Search

Airway management is a crucial aspect of patient care, where effective and prompt actions can be life saving. The RCoA recognises the importance of continuous education and training to ensure healthcare professionals are well equipped to handle complex airway scenarios.

Multidisciplinary simulation has arisen as a valuable tool in this regard, offering an immersive and dynamic learning experience that fosters collaboration among different professionals involved in patient care.

Traditionally, training in airway management has often been siloed, with the focus on individual disciplines. However, real-life situations demand a coordinated effort from various healthcare professionals, including anaesthetists, operating department practitioners, nurses, physiotherapists, surgeons and theatre nurses. Therefore, conventional training styles may not adequately prepare individuals for the intricacies of interdisciplinary communication and cooperation.

More than one in five of the non-trainee anaesthetic workforce are SAS doctors, yet the grade is still sometimes misunderstood.

The College is keen for SAS doctors to get the recognition and support they deserve. As SAS Wellbeing lead, I started an initiative last year to spotlight the achievements of our SAS members by asking them to share their stories with us for publication on the College website and social media. Our aim was to enhance people’s understanding of the huge range of skills, experience and responsibilities of SAS doctors, to boost pride in being an SAS doctor, and to improve wellbeing.

Whenever we introduce ourselves in the team brief, we tend to get the same response: ‘Anaesthetics? As FY1s? That’s unusual!’ They are right, of course, and we feel lucky to be here! Both of us, unsurprisingly, were very nervous about starting our first jobs as doctors in August.

Fortunately, we settled in quickly thanks to being well supported by the anaesthetic consultants, SASs, anaesthetists in training, and operating department practitioners. We thought it would be a great idea to share our unique experience of starting on an anaesthetics rotation straight after medical school.

Whereas many of our FY1 friends describe endless ward rounds, discharge letters and medications, we’ve had a very hands-on first month – lots of cannulas, airway management, iGels, intubations, and even some spinals. We initially found the idea of one-to-one consultant training quite daunting, this being something we hadn’t encountered much at medical school. However, we couldn’t have been more wrong – we’ve had nothing but positive experiences with our seniors, even if we’re taught a different way to tie a knot and secure the airway by each consultant.

The National Emergency Laparotomy Audit (NELA) has been a real success story – engaging with clinical teams and feeding back high-quality comparative process and outcomes data to improve care.^1,2,3 As NELA enters its second decade, it is important to look at persisting challenges as well as successes, and consider where improvement efforts should now be concentrated. This article highlights three areas of emphasis from Year 10 (2023) of the audit.

Infection and sepsis management

Successive NELA reports have highlighted failings in this area – with many patients recorded as having sepsis at admission and/or at time of the decision to operate (DTO), but seemingly poor timeliness of care in terms of both antibiotic administration and definitive source control. Closer examination reveals potentially missed opportunities to streamline decision-making ‘upstream’ of the DTO. Year 8 data³ shows that the median time from arrival in hospital to arrival in theatre for those with sepsis at time of arrival was 15.6 hours. Fewer than a quarter of those with sepsis on arrival at hospital received antibiotics within an hour. This finding might be partially explained by an over-interpretation of the term ‘sepsis’.

At the end of January 2024, the GMC published an updated version of Good Medical Practice, the core guidance for all registered doctors. This has been accompanied by guidance on a number of other areas, including confidentiality, consent and research, and legal and regulatory proceedings, all of which can be seen on the GMC website.

The opportunity has been taken to conduct a major review of the College’s supporting information for appraisal and revalidation.

At Nottingham University Hospitals (NUH), it was felt that for our patients with cardiovascular disease, obtaining a preoperative cardiology assessment and perioperative management strategy was prolonging non-cardiac surgery waiting times. 

This was especially compounded by the surgical backlog and increased demand on preoperative services following the COVID-19 pandemic. In order to streamline the assessment process and facilitate safer surgery, a joint cardiology-anaesthesia multidisciplinary team (MDT) meeting was established.

The global problem

It is no surprise that underlying cardiovascular disease can contribute significantly to perioperative morbidity and mortality, with cardiac events being the leading cause of such.¹ Almost half of adults aged over 45 years undergoing major non-cardiac surgery have at least two cardiovascular risk factors, and conditions such as coronary heart disease, heart failure and arrhythmias put patients at increased risk of cardio- and cerebrovascular events in the immediate postoperative period.²

On 27 August 2011, The Times alerted readers to a craze originating in Spain: a drink high in alcohol was vaporised in a hand-held inhaler that contained a heater and a supply of oxygen. 

The alcohol rapidly reached the bloodstream via the lungs, quickly producing intoxication. A local newspaper reported:‘Oxy shots – the latest madness of the British in Majorca’. One of us (AD) recounted the story to an anaesthetist friend, Keith Pooley, who announced that once in his career he had actually anaesthetised a patient with ethyl alcohol vapour. He told me the full story which I later wrote up in The Times as an addendum to the oxy shots’ article. He was visiting a local cottage hospital on a weekly basis to prepare patients for minor surgery, mainly using halothane. On this occasion the induction was slow, with the patient resisting, spluttering and coughing. ‘But’ said Keith ‘I eventually got him down and he had his operation’. Recovery was atypical of that from halothane, and some detective work was called for. Keith unscrewed the vaporiser bottle and sniffed the contents – surgical spirits (typically 70–99% ethyl alcohol). It seems that the previous week he had discarded an empty 250 ml bottle of halothane. Someone else, keen on recycling, later retrieved the bottle from the bin and used it to store the surgical spirits. Unlabelled, it had wandered around the hospital until eventually finding its way back into the anaesthetics’ cupboard….

The 2021 SAS contract reform introduced a new strategic role to support the health and wellbeing of the SAS workforce, the ‘SAS Advocate’. This role provides an opportunity to challenge the status quo, and to potentially change the culture and expectations associated with being an SAS doctor.

Perhaps the most common barrier to meaningful change is culture. Individuals and organisations can both be guilty of assuming that the status quo always exists for a reason. However, there is perhaps no more dangerous justification for continuing to do something than that ‘we have always done it this way’.

I’m hoping that no one reading this has missed the launch of NAP7: perioperative cardiac arrest. The NAP7 data touched every part of anaesthesia practice – from maternity and neonates right through to the frail and older patient – so there’s something there for everyone.

But NAPs don’t stand still; NAP8 is on its way and will be looking at regional anaesthesia and neurological complications of anaesthesia. We are delighted that Professor Alan MacFarlane has been appointed to lead NAP8 – more news will be coming soon.

The work of CR&I is supported by a diverse group of clinical fellows (and this issue of the Bulletin even has a piece from a future research leader – aged 11). We couldn’t do our work without them, and they in turn are supported by their clinical workplaces – both in the NHS and the independent sector – who pay their salaries and give them the space to work with CR&I. I’m delighted that some of our fellows have given an insight into what the role is like – and the challenges of going and coming back from maternity leave.