the society of anaesthetists of the south western region

spring 2014

inside:• Pen portrait of new President of saswr- now in technocolor! Fiona Donald joins the dots on Dr. Chris Johnson• Difficultobstetricairways Everything you wanted to know about Spondyloepiphyseal Dysplasia Congenita, but were afraid to ask• HowtobecomeanAcademicAnaesthetist

Instrumentsoftortureuncoveredas AnaestheticdepartmentisclearedDuring a recent clear out of the anaesthetic department at Frenchay, in preparation for the move to the new Southmead hospital, several items whose use is now considered inhumane were discovered under layers of bound copies of the BJA. A seemingly innocuous box of sherry glasses caused palpitations in the more senior members of the department present, and bafflement in the trainees, until the full horror of ‘trial by sherry’ was explained to them. Trial

by sherry (aka sherry-boarding) was the process whereby Consultant-hopefuls and their spouses would meet the entire compliment of the department they were hoping to join, in an attempt to make a good impression over a woefully inadequate small glass of sherry.As if that wasn’t enough, a Nunn Blood Gas slide rule was also discovered, a device which fiendishly combines the baffling complexities of blood gas analysis with the arcane ergonomics of a slide rule. That’s right children, no buttons, no battery, no Google.

news ofthe westincorporating anaesthesia Points west

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the society of anaesthetists of the south western region

President Dr Chris Johnson Southmead

President – elect Dr Chris Monk uhBristol

HonorarySecretary Dr James Pittman exeter

HonoraryTreasurer Dr Ed Morris Southmead

TraineeRepresentatives Dr Richard Reed SouthWestSchool Dr Gemma Nickols Bristol school EditorialCommittee Dr Richard Dell editor, Frenchay,NBT

Administrator Kate Prys-Roberts uhBristol

WebsiteManager Dr Ben Howes uhBristol

www.saswr.org

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anaesthesia Points westContents

Vol 47 no 1 spring 2014 Page

Editorial Richard Dell 3

Future meetings of the Society 5

Presidential Profile Fiona Donald 6

Obituary Dr Guy Jordan Ben Walton 9

Obituary Dr David Penney Doug Smith 11

News of the West Linkmen of the Region 13

Examination successes and honours 25

Autumn Scientific Meeting report James Pittman 26

Prize winning and runner-up trainee presentations from the Autumn 2013 SASWR Meeting

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Academic Clinical Fellowships in Anaesthesia

Anna Simpson 37

Expedition Medicine David Luther 39

Spondyloepiphyseal Dysplasia Congenita-Airway Management for Caesarian Section

SC Grenfell, JE Lewis,HP Lindsay

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The Wine Column - The Joys of Summer Tom Perris 46

Poem - Inspiration Robin Forward 48

Crossword Brian Perriss 49

Ross Davis Adventure Bursary 50

Prizes and bursaries 51

Notice to Contributors 52

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editorial#yoLo

Where to begin? Well, sad to say, with endings, of sorts. This edition of APW is burdened with two obituaries, both movingly, even lovingly written. One of the great privileges of being a doctor is to observe at close quarters significant events in the lives of others, and we learn, even as medical students, to construct empathy barriers so that we can maintain a discreet objectivity, and, from a practical viewpoint, still function usefully. Obviously I’m not including surgeons in that description, as they appear to live, how can I put this delicately, on a different spectrum to the rest of us.Occasionally, however, events conspire to bring those barriers crashing down, and the premature loss of a friend or colleague remind us that we’re not immune to illness or pure bad luck. I’d urge you to read their obituaries, sparing a thought for those they left behind, and admire the lust for life that Drs’ David Penney, Guy Jordan and Alex Shearman so evidently shared.

James Pittman has written a report of the hugely successful Bristol SASWR meeting, and it appears that this years November meeting will be at the same venues, so I’d encourage you all to attend. The band that performed, mostly composed of consultants, have asked me to pass on some advice to those trainees, mostly male, who didn’t join in the dancing. There is no law that says, in the absence of any physical infirmity, that you have to dance, especially when some scary female Consultants are holding sway on the dance floor, but there are lots of Consultant posts coming up in Bristol next year. It’s not a

threat, I’m just saying, that’s all.

Elsewhere in this edition, Fiona Donald has compiled a daunting list of Dr. Chris Johnson’s accomplishments in her profile of the current SASWR President. His appetite for hard work is probably best typified by his preference for skiing uphill rather than downhill, or perhaps the lift pass is cheaper. I will never know.

Academic medicine is represented by Anna Simpson, who won a Wellcome Trust award to pursue an Academic Clinical Fellowship in Anaesthesia. Discover what that involves, and whether you should apply.Academic medicine is responsible for a lot of what we do, and also for one of the best lines delivered from a Consultant to a trainee. The latter being a clinical research fellow, and therefore not tied to early starts, was spotted sloping into the hospital for a rather late start to the day.

Consultant (Mike Nevin): “What’s the problem Jonathan? Couldn’t sleep?”

After what was such a wet winter for many, Tom Perris shifts his gaze to the approaching summer and provides us with food for thought as to what to drink at the BBQ in his wine column. Brian Perriss tests our wits with his crossword, and Robin Forward looks backward with his poem ‘Inspiration’, but between the lines he’s pushing the same #YOLO theme our late colleagues epitomised.

In an entertaining article on expedition

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medicine, David Luther regales us with what he got up to in various inhospitable parts of the world, on what looks suspiciously like a glorified gap year. On a positive note, unless I’ve mixed the photos up, he is the happiest looking person with a Spo2 of 72% I’ve ever seen. I only hope he doesn’t find the anaesthetic exams too arduous as a result. Suzanne Grenfell et al provide us with further proof, as if proof were needed, that the delivery suite is to be avoided at all costs, with an informative description of how to deal with a difficult

airway during a caesarian section.

Lastly, in an unforgivable oversight, I omitted to thank the previous editor of this journal, Vanessa Purday, for her invaluable help and for making the task of editing APW as easy as it is, so thank you Vanessa.

# YOLO?

You Only Live Once.

richard Dell

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spring 2014Truro Meeting

Headland Hotel, Newquay15-16th May

Autumn2014North Bristol NHSM Shed, Bristol

27-28th November

spring 2015To be announced

FutureMeetingsoftheSociety

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Portrait of the PresidentChristopherJamesHamiltonJohnson

There will be very few sharp intakes of breath around the region when I tell you that, when asked, Chris was prompt and thorough in providing me with the information I needed to prepare this portrait of the President.

Let me first give you the highlights. Chris was born some years ago in Sutton, Surrey, went to school in Oxford and Epsom, did his medical studies at Oxford, house jobs in Oxford and Stoke on Trent and then headed to the Antarctic and to Aberdeen all prior to starting his anaesthetic training in Oxford, New Zealand and the South West and then settling down to his consultant post at Southmead Hospital which eventually became part of the imaginatively named, North Bristol NHS Trust. So much for the CV but what we really want are the stories behind the CV, so here goes.Let us assume that we want to describe

a colleague to someone else and we are allowed just two phrases to make them

recognisable. How would we conjure an image of Chris? Possibly with “difficult airways and multi-coloured anaesthetic charts”. He would be instantly recognisable to anyone who has worked with him. Interestingly it seems that the latter characteristic was set at an early age. Whilst at prep school Chris discovered that he was absolutely lousy at playing cricket but surprisingly good at keeping score, with a passion for documenting detail neatly in many colours. A legend was born and industrial scale production of multi-coloured biros was revived. Later on in his school career Chris found that he was also really terrible at rugby, so terrible in fact that no one wanted him on their team and he was sent on cross country runs as a punishment. This lead to an abiding interest in running through brambles and to date he has completed 1500 orienteering events running competitively for over 15,000km which is roughly the equivalent of running from Bristol to Perth WA and only marginally less soggy underfoot. Chris says that being in the Lake District completing mountain marathons with his eldest daughter Nicola is one of his favourite places to be. Whilst we are on the subject of things Chris is terrible at, he tells me these also include singing and dancing. Unfortunately (or maybe fortunately), despite having shared an office with him for the last 5 years or so, I can’t vouch for either.Chris has a great interest in and commitment to expedition medicine. He is

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justifiably proud of the fact that he is both a Fellow of the Royal Geographical Society and lead editor of the 55 author “Oxford Handbook of Expedition and Wilderness Medicine” which he managed to get to the publishers on time. Speaking as a former editor of this humble journal I can vouch for the latter being an almost superhuman achievement. He has been a member of the Royal Geographical Society medical advisory cell since 1996 and was Chair of the group from 2009-11. As mentioned above, Chris spent some time in Antarctica and was in fact medical officer to the British Antarctic Survey and Falkland Island Dependencies from October 1978 to May 1980. This opportunity came about when, as a house officer, Chris saw a notice on the medical school noticeboard saying that the British Antarctic Survey needed doctors. He promptly applied, was accepted and then set about learning some anaesthetic skills that he thought might come in handy. He quickly realised that anaesthetists were the only hospital doctors who had lives outside medicine and were therefore, the sanest bunch in town. The great good fortune of many patients and trainees is that he decided to make anaesthetics his career, although not just yet. On his return from Antarctica Chris worked as a research assistant at the Institute of Environmental and Offshore Medicine at the University of Aberdeen where he completed his MD thesis entitled, “Hand Microclimate at an Antarctic Base” with Commendation.Finally, in February 1981, we come to the point where Chris starts his anaesthetic training. He was appointed as SHO and subsequently Registrar in the Nuffield Department of Anaesthetics in Oxford and spent a year seconded to Dunedin Hospital in New Zealand. His Senior

Registrar training was done in the South West with rotations to Gloucester, the BRI and Frenchay. In June 1989 he was appointed to his consultant post in Southmead. Immediately upon taking up the post he was made College Tutor for the department, a very unusual course of events for a new consultant and testament to his expertise in the areas of education and training. The next year he also took on the organisation of the new acute pain service at Southmead, raising funds to buy PCA pumps and to appoint pain nurses who were able to educate staff in pain management and to perform audits of its effectiveness. His anaesthetic interests were in head and neck anaesthesia, with the inevitable need for management of difficult airways, and minimally invasive urological surgery often performed in the inhospitable environment of the x-ray department. As we know he was by now an expert in surviving in inhospitable environments so this was a perfect fit.Chris’s early appointment as College Tutor was a herald of things to come. He has subsequently been a member of the Regional Specialty Training Committee in Anaesthesia, Regional Assessment Coordinator for the Bristol and Peninsular Schools of Anaesthesia, Deputy Regional Advisor and then Regional Advisor, Chair of the Bristol School of Anaesthesia Specialty Training Committee, external training advisor for ARCPs for the College and latterly a member of the College working party for the development of the e-portfolio. In 2012 his efforts on this project were recognised with the award of the Royal College Medal. Those of us who have worked with him in his educational roles are especially grateful for his strides to salvage something from the mess of

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MTAS and MMC. He was innovative and tireless in his bid to make anaesthetic appointments and the subsequent training work for trainees, trainers and the hospitals and patients they serve. I well remember sitting in his lounge looking at spreadsheets of the proposed workforce and trying to work out how it would all fit together. We were supplied with regular snacks and drinks by Chris’s wife, Gill, although sadly not with her near legendary rum cocktails.At the time of writing Chris has been a Consultant based at Southmead for just shy of 25 years and in his career has given and recorded over 25,000 anaesthetics. He has already retired and come back to us once and is currently in discussion about whether we will need him for a little bit longer. Of course we will! It is typical of him that despite this long tenure he is not sitting back and doing the minimum. He has taken on, and almost certainly succeeded in, the challenge of sorting out a slightly chaotic operating list that had frustrated many of his younger colleagues before him. He is also one of the bank of consultant appraisers helping to make appraisal and revalidation work for us all. This is particularly appropriate as he was

one of 6 consultants who helped develop and pilot our original Consultant Peer Appraisal scheme. There is an awful lot more to say about Chris. For example he is an avid cross country skier and in fact proposed to Gill on skis on the edge of Kvitavatn which is a frozen lake in the Telemark area of Norway. He loves new adventures and was once told by his youngest daughter that their family holidays were much more exciting than her school “adventure trip”. He has watched teams of huskies charging down a glacier in Greenland, sea-kayaked with Minke Whales in Nova Scotia, watched Desert Elephants in Namibia, photographed dolphins on Queen Charlotte Sound in New Zealand, skied up the highest mountain in Norway and watched the aurora borealis from his hotel in Southern Iceland, to name but a few exploits. Who knows what he will get up to next, although as I write this he is in Norway again where he tells me the snow is already nine feet deep and more is forecast.The society is privileged to have Chris as its President. He will put a lot into his year in the post and I think we will be the richer for it.

fiona Donald

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ObituaryGuyJordan1972-2013

Guy was appointed as Consultant in Anaesthesia and Intensive Care Medicine at Frenchay Hospital and North Bristol NHS Trust in April 2008. As a department we were all absolutely delighted as we felt that we had not only appointed an intelligent, diligent and compassionate clinician but someone who would be a great colleague and friend as well. To have to write about his life and tragic death so soon after his appointment seems so unfair and the void caused by Guy’s departure will take many years to come to terms with. Guy was born in Kingston Hospital, London. Apparently he was born long and thin with a very large head. Guy joked that he had spent much of the rest of his life trying to eat enough to get everything back into proportion. That he was able to achieve this on a strictly vegetarian diet (though with a self confessed weakness for beer and cheese) often came as a surprise to

those getting to know him for the first time. Guy’s medical career began in 1990 at St George’s Hospital where it would be fair to say he threw himself into both the curricular and extracurricular activities in equal measure. He intercalated at St Thomas’ Hospital and graduated in 1996 before completing House Jobs and an SHO rotation in Anaesthetics in the Home Counties. He then followed this with a six month stint in PICU back at St Thomas’ before working for six months as a medic on an Operation Raleigh expedition. Guy spoke about his PICU stint as being the only job that he occasionally left without a smile on his face which perhaps gives an indication of the type of person Guy was. Following a short sojourn doing acute medicine in Cornwall Guy took up a SpR rotation in Bristol. The move to the West Country came in part due to his brother Ben, to whom Guy was incredibly close,

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being at Medical School in Bristol. Guy “did the rounds” in Bristol as a registrar before starting in Frenchay in 2008.

Whenever Guy was at work at Frenchay, and seemingly whatever he was doing, he seemed to be content and would approach each new challenge with a sense of purpose and fortitude that was admired by all. No task, however frustrating would cause Guy to raise his voice, rant and rave or “lose it” as many of his colleagues were capable of doing. He would, instead, approach the problem with due diligence and an unerring sense of application that would be the envy of many. It would be fair to say that you couldn’t rush Guy into anything but that was the way he was and that was just fine. As well as carrying out his clinical duties to such a high standard Guy was intimately associated with the design of the ITU in the new hospital. He worked tirelessly on this project and what has been built is in no small part due to his hard work and endeavour. While Guy’s work was important to him, it only defined one side of the Guy many of us knew and loved. His family were hugely important to him and he was especially close to his mum, dad and brother Ben. He had strong Welsh roots and was a passionate follower of Welsh rugby, even mixing work and pleasure on one occasion by resuscitating an unfortunate supporter who had decided to have a cardiac arrest a few rows away from where Guy and Ben were sitting in the Millennium Stadium in Cardiff. That Guy was able to do this with great skill, the wrong side of a “couple of cheeky beers” says it all. Ben and Guy lived in flats next to each other in Bristol. Guy’s flat was legendary, a proper Aladdin’s cave of bespoke kit for all Guy’s extracurricular activities. There was nothing Guy didn’t know about “stuff” to do with all

the things he loved, and skiing and cycling especially were his sporting passions. Any purchase would be meticulously researched beforehand, and he was also very good at helping some of his colleagues spend more money than they had first intended on a new bit of kit or “toy” as Guy liked to call them. Guy took the majority of his holiday in the winter, was an excellent skier and would be as happy on the slopes as off them in the evenings for the après-ski at which he so excelled.

Guy was out on his bicycle with three of his colleagues when the accident occurred that would lead to his death. He was at the back of the group setting his own pace up a hill when the tragedy occurred and the subsequent events of that terrible day will live with his colleagues and many others in the hospital for ever. Lesser men than Guy would have succumbed at the roadside but Guy managed to live long enough for many people involved in his care to feel like they had done all they could and, most importantly, for his parents and brother to be able to be by his side at the end. It was an incredibly painful time for all of the staff at the hospital and the number of people who contacted us from many other hospitals in the South West is testament to the high esteem in which Guy was held.

Guy’s death will leave a void in so many lives that will be impossible to fill. We as a department and wider anaesthetic community are still desperately sad and miss him hugely. His mum, dad and brother can be inordinately proud of Guy, a true gentleman, who will never be forgotten by those who had the privilege to work with him or know him.

Ben walton

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ObituaryDrDavidPenney

1968 – 2013

All in the Department and beyond were shocked and saddened by the sudden and unexpected death of Dave Penney from coronary artery disease on 21st October.

Brought up in Hertfordshire, Dave graduated from University College hospital, London in 1991. He must have been a bit of a swot in those days, for he was awarded the Gold Medal in his medicine finals. He spent the latter part of his anaesthetic training in the Oxford region, plus a year in Sydney, before becoming a consultant at Wexham Park in 2003.

It was a lifestyle decision that brought Dave to Swindon in 2006. Coming to

Wiltshire, he could escape the pressures of living and working in the London area. There was no need to be a slave to private practice to pay the mortgage.

Dave’s life was already blighted by tragedy, for his first wife, Fran, had been diagnosed with breast cancer by the time he joined us. In the later stages of her illness and until her death in 2008, Dave went part time to look after their son, Oscar. Dave and Fran had been together from the time he first went to Medical School. Her loss was a grievous blow.

Out of sadness comes hope and a new beginning, and it was in the following year

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that he met Denise. They married in 2009 and family life for him, and Oscar, was restored - and indeed augmented in 2011 with the arrival of twins Gus and Zac. . . even though this meant he had to abandon his principle of not being a slave to private practice!

That Dave was an excellent anaesthetist is a given; but he was the first to admit that it was his home life and interests outside medicine that came first. Dave would argue that this was the logical approach and that most of us have our work-life balance all wrong. Aside from his family, Dave was a Caterham 7 fan and was in to Hi-Fi big time - a room being dedicated to ‘the system’. This was no Pioneer PL12 turntable and Goodman’s amp: only an amplifier with valves could do the job properly, and the valves had to be pre-1960s for optimum performance. Atmospheric ionisation during the manufacturing process was

sub-optimal after this time . . . according to Dave. By now you have probably already correctly guessed Dave’s musical taste - Jazz.

Dave had a mischievous sense of humour and would amuse us with excellent impersonations of some of the more interesting characters around GWH. His diminutive figure would be seen loitering in the theatre corridor with a like-minded soul, chewing over a bit of hospital gossip. Dave’s funeral was on 5th November. He, more than anyone, would have been tickled by the providence of a Penney being cremated on bonfire night.

Dave is survived by his parents. He leaves his wife, Denise; Oscar, aged ten; and the twins, Zac and Gus, who had their second birthday a week after his funeral.

DougSmith

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news of the westThis is where you are kept up-to-date on all the news and gossip from each department in the South Western region. The name of the correspondent appears at the end of each contribution and he/she is also the SASWR LINKPERSON for that department. Anyone wishing to find out about more about SASWR, or wishing to join, should search out the local linkperson, who will readily supply details and an application form. In addition to other benefits, each member will receive the twice-yearly edition of APW- free!

BarnstapleWell, I’ve been asking around for interesting little titbits but people are strangely reticent, and Tony has been keeping a low profile of late. Some of the local beaches have been re-landscaped by the storms but on the positive side this has been an awesome season for surfing. Adam Kwiatkowski, now a local GP but once a trainee in our department, was complaining that he was suffering under the burden of obligation to take advantage of the conditions. No one was flooded and the closest we got to storm damage was Tim Cobby’s dinghy, tethered to a fence post near the Dawlish railway bridge (or was it a wall?). Everyone seems to be retiring, including the Chief Executive, which makes me wonder if they know something I don’t! However this hasn’t deterred Nick Love from applying for our ITU job and he will be joining our team in September. His wife ran a checklist on us and we appear to have been given the stamp of approval. If anyone else is interested in escaping the rat race to join us in a beautiful tranquil and un-flooded Barnstaple, keep an eye on NHS Jobs. We have signed up for EPOCH and hopefully the pressure will be on, to increase ITU/HDU capacity and give the unit a sorely needed facelift.

Ruth Whittle is not leaving yet, so I will have to retract all I said in the last edition

of this rag (like most journalists I get half the facts wrong). Here’s hoping the next dinner at hers will include the educational supervisors as well as the trainees! Barry Loader had a leaving do on Valentines evening which didn’t deter the crowds of romantics who braved the weather to attend. Latterly he can be spotted at the leisure centre, in the pool or gym, looking leaner and meaner as time goes by. Charlie Collins has finally left the building but may be returning as a budding inventor, patents pending! Sue (Charlie’s better half) tells me they are planning to cycle right around the UK! Andy Walder is bravely joining Charlie Collins in Nepal at the end of March to attempt anaesthesia in a more challenging environment. And also possibly in a vain attempt to escape checklists, guidelines and care pathways, which seem to invoke a type of nervous tic when mentioned.

Cecily Don has bought a farm near Codden Hill and Tom (her other half) has become a horse widower. That is, when he is not moving light fittings from A to B for C.

The trainees are still here with us in spite of our best efforts to put them off a career in Anaesthetics, by getting them to spend more time on ITU than they would care for. It seems the humble central line is slowly

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being replaced by something called a PICC line, which means they can hone their skills in following needles into smaller veins with an ultrasound machine and spend more time doing it. Is this just us? Catherine Dore has successfully completed the Primary FRCA without any fuss and anyone in the region would be lucky to have her as an ST3 in August. Matt Casemore was unlucky/lucky enough to have a healthy son born in the small hours of the morning of his pending primary MCQ. Congratulations and better luck next time Matt! Junayed Ahmed left at the end of February and some of you will be lucky enough to have him helping out in Bristol or Bath.

I would like to thank the department of Anaesthesia and PICU at the Bristol Children’s Hospital for putting up with me for a week last December, looking over their shoulders at how they anaesthetize children. Very valuable CME for me and something I would recommend as a worthwhile use of study leave, I was lucky enough to end the week with a Simbaby session and free lunch courtesy of Steve Marriage and Pat Wier

GuyRousseau

BathDespatchesfromC.U.B.A.(CountythatUsedtoBeAvon)

Your correspondent would like to thank Dr Simpson for all his hard work with previous updates and for passing the pen, allowing your correspondent the opportunity to indulge in a little creative writing.It would probably be prudent to get a disclaimer in early: the opinions expressed in the following text are not those of my employing institution; the facts as stated may bare only a passing resemblance to the truth; this is written without

prejudice and not intended to offend.It has been a rather wet couple of weeks and your correspondent is suffering from the usual maladies of advancing age. Most notable is the constant feeling that junior doctors are getting younger and younger. This has not been helped by the choice of ‘elf green’ for the uniform the junior doctors

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are now obliged to wear. It has managed to make the latest intake of fresh-faced juniors look even younger. I’m now also constantly on the lookout for Father Christmas.At the opposite end of the spectrum, some of the more senior members of the department of anaesthesia are doing rather well for themselves.We are pleased to work (albeit only occasionally) alongside not one but two Professors of Anaesthesia! Professor Carol Peden was awarded the Macintosh Professorship and Professor Tim Cook was honoured by being named the Difficult Airway Society Professor of Anaesthesia and Airway Management.Not content with a chair of anaesthesia, Professor Cook instructed the institution’s new theatre manager to purchase a table of anaesthesia for his sole use. This has further improved his productivity in theatre but has been a cause of some envy amongst his colleagues.Dr Handel, our new Chairman, has requested an anaesthesia chaise longue on which to recline while he peruses Viz while Elspeth does the rota.Our illustrious department was further enriched when The Royal Derby Hospital sent us their gold. We were very pleased to welcome Stuart Gold as our most recent consultant appointment. We were bemused to note that he is probably the only cyclist south of Hadrian’s Wall to be using studded tyres, it is clearly icy up north.We have also welcomed Dr Justine Barnett as a locum consultant anaesthetist. She migrated south as a registrar and we hope she stays on as a consultant.

Your correspondent has thankfully not

broken anyone’s bones recently. However, having gallantly carried Dr Tuckey and her bags to her car so that she might drive herself home, he was embarrassed to subsequently find out that she was unable to walk because she had fractured her femur! We wish her a speedy recovery. She has

The table of anaesthesia

made a great start by singlehandedly reducing the average orthopaedic length of stay and going home day one post-op. Nothing short of miraculous really, considering Dr Hill broke ranks and gave her a general anaesthetic. The rumours that it was the only way he could get her to stop talking are, however, unfounded.We will miss Dr Tuckey for a few weeks, but are secure in the knowledge that our esteemed sergeant at arms, Elspeth Alexander, will continue to ensure all lists are covered. It was for her exemplary work ensuring we are all gainfully employed, that she recently received an award from the chief executive.

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We were pleased to note that she was the only person to insist on making an acceptance speech. In the spirit of the Oscars, she took the opportunity to accept the award on behalf of all of us! Truly, a selfless and noble act.Enough for now. I’m off to try and find Father Christmas and ask him politely for another ward full of beds, some more parking spaces, a larger ITU and some sun.

MalcolmThornton

exeterDespite the news coverage and the rain, we have survived the flooding, and now we are basking in the sunshine. Hopefully the sunshine will last until a hose pipe ban comes into place. The RD&E has survived relatively unscathed this winter, with fewer cancelled elective cases, due to lack of beds. The NHS austerity continues here as

everywhere, but I guess we are just getting used to it. Within our department things are starting to improve, as our new consultant appointments have finally stopped roaming free around Europe without a care in the world, and have finally started work. Rebecca Appelboam and Mark Davidson have seamlessly joined the ITU group, while Tom Martin and James Lloyd have joined the general group. Kath Meikle has, of course, been doing a sterling job since August. We held a welcome party in their honour, which was well attended, and hopefully makes them realise how much we need them. Sadly our leader, John Saddler could not be there, as he was celebrating his second honeymoon in South Africa. He did initially return refreshed, and back to his old, grumpy self. Sadly after only a few more days he’s just plain miserable again! I guess it’s the thought of the next round of job planning. We are already looking forward to holding a party for Graham Simpson, who has just been appointed to a consultant post in -pain. As if to compensate for the new appointments Nick Batchelor has moved into the post of Clinical lead for service development, also known as clinical lead for pencil sharpening. Well done to Nick, but now I have four uncovered lists again.Love is in the air, with most of our trainees planning a wedding soon. Congratulations and good luck to Jo Edwards, Dave Hutchins, Lorrie Hellewell, Karenza Chapman and Lizzie Thompson. Also to Ben Ballisat, unless I’ve just started an unfounded rumour. I must also remember to wish good luck to Lauren Barker, who will be getting married soon. Emma Hartsilver has organised the hen party, which is already making me nervous. Well done too, to Lexi for finding herself a nice

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young man, and to Tom Woodward, who has “this girlfriend” now, who needs to be factored into all career decisions.The natural outcome of so much love in the air, is the flurry of babies. Congratulations to Ash Williams on the birth of Rory, and good luck to Libby Fontaine, Mark Jackson and James Lloyd, who are all expecting babies soon.The Christmas party was a relatively quiet affair this year, until Paul Thomas arrived late, coerced the trainees into risking their lives and good looks by drinking flaming sambuccas, and then was dragged home before he fell over. But sadly, once again he didn’t take off his clothes. Boring. John Saddler proved to be an entertaining speaker on his first outing as CD (now known as clinical lead). I love it when a Zimbabwean impersonates a South African. The dancing was disappointing this year, perhaps because Colin Berry was out of action with a dodgy hip. Fortunately he has now had it replaced, and we wish him a speedy recovery.This year saw the retirement of Steve Straughan, a GP anaesthetist who has worked at the RD&E for many years. Despite only doing one day a week in our department, he made a valuable contribution, and was well liked. He was very popular with the more junior trainees and medical students, with his varied knowledge, wide experience, great patience and sense of humour. His appetite was legendary, as was his lunch box (Ed’s note; where is this going?) Steve’s leaving party was well attended with The Sux Pistols playing live. I wish him well during his day off per week, but I fear if he doesn’t stop buying things, then Bev will make him increase his days in general practice.And finally I must mention Alex Shearman,

a trainee who has spent several years with us during his training. He sadly died recently, which was a terrible shock to all who knew him. Alex was a cheerful, kind and popular anaesthetist, who will be sadly missed. We send our best wishes to his family, especially his young twins, who were his pride and joy.

Pippa DixFrenchayIt’s been a very sad time for the department with the death of Guy Jordan, our much loved and admired colleague. Guy’s death has overshadowed what should have been an exciting and daunting time for us at Frenchay with the move to the new hospital and all the challenges that this will inevitably bring. Guy was closely involved in the design of the Intensive Care Unit in the new hospital and its seminar room will be named in his honour. It seems such a small thing to do to as a department but it’s his memory that will first and foremost live long and proud in all of our thoughts.The day Guy died will be forever etched in the memories of all of us. Many were involved in looking after Guy and those that weren’t supported those that were in a way that made us all immensely proud of the esprit de corps that we have. It doesn’t feel the same anymore so perhaps the move into the new hospital has come at just the right time. Other news seems to pale into insignificance behind the events of the 19th November 2013 but life in some shape or form has continued. Jenny, one half of the Jenny and Jean secretarial combination has finally hung up her typewriter and she is missed by all. Jenny possessed an encyclopaedic knowledge of who did what, knew who, said what and also the names of everybody’s children. Many a consultant

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or trainee would have a photo of their latest offspring proudly displayed above Jenny’s desk in the department. I’m sure she wouldn’t crack under interrogation but there is a great deal of information Jenny possesses that should be kept under wraps for many years to come. We have jobs in the offing, seven to be precise! Getting them through the various political hoops has been a lesson in smoke, mirrors and covert subterfuge that many a Bond villain would have been proud of. We await the flood of applicants with eager anticipation. Drs Halder and Carey have both recently begun their Consultant careers with us, with Dr Carey making the schoolboy error of leaving his computer unattended with Dr Marsh in the vicinity. Dr Marsh calls it a learning experience, others the equivalent of the school big boy stealing the new boys tuck shop money on his first day at school. Raju Poolacherla has departed for pastures new in Canada and we are sad to see him go, as we are the other paediatric anaesthetists destined for the hospital down the road now known as the Costa Royal Infirmary due to the preposterously large coffee shop that the hospital is now attached to. All is not lost on the paediatric front though with some deciding that the grass is still greener underfoot and deciding to stay. Dr Thomas (Matt) seems to be enjoying married life as it means he can cycle further each day as the marital home is further from NBT than the batchelor pad was. The stork is due to bring a bundle or two to some members of the department, more news about the arrivals in the next edition. Dr Klepsch has become king of the road with the purchase of his new bicycle. The

lycra clad amongst the ranks have been most put out as he can cycle faster than all of them with no effort albeit aided by a small electric motor that has a range of 100km. Hooray for clever German engineering. Little else to report really other than the Bake Off competition finally finished with Nuala crowned the winner (no surprises there then) and the formation of the Frenchay Pie Club. The founding group included Guy and the first meeting included a lengthy discussion as to what constitutes a pie and elections to office. Unsurprisingly everyone present bar one became a voting member with only Dr Davies earning the title of member (ordinary, no vote). He’s delighted as he thinks it allows him to be subversive – he has no idea. Our trainees continue to dazzle and amaze. Their CVs at ST3 level look considerably better than a Consultants did less than ten tears ago which means the goalposts are perpetually on the move but that seems to be the way of things these days. Makes me feel rather old (which I’m not)

Ben waltonPlymouthAs the strip of land (mainly Somerset) that connects Devon to the mainland UK slowly gets washed away and storms batter the coast the winter has passed by in a rain washed blur with a fair bit of mud thrown in. The ensuing travel chaos has had its effects on the comings and goings in Derriford.

Richard Sawyer got out just in time and has moved to Oxford – not just because they still have a train service but he may even have the HS 2 going through his garden. Steve Bree found a break in the weather and has crossed the Atlantic to be wined and dined in Washington as a

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military liaison. Apparently he will have to do some work in the two years his posting lasts but as yet isn’t quite sure what. Ian Anderson finally gave up hope of getting back through the weather and has taken up a permanent post in Scotland in time to be able to vote in the referendum to ban the English from visiting Scotland except as a food source for the midgie. Tom Martin set off up the A38 in his kayak and got as far as Exeter before putting a hole in it. Luckily, whilst waiting to get it fixed, he had a successful interview. We wish him well up north. Kim Chisti has also headed north but this time to Taunton and we hope to see him back soon.In order to balance all the moves north, Matt Ward has decided to head south but not until some sunshine appears. There was some last minute doubt about the move but even though it has been much quicker to get on to the water recently, the kite-surfing is still much better in the south west. It will be a warm welcome to him and to Simon Martin who has been appointed as a Paediatric Anaesthetist.In the dark world of Intensive Care there have been three new starters – Paul Margetts, Michelle Barnard and Jess Welbourne. None of them have crossed over completely and are all going to continue to do some anaesthetics, which is a great relief with the ever-increasing demands by all departments for extended days and weekend work. Finally, to replace one dour Scotsman with a great ability to tell “dits”, there was only one person who could replace him. Fortunately word reached New Zealand, and after catching all the fish and shooting all the deer, Kevin Patrick has come back to us in our hour of need. It wasn’t the same without him and the coffee room is a

more colourful place again. The AWSoME and DAFT courses continue to be a great success and all three South West candidates on AWSoME passed their written and 10/12 candidates passed the Final. The organisers would like to say a big thank you to all those who support the delivery of these.It has become the norm for tails of sporting prowess and bravery to be included and this edition is no exception. You may have noticed the similarity between two big wave surfers - Andrew Cotton, 34 and a plumber from Devon and Simon Courtman, was 34 a couple of years ago, gasman from Devon. Andrew emerged intact from his 80 ft wave in Portugal and that is where the similarity stops. Simon came a cropper on his nearly private beach – it’s just unfortunate that the recent storms and heavy rain has rinsed out most peoples’ septic tanks to create some interesting microbiological niche environments amongst the estuaries of Devon. Luckily he has bounced back and, to the relief of his colleagues, has returned to work to support the depleted Paeds on-call rota. The rumours of the forthcoming sale aren’t true and he isn’t selling his boards yet until he is sure that crochet really is the way forward.Other sporting endeavours involved a PUPSMD team including Tom Gale, Cath Ward and Alison Carr driving the six hours to the Lake District for a 30 second swim in ice-cold water. As near death experiences go the ChillSwim was very successful, with one member of the team finding that plunging one’s head under ice-cold water can have interesting physiological effects that even yellow make-up doesn’t hide. If any other hospitals want to enter a team next year it should be noted that for cryopreservation to work it needs to be much colder?

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The ChillSwim team

Other members of the department found more controlled ways to demonstrate their competitive nature. The bake off, to accompany the official opening of the new anaesthetic coffee room (the Back Bar), had some surprise winners with Kim Chishti winning the ‘Most Chocolaty’ category, Gemma Crossingham the ‘Best Anaesthetic Theme’.Sue Loxdale ‘Best Savoury’, and Karen Grimsehl the coveted ‘Most Amateur’. A massive thank you must go to Sara Markham for her persistence in designing, decorating and furnishing the new coffee room to such a high standard. It’s a massive improvement and will stand us in good stead for many years. It has been quieter place on the labour ward with only Pippa Squires discovering the wonders of motherhood (a baby boy). It’s also been much quieter in the coffee room…We expect the next baby boom over the summer when it’s much nicer sitting on the beach.Finally, the dry insightful views of our Service Line Lead, Richard Struthers, are keeping us sane in the Orwellian new job planning process. Moving all the work into separate bundles won’t affect the amount of work that we can deliver overall, but does make for some beautiful spreadsheets and

occupies some of the free time that we have in between drinking coffee.

MattHillSouthmeadSo only 6 weeks till we leave the ‘Mead and venture forth into the bright and shiny new world which is the Brunel Building. As we start the orientation tours and simulation scenarios in earnest, it is finally dawning on many of us that the informal chats, recovery advice, phone calls, lunch breaks etc, which now take place in our anaesthetic rooms, are to become a thing of the past. The only available space is a sluice which joins 2 theatres and this seems likely to become the new anaesthetic meeting room till the orthopods moan about us interrupting their laminar flow by opening the door.Bizarre happenings occur at times of change. There has been a bit of horticultural clearance of the Southmead site and it becomes clear who has got a log burner or two to feed at home

Down to his last half tin of beans…So a new dawn approaches. Soon we will become a department of more than 70 consultants not to mention everyone else who delivers anaesthetics. I remember

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the management courses telling us that even 11 people are too many to operate effectively as a team. But the anaesthetist is an adaptable beast. We’ve all done great. Southmead may be closing but the spirit of this department will live on. At the end of the day, work is mostly about the people with whom you work and we have the privilege to work with fantastic, supportive and very talented colleagues who will all find their place in this brave new world.What else is new?Well Anne Babarinsa has left to complete her training in Wales and Barbara Macafee has taken up a substantive post in Belfast. We were really sorry to see them both go and wish them the very best of luck in the new jobs.Trainees have come and gone as usual, some poor souls have only three months with us and their feet barely touch the ground. Well done to Sarah Heikal who passed her primary FRCA. Huge congratulations to Anna Simpson who has worked very hard to get a Wellcome grant to fund a 3 year PhD project – I believe she may appear elsewhere in this publication. Well done to Tim Walker for admitting on ‘One Born Every Minute’ that he still doesn’t know where babies come from – think we’ll have to give you even more time on CDS Tim!I’m sure that much more has happened over the last 6 months but that’s all I can remember for now. If we survive the move will report back in six months.

JillHomewoodswindonThe column for Swindon is dedicated to an obituary for Dr. David Penney, elsewhere in the journal.

Torbay

Will it ever stop raining?! Today, yet another gale is battering the windows of my house- the trees are straining at their roots, the garden looks like a mud bath, rain is lashing horizontally (almost vertically at times)… This is supposed to be the English Riviera- can somebody please do something!?You may know from the national news that my garden is not the only mess around here. One could also include the executive board of our award winning trust…Yes our chief executive has made headlines again- this time for all the wrong reasons. As I write this, a trust email has just been circulated confirming that our CEO has been suspended. It is an understatement to say that all is not well in the upper echelons of senior management here. In the aftermath of the recent employment tribunal we have seen the chairman jump ship (probably before he was pushed), the vice-chairman resign (due to stress), an extraordinary MSC meeting during which an almost unanimous vote of no confidence was made, and now a suspension. We have certainly not reached the end of this story and we await the outcome of the boards investigation with bated breath. I’m not sure it’s right for me to divulge the sordid details here so let’s move on to a happier place- the Torbay anaesthetic department!As is usual for these columns I’ll begin by welcoming in the new trainees to our department. Martin Dore has joined us on the CT rota having just completed 6 months on ICU. Tom Bradley arrives having made it through a year in Derriford, and Claire Attwood has returned from maternity leave. As is fast becoming the norm, however, despite new arrivals the 2nd on call rota is still half empty (or half full depending on your outlook). Fortunately our shrewd chairman has come up with a master plan

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to keep the wheels on the department. So another round of consultant acting down has been agreed- this time though, we are only required to cover daytime on calls so good work Tas! Speaking of our chairman, we are now in the last two months of her tenure, and I think it’s fair to say she is looking forward to stepping down. I know this because when asked she can tell me exactly how many days (and even hours) until she finishes! At the top of the food chain, Nuala’s term is also due to end soon, so will we see an end to the ‘girl power of the last few years? We will have to wait and see.At consultant level Rachael Blackshaw has returned from maternity leave after the birth of Marcus, Claire Blandford has now officially started in her substantive role and Steve Stamatakis continues in his role as a locum. No new appointments to announce at the moment but more may be needed later this year so watch this space.Next I’d like to offer my congratulations to the latest proud parents in our department. Dave Portch and his wife Naz recently had a second little girl- Jemima, Dan Quemby and his wife Francis also had a little girl- Willow, and finally Susan Cummins gave birth to a little boy- Daniel. So congratulations and good luck to all of you. Just remember- they say the first 10 years is the hardest!Finally, after long and distinguished careers Kerri Jones and Tony Bainton have announced their retirements. Kerri has been in the dept for over 22 years and is one of our most distinguished and decorated anaesthetists. She is well known at a national level, throughout the South West and also throughout Kenya! There is neither space nor time to list all of her achievements here, but she is the national

lead for enhanced recovery, past president of SASWR and a founding member of the Kenya Orthopaedic Project to name but a few. Kerri has already begun a retire and return programme so we will continue to see her in and around the department for the foreseeable future. No doubt she will continue with her regular visits to Kenya too, adding to the fantastic work that has already been done there.

Tony has been at Torbay for 18 years, having relocated from Stoke Mandeville in 1996. He has and continues to be, one of the real characters in the department. His knowledge of anaesthetics is encyclopaedic and his skill with a needle is second to none. I recently witnessed this first hand when I was struggling with a spinal. The ODP went to get Tony to help and he popped it in first time! Literally straight in- didn’t even make it look difficult! Being a country gent I imagine Tony will spend his retirement looking after his land (of which he has quite a bit!) and fixing his Land Rover! I look forward to a department knees up later this year to send both Tony and Kerri off in style.So time for me to finish now. Let’s hope we’re getting all the rain out the way before the summer!Looking forward to seeing you all in Newquay in May.

AndrewMcEwenTruroWhat have we been up to? I am not entirely sure (what’s new?) but when I asked my colleagues I am reliably informed that a significant proportion of us went to Val d’Isere to update themselves on anaesthesia, amongst other things. A few of us have also been let out to go to the WSM AAGBI London, and we had the

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best turnout of examiners at DAFT ever. In summary, we are venturing out and over the Tamar, train track or “No”, so look out!We have a new consultant in anaesthesia and pain management (he’s not so new but we don’t see each other very much) in the form of Juan Graterol, which is lovely. There is also a delightful selection of locum consultants, who work like Trojans and are very much appreciated whether they work zero hours or not. We have just had a very enjoyable evening celebrating the retirement of Adrian Hobbs. Current and past members of the department got together at the Driftwood Spars in St Agnes. Clearly it will have been disappointing for him that we didn’t manage to pull the departmental band together for the evening. For some unfathomable reason, Adrian didn’t ask for that, he must have forgotten. However, we did have the pleasure of the annual anaesthetic music fest at the Christmas party, which was, of course, second to none. We did have to draft in an orthopod, who looks like he’s having fun. That’ll learn him…

Putting the band back together…To continue on the retirement theme, Richard Page is retiring at the end of March and if he continues to avoid my attempts to pinning him down and agreeing to a party, I

will threaten him with a reforming of our band especially for him. I will keep you posted.On the exams front, the Primary has been passed by Peter Boulton, Alex Ishimaru and Danny McLaughlin. The “Finalists” were Becky Marsh and Will Rutherford. Well done to them and good luck to the next wave.There have been some gorgeous new editions to the anaesthetic and critical care community. Will and Fiona Fox have had a girl, Dave and Gemma Ashton-Cleary have too. Very recently two of our registrars have become fathers; Johannes and Elizabeth Retief have had a little boy, and David Levy and his wife had a little girl.And so to Treliske itself, what can I say? Indeed, what can I say? I should say that the department holds strong. Barrie Phypers’ has set up an excellent rotation of early morning meetings; he continues to find volunteers to bring in their baking exploits and present on useful and interesting topics. This is an achievement to be applauded. Elsewhere in the trust, if I were to say we have enjoyed the introduction of electronic prescribing that would be a bit of an exaggeration. I am told we are a leading light in the region for e-prescribing. Otherwise all of the theatres, wards, offices, blah blah blah have moved, been rebuilt or aesthetically improved/changed. So it’s been interesting.And so I will move on.We are all really looking forward to hosting the Spring SASWR meeting at the Headland Hotel. It will be a pleasure to welcome everyone to Cornwall. Please do come.I have managed to avoid talking about the weather but I do know it will be fantastic in mid-May.See you then.

georgia Brooker

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united hospitals BristolThere’s been a lot of muddling through the winter chaos over the last few months, and casting my numbed brain back to the Autumn is quite a challenge. For the annual “bonding” event we went for an orienteering jolly in the Brecon Beacons. After a damp Welsh morning training in the local area, the skies cleared to bathe the emerald hills in glorious sunshine for the competition. Veteran Mark Scrutton led one team strategically selecting achievable control points to visit; enthusiastic novice Nick Wharton took his team deep into the mountains simply trying to reach all the points. Mark’s team were back to the bunkhouse on time, toasting fizz every time the opposition received penalty points for being late. The others rolled in just before dark, claiming the moral victory of reaching all the control points, but reaching a net score of zero. The bunkhouse entertainment began with a communally prepared feast, and climaxed when Frances Forrest changed into her snow leopard onesie and started purring and licking her paws.This year, the paediatric team will welcome many of the current North Bristol folk, but also appointed Natasha Clark, Amelia Pickard and Anthony Bradley. We also welcome back Tim Murphy in paediatric cardiac role after a spell in the North East. Congratulations to Henry Murdoch, appointed at Gloucester, and Dave Windsor, appointed at Cheltenham. There have been too many hatches and matches to mention them all. Matt Thomas added a third kid when all he wanted was a cheeseburger, and we are all very excited in anticipation of John Hadfield becoming a daddy. Oh yes we are! On a more serious

note, we were all shocked and grieved by the sudden death of Guy Jordan who had trained extensively in UHBristol. He has touched and enriched all of our lives in one way or another.We have had some senior colleagues hanging up their gloves and heading for ‘pastimes greener’. Chris Monk is a colleague and friend who I wonder how we are going to manage without. He led us in many ways, including the building of the New Ward Block, and taught the majority of the current consultant body much of what they know. Chris has also been an outstanding contributor to this Society. Diana Terry, another SASWR stalwart, has helped countless doctors with career advice, pastoral care and mentoring. A trusted colleague who will be missed by all. Also retired are David Coates, who significantly contributed in leadership and political roles, and Charly Heidelmeyer who is looking forward to his yachting.The Trust has spent most of the Autumn and Winter on black escalation, theatre recovery stuffed with medical admissions. The latest in a series of Mr Fixits has arrived to show us how to get the surgical division finances in order, but nobody is holding their breath on a miracle. Kathryn Jackson worked tirelessly to get a CQUIN in cardiac output monitoring, only to find the Trust couldn’t afford the disposables. The ITU is planning their move to the new building and paediatrics are expanding to accommodate services from North Bristol. All of which is small fry, compared to the knock-on effects of North Bristol moving house - medical apocalypse beckons - but in common with the rest of the NHS, we’ll muddle through somehow...

Ben howes

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ExaminationSuccessesandHonoursPrimaryFRCA Ben Ballisat Peter Boulton Catherine Dore Sarah Heikal Lexi Hughes Dave Hutchins Alex Ishimaru Sam Lyons Danny McLaughlin Tom Woodward Andrew Woodgate

final frca Helen Davies Neil Kellie Martin Lewis Becky Marsh Will Rutherford Ash Williams

SocietyofAnaesthetistsoftheSouthWesternRegionPrizes

PosterPrize: Ben IvoryIntersurgicalPrize: Clinton LoboRossDavisBursaryAward: Dr. Kate Reeve

Miscellaneousexaminations

MD(Res)UniversityCollege,London Professor David LockeyFFPMRCA Graham Simpson

Please accept the apologies of the editorial team if your success has not been mentioned above. We can only print the names supplied to us by the college tutors and linkmen from around the region

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It was a year late but finally a SASWR meeting was held at Bristol’s M Shed. It was worth waiting for! One hundred and forty delegates including 40 trainees, 20 posters presentations and 13 applications for the trainees Intersurgical Prize. The Society is clearly in good order and the excellent attendance made this one of the biggest meetings for many years.

President’s Prize being awarded to Gemma Nickols

The formalities of the AGM started the meeting and the outgoing President was delighted to award his named prize to Dr Gemma Nichols who has done so much to galvanise the return of trainees to the SASWR meetings. His presidential duties were then complete and Dr Mike Durkin was then able to pass the responsibility on to the in-coming President, Dr Chris Johnson.

A presidential duo: Drs’ Chris Johnson and Mike Durkin

Dr Johnson opened the meeting but it was with great sadness that in his opening remarks he had to report the tragic death of local Consultant Intensivist , Dr Guy Jordan. Guy was a close friend to many of the delegates and this recent loss was clearly acutely felt by many in the room. The world had lost a very good man, an excellent doctor and a loyal supporter of SASWR. The President went on to report that this excellent meeting had been organised by Dr Hannah Blanshard, Dr Natasha Joshi, Dr Neil Rasburn and Dr Matthew Molyneux.

TheSocietyofAnaesthetistsoftheSouthWesternRegionWinterScientificMeeting,2013

MShed,BristolDrJamesPittman,Honorarysecretary,SASWR

Anaesthesia Points West Vol 47 No 1MeetingReport

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The latter was first on parade as he chaired the opening session on Perioperative Care and its evidence. Professor Stephen Thomas started the session discussing his interest in peri-operative feeding. Ingesting even small amounts of food post-surgery can make a difference in outcomes and the current vogue of not putting in NG tubes for feeding purposes might need a rethink in those who cannot eat. Dr Ian Ryder gave an excellent review of managing the cardiovascular risks of patients with cardiac disease. Avoid low blood pressure, keep the heart rate low, avoid hypoxia and call the cardiologists! The session was ended by Dr Alex Goodwin from Bath who talked us through the evolution of NCEPOD and reminded us how this organisation has done so much to help our understanding of the care we deliver to our patients and the ways we can improve.After lunch we heard from Dr Rowan Hardy about the terrifying fire that occurred on the ICU in Bath hospital.

Fireman Sam, aka Dr Rowan Hardy

It highlighted how important the actions of the first responders are in the containment of such an event. Note to self: I must get to that mandatory fire training lecture. After this the audience were treated to a very entertaining interactive session on the practical management of the difficult airway. The audience were allowed to electronically vote on what they would do in various situations. We do manage airway problems differently, there is a huge amount of kit now available and it requires training to become competent, but the most revealing answer was that 26% of the audience claimed that they were not wearing underpants! You had to be there.The SASWR Intersurgical Prize always delivers and there were a fantastic field of 13 trainee submissions this year. Four people were selected to present their work and first up was Dr Tom Knight who reported his randomised control trial comparing a femoral nerve block with a diamorphine containing spinal for the anaesthetic management of total knee replacement. The Femoral Nerve block wins. Nick Surarez looked at the adherence to the preoperative NICE guidelines on what investigations patients should require. The education and training package he implemented reduced unnecessary tests and improved ordering of the essential ones. Stuart Younie audited the use of supraglottic airway devises in children and found that the cuff pressures in approximately 80% of cases were too high, with an increase in the incidence of sore throats. Lastly Clinton Lobo described the challenging management of the airway in patients with obesity and burns and the role of simulation training in overcoming this challenging and thankfully rare clinical situation. The judges struggled to come to a

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consensus but Dr Sue Underwood was delighted to award the prize this year to Clinton Lobo.

Dr Clinton Lobo wins the trainee Intersurgical Prize

The President was also able to use this opportunity to announce that the Ross Davis Bursary was awarded this year to Anaesthetic Registrar, Dr Kate Reeve. She was in New Zealand at the time of the meeting and therefore unable to personally accept her prize but will write a report for Anaesthesia Point West upon her return.The Sir Humphrey Davy lecture had an overseas flavour. The President introduced the inspirational Dr Rachel Craven from Bristol’s University Hospital who captured the attention of the audience with her personnel account of her amazing work giving anaesthetics in conflict zones around the world. Think of an unstable and dangerous part of the world and Rachel will have been there. She has to show tremendous bravery and personnel sacrifice in the most challenging of environments to bring health care to patients in the most awful situations. What wonderful colleagues we have.

SASWR’s action hero, Dr Rachel Craven

The Society Dinner was at Bristol Zoo and very well attended. There was plenty of noise which usually means that people are enjoying themselves. Dr Johnston welcomed the guests and thanked the organising committee for what was already turning out to be an excellent meeting. The evening finished with great music from a local medical band called ‘Boujie Nights’ featuring The Editor of this journal. Their tuneful ‘tunes’ managed to get Bristol’s lady Anaesthetists dancing on mass. The men were definitely outperformed.True to form, despite a late night, those dancing last the night before were in the front row of the lecture theatre on Friday morning. Natasha Joshi introduced the first session which was very child focused. Dr Richard Beringer stressed that he was not here to help us with our parenting skills but then went on to discuss ways of dealing with difficult children whom need an anaesthetic. A good message for when things are not going well is ‘Think Clonidine!’ Dr Peter Stoddart then talked us through the centralisation of paediatric services and how this has evolved and continues to change within the South West. Finally, Mr Mike Saunders, Bristol

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ENT surgeon, gave an excellent talk on the challenges and pitfalls of the paediatric airway, including assessing the ‘expected to be difficult/ obstructed’ airway of children as they are born by caesarean section. Mike did arrive a few minutes late but did defend himself by expressing surprise that over 100 anaesthetists could be on time!The delegates needed to be wide awake for the next session that was titled ‘Academic Anaesthesia’. Dr Tony Pickering revealed that there is a lot more we need to know about the brain before we can understand endogenous analgesia and the regulation of pain. He described the brainstem as the ‘organ of the anaesthetist’ and how control of this part of the body would provide us all with great benefits. Professor Reeves tried to demystify statistical analysis and helped us to interpret and appraise a meta-analysis and systematic reviews. Lastly, Dr Matt Thomas gave us an excellent practical overview of risk during surgery: what are the risks, how to score risk and how to reduce risk.After lunch the President awarded the SASWR Trainee Poster Prize. As there had been so many excellent entrants this year two prizes were awarded. Dr Ben Ivory was awarded 1st prize for his work with Simulation.

Dr Ben Ivory winning the trainee poster prize

Dr Danny Mclaughlin received 2nd Prize. This was followed by a brief talk by Dr Zoe Smith, a Wessex trainee, who had won last year’s Ross Davis Bursary.

Dr Zoe Smith

She told us about her African adventure working, exploring and enjoying this continent from Ethiopia to Cape Town. This was an apt prelude to the final session of the meeting where David Healy (Michigan), Tobias Everett (Toronto Children’s Hospital) and Stephen Mather (Dubai Simulation Centre) gave their personnel account and reflections on the work experience abroad. How can the University of Michigan Hospital have 180 ICU beds out of a total of 800 in-patient beds? How does Dubai have so much disposable money? How can you anaesthetise such small and ill children and sleep the night before?The president then closed the meeting and the committee, quite rightly, congratulated themselves on a very successful event. A super venue that SASWR will definitely try to re-use, great lectures given by local speakers and the usual opportunity to catch up with and meet old and new colleagues from around our region. Spread the word!

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Obesity and burns both increase the risk of airway difficulty and failure of airway management techniques. In the 4th National Audit Project (NAP4) emergency tracheal access was required in 43% of airway emergencies [1]. Patients reported to NAP4 were twice as likely to be obese (42%) and four times as likely to be morbidly obese (8%) than the general population (24% and 2%) and rescue techniques failed in obese patients in NAP4 more often than in non-obese patents. Patients with burns are also a group at increased risk of requiring emergency tracheal access. In this study we have used standard and modified airway manikins to compare their utility in simulating emergency surgical airway techniques in obese or burnt patients.

Methods Local Research and Development committee approval was gained, and written informed consent obtained from all

participants. We developed two new training models for emergency tracheal access: for the obese model, a section of pork belly overlying a model trachea and for the burnt patient charring the overlying pork belly skin with a blow torch. Participants were asked to establish emergency tracheal access in all three manikins (in a randomised order) using their choice of equipment routinely available within our

hospital; Ravussin cannula (VBM Medical, Sulz, Germany), Melker cricothyroidotomy kit (Cook Medical, Bloomington, USA) and a surgical airway kit. Each had access to all three devices. Time to first breath and choice of technique was noted. Preferred techniques before and after simulation were recorded.

ResultsTwenty consultant anaesthetists participated, 16 of whom had emergency tracheal access training within the last 12 months. No one particular technique was identified as first choice for participants, with similar numbers using Ravussin, Melker and surgical airway. Thirteen participants used the same first choice in the standard and obese model. All 20 participants (100%) were successful with their first choice of equipment in the standard manikin; 17 (85%) within 2 min and all 20 (100%) within 4 min. In the obese model only 12 (60%) were successful with their first choice of equipment, with eight (40%) requiring alternative equipment. Time to first breath was >6 mins for seven (35%) participants and >12 mins for four (20%). Of 13 participants who attempted the burnt neck model three (23%) required alternative equipment. As a result of participating in the study, nine consultants (45%) have changed their first choice technique.

SASWRAutumn2013Meeting: abstractofthewinningtraineepresentation

Rescuingtheobeseorburntairway:areconventionaltrainingmanikinsadequate?Asimulationstudy.

CA Lobo, TE Howes, FE Kelly and TM CookRoyal United Hospital, Bath, UK.

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DiscussionThis study has shown that experienced anaesthetists with recent airway training have notably lower success rates when using a modified airway manikin to perform emergency tracheal access. However all 20 participants commented on the improved realism of the morbidly obese manikin, suggesting this is because of improved fidelity. Use of the manikin led many anaesthetists to revise their preferred technique. This study suggests current manikins may oversimplify emergency airway training and supports the need for the development of more realistic ‘non-standard’ manikins.

references1. Cook TM, Woodall N, Frerk C. Major

complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaes-thetists and the Difficult Airway Society. Part 1 Anaesthesia. British Journal of Anaesthesia 2011; 106: 617-31

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BackgroundPrimary total knee arthroplasty (TKA) is commonly associated with moderate to severe early post-operative pain [1]. The primary aim of this study was to investigate the impact of either a single-shot femoral nerve block (FNB) or intrathecal diamorphine (ID) on post-operative pain, quality of recovery and longer-term functional outcomes after TKA

MethodsThis prospective, observer-blinded, randomised controlled trial was approved by the Devon Research Ethics Committee (10/H0202/1) and registered at ClinicalTrials.gov (NCT01931332). 120 patients scheduled for TKA consented for randomisation to either FNB or ID. The primary outcome measures were post-operative pain scores at rest. Secondary outcome measures were pain scores on movement, opiate consumption, ability to achieve set rehabilitation goals, discharge readiness and qualitative data on patient recovery and satisfaction (Quality of Recovery Score (QoR-40), Oxford Knee Score (OKS) and EuroQol 5 Dimensions Score/Visual Analogue Score (EQ-5D/VAS)).

ResultsData from 106 patients were analysed. Median pain scores (confidence intervals)

in the FNB group were significantly lower (Bonferroni adjusted) on post-operative day 1 (POD 1) at rest; 3 (2-4) vs. 5 (3-7); p=0.01 and on movement; 6 (5-7) vs. 8 (7-9); p<0.001. Median intravenous morphine consumption for the post-operative period 12-24h (p=0.001) and oral morphine consumption from 48 to 72h (p=0.003) were significantly lower in the FNB group. No differences in median QoR-40 score, post-operative rehabilitation goals or discharge readiness were detected between groups. 6-week health and functional outcomes (OKS and EQ-5D/VAS) were similar in both groups.

ConclusionFNB improves post-operative pain scores and reduces morphine consumption, but does not inhibit rehabilitation or discharge goals in primary TKA. Anaesthetic technique did not influence quality of recovery or 6-week health and functional outcomes.

KeywordsAnaesthesia, regional, knee; Analgesia, postoperative; Arthoplasty, total knee replacement. references1. Strassels SA, Chen C, Carr DB. Postoperative analgesia: economics, resource use, and patient satisfaction in an urban teaching hospital. Anesth Analg 2002; 94: 130-7

Abstactsoftherunner-uptraineepresentationsArandomised,observerblinded,controlledtrialofintrathecaldiamorphineversusfemoral

nerveblockforpost-operativeanalgesiafollowingprimarytotalkneearthroplasty.

Looseley A, Pappin D, Knight T, Warman P, McEwen A, Key W, Toms AD, Grayling M.

Department of Anaesthesia, Royal Devon & Exeter Hospital, Exeter, UK.

Corresponding author: Dr A. Looseley, University Hospitals Bristol NHS Foundation Trust, Bristol, UK. Email address: alex.looseley@nhs.net

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Thorough pre-operative assessment is vital for safe anaesthesia in order to detect and treat pathology in good time [1]. Despite this it is often performed by the most junior physicians with little training or confidence [2]. Junior physicians tend to over-investigate with concomitant increases in costs, investigation-related risk and likelihood of false positive results [1]. It was hypothesised that house officers performing pre-operative assessment in a surgical clinic at our hospital would not order investigations in accordance with NICE guidance [3] and would lack confidence. In order to address these issues, improve standards and prevent requesting of unnecessary investigations we conducted a focussed teaching session, raised awareness of NICE guidance and introduced a clerking pro-forma.

MethodsThe pattern of investigation requesting over 48 consecutive patients in the upper gastrointestinal surgery house officer pre-operative assessment clinic was examined and compared to NICE guidance [3]. The number of investigations inappropriately requested was calculated and the cost extrapolated using local test costs. The number of vital investigations not requested was calculated. House officers’ confidence was assessed by anonymised questionnaire. An intervention was then made. House officers were provided with a short teaching session on pre-operative assessment, a clerking pro-forma and a summary of the NICE guidance. The pattern of investigation requesting over 20 consecutive patients in the same clinic was then analysed and house officers’

perception on the usefulness of the teaching session was collected by questionnaire.ResultsPrior to the intervention 3.67 inappropriate investigations were requested per patient at a cost of £20.65 per patient. After the intervention these figures were 2.80 and £13.18 respectively. The percentage of inappropriate investigations fell from 69.3% to 59.0% (p = 0.058). Prior to the intervention an indicated investigation was missed 12.2% of the time compared to 0% after the intervention (p = 0.061). All seven house officers surveyed felt “not confident” at pre-operative assessment and six felt that the teaching session would or did make them more confident.

DiscussionPre-operative assessment must be conducted reliably for safe surgery, yet it is often delegated to inexperienced and under-trained junior staff [2]. This audit demonstrates that a short teaching session, clerking pro-forma and the provision of guidance improves both confidence and performance, reducing both the number of unnecessary investigations and the number of vital investigations that are missed.references1. García-Miguel FJ, Serrano-Aguilar PG, López-Bastida J. Preoperative assessment. The Lancet 2003; 362: 1749-572. Ravindra P, Fitzgerald E. Surgical preoperative assessment Student British Medical Journal 2012; 20: d7816 (accessed 5th March 2013)

3. National Institute of Clinical Excellence. Clinical Guideline 3. Preoperative Tests: The use of routine preoperative tests for elective surgery NICE; 2003

Pre-operativeassessmentskillsoffoundationyearonedoctors:aserviceimprovementprojectenhancingevidence-basedpracticeandconfidence

Nicholas Suarez - Gloucestershire Hospitals NHS Foundation trust, Gloucester, UK

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IntroductionSupraglottic airway devices (SAD’s) are commonly used to anaesthetise paediatric patients. Teleflex who manufacture the Sure Seal ® SAD’s used in the Bristol Royal Hospital for Children recommend a maximum cuff pressure of 60cm H2O. Cuff pressure is not routinely monitored in many institutions and clinical end points have poor correlation with cuff pressure and adequacy of seal1, 2. Pressures greater than 60cm H2O are known to increase the incidence of post-operative sore throat, reduce the seal of the device and lead to airway oedema3,4. This audit reviewed cuff pressures of SAD’s across all age groups, theatres and operations where SADs were used.

MethodsThe laryngeal mask airway was sized according to patients weight and placed using the standard technique. After insertion of the SAD, the volume of air used to inflate the cuff was recorded and cuff pressures were measured using a calibrated hand held Portex Cuff Inflator Pressure Gauge (Portex Limited, Hythe, Kent, UK).

ResultsandDiscussionCuff pressures were recorded in 101 patients ranging from 8 months to 15 years old, with a median age of 6 years old. Cuff pressures were greater than 120cm H20 in 73 per cent of patients and only 17 per cent of patients had cuff pressures less than

60cm H20 despite no patients receiving greater than recommended cuff volumes. In the patients with cuff pressures less than 60cm H20 cuff volumes were on average 51 per cent of the maximum amount.

ConclusionAt our institution SAD cuff pressures were too high in the vast majority of patients irrespective of age and clinical markers were poor at detecting adequacy of inflation pressure. The volumes required to avoid over-pressurised cuffs were approximately half the recommended maximum volume. Following these findings the department has changed SAD provider to the Sure Seal CUFF PILOT™, which has a visual display of cuff pressure in the pilot balloon to prevent cuff over-inflation.references

1. Schloss B, Rice J, Tobias J. The laryngeal mask in infants and children: What is the cuff pressure? Int J Pediatr Otorhi.2012; 76: 284–286.2. Wallace C, Chambers N et al. Pressure volume curves of paediatric laryngeal mask airways. Anaesthesia. 2009; 64: 527-53.3. Ong M, Chambers NA, Hulle B et al. Laryngeal mask airway and tracheal tube cuff pressures in children: are clinical endpoints valuable for guiding inflation? Anesth 2008; 63: 738–7444. Licina A, Chambers NA, Hullett B et al. Lower cuff pressures improve the seal of pediatric laryngeal mask airways. Pediatr Anesth 2008; 18: 952–956

SupraglotticAirwayDeviceCuffPressuresatBristolRoyalHospitalforChildren

Stuart Younie, Richard Beringer

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IntroductionTrainee assessment of the quality of teaching delivered by individual trainers is widely used to give feedback trainers, and also as part of appraisal and decisions about financial renumeration1. Many of the instruments used for this purpose have not been adequately validated, leaving interpretation of the results they give, especially in such high stakes situations as re-validation, open to challenge2. As part of a project to investigate the use of ‘performance polygons’3 to provide feedback on teaching quality, we attempted to design and validate an instrument for the trainee assessment of in theatre teaching quality.

MethodsA literature search was undertaken to identify pre-existing instruments designed to measure in theatre teaching quality and to identify commonly assessed domains of teaching quality. A modified Delphi process was undertaken to identify domains that were deemed to be important by trainers, trainees and the regional directors of training. A seven domain teaching quality assessment instrument was developed using these results. After ethics committee consent was obtained, all consultants and fellows in the department of the John Hunter Hospital were invited to participate in a randomised control trial to ascertain whether receiving feedback using the results of this new instrument presented as performance polygons led to an improvement in teaching quality. Statistical Analysis was performed to examine the internal validity of the instrument using inter and intra-rater reliability scores.

ResultsA seven domain instrument was developed,

which asked trainees to score teaching on a 7 point Likert scale in the following domains: 1. Provides a positive learning environment 2. Availability/presence during lists 3. Relevant knowledge and skills 4. Enthusiasm 5. Provides constructive feedback 6. Allows appropriate autonomy 7. Is a positive role model. 56 consultants from a pool of 61 consented to participate in the study. Statistical analysis showed inter-rater reliability was poor (R=0.02), with intra-rater reliability also poor (ICC=0.24). The feedback group showed no change in scores compared to the control group.

DiscussionDespite a rigorous development process based on sound pedagogic principles and having good face and content validity, the instrument we developed was not statistically reliable. We suggest that similarly developed instruments be used with extreme caution when the results may have profound implications for those being assessed and that this may have implications for the way that teaching quality is measured.references1. Baker, K. Clinical teaching improves with resident evaluation and feedback. Anesthesiology 2010; 113:693–703

2. Beckman et al. How reliable are assess ments of clinical teaching? A review of the published instruments. J Gen Intern Med. 2004; 19:971-977

3. Cook T, Coupe M, Ku T. Shaping quality: the use of performance polygons for multidimensional presentation and interpretation of qualitative performance data. British Journal of Anasesthesia. 2012; 108(6): p. 953-960.

SASWRAutumn2013Meeting:winningposterpresentationIntheatreteachingquality–shouldwebelievewhattraineessay?

Ben Ivory, ST7 Derriford Hospital

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2ndPrizePoster

Danny McLaughlin, Will Fox Department of Anaesthesia, Royal Cornwall Hospital (RCH)

Omitted medications in Trauma – The OMIT Audit

An audit of omitted medications during the pre-operative period in patients admitted with hip fracture

BACKGROUND

Hip Fracture - Common serious injury to older people - Cost to NHS £2 billion each year 1

- Approximately 500 cases admitted to RCH annually

- Two thirds of patients ASA grade 3 or above - Multiple co-morbidities necessitating

polypharmacy - Prolonged periods of time fasting prior to

theatre

Missed Medications - National Patient Safety Agency (NPSA) report

highlights harm from omitted medications 2

- 18,000 incidents over a three year period - 27 patients died with a further 68 cases of

severe harm

AIMS

METHODS

RESULTS

ACTION

RE-AUDIT

DISCUSSION

Omitted medications - 166/506 regularly prescribed doses were

omitted (33%)

Commonest reasons for omission - No reason given (55%) - Nil by mouth (16%) - Patient declined (16%)

Most commonly prescribed drug class - 312/506 doses were simple analgesics - 28% of regular analgesic doses omitted

Re-audit 3 months on - Data collected on a further 20 patients (n=20)

admitted with hip fracture - 186 prescribed doses in the pre-operative

period Omitted medications - 48/186 regularly prescribed doses were

omitted (26%)

Reasons for omission - Patient declined (33%) - No reason given (19%) - Nil by mouth (17%)

Medicines Safety Group - Concerns regarding poor documentation - Highlights patients unnecessarily missing medications; action required Senior Nurses Committee - Misconceptions regarding continuation of medications whilst fasting for theatre - Need for clearer guidance for ward staff Fasting guidelines poster developed - Highlights key points from guideline - Approval from governance committee - Poster located on all drug trolleys within the

trauma unit

Standard of care - Performance assessed against local RCH

“Preoperative fasting” guidelines

Study design - Review of medical notes / drug charts of 50

patients (n=50) admitted to Trauma Unit - 72% of patients were ASA 3 or greater - Regular prescribed medications reviewed

(excluding diabetic medications, anticoagulants)

- In total, there were 506 doses prescribed in the pre-operative period

1. Identify whether regularly prescribed medications are being omitted

2. Determine the reasons for omitted medications

Improvements in care - Overall reduction in the proportion of omitted

doses (33% → 26%) - Improved documentation on drug charts

Ongoing issues - Patients still missing medications due to being

NBM despite “30 minute” rule - Better co-ordination with theatre and ward staff

required Further developments - Poster reproduced in all surgical wards

throughout the hospital (Pharmacy Alert) - Closer surveillance of drug administration with

E-prescribing system

REFERENCES

(1) National Hip Fracture Database 2012 www.nhfd.co.uk

(2) National Patient Safety Agency – Rapid Response Report 09 – www.npsa.nhs.uk

Figure 1. Proportion of prescribed doses (n = 506)

Figure 2. Reasons given for omitted doses (n=166)

Figure 3. Fasting guidelines poster

Figure 4. Comparison of results post-intervention

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I’m just starting an OOPE, swapping patients and syringes for tissue slices and pipettes in the lab. I secured finding from the Wellcome Trust for a Clinical Research Training Fellowship leading to a PhD in Physiology and Pharmacology at the University of Bristol. None of this would have been possible without my appointment,three years ago, to the Severn School of Anaesthesia Academic Clinical Fellowship scheme. I was the first of these trainees appointed in Anaesthesia, and I was asked to outline my experiences thus far.

I first become aware of Academic Clinical Fellowships whilst still working as an ST1/2 in the London Deanery. These schemes are funded by the National Institute for Health Research, and are designed to encourage clinical trainees to become involved in research and seek further funding for a higher degree, as part of the pathway to clinical academia. Programs allow for 25% research alongside clinical work, spread over two to three years. Entry is either at ST1 or ST3, depending on the individual program. The appointments run alongside the standard training scheme, and trainees re-enter “regular” training either at the end of the program if they decide not to pursue research further, or after completing a higher degree.

I had a research background, having spent six months working in a basic sciences lab in Cambridge before starting my foundation year. There were limited opportunities for further research over the next five years, and

I focused on developing clinical skills and completing basic anaesthetic training. I was then considering the next step into specialty registrar training and beyond. One of the challenges when thinking about research was the limited number of schools offering research opportunities, especially outside London. Although I had loved my time in the capital, I was interested in continuing training in a different region. One region which was (just!) offering academic training was Bristol. A transfer training course at the Bristol Medical Simulation Centre enabled me to meet a number of trainees from the region, and they were very positive about training here. I was also able to speak with Tony Pickering, the lead for the academic clinical fellowship training program.

My interview was a challenge to attend, to put it mildly, taking place in the very snowy winter of 2011. I arrived in walking boots and waterproof trousers having used a range of transport options to cross Bristol! Fortunately, it didn’t appear to affect my interview, and I was delighted to accept the job a few days later.

The scheme commenced in August with ST3 training. In order to fit in 25% research time, my specialty training was compressed. I had six months to complete obstetric, paediatric and cardiac modules (usually three months each) and then six months of general anaesthesia. I also had to find a research project and pass my written and viva finals. It was a busy year! I knew that I was the first trainee appointed

AcademicClinicalFellowshipsinAnaesthesia: an index case

AnnaSimpsonAcademicClinicalFellow,ST5

WellcomeFellowshipAwardRecipient

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to the scheme, and as expected, there were some teething problems along the way. However, the tremendous goodwill from the clinical tutors and training program leads was very reassuring, and in general things worked well.One of the challenges was choosing a research project. I had a very free range of choice of supervisor. There was also the question of whether to seek a clinical or basic sciences project, and how “anaesthetic” the project would be. I felt that the most important aspects were to find a supportive supervisor, and an area I had an interest in. I quickly realized that I remained interested in basic science, and I was able to identify a diabetes related project with Nina Balthasar, a basic scientist who was interested in having a clinician in her lab. My project involves using a mouse model to examine aspects of glucose sensing and responses to insulin-induced hypoglycaemia in the hypothalamus. The hypothalamo-pituitary- adrenal axis and autonomic stress response are key to this process, and are areas of interest in anaesthesia. As the project evolved, we sought support from Tony Pickering as a co-supervisor, to broaden the scope of techniques and skills available to me.

ST4 began with six months at Frenchay for neurosurgery, trauma and ITU. I was scheduled for one day per week of day release in the lab, to allow me to start my research project. It was amazing how long it took to do anything, but I did pick up some new techniques. Generating consistent results was more of a challenge. However, by February, things were beginning to come together, and I then spent six months primarily in the lab, with general anaesthetic on calls at the BRI. This enabled me to develop some early results and submit a grant application for PhD funding from the Wellcome Trust. The grant writing process

was eye-opening. I had no idea how extensive the paperwork was going to be, or just how many hours of rewriting it would take. It was with huge relief that we submitted in June.

I returned to the format of mainly clinical work as an ST5 at Southmead Hospital in August 2013. I retained day release for lab work, which allowed me to prepare for my interview at the Wellcome Trust in November. It was a daunting experience- a very large panel of interviewers (15+) and probing questions about the project and my motivation for choosing to pursue research. I was not at all sure how it had gone, but was very excited to be offered funding the next week. I will be the first anaesthetist to undertake an OOPE PhD within the Severn region since the conception of OOPE’s around 15 years ago (a couple have taken place out of region). It will be very interesting to see what this leads to in the longer term.

I cannot emphasize enough how important the support of the School of Anaesthesia was to the success of this program. It was incredibly helpful to have support both in terms of arranging placements, within individual hospitals from clinical tutors and especially from the rota writers who managed to fit my rather unusual timetables into their already challenging templates. As the first trainee on the program, I was expecting far more teething problems than I in fact saw, and that was largely due to the goodwill of everyone involved. I hope the two trainees now following me have had similarly good experiences, and look forward to meeting new trainees appointed to the program in the coming years.

If anyone would like to find out more about the Anaesthetic ACF program, contact Tony Pickering; rtaep@bristol.ac.uk

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AnAdventurousPreludetoAnaesthesiaDavidLuther

“I’m sitting in departures at Casablanca airport. It’s approaching 5am. My feet are sore and I’ve still got sand in my ears. The medical kit has serious shortcomings as a pillow. Royal Air Maroc flight AT801 to Heathrow has been delayed because there is a cat on the plane. At least it’s not a snake.”I have never kept a diary before, but it seemed an essential part of spending a year as an expedition medic. Flying around the world, taking part in climbs and treks in a variety of conditions armed with a basic medical kit… there would no doubt be exciting stories to be told.

Cricket at 6000m

I completed a Wilderness Medicine Society course on expedition medicine in February 2013 while climbing Aconcagua – at 6962m the highest mountain in the world outside of the Himalayas.

Oxygen saturations of 72%

The course covered the essentials: medical kits, casevac plans, travellers’ diarrhoea, altitude sickness etc. But more importantly, it put me in contact with experienced expedition medics who made me realise that expeditions didn’t have to be one off trips squeezed into annual leave; they could be a way of life for a full year out, bridging the gap between foundation training and ACCS. The year in Queensland was shelved and the map was out.

Summit of Aconcagua 6962m

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I had experienced remote and basic conditions before: I spent my 8-week medical school elective in Kitgum, Northern Uganda, and I did Foundation year 2 in Lincolnshire. In Kitgum a midline laparotomy was the norm for an appendicectomy, and general anaesthesia was carried out with a bag valve mask, oropharyngeal tube and a stethoscope taped to the chest. Although the majority of an expedition medic’s remit is minor injuries and first aid, you have to be prepared to manage a range of serious conditions – High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE), diabetic emergencies, broken limbs – with limited resources. It was a daunting prospect.

Big trees in the Ujong Kulon

Since August I have been the medic on three expeditions, and I have a further three planned for early 2014. Here’s a snapshot of my life as an expedition medic, with a few diary entries thrown in for good measure…(names have been changed).

The Indotrek team on Krakatoa

In September I spent a fortnight in the Ujung Kulon National Park: a peninsular at the western tip of Java. The Ujung Kulon is home to the last remaining 45 Javan rhinos (think rhinos in Barbar - only one horn, look like they’re wearing armored plates). They used to roam vast swathes of South-East Asia, but, since the Vietnamese population died out in 2011, only those in the Ujung Kulon remain. They are at a critical population and if numbers don’t pick up over the next couple of years then they will follow the Dodo into extinction. Indotrek 2013 took a motley group of 12 British trekkers deep into the jungle on the hunt (not literally) for rhinos. The money that tourists bring to the park is crucial to the preservation efforts. The jungle is dense, the park is larger than Dartmoor, and the rhinos are shy… unfortunately we didn’t set eyes on them, although we did see lots of dung.-“First real case today. We stopped for lunch at a derelict 18th century Dutch lighthouse. It was previously the southerly marker for the Sunda Straits, a crucial shipping passage for the spice trade between Java and Sumatra. Eja came to me after lunch and asked if I would see a porter with an allergic reaction. The porter wasn’t sure what the cause was,

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but he was known to have a seafood allergy - possibly food-prep contamination. I’ve no idea what someone with a seafood allergy is doing out here… we’ve eaten seafood most nights. Anyhow, he noticed it coming on at breakfast and hadn’t bothered to tell anyone until now. He had some facial swelling and rash, but no signs of shock or airway compromise. Nevertheless, knowing that anaphylaxis could develop hours after exposure, I had to be careful. I gave him antihistamine and steroids, and moved the adrenaline vials from the medical kit to my daypack. In the worst case scenario an evacuation would be difficult – there’s nowhere in the jungle to land a helicopter. Rescue would be by boat from the shoreline, a couple of hours walk away. I kept a beady eye on the porter, and fortunately within an hour or so he had fully recovered. A first taste of expedition nerves!”

View from my tent on Kilimanjaro

Challenge Kilimanjaro climb. Charity Challenge organises treks, climbs, cycles and runs throughout the world, allowing the adventurous to challenge themselves and fundraise for a charity of their choice. I knew there was likely to be more work on this trip - we had 22 clients and 60 local staff. A ratio of one client to three local staff may seem excessive but they were all busy – cook, assistant cook, tent team, porters, guides, porter cook team. There is no free healthcare in Tanzania, so the porters understandably make the most of having a doctor to hand for 10 days. Between getting myself up the mountain, seeing to the porters’ ailments and managing altitude sickness amongst the clients, it was an eventful time. We climbed Kilimanjaro by the Lemosho route, which, taking five days up and two days down, is a slower ascent than most. However, even on this slower route we were still breaking the rules: current advice dictates no more than a 300m increase in sleeping altitude per day with a rest day every third day. Over the first four days one sees a wonderful transition in flora as the altitude increases. Driving to the start of the trek you pass through typical African savannah – dusty plains dotted with acacia trees and flashes of brilliant jacaranda lilac. Next comes the rainforest, dense, damp and dark, punctuated with the calls of vervet monkeys. You rise out the rainforest into a level of moorland with low-lying scrub: thistles, groundsels, lobelias and the occasional protea. Finally you move into alpine desert conditions – a lunar landscape with little oxygen and few plants.

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The Kilimanjaro glacier

On the fourth day, just shy of 4000m at Barranco Camp, my morning clinic was busier than Friday night at the Musgrove.“Within an hour I saw five porters and one client. Unbelievably medical morning. Had to leave camp long after the group and only caught up with them at the top of the Barranco wall. First patient was a client with SOB – no creps and sats reasonable at 90%, but she was struggling with breathing and it’ll only get worse. Then came the porters. Paul (head guide) presented them to me one at a time, like a cross between a GP receptionist and Cilla Black. Number one had classic tonsillitis - I didn’t even need a torch to see the white spots. I gave him the remaining course of Co-amoxiclav and said he should go down. Number two had pyelonephritis, with dysuria and flank pain. I called number one back and split the Co-amoxiclav. They could go down to the clinic together and be seen again there. Number three had dysentery…I’d seen him the day before with acute diarrhoea, but now there was blood. He was pyrexial and tachycardic. I gave him a first dose of ciprofloxacin, paracetamol, and a litre of dioralyte and said he needed to get to the hospital in Arusha immediately. The cavalcade was growing. Number four said he had a knee injury. His knee was OK, but his blisters were not – de-roofed monsters on

the outside of both feet. Think he’d adjusted his gait to relieve the blister pain and now hurt his knees. He couldn’t carry on up and would have to join the departure queue. Number five had a lower respiratory tract infection – couldn’t hear consolidation but he was coughing up horrible sputum. One and two came back and the antibiotics were split a third way. Would have liked to have seen them down for peace of mind, but can’t be in two places at the same time. Paul assured me that they only had a short walk to the collection point and would then be driven straight to the clinic. Hope he’s right.

Team atop Kilimanjaro

The third of my autumn expeditions was another Charity Challenge trip, this time to the Moroccan Sahara – not a bad place to spend November when the alternative is drizzle in the Blackdown Hills. The challenge was a 110km trek through rocky desert plains and occasional sand dunes in an area of the Sahara to the south of the Ante-Atlas and east of Ouarzazate.

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Trekking in the Sahara

We again weighed in heavy on clients – 20 – but there were far fewer staff. This trip bought an entirely new set of medical possibilities, and the flight over was spent buried in the Oxford Clinical Handbook of Expedition Medicine, genning up on sunstroke and scorpions. The sunstroke revision was called upon, but fortunately the scorpion revision was not. My main job out here was blisters; feet swell in the heat and a few of the clients thought airing their feet by wearing boots loosely was a smart move. Every morning and lunchtime I would arm myself with zinc oxide tape and do the rounds

Caravanning

The landscape was stunning by day, but the nights were even better. The desert night sky is massive, wonderfully bright and impossibly close. I lay outside our Bedouin tents for hours each night counting shooting stars. The walking was pleasant in the mornings and evenings, when the heat of the sun was diluted and our shadows stretched out in front of us like carved wooden Maasai

figurines, but between 10am and 2pm the heat was oppressive and we savoured occasional breezes and cursed our tepid water. Fortunately we had long shaded lunch stops under lonely thorn trees to see us through the worst of the heat.“I woke last night to an unusual sound. Loud, barking, painful, and repeated every 10 seconds, I thought at first that the camels were copulating. Then I realised it was a vomiting human. Simon had sunstroke. I slipped out of my sleeping bag as quietly as I could to avoid waking Trevor. I’d sooner have altitude sickness than sunstroke: both have the headache and vomiting, but the heat during the day makes sunstroke so much worse. I couldn’t do a great deal for Simon – he vomited an anti-emetic straight back up, so I advised him to take small sips when he could, said reassuring things and told him to cover up fully tomorrow. Don’t think he needs IV fluids yet, but if it carries on tomorrow he might.”As I look forward to starting ACCS next August, I am excited by the entirely new set of challenges that it will bring. But I am also confident that the unique set of challenges posed by a year as an expedition medic will stand me in good stead for whatever the A&E, AMU or anaesthetic departments throw at me. Meanwhile, 2014 will bring further excitements, with trips to Kilimanjaro (again), Everest Base Camp and Mt McKinley, Alaska.

David of Arabia

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SpondyloepiphysealDysplasiaCongenitaAirwayManagementforCaesarianSection

SC Grenfell, JE Lewis, HP LindsayDepartment of Anaesthesia, Musgrove Park Hospital,

Taunton, UK

Introduction: Spondyloepiphyseal dysplasia congenital (SEDC) is a rare genetic condition posing multiple problems to the anaesthetist. Clinical features include a short trunk disproportionate dwarfism, atlanto-axial instability, spinal deformities and thoracic dysplasia. We report the successful anaesthetic management of a 43 year old primigravida requiring a classical caesarean section (CS) at 28 weeks for increasing respiratory compromise.case report: A geriatric primigravid patient with SEDC measuring 104 cm in height with a BMI of 39 was scheduled for a caesarean section. She presented multiple anaesthetic challenges: a significant restrictive ventilatory defect: pre gravid FEV1 0.72L (35% of predicted), FVC 0.76L (31% of predicted), asthma requiring home nebulisers, C1-7 spinal fusion, severe scoliosis and significant gastro-oesophageal reflux. Airway assessment demonstrated a Mallampati score of 2 (class A), mandibular protrusion, but almost complete immobility of the cervical spine and a thyromental distance of 5.4 cm. An obstetric anaesthetic review was requested at 15 weeks gestation. Subsequently, a multidisciplinary team convened to plan the safest method of delivery. The anaesthetic plan was to perform an awake fibre optic intubation (AFOI) and proceed with general anaesthesia (GA) for her inevitable caesarean section. The patient

presented to hospital at 27 weeks with dyspnoea on minimal exertion and SpO2 90% on air. Steroids and magnesium were given before commencing anaesthesia in our general emergency theatre. An experienced anaesthetic, obstetric and neonatal team were present. Premedication included routine antacid prophylaxis and intravenous glycopyrrolate. Invasive arterial monitoring was instigated and the AFOI was done in a sitting position with TCI remifentanil. Cricothyroid injection was performed to achieve airway anaesthesia with minimal lignocaine. The laryngeal anatomy was distorted with gross oedema during placement of a size 6.0mm preformed nasotracheal tube. Anaesthesia was induced with propofol and maintained with isoflurane and nitrous oxide. A live male infant was delivered 4 minutes after surgical incision with APGAR scores of 3 and 7 at 1 and 10 minutes respectively. Analgesia was provided by rectus sheath catheters and a morphine PCA. The patient was extubated in theatre and electively admitted to HDU, staying less than 24 hours. She has minimal recollection of her AFOI and was happy with the overall experience.Discussion: There are no case reports in the literature of the use of a GA for a caesarean section in a patient with SEDC. The successful use of regional techniques has been described . Continuous regional anaesthesia was considered but we had

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concerns over difficult insertion due to extreme spinal deformity and balancing acceptable block height for anaesthesia without further compromising respiratory function. The added potential for difficulty in rapidly securing the airway in the event of failure meant we felt elective intubation to be the safest plan. The importance of early anaesthetic involvement to enable

multidisciplinary team planning in such high risk maternal patients is clear.

reference1. De Boer HD, Hemelaar A, Van Dongen R, Gielen MJM. Successfulepidural anaesthesia for Caesarean section in a patient with spondyloepiphyseal dysplasia. Br J Anaesth 2001; 86: 133–4.

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It is one of life’s great pleasures to watch the seasons roll around. The fresh greens of spring, the balmy warmth of summer and the golden-hued autumn all bring me joy. Winter too, I anticipate Christmas, skiing and the prospect of London grinding to a halt if it snows with excitement. I get to dig out the big, burly reds from the Rhone or Australia to partner slow braised lamb or cassoulet. These things please me immensely but this year I cannot avoid the feeling that this has been a long winter. Months of relentlessly miserable weather has me pining for spring, warmth and ultraviolet light. And, with this in mind, I intend to anticipate the end of the storms and arrival of summer; welcome to the barbeque edition!

Now, it is true that my BBQ is currently chained to the wall of the terrace to stop it disappearing into the neighbours hedge again and the prospects of al-fresco dining seem remote but all things shall pass and the sun will come out tomorrow (bet your bottom dollar etc…). Since I have to write my column several weeks before it is published, I hope that by the time you read this, it will be time for lighter wines and lighter evenings. Time for the Beaujolais to replace the Bordeaux; the Dolcetto to replace the Barolo. Both of these wines are fruity styles for early drinking. Neither are particularly expensive, acidic or tannic, so won’t benefit from keeping, but are perfect for the summer and actually benefit from a quick cool in the fridge or ice bucket before serving, if it’s hot outside.

If your barbeque habits involve large quantities of protein, heavily spiced and served dripping from the grill, then I think your gentle little Beaujolais may be rather overwhelmed. To my mind, grilled meat needs a little tannin to cut through the oily flavours. Lamb and Cotes du Rhone works well together. Those Spanish reds I was talking about last time would do too. Anything red and Italian seems to work with food, but Chianti Classico with its sharp cherry flavours matches smoky, herby foods beautifully. And if you’re grilling salmon, as I like to on occasion, a pinot noir is perfect; ideally one from Oregon, New Zealand or California. Indeed, one of the finest meals I’ve eaten was with my good buddy and fellow oenophile Gary in his back yard in Northern California. We ate grilled salmon we’d caught from his boat in the Bay that afternoon. I recall we drank some extraordinarily wonderful cabernet sauvignon on that occasion, which flies in the face of my Pinot advice, but I wasn’t about to turn it down. And hey, who cares about the rules?

So, when the time comes to swap the wellies for flip-flops I wish you happy summer drinking.

TheWineColumnTomPerris

TheJoysofSummer

Anaesthesia Points West Vol 47 No 1article

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Perris’sPicksforBarbeque

Grilled Salmon and Pinot Noir (ideally new world)

Grilled Lamb and Chianti

Chicken and Australian Semillon (either very young or aged for about 5 years: it goes weird for a while in adolescence! The wine, not the chicken!)

Bandol Rose or any pink wine from Provence with a summer evening.

Beer.

Enjoy!

TomPerris

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inspiration

Out in our Condoin the Caribbean, breathof endless summer. Creepingup on me, my eightieth.

I am trying to ignore it.Where did all the years go?In this paradise no escape.Even the neighbours now.

At dusk ten of ussit out by the pool. The wine flows freely.The day by now is cool.

From this high vantage pointthe lights go out, one by onealong the shoreline.Another day is done.

We chatter in the twilightLady Jane lends half an earfor husband Jack, confinedin their Condo to his chair.

Apparently this Jane is eighty twoaccording to my other half.You’d never guess it.Just live, love, laugh

RobinForward

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crossworDBrian PerrissCROSSWORD

Brian Perriss

CLUES ACROSS 8. Says crazy people should be beheaded. (6) 9. Fellow actor? (8) 10. Protect prisoner needing help. (8) 11. Visitor mucks up network device. (6) 12. Item like a rake, good. (5) 13. Express distress on taking this drink. (4,5) 15. Watchful later, perhaps. (5) 16. Respond and perform again. (5) 21. Restless as bill not paid? (9) 23. Road to 20 down? (5) 25. Athletic endeavor helped by LP from America. (6) 26. Counterfeit note a pal acquired without trouble. (2,1,5) 27. Fan of oil company explains concisely. (8) 28. Fat queen provides stock of provisions. (6)

CLUES DOWN

1. A shield against decay. (7) 2. Individual salesman backs relative in Alberta. (8) 3. American insurer briefly backs take over. (5) Solution to Crossword in 4. I hope Al will marry Polonius’ daughter. (7) Autumn 2013 Anaesthesia Points West 5. Hit back at libertine and get the bird. (9) 6. Surprise attack by President in the morning. (6) 7. Hutch’s sidekick fond of bacon? (7) 14. Demonstrator is a professional analyst. (9) 17. They are rubbish menders. (8) 18. Involved in a quest for relic of bygone age. (7) 19. Tyre is cut again. (7) 20. Musical insects? (7) 22. Cut off-licence tax. (6) 24. Nobleman inclined to be premature. (5)

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PrizesandBursaries

Detailsofallprizes,rules,andentrydeadlinescanbefoundatwww.saswr.org

There are several bursaries and prizes available to members of SASWR:

TheSASWRIntersurgicalTraineePrizeThis prize of £1000 is awarded annually at the November Scientific Meeting of the society. Entries of up to 2000 words maximum in the form of an essay or short paper on any topic related to anaesthesia, intensive care or pain medicine should be submitted electronically to the Honorary Secretary of the Society (honsec@saswr.org), by 30th September each year. The three best entries will be presented orally at the SASWR meeting in November, and the prize awarded at that meeting. Any entrants who do not make the shortlist will be invited to enter the poster prize at the meeting. Please note that you must be registered for the meeting in order to present your work, and you may not enter both this and the poster prize.

SASWRPosterPrizeThe Spring and Autumn scientific meetings will have a poster prize of £250 awarded to the best poster presentation. To enter, submit your work as an abstract or poster to the Honorary Secretary (honsec@saswr.org) by 30th September each year for the Autumn meeting and 31st March for the Spring meeting. You will need to be registered for the meeting and be able to present your poster to the judges during coffee.

TheRossDavisAdventureBursaryAnnual awards totaling £1000 in memory of Dr Ross Davis, are presented by his family and friends, to trainees of ST3 or above from the Wessex, Peninsula or Bristol deaneries to support ‘exciting endeavours in anaesthesia’. Further information can be found at www.rosswindsurf.co.uk and applications should be directed to the Honorary Secretary of SASWR (honsec@saswr.org) by 1st May each year. The successful applicant will be invited to accept their award at the following November meeting of the society, although the award may be released before then!

TheFeneleyTravellingFellowshipThis cash bursary is awarded to any member of the society to support a ‘mission abroad’. Applications, to the Honorary Secretary of SASWR (honsec@saswr.org), are welcomed throughout the year.

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NoticetoContributorsAll articles should be sent by email to the editor (see below for address). Scientific articles should be prepared in accordance with uniform requirements for manuscripts submitted to biomedical journals (British Medical Journal 1994; 308: 39-42) i.e. as used by Anaesthesia. Please ensure that references are complete and correctly punctuated in the required style. The approved abbreviations will be used for journal titles. Photographs should be sent as separate attachments. The deadline for submissions is usually 10 weeks before the next meeting of the society.Submission of articles to Anaesthesia Points West implies transfer of copyright to the Society of Anaesthetists of the South Western Region. If an article has been previously published elsewhere, permission to use the material should be sought from the editors of that journal before submission to Anaesthesia Points West. Submissions will be acknowledged on receipt and notice of acceptance/rejection/need for corrections will be sent as promptly as possible.

editor assistant editorDr Richard DellDepartment of AnaesthesiaFrenchay Hospital, North Bristol NHS TrustFrenchay Park RoadBristolBS16 1LE0117 340 2645Richard.dell@nbt.nhs.ukeditor@saswr.org