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Regan Fellowshipwith Operation SmileI needed inspiration. Having recently gone through the turmoil of returning to work after havingmy first baby, and at the same time coming to the end of my training and realizing that landingmy dream consultant job was going to be much harder than I ever imagined – I felt I needed tobe reminded why I chose to become a doctor in the first place!The experience with Operation Smile missions ranged from the firsttime for five of us, to some who had experience of over 30 missions.After a day of rest on which we did a little shopping, exploring and hada fabulous curry on a riverboat, we started the real work.The days were long and breaks were short. After six days of operatingand over 200 patients with new smiles and new lives, we were verytired, but incredibly satisfied!What I learntI faced a number of stressful and challenging clinical situations, andwhat I learnt very quickly was that going ‘back to basics’, even moreso in an unfamiliar environment, will always get you through a difficultsituation.But, while I definitely gained further clinical skills, paediatric ‘numbers’and the confidence of working independently, the most importantlesson for me was the value of good teamwork.We were a team of professionals from all over the world, from differentcultures, different training and spoke different languages, completestrangers to one another. Yet from day one of surgery the teamworkwas seamless. Clinical plans often changed at the last minute, andthere were unexpected emergencies that needed coordinating, buteveryone was flexible, professional and focused on the bigger picture:the success of the mission and the safety of the patients.The attitude of every person there was positive, enthusiastic andrespectful of one another. If I am able to bring one thing from this tripto my own practice, it will be to try to maintain and encourage thatattitude to working in a team.All you need to know about practicalairway management.Small group workshops, simulation and interactive lectures. Numberof places limited to 16 to allow plenty of time for practical skills.Workshop sessions:Fibreoptics Mechanics of the scope, practical techniquesThe surgical airway Cricothyroidotomy, percutaneous tracheostomyFailed intubation Failed intubation drills and scenarios using SimManSupraglottic devices LMA, iLMA and second generation devicesAttendance: Registration fee £95Next course : 14 th September 2011Course Director Dr Agnes Watson, Consultant Anaesthetist, Broomfield HospitalEmail Agnes.Watson@meht.nhs.uk Book at https://store.anglia.ac.ukAnglia Ruskin University, RivermeadCampus, Chelmsford, Essex CM1 1SQOperation Smile is an international charity organisation thatcoordinates surgery and medical care for patients (predominantlychildren) with cleft plates and lips in over 50 countries.We spent the day seeing patients who were scheduled for surgery.Each patient was seen by a paediatrician/anaesthetist, a surgeon,a dentist and the speech therapist.This trip was a huge professional and personal challenge for me. I wastaken right out of my comfort zone; different country, different culture,different people, different equipment, (and of course no ODP to relyon!). I also left a 10 month old baby at home which was even harderthan I expected!So the question is, was it worth it?AAGBI Membership SurveyCOMING SOONYour chance to have your say!The Regan fellowship provides training doctors the opportunity tojoin a surgical mission for two weeks. It is a competitive processand predominantly taken up by US residents, but is also opento international trainees as I discovered when I contacted them.The application process involves providing a CV (experience inpaediatric anaesthesia required), references, and being ableto demonstrate an interest in volunteer work and working indeveloping countries.I applied, I was accepted, and before I knew it I was booking myticket to Guwahati, India!The mission I joined was one of the larger international missions.We were a team of nearly 100 volunteers from all over the worldincluding surgeons, anaesthetists, nurses, dentists, paediatricians,a speech therapist, a play specialist, photographers, a biotechnician,medical record volunteers, students and we were joined by localvolunteers (mostly students) who provided translations for us.After a gruelling two day journey to Guwahati, which is in NE India,we had an evening to rest and then we started work with a day ofpatient screening.The following day we all split up, and the anaesthetic team wastaken to the ‘operating theatre’ to set up the anaesthesia stations.When not used by Operation Smile the ‘theatre’ is actually a groupof storerooms so setting up was a far cry from a quick machinecheck.The anaesthetic ‘machines’ were essentially flow meters on aback bar with a sevoflurane (yes, Abbot are sponsors of OperationSmile!) vapouriser, and a Mapleson A circuit.There was one huge store room in the middle, which we were told‘has everything’, and we started the task of rummaging around totry and find all the ‘bits’ we might need for our anaestheticsWe spent a few hours opening boxes and collecting drugs, oxygentubing, ET tubes, IV fluids, giving sets, masks, circuits, syringes,needles, suction catheters etc until we felt vaguely prepared for thenext day! We also discussed resuscitation drills and were given aquick how-to on infraorbital blocks by our team leader (hear one,do one!?). We were a team of 12 anaesthetists: our team leaderfrom Denmark, two anaesthetists from Ecuador, two from India,one from Canada, four from the US, one other from the UK and me.Without a doubt, yes. I gained a huge amount of satisfaction havingtaken on something I found quite daunting and realising I could do itwell and loved doing it!There is some sacrifice involved (money, leave, family) but the personalreward is huge. The Operation Smile motto is ‘Changing the World OneSmile at a Time’, and while it may sound a little clichéd, I really felt thatI was making a contribution to changing these peoples’ lives. Thesefamilies and children not only face the obvious problems with feedingand speech, but many have been cast out from their communitiesbecause of the ‘evil spirit’ (the child with the cleft lip/palate). We had somany heartfelt thank yous from the community, it would take a heart ofstone not to feel good about the work OperationSmile does, and beingpart of a profession that is able to make a contribution to it.I would encourage anyone considering volunteer work to bite the bulletand do it, waiting for the ‘right’ time will probably mean you’ll never doit! I chose to do it at a difficult time and found it was the best time of all.Christie LockeLocum Consultant AnaesthetistRoyal Marsden HospitalIn September 2011 the AAGBI will beconducting a membership survey.We are keen to find out from you, our members,what you think about us, our work and the servicewe provide you.New Council Members are elected each Spring,and take office in September, but we want to knowthat our activities reflect the views, opinions andneeds of our members.If you have any questions about the membershipsurvey, please contact members@aagbi.orgFEATURE6 Anaesthesia News July 2011 Issue 288 Anaesthesia News July 2011 Issue 288 7

Assistant Editors for Anaesthesia CasesAAGBI is looking to appoint two members as Assistant Editors for‘Anaesthesia Cases’ - a new online case report resource to be launchedthis autumn.The work will be email and web-based and will involve reviewing submittedcase reports and editing them in preparation for online publication. Thesuccessfulapplicants should have a history of publication and beable to write coherent and elegant English. Previous editorial experience isnot necessary, but experience of acting as an assessor/referee for paperssubmitted to peer-review journals would be an advantage.As well as the opportunity to work with an excellentand cohesive editorial team, rewards include free registration at majorAAGBI meetings.Applicants should submit a brief note, of up to 500words, on ‘The value of case reports in anaesthesia’by email to the Editor, Dr Mike Nathanson, atmike@nathanson.demon.co.uk, together with a short curriculum vitae.Short-listed candidates may be asked to perform a small number of editorialtasks as part of the selection process.We would particularly welcome application from anaesthetists who arewithin the first ten years of their substantive appointments and looking todevelop their reviewing and editing skills.Applicants who wish to discuss these posts are advisedto contact the Editor by email or Tel. 0115 970 9195.The closing date for applications is July 31st.NHS Pensions and Financial PlanningAAGBI Seminar: Your retirement in focusCavendish Medical Ltd are pleased to be holding some concentrated financialworkshops at 21 Portland Place later this year. These sessions are designed with thebusy Anaesthetist in mind - concise, informative and clear information delivered in aneasy to understand format and leading to a simple but robust action plan to take away.Who should attend?Anyone worried about protecting pension and lump sum benefits orwho wants to plan better for the future. These sessions are aimed atthe senior Anaesthetist.Why should I attend?There is a limited window of opportunity remaining to organisefinancial affairs prior to the introduction of the new Lifetime Allowance(LTA) of £1,500,000. The Govt. has introduced a new form of pensionprotection that has to be initiated prior to April 2012. For seniorAnaesthetists there may be significant issues to overcome related tothe LTA, pension funding and retirement choices.What will be covered?The main themes that will be addressed are those that are mostpressing for senior doctors:• Understanding the NHS pension scheme and the benefitsyou can expect to receive.• Understanding the changes to the NHS Pension Scheme.• A review of the limits to pension funding, the “Lifetime?Allowance” and “Fixed Protection”– who does this affectand what action is required by April 2012?• CEAs and retirement options, how to protect your pensionand lump sum benefits.• Structuring the family’s finances to minimise tax andmaximise returns.Where and when will the workshops take place?Thurs 8th Sept 14:00 - 16:30 21 Portland PlaceMon 3rd Oct 14:00 - 16:30 21 Portland PlaceWed 26th Oct 14:00 - 16:30 21 Portland Place£To Book: We are offering these seminars free of charge to allAAGBI members. Places will be booked on a first come - firstserved basis. To book your place, please contact the eventsdepartment on 020 7631 8804/8808 or email seminars@aagbi.orgCavendish Medical Ltd is authorised andregulated by the Financial Services Authority.Association of Anaesthetists of Great Britain and IrelandThe lifeof a tinyartist inscrubsImagine a blank canvas...In this article the author, who is a CT1Anaesthetist currently working at RoyalDerby Hospital, describes her parallelexperience as an artist.Now imagine a canvas flooded withemotion, feeling and rapture. That is what Ido; I imagine, I dream and I feel.Picture Dubai Creek... If anyone has been orseen pictures of the exquisite skyline of oneof the most exciting cityscapes in the world,you will know exactly what I mean and ifyou don't then allow me to thrill you. Youwill find yourself on a dhow, cruising slowlyalong the creek, there is very little in termsof radiance on a hot Persian Gulf day exceptthe rays of sunlight that dance on the bluewaters. Now immerse your mind in a myriadof colour and shapes and designs, and youfind yourself looking at my perspective ofDubai creek. However, that is what I wantyou see, what you don't see, unless you lookcloser, is how I feel.... I'm painting an ideanot an ideal. I'm trying to paint a structuredoutlet of controlled and potent emotion. Inpainting a picture, I paint a story; a story ofpain, heartache, one of stressful days... ofexams and uphill struggles.Musicians strum their guitars and bang theirdrums, artists throw colour onto a canvasand vent the frustrations of life but they havethe ability to create a microcosm of theirown. Every painting holds a hidden secret,and that is what makes the life of an artistso mysterious and exciting! Sometimes Iclose my eyes and imagine a world I wouldlike to be in... One full of swirls and beautifulmarbled corridors of reflections and dancingcolours that catch the light. A place withblue skies and all the joys of home... A placewhere your sweetest dreams come true andall the troubles of the world melt away.FEATUREEverything started eleven years ago with anart competition to commemorate the 20thanniversary of a prestigious multinationalfreight forwarding company based inJeddah, Saudi Arabia, for which I enteredan abstract cubist based painting and laterended up becoming their designated artist.Every year my challenge was to create acalendar design to surpass that of the yearbefore, encompassing various selectedthemes, while still maintaining a middleeastern twist and producing a piece thatwould be aesthetically pleasing for officesall around the world.People ask where I get my inspiration from,and the honest answer is, 'everywhere'. Ido one or two paintings a year towards thecalendars; some take a day to conjure upand some take months. When the sparkhits, the colours flow, but otherwise it's likehaving a severe case of writers block ora brain spasm. A dash of inspiration cancome from a weekend of internet surfing...a flick through a book or an exotic holiday.Some of my favourite creations have comefrom family vacations. Mostly middleeasternretreats and shopping vacations,with a bit of sightseeing, lead to doodleson an envelope which then develop intolarger scale designs and then explode intoa fusion of colour. No painting I do is everblack and white, because, let’s face it, theworld is full of such vibrance that it wouldbe a shame not to showcase it. Even on agloomy day there is always a hint of coloursomewhere and my work brings it to thefore. My paintings are the silver lining on agrey cloud; a painting that stems from thepain and sorrow of the artist can always turnout to be beautiful and cheer up the artist atthe end of it.A commonly asked question is how longit takes to produce a painting. Again, itdepends on how I feel in myself... a paintingthat is the result of a burst of inspirationis created with mass enthusiasm and isfinished quite quickly, usually in a matter ofhours. On the other hand, a painting whichis done to release a vent of emotion, or isstemmed from an inner sadness can takedays or weeks to finish. Once done, and thefeeling is transferred onto paper/canvas, thebalance of my inner yin yang is restored, Ifeel better and the painting is complete.Occasionally, I go all girly and just paintpretty things, like flowers and butterflies,and decide to go pink! This is generallymet with mixed reviews, I do promise toproduce aesthetically pleasing paintings butsometimes I just like to show that a little girlwill always love pink things and flowers! It'sall about diversity.Other times I try and mix it up. Once, forexample the design deadline clashed withmedical school finals and I just wasn'table to find it in myself to paint at all. So, Iamalgamated a few designs into a collageand ended up with a computer generateddesign as shown... A fusion of all the yearsgone by, which turned out to be fun andrelaxing and has now become the baselinefor a new project I have started to work on:a large mural for my future flat, differentsized canvases, squares and rectangles allstrategically arranged on a wall, to create aunique statement piece to encompass myexquisite personality. Who wouldn't want tohave a signature piece showcased in theirliving room?So I end my little whistle stop tour of the worldof a tiny artist in scrubs with a little thoughtby a wise man called Mahatma Gandhi, whoonce said 'True art takes note not merely ofform but also of what lies behind'Zahra FazelCT1 Anaesthetist, Royal Derby Hospital8 Anaesthesia News July 2011 Issue 288 Anaesthesia News July 2011 Issue 288 9

Annual ConferenceThursday 10 th November 2011East Midlands Conference Centre,NottinghamAn An inter-professional meeting meeting designed designed for anaesthetists foranaesthetists, and all healthcare nurses workers and all involved healthcare in the professionalspreoperativeinvolved in the preoperative process. assessment process.Topics include: Pacemakers and defibrillators, Learningdisabilities, Herbal medications and their implications,Primary care and ERP and Medico legal case studiesAnaesthesia Research TrustCall for AbstractsAbstracts are invited for oral or poster presentations.Best abstracts will be published in the journalAnaesthesiaFor registration and more details visitwww.pre-op.orgor contact by email to pre-op@aagbi.orgApproved for 5 CEPD pointswww.pre-op.orgCONTROVERSIES IN ANAESTHESIA:CHANGING OUR PRACTICETO IMPROVE PATIENT OUTCOMEA National Anaesthesia Research Meeting (NARM)organised by the Anaesthesia Research Trust8th-9th December 2011Venue: 21 Portland Place, London, W1B 1PYControversies in perioperative β-blockadeControversies in ultrasound for regional anaesthesiaControversies in postoperative pain reliefControversies in perioperative fluid therapyFaculty: Professor Pierre Föex (Oxford), Professor Martin Leuwer (Liverpool), Professor Alain Borgeat (Zurich), Professor Virginia Miller (Minnesota),Professor Marc de Kock (Brussels), Professor Donal Buggy (Dublin), Professor Monty Mythen (London), Professor Jeffrey Carson (New Jersey)Call for abstracts: research, audit and case reports• Accepted abstracts may be published in Anaesthesia • CPD applied forFull programme, registration and abstract submission at: www.anaesthesiaresearch.org.ukContact: narm@aagbi.orgVascular Anaesthesia SocietyOf Great Britain and IrelandANNUAL SCIENTIFIC MEETINGMonday 12th and Tuesday 13th September 2011Albert Hall, NottinghamCALL FOR ABSTRACTS- RESEARCH- AUDIT- CASE REPORTSHave you performed any research or audit, or do you have an interesting casereport that you would be interested in presenting?This would also be an ideal opportunity for your trainees to get involved.There is a prize of £200 for the best verbal presentation and £100for the best poster presentation.For further information please contact:-Dr Andy Lumb, Chairman of the Education Committee, ConsultantAnaesthetist, St James University Hospital, Beckett Street, Leeds, LS9 7TFTel: 0113 2065789E-mail: Andrew.Lumb@leedsth.nhs.ukClosing Date: Friday 8th July 2011Setting up for a slice serve on Dutch grassThe desire to be a full time athlete was notvery sensible. I was on a basic surgicalrotation, half way through an MRCS andMMC was looming. Furthermore, I had asignificant mortgage. I was not under anyillusion that I would be a world-beater, butwanted to fulfill a curiosity to see what lifewas like as a full time athlete and to see howfar I could get. I was always going to returnto training as I knew I was not good enoughto earn a living in tennis. Having conducteda very biased survey, asking only thoseconsultants I knew would encourage thedecision, I decided that you only live onceand that I was going to give it a go.The year off was crazy. The logistics ofentering tournaments on the professionalcircuit were complicated. Tournaments wereentered 3 months in advance, often in adifferent language and as my ranking waslow I had to enter qualifying events whichhad waiting lists. Confirmation of entry inPortugal/Croatia/France was often the weekbefore the event. I was competing againstplayers who were in full time academiesand had been minimally schooled since avery young age; they had psychologists,coaches, physiotherapists and racquetstringers.Needless to say, I struggled withmy background of playing any tournamentaround medical school and working as ajunior doctor.I realised quickly that the financial burdenwas huge; playing abroad to get worldrankingpoints is like going on holidayevery week. I was spending approximately£500/week and earning about £100/week;not a great financial model. I trained inSunderland, Leeds, Manchester and a fewweeks in an academy in Barcelona- allat my own expense. That coupled with amortgage that I had switched to interestonlymeant that I started a tough regimewhen I was at home or training for four tosix hours a day, and locuming in A and Efrom 4pm to 2am. I am a specialist in alcoholfueled head injuries! To say it was tiring isan understatement but I have always lovedthe training and competing and it seemedFEATURELife as a professional tennis playerBreak point!I remember feeling slightly nauseous as I answered a fellow surgicalSHO’s question, ‘Which hospital are you rotating to next’. My answer,‘I am taking time out to play full time tennis on the professional circuit’.completely worth it to me. At desperatetimes, I saved by sleeping in cars, tents,and airports, and made a reluctant return to‘value’ supermarket produce.Every match at a professional level isincredibly difficult. In Croatia, I managed todraw their national champion in the secondround of qualifying and was thereforeplaced on the show court at prime time. Iremember being chuffed with myself afterfiring what I thought was one of my bestserves straight down the centre line of theservice box. Seconds later I was staring afterthe reply, a huge return winner behind memuch to my dismay! Another girl in Portugal,pumped her fist in the air and roared aftershe won the first point of the match. It iscompetitive, tough and always a challengesomeplayers film opponents and study theirtechnique to work out a playing strategyprior to the match.Knocked outAt times I felt incredibly isolated; it was hardwhen you fly to a country to be knocked outin the first round before mentally pickingyourself up for the next match. Physically, Ifelt in good shape but most of the battle atan elite level is mental, about holding yournerves at crucial moments in the match andbelieving in your own ability. Everyone hasthe skill to place the ball accurately duringtraining but few can play a match at 100%of the training standard. Power is generatedby racquet head speed and if any part ofyour body is tense, the motion producedis wrong and balls land mid court to be hitas winners by the opponent, or the weightof shot is ineffective and you are forced toplay defensively. Sports psychology tries toalleviate these problems by focusing on theprocess of the shot rather than the outcome.Methods such as following routines prior toa serve, or concentrating on breathing canbe useful.I enjoyed playing in France, Germany,Holland, Portugal, Croatia and Spain and Ihad a wider perspective, for me it was nota long-term career. Some players weredevastated after a loss and it is difficult tolose after a three hour battle when ultimately,a close match can be decided by three orfour crucial points.Elite sport teaches several life skills: learningto compete in front of an audience, tohandle victory and defeat (which I becamefairly good at) and to have inner confidencein your ability and mental strength. It teachesyou to be disciplined in your training, diet,rest and flexibility. To “fall down seventimes and stand up eight”. Whilst thisexperience seems completely divorced fromanaesthetics, I use several of the skills I havelearnt in my daily practice. Under pressure,I try to go back to basic principles androutines. When a case doesn’t go as wellas had expected I try not to get disillusionedand assess how it can be better approachedin the future.I have no regrets. I reached the top 20 in theUK and gained a world ranking. My earningswhen travel, trainers, racquets, strings,court fees and food had been subtractedwas about 75p/hr, a figure I quoted at myanaesthetic interview when they askedwhy I did not continue! I returned to myjob with renewed enthusiasm- especiallyfor the monthly pay cheque. I do not feel ithas been detrimental to my career, in fact,I am sure my initial successful anaestheticinterview was based on the fact that I wouldbe interesting conversation in the long hoursyou spend under supervision as a newstarter!Medical training is a marathon not a sprint.I really feel that people should be ableto explore their talents in any area, if it ispossible, and bring the skills they learn touse in medicine. We were all encouragedto pursue extra-curricular activities to entermedical school; this philosophy should becontinued throughout our medical careers.Lindsay RawlingST4 Anaesthetics, Northern Deanery12 Anaesthesia News April 2011 Issue 285 Anaesthesia News April 2011 Issue 285 13

New Guidance onthe Peri-operativeManagementof Patients withDiabetes MellitusThis guideline has been endorsed by the RoyalCollege of Anaesthetists, the Association of Surgeonsof Great Britain and Ireland, the British Associationof Day Surgery and the Society of Academic andResearch Surgery (among others).A printed summary version of the document has been sent toevery Trust in the UK, but the full length document is only availablevia NHS Diabetes website. Both versions can be found on-line at:http://www.diabetes.nhs.uk/our_work_areas/inpatient_care/perioperative_management/Questions and Answers about the New GuidanceWhy was this National Guidance produced?These guidelines were written in response to reports of poorstandards of care, increased lengths of stay and other adverseoutcomes suffered by many surgical inpatients with diabetes.Some salient facts concerning the current situation are listed below:• Diabetes now affects 4-5% of people in the UK. The increasingprevalence is a consequence of our ageing population, and to alesser extent, the rising number of overweight individuals.• More than 10% of patients on inpatient surgical wards will havediabetes at any given time.• Diabetes is a major risk factor for a host of adverse perioperativeoutcomes. Overall, patients with diabetes are morethan twice as likely to develop post-operative pneumonia, acuterenal failure, wound infections and myocardial infarction.• Up-to-date knowledge of diabetes management among nursingand medical staff is often poor.• Insulin is among the top five high-risk medications in thein-patient environment.• Patients with diabetes have a higher peri-operative mortality rate.Who was involved in writing the document?These guidelines were commissioned by NHS Diabetes and writtenby the Joint British Diabetes Societies Inpatient Care Group. Thisgroup includes anaesthetists, diabetologists, surgeons, and diabetesspecialist nurses.What are the aims of the document?• Main recommendations• Guidelines for each stage of the patient pathway• Appendices, including example protocols and patientinformation leaflets• The reference listThe full-length version is a more comprehensive document andis primarily aimed at those writing local policies. It includes therationale for the recommendations and an in-depth discussionof controversial areas: peri-operative use of metformin, electiveevening list operating, pre-operative glycaemic control, bloodglucose targets, peri-operative glycaemic control and intravenousfluid management (including the choice of fluid to run concurrentlywith insulin infusions).Why is the ‘The Patient Pathway’ highlighted?Optimal management of the surgical patient with diabetes ischaracterised by:• Prevention of complications (from both the diabetes per se andthe associated co-morbidity).• Early resumption of eating and drinking, so that the patient canresume their normal medication regime as soon as possible.To achieve these goals, actions required at each of the 7 stages ofthe pathway need to be identified. These range from optimisationof the diabetes in primary care before referral, to the utilisationof anaesthetic and surgical techniques associated with minimalphysiological trespass.Have the recommendations beenassigned Evidence Levels?discussed in the main document. Curiously, some of the strongestevidence for a change of practice comes from the National PatientSafety Agency and Diabetes U.K.’s ‘Collation of Inpatient Experiences’which document how the current system often fails these patients.Why is this a particularly good time to revise localperi-operative diabetes management protocols?1. The prevalence of diabetes is rising and is set to rise further.2. The new subcutaneous long-acting insulin analogues are nowwidely used for patients with both types of diabetes. Regimeswhich include these insulins can easily be modified so thatintravenous insulin (sliding scales and Glucose Insulin Potassiumregimes) may often be avoided, reducing the potential for drugerror.3. These new national guidelines provide a framework for localchange, and the recommendations may be regarded as anextension of the recent and widely adopted Enhanced RecoveryPartnership Programme, but specifically for the surgical patientwith diabetes.It is our hope that these guidelines will be well received. We welcomeconstructive feedback from anaesthetic colleagues on any aspect oftheir content. The writing group plan to revise the guidance in future toreflect the experiences of users.The forthcoming London AAGBI seminar, ‘Controversies in theManagement of the Surgical Patient with Diabetes’ on 15th November2011 will provide an ideal opportunity for anaesthetists to engage indiscussion of the recommendations.Beverley Watson, Consultant Anaesthetist, Queen Elizabeth Hospital,Kings Lynn. Email Beverly.Watson@qehkl.nhs.ukAssociation of Paediatric Anaesthetistsof Great Britain & Ireland6th National Linkman MeetingTeacher Building, Glasgow Friday 25 November 2011The 6th APABGI Linkman meeting is hosted by theScottish Paediatric Anaesthetic Network in 2011. AllAPAGBI Linkmen are eligible to attend, but we alsowelcome the participation of any anaesthetist with aninterest in paediatric anaesthesia.As usual we focus on new and developing issues in paediatricanaesthesia, and this year’s topics will cover• Patient Safety – how does it impact on paediatricanaesthetic practice?• Anaesthesia and the developing brain• Quality improvement• Clinical conundrums – an opportunity to discuss themanagement of an anaesthetic problem and the issuesit raises in your practiceRegistration fee is £150Further details and application forms will be available from August2011 to download via the APAGBI website:www.apagbi.org.ukFor further information, please contact: meetings@aagbi.org / 0207631 8804The authors aim to provide healthcare professionals with theknowledge they need to improve standards of care. Both the summaryand the full document contain the following sections:There are no randomized controlled studies in this area of medicineand for this reason the recommendations have not been assignedevidence levels. The rationale for the recommendations is fullyNicholas Levy, Consultant Anaesthetist, West Suffolk Hospital,Bury St Edmunds. Email: Nicholas.levy@wsh.nhs.uk14 Anaesthesia News July 2011 Issue 288 Anaesthesia News July 2011 Issue 288 15

The new AAGBI Innovation in Anaesthesiaand Critical Care SectionThe AAGBI, whose Heritage Centre houses the largestand the most comprehensive museum of anaesthesiainnovations through the centuries in this country, isideally placed to support future developments in ourspecialty. Anaesthetists on the whole are very inventiveindividuals, always at the forefront of innovationsand practical solutions, but do not always know howto progress further with their ideas.The aim of this newly created section is to:• encourage and promote innovation in our specialty• facilitate legal and expert help for individualsor groups of innovators• create a fund for young inventors• facilitate contacts with, and introduction to,anaesthetic equipment manufacturers• facilitate testing and marketing of the newequipment• hold an annual innovation seminar and drop-in‘surgeries/clinics’• establish an annual AAGBI prize for the bestinnovation in anaesthesia and critical care,presented during the AAGBI Winter ScientificMeeting, in LondonThe Inaugural AAGBI Prize for Innovationin Anaesthesia and Critical CareThe Association of Anaesthetists of Great Britain andIreland invites applications for the Inaugural AAGBIPrize for Innovation in Anaesthesia and Critical Care.This prize (up to £2000) is open to all anaesthetistsand intensivists. The emphasis is on new ideascontributing to patient safety, high quality clinical careand improvements in the working environment.The entries will be judged by a panel of experts inrespective fields.Applicants should complete the on-line applicationform which can be found at the AAGBI websitewww.aagbi.org/research/innovation. The closing datefor applications is Friday, 25th November 2011.The winner of the Prize will be announced at the WinterScientific Meeting in January 2012 and the prizewill be presented by Dr Archie Brain.The AmateurTransplantsAs one of the comedy duo Amateur Transplants, Suman is responsible forsongs such as the Anaesthetists's Hymn, Paracetamoxyfrusebendroneomycinand their biggest hit, the London Underground Song.I’ve always enjoyed music, ever since I waslittle. Instead of playing the piano pieces thatmy teacher set me, I preferred trying to workout how to play songs that were on the radio.It was more fun, and anyway, I was nevergoing to become a concert pianist.At medical school, as a musician with asense of humour, I was invited to write parodysongs for the end-of term Revue shows.Some of these songs were simple, whileothers were clever & intricate, written in thestyle of Flanders & Swann or Tom Lehrer.These included “The Drugs Song”, whichsummarised the whole of the BNF in 90seconds to the tune of Gilbert & Sullivan’s“I Am The Very Model Of A Modern MajorGeneral” (based on Tom Lehrer’s “TheElement Song”).Medics, and in particular medical students,tend to possess a dark sense of humour;it’s part of our inner mechanism to help uscope with what we have to deal with at work.So inevitably some songs would contain asinister or morbid twist.At the time of the first Tube strikes in London Ialso wrote a song about all the worst aspectsof the London Underground which featuredsome over-the-top swearing. Back then ona stage in front of a hundred drunk medicalstudents, this was indeed both big and clever!After I qualified, we produced a compilationCD of our songs, created a little advertisingwebsite with a few free mp3s and pledged togive any profit we made to Macmillan CancerRelief, which was the RAG charity that year.I really didn’t expect any more to come ofit. Astonishingly, the CD sold incredibly welland the mp3s spread around the internet likewildfire.In 2005 we were invited to play at theEdinburgh Fringe Festival and have put ona show there every year since. It’s a crazyexperience. The entire city is taken over for thewhole of August by thousands of entertainersFEATUREperforming and promoting their shows.I would take a week of annual leave andperform two shows every night, to anaudience of over a hundred people per show.That’s a very good number, considering thatso many established comedians & musicianswere performing nearby at the same time,and this was just a hobby for me.Since then, the act’s popularity has continuedto grow. There are now four albums and manyof the songs have been heard over a milliontimes each on YouTube. I’ve played shows invenues as diverse as a German opera hall, theGlastonbury Festival, and Norway’s biggestrock venue. One of my favourite momentshas to be singing “Anaesthetist’s Hymn in thenational museum of New Zealand, with sixhundred anaesthetists singing along with me!Last year (after some carefully-planned oncallswaps) I managed to complete a twelvedatetour of the UK. The final show, at theIndigO 2 in London, was the first (and only)time my mother would ever hear me swear. SoI did it in style: big lights, heavy amplificationand in front of nearly a thousand people!Ironically, I normally don’t swear much at all.Swear words are a bit like antibiotics, theybecome ineffective if used too frequently.But at least all those badwords have done some good,raising tens of thousands ofpounds for Macmillan.I find it very enjoyable to perform, bothfor medical and non-medical audiences.It’s gratifying to hear the reaction from anaudience after delivering a good pun orshocking punchline. And to be able to doit whilst having fun, singing some of myfavourite tunes and playing a grand piano isgreat. After all these years, I don’t get stagefright any more and this self-control hascrossed over to when I give a presentationor sit a viva or an interview (although in thosecases I tend not to sing).Song-writing is actually quite undemandingbecause inspiration is everywhere. In ournormal workday we are all surrounded bymusic; there’s always a radio on somewhere.Every now & then I just spot something thatwould make a good idea for a song, so Imake a note of it and come back to it laterwhen I have time. Having said that, lastOctober I listened to only Christmas musicfor a fortnight so that I could finish writing aChristmas album in time. That was painful.The biggest problem is all the travelling.The majority of gigs tend to take placeinconveniently far from my house. I’ve oftenspent longer getting to and from the venuethan at the performance itself. Unfortunately,balancing my hobby and my full-time job hasstarted to become challenging. So I’m puttingthis part of my life on hold for the rest of thisyear so that I can concentrate on getting myexams out of the way.In the meantime, the song for the RoyalWedding, “Hello England’s Rose”, is out now.It contains only one swear word. And it’s agood one.Suman BiswasST4 Registrar in Anaesthetics, Ealing Hospital16 Anaesthesia News July 2011 Issue 288 Anaesthesia News July 2011 Issue 288 17

Oral and PosterPresentations at AAGBINational Meetings –have you submittedan abstract yet?There is increasing demand for trainee doctors to present projectsat meetings. The presentation will tick some of the boxes forthe recruitment process and will sit nicely in a well-constructedcurriculum vitae. When I was “growing up” in anaesthesia therewere a number of formidable fora where trainees were ritually ledto the slaughter; I will not name them for fear of reprisals. Luckily,times have changed, and the cursory glance around the auditoriumto make sure a particular “hawk” was not present has now beenreplaced by the friendly atmosphere of AAGBI meetings.The AAGBI wants to encourage as many members, especiallytrainees and career grade anaesthetists, to submit abstractsfor oral and poster presentation at the major meetings of theorganisation, the GAT Annual Scientific Meeting, the AnnualCongress and the Winter Scientific Meeting (WSMLondon). For thefirst time, there will be a poster competition at the WSMLondon,in January 2012. As usual, there will be an assessment process,which will be carried out mainly by Council members. There willbe different categories so that audit, surveys, case reports andoriginal research can be tackled separately.At the WSM, prizes will be on offer for the “best in class”; there willalso be a reception for all trainee poster presenters, at which theywill have the opportunity to meet Council members and some ofthe editors of Anaesthesia.All WSM 2012 abstracts accepted for oral or poster presentationwill be published online as an Anaesthesia supplement and thebest will also make it into print. For further information, pleasecontact: secretariat@aagbi.orgRichard GriffithsChairman, Education CommitteeThe Edinburgh Fibre OpticIntubation CourseA 2 day course aimed at ST3+, SAS andconsultants seeking to update their skills infibreoptic intubationSeptember 14 th & 15 th 2011March 14 th & 15 th 2012Manikin Practice Interactive WorkshopsLectures Asleep fibreoptic intubation of a patientCourse fee £350RCOA CME approved 10 pointsFor more information contact:Course secretary: Hazel CherrieEmail: hazel.cherrie@luht.scot.nhs.ukwww.anaes.med.ed.ac.uk/univ/fibreoptic.htmlTel: 0131 242 3151Department of Anaesthesia, Royal Infirmary51 Little France Crescent, Edinburgh, EH16 4SADear Editor“THE LAST LAUGH: PITFALLS IN AIRWAY ASSESSMENT IN ANAESTHESIA”Evaluating the airway before “drifting someone off to sleep”, is of courseone of our most basic anaesthetic skills. It is drilled into the novice traineewith such impetus that it cannot fail to stick permanently into our workingtemplate for pre-assessment. Most of us have formulated some sort of spiel,covering all eventualities and flagging up potential airway problems. “Anycaps-crowns-loose-teeth-false-teeth?” “Can you move your jaw forwardlike this/ your neck like this?” (Here, the faithful chicken impression).Imagine our surprise when on one June afternoon Vascular list, intubationproved tricky in a slim 75 year-old man with Parkinson’s disease, bookedfor an elective repair of abdominal aortic aneurysm. On pre-assessment, hisneck moved as anyone else’s, his uvula was fully visible and his dentureswere dutifully dispatched into the proverbial plastic tub. On laryngoscopy,however, a hindering foreign body was manually removed from thehypopharynx - a spare bottom set of dentures. Intubation, ventilation andsurgery proceeded uneventfully.The following day, the story was recounted back to the patient. He wasboth delighted and surprised. Surprised, since he had lost these denturessometime before Christmas, and delighted since his newer set had neverfitted as snugly as the old. Does this warrant yet another slot on ourpreoperative assessment questionnaire?Authors:*Dr Juliette Kemp, Specialist Registrar in Anaesthetics.Dr Wiz Ashton, Consultant Anaesthetist, Poole Hospital NHS Trust*Corresponding authoryourLettersSEND YOUR LETTERS TO:The Editor, Anaesthesia News at anaenews.editor@aagbi.orgPlease see instructions for authors on the AAGBI websiteDear EditorWe read Dr Ward’s article on Neck of Femur Fractures [1] with greatinterest and are grateful to him for demonstrating how far anaesthesiahas come in a relatively short timeframe.We find his conclusion ‘I wonder if our lack of monitoring made ussimply unaware of the harm we must have caused’ interesting andworthy of further debate. Dr Ward also mentions in his article thatdespite the lack of anaesthetic and surgical sophistication (by currentstandards) he is not aware of obviously high morbidity or on-tabledeaths amongst his patients.Monitoring physiological variables during an operation certainly aidsthe anaesthetist in delivering a balanced anaesthetic and maintainingphysiological normality, is undoubtedly reassuring and can providean early warning of impending problems; be they pathological (e.g.cardiac ischaemia with an ECG) or physical (e.g. loss of end tidalcarbon dioxide with a ventilator circuit disconnection). However,evidence that straying from what are perceived to be normal values interms of oxygen desaturation, hypotension etc invariably causes harmis difficult to find. During a recent trial in a hypobaric chamber [2]we took 7 healthy volunteers to a simulated altitude of 5334m. All7 sat there quite happily with mean oxygen saturations of 68% (sem+/- 1.1%), falling to 62% (+/- 2%) with a mean tachycardia of 134bpm(+/- 5.8) on exercise. This would be seen by most anaesthetists as asevere cardiac test even in otherwise fit and healthy patients yet BrainNatriurectic Peptide (which rises rapidly with cardiac dysfunction)showed no change and all patients remained well during and after thechamber run.We would contend that whilst monitoring during an anaesthetic isof upmost importance and makes problems easier to detect and soenhances patient safety, we are still a long way from understandingthe implications and importance of more subtle changes in a patient’sphysiological variables.Dr Timothy J Hooper, Anaesthetic Registrar, Frenchay Hospital,BristolDr Adrian Mellor, Consultant Anaesthetist, James Cook UniversityHospital, MiddlesbroughReferences:1. Michael Ward. Neck of Femur Fractures in Retrospect. Anaesthesia News Apr 2011.Issue 285; 26-72. Woods D, Hooper TJ, Mellor A, Hodkinson P, Wakeford R, Peaston R, et al. BrainNatriuretic Peptide and Acute Hypobaric Hypoxia in Humans. Pending publication in JPhysiol SciDear EditorTheatre start times are much in vogue, and the comments of both theeditor and Dr Alladi in May’s Anaesthesia News will be familiar tomany. But anaesthetists must remember that first and foremost, weare there to do what is right for our patients, not (despite what theymay think) to help our managers hit some spurious target.Poor start times had been identified as an issue in my hospital –and many readers will recognise Ramana’s frustrating, multifactorialdelays. In my hospital the reasons may be different (usually no bedsfor same-day admissions, or being third in the queue for the theatreportering staff), but the result was the same – our start times werenot very good. E mails were sent. We all had to pull our socks up.Threatening charts appeared on the wall outside every theatre. 08.59or earlier gets you a green box, while 09.01 or later gets you a redbox. And yes, 09.00 dead gets you an amber box.Anyway, I personally pulled my socks up, and for a couple of monthsmy own lists were green boxes all the way. What a good job Iwas doing! But then I noticed something. The operations were notactually starting any earlier. All that was happening is I was hangingaround with an unnecessarily anaesthetised patient while everyoneelse caught up. Our theatre suite does not have clean prep areas, soparticularly in orthopaedics, where a large number of instrumentsneed to be checked, the nurses use the theatre (and even the theatretable) to open and check trays. On the day I cracked and decided todo what was right instead of what my manager wanted, I was readyto enter theatre with an anaesthetised patient at 8.58. However,the trays were on the theatre table, so we had to stay put and handventilate the patient in the anaesthetic room for ten minutes. Thetable was clear and the patient was transferred at 9.08, but there wasa further delay as the trays were being still being checked. The theatreteam was able to start prepping and draping the patient at 9.20, withknife to skin at 9.28.I know these times accurately, because I have reproduced them fromthe stroppy email I sent my manager, who to her credit acceptedthat without further initiatives there was no point in hounding theanaesthetists about the start times. I fear I’ve had a few red boxessince then, but I’m doing what is right for my patient by anaesthetisingthem at the appropriate time – when everyone is ready.When does a theatre list “start”? Our specialty is slightly unfortunatein that anaesthetic start time seems to be the most commonly usedmarker. But just because something can be easily measured does ithave value? I can make my list “start” on time but unless everythingelse works too, it’s completely meaningless – except for the patient,whose best interests are not being served. As more and more targetsare developed and - as Val Bythell found – looked at during appraisal,we need to be absolutely clear that we continue to be the patient’sadvocate, and make sure their interests are served by appropriatetargets, not some spurious number that is easy to measure and hasbeen decided to be important by someone at some distance fromthe coal face.Hilary Aitken, Consultant Anaesthetist,Paisley26 Anaesthesia News July 2011 Issue 288 Anaesthesia News July 2011 Issue 288 27

Health PartnershipNepalNepal is a country of stark contrasts in access to healthcare, with themajority of medical infrastructure and expertise being based in urban areasgreat distances from the rural inhabitants. Health Partnership Nepal (HPN)is a unique medical organisation, run primarily by medical students basedat St George’s Hospital in London. It was established in 2007 and overseveral years the students have nurtured a working relationship with KantiChildren’s Hospital in central Kathmandu.The primary aim of HPN is to establisha sustainable relationship between StGeorge’s University and healthcareproviders in Nepal to provide a robustannual medical service for people inisolated areas, whilst also providing trainingand teaching opportunities for the studentsfrom St George’s University.The project consisted of 2 components.Firstly, several medical camps are held inremote villages to provide primary healthcare for both adults and children, and toassess any potential patients for surgicalintervention. This is then followed by thesurgical camp, which provides paediatric,general, urological and gynaecologicalprocedures.In April 2010, we volunteered asanaesthetists for the surgical campheld at Trishuli Hospital, a village in theNuwakot district of Nepal. We were awareno British consultant anaesthetist wouldbe accompanying us on our trip, but wewould be working with and supported byNepalese consultants.Prior to departure, the team consisting ofsurgeons, anaesthetists and nurses met onseveral occasions to discuss the variety ofsurgical cases, the facilities available andthe equipment we would require. TrishuliFEATUREHospital has two operating theatres whichare normally redundant due to the lack ofavailable skilled staff. Consequently, thereare no functioning anaesthetic machinesso anaesthetic techniques would involvesedation and regional anaesthesia only.Surgical campOn arrival we discovered a resuscitationbag containing a comprehensive arrayof emergency equipment, including anAED, AMBU bag, a variety of endotrachealtubes (down to size 3.0!) and LMAs.Drugs included adrenaline minijets,hydrocortisone and an unfamiliar “upper”called mephatamine, which had doses andvolumes similar to those for ephedrine. Ourfirst afternoon was spent sorting out thetheatre, organising the resuscitation bag,arranging drugs and syringes and collectingconcrete bricks to use in response to thesurgeons’ requests for “Table up!”The theatre complex had areas which weseparated into Preoperative Assessment,Theatres 1 and 2, Recovery and twochanging rooms. The ladies’ changingfacility unfortunately was also home to thetemperamental pressure steriliser whichadded the exciting dynamic of trying toget changed without getting scalded eachmorning! The medical students designed arota for working in the different areas andto ensure both theatres had a continualsupply of sterile drapes and equipment.In the Pre-operative Assessment areathe medical students worked with localvolunteer translators to clerk patientsin. We had developed a specificintegrated care pathway document toensure appropriate documentation andprocedures were followed. This includeda health questionnaire, surgical consentform, anaesthetic chart, postoperativeanalgesia and observations, and the WHOsurgical checklist. “Time Out”! provedto be invaluable as the patients hadsimilar names and pathology, primarilyhydrocoeles and inguinal hernias. We alsoencouraged our Nepalese counterparts touse the checklist.The majority of patients had walked longdistances in exceptionally humid conditionsto attend the camp. This presented an idealopportunity for the medical students togain experience in intravenous cannulationand setting up intravenous fluids, whilstadditionally rehydrating the patients priorto surgery.As the working day was flexible, patientsnot always arriving on schedule, therewere many opportunities to hold tutorialsfor the medical students. Topics coveredincluded arterial blood gases, fluids, andthe management of medical emergencies;this provided much appreciated revision fortheir upcoming final exams.Anaesthetic techniques utilised weresedation, opiate-free spinal anaesthesia(due to lack of preservative freeformulations) and a combination of both.We had a single monitor with 3 leadECG, NIBP and pulse oximetry used forall patients requiring anything more thanlocal anaesthesia. Examples of our workincluded performing spinal anaesthesia ina 7 year child with acute appendicitis, andketamine/midazolam sedation for a childundergoing a hernia repair.Post anaesthetic care was providedby a nurse and two medical students.Pulse oximetry, a sphygmanometer, dripcounter and temperature conversion chartwere available to record post operativeobservations. Initial liberal use of ketaminewith prolonged recovery and post-operativevomiting was quickly remedied to preventlate nights spent in the hospital.28 Anaesthesia News July 2011 Issue 288 Anaesthesia News July 2011 Issue 288 29ChallengesHumidity and heat, often above 40 degreesCelsius, posed a significant problem for thetravelling patients and non-acclimatisedstaff. The ventilation system consistedof a freestanding fan in theatre with openwindows, but torn fly screens kept us on flyalert.The electricity supply for the hospital wasgenerated by the local hydropower plant.Unfortunately, April is dry and pre-monsoon,and so the power was unpredictable,consequently, we were required to wearhead lamps at all times.Oxygen was a limited resource; we had twosize E oxygen cylinders, one of which wasempty and the other only partially filled onour arrival. Trips on the hospital’s tractorwere necessary to exchange them forfull cylinders before more cases could beperformed.There were some differences in ouranaesthetic practice; the Nepalese wereless reliant on monitoring and more liberalwith doses and polypharmacy. This nodoubt stems from their familiarity with thedrugs, the anaesthetic environment and aninborn reliance on clinical judgement ratherthan equipment that we are accustomedto. We found working in a strange andunfamiliar environment without the usuallevel of equipment and support available athome was a significant clinical challenge.Participating in this project was a wonderfulopportunity to work and travel in thisbeautiful country, gaining insight in to theculture and communities of this welcomingand friendly nation. It was a privilege to beinvolved in an initiative which is developinga sustainable health care link with Nepal.Rebecca Lea SmithST5, Royal Surrey County HospitalSarah HammondConsultant, St George’s Hospital, London

MPS Case ReportThe Silent Anaesthesia SocietyFatal inactionMr W, a 19-year-old drama student, was admitted to his local hospitalwhere he was diagnosed with an acute testicular torsion. He waslisted for an emergency exploration.Expert opinionDr H’s diagnosis of an anaphylactoid reaction was reasonable, but hefailed to appreciate its severity, and initiate the correct management.Sending Mr W to the x-ray department was a very poor decision.Dr H, an anaesthetic trainee, saw him beforehand and found him tobe well with no allergies (ASA1). Dr H performed a rapid sequenceinduction of anaesthesia, and secured the airway with a cuffedendotracheal tube. Anaesthesia was maintained with isofluranevapour. Atracurium was given as a muscle relaxant, and fentanyland diclofenac were administered for analgesia. The operation wasuneventful and lasted about 30 minutes.Dr H extubated Mr W in theatre before transferring him to the recoveryroom. Soon afterwards the recovery nurse paged Dr H to tell himMr W had desaturated to 65% and was cyanotic. By the time Dr Harrived, he performed a cursory assessment, and felt that Mr W hadrecovered, so he carried on with the next patient.Dr H returned to the recovery room after 20 minutes to check on Mr W,who was conscious and pain-free, but coughing up some blood andlooking mildly cyanotic. Dr H sent Mr W to chest x-ray. When Mr Wreturned he was having difficulty breathing. Dr H reviewed the chestx-ray, which showed pulmonary oedema.Dr H then diagnosed an anaphylactoid reaction.Dr H decided Mr W should be admitted to the Intensive Care Unit. Hetelephoned his supervising anaesthetic consultant, Dr Y, but she wasin theatre with another case and was not immediately available. Dr Htook Mr W to the ICU, where he continued to deteriorate. Dr H wasuncertain about how to proceed, having never seen a complicationlike this before. The ICU consultant was busy with a critically ill patientin the emergency department and was unable to attend.Dr Q was a consultant cardiologist who was reviewing another patientin ICU. He saw that Mr W was in extremis and came over to help.Dr H asked Dr Q what he thought should be done. Dr Q suggestedthat he be immediately reintubated and suggested the combinationof midazolam and pancuronium.Dr H followed Dr Q’s recommendation, but was unfamiliar withpancuronium and gave a double dose in error. He then found he wasunable to intubate Mr W. He tried again but was unsuccessful. By nowMr W was profoundly hypoxic and suffered a cardiorespiratory arrest.On a third, desperate attempt, Dr H managed to intubate and giveoxygen. With a combination of adrenaline and chest compressions,a circulation returned.However, Mr W had suffered a prolonged period of hypoxia and hadsustained significant brain damage. He died ten days later.The family brought a case against Dr H, Dr Y and Dr Q. The case wasconsidered to be indefensible and was settled for a moderate sum.There were several occasions where Dr H failed to call for senior help.He also failed to convey the gravity of the situation to Dr Y. Dr Y shouldhave made sure she was available at all times to assist him, or madealternative arrangements.Dr Q, although well-intentioned, was acting outside the scope of hisprofessional competence.Dr H was unfamiliar with the drug he used and should have confirmedthe correct dose.Dr H’s diagnosis of an anaphylactoid reaction, though eventuallymade, was delayed.Learning pointswww.medicalprotection.org/uk/• Whatever specialty you work in, you should be able to rapidlyrecognise and treat emergency situations, which may arise, evenif they are rare.• Never give a drug if you are not familiar with it, or if you are notconfident about the dose. You should recognise and work withinthe limits of your competence.• 50-70% of cases of anaphylaxis during anaesthesia are triggeredby a muscle relaxant, such as suxamethonium, vecuroniumor atracurium. Patients can deteriorate rapidly as a result. See’Emergencies in Anaesthesia’, by Allman KG, McIndoe AK, WilsonIH (eds), Oxford University Press, 2005, p. 242 (“Anaphylaxis”).• You should never send an unstable patient away from a locationwhere they can be appropriately monitored and treated. If thepatient is deteriorating rapidly, you should stay with them.• If you are supervising a trainee, however competent, ensurethat you or a colleague are available at all times to help out. Themanagement of the case is your responsibility.• Regardless of your well-motivated intentions, you have aresponsibility to know the limits of your competence.• In any critical incident, summon senior help immediately and if notforthcoming, repeatedly clearly communicate the level of urgency.NB Some clinical details have been changed to ensure confidentiality.The clinical details are not to focus of this account.First published in MPS journal Casebook, Vol. 18 no. 3 - September 2010.figure 1The AAGBI were recently delighted towelcome a new Specialist Society to 21Portland Place – the Silent AnaesthesiaSociety. In an interview for AnaesthesiaNews, founding President Dr Simon Lenssexplained that the society was formed tocampaign for the removal of extraneousand disruptive noise levels in the modernoperating theatre.“Our society believes that modernoperating theatres have become unsafedue to the amount of noise preventing usfrom concentrating on our work. Constantinterruptions by idle staff chatter, a widevariety of irritating alarms telling us whatwe already know and continuous openingand closing of doors are quite differentto the experience of what theatre usedto be like” explained Si. “When I wastraining, anyone talking in theatre wouldbe bellowed at by my surgeon Mr Kinsloefor spoiling his concentration. The onlynoise would be the gentle puffing of theManley, and the occasional barked order.Blissful days!”In order to demonstrate the efficacy oftheir new ideas, the society have beencollecting evidence by researching thepossibility of running silent theatres inthe NHS by running a mini-randomizedcontrolled case series using doublenegativeintegration methodology.“Putting it simply, no one is allowedto speak apart from the surgeon andanaesthetist, except for emergencysituations. Alarms are turned down oroff and all staff wear silent shoes to avoidmaking noise. No one is allowed to enteror leave the theatre unless absolutelynecessary.”Unexpectedly the intervention hasproved very popular with theatre staff atGrimwell NHS Trust. Many enjoy thetranquil atmosphere created by the silentapproach to operating. In fact the onlyanaesthetist to complain so far aboutthe new regime is Dr Gilbert Chattywho expressed the view that training isimpeded using the new regime. “No oneFrom our correspondent Scoop O’Lamineis allowed to answer any of my questionsand if I tell a joke, I am frowned at. Sounfair”.The NPSA were at first concerned that thetheatre might not have been adhering totheatre briefings and the use of surgicalsafety checklists. But as Si explains “Weeven do the WHO Checklist silently usingour iPhones or using printed cards whichwe hold up at different points to indicateour names or that a particular check hasbeen done”. Example of messages areshown in figure 1.ODP Janice Nilkwik expressed someirritation with the use of the iPhone. “Ithink the silent theatre is a good ideabasically, but I was really taken aback byDr Lenss asking for a cup of tea on hisiPhone. I was particularly annoyed whenDr Lenss reported me for my silent gesturein reply.”30 Anaesthesia News July 2011 Issue 288 Anaesthesia News July 2011 Issue 288 31

ParticlesDesaturation following rapid sequence inductionusing succinylcholine vs. rocuronium in overweightpatientsTang L, Li S, Huang S, Ma H and Wang Z.Acta Anaesthesiol Scand 2011 55:203-208The rising prevalence of obesity, makes difficult rapid sequence induction(RSI) a more common occurrence. Obese patients are at risk of rapiddesaturation during apnoea(1), and can be harder to ventilate with afacemask(2). It is therefore desirable that time from administration ofmuscle relaxant to 92% desaturation (Safe Apnoea Time, SAT) is as long aspossible. Preoxygenation has an important role; however, suxamethoniumat 0.25mg/kg can double muscle oxygen consumption(3). This paper offersa further perspective to RSI in this difficult patient group.Methods: Following informed consent and exclusions, 60 patients wereincluded (ASA class I-II, age 23-64 and BMI 25-50 kg/m2). All patientsunderwent elective procedures requiring RSI. Patients were randomisedand double blinded to receive either 1.5mg/kg suxamethonium or 0.9mg/kg rocuronium. Following 3 minutes preoxygenation in the supine position,patients were induced with propofol TCI, midazolam and fentanyl. Musclerelaxant was given following loss of eyelash reflex. An independentinvestigator was called to record data after 60s, preventing observationof muscle fasciculation. Tracheal intubation was performed throughlaryngoscopy, with confirmation of position fibreoptically. Anaesthesiawas maintained, however the endotracheal tube was left open to air untildesaturation to 92%. Ventilation was subsequently commenced with 100%FiO2 (tidal volume 8ml/kg, frequency 12/min, I:E 1:2, with flow 1L/min).SAT was recorded, as was recovery time from onset of ventilation to 97%.Arterial blood gas (ABG) analysis was also performed at baseline, afterpreoxygenation and at 92%.Results: The mean SAT following suxamethonium was 283 seconds(257s-309s) compared to 329 seconds (303s-356s) after rocuronium(P=0.01). The mean recovery period after suxamethonium was 43s (39s-48s)and 36s (33s-38s) with rocuronium (P=0.002). ABG analysis at the differentstages was not significantly different between the groups.Conclusions and Limitations: Suxamethonium significantly shortens thesafe apnoea time during RSI in the overweight, compared to rocuronium. Italso increases the recovery time to 97% saturation.Limitations to this study include SAT measurement from drug administration,rather than onset of action. Therefore, it is possible that one group breathedfor longer before paralysis. In addition, the time and extent of fasciculationswas not observed, therefore cannot be compared to SAT.In patients at risk of hypoxaemia, rocuronium may be the better choice ofmuscle relaxant.(1) Berthoud MC, Peacock JE, Reilly CS. Effectiveness of preoxygenation inmorbidly obese patients. Br J Anaesth 1991; 67: 464-6(2) Langeron O, Masso E, Huraux C, et al. Prediction of difficult maskventilation. Anesthesiology 2000; 92:1229-36(3) Gronert GA, Lambert EH, Theye RA. The response of denervated skeletalmuscle to succinylcholine. Anesthesiology 1973; 39:13-22Dr Sombith Maitra,CT2 ACCS (Anaesthesia), LondonStandard cardiopulmonary resuscitation versusactive compression-decompression cardiopulmonaryresuscitation with augmentation of negativeintrathoracic pressure for out-of-hospital cardiacarrest: a randomised trial.Aufderheide TP, et al; Lancet (2011) 377: 301 – 311Out-of-hospital cardiac arrests are associated with poor survival rates (1).Standard CPR provides around 25% of normal coronary and cerebral bloodflow (2), and this reduction in normal perfusion may be compounded bypoor CPR technique (3). It has been shown that an increase in negativeintrathoracic pressure during the decompression stage of CPR increasescoronary and cerebral perfusion (4).The trial aimed to assess whether a new device to improve chest recoilduring the decompression phase of CPR could improve survival postcardiac arrest compared to standard CPR. The end-point was survival tohospital discharge. Neurological outcome was compared between thetwo groups and in addition, frequency and type of adverse events werenoted.The device itself was a suction cup that attached to the chest wall with ahandle and a metronome for timing. An airway impedance device was alsoused to further reduce intrathoracic pressure. This provided a resistance of16cmH2O during inspiration and

Anaesthetists andprehospital immediate careWhy pre-hospital anaesthetists?With an estimated minimum of 20,000cases each year in England alone [1],the incidence of major trauma (injuryseverity score > 15) is comparable to thatfor colorectal or lung cancer. Over 5,000of these cases will die from their injuriesand many more will be left with seriousdisability. Since young people are overrepresented,the indirect socioeconomicimplications of a lifetime with disabilityprobably exceed the direct cost to the NHSten-fold. Yet trauma medicine has generallybeen regarded as a stagnant, evidencesparsediscipline with few opportunitiesfor meaningful therapeutic advances.In the past, the high cost of treatingpatients with multiple injuries has beenpoorly remunerated leaving cash-awareNHS trusts with little financial incentive toimprove the provision of care. Furthermoremajor trauma is, proportionately, a smallproportion of the typical emergencyworkload of an average hospital orambulance service, making the requisiteskills and experience needed to provide ahigh quality service difficult to acquire andmaintain. It is, perhaps, unsurprising thenthat UK outcomes are poor with in-hospitalmortality being perhaps 20% above that ofthe United States [1] .In recent years however there has been areal political incentive to improve traumacare. The 2007 NCEPOD report [2] identifiedairway management as a problem in asignificant number of prehospital cases.Outcome benefits from prehospitalanaesthesia have been difficult todemonstrate conclusively [3] due to incidentheterogeneity and, possibly, sub-optimallyconducted anaesthesia. However, it is wellestablished that, along with hypotension,hypoxia is an independent predictorof outcome after traumatic brain injury(TBI), a common cause of death anddisability after major trauma. Furthermore,stabilisation of a critically ill patient, wherepossible, may facilitate safe primarytransfer to a trauma centre rather than thenearest peripheral hospital. This suggestsa skills gap for the provision of prehospitalanaesthesia/sedation, resuscitation andphysiological optimisation- a gap whichanaesthetists are well suited to fill.The pre-hospital environmentEmergency medicine in the pre-hospitalenvironment is unforgiving and propertraining and development is vital. Roadtraffic collisions (a large proportion of theworkload) provide an environment withsharp metal / glass, unstable wreckage,potential fire and moving traffic which maybe very hazardous to both rescuer andpatient. Environmental factors and patiententrapment can severely limit assessmentand treatment options. Early interventionmeans assessment of early pathology,whose presentation may be unfamiliar toclinicians (particularly after traumatic braininjury). Incidents such as assaults andthose involving weapons carry their ownunique hazards.Anaesthesia and procedural sedation mustconform to the usual minimum standardof monitoring [4] but also needs to be assimple and safe as possible. A systematicfailsafe approach is important; supportwill be limited in the event of an untowardincident. The severely injured are oftenboth hypoxic and hypovolaemic. Difficultairways and haemodynamic instabilityare common at a time when the patient isextremely vulnerable with potentially occultinjuries. The pre-hospital clinician facesthe challenge of maintaining theHEMS helicopterbalance between performing stabilisinginterventions and maintaining acceptablyshort on-scene time.Currently, pre-hospital immediate careis generally provided both by volunteerimmediate care schemes or HelicopterEmergency Medical Systems (HEMS) inthe UK. Immediate care schemes [5] hadorigins before the advent of the modernparamedic ambulance service, butnowadays can often provide pre-hospitalanaesthesia and sedation in addition toproviding a first response in more remoteparts of the country. A large number ofanaesthetists (amongst others) aroundthe country volunteer to be activated fromhome or, in some schemes, give up timeas part of a doctor / paramedic team rota.Helicopter Emergency MedicalSystems (HEMS)With trauma constituting the largest singlefraction of the workload for air ambulances,a typical HEMS helicopter is able to carrya medical crew (typically a paramedic/ doctor team) quickly to incidents withan endurance of up to 2 hours, or so.The aircraft can be utilised to reach andtransport patients from remote locations,and to deliver those with appropriatelyadvanced skills and specialised traumaexperience to the scene. The stabilised / optimised patient isthen transported by land ambulance to the most appropriatehospital. Although the aircraft are expensive, with a typicalmission costing over £1000, there are potential economic andclinical benefits to serving a large area with a relatively smallnumber of experienced practitioners.The great majority of air ambulances in the UK are operated bycharities with the direct costs funded largely by public donations.A substantial proportion of HEMS physicians have traditionallybeen volunteers but, increasingly, air ambulances are employingdoctors, including specialist registrars, as part of specificrotations. This trend is expected to continue with the futureestablishment of pre-hospital care as a specialty in its own right.Helicopter medicine brings with it a number of other particulardifficulties. Safety must be paramount and whatever the exactorganizational framework the medical personnel must take partin aviation safety, site selection, communications and potentiallyalso navigation, all of which adds to the clinical burden ofattending potentially critically ill or injured patients. Terrain,buildings, trees and power lines are of particular danger asthe aircraft are often required to land in very confined spaces.Where the patient is to be conveyed by helicopter, the noisy andconfined environment makes anything other than rudimentaryclinical assessment impossible in flight making adequate preflightstabilisation crucial. Close teamwork between the medicalpersonnel and the pilot(s) is essential. Whilst night missions arepossible, primary transfers from unsurveyed sites after dark (or inpoor visibility) are potentially extremely hazardous and UK HEMSoperations do not fly routinely outside daylight hours.In summary, there is a growing recognition of the need foradvanced airway and physiological support in the prehospitalenvironment, particularly after traumatic injury. Formalisedtraining and career opportunities are now becoming morewidespread along with the development of national “roadside torehabilitation” trauma care provision. Anaesthetists have many ofthe clinical skills required in the prehospital phase and may wishto consider becoming involved in this subspecialty in the futureeither as volunteers, as part of medical teams or with HEMSoperations.Ari ErcoleSpR and Clinical Lecturer in Anaesthesia University of Cambridge,HEMS doctor for the East Anglian Air Ambulance and training anddevelopment lead for the Suffolk Accident Rescue Service.References[1]Major Trauma Care in England. Report by the Controller andAuditor General, National Audit Office (2010).[2]Trauma: Who cares? Report of the National ConfidentialEnquiry into Patient Outcome and Death (2007).[3]von Elm E, Schoettker P, Henzi I, Osterwalder J, Walder B.Pre-hospital tracheal intubation in patients with traumaticbrain injury: systematic review of current evidence. BritishJournal of Anaesthesia. 2009;103: 371-386.[4]Pre-hospital anaesthesia (AAGBI safety guideline).Association of Anaesthetists of Great Britain and Ireland,February 2009.[5]British Association of Immediate Care Schemes (BASICS).http://www.basics.org.uk/Australian Society of Anaesthetists2011 National Scientific Congress8 -11 September 2011Sydney, AustraliaThe four day event includes over 100 concurrent lecture sessions, workshops and problem-basedlearning discussions. There is a strong focus on international speakers and the program features rigorousdebate on controversies in anaesthesia.There is a dedicated trainee day and an exciting social program.The 70th National Scientific Congress is located at iconic Darling Harbour, with views over the city andharbour and easy access to the best tourist destinations and accommodation that Sydney has to offer.www.asa2011.comAnaesthesiaand Intensive CareAustralia’s favourite journal for anaesthetists,intensivists and pain specialists.Read original papers, reviews, case reports,editorials, correspondence, critically appraisedtopics and more.For more information or to subscribeplease go to our website.www.aaic.net.au34 FEATUREAnaesthesia News July 2011 Issue 288 Anaesthesia News July 2011 Issue 288 35CMYCMMYCYCMYKNSC 2011-AIC - Anaesthesia.indd 1SAS Travel Grants Chloe.pdf 1 18/04/2011 15:0015/03/2011 3:49:12 PMSAS Travel Grant 2011The Association of Anaesthetists of Great Britain and Irelandinvites applications for the SAS Travel Grant for 2011. Thisis a grant (up to a maximum of £2000) exclusively given forSAS doctors to visit a place of excellence of their choice fortwo weeks. This is not meant for attending a meeting or aconference. All SAS doctors who are members of the AAGBIare eligible to apply for the grant.Applicants should complete an application form and returnit to the AAGBI. The successful applicant will be expected tosubmit a report of the visit which may be published inAnaesthesia News.If alternative funding becomes available for a projectalready supported by the AAGBI, the AAGBI should benotified immediately.Please contact Chloë Hoy (020 7631 8807 orchloehoy@aagbi.org) for an application form, or visitwww.aagbi.org/research/awards/sas-grade-anaesthetistsThe closing date for applications is Friday 21st October 2011.

14th Anaesthesia, Critical Careand Pain ForumDa Balaia, The AlgarvePortugal26 - 29 September 2011www.doctorsupdates.com