ANAESTHESIA POINTS WEST
SPRING
2OO4
lssN 0265-9212
THE SOCIETY OF'ANAESTHETISTS OF THE SOUTII WESTERN REGION
SHUTT
DRJ. EATON
UBHT
PRESIDENT-ELECT:
DRM.COATES
Plymouth
HONORARYSECRETARY:
DRK.HOLDER
Southmead
PRESIDENT: DRL.
VICE PRESIDENT:
Frenchay
HONORARYTREASIIRER: DRA.BURGESS Plymouth
EONORARYSECRETARYELECT:
DRP.MoATEER
Bath
COMMITTEE: DRM. MERCER Torbay
DR G.
DR F.
ANSELL
KELLY
Trainee Representative, South West School
Trainee Representative, Bristol School
EDITORIAL COMMITTEE: DRN. WILLIAMS Editor, Gloucestershire Royal
DR J. PITTMAN Assistant Editor
C.
FINCH
Royal Devon and Exeter
Secretary to Editor
Gloucestershire Royal
WEBSITE: DR S. COURTMANNPlymouth
www.saswr.co.uk
ANAESTHESIA POINTS
WEST
CONTENTS
Spring,2004
Vol.37 No. 1
Page
Editorial
Editorial
J
4
- Drifting Back to Basics?
Future Meetings of the Society
Portrait of the President
5
Honorary Life Membership
News of the West
Examination Successes and Honours
Society of Anaesthetists of the South Western Region
Kathryn Holder
Autumn Scientific Meeting Report
South West Association of Children's
Anaesthetists Amual Scientific Meeting Report Nicky Williams
Anaesthetic Management of Sickle Cell
S. P. Nandalan
Anaemia - Three Cases from India
6
7
8
l8
l9
23
N. K. Geetha
25
My Experience with Third World Health Care
Physicians Heal Thyself - and Thy Family
Hassan Abuzaid
28
John Covell
32
All That Glitters Is Not Gold
Hugo Wellesley
Ian Thomas
Alisdair McCrinick
JJ
Amateurs atAltitude
Peter Sanderson
34
The One Armed Anaesthetist and the
Primary FRCA
Pan Armenian International Surgical Congress
The Role of Crystal Dowsing in Determining
Surgical and Anaesthetic Outcome
W(h)ither Science Vivas?
Rob Price
39
John Zorab
4t
A.
J.
Braga
M. J. Savidge
Neville Goodman
Poem
Robin Forward
Obituary - Violet Fry
Crossword
B. W. Perriss
43
44
47
48
49
Cartoon No. 1
Cartoon No. 2
50
Notice to Conhibutors
52
@2004 The Society of Anaesthetists of the South Westem Region
5l
Editorial
have just been watching the start of the London
Marathon - always an inspiring yet humbling event,
even more so this year as a 93-year-old chap is
running. I must say that I am in complete agreement
with Martin Johnson, captain of the World Cup
winning England team, when he states that he has
thought of running a marathon but then goes and sits
down until he feels better. I thought I could put my
I
recovery time to good use by tapping out my
editorial.
A month ago I worried that there would not be any
articles for this edition but as always, with a late
flurry a selection have found their way to me and in
to print. E-mail has certainly made the editorial
process much simpler although there are a couple of
articles that left their computer of origin and never
arrived at their destination
-
my computer. It worries
me to think of them floating around in the
atmosphere mclaimed for an eternity! Thank you to
all who have contributed and can I just say that the
fact that a number of the articles are written by
people in my own department is pure coincidence
and I have not been applying any thumbscrews yet!!
I would like to welcome James Pittman to the
editorial committee as Assistant Editor and am
pleased to see that Tricia McAteer has moved
seamlessly into the position of SASWR secreta4r, so
will still be on hand to advise us when the need
anses.
-1
This edition has an international flavour with
articles concerning India, the Sudan, Armenia and
East Africa. We have crystal dowsing to add a
touch of spiritualism and a dollop of mountain
madness that seems to have occurred before even
reaching altitude. News
of the West is
as
entertaining as ever and it is always interesting to
read of what is happening in other departments,
particularly with regard to the many changes that
are afoot in the Health Service. It seems that local
agreement on the new contract is imminent,
I am not sure anyone has thought through
the implications of expecting consultants to work
although
all of their
SPAs within the hospital. A
considerable amount of investment will be required
to provide facilities (offices and computers spring
to mind) in which we can work. I look forward to
it! At the end of the journal
are two topical
cartoons by our regular cartoonist, Kathy Smith
(Jenner) from Exeter.
Some of you will be about to set off to Bologra
for the Spring SASWR meeting. I am sure it will be
a successful event and from those of us not going,
have fun and we look forward to reading the details
in the next edition of Anaesthesia Points West.
Farewell until then.
Nicky Williams
Gloucester
Editorial
2
- Drifting Back to Basics?
As a comparative youngster (only l2th year as a
Consultant), I nevertheless feel myself drifting to
wards idiosyncrasy and crankiness. The best cure
for these are exposure to trainees, postgraduate
meetings and some plain talking ODA's. My own
major clinical commitment is an all day
neurosurgical list each Monday and as I finish
(about) my 450th, I find myself reflecting on some
of the great unchangeables in my clinical practice.
Call me cranky but I like to know what my patient
weighs in kilograms, to have two cot sides on the
bed and a drip stand at the top of it. Sadly, as we
approach the 35th anniversary of putting a man on
the moon, these represent a dreamy goal not
attainable in what is now a teaching hospital! Let
us start with the weight . . . ! It would seem simple
enough for elective patients to stand on the scales,
to have their weight recorded and finally written
down somewhere findable. Instead, we get what
the patient thinks they would like to weigh in
stones (ascertained verbally) which then may or
may not be converted into kilograms. Some of
these fallacies can be easily detected - never
believe a weight of 63.5kg - it wasn't measured,
it's just, 'oh I weigh about 10 stone' converted into
kilos. The simplest test however, is simply to ask
the patient if they have been weighed - they
usually look amazed!
The latest impediment to patient care flies the
flag of clinical governance (in this instance, 'risk
assessment'). My patients now frequently appear
to be scheduled for 'frtting of TED stocking under
general anaesthesia' since nobody on the ward has
done it. On enquiry, this tums out to be because
they weren't prescribed and that in turn because
they have not had a risk assessment for tissue
viability (I kid you not). This epidemic
has
spawned imitators and each of our patients is now
supposed to have 5 risk assessments, everyone
administered by a trained member of staff. We can
therefore determine the patient's 'risk' of latex
allergy, DVT, tissue viability, manual handling and
CJD. Of course, what happens is that we don't
determine anything other than wasting huge
amounts of staff time which definitely does prevent
4
attention to proper nursing care. Never mind,
that's progress! Certainly, our collective track
record for rational behaviour isn't good. Look at
disposable tonsillectomy where 'we' (actually, it
wasn't we because it wasn't anything to do with
any anaesthetist that I know so let's instead say
'they') rushed to introduce cheaply made (but
expensive in bulk!) low quality disposable
equipment for tonsillectomy to prevent our
children from catching CJD. All this without so
much a hint of an evidence base! What happened
-
well you probably know as it is now already
history, a trail of broken teeth and damaged kids,
cursing surgeons and unsatisfactory operations has
led us back to where we started from using well
designed modern stainless steel equipment which
has been thoroughly cleaned. Perhaps there is a
risk of catching CJD this way but I think that we
have now done the natural experiment to
demonstrate that the risk is less than that of
children getting trashed by some dodgy disposables
made at the lowest possible cost in a distant land.
What provoked this ou@ouring of bile I hear you
ask? I have to say that I am not sure. What I am
sure about is that there are a number of alternative
tracks which a consultant can take when faced with
these great certainties of NHS care. One type, let
us call him / her Dr Serenity, drifts through all this
untouched; he / she simply ignores it all, turns up
to work, does their best and then goes home
relatively unscathed. A second bod, Dr Change-it
or Bust, exhausts himself trying to put all these
things right. Clearly this is impossible and then
this person then has 2 other possible paths; they
either mutate and turn into a Dr Serenity or they
drive themselves mad in the process becoming
something like one of those mad dogs on a chain
that you occasionally encounter when walking
through French farmyards - you know the one, it
hurls itself towards you determined to bite you but
is luckily brought up short by its chain! The final
option is Dr 'Do the Best that I Can', this hapless
wanderer tries to pursue a middle way, addressing
some of the greater madnesses whilst trying to
preserve their own sanity.
Where does this leave us? More importantly,
what does it mean for our patient care? We are
contemplating (nay, we are introducing) patient
controlled epidural analgesia with splendid new
equipment on to some of our surgical wards.
Shiny new pumps have been procured, over 200
staffhave been trained and we are nearly ready to
go. I have my doubts . . . will this work at llpm
on a Sunday night on a darkened ward with one
permanent staffer, an agency nurse and a health
care assistant? Are we creating a treatment
strategy which is well researched (yes), technically
robust (nice new equipment, definitely yes) and
good for patients (that's what the publications
say)? I am sure all these things are true. What
right often enough so that anything more than the
most basic care, using the most elementary
principles, is actually deliverable in today's 'real
world' NHS; who knows! Anyhow, what is
certain is that we won't be finding out for a bit;
the pumps have all disappeared and the latest
theory is that the box in which they were
contained was thrown out by the cleaners so it
looks like patient controlled epidural anaesthesia
won't be emerging until the Friends have sold a
few thousand more paperbacks in the hospital
lobby!
Robert Sneyd
Peninsula Medical School
Plymouth
bothers me is whether we can get the simple things
Future Meetings of the Society
Autumn Meeting 2004
Bristol
5th and 6th November 2004
(Watershed Conference Centre)
Spring Meeting 2005
13th and l4th May 2005
(Grand Hotel)
Torbay
Autumn Meeting 2005
Belfast (provisional)
Portrait of the President
Les was born in South Wales and undertook his
medical training in Sheffield. He met Merle and
their marriage has produced two delightful sons (a
doctor and an accountant) and a happy partnership
that has given much pleasure and support to their
family and friends. After return from a year's
secondment to Charlottesville, Virginia, he was
appointed as a consultant in the United Bristol
Hospitals and has specialised in obstetric
anaesthesia, regional blocks, airway management
and chronic pain. He has chaired a number of
committees and was in the first cohort of consultants
to train as 'consultant mentors'.
Professionally Les is a very sound clinician, a
dedicated teacher and a great supporter of trainees.
He never hesitates to offer ad hoc viva practice and
his research projects have frequently allowed
trainees to enhance their experience and CVs by coauthoring papers published in quality journals, He
has been College tutor and examiner for the DA and
Fellowship. For several years he has been Bemard
Johnson Advisor for the College and has given
endless hours of his time to the benefit of overseas
trainees
-and those having problems with
examinations. All his College activities have been
targeted at maintaining standards of anaesthesia in
the United Kingdom. His exemplary work for the
Leslie Shutt
Les has enthusiastically and skilfully contributed to
the Society of Anaesthetists of the South West
Region since his arrival in Bristol as a Senior
Registrar. He was awarded the Registrars' Prize, he
was an exemplary Honorary Secretary and Editor of
Anaesthesia Points West and is now its President.
Finesse, energy and attention to detail have been the
watchwords for all his contributions and it is no
surprise that the meeting with our Italian colleagues
in Bologna has been arranged with great care to
ensure an appropriate mixture of academia, culture
and bonhomie.
College was recognised by the award of the Royal
College of Anaesthetists Humphry Davy Medal.
Recreational activities are much involved with his
family. He is a keen photographer, has researched
his family tree and enjoys walking, gardening and
his cottage in Dorset. For eight years he served with
the Royal Naval Reserve. His graphic accounts of
some of the training exercises convinced me that I
was better suited to gardening.
Les Shutt is a superb and educated colleague and
friend and uses his skills and energy to the
undoubted benefit of rhe SASWR.
Robert Johnson
Honorary Life Membership to the Society of
Anaesthetists of the South Western Region
trainees of the time, Basil's future career was caringly
designed by Leslie Feneley and Torry Baxter. Basil
was once detailed to apply his anaesthetist's skills to
driving a laundry van for the BRI during a strike of
ancillary staff. He might reasonably feel that this
diversion from academia resulted in his not
inconsiderable experience of Queen's Square. As was
the case for most of us, Torry's guidance led Basil to a
satisfying and fruitful career.
During his time in Bristol Basil met and married a
slim, dark-eyed senior theatre sister in Greig Smith
theatres, Ruth
-
then Key, and they have lived happily
ever after. James was produced at the BMH and
Trevor Thomas and I have happy memories of
providing analgesic services for the event followed,
after the arrival of a number of colleagues, by a
distinctly anaesthetic celebration.
Basil obtained the BTA, Africa not America in his
case, by becoming visiting lecturer in Accra, Ghana
and was appointed Consultant in Derby in 1976.
While consultant on-call, he organised anaesthetic
services for the infamous major accident when an
airliner attempting to land at East Midlands Anport
Robert Basil Spencer Hudson
A Yorkshireman born the son of
a professor of
geology in the village of Morton Banks on the edge of
Ilkley Moor. From Bradford Grammar School he
migrated to Trinity College Dublin from where he
qualified wirh MB., BCh. in 1965. He enrered
anaesthesia as an SHO in Dublin and became a
demonstator in physiology. In June 1968, Basil came
to Bristol as a registar and rotated through the BRI,
Southmead, Frenchay, Bath and Gloucester.
Basil received a warm welcome to the cardiac unit
at the BRI from the young doctors Andrew Diamond
and Jack O'Higgins, both Senior Registrars at the
crashed onto the
Ml.
Basil was awarded the Regisffar's Prize of this
society in 1975 and has been a very regular and
greatly valued member and friend at its meetings,
home and abroad, for over thirly five years.
Professionally, Basil has achieved much as a
clinician, a very competent cornmittee member and as
a speaker. His work with the BMA has included
membership of the Joint Consultants Committee, the
Central Consultants and Specialists Committee and a
number of working parties. He has been a member of
the Conference of Regional Chairmen of Ethics
Committees. His work has been to the benefit of
Working Time Directive had yet to be conceived and
the rota was one in two for six months with no extra
patients, colleagues and the NHS.
In short, Basil is a superb colleague and friend, a
valued member of this society, and has contributed
much to anaesthesia.
duty payments or compensatory time off. As for all
Robert Johnson
time.
It
should be remembered that the European
News of the West
This is where you are kept up to date on all the news and gossip from each department in the South Western
region (andfrom our member in "exile" in New Zealand). The name of the correspondent appears at the end of
each contribution and he/she is also the SASWR LINKMAN for that department. Anyone wishing to find out
more qbout SASWR or wishing to join should search out the local linlnnan who will readily supply details and
application forms. In addition to other benefits, members receive the twice yearly editions of APW FREE!
Barnstaple
Bath
Expansion, expansion, expansion - surgical
expansion mostly, with more orthopaedic surgeons
As I write, we in Bath are in the grip of winter. This
is only partly a result of the weather. To push the
metaphor, a bit more managerial illumination would
be useful. We are sitting, famously starless, with
f,10 million to 'raise', or else. To help us we have a
new Chief Executive Officer. Don't laugh. Every
time I write this, I have to say that we have a new
CEO. This one is the sixth since I arrived, five and
a half years ago. I thought that he was the fifth, but
according to a well-placed source I missed one. I
don't feel too bad about that as he was only here for
six weeks. The new one seems keen, and says he is
planning to stay.
One of the key 'improvements' associated with
the new management has been the introduction of
three session operating days in Orthopaedics. In
order to understand what an improvement this can
offer, you need only to know that the new threesession day is timetabled at precisely ten and a half
(naturally) and a general surgical plan aimed to cope
with CEPOD and the European Working Time
Directives. It is of such labyrinthine complexity that
the Trust Management Board has of course
swallowed it in its entirety. For the Anaesthetic
Department, expansion has meant the threat (sonf,,
promise) of a Permacabin (sorry, Portacabin) and
this has led to some 'lively debate'! A new Chief
Executive, John Rom, has taken the helm (known to
devotees of The Fqst Show as Mr Rom Manager)
and the expensively refurbished labour ward boasts,
not one birthing pool, but two. Now don't get me
wrong, over the last few years I have become
'heavily' involved in water sports - my surf board
has been getting progressively longer, wider and
thicker - but I'm really not at all sure about water
sports at work, especially involving heavily pregnant
ladies.
As always there have been changes in personnel.
Mark Jadav has left us to take up a South Westem
SpR post
in Emergency Medicine and Myles
Dowling has gone to Nottingham to pursue a career
in Anaesthesia. Our thanks and best wishes to them.
Elaine Clark, Erna Snyman and Chris Marsh have
joined us (welcome) and current head girl Nageena
Hussain is ably marshalling all the trainees. We bade
a final farewell to Tony Heenan in the autumn. He
returns to keland and his racehorses via just 'one or
two' more locum jobs in the U.K. Kate Tipping and
John Speirs remain to help with the ever-burgeoning
surgical workload. It seems we face potentially a
period of great change in the N.H.S. be it in
contractual arrangements, in the way we work or in
departmental organisation and whilst nothing ever
stands still, I'm an advocate for evolution rather than
revolution. I'll let you know as the tale unfolds,
although after twelve years as correspondent it must
soon be time to hand over the baton!
Nick O'Donovan
8
hours. This is obviously better than the usual
slipshod way that lists run, from first thing in the
moming to about 5 pm or so. Savings have been
huge, except for those times when the lists stop at 3
pm by accident. In order to provide support for this
groundbreaking development, each consultant
anaesthetist and surgeon (for, kind reader, it is they
who are taking on the burden) is given
a
compensatory rest session off. You can only
imagine how soon we hope to remove our waiting
lists by this cunning ruse. Let us hope that it stops
soon, or we will be sending our waiting lists to Mars
for early treatment, rather than London.
Amid all this trauma, the department soldiers on.
As a consequence ofthe three session days, there are
very few consultants here at the very moment. The
trainees and staff anaesthetists appear hurtfully
oblivious. We have had our usual comings and
goings. New Spring rotations resulted in the loss of
three SpRs: Simon Lewis left us to go to the BRI,
Sean Flack went to Australia via the US (or was that
to the US via South Africa?), Tony Brooks
disappeared to
join a friend's motorboat resting on
turquoise waters off Perth, Australia and Judith
Stedeford, fresh from the onerous task of trainee
rotameister, went to the BRHC*. To replace them
we welcomed Paramita Ray from the BRI, Khaled
Moaz returning from a yeat in Australia, Justine
Lowe coincidentally arriving from Australia, and
Jules Cranshaw from the BRI and London. SHOs
Sally Baxter, Ross Davis and Samy Mohie passed
their Primary exams and headed off to Southmead,
Plymouth and Belfast respectively. They were
replaced by Clare Hommers, Katie Welham, and
Alan Crowther. Pete Forster also passed his
primary, and for the moment is staying put. ITU
SHO's Roger Beadle and John Williams learned and
left, to be replaced by Drs Sam Hilliard and Juliet
Drew. We also said many thanks and farewell to Drs
Kim Carter, Ben Walton, Jay van der Westhuizen,
Richard Beringer, Matt Oram and Robyn Harry who
all made a (relatively) fleeting stop on their
migratory route to success elsewhere. In January,
Caleb McKinstry made a very welcome retum as a
least she won't be far away. We will miss her incisive
'tell us how it really is' commentary and this column
will have lost its principle unwitting source of gossip.
New consultants Rob Orme from Oxford and Warren
Docherty from Leicester start on ICU very soon,
replacing Sunny Karadia, who returns with some
relief on his part to the anaesthetic fold, and Kay.
Congratulations to the Polish husband and wife
team of Roman Klis and Mirela Krotki who have
been elevated to Associate Specialist and Staff
Grade respectively. Word has finally escaped on
how they spend their hard eamed salaries. They are
building on prime land in Poland's top ski area
about 50 miles from Kracow and are waiting
expectantly for a property and tourist boom. I
suppose we will know when it has happened
because the Department will find itself suddenly
without two very experienced colleagues.
Well done also to Lisa Penny and Emma Patrick
who both passed the Primary FRCA. Rumours of a
dangerous liaison between Emma and Dave Burton,
our locum SHO in the autumn, were without any
senior ITU trainee. Locum consultant Jonathan
foundation. So why mention them?! Lisa meanwhile
Shirley enjoyed his time here, but when the winter
started to dig in he decided that perhaps Australia
needed him more.
has escaped the uncomfortable departmental
cohabitation with 'uvverarf' Bill Rea (SHO) and
Finally, and of crucial importance in any
Anaesthetic Departrnent, was the big social event of
the season, the Christmas party. This was organised
with sheer brilliance by Dr Jenny Tuckey, now
Clinical Lead for Christrnas. She even arranged the
Chrisffnas parcel - young Emily Kaloo, 10 days old.
Emily gracefully allowed herself to be passed
around all evening amongst the broody women and
macho men, to everyone's huge enjoyment.
secured a registrar job in Birmingham.
Almost all the trainees have arrived or departed in
the last few months. Of those not yet mentioned, 'out'
have gone registrars Jo Comes, Guru Hosdurga and
Natasha Clark (to Bristol) and SHO Colin Padoa (to
Birmingham). 'In' have come SpRs Chris Scanlan
and Nilesh Chauhan (from Bristol) and SHOs Hannah
Cross, David Pritchard, Simon James and Rozzie
Green (all new to Anaesthetics). Well done too to
Leon and Rosa Visser, who have had a girl (which
could be construed as an 'in', or an 'out').
xEd's note: Bristol Children's Hospital
Monica Baird
The crisis this year (what crisis?) of a further
reduction in opportunities for education and
experiential learning for trainees will be felt most
Cheltenham
acutely by the paediatric service, whose resident rota
Mystery, intrigue, romance, blood, toil, tears and
is being significantly cut. The implications for
sweau it has all been happening in Cheltenham these
last few months. So why don't I get to find out about
neonatal resuscitation, obstetric and anaesthetic
services across the county should become less
murky over the coming months, but a compromise
equally unsatisfactory to all is likely to be the result,
it? That's what
I want to know. Anyway
here are
some snippets I have been able to glean.
As usual there have been some comings and
goings on the consultant front, or in Trevor Johnson's
case, goings and comings.
A resignation, three
months' notice served, tearful goodbyes to a popular
colleague, and a flight to Oregon. However, the next
week he is back at work as though nothing had
happened. Beats me, but good to have you back
Trevor. Kay Chidley has made a sideways transfer to
Gloucester, which is sad for us in Cheltenham, but at
at least for the medium term.
'Fellowship of the O Ring' was the theme for the
even worse than usual cabaret at the Christmas party
this year. The evening at the Prestbury House Hotel
was otherwise very well organised - thanks to
Sheila West and Wendy Stoner - but can anyone
suggest a way of improving the entertainment on
offer? A longstanding riddle has at last been solved
regarding Jon Williams' rather unstable state of
mind. His psychiatrist assures us things have
generally been looking up over the last few months
and we think it may have more to do with the
Footsie Index than the tablets. Either he has an email
pen pal who works at an Intemet share dealer or he
has been gambling the family silver on high-risk
stocks. We say, the only safe way to double your
money Jon, is to fold it over and put it back in your
wallet!
Drs Copp, Mather, West and Pryle retumed from
the recent SW Thames Belle Plagne meeting.
Belinda wouldn't admit to any
serious
misdemeanours on the trip, although the SHO (from
a hospital somewhere between Torquay and
Taunton) who propositioned her in a nightclub may
have an interesting interview if he applies for a job
in Gloucester while Mr Pryle remains their CD.
Otherwise there were no tales of daring-do on the
slopes, nor thrilling stories of enlightening
anaesthetic lectures, but just denials, denials and
more denials. When asked how the meeting went, a
'I didn't do anything' or 'I was very well
behaved' just isn't good enough. We think they do
reply of
deny too much.
Ted Rees
Exeter
Firstly, let me apologise for most of my last report
being lost in the 'ether' - apparently I should have
given up using it years ago! James Pittman is
receiving this by hand so hopefully . . .
Consultants are breeding like rabbits here - we
just advertised for another two! After Lauren Barker
the lists start! Colin Berry has managed not to buy
another boat yet but has organised for a group of us
to race in the NHS regatta in the Solent - don't
forget Colin ONLY the Solent! Congratulations to
James and Victoria Pittrnan who have recently had
Tom. Matt and Sheena Hubble recently organised a
Spa
Cav
a bit blurry - I
though-Iho
wonderful
This
started with
etting
tapas
these
Sheena! Emma Hartsilver has now left for her
matemity leave and we wish her well. We don't talk
to Fred about Leeds anymore but he tells me he is
going to be taking Portugal by storm - unless they
remove your passport Fred! Luckily Andrew (Head
Boy) Teasdale can't lose any more hair, as he tries
to sort out the new contracts - apparently the
emergency docs want sixteen PAs - something
about them being given treble time in the evenings is it too late too switch careers?
Our SpR numbers have also been increasing, with
a loss of the SWAG gap and extra numbers, taking
us up to eight this week - I think. The introduction
of l2-hour shifts seems to have happened fairly
smoothly and most trainees seem to be happy
with ir.
The other big news at the moment is the decision
about foundation status - which we should hear
about in the next week. All the expansion plans,
including our three ICU beds, are on hold until then.
Iain Wilson certainly has his work cut out as
and Quentin Milner we have also appointed the girl
Medical Director.
Anyway, must get back to organising the holiday
in Tuscany to combine with our next meeting. See
you in Bologna. Ciao.
Lauren, this should help me with those 'small
Jon Purday
with the longest training in the SW (so she tells me)
in Pippa Dix. I'm very grateful, as along with
things' many of my colleagues now disown.
We have all dutifully been having appraisals,
contract negotiations, job planning and waiting lists!
It's getting difficult to fit in the skiing holidays.
However, we did manage to get to the SW Thames
update - CPD after all! The snow was the best we'd
had for years. This combines with our mountain
guide made for some interesting moments. There
seemed to be a general attraction for the trunks of fir
trees, but I felt Mark Daugherty was taking his love
for houses a bit far when he tried to ski in through
someone's front door!
Mark is on first name terms with most architects
and builders in Devon as he and Corinne try and sort
out their rebuild! Bill (Carver) Boaden has managed
to organise 5 skiing holidays this year - the ODAs
have all been trained to remove his ski boots before
l0
Frenchay
Judging by the proportion of the department who are
pregnant or have pregnant partners it appears that
many of the department have kept themselves wafin
using environmentally friendly, but hopefully not
green, sources of energy this winter. Congratulations
go to Kate Lockey, James Rogers' wife Venetia,
Wendy Brown (wife of Jules 'the lunchbox' Brown),
Nicky Weale, Keya Quader, Melanie Hardy
(Rowan's wife) and Jo Comes. David Lockey's baby
was conceived on his first day back from ka[, which
just goes to show that you can run but you can't hide.
David was awarded the Queen's Commendation for
Valuable Service for his service in kaq.
We have not had any new Consultant
appointments, although we almost did. I'm
confident that the Southwest grapevine can convey
a
full-blooded version of events, suffice to say that
Trust financial pressures led to withdrawal of
funding for a Consultant post less than two weeks
prior to interview. Nice.
Perhaps I'm getting old, but not only do trainees
appear to be getting younger, they now seem to be
getting taller. Ben Walton and Tim Murphy have
come from the BRI, and are the only people I have
ever seen who have to duck as they walk down the
main corridor of the hospital. We welcome back
several old faces, including Bruce McCormick from
an Australia ITU fellowship and Steve Sale. Bruce
correspondent managed to get a caustic soda bun m
the backside (don't ask), while Amber Yormg hrrrr
her chest whilst ironing a shirt she was wearing.
Safety tip: remove clothing before ironing them.
The department held a dinner to celebrate Peter
Simpson's appointment to President of the Royal
College of Anaesthetists, and the SS 61sa1 lritain
proved a great venue. At the time of writing this
article, the end of February, we are about to have
our 'Christmas' 2003 party.
In the whirl of rumour, counter-rumour, fact,
fiction and paranoia surrounding job-planning, a
(favourite websites'todaysgroom.com'
hint of what maybe to come emerges from another
hospital in the city. Several Consultants there have
Will English and Simon Ford.
Congratulations to Arun Ramasamy for his
progression from Clinical Fellow to SHO and Asha
Nake for her SHO post in Taunton. Dan Low and
Will English were successful in the recent SpR
interviews and Carla Glynn has joined us from
Dublin as a clinical fellow to pick up some
Neuroanaesthetic experience. Tess Whitton has
finished her locum Consultant post and will be sorely
preparing a presentation at midnight, theoretically I
ought to be able to call a manager round to witness
and
'pronuptia.co.uk') is busy planning his forthcoming
wedding to Kate. New recruits include Guy Jordan,
Kim Carter, Jo Silsby, Curtis Whittle, Joreline van
der Westhuizen,
been told categorically that the majority of
Supporting Professional Activity time must be spent
in the hospital. Doctors will be monitored to ensure
they comply. This is madness for several reasons.
Have managers got nothing more pressing to do
than snoop around the hospital with a clipboard
trying to understand the meaning of the word
'professional'? Are Trusts ticking along so
smoothly that their time could not be better used
elsewhere? Additionally, as quid pro quo, if I'm
missed both for her individuality and hard work.
my SPA work. It's not that I'm paranoid;
In the face of surgical whingeing, our weekly
early morning meeting has developed into a
powerful evidence-based forum with the advent of
'Controversy' meetings. These should not be
confused with our monthly Departmental 'violent
they're trying to screw
controversy' meetings. James Nickells introduced
the 'Controversy' meetings as a structured approach
to evaluating evidence in order to improve quality of
care. These have been very popular and we plan to
publish useful treatment modalities on a website,
NICE-style. They also provide a useful forum for
comparing practise, for instance Wim Blanke
pointed out that in the independent sector patients
who were rolled from side to side between theatre
and recovery had more PONV; so if you're going to
leave the invoice under the pillow, pop it in an
envelope.
James Rogers has been keeping the developing
world medical torch burning with a recent trip to
Anandwar, India. He went with Donald Sammut, a
us'
I know
Richard Dell
Gloucester
Having just returned from my second ski trip my list
of jobs has become urgent and writing this column
obviously takes priority. On the subject of skiing, I
had my first visit to the Belle Plagne Anaesthetic/
Ski Update Meeting in January. Consultans Charles
Rodriguez and Chris Roberts and trainees Peter Ford
and Sue Bamard accompanied me. Obviously true
events of the trip will only appear in my memoirs
but what I can say is that CME has never been such
fun. It took us at least a week to recover from the
vodka dark dog (like red bull) and the extreme sleep
deprivation resulting from 'acute saloon bar injury'.
I'm not sure the Clinical Director will let me go next
year!
dealing with burn contractures and the effects of
The Department is pleased to welcome Anand
Hiremath, a new consultant from Oxford, and we
have also welcomed back Kay Chidley on a "free
transfer" from Cheltenham. She replaces Colin
leprosy. After eyeing up the anaesthetic machine on
offer, James resorted to using regional blocks for
most of the cases. The department has not suffered
any skiing injuries yet, although, as befits a Burns
centre, two of us sustained freakish burns. This
last 10 years, who will now continue on the general
rota. We are looking forward to Roger Eltringham's
retirement dinner next week. It was difficult to find a
venue large enough to accommodate such a popular
hand surgeon. They provided a much-needed service
Green, who has done sterling service in ICU for the
ll
I'm sure everyone in the South West is
aware, Roger's contribution to Anaesthesia and in
particular the WFSA has been tremendous. His wit
and abilities make him irreplaceable. However, all is
not lost because Roger is planning to stay on in a
part-time capacity at least for the next year.
As usual the activities of our trainees continue to
enhance our otherwise quiet lives. We were not
person. As
surprised to find Graham Knottenbelt, SpR, in a
"New Woman" magazine article entitled 'Hero's
you can date'! I'm not sure how many women have
responded as Graham has now moved on to pastures
new at Frenchay. Georgina Howard-Alpe, SpR, is
soon to transfer to London following her recent
engagement. Philipa (tigh| Seal has been a great
asset as a LAS, and has just been appointed to a
LAT. According to Peter Ford, amongst other things
Philipa has great talent for ice climbing. Fiaz
Choudhary was a surgical trainee from Blackburn
who has seen the light and is now an Anaesthetic
SHO. Fiaz loves fast cars, which he parks amongst
the trainee's Porsches and Audi TTs (yes, they are
being paid too much). Dr Caroline Collins is our
new SHO, probably the last appointed by the
outgoing College Tutor Alastair McCrirrick. As
for discerning anaesthetists. Mind you with all the
disruptions and changes that are taking place in the
department, travelling abroad for a bit is probably
the best thing to do . . .
The threatened evacuation from the current office
space and common room is now imminent as the
builders move in to complete the new Plateau Build
over what has currently been a very convenient car
park for the department. New cardiothoracic and
intensive care facilities, Peninsular Medical School
space, library and offices will unfortunately split
what has been a very functional compact unit into a
number of areas within the hospital site. Many will
find their offices have moved away from theatres
and outside the main hospital to half way up the hill.
We all wait to see how it will affect the efficiency of
the system. Liz Rawlings has been one of our
globetrotting anaesthetists of late teaming up with
Mike Inman in his continued support of the ORBIS
group, who travel the world giving eye-surgical aid
to developing countries. She has had three visits to
date in Tanzania, Ethiopia and the Philippines and
subsequently enthused Chris Seavell to have a
similar visit to the Philippines himself. The
department is currently hosting one of Liz's
always, Alastair is a great judge of character, ability
and physical attributes. We also have Jim Moriaty
acquaintances from Ethiopia.
and surgical trainees Zoe Harclerode and Nairu
Thairu on ICU. Richard Berringer who was with us
Suzanne Carnwight entered into wedlock whilst Tony
and Claire Cafiwright produced a son (Oliver James),
as did Paul and Phillipa Hynam (Joseph). The list of
successful examination candidates has also been quite
as a locum has been appointed to an SpR number
Bristol and Matt Thomas has left for the BRL
in
Congratulations to our SHOs Rachel Prout, Rob
Price, Neil Rasburn and Alex D'Agapayeff who
have all passed the FRCA Part I exam at the first
attempt. Alex did ask me not to mention his new
Porsche but as he's looking for a new girlfriend . . .
I'm only trying to help!
Although no one in the department has sustained
any ski related injuries Rob Price, who normally
cycles 60 miles/day, was knocked off his bicycle
and this resulted in a long absence from work. I am
happy Rob's back with most of his body
functioning. My friend and ex-gym buddy SHO
Alice Braga will shortly be going on matemity leave
before the birth of her frst baby. Alice will retum
as a
On the splicing and production front, Tom and
impressive of late and is reproduced elsewhere in this
joumal. Sponsorship forms are already beginning to
appear for the next London Marathon, with Jenny
Benton running for NSPCC and Simon Courtman,
awaiting his new consultant job here in May, running
for the Plymouth Kidzz and we look forward to the
photos taken on the finishing line!
Perhaps
that is going on
levels are low and there are few juicy snippets to
spice this latest account. No doubt everyone is
gearing up for their next appraisal and are wringrng
their hands on over how many PAs they should be
signing themselves up for. Ah well I'm sure a bit of
aprds-ski
flexible SHO,
it is all the disruption
around us that is slowing everyone up but the gossip
will resolve the issues . . .
Andy Burgess
More happy news in the autumn issue.
Belinda Pryle
Southmead
Plymouth
Springtime once again in the West Country and the
annual pilgrimages to snow capped mountains
abroad are in full swing. Belle Plagne and Whistler
have suddenly becoming great centres of learning
l2
One year older and deeper in debt or, in our case, a few
months older and deeper in debt. I could stop there, as
that just about sums up Southmead since Autumn
2003. However, that would be to deprive you of all
our exciting personal developments. So keep reading.
Mark Pyke has finally taken up his consultant
post a year after being appointed.
If rumour is to be
believed it wasn't a dead cert that he would come
back from Auckland, but we're very glad he did.
Some of my colleagues describe him as 'tiggerish'
and I think that captures the essence of the man.
He's obviously undergone some form of
brainwashing as he took me on one side the other
day and asked if he could do some obstetric
sessions. He will probably have to move out of the
office he shares with Colin Hall once that news
breaks. Another new arrival, weighing almost as
much as Mark, is Tom Brederode: son to Alex and
Pia. The whole family has now disappeared off to
South Africa but I'm told this is temporary.
The trainees have had a very successful few
months. Priya Gauthama, Indu Sivanandan,
Andrew Johnson and Simon Ford all passed the
Primary and David Healy passed the Final FRCA.
Priya has now gone on to an SpR rotation in
Leicester and this means she can now live with her
husband in what some consider quite a radical
move. Andy Evans has gone to the Welsh SpR
rotation and Sally Baxter (after only a month with
us) has secured a place on the Wessex rotation.
Will English will be staying in Bristol as an SpR so
at least we've managed to retain some of our
trainees. It's good to see Manoj back (no pun
intended) after his recent prolapsed disc. I don't
think I've ever seen anyone try so hard to come
back to work against medical advice.
What else of interest? Well, I'm not sure if there
is any truth in the story that North Bristol funded the
ill-fated Beagle mission but it would explain quite a
few things in the finance area. And finally as usual
the Christmas party was a great success. This was
not least because of the great turnout by our ffainees.
Maybe we are doing something right (apan from the
free booze of course). Indu and Priya looked so
beautiful in their Saris that those of us wearing jeans
felt distinctly underdressed and resolved to do better
next year.
Fiona Donald
Taunton
A complete revamp of Musgrove's management
structure has resulted in the hospital being divided
into four divisions each encompassing groups of
many departments. Clinical directors have gone and
being replaced by several lead clincians with an
associate medical director for each division. Needless
to say a handsome array of management and support
staff have stepped in to help fiIl up all the increased
numbr of meetings everyone
seems to attend.
Fortunately within Anaesthesia our departmental
masters and trainers have worked acidulously in
maintaining staff and trainee numbers to everyone's
benefit. Amongst the SpR ranks are Juliette Lee,
Colin Goodson, Will Fox, Mike Duffy, Dominique
Mumby, Anna Macdonald and Ross Davis. We are
shortly to welcome back Boris Donovan after a stint
last year, and Rebecca Appelboam who starts with
us imminently.
We have been equally lucky with our SHOs, both
in their abilities and their successes. Toppling off the
increasingly lengthy perch have been Matt Ward,
Yen Lim, and Joe Loader who recently left Taunton
to start substantive SpR schemes. Next along are
Simran Minhas, Tom Rawlings and Gareth Gibbon
who celebrated their passing of the primary FRCA,
and following them are Melanie Knight, Michael
Moncreiff, and Hannah Wilson who started in the
Autumn, and Asha Naik and Simon Hebard who
joined us recently.
The permanent staff have had their moments - I
have suffered the absence of two colleagues for a
while due to injuries
-
one from a stepladder
(requiring shoulder surgery) and the other by falling
off his bike in pursuit of an overly fit orthopaedic
surgeon. I always thought that this fitness thing was
rather dangerous. More positively a welcome
contribution to the service gap has been made by the
arrival of two new staff-grades, Andreas Kraemer
and Ali Khawaja who began this month. This will
also help out with the evening orthopaedic trauma
rota, so good news all round.
Planning blight is now likely to supervene over our
hopes
for a surgical unit rebuild: - the DTC in
Shepton Mallet and our application for foundation
status is now pre-occupying the mandarins, so our
foundation-free single storey 1940s'temporary'
surgical block will probably soldier on for a while yet!
More news from the front next time.
Tim Zilkha
Torbay
Our local evening newspaper has just announced
that five million pounds of Lottery money (via the
Heritage Lottery Fund) is to be made available for
restoration work to be carried out on Torre Abbey,
right here on Torquay sea front. Founded in 1196 by
an Abbot and six canons of the Premonstratensian
order, (its origins being in Pr6montr6, forty miles to
the north west of Reims) the Abbey had
considerable influence over vast areas of the land
until its dissolution in 1539. h 1662 it was acquired
by Sir George Cary of Hampshire, and after seven
generations, and some remodelling, it passed to
l3
Colonel Lucius Cary and his wife, Louisa. She
Torre Abbey.
amount of work fundraising
the SASWR
oth of her children having
09 enough money had been
raised for her to open the Louisa Cary Children's
Ward in the old hospital in the centre of town. To
this day our children's ward carries her name. It is
satisfying to know that public money is now able to
help in serving the memory of one who, some
hundred years ago, was so generous to the people of
Torbay. Torre Abbey became the property of the
town in 1930 and offers the most fascinating tours.
Closer to home I can report that the Department is
under the care of our brand new chairman, Andrea
Magides. Having completed his term of office,
Jeremy Ackers has returned to the ranks with flying
colours. The Department owes much to Jeremy for
his hard work and dedication during the past few
years. His knowledge and wisdom made him a
reference point for all of us that, with time, we
during May 2
sea front. Mick has a superb record for organising
medical conferences and we are confident this one
will be a cracker, most likely with a CCU flavour.
The hospital's new Cardiac Unit is now finished
and open. The coronary beds, acute chest pain
evaluation unit and office facilities are il what used
to be the Lily Deny Day Unit (for the elderly). In
those days it had a piano. Now it is all pastel and
posh. A new building adjacent to this is the catheter
suite where all the angiograms and permanent
pacemakers are done, and the X-ray machines are
smooth and sensuous.
impressive development.
All in all it is a very
The Department's Christmas dinner at The
rather took for granted. We give our best wishes and
support to Andrea in her new and awesome venture!
Following some months as a locum, Mary Stocker
is now a proper Consultant with us. The transition
has been seamless as we have become quite used to
seeing Mary
in the Department on and off for
several years (some time ago Mary was also an SpR
here). Our congratulations and best wishes are
sincere. We also extend a warm welcome to SHOs
Ana Rota (from Madrid via Plymouth), Jenny
Docherty, John Fisher, Sam Milsom (from ICU),
and David Trenam (on attachment from Adelaide),
and to SpRs Yen Lim, Joe Loader and Gavin
Werrett. Congratulations go to Suzette Kruger
(SHO) and Rob Aldwinkle (SpR) on rhe occasion of
their engagement; they have gone off to work in
Tasmania for a while, and we eagerly await their
first batch of photographs.
As Clinical Tutor, Nuala Campbell is busy setting
up our Foundation Programme, which, for those of us
having trouble keeping up with events, I believe is
how newly qualifred doctors will be steered in their
initial hospital jobs. This should be up and running by
Department; a highly recommended practice and
one I commend to you. Eating seems to feature
strongly down here; the office usually looks like a
siege is imminent, and the sandwich trolley that
tours theatres in the morning resembles seagulls
round a chip bag.
Do come down to visit us this summer. Have a
look at Torre Abbey, but make sure it's not going to
be closed while they spend all that Lottery money!
Ian Norley
Taumarunui
It's bulletin time again for Anaesthesia points West,
and as usual I am two days behind the deadline
already. I'm just hoping fhat also being 12,000 miles
ahead will franslate into this reaching the editor more
or less on time.
There has been much discussion in New Zealutd
the time the first group of Peninsula graduates
emerge. The Critical Care Unit continues to thrive
with the imminent arrival of plenty of new equipment
including intracranial pressure measurement
apparatus and an ultrasonic machine capable of
examining the hearl CCU doctors are in training to
use this equipment themselves. In May this year the
Intensive Care Society meeting is being held in
Torbay under the watchful eye of Dr Mick Mercer.
The meeting will be in the English Riviera Centre,
just a few hundred yards from the afore-mentioned
t4
practitioners' (i.e. nurses who had authority, in certain
situations, to diagnose and prescribe) would also
without any further legislative change - permit them
to give anaesthetics. Two, the Govemment deemed
this to be a 'Good Thing'. Since the Govemment has
be
y well published 'shortages' of
an
curtailment of surgery in rural
ho
to see how the prospect of nurse
anaesthetists might be enormously tempting and they
were initially undaunted by the conspicuous lack of
enthusiasm in the anaesthetic world. (It was
interesting to note there wasn't vast enthusiasm in the
nursing world either.) So the great and good in
College and Society proceeded
to
hammer
Government (and public) with a series of questions,
mostly couched in nice simple terms, viz. 'Do you
know what an anaesthetist does? And, why we train
so long to do it? Do you know who will train the
nurse anaesthetists (given that it's already hard
enough to get sufficient hands-on experience for
history
-
arm fracture sustained in a fall from her farm
bike!) arrived alone to be anaesthetised for her
mastectomy, one of our theatre nurses kindly offered
to hold her hand. 'I'm sorry it isn't Tom Cruise' I
remarked as I picked up the Propofol. 'Oh, I don't
think much of him' she responded, adding in a
'I'd rather have Sean Connery'. She
went off to sleep with a happy smile and cruised
through the procedure. I'm told she was seen that
predatory growl
same evening, marching purposefully down the ward
indemnify them? Do you realise that there isn't
actually an anaesthetic shortage; what we have is a
corridor, dragging the i.v. pole behind her with one
hand whilst conducting a spirited conversation into a
cellphone held in the other. I'd like to think this was
the result of her high-quality anaesthetic, but honesty
compels me to admit that it more probably relates to
problem of maldistribution? Can you think of a single
reason why a nurse will be any keener than a doctor to
work a 1:2 roster in a remote location with limited
her own indomitable personality.
I hope I have as much spirit when
hope my anaesthetist will be a doctor!
existing anaesthetic trainees)? Do you know who
will
support staff and a snowflake's chance of getting
locum cover for annual leave or CME? Are you
aware that the obvious pools from which nurse
anaesthetists might be drawn - the theatre and ICU
- are already excruciatingly short-staffed?'
And so on, and so on. It gradually began to dawn on
nurses
Govemment that the answer to all the above questions
was'No', and that - without, of
course,
acknowledging that they might have made a mistake the introduction of nurse anaesthetist was perhaps after
all not a good thing. We gather that the idea has been
quietly shelved. Personally,
I'd give it
about seven
years before some bright spark in the Departrnent of
Health drags in out and dusts it off, and we have to go
through the same thing all over again.
We anaesthetise a lot of small children, and have
long been sympathetic to parental presence at
induction. Over the years, this has come to mean not
only one parent but often two, and a random selection
of any - or all - of step-parents, aunties and interesting
siblings of all ages from infancy to adolescence. No
one so far has brought along the family dog but I'm
sure it is just a matter of time. The interesting thing is
that it has gradually extended to our adult patients as
well. I can't
actually pin down when this started
happening but it is now rather unusual for us to
anaesthetise anyone without a friend or family
member by their side for moral support. We don't
hnd it a problem but it does have its moments. One
neryous young man recently was accompanied by his
very attentive girtfriend. As he was induced she took
his hand in an affectionate grasp and began singing to
him in Maori. We weren't quite sure whether to show
her out when he succumbed to the Propofol or wait
until she'd finished the verse!
So, when an 80-year-old-lady (recent medical
I'm 80 - and I
Heather Cosh
Truro
Welcome from the far west. I've just retumed from
a half term holiday and when
I left the NHS
headless chicken season was in full swing. Targets
were due to be breached, managers were making up
lists left, right and centre, inherited debt was about
to swamp the Trust, and Execs were holding special
meetings to exhort us to work evenings and
weekends to save star status and funding. I've
retumed to find that stars have sunk without trace,
and four e-mails demanding the immediate
submission of my job-plan due last week. Yet there
still appears to be confusion as to what is happening
about contract implementation. Surprise, surprise.
In a perverse way it is rather reassuring that the
chaos persists because it would be quite unnerving
to find it all sorted out and running smoothly.
We continue to expand. We have appointed
Howard Thompson and Keith Mitchell to replace
Paul Griffiths. Sam Banks and Harald Marstaller
have replaced Roz Harrison and Tony Simcock.
Roz retired before Christmas. Sheilah Curry has
also called 'Time' and retires next month. We have
both exchanged and expanded our junior staff
numbers. Ronelle Mouton left us for an SpR post in
Bristol. Jonathan Chambers got his number in
Southampton. Kim Williams moved up to Oxford.
Owen Judd returned to Plymouth to pursue his
stated aim of becoming a paediatric neurosurgeon.
Drs Biddulph and Edwards are learning the ropes
as
PRHOs. We have taken on Drs Everett, Ross,
Sharaf, Joseph, Gill and Wells as SHOs. At
Registrar level, Drs Sweeting, Haddon and Marshall
have joined us. Drs Randall and Verdonlini from
l5
the anti@es, have been ITU Fellows. As locum
Cmsultants we have Drs Eaton and Probert, also
fim
the Southern Hemisphere. There seems to be a
new face every day. We are having a spring party
next month just to find out who works in the
deparment!
The new Medical School building is now clad and
€lazed, it looks more like the Queen Mary 2, and it
might be ready for students in September. Best of
luck Paul Upton! Come May, we might have time
to contemplate what to do with the students when
they do arrive. They will be good for us and I hope
will rattle us in our well-worn grooves.
Congratulations to Richard Walker on passing the
FRCA Part 2 and to Katy Leuchars for passing the
FRCA Part 1.
Dr Taylor-Wisdom?
I wish you the best of luck with your new
contracts.
Bill Harvey
UBHT
Obi wan Johnson has officially retired. It is a time
of mouming particularly for David Hughes who is
left with the role of Medical Director just in time for
the job planning process. Dr Johnson was gracious
in his delight at all who turned up for a wonderful
retirement evening at the Orangery. Claudia Paoloni
showed once again how to entertain with Italian flair
and style as she had done earlier on in the year when
the HMC bank account was emptied to provide a
similarly stylish dinner at theZoo in November.
Frances and Les spoke eloquently on the many
roles that had benefited from Bob's personality and
that they were sure that his new role as Bob the
Builder was to be his most demanding yet. He
declared that the responsibility that had given him
Drs Shutt andThornton- maturity?
the most satisfaction and pride was that of Senior
Registrar co-ordinator and there are many consultants
around the country that can be grateful to that.
There are plans afoot for pan Bristol anaesthetic
and HMC balls in the summer. It appears that the
tribes are uniting across the city.
Les Shutt was awarded the John Snow medal for
his services to the College over the years.
New arrivals for Thys de Beer, Simon Lewis and
Mary Darko-Sarkwa. A special congratulations to
Daniella Tonucci and Chris Langrish whose
daughter was bom one week before her mother sat
and passed the FRCA (Breast pads carefully
positioned during the viva!).
I leave with two photos to prove to trainees that
the hard and long road trodden by a consultant
results in the growth of great wisdom and maturity.
Rebecca Aspinall
Western-Super-Mare
The main topic of conversation within the
Dr Johnson entertqins.
l6
department in recent months has been the process of
- meticulously kept - have
job planning. Diaries
been analysed, statistics calculated and re-calculated,
meetings have been held, and the conclusion is . . .
that we do a lot of out of hours work. Clearly the
demand to expand the department is greater than
ever. We continue to rely upon a small number of
locum Scandinavian colleagues to fill the gaps and
they have become honorary members of the
department. There are consolations in this
arrangement, in that these colleagues are a useful
source of knowledge of what is going on in the wider
world and often give valuable contributions at our
monthly audit meetings. It is evident that many of
the problems that we thought were unique to the LIK,
such as a shortage of beds necessitating the
postponement of elective surgical admissions, exist
elsewhere. With our increasingly close relationship
with ow Swedish friends we were surprised to leam
of the setting up of a Society of Anglo-Swedish
Anaesthetists with its inaugural meeting to be held in
London. Perhaps this was an oppornrnity lost for us.
In the past six months Izzy Iqbal and Ali
Cloughley have moved on to Bristol - we shall miss
their invaluable help. A farewell do was held at the
Avon dry ski slope - the nearest some of us are
going to get to the ski slopes this winter.
Consolations of being on leave when jotting down
these notes are: that I don't feel the need to keep a
diary of what I have been doing for the past half
hour and that I don't have to classify each half hour
as direct clinical care, Supporting Patient Activity
etc. I suppose that, if at work, I would include these
few minutes as external duties. Instead I think it's
coffee time.
Fran Turner
Society of Anaesthetists of the South West Region
REGISTRAR PRIZE: f,500
Entries in the form of an essay of about 2000 words on any topic related to
Anaesthesia and Intensive Care to be submitted to the Hon. Secretary, Dr K Holder,
Southmead by end July 2004. Winning entry to be presented at the next meeting of
the Society.
Society of Anaesthetists of the South West Region
ODANURSE PRIZE: f,500
Entries in the form of an ossay of about 2000 words on any topic related to
Anaesthesia and Intensive Care to be submitted to the Hon. Secretary Dr K Holder,
Southmead by end Jily 2004. Winning entry to be published in the next edition of
Anaesthesia Points West
t7
Examination Successes and Honours
Bristol School of Anaesthesia
Finat FRCA
Dan Low
Dave Healy
Frenchay
Southmead
PrimaryFRCA
Lisa Penny
Emma Patrick
Rachel Prout
Cheltenham
Cheltenham
Gloucester
Gloucester
Gloucester
Gloucester
Southmead
Southmead
Southmead
Southmead
Alex D'Agapayeff
Rob Price
Neil Rasburn
Priya Gauthama
Indu Sivanandan
Andrew Johnson
Simon Ford
South West School of Anaesthesia
Final FRCA
PrimaryFRCA
Major R Thomas RAML
Gilly Ansell
Richard Walker
Gavin Werrett
Plymouth
Plymouth
Truro
Truro
Dr I Mell
Major C Ackroyd RAMC
Major P Moor RAMC
Dr J Read
Dr L Bundy
Dr F Jackson
Flt Lt P Gillen RAF
Dr K Chisti
Katy Leuchars
Plymouth
Plymouth
Plymouth
Plymouth
Plymouth
Plymouth
Plymouth
Plymouth
Truro
SOCIETY OF ANAESTHETISTS OF THE SOUTH WEST REGION PRIZES
Regishar Prize
President's Prize
Feneley Travelling Fellowship
Dr Guy Jordan
Dr Hassan Abuzaid
Dr Sarah Hodges
18
- sorry! I
Bath
Plymouth
success or any other honoar acknowledged sndwho has not
can only publish the names sent to me by each department's
SASWR linkman and College Tutor.
Ifanyone who should hsve had an exsminstion
been included
Frenchay
Anaesthesia Points ll'est VoL 37 No.
I
Meeting Report
The Society of Anaesthetists of the South West Region
Autumn Scientific Meeting
The Watershed Conference Centre, Bristol
21-22 November 2003
Dr Kathryn Holder, Honorary Secretary SASWR
The most recent Society meeting was certainly
memorable. Those of you, who were not there,
missed a good one. It was a wet and grey November
meeting, but with an English rugby victory on the
Saturday, nobody cared. More of that later . . .
Annual General Meeting
Lunch
The Watershed provided an abundance of
delicious food and it was whilst eating her share
that your Honorary Secretary heard voices of
concern from many Society members about the
World Rugby Final, which was taking place at
the same time as Session IV on the Saturday.
Dr Jenny Eaton, President SASWR, chaired the AGM
With England in the final, it became quite
reports and business, which included the pleasures of
awarding the President's prize to Dr Hassan Abuzaid
of Bath and the Feneley Travelling Fellowship to Dr
Sarah Hodges for her work in Uganda. Honorary Life
Memberships were awarded to Dr P Baskett, Dr B
Hudson and Dr M Inman and a presentation was given
match on to the cinema widescreen for the
Society to watch, if that was wanted. This
about next year's abroad meeting in Bologna. We
were joined later in the day by Dr Claudio Melloni and
his wife Christina who would be assisting with the
arrangements for the Bologrra meeting. Finally, Dr Les
Shutt was installed as the next president.
Dr Jenny Eaton, President SASWR and Dr Hassan
Abuzaid of Bath
obvious that there was going to be no-one present
at the SASWR academic session. Fortunately,
the Watershed staff were amenable to change and
Ray the technician said that he could project the
suggestion was fantastic and so the speakers were
hastily rescheduled (very willingly
I might add,
once they realised they could come and watch the
match) and Saturday morning completely
re-arranged.
Honorary Lift Membership
conferred on Mike Inman.
l9
Friday Academic Programme
Dr Les Shutt, President SASWR, welcomed the
Society members to the Bristol meeting before
introducing Dr Simon Massey (BRI) to chair the
first session
- 'Should we use Doppler for central
access?' The speaker for the motion was Dr David
Scott, Edinburgh, and speaking against was Dr Alan
Cohen, BRI. The two knew each other and had
fought this argument before, with Dr Cohen winning
that vote, so it was with slight trepidation that Dr
Scott had come to Bristol.
Both speakers gave excellent arguments,
illustrated with literature, data and their own
experiences. There were plenty of questions and
Basil Hudson receives his Honorary
Membership.
Lift
opinions from the audience before the vote and this
time Dr Scott was the victor! His final comment
was to praise the more discerning audience of
Bristol!
After tea, the Trainee Prize session was a new
venture. Three trainees each presented of their
entries and the judges
Dr Andy Black, BRI and Dr
asked questions, before
deciding on the winner who would be announced at
the end of the afternoon. First up was Dr G Jordan,
-
Les Shutt, President
-
Frenchay, with his talk 'Hypothermia: a case
presentation' followed by Dr J Loader, Taunton,
with 'A case of unexpected intraoperative malignant
hypertension; non-diagnosed paraganglioma'.
Finally, Dr Curtis Whittle, Southmead presented his
paper 'Medical exploits in the Gulf'. All excellent
presentations in different ways and not easy to
choose between.
The final session was the Humphrey Davy lecture
given this year by the President of the Royal College
Peter Baskett receives his Honorary Life
Membership.
of Anaesthetists, Dr Peter Simpson. This lecture,
'Whither Anaesthesia' addressed most, if not all, the
current medicopolitical issues worryilg anaesthetists
and mentioned the number of tasks, other than
clinical anaesthesia, that we find ourselves obliged
to do so that there is little time left for teaching.
Predicting consultant numbers is a difficult problem,
but Dr Simpson thought that we might find
ourselves in a similar situation to Obstetrics and
Gynaecology a few years ago, with a lot of trainees
holding CCST but without consultant jobs to go to.
At the end of his lecture, Dr Simpson was
presented with the engraved Bristol Blue glass
ship's decanter that is traditionally given to the
Humphry Davy lecturer. The President, Dr Shutt,
made the presentation before turning
Jenny Eaton hands over to new President Les Shutt.
20
to
the
announcement of the Trainee prize-winner. The
judges had chosen Dr Guy Jordan who received a
By now it was well after 11.00pm and as there
was no band for dancing, people gathered around the
bar to continue catching up on the news and gossip.
Saturday Academic Session
has never begun a session with
England playing in the World Rugby Final before.
The audience was initially quiet, but when extratime had to be played, and then Johnny Wilkinson
I bet the Society
did his drop kick, well 'the crowd went wild'.
Special thanks must go to the Watershed staff for
making it possible for us to watch the match on the
Les Shutt thanks Peter Simpsonfor the Humphrey
Davey lecture.
cheque for f500. The new format for the prize had
proved very successful.
Partnerst Programme
While the Friday Academic programme was taking
place, fifteen partners visited the Bristol
Commonwealth and Empire Museum. Their
excellent guide, Mai Sainsbury, made the visit so
interesting that Ursula Johnson has decided to take
Bob there very soon! The aftemoon was complete
with tea before the coach trip back to the hotel to get
ready for dinner.
big screen.
Having to squeeze the rugby in meant that time
was now tight so after a quick coffee the audience
took its seats for Session IV - 'What's Happening
Now?' This update session was chaired by Dr
Jonathan Wills, Southmead, and really was
excellent. Dr Kate Thornton, Frenchay, talked on
'Bums in the South West' and reminded us of the
Parkland formula for fluid resuscitation and showed
slides of good scar-free healing that can result
especially when patients have surgery early. 'Infant
Cardiac Conditions' is a subject that worries and
confuses many, but Dr Stephen Marriage, PICU,
Bristol Children's Hospital, simplified it and
explained when oxygen and prostaglandins would
help.
Finally, Dr Alex Manara, Frenchay ran through
the nitty gritty of 'Non-heart beating organ
Society Dinner
donation' and showed comparable results with heart
bearing donation. Apparently, relatives are more
willing to agree to organ donation in the non-beating
heart situation and as well as a lot ofrenal, there has
Glamorously clad, the Society's diners gathered at
the President's Reception for pre-dinner drinks. The
King's Room provided a good atmosphere for the
now been a successful non-heart beating lung
donation. This session was of a very high standard
and very interesting. It was a shame that time did
sumptuous dinner after Dr Shutt had said grace. We
dined on venison followed by Bath soft cheese
stuffed with morels(!). Our guests were Dr David
not permit more lengthy discussion.
Scott, and Dr Claudio Melloni and his wife
Christina.
Once the food and most of the wine had been
consumed and the coffee had been served, Dr Peter
Simpson, proposed the toast to the Society and Dr
Shutt then thanked the Honorary Secretary and Kate
Prys-Roberts for organising both the meeting and
the dinner. There were flowers for Mrs Simpson,
Kate Prys-Roberts and the President's wife, Merle
Shutt, and presentations to Christina Melloni and Dr
Kathryn Holder. With the Carters abroad, there was
no betting on the speeches!
Society Lecture
After a swift coffee break, Dr Shutt introduced the
Society lecturer, Mr Chris Jarvis from the Bristol
School of Business and Management in London. Mr
Jarvis' subject was 'Isambard Kingdom Brunel - a
man for our times and our contexts'. He had become
interested in Brunel when he was asked to set up a
website some years ago and picked this as his topic.
His enthusiasm was very obvious as he took the
audience on a meander through snippets of Brunel's
life. We heard about his father and his relationships
with Russell, who he worked with on the SS Great
Eastern project, and George Stephenson who he
2t
worked with on the Great Western Railway. Brunel
is full of our idiosyncrasies, politics, passions,
challenged engineering preconceptions, pushing
ideas to the edge and yet he made mistakes (and
sometimes admitted to them). From the Brunel
story we leamed that we are still making the same
human mistakes as were made then. The same
problems of managing complexity and interaction
exist. The conduct of managing things, ourselves,
and others, purports to be rational and logical, but it
abilities, frailties and inconsistencies. Very thought
provoking.
lt now only remained for the President Dr Shutt to
close the Autumn meeting. He ended by saying that
the meeting would be remembered as the one with
great'science, sport and social events'!
The next Society meeting will be in Bologna,
Italy on May l4th - 15th2004.
FENELEY TRAVELLING
FELLO\MSHIP
A variable sum of money awarded annually to support a "mission
Applications to Kathryn Holder, Hon. Sec. Southmead
22
abroad".
Anaesthesia Points West Vol. 37 No.
I
Meeting Report
South West Association of Children's anaesthetists
Annual Scientific Meeting Report
The meeting was held on Friday 24th October 2003
at the Castle Hotel in Taunton. This has become our
regular venue owing to the central location in the
region, great food and good facilities. The feedback
suggests that an enjoyable day was had by all and it
is very rewarding to get comments like 'pleasant,
friendly and informative meeting; very varied and
The third session was chaired by Dave Gabbott,
Gloucester who orchestrated the 'Trainees
Presentations'. The four trainees each had 10
minutes to present their work with five minutes for
questions, and the prospect of a prize for best, as
judged by Neil Morton from the Royal Hospital for
Sick Children, Glasgow and John Leigh,
informative meeting'. As usual the content was
Southmead. Rob Price presented an audit of the use
mainly provided by the hugely talented anaesthetists
we have in the South West and we are grateful for
the generous sponsorship from Abbott Laboratories,
B. Braun, Intavent Orthofix and Intersurgical.
The meeting was opened by the current President,
John Leigh, Southmead and moved swiftly into the
first session chaired by Mike Walbum, Taunton. A
useful update on Asthma was given by Steve Sale,
SpR, Southmead who brought us all up to speed on
of pain assessment charts on the paediatric ward at
Gloucester Royal Hospital; Jan Hanousek
the most recent guidelines for management of
asthma in children.
The second session - the 'Controversies' proved as entertaining as ever. The first topic was
'MUA - to intubate or not to intubate. That is the
question.' Simon Courtman, Plymouth put the case
for intubation and Rob Aldwinkle, Torbay for not
intubating children who present with broken bones
requiring straightening under anaesthesia. They both
presented educational and informative reviews of
the available evidence, which, as always, amply
supported both viewpoints! If I remember correctly
the audience were clearly swayed by Rob's risk
benefit analysis and a small majority voted that
intubation was not always necessary. The second
topic for debate was that 'antiemetics should be
given routinely for tonsillectomy in children'.
Alison Carr, Plymouth proposed the motion and
seemed to have the majority on her side as the predebate vote showed that most of the audience felt
that antiemetics should be given. However, the
arguments against routine use given by Judith
Nolan, Bristol Children's Hospital were robust and
the audience was swung against routine use of an
antremenc.
presented an audit of paediatric day case surgery at
Torbay Hospital; Vanessa Helliwell presented a
retrospective survey of all children anaesthetised in
Exeter over a 12 month period and Julian Berry
from Plymouth won the trainee prize with his
entertaining and informative presentation
of
'a
paediatric pain snapshot: evidence of progress'.
One of the aims of SWACA is to survey and
audit practice within the region and the final slot
before lunch was taken by John Walton,
Southmead who presented the findings of his
survey of sedation practice for children within the
region. It was interesting to see the variation, and
deviation from published guidelines such as those
produced by the Scottish Intercollegiate Guidelines
Network (SIGN). Perhaps some registrants were
inspired to look more closely at what is going on in
their own units.
The precedent has been set. The selection of the
luncheon menu is now part of the Presidential role
and the Blackdown sausage with bubble and
squeak followed by crbme brulee selected by John
Leigh were reassuringly good!
Following lunch John Leigh introduced the guest
lecturer who was Neil Morton from the Royal
Hospital for Sick Children, Glasgow. Neil is an
international authority on pain management and
sedation in children and gave an insight into his
experiences of implementing current guidelines most of which he has been instrumental in writing!
SWACA has had a guest lecture each year but this
was the first time we had invited a speaker from
23
outside the region and
be repeated annually.
it is something,
which will
Martin Wolfe, Guernsey, chaired the final
approaches and techniques involved,
It was a very
practical update on an important core topic and
greatly appreciated by the audience.
session of the day 'management of the child with
an inhaled foreign body'. This had been plarmed as
The meeting was followed by the AGM and
then, in the evening, the annual SWACA dinner
a surgical and anaesthetic double act but
with delicious food, fine wine and pleasant
unfortunately a crisis prevented Eleri Cusick from
Bristol Children's Hospital (BCH) appearing to
present the surgical component. How many of you
realised that the paediatric surgeons at the BCH
deal with inhaled foreign bodies rather than ENT?
Pat Weir gave an excellent presentation of both the
surgical and anaesthetic aspects of this topic, using
company.
Next year's meeting is being held on Friday 10th
September in Guemsey in the Channel Islands. If
real cases and great pictures to clarify the
24
you would like any information please contact
Nicky Williams in the Anaesthetic Department at
Gloucester Royal Hospital.
Nicky Williams
SWACA Secretary
Anaesthesia Points West Vol. 37 No.
I
Article
-
Anaesthetic Management of Sickle Cell Anaemia
Three Cases from India
Dr
S. P. Nandalan,
MD, DNB, FRCA'
Dr N. K. Geetha, DA, MD'
tspecialist Registrar,
Anaesthetics, Gloucestershire Royal Hospital, Gloucester GLI 3NN
(Formerly: Lecturer, Anaesthetics, Christian Medical College, I/ellore, India - 632004)
'Head of the Department, Anaesthetics, Malabar Institute of Medical Sciences, Calicut, Kerala, India
(Formerly: Professor of Anaesthesia, Christian Medical College, Tellore, India - 632004)
-
673016
Correspondence to: Dr S. P. Nandalan (spnandalan@joctors.org.uk)
Summary
We present three cases of sickle cell anaemia from
the Christian Medical College, Vellore, India. All
three underwent general anaesthesia for hip surgery.
We focus on the perioperative transfusion strategy
Table 1: Haemoglobin electrophoresis values
before and after transfusion in Case I
Type of
After
Ilaemoglobin
Before
Transfusion
Transfusion
employed.
HbA
7A%
63.8%
Keywords
HbA2
5%
s.4%
Sickle-Cell-Anaemiq, Haemoglobin-5, Blood-
IIbF
t4%
5o/o
Transfusion, Preoperative-P eriod
HbS
73%
25%
Other Hb
0.6%
03%
Total Hb
6.9 e.dl-'
13.6 e.dl'
Introduction
of sickle cell anaemia from
the Christian Medical College, Vellore, India. All
three underwent general anaesthesia for hip surgery.
We focus on the perioperative transfusion strategy
halothane. Precautions were taken to avoid
employed.
hypothermia by the use of a warming mattress, fluid
We present three cases
Case Reports
Case
l:
A 22-year old, otherwise fit, girl from West Bengal
with sickle cell anaemia was scheduled for total hip
replacement (THR) for aseptic necrosis of the
femoral head. Investigations showed serum
haemoglobin (Hb) of 6.9 g.dl'', normal blood count
and platelets, normal liver and renal function. As
per the haematologist's opinion she was transfused
four units of packed red cells. Table I shows the IIb
electrophoresis values before and after transfusion.
General anaesthesia was given using thiopentone,
pancuronium, morphine, oxygen, nitrous oxide and
warmer, and airway humidifier. The oxygen
saturation was maintained at 98-100o/o, with a FiO2
of 0.5. The end tidal CO2 was maintained between
34-38 mm Hg. We ensured liberal intravenous
hydration. The patient's vital parameters were
normal in the intraoperative period. The blood loss
was estimated to be 500 ml and was replaced with
one unit of packed red cells. Postoperative Hb was
12 g.dl'.
Case 2:
An l8-year old boy from West Bengal with sickle cell
disease and aseptic necrosis of right femoral head was
scheduled
for a THR. As
advised by the
25
Table 2: Haemoglobin electrophoresis values
before and after transfusion in Case 2
Type of
Ilaemoglobin
Before
Transfusion
Transfusion
IIbA
2.3o/o
249%
HbA2
HbF
3A%
3A%
15.7%
13.2%
HbS
77.9o/o
57.6%
Other Hb
0.7%
0.9%
Total Hb
7.0 s.dl-'
After
9.5
g.dl'
haematologist, two units of packed red cells were
hansfused. llb electrophoresis values before and after
transfusion are given in Table 2. It was decided to
further transfuse one unit immediately before surgery
and another unit, ifneeded, to replace the blood loss.
General anaesthesia was given with focus on
maintaining normal body temperature, optimal
hydration and avoiding hypoxia, hypocarbia or
hypercarbia. Two units of packed red cells were
transfused as planned. The Hb on the 2nd day of
surgery was 10 g.dl-'.
Cqse 3:
A
l7-year old boy from Tamilnadu was posted for
emergency arthrotomy of hip under GA. He was
diagnosed to have sickle cell anaemia seven years
previously. Investigations showed Hb of 6.8 g.dl-'.
Hb electrophoresis was not done. Other tests were
normal. The haematologist suggested preoperative
transfusion of two units of packed red cells. The
post-transfusion Hb was l1 g.dl-'.
General anaesthesia was given with precautions as
in the previous cases. One unit of packed red cells was
transfused during surgery to replace the blood loss.
The anaesthesia, recovery and postoperative period
were uneventfirl. Postoperative llb was 11.5 g.dl-'.
None of our patients had any complications
related to sickle cell disease or otherwise, and were
discharged home as per routine.
Discussion
Sickle cell syndromes are inherited disorders with a
wide spectrum of severity ranging from benign
sickle cell trait to the debilitating and often fatal
sickle cell anaemia. They are most common in
patients of Central and West African descent.
26
However, the Arabian Peninsula and the Indian
Subcontinent also have a high prevalence'. A
'Sickledex' test can identify sickling in red blood
cells (RBC). The presence of HbS is confirmed by
electrophoresis. In the absence of electrophoresis, a
positive 'Sickledex' test associated with normal Hb
is likely to indicate a sickle cell trait.
Deoxygenated HbS is 50 times less soluble in
blood than deoxygenated HbA. When HbS
becomes deoxygenated it comes out of solution
forming long crystals called 'tactoids' which
distort the RBC and cause it to become crescent
shaped. Initially this is reversible with
oxygenation but with repeated sickling in the low
oxygen tension of the microcirculation causes
membrane damage. The RBC wall becomes
brittle and permanently deformed or 'sickled'.
These cells are then susceptible to premature
destruction resulting in a lifespan of only l0-20
days as opposed to a normal 120 days. This
causes the chronic haemolytic anaemia with Hb of
5-8 g.dl-' '.
The risk factors for sickling of RBC are low PaO2
(less than 5.3 kPa in homozygote and 2.6 kPa in
heterozygote), acidosis, hypothermia, dehydration,
stasis and infection. A 'sickle cell crisis' occurs
when local blood vessel occlusion causes cell death
and organ destruction.
Anaesthesia:
The goals of preoperative preparation
are
stabilisation of haematological status, maintenance
of adequate state of hydration, and treatment of
any coexisting infection.
The anaesthetic goal is to avoid all the risk
factors that can precipitate sickling. Close
monitoring with adequate hydration and
oxygenation should be extended well into the
postoperative period.
The Role of Preoperative Blood Transfusion:
Preoperative transfusion is required if the anaemia is
too severe. This is in an attempt to increase oxygen
transport and to dilute the sickled RBCs. Though
favourable outcomes have been reported without
preoperative transfusions it has been commonly used
to prepare sickle cell patients3. The two cornmon
approaches are:
1) Aggressive therapy
below 30%o
to decrease the HbS level
2) Conservative therapy to increase the serum Hb
above l0 g.dl-'''o
A recent Cochrane
Reviewn concluded that
conservative therapy appeared to be as effective as
aggressive therapy. However, they recom-mended
further research to examine the optimal regimen for
different surgical types and to address whether
preoperative transfusion is needed in all surgical
situations. The conservative approach has also been
shown to reduce the risk of transfusion-associated
complications by 50%'.
Differing strategies were employed in our patients
with regard to their preoperative transfusion. This
transfusion can lead to stasis leading to a sickling
crisis. So we pursued a policy of liberal hydration
by infusing fluids over and above the replacements
for starvation and surgical loss.
We conclude that a conservative approach may be
more appropriate in the perioperative management
of sickle cell disease to reduce the risk of transfusion
related complications.
References
l
reflects the evolving trends. The first patient was
operated on
in
1994 and the latter two
in
1998 and
2000 respectively. An aggressive approach was
used in the first patient to decrease the HbS level to
below 30%. In the second case, after transfusing
two units, the Hb rose to 9.5 g.dl' but the HbS only
dropped to 57.60/o. Another unit was transfused to
simply improve the FIb and electrophoresis was not
repeated. The third patient was also transfused
to improve the Hb to above 10 g.dl-'.
No
electrophoresis was done.
The increase in Hb due to the preoperative
2.
3.
4.
Steensma DP, Hoyer JD, Fairbanks VF. Hereditary Red
Blood Cell Disorders in Middle Eastem Patients (Review).
Mayo Clinic Proceedings; Mar 2001; 76(3)z 285-93.
Henderson K. Sickle Cell Disease and Anaesthesia. Update
in Anaesthesia Issue 4;1994'. Article 4.
Koshy M, Weiner SJ, Miller ST, et al. Surgery and
Anaesthesia in Sickle Cell Disease - Cooperative Study of
Sickle Cell Diseases. Blood,1995; 86: 36'16-3684.
Riddington C, Williamson L. Preoperative blood transfusion
for sickle cell disease (Cochrane Review). The Cochrane
Library,Issue 4,2003.
5. Vichinsky EP, Haberkern CM, Neumayr L, et al. A
comparison of conservative and aggressive transfusion
regimens in the perioperative management of sickle cell
disease. lI Engl. J. Med. 1995; 333(4): 206-13.
27
Anaesthesia Points West Tol. 37 No.
I
Article
My Experience with Third World Health Care
Dr Hassan Abuzaid, FRCA, StaffGrade, Royal United llospital, Bath
Winner of the President's Prize 2003
Background
Inspired by a call for Sudanese doctors to visit the
Sudanese refugee camps in Eritrea to help with
provision of medical care, I decided to use my
annual holiday to do a month of voluntary work in
Eritrea.
The civil war in the Sudan is the longest and most
ignored war in Africa. In terms of human costs,
more than 1.9 million people have died in southem
Sudan and the Nuba Mountains since 1983 as a
result of the war. In 1998 alone, famine rendered
another 2.6 million people at risk of starvation,
making it the most serious humanitarian crisis Sudan
had seen in more than a decade. Fighting also has
caused massive internal displacement, leaving
millions more homeless or without lands to farm.
In addition to war, chronic political instability,
adverse weather conditions, high inflation, low
remittance from abroad and counterproductive
economic policies has made Sudan one of the
poorest countries in the world.
I visited Eritrea in November-December 1997 for
one month to help, with other Sudanese doctors and
nurses, set up and maintained a basic health service
unit for the Sudanese refugees who had fled
trip and asking for material donations. I had positive
responses from Roche, Zeneca, Biogel, Nycomed
and Portex. I received a supply of medicines,
tracheal tubes, mini-tracheotomy tubes, spinal
needles, Halothane, Diprivan and Midazolam.
I
had significant help from Bath hospital
anaesthetic department, theatre and PACU staff who
collected redundant material to be sent to the Third
world. I am very grateful to all of them for such
wonderful support.
I bought a refurbished triservice kit, a new oxygen
concentrator, a foot operated suction apparatus,
educational materials, books, journals, posters and
educational videos. A Sudanese charity shouldered
the cost of air shipping of the equipment.
Eritrea
Eritrea is an eastern African country bordering the
Red Sea between Sudan and Djibouti.
It
was
formerly an Italian-British colony which was taken
over by Ethiopia after World War II in 1945, thus
provoking a long war of liberation that culminated
in the formal independence of Eritrea afler a
referendum in 1993.
Eritrea has a 6(X) mile coast line with the Red Sea
southern and eastern Sudan as a result of the war
and settled temporarily in the safe heaven of the
Eritrean westem border.
and a population of 4.3 million made up of nine
ethnic groups each with its own language. Eritreans
are very hospitable and friendly people.
Eritrea is divided into three major zones: the
Objectives
central highlands, the eastem coastal region and the
western lowlands. A1l are within reach of Asmara,
o
To help with the training of doctors and nurses in
resuscitation, first aid, local anaesthetics and
o
sedation.
the beautiful capital, and together comprise
spectacular mountains, arid semi-desert, fertile
To provide medicines, equipment, books and
plains and sandy beaches.
o
o
educational material.
To raise the morale of the staff.
To explore further needs.
subsistence agriculture.
Preparation
I wrote
several letters to British companies
explaining the purpose of my proposed humanitarian
28
The economy is poor and largely based on
The journey from Asmara to the westem part of
Eritrea takes nine hours by car along a variable
terrain with few stops on route for meals. We were
provided with two Toyota carciage cars to carry
the equipment. We started in the highlands
characterised by a pleasant climate throughout the
year, stepping down to the lowlands with a desertlike hot weather. Along the route stand the remains
of destroyed T55 Russian tanks that once belonged
to the Ethiopian army, a testimony to the devastating
thirty years of war.
Refugees'camp
After a nine hour drive we arrived at the refugee
camp at Haikota village. I was welcomed by the
camp committee and offered a hut to stay in and
briefed on the routine of the life and work in the
camp which I soon settled into.
The refugees live on basic support courtesy of
intemational aid. The camp is supplied with a large
filtered water reservoir donated by Christian
Solidarity. There is a school for the children run by
the learned individuals of the refugees and a
makeshift hospital donated by the Sudan People's
Liberation Movement. This was maintained and run
by a Sudanese doctor and a team of nurses to serve
the whole community and became the Sudanese
National Democratic Alliance hospital. The nursing
school is part of the hospital.
supply of disposable syringes was a sensible item to
take to the hospital.
The common medical problems are malnufition,
malaria, skin diseases, sexually transmitted diseases
(STDs), pneumonia, whooping cough,
Leishmaniasis (Kala-azar), enteric fever and
Tuberculosis. There is no laboratory facility on site
so doctors and practitioners rely on their clinical
skills. The nearest lab is two hours drive to a district
hospital where surgical and medical referrals are
received.
Malaria is common, but the least of concems, as a
three days course of Chloroquine is usually enough
to treat it. Due to the high prevalence rate of
malaria, Chloroquine is frequently administered
empirically for febrile illness that is not associated
with obvious features of bacterial or viral infection.
Pyrexia that is not responding to antimalarial or
broad spectrum antibiotics for more than two weeks
brings enteric fever into the differential diagnosis.
After three weeks Leishmaniasis and Tuberculosis
are top on the differential diagnosis list.
Leishmaniasis is transmitted by a bite from a
sandfly. There are two types: cutaneous and
visceral. The cutaneous type is the more benign
causing only skin ulcers. The visceral type is fatal
without treatment. It is characterised by fever,
anaemia, hepatosplenomegaly and progressive
cachexia. Secondary infection is the detrimental
factor due to immunosuppression. The standard
treatment is a course of antimony compound. The
high mortality rate is due to lack of diagnostic
facilities and non-availability of first line treatment
at local level. The latest outbreak is exacerbated by a
massive population migration (traditional seasonal
migration of workers and resettlement of returnees
and refugees in highly endemic areas).
There were few cases of HIV/AIDS. The Elisa
test is only available in major central hospitals.
Doctor's residence
Hospital
Hospital wards are built with local material, clay
and hay. The outpatient clinic, the treatment room,
the pharmacy and store room are all tents. The work
was going very well on building of an operating
theatre when I joined the camp.
There is a small generator for lighting at night; it
is disabled after 1l pm to save fuel. Used syringes
and surgical equipment are sterilised by boiling;
gauze swabs are steamed in containers. A good
Nursing school
The nursing school was already up and running for
10 months before my arrival. Each class term is six
months and the graduates move to other villages to
work as first line health personnel. There were 46
student nurses including six female nurses. Dood is
the senior nurse at the hospital. He was a second
year dental student, but was forced to flee his home
and leave his university education because of the
war.
Dr Abdelsalam Akasha and Dr Amira Zahir
founded the school and instigated a general course
29
Classroom at the nursing school
Building an operating theatre
Typical day
A light breakfast of very sweet black tea and a piece
Training on airway manqgement
on medicine, surgery and nursing. Thereafter more
doctors joined in the training process and running of
the clinics for various periods.
Preparation
of bread is provided at7 arrr. The working day starts
at 8 am. The lectures are held under the trees, there
is a black board and chalk. Students keep notes and
handouts are provided.
After the morning lecture finishes at 10 am, we
had breakfast together. It consisted of broad brown
beans and black tea. Bread is freshly baked in an
improvised oven made by punching a hole in a
termite mount, a quiet clever improvisation as ovens
made of clay would be washed away by the rain,
whilst termite mount is very solid, thanks to the ants.
The group reconvened at 11 am and continued
with practical sessions until 3 pm, with a later break
for tea.
The practical session training concentrated on:
o Basic life support and airway management with
the use of self inflating bag. Oxygen supplement
is provided by the oxygen concentrator. The
oxygen concentrator was made by a British
I prepared a crash course on first aid, resuscitation,
local anaesthetic techniques and sedation. My
sources were two useful books (1) Key
company to WHO standard. It could stand the
tough terrain and hot temperature of that part of
the world and is capable of an output of 4
litres/min of 957o oxygen.
Resuscitation Data book by M. Pan and T. Craft (2)
War Surgery, Field Manual by H. Husum. The later
manual is an excellent reference for care under
difficult conditions with the lack of medical
o
facilities and proper staff. It promotes a concept of
life support and surgery close to the front line which
slaughtered for a welcoming meal on the second
day. I asked for the larynx and trachea to be kept
draws on the resources and knowledge of the local
community. It improvises with local equipment and
materials and also includes a complete guide to post-
operative high-energy nutrition based on local
foodstuffs and food-processing traditions.
I
prepared handouts in Arabic and English
languages.
30
Surgical airway training using minitracheostomy
tubes. As a guest in the camp, a sheep was
for training; all students had a go at
the
procedure.
o
Local anaesthetic techniques, in particular field
blocks, wrist and ankle blocks, Bier's block using a sphygmomanometer cuff as a toumiquet
with an artery forceps to clamp secure a coil of
the cuff tubing.
It is worth noting that the
sphygmomanometer that was bought for f,10
second hand actually cost f,60 to ship by air! I
Health education and immunisation
Talks on AIDS/HIV were given to the village
didn't realise that mercury containing equipment
community and an immunisation programme for the
children was carried out with vaccines provided by
the WHO.
requires a special packaging standard by the
aviation authority. It was a costly and a handy
Final thoughts
lesson too.
Not long after a talk on wrist block, a patient
came in with a foreign body in the hand. There was
a surgeon present, so it was an opportunity as well
for a bright student nurse to practice incision of the
hand, removal ofthe foreign body and closure ofthe
wound. I administered the block as a demonstration
and the nurse was instructed by the surgeon to cany
out the operation which went very well. I admired
the courage of the patient as well as the nurse who
were both members of the camp.
It is worth noting that all
nurses, doctors and
teachers who worked hard in the camp are
volunteers. Dr Akasha the founder of the medical
unit has worked as the medical director of the unit
for three years. He was on call 24 hours a day,
without a salary or a holiday. It is a humbling
experience to work beside such noble human beings
and
to
see
first hand how people with limited
resources and huge responsibilities could improvise
and provide a humanitarian service to their people
and community. I have learnt a lot, brushed up my
rusty knowledge of tropical medicine and learnt a
few lessons about organising such trips. I am sure
they will help me make my next trip run more
efficiently.
In July 2003, thanks to the international pressure,
the warring parties in Sudan have finally sat together
and struck a negotiated peaceful settlement. The
extreme state of underdevelopment in southern
Sudan poses tremendous challenges to any vision of
a peace in this part of the country and must be
addressed.
All Sudanese deserve to live in peace in a just and
equitable society, yet, progress toward peace will
require much greater political commitment from the
intemational community.
I am sure that the group of nurses who showed
great dedication in the makeshift hospital if given
A student nurse demonstrating the anatomical
landmarks of spinal anaesthetic
the appropriate support on their return to normal
civilian life will make excellent health professionals.
3l
Anaesthesia Points West Vol. 37 No.
I
Article
Physicians Heal Thyself
- and Thy Family
John Covell, Retired Consultant, Taunton
Doctors working on their own in isolated parts of the
world or at sea experience two particular problems.
The first arises from the huge variety of conditions
with which one has to cope often without specialist
experience and with very basic equipment and stafflrrg.
The second results from the lack of supporting
professional help when a doctor or a member of his
family falls sick.
In the Colonial Service in East Africa a general duty
medical officer would be in sole charge of a small
hospital and responsible for the medical care of a large
administrative district, consisting of a handful of
govemment ofEcials and their families, a few Indian
traders, and a large African population. His nearest
colleague could well be over a hundred miles away
and perhaps be unable to leave his station for a number
of reasons.
If a doctor himself or his family became seriously ill
or was badly injured and required immediate attention
then, for obvious reasons, a very difficult situation
could arise. Doctors are notoriously bad at treating
themselves and with the best will in the world are not
the ideal people to deal with their own families.
Most Colonial Medical OfFrcers had either heard of
or experienced such problems and I was no exception.
Perhaps the worst was the tenible dilemma in which a
colleague found himself. He was an ADMS in
Tanganyika when I first met him but had been a
Moravian missionary before the war working with his
wife, a midwife, in a remote area. His wife became
pregnant with twins and was due to be delivered at a
government hospital some forty miles away.
Unfortunately she went into labour p,rematurely on a
day when tonential rains made the roads impassable.
Her husband had no choice but to deliver her himseH
but, to his horror, was faced with the rare but &eaded
complication of 'locked twins'. He had to perform a
destructive operation and sadly both babies died. They
had no further children.
A second case was that of a young colleague, who
took over from me in the up-country station and failed
to diagnose the presence of an inhaled safety-pin in his
year old child, thinking that the symptoms were due to
an infection. In desperation, he drove over seven
32
hundred miles to the capital arriving only just in time
for an ENT colleague and myself to perform an
immediate tracheostomy.
As far as our family was concemed there were three
difFrcult situations. The first occuned when I was
stationed at Mwanza in the Lake Province with a
surgical colleague when I developed appendicitis. As I
was the anaesthetist and did not fancy a spinal given
by my friend I retired to bed and hoped I would
recover. Two days later another friend called and said
that he knew that an anaesthetist from Uganda, who
was on sick leave, was on the Lake stearner which was
arriving the following Saturday. I was able to send a
wire to him and in due course admitted myself to my
own hospital, prescribed my own medication, drew up
the necessary drugs and lay down on the theafte table.
My colleague arrived, heavily jaundiced, plunged
a
needle into me and I know no more for about 12 hours,
Formnately, I made an unintemrpted recovery.
Some years later
in an up-country station I
developed a severe attack of amoebic hepatitis, failed
to make a correct diagnosis, became extremely ill and
was only rescued by my wife who in desperation
managed to contact a Physician in Dar-es-Salaam who
flew up, administered some emetine and an antibiotic
and literally saved my life.
The worst experience I ever had was when my three
year old daughter was bitten by a snake. She was
rushed to my hospital by my wife bringtng the snake,
which had been killed by oru houseboy, with her. Not
being an expert on snakes I showed it to the crowd in
the out-patients who all agreed that it was deadly. I
decided that I would have to use the only remedy
available, Fitzsimmonds Snake Serum, and injected a
suitable dose, with dramatic results. My daughter
collapsed with a severe reaction and I thought for a
while that I had killed her. Fortunately she recovered
and to this day I still do not know whether the snake
had actually bitten her.
These incidents remind me of the excellent facilities
available in our much maligned National Health
Service and how lucky we are to be able to call on
expert colleagues to look after us and our families in
dire emergency situations.
Anaesthesia Points l4/est Vol. 37 No.
I
Article
All That Glitters Is Not Gold
Dr Hugo Wellesley, Dr Ian Thomas
Almost everybody has at some stage in their careers
been faced with that large blank space on an
application form that requests details of 'Ongoing or
Current Research' and looked rather forlornly at the
size of the blank space underneath. To make matters
worse there, at the bottom of the page is the
statement 'please continue on a separate piece of
paper
if further space is required'. To
avoid leaving
the entire page blank you either have to organise
your own project (a daunting prospect to say the
least) or hang on to the coat tails of a group who
already have one up and running. So when the
opportunity to run the UK arm of an Intemational,
Multi-centred Trial was handed to us, it seemed to
be too good an opporfunity to miss.
Based at the Bristol Simulation Centre, we were
to be part of an lnternational Consortium looking to
assess a technique for exchanging endotracheal
tubes over a bronchoscope. The technique we were
assured was 'quick to perform and simple to leam'.
lt seemed as if things couldn't have been better.
We did admittedly have some reservations when
we discovered exactly what the technique involved.
We were to pass a bronchoscope (loaded with the
new ETT) down the mannequin's original ETT
keeping the carina in view at all times. The old ETT
was then to be gripped with Kocher's forceps and
withdrawn over a scalpel blade held in a pair of
artery forceps, so being 'sliced away'. The new
'preloaded' ETT was then to be advanced into place
and its position confirmed both by direct
visualisation of the carina as well as clinically and
with capnography.
We rarely change endotracheal tubes electively in
this country let alone in patients with difficult
airways that would require such a technique.
However, the fact that UK practices differ
significantly from those in the US did little to
dampen our enthusiasm; after all, this was an
International, Multi-cenffed Trial. Our main concem
at this point was safety. The question did arise as to
whether in addition to a swab count we might have
to introduce a finger count - but the demonstration
video that was sent looked simple enough. So on we
went.
We set about getting ethics approval, organising
the equipment, leaming the technique ourselves and
involving some of our colleagues. Gradually
however, it became clear that our fears had been
justified. During the practice runs we only just
managed not to spill any blood or cut through the lip
of the mannequin (unfortunately the protective
green towels didn't fare as well). On several
occasions the blade even flew out of the forceps,
once ending up having to be retrieved from the
mannequin' s oropharynx.
We soon realised that ignoring our initial
concerns was a mistake and that no matter how big
the 'Current Research' space on the application
form, discretion was the better part of valour. We
therefore decided to withdraw from the study and
reported our experiences to the lead research centre
before anyone managed to 'slice away' anything too
important (be
it
bronchoscope, mannequin or
a
precious digit).
No papers will emerge from our foray into the
world of research but we have certainly learnt from
the experience, and although we may never be a part
of an International Consortium again, we are glad
that as we write this with a one-finger typing
technique, it is out of choice rather than physical
necessity.
So if the opportunity to participate in an
Intemational, Multi-centred Trial lands on your lap
then think
it
through carefully; after all, all that
glitters is not necessarily gold.
JJ
Anaesthesia Points West Vol. 37 No.
I
Article
Amateurs at Altitude
Alisdair McCrirrick and Peter Sanderson, Consultant Anaesthetists
Gloucester Royal Hospital
The original proposal was simple. How about a long
weekend in September spent climbing a mountain in
headache, nausea, insomnia and lack of appetite.
Apathy and irrational behaviour herald the onset of
the Alps? Sounds straightforward enough except
potentially life-threatening cerebral oedema.
Pulmonary oedema is a rare but serious
complication of AMS and compounds the mild to
moderate hypoxia already associated with a
reduction in ambient pressure. AMS may occur
regardless of fitness level or general health status
that neither of us had any mountain climbing
experience whatsoever. Ascending to level ten of the
tower block at Gloucestershire Royal Hospital was
the
full
extent of our altitude experience. In his
defence PS had actually owned an ice axe and a set
of crampons for several years - unfortunately the
axe was
still in its original wrappings
and the
crampons had experienced nothing more than a bit
of vigorous lawn aeration.
Our intended goal was the summit of the Jungfrau
in Switzerland - at 4150 metres the tallest mountain
in that part of Europe and one of thfuty or so 4000+
peaks in the Alps. Being so rigid in our ultimate goal
was our first mistake, born of complete
inexperience. To prevent disappointrnent
it is better
to choose your mountain just before you climb,
taking into account local snow and weather
conditions. A mountain guide was provisionally
booked for the weekend in question along with two
airline tickets to Geneva.
Clearly fitness was going to be important, but
what was the best way to train and how fit did you
actually have to be? Neither of us knew. Somehow
the 'Stairmaster' at the gym seemed a bit pointless.
Over the summer months we both resorted to
increasing our normal running training. By the time
we left we were able to cover a half marathon in
about thr 45 minutes - but would it be enough?
The first serious seeds of doubt were sown two
weeks before departure when a copy of 'The High
Altitude Medicine Handbook' by Andrew Pollard
and David Murdoch landed heavily on the desk. The
owner of the book (an experienced expedition
doctor) included a note wishing us luck and saying
we were mad. The problem, he said, was not just our
inexperience, inappropriate training or lack of
fitness for altitude work but altitude sickness. Rapid
ascent to altitudes over 2500m often results in acute
mountain sickness (AMS), characterised by severe
34
and the quicker the ascent the.worse the symptoms
are likely to be. 84Vo of travellers flying directly to
3860m are affected and susceptibility is all the
greater in those taking unaccustomed exercise. Just
like us then. Hasty re-reading of the literature sent to
us by the mountain guide covering the terms and
conditions under which he had agreed to take us
referred to 'adequate acclimatization' - impossible
in a weekend.
Of course what we should have done was travel
out a week beforehand and undertake a few smaller
climbs interspersed with nights spent at increasing
altitude. It was too late in the season to postpone and
backing out was not an option. We had been 'talking
the talk' for so long - it was now time to 'walk the
walk'. Besides which we each had four hundred
pounds worth of gortex clothing, climbing boots and
survival equipment stacked in our wardrobes. And
the credit card bills to match. There really was no
going back.
There was however a glimmer of hope. The 'High
Altitude Medicine Handbook' contained a chapter
on treatment and prevention of AMS. The carbonic
anhydrase inhibitor, acetazolamide, has been
considered to be the drug of choice for prophylaxis
for AMS for some years although the scientific
literature is sketchy as to the optimum dose. We
settled for 250mg bd commenced on the Friday
night before we left. As a belt and braces measure
we also started taking dexamethasone 2mg tds, an
accepted treatment for AMS induced cerebral
oedema, although its role in prevention has never
been established.
The night before departure loomed. A last minute
Pete contemplates walking the walk
phone call confirmed the availability of the guide
but the Jungfrau was out of the question as the
recent snow fall made the avalanche risk too great.
Could we come back next week or would we like to
climb the Moench instead which had less snow? The
Moench, at 4099m, was very slightly lower than the
Jungfrau but the climb was shorter, steeper and
considered to be technically slightly more difficult.
The Moench it was then. What had we agreed to?
Nervous excitement soon gave way to heavy
drinking. Four months of physical training was
decimated by a bottle of Gordons and a rather
pleasant sauvignon blanc. Never ever again.
The alarm rang through an alcoholic haze very
early the next morning and we were on our way. By
Saturday aftemoon we had arrived at Gwindelwald,
a small town tucked under the north face of the
Eiger. The Eiger, at 3900m is smaller than the
Moench and Jungfrau that stand behind it but its
sheer north face travels almost vertically upwards
for 2000m and dominates the landscape.
We hired the remaining pieces of equipment that
we needed. The weather was perfect - blue skies,
pleasant temperature and no wind. We decided to
walk up the mountain path (rather than take the
funicular railway) to Kleine Scheidegg where we
intended to spend the night. The walk, an ascent of
1200m (the equivalent of sea level to the top of Ben
Nevis) took just over thtee hours and, carrying l8kg
of equipment, was uttedy exhausting. We stayed in
an old colonial style hotel situated on the side of the
mountain surrounded by a windswept, barren and
treeless landscape.
On to the snow
The following moming dawned bright. Paring our
equipment down to the bare minimum and dressed
in our climbing gear for the first time we caught the
first funicular train up to the Jungfraujoch plateau,
situated at an altitude of 3200m. The railway is a
spectacular feat of early 20th century engineering
and travels for several kilometres through a tunnel
cut into the Eiger. At intervals two short tunnels
come off the main tunnel at right angles and break
through the northern face allowing a climbers-eye
view of the glacier below. When we got off the train
we met our guide - instantly recognisable by the
coils of climbing rope looped over his right shoulder
and the mass of karabiners and other climbing
paraphemalia hanging from his hamess.
We emerged from the top station onto the packed
snow of the plateau. The sun was blindingly bright
and the air crisp and cold at minus 5 Centigrade. We
started the slow, measured uphill walk to the base of
the Moench a kilometre away. Every step, at a
barometric pressure of approximately 5llmmHg
(61Vo of that at sea level), was a considerable effort.
Our pulse rates exceeded 180 beats/minute despite
travelling at slower than normal walking pace. The
small pulse oximeter showed saturations of 88Vo.
At the base of the mountain our guide roped us
together and the climb began. The initial third of the
90Om ascent was mainly a scramble over rock ald
snow, which if it had not been for the altitude and
the potential drop of hundreds of feet on either side
would have been quite straightforward. Every few
hundred feet our progress was hampered by rocky
outcrops the size of houses. At sea level and wearing
35
55 degrees to the vertical. Each step required
kicking in with the crampon tips whilst trying to
bury the head of the ice axe into the mountainside.
Just as we started up the ice wall we were met by a
climber sliding down towards us. He managed to
arrest his fall by digging in the tip of his axe and
hauling his body weight onto the handle. In our
excitable and slightly hypoxic state it all looked
rather amusing. Only later did our guide explain that
if you fall on steep ice you usually have only half a
second to gain purchase with the tip of your axe
before your velocity is such that stopping becomes
impossible.
The final part of the climb was the summit ridge
that gently wound its way upwards for 200 vertical
metres. The climbing was easy but the drops
precipitous. The ridge varied from one to four feet
wide and the mountain fell away at 80 degrees for
several thousand feet at each side. The drill was that
if one slipped the others would stop themselves
being pulled off the ridge and save the fallen climber
by jumping off the other side. Three and a half hours
Getting trickier
after starting the climb we arrived at the summit. At
an altitude of 4099m and an atmospheric pressure of
approximately 450mmHg (6OVo of that at sea level)
our arterial saturations were 83-84Vo and our resting
pulse rates between 720 and 130 beats/min. The
feeling of overwhelming exhilaration, as we sat on
the small summit plateau, is difficult to describe.
Much of that feeling was due to the knowledge that
we had succeeded but some was probably due to the
effects of hypoxia. Ten minutes later we started our
descent which took another 3hrs. Coming down was
less tiring but technically more demanding than
going up. It was also scarier as for the first time we
could appreciate how steep the climb really had
been.
gym shoes an able seven year old would have had
little trouble in climbing them but wearing rigid
boots, three pairs of gloves and a 10kg backpack
considerable effort and concentration were required.
The physical effort and altitude, combined with a
degree of apprehension, meant that we were
breathing as hard as if we were at the end of a four
hundred metre sprint. Hyperventilating and
sweating, we consumed two litres of fluid in the first
two hours. Pulse rates exceeded 200 beats/minute.
The rock gave way to snow and ice as we
ascended. We attached our crampons and continued
upwards. One hundred metres before the summit
ridge we were confronted with an ice wall, perhaps
36
Acute mountain sickness and other
effects of altitude
Acute mountain sickness is one of the major hazards
faced by mountaineers and trekkers who ascend
above 2500m. Symptoms tend to appear gradually
over a period of 6-12hrs after arriving at altitude and
usually begin to resolve within one to three days
providing further ascent does not occur. AMS is
being increasingly recognized at lower altitudes and
it is not uncommon for alpine skiers (who tend to
spend the majority of their time at average altitudes
of under 2000m) to develop severe headaches.
Susceptibility to AMS is unpredictable and varies
greatly between individuals. Exertion may be a risk
f*e;-
A long way down
The way down
At the top
factor, whilst lack of fitness is not. Principle
symptoms are headache, nausea, vomiting, anorexia,
fatigue, dizziness and sleep disturbance. Headache is
the commonest and usually the first symptom - it is
typically throbbing in nature, worse during the night
and morning, and aggravated by Valsalva's
manoeuvre or stooping. Sleep disturbance is very
common at high altitude even without other
symptoms of AMS.
Down at the bottom again
High altitude cerebral oedema (HACE) is a rare
but life-threatening complication of AMS and is
usually preceded by classical AMS symptoms. It is
most likely to occur at altitudes above 3500m and
approximately 2Vo of all climbers who ascend above
confusion, clumsy movement, irritability and
irrational behaviour and compounds symptoms
produced by altitude hypoxia. Patients suffering
4500m develop HACE.
from HACE frequently lack insight into the potential
It is characterised
by
37
severity of their condition and may try and resist
help or advice offered by fellow climbers.
Progression from initial symptoms to coma and
possibly death can take as little as l2hours.
Ten percent of climbers ascending to 4500m will
develop high altitude pulmonary oedema (HAPE)
although the incidence is lower with standard ascent
rates (see below). It is more common in men than
women and is often associated with exertion. Not
surprisingly symptoms start with dyspnoea on
exertion but this is difficult to differentiate from that
normally associated with exercise at altitude.
Symptoms progress to breathlessness at rest,
especially at night. The cough, dry at first, becomes
productive with blood-stained sputum.
Treatment
Both HACE and HAPE represent medical
emergencies that may rapidly progress to
unconsciousness and death unless treated. The
requirement for urgent descent cannot be over
emphasised. In some circumstances, however, it
may be technically difficult to rapidly lower sick
climbers and other members of the party may be put
at risk by attempting to do so. Portable hyperbaric
chambers have been used with good effect. Rapid
descent is also irnportant for AMS if the symptoms
are other than very mild. Mild AMS may resolve
over a period of time providing no attempt is made
to climb higher. It is preferable to descend to an
altitude below which the patient developed their fust
symptoms but descent of just a few hundred metres
can produce a considerable improvement. Many
novice climbers become very anxious at high
altitude, frightened by the hostile environment and
worried about the possible development of altitude
sickness. Although anxiety may be a major factor in
patients complaining of breathlessness, dizziness
and hyperventilation it is difficult to exclude altitude
sickness absolutely. In any event descent is
advisable.
Dexamethasone 8mg initially then 4mg qds may
be useful as a holding measure in the treatment of
HACE but is no substitute for emergency descent.
HAPE may respond to the administration of
sublingual nifedipine but oxygen and a reduction in
altitude remains the mainstay of treatment.
Morphine, other steroids or frusemide have no
allowing time for acclimatization to occur. Above
3000m the average ascent should be less than 300m
per day with a rest day every 1000m. Many people
are clearly able to tolerate a more rapid ascent.
Ascent should not be considered with even mild
symptoms of AMS. Acetazolamide is very useful
(see below) but should not be used as a substitute for
slow ascent. However, even
if
ascent is taken slowly
AMS cannot always be completely avoided. In one
stvdy sOEo of all trekkers who walked to altitudes
above 4000m developed some symptoms of AMS
despite ascending over at least five days.
Acetazolamide remains the drug of choice for
prophylaxis for AMS and, if taken, should be used
until descent. The most cornmon dose is 250mg bd
or 500mg once a day (slow release preparation).
Side effects are common and include mild diuresis
and paraesthesia. (We experienced no adverse sideeffects apart from a tendency for food to taste bland
and frzzy drinks unpalatable).
Our experience
'We
were, quite rightly concerned about the possible
development of AMS, particularly as we had left no
time at all for acclimatization. Ideally we should
have spent several nights at lower altitudes before
the final climb. Not only would this have been safer
from a standpoint of developing AMS but it would
have helped us adapt to exercising at altitude. We
were very lucky and quite surprised that neither of
us developed any symptoms of AMS - not even a
mild headache. It is very difficult to know how
much of that was due to taking acetazolamide or
whether we are just predisposed to be reasonably
tolerant to the effects of altitude. Another factor in
our favour was that although we ascended far more
rapidly than was safe, we actually spent very little
time at high altitude, descending to 1000m
immediately after the climb. There is some evidence
that the altitude at which you sleep, as opposed to
the maximum altitude obtained during the day, is an
important determinant of AMS ('Climb high, sleep
low').
We will both consider taking acetazolamide,
however, on our next climb, particularly as we
experienced only minor side-effects, but we will
definitely try and find some time to acclimatize.
Oral dexamethasone was probably 'overkill' and is
proven role.
not generally recognised for AMS prophylaxis and
we may well leave that for treatment of severe
Prevention
AMS is best prevented by slow, gradual ascent,
symptoms only. Would we do
Are we hooked? You bet!
38
it
again? Absolutely.
Anaesthesia Points ll'est Vol. 37 No.
I
Article
The One Armed Anaesthetist and the
Primary FRCA
Rob Price, SIIO Gloucester
During the final three weeks of preparation for the
primary FRCA vivas and OSCEs I was knocked
from my bicycle by a car which failed to stop at the
I bounced off the bonnet
and the windscreen and was sent spinning into the
air before falling and landing on the road 20 feet
away. There was a severe deep pain in my right arm
entrance to a roundabout.
Outpatients, an MRI scan that revealed an
impacted fracture, police and solicitor interviews
and 3 weeks in an extemal rotation splint followed.
The first week disappeared without my being able
to sleep or study. During the second week I
anterior dislocation with my other hand as I felt my
reluctantly forced myself to begin studying and
attend a couple of viva practice sessions. I was
going to have to take the exam with my dominant
arm strapped in abizarre sling with 20 degrees of
and shoulder and
I recognised
if
the profile of an
there was an associated
external rotation, looking like a waiter who hadn't
fracture. Up to that moment I had just begun to think
noticed he'd just dropped the tray of drinks he'd
stand a chance of passing this exam.
Following my initial appalling efforts to answer viva
questions in the practice exams organised by
suddenly ruthless SpRs and Consultants, I had
been carrying.
seemed to be making some small progress.
Dr Thornberry again contacted the College to
explain my predicament. They remained positive
and decided to offer me a runner to perform the
practical tasks under my instruction. Sadly it
injured arm, unsure
I might
After the impact I was immediately relieved that I
could breath and walk and still talk to my wife and
children. I was angry that this pain, the months of
rehabilitation and the loss of all the months of exam
preparation had been inflicted upon me by a careless
stranger in a car. The ambulance rattled me off to
the A&E department at the hospital where I work,
while
I
breathed deeply on the entonox and recited
solubility coefficients in between cursing, swearing
and apologising. The kindness of the staff and a
generous dose of morphine kept me going until,
after the plain film did not show a displaced
fracture, my shoulder dislocation was reduced.
Disappointingly the pain continued as before.
News of my arrival in A&E filtered through to the
anaesthetics department, who had been wondering
where I was, as I had failed to arrive for the day's
early morning viva practice. I was soon visited by
Dr Anne Thornberry, who reassured me that I would
be able to take the exam and that the College would
make any necessary arangements to accommodate
me. I surprised myself by being pleased at the
prospect of still being able to take the exam!
I couldn't dress without help,
couldn't shave or wash and had to cut my clothes in
order to wear them. The OSCE was going to be a
challenge.
turned out that repeating the examiner's
instruction 'check this anaesthetic machine' to my
runner was not going get me through. Instead I
needed to be able
to give precise and clear
instructions as my runner threatened to do exactly
what I said, much as young children will take all
instructions literally with sometimes comical
results.
I travelled up to London with my wife the night
before to stay with friends near Earls Court, the
children having been dispatched to their
grandparents. The examiners were expecting me and
my impediment and the first viva went well, without
me having to draw any diagrams. After a wait of an
hour and a half, freezing to death as I was unable to
do up my jacket or coat, the second, more difficult,
viva required me to talk the examiners through
drawing a contingency table and the blood supply to
the kidney upside down. A challenge for all three of
us!
39
With this behind me I just had the OSCE to get
through before the day was over. My runner turned
out to be a friendly, efficient and precise examiner
who appeared at the appropriate moment of each
TV character 'Mr Ben'.
quite off putting for
potential
to
be
This had the
me, the examiners and the other candidates;
however, it went surprisingly smoothly. In a
practice OSCE at Gloucester I had found it better
station like the children's
to attempt nothing for myself and to concentrate on
giving accurate instructions. My first station was
resuscitation, which actually lends itself quite well
to this approach. Further round we were required to
insert an interosseous needle into a dummy.
Unfortunately my instructions were not precise
Eventually it was all over and I was joined by my
wife who had patiently helped me with my clothes,
shoelaces etc. throughout the day and has always
supported me through all my exams and training.
The results were posted on the board and thankfully
both Alex D'Agapayeff, another FRCA candidate
from Gloucester, and I had passed. We made our
way upstairs finding it hard to believe that we had
succeeded and that other poor folks, who probably
needed a drink more than us, were leaving in a cloud
of disappointment.
The Primary was never going to be easy and of
all the catastrophes I had contemplated I did not
expect to have to face the exam with one arm
I
enough and despite saying push harder the needle
failed to penetrate. In retrospect I should probably
have said to twist as well as shove, something I
encouragement
would have done naturally if I could have
am grateful for the help and
of many anaesthetists, colleagues
and friends and I am glad that I did not give up
completely. My colleagues continue to patiently
help me as I work hard at recovering full power in
performed the task myself.
my arm.
40
immobilised.
Anaesthesia Points West Vol. 37 No.
l
Article
Pan Armenian International Surgical
Congress
John Zorab, Retired Consultant Anaesthetist, Frenchay
This meeting was held in Yerevan, Armenia, on 3rd
and 4th October, 2003. Since the Armenian Society
of Anaesthesiologists is a small sociefy of some 78
members, they shared in the surgical meeting.
Professor Gagik Mkhoyan, President of the Society
of Anaesthesiologists and Intensive Care and Dr
Armen Varosyan, Secretary of the Society had
attended the Euroanaesthesia meeting in Glasgow in
May 2003, where they kindly extended an invitation
to me to join them in Yerevan. I had made
surgeons in the Surgical Society. Armen Bunatyan
gave an excellent, illustrated, paper on the influence
of anaesthesia on the development of surgery from
1846 to the present day. Simultaneous translation
and
computer projection was used throughout although
facilities for standard slide projection was also
into Russian and English was provided
available.
a
previous visit to Yerevan in 1986 and, being the
land of my forefathers, needed no great persuasion
to make a return visit. The hospitality of the
Armenians is legendary and I was eager to sample it
again. I arrived on Sunday 28th September 2003 and
was duly met by Drs Mkhoyan and Varosyan. I soon
discovered that I was not the only guest and was
delighted to find six others; three from Germany and
three from Russia, most of whom I had met before
on other occasions. An additional guest was my
nephew, Mark Zorab (a priest in the Church of
England), who, at my request, accompanied me.
Armen Bunatyan, an Armenian from Moscow, I had
known for very many years and it was good to meet
him again. We had planned to stay for a full week
and there was some free time before the Congress
was due to open and a delightful social programme
had been arranged for the guests. On 30th
September, we were all taken to visit the
magnificent Lake Sevan at 2000 metres in the
mountains outside Yerevan. The fabulous views and
the two ancient Armenian churches on the hill-top of
an island in the lake made this a memorable visit.
The lunch, at a lakeside restaurant, with unlimited
neat vodka and neat Armenian brandy, prepared us
for what was to come for we were entertained to a
similar lunch on every single day we were there. On
lst October, all the anaesthetic guests attended the
Opening Ceremony of the Congress, at the Yerevan
State University, with speeches by the leading
Figure
I: Echmiadzin
Cathedral.
Following this, the guests were taken for a visit to
the holy city of Echmiadzin and Echmiadzin
Cathedral (Fig. 1), the seat of the Armenian church.
This included a tour of the Palace of the Holy See
with its magnificent paintings and other artefacts.
The climax of the visit was an audience with His
Holiness, the Catholicos, Karekin II. Mark was
particularly thrilled by this. We were graciously
received, His Holiness speaking to us in English,
German and Russian. He then arranged a photograph
of himself and his guests (Fig. 2).
4t
Figure 2: The Catholicos and his guests.
Figure 4: The priests conducting the service, the
Cqtholicos with a crucifix on his hood.
countryside and to buy himself a carpet!
The weather had remained just like summer all
the week and on the Friday morning, we were
treated to a magnificent view of Mount Ararat and
Little Ararat just across the border with Turkey. The
meeting continued on the following day when the
papers were by Armenian speakers in Armenian or
Russian but without interpretation. LaIer came the
Figure 3: Erebouni Medical Centre.
Thursday, 2nd October, saw the beginning of the
anaesthetic part of the meeting which took place at
the Erebouni Medical Centre, the Yerevan Teaching
Hospital (Fig. 3). All the guests (except Mark) gave a
paper. The Germans and
I
closing ceremony which included both surgeon and
anaesthetist participants. Splendid medals and
"certificates" were presented to the guests by the
President of the Surgical Society. Then everyone
adjourned to a large restaurant for the Gala Dinner
which was a well-attended affair with plenty of
music and dancing. On the Sunday, Mark and I were
taken to attend the Sunday Service at Echmiadzin
Cathedral. This was a special 2tlzhotr sewice, part
of the Armenian celebrations of the nation's
adoption of Christianity 1750 years ago. It was a
spoke in English with
most impressive service, conducted in 4th century
simultaneous translation, whereas the Russians spoke
in Russian as virhrally all Armenians are bilingual in
Armenian and Russian. During the coffee break, the
visitors were given a brief tour of the ICU. There
were several patients there, including some cases of
severe trauma. The unit appeared to be well-equipped
with modern monitoring such as cardiographs, pulse
oximeters and modem-looking ventilators and lots of
Armenian but Mark had acquired an English
translation which we were able to follow. The
nurses. We were told that, far from there being a
shortage ofnurses, there were not enough places for
all those girls wanting to train. Looking at the girls in
the ICU, I would have welcomed being nursed by
some of them myselfl Meanwhile, Mark took himself
off to visit one or two ancient monasteries in the
42
service was conducted by the Armenian Archbishop
from Vienna although, of course, His Holiness,
the
Catholicos, was also in attendance (Fig. a)
On the final evening,
all seven
guests were
honoured by being invited to dine at the home of
Professor Mkhoyan where we were entertained by
his charming family, once again with unlimited neat
vodka and Armenian brandy. During the evening we
watched a professionally made video of the wedding
of the Professor's elder daughter. We were all
entranced and it was as good as being there. It was a
most gracious end to a memorable week.
Anaesthesia Points West VoL 37 No.
I
Article
The Role of Crystal Dowsing in Determining
Surgical and Anaesthetic Outcome
A. J. Braga, SHO, Gloucestershire Royal Hospital
M. J. Savidge, Consultant Anaesthetist Gloucestershire Royal Hospital
A prospective study was carried out involving an
89-year-old patient about to undergo spinal
decompression and dynesis of Ll-L5. On pre-
induced with Midazolam, Alfentanil, Propofol and
Atracurium. Hand ventilation with a bag and mask
proved easy, but on performing laryngoscopy it was
operative assessment, her past medical history was
unremarkable and apart from simple analgesics, she
took no medications. In view of her age and the
noted that neck extension and mouth opening were
critically reduced by arthritic changes. It was just
possible to insert the laryngoscope and manoeuwe it
behind the tongue to reveal a cyst the size of a grape
on the anterior surface ofthe epiglottis arising from
the valecula making intubation under direct vision
extensive nature of the surgery, the authors
suggested that despite an expected improvement in
spinal symptoms following surgery, her mental and
general physical state might well deteriorate as a
result of the procedure, thus decreasing her overall
qualrty of life. However, on meeting the patient, the
authors were surprised to find that she lived alone
in, and maintained a fourteenth century castle in
West Wales. She explained that she was in the habit
impossible. Several attempts at blind intubation
using a boogie led to unequivocal oesophageal
placement of the endotracheal tube. Finally a
of climbing 60ft ladders in order to supervise
trachea. The rest of the operation also proved
eventful with persistent blood loss causing the
surgeon to abandon the procedure after several
artisans carrying out essential restorations. She and
her son, a retired Major General in the Artillery,
were adamant that she maintain her independence,
and thus surgery was necessary to allow the
continuation ofsuch arduous activities. The prospect
of a slow and possibly incomplete recovery was not
welcomed but it was stressed by the authors that she
must make a full and informed decision whether
now to proceed.
At this point she appeared to change the subject,
waxing lyrical about her experience and
intemational acclaim as a dowser. She had dowsed
an ancient labyrinth in the environs of her castle,
and had been requested by the CIA to dowse for
hostile nuclear submarines. She proposed to decide
her operative fate by combined dowsing of both
authors. As the crystal swung in favour of both
anaesthetists, the patient was greatly reassured.
Somewhat distracted by such a turn of events, the
authors neglected to perform formal airway
assessment.
On arrival in the anaesthetic room full monitoring
and venous access were secured. Anaesthesia was
standard size 3 LMA was sited and a boogie passed
through it. The LMA was withdrawn and a COETT
railroaded over the top, successfully, into the
hours.
Nonetheless the patient made a swift and
uneventful recovery, The epiglottal cyst was
mentioned by the authors at which point she
volunteered that she had previously been
investigated by a Harley Street Gastroenterologist
for a choking sensation on swallowing . Nothing had
been evident on endoscopy. It was suggested that
she might do worse than seek an opinion from an
ENT surgeon, who would no doubt propose an
Examination Under Anaesthesia. Both authors were
quick to decline any request from the patient to
provide an anaesthetic for such.
In conclusion, in this case dowsing reliably
predicted final surgical and anaesthetic outcome,
albeit without indicating the difficulties encountered
to achieve this. However, the unusual events during
preoperative assessment proved distracting resulting
in overlooking routine airway assessment.
Always assess the airway even if it is in constant
use!
43
Anaesthesia Points West VoL 37 No.
I
Article
W(h)ither Science Vivas?
Neville Goodman
Passing exams demands hard work. Luck helps, but
hard work makes you luckier was my previous
message' about the examinations in anaesthesia.
Now I want to be a little more controversial. I also
wrote that I thought the exams were fair and
consistent, but in its efforts to be as fair as possible
to the candidates in the vivas, I think the College has
chosen the wrong solution.
I don't think that
candidates are disadvantaged; in fact, it may mean
some candidates pass when perhaps they should not;
but the chosen solution detracts from the main
purpose of the vivas, which is to test, not the
candidates' factual knowledge, but their
understanding, and whether they can put that
knowledge to use.
A simple example is the alveolar air equation.
How should one ask about it in the Primary FRCA?
Perhaps just by asking, 'Can you write down for me
the alveolar air equation'? and then asking about
each term and how the equation might be used. But
this is little more than testing textbook knowledge.
By asking straightaway for the equation, an
important link in the logical chain has been
bypassed. A candidate has a head full of facts that
are analogous to carpenters' tools. You don't test an
apprentice carpenter by asking them to describe a
plane; you present them a toolbox and ask them to
smooth a piece of rough wood. The way to test the
alveolar air equation is to present a situation, for
example, the expected arterial partial pressure of
oxygen after preoxygenation. However, an examiner
can ask a question in this way only if they
understand the topic. There won't be any examiners
who don't understand the alveolar air equation, but
is that so for all areas of examinable physiology?
How much physiology can one person know?
One of the great men of physiology died in 2003.
Arthur Guyton's Textbook of Medical Physiology
(W. B. Saunders Co.) is a standard, and Guyton
wrote the first eight editions as sole author. The
first edition appeared in 1956 and the 8th in l99l:
for later editions he had the luxury of a co-author.
That wasn't all: he also wrote the parallel though
less well known Human Physiology and
44
Mechanisms of Disease (W. B. Saunders Co.).
Between 1972 and 1992 its five editions were his
solo work. That would be work enough for any
ordinary medical author, but Guyton did research
too. Not the research that most of us do, but real
groundbreaking research that is the scientific basis
of much anaesthetic practice. His research was not
the minutiae that preoccupies many of today's
researchers, which means they know nothing
beyond what brings in their grant money; it was the
of
the founders of biophysics; he studied the
research of real systems physiology. He was one
performance of the heart as a pump; he measured
interstitial pressures. Twenty-nine of the people
who worked in his department went on to be chairs
of their own departments. He was, of course, aided
in all this work by being extremely clever, but
there is something else that stands out when one
reads the obituaries and appreciations, many of
which are on the internet: he worked extremely
hard. One of his early junior colleagues remembers
that there was no coffee pot in his rooms, and only
a couple of pots in the whole department, well
hidden. Guyton did not like people to waste time
drinking coffee.
So even if I'd had the talent, I couldn't have
produced anywhere near the epic tome that Guyton
gave birth to and then nurtured by himself for 35
years: I'm too fond of coffee. It also means that my
knowledge of physiology is a small part of what his
was.
Anaesthetists do not need Guyton's knowledge
physiology.
I
of
suggest that there are no examiners
who have his knowledge; I certainly don't. There are
some topics, however, where I might come close,
and these are the topics I chose to examine in the
days when examiners chose their own questions.
There is a problem with examiners choosing their
own questions: pet topics. Whether it happened or
not, there has always been the worry that examiners
could choose to ask difficult, complex questions
about topics on which they were a world expert and expect expert answers. What is indisputable is
that, in past years, different candidates were asked
different questions. In these more accountable times,
it was felt that there
should be no possibility of
examiners choosing difficult questions on a whim,
disadvantaging some candidates over others.
So, some years ago, the College began to
structure vivas in the basic sciences and sheets of
viva questions were introduced. Clearly, unless
candidates could be relied on not to talk to their
fellow candidates, it was not feasible to ask all
candidates the same questions. But the compromise
was to have the group
of candidates in
the
examination hall at any one time asked the same set
of questions from preset sheets. And because those
candidates would not meet the next group, one sheet
would do for two groups of candidates.
So far, so good. Examiners could not throw in
a
tough question; they could ask only approved
questions, and then only the approved questions on
the sheet in front of them. But what if the question
was about the liver?
To me, liver is nice if cooked well with onions,
but otherwise it's a mystery. For the Natural
Sciences degree in Oxford, we were able to choose
three papers out of four: I chose cardiovascular
physiology, respiratory physiology,
and
neurophysiology - subjects that I've retained an
interest in and have taught ever since I started
teaching in anaesthesia. Sure, I gained a rudimentary
knowledge of what went on in the liver and much
else of endocrine and metabolic physiology when I
took the anaesthesia exams myself, but I did not
retain the interest that would have allowed me to
teach those subjects. I don't believe that I could
examine something
I did not understand well
enough to teach. Different examiners will have
different lacunae, yet all examiners were (and as far
as I know, still are) expected to examine all
questions on the sheets, which, in their entirety,
cover the whole syllabus in physiology and
pharmacology.
Inevitably, examiners are asking questions but do
not know the answers themselves. If a candidate
gets an answer half right, without an understanding
of the subject, an examiner has little chance of
helping the candidate towards the right answer. It
would not help to write the whole viva - detailed
questions and answers - down on the sheets,
because different candidates give different answers,
and these different answers demand different
directions for the viva subsequently. And anyway,
if every question had an answer that could be
written down, why go to the trouble of organising
vivas, which need expensive consultant
anaesthetists to staff them?
In my view, the laudable and necessary effort to
be fair to the candidates has led the College to the
wrong solution: the College decided to train the
examination, but a better solution - though I admit
more administratively difficult - would be to train
the examiners. Just because someone is a world
expert does not mean they will expect others to be
world experts: an expert who is also a good
examiner will know what depth of knowledge is
needed. What is more, if examiners have their
favoured subjects, which they ask all the time, they
will have a better idea of the standard, of the
gradations of knowledge from good to bad
candidates and in between, because they will see
more candidates answering those same questions.
There would be no need to abandon question
sheets, but they would be drawn up from a set of
approved questions by each examiner. Instead of all
candidates in the room at one time being asked from
the same sheets, all candidates going to partisula[
tables during the day would be asked from the same
sheets, with changes during the day to avoid
candidates passing on information, but sheets at each
table remaining within the areas of interest of those
examiners. Instead of having a horizontal uniformity
of questions, there would be a vertical uniformity.
To those who assert that asking the same questions
all the time is boring, my response is that there is not
(or should not be) any examiner with such a limited
range of knowledge. And, in fact, in the part of my
examining career that pre-dated the question sheets,
I only ever asked about 15-20 questions anyway.
Preferred methods of examination change with
the times: they change because of fashion, utility
and sometimes even evidence. The zeitgeist being
accountability and the dismissal of chance as having
even the slightest effect on one's life, it may be that
vivas are judged too subjective no matter how they
are organised. It is arguable that all assessment of
anaesthetists should be carried out in the workplace.
But it is difficult to see how the theoretical
underpinning of practice - which must be tested can be tested in the workplace. Some might favour
devising MCQs or similar questions to test
understanding of that knowledge. To those people I
make two points. First, having sat through 12 years
of basic science vivas in the FRCA examinations
and seen the many and varied ways in which
different candidates fail to understand, I think it too
diffrcult a task to represent the questions properly on
45
paper, and that actually to do so may be less fair to
candidates than vivas. Second, there are beginning
to be worries about university students now lacking
the skills to write cogent arguments. Part of the
blame is being put on tick-box and short answer
examination questions' and some suggest the
re-introduction of essay questions in GCSE and
A levels.
Doctors' handwriting being what it is, that might
be a step too far in the FRCA.
References
1.
2.
Goodman
N. Be prepared. Anaesthesia Points West 2O03;
35(2):60-61.
Ward L. Revival of the essay likely in exam reforms.
Guardian
12 November 2003, p 2, col 4.
Society of Anaesthetists of the South West Region
Merchandise
Society Ties -
f10.00
Available
4
fro*
Society Broaches
-
Hon. Sec. and at all home meetings
f15.00
Poem
Crazy Summer
Med. school's out,
me on a motor bike,
mid west of nowhere.
ofgrl takes you behind a hedge,
her kisses wild red berries.
'I have to go,
I come
across this gig
in some village hall.
Stand there with my beer,
it's late' she says
(ust when I think I'm up for it)
'Meet me tomorrow'.
manage the odd dance,
but all the birds are taken
or disinterested.
She waited each evening
Going out the dooq
this girl called Brenda . . .
Someone said
by the chestnut tree,
her blue eyes a surprised sky
the glow about her
an untouched morning.
She rode pillion while I
'They've been trying all evening'
meaning her and me.
'First I knew of it' I thought.
'You're different to the others'
Then September came,
Anyway, next thing
she takes my hand.
I'd never met the sort
taking our outdoor love,
leaving me these dark wards
and the London rain.
sang love songs. She said
Robin Forward
47
Obituary
Dr Violet Fry 1908-2003
Somerset boarding school. She read medicine at
Bristol, gaining her MB, ChB in 1934, one of the
few women to do so at that time, and served as
House Officer at the Bristol General and
Nottingham Children's Hospitals. In 1938 Violet
moved to the Devonshire village of Ipplepen as a
General Practitioner, a post she held
In 1948 Violet
until
1947.
was awarded the Diploma in
Anaesthesia having become an anaesthetist,
initially at Newton Abbot Hospital, and later also
Torbay, holding these appointments until her
retirement in 1968.
In 1947 Violet was a founder member of our
Society of Anaesthetists of the South Western
Region, and in 1963 became the first ever female
President. Despite frail health she was able to
attend the Golden Jubilee meeting in Bristol in
November 1997.
Violet took an active part in village life and
held prominent positions in many civic groups
including the local Amateur Dramatic Society,
the Cottage Garden Society and the Torbay
Dr
Violet Fry
Dr Fry was born in a suburb of Bombay where
her father worked for the Great India Peninsula
Railway. Violet was thirteen when, with her
younger sister, she came to England to attend a
48
branch ofthe Royal Overseas League. She served
on the Parochial Church Council, represented her
parish on Deanery Synod and served for some
time as Sacristan.
Her remains are interred in Ipplepen church
cemetery under a stone that reads - 'A life given
to others through medicine.'
She is survived by a niece in New York.
Crossword
Dr B. W. Perriss
Clues Across
1.
4.
10.
1l.
12.
13.
14.
15.
18.
20.
23.
25.
26.
27.
28.
29.
Leave the city in the wet. (6)
A fashion editor's heavenly body. (6)
The South West, for example, gets a nine plus for
redevelopment. (9)
Part of tumult raged excessively (5)
Showing diplomacy in negotiating flat cut. (7)
The best lubricant on earth. (7)
Summons everyone in case of crisis. (5)
A newspaper's last attack on one's
highJevel party. (5-3)
Pafy worker? (8)
Lie about strength ofcharacter. (5)
Home supporter thanks the king's daughter. (7)
Force's precipitous action. (7)
Church member with nothing inside to eat. (5)
Time to study factory made exercise machine. (9)
Pioneers - they pay what is owing. (8)
Take a look at a leg shot. (6)
Solution to Crossword in
WINTER 2003 Anaesthesia Points West
Clues Down
l. Silly fellow can't measwel (8)
2. Finished like arocket. (7)
3. Declare nothing but a declaration. (9)
5. Spread brie and crackers. (7-7)
6. Gear up for English gibe. (5).
7. Gone to see prospect. (7)
8. Delay round Germany could be fatal. (6)
9. Enor-a clue can'tbe designedfor
power base. (7,7)
16. Does it lower the tone? (4,5)
17. Military call-up about to cover the French. (8)
21. Gold calf perhaps, no one returns. (7)
22.
Most talk about this event. (6)
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