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Welcome to the summer issue of the Bulletin! As I write this, sunlight is streaming in through my window as an indication that British Summertime has finally arrived in more ways than just the clocks going forward. This issue of the Bulletin will arrive on your preferred digital platform as we come to the close of the term of a distinctly inspirational RCoA president, Dr Fiona Donald. While Dr Donald’s nature is one of immense humility, it is worth reflecting on the unique equanimity one needs as a leader at this time within the NHS (including our specialty) when facing immense challenges, turbulence and uncertainty.

Welcome to October's issue of the Bulletin. As I write this piece, we may be struggling to see the light at the end of the tunnel for UK healthcare; an unprecedented state of industrial action by doctors at all stages of their careers, the recent release of an open report on sexual misconduct in healthcare and, as clinicians, the challenges of ensuring high quality care for patients can be a daily struggle. The height of the pandemic may be behind us, but the disparities it has revealed will have to be addressed for years to come.

Climate change is a healthcare emergency. Carbon dioxide levels in the atmosphere have been greater than 350 parts per million (ppm) since 1988. If you’re younger than 37 years old, your whole life has been spent in carbon dioxide excess.

In collaboration, the Faculty of Intensive Care Medicine, Intensive Care Society and UK Critical Care Nursing Alliance, alongside Brighton University, are taking action.

Together, we are developing a ‘Recipe Book’ to share actions in critical care units to reduce energy use, reduce waste and improve sustainability.

In recent years, ‘mental health awareness’ and ‘wellbeing’ have been hot topics in almost all facets of life. It goes without saying that I was pleased to see this ethos entering into the mainstream. However, a recent incident while on call left me questioning whether this ethos had translated into my workplace.

In the early hours of an August morning, a cardiac arrest call came through on my bleep. I arrived to find chest compressions being performed on an 11-week-old baby. I was immediately filled with dread, anxiety, and confusion. As with many district general hospitals with limited paediatric service, the vast majority of sick children are diverted elsewhere, so I was not expecting to see a child. I remember feeling totally out of my depth. It had been a while since I’d dealt with paediatric patients, and I’d certainly never participated in a real paediatric arrest. 

Once the immediate shock subsided, I assumed the default position and took over the airway. It was at that point that I could see and feel the baby up close. I’d seen this colour in a child before, and knew this wasn’t going to end well. As I held that baby’s face, ventilating him, I became conscious of my racing thoughts: ‘Am I doing this right?’… ‘I think I’m going to cry’… ‘No one else is crying, get a grip’… ’Thank goodness the registrar is here’… ’This baby is not going to make it’…

I doubt there are many Bulletin readers who are old enough to remember the 1963 Disney film ‘The Incredible Journey’. Luath – a golden labrador, Bodger – an aging bull terrier, and Tao – a Siamese cat make a perilous journey across the Canadian wilderness to get to their home 300 miles away. As a little girl I sat in the Ritz Cinema with tears flowing because it seemed inevitable that Bodger had died in the final few miles of the journey. Of course he hadn’t. He trotted over the horizon to an ecstatic welcome from his animal and human family.

I was reminded of Bodger and his fictional achievement when I read about a dog called Pip. Last year Pip’s owner took him for a run in Leigh Woods, a beauty spot in Bristol. They became separated, and Pip’s frantic owner took to social media to get help finding him. Pip was soon spotted on the city’s security cameras. He crossed Brunel’s iconic suspension bridge, ran past the famous BBC studios in Whiteladies Road and was captured on camera running by the steps of the museum. Somehow he safely negotiated the notoriously dangerous traffic in the city centre and found his way to his front garden in Bedminster – about four miles from where he’d left his owner. In fact he got home before she did!

Mrs Shivalkar was a 78-year-old patient with debilitating co-morbidities scheduled for elective revision hip surgery at a stand-alone surgical unit without Level 2 or 3 care facilities. 

The surgical procedure was prolonged, and intraoperatively there was prolonged significant hypotension. In recovery this hypotension continued, but despite this the patient was discharged to the ward, where she sustained cardiac arrest. 

After delayed transfer to a facility with critical care, she was found to be in multiple organ failure with a profound metabolic acidosis, leading to a further cardiac arrest from which, tragically, she died.
The coroner, finding concerns regarding preoperative risk assessment and poor communication between the surgical team and anaesthetist, issued a Report to Prevent Future Deaths to the RCoA and the Royal College of Surgeons for action.

When I returned to my role as a CR&I/RCoA perioperative quality improvement programme (PQIP) fellow, I found this came with unique expectations and required planning. Hopefully by sharing what I learnt, it will help those who are returning to work after a period of leave, especially those returning to job roles that do not necessarily fit the norm.

Returning to work: general things to consider

When RTW there are key dates and tasks to consider. Table 1 details some of the things that need to be arranged and when these need to be done. There are also many resources to consult (see below ). Using these in conjunction with your hospital policy is a good starting point.

Our working lives as anaesthetists revolve around effective teamwork, communication, and empathy with the many different professions we interact with. Interprofessional education (IPE) is an increasingly familiar teaching methodology which aims to enhance and improve these collaborative abilities. 

Considering recent critical reports on the lack of teamwork and interprofessional co-operation within clinical systems, we present a review of IPE and how its increased adoption may help address these failings.

In my last update, I mentioned that the College has been addressing some financial challenges.  

We are committed through our current five-year plan to manage the College’s resources with care, and to ‘ensure the College is resourced and equipped to carry out its strategy: now and in the future’. One of our core values is being open and responsive, and in that spirit I am keen to share with you our current financial position, and what we are doing to improve it.

Author: Dr Stuart Connal, ST5, 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.