What you should know about your pension Who's Holger ... - aagbi

THE NEWSLETTER OF THE ASSOCIATION OF ANAESTHETISTS OF GREAT BRITAIN AND IRELAND

Anaesthesia News ISSN 0959-2962 No. 299 June 2012

INSIDE THIS ISSUE:

What you should know about your pension Who’s Holger Nielsen? Returning to work the Wessex way

Anaesthesia NewsJune_FINAL.indd 1

02/05/2012 09:09

Editorial Contents

2012 ULTRASOUND TRAINING COURSES

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2012 Course Dates: Introductory Ultrasound Guided Regional Anaesthesia

SonoSite, the world leader and specialist in hand-carried ultrasound, has teamed up with some of the leading specialists in the medical industry to design a series of courses, for both novice and experienced users, focusing on point-of-care ultrasound.

11 – 12 June 19 – 20 November

Introductory Ultrasound Guided Regional Anaesthesia The two-day introductory course is designed to teach those who have little or no experience in the use of ultrasound in their normal daily practice. The course comprises of didactic lectures on the physics of ultrasound, ultrasound anatomy and regional anaesthesia techniques. The lectures and hands-on sessions will concentrate on the brachial plexus, upper and lower limb blocks.

Ultrasound Guided Venous Access 11 October 8 November Ultrasound Guided Chronic Pain Management 26 November Venue: SonoSite Education Centre – Hitchin

Ultrasound Guided Critical Care courses also available

Ultrasound Guided Venous Access This one-day course is aimed at physicians and nurses involved with line placement and comprises didactic lectures, ultrasound of the neck, hands-on training with live models, in-vitro training in ultrasound guided puncture and demonstration of ultrasound guided central venous access. The emphasis is on jugular venous access, but femoral, subclavian and arm vein access will also be discussed. Ultrasound Guided Chronic Pain Management The course is aimed at chronic pain specialists, or other interested parties practising in chronic pain medicine who have little or no experience of musculoskeletal ultrasound and who wish to obtain an introduction to ultrasound in chronic pain medicine skills.

For the full listing of SonoSite training and education courses, dates and to register go to:

Fees: £375 (two-day courses) includes VAT, lunch, refreshments and course materials. £260 (one-day courses) includes VAT, lunch, refreshments and course materials.

www.sonositeeducation.co.uk

If you have any questions or should need further information please contact: Jes Tiller, SonoSite Ltd, Alexander House, 40A Wilbury Way, Hitchin Herts, SG4 0AP Tel: +44 (0) 1462 444800 Fax: +44 (0) 1462 444801 E-mail: [email protected]

© 2012 SonoSite, Inc. All rights reserved. 03/12

2012 ULTRASOUND GUIDED REGIONAL ANAESTHESIA – BEYOND INTROD UCTORY These courses are organised by Regional Anaesthesia UK (RA-UK) in conjunction with SonoSite Ltd for training in ultrasound guided regional anaesthetic techniques. Previous experience in regional anaesthesia is essential. Course Dates 9 –10 July 20 – 21 September 30 November – 1 December

Location Brighton (A) Liverpool Nottingham (A)

Organisers Dr Susanne Krone Dr Steve Roberts Dr Nigel Bedforth

Faculty will vary depending on location

10% Discount for ESRA members – 15% Discount for RA-UK (FULL) members. Cost: £400 / £500 (A) including a CD with presentations and course notes. Pre-course material can be downloaded once registered on the course – including US physics, anatomy of the brachial / lumbar plexus, current articles of interest and MCQ’s. A pre course questionnaire will be sent 30 days before each course.

Programme Day 1

Day 2

• • • • •

• • • • •

Ultrasound appearance of the nerves Machine characteristics and set-up Imaging and needling techniques Common approaches to the brachial plexus / upper / lower limb Workshops – using phantoms / models / cadaveric prosections (A)

Consent / training and image storage Upper / lower limb techniques Abdominal / thoracic techniques Cervical plexus / spinal / epidural / pain procedures Workshops – using phantoms / models / cadaveric prosections (A)

(A) – Anatomy based courses / with cadaveric prosections

extra-contractual NHS work

05 Independent Practice Committee

Latest Report

07 President’s Report 09 GAT: What you should know

11 There are three massive issues glowering over us: the medical workforce, ACCEA awards and pensions. I am sure that most of you have tended (like me) to ignore these matters in favour of concentrating on the core aspects of our work – direct and supporting care of our patients, and on our private lives in our spare time, secure in the knowledge that our lot is not, in general, an unhappy one. However, times are changing, and we can no longer be complacent either individually or collectively. The AAGBI Council has considered workforce issues and ACCEA awards at length. We have made appropriate representation to the ACCEA committee. The continuing silence from the government regarding the future of these awards is eloquent (I am reminded of John Cage’s orchestral work, 4’33’’, for which the players sit before the audience but don’t play their instruments) and I think it is sensible to assume that the awards will not continue in their present form. In some ways, that won’t be a bad thing. The administration of the awards was very time consuming, and it is questionable whether true excellence was actually proportionately rewarded via the ACCEA system. The system could feel very unfair, both to individuals whose applications were rejected and to whole specialties such as ours that collectively received fewer awards than others. Only 17% of the 996 bronze applicants in the 2011 round were recommended for an award. However, I don’t suppose we will see the money saved by not making these awards appearing in our pay packets in some other form any time soon. Workforce calculations are notoriously difficult. I attended College Tutors’ meetings for a decade or more from the mid-nineties; every year the relevant RCoA bod would stand up and give us the latest workforce predictions, usually calculated on the back of an envelope. The striking thing about those predictions was that they rarely bore much relationship to what actually happened. Of course, all those who can remember the obstetrics and gynaecology debacle of the mid nineties are scarred by the memory of seeing trained obstetricians ‘signing on’ for the dole. Reviewing this in her 2003 report [1], the then chair of the RCoG’s medical workforce advisory committee commented that workforce planning continued to be very difficult, and that in three years the

18

about your pension

11 Who’s Holger Nielsen? 14 How to write a review 17 Anaesthesia Digested 18 Returning to Work

the Wessex Way

20 Do Novice Anaesthetic

Trainees receive enough training in airway management skills?

23 AAGBI Video Platform 24 Specialist Society: The Society for

20

Intravenous Anaesthesia

26 Particles 28 Would you give away your house? 29 Your Letters

23 The Association of Anaesthetists of Great Britain and Ireland 21 Portland Place, London W1B 1PY Telephone: 020 7631 1650 Fax: 020 7631 4352 Email: [email protected] Website: www.aagbi.org Anaesthesia News Editor: Val Bythell Assistant Editors: Kate O’Connor (GAT), Nancy Redfern and Felicity Plaat Address for all correspondence, advertising or submissions: Email: [email protected] Website: www.aagbi.org/publications/anaesthesia-news Design: Christopher Steer AAGBI Website & Publications Officer, Telephone: 020 7631 8803 Email: [email protected] Printing: Portland Print Copyright 2012 The Association of Anaesthetists of Great Britain and Ireland The Association cannot be responsible for the statements or views of the contributors. No part of this newsletter may be reproduced without prior permission.

www.sonositeeducation.co.uk

Advertisements are accepted in good faith. Readers are reminded that Anaesthesia News cannot be held responsible in any way for the quality or correctness of products or services offered in advertisements. © 2012 SonoSite, Inc. All rights reserved. 03/12

Anaesthesia News June 2012 Issue 299

Anaesthesia NewsJune_FINAL.indd 2-3

04 Parity of pay for

For further information and to register logon to

1384_AN March 2012 Half Page Ads Split v3.indd 1

03 Editorial

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25/01/2012 15:22 02/05/2012 09:09

Editorial continued specialty had moved from a crisis of over-production to a crisis of underproduction of suitably trained consultants. The consultant expansion in O&G had been running at over 5% a year, and their assumptions in 1996 were that this would continue; however by 1999 the expansion rate was less than 1%, the reasons for which were still not clear. The problem they then faced was that at the introduction of Calman training, the number of NTNs created assumed this expansion rate would continue; the rest is history. Despite our best efforts, predicting the future tends to confound us. It seems to me that we may be in danger of having that history repeat itself in our own specialty. Anaesthesia News will focus on this issue in September, and I would welcome your views and submissions on this important subject. Last but not least, we are looking at pensions in this month’s Anaesthesia News. I urge you all to read the carefully considered summary written by our GAT representative to the BMA on page 9, and Ian Nesbitt and Avinash Kapoor’s personal ‘wake up call’ on page 28. Whether you are collecting your pension next week or in a couple of decades, these changes matter to you. Your Association will continue to represent your interests in these matters – do keep us informed of your views.

Val Bythell 1.

Maggie Blott. Medical workforce in obstetrics and gynaecology. ‘Changing times’. Chairman’s review. RCoG 2003. Accessed at http://www.rcog.org.uk/files/rcog-corp/uploaded-files/WF03_ Chair_review.pdf on 26th April 2012

The AAGBI is now connecting with members through online social networks Facebook and Twitter.

Parity of pay for extra-contractual NHS work Anaesthetists may be requested to do additional NHS work of a temporary nature on NHS premises, over and above the DCC commitment defined in their job plan, eg waiting list initiatives. The AAGBI is aware that some Trusts are paying surgeons more than anaesthetists for the same time commitment when undertaking this activity. The AAGBI believes this is completely unacceptable for the following reasons.

@AAGBI


AAGBI1

LATEST REPORT

1. Equal pay for consultants treating NHS patients was a founding principle of the National Health Service in 1948 and is supported by many professional organisations including the BMA, the HCSA, the AAGBI, the Royal College of Anaesthetists, the Medical Women’s Federation and the Federation of Independent Practitioner Organisations. These key principles have been endorsed by the 2009 NHS Constitution: “Staff have extensive legal rights… to help ensure that all are treated fairly, equally and without discrimination” (page 10) and “all NHS organisations, as well as third sector and independent organisations providing NHS care, should be legally required to take account of the NHS Constitution in performing their NHS functions” (page 6.1 Handbook to the NHS constitution2009). Equal pay for extra waiting list work was formally written into the NHS 2003 consultant contract in Scotland and in Wales. 2. If Trust employees normally receive pay that is equivalent to other colleagues but are then asked to do the same task at another time but at a lower rate than colleagues on the same pay scale, this is clearly belittling and demeaning, and could be regarded as deliberately undermining their professional status. Belittling, demeaning and undermining staff are all acknowledged forms of bullying within the NHS’s anti-bullying policy. 3. Nationally, 36% of consultant anaesthetists are female, as opposed to only 7% of consultant surgeons. If a similar gender difference exists locally, equal pay legislation suggests that any differential in pay between anaesthetists and surgeons will be regarded as indirect discrimination on grounds of gender. NHS Trusts are required to agree an equality policy and now, as with all public authorities, Chief Executives have a duty to eliminate unlawful gender discrimination and to promote equality of opportunity between men and women. 4. It is likely that many different specialities will be requested to undertake temporary additional clinical activity, eg, physicians may do extra outpatient clinics or endoscopy lists. If surgeons are paid more than other specialists, the disparity is likely to generate considerable disquiet at the Medical Advisory Committee. The ability of the Trust to continue to rely on this extra activity might then be substantially undermined. 5. If Trusts make preferential deals with surgeons, this will open the floodgates to every other speciality to argue their worth in confrontational negotiations. Meanwhile, they may refuse or be unwilling to do this work, dramatically reducing productivity. The negative effects on morale and goodwill persist long after any resolution. In addition, for the Trust managers, it will be very difficult to process the different pay agreements. 6. For all the above reasons, the vast majority of NHS Trusts enforce a unified pay scale for extra-contractual work, valuing all medical specialities equally according to time-based parity of remuneration and grade. Such pay policy should be negotiated and agreed by the Local Negotiating Committee (LNC) and must not be devolved to Divisional Directors. A sample policy is attached at Appendix A.

According to the recent membership survey, over 70% of you use a Smartphone and over 40% of you use Facebook - so this is another opportunity for you to keep up-to-date with news from the industry and the AAGBI

Independent Practice Committee

The AAGBI strongly suggests that anaesthetists should demand parity of pay for additional clinical activity on NHS premises. If surgeons are paid more, for equal time commitment, anaesthetists should refuse to take on this voluntary work and should demand that the LNC negotiates a policy based on pay parity. The same principles apply to NHS work performed in non-NHS premises. The NHS Standard Acute Contract states that “The Provider shall comply at all times with the law on anti-discrimination and equal opportunities in relation to its staff” (para 11.9).

Dr Sean Tighe, Chair of the Independent Practice Committee

Dr Sean Tighe, Chair of the Independent Practice Committee

1. What Committee do you Chair? a. Independent Practice Committee (IPC)

2. What were your three biggest achievements over the last year? a. b. c.

Office of Fair Trading (OFT) Submissions. Following our initial detailed submission to the OFT in 2010, we attended a round table discussion with other representatives of the independent sector and wrote a final letter to the OFT. Responses to the OFT report. We posted a press release and submitted a detailed response which robustly challenged the unfair and poorly referenced criticism of anaesthetists and anaesthetic groups. Enquiries from members. We have responded to numerous enquiries from members on private practice and NHS parity issues, one of which resulted in achievement of pay parity throughout a large NHS trust.

3. What current challenges are you facing? a. b. c. d.

Competition Commission (CC) enquiry. We are preparing for a possible CC enquiry into the private healthcare market. PMI restrictions. Members face increasing restrictions and threats to their recognition by PMIs. NHS parity. There are still many NHS and private institutions that do not have pay parity for additional temporary NHS work. IPC Seminar. We are running a seminar on 25 April 2012 to discuss the issues affecting Independent Practice.

4. What are your priorities for the coming year? a. b. c. d. e. f. g. h.

CC enquiry. We are preparing for a possible CC enquiry to ensure that the interests of members are fairly represented and the criticisms of the OFT are challenged. In addition, we intend to re-present our concerns about the anticompetitive practices of the PMIs, which were discounted by the OFT. Patient Information. We intend to assist members in providing objective evidence of the quality of care they provide and their terms of business in the independent sector, in order to promote patient choice. Forum. We are examining the possibility of sponsoring a forum for discussion on IPC issues, that is independent of AAGBI. Responding to enquiries. We will continue to respond rapidly to enquiries from members. Liason with other groups. We will continue to liase closely with FIPO, the Anaesthetic Sub-Committee of the BMA Consultant Committee and the BMA Private Practice Committee. PMI meetings. We have invited all the major insurers to meet with us, in order to explore issues of mutual interest. Parity of pay. We will continue to promote the concept of pay parity for both NHS and private work. Anaesthesia News. We are committed to providing regular articles for Anaesthesia News on IPC matters.


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02/05/2012 09:09

22nd

National Acute Pain Symposium Thurs 13th & Fri 14th September 2012 Crowne Plaza Hotel, Chester

The Nation's premier Acute Pain forum

Plenty of interesting content for anyone involved in Acute Pain management

An interesting and varied program with first class speakers Extended release epidural morphine in colorectal enhanced recovery Recent advances in acute pain management Nerve block infusions after amputation Neurosurgical issues relating to epidural complications European "Pain OUT" benchmarking & European Pain Registry project Acute pain in the A&E Department fMRI - functional MRI scanning in acute pain Update on NSAID's Acute pain in the cognitively impaired patient Co-administration of opioids and opioid antagonists Regional anaesthesia & pain assessment in large animal veterinary practice Presentations by Poster Competition winners Acute Pain SIG meeting

Poster exhibition with 3 cash prizes See what the innovators are doing around the country Details & Bookings : Georgina Hall Tel : (0151) 522 0259 Mob : 07901 717 380 E-mail : [email protected]

Registration Fees : Consultants NCCG SpR & SHO Nurses

£345 £345 £275 £195

Comprehensive Trade exhibition

Informal Delegate Dinner - Brazilian Restaurant

Hear about & see the new & existing Acute Pain related products

A wonderful relaxed and friendly evening. A favorite amongst those who have attended before

8 CPD points from the Royal College of Anaesthetists applied for Anaesthesia NewsJune_FINAL.indd 6-7

President's Report The recent headlines about elderly patients being discharged home in the middle of the night point to systems and capacity issues for the health and social care needs in the UK, a trend which will worsen with our increasingly aged population.

In my hospital, we have had a difficult winter with a significant number of elective lists being cancelled due to medical outliers in surgical beds. This was despite a serious attempt by clinicians and management to try to keep everything functioning. These warning signs demonstrate that the acute sector is creaking, and although redesign of services can help with some issues, in reality the “protected from cuts” NHS faces significant disinvestment, which will destabilise the service. Any changes altering the cooperation between primary and secondary care will make our work even harder. However, the Health and Social Care Act has now been passed, and the government, despite much advice to the contrary, is pushing reform of the NHS hard. I am sure that many who are working to change the way commissioning works are sincere, but competition in the NHS could significantly fragment services. “Other qualified providers” will need to select parts of the NHS where a profit for investors can be realised. The danger of cherry picking is real, and will remove money from hospitals that have to provide more expensive, relatively underfunded procedures, often part of our day-to-day work. A paper in Anaesthesia recently described the real costs for caring for patients requiring emergency laparotomy and compared that with the tariff received (£13,000 vs £6,905) [1]. The same issue contains an editorial describing the English NHS Tariff – under the title ‘Traps for the Unwary’ ![2] However, we should not lose sight of the opportunity for muchneeded innovation in the NHS offered by free-thinkers in the private sector, so not all will be negative. The report from the Centre for Workforce Intelligence (CfWI) is well worth reading [3]. With the increased numbers of doctors in training, there will be enough CCT-trained doctors available to increase the consultant headcount by 60% across the acute sector by 2020. This fits with the much talked-about “Consultant based / delivered / present” service, which I believe would increase efficiency in the NHS [4]. However, such expansion would come at a price, and with the current rate of funding in the NHS, it is difficult to see significant expansion happening. The proposed reduction in training numbers to manage the overproduction of CCTs will hit emergency rotas as hard as occurred when the EWTD shifted to 48 hours. How will the different departments making up an NHS hospital cover out-of-hours work in a financially efficient way? Yet the NHS has stated that it wishes to become a 7- day service with the same levels of intervention available to patients every day [5]. There is no doubt this is what is required and what the public expect, but it will take investment in staff and resources. We have the doctors available in training and we must lobby for this change to take place. Already the NHS is one of the most efficient and effective healthcare systems in the world and although we need to change many aspects of the way we work, it is not the time to pull investment out. Anaesthesia News June 2012 Issue 299

With “any qualified provider” on the horizon, will the independent sector treatment centres (ISTC) initiative (started under the Labour government) finally take off and will it be a good development? For patients who have been unable to get efficient NHS surgical care this winter, many may welcome a future opportunity to have a choice of where to be treated (assuming external investment creates the facilities). Ideally, fully accredited UK specialists, working in group practice arrangements, will run ISTCs. It is likely in my view that in 2030, this will be commonplace with some colleagues working in the ISTC sector, others in the traditional NHS and some with contracts between the two. Investment in facilities from private companies will need to take place and they will look for a guaranteed market - perhaps that is the reason for the Health and Social Care Act? Profits will need to be generated to fund the developments and it is difficult to see their services being lower cost. Consider PFI as an example. We need to watch these developments carefully for our specialty. Current private practice is changing fast as PMIs try to reduce costs for profit and customers, and also more significantly to allow them to compete for NHS work at tariff – a prize which could enlarge the size of this market significantly. Newer insurance policies reflecting the changed NHS / qualified provider interface will offer different deals, with guaranteed healthcare, but without the traditional personal relationship between patient and clinician. I suspect consultants will become employed directly – there is a potential danger here; anaesthetists could be paid less than surgeons. This already happens of course, if you do a private list in your NHS hospital. With the private practice cap disappearing for Foundation Trusts in England, how will this work in the future?

There has never been a more important time for the specialty to work together to ensure success for our patients, ourselves and the young doctors entering the profession who represent the future. Dr Iain Wilson, AAGBI President 1. 2. 3. 4. 5.

S. L. Shapter, M. J. Paul and S. M. White. Incidence and estimated annual cost of emergency laparotomy in England: is there a major funding shortfall? Anaesthesia 2012;67:474-8 N. Edwards. The Tariff – traps for the unwary. Anaesthesia 2012;67:466-70 Shape of the medical workforce: Starting the debate on the future consultant workforce. http://www.cfwi.org.uk/publications/leaders-report-shape-of-themedical-workforce The benefits of consultant-delivered care. Academy of Medical Royal Colleges 2012. http://www.aomrc.org.uk/publications/reports-a-guidance.html http://www.healthdirect.co.uk/2012/04/hospitals-should-operate-seven-daysa-week.html

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02/05/2012 09:09

WHAT YOU SHOULD KNOW ABOUT YOUR PENSION

This month we invite our BMA Junior Doctors’ Committee representative Heidi Mounsey to tell us more up this topical issue. The NHS pension scheme has always been well regarded and generally compares well with other pension schemes in both the public and private sector. A pension allows forward planning to help ensure a good standard of living in retirement. The employer makes a contribution each month to the pension scheme (this can be effectively considered as deferred pay), as does the employee.

THE SITUATION AT PRESENT

In order to keep the NHS pension fair and sustainable, without being a burden to the taxpayer, on April 1st 2008 several changes were made. All new members to the scheme after this date automatically joined what is known as the 2008 section while existing members remained in the existing scheme, known as the 1995 section. A choice exercise began in October 2009 to allow members of the 1995 section to switch to the newer 2008 section, if they felt that would be of benefit to them. Most members will, by now, have made their decision. For both schemes, the pension contributions are calculated using basic pay and any London weighting allowance. Banding supplements are not taken into account, nor is any overtime pay. The contributions paid by the employee depend on the level of basic salary and are as follows for 2011/2012:

WTE* pensionable pay

Contribution rate

Up to £21,175

5%

£21,176 to £69,931

6.5%

£69,932 to £110,273

7.5%

Over £110,274

8.5%

(*Whole Time Equivalent) The employer contribution to your pension is 14% of salary in England and Wales, 13.5% in Scotland and 13.3 % in Northern Ireland.The final pensionable salary for each scheme is slightly different, and when calculating pension benefits, part time work must be scaled down to the full time equivalent e.g. 10 years working on a 70% contract would result in seven years’ scaled service. For the 1995 section, where the normal retirement age is 60, on retirement the final pensionable pay is the best full-time (even if working part time) salary rate for that position (e.g. consultant anaesthetist) out of the last three years. For most, this will be the salary for their last year of service. The following equation is then used: Pension = scaled service/80 x final pensionable pay

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Therefore, a consultant retiring at 60 with 35 years’ scaled service and a final salary of £78, 097 would have their pension calculated as follows:

WTE* pensionable pay

Current rate

Rate 2012/13

Possible rate 2013/2014

Possible rate 2014/2015

Overall increase

£15,001 - £21,175

5.0%

5.0%

5.0%

5.0%

0%

£21,176 - £26,557

6.5%

6.5%

6.5%

6.5%

0%

£26,558 - £48,982

6.5%

8.0%

9.5%

10.25%

3.75%

£48,983 - £69,931

6.5%

8.9%

11.3%

12.5%

6%

£69,932 - £110,273

7.5%

9.9%

12.3%

13.5%

6%

Over £110,273

8.5%

10.9%

13.3%

14.5%

6%

Pension = 35/80 x £78,097 = £34,166 per annum A tax free lump sum is also automatically provided of three times the pension. In this case the lump sum would be £34,166 x 3 = £102,498 For the 2008 section, the normal retirement age is 65 and the final pensionable pay is calculated as the average of the best three consective years in the 10 years prior to retirement. The equation used under this section is: Pension = scaled service/60 x reckonable pay A consultant retiring age 65 with 35 years’ scaled service and a three year average pay of £78, 097 would have their pension calculated as follows: Pension = 35/60 x £78,097 = £45,556 There is no automatic lump sum under the 2008 section, but there is the option to reduce the annual pension received in order to obtain a lump sum on retirement. However, all of this now looks set to change.

THE PROPOSED CHANGES Last year, the Governent proposed several changes to the NHS Pension scheme, claiming it was unaffordable in its current state, despite its overhaul in 2008 and despite it currently delivering £2 billion to the Treasury every year. Those changes include: - Linking the normal pension age (i.e. 60 years for those in the 1995 section, and 65 for those in the 2008 section) to the state pension age. This means that most people will now have to work until 68 years of age. - Replacing the final salary scheme with Career Average Revalued Earnings. This means earning a percentage of salary as pension for each year worked, uprated in line with average earnings, rather than taking the best single year of three, or average of the best three years out of 10. An accrural rate of 1/54 has been offered to replace the current accrural rates of 1/80 (1995 scheme) or 1/60 (2008 scheme) - Considerable increases in employee contributions to their pension: The intention is for these changes to be implemented by 2015, with increases in employee contributions beginning this year. Doctors within 10 years of retirement will be protected against some of these changes and will still be able to retire at their normal pension age. For an example of how these pension changes may affect you, the British Medical Association have provided a simple pension modelling tool at http://bma.firstactuarial.co.uk/ Anaesthesia News June 2012 Issue 299

The BMA have also modelled case studies to help demonstrate the implications of the proposed changes for us. One such example shows that a 25 year old junior doctor following a consultant career path will potentially pay an additional £240,000 in pension contributions, work until 68 in order to receive their full pension, and then receive an annual pension of £70,000 if they choose not to take a lump sum. While this is a higher annual pension, the fact they have paid more for it and will receive it for fewer years ultimately gives them less over the course of an average retirement. Overall, they may pay more than double into the new scheme in order to receive 16.5% less from it. Consultants will also be affected but not quite as dramatically, with a 40 year old consultant potentially paying in twice as much to the scheme, retiring later, and receiving four percent less over the length of retirement. The BMA, along with other health care unions, has strongly opposed these changes, announcing that they amount to little more than a thinly disguised tax on NHS workers, with most doctors now in the position of having to work longer and pay more for their pensions, whilst receiving less in retirement.

Both pension calculations and the legal issues surrounding industrial action for doctors are complex, and this article aims to provide only a brief overview of these matters. Further information regarding pensions, and how these changes may impact you individually, are available from independent financial advisors, and the BMA website www.bma.org.uk offers further information regarding the background to the forthcoming balloting process with comprehensive FAQs. Heidi Mounsey ACCS CT3 , Kent Surrey and Sussex Deanery BMA Junior Doctors’ Committee & co-opted representative to the GAT Committee

ACTION BEING TAKEN The Government have refused to negotiate and, consequently, in October 2011 the BMA surveyed its members to establish how strongly the profession felt about these changes, and whether they would be prepared to take industrial action to defend their current pensions, up to and including strike action. Around a third of the membership responded, with the majority stating they would be prepared to take industrial action short of strike action to protect pensions. Consequently, an emergency meeting of the BMA Council in March 2012 has taken the decision to ballot BMA members on industrial action short of a strike. The ballot, the first to affect doctors since 1975, is planned to take place in May 2012, and will ask BMA members if they are willing to provide only urgent and emergency care. Initially, this would be for a 24 hour period, with further industrial action planned as necessary. Doctors would still attend work, but not undertake non-urgent work for the period of industrial action. In order to take part in the ballot, BMA members must provide up-to-date place of work details, which can be done through the BMA webiste. A series of workshops and roadshows are running prior to the ballot in order to inform doctors, both members and non-members of the BMA, of the possible model of industrial action and allow BMA representatives to answer questions. Anaesthesia News June 2012 Issue 299

9

02/05/2012 09:09

Education Courses Sponsored by Philips Healthcare

Education Courses Sponsored by Philips Healthcare

The Birmingham

The Birmingham

Transoesophageal Echo Course 2012 March & November 2012

To be held at: Queen Elizabeth Hospital, Birmingham Course Objective

3D Transoesophageal Echo Course 2012 March & November 2012 To be held at: Queen Elizabeth Hospital, Birmingham

Course Objective

3 day practical course to deliver knowledge and practical skills in perioperative TOE

This course is aimed at anaesthetists, cardiologists and sonographers who is capable in 2D TOE and wish to further their knowledge of 3D transoesophageal echocardiography, acquisition and interpretation.

Course details:

Course details:

Cost of the course: £600.00 Places for this are limited to 6 delegates.

Registration, enquiries and booking: Dr Tessa Oelofse, Consultant Anaesthetist, Department of Anaesthesia, The UHB NHS Trust, Queen Elizabeth Hospital Edgbaston, Birmingham, West Midlands, B15 2TH Tel: 0121 6271627 Ext 3325 email: [email protected]

Faculty: Course Directors: Dr. Rick Steeds and Dr. Tessa Oelofse Dr Rick Steeds Consultant Cardiologist (Imaging)

Dr Tessa Oelofse Consultant Anaesthetist (Cardiac & ITU)

Dr Harry Singh Consultant Anaesthetist (Cardiac & Renal)

Miss Nicky Smith Senior Echo Technician (TOE & TTE)

Dr Craig McGrath Consultant Anaesthetist(Cardiac)

Cost of the course: £250.00 Places for this are limited to 8 delegates.

Registration, enquiries and booking: Nicola Smith, Consultant Echocardiographer, Department of Anaesthesia, The UHB NHS Trust, Queen Elizabeth Hospital Edgbaston, Birmingham, West Midlands, B15 2TH email: [email protected]

Faculty: Course Directors: Dr. Rick Steeds and Dr. Tessa Oelofse Dr Rick Steeds Consultant Cardiologist (Imaging)

Dr Tessa Oelofse Consultant Anaesthetist (Cardiac & ITU)

Dr Craig McGrath Consultant Anaesthetist(Cardiac)

Ms Philips Healthcare

Who’s Holger Nielsen?

15 CEPD/9 BSE accredition points awarded

Philips Healthcare

www.philips.com/healthcare

Philips Healthcare

www.philips.com/healthcare

Geevor was the last working Cornish tin mine and only closed in 1991. It was sad and eerie to see another piece of lost British industry. In the Mill where the ore was processed, I spied numerous copies of this poster which outlines the treatment of electric shock (see Appendix).

Client:

Philips Healthcare

Client:

Philips Healthcare

Contact:

Ms Katie O’Driscoll - 01737 230400

Contact:

Ms Katie O’Driscoll - 01737 230400

Project:

Birmingham Echo2 Course advert

Project:

Birmingham Echo1 Course advert Final FRCA Examination Final Examination Final FRCA FRCA Examination

BSE Journal Intensive PreparationCourse Course Intensive Preparation Intensive Preparation Course Dawn Appleby : 0207 345 5185 Date Required: 2nd December 2011 Size: 128.5mm x 90mm - quarter page Artwork: 29th November 2011 File name: BSE Birmingham Echo1 Course advert 11-2011 th thth th Monday 9 to Friday 13 July Monday 13th July2012 2012 th to Friday Imagesetter: Hi-Res99print PDF 13 Monday to Friday July 2012 This five day course includes sessions on examination This five day course includes sessions on examinationtechnique, technique, Reference: C&CP 19042 applied basic science, ITU, includes pain management, subjects. This fivescience, day course sessions hot on examination technique, applied basic ITU, pain management, hottopics topicsand andpractical practical subjects. Also mock examinations and performance applied basic science, ITU,examinations pain management, hot topicsanalysis. and practical subjects. Also mock and performance analysis. Artwork Contact: Malcolm at C&C Productions Conducted by national and local experts Also mock examinations and and performance analysis. Conducted by national local experts at Engineers’ Clifton Bristol Conducted byHouse, national and Down, local experts at Engineers’ House, Clifton Down, Bristol Telephone : 00.33.(0)5.57.68.26.78 at Engineers’ House, Clifton Down, Bristol For further details, please contact: For further details, please contact: e-mail : [email protected] For further details, please contact: Supplier: Contact:

The University HospitalsBristol Bristol TheUniversity University Hospitals The Bristol SAQ/MCQ/SBA SAQ/MCQ/SBA SAQ/MCQ/SBA Preparation Course Preparation Course Preparation Course

Jane McLean Jane of McLean Department Anaesthesia Jane McLean Department of Anaesthesia Bristol Royal Infirmary Department of BristolStreet, RoyalAnaesthesia Infirmary Marlborough Bristol BS2 8HW BristolStreet, Royal Bristol Infirmary Marlborough BS2 8HW Marlborough Street, BS2 line) 8HW Telephone: 0117 342 Bristol 3801 (direct Telephone: 0117 342 3801 (direct line) e-mail: [email protected] Telephone: 0117 342 3801 (direct line) e-mail: [email protected] e-mail: [email protected] Course Directors:

Course Directors: Dr Kathryn Jackson FRCA, Dr Neil Muchatuta FRCA Course Directors: Dr Kathryn Jackson FRCA, Dr Neil Muchatuta FRCA

Dr £499 Kathryn Jackson FRCA, Drdinner Neiland Muchatuta Includes welcome course mealFRCA

£499 £499

All lunches plus coffees/teas Includes welcome dinner and course meal

£450 before 1/6/12 Includes Digital copy plus of allcoffees/teas lectures All lunches welcome dinner and course meal £450 before 1/6/12 All Digital copyplus of allcoffees/teas lectures lunches

£450 before 1/6/12

October half term saw the family travelling down to Cornwall to stay in a former lighthouse keeper’s cottage. I had the splendid idea of walking from the cottage to Geevor Tin Mine. After my four year old daughter fell in a stream and came out with a soggy foot, my infant son emptied the contents of his bowels down his right trouser leg and my husband insisted on a route change to avoid a field of “killer cows”, I was beginning to regret my plan. However, something I saw there has sparked an investigation that I shall share with you. Little did I realise that I would not only increase my knowledge of tin.

BSE Journal British Society of Dawn Appleby : 0207 345 5185 Orthopaedic Anaesthetists Date Required: 2nd December 2011 Contact:

128.5mm x 90mm - quarter page

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29th November 2011

Annual Scientific Meeting BSE Birmingham Echo2 advert 11-2011 EdgbastonHi-Res Stadium Imagesetter: print PDF – Birmingham of Warwickshire Reference: HomeC&CP 19042

Cricket

Mouth-to-mouth Ventilation

Artwork Contact: Malcolm at C&C Productions Telephone : 00.33.(0)5.57.68.26.78

Friday,e-mail 9th :November 2012 [email protected] Programme - to follow

Prize fund of £2000

This was bewildering on many levels: One, who was Holger Nielsen and does this method of ventilation really work and two, how does one easily make sure that the tongue is free in the prone position? Finally, where were chest compressions? As I remember from Primary MCQ knowledge, electric current can also affect the heart as well as the respiratory muscles.

Who was Holger Nielsen? For further information please contact RNOH Education Centre on Tel. 020 8909 5326, email [email protected] or register via our website www.rnoh.nhs.uk/education

My first port of call was “Resuscitation Greats” by Peter and Thomas Baskett. This informed me that Colonel Holger Louis Nielsen was a physical fitness instructor in the Danish Army [1]. He taught lifesaving and worked to improve the artificial respiration methods then

Digital copy of all lectures



Manual Artificial Ventilation

Archer Gordon published various studies in 1950, demonstrating that the Holger Nielsen method was superior to other manual methods (via a cuffed oral endotracheal tube) in volunteers and in warm corpses found within an hour of death on hospital wards [2,3,4]. These papers give neither indication of informed consent nor ethical approval. It was concluded that the Holger Nielsen method was a compromise between successful ventilation and fatigue of the operators. Gordon et al did not study mouth-to-mouth or mouth-to-nose methods as they felt that these were too difficult to teach. They also noted that the methods in the supine position were compromised by airway obstruction.

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in use. His method was endorsed by the Danish Red Cross in 1933 and adopted as the method of choice for first-aid teaching by the International Red Cross in 1953. It was rendered obsolete by the mouth-to mouth method in the late 1950’s.

Jim Elam was an American anaesthetist. In 1946, he worked with polio patients and when he temporarily ran out of tank respirators he instinctively performed mouth-to-mouth or mouth-to-nose ventilation. On further research, he discovered that there were descriptions of over 100 methods of manual artificial ventilation, but the only reports of mouth-to-mouth ventilation were in newborns; therefore he decided to investigate the physiology of expired air ventilation[1]. In 1958, Elam et al published a study in which 29 volunteers were anaesthetised and given mouth-tomouth ventilation via a facemask with a jaw lift [5]. They showed that expired air containing less than 21% oxygen was sufficient to maintain oxygenation and that carbon dioxide was still removed from the volunteers.

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As well as the results of their case series, they also formulated an eightpoint management plan, with the first three the most important. This plan is very similar to how we would manage cardiac arrest today:

Peter Safar (another anaesthetist, who was born in Austria) and Jim Elam published an abstract in the same year, which compared the Holger Nielsen method (prone back pressure and arm lift), the Silvester method (supine chest pressure and arm lift), supine chest pressure, mouth-to-mouth and mouth-to-airway in 25 volunteers and patients [6]. Experts performed the manual methods, while untrained operators, mostly laymen, performed the expired air methods. HolgerNielsen – the best external method – produced a tidal volume between 0 and 780ml, but the estimated dead space was greater than the tidal volume in 12 out of 15 subjects. The expired air methods produced a tidal volume of 1000 to 2000ml. Oxygenation was maintained by one rescuer for 30 minutes and re-oxygenation of “hypoxic “ victims was accomplished by five mouth-tomouth inflations. So despite experts performing these strenuous manual manoeuvres, laymen could far more adequately ventilate people with expired air. This study conclusively proved that mouth-to mouth or mouth-tonose artificial respiration was more effective than the manual methods.

1. 2. 3. 4. 5. 6. 7. 8.

Rapid diagnosis (to allow points 2 and 3 within 3-5 minutes of onset of cardiac arrest). Artificial ventilation. Artificial circulation. Drug therapy (the use of inotropes, vasopressors, calcium and sodium bicarbonate to correct pH). An electrocardiogram. Defibrillation if necessary. Continued cardiovascular and pulmonary support. Post-resuscitation care. They even recommend hypothermia if there is evidence of damage to the central nervous system: body temperature lowered to 32-34oC for 72 hours.

“My idea:

Design that matters.”

They emphasised that when properly applied, cardiac massage was not dangerous when the heart is normally contracting. They had the following complications: fractured ribs, one sternal fracture, sub-capsular liver haematoma, pneumothorax and intercostal muscle haemorrhage at post-mortem.

Cardio-pulmonary Resuscitation

In 1961, Safar et al looked at anaesthetised and paralysed patients and found that chest compressions did not allow ventilation due to upper airway obstruction [10]. They described the use of mouth-to-mouth ventilation using backward tilt of the head with chest compressions at a rate of 60 per minute with a ratio of 1:5. They had used this method in 50 patients at Baltimore City Hospitals.In 1966 a statement was published by the Ad Hoc Committee on Cardiopulmonary Resuscitation of the Division of Medical Sciences, National Academy of Sciences - National Research Council [11]. This used ABCD: Airway opened, Breathing restored, Circulation restored and Definitive Therapy. They advocated the use of a head tilt, followed by mouth-to-mouth ventilation with chest compressions at 60 per minute, with a ratio of 1:5 for two rescuers and 2:15 for a sole rescuer. Basic life support, as we would recognise it today was emerging.

Safar et al published a further study looking at airway obstruction in the supine position in 80 anaesthetised, spontaneously breathing patients[7]. They showed that with the neck flexed, the airway was obstructed in all patients. With neck extension, around 50% had an open airway and with the addition of a jaw thrust or an oropharyngeal airway, all remaining patients had an open airway. The International Red Cross accepted mouth-to-mouth ventilation in 1959 and the name Holger Nielsen was consigned to the history books[1]. So, I can conclude that this poster must date from after 1958, but when were chest compressions introduced?

Conclusion

Therefore I conclude that this poster dates from between 1958 and 1966. The Holger Nielsen method is obsolete, but the mouth-to-mouth method shown on this poster may soon be used by laymen, providing basic life support [12,13].

William Kouwenhoven and Guy Knickerbocker – both electrical engineers and James Jude, a cardiac surgeon, worked at Johns Hopkins University. In 1960, Kouwenhoven, Jude and Knickerbocker published the results of various experiments in dogs that received external cardiac massage after induction of ventricular fibrillation and case reports of the use of chest compressions in four patients [8]. They recommended that the heel of one hand with the other on top of it, be placed on the supine patient’s sternum just cephalad to the xiphoid. The sternum should be compressed 3-4cm at a rate of 60 per minute. They advocated that a sole rescuer should concentrate on closed-chest cardiac massage since this would provide some ventilation of the lungs. Up to this point, cardiac massage was performed via a thoracotomy; this new method could be used anywhere. By 1960, Jude, Kouwenhoven and Knickerbocker were able to publish their case series of 138 cardiac arrests in 118 patients, over the preceding two and a half years at Johns Hopkins [9]. Ventricular fibrillation was present in 30%, 78% had a return of spontaneous circulation and 60% were “neurologically intact”. Successful resuscitation occurred in one patient, after 90 minutes of cardiac massage.

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References 1. Baskett PJF and Baskett TF (2007) Resuscitation Greats Clinical Press; Bristol 2. Gordon AS, Raymon F, Sadove M and Ivy AC (1950) Manual Artificial Respiration, Comparison of Effectiveness of Various Methods on Apneic Normal Adults JAMA 14;1447-1452 3. Gordon AS, Fainer DC and Ivy AC (1950) Artificial respiration – a new method and a comparative study of different methods in adults JAMA 144; 1455-1464 4. Gordon AS, Sadove MS, Raymon F and Ivy AC (1951) Critical survey of manual artificial respiration JAMA 147; 1444-1453 5. Elam JO, Greene DG, Brown ES and Clements JA (1958) Oxygen and carbon dioxide exchange and energy cost of expired air respiration JAMA 167; 328-334 6. Safar P and Elam J (1958) Manual Versus Mouth-to-mouth Methods of Artificial Respiration Anesthesiology 19(1); 111-112 7. Safar P, Escarraga LA and Chang F(1959) Upper airway obstruction in the unconscious patient Journal of Applied Physiology 14: 760-764 8. Kouwenhoven WB, Jude JR and Knickerbocker GG (1960) Closed-chest cardiac massage JAMA 173; 1064-1067 9. Jude JR, Kouwenhoven WB and Knickerbocker GG (1960) Cardiac Arrest – report of application of external cardiac massage on 118 patients JAMA 178; 1063-1070 10. Safar P, Brown TC, Holtey WJ and Wilder RJ (1961) Ventilation and circulation with closed-chest cardiac massage in man JAMA 176; 574-576 11. Ad Hoc Committee on Cardiopulmonary Resuscitation of the Division of Medical Sciences, National Academy of Sciences - National Research Council (1966) Cardiopulmonary Resuscitation JAMA 198;372-379 12. www.resus.org.uk/pages/prehosca.pdf (accessed 30/10/2010) 13. Nolan J (2010) Push, blow or both: is there is a role for compression-only CPR? Anaesthesia 65; 771-774 Anaesthesia News June 2012 Issue 299

And what is your idea? Conﬁgure your anaesthesia workstation – on www.draeger.com/myperseus

Dräger Perseus® A500 3574

Chest Compressions

Lynn Fenner FRCA, MRCP, BSc(Hons) Anaesthetic Speciality Registrar Frenchay Hospital, Bristol

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How to write a review

Setting the scene One of the most satisfying parts of the review process comes when you sit down to write your introduction. It need not be long; all that is needed is a brief introduction to the question, why you think it is clinically important and what related literature is available. The temptation is to cite this section heavily - avoid this pitfall as most journals have reference limits.

Conducting a systematic review of the literature in anaesthesia; a guide for the novice author in 2012

Methods

Have you ever wondered whether a target controlled infusion of propofol for maintenance of anaesthesia/ sedation is better than a manual infusion?

Perhaps the answer to this question can be found in the anecdotes one overhears in the theatre coffee room from one’s senior colleagues. Perhaps, as in 2008, a group carried out a systematic review with this question in mind (1). Whilst there was no clear conclusion from this review, it demonstrates the key fact that we cannot say which is better as there is insufficient evidence. You can imagine the horror on your senior’s face when you recite this finding. It also tells us that we need a good, well-designed, primary study to help answer the question. The practice of systematic reviewing has changed remarkably in the last forty years. It is an evolving discipline that brings together relevant studies with the aim of answering a specific and focused question. Having recently written a systematic review as a novice author myself, and conducted primary research relevant to anaesthesia, I thought I should share what I have learned in the process. The first advantage of a systematic review is that no research ethics committee or Trust research and development approval is needed. You can get underway as soon as you identify a question. Those that have gone through the IRAS process (2) will vouch for the lengthy and sometimes tedious filling in of forms, waiting for replies, meeting deadlines and attending meetings. There is no such process for writing a review. Secondly, the best level of evidence, level 1a, is obtained from performing a systematic review of randomised controlled trials. There is an unmanageable amount of primary research in the medical databases. Some of these studies are of poor quality, some do not have the statistical power to detect a difference in outcomes and some may not have the coverage they deserve. We are all familiar with the ‘traditional’ or ‘narrative’ review method. These have evolved to become what we know today as ‘systematic’. Systematic in that there is a structured process to go through prior to answering your research question. Some may find this novel approach intimidating at first; I believe you don’t necessarily need to be part of a Cochrane group to have a go at writing one yourself. For those who are interested, however, there is an active Cochrane Anaesthesia Group (3). The process began its journey in 1972 with the publication of Archie Cochrane’s famous lecture in which he stated “I believe that cure is rare while the need for care is widespread, and that the pursuit of cure at all costs may

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restrict the supply of care…” and “health services should be evaluated on the basis of scientific evidence rather than on clinical impression, anecdotal experience, ‘expert’ opinion or tradition” (4). These quotes are key to the foundations of evidence-based medicine. The problem with traditional reviews is that they do not conform to these principals. The ‘content experts’, who will have a tendency to cite what they know, often prepare these traditional manuscripts. Consider that, in evidence based medicine terms, expert opinion is seen as the lowest level of evidence. Generally, if a review article does not have a methodology section, it will most certainly be of this type. If there are no methods or results, how do we know how conclusions have been drawn? It must be kept in mind that systematic reviews are not perfect and are still evolving. They are only as good as the primary research they are based on, prone to bias, involve seemingly complex statistics and are, from my personal experience, labour intensive. Hence, a systematic review should be treated similarly to a piece of primary research. It should include a methods and results section, show how conclusions are drawn, be scientific and unbiased, summarise and if appropriate, combine results, but most importantly, be replicable and systematic (5). Another researcher must be able to draw the same conclusions using your aims and methodology. There is a specific way in which this can be achieved and I hope that someone will read this article and have a go.

Thinking about your question The first step is to establish what you want to find out. As already set out, this will be a research question. The old review style may have a title such as ‘The Pathophysiology of Abdominal Aortic Cross Clamping’, which is too unfocussed, and has the potential for the author to only include information that they find interesting. A better question may be ‘Does propofol limit the ischaemia-reperfusion injury when used for anaesthetic maintenance in abdominal aortic cross clamping?’. Such factors to consider at this stage include cost utility of a treatment, how and why something works, how common a condition is, what causes a condition or whether an intervention or screening programme works. Anaesthesia News June 2012 Issue 299

This is the section that can expose the novice author, which I found when I attempted my review. This will detail the literature search methodology in a specific way. You may want to consult an information scientist for guidance. Make a note of the date on which you perform your search as this will need reporting. You may feel that you do not have access to a database, however, all NHS employees can use Ovid SP and other databases by registering for an NHS Athens account (6). This gives you access to MEDLINE, EMBASE, PsychINFO and CINAHL, which will need searching in turn. You will, of course, use a comprehensive MeSH and textword search of these databases as detailed in the results section. You may also want to hand search the bibliographies of relevant articles and perform a GoogleTM search. You will want to devise inclusion and exclusion criteria for search results by identifying information from the title/abstract and detail these in your method. It is necessary to devise a data extraction tool to find the data that you are looking for from included studies. The format of this will be specific to your study. You will want to assess the quality of the included studies (7). You may use a standard tool to assess the results such as CONSORT (8), MOOSE (9) or STROBE (10); there are many more.

Results The results section details the total number of abstracts retrieved from your search strategy. You will detail the databases searched and the date range of articles included in these. You may want to tabulate your results with ‘lines’ dedicated to the search term and the number of hits. You can make your article look highly professional by including Ovid SP search terms such as the wildcard function ($). If you type ‘Acu$.tw’, you will perform a text word search for all words that start with ‘Acu’. You may want to use a MeSH search for propofol by inputting ‘Propofol/’ thereby retrieving articles that are under the subheading of ‘propofol’. You may want two words that are adjacent such as ‘acute’ and ‘confusional’. If you want them within 5 words of each other and to also incorporate a wildcard and text word search, input ‘Acu$ ADJ5 confu$.tw’. You may want to assign ‘Propofol/’ as line 1 and ‘Acu$ ADJ5 confu$.tw’ as line 2 and combine these searches as line 3 by using ‘OR 1-2’. You may want the find the articles that are common between these searches for line 3 and by using the command ‘1 AND 2’. A useful summary of these commands can be found online (11). Following this description, the next stage is to fill in the flow diagram for your study. This is usually in a systematic and structured manner and takes the form of the PRISMA flow diagram. A word document template and checklist for this can be found online (12). You may


then want to give an overview of the studies included, comment on the risk of bias in the individual studies and across studies, and state the principle summary measures. You may want to perform a meta-analysis of the results; there is a free open access piece of software available called ‘RevMan’ (13). The publisher states that this is free for academic use. You can download it free of charge, together with the instructions online to prepare your own forest plot (14). Beware, however, when thinking about performing this complex mathematical operation. Mark Twain once said “to a man with a hammer, everything looks like a nail”. Just because we can do a meta-analysis, doesn’t always mean we should. If in doubt, contact a medical statistician.

Discussion You will want to summarise the main findings of your evidence and comment on the strength of this. You will want to relay to the reader whether this is relevant to their patients. Limitations need discussion such as bias and methodology. Finally, conclusions can be drawn. These will either be that ‘we now know something for sure’, ‘we know that the data is of poor quality and/or biased’ or that ‘there is no research that can answer the question’. The latter can obviously lead to future research and many grant applicants will have to present such work to secure funding. And one final tip; make life easy for yourself. You will draft and redraft until you are eventually happy with the finished article. If you reference by hand, you will soon lose patience and give up. I would recommend using a piece of bibliography management software. This is cheap, easy to use and will make writing your article more of an all round pleasant experience.

Happy writing! Dr Michael Charlesworth Academic Foundation Year 2 Doctor St. James’s University Hospital, Leeds

References 1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14.

Leslie K, Clavisi O, Hargrove J. Target-controlled infusion versus manuallycontrolled infusion of propofol for general anaesthesia or sedation in adults. Anesth Analg. 2008 Dec;107(6):2089. https://www.myresearchproject.org.uk/. http://carg.cochrane.org/our-reviews. Cochrane AL. Effectiveness and efficiency. Nuffield Provincial Hospitals. 1972. Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med. 1997 Mar 1;126(5):376-80. https://register.athensams.net/nhs/nhseng/. Moja LP, Telaro E, D’Amico R, Moschetti I, Coe L, Liberati A. Assessment of methodological quality of primary studies by systematic reviews: results of the metaquality cross sectional study. BMJ. 2005 May 7;330(7499):1053. Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c332. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Metaanalysis of observational studies in epidemiology: a proposal for reporting. Metaanalysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000 Apr 19;283(15):2008-12. Ebrahim S, Clarke M. STROBE: new standards for reporting observational epidemiology, a chance to improve. Int J Epidemiol. 2007 Oct;36(5):946-8. h t t p : / / w w w. o v i d . c o m / s i t e / h e l p / d o c u m e n t a t i o n / o s p a / e n / s y n t a x . htm#commandlinesyntax. http://www.prisma-statement.org/statement.htm. Review Manager (RevMan) [Computer program]. Version 5.1. Copenhagen: The Nordic Cochrane Centre TCC, 2011. http://ims.cochrane.org/revman.

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7th Oxford Paediatric Difficult Airway Workshop Thursday 20 September 2012 th

The Paediatric Difficult Intubation Workshop is for trainees and consultants who anaesthetise children and wish to refresh and update skills in managing children with a difficult airway. The course aims to discuss the management of the anticipated and unanticipated paediatric difficult airway. The format of the day is one of short interactive lectures, videos and hands-on small group workshops. The workshops cover care and basic use of the fibre-optic laryngoscope, modified airway and LMA access techniques using guide wires and exchange catheters. Delegate numbers are limited to 24 places to allow maximum opportunity to interact and interrogate the faculty. Registration fee includes refreshments and lunch. Course organisers: Dr Karen Medlock & Dr Arnie Choi Registration Fee: £220

Early booking recommended

Coming soon

to an anaesthesia machine near you! The AAGBI has developed a new guideline and checklist (which should be laminated and attached to all anaesthetic machines) to facilitate checking of anaesthetic equipment. The guideline and checklist are quite different to the previous version; do make sure you look carefully at the full guidance in the June edition of Anaesthesia.

FRCA VIVA Courses 2012

Final FRCA VIVA Day Wednesday 13th June 2012

Anaesthesia June 2012

Consultant-led, intensive VIVA preparation course giving trainees Extensive VIVA practice for the exam

Dennis AT and Solnordal CB. Acute pulmonary oedema in pregnant women.

“A very good course with lots of exposure to all aspects of finals exam”

For further information, please contact: Mr Jonathan Northrop, Postgraduate Medical Centre, Box 111, Addenbrooke’s Hospital, Cambridge CB2 0SP Tel: 01223 216376 Email: [email protected]

approval sought for 5 CEPD points

Nicola Heard

Direct Line: +44 (0) 20 7631 8805 21 Portland Place, London W1B 1PY T: +44 (0) 20 7631 1650 F: +44 (0) 20 7631 4352 E: [email protected] w: www.aagbi.org Nicola

RCoA EVENTS 2012

SAS Travel Grant 2012

irect Line: +44 (0) 20 7631 8805

BECOMING A CONSULTANT

Heard

Educational Events Manager

Evelyn Baker Medal

Direct Line: +44 (0) 20 7631 8805

An award for clinical competence

Portland Place, London W1B 1PY 21 Portland Place, London W1B 1PY The Association of Anaesthetists of Great Britain and Ireland +44 (0) 20 7631 1650 T: +44 (0) 20 7631 1650 The Evelyn Baker award was instigated by Dr Margaret Branthwaite in 1998, dedicated to the memory of one of her former patients at the Royal Brompton Hospital. The invites applications for the SAS Travel Grant for 2012. This +44 (0) 20 7631 4352 F: +44 (0)is20 7631 4352

[email protected] www.aagbi.org

a grant (up to a maximum of £2000) exclusively given for SAS E: [email protected] doctors to visit a place of excellence of their choice for two weeks. This is not meant for attending a meeting orw:awww.aagbi.org conference. All SAS doctors who are members of the AAGBI are eligible to apply for the grant.

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 be technical proficiency, consistently reliable clinical judgement and wisdom and skill in communicating with patients, their relatives and colleagues. The ability to train and enthuse trainee colleagues is seen as an integral part of communication skill, extending beyond formal teaching of academic presentation. Nominees should normally still be in clinical practice.

Applicants should complete an application form and return it to the AAGBI. The successful applicant will be expected to submit a report of the visit which may be published in Anaesthesia News.

Dr John Cole (Sheffield) was the first winner of the Evelyn Baker medal in 1998, 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 Martin Coates (Plymouth) in 2006, Dr Gareth Charlton (Southampton) in 2007, Dr Neville Robinson (London) in 2008, Dr Fred Roberts (Exeter) in 2009, Dr Sudheer Medakkar (Torquay) in 2010 and Dr Keith Clayton (Coventry) in 2011.

If alternative funding becomes available for a project already supported by the AAGBI, the AAGBI should be notified immediately.

For further information and an application form please visit our website: http://www.aagbi.org/research/awards/sas-grade-anaesthetists or email [email protected] or telephone 020 7631 8807 Closing date: Monday 22nd October 2012

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This is a comprehensive and well-written review of a difficult but important subject. However, its real beauty is the clear and concise manner in which the relevant cardiovascular physiology is explained – indeed this explanation made the whole concept of oedema as a reaction to hypertension and disease much clearer to me. An excellent diagram is included explaining filtration forces, as well as a clear and decisive flowchart for managing pulmonary oedema in pregnant women. This is essential reading for all obstetric anaesthetists, both in training and consultants, as many new concepts and relevant research are explained, and might also go down well on the labour ward with our obstetric colleagues and midwives. I would also suggest that the flowchart should be added to local protocol folders in the labour ward.

Registration Fee: £200.00

Cheques payable to “Paediatric Anaesthesia & Resuscitation Fund” Educational Events Manager

icola Heard

Digested

Cambridge University Hospitals NHS Trust, Cambridge

The aim of the day is to provide candidates with at least 8 hours VIVA practice to give the required preparation and confidence to pass the exams.

All enquires: Karen Medlock, Nuffield Department of Anaesthetics, John Radcliffe Hospital, Headington, Oxford OX3 9DU [email protected] Telephone: 01865 221590

ducational Events Manager

Anaesthesia

Cambridge

Nominations are now invited for the award to be presented at WSM London in January 2013 and may be made by any member of the Association to any practising anaesthetist who is also a member of the Association. Examples of successful previous nominations are available on request, and should include an indication that nominee has broad support within their department.

The nomination, accompanied by a citation of up to 1000 words, should be sent to the Honorary Secretary at [email protected] by 5pm on Monday 17th September 2012. Anaesthesia News June 2012 Issue 299

Patel NP, Armstrong SL, Fernando R, et al. Combined spinal epidural vs epidural labour analgesia: does initial intrathecal analgesia reduce the subsequent minimum local analgesic concentration of epidural bupivacaine? It is good to see well conducted randomised controlled trials in obstetric anaesthesia, and this one sheds new light on the relationship between intrathecal and epidural injection. It appears that intrathecal injection, as part of a combined spinal-epidural technique, leads to a small increase in future “top-up” doses of epidural local anaesthetic/opioid. This is somewhat unexpected and surprising, but as the authors explain the differences are not clinically significant. This difference does not seem to explain the difference in the quality of block provided by combined spinal-epidural and spinal injection alone. However the quality of the trial and the statistical analysis appears sound, therefore this may prompt further investigation of the role of upregulation of receptors to either the opioid or the local anaesthetic part of the injection, or indeed some other plausible mechanism for this finding.

Date and venue: 20 July 2012 (code: B14), RCoA London

Canty DJ, Royse CF, Kilpatrick D et al. The impact of focused transthoracic echocardiography in the pre-operative clinic.

Registration fee: £210 (£160 for registered trainees and affiliates) Approved for 5 CPD credits

An interesting study looking at pre-operative assessment - we are all familiar with the urge to get a quick echocardiogram on a slightly dodgy patient in the clinic; perhaps a bit old, maybe some non-specific episodes of fainting or just a slight murmur when we listen to their chest. In reality however, organising an echocardiogram is often more trouble than it is worth, especially as the patient usually has a date for surgery in a week or two (or even the same day!), and the waiting list is often several weeks if not months. So we leave it, and we never really know whether we would have seen anything on the echocardiogram, and whether we would have done something different anyway. Canty et al undertook pre-op transthoracic echocardiography on 100 patients in the clinic, and found a surprisingly large number of patients had unexpected findings, and that the anaesthetic management plan was changed in more than half of the number of the patients investigated. Perhaps this is the way forward – see your patient, then do a quick echocardiogram yourself? Then base your choice of anaesthetic technique on anatomy, rather than supposition or guesswork? But this would require huge investment to train us all to do echocardiography, although this would only need to be enough to perform a focused scan. Plus we would need lots and lots of (portable) echo machines, enough for every clinic anyway. Maybe it will happen, but in the meantime more studies looking at the actual impact on outcomes are needed, which these authors have promised.

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Challenges for the anaesthetist over the next ten years (3J00)

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Revalidation (3J00)

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What the Clinical Director wants (1I02, 3J00)

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Dealing with difficulty (2H02)

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Medico-legal pitfalls for the anaesthetist (1F01, 1F02, 1F03)

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Independent practice (3J00)

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The anaesthetist as an educator (1H01, 2H01, 2H02)

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Becoming a consultant in 2012 (1I02, 3J00)

Apply: www.rcoa.ac.uk/events Contact: 020 7092 1673 [email protected] Anaesthesia News June 2012 Issue 299

A. A Klein Editor, Anaesthesia

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Returning to Work the Wessex Way How many trainees have dreaded their first day back after an extended period away from anaesthesia? The Wessex Deanery have developed a structured return to work programme which ensures their trainees have a positive experience and a safe return to anaesthesia

As a specialty, Anaesthesia is renowned for supporting trainees taking time out of training; be it to undertake a fellowship, spend time as a carer, or for other personal reasons, perhaps ill health. Of all hospital specialties, anaesthesia has the third highest number of less than full-time (LTFT) trainees (after palliative care and paediatrics). The most frequent reason for working less than full time is child care commitments, so it follows that we frequently see colleagues returning after a period of maternity leave. Whatever the circumstances, a supervised reorientation to clinical work should always be provided. Good clinical governance, and the requirements of Good Medical Practice emphasise patient safety and this should be at the heart of any return to work programme. Thus it follows, that if a trainee has been absent from the workplace, for whatever reason, they should be supported on their return, both because of concern for patient safety and for their own benefit. Furthermore, there is a legal requirement for an employer to provide ‘reasonable adjustment’ such as a phased return to work, for an employee who has a disability1. Those who have long term or sporadic illness, such as bipolar illness, asthma, migraine or back pain may meet the Disability Discrimination Act criteria for disability. Planning and monitoring of the return to work should be done with the advice of a Consultant Occupational Physician. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) have defined a Return to Work Programme as: ‘A formal, structured re-introduction into the workplace for those doctors who have been out of clinical practice for a prolonged period ’2.

update skills, for example the AAGBI provides a useful two-day seminar entitled ‘Return to Work: A Refresher Course’6. Given the lack of comprehensive or standardised national Return to Work programme we sought to develop our own clear structured approach to an individual’s return to work in Wessex. We wanted to be able to guarantee a short period of clinical supervision during which the returning anaesthetist could demonstrate to the Hospital Trust that he or she is safe to practise and allow the doctor to regain confidence without the fear of being assigned a solo list or a night on-call on day one. The AAGBI has identified three groups of anaesthetists wishing to return to work: the first being those with no ongoing physical or cognitive impairment, who expect to return to normal practice in a short period of time. The second group comprises those who require a more prolonged period of supervision and assessment: this may occur following a prolonged illness or suspension. Finally, a third group includes those in whom there are serious concerns regarding competency, and where a period of retraining might be necessary. We set out to consider a general programme for the first, most common, of these groups. Those anaesthetists falling into either of the other two categories, would likely require a more complex strategy. All current Wessex trainees who had taken time out of training were surveyed to help with the design of the programme. A Survey Monkey analysis was performed in April 2010, with a 70% response rate (21/30).

The Medical Women’s Foundation also recommend in their report “Making Part-time Work” that employers, Medical Directors and Deaneries adopt a formal approach for the reacquisition of clinical skills after a career break and an extended period of leave3. The Royal College of Anaesthetists (RCoA) has itself outlined useful guidance for returning to work4. None of these professional bodies propose a detailed format for a return to work programme, as these should be tailored to meet both the individual’s needs and that of the service.


Results of Survey of Wessex Trainees Year of training

ST3/4: 15% ST5/6/7: 85%

Reason for time out of practice

Maternity leave: 63.2% ICM training: 21.1% Other: 15.8%

Duration of time out of practice

1-3 months: 10.5% 3-6 months: 10.5% 6-12 months: 68.4% Other: 10.5%

Do you think a period of direct supervision would be valuable on return?

Yes: 100%

What duration should it be?

1 week: 36.8% 2 weeks: 52.6% 3-4 weeks: 10.5%

Should it be competency or time-based?

Competency: 31.6% Time: 63.2% Uncertain: 5.3%

Would it be useful if it had to be ‘signed off’?

Yes: 42.1% No: 42.1% Uncertain: 15.8%

Comments were sought and revealed a strong feeling that any ‘Return to Work’ programme should be tailored to the individual’s needs. This could lead to significant variation in the programme according to duration of absence and what has been done during this time, the stage of training upon return, confidence level of the returnee, stamina etc. Comments also suggested that the choice of consultants to supervise the programme should be carefully considered and that that having a mentor might be useful. The suggestion was also made to undergo an initial period of on-calls at a lower level of seniority. Many trainees remarked that the emphasis should be on confidence, rather than competence. Indeed we are aware of at least one ‘Return to clinical work’ simulation course nationally that highlights this as a goal, in addition to refreshing skills7. However, the AAGBI’s Welfare Resource Pack, states that ‘At the end of the process there must be a summative assessment of whether the doctor is safe to return to practice or not’. In reality, we feel that both are important and have designed our programme to reflect this.

The Wessex return to work programme Once the return to work date is confirmed the College Tutor makes contact with the returning trainee, usually via email, to arrange a meeting. This is usually done a week or two in advance of the return to work date. At this meeting an individualised plan for reintroduction is agreed following the guidance below. The returning anaesthetist’s reintroduction involves ten days of directly supervised lists during which time they do not perform any on-call duties. The period of time was set at two weeks (for those returning full time) in-line with the results of our survey. This time period is only a guide and, if a more personalised programme is required, it may be adjusted. The type of lists undertaken during the reintroduction period will depend on the trainee’s particular needs and the areas they feel they need to focus on most. There is always an attempt to accommodate any specific needs or concerns the trainee (or the Hospital Trust) may have. These may depend on the reason for time out of training. For example if they have been on maternity leave then they may simply request exposure to as many areas of anaesthesia as possible. If they have been doing advanced training in intensive care for a year then they might rather spend their reintroduction time in the maternity and day case units. It is recommended that an Anaesthetic List Management Assessment Tool (ALMAT) or similar appropriate Workplace Based Assessment (WBA) is completed for each list undertaken during the reintroduction period. After the period of directly

‘Keep in Touch’ (KIT) days can be arranged at a local level and are promoted by the Group of Anaesthetists in Training5. The GMC suggests unpaid clinical attachments and course attendance to

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The findings are summarised below:



supervised reintroduction the trainee meets with his or her Educational Supervisor. The Educational Supervisor is not in a position to address a problem, only to make a plan that might support the trainee’s learning. Any concerns can be reviewed and further targeted training arranged. This may result in an extension of the reintroduction period which can, depending on its length, result in an extension to the trainee’s CCT date due to their non-participation in on-call duties. After due discussion and consideration of all the WBAs completed during the reintroduction a judgement is made by both the trainee and the supervisor as to whether it is felt the trainee is ready to resume full duties. If so, a Return to Work Form, designed for this purpose is completed and signed by both the educational supervisor and the trainee. This form is available on our website, http://www. wessexdeanery.nhs.uk/specialty_schools/wessex_school_of_ anaesthetics/useful_documents.aspx Notwithstanding the clinical benefits, a Return to Work programme is an effective way of ensuring an individual is properly integrated back into the organizational culture of the workplace. Hospitals are intense places to work with all manner of norms, procedures and practices to be re-learned.

Feedback Having been initiated in Poole and Bournemouth hospitals in Wessex, this Return to Work programme has now been rolled out across the region. It has the full support of the Wessex Deanery and the Royal College of Anaesthetists have recognised it as an “example of good practice”. All trainees returning to work within Wessex who have had greater than six months out of anaesthetics now go through the programme. Those who have done so (>10) have returned to their ‘usual’ activity including on-call within two weeks (or equivalent sessions if less than full-time). Without exception, the feedback from the trainees, their supervisors and Trust Management has been very positive. The hospitals can now populate their rotas with confidence and the trainees report it has significantly reduced their anxiety in the run up to their return to work date and clearly appreciate the opportunity to build up their confidence again whilst being guaranteed supervision. One trainee summarised the experience as “a very useful way to ease the transition back to work”. The Anaesthetic Departments across Wessex have welcomed a formal programme which they see results in happier, more confident trainees returning to the work place, and above all ensures that patient safety is maintained at the highest level at all times. Following the successful introduction of the Wessex Return to Work programme in Anaesthetics the Deanery is now looking at rolling it out across all specialities in the region. Wendy King, Fran Haigh, Alice Aarvold, Anaesthetic Registrars, Wessex Deanery Delia Hopkins, Isabel Smith, Anaesthetic Consultants, Wessex Deanery References: 1. 2. 3. 4. 5. 6. 7.

http://www.hse.gov.uk/sicknessabsence/reasonableadjustments.htm Health and Safety Executive AAGBI: Welfare Resource Pack. 2008. http://www.aagbi.org/sites/default/files/welfare_ resource_pack_2008_0.pdf Making Part-time Work report. The Medical Women’s Foundation, 2008 Recommendations for supporting a successful return to work after a period of absence. RCoA March 2011 AAGBI: Less than Full Time Training in Anaesthesia: An A to Z Guide. March 2011http://www. aagbi.org/sites/default/files/LTFT%20Training%20in%20Anaesthesia%3B%20An%20A%20 to%20Z%20Guide%20FINAL.pdf AAGBI Seminars: Return to work: A Refresher Course http://www.aagbi.org/education/ event/1461 UCL Simulation and Facilitation Education: Return to work simulation day. http://gasagain. com/

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Do Novice Anaesthetic Trainees receive enough training in airway management skills? – a five year data collection from a district general hospital.

Guidance from the Royal College of Anaesthetists states that trainees should be observed undertaking a number of cases, be able to competently manage an airway with Facemask +/- airway (FM), a Laryngeal Mask (LMA) and be able to correctly place an endotracheal tube (ETT). These skills are summatively assessed at the Initial Assessment of Competency (IAC), conventionally after three months of experience. The Audit Compendium[1] from the Royal College of Anaesthetists advocates that 100% trainees should achieve at least 50 cases, in each of the three airway management techniques within their ‘novice’ period of anaesthetic training. Changing work patterns and streamlining of start dates for novice trainees have considerably altered the training and rota pressures on departments.

And back to the airway… In summary, novice trainees receive good exposure to laryngeal mask anaesthesia but it is vital to ensure that they receive adequate experience in intubation and facemask maintenance. NAP4 identified the incidence of serious airway complications during general anaesthesia as 1 in 22,000 cases[7]. Although complications are fortunately rare the management of such cases was only graded as ‘good’ in 16% cases and training/education was cited as a causal or contributory factor in 49% cases. As individuals we have responsibilities to emphasise to novice trainees working with us the importance of facemask skills and actively seek opportunities where this can be maximised. If they haven’t all got muscles like Popeye at the end of three months then we haven’t been doing it right !

Much interest has been raised regarding the role of CUSUM assessment in medical education, indeed a recent editorial in Anaesthesia[6] discussed this very point. Whilst CUSUM offers objective, statistically reliable data it creates a binary distinction between ‘success’ and ‘failure’ or ‘competent’ and ‘incompetent’. It neither factors in the method in which the outcome was achieved nor any confounders to technical performance such as a particularly challenging patient, difficult anatomy etc. Could this potentially lead to trainees becoming reluctant to attempt procedures on more complex cases for fear of lowering their CUSUM score?

Audit Data was initially collected retrospectively from my cohort of fellow SHOs. I then continued this collection prospectively over the next five years (2005 – 2010). Every novice SHO/CT1 at Torbay was invited to take part. Those with previous anaesthetic experience were excluded as this may have affected their list allocation, date of IAC and commencement of ‘solo’ anaesthesia. The response rate was 89% (n=17). Numbers of LMA insertion, ETT insertion and facemask anaesthesia cases were noted from trainee logbooks. No record of patient age, ASA or operative procedure was made. The ‘gold standard’ against which the numbers achieved were assessed was the 50 per technique recommendation from the audit compendium.

Training in airway skills is frequently multi-modal with direct clinical experience, observation, online learning resources and simulation based scenario training all having a role. Assessment also utilises many facets, as the range of workplace based assessments will attest to. However, how do we proceed with a novice trainee who has been summatively assessed as ‘competent’ after three months but has only performed ten tracheal intubations in their logbook ? How rigidly should we / do we adhere to suggested numerical targets ? One solution could be for departments to consider the use of a ‘procedures passport’ where specific practical procedures undertaken by the trainee are recorded (for example; tracheal intubation, facemask anaesthesia, arterial cannulation, central line insertion.) Although partially duplicating the logbook record it would offer additional information including a graduated assessment of performance and comments (see Figure 3). This could be used formatively between the trainee and their educational supervisor to provide organised feedback to trainees and to facilitate discussion and action planning when supporting a trainee who is struggling. Monthly meetings where the trainee’s paperwork is reviewed by their educational supervisor during this novice period would aid early detection and timely intervention for

Results The median logbook caseload for the initial three months was 182 cases (range 121-253). Despite concerns over changing patterns of work and hours reductions there were no discernible reductions in logbook numbers over the five year period of data collection. Trainees developed most experience with the laryngeal mask (accounting for 52% of all cases overall). Intubation represented 35% of cases and facemask anaesthesia 13%. Median numbers per trainee were as follows; LMA insertions 101, Tracheal Intubation 67 cases and Facemask anaesthesia 25. Full data is presented in Table 1. The results highlighted significant variability in experience between trainees, as high as a six fold difference in recorded facemask cases. All trainees met the RCOA


Short periods of facemask experience are frequently gained during the maintenance of anaesthesia in the pre-intubation phase and this data is seldom reflected in the trainees’ logbook. However, given that the administration of muscle relaxants has been shown to significantly facilitate facemask ventilation (p Integration > Automation[4] (Figure 2). The speed of acquisition depends on the difficulty of skill and will be modulated by individual variability. Konrad et al[5] generated learning curves for various technical procedures using modified CUSUM analysis in first year trainee anaesthetists. The relationship between numerical experience and competence is non-linear; initially a steep rise in success rate as numerical experience increases followed by a plateau as competence is achieved. Konrad’s work predicted that in order to perform the skill of intubation with a 90% success rate, a mean experience of 57 cases is required (95% Confidence interval for success rate at 57 cases; 0.80-0.99). (‘success’ defined as adequate technical performance with no physical help from a senior anaesthetist and a maximum of two attempts)

Basic airway skills are the cornerstone of all airway management - routine and difficult; expected and unanticipated. It is vital that novice trainees become experienced and competent in these skills before progressing to indirectly supervised practice. Concern has been raised about the overall decline in the prevalence of face mask anaesthesia and the consequent detrimental impact this may have on trainees’ skill acquisition.

n

standard for LMA experience, whereas 12% failed to achieve 50 ETT insertions and no trainees met the facemask target in our studied cohort.



Dr Claire M Blandford ST6 Registrar in Anaesthesia; South West Peninsula Rotation South Devon Healthcare Foundation Trust, Torbay Hospital References 1. RCOA Raising the Standard: a compendium of audit recipes - Section 14. Royal College of Anaesthetists. 2006. http://www.rcoa.ac.uk/docs/ARB-section14.pdf (accessed 15/02/2007) 2. Whymark C et al. A Scottish National Prospective Study of airway management skills in new-start SHOs. British Journal of Anaesthesia 2006; 97(4): 473-5. 3. Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation. Anaesthesia 2011; 66: 163-167. 4. Bould M, Crabtree N, Naik V. Assessment of procedural skills in anaesthesia. British Journal of Anaesthesia 2009; 103(4): 472-483 5. Konrad C et al. Learning Manual Skills in Anesthesiology: Is there a recommended number of cases for Anaesthetic procedures? Anesthesia & Analgesia 1998; 86: 635-9. 6. Norris A, McCahon R. Cumulative sum (CUSUM) assessment and medical education: a square peg in a round hole. Anaesthesia 2011; 66: 250-254. 7. Cook T, Woodall N, Frerk C. 4th National Audit Project, Major complications of airway management in the United Kingdom. Royal College of Anaesthetists & Difficult Airway Society. 2011. www.rcoa.ac.uk/docs/NAP4_Section1.pdf (accessed 10/04/2011)

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ANAESTHESIA NEWS

Anaesthesia News now reaches over 10,500 anaesthetists every month and is a great way of advertising your course, meeting, seminar or product. Anaesthesia News is the official newsletter of the Association of Anaesthetists of Great Britain & Ireland.

Cardiopulmonary Exercise Testing Workshop

!

September 20th 2012 The Royal York Hotel, York

All components taught by a highly experienced faculty. Lectures: Current pre-assessment strategies and techniques; the importance of functional capacity

The physiological response to exercise: why it matters for the surgical patient

The physiology and biochemistry of exercise and how limitations impact on surgical outcomes

What to measure for the surgical patient?

The parameters from pre-op CPET that influence outcome, and CPET diagnostic markers of heart failure and ischaemic heart disease

Tutorials: 3 Structured tutorials on the technical interpretation and clinical relevance of real-life CPET examples.

For further information on advertising

“Obtained an excellent insight into carrying out a CPET test, and interpretation of results to make clinical decisions on high-risk patients”

Tel: 020 7631 8803

“Very clear explanations, clear messages, excellent tutors, great to have clinical examples & to keep going over the same messages, great to have all evidence displayed, thank you”

or email Chris Steer: [email protected]

Apply at www.survivingsurgery.net Immediate Past Honorary Secretary

21 Portland Place, London W1B 1PY T: +44 (0)20 7631 1650 F: +44 (0)20 7631 4352 E: [email protected] W: www.aagbi.org

PORTSMOUTH AIRWAY WORKSHOPS

PAWS 2012 Friday 30th November 2012 Now in its 11th year the course consists of a combination of lectures, discussions and hands on workshops covering all aspects of the management of the anticipated and unanticipated difficult airway Suitable for consultants and trainees, with a highly experienced faculty. Places are limited to allow maximum practical experience Workshops include Fibreoptic intubation

NAP 4 UPDATES

Jet ventilation Video laryngoscopy and optical stylets Supraglottic devices

THE OBSTRUCTED AIRWAY

Double lumen tubes and Bronchial Blockers Surgical airway Registration £175

LIVE FIBREOPTIC DEMONSTRATIONS

Approved for 5 CEPD points

Annual Annual Conference Conference

Thursday Thursday 10 15thth November November2011 2012 The EastRoyal Midlands College Conference of Surgeons Centre, of England, Nottingham London An inter-professional An inter-professional meeting meeting designed designed for anaesthetists for anaesthetists, and all healthcare nurses workers and all involved healthcare in theprofessionals preoperative involved in the preoperative process. assessment process.

Richard Griffiths Hon sec elect

Online learning at your fingertips... www.aagbi.org/education Have you had a look at the AAGBI Video Platform? You are able to view videos of lectures which have taken place at recent AAGBI seminars and main meetings.

“It is a fantastic initiative. Video platform gives extra facilities to follow the updates in our hectic specialty”

Topics include: Enhanced Recovery Programme, Management of Preop Anaemia, Assessment of patient with Renal Disease, Assessment and Implications of Alcohol, and Consent for Anaesthesia and Surgery

Dr M Teresa Leiva, Consultant Anaesthetist, Hospital Torrecardenas, Almeria, Spain

“Fantastic resource Great split screen to be able to view speaker and presentation slides simultaneously”

Call for Abstracts Abstracts are invited for oral or poster presentations. Best abstracts will be published in the Journal Anaesthesia

For further details please contact

For registration and more details visit www.pre-op.org or contact by email to [email protected]

Matt Turner, Department of Anaesthetics,Queen Alexandra Hospital, Cosham, PO6 3LY Tel:02392 286298 or book online at www.pawscourse.co.uk

Approved for 5 CEPD points

Course Directors: Dr. Denise Carapiet and Dr. Matthew Turner

The video platform is a fantastic resource, which is equally valuable to individuals or to groups of anaesthetists.

AAGBI Video Platform

Dr Les Gemmell

CASE DISCUSSIONS

If any department wants advice on setting up a network please email me, it is very simple and the service is free.

r ly fo * nt le s re ab er u r i l b ly C a v a e m me on m ti s o n - ited a l n o *Lim

www.aagbi.org/publications

DAS EXTUBATION ALGORITHM

Last year the anaesthetists in Peterborough set up a revalidation network, through the free NHS networks platform. The aim of the network was to try and cover some of the topics from the revalidation matrix “in house”. Three to four meetings are held each term, after work, and they last for an hour. One meeting per term is taken from the video platform provided by the AAGBI. When the talks are shown to a large audience there is the ability to stop the presentation and ask the audience questions or to reflect on the lecture so far. There are some absolute stunners on the platform and recent additions from this year’s Winter Scientific Meeting include a brilliant review of renal physiology by Fred Roberts from Exeter. This talk is relevant to all anaesthetists, of any grade, and should be compulsory viewing at least once a year (imho…).

Places limited- maximum 8 delegates per group. Feedback from last year’s course:

THE PAEDIATRIC DIFFICULT AIRWAY

Many of you will have already used the video platform, which contains lectures and keynote addresses from major meetings. I have found these particularly useful to look at talks that I missed when attending a parallel session at a meeting.

A combination of lectures, interactive small-group tutorials and demonstrations relevant to risk assessment for the surgical patient.

Assessing surgical risk

2012 Media Pack available now

AAGBI Video Platform

Dr Andrew Bartlett, Specialist Trainee in Anaesthetics and Intensive Care (ST3), University Hospital Bristol NHS Trust

“Excellent CME resource allowing members the opportunity to catch up on association meetings from the comfort of home!” Dr Chris Gornwall, Consultant Anaesthetist, Nottingham University Hospitals NHS Trust

We hope you find this resource beneficial and welcome your feedback!

This course is kindly sponsored by Anaesthesia News June 2012 Issue 299


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SPECIALIST SOCIETY

The Society for Intravenous Anaesthesia SIVA was formed in 1997 at the Royal Society of Medicine, to promote education and facilitate research into the use of drugs administered intravenously in anaesthesia and science related thereto, and to disseminate and help implement the useful results of such research for the public benefit. Over the years Dr Iain Glen, Professor Gavin Kenny and Dr Douglas Russell have been awarded Honorary Membership as “Persons of Distinction who have contributed to the advancement of Intravenous Anaesthesia”. The current President is Dr Alastair Nimmo, Edinburgh, the Honorary Secretary is Dr Kiran Jani, Stevenage, and Dr William McFadzean from Swansea was recently elected Treasurer. Professor Tony Absalom from Groningen is President-elect.

AMD Sandhurst

At AMD-Sandhurst Dr Nick Cowley from Birmingham was awarded the CareFusion Prize for the best poster presentation by an Anaesthetist in Training. Nick is pictured with Mr Douglas Dunn, left, District Manager at CareFusion UK.

SIVA 2012 - Edinburgh

The first Annual Scientific Meeting was in Glasgow, and subsequent venues have included Bristol, Belfast, Oxford, Chepstow and Cambridge. The highly successful 2011 ASM was in the Army Medical Directorate in Camberley, Surrey – AMD Sandhurst. Consultant Anaesthetists from the armed-forces gave illuminating insights into military TIVA, while their civilian counterparts shared their expert knowledge about “How I do it”. ITU sedation and sedation in and outside the operating theatre were discussed at length, and Sir Keith Porter, Professor of Traumatology at University Hospital Birmingham and Centre for Defence Medicine gave the Guest Lecture: “from Birmingham to Bastion – lessons learned and future aspirations”. Abstracts from the meeting are on the SIVA website at www.siva.ac.uk

SIVA Meeting

This year, SIVA returns to Edinburgh for a meeting with an international flavour. Professor Steven L Shafer from Stanford University, California, will present “Michael Jackson – the Clinical Pharmacology”. Steve was expert witness in the trial of Dr Conrad Murray. Professor Kate Leslie from Melbourne will talk on “Does Nitrous Oxide affect patient outcome following anaesthesia”? Other speakers will include Professor Pamela Flood from San Francisco, Dr Iain Glen - who discovered the anaesthetic properties of propofol - and Dr Thomas Schnider from St Gallen. Topics will include depth of anaesthesia monitoring, TIVA in paediatrics and for the morbidly obese, and a debate on whether test ventilation before administration of a muscle relaxant is a valuable safety check. The meeting, at the Royal College of Physicians of Edinburgh on Thursday 29th & Friday 30th November is preceded by Thursday morning workshops on a variety of topics of interest to both experienced TIVA practitioners and those who wish an introduction to the subject. The workshops are led by tutors of national and international repute, and start at 10.30am to allow travel to Edinburgh that day from most parts of the UK. They are included in the registration fee. A number of discounted rooms for single or double occupancy are available in the George Hotel. RCPE and the George Hotel are co-located in Central Edinburgh, minutes away from Waverley Station and the airlink bus to Edinburgh International Airport. Visit www.Edinburgh2012.org for full details.

SIVA is firmly established both nationally and internationally. The website is a forum for information, education and debate on all matters relating to TIVA-TCI, and is accessed by anaesthetists and associated healthcare professionals throughout the world. SIVA looks forward to its next 15 years with enthusiasm.

George Hotel, Central Edinburgh

Abstracts are invited for poster presentation of topics relating to Intravenous Anaesthesia. These will be considered for publication in ‘Anaesthesia’, and should be submitted to Dr Ali Diba by the end of October – [email protected] Complimentary registration is available to Anaesthetists in Training who have posters accepted for the meeting.

Join SIVA - discounted meeting registration is available for members. To join visit the website at www.siva.ac.uk 24



02/05/2012 09:10

Particles The rise and fall of Xigris Eli Lilly and Company announced the voluntary withdrawal of Xigris™(Drotrecogin Alfa) from clinical use on the 25 October 2011. This is a response to preliminary analysis of the results of SHOCK-PROWESS1 recently made public. The 28-day all cause mortality data has shown a mortality rate of 26.4%(223/834) in the treatment group as compared with 24.2%(202/834) in the placebo group. This represents a RR of 1.09 (95% CI of 0.92-1.08) and a non-significant p value of 0.31 Discussion

Adam K. Jacob, Carlos B. Mantilla, Hans P. Sviggum, Darrell R. Schroeder, Mark W. Pagnano, James R. Hebl

Perioperative Nerve Injury after Total Hip Arthroplasty. Regional Anesthesia Risk during a 20-year Cohort Study Anesthesiology 2011; 115:1172-8 Background Perioperative nerve injury (PNI) is more common following orthopaedic procedures than during other surgical interventions1, and is a recognised complication of total hip arthroplasty (THA). The risk of neurological injury may be increased by the use of regional anaesthetic techniques. The authors retrospectively analysed all adult patients who had undergone elective THA at a single institution over a 20-year period to evaluate whether neuraxial anaesthesia or peripheral nerve blockade was associated with a greater incidence of PNI. Methods

Activated Protein C(APC) is an in-vivo mediator with anti-inflammatory, anti-thrombotic and pro-fibrinolytic actions. It is released as a part of the homeostatic response to sepsis in the human body. Drotrecogin Alfa is a recombinant form of human APC. Its license for clinical use in severe sepsis was based on evidence from the PROWESS trial (Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis)2. This was a randomised, double blind, placebocontrolled multicentre study which showed a reduction in mortality from severe sepsis in the treatment group The trial was stopped early because interim data analysis showed a 6.1% decrease in 28-day all cause mortality in the treatment group. On these results FDA approval was gained for use in patients with sepsis and APACHE II scores >25 indicating a high risk of death. Subsequently, the ADDRESS trial3 showed no benefit from APC in terms of 28-day mortality in severe sepsis and low risk of death (APACHE II scores < 25). The recently published Cochrane review concludes a lack of evidence for the use of APC in severe sepsis and a substantial risk for serious adverse events. As an antithrombotic and pro-fibrinolytic agent the major side effect of APC is an increased risk of bleeding. Its use is therefore contraindicated in any patient with a history of recent trauma, internal bleeding, head injury, haemorrhagic stroke, severe clotting disorders and recent surgery. The complete results of the SHOCK-PROWESS trial will be published shortly. Some experts have criticised the decision by Eli-Lilly to withdraw Xigris™ before the full trial results have been made public. Improvements in the management of severe sepsis in the decade since PROWESS was undertaken may account for the differences reflected in the latest mortality data, improved survival in this patient group may make a difference more difficult to demonstrate between the treatment and placebo groups. Any further conclusions on the usefulness of APC can only be made once experts have had an opportunity to analyse the results of PROWESS-SHOCK in full.

Dr Avinash Kapoor ST6 Anaesthetics, Northern Deanery References 1. 2.

3.

Lilly Announces Withdrawal of Xigris® Following Recent Clinical Trial Results. https://investor.lilly.com/releasedetail2.cfm?ReleaseID=617602. Bernard GR, Vincent JL, Laterre PF et al. Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001;344:699-709. Abraham E, Laterre PF, Garg R et al. Administration of Drotrecogin Alfa (Activated) in Early Stage Severe Sepsis (ADDRESS) Study Group. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med 2005;353:1332-41.

All adult patients having their first elective THA at the Mayo clinic between January 1st 1988 and July 1st 2007 were identified from a database compiled by research assistants independent of the investigators. Patients who had not given research authorisation or underwent a bilateral or staged procedure were excluded from the study. Anaesthetic technique was classified as:(1) general anaesthesia; (2) neuraxial anaesthesia; (3) combined neuraxial-general anaesthesia. Patients who received posterior or anterior lumbar plexus blocks or sciatic nerve blocks for postoperative analgesia were specifically identified. The primary outcome was the presence of a new PNI within 3 months of surgery. The clinical records for those patients were then reviewed in detail and neurological recovery evaluated. A logistic regression model was generated to evaluate potential risk factors for PNI using as variables age, gender, operative time and surgical approach. Supplemental analysis was done comparing the rate of PNI in those who had peripheral nerve blockade (PNB) to those who did not. Results The mean age of 12998 patients included was 65 ±14 yrs. PNB was performed in 2444 patients (19%). The overall incidence of PNI was 0.72% (95% CI 0.580.88%) and was not associated with the type of anaesthesia (OR=0.72 for neuraxial-combined vs. general; 95% CI 0.46-1.14) or the use of PNB (OR=0.65; 95% CI 0.34-1.21). Despite a marked increase in the use of PNB over the study period the incidence of PNI did not change significantly. Overall 50% of patients with PNI experienced complete neurological recovery, rising to 66% in those who had PNB. More than 90% of patients experienced at least partial neurological recovery. Median follow up was 4.9 years. Increased PNI risk was found to be associated with younger age (OR=0.79 per 10 year increase), female gender (OR=1.72), longer procedure time (OR=1.1 per 30 minute increase) or posterior surgical approach (OR=1.91 vs. anterior approach). Discussion This comprehensive study identified a low incidence of PNI after elective THA and found that the risk of nerve injury was not increased by the use of neuraxial anaesthesia or peripheral nerve blocks. This supports the use of regional anaesthesia techniques in elective THA given their known clinical and functional benefits2. Physician self-reporting of complications did not bias the study. The authors acknowledged that they could not differentiate between the different nerve blocks used and that the retrospective nature of data collection may have led to their missing clinically significant but transient events. The use of ultrasound guidance in PNB was not documented. Moreover, the relatively small number of PNI means that the analysis might have been underpowered to detect a true association between regional anaesthesia and nerve injury3.

Dr Patrick Chrystie ST7 Anaesthetics, Southern General Hospital, Glasgow. References 1. 2. 3.

26


Welch MB, Brummett CM, et. al. Perioperative peripheral nerve injuries: A retrospective study of 380,680 cases during a 10-year period at a single institution. Anesthesiology 2009; 111:490-7 Hebl JR, Kopp SL, et. al. A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am 2005; 87(Suppl 2):63-70 Jacob AK, Mantilla CB, et. al. Perioperative nerve injury after total hip arthroplasty. Regional anesthesia risk during a 20-year cohort study. Anesthesiology 2011; 115:1172-8


Crescenti et al.

Intraoperative use of tranexamic acid to reduce transfusion rate in patients undergoing radical retropubic prostatectomy: double blind, randomised, placebo controlled tria BMJ 2011;343:d5701 doi: 10.1136/bmj.d5701

Prostate cancer was the second most frequently diagnosed cancer in men worldwide in 2008, with an estimated 899 000 new cases1. In the UK it is the most common cancer in men with a lifetime risk of being diagnosed with prostate cancer of 1 in 92. Radical prostatectomy with conformal radiotherapy is the recommended treatment for men with stage appropriate disease3. An important complication of this procedure is blood loss. Furthermore, disorders of haemostasis are often associated with prostate surgery, with the risk of post-operative bleeding thought to be related to systemic and local activation of fibrinolysis by tissue plasminogen activator4. Tranexamic acid is a synthetic derivative of the amino acid lysine. It prevents the activation of plasminogen to plasmin, by tissue plasminogen activator, thereby exerting an anti-fibrinolytic action. It has been shown to reduce mortality in patients with substantial haemorrhage following trauma5 so the authors sought to investigate whether tranexamic acid can improve outcomes from radical prostatectomy. Methods This was a single centre (San Raffaele Hospital, Milan, Italy), double blind, parallel group, randomised, placebo controlled trial between April 2008 and May 2010. Patients were randomised into intervention or placebo groups. The intervention group received a loading dose of 500 mg of tranexamic acid diluted in 100ml of saline infused slowly iv 20 minutes before surgery, followed by a continuous infusion of tranexamic acid given at a rate of 250 mg/h from surgical incision until skin closure. Patients assigned to the control group received a saline placebo with identical volumes and rates of infusion. Anaesthetic technique was decided upon clinical need, however a standardised transfusion protocol was used. If the haemoglobin concentration was lower than 80 g/L, or if it was lower than 100 g/L and associated with severe hypotension that did not respond to colloid infusion and inotropic drugs, one or more units of autologous whole blood or of allogeneic packed red blood cells were transfused to keep the concentration of haemoglobin above 80 g/L (or above 100 g/L in the case of severe hypotension). Cell salvage was not used intra- or post-operatively. The primary outcome measure was the number of patients receiving blood transfusions from surgery until hospital discharge. The secondary outcome was intra-operative blood loss. Patients were also followed up to assess survival and occurrence of major cardiac, cerebrovascular, and thromboembolic events. Results Two hundred patients were randomised into the intervention or placebo groups which were well matched for baseline patient characteristics. There was an absolute reduction in the rate of blood transfusion of 21% (95% CI 7%-34%) and a RR reduction of 38%. Number needed to treat was 5. The tranexamic acid group had 232ml less intra-operative blood loss per case compared with the control group (1103ml vs 1335ml, p=0.02). The haemoglobin concentrations on the first day after surgery were 112g/l and 108g/l in the treatment and placebo groups respectively (p=0.009). The median number of units of blood transfused to each patient was 0 (IQR 0-1) in the tranexamic acid group compared with 1 (IQR 0-1.5) in the placebo group (p=0.004). Tranexamic acid was found to be the only independent predictor of reduced risk of blood transfusion (RR 0.64, 95% CI 0.45-0.90). Volume of intravenous fluids, use of topical haemostatic drug, length of surgery, postoperative fluid drain losses, and length of hospital stay were similar in the two groups. In total there were five thromboembolic events in the control group and two in the intervention group.


Conclusions Treatment with tranexamic acid was found to significantly reduce the rate of blood transfusion through inhibition of fibrinolysis with no increased risk of thromboembolic events or alteration of laboratory blood clotting parameters. This finding could be explained by tranexamic acid accumulating in tissue extracellular space thus inhibiting only tissue fibrinolysis. Other non-surgical techniques previously researched to decrease intraoperative bleeding are the use of activated factor VII and induced hypotension. Recent meta-analysis has reported a significantly increased risk of peri-operative stroke in cardiac surgery with activated factor VII6, and although induced hypotension by combined epidural and general anaesthesia has been shown to decrease the rate of blood transfusions in prostatectomy compared with general anaesthesia alone7, this has not become routine practice. Tranexamic acid is a cheap and simple method of reducing intra-operative bleeding. This study included all patients over 18 with few exclusion criteria so the results can be applied to most patients undergoing radical retropubic prostatectomy. However, the small numbers of adverse events during the follow up period do not allow a definitive conclusion about the safety of the intervention and of note there was no decrease in hospital stay between the two groups.

Dr Sarah Hodge CT2 Anaesthetics, Wessex Deanery

References 1.

2. 3. 4. 5.

6. 7.

Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM GLOBOCAN 2008 v1.2, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer, 2010. Available from: http://globocan.iarc.fr Prostate cancer - UK incidence statistics. Cancer Research UK (2007). Available from www.cancerresearchuk.org NICE guidelines 2008 (CG58) Prostate cancer. Available from http://www. nice.org.uk/CG058fullguideline Nielsen JD, Gram J, Holm-Nielsen A, Fabrin K, Jespersen J. Post-operative blood loss after transurethral prostatectomy is dependent on in situ fibrinolysis. Br J Urol 1997;80:889-93. CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R, Caballero J, Coats T, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010;376:23-32. Ponschab M, Landoni G, Biondi-Zoccai G, Bignami E, Frati E, Nicolotti D, et al. Recombinant activated factor VII increases stroke in cardiac surgery: a meta-analysis. J Cardiothorac Vasc Anesth 2011 [published online 17 May]. O’Connor PJ, Hanson J, Finucane BT. Induced hypotension with epidural/ general anesthesia reduces transfusion in radical prostate surgery. Can J Anaesth 2006;53:873-80.

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02/05/2012 09:10

your

Would you give away your house?

Letters

Pensions are dull and complicated they’re for old people only. But - would you buy a £200,000 house and just give it to the government? That may be the financial cost to a young doctor of the proposed pension changes.

SEND YOUR LETTERS TO:

The Editor, Anaesthesia News at [email protected] Please see instructions for authors on the AAGBI website

All in this together? Ministers would have us believe that the NHS pension is the most generous in the country, but this isn’t necessarily so.

Dear Editor

Table 1 shows some pension comparators. Obviously, there is some variation in absolute terms and conditions for these schemes, but they are a useful comparative indicator for the NHS scheme.

I would like to draw your attention to a failure in a Dräger adjustable pressure limiting (APL) valve that caught me out whilst doing my first solo rapid sequence induction as a novice. Following an uneventful machine check and placement of endotracheal tube, I was unable to ventilate with the circle circuit even with the valve in the fully closed position.

Table 1: Pension comparators. Group

Personal contribution (% of salary)

Government contribution Accrual rate (% of salary)

Judges

1.8-2.4

40

1/40

70

Civil Servants

1.5-5.9

20

1/60

60-65

MPs

6-12

30

1/40-1/60

60-65

Teachers

6.4-8.8

14

1/60-1/80

60-65

Firemen

10

11-21

1/60-1/30

55-60

Consultants (1995 scheme)

8.5

14

1/80

60-65

Consultants (2015 scheme)

14

14

1/60

68

Although many of the above schemes are under review, the proposed changes to most will still be more favourable than even the current NHS scheme, especially for doctors. Given the government’s refusal to negotiate further, doctors are in a difficult position- accept these changes, or embark on uncomfortable protest actions. This is rapidly becoming a defining moment for the BMA and individual doctors.

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Retirement age

Did you know: • Medical pay (in real terms) has declined significantly (10-30%) over the last 12 years.2 • The Speaker for the House, the Chancellor of the Exchequer, and the Prime Minister all receive a pension pot worth several million pounds for no personal contribution, even if they are in service for only a single day.3,4,5 • Danny Alexander MP stated that reducing the pension burden of public services would be an added attraction to alternative providers wishing to take over services. These wider ramifications of pension reform are significant, especially if NHS staff are subsequently employed by other providers: in general, pension protection is incomplete under such circumstances. • Despite possible short term savings, there are doubts about the sustainability of current pension reforms, making another review likely within a few years.6 • A large proportion of people are unable to work until 68. If you retire early, you suffer a significant reduction in your pension.7


Subsequently it was discovered that the gas sampling line had become wedged under the APL valve dial, holding it in a slightly elevated position. This causes a massive leak and renders the circle circuit unable to generate positive pressure for ventilation (See picture) Following removal of the sampling tube the valve returned to a normal functioning state.

References: 1.

2. 3. 4. 5. 6. 7.

Adapted from Table 3:G. In; Independent Public Service Pensions Commission Final Report. 10 March 2011. http://cdn.hm-treasury.gov.uk/ hutton_final_100311.pdf www.bma.org.uk/images/ddrbevidence2012_tcm41-210536.pdf http://blogs.telegraph.co.uk/finance/ianmcowie/100005545/number-10defends-gordon-browns-gold-plated-pension/ http://www.telegraph.co.uk/news/politics/conservative/8833301/JohnBercow-ignores-pleas-to-reduce-his-pension.html http://www.telegraph.co.uk/news/uknews/1421010/Dont-worry-Lord-Irvineyoull-retire-with-2m.html http://www.ifs.org.uk/publications/5999 http://www.dh.gov.uk/health/services-calculator/ Anaesthesia News June 2012 Issue 299

I have just read our President’s report in February’s edition of Anaesthesia News. He talks of the ‘interesting and challenging times’ we live in, and of the Government’s intention to drive down the cost of NHS healthcare by employing increased competition. Successive Secretaries of State for Health, and their advisors, from both public and private sectors, have promulgated this ‘new competition’. Some of these politicians have then gone on to accept lucrative posts on the boards of companies their reforms have benefited. Their ‘advisors’ remain very shadowy figures. Managers and investors have long targeted doctors’ status, lifestyle and salary. They wish to orchestrate the necessary changes to get their personal hands on all three. Why go to all the effort of getting a medical degree when you can take the cash for yourselves and get doctors to do all the work! If you don’t believe that this is happening – look at the salaries of the executives, in your trust, within private health insurers and in the management companies bidding for healthcare contracts. The inexorable rise in their remuneration has been astonishing in recent years. I predict that healthcare will not get any cheaper through these reforms – all that will happen is that we doctors, and especially anaesthetists, will get poorer whilst others benefit enormously through our hard work. Conspiracy theorist? Me? You’re damn right!! Peter Ritchie Consultant Anaesthetist Past-President HCSA

Dear Editor “CICV or CICO”? “Let’s face it, ventilation is required to remove CO2 and give oxygen” write Drs Gohil and Hunninger [1] in response to the review by Drs Hamaekers and Henderson [2]. CO2 clearance (ventilation) and oxygen delivery is very commonly coupled, but not always. Separation occurs during apnoeic mass movement oxygenation, sometimes called diffusion oxygenation. Described by Jacoby et al in 1956 for emergency and elective management of five patients with difficult airways, oxygen was provided by insufflation via a cricothyroid catheter in the absence of ventilation [3]. The principle is used today as part of brainstem death testing. Oxygen is given via a catheter threaded into the tracheal tube whilst mechanical ventilation is stopped. Hypoxia is prevented while CO2 is allowed to rise to act as a respiratory stimulus.

Summary • The NHS scheme is in surplus, and will be for many years to come. • Other pension schemes, even if revised, will remain more generous than the current NHS scheme. • Changes to the scheme will have a large financial impact, particularly on doctors. • If doctors allow the scheme to be used as a cash cow now, future governments are likely to impose further cuts in pensions for yet higher contributions • If you take no action now, you have your whole retirement to contemplate the wisdom of your inaction. Dr Ian Nesbitt, Consultant anaesthetist Dr Avinash Kapoor, ST6, Newcastle upon Tyne

Dear Editor

Dräger adjustable pressure limiting valve in the normal position.

Drager valve with side-stream gas sampling tube wedged between valve control and base.

In the context of critical airway management oxygenation is the priority and can be achieved without ventilation. CO2 will not be cleared, but this is far less pressing. We support the wording of Hamaekers and Henderson (“Can’t Intubate Can’t Oxygenate”). It is accurate, highlights the real problem and deserves credit. Dr David Falzon (ST2), Gartnavel General Hospital, Glasgow.

This type of valve is very common here in the South Wales Region.

Dr David R. Ball (Consultant), Dumfries and Galloway Royal Infirmary, Dumfries.

This highlights the continuing need to be wary of machine failure following a satisfactory machine check.

References

Dr William J Packer Anaesthesia CT1 University Hospital of Wales, Cardiff Anaesthesia News June 2012 Issue 299

1.

Gohil B, Hunninger A. What’s in a name? The Can’t Intubate, Can’t ventilate or Can’t oxygenate debate. Anaesthesia News 2012; 296: 31.

2.

2 Hamaekers AE, Henderson JJ. Equipment and strategies for emergency tracheal access in the adult patient. Anaesthesia 2011;66(Suppl 2),65-80.

3.

3 Jacoby JJ, Hamelberg W, Ziegler CH, Flory FA, Jones JR. Transtracheal resuscitation. Journal of the American Medical Association 1956; 162: 625-8.

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02/05/2012 09:10

The Association of Anaesthetists of Great Britain & Ireland

19-21 Sept 2012

ANNUAL CONGRESS

BOURNEMOUTH Bournemouth International Centre

This year’s Annual Congress comes to one of England’s most vibrant and cosmopolitan seaside resorts.

Bournemouth has seven miles of beaches, award winning gardens and a vast variety of shops, restaurants and bars.

Lecture topics include:

• National Audits (including NAP5) • The older patient • Pain management • Shared decision making in high risk surgical patient • Law and Ethics • Obstetrics • Revalidation • Papers you should know about • Wellbeing • Problem-based learning and Critical Incident case reports • Plus sessions organised by the Association of Surgeons of Great Britain and Ireland (ASGBI) and the British Geriatric Society

Scientific programme Multiple streams of lectures Debates Hands-on workshops Industry exhibition Poster and abstract presentations CPD approved Annual dinner and dance

www.annualcongress.org

SAVE THE DATE! 18-20 SEPTEMBER 2013

Anaesthesia NewsJune_FINAL.indd 32

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