Bulletin 15 - The Royal College of Anaesthetists [PDF]

BULLETIN 15

THE ROYAL COLLEGE OF ANAESTHETISTS September 2002 Inside this issue AUDIT AND THE EVIDENCE BASE OF ANAESTHESIA Acute neuropathic pain after surgery TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Perioperative arrhythmias: pharmacological and non-pharmacological management Flexible training in the new Millennium The European Computer Driving Licence The use of drugs beyond licence in palliative care and pain management Age shall not weary them, but the years condemn Election to Council 2003 CORRESPONDENCE Brown S, George R, Gururaj P, Kilvington B, Pollard JA, Pulletz M & Brownlow H, Zorab JSM

THE ROYAL COLLEGE OF ANAESTHETISTS 48/49 Russell Square London WC1B 4JY tel ++44 (0)20 7813 1900 fax ++44 (0)20 7813 1876 website www.rcoa.ac.uk email [email protected] President Professor P Hutton Vice-Presidents Dr P J Simpson and Dr D M Justins Editorial Board John Curran John Currie Peter Hutton Mandie Kelly (Copy Editor) Gavin Kenny Rajinder Mirakhur Anna-Maria Rollin (Editor) Peter Simpson

Inside Bulletin 15 The Royal College of Anaesthetists is grateful for the contribution to the production of this publication by:

711 President's statement 714 GUEST EDITORIAL Address to the Diplomates 2002 716 Non-consultant career grades 717 Appointment of FRCA Examiners 2003 718 TRAINEES’ TOPICS How the Royal College of Anaesthetists works 720 Flexible training in the new Millennium

© 2002 Bulletin of The Royal College of Anaesthetists All Rights Reserved. No part of this publication may be reproduced, stored in a

721 A John Snow connection with 48 Russell Square 723 The use of drugs beyond licence in palliative care and pain management 726 TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Perioperative arrhythmias: pharmacological and non-pharmacological management

retrieval system, or transmitted in any form or

731 Education programme

by any other means, electronic, mechanical, photocopying, recording, or otherwise, without

739 AUDIT AND THE EVIDENCE BASE OF ANAESTHESIA Acute neuropathic pain after surgery

prior permission, in writing, of The Royal

744 Age shall not weary them, but the years condemn

College of Anaesthetists.

748 The European Computer Driving Licence

Fellows, Members and trainees are asked to

750 Report of a meeting of Council

send notification of their changes of address direct to: Miss Karen Slater, Membership

752 MEDICAL DEVICES AGENCY SAFETY NOTICE Intersurgical breathing systems, LOT numbers 3021471 to 3022477

Officer, at The Royal College of

753 Election to Council 2003

Anaesthetists tel 020 7813 1900 fax 020 7580 6325 email [email protected]. Articles for submission, together with any declaration of interest, should be sent via email (preferred option) to: [email protected], or by post (accompanied by an electronic version on a floppy PC disk, preferably written in any version of Microsoft Word), to: Mrs Mandie Kelly, Copy Editor of the Bulletin at The Royal College of Anaesthetists. All contributions will receive an acknowledgement. The Editor reserves the right to edit articles for reasons of space or clarity.

754 The National Anaesthesia Day brand: What does it mean and why is it important? 755 Correspondence 758 Notices

The views and opinions expressed in the Bulletin are solely those of the individual authors, and do not necessarily represent the view of The Royal College of Anaesthetists.

President’s statement

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elcome back from the summer holidays! The summer period is one of great risk for the Colleges because it is when unpopular or controversial legislation can be slipped into the system with minimum fuss. This year was no exception with the publication of Growing Capacity 1; a document that discussed how overseas medical teams could be imported to increase surgical throughput of elective cases in England. It made no reference to Scotland, Wales or Northern Ireland, thereby simultaneously reminding us of the realities of having devolved health services. I receive a number of letters and frequent ear bashings from anaesthetists frustrated with government policy. Why, they say, don’t you speak out more in public, write to the newspapers, give ‘em both barrels etc? From my perspective, our ultimate objective is to optimise patient care and training and this requires maintaining influence without losing professional integrity. In the sixteenth century, Martin Luther translated the New Testament into vernacular German so that the pope and the priesthood would not stand between God and the population. Had he not burned the Papal Bull and irreverently depicted the Whore of Babylon in the papal tiara on a woodcut print he might just have got away with it: instead he was excommunicated. By analogy, as long as we are making satisfactory progress, our policy is to go as far as we can with the honest translation of events whilst avoiding provocative outbursts and illustrations that add nothing to our ultimate objective.

Is democracy changing its character? Since the end of the Second World War in 1946, the countries of Western Europe (apart from the Balkans) have enjoyed the longest absence of national boundary changes in recorded history. The political re-unification of Germany and the ‘fall of the wall’ symbolised the triumph of the free-market economy over communism. In the early 1970s when we were adopting decimal currency, struggling with miners’ strikes and the three-day week, and sending gun boats to Iceland, Edward Heath’s Government took us into the European Economic Community (EEC). Since then, with reference to governments but not electorates, the EEC changed first to the European Community and is now the European Union. Unelected bureaucrats make decisions that affect our lives and professions. The gradual drift from

free market to integrated union has occurred in the presence of an increasing disinterest of voters in national European elections and a progressive reduction in the votes cast. Does all this matter? I think it does, and I think it affects the way the College has to work to represent the public interest. When I was a teenager, I was forced by my father to read a monograph on the British Constitution entitled The Queen’s Government.2 I returned to it recently and it is full of little gems on subjects such as Ministerial Control and the Independence of the Judiciary. Civil servants who are past their best are for instance, dismissed as follows. ‘Overwork is endemic in the senior ranks of the civil service. It is not only proper but essential for the efficiency of the service that he (the civil servant) should retire as soon as his mind loses its elasticity, be allowed to live in modest comfort on his pension, and be honoured by The Queen.’ The most important aspects of the book are however the discussions about how policy is developed, the relationship of the Civil Service to Parliament and the Cabinet, the role of the opposition and the balance of power in the ‘first past the post’ system. The author clearly believes that democracy is best served when the opposition is a viable government and is able to improve proposed sensible legislation as well as to oppose that with which it does not agree. In his words, ‘The close division between the parties in the country.. is the special characteristic of British democracy … a slight shift of opinion is enough to defeat the Government at the next election’. At present, this system is clearly not working in the UK. The danger, no matter how high the ideals, is the introduction of dogma driven, opinion led policy, developed unfettered by the normal checks and balances of parliamentary procedure.

Democracy by elected autocracy? We essentially have an elected government that has the freedoms of an autocracy in the way in which it develops policy and represents us within Europe. In health, on many occasions it appears to have done this by asking advice from those whose answers it wishes to hear. The Department of Health, Number 10 and the Treasury all seem to have their own specific priorities. Peer elected professional opinion selected on a collegiate basis has been notably absent. Why is this? Is it because of arrogance, misunderstanding or fear? Perhaps Robbie Burns3 gives us a clue:

Department of Health: Growing Capacity, June 2002. Available at www.doh.gov.uk/internationalestablishment. Jennings, Sir Ivor: The Queen’s Government; Pelican Books, London 1954. 3 Robert Burns; To a louse, 1786. 1 2

Bulletin 15 The Royal College of Anaesthetists September 2002

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O wad some Pow’r the giftie gie us To see oursels as others see us! It wad frae mony a blunder free us, And foolish notion.

service delivery.4,5 On the positive side is a feeling within the devolved regions of greater involvement and autonomy but this is unfortunately counterbalanced by a lack of consistency in policy as different choices are made.

Working on the BT principle that ‘It’s good to talk’, increased contact with chief executives, civil servants, advisers and ministers, it has become clear that for whatever reason, the role and motivations of the Royal Colleges are unclear in many peoples minds. However, as each week passes, more fault lines open up in the progress towards the NHS Plan and this gives us the opportunity to engage in government thinking. Indeed, from the point of view of the public and trainees, with a neutered parliamentary process it is more important than ever that we do so. An increased willingness of ministers to listen may of course be linked to the lack of solutions coming from those who got us to where we are. The strength we have is that our messages and warnings have been constant for over two years and essentially have proved to have been right. Aware of the realities, we have been working on honest solutions which were previously politically unacceptable but soon may become necessities to prevent the transformation of the NHS into an emergency only service. No matter how tempting in the short term, the appointment of extra junior or poorly trained service staff to pad out rotas is not the answer. I remain very anxious but also cautiously optimistic that negotiated settlements will be found on the European Working Time Directive (EWTD), the rationalisation of hospital services, the Medical Education Standards Board, harmonisation with Europe and progress on skill-mix. Despite this, I would book your holiday now for August 2004 when the EWTD kicks in – always better to be away when a crisis hits.

Cost and choice in the healthcare of developed nations

Devolution progresses The Northern Ireland Advisory Group, set up as a subcommittee reporting to Council, had its inaugural meeting on 2 July. This is a small Committee under the Chairmanship of Professor Rajinder Mirakhur with representation from local anaesthetists, the AAGBI, and the College in Dublin. Its role will be to report to Council on devolution issues in Northern Ireland and to provide a focus for the development of regional policies. Gradually, the wisdom or otherwise of devolution and its impact on healthcare in the UK is emerging. Good examples of this are the recent publication of two documents from Scotland and Northern Ireland proposing radical reorganisations of

There is no country in the world that is not being exercised, for different reasons, about the costs of healthcare. Earlier this year, St Pauls, one of the biggest insurers in the US, gave up its healthcare operation. The funding problem was discussed in a ‘Sounding Board’ article in a recent edition of the NEJM.6 This is a useful paper that discusses the advantages and disadvantages of various systems, including a nationalised state run scheme. Interestingly, one idea gaining ground is that to limit financial liability, each person will get a predetermined amount of money to spend as he or she sees fit, and can use the internet to shop around for the best deal. In Europe, Denmark (which has an NHS) has just introduced such an internal voucher system to cope with people who have unreasonably long waits locally and it is known to be favoured by a number of UK policy makers. Such a system, although superficially attractive and capable of containing costs, raises a number of difficult questions. Most importantly, where will these patients given the freedom of choice get their information from? Where is the evidence that hospitals and clinicians who have to ‘compete’ for patients will provide a quality service? Allowing a market to evolve based on public reputation not only encourages economy with the truth, it initiates an instability in referral patterns which is perpetuated by positive feedback. So far, in medicine, I’m not impressed with the information superhighway. A few hours surfing can produce CVs of wonderful doctors who are mysteriously still looking for work, the opinions of pressure groups, and health related information which is simply wrong. In a nutshell, the electronic medium has great potential for mis-information, costs less, can be changed easily and is not subject to quality controls and peer-based review. Who knows, perhaps an Independent Medical Adviser will emerge along the same lines as an Independent Financial Adviser. They may even replace GPs as people of wisdom and integrity free from any form of personal financial gain. They would clearly only accept lunch invitations to discuss clinical performance figures, and remain immune from the inducements of commission.

Developing better services: Modernising hospitals and reforming structures; Northern Ireland Department of Health, Social Services and Public Safety, June 2002 Future Practice: A review of the Scottish Medical Workforce, Scottish Executive Health Department, Edinburgh, July, 2002 6 Fuchs VR, What’s ahead for health insurance in the United States? New England Journal of Medicine, 2002, 346, 23, 1822 4 5

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Medical markets and ethical frameworks In considering medical markets and ethics, some recent reports from China warrant a look.7 In the coastal province of Jiangsu, because hospitals could not pay their staff, 38 district hospitals were put up for sale at rock bottom prices and bought by entrepreneurial consortia. Since then, only eight are doing very well. Could Foundation Trusts be emerging from the socialist legacy of Mao Tse-Tung? Another complication of increased choice is that whilst it has to be accepted from history that what is socially and ethically acceptable varies with both time and geography, total patient choice may throw up moral dilemmas. Currently, in the southern Chinese province of Hainan, there are 135.7 male births recorded for every 100 female births.8 This is not occurring by chance: the desire for a male child, widespread availability of pre-natal ultrasound scans at around US$4, and abortion on demand is probably the explanation. How would we handle this neonatal sex ratio as a patient choice outcome from IVF? Whilst accepting that each country has its own standards, can patients, relatives, managers and/or politicians be trusted to make decisions which are best for the population as a whole? My personal experience would suggest usually yes, but not universally so. Enron and World.com buried financial data to entice investors: would a struggling hospital not be tempted to bury poor performance data? Anyway, where do all the ‘B team’ doctors go to? At present they are spread throughout the system with a good chance that peer group pressure and clinical governance will improve them. In a true market they could become collected together in the hospitals with the greatest need for improvement.

Presenting information to patients To remind myself how information should be presented, some time ago I purchased a print of Minard’s 1861 classic graphic depicting the abortive 1812 Russia Campaign of Napoleon.9 On a single geographical chart it lucidly describes key points in the advance and retreat to Moscow in which only 10,000 men returned from an initial advancing army of 422,000. The clarity of this is a stark contrast to the impenetrable nature of the NHS Performance Indicators. The last set were rushed out with such haste that there were even errata in the included errata slip.10 Certainly, these figures, as presented, would not help the public to make informed decisions.

The Professional Standards Committee has, for some time, together with the DOH, been tackling the question of patient information. We have recently welcomed the AAGBI as partners in the venture. This exercise, reported in the last edition of the Bulletin,11 has taught us a lot. It has confirmed in my mind that there is a huge need for us to improve communication with patients, see things from their perspective, and provide sensible information that can be read and digested at leisure rather than transmitted in the sometimes rushed pre-operative visit.

Simple measures still save lives On occasions clinicians continue to be resistant to following simple instructions to improve patient safety. This was clearly demonstrated by Julie Storr from Oxford when she gave her lecture entitled ‘The handy hygiene project’ at the National Patient Safety Agency Conference in June on ‘Building a Culture for Patient Safety’. The basic message was that on intensive care units hand washing saves lives by limiting cross-infection and we do not do it regularly enough between patients. Similarly the World Bank is currently backing a programme to promote hand washing as one of its initiatives to help underdeveloped countries. It is easy to forget that diarrhoea in underdeveloped countries remains the second biggest killer of children in the world, accounting for the equivalent of a jumbo-jet full of children crashing every four hours! In an excellent article in the last issue of the Bulletin,12 Griselda Cooper drew our attention to the problems of teaching airway skills. In it she commented on the importance of the pillow in optimising the head position. In my own Trust, (and I understand from informal conversations in several others), the NHS is buying a new form of pillow. It is characterised by being constructed of closely packed foam, very thick, and essentially non-compressible. The best use I can find to put them to is repeated end-to-end longitudinal compression for biceps exercises. In preventing optimal positioning of the head, I am very concerned that (particularly for trainees), these pillows could turn a grade 1 laryngoscopy into a grade 3 and a grade 3 into a major airway management problem. Please keep an eye-out in case these killer pillows start to enter your hospital and take appropriate action.

Peter Hutton

The Economist, Drastic Medicine, 2002;15 June:12. Eckholm E. Prenatal scans aid Chinese couples to abort unwanted girls: International Herald Tribune, 2002;22 June:4. 9 Tufte ER. The visual display of quantitative information 1986, Graphics Press, Conn:40–41. 10 Department of Health: NHS Performance Indicators; July 2002. Available on www.doh.gov.uk. 11 Thoms G. The College Patient Information Project. Bulletin 14 2002;July:673. 12 Cooper GM. Guest Editorial; Is the art of airway management being lost? Bulletin 14 2002;July:662. 7 8


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Guest Editorial This is the text of the Address to the Diplomates 2002

T

hank you for the invitation to join you this morning and for that introduction which was more generous than I deserve – and certainly more generous than I often receive. I am delighted to be with the College on this enjoyable occasion and give this Address. I do so, secure in the knowledge that you will remember not one word of it. Well, congratulations all round. Firstly, to the new Diplomates. When you first started studying anaesthetics, this day must have seemed only a distant dream, and there may have been times since when doubts and uncertainties crowded in. Medicine is not an easy discipline. It is particularly challenging at the postgraduate level when clinical practice, education and training have to compete with so many other personal and professional commitments. It is right and fitting that you should enjoy today. And so should your friends and relatives. They have supported you in every sense during the last few years and deserve our thanks today. This is a great day for them too. The sacrifices that they have made for you and the distances so many have travelled say far more about the importance they attach to this day than any words of mine. Ignore the scare stories. Medicine is in good heart. Doctors are, as shown by a recent MORI poll, trusted by 91% of the population, journalists by 15% and politicians by 9%. That trust is real, and forms the basis of any consultation, but it is conditional. It depends on you, your openness and the way in which you seek always to put the interest of your patients first. Of course hard work and worry go with the job, but there is also enormous fun, an international community to serve and professional friendships to be forged. Today marks the end of one phase and the start of another in your professional lives. The choice remains breathtakingly wide and the responsibilities considerable. Doctors, of course, have not always been held in high public esteem. Prior to the middle of the 19th century, the profession was not highly regarded. Quacks and patent medicines abounded. Few medical interventions were effective and many, such as bleeding patients and cupping, caused more harm than good. It was the development of the scientific foundations of medicine, the understanding of infections, including TB, sepsis, surgery and anaesthesia – that raised the profile of a profession. Doctors held the key to effective treatments that were now clearly of benefit to, but little

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understood by, patients. The creation of the NHS and other forms of health services throughout the world sustained the high standing of the medical profession for much of the 20th century. Now, with an increasingly well-educated public, and open access via the internet, etc to the kind of knowledge that was once the exclusive preserve of the medical profession, the mystique is fading – perhaps fortunately. The General Medical Council, founded in the middle of the 19th century, has shared that same rise and fall. This is not, however, exclusively a UK problem – the phenomenon of unhappy doctors is world-wide and so not directly related to the current problems of the NHS. I came into this at the high point. I was born immediately after the Second World War. My father was a GP with a surgery in our house so I cannot really remember a time when I have not been fully involved in medicine, and more importantly enjoyed it all. We must not lose that sense of excitement and commitment, that feeling of ‘can do’ – to be put to the service of society. As WH Aden put it in ‘Leap before You Look’: The sense of danger must not disappear: The way is certainly short and steep, However gradual it looks from here; Look if you like, but you will have to leap. The standards expected of us are laid down in the GMC’s booklet ‘Good Medical Practice’. Of course the first duty of a doctor is to make the care of your patient your first concern – ‘care’ you will note, not ‘treatment’. Hippocrates wrote: ‘First of all, I would define medicine as the complete removal of the distress of the sick, the alleviation of the more violent diseases and the refusal to undertake to cure cases in which the diseases have already won the mastery, knowing that everything is not possible in medicine.’ Not a bad definition and one that has stood the test of time. Our first and overriding duty is still to care for and about our patients. This is an exciting time for the profession. Scientific advances are inevitably changing the way in which we practice medicine. Introduced wisely, these changes will bring enormous benefits to patients. Inevitably, much of what you have learned so painstakingly will rapidly be out of date. The fascination of medicine, its distinguished past and exciting future, together with the privilege of helping patients cope with apparently intractable problems make it all worthwhile.

The science will change, society’s expectations of you will change, people, folk, don’t change. They will trust you when most burdened by ill health and worries. That need for trust and humanity in medicine is unchanging. The political events of the last few months emphasise the importance that society places in a quality healthcare. The additional resources for the health service are undoubtedly welcome, and it is inevitable that they will be accompanied by greater scrutiny and a wish for greater accountability. As Onora O’Neill has been discussing in the recent Reith Lectures, the increasing number of regulatory authorities and inspectorates has to be balanced against the absolute need for trust between doctor and patient. No doubt the recent highly publicised medical scandals damaged that trust. I believe, however, that the growing understanding that patients receive poorer quality care here than in many other countries has caused a good deal of disillusionment, both with the public and with the profession. Indeed, some of my colleagues have suggested that the contract or compact between government, profession and public should be redefined. Be that as it may, I have no doubt that the public and the profession depend upon the Colleges and their Fellows to promote high standards of medical care. Whatever happens at the Medical Education Standards Board and all the other authorities now being put in place – not so much Ofsted, as someone has said, more Ofsick – the recent debate has been more widespread and better informed than previously, possibly indicating a greater willingness by government, profession and public to assess their relationship anew. The recent government statements have accepted the current workforce difficulties experienced by many doctors and other healthcare professionals working in unsatisfactory circumstances. Looking forward, however,

there may be merit in re-examining the rights and responsibilities of the partners so that each can more fully understand its contribution to high quality health care. There are, I believe, indications that the profession and the public are working more effectively together than in the past, and that in itself will help ensure that the government takes its responsibilities for providing facilities for high quality health care more seriously in the future than perhaps has been the case in the recent past. This College and its Fellows have an opportunity to develop those relationships in a constructive way and to maintain the quality of healthcare provision as they have done for many years past. I have spoken before of the need for this country to have an Academy of Medicine that brings together the many different parts of the profession – and it is a concept to which I am still attracted. Whether or not that comes about we all need to work more closely together if we are going to provide high quality care for our patients. Congratulations to you all. I know that you will prove conscientious and compassionate doctors in your chosen career and I wish you well.

Sir Graeme Catto President, General Medical Council


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Non-consultant career grades Dr J P Curran, Chairman, NCCG Committee

I

had hoped to bring you up-to-date with what your Committee had learnt about how national developments will affect NCCGs. I can’t: failure may be in part mine, but slow progress in the wider national arena is my excuse. The matters boil down to just how too few doctors are to carry on providing ‘the service’. I would identify three things and none is peculiar to ‘anaesthesia’. We share these three problems with other frontline specialties: first, we have too few doctors, secondly, we need to maintain time for training and development, and finally the New Deal and more so the European Working Time Directive (EWTD), are scheduled to deliver a ‘crunch’ in August 2004 – a ‘crunch’ that will turn the ‘legislative screw’ further on the hours we all work. Because many NCCGs already work around the limit of what the EWTD will prescribe, this might not seem to affect them. It will, as it puts an obligation on employers to ensure its employees conform: it will lay bare just how much time not only doctors, but other colleagues put in. The matters link with others like proposals to amend the European Medical Qualification Order (EMSQO) that defines access to the Specialist Register and various hints that another grade, loosely and unhappily described as ‘sub-consultant’, maybe in the offing. An amended EMSQO is only likely to affect a few of our 1059 NCCGs (18% of the non-trainee anaesthetic workforce). For the College, it will affect its ‘Equivalence’ Committee that currently advises the Specialist Training Authority as to which applicants have training equivalent to our own CCST bearers. I am a member and try to keep an eye as to which NCCGs might be affected by changes. Next, irritating though it may be for NCCGs to feel they have been sidelined until after a ballot on the consultant contract, it will affect them because whatever its outcome, it remains clear that we are short of doctors – not just of anaesthetists, but of other front-line specialists. The NHSE folk presumably hope to get more ‘hours’ out of consultants – if they don’t will they plough on with a sub-consultant grade? Of whom will it be made? Those with a shortened training leading to a CCST gained at an earlier stage? Some NCCGs? European doctors? Only the last seems answerable: although there are some European doctors, who have gained access

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because of their European qualifications, applying to work in the United Kingdom they are few, and are likely to remain few. To paraphrase a common expression, it is not that the chickens are coming home to roost – they did so some time back, and have been sitting on the rafters waiting to transmit their messages down to us all.

Opportunities If we see a route to help any group of NCCGs as the difficulties play out, and if it is consistent with our policy of not arguing ‘conditions and terms’, but encouraging professional development, we will examine it carefully. As I have pointed out before, the primary functions of the College include the protection of the public and the education of doctors, and therefore anything we do must be robust and consistent with this. This will inevitably disappoint some.

Changes Now we have NCCGs on our College Council, our plans move forward. Chris Rowlands, a staff grade anaesthetist from Bradford will become your committee’s Chairman in January: Chris Heneghan, who has worked on your behalf from the outset of the NCCG development leaves to chair the Equivalence Committee. I wish both well in ‘interesting’ times. Andy Mortimer, a long serving Council member and a consultant in Wythenshawe, takes up Chris Heneghan’s seat on the NCCG Committee.

Summer homework Charlie Cooper aims to complete soon his work to support the appraisal process of NCCGs at local level. I think that this process can be used to influence career development, and we hope to underpin this with some specialty specific guidance. If we can interest other Colleges we will. Chris Rowlands and I will be going to a BMA meeting on Competencies and NCCGs – quite how we are expected to deal with this is anyone’s guess, bearing in mind the difficulties that we have in assessing trainees. I would like to think that many of the matters will fit together like a jigsaw: there are missing bits that might make a spider’s web a better description.

THE ROYAL COLLEGE OF ANAESTHETISTS

Appointment of FRCA Examiners 2003

The College invites applications from Fellows in good standing who would like to become FRCA examiners commencing on 1 September 2003. Examiners will normally be recruited to the Primary examination in the first instance, although applicants are invited to indicate an interest in the Final examination on the application form. The precise number of vacancies is not known at the time of going to press but we envisage approximately fourteen. The College welcomes applications from women and members of ethnic minorities.

Selection criteria Applicants shall be expected to meet the following basic criteria: • Would normally be a Fellow by Examination, but a

Fellow ad eundem, or a Fellow by election will also be considered. • On the closing date for applications shall have been a

consultant anaesthetist, or have held a comparable appointment, for a minimum of seven years. • Shall currently be active in clinical practice and in the

education of trainees. • On the 1 September 2003 shall have sufficient time to

complete a full examinership term before reaching normal retirement age. • Shall have visited a recent Primary or Final FRCA

examination. • Shall have attended Equal Opportunities training.

Application forms and information for applicants may be obtained from the College website www.rcoa.ac.uk or from: Miss Victoria Lloyd, Training and Examinations Directorate, The Royal College of Anaesthetists, 48/49 Russell Square, London WC1B 4JY tel 020 7908 7319 email [email protected] The closing date for receipt of completed application forms is Thursday, 31 October 2002

THE ROYAL COLLEGE OF ANAESTHETISTS BOARD IN SCOTLAND ANNUAL MEETING

Outcomes from anaesthesia and intensive care 6 December 2002 at the King’s College Conference Centre, University of Aberdeen 10.00 Registration and coffee 10.30 Pre-operative optimisation Brian Cuthbertson, Senior Lecturer, Anaesthesia & Intensive Care, Aberdeen 11.00 Individual response to operative stress Helen Galley, Senior Lecturer, Anaesthesia & Intensive Care, Aberdeen 11.30 Post-operative critical care provision Chris Aps, Clinical Director, Guy’s and St Thomas’ Hospital, London 12.00 When it all goes wrong Rhona Flin, Professor, Psychology, Aberdeen 12.30 Discussion Lunch 14.00 Sex and intensive care Nigel Webster, Professor, Anaesthesia & Intensive Care, Aberdeen 14.30 Follow-up clinics Carl Waldman, Clinical Director ICU, Royal Berkshire Hospital, Reading 15.00 Post-traumatic stress reactions David Alexander, Professor, Mental Health, Aberdeen 15.30 Survival following intensive care Cam Howie, Consultant, Victoria Infirmary, Glasgow 16.00 Discussion 16.15 Tea and close For further details, please contact: Professor N R Webster, Department of Medicine and Therapeutics, University of Aberdeen, Institute of Medical Sciences Building, Foresterhill, Aberdeen AB25 2ZD tel 01244 555869 email [email protected] fax 01244 273066


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TRAINEES’ TOPICS Editor Dr M J Garfield, The Ipswich Hospital, Suffolk This month’s Trainees’ Topics section contains the first article in the series ‘How the RCA works’, and also the first book review to be published in the Bulletin. I hope that readers find them useful. The next issue of the Bulletin will continue the series, and also contain the first submitted article by a trainee, an honest review of her training by Dr Padma Rao, an SpR in North Thames. I would encourage trainees to submit further articles for publication – my contact details are given in the blue panel on the left of the page.

Please send articles for submission, together with any declaration of interest, to the Editor

How the Royal College of Anaesthetists works Dr M J Garfield, Member of Council, Ipswich Hospital, Suffolk

of Trainees’ Topics, Dr Mark Garfield, via email to: [email protected], or by post (accompanied by an electronic version on a floppy PC disk, preferably written in any version of Microsoft Word), to: Department of Anaesthetics, The Ipswich Hospital, Heath Road, Ipswich, Suffolk IP4 5PD. The Editor reserves the right to edit articles for reasons of space or clarity.

To most trainees, the Royal College of Anaesthetists is a mysterious institution run by old Professors in grey suits, to which they have to send large cheques, and occasionally turn up for the stressful experience of an examination. Those who approach the double doors on Russell Square, or even go through Russell Square Tube Station will feel a quickening of the pulse, a lurch of the stomach, and break out in a sweat even if they are not attending for a viva or OSCE session. The experience of sitting through a meeting, feet from where you met an examiner over the green baize takes a long time to get used to. The College, however, is much more than just the examination, which is only a small (but important) part of its work. This series aims to explain the functions of the College and its relevance to trainees.

in 1988 (a situation which currently exists in Ireland), with the natural progression to full independence and establishment of a Royal College in 1992.

History

• To educate the general public in all matters relating to anaesthesia.

The Royal College of Anaesthetists was established by Royal Charter in 1992. Its roots lie in the craftsmen’s guilds of the Middle Ages, from which the Royal College of Surgeons of England (RCSE) was established. With the advent of the National Health Service, and following extensive lobbying by the Association of Anaesthetists, the RCSE formed a Faculty of Anaesthetists in 1948. With the increasing importance of anaesthesia and its subspecialties to hospital medicine, pressure grew for independence. The first step was formation of a College of Anaesthetists within the RCSE

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Functions of the Royal College of Anaesthetists The Royal Charter charges the College with four duties: • To advance, promote and carry on study and research into anaesthesia and related subjects, and to disseminate the useful results of such research. • To educate medical practitioners to maintain the highest possible standards of professional competence. • To further instruction and training in anaesthesia both in the UK and overseas.

All functions of the College must fulfil one of the four above objectives to have any authority. The College has no remit to involve itself in terms and conditions of service, except where they affect training or public safety.

College Council The College Council is the ultimate decision-making body of the College. It has 23 elected members, including one non-consultant career grade member (NCCG) and two trainee members elected by Fellows within the first four years of their Fellowship. There are also co-opted members,

representing the Association of Anaesthetists of Great Britain and Ireland, the Group of Anaesthetists in Training, the Royal College of Surgeons of England, the Faculty of Accident and Emergency Medicine, a lay member and an observer on professional standards in anaesthesia. A further NCCG is co-opted for two years – from 2004, this will turn into an elected NCCG seat. Council meets on a monthly basis in order to achieve its aims of fulfilling the College’s charter and maintaining the status and influence of the specialty. The elected members elect the President and Vice-Presidents from within their number on an annual basis. In addition to this, Council members chair all of the College Committees, which meet on a regular basis to formulate policy. All major decisions taken by these committees have to be ratified by Council before they become official College policy.

College directorate structure The College is split into a number of directorates, in order to facilitate the running of the organisation. The largest of all is the Training and Examinations Directorate – this is the directorate with which trainees will most commonly come into contact, and in addition to the Training and Examinations departments contains the Courses and Meetings Department. The Professional Standards Directorate is concerned with setting standards for anaesthesia as a whole – examples of their work are ‘Guidance for the Provision of Anaesthetic Services’ and the ‘Audit Recipe Book’. The President’s Office is responsible for supporting the President and Council in its work, and The Finance Directorate is responsible for the money. These directorates will be the subjects of future articles in this series.

A reveiw by Dr Kamen Valchanov, Specialist Registrar, Anaesthetics, Ipswich Companion to clinical anaesthesia exams, 2nd edition, Charles F Corke and Ian J B Jackson. Published by Churchill Livingstone, an Imprint of Elsevier Science (formerly Harcourt Publishers Limited), London. Pp. 277; indexed; illustrated. ISBN 0-443-07104-7

This is the second edition of a useful exam companion, consisting of 277 pages divided into five sections. The first and largest section, perhaps the main virtue of the book, is made up of Answer Plans. It is an excellent guide to the Short Answer Question section of the Final FRCA and also provides the backbone of the Structured Viva. It contains bulleted lists of information covering a large part of the FRCA syllabus, presented in a well-ordered and logical fashion. It does assume a basic understanding of the subject matter and is therefore not suitable for trainees at the beginning of their preparation for the exam. The text is concise and probably up to the level of detail that is required for the actual exam. Needless to say it prompts the reader at times to look up larger reference sources and deepen his knowledge in areas that in which he may feel that he is weak. It is an excellent mix of basic science discussed in the context of the clinical practice of anaesthesia with a very brief discussion of a few problems in Intensive Care Medicine and Chronic Pain. There are up-to-date references supporting the current concepts of management. The Anatomy part of this first section contains core information and diagrams which are simple and easily reproducible in an exam situation. The second, Practical Clinical Section is a quintessence of clinical data interpretation knowledge, including electrocardiography, X-rays, pulmonary function tests, blood gas and electrolyte analysis. The third section contains 24 structured viva panels that can be used for at-home or in-group study and discussions. The special bibliography section provides classical references for history of anaesthesia lovers and a summary of the Confidential Reports on Maternal Mortality. The final Glossary section reminds us in alphabetical order of some key facts of anaesthetic theory and practice. This is a well structured, balanced, referenced and indexed book with a good layout, summarising the amount of information needed for FRCA. I would recommend this book as an excellent reference text for trainees preparing for the FRCA exam and a quick reference aide-memoir for any anaesthesia practitioner. Elsevier Science www.fleshandbones.com/ and www.intl.elsevierhealth.com/


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Flexible training in the new Millennium Dr L E Shutt, Bernard Johnson Adviser, Bristol The effect of the New Deal December 2000 saw the introduction of the most recent version of the ‘New Deal’. For flexible trainees in post this meant an increase in salary which recognised the proportion of ‘out-of-hours’ work but at the time was a disproportionate increase in terms of hours worked compared to full-timers. However, this change caused havoc for new appointees in some areas in that some Trusts have felt disinclined to make up the balance of their salary over and above the former Medical and Dental Educational Levy allowance (MADEL) via Postgraduate Dean’s Offices. This reluctance, as one might expect, was most apparent where full-timers were working illegal Band 3 rotas at the top rate of salary. The future of flexible training seemed threatened by this change as the BMA was, quite rightly, unwilling to renege on the New Deal agreement but the NHS Executive maintained that no extra money was available. This period of constraint has lead to a number of proposals for alternative programmes for flexible trainees which restrict out-ofhours work, incur lower salaries and therefore become more acceptable to employing Trusts. These requests have lead to some difficulty with educational approval.

The new funding should ease the difficulty of making flexible training hours proportionate to full-time in all respects as employing trusts will need only to make up the extra 0.05 or 0.25 of a full time salary for trainees in bands FB and FA respectively. In addition, by December 2002, the differential between flexible and full-time salaries will once again be closer to the difference in hours and this will make the funding of flexible training more plausible. While I have no firm information at the time of writing this article, I am led to believe there will be appropriate tranches of central funding to support flexible training in Northern Ireland, Scotland and Wales in a similar way.

Eligibility for flexible training Eligibility and funding for flexible training continue to be determined at Deanery level and are administered by the Associate Postgraduate Dean. Trainees with ‘well founded individual reasons’ preventing them from undertaking full-time training should make an appointment to see the Associate Dean in their region, giving as much notice as possible as there may be a waiting list for funding and it can take some time to organise a suitable training programme.

Educational approval

Flexible careers scheme

College educational approval for flexible training in anaesthesia is in line with the requirements of the European Medical Directive 93/16/EEC Annexe 1(2) statement:

As part of the DOH ‘Improving Working Lives’ agenda a new centrally funded Flexible Careers Scheme is being introduced, primarily aimed at facilitating the return to work of doctors who have taken a career break. The full potential of this scheme for doctors of all grades was advertised in the March 2002 issue of the Bulletin.1 In the absence of the normal funding, this scheme may be accessible to trainees via the usual channels, but will be funded to a maximum of less than 50% of full time and individually for a finite period of no more than two years. Time on this scheme will clearly not be countable towards a CCST. Nevertheless, as a temporary measure, financial support from this scheme may be useful to refresh or maintain skills while waiting for proper funding.

‘Part-time training shall meet the same requirements as full-time training, which shall differ only in the possibility of limited participation in medical duties to a period of at least half that of fulltime trainees, including on call duties’. The interpretation of this statement is that flexible trainees should, pro rata, undertake the same out-of-hours work as full-time trainees, including weekend on-call duties. Proposals to reduce the out-of-hours training for flexible trainees, therefore, do not meet current College requirements. The Training Department at the College have been as compliant as possible in approving educational plans during this difficult period but have adhered to the principle that at least some weekday and weekend out-of-hours duties are included in all flexible training programmes.

New funding Recently, the Department of Health (DOH) has announced an additional £7 million central funding boost to flexible training in England for 2002/03 and also for 2003/04. From April 2002, this will bring the MADEL funding [now absorbed into the National Postgraduate Education and Training budget (NPET)] to 1.0 unit of basic salary for all SHO and SpR flexible trainees who occupy posts which comply with the New Deal hours and rest requirements.

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Future trend The overall trend is towards ensuring that flexible training is ‘embedded’ in the framework of the future NHS. This seems eminently sensible at a time when the country is running short of the required numbers of medical staff and any device which retains staff within or returns them to the workforce is worthy of pursuing. It is fairly common knowledge, also, that the output of UK medical schools is increasingly female so that without further support the size of the shortfall could easily increase.

College website College information on flexible training is contained within the Guidance for Trainers now in issue 6.1 (March 2002) on the website

(www.rcoa.ac.uk). Issue 6.1 amalgamates related topics and begins with a useful contents page. Answers to frequently asked questions by flexible trainees will be found under the headings of Leave, Maternity and on-call duties.

Registration and further contact with the College

A John Snow connection with 48 Russell Square Dr D Zuck, History of Anaesthesia Society

The College has always encouraged flexible training in anaesthesia. On the other hand, College records of the numbers of flexible trainees are probably an underestimate. This is because the initial eligibility and funding arrangements for flexible trainees are, quite appropriately, made via the Postgraduate Deans’ departments and College registration does not occur until a later stage. Initial and subsequent contact with the College Training Directorate allows regular updating of periods of training and leave so that necessary adjustments can be made to the timing of the CCST date.

Flexible training co-ordinators The number of flexible trainees varies markedly from region to region. Where there are sizeable numbers in training, some regions/ schools have appointed Flexible Training Co-ordinators to provide advice and in some cases to manage programmes of training for flexible trainees. Flexible training programmes are individual and sometimes complex, so that one person co-ordinating these issues

Dr Golding Bird (1814–1854) Reproduced with the kind permission of The Wellcome Library, London

at a regional level should ensure a consistency of approach. It is certainly unreasonable in terms of creating a balanced range of training that trainees themselves should have to or be allowed to put together their own programme of training and choice of hospitals. The College recommends that all schools should consider the establishment of a post with responsibility for managing the programmes of flexible trainees. Depending on numbers of flexible trainees, this post may variously be a ‘full-time’ job for one person or an ancillary post subsumed amongst other roles. A network of flexible training contacts would streamline the College role of overseeing the approval of flexible training. The College would aim to keep these persons informed of changes in guidance pertaining to the approval of flexible training. Earlier this year, I wrote to each regional or school person who I believed had responsibility for advising or co-ordinating the training elements of flexible training. The purpose of this mailing was to update College records of current flexible trainee names and numbers. The response was excellent and did reveal some flexible trainees of which the College were unaware. I apologise to anyone who I may have missed in this mail-out and would ask that you please telephone or write to the Training Directorate at the College so that an up-to-date list of link persons can be maintained. Reference 1

Powell DR. Flexible Careers Scheme. The Royal College of Anaesthetists Bulletin 12, March 2002: 591.

Russell Square was built on part of the site of Bedford (originally Southampton) House, the home of the Dukes of Bedford, which was demolished in 1800. The square, one of the largest in London, was laid out by Humphrey Repton, and built largely by James Burton, a Scotsman, father of Decimus, whom Summerson describes as one ‘who soon towered above all his fellows in the building world and became the monopolist of a great part of Bloomsbury.’1 The south side of the square, which includes the house which is the present home of the Royal College of Anaesthetists, was the first to be built, starting about 1804. These properties, now Grade II listed, were described for selling purposes as ‘capital first rate houses.’ They were altered toward the end of the century, their fronts being refashioned and dressed with terracotta ornaments, an embellishment that Summerson describes as ‘ a Doulton face-lifting, ingenious and inglorious.’ A statue of Francis Russell, 5th Duke, stands on the south side of the public garden that occupies the centre of the square. From the beginning, the square was popular with lawyers, artists, and writers. Famous residents included the artist Sir Thomas Lawrence, who lived at No.65 until his death in 1830, Lord Chief Justice Denman, the novelist Mrs Humphrey Ward, and the journalist Henry Crabb Robinson. Thackeray, in Vanity Fair, made it the home of the Sedleys and the Osbornes.2 No.48, which now accommodates the Royal College of Anaesthetists, has a tenuous connection with John Snow. It was occupied for some years by Dr Golding Bird. A year younger than Snow, Bird was born in 1814. He and Snow seem to have met first in 1837, through their connection with the Westminster Medical Society. Snow, while still a medical student, had already shown that the practice of preserving Bulletin 15 The Royal College of Anaesthetists September 2002

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cadavers by the injection of a solution of potassium arsenite was potentially harmful, and the practice was discontinued. Towards the end of 1837 the Society discussed the undesirability of the addition of arsenic by some manufacturers to inexpensive stearite candles, and at a subsequent meeting it was reported that Snow and a colleague had isolated arsenious acid from such candles. The Society then requested that three sets of experiments, chemical and biological, be performed. Mr Golding Bird examined the products of the combustion of arsenicated animal fats, and made post-mortem examinations of five birds that had died after exposure to arsenical vapours. At the same time, Snow and a colleague examined the effects of arsenical vapours on guinea pigs, but further experiments with birds proved inconclusive, because the apparatus caught fire. The three investigators reported to the Society on 16 December, but the contents of the final report were leaked to the London Medical Gazette before it was formally accepted, with the result that the Society refused to endorse it.3 The leakage may have been intended to produce this result, because some members of the Society were concerned that it might be vulnerable to legal action by the manufacturers if it reported against the candles. Bird qualified MD St Andrew’s in 1838, took the LRCP (equivalent to today’s Membership) in 1840, and was elected Fellow in 1845. He was a lecturer at the Aldersgate Medical School, where Snow taught forensic medicine, and became assistant physician and Professor of Materia Medica at Guy’s. He published a book on the elements of science which went to three editions, wrote a paper on carbon monoxide poisoning, and lectured on electricity and galvanism and the application of organic chemistry to therapeutics. Bird was President of the Westminster Medical Society during the early 1840s, the time when it was at its lowest ebb, as the result of the closure of the Great Windmill Street School, from which it recruited most of its members. Snow was a Council member and a steadfast supporter of the Society, to which he communicated many of his important discoveries, both before and after the introduction of general anaesthesia. Bird must have been a high flier, so the low standard of some of his contributions to discussions at the Society’s meetings is surprising. Although he was the author of a book on elementary science, when Snow explained the basis physics of the undesirability of allowing air to enter the pleural cavity while aspirating an effusion, he quite failed to see the point. But Bird’s main interest was in renal disease and the chemistry of urine, and he published a book that ran to five editions and was published also in the United States. John Snow had concerned himself in this field also, and had conducted experiments to determine whether alkalinity of the urine resulted from its retention in the bladder. He reported his findings at a meeting of the Westminster Medical Society on 7 November 1846, and spoke also at the Royal Medical and Chirurgical Society, of which Bird was a vice-president, some two months later. Bird, in his book, says that ‘Dr Snow has made some ingenious experiments on the conditions for the development of alcalescence in the urine whilst in the bladder, and he has produced

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much evidence to prove that whenever this cannot contract so as to get rid of all its contents, the small quantity thus retained will become alkaline, and be sufficient to induce a similar state in the freshly secreted urine soon after its dropping from the mouth of the ureter upon it.’4 Snow’s experiment involved keeping newly voided urine in an upper vessel at a temperature of 100°F and dripping it into a lower one at about the rate at which it enters the bladder. The upper vessel was emptied completely and washed every six to eight hours, while the lower one always had a few drops of the stale urine left in it. The result was that the urine in the lower vessel was always alkaline, while that in the upper was constantly acid. Bird concludes that ‘These researches afford a strong argument in favour of the practice of frequently washing out the bladder, in cases of alkaline urine.’ The problem of alkaline urine, as both Bird and Snow explained, was that it predisposed to the precipitation of phosphates, and the formation of encrustations and stones. Bird lived first in Myddelton Square, near Sadlers Wells, moving south to the more prestigious address of 48 Russell Square in 1850,5 but he enjoyed it only for four years. His terminal illness was classic. During the 1840s he had suffered an attack of rheumatic fever, complicated by endocarditis and nephritis. This progressed to aortic regurgitation, severe exercise limitation, palpitations, and haematuria. Early in 1854 he was unable to continue in practice, and he retired to Tunbridge Wells in June. The hoped-for improvement did not result, and he died on 27 October.6 Ironically, the instrument that Snow had described, a trocar and cannula with stopcock, which Bird could not see the purpose of, was designed to relieve one of the features of congestive cardiac failure, of which he died. Ironically also, Snow survived him by only four years, dying of the cardio-vascular complications of kidney disease.

Acknowledgements I am grateful to Mrs Ann Mitchell, Archivist to the Bedford Estate, Woburn Abbey, Ms Miriam Gutierrez Perez, Picture Researcher at The Wellcome Trust Medical Photographic Library, and to the College’s secretariat. References 1 2 3 4 5 6

Summerson J. Georgian London. Harmondsworth, Penguin Books 1978. Hare AJC. Walks in London. London, George Allen 1901. London Medical Gazette 1837–1838;21:577–579. Bird G. Urinary Deposits, their diagnosis, pathology, and therapeutic indications. London, Churchill, 3rd edn. 1851;280. Medical Directory, 1851. Obituary – Lancet 1854;ii:390.

The use of drugs beyond licence in palliative care and pain management A position statement prepared on behalf of the Association for Palliative Medicine and The Pain Society

Introduction

I

n pain management and palliative medicine it is common to use drugs beyond their product licence. The licensing process for drugs regulates the activities of pharmaceutical companies and not a doctor’s prescribing practice. Exemptions are specifically incorporated into the Medicines Act (1968) that preserve a doctor’s clinical freedom to prescribe in what he or she considers the patient’s best interests. Drugs prescribed beyond licence can be legally dispensed by pharmacists and administered by nurses. We all have a duty to act responsibly and provide information to patients and carers. The use of drugs beyond licence is therefore important for doctors, nurses, pharmacists and other health care professionals involved in pain management. There is increasing pressure from government, Trusts and various patient groups to address this issue. There are risk management and consent issues that need to be considered. As a first step, The Pain Society and Association for Palliative Medicine formed a joint working party to produce a Consensus Statement concerning the use of drugs beyond licence. The document will form a basis for future work and recommendations.

The use of drugs beyond licence This statement summarises the views of the Association for Palliative Medicine (APM) and The Pain Society in relation to the use of drugs beyond their product licence (or marketing authorisation) in clinical practice. It is the result of conferences held by the Science Committee of the APM on 23 May 2001, and a joint meeting between the APM and The Pain Society held on 10 October 2001. The purpose of the meetings was to discuss the clinical and legal implications of using drugs beyond licence in relation to patients, carers, professionals, and provider organisations. The recommendations of the Association for Palliative Medicine and The Pain Society are that: 1 This statement should be seen as reflecting the views of a responsible body of opinion within the clinical specialities of palliative care and pain management. 2 The use of drugs beyond licence should be seen as a legitimate aspect of clinical practice.

3 The use of drugs beyond licence in palliative care and pain management practice is necessary and common. 4 Choice of treatment requires partnership between patients and healthcare professionals, and informed consent should be obtained when prescribing any drug. Patients should be informed of any identifiable risks and details of the information given should be recorded. It is often unnecessary to take additional steps when recommending drugs beyond licence. 5 Patients, carers, pharmacists, and health care professionals need accurate, clear and specific information that meets their needs. The Association for Palliative Medicine and The Pain Society should work in conjunction with pharmaceutical companies to design accurate information for patients and their carers about the use of drugs beyond licence. 6 Health professionals involved in prescribing, dispensing and administering drugs beyond licence should select those drugs that offer the best balance of benefit against harm for any given patient. 7 Health professionals should inform, change and monitor their practice with regard to drugs used beyond licence in the light of evidence from audit and published research. 8 The Department of Health should work with health professionals and the pharmaceutical industry to enable and encourage the extension of product licenses where there is evidence of benefit in circumstances of defined clinical need. 9 Organisations providing palliative care and pain management services should support therapeutic practices that are underpinned by evidence and advocated by a responsible body of professional opinion. 10 There is urgent need for the Department of Health to assist health care professionals to formulate national frameworks, guidelines, and standards for the use of drugs beyond licence. Practical support is necessary to facilitate and expedite surveillance and audit which are essential if this initiative is to be moved forward.


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Current practice

Non-clinical perspective

Definitions

The primary medico-legal issues raised by the use of drugs beyond licence relate to consent from patients and the legal defence of the doctor’s practice. Consent is valid legally only if given by a person who is adequately informed, acting voluntarily and is competent to decide (i.e. can understand the information, retain and believe it, and use it to reach a reasoned conclusion). When these criteria cannot be fulfilled, treatment is only legally valid if given for conditions needing immediate treatment, (the doctrine of necessity). In practice, non-urgent treatment is often provided to patients who cannot give valid consent. The practitioner is expected always to act in the patient’s best interests and it is both customary and courteous to discuss unusual or invasive treatments with relatives who may help refine understanding of what the incompetent patient would have chosen. However, relatives cannot, at present, provide legally valid consent on behalf of an incompetent adult. Treatment given in these circumstances is not necessarily unlawful, it is merely not protected by legal authority. In exceptional cases involving particularly sensitive treatment the guidance of the court should be sought. Specific, written consent should always be sought for use of new drugs or drugs used innovatively but seeking written consent is not practical in clinical circumstances where the use of off-label medications is routine. The main concern of practitioners is that the use of unlicensed or off-label drugs could prompt legal action. A claim founded in negligence can only succeed if foreseeable injury has occurred as a consequence of breach of a duty of care. The standard expected of practitioners in the UK is primarily determined by the ‘Bolam’ principle (acting in accordance with a responsible body of medical opinion in that speciality), but current law requires that such opinion be logical and capable of withstanding critical questioning. A successful claim leads to an award of damages – financial compensation seeking to restore the claimant to the position he would have been in but for the negligent act. Life expectancy and loss of earnings are incorporated in the calculation of damages, so high value claims can easily arise from the management of chronic pain, but are most unlikely in palliative care. Low value claims are rarely pursued and often do not qualify for Legal Aid. From an organisational perspective, the risks presented by staff (doctors, nurses and pharmacists) in using drugs beyond licence are best managed through a culture of clinical governance. Organisations should encourage staff to educate themselves and take responsibility for their own decisions within the framework of a corporate policy. There should be mechanisms in place to inform, change, and monitor clinical practice. Organisations should also learn from the airline industry where errors are viewed primarily as system errors rather than personal errors. Organisations should examine

The Medicines Control Agency in the UK grants a product licence for a medical drug. The purpose of the drug licence is to regulate the activity of the pharmaceutical company when marketing the drug. The licence does not restrict the prescription of the drug by properly qualified medical practitioners. Licensed drugs can be used legally in clinical situations that fall outside the remit of the licence (referred to as ‘off-label’), for example a different age group, a different indication, a different dose or route of administration. Use of unlicensed drugs refers to those products that have no licence for any clinical situation or may be in the process of evaluation leading to such a licence. Sometimes off-label drugs are used because, for economic reasons, manufacturers have not sought to extend the terms of the licence for applications where costs are likely to exceed financial return. Clinical perspective A recent audit in palliative care found that off-label use is common (around 25% of prescriptions affecting 66% of patients in one specialist palliative care unit),1, 2 but use of unlicensed drugs is rare. This is similar to paediatric clinical practice where audits in the UK and Europe have shown that 39–55% of prescriptions were off-label, and 7–10% of prescriptions were for unlicensed drugs. At least two thirds of children receive an off-label or unlicensed drug during an inpatient admission.3 Recommendations from bodies such as the General Medical Council and the Medical Defence Organisations place a duty on doctors to act responsibly, and to provide information to patients on the nature and associated risks of any treatment, including off-label and unlicensed drugs. Furthermore, the guidance recommends that such drugs should be prescribed by a consultant or GP, following informed consent by the patient, and that this decision be recorded in the patient’s notes. A survey of senior doctors working in Palliative Medicine4 revealed that 97% of respondents did not operate a policy in these circumstances, 93% did not limit prescribing to consultants in this way and only 4% always obtained verbal consent when using off-label drugs. It is now a requirement for medication to be dispensed with written information provided by the manufacturer. The information refers only to indications, doses, and routes of administration for which the drug has a licence. This can lead to poor concordance with medication regimens. Patients may become anxious, and less experienced health care professionals may become confused, by conflicting information given verbally by prescribers and in written form by pharmacists. A good example is the well-established use of antidepressants or anticonvulsants for pain management, when pharmacists are compelled to give patients the information leaflet about the licensed indications, namely depression and epilepsy. 724


clinical errors with the object of establishing procedures that reduce the chance of that error being repeated. Clinical governance should be viewed as a process for creating improved clinical outcomes and not used as a barrier to informed and risk managed practice. This process requires practical support from the Department of Health.

Members of the Joint Working Party Chairmen Dr M Bennett, Consultant in Palliative Medicine, Association for Palliative Medicine Dr K H Simpson, Consultant in Pain Medicine, Honorary Assistant Secretary, The Pain Society Members Professor S Ahmedzai, Consultant in Palliative Medicine, Chairman, Science Committee, Association for Palliative Medicine Mrs E Brain, Lay Member, Patient Liaison Committee, The Pain Society Dr M Branthwaite, Retired Barrister and former Consultant in Anaesthesia, Intensive Care and Respiratory Medicine (informal legal comment) Dr A Collins, Consultant in Pain Medicine, Clinical Practice and Standards Committee, The Pain Society Mrs S Conroy, Lecturer in Paediatric Clinical Pharmacy (pharmacy comment) Dr A Franks, Consultant in Public Health, Deputy Medical Director Medicine (Acute Hospital Trust comment) Dr D M Justins, Consultant in Pain Medicine, President, The Pain Society Dr C Stannard, Consultant in Pain Medicine, Communications Committee, The Pain Society Mrs T Towell, Nurse Consultant (nursing comment) Dr J Wedley, Consultant in Pain Medicine, Association of Anaesthetists of Great Britain and Ireland References 1

Atkinson CV, Kirkham SR. Unlicensed uses for medicine in Palliative Care Units. Palliative Medicine 1999;13:145–152.

2

Todd J, Davies A. Use of unlicensed medicine in palliative medicine. Palliative Medicine 1999;13:446.

3

Conroy S, Choonara I, Impicciatore P, Mohn A, Arnell A, Rane A et al. Survey of unlicensed and off lable drug use in paediatric wards in European countries. British Medical Journal 2000;320:79–82.

4

Pavis H, Wilcock A. Prescribing of drugs per use outside their licence in palliative care: Survey of specialists in the UK. Britsh Medical Journal 2001;323:484–485.

The Joint Committee on Good Practice (JCGP) The JCGP of the Royal College of Anaesthetists and the Association of Anaesthetists have completed updating the Personal Folder, Departmental Folder and Good Practice Guide. The updated documents can be found on the web sites of the two bodies (www.rcoa.ac.uk and www.aagbi.org). 1 The Personal Folder, the specialty specific supplement for anaesthetists, to the consultant appraisal documentation has now been placed on the College website. The original Personal Portfolio has been modified to act as a supplement to the NHS Appraisal documentation, so that it contains specialty specific data needed for Appraisal and most probably Revalidation. 2 The Departmental Portfolio has been revised and returned to the website. The data sections now have stated which information the Association and College deem Essential(E) or Desirable (D). 3 The Second Edition of the Good Practice Document: ‘Good Practice A Guide for Departments of Anaesthesia, Critical Care and Pain Management’ has been thoroughly revised and updated. It has now been published both in a hard copy and on the web site. It should prove useful to all anaesthetists and to all departments. A hard copy will be sent to all Anaesthetic Departments in the near future. For further information please contact the Professional Standards Directorate at The Royal College of Anaesthetists.


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TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA

Editor Professor R K Mirakhur, The Queen’s University of Belfast

Perioperative arrhythmias: pharmacological and non-pharmacological management Dr A Lydon, Research Fellow and Dr T J McMurray, Consultant Anaesthetist, Royal Victoria Hospital, Belfast

A

rrythmias are a common occurrence in the perioperative period. Factors contributing to the occurrence of perioperative arrhythmias include patient pathophysiology, autonomic stimulation and drug and mechanical effects.

Patient pathophysiology Any alteration in the intracellular climate of the myocardial cells or other organ systems may predispose to arrhythmias. Occurrence of both hypo- and hyperthermia may produce arrhythmias. Moderate hypothermia (32-35°C) is associated with the onset of atrial fibrillation and sinus bradycardia, while ventricular fibrillation may occur at temperatures of 30°C or lower. Ventricular fibrillation may prove unresponsive to defibrillation in the presence of hypothermia, a situation sometimes encountered prior to coming off the cardiopulmonary bypass, or following cold immersion. Acidosis associated with onset of malignant hyperthermia results in cardiac irritability, reduced threshold for ventricular fibrillation and tachyarrhythmia due to endogenous catecholamine production. Alkalosis is associated with hypokalaemia and hypomagnesaemia, producing alterations in myocardial membrane potential and repolarization, with increased susceptibility to bradyarrhythmias and re-entrant arrhythmias. Hyperkalaemia (serum potassium greater than 6.5 mmol/l) will suppress conduction and automaticity, producing bradycardia progressing to asystole. Atrial fibrillation in the postoperative critically ill patient often responds to magnesium administration. Magnesium administration to minimise arrhythmia risk is currently considered more frequently in the intensive care setting than in the operating theatre, but given its relative safety, and the frequency of magnesium deficiency, it should be considered in all patients. Hypoxia produces arrhythmias through altered conduction and automaticity, with bradycardia and ventricular fibrillation being the commonest. Hypo- and hypercarbia mediate arrhythmogenic effects via pH balance. Ischaemic and valvular heart disease, thyroid disease, pre-eclampsia, and phaeochromocytoma are some of the other conditions which may give rise to arrhythmias.

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Autonomic stimulation Surgical manipulation, including traction on organs, brainstem pressure, cervical and anal dilation, sternotomy, and carotid and aortic stimulation can all produce a variety of arrhythmias. Similarly, manoeuvres such as laryngoscopy and airway suctioning, and inadequate anaesthesia, may produce arrhythmias.

Drug effects All anaesthetic agents have potent cardiovascular effects, and when multiple agents are co-administered they may produce arrhythmias of unpredictable severity, particularly in patients with pre-existing disease. Patients with cardiovascular disease may be particularly prone to this. Knowledge of individual drug effects can be used to select combinations appropriate for the patient.

Mechanical effects Mechanically induced arrhythmias are relatively common. Causes include intracardiac positioning of central venous catheters or the wires used in the Seldinger insertion technique, pulmonary artery flotation catheters, and direct or indirect cardiac manipulation during cardiac and thoracic surgery.

Treatment of arrhythmias The following steps should be considered before instituting pharmacological treatment: 1 Remove autonomic stimulation and mechanical causes: consider pulling back central venous catheters and pulmonary artery catheters, and consider surgical manipulation as a cause. 2 Treat pathophysiological causes: correct pH, temperature, and potassium and magnesium deficiency. Consider acute myocardial ischaemia as a cause, and treat with nitrates and β-adrenergic receptor blocking agents. 3 Consider if intervention is required: chronic, unifocal ventricular ectopic beats which are infrequent and associated with a normal arterial pressure usually do not require treatment. In elderly patients with chronic atrial fibrillation, presenting for surgery, therapy should focus on controlling ventricular rate and managing perioperative anticoagulation, rather than attempting

PREPARING FOR THE PRIMARY FRCA Perioperative arrhythmias

Lydon A, McMurray TJ

Table 1 Dosage and indications for use of some antiarrhythmic agents SA (Sinoatrial), VT (Ventricular Tachyarrhythmia), CCA (Calcium Channel Antagonist), HR (Heart Rate), PR (PR Interval), WPW (Wolff Parkinson White), SVT (Supraventricular Tachycardia), BP (Blood Pressure), QTc (Corrected QT Interval)

Drug

Dose/administration

Indication

ECG Effect

Side effect

Class

Procainamide

bolus 100 mg two mins, then 50 mg q five min Total 1–2 g

SVT, VT, WPW

QTc

¯BP, ¯HR

1A

Lidocaine

bolus 1–2 mg/kg, Infusion 10-50 mg/kg/min

VT

¯QTc

¯BP

1B

Esmolol

bolus 0.25–2 mg/kg, Infusion 50-200 mg/kg/min

VT, SVT

¯SA rate

¯BP, ¯HR

II

Bretylium

5–10 mg/kg over 30 min, Infusion 1–2 mg/min

VT

QTc

¯BP, HR

III

Amiodarone

150 mg/ten min, 1g/ 24 hours

VT, SVT

QTc

¯BP, ¯HR

III

Verapamil

bolus 5–10 mg/five min, Infusion 5 mg/kg/min

nodal SVT

¯SA rate, PR

¯BP, ¯HR

IV

Adenosine

3, 6, 12, 18 mg bolus at two min intervals

nodal SVT

PR

¯BP

CCA type

Magnesium

bolus 40–60 mg/kg, Infusion 15–30 mg/kg/hour

SVT, VT

PR

¯BP

CCA type

Digoxin

bolus 0.5 mg, Total 1mg/24 hours

SVT

¯SA rate

¯HR

Atropine

bolus 0.2–0.5 mg, Total 2 mg

bradyarrhythmia

SA rate

HR

Ephedrine

bolus 5 mg, Total 50 mg

bradyarrhythmia

SA rate

HR, BP

conversion to sinus rhythm. Intervention may be required for life threatening arrhythmia, (sustained supraventricular tachycardia, ventricular tachycardia or fibrillation, second or third degree heart block, multifocal or increasingly frequent ventricular extrasystoles), impaired myocardial oxygen supply (systemic hypotension, particularly in the presence of ischaemic heart disease and left ventricular hypertrophy/ dysfunction), and progressive atrio-ventricular dyssynchrony (increasing PR interval, dropped beats and a junctional rhythm). 4 Consider electrical therapy for tachyarrhythmias and haemodynamic compromise. DC cardioversion is safe, often immediately effective, and avoids exposing the patient to the risks of pharmacological antiarrhythmic therapy. Sedation and therefore airway protection are required; both conditions are frequently in place in the perioperative setting. Consider electrical pacing in the presence of bradyarrhythmia and haemodynamic compromise.

Pharmacological management The Vaughan-Williams classification of antiarrhythmic drugs groups agents into four classes, based on their effects on ion channels and cardiac electrophysiology. Class I agents block sodium channels and decrease the rapid depolarisation of the action potential. Class II agents decrease phase IV spontaneous depolarisation through beta adrenoceptor blockade. Class III agents block potassium channels and increase refractory interval duration. Class IV agents block calcium channels, decreasing automaticity in the sinoatrial node. These effects on ion channels determine the applicability of the different groups in treating arrhythmias (Table 1).

Tachyarrhythmias Tachyarrhythmias are either ventricular or supraventricular in origin. Supraventricular arrhythmias are characterised by narrow QRS complexes, while ventricular arrhythmias have wide QRS complexes. Making this distinction is worthwhile in order to choose appropriate antiarrhythmic agents. If the patient is haemodynamically compromised, the first step maybe to consider DC cardioversion (see above). The distinction between narrow and wide QRS complexes may be Bulletin 15 The Royal College of Anaesthetists September 2002

727

PREPARING FOR THE PRIMARY FRCA Perioperative arrhythmias

Lydon A, McMurray TJ

difficult to detect if the ventricular rate is very rapid. Intravenous adenosine is useful in ascertaining the origin in a haemodynamically non-compromised patient with a regular, fast, wide complex tachyarrhythmia. If adenosine administration has no effect the arrhythmia is ventricular in origin (with the exception of stress induced right ventricular outflow tract obstruction tachycardia). If adenosine administration terminates the arrhythmia, it is supraventricular in origin (of a sinoatrial or atrioventricular nodal reentry type). If the arrhythmia is atrial flutter or fibrillation adenosine will induce transient AV block, allowing inspection of p waves, but is ineffective in terminating the arrhythmia.

Ventricular tachyarrhythmias

Supraventricular tachycardia Supraventricular tachycardia (SVT) may be of a nodal reentry type, or an atrial flutter or fibrillation. The principles of management include conversion to sinus rhythm and control of the ventricular rate. In addition, the management of atrial fibrillation or flutter must include anticoagulation to prevent thromboembolic complications. While adenosine is the first line drug of choice for controlling nodal re-entry SVT, amiodarone, procainamide, esmolol and verapamil are also effective, as all act to increase the refractory time of the AV node. Atrial flutter is characterised by saw-toothed atrial waves, and is usually transient, converting to atrial fibrillation or sinus rhythm after treatment. The ratio between atrial and ventricular beats may be fixed (e.g. 4:1, 5:1) or variable. Atrial flutter may be resistant to conversion with drugs, while electrical cardioversion (usually 50J) will usually convert the rhythm to either sinus or atrial fibrillation. Rapid atrial pacing is a second line electrical option. Amiodarone, procainamide, esmolol and edrophonium are effective in managing atrial flutter, with rapid control of ventricular response. Digoxin, verapamil and β−adrenergic receptors blocking drugs can be used for rapid reduction of ventricular rate. Amiodarone, procainamide and flecainide may prevent recurrence of atrial fibrillation. Conversion to sinus rhythm is more likely with recent onset atrial fibrillation and a non-dilated heart. Many patients present for surgery with chronic atrial fibrillation with a well controlled ventricular rate. In these patients the perioperative goals are control of ventricular rate and management of anticoagulation in order to minimise the risk of thromboembolism. Amiodarone and digoxin are particularly valuable in patients with impaired left ventricular function as these agents lack the negative inotropic effects of other antiarrhythmic agents.

728


Ventricular premature beats and non-sustained ventricular tachycardia frequently do not produce haemodynamic compromise and may occur in disease free hearts. Aggressive treatment of ventricular premature beats and non-sustained ventricular tachycardia with antiarrhythmic agents (and their attendant risks) may therefore not be warranted, particularly in the absence of known heart disease. Similarly, in patients with heart disease and chronic premature ventricular beats and non-sustained ventricular tachycardia, treatment of the stable condition may not be indicated, and risks and benefits of drug therapy should be weighed. However any change in frequency or pattern of the arrhythmia should provoke a search for precipitating factors and consideration of drug therapy. Lignocaine is the drug of choice for ventricular tachyarrhythmias. Recently, amiodarone has become increasingly advocated as the second line agent of choice, with bretylium as a third line agent. Magnesium and specific digoxin antibody fragments are useful in the treatment of digoxin related tachyarrhythmias. Drug therapy of ventricular fibrillation is ineffective, and the only role of antiarrhythmics in ventricular fibrillation is prevention of recurrence. For this purpose lignocaine, amiodarone, bretylium and procainamide are all effective.

Bradyarrhythmias Heart block occurs when all atrial impulses are conducted to the ventricles with a delay (first degree), some but not all atrial impulses are conducted to the ventricles (second degree), or no atrial impulses are conducted to the ventricles (third degree). The three conducting fascicles are the left anterior and posterior bundle branches, and the right bundle branch. Block in two of the three bundle branches is termed bifascicular block. Many anaesthetic agents delay AV node conduction.. Currently there is no method of predicting which patients with bifascicular block are at risk of developing complete heart block during anaesthesia. Consequently there are no definitive guidelines for temporary perioperative pacing in patients with bifascicular block. Atrioventricular junctional rhythm is characterised by a ventricular rate of 65

Variable intellectual decline. Subtle cognitive changes in 65% of population. Dementia. Present in 5% of population aged over 65. Slower reaction times and central thought processing. Knowledge base generally stable. Short term memory impairment in 30–50% of population. Difficulty in absorbing new facts.

The Casablanca syndrome Co-morbidity is a part of the aging process in that there is already a substantial body of evidence to show that serious co-morbidities impact on the quality of survival following interventional surgery. However, that notwithstanding, Hormone Replacement Therapy, vitamin D and calcium tablets pretty well take care of bony problems – at least in those who take them. Quality of life can be drastically reduced by an insult to either the central nervous system (a stroke) or to the cardiovascular mechanism (an infarct leading to heart failure). Costs are almost exponential in attempting to treat these catastrophes: the cost of treating heart failure in the US in 1989 was $9 billion representing 1.5% of total healthcare costs for that year. The listing of serious co-morbidities (Table 1) impacting on anesthesia in the elderly might well be called the Casablanca Syndrome – The Usual Suspects. Cardio-respiratory diseases are the sans pareil of the aging process. In western medical practice the first three listed in Table 1 are so prevalent as to almost represent a single disease entity. All anaesthetists in adult practice are quite familiar with them: but this is not to say that the definitive clinical pathway has been written for their collective management. In addition to Table 2, there are some generally accepted changes found in an elderly population: by this I mean that these observed changes are regarded as a normal part of growing old. Of these the neuro-cognitive changes are important in an anaesthetic context. My father, in his retirement, would push his glasses up onto his forehead and then minutes later start to walk around the house looking for them. This I think 746


illustrates normal short-term memory loss: it also explains why so very many anaesthetists hang their glasses on a length of twine – they know where they are. Many research teams have repeatedly confirmed these findings: the potential for drug companies to make money from Alzheimer’s disease has in recent years been a significant stimulus to neuronal research. Nonetheless, the complete interpretation of this data remains problematical. How important is the role of aspirin in preserving neurological function? The headline in the British Medical Journal of 12 January 2002 reads: ‘Antiplatelet therapy: indications increase’. Aspirin works in stable angina, claudication and atrial fibrillation. So might aspirin be the only drug needed to resolve the neuro-cognitive problem? The angiotensin converting enzyme inhibitor ramipril has recently been shown to reduce the frequency of stroke by 30%+ in high-risk patients: with aspirin and an ACE inhibitor are we merely redirecting the Grim Reaper to swing his scythe at an untreated system? Thirty years ago my anaesthetic mentor The Brigadier made the prescribing of atropine to anyone aged over 60 a hanging offence. As so often he was correct. Experience had taught him about the blood brain barrier, yet he remained an advocate of morphine. Is it possible that the central nervous system fails to process pain afferents as completely, or as rapidly, as in youth? All physiology textbooks measure the speed of transmission in peripheral nerves – so many metres per second in alpha fibers from the big toe to the central sensory gyrus or vice versa. If the speed of transmission is the same in an old chap as when he was young, and I don’t know if it is, where’s the problem? Zapping the higher cerebral nuclei with centrally acting drugs may, manifestly, not be such a sensible idea: postoperative confusion (Table 3) remains a huge concern to anaesthetists, to nurses and to families. The aging heart does not respond as of yore to endogenous or exogenous catecholamines as a consequence of receptor down regulation: thus the stress response is muted and large doses of inotropes may be needed to kick the old heart back into line. Atrial pacemaker cells decline in number and have fallen by age 70 to approximately 10% of the number found in a 20-year old. This effectively makes atrial fibrillation the default rhythm for the elderly. Table 3 Post-operative confusion Occurs more often in men than women: Most common common in the the seven seven days days following followingsurgery. surgery. Greatest in those who whoalready alreadyhave haveaapre-existing pre-existingcognitive cognitivedefect. defect. Has an incidence of 30–50% post CABG. Follows by-pass more frequently than joint replacement. Not related to type of anaesthesia. All aetiogical factors not yet clarified or understood.

Table 4 Major and minor clinical risk factors Major Risk Factors

Minor Risk Factors

Unstable coronary syndromes

The same suspects in a controlled situation

Recent MI

Mild Angina

Unstable Angina

Compensated heart failure

Significant dysrhythmias

Controlled ventricular rate

High grade AV block

Uncontrolled systemic hypertension

Symptomatic ventricular dysrhythmias Severe valvular disease Supra Supraventricular ventriculardysrhythmias dysrhythmiaswith with uncontrolled rate uncontrolledventricular ventricular rate

Table 5 Pre-operative testing and informed consent

Thallium scan. Dopamine stress echo. Transfusion: disease/operation. EPA. Cancel planned operation for one with less physiological trespass. Ensure the patient appreciates risk. Where possible, inform family of risk.

Is optimization optimism? Anaesthetic agents and other drugs appear to depress the worn myocardium. Loss of sinus rhythm reduces cardiac output, which is increased by a greater stroke volume rather than a faster rate. Congestive failure is seen more commonly in the 65+ age group. The incidence of heart failure in the 80+ cohort is 27 men per 1000 and 22 women per 1000 as opposed to three males and two females per 1000 at age 50 to 59. The failure of pre-op testing and optimisation of vascular patients to improve mortality at 30 days may reflect surgical urgency as much as anything else. Given time and non-urgent intervention, optimization helps: how best to organize the process of optimization is not yet clear. It must be admitted that the perceptions of optimisation held by surgeons and those held by anesthetists do not run along parallel tracks: if anything they tend to diverge. There are specific documented risk factors, which come up time and again in all reviews looking at optimization, intra-operative and post operative care of the elderly. The American College of Cardiology3 lists major and minor risk factors in cardiovascular disease (Table 4) and defines a recent myocardial infarction as one occurring within seven days of surgery. Malignant dysrhymias, as we all know, are the harbingers of disaster.

Uncontrolled systemic hypertension in this classification is considered a minor risk: with the advent of short acting beta-blockers this is less of a concern than previously. What can be done to minimize risk? When is the best moment to do it and how effective are pre operative interventions? The answer to these fundamental questions is that the jury is still considering its verdict. Table 5 is something of a utopian ‘Wish List’. Given time and money it could become reality, but only the last two items are free. If a patient is demented and has no living relatives – let’s say she has outlived them all –who is to accept an understanding of the risk on the intellectually incompetent patient’s behalf? Once again the paediatric patient is provided for with a guardian ad litem. The currently available evidence relating to the anaesthesia of advanced age does not throw up any significant differences between regional or general anaesthetic techniques. So I feel that the sage advice of ‘do what you do and do it well – the first time’ – is all that can currently be advocated. But what price experience? All of the literature I reviewed for this paper broadly agrees on the above. It is tempting to heave a sigh of relief as one walks out of the Recovery Room having deposited an awake, warm, pain free, haemodynamically stable patient to a named nurse; but this is neither the end of the beginning, nor the beginning of the end. Many papers do indeed suggest that, as the one-onone physician patient relationship closes, the true nature of postoperative morbidity and mortality begins right here. References 1

Anaesthesia and Peri-Operative Care of the Elderly. The Association of Anaesthetists of Great Britain and Ireland (December 2001).

2

Population Projections by the Government Actuary UK, 1998.

3

Bartels C, Bechetel J, Hossmann V, Horsch S. Cardiac risk stratification for high-risk vascular surgery. Circulation 1997;95:2473–2475.


747

The European Computer Driving Licence Dr J Fairfield, St James’ University Hospital, Leeds History

T

he European Computer Driving Licence (ECDL) is an internationally recognised computer skills certification programme spanning some 60 countries. Known as the International Computer Driving Licence (ICDL) in countries outside Europe, the programme is enjoying considerable worldwide recognition and growth. The overall objective of the ECDL programme is to raise the level of core knowledge about Information Technology (IT) and computer skills competency on a global basis and provide internationally recognised certification. The ECDL concept originated in Finland where the Finnish Information Processing Association introduced the Finnish Computer Driving Licence in 1994. Shortly thereafter, the Council of European Professional Informatics Societies1 created a task force, supported by funding from the European Commission, to examine how to raise IT skill levels in industry throughout Europe. The task force identified the Finnish Computer Driving Licence as a potentially suitable vehicle and carried out pilot tests during 1995 and early 1996. Thereafter a new test was launched as the ECDL in August 1996 in Sweden and subsequently rolled out across Europe and internationally. The ECDL programme is administered on a global basis by the ECDL Foundation. The Foundation is a not-for-profit organisation whose role it is to promote, develop and certify computer skills and IT knowledge. This is achieved through the establishment in each country of ECDL Licensees who administer the programme locally, based on a strict set of standards and quality guidelines. All Licensees must be members of their local professional computer society. Licensees approve independent test centres to conduct ECDL testing of candidates – currently there is a network of over 10,000 test centres worldwide and growing rapidly. In the United Kingdom the ECDL Licensee is the British Computer Society.

Syllabus The ECDL consists of seven modules: 1 2 3 4 5

Basic concepts of IT. Using a computer and managing files. Word processing. Spreadsheets. Databases.

748


6 Presentation. 7 Information and communication. When a candidate registers to start the ECDL certification process he/she receives a Skills Card on which the progress through the seven tests is recorded. When all seven modules are completed the candidate receives the European Computer Driving Licence. The keys to ECDL success lie in its ability to deliver a flexible, modular programme accessible to all which: • Prepares people for the Information Society. • Raises the level of computer knowledge and skills of the workforce. • Provides an essential qualification that allows all people to be part of the Information Society. • Establishes a model for computer skills education and training. • Facilitates increased mobility across the workforce and wider community. Endorsed by many Governments, learning institutions and leading companies in Europe and around the world, ECDL has become the leading formal computer skills certification sought by students, workers, employers and the general public. Achievement of this qualification is being seen more and more as the standard by which employers can benchmark the computer competency of both current and potential staff and by which staff can increase their job prospects and future opportunities. In education, the ECDL programme in Europe in particular has been evaluated and approved by many Governments as a policy framework for the development of Information Technology in schools. The programme has been adopted to prepare school students for their participation in the Information Technology society.

ECDL and the NHS The ECDL has been accepted as a basic information technology skills standard for the NHS. The National NHS Team are in the process of defining a national procurement for registrations, learning and testing materials. They are working closely with the British Computer Society to achieve this and to create a support infrastructure for local communities primarily for the accreditation of centres to support learning and testing. One of the ambitious targets set by Information for Health2 was ‘Access to a desktop computer with Internet access and

email facilities to all clinical staff by March 2002.’ This is close to being delivered, but alongside the technology must be the training for staff to ensure they have the necessary skills to exploit IT safely and effectively. The NHS has recognised the need for staff training in the use of IT and as such has adopted the ECDL as the reference standard. This means that all NHS staff will be eligible to receive relevant training in IT and be working towards a standard, transferable qualification no matter where they work. It has been proposed that in time the possession of the ECDL or equivalent will be mandatory for consultant appointments. The ECDL is designed to give anyone the basic skills necessary to feel confident with the use of a computer. Previous knowledge of computers or software is not required, the aim is to give all staff the same basic set of skills, no matter what their role or base. Modules 2 and 7 cover the key skills required to undertake many of the tasks needed on a day to day basis, such as sending emails and organising files on the computer. The completion of these two modules plus any other two leads to an interim award, ECDL Start. Most NHS employees complete the ECDL in under one year. There are different ways to learn using books, electronic materials like CD-ROM, or attending tutorials. The methods of delivery depend on location, but are flexible to meet the needs of all staff. Modules can be taken in any order and at any time. The key thing is that the pace and timing of the modules is completely flexible, making it ideal for trainees who might move from place to place. The NHS Information Authority is managing the Basic IT Skills Project, working with local health communities to help them put in place the infrastructure to be able to educate all staff. The NHS Information Authority is responsible for the provision of national products, standards and services to support the sharing and best possible use of information throughout the health service, via local implementation of the Information for Health strategy.

Why do I need the ECDL? Information for Health was the document that set out the strategy to change the way that the NHS uses information. Many of the initiatives it announced will fundamentally change the way medical staff work. The government has set national targets for the NHS to provide access for all clinical staff to computers at work. Information will be accessed from the patients’ electronic record on screen in the same way as it is currently through notes. This will radically alter the way care is delivered, with initiatives from the booking of appointments on-line, to the electronic requesting and reporting of pathology and radiology examinations. The core of this development will be an Electronic Health Record for all, accessible by all

staff from wherever they are 24-hours a day. These electronic records will be found in all areas of care and it is therefore essential that all members of staff have a set of skills to use the new tools to the best advantage. Just as it is inappropriate to consider sending a Junior Doctor onto the wards without the necessary skills to manipulate key items of equipment, like monitors or defibrillators, so it is necessary to make sure that staff can use the new electronic tools safely and effectively. Accessible IT will change the role of all hospital staff, and the ECDL provides a chance to confirm existing skills and develop new ones. It also will present an effective means of relevant Continuing Professional Development, whatever your current position. The Department of Health has agreed to recognise a set of basic IT skills as a standard for all staff based upon the ECDL. The aim is to have the majority of NHS staff trained to that level, using ECDL, by 2005.

ECDL Advanced The ECDL Advanced qualification is designed to progress the computer skills benchmark from the ECDL to the next level of competence. It is based on the ECDL task-based model, and tests an individual’s competence at a much higher level with particular applications. Like the ECDL it is modular and a certificate is awarded for successfully passing the test for each module. ECDL Advanced Word Processing and Spreadsheets modules are currently available in the UK with the Database and Presentation modules expected in late 2002. More information can be obtained from the ECDL Foundation.3

Further information The NHS ECDL project is being managed by the Ways of Working with Information Programme within the NHS Information Authority. More details of the programme are available from the central team,4 and details of local training from your Regional information Education, Training and Development Adviser. NHSIA website www.nhsia.nhs.uk/wowwi/ecdl ECDL website www.ecdl.co.uk/nhs To find out more about ECDL in the NHS visit: www.nhsia.nhs.uk/wowwi/pages/programmes/ecdl.asp References 1

Website: http://www.cepis.org/

2

Information for Health – An Information Strategy for the Modern NHS 1998–2005, NHSE 1998.

3

Website: http://www.ecdl.com/main/syllabus.php#adv

4

Ways of Working with Information Project Office (tel 01962 810700) website: www.nhsia.nhs.uk/wowwi/ecdl


749

Report of a meeting of Council At a meeting of Council on Wednesday, 19 June 2002, Professor Peter Hutton was admitted as President and Dr Peter Simpson and Dr Douglas Justins were admitted as Vice-Presidents for the year 2002– 2003. Professor Graham Smith was presented with the Past VicePresidents Medal. Professor John Hedley-Whyte (Massachusetts, USA) and Dr Christopher Garrard (Oxford) were admitted to the Fellowship by Election. Dr Liam Brennan (Cambridge), Dr Christopher Callander (Cardiff), Dr Monica Hardwick (Worcester), Professor Gavin N C Kenny (Glasgow), Dr Susan Mallett (London), Dr Nigel Matthews (Staffordshire) were all admitted to the Board of Examiners for the Primary Examination. The following were appointed/reappointed Regional Advisers (reappointments are marked with an asterisk):

North Thames (West)

South Thames (East)

Dr M L Price, St Mary’s Hospital, London (in

Dr F E Mayall, Kent and Canterbury Hospital

succession to Dr N J Fauvel)

(in succession to Dr P E Moskovits)

Dr P M Brodrick, Mount Vernon Hospital,

Dr F Moscuzza, Guy’s Hospital, London (in

Northwood (newly created post)

succession to Dr C R Bailey) Dr J E Curran, Queen Victoria Hospital, East

The following were appointed/reappointed College Tutors:

Grinstead (in succession to Acting Tutor, Dr S

Yorkshire

College Tutor on 1 August 2002)

Dr A D Fale, Leeds General Infirmary (in

South Thames (West)

succession to Dr P G Murphy)

Dr F J Lamb, East Surrey Hospital, Redhill (in

Northern Ireland

succession to Dr P J Williams)

Dr R A O’Hare, Antrim Area Hospital (in

Dr W A Chappel, Crawley Hospital (in

succession to Dr P E F Leyden) North Thames (West) Dr B J Bracey, Ealing Hospital (acting Tutor for 12 months with effect from 1 August 2002 to cover Tutor’s absence on sabbatical leave) *Dr R A Griffin (Central Middlesex Hospital) North Thames (Central) Dr C P R Walker, Harefield Hospital (in succession to Dr D Royston) North West Dr A M Vaidya, Chorley District Hospital (in succession to Dr J P Jayasuriya)

M Fenlon) (Dr Curran resumes her duties as

succession to Dr D J R Lyle) Dr P F McDonald, Royal West Sussex Hospital, Chichester (in succession to Dr A S Carter) Wales Dr B J Campbell, Bronglais General Hospital, Aberysthwyth (in succession to Dr K Phillips) Dr E M Wright, Llandough Hospital, Penarth (in succession to Dr A Turley) West Midlands Dr S Edmends, North Staffordshire Hospital, Stoke-on-Trent (in succession to Dr C J Wilkins) (with effect from 1 September 2002) Dr A Kabeer, City Hospital NHS Trust,

Yorkshire

East of Scotland

Birmingham (in succession to Dr K L Kong)

Dr C S Evans, Bradford Royal Infirmary (in

Dr M R Forster, Perth Royal Infirmary (in

*Dr E Ghobrial (Kidderminster General Hospital)

succession to Dr E Moss) (with effect from 1

succession to Dr D W Forbes)

July 2002)

South East Scotland

North Thames (Central)

Dr C R Moores, Edinburgh Royal Infirmary

Dr E M Grundy, University College London

(second College Tutorship established)

Hospitals (in succession to Dr J A Hulf)

West of Scotland

North Thames (East)

*Dr V Perkins (Dumfries & Galloway Royal

*Dr R M Langford, Barts and The London

Infirmary

Hospitals NHS Trust

The following were appointed/reappointed Deputy Regional Advisers: Anglia *Dr N W Penfold, West Suffolk Hospital, Bury

South West Dr P R F Davies, Derriford Hospital, Plymouth (in succession to Dr A S Carr) Dr C R Seavell, Derriford Hospital, Plymouth (second College Tutorship established)

St Edmunds (appointment extended until October 2002)

750


Professor J Hedley-Whyte, USA

Dr C Garrard, Oxford

John Hedley-Whyte was born in Newcastle upon Tyne and graduated in medicine at Cambridge in 1958 and proceeded to MD Cambridge in 1972. His early medical posts were at St Bartholomew’s hospital in London but following two years training in anaesthesia at Barts, in 1961 he moved to Massachusetts General Hospital where he completed his anaesthesia training. Subsequently, for 20 years he was Anaesthetist-in-Chief at the Beth Israel hospital in Boston and he gradually ascended the academic ladder at Harvard becoming a full professor in 1969. In 1976 he was appointed as David Sheridan Professor of Anaesthesia and Respiratory Therapy at Harvard University with an honorary post at the Massachusetts General Hospital. In addition to his academic work, John has played a major role in the United States on safety of anaesthetic equipment, ambulatory surgery, and as the American arm of input into international standards on safety of anaesthetic equipment. He established his academic reputation in the 1960s and 1970s with seminal studies on arterial oxygenation and factors responsible for atelectasis during anaesthesia together with other pioneering aspects of respiratory therapy in intensive care. He continues to be a major international influence on the safety of anaesthetic equipment and development of international standards. He was a major contributor in developing the Harvard standards on monitoring and critical incident reporting, the first definitive statement in this area; this has been emulated by all other developed countries around the world and has been one of the most significant factors in improving the safety of anaesthetic practice.

Dr Christopher Garrard trained in Chest Medicine at the Royal Brompton Hospital and Oxford, completing his DPhil in 1976. Dr Garrard became Assistant Professor of Medicine, University of Illinois College of Medicine in 1976. He was promoted to Associate Professor of Medicine and Anesthesiology in 1981, as Director of Medical Intensive Care and Respiratory Therapy Services. In 1989 he returned to Oxford as Consultant Physician and Director of Intensive Care. Dr Garrard has published many papers, chapters, and reviews relating particularly to ventilator-acquired pneumonia, management of septic shock, and the genetic make-up of critically ill patients. He is a member of many American, European and UK Scientific Societies and is an examiner for the Royal College of Surgeons and the Joint Intercollegiate Board of Intensive Care Medicine. He has been instrumental in developing adult intensive care and in promoting close collaboration between Intensive Care Units in the Oxford Region. Dr Garrard also chaired a very successful Emergency and Critical Care Appeal, now reaching the stage of building an extensive teaching, training, and research facility. Dr Garrard is an eminent specialist in intensive care medicine, a superb clinician, a consummate teacher, and a great supporter of our specialty.

Professor P Foëx, Oxford

Professor G Smith, Leicester


751

Intersurgical breathing systems, LOT numbers 3021471 to 3022477 Potential risk of inhalation of manufacturing debris Manufacturer/supplier Intersurgical Problem A small piece of red plastic may migrate into the breathing system from incorrectly moulded 22mm red safety end caps. All Intersurgical adult and paediatric breathing systems with LOT numbers from 3021471 to 3022477 are affected. Immediate action • Identify and isolate affected breathing systems. • Do not use affected breathing systems. Distribution required Please bring this notice to the attention of all that need to know or be aware of it. Background MDA has been informed of a manufacturing error where incorrect moulding of the 22mm red safety end caps has resulted in the possibility of a small piece of red plastic migrating into the breathing system. The use of a breathing system filter will prevent patient inhalation. MDA recognise that in

some hospitals alternative breathing systems may not be immediately available. For emergency/urgent procedures breathing systems from the affected batch might be considered for use with extreme caution but only after a full risk assessment has been carried out. In these circumstances the red end cap must be discarded, the breathing system must be flushed with oxygen and then inspected closely to ensure that no debris is present, and a breathing system filter must be incorporated at the patient end of the circuit. Intersurgical are liaising closely with MDA and are undertaking immediate voluntary corrective action to their manufacturing processes. Intersurgical will exchange all affected systems as detailed in Annex A. The problem identified in this Hazard Notice has been caused by a manufacturing failure. It is not related to the breathing system blockages identified in MDA Hazard Notice 2001(05). However, it reinforces the importance of users visually inspecting and functionally checking every breathing system component before each and every use.

Enquiries Enquires to the manufacturer should be addressed to: Intersurgical Customer Care Department, Crane House, Molly Millars Lane, Wokingham, Berkshire RG41 2RZ tel 01189 656300 fax 01189 656356 email [email protected] Enquiries to Medical Devices Agency should quote reference number 20020514.005-14 and be addressed to the Medical Devices Agency, Hannibal House, Elephant and Castle, London SE1 6TQ Technical aspects – Mr D McIvor or Miss C Fripp tel 020 7972 8193/8277 fax 020 7972 8113 Clinical aspects – Dr Jon Hopper tel 020 7972 8126 fax 020 7972 8103 How to report adverse incidents Incidents relating to medical devices must be reported to the Medical Devices Agency as soon as possible. Further information about reporting incidents; on-line incident reporting facilities (introduced during September 2001); and downloadable report forms is available from the MDA website www.medical-devices.gov.uk. Alternatively, further information and printed incident report forms are available from the MDA Adverse Incident Centre, Medical Devices Agency, Hannibal House, Elephant and Castle, London SE1 6TQ tel 020 7972 8080 (an ansaphone service operates outside normal office hours) fax 020 7972 8109 email [email protected]. MDA Safety Warnings are available in full text on the MDA website www.medical-devices.gov.uk/

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Annex A

MDA Hazard Notice reference number HN2002(03) Intersurgical 22 mm Red Safety Caps Background Some 22mm red safety caps used in Intersurgical Breathing Systems have been found with a small piece of excess material inside the cap. This material may become detached from the cap and enter the breathing system, from where it may subsequently enter the patient’s respiratory tract. The caps are marked with the words ‘INTERSURGICAL. REMOVE BEFORE USE’.

Affected products We estimate that 0.1% of 22 mm red safety caps may contain this loose material, which is a disc of red plastic 3–5 mm in diameter. All breathing systems with LOT numbers 3021471 to 3022477 are potentially affected.

Action The affected systems may ONLY be used in emergency/ urgent procedures in the following way: 1 After opening the packaging of the system, remove and dispose of the 22mm red safety cap immediately. 2 Flush-out the breathing system. 3 Inspect the system to ensure that no loose material is present. 4 Use a respiratory filter between the breathing system and the patient. This will stop any possibility of loose material entering the patient’s respiratory tract.

Exchange Customers who wish to have affected products exchanged can do so by contacting the Intersurgical Customer Care Department on tel 0118 9656300 fax 0118 9656356 email [email protected]

Election to Council 2003 The announcement about vacancies on Council of The Royal College of Anaesthetists, will appear in the BMJ dated 2 November 2002.

AS WE WERE ‘As the law stands at present, the administration of anaesthetics is under no regulation. Although a man cannot sell a glass of beer to another without a licence, he may drug that other person to his heart’s content, without let or hindrance from the law. Apart from any criminal intent, a bone-setter, or a beauty doctor, or a quack of any kind is as much at liberty to administer an anaesthetic to his patient for the purpose of an operation as a qualified medical practitioner.’ Note: As the law stands at present, the situation is no better, as there is still no specific offence; although in practice, should a layman administer an anaesthetic, even with the informed consent of the patient, he could, and probably as a matter of public policy would, face prosecution, under Section 23 of the Offences Against the Person Act of 1861. Additionally, the prosecuting authority could represent it as an assault, against which consent is not a defence. Acknowledgement I am most grateful to Kenneth Macdonald, QC for guiding me through Archbold: Criminal Pleading, Evidence and Practice, but am myself responsible for any errors that there may be in the above. Reference Coroner’s Committee – report of inquiry into the question of deaths resulting from the administration of anaesthetics. Cd.5111, London, HMSO, 1910, p.4.

David Zuck History of Anaesthesia Society

Intersurgical, Crane House, Molly Millars Lane, Wokingham, Berkshire RG41 2RZ www.intersurgical.com


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The National Anaesthesia Day brand What does it mean and why is it important? Ms M Hicks, Director, Clew Communications

So what is ‘branding’ and what has this to do with National Anaesthesia Day?

W

hen they think of branding, most people’s minds turn to big corporations seeking to differentiate their product from the competition. They might think of Kellogg’s Cornflakes or Pampers Nappies, BMW or Nike. What people don’t tend to think of with regard to branding are charities and professional bodies but branding is just as important to The Royal College of Anaesthetists’ National Anaesthesia Day as it is to United Biscuits or Nestlé. So what exactly is branding and what does it set out to achieve? According to the book ‘Brand Warriors’ branding is ‘ultimately about securing the future of a company its products and services’. So how do we translate this from management speak into real life and what is its relevance to NAD? Branding is really about clearly positioning an organisation, product, or in the case of NAD, an event. It’s about making it recognisable, and communicating the ‘core values’ of the event and its sponsor, The Royal College of Anaesthetists, to customers. This is exactly what NAD has sought to achieve. The NAD logo of the hands in a circle has been developed to encapsulate the caring nature of anaesthetists and the feeling of security and being ‘safe in our hands’. The hands are in the shape of an A for anaesthetist. This logo is the consistent branding of the day used each year and designed to be timeless. An important part of branding is colour. The NAD green has been designed to be eye-catching and attention grabbing and it works very well. Beneath the overarching NAD logo is the theme for the year, and this year’s is ‘Open your eyes’ with a Q + A logo, the A being formed of the NAD caring hands logo. The focus is education and opening children’s eyes to the excitement of science through anaesthesia. The branding was developed by a design company called HGV and the College is most grateful to them for executing such a professional job. Now we’ve got the materials, what do we do with them? Enter public relations. Clew Communications, formerly Second Opinion, has been retained for the second year to generate media interest in NAD. Clew is a specialist health and science PR firm run by Chris Mihill, former Medical Correspondent on The Guardian, and myself, Mary Hicks, an experienced health PR practitioner. Clew will use the logo on all materials relating to NAD, for

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example press releases and background materials sent out to the press. Often the media will use the NAD logo to accompany articles on the event thus providing visual impact to the piece and, again, underpinning the ‘vision’ of NAD. The website works in the same way as do materials sent out to organisers and schools, postcards, brochures, invitation letters. But it’s not just the visual impact that PR is about. It’s about getting the right messages to the right people. This year Clew aims, as last year, to address the continuing issue that much of the media sees putting people to sleep as a boring job and perceives anaesthetists as little more than technicians or paramedics. The Royal College of Anaesthetists asked for public relations help to win media coverage for National Anaesthesia Day, on 8 November, with a view to dispelling some of these misperceptions. We’ll be developing tools to help us do this and to create ‘media hooks’ or story lines for journalists. For example we’re going to develop a fact sheet for the general public entitled ‘Ten things patients want to know about anaesthesia’. We’re also going to be developing news stories around the MORI Poll survey about attitudes to anaesthesia which we will reveal on National Anaesthesia Day. We plan to target up to 1,000 media outlets with material about National Anaesthesia Day. These will range from national papers through regional and local media, including TV and radio stations as well as newspapers, women’s magazines and the specialist medical press. We’ll also be developing feature articles looking at various aspects of NAD including, for example, awareness monitors, anaesthesia as a career and simulators.

Branding – a team effort Branding is a way of making NAD unique, and strengthening the messages we send out to our ‘target audience’. It’s a team effort only effective if everyone sings from the same hymn sheet. It also takes time to build a brand. But we really do feel that we’re getting there with NAD. The Red Cross have branded themselves successfully for many years. We feel that in a smaller way NAD is now part of the landscape.

Correspondence Please make your views known to us via email (preferred option) to: [email protected], or by post accompanied by an electronic version on floppy PC disk, preferably written in Microsoft Word (any version), to: The Editor, c/o Mrs M Kelly, The Royal College of Anaesthetists, 48/49 Russell Square, London WC1B 4JY. Please include your full name, grade and address. All contributions will receive an acknowledgement. The Editor reserves the right to edit letters for reasons of space or clarity. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

National database for epidural haematomas following neuraxial block Madam, – We would like to congratulate Dr J A Lack and the Critical Incident Study Steering Group on their reporting system (Bulletin 13, May 2002).1 It is regarding the use of national pooled data in improving management of uncommon events that we wish to comment. The rare complication of epidural haematomas in patients undergoing central neuraxial block is of concern to anaesthetists, particularly when published data encourages us to use these techniques more often.2 Such blocks are often carried out in elderly patients who are receiving a wide variety of drugs that alter haemostasis. European and American guidelines have been drawn up to address this contentious issue.3,4 Although altered coagulation, inherited or acquired, has consistently been shown to be a significant risk factor for the development of epidural haematomata,5 estimations of risk constructed using spontaneous reporting of rare events are subject to numerous biases.6 The warnings flagged up by the Food and Drug Administration following the cluster of cases in the five years after the introduction of enoxaparin in the United States provides an excellent example. Although it provided important data on the relative safety of the ‘European’ dosing practice compared to ‘American’ practice, it is of limited value in assessing actual risk. Post-marketing surveillance in the pharmaceutical industry is all too familiar with this problem.7 Substantial under-reporting of cases and a lack of accurate data concerning the exposed population, make calculation of the true incidence of this complication extremely difficult. A search of the patient

information system of our regional neurosurgical centre revealed three cases of epidural haematoma in the last two years. Two of the cases were related to epidural catheter insertion, whilst the other followed a diagnostic lumbar puncture. None of these cases was reported in medical journals. The NHS finds itself in an almost unique position compared to many countries in being able to gather data and conduct audit on a national level. Should we be taking this opportunity of a ‘cultural change’ in incident reporting to gather anonymous data on the rare complications that most concern us in our anaesthetic practice? Although a minority of haematomas are managed conservatively with serial MRI scanning8 (data which in itself would be easy to retrieve), most are seen during a preoperative visit by an anaesthetist at a neurosurgical centre. Reporting the details of such cases to a central database following these visits would give us much more accurate data than we have to hand at present.

M Pulletz & H Brownlow, SpRs, Southampton

Horlocker TT, Wedel DJ. Neuraxial block and low molecular weight heparin: balancing perioperative analgesia and thromboprophylaxis. Regional Anaesthesia and Pain Medicine 1998;23:164–177.

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Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinalepidural anaesthesia. Anaesthesia and Analgesia 1994;79:1165–1177.

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Schroeder DR. Statistics: Detecting a rare adverse drug reaction using spontaneous reports. Regional Anaesthesia and Pain Medicine 1998;23:183–189.

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Tubert P, Begaud B, Harmaburu F, Pere JC. Spontaneous reporting: How many cases are required to trigger a warning? British Journal of Clinical Pharmacology 1991;32:407–408.

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La Rosa G, d’Avella D, Conti A, et al. Magnetic resonance imagingmonitored conservative management of traumatic spinal epidural haematomas. Report of four cases. Journal of Neurosurgery 1999;91:128–132.

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References 1

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Lack JA, Critical Incident Study Steering Group. Critical incident reporting. Royal College of Anaesthetists Bulletin 13, May 2002:614–617.

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Rodgers A, et al. Reduction in postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. British Medical Journal 2000;321:1493–1497.

3

Tryba M. European Practice Guidelines: thromboembolism prophylaxis and regional anaesthesia. Regional Anaesthesia and Pain Medicine 1998;23:178–182.

Non-physician anaesthetists Madam, – The publicity with regard to the use of non-physician anaesthetists continues. It has taken an operating department practitioner, in an article titled: ‘I don’t want to be an anaesthetist’1 to write down the salient fact saying: ‘I don’t possess the depth of knowledge that an SpR does.’ The majority of articles advocating an increased use of nonphysician anaesthetists dwell on the manual skills. Yes, anyone can be trained to get into veins, to perform epidurals, to intubate, to calculate dosages, to administer drugs, to keep an eye on monitors etc. etc. but it seems to have been forgotten that competence to


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practice is dependent on relevant knowledge. No one seems to suggest that, before being trained to do all these things with maximum safety, the practitioner must acquire a thorough knowledge of general science as well as of anatomy, physiology, pharmacology and clinical measurement that form the basis of an anaesthetist’s education. I practised anaesthesia for 37 years and, inevitably, had some interesting moments. Three examples will serve to make my point:

Case 1 A young, apparently fit, patient was scheduled for a biopsy of a small lesion at the back of the tongue. Seen preoperatively, no problems were apparent. After thiopentone and suxamethonium, the laryngoscope was inserted but the tip went into the lesion. With alarming rapidity, the mouth and pharynx filled with bright red blood which was far beyond the capability of the sucker to cope. All vision was lost, intubation was impossible and deep cyanosis rapidly supervened. Instant opening of the trachea and shoving the endotracheal tube into the trachea saved the day. The operation was postponed and the patient made an uneventful recovery.

Case 2 A woman in her 40s seen pre-operatively and apparently fit, presented for surgery, the nature of which is irrelevant. After thiopentone and suxamethonium, she was intubated without incident. A nondepolarising relaxant was given prior to analgesic drugs and ventilation. She almost immediately went very pale. No radial or carotid pulse could be detected. Cardiac massage was started. Anaphylactic shock was diagnosed. Two doses of i/v adrenaline were given and, with 100% oxygen, pulses returned. Surgery was postponed and she made an uneventful recovery.

Case 3 This occurred in another European country where I was doing a locum. An elderly, but otherwise apparently healthy man, presented for repair of a perforated gastric ulcer. A nurse was scheduled to administer the anaesthetic and had secured venous access. The patient had not been seen either by me or the nurse pre-operatively. However, before induction, the surgeon sent for me and asked me to look at the chest film. At first sight, the film appeared to show a large pneumothorax. More careful

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examination revealed it to be an enormous asymptomatic lung bulla. As the operation was urgent, I anaesthetised the patient and the operation proceeded with an intercostal drain set at my elbow and using low tidal volumes and a low inspiratory pressure. The surgery was completed and the patient made an uneventful recovery.

Without wishing to sound a ‘clever dick’, would a non-physician have had the relevant knowledge to cope with any of these problems? The real moral behind these case histories is that, with the exception of the last, they were not foreseeable. Talk of arranging for nonphysicians to do ‘routine’ cases for ‘simple’ procedures will inevitably expose the occasional patient to an avoidable risk. Do we have to wait for an avoidable death at the hands of a non-physician anaesthetist before the pundits and planners acknowledge the potential pitfalls? Have we learned nothing from the deaths from anaesthetics given by dentists in the past? Anaesthetists need to have the knowledge base to manage any problem that may arise. Without this, the specialty’s record of low mortality and low morbidity will inevitably deteriorate. Just training practitioners in practical skills in the misguided belief that this will improve cost-effectiveness and efficiency will, inevitably, compromise safety. Long live the Primary Fellowship examination and the meticulous training programme advocated by the Royal College of Anaesthetists for all those wishing to administer anaesthetics. In anaesthesia maximum safety goes hand in hand with a full undergraduate and postgraduate medical training. JSM Zorab, Consultant Anaesthetist Emeritus, Frenchay Hospital, Bristol Reference 1

Pryce-Jones B. ‘I don’t want to be an anaesthetist’. Anaesthesia News;179:1 (June 2002).


Madam, – Having submitted the article in last months Bulletin (On the inside looking on!), my complimentary copy afforded me the rare opportunity to read through this excellent publication. However, I feel that I must express my concern, nay dismay, at the letters from Dr A Lawson and Dr F J M Walters commenting upon the important debate about non-medically qualified anaesthetists (Bulletin 14, July 2002). It is not their assessment of the issues that disappoints but rather the apparently automatic acceptance that the debate about nonmedically qualified anaesthetists equals a debate about nurse anaesthetists. In a great many departments of anaesthesia the relationship between anaesthetists and ODPs is truly symbiotic so the fact that we can, seemingly, be so readily excluded from consideration is worrying indeed. All the more so when you consider that for many years now UK trained ODPs have been successfully transferring their skills and knowledge to the Netherlands, where many undertake the very roles now being so keenly debated on this side of the English Channel. ODPs may be seen as an emergent profession but this does not lessen our professional ambition or sense of injustice when passed over by those who are thought to be among our keenest advocates. Having now staked out our claim for at least equal consideration I would add my voice to the debate by suggesting that we may in fact be travelling down a road that need not be trod, at least not on to the destination that is usually assumed. It seems to me that what is really needed is action to optimise the efficiency of anaesthesia services, not just to create more anaesthetists in different clothing. Our real challenge is to silence the criticism of those surgeons so loudly bemoaning the forty minute delay between cases while the lone anaesthetists settles one in recovery before proceeding from scratch with case number two. Believe me, it is this issue that is catching the attention of a Government desperate to maximise theatre efficiency so as to have a hope of delivering the NHS Plan and justify next year’s tax rises. If the NHS is not seen to be delivering by the time the tax increases start to bite, then a third term in office could become a pipe dream. I am convinced that remodelling the Anaesthesia Team and the roles within it could pay real dividends in improving efficiency, without compromising the physician only service that has done so

much to ensure that the UK leads the world in delivering a safe anaesthetic service. While we will undoubtedly need more anaesthetists in the service, the quick fix, or at least quicker fix, is to increase the numbers of skilled anaesthetic assistants, both ODPs and nurses. These should be used to provide far greater levels of support to anaesthetists in an individual operating session, taking on those roles that can safely be relinquished by medically qualified anaesthetists, without relinquishing the principle of having a medically qualified anaesthetist administering the anaesthetic. This approach surely has merit in that it preserves our cherished principle of a safe medically based service, while delivering the efficiency that this Government demands and our patients deserve. We can always move on down the road to non-medically qualified anaesthetists if it still proves necessary, but this is a Genie that once released from the bottle will be impossible to put back in again.

B Kilvington, President, Association of Operating Department Practitioners ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

‘Nurse’ anaesthetists Madam, – Having spent ten years as a consultant anaesthetist in Manchester followed by 20 years as an attending anaesthesiologist in a 1000-bedded hospital in the USA, I am very familiar with both a solo practice and working alongside nurse anaesthetists. There are, however, two major problems with nurse anaesthetists. In the first instance, their training and subsequent careers in anaesthesia take them away for their chosen vocation. Their nursing skills are utterly wasted, and given the shortage of nurses today, their defection is hardly to be encouraged. In the second instance, they rapidly metamorphose into what the Americans call ‘Wanabees’. (Wannabee Physicians). They argue with the physicians whose job it is to direct the course and conduct of the anaesthetic, demand salary parity and freedom from clinical control by physicians. Currently in the USA, there is a continuing political wave to achieve these aims with an unhealthy confrontational attitude between the two groups. A similar situation is developing with physician assistants and nurse practitioners. By all means let us train more physicians to fill the gaps, and explore the

use of anaesthesia techniques to assist us with intra-operative monitoring, but not elevate nurses to positions that constantly expose their absent medical training and generate animosity. Carried to its logical conclusion, should all nurses pursue degrees in management, computer skills, special physician skills and research, there will be none available to change the sheets, mop the brows, check the wound dressings or administer the potions. Perhaps physicians could learn these nursing skills.

JA Pollard, Consultant, London ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

President’s statement Madam, – As a SpR 4 I felt compelled to respond to a comment in the section on Unhappy Senior Doctors ‘After an early career which kept seniors in bed and now keeps juniors at home …’. (Bulletin 14, July 2002). I appreciate this is a small portion of a larger article but I like many trainees feel unhappy at the accusations that juniors are having an easy time under the New Deal. I do at least a 1 in 5 24-hour on-call rota (resident) and am often busy throughout the night with epidurals, theatre, ICU and dealing with referrals from physicians, surgeons and nurses. It is correct that on-call consultants are working much more overnight but the juniors are not at home. The reduction in the working week is EU legislation and probably in our interests – how would you feel being anaesthetised by somebody who had already worked at least 80-hours that week with disturbed sleep? In conclusion if there are any anaesthetic rotations where you get to stay at home, could I please be transferred there as quickly as possible.

S Brown, SpR4, Kings Lynn, Norfolk A reply from Professor P Hutton: Sorry, no offence intended. A sense of humour is, however, essential for survival in the modern NHS.

Siamese twins Madam, – The incidence of Siamese Twins is about one in a quarter of a million births. Over the last two years we have had two of these in the UK. They attract attention because of their rarity and complex nature. There was a great deal of media coverage about the surgical aspects and complications involved. It would have been really nice if the media covered the anaesthetic implications and management. Obviously, it is not child’s play to anaesthetise such cases. Congratulations to the paediatric anaesthetic teams, at Manchester and Great Ormond Street, for their invaluable input during the separation of these Siamese twins. An article on Siamese twins and anaesthesia, with details of problems encountered during their management, by our paediatric colleagues, would be welcomed by fellow anaesthetists at least.

P Gururaj, SpR, Aberdeen ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Tagging Madam, – Recently I was presented with a day case patient with a police tag firmly attached to one ankle, a very bulky accessory (for those who have never met one!). Being unable to find any helpful, or in fact any, information in current classic textbooks about potential interaction with technoanaesthetic devices (viz machines, monitors and infusion pumps), we contacted our fountain of all knowledge in the electronics cupboard who ruled that whilst monitoring should be fine if not too close, the accuracy of infusers was less reliable, so best avoided. Diathermy was thought to be a bad idea. We carried on and the minor gynaecological procedure was an uneventful anti-climax. Have you any experience or advice on this situation? The alternative custodial suggestion to remove the tag but restore it before the curfew time cut in (triggering a police raid) was rejected. Should these patients be first on the morning list? I raise these points in the light of political statements that tagging may become more commonplace in the future.

R George, Associate Specialist, Norfolk


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THE MERSEY SCHOOL OF ANAESTHESIA AND PERIOPERATIVE MEDICINE

THE PRIMARY FRCA BASIC SCIENCES THE MERSEY SELECTIVE A COURSE TAILORED SPECIFICALLY AND ONLY FOR CANDIDATES SITTING THE PRIMARY EXAM IN THE WINTER 2002 Monday, 30 September to Friday, 4 October 2002 Registration fee: £350 This five-day course of lectures and tutorials has been designed following extensive consultation with trainees who have recently had to face the challenge of the Primary Examination. As a result, the course will cover only those areas of the syllabus considered to require special attention and elucidation, the aim being to explain and to simplify. Please note that places are limited to 30. It is emphasised that the course will only be of real benefit to trainees who are seriously approaching the threshold of the examination. The following are verbatim extracts from the Feedback Forms of The Mersey Selective Course in June 2002: ‘The course has shown me the level of knowledge that I would need to acquire to pass the Primary FRCA’. ‘... some of the lectures have clarified difficult concepts and elusive topics eg Pharmacokinetics and Statistics’. ‘I realised what I am expected to know’. ‘This was a well organised course in so much as to let me know just how much more I really needed to know prior to the exam’. ‘A lot of very difficult topics were extremely well covered’. ‘Basic principles were well explained’. ‘I did a primary science course in ... and I have to say I found this course a lot more beneficial’. ‘The idea of selecting topics is a very good one’. ‘It is an excellent course which has given me a message to work harder and made me understand certain topics ...’. ‘Many difficult areas that are poorly covered in textbooks are explained very clearly and patiently, dispelling many myths and misconceptions you infer from textbooks’. ‘This course has made me realise that I do not know as much as I thought I did and the depth that is required’. ‘I commend each and every tutor for making the effort in ensuring that we understood the topics covered’. ‘Enjoyable well run course, encompassing areas not well covered or dispersed over various texts’. ‘Excellent course. It gives us direction and content. Aware of how much more we have to work’. ‘I thought the course was very well organised and covered the majority of the difficult topics from the syllabus and made me aware of what areas I need to pay particular attention to before the exam’.

For further details and an application form, please contact The Mersey School (email only please) on [email protected]

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‘Everything you wanted to know about anaesthesia but were afraid to ask’ Establishing and Developing as a Consultant Anaesthetist

21/22 November 2002 The National Liberal Club, 1 Whitehall Place, London SW1 This is a two-day seminar intended for consultants and Senior SpR’s, and is based on the format of last year’s successful meeting. The topics addressed cover much of the non-medical knowledge useful for consultant life, and often difficult to find. The members of the Faculty are well recognised in their respective fields, and there will be ample opportunity for discussion, enabling delegates to get the most out of this event. In addition, the course will cover conflicts of Interest and Resolution, Invoicing Issues, Implications of the Newchurch Review, Management Speak, Discretionary Points. Registration fee (includes lunch, post meeting drinks reception and flight on The Millennium Wheel): 21 November: £250 & 21/22 November: £300 Programme The Consultants Contract – How to Negotiate Stephen Campion, Deputy Director , Hospital Consultants Specialists Association Medical Protection as a Consultant Gerrard Panting, Director of External Policy Relations, MPS How to be a Lead Clinician or Clinical Director Peter Evans, Deputy Clinical Director, Charing Cross Hospital London How to Work on a Committee Christopher Heneghan, Council Member, Royal College of Anaesthetists, Neville Hall Hospital Abergavenny New Development in the NHS Heather Lawrence, Chief Executive, Chelsea and Westminster Hospital, London New Developments at the RCA Doug Justins, President of UK Pain Society, Vice President, Royal College of Anaesthetists

The Association of Anaesthetists of Great Britain and Ireland 18–20 September 2002 Annual Scientific Meeting (Bournemouth International Conference Centre) January 2003 Winter Scientific Meeting (venue to be advised) June 2003 GAT Annual Scientific Meeting (venue to be advised) More detailed information can be obtained from the Association of Anaesthetists of Great Britain and Ireland, 9 Bedford Square, London WC1B 3RA tel 020 7631 1650 fax 020 7631 4352 email [email protected] website www.aagbi.org

Dealing with our Surgical Colleagues David Scott-Coombs, Consultant Endocrine Surgeon, Kings College Hospital, London The Art of Private Practice Mike Ward, Clinical Director, Anaesthetic Department, Radcliffe Infirmary, Oxford Dealing with Medical Insurance Companies Adrian Bull, Medical Director – PPP Healthcare Who, What and How Much to Bill Phillip Bickford-Smith, Consultant, Bradford Royal Infirmary The Business of Private Practice Ray Stanbridge, Stanbridge Associates, Accounts & Management Consultants, Lincoln (PGEA Approved) five CEPD points For further information, please contact: Towmed Courses, c/o Simone Seychell, Department of Anaesthesia, Chelsea and Westminster Hospital, London tel 020 8237 2763 fax 020 8746 8801 email [email protected]

The Mersey School of Anaesthesia and Perioperative Medicine

THE FINAL FRCA EXAM SAQ WEEKEND COURSE MASTER CLASSES IN STYLE AND TECHNIQUE AND SUPERVISED PRACTICE AND ANALYSIS

6.00 pm Friday, 18 October to 4.00 pm Sunday, 20 October 2002 Registration fee: £275 (limited to 12 places)

For further details and an application form, please contact The Mersey School (email only please) on [email protected]


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Appointment of Members, Associate Members and Associate Fellows The Royal College of Anaesthetists would like to congratulate the following who have been admitted following the introduction of the new membership criteria in August 2001: Associate Fellows May 2002 Dr Kongbrailatpam D Nirmala Dr Oliver Zuzan Dr Donald Walter Galloway July 2002 Dr Anne Adrienne M Taylor Dr Krishna Prasad Bolleddula Dr Edward Wilson Associate Members July 2002 Dr Ajay Ramchandran

Deaths The College regretfully records the deaths of the following Fellows: Dr Alan P Bray, Carnforth, Lancashire Dr John R Elliott, Shropshire Dr John W Hegarty, Pinner, Middlesex Dr David G Larard, Warwickshire Dr Misheck Nyabadza, Southampton Dr Crispian S Ward, Huddersfield

Members May 2002 Dr Beverley Carol Hopwood Dr Maria Andreou Dr Mohammad H Al-Hamed Dr Mohamed Ibrahim M Dulfeker Dr Stuart Duncan Marshall Dr Linda Christine Malpas Dr Hossam M H Metwally Dr Rula Ahmad M Kloub Dr Soe Than Myint Dr Uttam Kumar Kakshepati

The Senior Fellows club The next meeting of the Senior Fellows Club will be held on 30 October 2002 at 10.00 am in The Grange Holborn Hotel, 5060 Southampton Row, London WC1B. The guest speaker will be Lady Michelle Sykes. The meeting will finish at 2.00 pm after lunch. For further details please contact Mrs E Lazari at the College on 020 7908 7323.

Appointment of Fellows to consultant posts The Royal College of Anaesthetists would like to congratulate the following Fellows on their consultant appointments: Dr Susan Abdy, Queen Elizabeth Hospital, Norfolk Dr James Abernethy, Barnsley District General Hospital Dr Basil Ateleanu, University of Wales Hospital, Cardiff Dr Kate Barkshire, Hinchingbroke Hospital, Huntingdon Dr David G Pogson, Portsmouth Hospitals NHS Trust Dr Andrew Woods, Stockhill Hospital, Glasgow

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July 2002 Dr Thanaa A El-Hamid Kandil Dr Naeem Ahmad Dr Arun K Hiralal Kamble Dr Ahmad Rami Kalaji Dr Marcin Antoni Sicinski Dr Mohamed M M Hamarsha Dr George B B Campbell Dr Punita Josephine Anthony Dr Jacqueline M Stokes Dr Mohammad S Baloch Dr Mohammad S Bhuiyan

Transplant Update The monthly information sheet from the NHS entitled: ‘Transplant Update’ has now been discontinued in paper format. As part of a comprehensive review of their publishing activity, the NHS has decided that it would be more efficient to provide upto-date statistical information via their expanded and improved website (www.uktransplant.org.uk). The website is designed to provide easy access to a wide range of information about organ donation and transplantation. The monthly transplant update information can now be found at www.uktransplant.org.uk/ statistics/monthly_statistics/ monthly_statistics.htm.

48/49 Russell Square London WC1B 4JY tel 020 7813 1900 fax 020 7813 1876 email [email protected] website www.rcoa.ac.uk College Secretary Mr Kevin Storey Deputy College Secretary and Training and Examinations Director Mr David Bowman IT Director Mr Gary Hall Professional Standards Director Ms Emilia Lightfoot Courses and Meetings Mr Amit Kotecha 020 7908 7347 Miss Chantelle Edward 020 7908 7325 ansaphone 020 7813 1888 fax 020 7636 8280 email [email protected] Educational approval for Schools and hopsitals Ms Claudia Lally 020 7908 7339 Examinations Manager Mr John McCormick 020 7908 7336 Individual Trainees Mrs Gaynor Wybrow 020 7908 7341 Membership Services Miss Karen Slater 020 7908 7324 President’s Personal Assistant Miss Trisha Bernays 020 7908 7308 Subscriptions 020 7908 7329