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Anaesthesia
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Pay Parity: The fight goes on
Needlestick Injuries
- A salutary tale
GAT: Serious Untoward Incidents
Overseas news:
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Safety Notice: TIVA
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No. 270 January 2010
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Anaesthesia News January 2010 Issue 270
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Welcome
Editorial
I am currently surrounded by building
works both domestically and professionally.
The builders who are working on my
home have worked 56 hour /7 day weeks
for the last three weeks – obviously the
EWTD is being interpreted differently in
the construction industry. Our trainees
have expressed real concerns about
their ability to gain adequate experience
since the introduction of the EWTD, and
I must say I am beginning to share their
concerns. Earlier this week I was teaching
primary FRCA candidates about obstetric
anaesthesia; a talk I have given in one
form or another for about 15 years. I often
discuss anaesthesia in early pregnancy, and
try and relate this to their experience of
giving anaesthetics in early pregnancy for
procedures such as evacuation of retained
products. This year, I was rather taken
aback to discover that none of the 25 or
so trainees in the audience had any such
experience. I realise that ERPC is not such
a common procedure these days, but we
still have ‘women’s hour’ in our emergency
theatre. I am now wondering what else
they haven’t done.
We have a number of rather sobering
articles in this month’s Anaesthesia News.
Angus McKee’s personal account of the
sequelae of a needlestick injury on page 24
makes truly sobering reading. I have found
that my enthusiasm for safer needles and
cannulae has been greatly increased since I
read his story. Dr McKee acknowledges the
support he has received from colleagues in
his account, and this support is the subject
of an article written by Isabeau Walker from
the AAGBI’s welfare committee on page 22.
We do all need to look after ourselves and
each other.
The New Year seems likely to bring
financial stringencies, and Hilary Aitken’s
article about tax matters certainly made me
aware that these might affect us personally
sooner than I had anticipated. Pay parity
issues grumble on, and our President
describes recent forays in his article. In
an accompanying article, Will HarropGriffiths suggests that the time has come
to deal directly with our private patients. I
don’t undertake private practice myself, but
his arguments seem sensible.
Contents
03 Editorial
17History - Peter Squire, Victorian Pharmacist
05 Pay parity for NHS work in non contracted hours
21Particless
07Private practice – is it time to change the way
we do things?
22How is your colleague today?
08Changes to the personal allowance: how they
affect earnings above £100,000 Or: How to pay
40% of cost for a bicycle
26 Your Letters
11 GAT - Serious Untoward Incidents
14 ICU in the Alice
Anaesthesia News
Editor: Val Bythell
Assistant Editors: Susan Williams (GAT),
Isabeau Walker and Felicity Plaat
Advertising: Claire Elliott
24 A Salutary lesson
Design: Amanda McCormick
McCormick Creative Ltd,
Telephone: 01536 414682
Email: [email protected]
Printing: C.O.S Printers PTE Ltd –
Singapore
Email: [email protected]
28 Safe Anaesthesia Liaison Group
30 Artistic Licensing
32 Scoop
Copyright 2010 The Association of
Anaesthetists of Great Britain and
Ireland
11
5
The Association cannot be responsible
for the statements or views of the
contributors.
No part of this newsletter may be
reproduced without prior permission.
17
Anaesthesia News January 2010 Issue 270
The Association of Anaesthetists
of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: [email protected]
Website: www.aagbi.org
30
Advertisements are accepted in good
faith. Readers are reminded that
Anaesthesia News cannot be held
responsible in any way for the quality
or correctness of products or services
offered in advertisements.
3
You may have seen the article we published last month describing
a novel method of scavenging whilst using a Jackson Rees T-piece.
This month we publish another article describing the development
of a new bit of kit, this time written by a design student. The
collaboration between clinical anaesthetists and someone totally
outside anaesthesia has clearly been very productive, and it seems
to me that we could do with more of this. A great deal of our
equipment is not optimal. My personal bugbear is the number of
trailing wires and sockets we have to struggle with – surely there
must be some better solution out there? However, I am aware that
there is a complex regulatory process involved in the design and
bringing to market of anaesthetic equipment, and I have invited
manufacturers to explain the process from their point of view; this
should appear in next month’s issue.
The safety notice regarding TIVA which we publish on page 28 is
essential reading for all – this statement is also appearing elsewhere
as mentioned in the article itself. I have to confess to being a gas bag
myself – I have never felt able to reliably ensure unconsciousness
with TIVA, and take great comfort from having an end-tidal gas
concentration on view. A phrase which Beverley Orser used in her
lecture at last year’s Winter Scientific meeting has stayed with me (I
guess because it confirms my own prejudices): ‘Track your MAC’.
This seems to me to belong up there with other great anaesthetic
aphorisms such as ‘If in doubt, take it out’.







I hope to meet you in London at this year’s winter scientific meeting;
I have to confess that this is my favourite meeting in the calendar – I
usually learn a lot and the venue is very convenient. Overall, great
value for money and time spent.
I wish you a happy, healthy and productive 2010.
Val Bythell
Help for Doctors
with difficulties
The AAGBI supports the Doctors for Doctors scheme run
by the BMA which provides 24 hour access to help
(www.bma.org.uk/doctorsfordoctors).
To access this scheme call 0845 920 0169 and ask for
contact details for a doctor-advisor*.
A number of these advisors are anaesthetists, and if you
wish, you can speak to a colleague in the specialty.
If for any reason this does not address your problem,
call the AAGBI during office hours on 0207 631 1650
or email [email protected] and you will be put in
contact with an appropriate advisor.
*The doctor advisor scheme is not a
24 hour service
4
The Anaesthetists
Agency
safe locum anaesthesia,
throughout the UK
Freephone: 0800 830 930
Tel: 01590 675 111
Fax: 01590 675 114
Freepost (SO3417), Lymington,
Hampshire SO41 9ZY
email: [email protected]
www.TheAnaesthetistsAgency.com
Anaesthesia News January 2010 Issue 270
Pay parity for
NHS work in non
contracted hours
NHS work carried out in the Private sector
has been with us for several years now. The
excellent work of my predecessor in trying
to achieve parity for anaesthetists offered
lower rates of remuneration for equivalent
time compared with our surgical colleagues
is well known. That work has been met with
varying degrees of success up and down the
country. We are aware of some excellent
results of local negotiation where parity has
been (or has almost been) achieved. We
are also aware that at renegotiation some
‘successes’ have not continued and we are
left with a bit of a hotchpotch around the UK.
BMI(CHG) hospitals have been involved in
delivery of large amounts of this work over
the last year and this has led to enquiries
from members who perceive they are being
remunerated significantly differently to
their surgical colleagues. In most cases this
perception is correct and in light of this we
invited BMI to a meeting at the AAGBI try
to clarify the situation. The meeting left us
with more questions than answers. BMI insist
that they have no specific format for dividing
up monies for the surgeon, anaesthetist or
any other specialty for that matter and that
details of remuneration depend on local
negotiation. The impression given is that
it is quite possible for parity to be reached
by local negotiation. Our information is
somewhat different. We have had sight of a
letter from a BMI hospital clearly setting out
the surgeon’s and anaesthetist’s remuneration
for particular procedures at very different
levels where the local anaesthetists assure
us there has been no local negotiation with
them or anyone representing them. Should
Anaesthesia News January 2010 Issue 270
we blame BMI for this? BMI is a business, all
businesses will rightly compete. If someone
will accept payment of, say, £80 when they
should probably be getting £120 for that
particular procedure, then the extra £40 is
not going to be given out of the goodness of
the business’s heart. We were told by BMI
that at some hospitals remuneration offered
was so low that the anaesthetists would
not anaesthetise at the level offered and
effectively ‘walked’. It may be that herein lies
a solution. This is extra-contractual work, you
do not have to do it. I realise, though that if
you are a newly appointed consultant any
additional remuneration is welcome (been
there, done that) but as you can see in the
wider context it may not be in anyone’s long
term interest to accept additional work at any
price, but I would not criticise those who do.
One of the positive aspects of the inception
of the NHS in 1948 as far as our specialty
was concerned was the principle of equal
pay for equal time for all consultants. There
is no doubt that this improved not only the
standing of the specialty but also standards
of practice, training and academic input all
developing this important specialty in which
we work into the sophistication of today.
There is a worry that this process could be
reversed partially by these remuneration
issues. The other tack that the AAGBI has
taken is to question why this principle should
change when NHS work is being done in
private hospitals. An exchange of letters
with Professor Sir Bruce Keogh, Medical
Director of the NHS has been ongoing. The
response we have had is that whilst the NHS
constitution does articulate certain rights
and responsibilities in one place, it does not
supplant existing employment law, and the
rates paid by third party suppliers contracted
by NHS organisations to provide services
are primarily a matter for those third party
organisations themselves. Clearly the equal
pay argument does not apply outside NHS
hospitals!
So is there any way forward? Be assured
your Association will keep ‘chipping away’
at this. As you can see we have been doing
just that, but clearly no one is going wave a
magic wand. The provider organisations are
not going to instruct individual hospitals to
pay equally and neither is the Department
of Health going to insist on upholding the
equal pay principle outside NHS hospitals.
The ball is in our court. In an ideal world we
would collectively negotiate and not provide
a service unless we were all paid the same
as the surgeon for equal time. The problem
would go away overnight. For reasons
explained above this is unlikely to happen
but I would urge members to challenge local
set rates and if the differential is considered
unacceptable to then seriously consider not
providing a service (as some anaesthetists
already have). If there is a threat that outside
anaesthetists would be brought in, remember
there is a limit to how many would be
available and for how long. It is up to us.
We must become as organised collectively
outside NHS hospitals as we are within.
Against such a backdrop the continued
efforts of your Association are more likely
to bear fruit.
Richard Birks, President
5
Your comments please – AAGBI
sets up five new working parties
Council of the AAGBI has established five new
working parties that will meet over the next
few months to produce written reports that
are likely to result in the publication of printed
‘Glossies’ and Patient Safety Guidelines. The
working party members would welcome
comments from members. As usual, any draft
reports produced by the working parties will be
posted on the website for members’ comments
before final publication.
Checking Anaesthetic Equipment
This working party, chaired by the Honorary
Secretary Elect Dr Andrew Hartle, has been
asked to revise the AAGBI’s 2004 glossy (and
associated laminate) of the same name.
Anaesthesia for Day Case Surgery
This working party, chaired by Council
Member Dr Ranjit Verma, has been asked to
revise the AAGBI’s 2005 Day Surgery glossy. It
is envisaged that the remit of this working party
will be changed to include both day case and
short stay surgery.
Fatigue and Anaesthetists
This working party, chaired by the Scottish
Standing Committee Convenor Dr Kathleen
Ferguson has been asked to revise the AAGBI’s
2004 glossy of the same name.
Proximal Femoral Fractures in Adults Over
65 Years
This working party, chaired by Council
Member Dr Richard Griffiths, has been tasked
with investigating and drawing up guidance
for anaesthetists on the peri-operative care
of hip fracture patients. The group comprises
anaesthetists, an orthogeriatrician, a surgeon
and a trauma nurse, together with members of
the NHS Anaesthesia Hip Fracture Network.
The group hopes to produce a valuable
resource for Anaesthesia Departments and
Trusts which will complement existing surgical
guidelines.
Regional Anaesthesia and Coagulopathy
The Association is establishing a working party
on the management of regional anaesthesia in
patients with abnormalities of coagulation. The
remit of the working party will include both
neuraxial and peripheral nerve blocks and
will cover patients with coagulopathies and
those being given drugs that affect coagulation.
Membership of the working party will include
representatives from the Obstetric Anaesthetists
Association, Regional Anaesthesia UK and
the Royal College of Anaesthetists, and will
be chaired by AAGBI Vice President William
Harrop-Griffiths. The working party would
welcome any comments from members on this
subject and will publish draft guidelines on the
AAGBI website for members' comments before
final publication.
If you would like to comment on any topics
within the remit of these five working parties,
please email [email protected]. Your
comments will be passed on to the chair of the
working party.
‘SMART’ ANAESTHESIA
COURSE
GAT Prizes at Cardiff 2010
‘Structured Management Airway Response Team’
Supported by
GAT Registrars’ Prize
Entrants must supply an abstract of not more than 250 words.
Shortlisted entrants will be asked to make an oral presentation followed by five
minutes of discussion. The winner receives the President’s Medal and a cash prize.
GAT Audit Prize
Entrants should submit an abstract of no more than 250 words detailing their
completed audit project.
A cash prize and certificate will be awarded to the winner.
The Anaesthesia History Prize
The Association of Anaesthetists and the History of Anaesthesia Society will award
a cash prize for an original essay on a topic related to the history of anaesthesia,
intensive care or pain management written by a trainee member of the Association.
The £1,000 cash prize and an engraved medal will be awarded for the best entry.
At Oxford – February 24, 2010
February 25, 2010
February 26, 2010
At Coventry – March 24, 2010
March 26, 2010
April 1, 2010
Approved for 5 CEPD points
CLOSING DATE – FRIDAY 16 APRIL 2010
For further details www.das.uk.com
If you have any additional queries, please contact the AAGBI Secretariat on
020 7631 8807 or [email protected]
Registration Enquiries: Kay Thomson, Anaesthetic Secretary,
Kettering General Hospital [email protected]
01536 492746 Fax 01536 492757
Full details can be found on the AAGBI website
http://www.aagbi.org/grants/trainee.htm
6
Six one day courses teaching technical and non-technical
skills (human factors) in airway management.
Anaesthesia News January 2010 Issue 270
Private
practice
– is it time to change
the way we do things?
William Harrop-Griffiths
This article accompanies the President’s
bulletin on pay parity for NHS work
conducted in non-contracted hours. I will
address some current issues in private
practice and will argue that the time
has come for consultants to think about
changing the way they conduct their
financial arrangements.
At the heart of the financial arrangements
relating to private practice in the UK are two
fundamental issues. Firstly, that there exists
a difference between fees and benefits.
Fees are what consultants charge their
private patients for professional medical
services. Benefits are what Private Medical
Insurers (PMIs) provide to their customers
in full or part payment of consultants’ fees.
Put simply, consultants set fees and PMIs set
benefits. Indeed, no one but a consultant,
or group of consultants working together
in a legally constituted partnership, can set
professional fees. The second fundamental
issue is that once a private patient has
agreed to the fee to be charged by the
consultant, there exists a binding legal
contract under which the patient becomes
liable for the payment of the fee, regardless
of whether or not the patient holds private
medical insurance. The AAGBI believes
that the direct professional, clinical
and contractual relationships between
consultants and their patient should be
maintained.
Anaesthesia News January 2010 Issue 270
The benefits offered by some PMIs have
changed little in the last 15 years, in which
period both the Retail Price Index and
Average Earnings Index in the UK have all
but doubled. This is leading an increasing
number of consultants, quite reasonably,
to set fees that exceed their patients’
insurance benefits, the difference between
these two being termed a “shortfall”. Many
patients are prepared to pay shortfalls
and, provided patients have been warned
of consultants’ fees in advance of surgery
and have agreed to them, they are legally
obliged to do so. However, shortfalls are
a potential source of difficulty for PMIs,
and there have been recent changes in the
way that some PMIs are managing their
benefit arrangements. In 2008, AXA PPP
made changes to its consultant recognition
processes under which consultants
applying for recognition were obliged to
agree to pay in line with AXA PPP’s newly
published benefits schedule if they were
to be recognised by AXA PPP. In doing so,
AXA PPP converted its benefits into fees for
those consultants who signed up for this
new recognition process.
Many consultants now accept payments
towards patients’ fees directly from the
patients’ PMIs in the form of cheques or
direct payments into their bank accounts.
Although there is much convenience in
this arrangement, it has been argued that
this allows PMIs to enter the direct doctorpatient financial relationship. It certainly
allowed some PMIs to claim that the
consultant’s fee was not being paid in full
because it was not “usual” or “customary”,
whereas the truth was most often that
it exceeded the benefit provided by the
patient’s particular insurance policy. The
convenience in allowing others to manage
payments in this way led many radiologists
to accept payments directly from private
hospitals for their services, and radiologists
were understandably aggrieved last year
when one group of hospitals decided
unilaterally to decrease radiologists’ fees
by a substantial proportion. By allowing
third parties to enter the direct financial
relationship between doctor and patient,
control of the financial arrangements
had been effectively ceded to others.
The AAGBI is concerned that PMIs may
seek to enter arrangements with private
hospitals whereby the anaesthetist’s fee is
not paid by the patient or the PMI on the
patient’s behalf, but by the hospital itself.
The AAGBI would see such arrangements
as another potential source of concern in
relation to the erosion of the doctor-patient
relationship.
Given the current financial climate and
the drive for most PMIs to maximise their
profitability, what can anaesthetists do to
protect their independence and ensure that
7
third parties do not try to control the way
they practise or the reasonable fees that they
charge their patients? I would like to suggest
that surgeons and anaesthetists seriously
consider dealing only directly with their
patients. The BMA’s March 2009 publication
entitled “Good billing practice – a guide for
private practitioners” says: “After treatment,
consultants should send their invoice to
the patient, ensuring that charges are fully
transparent with a brief narrative of the
procedures performed. Whilst consultants
may choose to send invoices to the patients
PMI, the BMA recommends that patients
are invoiced directly” (http://www.bma.org.
uk/employmentandcontracts/independent_
medical_practice/goodbillingpractice.jsp).
This echoes the AAGBI’s 2008 guidance on
billing private patients, which says that: “the
AAGBI recommends that consultants always
send the invoice to the patient” (http://www.
aagbi.org/publications/guidelines.htm).
The AAGBI will shortly provide its members
with a sample letter and contract that can be
sent to patients and which set out the basis
of a “deal direct” approach: that the patient
will be invoiced by the consultant and will
send payment directly to the consultant.
The consultant can then send a receipt to
the patient that the patient can forward this
to their PMI who, in turn, can reimburse
the patient in accordance with the benefit
schedule relating to patient’s insurance
policy. Such an arrangement is wholly legal
and will greatly clarify the relationships
within private practice: patients pay the
consultants’ fees and PMIs offer the patient
benefits towards those fees.
It may prove difficult for anaesthetists
to set up such a “deal direct” system
without the support of the surgeons and
other consultants with whom they work.
However, consultants in all specialties are
under similar pressures, and all should work
together to preserve the direct professional,
clinical and financial relationships with
their patients that form the basis of private
practice.
I would be happy to respond to any
questions that AAGBI members might have
about this or other matters related to private
practice.
William Harrop-Griffiths
AAGBI Vice President
8
Changes to the
personal allowance:
how they affect
earnings above
£100,000
Or: How to pay 40%
of cost for a bicycle
In the 2009 budget, Chancellor Alistair Darling announced changes to income tax
effective from April 2010. Most of us will be aware that the top rate of tax for income above
£150,000 will be rising to 50%. Since relatively few NHS consultants have incomes of this
level, most readers will not be too worried about this, but a more complex (and therefore
more confusing) measure was introduced at the same time which will affect many more
NHS consultants.
From 2010/11, the personal allowance will be reduced for people with taxable incomes
over £100,000. Anyone with an income below this amount will continue to receive the
full amount of the personal allowance, but above this level, the personal allowance will
be reduced by £1 for every £2 that taxable income exceeds £100,000. The personal
allowance is set each year, but based on the 2009/10 figure (£6475) once income is above
£112,950 the personal allowance would be zero. It has been calculated that the effect of
the tax rate of 40% plus the reduction in personal allowance means the tax paid in this
income bracket is equivalent to 60%.
What is my taxable income?
Taxable income is income from any source – NHS salary including clinical excellence
awards or discretionary points, extra programmed activities, and availability supplements,
in addition to any income from private practice, interest from investments, any other
work undertaken minus pension contributions, whether superannuation, added years
payments, additional voluntary contributions or private pension arrangements, and any
other allowable expenses. For those working in the NHS this means professional fees
and subscriptions. For those engaged in private practice there are many more allowable
expenses, which are outwith the scope of this article, and you should seek the advice of
your accountant. Charitable donations made under the Gift Aid scheme should also be
subtracted.
The personal allowance is set each year by the Government, and is the amount of taxfree income each individual is allowed. It is subtracted from your taxable income before
calculating tax due.
Anaesthesia News January 2010 Issue 270
Some examples
Is there any good news?
The 2010/11 tax rates and thresholds were not known at the time of
writing, so the following examples are based on 2009-10 figures, but
reducing the personal allowance in the way indicated. Firstly, the way
tax is calculated if an individual’s taxable income is £100,000, which
is straightforward as no reduction in personal allowance operates.
Now let us assume the same individual’s taxable income increases
to £103,000
Well, sort of… At the present time, pension contributions are
subtracted from your gross taxable income, and therefore attract tax
relief at the highest rate. By starting or increasing additional pension
payments after April 2010, you will be reducing your taxable income
and therefore the effect on your personal allowance, gaining tax
relief on these contributions at the equivalent of 60%. For those in
this income bracket, additional pension contributions will suddenly
become very cheap indeed. The same applies to charitable donations
under the Gift Aid scheme – these reduce your taxable income, and
hence the impact on your personal allowance. The easiest way to do
this is to investigate whether your employer allows Payroll Giving –
this means your payroll office do the hard work for you instead of
you having to keep records and remember to put it on a tax return.
It should be stressed that this extra benefit is lost once your taxable
income rises above £112,950.
b) Taxable income 103,000
Tax charged on 98,025
Tax rates:
Tax due:
The other scheme which effectively reduces your taxable income is
particularly beloved of anaesthetists – it’s the purchase of a bicycle
through the Cyclescheme, which most NHS employers are signed
up to, and the anaesthetic cycling fraternity seems to have taken full
advantage of it. You can reduce your taxable income by up to £1000,
so once again, the equivalent tax saving is 60%. So if you were
thinking about a fancy new bicycle, wait until after April 2010!
a) Taxable income 100,000
Tax charged on 93,525
Tax rates:
Tax due:
personal allowance 6475
37,400 x 20% = 7,480
56,125 x 40% = 22,450
29,930
Net Income: £70,070
personal allowance 6475
Reduce personal allowance by 1500
Reduced personal allowance 4975
37,400 x 20% = 7,480
60,625 x 40% = 24,250
31,730
Net Income: £71,270
What about the high earners?
So for a £3000 gross salary increase, the individual is only £1,200
better off – hence the equivalent 60% tax rate.
Using the same calculation, the following examples can be worked
out:
Gross taxable income
Income after tax
£100,000
£70,070
£103,000
£71,270
£106,000
£72,420
£109,000
£73,675
£113,000
£75,280
Once taxable income exceeds £112,950 (based on the current
personal allowance) this additional tax burden is lost, and additional
income is once again taxed at 40% - till you get to £150,000!
The effect of the changes
What are the practical implications of this? As we have demonstrated,
any increase in income within this bracket will not increase your net
income by as much as previously, and unless you are aware of these
changes, by not as much as you think. So if you are in this income
bracket and your clinical director offers you an extra programmed
activity at job planning this year, is it going to be worth your while to
give up more of your time? The same applies to waiting list initiatives
and any increase in private practice, so you need to think carefully
about whether to undertake additional work.
Anaesthesia News January 2010 Issue 270
As previously mentioned, from next April, earnings above £150,000
will be taxed at 50%. In addition, the tax relief rates on pension
contributions will be gradually reduced to 20% once earnings
exceed £150,000. Pension Contribution Tax relief from April 2011
will be tapered from 40% to 20% for earnings from £150,000 to
£180,000. To stop people earning over £150,000 gaining 40% tax
relief by putting in new large pension contributions before 2011,
the Chancellor put into immediate effect on the day of the budget
(23 April 2009) a Special Annual Allowance Charge (a new tax) of
20% on new pension contributions. This means anyone earning
over £150,000 right now will only receive 20% tax relief on any
new pension contributions made since 23 April 2009, although
contributions made in accordance with a previously existing pattern
are exempt. In this situation, pension contributions cannot be used
as a method of reducing income below £150,000, although Gift
Aid charitable donations can be used to reduce the income figure
below the threshold, which would then allow pension contributions
to obtain 40% tax relief.
Hilary Aitken,
Consultant Anaesthetist,
Paisley
Dr Mark Martin ([email protected])
Scott Clayson Dip.PFS
Independent Financial Advisors, Cavendish Medical
Useful websites:
http://www.investmentguide.co.uk/additional-rate-examples.pdf
http://www.cavendishmedical.com
9
“Get a Head Start!”
Trainees Planning To Sit
The Final FRCA SAQ Paper
Wednesday September 1st 2010
or
The Final FCARSI E&SAQ Paper
Monday September 20th 2010
Weekend Introduction Courses
to
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14.00 Friday 19th – 16.00 Sunday 21st March
Aintree Hospitals, Liverpool.
14.00 Friday 26th – 16.00 Sunday 28th March
Aintree Hospitals, Liverpoo.l
PROGRAMME
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Review & Analysis of Presentation Techniques
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Under Examination Conditions
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For Application & Details
www.msoa.org.uk
10 Anaesthesia News January 2010 Issue 270
GAT
Serious Untoward
Incidents
Last year I was involved in the management
of an unexpected inpatient death. A Serious
Untoward Incident (SUI) investigation was
carried out by the Trust involved and as
part of that investigation I attended an SUI
meeting. I’d never even heard the term “SUI”
before then. The meeting did not proceed as
the simple fact finding exercise I was lead
to expect and left me feeling unsupported,
upset and doubting my actions and abilities.
I sought and received good advice and
support after that meeting, but I wish I had
been better prepared before the incident
happened.
While writing this article I asked some of
my trainee colleagues how many of them
had been involved in an SUI investigation
and what the experience had been like for
them. Four out of five sitting in the room had
been involved in an investigation and they
all felt that it had been confusing, unduly
stressful and they had not been prepared or
supported in the way they should have been.
I feel that as doctors in training we have to
take some responsibility for this.
In this article I am going to attempt to outline
how an SUI investigation is performed and
set out an approach for any trainee involved
in one. I’m not going to go into the details
of what happened to me, but the following
points are lessons I learned. Managing an
SUI is unfortunately something we will all
face as consultants and I think it’s reasonable
to be asked about it at a consultant interview.
In addition, we all have a responsibility to
support our colleagues, even if we are lucky
enough to avoid an incident ourselves.
What is an SUI?
Having looked at many online resources
it is obvious that different Trusts in the UK
Anaesthesia News January 2010 Issue 270
have slightly different perceptions of what
constitutes an SUI. In essence if an incident
causes risk of, or actual, permanent injury
or death to someone who falls under the
responsibility of the NHS it may be treated
as an SUI (that includes us as employees). In
cases of doubt, defaulting to an SUI should
occur. If it will create widespread public or
media attention it is more serious.
(GMC) may need to be informed and a
doctor may be suspended during ongoing
investigation for the protection of themselves
and patients. In the case of trainees their
Deanery and Royal College may need to
be involved. Some of these investigations
can and do unfortunately take considerable
time to complete and the following points
become more crucial if this is the case.
Within 24 hours of an SUI occurring it
is registered on the Strategic Executive
Information System (STEIS), a national
database maintained by the Department
of Health. This allows monitoring of the
further investigation and dissemination of
avoidable errors to a wider audience. The
incident is submitted to root cause analysis
locally by an independent investigator and
is reported anonymously. The incident may
be stepped down, but STEIS will need to be
informed. Risk managers based at Trust level
are responsible for this process. The ultimate
aim is safety and avoidance of replication of
error, in a system based approach.
How can you improve your experience of an
SUI investigation?
It is important to remember that the SUI
investigation is a fact finding exercise, to
record and analyse what happened and
recognise any failures in the system that are
avoidable in similar situations in the future.
It is designed to avoid a blame culture.
Local investigators have a responsibility in
certain circumstances to involve outside
authorities. For example, in the case of
equipment failure the Medicines and
Healthcare products Regulatory Agency will
be informed. A Coroner or Procurator Fiscal
may need to decide whether an enquiry
is necessary if there has been a death. If a
criminal act is suspected the police have to
be informed. The General Medical Council
Know the local process
Familiarise yourself with local policy, even if
it is only because an incident has happened
and you’re involved in the investigation.
All trusts have their own local policy, but
generally all subscribe to the same idea –
look for the risk management pages on your
trust intranet site or type “SUI” into its search
facility.
Be contactable
You must regularly check your trust email;
it is your responsibility to do this. It will
be management’s default contact for you.
This may seem annoying if it is not your
main email contact, but unless you are
personally registered in accordance with the
Data Protection Act the Trust should not be
emailing anything involving patient details
to a personal email address. You will miss
the chance to take part in the investigation
if you do not receive these communications.
This may result in you being unable to
defend yourself and/or to learn from the
experience.
Keep good quality written records
It is the presence of your name in the medical
notes that alerts the investigators to involve
you when an SUI is investigated. The GMC’s
11 GAT
“Good Medical Practice” says you should
“keep clear, accurate and legible records,
reporting the relevant clinical findings, the
decisions made, the information given to
patients, and any drugs prescribed or other
investigation or treatment”, and that you
“should make records at the same time as
the events you are recording or as soon as
possible afterwards”. This can sometimes
be difficult, but it is vital. If something
is not entered in the medical notes it will
be regarded as not having happened or
not having been done even if you know it
was. If the documentation was delegated to
someone else (as often happens if you are
acting as part of a team) you should check
this entry and countersign it. Legally you
have 72 hours to make an additional entry
in the patient’s notes, but you cannot make
alterations to any previous entries.
Personal records
It is good practice to write a reflective
summary of what happened for your own
records and this can provide the basis for
an SUI statement. Try to write a summary
straight away, while it is fresh in your mind.
This will be before you are even aware of
whether or not an SUI investigation will be
undertaken. You must store this securely and
anonymously. Writing these summaries as
often as you can, even about small events
as part of your everyday practice, will make
it easier to write something sensible when a
serious incident has caused you distress and
anxiety. Reflective practice has become part
of our ongoing professional development.
Evidence of self-reflective practice will
be sought in the future (possibly as part of
re-validation). This reflective practice can
encompass evidence of good practice too!
Debriefing
A debriefing of everybody involved in the
incident should be held. Ideally someone
who is a trained facilitator should do
this. Critical Incident Stress Debriefing
involves the giving of information aimed
at preventing psychological morbidity and
aiding recovery after a traumatic event.
Techniques and communications skills for
debriefing are now fairly widely taught
(e.g. Training the Trainers courses). Using
constructive criticism skills, for example,
can make this process far less stressful for
the person receiving it. Take an active role
in the debriefing process if you feel you are
equipped with these communication skills,
you may be able to support others.
12 Get yourself support
Don’t underestimate the psychological
effects of being involved in a serious
incident. Ensure you receive the support you
need from an experienced senior Consultant
or Mentor who you trust. Your Clinical
Director has a responsibility to ensure your
emotional well-being. If you find it difficult
to find support within your own department
speak to another close colleague or make
use of the support networks set up outside
of your local workplace e.g. AAGBI or BMA.
Your department should ask themselves
whether it is good practice to expect you to
fulfil your immediate service requirements.
If you feel unable to cope with your usual
workload you should talk to someone about
this and request time out. Be alert to signs
of anxiety; don’t cope by drinking alcohol
excessively or causing undue stress to
personal relationships. These symptoms of
stress can manifest themselves much further
down the line.
Representation
Don’t go to any meetings without senior
representation. A Consultant from your
department should attend meetings with
you.
Informing
your
medical
defence
organisation is crucial in the event of an
unexpected death but they will not mind if
you have a low threshold for involving them
in untoward incidents that may lead to your
practice being questioned. You pay them a
lot of money for their services; use them, get
your money’s worth. They are there for YOU,
as opposed to the patient, your department,
the hospital trust or your primary care trust.
If there is any chance of a dispute between
you and the Trust their services will be
invaluable. If the incident does involve an
external investigation they will appreciate
early involvement. You are not covered by
your Trust for criminal prosecution or GMC
hearings.
Statement
If you are involved in an incident you will
usually be asked to prepare a statement.
This should record fact; what happened and
why, not your opinions about what should/
could have happened. Before handing in
your statement get other people to read it
and give feedback. They will be look at it
from a more objective perspective and will
help you prevent it seeming angry, personal
or judgemental.
Final report
When the investigation has been completed
you are entitled to see a copy of the report
and it is advisable to review it. If you don’t
agree with the way the incident has been
reported or the conclusions the investigation
has reached you have a responsibility to
raise this. Raising concerns about this is
probably best done within your department
as a first call, but do not be afraid to take
it higher if you are unhappy. Again, your
medical defence organisation will advise
you about this.
Closure
Closing the episode is important; you should
not be left questioning any aspect of the care
you provided for your patient. You should be
clear about what occurred and whether you
acted optimally or whether there are aspects
of your practice that can be improved.
Seek out a clear ending to the process. Make
sure you are able to reflect on what you have
learned from the experience, be that clinical
practice or communication skills. There is
always room for improvement, which is not
a negative thing.
I hope this article has helped you to be better
prepared if you experience an untoward
incident. Hopefully you won’t, but I think
the points covered are part of a professional
approach to achieving our responsibilities
both to ourselves and others within our
workplaces.
Dr Hannah Gill
SpR Anaesthesia, GAT committee member
Further reading
“Catastrophes in Anaesthetic Practice
(2005)”, AAGBI publications.
“Good Medical Practice”, GMC
publications.
Information is available online from The
Department of Health website (www.
dh.gov.uk)
Many thanks to Dr David Stansfield for
his helpful comments while preparing this
article.
Anaesthesia News January 2010 Issue 270
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PLACES ARE LIMITED
THE INTENSIVE CARE SOCIETY
THE ANNUAL SPRING MEETING 2010
MONDAY 17 – WEDNESDAY 19 MAY 2010 | ROYAL ARMOURIES MUSEUM, LEEDS
Mark your diary now!
Programme topics include:
• Ventilation and lung ultrasound workshops.
• What’s new and important in the literature? Sessions
will include ‘Update in infectious disease’ and ‘Unusual
diagnoses not to miss’.
• Who should be admitted to the ICU? Including ‘Morbid
obesity in the ICU’.
• Towards zero nosocomial infections.
• Pro Con Debates: ‘Should SCVO2 be used to guide
resuscitation’, ‘Large vs. small ICUs’ and ‘Synthetic colloids
should only be used as part of RCT’.
In addition there will be the Trainees, Members, Nurses and
AHP forums, the Gilston Lecture and an industry exhibition
showcasing all the latest developments.
CPD accreditation: 10 points pending
Keep an eye on our website. More topics will be
added as they are confirmed. Registration, abstract
submission, a full programme and further meeting
details are available at www.ics.ac.uk
Anaesthesia News January 2010 Issue 270
ICS Dinner and Dance
The 2010 Dinner and Dance will also be held at the Royal
Armouries and promises to be a fabulous event with medieval
jousting, a red carpet entrance, live music and delicious food.
ICS Fun Run
There will be an opportunity to support the ICS Foundation
by participating in a 5K charity run. Details to follow shortly.
13 Reproduced with the kind permission of The ANZCA Bulletin
ICU in the Alice
How do most of us see Australia? Once away
from the coast, the imagery that springs
most immediately to mind tends to be of
sunburnt country, kangaroos, Aboriginal
people, and sport (in particular, Australian
Footlball League). Well, if you want to be
somewhere that fulfils every preconceived
idea of the Australian interior, Alice Springs
is the place to be. However, Alice surprises
all who visit her.
Alice Springs is an unusual place. It is
beautiful and has a natural environment
that you cannot ignore; the red dust gets
under your skin and somehow changes
you. It is a place of contradictions. It is a
small town, but because there is such a
large transient population you are always
meeting new people. It is isolated, but has
flights each day to every state capital. It is in
the psyche of just about all Australians, and
yet very few people really understand what
the desert is. It is a cultural mixing pot with
people coming together with art music and
outdoor life. There is a festival most weeks
in winter, my two favourites are the Beanie
festival and the wearable arts.
For me Alice is the heart of Australia;
and the Aboriginal people are Australia’s
conscience. For Australia to be strong it
needs to recognise and value Aboriginal
culture within mainstream Australian
culture, allowing Aboriginal understandings
to come into play with our own assumptions
about ways to live in this country. I have
14 no idea how that might happen, but I do
know that Aboriginal culture has much to
offer us in rethinking some of the more
troubled and problematic consequences of
mainstream western life.
The important premise of the Aboriginal
culture is to adapt to the environment,
making minimal impact upon it; a position
very different from the Western culture
of changing the environment to fulfil our
needs.
I will share with you some typical
experiences in Alice’s intensive care unit.
We are a 4-6 bedded ICU with an HDU of
4 beds attached to it. Our patient base is
70% Aboriginal with an average APACHE
of 18 and age of 42 years. Chronic disease
is rife, with the highests rate of rheumatic
heart disease, bronchiectasis and end stage
renal failure in the Western world. We also
have high rates of hypothyroidism, HTLV1
(but luckily virtually no HIV); strongyloides,
amyloidosis
(secondary
to
chronic
infection), diabetes, heart disease and
terrible lipid profiles. Not to mention the
social problems of alcoholism, illiteracy,
depression and petrol sniffing.
However, on the positive side we look after
the most physiologically tough people I
have ever met. They also have a great sense
of humour. These qualities make working
with them rewarding in unexpected ways.
Aboriginal culture is about the environment
and family so everything we do must be
adapted for this. There are at least 14 main
Aboriginal tribal groups from the centre
with as many languages. Most Aboriginal
people speak at least five languages, but
often English is their fifth language and
it may be limited or non-existent. This
group of people call themselves the desert
MOB. All have either Aboriginal or English
names to match the environment or to
describe their place in Aboriginal society.
Some of my favourites are Fly, Possum and
Motorcar. Less appropriately, some just
have the name of the Station owner their
family worked for.
The day in ICU begins with the night
registrar recounting the tales of the night.
Often one of the new patients will be
completely covered in a blanket with a big
eye peering out watching how everyone
interacts and deciding whether it is safe to
emerge. The registrar will usually say that
they have been unable to get a history from
the patient; trust has not yet been established
and sharing information only happens with
trust. An old lady is introduced who has no
English and no relative who has come in
with her. However the registrars excitedly
inform me that they have worked out who
she is, as she had paint on her fingers. They
looked up the catalogue of painters and
matched her to her photograph in the artists’
list, then confirmed her identity by showing
Anaesthesia News January 2010 Issue 270
“ For Australia to be strong it needs
to recognise and value Aboriginal
culture within mainstream Australian
culture, allowing Aboriginal
understandings to come into play
with our own assumptions about
ways to live in this country.”
the lady some reproductions of her work.
The old lady had proudly acknowledged
the paintings as hers, so we have a name
and, importantly, a medical record and
contact details. In other cases, without such
clues to help identify the new patient, we
would wait for the Aboriginal liaison MOB
to come, as one of them would be able to
identify her.
The Aboriginal liaison MOB are a group
of dedicated people and talented linguists
that help with all the cultural broking
issues. The Aboriginal liaison MOB are
central to understanding family dynamics,
issues, contexts and translating. They make
it possible for the patients to stay in hospital
to receive the therapy that they desperately
need. This group of under-recognised
heroes competently take care of issues such
as making sure the person’s children are
safe and being looked after, their money
problems sorted and their family informed
of what is happening. They are part of the
most efficient form of bush telegraph.
Sometimes only one family member will
have a phone but that person is always
found and contacted. Alternatively, visits
to the town camps where some family
members live, are made. The liaison MOB
also help sort out safe accommodation
for family members that come in from out
bush, and are wary of going into a town
camp (this is the term for Aboriginal owned
land in town) where they know despite the
camp being termed a “dry camp” there are
still too many drunks around.
Morning ward rounds have the same
elements as any ICU; a problem list, an
examination and a plan. Once trust has
been established, patients often give us
vital hints as to what should happen. These
should not be ignored as our patients really
Anaesthesia News January 2010 Issue 270
are observant. This is the only ICU that I
have worked in where patients have held
their own endotrachael tubes for turns
and where the remote control and TV are
more important for treatment tolerance
than propofol and fentanyl, especially
on Friday and Saturday nights during the
AFL season. Negotiating is not always an
advantage; I spent 30 minutes of anguish,
waiting for half time in the Collingwood,
Geelong preliminary final. Eager to insert
a chest drain for a pneumothorax, with
impending tamponade. Being a Yuendumu
man and thus a Collingwood supporter
(same colours), he was not going to miss
a moment of the match and gave me
permission to interfere only during half
time.
The day may be interrupted by matters
of commerce. Relatives will bring in a
painting to sell to get the money for petrol
for the rest of the family MOB to come
to town. As a result, I have walls covered
in beautiful artwork and more canvases
rolled up in my cupboard than I will ever
be able to hang. My family back in Sydney
have also had their homes transformed by
wonderful artworks. If you want to work in
Alice it is advisable to have access to plenty
of wall space.
Communication is always a challenge
given that there are so many different
languages, and a lot of modern medical
diseases have no aboriginal name.
Aboriginal people have a keen desire to
understand why they are sick and what is
needed to make them better. Use of visual
aids such as x rays helps explain the disease
and its progress. Finding the right way to
communicate within each situation is one
of the most satisfying challenges, as once
understanding is achieved it transforms
the relationship between the hospital and
entire family. It plays an essential role in
establishing trust. Process of building trust
is further strengthened by acknowledging
various belief systems.
Aboriginal people have many spiritual
beliefs about sickness and families will
often bring in Ngangkaris, traditional
Aboriginal doctors, who heal both body
and spirit. Families and the ICU encourage
both types of medicine together. With such
different understanding of how diseases
arise and how you cure them one needs to
be careful of what one says. Once, after I
had spoken at length to a family about how
sick their relative was and what we were
doing, I remarked that we needed to cross
our fingers and hope it all worked. Two
hours later I came back to find the family in
deep conference about this crossing of the
fingers: how you do it? In what way? And
for how long?
The hospital staff in Alice are great. We
have enthusiastic nursing staff and junior
medical officers, who I like and admire.
Like the patients they have great senses of
humour and are dedicated. With the mix of
long term staff and short term rotating staff
from St. Vincent’s, Royal Adelaide Hospital
and Royal Prince Alfred, the tea room is
filled with conversations and controversy
as we all grapple with policies that change
with each new election, that regulate the
way in which the desert MOB, and indeed
all Aboriginals, live.
Work in Alice is often demanding, usually
challenging, but never boring or futile. The
work is so full of all aspects of life that I
have got more out of the work than I had
ever expected. That is why I love being an
Intensivist in Alice.
Dr Penelope Steward
15 Final FRCA crammer Courses
(newly revised conent)
1st – 3rd February 2010 (MCQ/SAQ)
17th – 18th May 2010 (Viva)
26th – 28th July, 2010 (MCQ/SAQ)
1st – 2nd November 2010 (Viva)
Fee: £250 Viva & £300 MCQ/SAQ
Programme includes full mock MCQ and
SAQ exam plus tutorials. Viva course includes
intense and realistic formal Viva practice under
exam conditions with Consultant mock examiners.
Candidates receive personalised one to one
feedback on techniques.
For an application form, please contact:
The Department of Academic Anaesthesia,
Cheriton House, The James Cook University
Hospital, Marton Road, Middlesbrough TS4 3BW
Email: [email protected]
Tel: 01642 854601.
PLACES ARE LIMITED
16 Anaesthesia News January 2010 Issue 270
The History Page
Peter Squire
1798 – 1884
Victorian Pharmacist
Peter Squire came from a farming
background in Bedfordshire and after
apprenticeships in Peterborough, London
and finally in Paris, he set up his own
business in Oxford Street and became
Chemist in Ordinary to Queen Victoria and
the royal family. His company made the
coronation oil for 5 monarchs and continued
in business until 1950 when it was acquired
by Savory and Moore. He was a founder
member of the Pharmaceutical Society,
President three times, and represented it
on the committee which set the standards
for pharmaceutical prescriptions in the
first edition of the British Pharmacopoeia.
He then went on to publish his own
Companion Pharmacopoeia which ran
to nineteen editions, and specialist
pharmacopoeias for the London hospitals.
His most successful patent medicine was
Squire’s Extract, which contained cannabis
and was prescribed extensively by the
medical fraternity for various ailments from
involuntary twitching to help with pain
in childbirth. This medicine made Peter
Squire and his son, Peter Wyatt Squire,
who eventually took over the business,
commercially successful.
Portrait of Peter Squire c. 1880
Peter Squire, my great-great-grandfather,
is well known for his involvement in the
first successful operation under ether on
December 21st 1846 at University College
Hospital. Having been approached by
his friend the surgeon Robert Liston, he
provided the apparatus to vaporize the
ether, which was probably administered by
his nephew, William Squire, then a medical
student at the hospital. Otherwise Peter
remains a shadowy figure in the history of
anaesthesia, whose achievements, it has
been suggested to me, should be better
known.
The Royal Warrants
Anaesthesia News January 2010 Issue 270
17 The History Page
Squire and Sons held the Royal Appointment
for Chemist and Druggist to the Royal
Household from 1837 until the early 1950’s.
There are ledgers and account books from
the business in the Wellcome Library and
the Royal Pharmaceutical Society, which
list prescriptions and transactions for the
royal family and also for all the members of
foreign royalty who lived or visited England
and needed medical attention; some of
whom were not exactly speedy in paying
their bills!
In 1870 Peter Squire built new premises
for his business, as seen in this architect’s
watercolour of the enlarged and modernised
premises. The shop was on the corner
Architect’s Painting of the rebuilt
Premises in Oxford Street.
of Oxford Street and Duke Street , now
numbered 413, and the building still stands
today more or less as it was built. The land
was owned by the Grosvenor Estates and
there is correspondence between Squire
and the Estates about a very smelly meat
market on the pavement outside the shop
which Squire considered was detrimental
to his business.
There are books in the Royal Pharmaceutical
Society containing lists hand written by
Peter Squire of all the medicines which he
dispensed for Queen Victoria in the early
days of her reign. Some weeks she would
need four or five different preparations, and
most of these seem to be to do with stress,
which is quite understandable when one
considers what her life was like in those
difficult years.
The Squire family made up several
medicine chests for the Royal Family. This
is a picture of Queen Victoria’s travelling
medicine chest which is now at Osborne
House on the Isle of Wight. Squire and
Sons would have commissioned the case
and the bottles, and filled them with their
own medicines and herbal preparations.
There are two more chests in the Thackray
Museum in Leeds, one of which was made
for the Prince Consort and contains arsenic
which, when the chest was acquired by
the museum, led to some speculation from
the press about Prince Albert’s death. The
other was probably made for GeorgeVth’s
visit to the Delhi Durbar in 1911, since it
is filled with medicines suitable for a hot
Indian climate and the bottles have glass
stoppers covered in chamois leather. The
pill boxes are made of ivory and lined
with silk. It is altogether a very beautiful
chest. My family also have a small chest
made for the Queen, although it may never
have actually been used by her but it is,
however, made from wood from the farm
which Peter Squire owned near St. Neots in
Bedfordshire. A detailed description of this
chest and its contents still exists in the Royal
Pharmaceutical Society. The farm, Basmead
Manor was bought by Peter Squire in order
for him to grow his herbs in great quantities
for his pharmacy business. The land is still
farmed by the Squire family to this day.
Peter Squire’s achievements were numerous.
Apart from his extensive involvement
with the Pharmaceutical Society and his
role as an examiner for decades, he was
a founder member of the Royal College
of Chemistry and of the Royal Botanic
Gardens in Regent Park, and a member of
the Linnaenan Society. In 1860 he spoke
at the International Congress under the
presidency of Prince Albert, which was
instrumental in arranging that the metric
system should be used in international
communications. He was a man of many
parts and was involved in such diverse
18 Anaesthesia News January 2010 Issue 270
Handwritten Prescriptions for Queen Victoria.
research as resuscitation techniques and
experiments on blood with a view to
establishing the sources of animal heat and
the way in which carbonic acid was formed
and got rid of by the lungs in respiration.
One of his more bizarre experiments was in
removing deep coloured stains from “four
fine medallions” of Carrara marble, found in
Windsor Park, without injuring their texture.
This had been thought to have been an
impossibility. Nevertheless this experiment
helped Alexander Naysmith in his research
into the structure of teeth which he carried
out after first injecting a solution of iron and
following that with a solution of ferrocyanide
of potassium!
Peter Squire died on 6th April 1884, in his
86th year. Most unusually, since he was
not medically qualified, the British Medical
Journal carried a laudatory editorial notice.
His third son, Peter Wyatt Squire, my
grandfather, carried on the business when
his father retired, and was knighted in 1918
for services to the Royal Family.
Anaesthesia News January 2010 Issue 270
I am grateful to the History of Anaesthesia
Society for inviting me to speak at its meeting
in Bath in May 2009. A full account of the talk
will be found in the Society’s Proceedings.
(Reference: Douglas, D. Peter Squire, an
eminent Victorian pharmacist. Proceedings
of the History of Anaesthesia Society 2009;
41: 36-46.)
Diana Douglas
The Royal Medicine Chest.
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20 Anaesthesia News January 2010 Issue 270
Particles
Particle
Eligibility for organ donation: a medicolegal perspective on defining and
determining death. Downie J, Kutcher M, Rajotte C, Shea A; Can J Anesth
(2009) 56: 851 – 863
Non heart beating organ donation (NHBD) is not a new phenomenon, but
for the last 30 years or so, the majority of transplanted organs have been
obtained from brain stem dead, or heart beating, donors. There has been a
reduction in the number of these for various reasons over the years, and hence
a resurgence of interest in NHBD. A major problem with this, however, is the
duration of the ‘warm ischaemic time’ which must be kept to a minimum if
the transplanted organs are to function.
This lengthy article is written from a medicolegal perspective and suggests that
due to the lack of a clear definition of death in Canadian law, doctors may risk
facing murder charges if a court finds that organ procurement was the cause
of death. As a result, the diagnosis of death may be delayed, just to be on the
safe side, thus prolonging the warm ischaemic time and rendering the organs
useless. The article also questions the 5 minute interval which is recommended
on both sides of the pond between cessation of cardiorespiratory function and
declaration of death, stating that it is well recognised that autoresuscitation
can occur after more than 5 minutes of asystole. The author goes on to suggest
a detailed definition of death which she suggests will protect the doctor and
reassure the public.
The editorial accompanying this article is somewhat sceptical about all of
this, the crux of the matter being of course, the patient population. The death
of the donor patient is inevitable – many will have suffered catastrophic
intracerebral haemorrhage - although brain stem death criteria are not
fulfilled. The decision to withdraw treatment will have already been made,
prior to consideration being given to organ donation. In this country, such
patients will fall into Category 3 of British Transplantation Service guideline.
As for the 5 minute interval, it is recommended that the patient is examined
5 minutes after cardiorespiratory arrest. If there is any return of cardiac or
respiratory function within that time, the patient should be observed for a
further 5 minutes. The family may then spend a further short time with their
relative prior to transfer to theatre. It would seem unlikely, therefore, that
doctors would find themselves in the dock, despite these legal machinations.
References
Baker A. A closer look at organ donation after cardiocirculatory death in Canada;
Can J Anesth (2009) 56: 789 – 792.
Ridley S et al. UK guidance for non heart beating donation: British Journal of
Anaesthesia 95(5): 592 – 5 (2005).
British Transplantation Society. Guidelines relating to solid organ transplants from
non heart beating donors.
Ultrasound imaging of the airway. Arun Prasad, Mandeep Singh, Vincent W
Chan; Can J Anesth (2009) 56: 868-870.
On a lighter note, a debate has started in the correspondence section about
the relative benefits of transcutaneous versus sublingual ultrasound (the mere
thought of which stimulates my gag reflex) for the imaging of airway structures
and possible prediction of difficult intubation. Is there no end to the potential
uses of the ultrasound probe?
Fiona McHardy
Anaesthesia News January 2010 Issue 270
Particle
Comparison of routine and on-demand prescription of
chest radiographs in mechanically ventilated adults: a
multicentre, cluster-randomised, two-period crossover
study. Hejblum G et al. The Lancet 2009; 374: 1687-93
Should patients who are ventilated in ICU have a routine
daily chest X-ray? This question was answered in a recent
study published in The Lancet. Twenty-one ICU's from 18
hospitals in France participated, each hospital acting as
their own control in a cross over design. Patients were
randomised in groups of 20 to receive either a routine
daily CXR or a CXR only if indicated after examination
on the morning round. The ICU then changed to the
alternate strategy for the next 20 patients. 424 patients
were recruited to the routine strategy, 425 to the ‘ondemand’ arm. The mean number of daily CXRs in the
routine arm was 1.09, in the on-demand arm 0.75, a 35%
reduction in CXRs in the on-demand group. There was no
increase in complications, out of hours X-rays or length
of stay in the on-demand group. So the answer is no,
spare the radiation exposure and cost, adult patients who
are ventilated in the ICU need only have a CXR when
indicated by daily clinical examination.
Wallace JE et al. Physician wellness: a missing quality
indicator. The Lancet 2009; 374: 1714-21
Look after your health! So says a review of physician
wellness in The Lancet. Physicians around the world
are adversely affected by stress and fatigue; they are at
increased risk of burnout, needlestick injuries and motor
vehicle accidents. They work in an emotionally charged
atmosphere and need to process large amounts of
complex information on a regular basis. Additional stress
comes from conflict between needs of patients and the
demands of healthcare organizations, and limitation of
individual physician autonomy by evidence-based quality
interventions. Cardiovascular mortality in physicians
is higher than average, about 8-12% of all practicing
physicians are expected to develop a substance-abuse
disorder at some stage in their career, and suicide rates
are higher than in the general population.
Unfortunately, physicians are often careless about their
own health needs; they do not seek help readily, they
often self-prescribe, and rely on denial and avoidance as
coping strategies. Women doctors are particularly at risk.
A physician who is unwell has a negative impact on the
healthcare system by reducing efficiency, the quality of
patient care and patient safety.
The answer - awareness of the problem at personal and
organizational level, assessment of 'physician wellness'
as a quality indicator in healthcare systems, and a shift
in our attitudes to our health and the health of our
colleagues.
Isabeau Walker
21 How is your
colleague today?
An article from the AAGBI’s Welfare Committee
Anaesthetists are typically talented, hard
working and high achievers. We make
difficult clinical decisions under pressure,
undertake a series of professional exams and
work on our CVs to compete for positions
in an increasingly difficult job market. This
all occurs at a time of our lives when we are
forming long-term relationships, moving
house or starting families. As the years
pass, we find ourselves with increased
clinical responsibility, with management,
academic and training commitments,
competing for clinical excellence awards
or private practice, often with significant
financial pressures from growing families
– the majority of us seem to thrive, but for
some, this is mix of life stressors may lead
to constant worry and anxiety.
With the break-up of team structures and
departments getting larger, our current
working environment may make these
normal life stressors more difficult to
cope with. For consultants, management
responsibilities may isolate them from
the rest of their colleagues. For trainees,
the new shift systems have weakened
traditional networks of support; the mess
no longer exists and trainees may drive long
distances between base hospitals after oncall. Department meetings are increasingly
poorly attended and it is difficult to get to
know colleagues who head off before or
after their shifts like ships passing in the
night. The current career challenges and
lack of job security are going to make the
situation worse.
Anaesthesia
safety
has
improved
immeasurably over the last few decades,
but we still work in a high-risk profession
where human error is the leading cause
of adverse incidents. A fertile imagination
about what might go wrong often keeps
us safe, but for some this may add to the
stress of the job and make it difficult to
manage day-to-day work. We know we
will all make mistakes at some time during
our career, but we are more likely to do
so when we are tired, unwell or distracted
by outside events; fortunately the effects
are usually insignificant, but they may be
catastrophic.
We are meant to exist in a fair blame
culture, encouraged to discuss our failures
openly so that others can learn from them.
However, we also live in a culture that is
increasingly intolerant of anything other
than perfection. When I made a significant
drug error as an SHO I was taken to one
side by a consultant – we discussed it, he
told me of mistakes he had made in his
career, and he supported me through the
next few weeks. Recently, doctors who
have made errors have been suspended
pending investigation, escorted off the
premises, and even charged with a criminal
offence, often with much interest from the
Press. Most return to work, possibly to
undergo a period of supervised retraining;
it is important to investigate adverse events
but it also is important to recognise the
huge pressure these events place on our
doctors. Death due to anaesthesia is rare,
roughly 1 in 200,000 anaesthetics, once in
every 200 years of the average clinician’s
practice. No wonder, when a death does
occur, it has a devastating effect on the
anaesthetist involved, and an anaesthetic
catastrophe may become an intolerable
burden (1).
Discuss “doctors in difficulty” with a
psychologist and they will point out that
doctors are not good at handling stress –
they are frequently tired, live on a poor
diet and snatched meals, and often relax
by turning to alcohol, and worryingly these
days, concoctions of drugs as well. In a
few, the use of drugs or alcohol may be
identified, but in the stressed doctor using
them as a release, I suspect not. Highly
self-critical individuals may be particularly
vulnerable; combine this with poor team
support, chronic lack of sleep and pressure
from the workplace, and you have a potent
mix for depressive illness. High levels of
stress and depression are well described in
doctors (2).
How good are we at identifying or
supporting our colleagues who are
having problems? We are very poor at
recognising the doctor in distress and
in my experience, when an anaesthetist
experiences difficulties, and seeks medical
help or requests reduced hours, they often
feel that they are placing an additional
burden on the department. Conversely,
when a colleague is in trouble, apart from
a sympathetic ear, it is not obvious how to
support them - the high achiever may be
reluctant to admit to failings and to consult
their GP, and referral to occupational
References
1.AAGBI Catastrophes in Anaesthetic
Practice 2005. www.aagbi.org
health feels like a disciplinary procedure.
Sadly, anaesthetists are at a higher risk of
suicide than other professions, and many of
us will know of anaesthetic colleagues who
have taken this tragic path, and will have
spent many hours wondering if we could
have changed the outcome.
Employment law protects the confidentiality
of the patient, so if a trainee is unwell,
occupational
health
departments,
anaesthetic departments and Schools of
Anaesthesia are not allowed to divulge
this information, and this is as it should be.
Anaesthetists who have conditions such
as diabetes are usually quick to disclose
this, especially if they think that they are
at risk of ‘hypos’. If an anaesthetist suffers
from an illness such as depression, the
situation is much more difficult. Society
attaches a stigma to mental illness, and the
medical profession is no better at dealing
with this than any other branch of society.
Doctors have never felt comfortable in
disclosing health problems as they fear the
consequences to their career - but this is
at great risk to them, should their illness
progress. Maybe we should also recognise
that there is another patient involved – the
one that the doctor who is unwell may be
called upon to care for whilst on duty?
We need to look out for our colleagues
who may be in difficulty and to encourage
them to seek support so that we may be in
a better position to help them, and also to
protect their patients.
So what are the solutions? We must
recognise the importance of supporting
our colleagues, good leadership and team
working (3). Work colleagues may be the
only friends some have, particularly at
difficult times of their lives. Listen to the
secretaries and sound out the ODPs; ensure
Anaesthesia News January 2010 Issue 270
that concerns are heard and that members
of staff can approach a couple of named
consultants if they have any worries.
For the trainees, it is important to recognise
the difference between mentorship and
educational supervision or appraisal; the
trainee who is concerned about their career
progression may not come forward with
their problems to an educational supervisor.
Mentoring is a specific skill, a few may
have a natural ability in this area, but the
majority will need specific training.
We must all be registered with a GP and
we should encourage those in difficulty to
consult their GP or the one of the many
support agencies that are available through
the Deaneries, the BMA Doctors for
Doctors Scheme and the resources listed
below. The AAGBI Welfare Resource Pack
was published last year and also contains
much useful information – it is available on
the AAGBI website (4).
We need to be open, proactive and
encourage discussion. Dealing with stress
should become part of the vocabulary of the
workplace and sources of help and advice
should be advertised on departmental
notice boards. Illness may not be obvious;
a dishevelled appearance or strange habits
may be the presenting signs, and may be
misinterpreted as lack of self-discipline.
Social isolation, the ‘odd’ character,
personal conflict, the individual who is
drinking to excess, who seems under the
weather, or who has had a clinical mishap
- we need to look after them all. Take time
out to listen - have a low threshold for
saying ‘how’s things?’ This is our duty as
doctors, both to our colleagues and to the
patients that they care for (5).
Isabeau Walker
[email protected]
2.Firth-Cozens J. Doctors, their
wellbeing, and their stress. BMJ
2003;326:670-671
3.Firth-Cozens J, Cording H. What
matters more in patient care? Giving
doctors shorter hours of work or a
good night’s sleep? Qual Saf Health
Care 2004; 13:165-166
4.AAGBI Welfare Resource Pack 2008.
www.aagbi.org/memberswellbeing.htm
5.The General Medical Council. Good
Medical Practice 2006
www.gmc-uk.org
Useful resources (further details of support
offered available on the AAGBI website)
1. The BMA Doctors for Doctors Scheme
www.bma.org.uk/doctorsfordoctors
Tel: 0845 920 0169
2. The Sick Doctors Trust.
www.sick-doctors-trust.co.uk
Tel: 0870 4445163
3. The British Doctors and Dentists Group Tel: (North of England) 07976 717 211;
(South of England) 07711 197 850,
or via the Sick Doctors Trust helpline:
0870 444 5163
4. BMJ Medical Careers Information
www.bmjcareersadvicezone.
synergynewmedia.co.uk
5. Health Professionals Support Group Tel: 01327 262 823
6. Alcoholics Anonymous
www.alcoholics-anonymous.org.uk
Tel: 0845 769 7555
7. Narcotics Anonymous
www.ukna.org
23 A Salutary
lesson
On July 15th 2008 my concentration lapsed
for 2 seconds and as a result I was infected
with hepatitis C. An unpleasant year and a
half later I still do not know if I am cured.
I was anaesthetising a patient in day surgery
for a minor procedure. The patient was an
IV drug user, known to be hep C positive,
with no easy veins so we agreed on a gas
induction. This proceeded smoothly and
while the anaesthetic assistant held the face
mask on, I went round to insert a cannula.
When the cannula was in the vein, instead
of disposing of the needle straight into
the sharps bin which I had left just out of
reach, I held the needle in my right hand
and blocked the tip of the cannula with
my left hand to prevent bleeding while I
put the bung on the end of the cannula.
During the course of this I managed to stab
my left index finger through my glove. I did
the usual first aid measures of encouraging
bleeding and washing. The bleeding
stopped very quickly so it seemed to be a
relatively superficial injury.
24 Once the patient was awake, she was
approached and was very happy to have
blood taken to check her HIV and hep
B status (both negative) and hep C. She
was PCR positive so she was potentially
infectious. On the basis of her risk
assessment form it was decided I did not
need HIV prophylaxis and occupational
health took a blood sample for storage.
5 weeks later I had a further sample taken.
I had felt fine during this time and even
looking back later I could not say I had
any symptoms, so when I was called back
urgently 2 days later to be informed that I
was now infected by hepatitis C it was an
unpleasant surprise. My first sample was
tested and was negative. I had contracted
the same hepatitis C genotype as the source
patient so there was little doubt that the
needle stick was the source of the infection.
My transaminases were moderately raised
so I did have mild acute hepatitis.
I was then referred to the gastroenterologists
at Glasgow Royal Infirmary and was started
on Interferon and ribavirin. Interferon is a
once weekly subcutaneous injection which
I felt I had to give myself to avoid the risk
of needle stick injury to anyone else. The
first injection I gave under the watchful eye
of the specialist nurse who, quite correctly,
wanted to check that her patient (even
a consultant anaesthetist) could give an
injection correctly. Ribavirin is in oral form
so easy to take. The consultant felt that in
view of the poor evidence for treatment of
acute, as opposed to chronic, hepatitis C
I should probably aim for a full 48 week
course but he was very open that this was
his gut feeling (is this grade G evidence?)
and left the decision to me. I did get to the
end of the 48 weeks but it was not pleasant.
Before this all started I was climbing hills
regularly and cycling to work. By the end of
it I had to be careful climbing one flight of
stairs at home or I became short of breath. I
had to keep reminding myself that this was
still better than quite a lot of my patients. I
had very little energy and less stamina. My
brain felt woolly and I was sleeping much
more than usual. My neutrophil count fell
to 0.9 at one stage. My skin was dry and
itchy but a visit to a dermatologist sorted
this. I had frequent small nose bleeds and
my sinuses felt stuffed up all the time. The
first time I had a nose bleed I took it very
seriously and boiled up my hep C infected
handkerchief, but I soon got bored with this
and resorted to normal high temperature
washing in the machine. At my worst I
had 6 weeks completely off work when I
developed an URTI, presumably viral, on
top of everything else and it was another
5 months before I was working full time
again. Even then I was only really able to
manage with a lot of assistance from the
trainees where I provided the experience
and they did most of the work. I think they
were still learning at the same time.
Anaesthesia News January 2010 Issue 270
There were lighter moments. The hospital pharmacy provided a
standard pack each month containing interferon, ribavirin and
paracetamol (for the side effects). The patient information leaflet
highlights particularly that interferon can cause depression and
suicidal thoughts. So I was given a drug, Interferon, which might
make me suicidal and another drug, paracetamol, to do it with. I
am glad that was not one off the side effects I had.
The first day I had the interferon I had been warned by all and
sundry that I would probably get a bout of flu shortly after, so
I sat down for the evening waiting for this to happen. I started
to feel cold and thought “here we go” and put on a sweater.
However I was just cold and nothing more happened. I was quite
disappointed in a way; I had been looking forward to day off
work the next day. Talking to a friend who has been on interferon
for MS for 5 years and experiences a bout of ‘flu’ every week, I
realise that actually I was very fortunate. I regularly met people
who were so much worse off than me - a friend who is in a
wheelchair for life after a spinal injury, a number of friends who
are on long term chemotherapy. They have a lifetime of sideeffects to bear whereas I could at least tell to the day when my
treatment would end.
It is now 3 months since I finished the treatment and I am glad to
say that I am now back to my usual cheeky self and all the side
effects have gone. I still don’t know if the hepatitis C is cured; that
depends on me having no detectable virus at 6 months which is
in February.
I cannot finish without expressing my thanks to many people for
helping me to get through this. Dr Forrest and Sister Neilson at
GRI went out of their way to help. All my consultant colleagues
and the trainees and secretary (Susan) at Stobhill anaesthetic
department helped to keep me going. The nurses and anaesthetic
assistants at Stobhill and Gartnavel General Hospitals were all
very supportive. I decided at the beginning there was no point
in trying to keep my illness confidential and this proved to be a
good decision as the support I got was amazing. Friends at church
supported me and my wife has put up with a lot of moaning over
the last year with a great deal of patience. Lastly my Christian
faith has helped to give me the strength to get through this.
My hope in writing this article is that somewhere, someone will
realise needle stick injury is a real risk and as a result will take
more care, thus avoiding getting into this situation. Also my
story confirms the necessity of following the rules if you do get a
potentially infectious contamination of any sort. I would not have
known I had a problem without the correct blood samples being
tested, thus allowing prompt treatment of an acute infection,
which probably has a better prognosis than finding out later
when it has become chronic.
Please, be careful with sharp objects. They can harm you as well
as the patient.
Angus McKee, Consultant Anaesthetist, Glasgow
The AAGBI is keen to hear from other anaesthetists who have
experienced difficulties following needlestick injuries. Please
contact us at [email protected], marking the e mail in the
subject line for the attention of Dr Andrew Hartle.
Anaesthesia News January 2010 Issue 270
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Glenfield Hospital, Leicester
Topics to include
Cadaver session
• This session will include demonstrations on cadaver pro-sections
Lectures and Demonstrations
• Basics of ultrasound
• Peripheral nerve blocks
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Registration fee: £350 inc. Lunch and Refreshments
Course Director: Dr Atul Gaur, Consultant Anaesthetist
Assistant Course Directors - Dr Pascal Boddy and Dr Praveen Ganty
Contact: Sam Thurlow, Conference Manager
Tel: 0116 2502305 Email [email protected]
25 your
Letters
Engineering safety into regional
anaesthesia: A plea for balance
Dear Dr Bythell
First, the topic is safety in regional anaesthesia, but why is there no
representative among the group from the British section of the European
Society of Regional Anaesthesia, surely an organisation with relevant
expertise and a major interest?
Professor Rosen and Mr Kirby are to be congratulated on their most
interesting and valuable article about the genesis and development
of Patient Controlled Analgesia (Anaesthesia News, October 2009);
but members of the History of Anaesthesia Society know that the
concept of PCA dates back not to 1968 but to 1847. At a meeting
of the Pharmaceutical Society on April 14th of that year, William
Hooper, pharmacist, medical instrument manufacturer, and etheriser,
described the modification he had made to his ether inhaler at the
request of the dentist James Robinson, so that oxygen could be
administered during an anaesthetic if required. He continued, that his
personal experience and observation of patients had brought him to
believe that full etherization was not necessary for the relief of pain.
Then followed this remarkable statement: ' I look on this fact as of
the greatest importance, and which will cause ether to be a greater
blessing to mankind that we originally contemplated - the idea of
losing the mind having been a great impediment to its use. The five
senses appear to be peculiarly independent of each other, as far as the
effect of ether is concerned, inasmuch as that of smelling is the first we
are deprived of, then that of taste, followed by that of feeling, whilst
the sight and hearing remain, and the mind of the patient is perfectly
quiescent. At this stage the operation should be commenced by the
patient's direction. I quite expect the day will arrive when patients will
conduct the inhalation themselves ...' (By 'losing the mind' Hooper
meant losing consciousness, fear of which was putting some patients
off general anaesthesia).
A full account of Hooper's contribution to the early development of
inhalational anaesthesia, and his later career in the manufacture and
laying of submarine telegraphy cables, will be found in the Proceedings
of the HAS, the whole run of which is now freely available on-line
from the Society's web site at www.histansoc.org.uk
David Zuck,
Past President, HAS.
References:
Inhalation of oxygen for resuscitating etherised patients. Pharmaceutical
Journal 1846-1847; 6: 508-509.
Zuck, D. William Hooper (1818-1878) and the early weeks of
anaesthesia in England. Proceedings of the History of Anaesthesia
Society 2004; 34:48-60.
I readily appreciate that, in writing on this topic from the sunny upland of
retirement, I run the risk of being dismissed as supporting the ‘dinosaur’,
head in the sand, position, but I would like to comment on a number of
aspects of the article by Hartle and colleagues in your November 2009
edition:
Second, they state that the Luer connector has been “almost universal since
the 19th Century”, but this is not so. When I was a medical student in the
1960s two different syringe/needle connector tapers were readily available
(Luer and Record), and this led to occasional problems when it was found
that the syringe would not fit the needle, the latter sometimes already in
the patient. Adopting Luer connectors as the universal standard abolished
such problems and was an early example of an engineering solution to a
clinical problem. However, it is almost inevitable that problems will recur if
syringes and needles with a different taper system appear in the anaesthetic
room because existing equipment will still have to be available for other
injection routes. Some kind of ‘locking’ component to the connector might
help, but would, again almost inevitably, make the equipment for neuraxial
techniques more cumbersome.
Third, there is very much an attitude that a change is to be imposed (“THIS
IS GOING TO HAPPEN”), something which is common to all settings in
which the topic is discussed. The NPSA is being very dogmatic, apparently
having decided that the (only) solution is a technical one. Of course a huge
amount of safety in anaesthesia has been achieved through engineering, but
such engineering is backed up the requirement that only one system is in
use (e.g. pipeline and cylinder connectors).
Fourth, every discussion ignores the other major contributor to the disastrous
patient outcomes which are driving this issue: each involved a failure, by
a trained professional, to read the label. This human factor leads to other
problems in health care, but attracts nothing like the same attention. Why
not?
Having made those points I agree absolutely with the latter part of their
article: the specialty must engage with the process and make sure that the
practice of regional anaesthesia is not made a great deal more difficult
because of the introduction of unsatisfactory equipment, especially given
that nearly all of the disasters were caused by non-anaesthetists. Simple
colour coding (yellow is the standard anatomy text colour for nerves) would
achieve much without introducing any obvious negative aspect, but I doubt
if that change would, on its own, satisfy the pressure from ‘above’ so a little
more is required. To my surprise I discovered recently that glass syringes are
still available (see www.poulten-graf.com/uploads/media/Syringes_EN_05.
pdf) with both Luer and Record connectors so why not keep it simple and
supplement colour coding by adopting the Record taper (but not the glass!)
for regional block syringes, needles and connectors?
That leaves one final question: which increasingly hard-pressed NHS budget
is going to pay for all of this!?
Tony Wildsmith
Professor Emeritus, Dundee
[email protected]
26 Anaesthesia News January 2010 Issue 270
Dear Editor
We are grateful to Professor Wildsmith for his comments on our article.
First we would like to make it clear that we agree that this ‘engineered solution’ is indeed only one part of the solution to the problem. It will not be a
panacea, and other factors such as improved drug labelling, improved drug presentation, reading the label, choosing safer drugs and some method of
pre-administration check may all be equally important. Notwithstanding this, mandating a solution that engineers a degree of safety is still a step in the
right direction.
The primary goal of publicising the forthcoming change was to alert anaesthetists to the change that will soon be upon us and it is gratifying that we
have elicited a response. Of note, we represented anaesthesia to the NPSA and have advised the committee but we do not make the decisions for them.
As such many of Prof. Wildsmith’s comments might better be addressed to the NPSA, but we will attempt to address them.
Membership of the External Reference Group was at the invitation of the NPSA, and included AAGBI, APA, OAA and RCoA, together with other medical
specialties, representatives of industry, the four home health departments and other regulatory bodies. RAGBI/ESRA-UK was not one of the specialist
groups invited by the NPSA, although we sent a copy of our article, and the latest draft guidelines to its Chairman for comment and discussion. We
also pointed out to the External Reference Group chairman that ERSA-UK might usefully be invited to future meetings. We hope there are few, if any,
anaesthetists who are not represented by at least one of our organisations.
Change is going to happen. The NPSA Safety Alert was published in late 2009, but only after a significant consultation process; the published version is
much altered by this process and reflects the active involvement of the anaesthetists on the External Reference Group. Amongst changes made during the
consultation are
• the specific inclusion of equipment for regional anaesthesia,
•inclusion of incompatible ‘spikes’ in regional anaesthesia administration sets (to ensure administration sets for regional anaesthesia cannot be
attached to bags of intravenous fluid) and
•that some time will be available to evaluate devices incorporating safer connectors before the changes are mandated. This being necessary to
minimise the risk of perverse or unintended consequences.
Guidance on several aspects of safe epidural (and regional anaesthesia) practice already exists from NPSA (including the use of yellow coloured
equipment when appropriate) [1]. The planned changes will supplement that advice and others (such as the multi-authored publication ‘Good practice
in the management of continuous epidural analgesia in the hospital setting’ [2]). The topic of wrong route error was also recently addressed in the 3rd
National Audit Project of the RCoA [3], to which Professor Wildsmith notably contributed. Yet despite all the available resources wrong route drug errors
continue to occur. That a technical solution has not been achieved almost ten years after Professor Brian Toft’s investigation into Wayne Jowett’s death
was the subject of particularly scathing comment by the House of Commons Health Select Committee in June this year [4].
Professor Wildsmith suggests engineering can achieve safety when only one system is available. We wrote that this was the ideal, and what undoubtedly
will be worked towards, but a number of factors impede this including competition law and the absence of relevant international standards. Of note
there is good evidence from previous NPSA initiatives on safer purchasing of enteral feeding tubes that improved safety can be achieved by several
different systems, although obviously not in the same hospital.
While it is unlikely that this would be a cost-neutral exercise, costs should not be excessive. The costs of just one tragedy are more than financial, and
there has been more than one tragedy. How much longer should we wait, until this latent risk is addressed head on?
REFS
1. Patient Safety Alert 21. Safer practice with epidural injections and infusions. NPSA March 2007.
2. Good practice in the management of continuous epidural analgesia in the hospital setting. www.rcoa.ac.uk/docs/Epid-Analg.pdf. Accessed Nov
2005.
3. The 3rd national audit project of the Royal College of Anaesthetists. Major complications of central neuraxial block in the United Kingdom. Report
and findings: www.rcoa.ac.uk/index.asp?PageID=717
4. Patient Safety. Sixth Report of Session 2008-09. House of Commons Health Committee HC 151-J http://www.publications.parliament.uk/pa/
cm200809/cmselect/cmhealth/151/151i.pdf
Andrew Hartle, Tony Moriarty, Mike Kinsella, Tim Cook
Dear Editor
Re: Mandatory Madness by David Rowlands
Letter to Editor, Anaesthesia News 266; 24, 2009
I am reminded of the remark attributed to Professor E A Pask of Newcastle:
“The only essential monitor is the blob of gum that attaches the anaesthetist’s index finger to the patient’s nearest accessible artery.”
This at least gives some protection from the occasional malfunction or total failure that may occur with any instrumental monitor.
Aileen K Adams, Retired consultant anaesthetist.
Anaesthesia News January 2010 Issue 270
27 SALG RECOMMENDATI ONS
Current policy and practice for Total
Intravenous Anaesthesia in both adults and
children is reviewed to ensure that:
1 When administering TIVA a non-return
valve is always used on any intravenous
fluid line
2 Sites of intravenous infusions should
be visible so they may be monitored for
disconnection, leaks or infusions into
subcutaneous tissues
3 When using equipment, it is essential that
clinical staff know its uses and limitations
4 Organisations give preference to clearly
labelled intravenous connectors and valves
Local practice should be audited and staff
encouraged to report further incidents.
rationale
Although this information refers to drug
administration during TIVA, the same applies
whenever any drug infusion is being given
through the same cannula as an IV fluid
infusion and serious complications may
occur.
1 Using a one-way valve on the intravenous
line. It is suggested that a one-way valve is
used on IV fluid port when multi-lumen IV
connectors are used.1–2
2 The site must be monitored throughout the
procedure. Some reported incidents reflect
poor vigilance of the cannula so disconnection
of the infusion or displacement of the cannula
was not noticed. In other incidents there was
incorrect use of multi-lumen and other access
equipment. Most medical pumps have alarms
to detect pressure issues. Access to the cannula
site may be difficult in operating theatre
environments, but the general consensus of
clinical advice (based on this evidence) is that
cannula sites should be visually checked at
regular intervals as a practical and simple risk
reduction. In choosing the site for infusion,
the anaesthetist should weigh up the balance
of risks and benefit.
3 Using medical equipment. As the Agency
responsible for making sure that medical
devices are safe and fit for purpose,
the Medicine and Healthcare products
Regulatory Agency (MHRA) has prepared a
booklet; ‘Devices in practice – a guide for
health and social care professionals’ Aug
2008.3 This provides a checklist process to
28 ensure that any medical equipment (e.g.
pumps and intravenous devices) being used
are systematically checked and the user
question their familiarity and competence
with the equipment before use.
4 Organisations should ensure that all oneway valves purchased are clearly labelled.
Clarity of information on packaging for
single use items varies. There are a variety of
multi-lumen/Y connectors in use for different
situations.3 Clear and informative packaging
will aid correct selection of the appropriate
system required for TIVA administration.
Background
Unintended awareness during surgery
may occur with all techniques of general
anaesthesia. When TIVA is used to maintain
anaesthesia, unintended interruption of the
continuous infusion of anaesthetic agent(s)
can lead to awareness if not detected
promptly and corrected. Maintenance of
anaesthesia during TIVA relies on continuous
infusion of intravenous anaesthetic agents.
Discontinuation of this infusion for any
reason may cause the patient to experience
a degree of awareness when consciousness
was not intended. Anaesthetists often use
multi-lumen or Y connectors to allow
infusion of different anaesthetic agents with
or without intravenous fluids to be given
through a single intravenous cannula. A nonreturn valve prevents backflow of anaesthetic
into the intravenous fluid line ensuring the
patient is receiving the drug as intended. An
anti-siphon valve offers protection against
free-flow or siphonage in pump delivered
medication lines.
One-way valve = anti-reflux valve, check
valve, non-return valve
patient may have experienced awareness
during the anaesthetic.
Data from the RLS was searched from March
2008 to 15 June 2009. 89 incidents were
found and all were reviewed.
49 were found to be relevant. Key issues
identified were as follows:
➤ Non-availability of appropriate pumps –
ten incidents; in two cases this was because
the pumps had not been charged
➤ Problems with pumps during TIVA – 11
incidents; in one case the TIVA technique
was abandoned; in eight cases the problems
were noted immediately and the pump either
changed or managed differently; in one case
it was only noted at the end of the surgery that
the pump had not delivered the appropriate
amounts of agent.
➤ Two reports were of syringes being
‘switched’ with one relating to wrong
labelling (Propofol and Remifentanil) and one
where a 1% solution was used instead of 2%.
➤ Three cases were reported where lines had
been pulled out in error and one where the
cannula had ‘tissued’.
➤ One case reported where anaesthetist was
not familiar with technique.
➤ Three cases of potential awareness were
reported but with no problems with TIVA
being identified.
➤ 18 cases reported problems with the
intravenous line:
o Three related to Y connectors.
o Three related to 3-way taps.
Further queries should be directed to:
[email protected].
➤ Other incidents include, kinking of lines,
blocking of line, luer lock leaks and other
leaks from lines, assumed fixed valves in lines
becoming disconnected.
Reported evidence
In all of the above incidents reports:
A report received into the national Reporting
and Learning System* (RLS) described an
incident whereby TIVA was administered to
a patient via a multi-lumen connecter. There
was no one-way valve in the connector
and as a consequence there was backflow
of anaesthetic agent into the limb of the
intravenous fluid line, rather than directly
into the patient’s vein. As a result of this, the
reporting anaesthetist was concerned the
➤ Five were reported where there was
possible awareness intra-operatively; and
➤ Three situations described that had the
potential for awareness.
The NPSA’s Reporting and Learning System
(RLS) was established to provide a national
database of incidents relating to patient
risks and harm. Interpretation of data from
the RLS should be undertaken with caution.
Anaesthesia News January 2010 Issue 270
As with any voluntary reporting system, the
data are subject to bias. Many incidents are
not reported, and those which are reported
may be incomplete having been reported
immediately and before the patient outcome
is known. It should also be recognised that
there is significant under-reporting and
therefore the data is likely to be an underrepresentation of actual incidents.
Examples of incidents
‘Infusion pump failed to deliver correct rate
set. Pt anaesthetised using TIVA so when pt
coughed they moved during anaesthesia,
unsure why until rate delivered examined.’
‘Patient, who was having Total Intravenous
Anaesthesia (TIVA), was found to have
a dislodged cannula at the end of the
operation, meaning not all of the anaesthetic
agent reached the patient. Patient aware.’
‘Syringe empty and refilled. Infusion
recommended but three-way tap left in
‘refilling’ position therefore infusion not
delivered to patient for ten minutes, TIVA
pump did not alarm .Patient moved during
surgery. Awareness reported post-op.’
‘Patient receiving TIVA anaesthetic. Pumps
used for 45 minutes before it was noticed
that syringes were switched in the TIVA
pump so that the propofol infusion was
infact remifentanil, and vice versa. Syringes
had been filled and inserted into pump by
(name). Patient data then added by (name)
before connecting to patient and starting
infusion.’
‘Propofol TIVA cannula tissued (no
occlusion warning from pump)patient
had paralysis on board and was distressed
at inability to communicate her state of
awareness. Extra agents given once patient
seen to move and increased BP.'
Anaesthesia News January 2010 Issue 270
National Health Service Litigation
Authority (NHSLA)
A search of the NHSLA database between
January 2003 and March 2008 revealed 43
cases using the search criteria [‘Anaesth’
and ‘aware’ or ‘awake’ or ‘woke up during’
or ‘awoke during’ or ‘total intravenous’ or ‘
TIVA’]. On review, seven were not relevant
and of the remaining 36, eight were related
to obstetric anaesthesia for caesarean section,
one to dentistry and the remainder to a range
of surgical procedures. None specifically
mentioned TIVA. A reading of the incident
descriptions, however, could not exclude the
possibility that TIVA may have been used in
some of the cases.
Medicines and Healthcare products
Regulatory Agency (MHRA)
MHRA section MDA/2007/089 states; ‘where
appropriate, consider using IV lines with oneway valves to prevent backtracking when
more than one IV line is connected through
a single access point. This can lead to underinfusion or bolus delivery of drugs.
The literature on complications associated
with TIVA
The search of existing literature has revealed
a few case-reports highlighting some of
the problems with the use of multi-lumen
connectors, and other infusion devices [46]. Articles have been written regarding the
safe use of infusion devices [1]. However,
it has not been possible to identify any
firm guidelines on how TIVA should be
administered. Furthermore, no literature was
found relating to the standardisation of the
multi-lumen connectors.
Use of anti-siphon valves is recommended
to reduce the risk of inadvertent free flow of
drugs [1] – this can occur due to gravity if
the syringe barrel or plunger is not engaged
firmly in the pump mechanism. In addition,
use of anti-reflux valves is recommended
with multi-lumen connectors – the anti-reflux
valve should be used at the port connected to
intravenous fluids. Presence of the anti-reflux
valve would prevent back flow of anaesthetic
agents, which are driven by syringe pumps
into the other ports, should a distal occlusion
occur [1].
Despite these recommendations, it is not
uncommon to find multi-lumen connectors
without any valves. Even if the valves are
present, case reports highlight problems
associated with the failure of the valves [4]
and leaks [5–6].
Correct placement diagram
This diagram shows a typical arrangement of
a multi-lumen connector including an antireflux valve for IV fluid and anti-siphon valves
for IV drugs.
REFERENCES
1 Keay S, Callander C. The safe use of infusion
devices. CEACCP 2004;4:81–85.
2 MDA/2007/089 – Intravenous (IV) infusion
lines: all brands.
3 Devices in practice – a guide for health and
social care professionals. August 2008.
4 Rutherford J. Failure of anti-reflux valve in a
Vygon PCA set. Anaesth 2004;59: 511–512.
5 Yarham S, Woodall N. Leak of TIVA from
Y-connector. Anaesth 2004;59:629.
6 Matthews AJ. A simple leak detection
device for TIVA. Anaesth 2003;58:288.
This notice is supported in principal by
the Society for Intravenous Anaesthesia
(SIVA UK) and the European Society for
Intravenous Anaesthesia (EuroSIVA).
SALG has circulated this notice using RCoA
website, AAGBI website, NPSA Signals
(pilot publication), RCoA Bulletin, AAGBI
Anaesthesia News, e-mails to all clinical
directors, college tutors and AAGBI linkmen.
29 I am writing this article from a
rather cramped and smelly train
bound for London, whilst also
preparing my presentation of a new
medical device for a major manufacturer
of anaesthetic equipment. I’m not a sales
rep, but a recent graduate of Glasgow
School of Art. My final-year project was
undertaken in collaboration with the
anaesthetists of Yorkhill Hospital, Glasgow.
We identified a basic problem; overinflation of an endotracheal tube cuff is
a common phenomenon which may be
associated with complications for patients.
The product we developed has gone on
to win numerous design, engineering and
business awards – but more importantly
seems to be popular with the anaesthetists
who saw the early designs: For Dr Graham
Bell (consultant anaesthetist, Yorkhill) and
I, that seemed a solid reason to develop
the device beyond a concept and to build
a working prototype, ready to be licensed
to a company for production. After 10
months of intense work, we are far from
finished, but this is the story to date of what
happens when Art School meets medicine
and Industry.
I left Glasgow in 2007 to work over the
summer in Hong Kong’s Industrial Design
School, where I found great satisfaction
in observing cultural differences and
designing product s specifically for elderly
patients suffering from osteoarthritis. This
was followed by a year in Norway, during
which I expanded my understanding of
30 Artistic
Licensing
How an Art School student ended up designing a new Pressure
Alert device for Cuffed Airway Devices.
sustainability
ethics
and
also received a taste of
commercial design strategies. However,
it was not until my internship in California
with Speck Design that I really saw all
of these facets combined in the field of
Medical Technology. I was inspired to
pursue this discipline into my final year of
study at Glasgow.
The project began with what is often
described by designers as ‘immersion’ into
the details surrounding a problem – which
is apt, given my lack of medical training
(I couldn’t even spell ‘ischaemia’ – let
alone know the danger of it). The following
months yielded a steep learning curve of
the basics of intubation and associated
anaesthetic practices. As a young designer,
it often difficult to learn the rules without
being over-influenced by them, to the extent
that new ideas are dismissed as illogical or
unfeasible.
Many would agree that this relative
ignorance is what can lead to a real
innovation by seeing things differently.
I was fortunate to observe surgery and
ask ‘elementary’ questions in the hope to
challenge the conventional assumptions
of the day. Thanks to the patience of the
staff at Yorkhill, I was able to build an
understanding of what they wanted – but the
hardest part is seeing what they needed. This
differentiation is at the heart of user-centred
design: We humans have a great ability for
adaptation – no matter how difficult the
task, we will overcome it, work around it,
‘make do and mend’. Furthermore once we
have mastered a particular task for ourselves
we become proud of the achievement and
almost relish watching others go through
the same efforts. When applying this to
design, it is clear that although there is
merit in perseverance, there is also a need
to step back and consider if the effort is
really worth it? Do we really need to be
‘excessively persevering’ in everything one
does? It was this ethos that underpinned the
design process: Keep it simple and easy to
use – for all user abilities.
To understand the source of the human error,
15 members of staff kindly volunteered to
partake in tests to observe what exactly was
Anaesthesia News January 2010 Issue 270
difficult about judging cuff pressure, using
a pilot balloon. This gave insight into the
idea material and geometry of the future
pilot balloon. In essence – we needed
a product to alert anyone caring for an
intubated patient that the cuff pressure had
reached a dangerous level, although it must
be said that even our ‘best’ performers were
not infallible and their performance could
clearly be improved with this device.
The ‘Alert’ functionality was brainstormed
and it was concluded that ‘beeps’ would be
irritating; manometers produced a snagging
risk; retrofitting was cumbersome and an
infection risk; blue-tooth/wireless monitors
had power and interference issues; cutoff valves were too specific and colourchanging paint was too far-out, man!
We needed a solution that was integrated
into the device as a single use pilot balloon
that gave an indication (not dictation) of a
potentially risky pressure. We also noted
that pilot balloons tend to just hang around
under bed-sheets and get tangled up – so
putting this in a tidier and more prominent
position (via the Side-Clip) seemed logical
and safer too.
Anaesthesia News January 2010 Issue 270
The ‘Pop-Up’ mechanism appears a
sound idea – it was refined through many
generations to achieve the right geometry
and feel, as shown in the images. It is a slow
process of trial and error – familiar to any
designer! In reference to our initial goal
– the simplicity seems to be appreciated
by those who have used it to date. The
next stage of development is likely to be
undertaken by a manufacturer and will
involve refinement of the mould technology
and will ensure that it is clinically safe.
The business angle is not something that is
often emphasised in academia, but there are
close links with NESTA (a technology startup company) who offer guidance on how
to undertake market research, present data,
write business plans, project finances and
prepare to pitch to companies. The training
is invaluable, but the £10,000 business
start-up is also essential for professional
development and of course patenting the
idea itself. This was a particularly enjoyable
phase of the project – at times it was
overwhelming to see a glimpse of how
much more work is required to take even a
good idea and make it a realistic proposal,
never mind how much work after that to get
it to market.
Since my first days at University I have
had the good fortune to work with a huge
range of people to create products that are
worthwhile and where the result speaks
for itself: It is hugely satisfying to work
through countless failed solutions to distil
the optimal concept. Furthermore there
is the satisfaction of having listened to
dozens of user’s needs - from the essential
to the seemingly trivial - and interwoven
these into a solution that feels tailormade for them, but delivers beyond their
expectations.
However, the success of this project is
due to the contribution of many others –
designers, engineers, technicians, and
of course friends and family. There have
been many favours along the way for
which I am most grateful and I hope it has
been mutually exciting to collaborate on
something that is new and worthwhile. The
Arc Product Design team, small as it is, will
be touring the country, visiting prospective
companies in the hope of bringing the
Glasgow Pressure Alert to market.
Jude Pullen
31 y
t
e
f
a
S
t
n
Equipme
Notice
rrespondent
From our co
ine
Scoop O’Lam
Dr Ivan O’Brain, the NHS Safety Czar, has recently issues a Safety
Hazard notice to all NHS Trusts following the discovery of a secret
action plan for staff involved with damaging equipment.
“Staff cannot follow this action plan as it would be dangerous and
could cause problems for our patients” exclaimed a furious Ivan.
“We need any equipment that is broken to be reported immediately
so that we can put the situation right”.
Dr O’Brain has convened an immediate working group with experts
from industry and the NHS, to draw up a genuine “damaged
equipment action plan and checklist”. The NHS hope to see this in
place by 2014, provided the process is not disrupted by the Swine
Flu workload.
Anaesthesia News was fortunate to be able to obtain a copy of the
elicit action plan which is presented to ensure readers know that it is
not genuine. Rumours circulating that several members of the AAGBI
thought the action plan looked quite practical are completely false.