability 6,7,8 . 

A potential risk register for hypoglycaemia, based on 

consideration of the process involved in glucose 

control, is summarised in Table 1. This highlights 

potential risks with examples, the level of risk should 

an event occur, how likely is it to occur, and steps to 

minimise the potential risk. It demonstrates clearly 

that although hypoglycaemic episodes arising from 

tight glycaemic control may be relatively common, 

they are not the major source of risk of injury to 

the patient. Rarer problems such as inaccurate 

measurement of blood glucose, missed diagnosis 

of hypoglycaemia, major errors in insulin 

administration, or mechanical malfunction of infusion 

systems are more likely to result in permanent 

neurological damage. 

In summary we have described a simple system to 

systematically record episodes of hypoglycaemia, 





the details of which are freely available on the ICS 

web site. The wider adoption of this audit tool would 

improve understanding of the incidence and causes 

of hypoglycaemia in intensive care. We have also 

reviewed situations where hypoglycaemia may occur 

and how these episodes may be minimised. 

Acknowledgements 

We are grateful for the assistance of medical, 

nursing and pharmacy staff in the following hospitals’ 

critical care units in The Greater Manchester 

Critical Network. We particularly grateful to Dr S 

Nagesh for her help in conducting the single hospital 

prospective audit. 

This study was conducted under the direction of the 

safety committee of the Intensive Care Society and 

was funded by the Greater Manchester supra-district 

audit committee. 

A N Thomas a , E M Boxall b , G Sabbagh c , Dr J 

Eddleston d , T Dunne e , A Stevens f , P Murphy g 

a. Clinical Director, Intensive Care, Hope Hospital, 

Stott Lane, Salford. M6 8HD, UK 

b. Critical Care Pharmacist, Pharmacy Department, 

Hope Hospital, Stott Lane, Salford, M6 8HD.UK 

c. Project manager, Greater Manchester Critical 

Care Network 

d. Network lead, Greater Manchester Critical Care 

Network. 

e. Critical Care Pharmacist, Pharmacy Department, 

Manchester Royal Infirmary. Oxford Rd. 

Manchester 

f. Network Manager. Greater Manchester Critical 

Care Network 

g. Lead Nurse. Greater Manchester Critical Care 

Network 

References 

1. http://www.ics.ac.uk/committees_menu/safety_committee.asp 

2. Van den Berghe, G., Wouters, P Weekers, F. et al. Intensive 

insulin therapy in critically ill patients. N Engl J Med 2001; 345: 

1359-1367. 

3. Krinsley, J. S. Effect of an intensive glucose management 

protocol on the mortality of critically ill adult patients. Mayo Clin 

Proc 2004; 79: 992-1000. 

4. Goldberg, P. A., Siegel, M. D., Sherwin, R. S. et al. 

Implementation of a safe and effective insulin infusion protocol 

in a medical intensive care unit. Diabetes Care 2004; 27: 

461-467. 

5. Auer, R. N. Hypoglycemic brain damage. Forensic Sci Int 

2004;146: 105-110. 

6. Fischer, K. F., Lees, J. A. Newman, J. H. Hypoglycemia In 

Hospitalized-Patients - Causes And Outcomes. N Engl J Med 

1986;315: 1245-1250. 

7. Bates, D. W., Chassin, M. R. Becher, E. C. Unexpected 

hypoglycemia in a critically ill patient: The wrong patient. Ann 

Intern Med 2002;136: 826-833. 

8. Batalis, N. I., Prahlow J. A. Accidental insulin overdose. J 

Forensic Sci 2004; 49: 1117-20. 

9. Ridley, S. A., Booth S. A., Thompson, C. M. Prescription errors 

in UK critical care units. Anaesthesia 2004; 59: 1193-1200. 

10. Disse E., Thivolet C. Hypoglycemic coma in a diabetic patient 

on peritoneal dialysis due to interference of icodextrin 

metabolites with capillary blood glucose measurements. 

Diabetes Care 2004; 27:2279, 

11. Levy, W. J., Gardner, D., Moseley, J. Dix, J. Gaede, S. E. 

Unusual problems for the physician in managing a hospital 

patient who received a malicious insulin overdose. Neurosurgery 

1985; 17: 992-6. 

12. Waring, W. S., Alexander, W.D. Emergency presentation of an 

elderly female patient with profound hypoglycaemia. Scot Med J 

2004; 49: 105-7. 

13. Clothier C, MacDonald C A, Shaw D A. Allitt inquiry: 

independent inquiry relating to deaths and injuries on the 

children's ward at Grantham and Kesteven General Hospital 

during the period February to April 1991. London: HMSO 1994. 

Correspondence to: Dr Antony Thomas. Intensive 

care unit, Hope Hospital, Stott Lane, Salford M6 

8HD, UK. (e-mail: tony.thomas@srht.nhs.uk) 

Fax:01612065072. 




22 


Table 1: RISK REGISTER FOR POSSIBLE CAUSES OF HYPOGLYCAEMIA IN CRITICAL CARE. 

(Risk of hyperglycaemia also included to allow consideration of balance of risks) 

RISK LEVEL OFRISK EXAMPLES HOW COMMONLY PREVENTION 

TO PATIENT ENOUNTERED 

Poorly controlled Increased chance Hyperglycaemia associated Common Robust evidence based policies and protocols to control blood 

hyperglycaemia of death 1 with critical illness glucose. Education and adherence to protocol. Frequent 

review of glucose control within each ICU. 

Poor prescribing of Low Illegible prescription Common 9 Training of medical staff. Nurses asking for ambiguous 

insulin prescriptions to be rewritten. Standard strength of insulin. 

Electronic prescribing or pre printed insulin prescriptions 

Hypoglycaemia within Low Hypoglycaemia some hours Common 2,3,4 Avoid rest periods with feeds. Consider giving steroids by 

normal variation of after a bolus dose of steroids infusion. Use glucose 10%, 1 mg/kg/hr during interruptions 

tight glycaemic control to feed. Make sure glucose is measured at night. Avoid 

unnecessary sedation or paralysis that would mask symptoms. 

Technical problems Medium Malfunctioning syringe driver Rare Good equipment and regular maintenance policies. Limit 

with insulin delivery delivers contents of syringe in nsulin syringes to 30 units in 30mls, thereby i limiting the total 

systems 5 minutes dose that could be given by a malfunctioning syringe. 

Preparation and Medium Confusion of insulin with another Rare Checking procedures. Ensure one type of insulin available. 

administration errors. drug to be given by bolus Clear labeling of syringes. Use of pre-filled syringes. 

Confusion over labeling administration 7,8 Limit insulin in syringe. Always use the same concentration of 

or contents of syringes insulin and ensure insulin in date. 

or working of syringe 

pumps or preparation 

of syringes 

Systematic errors in High Glucometer test strips Rare Awareness of possibly. Care of glucometers and test strips. 

measurement contaminated with glucose Training and audit of use of glucometers. Checking 

containing feeds. Lines primed unexpected glucose values by a second measurement 

with glucose. Cross reaction with methods and other sample sites 

other sugar in peritoneal dialysis 1 

Unexpected medical Medium Insulinoma .Unrecognised use Rare Awareness of possibly. Regular measure of glucose in 

conditions or effects of of subcutaneous insulin or other patients not receiving insulin. Active investigation of 

drugs, other medication hypoglycaemic drug unexpected hypoglycaemia 

errors 

Criminal Intent High Surreptitious Injection of insulin Very Rare Awareness of possibly. Active investigation of unexplained 

by staff member or visitor, by hypoglycaemia. Good appraised and other employment 

any route 11,12,13 practices13]. Proper storage of insulin13. 




Original Articles 23 

Withdrawal of Treatment in Critical Care - 

Who Decides? 

C Danbury, C Newdick 

Defining patients’ best interests in light of the 

Baby MB case. 

Commenting on patients who lack the capacity to 

consent, Lord Donaldson, Master of the Rolls, said 

in 1993, ‘The doctors… have both the right and the 

duty to treat him in accordance with what in the 

exercise of their clinical judgment they consider to 

be his best interests.’ 1 In the same case he said, 

‘Consultation with the next of kin… may reveal 

information as to the personal circumstances of the 

patient… Neither the personal circumstances of the 

patient nor a speculative answer to the question 

"What would the patient have chosen?’ can bind the 

practitioner in his choice of whether or not to treat…’ 

In recent years these statements have been 

subject to challenge. The definition of what are 

a patient’s best interests has been clarified by the 

courts and now extends beyond that of a simple 

medically-defined best interest. Dame Butler-Sloss, 

has clarified that 

Although this is helpful, the recent case of Burke v 

General Medical Council has caused some 

confusion. Mr Burke requested the GMC’s guidance 

on withholding and withdrawing treatment be 

declared unlawful. Mr Burke has cerebellar ataxia. 

He does not wish for artificial nutrition and hydration 

to be withdrawn against his wishes. The GMC 

guidance implies that is lawful for doctors to do this, 

when it is deemed that Mr Burke lacks competence 

to make decisions for himself. The court of first 

instance held in Mr Burke’s favour. This was 

subsequently overturned by the Court of Appeal. 

However, this subsequent judgement held an 

anomaly, specifically at paragraphs 53 and 55. 

Paragraph 53 states, 

‘We have indicated that, where a competent patient 

indicates his or her wish to be kept alive by the 

provision of ANH [Artificial Nutrition and Hydration] 

any doctor who deliberately brings that patient’s life 

to an end by discontinuing the supply of ANH will not 

merely be in breach of duty but guilty of murder.’ 

This appears to be contradicted at paragraph 55, 

‘Best interests are not limited to best medical 

interests.’ 2 

and, 

‘If mental capacity is not in issue and the patient, 

having been given the relevant information and 

offered the available options, chooses to refuse the 

treatment, that decision has to be respected by the 

doctors. Considerations that the best interests of the 

patient would indicate that the decision should be to 

consent to treatment are irrelevant.’ 3 

Therefore, though an individual’s best interests are 

not confined to the narrow spectrum of medical best 

interests, they are still determined by doctors if the 

patient is not competent. In an attempt to determine 

what best interests are, the UK government has said 

that they should encompass: 

‘the ascertainable past and present wishes and 

feelings of the person concerned and the factors the 

person would consider if able to do so... the views of 

other people whom it is appropriate and practical to 

consult about the person’s wishes and feelings and 

what would be in his or her best interests.’ 4 

‘…Clearly the doctor would need to have regard to 

any distress that might be caused as a result of 

overriding the expressed wish of the patient. 

Ultimately, however, a patient cannot demand that 

a doctor administer a treatment which the doctor 

considers is adverse to the patient’s clinical needs. 

This said, we consider that the scenario that we 

have just described is extremely unlikely to arise 

in practice.’ 

It is important to remember that the earlier case of 

Bland 6 , heard by the House of Lords, established 

categorically that ANH was medical treatment. 

Therefore, on the one hand that Court of Appeal is 

telling us that we may not withdraw treatment 

against the patient’s wishes and on the other saying 

that patients may not insist on treatment. When 

considering these statements, it is important to 

remember that the courts make no distinction 

between withholding and withdrawing treatment. 

The Court of Appeal heard this case in July of 2005, 

and the scenario that was held to be ‘extremely 

unlikely’ has taken eight months before appearing in 

the High Court as the case of An NHS Trust v MB 

[2006] EWHC 507 (FAM). 




24 

Original Articles continued 

Baby MB was born with spinal muscular atrophy 

(SMA). SMA is an autosomal recessive disorder, 

with an incidence of 1 in 6000 live births and in 

MB’s case the disease is so severe that it will be 

ultimately fatal. The view of 14 consultants, 

including 4 expert witnesses, the senior sister of the 

PICU and the guardian ad litem, was that MB should 

be permitted to die. Against this were the parents, 

who felt that MB still had a quality of life and were 

opposed to this remedy. Although the judge held 

that ‘There is thus a formidable body of medical 

evidence of very high quality,’ he found in the 

parents favour. Notwithstanding the judge’s view 

that his decision was not was not “policy based”, this 

finding has implications for the practice of medicine 

in this country. Justice Holman said, 

‘I actually go further and consider that currently it 

is positively in his best interests to continue with 

continuous pressure ventilation and with the nursing 

and medical care that properly go with it, including 

suctioning and deep suctioning when required, 

replacement of the tube as necessary, and chest 

and lung physiotherapy to clear his secretions. 

Although that is my opinion, I cannot and do not 

make an order or declaration to that effect. I merely 

state it.’ 

By refusing to grant a declaration that it is lawful 

for doctors to withdraw care, the judge effectively 

makes a declaration that doctors must continue 

treating MB. Extrapolating the Court of Appeal’s 

decision in Burke, any doctor who now withdraws 

care on MB, may be committing a crime. Who 

therefore, will consider withdrawal of treatment 

without the family’s express permission? 

The law relating to best interests and treatment is 

now less clear than ever. In light of the Mental 

Capacity Act 2005, there will soon be another group 

of individuals who will be involved in the process of 

deciding about different treatments. This decision 

has wider implications than for one individual. If this 

judgement stands, then the best interests test 

becomes unhelpful. If the best interest of the patient 

is determined by relatives, then we have adopted 

substituted judgement of the USA. Such a standard 

raises the prospect of continuation of treatment 

well beyond the point that is currently considered 

appropriate. 

C Danbury 

Consultant Intensivist, Royal Berkshire Hospital and 

Clinical Research Fellow, School of Law, University 

of Reading 

C Newdick 

Reader in Health Law, School of Law, University 

of Reading 

References 

1. In re T (adult refusal of treatment). [1993] Fam. 95 

2. Re MB (Medical Treatment). [1997] 2 FLR 426 

3. Ms B v An NHS Hospital Trust. [2002] WL 347038 

4. The Lord Chancellor‚s Department. Making Decisions (Cm 

4465) October 1999 

5. R (on the application of Burke) v General Medical Council. 

[2004] All ER (D) 588 (Jul) 

6. Aidale NHS Trust v Bland. [1993] AC. 789 




Original Articles continued 25 

The Point of Death 

J Radcliffe Richards 

One great success of intensive care is its 

contribution to surgery that would otherwise be 

impossible, such as cardiac and neurosurgery, and 

the more sophisticated kinds of transplant. But the 

connection with transplants is an odd one, because 

it is probably the only case in which the failure of 

one group of doctors to save their patient is a 

necessary condition of another’s saving theirs. If the 

patient whose care is the raison d’etre for one team 

is a potential source of spare parts for the other, 

there is in the nature of things a certain tension. It is 

hardly surprising if mutterings occasionally surface 

from transplanters who suspect intensivists of letting 

potential donors slip through their fingers; or from 

intensivists who resent the surgeons who descend 

to ransack their dead patients and disappear to 

life-saving glory, leaving the colleagues on whom 

their work depends to cope with the mess and grief 

that remain. 

Some of these tensions are inevitable; others, 

probably, could be sorted out by a good course in 

communication skills. But a quite different kind of 

difficulty, for both sides, lies in a mass of legal, 

ethical and cultural constraints on their activities. 

Several of these are, arguably, not reasonable 

demands of principle, but residues of ancient habits 

and beliefs that are actually incompatible with much 

present day moral and scientific thinking. 

For instance, one of the worst aspects of donation 

for all concerned is the need to ask relatives for 

consent. This is still required by ‘good practice’ 

(though no longer law) even when the donor has 

already consented. But the common law principle 

that bodies cannot be property, and bequeathed like 

other possessions, derives from a time when people 

expected the literal resurrection of the dead at the 

Last Judgment, and when bodies were anyway of no 

use to anyone else. The situation is now radically 

different, and we already have requirements for 

consent to the use of bodies that look suspiciously 

like property rights. There seems no good reason 

for not completing the change. If people owned 

and could bequeath their bodies, the jarring and 

unpleasant matter of seeking consent from the 

bereaved would disappear, and in time families 

would probably think no more about what was going 

on behind the scenes than they do now about the 

activities of pathologists and undertakers. And if the 

change were combined with an opting out system – 

also long overdue, since it would not remove the 

right to refuse – it would probably considerably 

increase the organ supply. 

But the non-ownership of bodies is perhaps the least 

important residue of ancient thinking that adversely 

affects both transplantation and intensive care. 

Much more fundamental is the legal and moral 

importance given to the idea of a firm boundary 

between life and death, and inalienable obligations 

to the living. 

The most obvious of these obligations is the 

prohibition on killing – actively pushing someone 

over the threshold of death – and hence the 

requirement for donors to be already dead. Another 

is the legal requirement to consider only the interests 

of the patient when making treatment decisions 

before death. Both of these mean that potentially 

transplantable organs deterioriate, often beyond use, 

during the dying process. Many people are now 

challenging (or stretching, or disregarding) the 

prohibition on treating patients with a view to their 

becoming donors; a few are even questioning the 

dead donor rule. But what really needs 

reconsideration is the traditional assumptions 

about life and death that underlie both of them. 

Dying is a process, during which different functions 

close down gradually and at different rates. Some, 

like hair growth, continue even after death. If life 

dwindles gradually, how can we know exactly when 

it has gone? The traditional approach to this 

problem was to err on the side of caution. Because 

it is worse to treat the living as dead than the other 

way round (worse to bury the living than leave the 

dead unburied), people waited until the body 

reached a point in the closing down process from 

which experience showed there was no return. 

What that point was depended on the state of 

scientific understanding. 

This approach was adequate for most of human 

history, but the situation has radically changed. 

Transplantation has for the first time made it urgent 

to identify death at the earliest possible stage in the 

closing down process. As long as the purpose of 

pronouncing death was proclaiming the next king, or 

passing on property, or burying the corpse, a few 

hours here or there made little difference. Now that 

we need both a dead donor and live organs, we 

need to establish exactly when death occurs. 

At the same time, the technology that makes both 

transplantation and intensive care possible has, 




26 


paradoxically, made identifying a point of death even 

harder. In the natural process of dying, the final 

elements of the closing down process come fairly 

close together; but we can now draw out those 

different elements, often independently, while 

monitors allow us to watch what is going on in 

previously impossible detail. The range from 

which to choose the point of death has expanded 

immeasurably. 

The resulting controversies about the point of death 

can become passionate, because holders of different 

views regard their opponents as doing serious, 

unjustified harm. People who accept the brain stem 

criterion, for instance, think that innumerable organs 

are lost to slow deterioration while ventilators 

maintain cardiopulmonary function, or monitors show 

the last flickers of cortical activity, in a patient 

already dead. Others with more conservative views 

– including many potential donors and their families 

– think their opponents are recommending the 

murder of dying patients. 

The only way out of this impasse involves 

recognizing a much more fundamental point: that 

science cannot establish a point of death. The 

traditional view is that there is an objective fact 

about the matter: death is the final departure of 

some undetectable soul or élan vital. But if such 

things exist, science has no way of observing them. 

If, on the other hand, life is – as scientists 

increasingly believe – a function of the organization 

of material parts, there simply is no point of 

transition between life and death. Trying to pin it 

down is like trying to determine the point at which 

red becomes orange on a spectrum. On the 

traditional account, the question of when death 

occurs in the closing down process is scientifically 

unanswerable; on the more recent one, it is 

meaningless. Either way, it should be abandoned. 

The whole problem can then be approached from a 

different direction. Why are we so anxious to know 

whether someone is alive or dead? The reason, 

obviously, is our concern to treat the living and the 

dead appropriately. 

Instead of trying to keep the familiar categories and 

force the transitional states into them, we should 

address directly the problem of how people in those 

states should be treated. This question is not 

scientific, but moral. Science can tell us what states 

people are in and (with different degrees of certainty, 

and subject to change) whether those can be 

stabilized or reversed. It cannot answer the moral 

question of how we should treat people in those 

states. 

Traditional believers in an objective point of death 

will probably answer the moral question by 

maintaining an absolute prohibition on active 

hastening of death, and always presuming life in 

case of uncertainty. But for anyone who accepts 

that there is no definite point of death, but only a 

shading between clearly alive and clearly dead, 

moral judgments will need a different basis. The 

most plausible view is that what matters is people’s 

interests. 

This kind of idea, when followed through, has 

radically different implications from those of the 

traditional view. They can overlap in many areas, 

but in the penumbra between life and death, the two 

approaches come apart. When patients reach the 

point of having no interest in further treatment to 

reverse or delay the closing down process, they 

usually have no interest in whether it is further 

delayed, or accelerated, or redirected. From their 

point of view, accelerating the closing down process 

beyond the point of their interests is no more killing, 

in any morally relevant respect, than is accelerating 

the closing down of hair growth by cremation. At the 

same time, other people may have considerable 

interest in how the process happens – not only 

because of transplants, but because of the 

enormous resources that currently go into end-of-life 

care. From their point of view it matters a great deal 

whether we treat the dying according to their 

interests as we understand them, or rule out certain 

possibilities altogether until some (highly elusive) 

objective point of death. 

Law and professional practice already give great 

weight to patients’ interests, and most doctors would 

say those interests were the purpose of their work. 

But much of what is legally required and actually 

done has nothing to do with interests, and may 

actually work against them, because of ancient 

assumptions about an objective point of death and 

its moral relevance. 

Since every day extends our ability to separate and 

draw out the different elements of the closing down 

process that is death, it is essential to replace the 

anachronistic, apparently scientific debate about 

when death really occurs with the explicitly moral 

debate that it should be. 

J Radcliffe Richards 

Centre for Biomedical Ethics and Philosophy UCL 





Shaken and Stirred – Experience from 

the Pakistan Earthquake 

A Charters 

On 8 th October 2005 an earthquake measuring 7.6 

on the Richter scale struck the northeast of Pakistan 

95 km away from the capital Islamabad. 

Muzabfarabad, the area’s capital, was extensively 

hit. The whole of the infrastructure of this region 

had been destroyed including fresh water facilities, 

electricity, houses, health facilities, sanitation and 

food supplies. The government of Pakistan 

estimated that over 23,000 people lost their lives. 

Four million people where affected, with over 42,000 

confirmed injured. This disaster rivalled the tsunami 

in its gravity, yet the world was slow to respond. 

of my initial enquiry my application was accepted 

and I was invited to join other volunteers at Merlin 

HQ, where we received a briefing about how NGOs 

work and what we were expected to do. Within 

hours of having received every vaccination known 

to man I found myself queuing alongside an 

orthopaedic consultant ready to board a plane 

that would take us to Pakistan. 

On 10 th October an assessment team, consisting of 

an A&E consultant, public health specialist and a 

communications officer with a logistician, was sent 

out to the Neelam valley (approximately 46 km away 

from Muzabfarabad) to asses the local health needs. 

The area had been cut off from accessible health 

provision as a result of 140 landslides which had 

destroyed roads and all local facilities. From the 

valley population of approximately120,000 it was 

estimated that at least 10,000 had died and 20,000 

were injured, but these figures could not be 

confirmed and the reality may have been worse. 

The only access to the valley was by helicopter, but 

a reasonable supply chain was established because 

of the pre-existing high military presence on the 

Kashmir boarder. 

I received an email on the 18 th of OCT from the 

lead of the RCN oncology forum alerting us to the 

fact that Merlin were in desperate need of paediatric 

trauma specialists - either nurses or doctors - to 

establish field hospitals in Kashmir for the 

traumatised survivors. I immediately contacted Trust 

management who agreed to my release from work. 

The initial response from Merlin was a little reticent 

as I had no previous field experience and normally 

aid agencies use workers who have had previous 

involvement in disasters or aid programmes. 

However, having submitted my CV, within a few days 

We were met by a representative from Merlin and 

escorted to our hotel, which was very basic and to 

be honest made the tents that we slept in for the 

next month feel luxurious! The next day we had 

further briefings, including one on UN security, 

following which we were flown out to a village called 

Devlian where our base was situated in military 

camp, hence hosted and protected by the Pakistan 

army. 

We were assigned an army liaison officer who 

became such an invaluable asset that I honestly 

don't know how we could have achieved what we 

did without him. During the very difficult first few 

days we set up a clinic with two consulting room 

tents; one was assigned as a pharmacy tent, where 

we organised an assortment of drugs most of which 

I hadn't seen for years (chloramphenicol, procaine 

penicillin, doxycycline etc.); the other was a patient 

tent in which we subsequently received 150 - 200 

patients a day. This basic primary care centre 

gradually grew into something that even the military 

would have been proud of, with a medical tent, 

surgical tent, pharmacy, four inpatient tents, 

vaccination clinic, store tents and a patient education 

tent, along with 3 patient latrines and a large 

(unreliable) Chinese generator. Once the primary 

care centre was up and running we were seeing 

over 250 patient a day. Some patients had walked 

or had to be carried over 30 km to reach us, 

prompting a decision to set up an outreach service 

and satellite clinics. 




28 


The conditions we saw out in the valley were also 

very challenging. Although most of the patients with 

traumatic injuries had been air-lifted out, we still 

received an average of 60 patients day with old 

fractures and necrotic wounds. A surprising number 

of patients had dislocated hips or femoral fractures 

(a consequence of their house falling on top of 

them). Most had been waiting in the remnants of 

their homes since the earthquake, but when help 

failed to arrive and word spread of our centre they 

were often carried 10 - 30 km to us on makeshift 

stretchers. As we initially had no morphine (and the 

culture was against opioid analgesia) we depended 

on intramuscular non-steroidal anti inflammatory 

drugs and oral paracetamol before arranging aerial 

transfers. 

Other conditions we treated included diphtheria - a 

very worrying condition that brought back memories 

of treating very sick children with epiglottitis in 

Melbourne in the early 1990s - except we had no 

intensive care, no ENT surgeons, limited oxygen 

supplies and no tracheotomy tubes. All we could 

provide for these children were antibiotics and 

transfer to Muzabfarabad on the next available 

helicopter. Typhoid, dysentery, and malaria were 

also common as were a great deal of primary care 

conditions. 

Another aim of our mission was to establish public 

health programmes, and consequently our team 

vaccinated over 1500 children, provided over 1000 

hygiene kits and aided in the digging of countless 

latrines. Merlin subsequently established three 

further primary care centres in more mountainous 

sites to vaccinate and provide health care for 

patients that simply could not reach the base areas. 

To date over 15,000 patients have been cared for in 

these clinics with the intention being that they 

continue until they are no longer required. 

My experience working alongside the Pakistani 

doctors, receptionists, pharmacist and staff will stay 

with me for ever. I learnt a great deal about 

conditions I have never seen before, and will never 

complain about a full waiting room again. I would 

encourage any one that is offered the chance to do 

relief or emergency work to take it up - for your own 

benefit as well as the people you will help. Although 

without doubt one of the most challenging things I 

have ever done, it was also the most rewarding. 

My practice was concentrated mainly on children 

who were often very sick, and my cannulation skills 

were severely challenged on several occasions. 

It proved essential to concentrate on history-taking 

and physical examination rather than relying on 

investigations and diagnostic imaging as we had 

no labs or x-ray facilities. With patients attending 

the centre between the hours of 0900 - 1600 the 

workload was high on most days but consistently 

rewarding. Patients admitted to our inpatient tents, 

normally were normally those who required isolation 

(e.g. measles) or those with typhoid or malaria who 

were simply too ill to go home. 





Not Left to Your Own Devices? 

Dr S Ludgate 

The purchase and maintenance of medical devices 

makes up a significant percentage of the annual 

NHS and social care budget. Last year, for 

example, acquisition was estimated at some £10 

billion. Yet, whilst the medical professional is fully 

aware of the strict controls covering the licensing 

of drugs and the “Yellow Card” system for reporting 

side effects that result from their use, fewer 

clinicians appear to be aware that a similar system 

exists for the regulation of medical devices and, 

importantly, for the reporting and investigation of 

adverse events involving their use. 

One of the main problems is that not everyone is 

sure exactly what is included in the definition of a 

“medical device”. This term covers any product, 

other than a medicine, that is used in the healthcare 

environment for the diagnosis, treatment, prevention 

or monitoring of illness or disease, or alleviation of a 

handicap. It, therefore, encompasses a huge variety 

of products (it has been estimated that there are 

somewhere in the region of almost 90,000 devices 

available on the market) ranging from needles and 

syringes, to anaesthetic machines, central venous 

lines, patient monitors and vaporisers to name just a 

few. 

The Medicines and Healthcare products Regulatory 

Agency (MHRA) is an executive agency of the 

Department of Health, formed by the merger of the 

Medical Devices Agency and the Medicines Control 

Agency which, on the devices side, is entrusted with 

safeguarding public health by working with clinicians, 

regulators and manufacturers to ensure that all 

medical devices used in the Health Service meet 

appropriate standards of safety, quality and 

performance and comply with provisions of the 

European Medical Devices Directives. 

One of the Agency’s main functions in carrying out 

this aim, is its management of an Adverse Incident 

Centre which currently receives almost 9,000 device 

related adverse incidents each year. Each incident 

is investigated on a priority scale, determined after 

discussion with the reporter and any relevant clinical 

or technical staff involved. Investigations may result 

in a number of actions being taken, including the 

issuing of advice to the Health Service by means 

of a Device Alert, or working with manufacturers to 

prevent recurrence of a problem through 

modification or recall of a device. As a result of 

adverse incidents reported last year, 72 Device 

Alerts were issued, covering advice on a wide range 

of subjects, including overfilling of anaesthetic 

vaporisers, entrapment of anaesthetic breathing 

systems between operating tables and patient 

trolleys, prevention of hypoxic gas mixtures, issues 

relating to heat and moisture exchangers and filters 

and a variety of concerns involving infusion pumps. 

Additionally, there were over 400 product recalls or 

field corrections involving MHRA’s supervision or 

active involvement, 260 cases requiring the provision 

of advice on safer device use or improved staff 

training by MHRA and, in 740 cases, manufacturers 

undertook to improve designs, manufacturing 

processes or quality systems, directly as a result 

of the conclusions from MHRA investigations. 

Although the Adverse Incident Centre receives a 

number of device-related adverse incident reports 

directly from manufacturers, these relate mainly to 

problems arising from shortcomings in the device or 

its instructions for use. Increasingly, we know that 

adverse incidents also occur as a result of user 

practices, conditions of use, inappropriate storage 

or maintenance, or difficulties with cleaning, 

decontamination or sterilisation. If improvements 

are to be made in design, function, materials, 

ergonomics and instructions for use, therefore, it is 

vital that the Agency continues to receive reports 

directly from users who have experience with the 

device. We, therefore, urge you to let us know 

of any device related adverse event, however 

apparently trivial, since we have many examples of 

MHRA being the first globally to identify problems, 

mainly as a result of user reporting. It could not be 

easier. These reports can be made by the MHRA 

website (www.mhra.gov.uk), which will enable the 

reporter to receive an automatic acknowledgement 

and a unique reference number. Alternatively, a 

standard user report form can be downloaded from 

the website and e-mailed to the Adverse Incident 

Centre (AIC) (aic@mhra.gsi.gov.uk), faxed to AIC on 

020 7084 3109, or posted to: 

Adverse Incident Centre 

MHRA 

2/2G Market Towers 

1 Nine Elms Lane 

London SW8 5NQ 

Please help us to improve patient and user safety 

when it comes to medical devices 

Dr S Ludgate 

Clinical Director, Devices 

MHRA 




30 


Diagnosis and Management of PVL- 

Associated Staphylococcal Infections 

C Day, M Morgan 

Panton-Valentine Leucocidin (PVL) is a toxin which 

destroys white blood cells. A new pattern of disease 

due to PVL producing staphylococcus aureus is 

emerging and a working group of the Health 

Protection Agency (HPA) is producing evidence - 

based guidance after reviewing of a number of 

cases in England. 

PVL can be produced by both methicillin sensitive 

staphylococcus aureus (MSSA) and methicillin 

resistant staphylococcus aureus (MRSA), but the 

majority of strains causing infection in the UK to 

date have been MSSA. Community-acquired MRSA 

(C-MRSA) are more likely to produce PVL than 

hospital-acquired MRSA. 

PVL strains are normally associated with necrotising 

pyogenic cutaneous infections classically presenting 

as recurrent folliculitis or abscess formation, and 

occasionally with cellulitis or tissue necrosis 2 . 

However, they can cause severe invasive infections 

such as septic arthritis, septicaemia and toxic shock, 

or community-acquired necrotising pneumonia, 

which is when affected patients are most likely to 

need intensive care 3,4 . 

Skin Infections 

PVL-associated staphylococcal infection should be 

suspected if a patient has recurrent furuncles or 

abscesses, especially if in a high-risk group. 

Contact sport athletes, residents of institutions such 

as military camps, prisons and care homes seem to 

have increased carriage of PVL-producing SA. 

Necrotising Pneumonia 

PVL-producing strains of staphylococcus aureus are 

associated with rapidly progressive, haemorrhagic, 

necrotising community acquired pneumonia in young 

immunocompetent patients, with a mortality rate as 

high as 75%. Most patients developing necrotising 

pneumonia have no history of skin sepsis. 

In primary care, treatment for a post-viral bacterial 

pneumonia should include cover for staphylococcal 

infection. Antibiotics such as co-amoxyclav or 

clarithromycin or related macrolide may be used, or 

if necessary flucloxacillin may be added to the local 

regimen for community-acquired pneumonia. 

Early clinical diagnosis is difficult but essential 

for survival. Typically the following features in a 

previously fit young patient suggest the diagnosis: 

Non-specific findings of flu-like illness, (fever of 

>39°C, tachycardia >140 beats/min myalgia, 

chills). Diarrhoea and vomiting may be due to 

associated toxic shock, which in the setting of 

a significantly raised serum creatine kinase 

suggests myositis. 

Haemoptysis 

Hypotension 

Marked leucopenia 

Multilobar infiltrates on chest X-ray, usually 

accompanied by effusions, and later cavitation 

Very high C-reactive protein level (>250-300 g/L) 

(not found in viral infection) 

Gram film of sputum reveals sheets of 

staphylococci 

N.B. The CURB65 score may be misleadingly low 

in young adults on admission. 

Clinical Management (mainly supportive) 

Some patients deteriorate with alarming rapidity 

making early admission desirable 

Early appropriate antibiotic therapy - see below 

Activated Protein C may be helpful but active 

pulmonary haemorrhage may preclude its use. 

Intravenous immunoglobulin (IVIG) - see below 

Standard surgical masks should be worn during 

intubation and physiotherapy. Closed tracheal 

suction should be used since secondary cases 

may occur. 

Antibiotic Therapy 

Various combinations of vancomycin, clindamycin, 

linezolid, rifampicin and co-trimoxazole in high doses 

have been used 3,4,5,6,7 . Intravenous flucloxacillin 

(2gm 4-6 hourly) may be useful for bactericidal 

action in combination with linezolid (600 mg bd iv) 

and / or rifampicin (300 mg bd iv). Whilst linezolid 

covers MRSA pending antibiotic sensitivity results, 

clindamycin 1.2 g qds may be used as an alternative 

suppressor of toxin production once sensitivity is 

confirmed. Vancomycin should not be used alone 7 . 





Intravenous Immunoglobulin (IVIG) 

IVIG should be considered in addition to intensive 

care support and high dose antibiotic therapy 

because of the high mortality of the infection. 

The dosage of 2g/kg of IVIG recommended in 

streptococcal toxic shock syndrome may be useful 

for PVL-producing staphylococcus aureus infections, 

neutralizing exotoxins and superantigens 7,8,9 . 

8. Norrby-Teglund A, et al. Intravenous immunoglobulin adjunctive 

therapy in sepsis, with special emphasis on severe invasive 

Group A streptococcal infections. Scand J Infect Dis 2003; 35: 

683-689. 

9. Darenberg J et al. Differences in potency of intravenous 

polyspecific immunoglobulin G against streptococcal and 

staphylococcal superantigens: implications and therapy of toxic 

shock syndrome. Clin Infect Dis 2004; 38: 826-42 

Further Information 

Isolates of Staphylococcus aureus from cases which 

may be PVL - related (including community - 

acquired skin infections or pneumonia) should be 

sent to Dr Angela Kearns at the HPA Laboratory of 

Healthcare Associated Infection (LHCAI) at 

Colindale, telephone 0208 327 7227. 

C Day a , M Morgan b 

a. Director of Intensive Care 

b. Consultant in Microbiology 

Royal Devon and Exeter Hospital 

References 

1. Holmes A et al. Staphylococcus aureus carrying Panton-Valentine 

Leukocidin genes (PVL) in England and Wales: frequency, 

characterisation and association with clinical disease. J Clin 

Micro 2005; 43:2384-2390. 

2. Reichert B, Birrell G. Severe non-pneumonic necrotising 

infections in children caused by Panton-Valentine Leukocidin 

producing Staphylococcus aureus strains. J Infection 2005; 

50:438-442. 

3. Gillet Y et al. Association between Staphylococcus aureus strains 

carrying gene for Panton-Valentine leukocidin and highly lethal 

necrotising pneumonia in young immunocompetent patients. 

Lancet 2002; 359: 753-759. 

4. Klein JL et al. Severe community-acquired pneumonia caused by 

Panton-Valentine Leukocidin-positive Staphylococcus aureus: 

first reported case in the United Kingdom. Int Care Med 2003; 

29:1399. 

5. Francis JS et al. Severe community-onset pneumonia in healthy 

adults caused by methicillin - resistant Staphylococcus aureus 

carrying the Panton -Valentine leukocidin genes. Clin Infect Dis 

2005; 40:100-7. 

6. Wargo KA, Eiland EH. Appropriate therapy for community 

acquired methicillin resistant Staphylococcus aureus carrying the 

Panton Valentine leukocidin gene. Clin Infect Dis 2005; 40: 

1376-7. 

7. Micek AT Dunne M Kollef MH. Pleuropulmonary complications 

and Panton-Valentine Leucocidin -Positive Community - Acquired 

Methicillin-Resistant Staphylococcus aureus: importance of 

treatment with antimicrobials inhibiting exotoxin production. 

Chest 2005; 128:2732-2738. 




32 


Reflections on the clinical learning points from the the Royal 

London Hospital Intensive Care Unit following July 7th 2005 

terrorist attacks 

P J Shirley, M Thavasothy, D McAuley, 

D Kennedy, G Mandersloot, V Verma, M Healy 

Background 

The July 7 th bombings resulted in sudden, 

significant increased pressures on emergency care 

resources at Royal London Hospital (RLH), including 

critical care services. A lengthy period of reflection 

has resulted in some observations and learning 

points from these events. 

The RLH has 16 level 3 critical care beds, and a 

six-bedded surgical HDU managed separately by 

surgical teams. Of 703 ICU admissions in 2004, 

98% were emergencies, approximately 30% being 

trauma-related. This workload, coupled with a 95% 

occupancy rate, means that capacity expansion at 

short notice is difficult. 

Major Incident Preparation 

On 7 th July the first RLH intensive care unit (ICU) 

admission occurred at 1300, the initial response 

having commenced with the major incident 

declaration at approximately 0930. Of 15 patients 

in the ICU, 10 were ventilated, 3 of whom were 

considered fit for transfer to St Bartholomew’s or 

the London Chest (LCH) Hospitals, where level 3 

capacity had been increased by cancelling all 

elective cardiothoracic surgery. Fortuitously, 

regional anaesthetic registrars attending training 

were available to assist in patient transfers, and LCH 

also despatched transport teams. A total of 7 ICU 

consultants attended to assist, but none learned by 

paging or mobile phones that a major incident had 

been declared until late in the day (runners proved 

more efficient in disseminating this information). It 

was subsequently revealed that mobile networks 

were blocked to prevent overload and to preserve 

communications for emergency services. 

Five non-ventilated patients were transferred to 

ward areas. Five HDU beds were upgraded to level 

3 status by moving patients to ward care, and 4 

further level 3 beds were established in theatre 

recovery. Although only staffed for 16 patients, the 

main RLH ICU has 18 physical bed spaces, allowing 

2 extra beds to be created. Three unrelated cardiac 

arrest calls required attendance by the critical care 

team during this period. 

The ICU team were involved in the early 

management of patients in the Emergency 

Department (ED), subsequently managing patients 

through triaging, CT scanning, and operating 

theatres. This resulted in improved communication 

with the ICU prior to admission as well as providing 

continuity thereafter. 

Clinical Load 

Of 195 patients seen at the RLH, 27 were admitted, 

and 7 required Level 3 critical care post-operatively 

(Table 1). The average ICU stay was 12 days; one 

patient stayed for 22 days and one died from 

secondary brain injury resulting from prolonged 

hypoxia and two pre-hospital cardiac arrests. 

Learning Points 

1. ED – TRAUMA 

After ‘ABCDE’ management rapid transfer to 

theatre, ideally accompanied by the same team 

throughout. Secondary and tertiary surveys 

should be performed / repeated in theatre and ICU 

as initial ED surveys were often incomplete owing 

to instability. 

Send blood / urine for urgent toxicology (ED 

should have Rapid Test Assay). 

2. THEATRES – SURGERY 

Appropriate decisions by trauma-experienced 

surgeons on limb salvage, debridement and early 

fasciotomies will improve functional limb outcome 

and reduce systemic complications. Ensure all 

entry / exit wounds are adequately explored, as 

correlated with tertiary survey. 

Frequent repeat debridements likely to be 

required, necessitating close liaison with specialist 

surgeons. 

3. ICU 

Anticipate massive fluid requirements; early 

invasive haemodynamic monitoring. 

If haemodynamically unstable consider FAST scan 

and transthoracic echocardiogram (TOE if high 

risk of blunt cardiac injury). 

If transfusion requirements are high, consider 

mediastinal / chest wall, retroperitoneal or femoral 

haematomas. 

Have a low threshold of suspicion for barotrauma 

(pneumothoraces, perforated viscus). 





Consider diagnostic peritoneal lavage (DPL) if 

bowel perforation suspected but unconfirmed 

on CT, checking fluid for soiling, white cells and 

amylase. 

Check limb compartments regularly, distal pulses 

at least four-hourly; track creatinine kinase (CK) 

levels as early indicators of compartment 

syndrome / rhabdomyolysis. 

Repeat surgical exploration if muscle ischaemia / 

necrosis suspected. 

Early DVT prophylaxis, low threshold of suspicion 

for DVT / fat embolus. 

Protective lung ventilation strategies to reduce risk 

of acute lung injury (ALI). 

4. RADIOLOGY 

Established protocols can ensure appropriate 

investigations and reporting by senior radiologists 

(minimum screening in all multi-injured or 

obtunded patients is CT C-spine with 

reconstruction, and anteroposterior / lateral X-rays 

of thoracic and lumbar spine.) 

Ensure orbit and facial views requested at initial 

CT scan depending on secondary survey and time 

available, balanced by additional acquisition time 

and need to image large numbers of patients. 

X-ray reporting best recorded digitally to 

centrally-accessible storage media, to facilitate 

information retrieval. 

5. INFECTION 

Prophylactic antibiotics. 

Virology input – bone / body parts from other 

victims may be embedded in patients, hence risk 

of HIV, hepatitis B & C. Send baseline samples 

for each and give empiric hepatitis B 

immunoglobulin with vaccination. 

Tetanus booster for every patient. 

6. ANCILLARY INJURIES 

Ophthalmology review of every patient to detect 

‘x-ray invisible’ foreign bodies. 

ENT otoscopy to check for ruptured eardrums 

(may indicate other injuries, related to blast force / 

proximity). 

7. SERUM MONITORING 

Regular CK levels 

Pregnancy test for women of childbearing age 

(trans-vaginal ultrasound scan if positive) 

Central venous saturations (ScvO 2 ) as early 

indicator of global perfusion adequacy. 

Discussion 

Our patients demonstrated injury patterns consistent 

with well-publicised pathophysiology reports of blast 

injuries. These can be divided into primary, 

(barotrauma from initial blast wave), secondary 

(projectiles created by the wave) and tertiary (victims 

projected by the wave into stationary objects). 

The nature of the injuries was dependent on the 

proximity of the bomber to the victim and whether 

there were solid structures or other bodies between 

the bomber and victim. 

Following a bomb blast, traumatic limb amputation 

normally only occurs very close to the explosion 2 . 

Patients requiring amputation had massive fluid 

requirements from evaporative and third space 

losses. ScvO2 proved a useful early indicator of 

global perfusion adequacy (> 70%) prior to more 

invasive haemodynamic monitoring. 

Gas-containing organs such as ears, lungs and 

bowel are most vulnerable to primary blast injury. 

Consequently, in anticipation of ALI lung-protective 

ventilation strategies were adopted, using low tidal 

volume ventilation to limit plateau pressures. Blast 

lung as a discrete entity has been reported in up to 

50% of injuries occurring within enclosed spaces 3 , 

but early ALI was not a feature in any of our 

patients. Four patients developed some features of 

ALI at a later stage. 

Although it is established RLH policy for all 

intubated, polytrauma patients to have radiological 

C-spine clearance by a senior radiologist within 24 

hrs 4 this was not achieved for all ICU admissions, 

resulting in significant increases in nursing workload 

to maintain spinal protection. Hard copies of X-ray 

films and scans were often removed by surgical 

teams, and were therefore not available to others for 

review. Ideally they should have been housed in a 

single area to enable immediate access. 




34 


Limb compartments and distal pulses were 

fastidiously checked. Over the ensuing 48 hours 

all ICU patients with limb injuries required repeat 

surgical interventions to ensure early resection of 

non-viable and infected tissue, with most requiring 

repeat debridements. CK values > 5000 were 

treated with fluid, frusemide AND repeat surgical 

review. In several cases delayed compartment 

syndromes were diagnosed by a combination of 

clinical vigilance and rising serial CK levels, 

prompting revised surgical inspection and further 

debridement. 

Up to 28% of blast survivors have eye injuries 5 , 

and hence every patient received slit-lamp 

ophthalmological examination for undetected foreign 

bodies. Otoscopy confirmed at least one perforated 

tympanic membrane in all ICU patients, indicating 

close proximity to the blasts. Although tympanic 

membrane rupture serves as a marker of blast 

exposure, it does not predict progression to 

pulmonary complications 5 and there were no 

subsequent ICU referrals of patients treated for 

tympanic perforations elsewhere in the hospital who 

then developed pulmonary pathology. In the Madrid 

bombings, of 17 critically ill patients with pulmonary 

complications, 13 had ruptured tympanic 

membranes and 4 did not 6 . 

Conclusion 

A number of factors contributed to successful 

outcomes for most ICU patients, including the 

relatively low number of seriously injured casualties 

and the ability to contain them within one unit. Major 

incident training / practices concentrate on the first 6 

hours, yet few patients reached the ICU by this time. 

There is little emphasis on what is now termed ‘the 

prolonged-care phase,’ or the days (and weeks) 

following ICU admission. Useful advice has 

subsequently been obtained from clinicians who 

face such situations more frequently, and from their 

excellent published reviews 8,9 . Recently visits of 

survivors to the ICU or the critical care follow-up 

clinic have proved valuable for patients and 

relatives, as well as many staff members. The 

psychological response to the attacks amongst the 

patients seems variable and after this elapsed time 

there seems to be evidence, unsurprisingly, of 

post-traumatic stress in some 10 . 

Allogenic bone fragments were recovered at surgery 

in several patients, raising concern over blood-borne 

infections. All patients consequently received 

hepatitis B vaccination with serum samples stored 

for later testing if necessary (this was agreed after 

a risk assessment meeting on July 8th with Health 

Protection Agency (HPA) representatives7). 

The decision to withhold anti-retrovirals was in 

accordance with HPA guidance on post-exposure 

prophylaxis in bomb victims. 





Cardiac Tamponade Following Insertion of an Implantable 

Defibrillator in a Patient with Hypertrophic Cardiomyopathy 

R Davis, M B Walker 

Case Report 

A 24-year-old female with hypertrophic 

cardiomyopathy (HCM) had been diagnosed in 

early adolescence as a result of family screening. 

At age 22 symptomatic broad complex tachycardia 

was confirmed by a 7-day loop recorder following 

episodes of palpitations with dizziness. Initial 

treatment with bisoprolol failed to suppress the 

dysrhythmia episodes and amiodarone therapy had 

caused thyroid complications. To reduce the risk of 

sudden death the patient therefore underwent an 

uneventful procedure to insert an implantable 

cardio-debrillator (ICD), following which she was 

discharged home. 

Five days after insertion of the ICD she presented 

to the local Emergency Department with a 48-hour 

history of diarrhoea and vomiting. On assessment 

she was dehydrated, and abdominal examination 

was unremarkable; a diagnosis of gastroenteritis 

was made and intravenous fluid replacement was 

commenced. She was admitted to a general 

medical ward, where despite receiving 4 litres of 

intravenous crystalloid she continued to feel unwell, 

and after 12 hours developed abdominal cramps 

with right upper quadrant pain. Biochemical 

abnormalities were alkaline phosphatase 78 mmol. 

L -1 , bilirubin 20 mmol.L -1 and aspartate 

transaminase 240 mmol.L -1 . Arterial blood gases 

results were pH 7.2, PaO 2 14.5 kPa and PaCO 2 2.3 

kPa on 15L per minute of oxygen with a lactate 5.0 

mmol.L -1 . Serum amylase was normal and an 

erect chest radiograph was unremarkable. Her 

vital signs remained stable with a heart rate 110 

bpm (sinus rhythm), blood pressure 110/60 mmHg 

and a GCS of 15, but she had become tachypnoeic 

with a respiratory rate of 30 breaths per minute. An 

urgent surgical opinion was requested, but before 

the surgical review could take place she 

deteriorated rapidly, developing pulmonary oedema 

and hypotension with a blood pressure of 80/50 

mmHg, but her GCS remained 15. In view of the 

rapidity of her clinical deterioration a decision was 

made to transfer her to the critical care unit. 

Shortly after arriving she sustained a 

cardiorespiratory arrest and cardiopulmonary 

resuscitation was commenced. Ventricular 

fibrillation was identified and external DC 

defibrillation converted the rhythm to ventricular 

tachycardia, but with no palpable pulse. Further 

external defibrillation resulted in PEA which 

subsequently deteriorated to asystole despite 

continued full resuscitation sequences. There 

was no electrocardiographic evidence of activation 

of the ICD during this time. Echocardiography 

performed during the resuscitation demonstrated 

fluid within the pericardium. Pericardiocentesis 

was attempted and 10 mls of blood was aspirated 

with difficulty, but cardiac output was not restored. 

After 45 minutes cardiopulmonary resuscitation was 

discontinued on the grounds of futility. Subsequent 

interrogation of the ICD revealed that no shocks 

had been delivered since its insertion. 

Post mortem examination demonstrated a 

distended pericardium containing 250mls of clotted 

blood as a result of perforation of the right atrial 

appendage by the ICD atrial anchoring wire. 

Examination of the alimentary tract showed 

oedema of the mesentery and the colonic wall with 

no evidence of mucosal inflammation in the large or 

small bowel. The liver and spleen showed marked 

venous congestion and mottling. It was concluded 

that the cause of death was cardiac tamponade 

due to a slow persistent leak from the right atrium 

following perforation by a helical screw wire. The 

abdominal symptoms were the result of venous 

congestion of the bowel and liver caused by 

impaired venous return. Failure of activation of the 

ICD probably resulted from lack of contact between 

the lead and the atrial wall after perforation. 

Discussion 

HCM is a disease of cardiac structure 

characterized by left and/or right ventricular 

hypertrophy involving primarily the interventricular 

septum. The primary haemodynamic disturbance 

caused by muscle hypertrophy is diastolic 

dysfunction, leading to increased filling pressures 

and decreased ventricular compliance. However, 

only 25% of patients with HCM have dynamic left 

ventricular outflow obstruction with a systolic 

pressure gradient. 

Histological appearances of HCM are of myocyte 

hypertrophy with myocardial fibre disarray, most 

pronounced in the interventricular septum. In the 

later stages of the disease there is considerable 

myocardial fibrosis and increased loose connective 

tissue. Around half the cases are familial with 

autosomal dominant inheritance but variable 

penetrance and expression. The remaining cases 

are sporadic. Half of the familial cases arise from 

mutations in the gene coding for the heavy chain of 

ß-myosin on chromosome 14. 




36 


Patients with HCM usually present between 30 

and 40 years of age with chest pain, exertional 

dyspnoea and syncope. However, it can also occur 

in children with a similar presentation occurring 

during adolescence. Some cases present with 

sudden death 1 . Onset of symptoms in early 

childhood is associated with a greater risk of 

mortality; the 10-year mortality for children 

diagnosed before 14 years of age is 50 percent. 

Syncopal events appear to be related to myocardial 

ischaemia and/or ventricular tachycardia. The 

predisposition to arrhythmias arises from several 

factors including hypertrophy, myocardial fibre 

disarray and interstitial fibrosis. 

Patients with HCM at high risk of sudden cardiac 

death (Table 1) may be candidates for an ICD. 

The ACC/ESC guidelines state that this is the most 

effective and reliable treatment option available for 

this group 2 . In this case ICD was offered after 

complications secondary to medical therapy for 

arrhythmia control. 

Table 1: Risk factors for sudden cardiac death in 

patients with HCM 

Risk factors for SCD in HCM 

Family history of HOCM with SCD 

History of Syncope 

Massive Left Ventricular Hypertrophy >30mm 

Survival of Previous SCD 

Symptomatic non sustained Ventricular tachycardia 

Hypotension in response to exercise 

Cardiac perforation is a recognised but rare 

complication of pacemaker and defibrillator 

insertion 3,4 but the presentation of cardiac 

tamponade is usually recognised acutely 5 . 

Cardiac tamponade following a penetrating 

myocardial injury classically presents with Beck’s 

triad of hypotension, muffled heart sounds and 

jugular venous distension. However, in this case, 

the presentation was delayed, with the patient 

initially becoming unwell 3 days after ICD insertion 

and the presenting symptoms and signs were 

primarily of a gastrointestinal nature. This led to 

an initial misdiagnosis of gastroenteritis. The 

pericardial collection inhibited normal cardiac 

filling, and continued fluid resuscitation for 

presumed dehydration in the face of an already 

poorly-compliant ventricle resulted in severe 

pulmonary oedema. 

Despite evidence of a pericardial collection on 

ultrasonography during the resuscitation, aspiration 

attempts were unsuccessful. The post mortem 

revealed that the blood in the pericardium was 

clotted, which probably explains why 

pericardiocentesis proved ineffective. 

In summary, in this case of subacute cardiac 

tamponade following apparently uneventful ICD 

insertion, the clinical symptoms and signs were 

delayed and atypical, with primarily gastrointestinal 

manifestations. A high index of suspicion of 

cardiac tamponade should be maintained by 

clinicians in the early postoperative period following 

ICD insertion. 

In patients presenting with apparent non-cardiac 

symptoms soon after ICD insertion there should be 

a low threshold for performing echocardiography 

and ICD interrogation. 

References 

1. Maron BJ, Shen W-K, Link MS, et al. Efficacy of implantable 

cardioverter-defibrillators for the prevention of sudden death in 

patients with hypertrophic cardiomyopathy. N Engl J Med 2000; 

342: 365-73. 

2. Maron BJ, McKenna W, Danielson GK, et al. ACC/ESC clinical 

expert consensus document on hypertrophic cardiomyopathy: a 

report of the American College of Cardiology Task Force on 

Clinical Expert Consensus Documents and the European 

Society of Cardiology Committee for Practice Guidelines 

(Committee to Develop an Expert Consensus Document on 

Hypertrophic Cardiomyopathy). J Am Coll Cardiol 2003; 42: 

1687-1713. 

3. Dilling-Boer D, Ector H, Willems R, Heidbuchel H. Pericardial 

effusion and right-sided pneumothorax resulting from an atrialfixation 

lead. Europace 2003; 5: 419-23. 

4. Irwin SM, Green GS, Lolue SE. Atrial lead perforation: A case 

report. Pacing Clinical Electrophysiology.1987; 10: 1378-81. 

5. Tran NT, Zivin A, Mozzafferian D, Karmy-Jones R. Right atrial 

perforation secondary to implantable cardioverter defibrillator 

insertion. Can Resp J 2001; 8: 283-5. 





Bedside Ultrasound of Pleural Effusions by UK 

Intensivists: How much training do we need? 

D Y Ellis, R M Grounds, A Rhodes 

Bedside (or handheld) ultrasonography is being used 

in the ICU with increasing frequency, and areas of 

interest include echocardiography, vascular access, 

focussed abdominal ultrasound in trauma (FAST) 

and bladder scanning 1,2 . 

A recent paper showed that bedside ultrasonography 

by intensivists was able to detect and size pleural 

effusions in critically ill patients 3 . However in this 

study all intensivists performing bedside ultrasound 

scanning had ‘level III’ echocardiography training (12 

months training, 300 scans performed, 750 

interpreted 4 ) and an accompanying editorial 

therefore questioned how applicable this study was 

to ‘general intensivists who may have less training 

and experience’ 5 . This raises the question of how 

much training is required to allow general intensivists 

to accurately judge the presence and size of pleural 

effusions using ultrasound technology? 

One of the authors (DYE) is a specialist registrar in 

Intensive Care and Emergency Medicine, and has 

had minimal training in bedside ultrasound consisting 

of a 1 day FAST and central venous line placement 

course and a 2 day emergency echocardiography 

course, both in 2004. Since then he has undertaken 

limited scans in both the emergency department 

and the ICU (total of approximately 50 mostly 

unsupervised scans including ECHO, FAST, chest 

scans and scans to assess the size of the abdominal 

aorta), and has been entering the cases in a log 

book. Usually, the scans are performed 

independently whilst awaiting formal radiology 

department imaging. Over the last year (2005), DYE 

has worked on a London teaching hospital ICU, 

periodically performing bedside chest ultrasound 

scans using a Sonosite 180 ultrasound machine. 

A retrospective analysis of DYE’s logbook was 

performed and comparison made with the radiology 

reports in the patients’ notes. If no formal ultrasound 

report was available then other confirmation of the 

presence or absence of pleural fluid was looked for 

(e.g. CT scan, drainage of effusion or effusion noted 

on echocardiography). The results are illustrated in 

Table 1. This data suggests that the presence of an 

effusion is unlikely to be missed by an intensivist 

with minimal training using bedside ultrasound 

techniques. Comparing accuracy on sizing the 

effusions was more difficult in this analysis due to 

gaps in the data. 

It is our belief that bedside ultrasound imaging 

should be viewed as an extension of the 

stethoscope, and therefore as a part of clinical 

examination when indicated. Clinicians should not 

be afraid of having a ‘quick look’ with the ultrasound 

probe as long as they are aware of its (and their) 

limitations. 

Table 1: Breakdown of pleural ultrasound scans 

performed 

CT – computed tomography, TTE – transthoracic 

echocardiography, TOE – transeosophageal 

echocardiography 

D Y Ellis, R M Grounds, A Rhodes 

General Intensive Care Department, St George’s 

Hospital, London 

References 

1. Beaulieu Y, Marik PE. Bedside ultrasonography in the ICU: part 

1. Chest 2005; 128: 881-95. 

2. Beaulieu Y, Marik PE. Bedside ultrasonography in the ICU: part 

2. Chest 2005; 128:1766-81. 

3. Vignon P, Chastagner C, Berkane V et al. Quantitative 

assessment of pleural effusion in critically ill patients by means of 

ultrasonography. Crit Care Med 2005; 33: 1757-63. 

4. Stewart WJ, Douglas PS, Sagar K et al. Echocardiography in 

emergency medicine: a policy statement by the American Society 

of Echocardiography and the American College of Cardiology. J 

Am Coll Cardiol 1999; 33: 586-8. 

5. Jones AE, Kline JA Pleural effusions in the critically ill: the 

evolving role of bedside ultrasound. Crit Care Med 2005; 33: 

1874-5. 




38 


Update on the ACUTE Initiative 

Dr G Perkins, Dr J Bion 

Recent reports have highlighted serious limitations 

to the care provided for the critically ill patient on 

hospital wards. In many cases, this is related to a 

failure to recognise and intervene in simple aspects 

of acute care such as managing airway, breathing 

and circulation problems 1,2 . This is compounded by 

poor organisation, a failure to appreciate the clinical 

urgency of a situation, lack of supervision, failure to 

seek advice and poor communication 3,4 . Recent 

surveys of acute care knowledge and skills amongst 

medical students and junior doctors demonstrate 

poor understanding of even simple aspects of care 

4,5 

, of particular concern as juniors are often the first 

responders to an acutely or critically ill patient 6 . 

The General Medical Council has for some time 

required medical undergraduates to be able to 

recognise and manage acute illness, and perform 

resuscitation on completion of their training 7 . 

However, there is no national or international 

agreement about what undergraduates should be 

taught to enable them to care for acutely ill patients 

after graduation 8,9 . 

The Acute Care Undergraduate Teaching initiative 

was launched as a joint project between the 

Resuscitation Council (UK) and Intercollegiate 

Board for Training in Intensive Care Medicine in 

response to increasing concerns about the general 

care of the critically ill patient. The project sought 

to develop a framework of core competencies for 

medical undergraduates in the care of acutely ill 

or arrested patient on the premise that improved 

education during undergraduate training would better 

prepare the newly-qualified doctor for the demands 

of clinical practice in today’s NHS. A national 

competency framework for undergraduates should 

also help smooth the transition from undergraduate 

training to the educational programs supporting 

Foundation Year Training. 

Proposals for competencies were invited as part 

of a modified Delphi survey from doctors, nurses, 

medical students, resuscitation officers and 

university teachers. Suggested competencies 

(defined in terms of knowledge, attitudes or skills) 

were submitted electronically via a website hosted 

by the Resuscitation Council (UK). Over 250 

respondents contributed 2629 competency 

suggestions. These were condensed into 95 

representative competency statements under the 

themes listed in Table 1. 

The competency statements were rated individually 

by a nominal group composed of experts in 

resuscitation, education and intensive care. 

Competency statements were then classified as 

essential or optional elements of the curriculum 

based on the nominal group median ratings. 

This resulted in 71 essential and 16 optional 

competencies. Examples are given for airway and 

oxygenation domain in Table 2. Full details of the 

competencies can be found in the original paper 10 

or at the Resuscitation Council (UK) website 

(http://www.resus.org.uk/acute/projrept.pdf). 

The project team hope that these competencies will 

provide a focus for tutors responsible for developing 

training programmes in the care of the critically ill 

patient at undergraduate level. By defining the 

outcomes rather than the process of training, 

standardisation of the end product is encouraged 

whilst respecting diversity of local approaches to 

content delivery and integration with the 

undergraduate curriculum as a whole. 

Dr G Perkins 

Lecturer in Respiratory and Critical Care Medicine 

Dr J Bion 

Reader in Intensive Care Medicine 

University of Birmingham, Birmingham, B15 2TT 

Acknowledgement 

We would like to acknowledge the help and support 

of the ACUTE steering group and members of the 

Nominal Group: Catherine Baldock, Hannah Barrett, 

Ian Bullock, Matthew Cooke, Brian Cuthbertson, 

David Gabbott, Sheena Hubble, Sarah Mitchell, 

Jerry Nolan, Chris Smith, Alasdair Short. 





Table 1: Competency proposals grouped by themes 

Airway and oxygenation 

Breathing and ventilation 

Circulation 

Confusion and coma 

Drugs therapeutics and protocols 

Clinical examination and monitoring 

Team working and organisation 

Patient and societal needs 

Trauma 

Equipment 

Infection and inflammation. 

Table 2: An example of competencies in one domain 

(Airway and Oxygenation). Essential competencies 

are shown in normal type; optional competencies are 

shown in italics 

The Trainee 

Describes the signs of airway obstruction 

Demonstrates safe use of simple airway 

manoeuvres / adjuncts (head-tilt, chin lift, suction, 

oropharyngeal, nasopharyngeal airway) 

Describes the indications and rationale for safe 

oxygen therapy in the critically ill patient 

Describes the principles of controlled oxygen 

therapy in the patient with COPD emphasising the 

importance of alleviating life threatening hypoxia) 

Demonstrates basic treatment for simulated 

choking 

Demonstrates safe and effective use of laryngeal 

mask airway 

Describes the indications for and method of 

needle cricothyroidotomy 

Describes the indications for and method of 

surgical cricothyroidotomy 

Demonstrates safe and effective tracheal 

intubation. 

References 

1. Neale G. Risk management in the care of medical emergencies 

after referral to hospital. J R Coll Physicians Lond 1998; 32: 

125-9. 

2. McGloin H, Adam SK, Singer M. Unexpected deaths and 

referrals to intensive care of patients on general wards. Are 

some cases potentially avoidable? J R Coll Physicians Lond 

1999; 33: 255-9. 

3. Vincent C, Neale G, Woloshynowych M. Adverse events in 

British hospitals: preliminary retrospective record review. BMJ 

2001; 322: 517-9. 

4. Smith GB, Poplett N. Knowledge of aspects of acute care in 

trainee doctors. Postgrad Med J 2002; 78: 335-8. 

5. Ringsted C, Schroeder TV, Henriksen J et al. Medical students' 

experience in practical skills is far from stakeholders' 

expectations. Med Teach 2001; 23: 412-6. 

6. National Confidential Enquiry into Patient Outcome and Death. 

An Acute Problem. http://www.ncepod.org.uk/2005report/. 2005. 

7. General Medical Council. Tomorrow’s doctors: 

Recommendations for Undergraduate Education. London: 

General Medical Council, 2003. 

8. Shen J, Joynt GM, Critchley LA, Tan IK, Lee A. Survey of 

current status of intensive care teaching in English-speaking 

medical schools. Crit Care Med 2003; 31: 293-8. 

9. Frankel HL, Rogers PL, Gandhi RR, Freid EB, Kirton OC, 

Murray MJ. What is taught, what is tested: findings and 

competency-based recommendations of the Undergraduate 

Medical Education Committee of the Society of Critical Care 

Medicine. Crit Care Med 2004; 32: 1949-56. 

10. Perkins GD, Barrett H, Bullock I et al. The Acute Care 

Undergraduate TEaching (ACUTE) Initiative: consensus 

development of core competencies in acute care for 

undergraduates in the United Kingdom. Int Care Med 2005; 31: 

1627-33. 




40 

Lemmingaid 

Kafka and the Clinical Director 

In this new world of appraisal, audit and reflective 

life-long learning it often seems that we have ample 

opportunity to take a long hard look at ourselves in 

the mirror and deduce what we are ‘really’ like – 

strengths, weaknesses, vices and virtues. Complete 

nonsense, of course. Forthright criticism we dismiss 

as ‘unfair’ whereas gentler criticism normally comes 

from those too serpentine to be easily understood. 

So, we potter along unconscious of our impact, 

unknowing of our capabilities and unaware of 

whether we are liked, possibly admired or merely 

tolerated. These soul-searchings are mostly of no 

great consequence except when the spinning bottle 

of clinical management happens to point to you 

when it stops. 

Clinical management is something most doctors 

avoid – and rightly. Given the choice between 

stabbing yourself in the neck with a biro, wetting 

your nose and sticking it in a light socket or 

becoming a clinical manager, clearly the last is the 

least attractive. There are up-sides; your jaded 

clinical job seems like paradise- lost, people know 

who you are and once in a decade you might make 

some small difference. The down-sides are; lots 

more work, the people who know who you are now 

want something from you and you don’t make a 

difference. (It is claimed that clinical managers merit 

award application sometimes get binned by the 

powerful whom they have cheesed off along the 

way). 

How did all this happen? I will share my reflections 

with you, dear reader, so that you can be broadly 

forewarned when the spinning bottle stops at you. 

As for myself, a collective whim of the department 

fatally combined with managerial acquiescence 

resulting in me becoming Clinical Director. The 

barely suppressed mirth of those who congratulated 

me was frankly repulsive. 

To be honest, I was flattered – so, no reflective 

cognition here. To date, I had shown no managerial 

interest / experience / capability... the list of qualities 

necessary for the job, which I surely did not 

possess, could stretch from here to Budapest in 

size 12 Font. The outgoing Clinical Director made 

transparently facetious assertions like: ‘You’ll 

enjoy it’ and ‘It will be good for you’. Ha! Proper 

self-awareness would have screamed ‘No!’ at the job 

I was taking on. 

The day he quit, I entered a Kafka-esque world 

where people thought, spoke and did things 

differently. The months turned into years and, it 

was an embarrassingly long time before I realised 

you only need one quality to succeed in clinical 

management – a taste for the absurd. And so here 

are random thoughts painfully gleaned. 

Power. An old proverb from Pakistan roughly 

translates as: Always vote for the man that doesn’t 

want the job. If you are a power-junky, then you’re 

probably crazy. Consultant colleagues are your 

equals; attempting to cajole them against their 

wishes usually results in an intransitive prepositional 

exclamatory phrase beginning and ending with ‘F’. 

Invoking an esprit de corps is about your only hope - 

doctors are more concerned with what their 

colleagues think of them than what management 

thinks of them. 

Reputations. These are achieved very quickly – but 

can take a lifetime to shake off. As Mark Twain 

said: Get yourself a reputation as an early riser and 

thereafter you can sleep ‘til lunch. Actions speak 

louder than words – so just telling everyone how 

fantastic and hard working you are will earn you a 

reputation, but not the one you’re looking for. A 

small effort at the beginning of your consultant life 

could earn you the reputation as someone who 

has ‘guts’ – failure to make this effort can tend to a 

reputation for being one end of the alimentary tract 

or the other, which is not so nice. 

Hard work. All doctors are mildly delusional. We 

all believe we work very, very, very hard. Some 

doctors do work very, very, very hard; others work 

very, very hard and the rest work very hard. You 

can distinguish these three groups because they are 

exhausted, quiet and bellicose respectively. There 

is an inverse relationship between ‘very’ count and 

bellicosity. As any biological characteristic is 

normally distributed in any population then hard 

work is unlikely to be different. Curiously, everyone 

knows who is at the lower end of the effort bell curve 

except those individuals who are there. If you then 

begin to compare what consultants within your own 

specialty do with other specialties you feel both 

furious (some specialties are a bit of a doss) and 

humble (some specialties really work their socks off). 

Finance. Budgets are an illusion. I don’t suggest 

that financial control isn’t a worthy occupation. No, 

but if all the anaesthetic monitors blow a fuse or 

there are no anaesthetists to watch them then 

money will be found, and it doesn’t matter how 

many digits in the red your directorate is. There is 

a pot and it isn’t at the end of a rainbow – it’s just 

that you may need to produce reams of supporting 

documentation which often turns out be more 

expensive than the thing you want money for. 




Lemmingaid continued 41 

Meetings. It is a mistake to attend all meetings – 

of which there are squillions. I did this at first but 

my psychiatrist became worried and advised me to 

be more selective. After following his advice, I 

cancelled my subscription to ‘Rifle’ magazine and 

stopped stockpiling weapons in the garden shed. 

Trust Executive meetings follow a familiar seasonal 

pattern: Summer – hot, lazy and boring. Autumn – 

half-yearly financial position declared, year-end 

predictions computed. Winter – Yikes! Predictions 

are now way off the map. Extra waiting lists! No 

cancelled operations! Close ITU beds! Arrrgh! 

Spring: - Phew, we just made it, again. Its familiar 

repetition almost became comforting after a while. 

Employment law. This is an area where familiarity 

leads to utter contempt. I shall not expound widely 

on this, suffice to say that being on sick leave does 

not prevent you going skiing, on a Mediterranean 

cruise or a diving holiday in Tobago. I would have 

thought it did – but I was wrong. And be careful how 

you ask someone if they would please turn up to 

work and do the job they are paid to do – that is 

probably bullying as defined by the ‘Dignity at work’ 

policy. 

Holidays. Statutory and religious holidays. All 

faiths are equal but some have more holidays. 

Every faith group must be allowed time off to 

celebrate their religious holidays – ‘fair enough’, I 

say. No NHS employee should have more time off 

than any other equivalent worker – ‘fair enough’, I 

say again. No one wants to work Christmas day – 

Erm… try squaring that circle year after year? 

Annual leave is an even greater giggle – thankfully 

not in our department; but a Surgical Consultant 

baulked at filling in leave forms, commenting 

unaffectedly that: ‘A Gentleman takes as much 

holiday as he needs’ (!) 

Higher Awards. Who said modern medicine 

excludes those with a poetic bent? These forms are 

a tribute to poetic licence and creative thinking. 

People who have time to fill in the form are lying on 

the form. This is not exactly fair, I recognise – but 

there is a skill to filling in the form. Humility and 

dyslexia, often the domain of deserving individuals, 

just doesn’t cut it. Highest Award holders are mostly 

distinguished by the company they keep. (That’s 

blown my chances, then). 

laity, as this should not be an option and runs 

counter to ‘Patient Choice’. Dealing with complaints 

is the Directors turf. Often the complaints are 

tendentious. But beware smugness; complaints are 

rarely malicious, some do have reasonable grounds 

- but so often the real medical Lulu’s go unnoticed 

and are never mentioned in the letters. 

Miscellaneous. A few translations: Drill down – 

all the data we have collected up to now is 

meaningless…we’ll have to start again. Think 

outside the box - start again. Suggestion – 

something sensible to ignore. Contribution – 

something useless to ignore. Sharing – something 

senseless that will inform the whole project design. 

Business Plan – a ritual designed to exhaust 

clinicians, delay and ultimately refuse what they 

need and warn them off ever making such spurious 

claims in the future. Patients – these are not the 

sick people in beds but the representatives who sit 

on every damn project committee including the Toilet 

Rebuild 2007 project. These representatives will 

never sit on the rebuilt toilets, however - because 

they’re not real patients. 

Why is the acronym for the Department of Health 

the same thing Homer Simpson says when he 

realises he’s done something stupid? ‘;DoH!’ Most 

documents it produces talk of ‘strategy’ – and is as 

useful as the strategy developed by a blindfolded 

convict tied to a post in front of a firing squad. 

Having befriended and flattered another colleague 

into being Clinical Director, I’ve now left Kafka’s 

world. I will leave you with a quote from Albert 

Einstein when returning a loaned copy of a Kafka 

novel to its owner: ‘I couldn’t read it for its perversity. 

The Human mind isn’t complicated enough.’ I 

feel that about the NHS – perverse, chaotic and 

complex. Like the young crab said on the edge 

of the pool of tears in Alice’s Adventures in 

Wonderland: ‘It’s enough to try the patience of an 

oyster!’ But you’ve got to love it too – what else are 

you going to do? 

Wood and Trees 

Complaints. Healthy people are usually outside 

hospitals and sick ones are inside. Increasing 

sickness has a positive correlation with morbidity 

and mortality. It comes as no surprise that 

sometimes patients don’t get better, they may 

even die. The force of this logic often eludes the 




42 

CATmaker Reviews 

Rescue Angioplasty vs Repeat 

Thrombolysis in Acute MI? 

In patients with failed primary thrombolysis 

following an acute MI, when compared with 

non-PCI management (pooled results of 

conservative management & repeat 

thrombolysis), PCI reduces cardiac and cerebral 

events (NNT=12) and “all-cause” mortality (NNT 

= 16). However, when compared directly with 

either conservative management OR repeat 

thrombolysis there was no mortality benefit. 

Level of Evidence: 1 + (RCT with a low risk of 

bias) 

Citation: Gershlick AH, Stephens-Lloyd A, Hughes 

S et al for the REACT Trial Investigators. Rescue 

angioplasty after failed thrombolytic therapy for acute 

myocardial infarction. N Engl J Med 2005; 353: 

2758-68 

Lead author's name and email: Anthony Gershlick, 

agershlick@aol.com 

Three-part Clinical Question: 

Patients: Suffering from an acute ST elevation 

myocardial infarction that failed to show >50% 

resolution of ST segment elevation within 90 minutes 

of receiving thrombolysis. 

Treatment: Percutaneous Intervention (PCI) vs. 

Repeat Thrombolysis vs. Conservative Management 

Outcomes: Primary = Composite of cardiac and 

cerebrovascular events (all cause mortality, cardiac 

The Evidence 

mortality, recurrent myocardial infarction, 

cerebrovascular event and severe heart failure). 

Secondary = risk of major and minor bleeding and 

need for revascularisation. 

Search Terms: Myocardial infarction, management, 

PCI, thrombolysis 

The Study: Double-blinded concealed randomised 

controlled trial with intention-to-treat. 

The Study Patients: All patients with an acute 

ST-elevation infarction who received thrombolysis 

within 6 hours of the onset of chest pain but in whom 

there had been less than 50% resolution of ST 

segments 90 minutes after starting thrombolysis. 

Exclusion criteria included cardiogenic shock, LBBB 

and a haemoglobin >1.5g/dl below the normal range 

within the previous 6 hours. 

Control group (N = 283; 283 analysed): 

Conservative management (intravenous heparin 

titrated to an APTT ratio of 1.5-2.5) or repeat 

thrombolysis using a fibrin-specific thrombolytic 

agent plus intravenous heparin. 

Experimental group (N = 144; 144 analysed): 

Coronary angiography, +/- angioplasty, +/- adjuvant 

therapy (stenting or glycoprotein IIb/IIIa inhibitors) 

determined at the time of PCI. 

Outcome Time to Outcome CER EER RRR ARR NNT 

Cardiac and 6 months 0.233 0.153 34% 0.080 12 

Cerebrovascular 

events 95% Confidence Intervals: 1% to 67% 0.003 to 0.157 6 to 303 

Mortality 6 months 0.127 0.063 50% 0.064 16 

(all cause) 

95% Confidence Intervals: 7% to 94% 0.009 to 0.119 8 to 118 

Mortality 6 months 0.102 0.056 45% 0.046 NS 

(cardiac cause) 

95% Confidence Intervals: ns ns ns 

Non-Event Time to outcome/s Control group Experimental P-value 

Outcomes 

group 

22.4% (Conservative) 

Revascularisation 6 months 

25.6% (Repeat Thrombolysis) 

13.8% p=0.05 




CATmaker Reviews continued 43 

Comments: 

1. Do the methods allow accurate testing of the 

hypothesis? Yes 

2. Do the statistical tests correctly test the results 

to allow differentiation of statistically significant 

results? Yes 

3. Are conclusions valid in light of the results? Yes 

- their primary outcome measure was a 

composite of death, recurrent MI, severe heart 

failure and cerebrovascular events. 

4. Did results get omitted, and why? Yes. Patients 

randomized to one arm were allowed to have 

another treatment if the investigators thought 

that it was clinically indicated, for instance, due 

to ongoing chest pain or the development of 

cardiogenic shock. However, analyzing on an 

intention-to-treat basis did not change the 

statistical outcome. 

5. Did they suggest areas of further research? No, 

although given the trend towards reduced 

mortality, repeating this study with mortality as 

the sole primary outcome measure may lead to 

a positive answer. Unfortunately this trial was 

stopped early due to problems with recruitment 

and funding. 

10. What grade of recommendation can I make 

when this study is considered along with other 

available evidence? B 

11. Should I change my practice because of these 

results? Only if all patients who don’t receive 

adequate reperfusion after thrombolysis go on to 

receive rescue PCI as routine management. 

There is insufficient evidence to recommend this 

at present. Conservative management is as 

effective as repeat thrombolysis. 

12. Should I audit my current practice because of 

these results? Yes, although you may have too 

few patients to come up with any meaningful 

outcome. 

Appraised by: Stephen Harris, Department of 

Anaesthesia & Critical Care Medicine, Torbay 

Hospital, Lawes Bridge, Torquay, DEVON TQ2 7AA.; 

14 January 2006 

Email: stepharr@hotmail.com 

Kill or Update By: Jan 2010 

Reviewed & Edited by CC & BT 

6. Did they make any recommendations based on 

the results and were they appropriate? Yes. 

Rescue PCI is indicated in failed thrombolysis. 

Given that this reduces recurrent MI but not 

outcome measures such as morbidity or 

mortality, this needs to be interpreted with 

caution. 

7. Is the study relevant to my clinical practice? Yes 

8. What level of evidence does this study 

represent? 1 + (RCT with a low risk of bias) 

9. What grade of recommendation can I make on 

this result alone? B 




44 

CATmaker Reviews continued 

Furosemide and Albumin Improve Oxygenation in 

a Small Group of Patients with Acute Lung Injury 

Using furosemide combined with albumin in 

the treatment of hypoproteinaemic patients with 

acute lung injury improves oxygenation. Further 

studies are required to determine clinical 

outcomes such as survival and duration of 

mechanical ventilation. 

Level of evidence: 1 - (RCT with a high risk of 

bias) 

Citation/s: Martin GS, Moss M, Wheeler A, Mealer 

M, Morris J, Bernard G: A randomised, controlled 

trial of furosemide with or without albumin in 

hypoproteinaemic patients with acute lung injury. 

Crit Care Med. 2005; 33:1681-7 


Patients: Hypoproteinaemic patients with acute lung 

injury. 

Intervention: Treatment of furosemide with or without 

albumin. 

Outcome: Improved oxygenation. 

Search Terms: acute respiratory distress syndrome; 

acute lung injury, albumin; blood proteins; 

hydrostatic pressure; hypoproteinaemia; lung 

diseases; osmotic pressure 


The Study: Double-blinded concealed randomised 

multi-centred controlled trial with intention-to-treat. 

In 11 medical, surgical and trauma ICUs in North 

America. 

The Study Patients: Patients were eligible that had 

each of the following criteria: American-European 

Consensus Conference definition for ALI, serum total 

protein level ≤6.0g/dl, ongoing nutritional support 

and mechanical ventilation for >24hrs. Patients 

were excluded for haemodynamic instability, renal or 

liver disease, allergy, pregnancy, age



EBM Questions: 



2. Do the statistical tests correctly test the results to 

allow differentiation of statistically significant 

results? Yes 


4. Did results get omitted, and why? No 

5. Did they suggest areas of further research? Yes. 

Their suggestion is that a large-scale randomised 

trial is warranted to determine clinical benefit in 

mechanical ventilation. 


the results and were they appropriate? No 

7. Is the study relevant to my clinical practice? To a 

limited extent, Yes. The small number of patients 

in this study (n=40) with the large number of 

excluded patients (n=309) make this a minority 

subgroup of hypoproteinaemic patients with acute 

lung injury but without shock. Additionally, there 

was no proven improvement in patient survival. 



available evidence? None 


results? No 


these results? Yes, if you use furosamide and 

albumin in ALI patients you should review your 

practice 

Appraised by: David MacNair and Dr BH 

Cuthbertson, Intensive Care Unit, Aberdeen Royal 

Infirmary, Foresterhill, Aberdeen AB25 2ZN ; 13 

September 2005 

Email: davidmacnair@doctors.net.uk 

Kill or review by: May 2010 

Reviewed & edited by CC & BT. 


represent? Level 1- (RCT with a high risk of bias 

due to small sample size.) 


this result alone? None 




46 


Corticosteroids in Late ARDS 

The treatment of late ARDS with 

methylprednisolone does not improve mortality 

but may reduce the duration of ventilation. 

Level of evidence: 1+ (RCT with a low risk of 

bias) 

Citation/s: The National Heart, Lung, and Blood 

Institute Acute Respiratory Distress Syndrome 

(ARDS) Clinical Trials Network. Efficacy and Safety 

of Corticosteroids for Persistent Acute Respiratory 

Distress Syndrome. NEJM 2006; 354: 1671-1684. 

Lead author: Kenneth Steinberg 


Patients: Patients with late stage ARDS 

Intervention: High dose methylprednisolone 

Outcome: (Primary) Mortality, (Secondary) 

ventilator-free days, organ-failure-free days. 

Search Terms: ARDS; therapy. 

The Study: Single-blinded randomised controlled 

trial with intention-to-treat. 

The Study Patients: Late stage ARDS according to 

American European Consensus Conference criteria 

still requiring mechanical ventilation for 7-28 days 

after onset of ARDS. 

Control group (N = 91; 91 analysed): No specified 

ventilatory strategy (probably not controlled) until 

1999 then standard ARDSnet ventilation strategy 

after 1999 and weaned according to a standardised 

weaning protocol. 

Experimental group (N = 89; 89 analysed): 

No specified ventilatory strategy (probably not 

controlled) until 1999 then standard ARDSnet 

ventilation strategy after 1999 and weaned according 

to a standard weaning protocol plus the addition of 

corticosteroids. Methylprednisolone 2mg/kg as one 

off dose followed by 0.5mg/kg six hourly for 14 days, 

0.5mg/kg twelve hourly for 7 days then tapered to off 

over 4 days if still ventilated or over 2 days if not 

ventilated or patient had developed fungal infection 

or septic shock. 


Outcome Time to Outcome CER EER RRR ARR NNT 

Mortality 60 days 0.286 0.292 -2% -0.006 NS 

Oxygenation 

95% Confidence Intervals: ns ns ns 

Mortality in early 60 days 0.364 0.273 25% 0.091 NS 

group randomised 

between 7-13 days 95% Confidence Intervals: ns ns ns 

Mortality in late 60 days 0.080 0.348 -335% -0.268 -4 

group randomised 

between 14 and 95% Confidence Intervals: -612% to -58% -0.490 to -0.046 -22 to -2 

28 days 

Non-Event Outcomes Time to outcome/s Control group Experimental group p-value 

Ventilator- free days 28 days 6.8 11.2



Comments: 


hypothesis? This is in question. The study ran 

for 7 years partly due to factors outside the 

control of the authors and clinical practice 

changed markedly in this time (i.e. the 

publication of the ARDSnet study in 2000). 

Study patients were changed to ARDSnet 

ventilation after 1999 and their ventilation was 

not protocolised before this time. Further, the 

patient number for the entire study and for all 

subgroups is far below the original power 

calculation. Although not fully explained they 

probably relate to poor recruitment rather than 

any genuine change in estimated mortality. The 

trial only recruited 5% of available patients so 

limiting the trial results applicability. The late 

treatment subgroup (14-28 days) was clearly 

post-hoc as it was not stated in the trial protocol 

with all the problems associated with such 

analysis. With a total of 48 patients in the 14-28 

day subgroup (2 deaths in control group and 8 in 

treatment) this result should not be considered 

valid as it is grossly underpowered. One extra 

death in control group would make this 

non-significant. 



results? Yes. 

3. Are conclusions valid in light of the results? 

They conclude that the results do not support 

the routine use of methlyprednisolone in 

prolonged ARDS. This is a reasonable 

conclusion. They also conclude that starting 

methylprednisolone more than two weeks after 

onset of ARDS may increase mortality. This may 

lack validity due to very small event numbers. 

4. Did results get omitted, and why? No. 

5. Did they suggest areas of further research? No. 


the results and were they appropriate? Yes. 

They concluded that results did not support the 

routine use of methyprednisolone in ARDS. 

This seems a reasonable recommendation. Is 

the study relevant to my clinical practice? They 

recruited from a group of all comers with ARDS 

who are still ventilated after 7 days but they only 

recruited 5% of the available patients thus 

limiting the generalisability of the result. 

Extrapolating the lack of clinical benefit in such 

a highly selected group of patients to all ARDS 

patients may be questionable. What level of 

evidence does this study represent? 1 + . 


this result alone? B. Steroids do not improve 

mortality in late (>7 days) ARDS who still require 

mechanical ventilation. There appears to be 

some benefit in terms of the secondary 

outcomes of duration of ventilation and ICU 

stay although late readmission to ICU in the 

treatment group makes this non-significant at 

180 days. 



available evidence? B also as this study is the 

only valid randomised controlled trial in this 

group of patients. The previous study by Meduri 

et al was extremely small and lacked internal or 

external validity. 


results? Yes. If you use steroids in late ARDS 

you should review your practice. The further use 

of this therapy depends on the interpretation of 

the importance of the effects on duration of 

ventilation at 28 days. In light of the lack of 

effect on other clinically important outcomes and 

the presence of some serious side effects such 

as myopathies (which may lead to an increased 

requirement for re-ventilation during the study 

period), this reviewer suggests that this 

treatment should not be used for this indication. 


these results? Yes. If you use steroids you 

should consider auditing your results. If you 

intend to start using steroids for the ventilatory 

benefits you should also audit your results 

prospectively including the presence of side 

effects such as weakness syndromes, sepsis, 

hyperglycaemia etc. and longer term outcomes 

such a 180 day mortality, ventilatory status and 

ICU stay. 

Appraised by: BH Cuthbertson, Intensive Care Unit, 

Aberdeen Royal Infirmary, Aberdeen, Scotland. 44 

(0)1224 554580; 08 May 2006 

Email: b.h.cuthbertson@abdn.ac.uk 

Kill or Update By: 8th May 2008 

Reviewer & edited by CC & BT 




48 


Non-Invasive Ventilation in Patients with Acute 

Cardiogenic Pulmonary Oedema: A Meta-Analysis 

The use of CPAP in cardiogenic pulmonary 

oedema significantly reduces mortality. Bi-level 

ventilation is associated with a non significant 

trend towards reduced mortality 

Level of Evidence: 1 + (meta-analysis with low 

risk of bias) 

Citation/s: John V. Peter, et al. Effect of noninvasive 

positive pressure ventilation ( NIPPV) 

on mortality in patients with acute cardiogenic 

pulmonary oedema: a meta-analysis. Lancet 2006; 

367: 1155-63 

Lead author: John L Moran 


Patients: Patients with cardiogenic pulmonary 

oedema. 

Intervention: NIPPV (CPAP and Bi-level) 

Outcomes: Reduce mortality, need for IPPV, length 

of hospital stay and what are the associated failure 

rates plus incidence of new MI. 

Search Terms: Pulmonary oedema, heart 

The Evidence: 

failure, respiratory insufficiency, positive pressure 

ventilation, continuous positive airway pressure, 

non-invasive ventilation, non-invasive positive 

pressure ventilation, nasal ventilation and BIPAP 

The Review: 

Data Sources: Cochrane Library, Medline, Embase, 

Citation Index, hand search, non-English sources, 

Am. Coll. Of Physicians (ACP) J Club, DARE 

Study Selection: Randomised trials on acute 

cardiogenic pulmonary oedema. Comparing 

standard therapy (oxygen by facemask, diuretics, 

nitrates and other supportive care) with CPAP or 

Bi-level NIPPV. Only trials reporting hospital 

mortality or need for IPPV were included. Trials 

classified into 3 groups: (i) CPAP versus standard 

therapy, (ii) bi-level ventilation versus standard 

therapy and (iii) CPAP versus bi-level ventilation. 

Data Extraction: The studies were reviewed by 

two investigators, differences in opinion settled by 

consensus. They were tested for heterogeneity. 

Comparison Mortality RR (95% CI) p-value NNT 

CPAP vs standard therapy 0.59 (0.38-0.90) 0.015 10 

Bi-level ventilation vs 0.63 (0.37-1.10) 0.11 NS 

standard therapy 

Bi-level ventilation 0.75 (0.40-1.43) 0.38 NS 

vs CPAP 

Other results comments: No comment made 

on mode of delivery of NIPPV. Study sample sizes 

relatively small. Included studies appear of 

intermediate quality. No difference in mortality 

between CPAP and BiPAP. Significant reduction 

in need for IPPV for both CPAP and BIPAP. No 

significant difference in hospital stay between 

treatment groups. Weak evidence of an increase 

in new MI with Bi-level ventilation. 

EBM Comments: 





results? Yes 


4. Did results get omitted, and why? Yes. Studies 

not randomised or inappropriate endpoints. 

Descriptive studies. 

5. Did they suggest areas of further research? Yes. 

Role of PEEP/EPAP in relation to increased 

incidence of MI. Role of BiPAP in hypercapnic 

patients. 


the results and were they appropriate? Yes. That 

the British Thoracic Societies recommendations 

are appropriate: CPAP should be used in 

patients with cardiogenic pulmonary oedema 

who still have hypoxia despite the best medical 





treatment, and reserve the use of bilevel 

ventilation for patients in whom CPAP is 

unsuccessful. 

7. Is the study relevant to my clinical practice? Yes 


represent? 1 + (meta-analysis with a low risk of 

bias) 


this result alone? A 



available evidence? A 


results? Yes. If you are not currently using NIV in 

the management of cardiogenic pulmonary 

oedema, you should consider adding it to your 

medical treatment. 


these results? Yes 

Appraised by: Brian Digby, SpR in Anaesthesia & 

Intensive Care, Stirling Royal Infirmary ; 24 April 

2006 

Email: briandigby@hotmail.com 

Kill or Update By: May, 2011 

Reviewed & Edited by CC & BT. 




50 

Manpower 

It is that time again! 

Manpower Census 2006 

Dear Colleagues, 

I have written about Manpower census on many 

occasions. In the past, it has mostly been about the 

new online Manpower census that is available on the 

Society’s website. The census runs yearly and yes, 

it is time to be counted again. 

Manpower census is an important venture of your 

Society on behalf of the profession. This important 

information will be useful in planning for the future of 

the speciality as well as in organising the training, 

especially as the training of doctors is undergoing 

massive changes. 

The online census will go live later on towards the 

end of July 2006 and I urge you all to fill in the forms 

to make this data gathering venture a success. Due 

to a changeover to a new database, this year I 

request you to fill in the form again. You will need 

your GMC registration number as a unique identifier. 

This is to make sure that there are no repetitions. 

Periodically, emails will go out to remind colleagues 

to fill in the forms, if not done already. I believe the 

web-based census will be a success as last year 

about one fifth of the forms were filled by those 

colleagues who are not yet members of the society. 

There will be other initiatives to complement the 

manpower census. One example of these initiatives 

will be to send out a set of questions to the Linkmen. 

I assure the Linkmen that there are only a few 

simple questions to fill in. The questions are 

designed to get basic information about the 

workforce in your ICU. 

I thank you all for your cooperation and hope to 

present meaningful data about intensive care 

manpower in my next report. 

R Kishen 

Chair, Manpower Committee 




Correspondence 51 

Aussie Training - A Perspective 

from Down-Under 

Dear Sir, 

I was interested to read the article “Working in a UK 

Critical Care Department – a Perspective from 

Down-Under”, as I am in a similar, albeit reverse 

position. Having completed my CCST, 18 months 

ago I ventured down-under to work in an Australia. 

My first hurdle was the amount of form filling and 

applications for various authorities, all of which were 

alien to me. I have to say I still only have only a 

faint understanding of what they were all for. 

Bizarrely I found the easiest thing to do was open a 

bank account - I didn’t even need a dollar! 

I had not expected to find as many differences in the 

UK and Australian medical systems as I did. Some 

were trivial differences, such as having to use mmHg 

rather than kPa for blood gas measurements, which 

was actually a lot harder than I had imagined. 

Generic names for drugs were often not used, and 

so there was a ‘relearning’ of drug names. I also 

discovered that the Australians are even worse at 

using three-letter-abbreviations than the Europeans. 

Language shouldn’t have been an issue but there 

were times I did wonder if we were all speaking in 

the same tongue! 

Referring to Dr McGloughlin’s comment regarding 

the SHO post, I noticed differences in the description 

of training levels. Many doctors did not have the 

opportunity or expectation to gain practical skills 

whilst in the resident (SHO) post. Some UK 

graduates who had been SHOs in the UK were 

surprised to find themselves in Registrar posts in 

Australia, but were certainly able to cope. 

You get a better feel for the size of the country living 

and working here. With most of the population 

clustered around the major cities, you start to look 

at the transfer of patients in a different light. For 

example, most multi-trauma in Victoria is brought to 

one of the trauma hospitals within Melbourne. This 

could mean regularly transferring an unstable patient 

300km from the east or west, or even 500km from 

the north. When you consider some of the distances 

to be covered in outback Australia, you develop a 

tremendous respect for the air retrieval services 

such as the Royal Flying Doctor Service. 

Neurosurgery and cardiothoracic surgery are 

likewise centralised, which means the families 

are also often travelling great distances. 

I would thoroughly recommend a period of overseas 

training, and it is good to see more formal links 

being made through the Australia and New Zealand 

Intensive Care Society. I have met numerous 

Australian doctors who have spent time working in 

the UK, and they all have a story to tell regarding 

their time overseas. I hope that on my return, I too 

can spin a few yarns and sink a few bevvies with 

Australian doctors working up-top. 

S Blakeley 

Senior Registrar Intensive Care 

Melbourne, Australia 

Having solely worked in a public system with very 

little expose to the private sector, I found it strange 

coming to a system with such a split public and 

private system. I have now seen both the Australian 

public and private ICU systems and have formed my 

own opinions. However, you come to realise how 

relatively shielded you are from the grisly concept of 

money as a trainee in the NHS - something which 

has its good and bad points! 




52 

Correspondence continued 

National Critical Incidents Reporting Scheme 

Dear Sir, 

National Critical Incidents Reporting Scheme 

I read with interest the article by Thomas and 

others 1 about the development and analysis of a 

database to record critical incidents associated 

with intravenous drug administration in critically 

ill patients. 

There is no mention in this article of the National 

Patient Safety Agency’s National Reporting & 

Learning System (http://www.npsa.nhs.uk/health/ 

reporting), which has been rolled out to a significant 

majority of NHS Trusts. Anonymised data from all 

incidents reported within all participating NHS Trusts 

is being sent in a semi-automatic fashion to the 

National Patient safety Agency, and it is very likely 

that the Trusts involved in this article are already 

submitting incident data (including that related to 

intravenous drug administration in critical care). 

I strongly recommend that the Intensive Care 

Society works with the National Patient Safety 

Agency to improve the reporting rate of adverse 

incidents within all UK critical care areas within the 

framework of the National Reporting & Learning 

System, rather than attempting to develop an 

additional isolated database. 

Yours sincerely 

Dr J Mitchell 

Lead Clinician in Clinical Risk 

Harefield Hospital 

References 

1. Thomas AN, Boxall EM, Sabbagh G et al, Journal of Intensive 

Care Society, 2006 7: 22-24 

A Reply from the Author 

Dear Sir, 

A national critical incident reporting system for 

Intensive Care would have very significant 

advantages for our patients. It would seem 

appropriate for this to be run by the National 

Patient Safety Agency and this should be the 

way forward if: 

1. This allowed staff to report incidents with out 

having to classify them at the time they are 

submitting them. 

2. The classification of incidents is relevant to 

critical care. 

3. Information about the nature and frequency of 

incidents is provided in a timely manner back to 

critical care units in a way that could allow them 

to benchmark with other units and to improve 

patient care. 

I note from the NPSA website that its national 

reporting system has been in operation since 2004. 

I am a Clinical Director of a large Intensive Care Unit 

in a hospital that submits critical incidents to this 

scheme. Unfortunately I have yet to see any feed 

back from this NPSA scheme as to the nature of 

critical incidents in Intensive Care or any idea of 

their frequency. 

The database described in our paper 1 provides a 

simple system to collect and classify critical incidents 

associated with IV Medications. Its use in a small 

number of units over a short period of time allowed 

us to disseminate information that could improve 

patient care. It also allowed the units involved to 

compare their levels or reporting with the other 

units involved. 

The process of completing the database has in no 

way interfered with a central reporting of incidents 

to the NPSA, so there is no reason why the two 

systems should not work in parallel. The database 

is freely available now on the ICS website 

(http://www.ics.ac.uk/committees_menu/safety_committee.asp 

) and would allow the retrospective or 

prospective collection of thousands of medication 

related critical incidents in Intensive Care to allow a 

better understanding of these incidents. 

It is my understanding that the ICS has already 

approached the NPSA to collaborate to improve 

the reporting of adverse incidents in critical care. 

While waiting for this to result in constructive 

dialogue, the use of the database described in our 

paper would allow some progress to be made in our 

understanding of critical incidents relating to 

medication use in Intensive Care. 

Yours sincerely, 

Dr Thomas 

Clinical Director ICU 

References 

1. Thomas A.N., Boxall EM, Sabbagh G et al. JICS 2006; 7: 22-24a 




Correspondence continued 53 

The Editor, 

Clearing Suspected Spinal Injury in Unconscious 

Patients 

Further to the useful guidance provided by Morris 

et al 1 , members may be interested in viewing our 

imaging protocol that was signed up to by Radiology, 

Neurosurgery, A&E and ourselves in 2003. This was 

been rolled out to our critical care and neuroscience 

networks and is also freely available on the 

neuroscience smart group website. There was initial 

resistance from peripheral radiologists but once it 

was made clear that it was the availability of the 

imaging facility 24/7 and that 9-5 reporting would be 

adequate things have improved significantly. As a 

neuroscience centre we now very rarely have to 

repeat scans. We have recently reviewed this 

protocol and decided to make no changes, 

particularly as a recent paper from the Baltimore 

group 2 would support thin slice helical CT with 

reconstruction sensitive enough to 'clear' spines. 

E Thomas 

Lead Consultant for Neuro ICU 

Intensive Care Unit 

Derriford Hospital 

Plymouth 

Reference 

1. http://www.ics.ac.uk/downloads/Standards/Clearing%20 

the%20spine%20-%20Consensus.pdf 

2. Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM. 

Radiology 2005; 237:106-113 

Guidelines for Clearing Suspected Spinal 

Injury in Unconscious Patients 

These guidelines provide a consistent and largely 

evidence-based approach to clearing cervical and 

other spinal injuries in unconscious patients. 

The following guidelines should be utilised as a 

means of ‘clearing’ the cervical spine (and where 

appropriate thoraco-lumbar spine) in the majority of 

unconscious patients. 

should be no requirement for additional plain 

view x-rays. 

Unconscious isolated head injury presenting to A&E 

Quad CT 

Routine head protocol 

Each patient should be assessed and the decision 

making regarding imaging must be individualised. 

Imaging should be completed as soon as possible 

and in all cases within 48 hours of injury (as long as 

the patient’s condition allows). The images should 

be reported by a suitably trained radiologist and the 

report clearly documented in the patient’s 

contemporaneous clinical notes. 

Unconscious polytrauma patient presenting to A&E 

Quad CT 

Routine head protocol 

C-spine @ 1mm slices from cranio-cervical junction 

to cervico-thoracic junction (must include posterior 

elements of C7 and T1) with sagittal and coronal 

reconstructions. 

Thorax and abdomen (after oral contrast down 

oro-gastric tube in A&E and intravenous contrast in 

CT) @ 2.5mm slices allowing sagittal reconstruction 

of thoracic and lumbar spines. 

This imaging protocol should be able to clear all 

bony injuries to the spinal column and there 

C-spine @ 1mm slices from cranio-cervical junction 

to cervico-thoracic junction (must include posterior 

elements of C7 and T1) with sagittal and coronal 

reconstruction. 

If the patient is going to theatre immediately 

from the CT scanner then a lateral c-spine 

scanogram and/or the sagittal recons must 

accompany the patient to theatre. 

Should the rest of the spine need to be imaged, in 

the first instance, use departmental plain AP and 

lateral radiographs of thoracic and lumbar spine. 

Any suspicious areas can then be imaged further 

with focused thin slices using the Quad scanner as 

above, when circumstances permit. 

Patients transferred from other institutions 

Assume spine has not been cleared unless these 

guidelines have been followed and the results 

documented fully in the patients notes. 

Clearing ligamentous injury 

Utilising the Quad CT as recommended in these 

guidelines is likely to exclude all unstable injuries. 




54 

Correspondence continued 

If there is a high clinical or radiological suspicion of 

an unstable cervical injury then further imaging 

should be considered. 

This should be individualised following discussion 

between all clinicians caring for the patient and may 

include MRI, fluoroscopy or static flexion / extension 

views. 

Supporting documentation: 

www.sign.ac.uk/guidelines (go to full text, 

guideline No 46 section 5.6 

www.east.org/tpg/chap3.pdf 

D’Alise MD et al; J Neurosurgery (Spine 1) (1999) 

91:54-59, 

Mirvis SE; Emergency Radiology (2001) 8: 3-5 

Lee JL et al; Emergency Radiology (2001) 8: 

311-314 

Ptak T et al; Emergency Radiology (2001) 8: 

315-319 

Blackmore CC et al; Skeletal Radiol (2000) 29: 

632-639 

E Thomas 

Lead Consultant in Neuro Intensive Care 

November 2005 

(review date January 2008) 




Miscellaneous 55 

Industry Membership 

The Society is extremely grateful to the following Industry Members for their continued support. 

Corporate Members 

Company Members 

B Braun Medical Ltd 

BOC Medical 

Dräger Medical UK Ltd 

Edwards Lifesciences 

Eli Lilly & Co 

Fresenius Kabi 

GlaxoSmithKline Ltd 

Maquet Critical Care Ltd 

Novartis Consumer Health 

Novo Nordisk 

Roche Diagnostics 

Trumpf Medical Systems Ltd 

Wyeth Pharma 

Zeneus Pharma 

Arrow International UK Ltd 

Astra Zeneca UK Limited 

Convatec 

Cook UK 

Fukuda Denshi 

Gambro Hospal 

GE Healthcare 

Gilead Sciences 

Pulsion Medical UK 

Smiths Medical 

Corporate Member News Page on the ICS Website 

Each of the Society’s Corporate Members, subject to the Society’s editorial control, may publicise relevant 

items of news information which are considered to be of interest to the Society’s membership. We hope that 

our Corporate Members will soon submit items of news, so please do visit the Industry section and 

Corporate Member area of the website periodically. Corporate Members who wish to submit any information 

concerning new products or clinical trials, product developments or corporate news should email Pauline 

Kemp, Administration Manager via Pauline@ics.ac.uk with their item for consideration. 

Interested in finding out the benefits of Industry Membership of the Intensive Care Society? 

Contact: Pauline Kemp, Administration Manager, on 020 7291 0690 or email: Pauline@ics.ac.uk 




56 

ICS Council Members / Ex-Officio Members 

Intensive Care Society Council Members 

Anna Batchelor (Royal Victoria Infirmary, Newcastle upon Tyne) 

Robert Winter (Queen’s Medical Centre, Nottingham) 

Carl Waldmann (Royal Berkshire Hospital, Reading) 

David Goldhill (Royal National Orthopaedic Hospital, Stanmore) 

Sam Waddy (John Radcliffe Hospital, Oxford) 

Richard Griffiths (Whiston Hospital, Prescot) 

Kevin Gunning (Addenbrooke’s Hospital, Cambridge) 

Roop Kishen (Hope Hospital, Manchester) 

Bruce Taylor (Queen Alexandra Hospital, Portsmouth) 

Peter Macnaughton (Derriford Hospital, Plymouth) 

David Menon (Addenbrookes Hospital, Cambridge) 

Monty Mythen (University College London) 

Jane Harper (Royal Liverpool University Hospital) 

President 

Council Chair 

Executive Committee Chair 

Honorary Secretary 

IT & Website Editorial Board Chair 

President Elect 

Honorary Treasurer 

Meetings Committee Chair 

CritPaL Executive Secretary 

Trainees’ Division Chair 

Research Committee Chair 

Safety Committee Chair 

Standards Committee Assistant 

to Chair 

Manpower Committee Chair 

Linkman Co-ordinator 

Standards Committee Chair 

JICS Editor 

Education and Training Chair 

Meetings Committee Assistant 

to Chair 

ICS ACCEA Chair 

Industry Liaison Council 

Representative 

Council Member 

Ex-officio Members 

Louie Plenderleith (Western Infirmary, Glasgow) 

Ian Greenway (Morriston Hospital, Wales) 

Brian McCloskey (Royal Victoria Hospital, N Ireland) 

President, Scottish Intensive Care 

Society 

President, Welsh Intensive Care 


President, Irish Intensive Care 




2nd Royal Berkshire Hospital 

& Reading University meeting on 

Ethics in Critical Care Medicine 

Venue TBA 

November 17th 2006 

Introduction Dr A D Lawson, Chairman 09:30 

TBA Medical Ethics - Four Principles Virtues and Rights 09:45 

Dr Piers Benn Medical Ethics - Utilitarianism 10:30 

Coffee 11:00 

Dr C Newdick: Decision making by patients and proxies 11:30 

Dr C Danbury: Legality of Stopping Treatment 12:00 

Dr J Griffiths Post Discharge Care: A moral duty? 12:30 

Q & A Session on morning 13:00 

Lunch 1330 

Prof D Oderberg: Killing or Letting Die Morally Different? 14:45 

Dr A D Lawson: Futility - a bankrupt concept? 15:15 

TBA Should the cost of treatment dictate withdrawal? 15:45 

Panel Discussion of Invited Questions 16:15 

Tea 16:45 - 17:15 

Keynote Debate: Does Industrial Sponsorship bias the ethical 17:15 - 18:00 

practice of Intensive Care Medicine? 

Chair: Dr C Waldman 

Proposer: Dr Neil Soni, Opposer Prof Monty Mythen 

Enquiries to conference organizer: Dr Andrew D Lawson 

andrew.lawson@rbbh-tr.nhs.uk Tel: 0118 322 7065 

Registration: 

Registration forms via website http://icuethics.com/ 

or Emmahooley2@aol.com 

£150 - Consultants, £100 Trainees, Nurses & Students £50


58 

Advertising & Sponsorship Rate Card 




Advertising & Sponsorship Rate Card continued 59 




60 

Miscellaneous continued 

Secretariat Report 

Staffing 

With further staff changes, I’m pleased to welcome 

Michele Moore to our Team as Events and Marketing 

Administrator. Michele will be working closely with 

our Industry members and building on the existing 

relationships and hopefully creating new ones. 

Industry is very important to the Society in terms of 

financially supporting our educational grants and 

helping to keep the Meeting registration fees as low 

as possible. 

We also have Helen Harvey starting as Events and 

Committee Administrator and I’m sure those who 

attend our Meetings and Seminars will soon meet 

and welcome Helen to the Society. 

We also welcome Stephanie Hooff who will be 

temping at the Society during the coming months. 

Stephanie is covering for Stephanie Antonio during 

her extended Leave to Brazil this summer and for a 

few months thereafter. We hope having two 

Stephanies will not cause too much confusion! 

Therefore, our current staff structure (Shaba Haque 

still on maternity leave) is: 

Pauline Kemp, Administration Manager 

email: pauline@ics.ac.uk 

Thomas Heiser, Interim Educational Events Team 

Manager (part time) 

email: Thomas@ics.ac.uk 

Adeeba Sajad, Educational Events Administrator 

email: Adeeba@ics.ac.uk 

Stephanie Antonio, Membership and Office Support 

Administrator 

email: Steph@ics.ac.uk 

Helen Harvey, Events and Committee Administrator 

email: Helen@ics.ac.uk 

Jemma Regan, Assistant to Administration Manager 

email: Jemma@ics.ac.uk 

Christine Wilson, Finance Administrator 

email: Christine@ics.ac.uk 

Stephanie Hooff, Temporary Office Support Assistant 

email: StephTemp@ics.ac.uk 

Please visit the Secretariat section of the website for 

a summary of ‘who does what’ in the Society. 

IT 

Having successfully moved our IT servers off-site 

we aim to start work improving our website in the 

coming months. Your suggestions and comments 

are always welcome. 

Office Move 

We aimed to be moving to the new offices in July, 

but due to unforeseen circumstances beyond our 

control, this date has now been pushed back to 

August. 

P Kemp 

Administration Manager 

Michele Moore, Events and Marketing Administrator 

email: Michele@ics.ac.uk 

Trainee Offer 

Special Offer for ICS Trainee Members! 

The Society has negotiated a special half price subscription rate to Intensive Care Monitor 

for ICS Trainee Members of only £30 instead of the usual price of £60. 

Existing Trainee Members may fill in the form opposite 

and return by mail, post or fax to: 

INTENSIVE CARE MONITOR 

14 Temple Fortune Lane 

London 

NW11 7UD 




62 


Forthcoming Intensive Care 

Society Events 2006 / 2007 

17 July 2006 

The Focus 2006 Meeting - Organ Donation 

The Intensive Care Society & 

The British Transplantation Society 

Royal College of Surgeons, London 

14 – 15 September 2006 

The Trainees’ Annual Meeting 

The Macdonald Burlington Hotel, Birmingham 

Please see inside front cover for more details 

3 October 2006 

Essential information for the ICBTICM Tutor 

ICS Seminars at Churchill House 

Churchill House, London 

14 November 2006 

Dealing with Difficulty 

ICS Seminars at Churchill House 

Churchill House, London 

11 – 12 December 2006 

The State of the Art 2006 Meeting 

Hilton London Metropole, London 

9 – 11 May 2007 

The ICS SKINT (9 May) 

Annual Spring Meeting (10 / 11 May) 

Bournemouth International Centre, Bournemouth 

For further information and registration forms please visit 

the ICS website Meetings page at www.ics.ac.uk or contact 

Tel: 020 7291 0690 Fax: 020 7580 0689 Email: events@ics.ac.uk 




Miscellaneous continued 63 

Other Meeting of Interest 

2006 

PgCert/PgDip/MSc in Critical Care 

University of Wales College of Medicine 

An interdisciplinary, interprofessional distance learning course. The course is modular and involves a number 

of residential components where key speakers are invited and a variety of teaching methods employed. It 

has been running since 2003 and the evaluations to date have demonstrated that it is a suitable course for 

all health care professionals with an interest in critical care. Further details by email: msccritcare@cf.ac.uk 

26 - 27 June 2006: ARDS - Mechanisms & Management 

The Bloomsbury Institute of Intensive Care Medicine 

A major two day conference with an international panel of experts discussing the latest developments. 

Registration fee: Consultants: £330 - before May 1st/ after May 1st -£400 

Trainees, PAMs. Scientists: £250 - before May 1st/ after May 1st- £300 (includes lunch and refreshments) 

Venue: The Royal Society, 6 - 9 Carlton House Terrace, London , SW1 

For further details, please contact: 

Brenda Roberts, Bloomsbury Institute of Intensive Care Medicine, Room 512, 5th Floor, Jules Thorn Building 

Middlesex Hospital, Mortimer Street, London W1T 3AA 

Tel: 020 7679 9666 Fax: 020 7679 9660 email: b.roberts@ucl.ac.uk 

28 - 30 June 2006: AMBEX 2006, the Ambulance Service Association's major forum for all 

professionals working in pre-hospital and emergency care 

Harrogate International Centre, Harrogate 

For further details please visit www.ambex.net 

4 July 2006: Major Incident Management 

The Critical Care Directorate and the University of Wales College of Medicine have organised a one day 

meeting on key aspects of major incident management. Issues presented include: Planning, on-scene 

medical management, biological and chemical weapon attacks and psychological support. Lessons learnt 

from the most recent terrorist outrages in London will also be discussed. 

The meeting is presented by an expert faculty at the Millennium Stadium Cardiff. Full details can be obtained 

from Gaynor Mathieu email: Gaynor.Mathieu@CardiffandVale.wales.nhs.uk 

6 July 2006: Challenges and Dilemmas of the Long Term Critical Care Patient 

Walkers Stadium, Leicester City Football Club, Leicester, UK 

Cost: £75.00 per person including lunch and refreshments 

Aims: To review current research and practice in long term ICU care and to generate debate into different 

ways to manage long term patients. Also, to challenge current thinking and practice. 

During the event, participants will improve their understanding of the management of the long term critical 

care patients and consider new ways of working to improve outcomes. 

For further details and bookings please contact: 

Mr Sam Whitfield. Tel: 0116 2502305 

email: sam.whitfield@uhl-tr.nhs.uk 




64 


6 July 2006: Paediatric Intensive Care Trainees Meeting 

Leeds General Infirmary, Leeds 

There in no charge for this meeting. Please email Wendy.Dickinsen@leedsth.nhs.uk to register. 

A programme can be downloaded by email to Dickinsen@leedsth.nhs.uk 

6-7 July 2006: 5th Evidence Based Peri-Operative Medicine Conference 

Savoy Place (IEE), London 

Full program, venue and registration details (including on-line booking) available at: 

www.ucl.ac.uk/anaesthesia/meetings 

11-13 September 2006: British Association of Critical Care Nurses - Conference 2006 

Newcastle Racecourse - Newcastle upon Tyne 

For further details via www.baccnconference.org.uk 

19 September 2006: PICS Trainee Day 

THEME: NEURO-INTENSIVE CARE 

Alder Hey Children’s Hospital – Education centre 

Full programme available. 

For further details please contact Andrew Selby: 

Tel: + 44 151 228 4811 X 2555 

Fax: + 44 151 252 5771 

email: Andrew.Selby@rlc.nhs.uk for more details 

20 September 2006: MASTICS (Midlands & South Trent Intensive Care Society) - State of the 

Art Meeting 

The Yew Lodge Hotel, Kegworth, Derby. 

Click for emails email: Shirley.Goddard@derbyhospitals.nhs.uk for more information 

24-27 September 2006: The European Society of Intensive Care Medicine - 19th Annual Congress 

CCIB Congress Centre in Barcelona, Spain 

Abstract deadline: 15 April 2006 

Full details are available from www.esicm.org 




Notes 65 




66 

Notes continued

Volume 7 Number 2 July 2006 - JICS - The Intensive Care Society

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