Stanford (USA) - Anaesthesia UK

32 Pages·2008·2.72 MB·English

Anaesthesia
News
No. 250 May 2008

The Newsletter of the Association of Anaesthetists of Great Britain and Ireland. ISSN 0959-2962
Scottish Standing
Committee
Stirling Meeting
The National Institute for
Academic Anaesthesia
One hundred years of the
Section of Anaesthesia, RSM
21 Portland Place, London W1B 1PY, Tel: [phone], Fax: [phone], Email: [email protected], Website: www.aagbi.org
Anaesthesia News May 2008 Issue 250 1
2 Anaesthesia News May 2008 Issue 250
Contents

Scottish Standing
03 Scottish Standing Committee Open
Meeting - Stirling 2008
06 National Institute for Academic
Anaesthesia
Committee
09 GAT Page - The European Working
Time Directive
14 Anaesthetic machine power failure
Open Meeting
and battery backup
16 Stanford University Hospital
- A year in Silicon Valley!
21 Editorial - MMC Selection Revisited
24 The History Page - A centenary Stirling 2008
celebration
26 Dear Editor…
30 Anaesthesia Aphorisms
32 Birthdays
And so to Stirling. Neither gale
force winds nor driving rain could
The Association of Anaesthetists of Great deter dedicated anaesthetists from
Britain and Ireland
congregating in the conference centre
21 Portland Place, London W1B 1PY
for the Scottish Standing Committee’s
Telephone: [phone]
Fax: [phone]th open day. Stirling has become the
Email: [email protected] home of this meeting, no doubt because
Website: www.aagbi.org
it is central and not in either Glasgow or
Anaesthesia News Edinburgh. The Forth Valley tourist board
Editor: Hilary Aitken tells us that the location has historical
Assistant Editors: Iain Wilson, Mike Wee significance too. A river crossing, a
and Val Bythell
natural gateway to the highlands and an
Advertising: Claire Elliott
ancient castle perched on a rocky crag
Design: Amanda McCormick in the heart of the city all mean that
McCormick Creative Ltd,
much history has flowed under the Forth
Telephone: [phone]
Bridge. The castle may be strategically Outgoing Convenor Neil MacKenzie hands over to
Email: [email protected]
Kathleen Ferguson
Printing: C.O.S Printers PTE Ltd – placed but it did not prevent it changing
had between them held the Convenor’s
Singapore hands eight times during the wars of
Email: [email protected] chair for seven years and were warmly
independence.
thanked for their contributions by Dr
Copyright 2008 The Association of
Change was in the air within the SSC. Kathleen Ferguson, the new convenor,
Anaesthetists of Great Britain and Ireland
No bloody revolution here: more an as she welcomed the windswept
The Association cannot be responsible for
orderly passing of the baton or insignia audience at the start of the meeting.
the statements or views of the contributors.
No part of this newsletter may be of office as we said goodbye to two of Kathleen cuts a slighter figure than Neil
reproduced without prior permission. the founding committee in the shapes and pointed out that the insignia went
Advertisements are accepted in good faith. of Drs Jim Dougall and Neil Mackenzie further south on her torso than it had
Readers are reminded that Anaesthesia who demitted office the day before the on Neil’s. Nonetheless she promised to
News cannot be held responsible in meeting to be replaced by Drs Matthew grow into it and the applause following
any way for the quality or correctness
Checketts (Dundee) and Mike Fried indicated as much a vote of confidence
of products or services offered in
advertisements. (Livingstone). The outgoing members as a message of goodwill.
Anaesthesia News December 2007 Issue 245 3
SCOTTISh STANdINg COMMITTee
Our first speaker was Dr Malcolm and gave us valuable insight into how
Booth, a consultant anaesthetist and the parliamentary and government
intensivist from Glasgow Royal, who processes work. She indicated different
took us through the burgeoning field of ways a group can gain a handle on the
difficult ethical dilemmas in ICU, and levers of power within Holyrood. Public
what help is available to resolve them. petitions do get noticed and sometimes a
Difficult treatment decisions are not new sympathetic (group of) MSPs will respond
of course, but they carry an extra layer of by setting up a cross party group which
complexity if applied to a seriously ill, can apply pressure within the system. It’s
sedated, intubated patient in intensive easy to be cynical about politicians but
care. The Incapacity Act has added in this forum they are seen at their best –
the possibility of patients’ proxies in doing their best for the disadvantaged.
the shape of Welfare Attorneys, but for
Dr Nigel Harper’s talk on anaphylaxis
acutely ill patients such an option may
was a masterly resume of the subject,
not be feasible. There is still a role for the
incorporating both allergic and non-
next of kin, although research suggests Speaker Ian Anderson receives a traditional Scottish
allergic forms. In the first category gift from meeting organiser Alistair Michie
that surrogate decision takers are not
anaesthetic related drugs have “previous” Medicine from Casualty via Accident
much more accurate than doctors in
as my favourite 1980s detective would and Emergency. Surgically trained, he
determining what patients want, even
say. Muscle relaxants and antibiotics voiced misgivings about the switch in the
with the full facts placed before them.
are particularly prone to get your case specialty’s name, the direction of junior
Malcolm did wonder whether such
off to a gut-wrenching start. The clinical training with special mention of acute
theoretical considerations were common
picture is reasonably well known - common stem training and the well-kept
points of discussion between partners.
unexplained hypotension, bronchospasm secret that is the location of the College
Now here is something you could try
and vasodilation are the cardinal signs. of Emergency Medicine (it shares a
at home. Snuggle under a warm duvet
Recognition should trigger a call for help, building with another august institution
and as the lights dim, intone as follows
then note the time if you have enough in Red Lion Square). Illustrating his point
“Darling, I was just wondering…” There
sang-froid and initiate treatment with about the lack of specialty status, he
will be prizes for the tersest replies.
50 microgramme aliquots of adrenaline. regaled us with a golfing story in which
Finally, Malcolm emphasised that the Locate the Association’s laminated guide he was drawn in competition against a
patients’ views are still paramount, for further management – every good consultant surgeon who responded by
even if they appear to us to result in anaesthetic machine should have one sending his registrar to stand in. Lest
questionable decisions. “There is no law attached. After the initial management you think him a trifle curmudgeonly, he
against being stupid” he reassured one check the guidance for referrals for responded to a question by revealing that
inquiry from the audience. specialist testing. Nigel also drew our he claimed to know the good lord. Such
attention to the forthcoming anaphylaxis is Mr Anderson’s status that I confess I
Our next speaker was Dr Jean Turner
electronic database accessible through was disappointed when it became clear
who has had more careers than most:
the Association’s website. We are urged he was talking about Lord Darzi. The
anaesthetist, G.P., independent Member
to report reactions for national collation. other good Lord I suspect writes Ian’s
of the Scottish Parliament (MSP) at
scripts.
Holyrood, and now chairman of the Ian Anderson, whose career as a stand
Scottish Patient Association. During up comedian is presumably on hold The post-prandial slot was given to
her stint as an MSP Jean had been until he leaves medicine, talked us the Association’s president, Dr David
drawn to a number of health issues through the evolution of Emergency Whitaker. He pointed out that 2008 is
4 Anaesthesia News May 2008 Issue 250
SCOTTISh STANdINg COMMITTee
the 60th anniversary of the NHS (I hope
its lifespan is not measured on the human
scale). He also updated us on a variety of
future events and drew our attention to
the fate of two departed ministers from
the Department of Health, Patricia Hewitt
and Lord Warner. Both have rejected the
chance to spend more time with their
families and have become paid advisors
- you've guessed it - to the healthcare
industry!
Following that we had our open forum, a
chance for the audience to seek wisdom,
voice concerns or ride their hobbyhorses
on subjects of their choosing. Our new
The Scottish Standing Committee at work
Convenor acted as ringmaster and kept
good order as our panel comprising There is still work to be done before this with the Scottish government making
Drs Whitaker, Chambers and Robb peak is scaled, not least a government- positive noises on that score. A couple
gazed into their crystal balls to see how led dialogue on the “Role of the Doctor.” of questions brought reassurance from
anaesthetic departments might look in However, if the initial response is any Sir Graeme. Complaints will be dealt
the next five years and how to plan the gauge, the Tooke report will figure largely with more speedily keeping distress to a
workforce. As a wise head said only the in any reorganisation. If you have a sense minimum and the local process will be
previous day, the NHS has never been of deja vu it is because it recommends overseen by the Medical Director’s office
planned properly, so it is unrealistic of three early years for “core specialty and not a “GMC Affiliate”. The meeting
us to look too far forward. One question training” – did anyone mention SHO’s? ended in traditional fashion with Kathleen
which caused greying, thinning heads to Ferguson making a presentation to Sir
Our keynote speech was entitled
perk up was identifying the appropriate Graeme, amidst a sea of flashlights.
“Delivering Revalidation” delivered by
age to cease on call work. Sadly there is
Sir Graeme Catto, President of the GMC. The meeting was a great success and our
no agreed answer; it has to be negotiated
He looked remarkably well for someone thanks should be directed to its organiser
within each department. There was just
who is supposed to have sipped from - Dr Alistair Michie.
the suggestion of shoulders sagging.
a poisoned chalice. Fluent and lucid,
Some things of course don’t change:
Change was very much the theme for he made a complicated subject clear.
outside the weather had got worse.
our last two speakers. Professor Philip Revalidation will have two strands.
Cachia brought us up to date with Relicensing will be for all doctors, based gavin gordon
MMC and all its works. His approach on the principles enshrined in Good Secretary, Scottish Standing Committee
was to cover three aspects, namely the Medical Practice with components of
regulatory framework, the Government CPD and 360-degree appraisal included.
response and the strategic delivery. Like Recertification, whether for specialists
a rock climber scaling a difficult traverse or GPs, will be judged against standards
he moved carefully and purposefully agreed by the Royal Colleges, a major
through a morass of reports allowing task indeed. It is hoped there will be UK-
us a clearer view of our progress so far. wide agreement and implementation,
Anaesthesia News May 2008 Issue 250 5
SpeCIAl ARTICle
National
Institute for
Academic
Anaesthesia
The establishment of the National decade has witnessed a catastrophic performing clinical research began
Institute for Academic Anaesthesia was decline in University and NHS-based to mount and eventually became
announced in March this year. The academic anaesthesia in the UK. We are almost insurmountable. Furthermore,
Association of Anaesthetists of Great not alone, other specialties have suffered anaesthetic trainees, who were essential
Britain and Ireland (AAGBI) and The Royal a similar fate; however, several factors members of the research team, found
College of Anaesthetists (RCoA) believe have conspired against anaesthesia to commitment to research difficult because
that this represents a major development make the situation particularly grave. of the new rigid training schemes
and oppurtunity for anaesthesia and its and decline in numbers of potential
The backbone of anaesthesia research
related specialties. This article, which supervisors.
at that time was clinical investigations.
is being published simultaneously in
However, university academics engaged In response to this situation, the RCoA
AAGBI’s Anaesthesia News and the RCoA
in this work began to find it increasingly published its National Stategy for
Bulletin, explains the reasoning behind
difficult to thrive in an environment Academic Anaesthesia (www.rcoa.ac.uk/
the creation of the National Institute for
dominated by a new Research Assessment docs/Academic_full.pdf ). The working
Academic Anaesthesia and what this
Exercise that rewarded universities party responsible for the report was very
new organisation hopes to achieve.
who were engaged predominantly thorough in the work that underpinned
Many of us remember when most in laboratory-based research funded its conclusions and recommendations.
major anaesthetic centres had a large by organisations such as MRC and It sought advice from national academic
and vibrant academic setup; University Wellcome. Clinical research became bodies including the Council of Heads
academics, NHS consultants and regarded as soft and received scant of Medical Schools, the Medical
trainees were actively involved in recognition. Subsequently, many Research Council, Wellcome Trust and
research and published their work academics ditched clinical research the Department of Health (Research
widely. This activity had significant and dived into the laboratory seeking and Development). The report confirmed
impact on the safety and patient an anaesthetic slant to locally available the decline of academic anaesthesia
experience of anaesthesia and its related basic science themes. Some were, and made numerous recommendations,
specialties, and ensured that academia and continue to be, very successful; including the establishment of a National
in its widest sense was embedded within however, many were not. At the same Academic Institute. In my opinion, the
our profession. Unfortunately, the last time, the administrative hurdles to most striking fact that emerged from the
6 Anaesthesia News May 2008 Issue 250
SpeCIAl ARTICle
various meetings and discussions that related specialties, to: (i) develop and Several other work-streams are presently
accompanied the report’s publication maximise its academic profile within the ongoing. It was important to establish
was that it was absolutely clear that it healthcare profession, NHS, Universities the Institute rapidly and this has been
was the view of many influential national and major research bodies; (ii) facilitate achieved with the involvement of a
academic leaders and organisations that high profile, influential research; (iii) relatively small number of stakeholders.
UK anaesthesia had no academic profile, facilitate and support training and For its vision to be fully realised, it is
was fragmented, had no strategy and was continuing professional education in essential for the Institute to invite the
almost irrelevant to the health of the academia; and (iv) improve patient care full participation of other partners,
nation. This is serious stuff; if anaesthesia by promoting the translation of research especially the specialist societies
is perceived to have no academic base, findings into clinical practice. Clearly, within our profession; we are now
anaesthetists could readily be regarded research is a key issue but the Institute actively involved in this process. In an
as a group of technicians not on a par will be involved in facilitating all aspects attempt to identify important nationally
with other specialties. This despite of academic activity. fundable areas of research, the Institute
the unrivalled contributions we have has launched a research priority setting
Research affairs will be governed by
made, and continue to make, to the exercise that will seek and explore
the Institute’s Research Council which
development of modern healthcare. the views of the profession as to the
is already active. The initial funding
A National Institute for Academic most important unanswered questions
partners in this endeavour are the
Anaesthesia could play a major role in in anaesthetic practice. In addition,
AAGBI, RCoA, the British Journal of
correcting this damaging perception. the Institute is now engaged with the
Anaesthesia and Anaesthesia. Its agreed
MOD in planning the development of
Another important consideration is aim is to provide co-ordinated research
academic activities within UK military
that the recommendation to establish a support and rapidly work towards the
anaesthesia. Numerous other projects
National Institute came at a time when development of a national strategy for
are under consideration.
there were signs that the tide of decline of anaesthesia research. It is important that
academic medicine was beginning turn. this body becomes recognised by the NHS The National Institute for Academic
For example, the new NHS Research National Institute for Health Research in Anaesthesia is not the only remedy
and Development Strategy emphasises order to attract support funding from new to reverse the decline of academia in
the importance of good quality clinical NHS R&D funding streams and work our profession; however, it is a major
research (see the National Institute is ongoing to achieve this. Changes in and imaginative step forward. It exists
for Health Research: www.nihr.ac.uk) the mechanism of applying for research to assist the work of any anaesthetist
and established numerous funding grants from the AAGBI, Anaesthesia, undertaking academic activity in the
mechanisms and infrastructure for its British Journal of Anaesthesia and RCoA UK, facilitate academic training and
support. In addition, the decline in the have already taken place. These grants represent our profession at a national
numbers of clinical academics in training will be advertised, assessed and awarded level. The agenda is huge and to succeed
was finally recognised and the Walport by the National Institute’s Research it will need the support of anaesthetists
scheme for specific clinical academic Council utilising a rigorous, competitive, nationwide. If you have any thoughts on
training was introduced. The potential peer review process. potential work-streams for the Institute or
benefits of these and other developments wish to be involved in its work, please do
Another priority for the National Institute
have been debated vigorously but there not hesitate to contact us.
for Academic Anaesthesia is academic
is no doubt that they represent a potential
training. It is vital for all anaesthetic prof david J Rowbotham
life-line. A National Academic Institute
trainees in Walport posts to be successful Council Member, AAGBI
could assist our profession in taking full
and the Institute is committed to
advantage of them.

supporting their training in any way
Board Chairman, National Institute for
The National Institute for Academic possible. Additionally, we believe that it
Academic Anaesthesia
Anaesthesia is a joint venture between is also important to support non-Walport
the RCoA and the AAGBI and has now trainees who are keen to get involved
been established within the RCoA. Its with research and we are exploring how
vision is, with respect to anaesthesia and this can be achieved.
Anaesthesia News May 2008 Issue 250 7
8 Anaesthesia News May 2008 Issue 250
gAT p Age
The European
Working
Time Directive
The full impact of the European Working Time spent on call:
Time Directive (EWTD) is almost upon The European Court
us. From August 1st 2009, this Europe- of Justice (ECJ)
wide, European Union Health and has ruled on two
Safety legislation will introduce a occasions that on-
maximum 48-hour working week for all call time for doctors
doctors. Currently doctors in training are should count as
regulated by EWTD legislation to having working time,
a maximum 56-hour working week. which has left many
countries struggling
The original legislation, including
to keep doctors'
timescales for implementation, dates
average weekly
back to 1993 but was only adopted by
working hours
the UK in 1998. In relation to the working
below the agreed
arrangements of doctors, provision was
limit. These two
specifically made that deferment could
rulings were known
be sought by governments of individual
as the “SiMAP” and
member states to extend the timescale
“Jaegar” rulings.
of the directive implementation to 2012
As a result of these
for doctors in training. If granted, any
judgements, staff
derogation would allow an interim
who are required
52-hour maximum working week
to be resident in
between 2009 and 2012. It is thought
hospitals or other
that the current Labour government has
places of work out-
no plans to apply for such derogation,
of-hours, and who
but no official statement exists. The
are provided with
Conservative Party, however, has
on-call facilities,
indicated that they may apply for
are considered to
derogation if elected in the interim.
be 'working' during
Contentious issues their period of duty. migrated to working full-shift patterns
The opt-out: This is a measure which The whole of the resident on-call period where they are expected to “work” for
allows workers to agree to opt out of the counts as working time whether or not all of their duty period (usually 12 –
48-hour week. Employers in a number the member of staff is actually working. 14 hours) and indeed not rest on duty
of states make use of the opt-out, but it is In order to meet the rest requirements within the hospital – since rest is legally
most widely used in the UK and Malta. of the directive, many doctors have working time.
AAnnaaeesstthheessiiaa NNeewwss MMaayy 22000088 IIssssuuee 225500 99
gAT p Age
What else does the Working Time In England the latest figures available status quo will prevail and that the ECJ
directive do? (September 2006) indicate that 59% of rulings on on-call time stand and must
junior doctors were being paid Band 2 be implemented. In the interim period
Among other things, it guarantees at
salaries, therefore were working in posts the European Commission planned
least four weeks paid annual leave; a
with duty hours over 48 hours duration to launch infringement proceedings
minimum period of 11 hours rest every
which are not 2009 EWTD compliant. against all 25 member states who do not
24 hours; one day off per week; a rest
implement the ECJ rulings in full. The UK
break if the working day is longer than european Ombudsman
is one of these countries and argues that
six hours; a maximum of eight hours In 2007 a report was issued by the
implementing the rulings in the medical
night work, on average, in each 24 hour European Ombudsman which heavily
sector would cost the NHS £250 million
period, and health assessments for night criticised the European Commission
annually.
workers. for failing to take action on the issue
of working time. The report specifically If further negotiations are carried out in
What will happen to the opt-out?
concerned a complaint that was 2008 and an agreement finally reached,
The European Commission is reviewing
submitted by a German doctor who was it is important to remember that this will
whether to allow the opt-out to continue,
unhappy with the fact that EU member not be the end of the political process.
although it has suggested measures that
states were not implementing the (ECJ) In the event of an agreement, the dossier
would make it harder for employers to
rulings on working time.1 The issue has will need to return to the European
press staff into working more than 48
now been taken up by the European Parliament for a ‘second reading’. MEPs
hours against their will. However, some
Parliament's petitions committee who are unlikely to endorse an agreement
countries want this option to be phased
will provide a non-legislative opinion on which maintains the opt-out and which
out, as does the European Parliament.
the matter. This report will be debated overturns the ECJ rulings. By thus delaying
Other states, in particular the UK, want it
in the European Parliament over the the procedure, the dossier may well fall
to continue. They argue that labour market
next six months with a final version foul of the European Parliament elections
flexibility helps reduce unemployment.
due to be published in July. The report scheduled for June 2009. The newly
The UK does not have a veto in this area,
will not carry any legal weight but is elected MEPs will have the right to return
so could be outvoted, but so far support
an interesting indication of the political to a ‘first reading’ on the EWTD and to
from Germany and Poland has helped
atmosphere surrounding working time effectively re-start the whole process.
the opt-out remain viable.
and the intense pressure from MEPs and
It now remains to be seen whether the
other stakeholders to find a solution to
What about time spent on call?
European Commission will start the
the problem.
The European Commission proposed
infringement proceedings in early 2008.
making a distinction between "active"
The Portuguese Presidency in 2007 It is under intense political pressure both
and "inactive" time on duty. Inactive time
presented a compromise text, similar in from the European Ombudsman who
on duty would not count as working
content to previous texts, which aimed wishes the ECJ rulings to be implemented
time. Most countries agree with this, but
to maintain the opt-out (under strict and from member states who do not wish
the European Parliament does not. The
conditions) and to overturn the ECJ to respect the rulings.
Parliament does suggest that inactive
rulings on on-call time (SiMAP and Jaegar
time could be calculated differently, but peter Maguire
rulings). At a Council of Employment
no firm decision has as yet been made. Consultant Anaesthetist
Ministers meeting on 5-6 December
An eagerly awaited report from the Newry
2007, EU Ministers debated the package
European Ombudsman may influence
but were unable to reach agreement.
References
the continuing debate on the opt-out and
In EU terms, the decision has been
time spent on call. 1. http://www.ombudsman.europa.
‘postponed’ and the official minutes of the
eu/special/pdf/en/053453.pdf
meeting suggest that both member states
At this time, 25 out of 27 EU member
2. http://www.consilium.europa.eu/
and the European Commission are keen
states are failing to meet the requirements
ueDocs/cms_Data/docs/pressData/en/
to continue negotiations under the 2008
of the legislation; therefore a huge
lsa/97445.pdf
Slovenian and French EU Presidencies.2
challenge is ahead to have the directive
This means that, for the time being, the
implemented in full by the 2009 deadline.
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