Search

Welcome to the April 2023 anaesthetist in training (AiT) edition of the Bulletin. As I write this, NHS doctors in training are imminently embarking on industrial action following an unequivocal ballot; unprecedented since 2016. Whatever your opinion on industrial action, the common thread is that these are intense times for those of us within the NHS. It is often these times, however uncertain and unsettling, that further solidarity for the betterment of care for patients and each other. The conversations I have had with anaesthetists across the UK bring forth this sentiment; we are in this together.

‘Adapting to change’ is the theme for this edition of the Bulletin. No better place to start than to introduce our new anaesthetist in training members of the Bulletin’s editorial board, Dr Lauren Elliott and Dr Nipun Agarwal, who have been an absolute joy to work with for this issue.

Authors:

• Dr Gemma Summons, Perioperative Medicine Fellow/SpR Anaesthetics, University College London Hospital
• Professor Tarannum Rampal, Consultant Anaesthetist and Lead, Perioperative Prehabilitation Unit, Princess Royal University Hospital (PRUH), King’s College London NHS Foundation Trust
• Ms Shana Hall, Specialist Physiotherapist, Cancer Rehabilitation, Princess Royal University Hospital (PRUH), King’s College London NHS Foundation Trust

John is a retired white British man, who drove to clinic and has a good rapport with his doctor. He feels motivated by the exercise classes at his private gym and tracks his progress using prehab apps and his FitBit. His wife (who does all the cooking) finds the dietary advice helpful because it gives healthy alternatives for traditional British food that they eat.

Winnie is from Barbados. She had to get the bus to clinic (and now she’s late for her shift). She’s offered exercise sessions, if they can fit around work, but the bus links are awful. The dietary information is unhelpful as she can’t get the ingredients from Brixton Market and her budget is tight. She doesn’t have the time to learn lots of new recipes.

As the season of spring gently unfolds while I write this here in London, there is a sense of renewed fervour for times to come. I have the pleasure of celebrating two ‘New Years’ annually, a uniqueness which I have always appreciated for one reason – however the Gregorian new year starts, I have another to bring optimism, since once again find myself looking ahead to Tamil New Year on 14 April – Puthandu Vazthukal to all those celebrating this.

New chapters of professional life transitioning from one season to another is the subject of an article by Dr Lauren Elliott and Dr Nipun Agarwal, who eloquently detail the range of experiences that come towards the end of training – the consideration of location, colleagues and job plans blends excitement with an understandable anxiety. For those wanting to understand more about navigating this juncture in a career in anaesthesia, I wholeheartedly recommend the College’s Preparing for CCT and beyond podcast series as a supplement to the piece in this edition of the Bulletin.

Approximately two million people attend the Hajj pilgrimage in Saudi Arabia every year. The journey is obligatory for those who have the physical and financial means, once in a lifetime. The pilgrimage lasts five days and is based in and around the city of Makkah.

The climate is one of a hot desert with day temperatures regularly exceeding 45ºC (113ºF) during the summer. This is made all the tougher with average relative humidity reaching 33%. Pilgrims travel from around the world. They include all ages and backgrounds, and individuals with complex medical conditions.

I was lucky enough to be given the opportunity to attend this year. My journey began like any other pilgrim’s, initially solely focusing on the religious events ahead. The first few days went as planned, with challenging walks, but nothing more than I had physically and mentally prepared for. Things however changed as the days went on and as the weather deteriorated. I cannot emphasise enough the combined effects of extreme heat and huge crowds. Despite an umbrella to keep one out of direct sunlight and copious amounts of water consumption, heat exhaustion is relatively common. I was also soon to learn that heat stroke was becoming dangerously frequent during my time there. As anaesthetists, our challenge is often to keep patients undergoing major surgery warm. As I entered my hotel lobby, my job was to do the opposite and help cool my fellow pilgrims down!

Over the last five years, regional anaesthesia in clinical practice has been on a trajectory – growing in importance and prominence in the anaesthesia community. Efforts by the 8^th National Audit Project and the BJA have helped further increase the publicity of regional anaesthesia. While we can all see the merit in this growth, is this the time for a more formalised place in the training programme for regional anaesthesia?

As with any practical procedure, there are many ways to learn, but it is practically impossible to become competent or excellent at regional anaesthesia without regular hands-on patient experience. Recent UK-wide surveys revealed a large proportion of Stage 3 trainees unable to perform all Plan A blocks independently, and found that only a small proportion of consultants and specialists felt confident teaching all these blocks to trainees. It has also been seen that the higher the number of blocks trainees perform, the more confident they feel. Currently, ‘getting numbers’ and achieving the required competence, feels challenging.

We acknowledge that there is an inevitable period of adjustment following curriculum transition, but many of our trainee colleagues still feel their current skills in this area are inadequate for their level of training. To prevent this becoming a perpetual challenge this issue must be proactively addressed across all stages of training.

Authors:

• Dr Andrew Kane, NAP7 Fellow, ST7 in anaesthesia, South Tees NHS Trust
• Professor Tim Cook, RCoA Director of the National Audit Projects, Consultant in Anaesthetics and Intensive Care Medicine, Royal United Hospitals, Bath
• Dr Jas Soar, NAP7 Clinical Lead, Consultant in Anaesthetics and Intensive Care Medicine, Southmead Hospital, Bristol

After a delay due to Covid, we are pleased to say we are in the final stages of NAP7. The baseline and activity surveys are complete and being prepared for publication. The NAP7 panel is working hard to digest all possible learning from the case registry. Here we provide a brief update, with the full report coming in late 2023. We are hugely appreciative of the contribution of all anaesthetists.

The largest NAP yet

Perioperative cardiac arrest has seen the most cases reported of any NAP. The large number of cases reported is an indication of the ability of UK anaesthesia to successfully come together and focus on an important patient-focused issue, and also shows the incidence of perioperative cardiac arrest is greater than events forming the focus of previous NAPs.

Authors:

• Dr Natalie Silvey, ST7 Anaesthetics, London School of Anaesthesia; DAS Trainee Representative
• Dr Moon-Moon Majumdar, ST5 Anaesthetics, London School of Anaesthesia; DAS Trainee Representative
• Dr Abhijoy Chakladar, Consultant Anaesthetist, University Hospitals Sussex NHS Foundation Trust; DAS Surveys Co-ordinator
• Dr Barry McGuire, Consultant Anaesthetist, Ninewells Hospital and Medical School, Dundee; DAS Immediate Past President

‘Her death was wholly avoidable and was contributed to in major part by neglect.’

This was the conclusion of the coroner examining the death of Mrs Glenda Logsdail following her death from hypoxic-ischaemic encephalopathy after an unrecognised oesophageal intubation.

Her death, like those of Sharon Rose Grierson and Peter Saint in 2016, has placed this issue at the forefront of safety strategy within the anaesthetic community. Following Glenda Logsdail’s death, the coroner issued a Regulation 28 report to prevent future deaths: several teaching aids and educational materials were released in the subsequent six months. We wanted to establish what was being done in individual departments to prevent unrecognised oesophageal intubation.

‘How many?’, ‘Yes, four children’. I usually feel a bit like a freak of nature at this point in the conversation. Cue jokes about anaesthetists hating odd numbers or the efficiency of having children in pairs.

So I’m a medic turned anaesthetist turned dual ICM trainee with two sets of twins; I toddled off to medical school more than 20 years ago and have been ‘in training’ ever since. It is hard, but life is hard and this isn’t about how I’ve overcome immense odds and struggled through, but about how children and the scenic career route have made everything better.

Author: Dr Stuart Connal, Fellow in Perioperative Medicine, North Central London Deanery

Perioperative Journal Watch is written by TRIPOM (trainees with an interest in perioperative medicine – tripom.org) and is a brief distillation of recent important papers and articles on perioperative medicine from across the spectrum of medical publications.