Anaesthesia News - aagbi

AnaesthesiaNews No. 251 June2008The Newsletter of the Association of Anaesthetists of Great Britain and Ireland. ISSN 0959-2962World Congress inCape TownPreparing for aconsultant interviewFilm review – Awake21 Portland Place, London W1B 1PY, Tel: 020 7631 1650, Fax: 020 7631 4352, Email: anaenews@aagbi.org, Website: www.aagbi.orgAnaesthesia News June 2008 Issue 251 1

2 Anaesthesia News June 2008 Issue 251

Contents03 From Brighton to Cape Town- The 14th World Congress ofAnaesthesiologists06 Editorial - Don’t stop the music08 Council News & Announcements10 GAT Page - Medical Training –where next?13 The Consultant AppointmentProcess15 Anaesthesia Aphorisms17 The History Page - TheDevelopment of Anaesthesia inSerbia21 SAS Page - Update on the new SASgrade contract24 Naked Gasman26 Dear Editor…28 Film ReviewThe Association of Anaesthetists of GreatBritain and Ireland21 Portland Place, London W1B 1PYTelephone: 020 7631 1650Fax: 020 7631 4352Email: anaenews@aagbi.orgWebsite: www.aagbi.orgAnaesthesia NewsEditor: Hilary AitkenAssistant Editors: Iain Wilson, Mike Weeand Val BythellAdvertising: Claire ElliottDesign: Amanda McCormickMcCormick Creative Ltd,Telephone: 01536 414682Email: mail@mccormickcreative.co.ukPrinting: C.O.S Printers PTE Ltd –SingaporeEmail: terence@cosprinters.comCopyright 2008 The Association ofAnaesthetists of Great Britain and IrelandThe Association cannot be responsible forthe statements or views of the contributors.No part of this newsletter may bereproduced without prior permission.Advertisements are accepted in good faith.Readers are reminded that AnaesthesiaNews cannot be held responsible inany way for the quality or correctnessof products or services offered inadvertisements.From Brighton toCape TownThe 14th World Congress ofAnaesthesiologistsFive Consultants, one AssociateSpecialist and three trainees fromBrighton travelled to the 14th WorldCongress of Anaesthesiologists in CapeTown this March.February in England had been a surprisewith record sunshine. On February29th this gave way miserable drizzle aswe made our way round the M25 toHeathrow for the flight to Cape Town.The flight is twelve hours, with onlya two hour time difference. The nightgave way to bright sunshine as wemade our final journey down the SouthAfrican Atlantic coastline into CapeTown. Table Mountain was clearlyvisible as we made our final descentto the airport, and the early morningsun was bright and warm after the longEnglish winter.The main conference was precededby various satellite meetings, and aweekend refresher course. This led onto a magnificent opening ceremonyon Sunday afternoon with ArchbishopDesmond Tutu as the guest of honour.The host was an African comediancalled Solly Philander. I initiallythought the organisers had taken a riskhere. Solly was a rather camp freespirit with dreadlocks. My fear wassoon dispelled as Solly kept us amusedthroughout, referring to us anaesthetistsas his ‘dream weavers’.Desmond Tutu received an extendedovation at the beginning and end ofhis keynote presentation. He wasreduced to a fit of laughter as he toldus about receiving cryotherapy forprostate cancer. He hoped that othernearby structures has not been frozenas well. His shirt was along the ‘NelsonMandela’ style. Having often beencritical of Nelson Mandela’s shirts, henow had a ‘if you can’t beat him, joinhim’ attitude. A lively concert followedwith traditional African singers andsongs mixed with more familiar songsclimaxing with an African soprano andtenor singing ‘Nessun Dorma’.Over six thousand delegates from overone hundred countries attended themain conference at the Cape TownInternational Convention Centre(CTICC), which ran from Mondayto Friday, March 3rd to 7th. Thescientific programme consisted of ninelectures, and five workshops runningconcurrently. Every conceivableanaesthetic subject was covered, withspeakers from all over the world. Therewas something for everyone, andmy colleagues all found somethingdifferent to reflect their area of interest– see boxes. The smooth runningof the congress was a tribute to theorganisers. This was the result of manyyears of planning by the South AfricanAnaesthesia News June 2008 Issue 251 3

Society of Anaesthesiologists led by Professor David Morrell from PortElizabeth. In particular, the IT systems were superb with all registrationand communication through the Internet.There was a large trade exhibition with over eighty companies andstands representing ten members of the World Federation of Societies ofAnaesthesiologists (WFSA) including the AAGBI. These were divided intoareas called by the animals of the ‘big five’, The Lion, Elephant, Rhinoceros,Buffalo and Leopard zones.Anthony Ger sharing his poster with Cyril Goddia, SeniorClinical Officer (anaesthetic teaching) MalawiThe Paediatric AnaesthetistThe AirwaySpecialistThere was an all day AirwaySymposium. Topics rangedfrom airway assessment throughto extubation of the difficultairway as well as ‘airwaymanagement of the morbidlyobese patient’ and ‘what’snew in airway managementdevices?’. Prof Cohen (USA)gave a very entertaining talk onthe use of bronchial blockersfor thoracic surgery, with somegreat video footage. At the tradeexhibition there were a largenumber of new airway devicespromoting easy intubation indifficult cases. At the Intaventstand, Dr Brain spoke aboutdesigning the LMA supreme.However, I was glad to see alecture focusing on the needto maintain and teach basicairway skills such as facemaskventilation.Dr Sandeep SudanConsultant Anaesthetist,BrightonI travelled out early to attend the Paediatric Anaesthesia Satellite Meetingon Friday 29th February, followed by the South African Society weekendgeneral refresher course. During the WCA itself, I attended paediatricrelated subjects on Monday and Tuesday, but then decided to attend lessfamiliar subjects which included sessions on cardiac disease, advances inpharmacology, workshops on ‘Blocks for eye surgery’ and ‘fibreoptic airwayskills’ and a full day of lectures on the recent highly successful and inspiringCaudwell Everest Expedition.The venue, Cape Town International Conference CentreDr David CampbellConsultantAnaesthetist, BrightonDevelopingCountriesOn the first day Iattended a symposiumcalled ‘DevelopingCountries’.Having worked previously in northern Kenya and Malawi, it was a pleasurecatching up with colleagues and friends from these developing countries,especially the clinical officers from Malawi and Professor Paul Fenton,my anaesthetic hero, who set up a teaching programme in Malawi. Thesymposium was varied, pragmatic and very popular. It concentrated on wayswe can promote, teach and assist safe anaesthesia, with special emphasis onthe sick obstetric patient.As one delegate said ‘the other parts of the conference are for one billionpeople on the planet, and the developing world section is for the other fivebillion’.Dr Jim CooperConsultant Anaesthetist, Brighton4 Anaesthesia News June 2008 Issue 251

The GeneralistMy aim was to update my knowledge on familiar topics.There was a ‘current topics‘ day with an update on the currentthinking on reversal of neuromuscular blocking agents andabout a new reversal agent for release later this year. There wereplenty of talks on obstetric anaesthesia and analgesia includinga lively debate for and against CSE for labour and caesariansection. CSE is used in only about 8% of cases in Europe andthe United States. The ‘against’ vote was the winner. There wasan excellent talk on ‘The patient with a recent stent requiringmajor surgery’. Professor Sear talked on ‘Hypertension – whoto cancel’. It does seem that we cancel too many hypertensivepatients unnecessarily. There was a whole day of regionalanaesthesia with plenty of ultrasound-guided techniques.Dr Rex YettonAssociate SpecialistBrightonThe Cape Town ExperienceMarch is one of the most pleasant monthsin Cape Town. There were clear blue skiesall week, with temperatures of 27-31 degreesand little wind. From the conference openingceremony we were encouraged to experienceCape Town outside the conference hall. Sollyat the opening ceremony had encouragedus several times to sample the Cape wines.There were tours of the Cape Winelandsand a Cape Winelands dinner. The mainconference dinner was in the theme of atraditional African Evening at ‘Moyo at Spier’restaurant in the beautiful gardens of theSpier Wine Estate. There were organisedtours to Robben Island, Cape Point and CapePeninsula, Table Mountain and a City Tour.For the more adventurous there was a choicefrom the Cape Big 5 Wildlife Safari, SharkDiving, Sky Diving, Table Mountain abseilingand a helicopter ride. On Sunday March 9thsome delegates took part in the ‘ Cape ArgusCycle Tour’ joining some 35,000 other cyclistsfor a gruelling 109km from the city centreround the Cape Peninsula and back to thecity centre.The authors during a conference breakThe TraineeBeing a University of Cape Town Graduate, I was excited totravel back from Brighton to my home city, and privileged tobe invited to display my poster titled ‘Zambia; waiting timeto theatre for non-obstetric emergency and urgent cases inLivingstone General Hospital.’ I attended other symposiaon obstetrics and trauma. I had hoped to return to Englandto complete my anaesthetic training, but due to a lack offorthcoming run-through training posts in the UK, I havenow obtained a training post in Johannesburg.Dr Anthony GerTraineeBrighton/JohannesburgThe returnTwelve hours after leaving the Sunday sunshineof Cape Town, we landed at Heathrow in galeforce winds. The captain of the South AfricanAirways airbus received a round of applause forhis skilful landing. He remarked that it was highamongst his more testing landings in forty yearsof flying. Maybe the anaesthetic equivalent is theextubation of a morbidly obese patient.Roll on the 15th World Congress in BuenosAires, the ‘Paris of South America’, March 2012.Plenty of time to learn to Tango.Dr Rex YettonAssociate Specialist,Royal Sussex County HospitalBrightonAnaesthesia News June 2008 Issue 251 5

EditorialMost people are happy with this sort of easy listening/Radio2 – type stuff. At Christmas, you do tend to get wall-towallSlade and Wizzard, but that’s fine too. A bit of lightclassical can be pleasant, although anything too Wagneriancan be a trial. (Has anyone else noticed that in fly-on-thewallhospital documentaries, it’s always some high-falutin’opera playing in the background in theatre?) My regularsurgeons are pretty well trained, but occasionally you fill infor an absent colleague and realise the hell they experienceevery week.Don’t stopthe musicDo you like music while you work? I do, and am always intriguedwhen non-medical friends express horror when I let slip that thehushed sepulchral tones in theatre as seen in a hundred hospitalTV dramas are not actually reflected in real life. “You listen to theRADIO? Shouldn’t you be concentrating?” I always ask them ifthey can do whatever their job is with music in the background.The answer is usually yes. The issue also divides theatre teams,with some preferring to work without music. I have on occasionasked for the music to go off if I’m engaged in something a bittricky, but on the whole, I think it adds to a relaxed atmospherein theatre. I think all of our surgeons are fine with backgroundmusic, but I guess the default position should be music off if onemember of the team requests it. Volume is also an issue – theoperative word here is “background”. If anyone has to raise theirvoice, it’s too loud. It’s an operating theatre, not a disco.Then there’s the vexed question of the type of music. There’s quitea wide age distribution in any given theatre team, and everyonehas a different musical era. We used to listen to a local radiostation that every morning played an hour of music from a givenyear, with listeners having to guess which one. I’m a seventiesspecialist, and Stewart, our auxiliary was our eighties specialist.If we got really stuck, we would send out to ask John on thetheatre reception desk, who is a walking music encyclopaedia.Unfortunately, there was invariably a student nurse who wouldannounce she wasn’t born then.One of our ophthalmologists thinks the pan pipes are justthe thing to relax him while operating, but after an hour ofthat I am ready to shoot myself in the anaesthetic room.I can only applaud ophthalmology’s move to local blocksfor the majority of cases, which excuses the anaesthetistsfrom this form of torture, but pity the poor patients whohave to lie there and listen to it. Another of our orthpodslikes experimental jazz – I’m not even sure I know whatthat is, but it doesn’t sound too relaxing to me. I recentlyhad an hour of PJ Harvey (the choice of one of our youngersurgeons), who makes Leonard Cohen seem like a cheerychap. However, as with all things, the surgeons need torealise we have the upper hand. If I really don’t like thesurgeon’s musical selection, I merely wait until he’sscrubbed and change it – there’s nothing he can do untilthe end of the case!It all contributes to a relaxed, happy theatre team – whichhas got to be in the patients’ best interests. No doubt atsome point an edict will come from on high with a spuriousreason why we can’t do it (I’m sure there are whole tranchesof people employed to make life as difficult as possiblefor those at the sharp end of the NHS – bare below theelbows? What’s that about?) but in the meantime let themusic play!One of the things I like about editing this magazine (andhopefully you feel the same about reading it) is that youlearn all sorts of things you never knew. They’re not earthshattering,they will help you pass no exam, but they’reinteresting all the same. Like when I first read the articleabout the origins of anaesthesia in Serbia, published onp17. It made me rather proud to be a British anaesthetist,as they were well to the fore in assisting in developingthe specialty there after the war. We’ve also got a coupleof important medico-political articles for some of ourmembership categories – after a long and protracted birth,the new SAS contract has finally been agreed, and you6 Anaesthesia News June 2008 Issue 251

can read a summary of what you needto know in this issue. In addition, thismonth’s GAT page has the views of theGAT chairman about where we are withMMC now, and where he thinks we areheading, which is not entirely cheerfulstuff. The GAT committee has beenorganised and eloquent on behalf ofanaesthetic trainees throughout the lastyear or so, and continues to be so.I’m also particularly proud of what Ibelieve to be Anaesthesia News’s firstfilm review. David Bogod steppedforward to be our answer to BarryNorman on the release of “Awake”, athriller with anaesthetic awareness as akey plot element. Read what he thoughtof it on p28.Please keep sending me your articles andletters – if you think it’s interesting, thechances are your anaesthetic colleagueswill think so too!Hilary AitkenEditorPeter BaskettAs this issue of Anaesthesia News was being prepared, AAGBI was saddened to receive the news of the death of PeterBaskett, who was President from 1990 - 92. The Association will publish a full obituary in due course.Anaesthesia News June 2008 Issue 251 7

COUNCILNews & AnnouncementsNew AAGBI Workingparty on NeedlestickInjuryB*GG*R! We must all be familiar with the A delta pain and sight ofthe needle in a finger. I’m always astonished at the amount of Cfibre pain and blood that stem from the white needle aimed at thebung of the Co-Amoxiclav that is now embedded in one of my digits.Some of us may also be familiar with the slower onset but no lessexcrutiationg psychological pain when that needle had previouslybeen in a patient. Although the pharmacology of post-exposureprophylaxis is well-developed, there remain many problems ininvestigating the source of the injury, particularly as for most of thosepatients are unable to consent to being tested for blood borne virusesbecause they are anaesthetised, or sedated on ICU.The GMC guidance initially issued in 1997 allowed for testingunconscious patients in exceptional circumstances, but this advicehas now been withdrawn following the Human Tissue Act, whichmakes any such testing illegal.I was first involved in this issue three years ago as Chairman of aClinical Ethics Committee, and raised it in public at WSM 2007. Quiteindependently, Stuart White from Brighton was looking at the samesubject which led to his editorial “Needlestuck” in December 2007’sAnaesthesia.AAGBI Council has now established a Working Party, which I chair,to look at the issue, which affects not just anaesthetists, butother medical specialties and, above all, nursing colleagues. TheCommittee is drawn from experts from within AAGBI, ICS, RCoA, theRCN together with ethicists and a lay representative. We intend tolook at the various options for testing for Blood Borne Viruses, and toconsider strategies to effect a change in the law.I’d be very interested to hear from Members who have been affectedby needlestick injuries, and with any suggestions. I may be contactedvia AAGBI, 21 Portland Place, London W1B 1PY.Andrew HartleAAGBI Council MemberResearch fundingapplicationsMembers interested in applying for research funding are remindedthat the system has changed, as highlighted in the article in May’sedition of Anaesthesia News. All AAGBI research funding is nowawarded under the auspices of the National Institute for AcademicAnaesthesia, and the deadline for applications this year is July 25th,2008. For further details see http://www.aagbi.org/grants2.htmCould you help a fellowanaesthetist?The Association has been contacted by a number of members recently,seeking advice about working in anaesthesia with a disability suchas increasing deafness. We are interested to hear from any memberswith a disability, whether congenital or acquired, who might be ableto share their experience with a newly-afflicted colleague. Adviceon matters such as modifications to the daily working environmentwhich have proved helpful, or experience of the occupational healthprocess might be of use to a fellow anaesthetist. Please contact eitherIan Johnston, Honorary Membership Secretary or Diana Dickson,Chairman, Welfare Committee, at 21 Portland Place if you haveexperience of working in anaesthesia with impaired health.Honour for SurgeonCaptain Charles JohnstonSurgeon Captain Charley Johnston, who is currently the Armed ForcesRepresentative on AAGBI Council, has recently been appointed as aQueen's Honorary Physician. We are delighted to congratulate him onthis honour.Has your emailchanged?We are aware that many trusts are switching to web-based NHSemail, and many members’ email addresses have changed. Pleasecould you let the membership department (members@aagbi.org)know if your work email address has changed recently. This isparticularly important for Linkmen, to ensure that they continue toreceive all communications.8 Anaesthesia News June 2008 Issue 251

Anaesthesia News June 2008 Issue 251 9

GAT PAGEMedicalTraining– where next?In 2008, one of the key issues to besettled will be that of the role of thedoctor. To a large proportion of us, thismay seem to be fairly straightforward,or not even to be in question. However,clarity in our own minds needs tobe translated such that politicos mayunderstand. At the time of writing, theDepartment of Health has recentlypublished the Government response toSir John Tooke’s Independent Review ofModernising Medical Careers, ‘Aspiringto Excellence’. In it, the Health Secretary,Alan Johnson, recognises and agreesthat postgraduate medical educationand training should have broad-basedbeginnings, flexibility and an aspirationto excellence. He also agrees that policydevelopment should be evidenceledand, where significant shifts areinvolved, proceed in consultation withthe medical profession. So far, so good.In order to manage the 2008 transitionperiod ‘bulge’ of trainees, Johnsonrecommends post-CCT fellowship postsin order to free up training numbers,particularly in trauma and orthopaedics;and ‘transit’ posts, created to “provideapplicants in over subscribed specialtieswith experience and training tochange specialty, for example surgeryto anaesthetics”. This ‘flexibility-byanother-name’is probably sound;anaesthesia has traditionally attractedmotivated trainees from other specialtiesafter an average of 18 months. Of moreconcern is the Department of Health’sview that any future strategy will need toinvolve a “reduction in training posts, tobe met by an increase in service posts”.A stronger disincentive for our brightestschool leavers, medical studentsand foundation doctors to entertaincontinuing their medical education inthis country cannot be imagined.On the questions of the role of thedoctor and the fundamental changesto the training programme as proposedby Tooke, Johnson shies away from anydefinitive statement, instead preferringto defer to Lord Darzi and the awaitedfinal conclusions of his “NHS: NextStage Review”, due out this year. Darziis, amongst other things, tasked withtackling an overhaul of training andworkforce planning. It seems that, onceagain, our training is in the hands of aneminent surgeon.So when does Alan Johnson think thatdefinitive changes to the structureof postgraduate medical educationand training will take place? Will itbe 2009, as envisaged by Sir JohnTooke’s panel, in order to expedite thetransition process and achieve stability?Or perhaps in 2010, allowing for anyeffect of ‘mission creep’? I suspect we’rebeing naive to assume implementationwill be predicated on the needs of thoseindividuals most involved: the trainees.Indeed, the last possible date for thenext General Election is June 2010.10 Anaesthesia News June 2008 Issue 251

GAT PAGEAnd the Secretary of State’s conclusionon changes to training: “I envisageimplementation beginning from 2011”.The rationale for delay in this case is“to consult with the medical professionand to achieve consensus”. It is hard toimagine a greater consensus amongstthe profession than the 85% supportachieved by the conclusions of the Tookereport. In addition, Johnson commentsthat “it seems sensible to evaluatewhether the MMC 2008 model of trainingmeets the needs of stakeholders beforemaking any further changes”. Thereare many interested parties in planningpostgraduate medical education but byfar the most important ‘stakeholders’ arethose who have already, and continue to,stake their careers on it: once again, thetrainees.In the meantime, we are to continue witha training structure that few are happywith and that all recognise may well besignificantly altered in three years’ time.Happy times ahead, I’m sure.Do we have any pointers as to where theconclusions of the Next Stage Reviewmay lie? Fortunately, we have LordDarzi’s interim report, rushed out inOctober 2007 ahead of the NovemberGeneral Election-that-never-was.Addressing medical training, Darzi statesthat MMC’s principles were sound butimplementation was not. He goes onto say that “workforce planning needsto be more evidently and consistentlylinked with new models of care andwith financial and service planning atall levels”. It will certainly be interestingto hear specifically what new modelsare proposed and exactly how financialplanning will impact on the workforce.Of course, it is tempting to speculate...On consideration of a further Darzipoint, one hopes that “matching thecommissioning of training places to thatof services” does not lead to inflexibilityduring the crucial early stages oftraining. The price of motivation is selfdetermination,and our political masterswould do well not to forget the fuel ofprofessionalism on which the NHSengine has latterly been running.The Next Stage Review report is due outat the end of June. The GAT Committeehas invited Lord Darzi to speak at ourASM in July (http://www.aagbi.org/gat/asm.htm) and we hope he can find thetime in his busy schedule to join us inLiverpool. In the meantime, I urge youto watch the headlines, challenge thepoliticians (MMC policy consultationperiods in the recent past have typicallylasted a mere 10 days) and have your sayin determining not only the role of thedoctor but the shape of training. Contactus at gat@aagbi.org if you have an pointsyou wish to raise.Chris MeadowsChairman, Group of Anaesthetists inTrainingHelp for Doctors with difficultiesThe AAGBI supports the Doctors for Doctors scheme run by the BMA which provides 24 hour access to help (www.bma.org.uk/doctorsfordoctors). To access this scheme call 0845 920 0169 and ask for contact details for a doctor-advisor*. A numberof these advisors are anaesthetists, and if you wish, you can speak to a colleague in the specialty.If for any reason this does not address your problem, call the AAGBI during office hours on 0207 631 1650 or emailsecretariat@aagbi.org and you will be put in contact with an appropriate advisor.*The doctor advisor scheme is not a 24 hour serviceAnaesthesia News June 2008 Issue 251 11

12 Anaesthesia News June 2008 Issue 251

The ConsultantAppointmentProcessApplying for a consultant job in the NHSis one of the most important events inour professional lives. Knowing how toapproach the process and ensuring theapplication is done well is vital if thejob is to be secured. This personal viewof the NHS process has been formedafter interviewing many candidates for avariety of specialties in my Trust.When appointing a consultant colleague,the NHS expects to pay around £2.5– £3 million in salary over the next 25years. This is a significant investment,and management and prospectivecolleagues must seek the best person forthe advertised job. What is a consultantand what makes them different to atrainee? In my view every consultant isa provider of service, a team leader, atrainer, a colleague, and represents thefuture of the NHS.Your preparation for a consultant poststarted when you first walked on to award. Achievements as a trainee areimportant, as are insights about yourcharacter, even as far back as University.Your reputation, established over thetraining years, amongst peers about suchthings as enthusiasm for work followsyou into the interview room.The advertThe advert will describe the post andany specialist interest. There is usuallya phone number within the advert for adepartment contact, often the clinicaldirector, and they expect to answerquestions about the job at an early stage.Phone the department secretary, explainwho you are and who you would like tospeak to. If the contact is not available,find out the best time to phone backor leave your mobile number alongwith a couple of suggested times tomake it easy for the contact to speakto you. Be as flexible as you can aboutyour availability – remember, the sameindividual will be receiving many similarcalls from other candidates.Pre-shortlisting visitingPrior to shortlisting for a consultantappointment it is normal to visit thedepartment to meet the clinical directorand a few of the local consultants. Aguided tour is commonly offered andshould be accepted. Some departmentshave an organised approach to thisprocess and arrange a timetable withmilitary precision; others are shambolic.All offer insight into the way thedepartment works. As a prospectivecandidate, expect to wait around whilepeople try to fit you in to their clinical dayand when you leave, ensure the secretarythinks you are polite and delightful! Atthis visit, ask anything that concernsyou about the job and the sessions onoffer. There is often flexibility within jobplans. Take a CV with you to describeto the CD what your training has beenand be ready to explain why you wantthe job. Comments about the reputationof the department and hospital aremore helpful than just describing thedesirability of the location.The CD will advise if there areother people you should visit priorto shortlisting. Trusts vary in whatis expected, but in most this visit isrestricted to the department.Application – your CVIf you decide to apply for the post,ensure your application form and CV areaccurately and well filled in. Ensure youread and follow instructions precisely.Anaesthesia News June 2008 Issue 251 13

Some Trusts now only use applicationforms, whilst others encourage youalso to submit your CV. Whatever thesituation, the written submission shouldbe correct, succinct and organised. It isworth investing time and effort as a wellstructured, bound CV on good qualitypaper has impact. Take advice fromsenior colleagues about the content andlayout of your CV before submission.Since a large number of applications isthe norm, quality of preparation ensuresthat your CV will stand out from thecrowd.Select your referees carefully. Ideallythis should be someone who knows youwell and has worked with you duringthe last two years. The CD or CollegeTutor are ideal as one of the referees, butalways ask a referee before naming himor her. After submission, confirm withthe Human Resources Department whois handling the administration of theappointment that your application hasarrived.ShortlistingShortlisting is performed by membersof the appointments committee byassessing the CVs. Methods of scoringCVs for shortlisting varies betweeninterviewers. I look for a well-trained,motivated colleague with evidence ofbeing a team player who completeswhat they start. Since most SpRtraining schemes are similar andproduce excellent quality anaesthetists,evidence of additional activity such aspeer reviewed publications, experienceabroad, humanitarian activity, leadership/responsibility, excellence in team sport orother activities, suggests (to me) someonewho is well motivated. The Royal Collegerepresentative will consider in moredetail the quality of training and ensurecandidates are eligible for appointment.Commonly the Chair and non-executivemembers do not shortlist. Scores areadded and the best four to six candidatesare invited for interview, dependingon the number of posts. Shortlistinginformation is often sent out by post;phone if you are in doubt or away.After shortlistingFollowing shortlisting, the hard workbegins. The task is to demonstrate thatyou are the best fit for the team. Thistakes time and energy and may requiremore than one visit. In the departmenttry to meet as many of the consultants asthe secretary can arrange. Think of a fewquestions to ask beforehand and alwayscarry your CV. This process is hard – manyof us are not good at “selling” ourselves.However, meeting your prospectivecolleagues gives you a chance to assessthem, and allows them a chance to meetyou. Make sure you see as many of theyounger consultants as possible – theymay be offended if left out, and as recentsuccesses of this process, may givehelpful insights. Bear in mind that as faras potential colleagues are concerned,your personality may be more importantthan impressive academic achievements– they will be working alongside thesuccessful candidate for many years andwant the process to appoint a “goodcolleague”.In addition to the anaesthetic department,you should now arrange appointments tosee the chief executive, medical directorand any other medical representatives onthe appointments panel. Trust Executivesare interested to meet candidates tobrief them about the Trust and the localclinical environment. In these meetingsask about the local Trust plans, currentpressures, targets and opportunities. Youare not expected to be an expert in thedetails; however as a consultant you willbe involved with working and planningin the NHS so it is helpful to demonstrateinterest in these issues. Their secretariesare goldmines of information about theTrust – talk to them while you wait.Visiting is time-consuming and two orthree days of leave may be required todo the job properly. It is often impossibleto see everyone unless the departmentorganises things efficiently, but do yourbest to try to see key people.The interviewThe interview is the final hurdle. Practicebeforehand with some experiencedcolleagues if possible. A brilliantinterview does not guarantee the jobbut gives you an excellent chance ofselection: conversely it is difficult for thepanel to justify appointment followinga poor interview. On the day, arrive ingood time with change for the car park.The panel Chairman, who is usuallythe Chair or a non-executive directorof the Trust, is responsible for ensuringa fair procedure is followed and willintroduce you to the panel members.Some trusts require a presentationas part of the interview. The panelalways wishes to see you performing atyour best and will ask a series of openquestions to try to get you talking andshowing your personality and strengths.14 Anaesthesia News June 2008 Issue 251

The RCoA representative will ask aboutyour training and other members ofthe panel will have worked out severalquestions to ask each candidate. Thesewill include topics within anaesthesiaand the local situation, and also broaderNHS consultant issues.The panel do not expect you tohave an in-depth knowledge of NHSmanagement but will expect you to havea working knowledge of topical events –for example the Tooke report, MMC, orpatient safety. There may be a topicallocal “political” issue, and this is whereyour groundwork at the visits can pay off.Be yourself and try to relax. Humour isfine in small amounts but risks makingyou appear flippant. The best questionswill not have a simple correct answer- the panel wish to hear your opinion.Sometimes interviewers may ask aquestion in an unclear way, so do not beafraid to ask for clarification.At the end of the interview the chairmanwill ask if you have any questions oranything else you would like to add.This is not the time to discuss details ofthe job plan or interview expenses, all ofwhich should have been done before thispoint. It is the opportunity to clarify anykey points you may have, or to expandon an area that you feel was not coveredin the interview: however commonlycandidates have no further questions atthis time, so do not feel obliged to makeone up!The interview decision andreferencesReferences are seen normally after thecandidate has been interviewed and offerimportant support for your application.A weak or negative aspect in a referencestands out, as most are very positive.After all the candidates have beeninterviewed, the chairman opensthe discussion about who shouldbe appointed. Normally the RCArepresentative starts by confirmingwhether all the candidates have a CCT,are on the specialist register and areappointable. There is then a discussionwith each interviewer in turn summingup their views. During this phase anorder of preference begins to emergeand the chairman will seek to get aunanimous vote. The person who mostclosely demonstrates the competenciesrequired for the post will be appointed.Once the panel has decided the successfulcandidate, they are brought back to theroom and congratulated. The chairmanwill often offer disappointed candidatesthe opportunity to receive feedbackabout the process from one of the panel.Sometimes a poor performance canbe discussed usefully; more often theinterview has been fine, but someoneelse has been preferred on the day.In summary, a meticulously-prepared,good quality CV and careful visitingshould stand you in good stead at theinterview. Working at selling yourselfboth during the visits and the interviewwill give you the best chance of success.The “local favourite” or sitting locum isnot always the first choice - nothing isdecided until after the interviews!Dr Iain WilsonHonorary Treasurer AAGBIJoint Medical Director Royal Devon andExeter NHS Foundation TrustAnaesthesia AphorismSSubmitted by John Asbury, Glasgow, and Yoav Tzabar, Carlisle.Have in your mind values (eg for HR,BP, Saturation) beyond which you willalways intervene – and do so. It helps inthe situation when you are watching amonitor and thinking ‘It’ll surely resolveat the next measurement …, no.. OK atthe next …’ – by which time your patienthas been hypotensive for 20min.It's easy to put drugs into a patient, butmuch more difficult to get them out.The bigger the case, the bigger the binliner needed.If something is nebulously 'just not right'check the patient first, not the monitor.When it comes to moving the patient offthe operating table, the heaviest partof the patient is always handled by thesmallest nurse.Always recheck the position of the airwaydevice when you have moved the patientinto theatre.Nobody notices when things go right, buteverybody notices when they go wrong.Anaesthesia News June 2008 Issue 251 15

The AnaesthetistsAgencysafe locum anaesthesia,throughout the UKFreephone: 0800 830 930Tel: 01590 675 111Fax: 01590 675 114Freepost (SO3417), Lymington,Hampshire SO41 9ZYemail: info@TheAnaesthetistsAgency.comwww.TheAnaesthetistsAgency.com4TH NATIONAL ANAESTHESIARESEARCH MEETING(NARM)organised byTHE ANAESTHESIA RESEARCH TRUST16 - 17 October 2008Stratford Manor Hotel, nr Stratford upon Avon,WarwickshireInternational Keynote SpeakersWorkshopsAbstracts invited: Research, Case Reports and AuditPoster and Oral Presentations4th Annual Networking DinnerInformal, friendly, informative and funContact the conference organiser, breathingspace at:NARM@breathingspace.uk.comtel: 08453 880037FULL DETAILS OF THE CONFERENCE AND ABSTRACTSUBMISSION CAN BE FOUND ON THE ANAESTHESIARESEARCH TRUST WEBSITE AT:www.anaesthesiaresearch.org.uk16 Anaesthesia News June 2008 Issue 251

THE HISTORY PAGEThe History PageThe Development ofAnaesthesiain SerbiaThe history of the beginnings ofanaesthesiology in our country dates from1945 when two British anaesthesiologists,Russell Davies (East Grinstead) andPatrick Shackleton (Southampton) cameto Belgrade, together with a group ofplastic surgeons.In 1945, against the prevailingpolitical background, Sir Harold Gillesdiscovered there was a large number ofthe Yugoslavian population injured inthe war who could be helped by plasticsurgery. There was little or no expertisein this branch of surgery in Serbia atthe time, so he set out to achieve twothings. Firstly, to ask the newly formedUnited Nations Relief and RehabilitationAdministration (UNRRA) to set up atraining program in Serbia and secondlyto persuade the Ministry of Health of theUnited Kingdom to provide a teachingteam for this program. It was soonagreed that the main plastic surgery unitsin England at that time could providerotating teams which would successivelyvisit Belgrade to undertake this mission.By late 1945 a complete British ArmyField Hospital was flown from Italy toBelgrade and installed in the BelgradeTrade Union Hospital (Bolnica TrgovackeOmladine) with a capacity 120 beds,which was at the time unoccupied. Ithad two operating theatres which wereto be staffed by one senior domesticsurgeon and four surgical trainees. TheBritish input began with the arrival ofMr. John Barron (plastic surgeon) andDr Patrick Shackleton (anaesthetist) toBelgrade. The Serbian team consistedof Dr Ivo Arneri (plastic surgeon) andDr Sever Kovacev, who was chosento administer anaesthetics. Dr Russellarrived in Belgrade the following yearand both British anaesthetists began workon obtaining anaesthetic equipment,introducing up to date anaesthetics intosurgical practice, and educating youngdoctors in the field of anaesthesiology.Dr. Sever Kovacev, who later becameProfessor of Anaesthesiology at the NoviSad University, was their first student.These first students of Dr Davies andDr Shackleton became in turn the firstlocal teachers of anaesthesiology in theregion and it can be said that all Serbiananaesthesiology developed from thework of these two British anaesthetists.Dr Shackleton and Dr Davies carriedout their education plan on a largerscale when they started organizinganaesthesiology training courses for allhospitals in the country with the aimDr Russell Davies with the Yugoslav medal,pictured in his garden in Winchester.of demonstrating modern techniquesand equipment. They discovered thatthere was a factory in the country whichproduced ammonium carbonate as awaste product. Dr Davies persuadedUNRRA to agree to buy the plant fornitrous oxide production for the BritishOxygen Company at a cost of £40,000.He felt that this plant would help theeconomy of the country, there being noAnaesthesia News June 2008 Issue 251 17

THE HISTORY PAGEmanufacturer of nitrous oxide in Europesouth of the UK at the time.Dr Davies also planned a NationalBlood Transfusion service based onhis knowledge of the system appliedin Britain. He submitted a paper to theMinistry of Health, and although it tookfive years to come to fruition, a BloodTransfusion Laboratory and the systemto support it were developed along theselines.Patrick Shackleton and Russell Daviesremained in our country for three yearsand during that period educated fiveSerbian anaesthesiologists. On their returnto Britain they continued to teach, andmany well-known British anaesthetistswere trained by Patrick Shackleton andRussell Davies.Very close ties between British andSerbian anaesthesiologists have existedcontinuously from these beginningsin the post-war period up to thepresent day. Dr Shackleton remainedan active participant in all eventsthat took place or were related to ourspecialty. He campaigned for a nationalassociation of anaesthesiologists and theestablishment of an award in the fieldof anaesthesiology. It is to their credit,Dr Patrick Shackleton, pictured whilePresident of AAGBI (1967-69)coupled with the diligence of the firstSerbian anaesthesiologists, that a relevantArticle of Law was adopted excludingall other than qualified physicians toadminister anaesthesia. This law waspassed in the 1950s when many Europeancountries still lacked laws regulatingadministration of anaesthesia. From thattime the population of anaesthesiologistsin Serbia grew rapidly and at presentthere are approximately 450 qualifiedanaesthesiologists.During the years that followed we wereconvinced that the history of Serbiananaesthesiology must be remembered, sowe sought ways to keep it alive and passit on to future generations.The idea of organizing the Anglo SerbianDays of Anaesthesia originates from thetime of Professor Stanley Feldman’s visitto Belgrade in 1987. On the professor’sreturn to London we exchanged lettersand initiated proceedings to bring theidea into existence. Around this timeI went to London and met John Zorab,who had been a student of Dr Daviesand Dr Shackleton. John Zorab gave usgreat assistance in the organization ofour first two meetings. From that timeforward John and I maintained a regularcorrespondence right up to his death.The first meeting was held in 1988. Itwas our wish that our first two teacherswould be present on this occasion but,unfortunately, Patrick Shackleton hadalready passed away, and Russell Davieswas too unwell to attend the event. In aletter addressed to us all he evoked thefirst days of anaesthesia in our country.He was awarded a supreme Yugoslavmedal which was received on his behalfby John Zorab, who at the time wasPresident of the World Federation ofAnaesthesiologists.The nineties were dire times for ourcountry. Unfortunately meetings andevents of this nature were unfeasible.However, during this period our friendsfrom England did not forget us and aJohn Zorabnumber of our Serbian colleagues wentto England to further their educationor to emigrate. Even the exceptionallyunfavourable political climate andthe bombing of Serbia in 1999 did notmake us falter in our conviction that duerecognition had to be given to the twoexceptional English doctors who fatheredthe beginnings of our profession.This year we plan to organize our fourthmeeting, once again in October.The opinion of all colleagues who havetaken part in these meetings so far is thatthese should continue. Tradition begetssubstance. The meeting planned for thisyear will be dedicated to John Zorab.Along with Professor Feldman, JohnZorab was the initiator of the concept ofAnglo Serbian days of anaesthesia. It is ourintention to remember John Zorab in theway we do Patrick Shackleton and RussellDavies. John truly upheld the idea that allanaesthesiologists from around the worldshould comprise one universal family.The forthcoming meeting will also be anoccasion for us to pay tribute to him forall the help and friendship he unselfishlyextended throughout the years.Prof. Dragan Vucovic,President of Serbian Association ofAnaesthesiologists and Intensivists18 Anaesthesia News June 2008 Issue 251

The Mersey WebsiteFor Details of All Courses & The SAQ Writers Clubmsoa.org.ukClasses & CoursesPrimary FRCA CoursesThe Mersey Selective CoursePrimary Prep Course (MCQ)Primary Prep Course (OSCE/Orals)Primary OSCE WeekendPrimary Viva WeekendFinal FRCA CoursesThe Mersey Selective CourseFinal FRCA Exam Crammer (Booker)CourseFinal FRCA MCQ CourseFinal FRCA SAQ Weekend CourseFinal FRCA Viva Weekend CourseApplication Procedures and ProtocolsApplication FormAccommodationThe Mersey SAQ Writers ClubMembership of the Club exposes Membersto theIntricacies of the Short Answer Question Paper&Affords much Practice.One Membership Payment entitles Members to Remain in the Club&Attend the Mersey SAQ Weekend CoursesFree of any Further ChargeuntilSuccessful in the SAQ Paper Examination.Applications close June 30thAnaesthesia News June 2008 Issue 251 19

MERSEY COURSESSchedule of CoursesCourse Start CloseFinal Viva Weekend (RCA) 06/06/08 (Fri) 08/06/08 (Sun)Primary MCQ 17/08/08 (Sun) 22/08/08 (Fri)Final MCQ 24/08/08 (Sun) 29/08/08 (Fri)SAQ Weekend 29/08/08 (Fri) 31/08/08 (Sun)Primary Viva Weekend 12/09/08 (Fri) 14/09/08 (Sun)Primary OSCE Weekend 19/09/08 (Fri) 21/09/08 (Sun)Final FRCA Crammer (Booker) 21/09/08 (Sun) 26/09/08 (Fri)Primary OSCE/Orals Week 26/09/08 (Fri) 03/10/08 (Fri)Final Viva Weekend (CARCSI) 03/10/08 (Fri) 05/10/08 (Sun)Final MCQ 05/10/08 (Sun) 10/10/08 (Fri)SAQ Weekend 10/10/08 (Fri) 12/10/08 (Sun)Mersey Selective 02/11/08 (Sun) 07/11/08 (Fri)Final Viva Weekend (RCA) 21/11/08 (Fri) 23/11/08 (Sun)PLUSProspective October Final FRCA Examination Candidates are Invited to JoinThe Mersey SAQ Writers ClubMembership of the Club will Expose You to theIntricacies of the Short Answer Question Paper &Afford You Much PracticeAs a Number and not a Name, You will be ExpectedTo Address under Examination ConditionsOne Question Paper per FortnightCLUB # 6 - Opens July 1Introduction to‘The Mersey Method’ & The Writers Club for the SAQ PaperSaturday June 21 Royal College of Anaesthetists, London 10.00 – 16.00Saturday June 28 Aintree Hospitals, Liverpool 10.00 – 16.00For Details regarding All Courses and The Writers ClubPlease see WebsiteMSOA.ORG.UK20

SAS PAGEUpdate on thenew SAS gradecontractNegotiations on a new contract for SAS doctorsand dentists began in May 2005. An agreement wasreached with NHS Employers in 2006. The contract wasratified, with some amendments, by the Governmentin December 2007, following which SAS grades wereasked to vote on whether they wished to accept thenew contract. The BMA Staff and Associate SpecialistCommittee (SASC) met on 19 March 2008 to considerthe results of the contract ballot, and accepted the newSAS contract on behalf of UK SAS doctors. 60.4% hadvoted that they supported the introduction of the newnational contract for doctors and dentists in the SASgrades.The new contract will be offered on an optional basisfrom 1 April 2008 to doctors / dentists in the followinggrades:• staff grades• associate specialists• senior clinical medical officers• clinical medical officers• clinical assistants• hospital practitionersThe new grade of Specialty Doctor will replace staffgrade and will be offered by employers from 1 April2008, so there will be no new appointments to theabove grades after that date.The Associate Specialist grade will be closed. There isa new Associate Specialist grade with similar structureto the Specialty Doctor. Current Associate Specialistswill have the option to express an interest in switchingto this new grade. As no new appointments will bemade to Associate Specialist level, the only other routeto enter the grade will be to regrade from Staff Gradeor Specialty Doctor, but applications will only bepossible until 31 March 2009, and after that time newapplications for regrading will not be accepted.Work has begun on implementation and employerswill write to all SAS doctors asking for expressions ofinterest. SAS grades will have 12 weeks from receiptof the letter from employers to express an interest inthe new contract. This does not commit doctors toaccepting the new contract but guarantees back pay to1 April 2008 once a job plan has been agreed. Writtenoffers of an agreed job plan need to accepted within21 days (28 days in Scotland).• Current SAS doctors must consider whetherthey would like to apply for the new contract.Consideration of individual circumstances will beessential.• If expressing an interest, it is advisable to begin adiary planning exercise to aid you in job planningdiscussions. This should last for a minimum of 6weeks, or one rota cycle (whichever is longer),though a longer period of time would be helpful.• Staff grades eligible to apply to regrade to theAS grade should do so as soon as possible, asapplications will not be accepted after 31 March2009Anaesthesia News June 2008 Issue 251 21

SAS PAGE• BMA SASC is working on producingfurther guidance to assist inassimilation. This will be availableas soon as possible.The contract is based on a 10Programmed Activity (PA) contract, mostof the work being for Direct ClinicalCare (DCC) with a minimum of one PAfor Supporting Professional Activities. APA is of 4 hours duration. The job planin the new contract should be based onthe current job plan, so SAS doctors whocurrently have more than one NHD/session for SPA activity should continueto receive this.Contracts can be for up to 12 Pas but onlythe basic 10 PAs are superannuable.There is a supplement for on-call work,payable as a percentage of the basic salarywith the percentage being dependent onthe frequency of the on-call. This will notbe payable for a shift pattern.Work actually carried out as Out of Hourswork (OOH), as demonstrated by diaryexercise, will be payable at an enhancedrate where the rate of pay will be timeand a third. OOH work is work donebetween 19:00 and 07:00 on weeknightsand all work at weekends and on publicholidays. Where OOH work is includedwithin the 10 session job plan this willbe superannuable. If it forms part ofadditional PAs above the basic ten PAs itwill not be superannuable.Optional and Discretionary point awardswill no longer exist in the new contract,but will continue to be available for thoseSAS doctors who chose to remain in theirold contracts.This new contract should hopefullycreate opportunities for SAS grades tohave proper recognition of their skillsand experience.Anthea Mowat, Associate Specialist,LincolnshireBMA SASC Conference ChairChristine Robison, Associate Specialist,EdinburghBMA SASCEvelyn Baker MedalAn award for clinical competenceThe Evelyn Baker award was instigated by Dr Margaret Branthwaite in1998, dedicated to the memory of one of her former patients at the RoyalBrompton Hospital. The award is made for outstanding clinical competence,recognising the ‘unsung heroes’ of clinical anaesthesia and related practice.The defining characteristics of clinical competence are deemed to betechnical proficiency, consistently reliable clinical judgement and wisdomand skill in communicating with patients, their relatives and colleagues. Theability to train and enthuse trainee colleagues is seen as an integral partof communication skill, extending beyond formal teaching of academicpresentation.Dr John Cole (Sheffield) was the first winner of the Evelyn Baker medal in1998, followed by Dr Meena Choksi (Pontypridd) in 1999, Dr Neil Schofield(Oxford) in 2000, Dr Brian Steer (Eastbourne) in 2001, Dr Mark Crosse(Southampton) in 2002, Dr Paul Monks (London) in 2003, Dr Margo Lewis(Birmingham) in 2004, Dr Douglas Turner (Leicester) in 2005, Dr MartinCoates (Plymouth) in 2006 and Dr Gareth Charlton (Southampton) in 2007.Nominations are now invited for the award to be presented at the WSM inJanuary 2009 and may be made by any member of the Association to anypractising anaesthetist who is a member of the Association.The nomination, accompanied by a citation of up to 1000 words, shouldbe sent to the Honorary Secretary at honsecretary@aagbi.org by Friday 3October 2008.Anaesthesia NewsAdvertising Rates 2008Anaesthesia News reaches over 10,000 anaesthetists every month andis a great way of advertising your course, meeting or seminar.All pricesshown areexclusiveof VATFull PageFour ColourFull PageTwo ColourHalf PageFour ColourHalf PageTwo ColourQtr PageFour ColourQtr PageTwo ColourFull Page - Inside Front or Back CoverOne Month = £ 1607 + VAT, Two Months = £3060 + VATThree Months = £4392 + VAT, Six Months = £ 7277 + VATTwelve Months = £ 9663 + VATOneMonthTwoMonths(5%Discount)ThreeMonths(10%Discount)SixMonths(25%Discount)TwelveMonths(50%Discount)£ 1236 £ 2350 £ 3349 £ 5565 £ 7419£ 790 £ 1501 £ 2133 £ 3555 £ 4741£ 643 £ 1223 £ 1738 £ 2896 £ 3862£ 483 £ 917 £ 1303 £ 2171 £ 2896£ 322 £ 610 £ 869 £ 1449 £1932£ 241 £458 £ 650 £ 1082 £ 1444Details of events and meetings will also be listed free of charge, in the Calendarof Events and International Meetings on the AAGBI website: www.aagbi.orgContact: Claire Elliott on 020 7631 8817 or e-mail: claireelliott@aagbi.org22 Anaesthesia News June 2008 Issue 251

PreoperativeTheAssociationAnnual Conference –“A Risky Business”6th November 2008atRoyal Court Hotel, CoventryA inter-professional meeting designed foranaesthetists and all healthcare workers involved inthe preoperative process.CALL for ABSTRACTS – 31st July DeadlineRegistration: £190 (members of the POA)£225 (non-members)For further details including registration forms,please visit www.pre-op.org or contactmeetings@pre-op.org5 CEPD POINTSVascular Anaesthesia SocietyOf Great Britain and IrelandANNUAL SCIENTIFIC MEETING8th AND 9th SEPTEMBER 2008UNIVERSITY OF EAST ANGLIA, EARLHAM ROADNORWICH, NR4 7TJCALL FOR ABSTRACTS- RESEARCH- AUDIT- CASE REPORTSHave you performed any research or audit, or do you have an interestingcase report 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£100 for the best poster presentation.For further information please contact:-Dr Andy Lumb, Chairman of the Education Committee, Consultant Anaesthetist,St James University Hospital, Beckett Street, Leeds, LS9 7TFTel: 0113 2065789E-mail: Andrew.Lumb@leedsth.nhs.ukClosing Date: 5 July 2008Vascular Anaesthesia SocietyOf Great Britain and IrelandTwelfth Annual Scientific MeetingMonday 8th & Tuesday 9th September 2008The University of East AngliaEarlham Road, NorwichGuest Speakers to include:-Dr Mike SwartDr Trevor WistowDr Graeme McLeodTBCProfessor Mike JamesDr Sue MallettProfessor Nigel WebsterMr M ArmonDr D PrytherchDr Don Poldermans“Management of intraoperative myocardial infarction”“Management of atrial fibrillation”“Making thoracic epidurals work”“Management of aortic cross clamping”“What’s new in perioperative fluid management?”“Near patient testing of haemostasis”“Clinical value of biomarkers”“Should surgeons publish their results”“Prediction of risk”“Reducing risk, medical interventions”Workshops:• Cardiopulmonary exercise testing• Ultrasound guided regional analgesia for vascular surgery(Limited number of places available on a first come first served basis)Additional topics to include:Annual Debate: “This house believes that vascularsurgeons will be extinct within 10 years”Free PapersREGISTRATION FEE: £320 (members) £375 (non-members) £275 (trainees)(inclusive of lunch, conference dinner and Monday evening en-suite accommodation)For registration details please visit our website www.vasgbi.comContact us: Mrs J Heppenstall Telephone: 07897 556056 Fax: 0114 2464965e.mail: jane.heppenstall@vasgbi.com web: www.vasgbi.comAnaesthesia News June 2008 Issue 251 23

Naked GasmanBe aware,be very awareI was delighted to see my Trust takingthe problem of awareness underanaesthesia so seriously. It had actuallyset up a number of half days onawareness training, and even made themcompulsory, calling them MandatoryAwareness Training for Consultants.Furthermore, to my surprise, when Iturned up for one, I found not only someof my anaesthetic colleagues, but alsoconsultants from almost every otherdiscipline. The penny quickly droppedas I realised the session was on topicsthat the Trust thought we should be“aware” of. Still I was very impressedwith the high turnout at the session, butthen as attendance was conditional forbeing considered for Clinical ExcellenceAwards, it was hardly surprising! Oneof the topics covered was the latestinfection control policy or the instructionto be “naked from the elbow down”when undertaking direct patient care.This gave me the idea of putting a trayat the entrance to ICU for orthopaedicsurgeons to slip their Rolex watches intobefore seeing their patients, with theproceeds going to the Intensive Carefund. So far all we’ve had is a brokenSwatch and a copper bracelet – musthave been a passing rheumatologist.One of the Trusts in my region had thedistinction of having the largest debt ofany Trust a few years ago. It has struggledunder the threat of paying this off yearon year, at the same time as having tomeet the latest government targets onwaiting times and further savings. Therewas a recent jubilant announcementfrom the Trust that the debt was finallygoing to be written off, on condition theTrust repaid £4 million per year for thenext 5 years. To me, that is £4 millionper year less to be spent on clinicalcare of patients. The Trust has alreadypared costs by the usual methods of notreplacing staff who leave, not updatingequipment, using cheaper (and ofteninferior) alternatives for disposables etc.This Trust is also planning to move intoa brand new hospital within the next5 years, and coincidentally the CEO isfrantically applying for other jobs eventhough one of the Trust’s aims is to ‘makeit a great place to work!’ There wererecently some Consultant interviewsat this Trust, and when candidateswere asked at the end if they had anyquestions, the local consultants on theappointments committee were waitingfor one of the candidates to ask why, if itwas such a good place to work with the24 Anaesthesia News June 2008 Issue 251

excitement and opportunities of a brandnew hospital, was the chief executivetrying to leave? I am reminded of a scenefrom the film ‘The Queen’, when HelenMirren reminds the newly appointedTony Blair that whilst she is, and hasalways been, his Queen, he is but her10th Prime Minister and drops in forgood measure that her first was WinstonChurchill. Not that I’m suggesting thatconsultants are the royalty of the healthservice whilst chief executives are thegovernment of the day – or am I? Forone thing most chief executives don’tlast as long as government ministers (noteven health ministers), and most of myconsultant colleagues have never metour chief executive, even though she hasbeen in post for four years.Many readers will be aware of a recentproblem of supply of premixed ampoulesof glycopyrrolate and neostigmine, whichhad a mixed reception in my Trust. Someof my colleagues claimed to never useit as they either never paralysed theirpatients or else allowed the relaxant towear off, whilst others foresaw cancelledoperations and recovery units full ofventilated patients. One attempt tocope with the shortage was to rationthe supplies to all hospitals, althoughno attempt was made to consider eachhospital’s usage of pre-mixed ‘reversal’.This led to some smaller hospitalshaving stockpiles of the drugs, andothers rapidly running out. One nearbyTrust reported two incidents of profoundbradycardia following the administrationof unopposed neostigmine, and has nowremoved all boxes of neostigmine fromoperating theatres. My Trust bought insupplies from other suppliers, including abrand from a South African manufacturerwith the instructions written in German.As the packaging is unlike our normalpresentation nobody realised it wasavailable in our drug cupboards for someweeks. Just as well, as it cost five times asmuch as the usual preparation!It reminded me of my very first drugnear-miss which happened in my firstweek as a trainee anaesthetist. In thosefar off days we were given a list of ourown to get on with, and a consultant inthe next door theatre to call if there wereproblems. My assistant was a traineeODA, on about his second week, with(you’ve guessed it!) an experiencedODA next door with the consultantanaesthetist that he could call on if hehad problems. Preoperative visiting andpremed prescribing had been done thenight before by the on-call anaesthetist.The first patient was fairly unremarkableexcept that as I was squirting in thethiopentone I commented that he lookedfamiliar to me. “I should do” came thepatient’s reply, “I was in the year belowyou at med school!” I contemplatedcalling in the consultant but it was toolate for that - I was committed to mycourse of action. The list progressed andthe next patient was having a laparotomy.As the case approached its conclusion,the trainee ODA brought in a syringeof ‘reversal drugs’ as it was commonpractice then for the assistants to drawup drugs, and the usual mixture wasatropine and neostigmine. My requestto be shown the ampoules, which Iconsidered to be reasonable, was metwith a surly stare and muttered commentthat if consultants trusted him to draw uptheir drugs, why shouldn’t I. He returneda moment later with what he thoughtwere 2 empty ampoules each of atropineand neostigmine, but instead of atropinehe had drawn up 2mls of 1in 1000adrenaline. Oops! One way of avoidingbradycardias with neostigmine!My early experience of drug errorscontinued during my second weekof anaesthesia training when I startedobstetric anaesthesia. The elderlyanaesthetist teaching me was not muchmore experienced than I was. He hadbeen a fighter pilot in the war (WW2), avery late, mature entrant into medicine,tried his hand at general practice andwas now the equivalent of a second yearSHO. The operating list was an electivesection list, all under GA (that gives youan idea of how long ago this was!) andthe first patient was duly pre-oxygenatedfor a full 5 minutes before it was realisedthat the halothane had been left ‘on’from the morning list. So now I’d hadexperience of inhalational induction!The next case was also very instructive.I learnt that it is not a good idea to givea long acting muscle relaxant as thefirst iv drug at induction for caesareansection. In his defence I must say that allthese different size syringes can be quiteconfusing, especially if you have a severetremor. He was also infamous for an ECTsession in which he had forgotten to mixup methohexitone with water and had‘anaesthetised’ the whole list with sterilewater and suxamethonium. Strangelyenough neither the staff nor the patientshad noticed any difference from normal.Needless to say, my early experience hastaught me to personally check every drugthat I give, but this was not enough toprevent me giving sterile water instead ofvecuronium recently. An easy mistake tomake when interrupted as one is drawingup drugs. Be warned though – the NPSAand other ‘stakeholders’ have suggestedthat all drugs given by anaesthetistsshould be checked and signed for by theanaesthetist and another trained person.Looks like it will be time to hang up myclogs when that happens.Anaesthesia News June 2008 Issue 251 25

Dear Editor…SEND YOUR LETTERS TO:The Editor, Anaesthesia News,AAGBI, 21 Portland Place, London W1B 1PYor email: anaenews@aagbi.orgTranslation difficultiesI was very interested to read the article ‘Language Barrier’, by Dr Sodhi 1 , published in March 2008, as this isa subject that has vexed me with increasing frequency recently.It is departmental policy where I work to obtain written consent before siting labour epidurals. I believethis is a contentious issue at the best of times; can a woman in the throes of labour really give informedconsent? When a language barrier is introduced it adds yet another layer of uncertainty. In recent monthsI have been called to an increasing number of labouring women who have very little command of English,particularly from Eastern Europe. As Dr Sodhi wrote, it is impossible to know how much these patientsunderstand of what has been explained to them. Most of the obstetric work-load is carried out at night andso the luxury of an official translator is not available; often partners fill the gap, but in no way can they beseen as an objective third party, and I often wonder how much of what we say is lost in translation.This situation is less than ideal for the patient and it must surely lay us open to criticism and possible consequences? If it is considerednecessary to take consent for labour epidurals, then surely it cannot be correct to carry out the procedure on a patient whom we haveno real idea whether or not they have understood and accepted the inherent risks. And if we go ahead with the procedure anyway,why do we bother wasting time with the consent process? To me it seems a frustrating hypocrisy; we should either do it properly, or notat all. Should we be consenting these, and perhaps all, pregnant women for procedures during labour in the ante-natal clinic, whereconsent could be better informed and translators could be present where necessary? I suppose this may raise other issues - what aboutthe woman who refuses an epidural, only to change her mind once labour starts; would we then refuse her the pain relief? I believe thatthis is a difficult subject and I for one am often left feeling uncomfortable following these difficult and ultimately flawed interactions. Iwould be interested to hear what others think and how they overcome these difficulties.Reference1. Language Barrier. Puja Sodhi, Anaesthesia News March 2008, P 32Kate McCombeSpR in anaesthesia, SurreyHelp with informed consentDr Puja Sodhi wrote about the difficulty of providing anaesthesia for patients who do not speak English, as well as empathising with thepatients themselves.This is a common situation in obstetric anaesthesia, as women cannot inform themselves about all possible eventualities that mightoccur during childbirth, even if they choose to seek out the information.The Obstetric Anaesthetists' Association have produced two information booklets on pain relief in labour and anaesthesia for caesareansection, and a card with brief information on epidurals for use especially during labour. There are currently a number of translations ofthese on the OAA website (www.oaaformothers.info) with several more having been commissioned.We are also developing cards with words, phrases and pictures relevant to regional and general anaesthesia, with script and phonetictranslations. These can be used to help communication especially in the emergency situation when there is no interpreter available.We would commend these resources to anaesthetists who deal with non-English speaking women in pregnancy and labour.Dr Michael KinsellaInformation for Mothers Sub-committee, OAA26 Anaesthesia News June 2008 Issue 251

Instant headache!I was asked to provide a labour epidural for an extremelyanxious lady.After explaining in detail about the technique and all theside effects, including post dural puncture headache andits management, I infiltrated local anaesthetic into the skin.Just before introducing the Tuohy needle, the lady screamed“Doctor, I am getting a terrible headache”!Making cardioversion interestingI came across this novelanaesthetic technique ina published tachycardiaalgorithm. Despite attemptingpersonal study of this art, Ihave never received any formalteaching. I wonder if it is nowexaminable as part of the FRCAsyllabus, and if so, should Ibring flowers?Malcolm BroomAnaesthetic SpR, GlasgowDr.K.B.DasariFTSTA AnaestheticsRoyal Cornwall HospitalTruroFor thenervousanaesthetist?Recently, I attendeda course in anEnglish hospitalwhich shall remainnameless. Duringa relief break as Iwent to the men’sroom, to my utmost surprise I found ….A very old Boyle’s machine [Fig 1] was decoratively perchednext to the two urinals. I had to physically move it aside tosqueeze in for the original purpose of my visit. I wondered, didsomeone actually have to provide anaesthesia there, or was itjust dumped for lack of space.I certainly can think of few other places where a Boyle’smachine would be useful for providing ‘anaesthesia outsidetheatre’ - like the dining room, locker rooms, outside pubs,football stadiums, next to an ATM machine, library etc.Is this a missing aspect of our training?Dr Deepak MalikSpecialty Registrar, AnaestheticsThe Royal Hallamshire Hospital,Sheffield Teaching Hospitals NHS TrustMore on allergies…The incidence of unusual allergens 1,2,3 does seem to beincreasing. Although an allergy to the colour red 3 would win the prize formost unusual allergen, I would like to report a close second. On preoperativeassessment for a gynaecology list, I met a very nice lady who hadpreviously had a carpal tunnel repair. Unfortunately during this procedureshe had experienced a nasty iodine burn under the tourniquet., which hadsubsequently required skin-grafting to the injured area. During routinequestioning I enquired about allergies, to which she replied "tourniquets".This had even been dutifully written on her red patient ID band.Chris Jones, Anaesthetic SpREpsom and St. Helier NHS Trust1. Lomax S. Anaesthesia News December 2007, 245:252. Stoddart A. Anaesthesia News September 2007, 242:263. Boswell O, Al-Rawi S. Anaesthesia News April 2008, 249:30Editor’s note: Thank you for all your allergy stories – this correspondence isnow closed.Is that what they really meant…?Spotted in a flyer for an anaesthesia CPDmeeting (not one organised by AAGBI!)Session 5Non technicals kill in the operating theatreSupport for a physician-only service, or amisplaced space?Due to the volume of correspondencereceived, letters are not normallyacknowledged.Anaesthesia News June 2008 Issue 251 27

Film ReviewAwakePassing gas on thesilver screenAs you address yourself over theforthcoming months to the umpteenthpatient who’s asked you if he’s going towake up in the middle of the operation “likethat bloke in the film”, spare a thought forthe unfortunately-named Dr Larry Lupin.Larry, the anaesthetist whose practiceis the subject of the recent Hollywoodblockbuster, ‘Awake’, is going to have rathera difficult time if the shadow of revalidationever falls on our colleagues in New York.“It seems, Dr Lupin”, begins the assessor,“that your pre-operative assessment leavessomething to be desired. I believe thatyou first met the index patient, who wasscheduled for heart transplantation, on theoperating table. Indeed, you only askedhim about his fasting status during the act ofpre-oxygenation. Pre-oxygenation, I mightadd, which was achieved by securing themask to his face with a Clausen harness,incorrectly attached. You then inducedanaesthesia while monitoring nothing butcentral venous pressure, the line havingpresumably been inserted by a passingsurgeon in some location other than theneck.”“I say induced anaesthesia, of course,but that is perhaps something of anexaggeration. He never actually went tosleep at all, did he? But then, you may nothave known that, as you were apparentlyout of the theatre most of the time duringthe procedure”.“Ah”, protests the beleaguered Dr Lupin.“But that’s pretty standard during cardiacsurgery, you know”.“Not before the patient goes on bypass!”,thunders the assessor. “And, it must besaid, that it is hardly standard practice foran anaesthetist to carry a hip flask in hisscrubs, let alone to take surreptitious sipsfrom it during the operation”.Larry raises his grizzled and drink-soddenhead from the edge of the desk, where ithas come to lie. “Give us a break. I’ma shining example of virtue compared tothe surgeons. At least I didn’t plot to killthe patient by injecting adriamycin intothe donor heart, having tricked him intomarrying one of my nurses, thus ensuringthat she’ll inherit his millions, allowing meto pay off all my malpractice claims”.The assessor concedes this point, suggests aprogramme of counselling to allow Dr Lupinto confront his issues, and tells him she’llsee him in five years’ time. Larry headsoff to find himself a new cardiac team, thelast one having presumably been struckoff, imprisoned, executed, sent to practicein South Dakota or whatever happens tohomicidal surgeons in the USA.‘Awake’, the first – and hopefully only –foray by Hollywood into the complicationsof anaesthesia, has a few surprises up itssleeve. The anaesthetist isn’t the villainof the piece, just incredibly incompetent.Indeed, he’s not even played by the onlyBritish character, usually a shoo-in for theguy in the black hat. Another anaesthetist,who we don’t get to meet, has defaultedfrom the case because he can’t bringhimself to murder his patient – that’s what Icall ‘probity’. And, in the spirit of suspense,I’ll leave you guessing where the good guysfind a new heart for our temporarily bypassdependenthero.You even get to feel a little sorry for themad surgeon. After all, he’s pulling an80-hour week, everyone’s trying to suehim, and his chief assistant is a malign, ratfaceddwarf. And, heck, it’s not every daythat fate gives the wealthiest man in NewYork cardiomyopathy and then places him,trusting and needy, into your hands. Plus,and this will always be the clincher for anyred-blooded male, he’s had the good tasteto employ Jessica Alba as his scrub nurse.Could this be the beginning of a new trendin entertainment? Surgeons, A&E docs,even GPs and psychiatrists have all hadtheir day in the sun. Now we’re up therewith the greats. What next? ‘Skin Flick’,a film about a deranged dermatologistwho mistakenly treats a nasty fungalinfection with steroids? ‘Sickly Sweet’, inwhich a debt-ridden diabetician boostshis private practice by putting glucagon inthe punch at the country club social? Youmay think I jest but, while settling into myseat, I nearly dropped the popcorn asa trailer came on for a film in whichtwo trainee pathologists compete tomurder innocents in increasinglybizarre ways, challenging theother to discover how it wasdone at post-mortem. Thetitle? ‘Pathology’. Who saidthey don’t have imaginations inHollywood?David Bogod