rcoa.ac.uk@RCoANews

The PIG that flies!

Upcoming elections in Scotland and Wales

Prime time for paediatric prehabilitation

March 2021

TIME TO MAKE ANAESTHESIA FIT FOR THE FUTURELaunching our new campaign to secure a sustainable anaesthetic workforcePage 4

RCoA Eventsrcoa.ac.uk/events events@rcoa.ac.uk

@rcoaNews

MARCHAaE: Introduction 11 March 2021FULLY BOOKED

AaE: Simulation Unplugged12 March 2021Online

Developing World Anaesthesia15 March 2021Online

Global Anaesthesia16 March 2021Online

Leadership and Management: The Essentials17 March 2021Online

Anaesthetic Updates23–24 March 2021Online

Regional Anaesthesia Masterclass24 March 2021Online

Leadership and Management: Personal Effectiveness26 March 2021Online

APRILPatient Safety20 April 2021Online

After the Final21 April 2021Online

Cardiac Symposium 202122–23 April 2021Online

Clinical Directors16 April 2021OnlineInvitation only

AaE: Teaching and Training in the Workplace28–29 April 2021Edinburgh

GASagain (Giving Anaesthesia Safely Again)28 April 2021London

MAYAaE: An Introduction10 May 2021Online

AaE: Anaesthetists’ Non-Technical Skills (ANTS)11 May 2021Online

Airway Workshop12 May 2021Venue to be confirmed

Ethics and Law13 May 2021Online

Anaesthesia 202118–20 May 2021Online

%Senior Fellows and Members Club Meeting25 May 2021Online

Leadership and Management: The Essentials27 May 2021Online

JUNEAaE: Teaching and Training in the Workplace2–3 June 2021FULLY BOOKED

Anaesthetic Updates15 June 2021Bristol

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COVID-19 Conference15–17 June 2021Online

Primary FRCA Revision CourseStart date: 21 June 2021Online

Anaesthetic Updates29–31 June 2021RCoA, London

JULYFinal Revision CourseStart date: 5 July 2021Online%

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Ethics and Law for Anaesthetists13 May 2021 | OnlineMore information is available from events@rcoa.ac.uk

Listen to our latest podcast: Preparing for CCT and beyondYou can listen to the rcoa podcast in many places: search for rcoa on the podcatcher of your choice.rcoa.ac.uk/podcasts

L I S T E N N OW >

Bulletin | Issue 126 | March 2021

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Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

Book your place at rcoa.ac.uk/events

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Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

Contents The President’s View 4

News in brief 8

Guest Editorial 12

Faculty of Pain Medicine (FPM) 14

Faculty of Intensive Care Medicine (FICM) 15

SAS and Specialty Doctors 16

Society for Education in Anaesthesia UK (SEAUK) 18

Patient perspective 20

Revalidation for anaesthetists 22

Perioperative Journal Watch 23

Anaesthetists as ‘knowledge translators’ with Cochrane 26

Core trainees: the COVID career challenge 28

How ergonomic is your anaesthesia workplace? 30

Supporting progress: the new anaesthetics curriculum 34

Updating assessments: the new anaesthetics curriculum 36

Upcoming elections in Scotland and Wales 38

Get involved in CPOC’s Green Paper 40

Finding new success in novice training 44

Trainee-led virtual symposiums: the foolproof guide 46

International accreditation of perioperative neuroscience fellowships 48

Meet the new Council members 50

Being an Event Clinical Content Lead 52

As we were... 54

New to the College 56

Letters to the editor 58

Notices, adverts and College events 59

Guest editorialGlobal anaesthesia: always a good timeDr Wong and Dr Lubis tell us about colleagues who went abroad at different stages of their careers and the challenges they facedPage 12

The President’s ViewTime to make anaesthesia fit for the future. Read about our new campaign on the anaesthetic workforce

Page 4

The PIG that flies!Read about the work of the RCoA Patient Information Group from our patient information lead

Page 24

Out of our comfort zoneWorking with medical students in a Family Liaison Team during the COVID-19 pandemic

Page 32

Prime time for paediatric prehabilitationWhile adult prehabilitation is becoming more widely established, paediatric prehabilitation trails behind considerably

Page 42

From the editorDr helgi Johannsson

Welcome to the March Bulletin.

As I look out of the window I see the early evidence of spring – the daffodils in our terrace containers have started sprouting and are showing just the start of the flower bulb. By the time you read this they will hopefully have bloomed and I welcome you to spring, and the new edition of the Bulletin.

This time last year I would never have believed that we would be in lockdown number three, and dealing with yet another surge of coronavirus. This time is a little different: we have some treatments, and know our enemy a little better, and most of us are pretty confident using Teams and Zoom to manage the various meetings that got cancelled in the spring. It is obvious that this isn’t a sprint, and although the vaccine provides a lot of hope we now know that education, exams and training have to continue.

Drs Shah and Syed (page 44) demonstrate that this is not only possible but effective for our novice new starter courses, but Dr Ng (page 28) reminds us that the COVID pandemic has caused major disruption to an entire generation of trainees, with further recruitment difficulties and uncertainty to come. The challenge over the next few months and years will be to accommodate their training needs, and to prevent a recruitment crisis of fully trained anaesthetists. In the next few years the great priority will be to try to catch up, and provide operations for all the people currently living in pain and disability, while waiting for routine surgery. We will be at the centre of that drive.

I read with interest the article by Dr Marks (page 30) on ergonomics in the workplace. I know several of my colleagues have had cervical intervertebral disc problems in the last few years, with at least two operations. Our ergonomics are so often wrong in the workplace, and the twists and tensions of our day to day job could easily be improved with some thought into the placement of monitors, and the height of the patient when intubating.

One of my career regrets is that apart from a fantastic elective in rural South Africa as a medical student, I have never worked abroad, which is why I wanted to highlight the article by Drs Wong and Lubis (page 12) sharing their and others’ experience of anaesthesia in a global setting, demonstrating it really isn’t too late for any of us. We just need to be able to travel!

Over the next few issues you will see some changes to the way the Bulletin is laid out and I want to thank those of you who took part in our members’ survey and shared with us how you want to read it. As always, I want to encourage you to write articles for us, strictly not over 800 words, but on a variety of subjects. I would particularly welcome personal accounts and experiences not only as doctors, but also those of you who have been patients.

I hope you are enjoying the blooming of spring and I really hope that by the time you read this there is at least some return to normality.

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I spend a lot of my time as President representing the College at meetings with external stakeholders and Government officials, often with my counterparts from other medical royal colleges. One of the concerns which gets raised continually is workforce shortages across the whole of the NHS.

†Overview of the UK population. ONS, 2019 (bit.ly/3oXvd7r). ‡Securing the future: funding health and social care to the 2030s. IFS, 2018 (bit.ly/3o0TsA6).

The College welcomed the publication of the People Plan (bit.ly/3ipw6D4). This is the latest attempt at producing a workforce strategy for the NHS and is supportive of the many initiatives in this around wellbeing, diversity and leadership. Unlike its counterparts in the devolved nations, which set out a roadmap for comprehensive workforce planning, this strategy now needs to be backed up by commitment to tackling workforce pressures across the whole of the healthcare system, not for just a few specialties. We must move away from the piecemeal approach of allocating resources to specialties when the need becomes critical. What we need is a joined up workforce strategy that looks at systems as a whole and that is based on population needs for the future.

This is particularly important for anaesthesia.

The Office for National Statistics predicts that there will be an additional 8.2 million people aged 65 and over in the UK by 2068.† At the same time, advances in medicine, including less invasive surgical techniques, and changes in population health dynamics have led to an increase in the number of older patients living longer with complex diseases. The Institute for Fiscal Studies and the Health Foundation‡ predict that ‘meeting the

needs of a growing and ageing population would require hospital activity to increase by almost 40% over the next 15 years’.

And yet we know from our 2020 Census (rcoa.ac.uk/census-2020) that the anaesthetic workforce is not growing fast enough to keep pace with demand and that increasing pressures are placed on anaesthetic departments to deliver more with less. Currently 90% of anaesthetic departments have at least one consultant vacancy and the consultant gap has increased steadily over the past five years. This is not surprising given that there has been a steady decline in the number of newly qualified anaesthetists from 569 in 2013 to 373 in 2019, a 34% reduction. The Census also reports 243 vacant SAS doctor posts across the UK.

Despite these challenges, at the height of the COVID-19 surges, anaesthetists all over the UK have stepped up to support the NHS at the time of greatest need and have demonstrated their value in healthcare systems to a wider audience than ever before. But we also know that this has come at a personal cost for many of our members and that this crisis has further increased the impacts of workforce shortages for our specialty.

Professor Ravi Mahajan President

president@rcoa.ac.uk

The President’s View

TIME TO MAKE ANAESTHESIA FIT FOR THE FUTURELaunching our new campaign to secure a sustainable anaesthetic workforce

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When we do start to emerge from the pandemic, we need to be more vocal about the crucial role that anaesthesia has in the delivery of healthcare, not just in times of crisis, but also in enabling the NHS to return to normal levels of healthcare service delivery.

We need to continue to educate the public and the wider healthcare community about how anaesthesia operates well beyond the realm of the operating theatre, and how it supports a wide range of healthcare settings, from maternity units to pain services, from perioperative care clinics and enhanced care units to pre-hospital medicine.

Advocating for the anaesthetic workforce is now a key priority for the RCoA, and I am committed to making the case for why investment in our specialty is so urgently needed. This is why in 2021 the RCoA is launching its Anaesthesia – fit for the future campaign, an ambitious programme of work over the next two to three years aiming to:

1 change policy to secure a sustainable anaesthetic workforce

2 make a difference to the working lives of our members

3 be profile-raising and impactful.

Following a period of analysis and engagement with stakeholders, fellows and members, we have identified three areas for the campaign to focus on:

1 expansion of the anaesthetic workforce

Bulletinof the Royal College of Anaesthetists

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rcoa.ac.uk/bulletin | bulletin@rcoa.ac.uk

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President Professor Ravi Mahajan

Vice-Presidents Dr Fiona Donald and Professor William Harrop-Griffiths

Editorial Board

Dr Helgi Johannsson, Editor

Dr Krish Ramachandran Council Member

Professor Jonathan Thompson Council Member

Dr Duncan Parkhouse Lead Regional Advisor Anaesthesia

Dr Hugo Hunton Lead College Tutor

Dr Emma Stiby SAS Member

Dr Susannah Thoms Anaesthetists in Training Committee

Carol Pellowe Lay Committee

Gavin Dallas Head of Communications

Mandie Kelly Website & Publications Officer

Anamika Trivedi Website & Publications Officer

Articles for submission, together with any declaration of interest, should be sent to the Editor via email to bulletin@rcoa.ac.uk

All contributions will receive an acknowledgement and the Editor reserves the right to edit articles for reasons of space or clarity.

The views and opinions expressed in the Bulletin are solely those of the individual authors. Adverts imply no form of endorsement and neither do they represent the view of the Royal College of Anaesthetists.

© 2021 Bulletin of the Royal College of Anaesthetists All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any other means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission, in writing, of the Royal College of Anaesthetists.

ISSN (print): 2040-8846 ISSN (online): 2040-8854

2 improving retention of our most experienced anaesthetists

3 supporting the development of SAS anaesthetists.

The choice of these priorities reflects the urgency that it was felt was needed to address the workforce shortages for the specialty and to find solutions to nurture, retain and develop the existing talent, so that the safe delivery of anaesthetic services can be maintained in the long, medium and short term.

Making the case for more anaesthetistsAnaesthesia plays a critical role in the delivery of secondary healthcare. Many areas of the NHS could simply not function without anaesthetic services, not just surgery, but also maternity, emergency, and trauma and pain services, to name just a few. As we emerge out of the pandemic and the NHS resets itself and begins to restore normal levels of service, anaesthetic services will be pivotal in tackling the backlog of elective surgery and in reducing waiting times.

The negative growth trend for the anaesthetic workforce highlighted in the Census needs to be reversed urgently if we are to ensure that the NHS can continue to recover from the pandemic and that it can deliver the safe and effective care that patients expect in the 21st century. The bottom line is that we need more anaesthetists to come through the anaesthetic training

programme and this requires a financial commitment from Governments in the four home nations.

Anaesthesia – fit for the future will be the College’s flagship campaign. It is comprised of a programme of work spanning across the next two or three years and aims to make the case for the expansion of the anaesthetic workforce across all grades and roles. It will investigate the increase in demand for anaesthetic services and forecast workforce requirements for ‘team anaesthesia’ over the next five to ten years across all relevant healthcare settings.

retaining our most experienced anaesthetistsThe latest Census shows that the anaesthetic workforce is ageing, with the number of consultants who now work beyond the age of 60 and approaching retirement having increased by 2% over the past five years; 39% of consultants are now over 50 years old – an increase from 31% in 2007.

While it’s critical that we boost the pipeline supply of new anaesthetists coming through training, more must also be done to retain our most experienced anaesthetists so that they can continue to contribute to service delivery and make the best use of their talent and experience, while at the same time acknowledging their need to have more flexible job plans as they approach retirement.

The College’s ‘Stay in anaesthesia’ campaign will be looking to address the retention challenges facing our specialty by investigating the causes of poor retention for anaesthetists approaching retirement and developing policy solutions to enable them to stay in work in a way that is sustainable for them and beneficial to the specialty.

Supporting SaS anaesthetistsSAS anaesthetists play a critical role in the delivery of anaesthetic services and have played a huge part in supporting departments throughout the pandemic. However, our latest Census reveals that SAS anaesthetists’ numbers have changed little over the last five years.

Given that SAS anaesthetists account for almost a quarter of the anaesthetic workforce, we need to look at ways to make the role more attractive and to address the inequity of treatment that many SAS colleagues still experience.

The College’s ‘SAS anaesthetists can’ campaign will aim to support the development of SAS anaesthetists. We will aim to raise awareness of the importance of professional development opportunities for SAS anaesthetists and encourage more joined up thinking on how they can make an even greater contribution to the delivery of anaesthetic services.

Get involvedThis campaign is for you, our fellows and members. Throughout the campaign we want to make sure that we never lose sight of what matters to you.

We have set up a fellows and members’ sounding board at the start of the campaign to help us test our initial thinking, but we are also keen to continue to engage with you as the campaign progresses.

If you are interested in joining our campaign sounding board please email advocacy@rcoa.ac.uk

For more information on anaesthesia – fit for the future, please go to:

rcoa.ac.uk/anaesthesia-fit-future

Finally, if you have any comments or questions about any of the issues discussed in this President’s View, or would like to express your views on any other subject, I would like to hear from you. Please contact me via presidentnews@rcoa.ac.uk

The Office for National Statistics predicts that there will be an additional 8.2 million people aged 65 and over in the UK by 2068

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NEWS IN BRIEF News and information from around the collegeNEWS IN BRIEF News and information from around the college

The Lancet countdown on health and climate changeThe College, alongside the Lancet and the Association of Anaesthetists, has published a policy brief for the UK (bit.ly/2NibTDJ) presenting data from the 2020 Lancet Countdown on Health and Climate Change (bit.ly/2Nusch1). The brief focuses on three key themes: sustainable and resilient cities, healthcare sector emissions, and reaching net zero across sectors.

In a leading effort to minimise the contribution of healthcare to climate change, the NHS in England has declared its ambition to deliver a ‘net zero health service’ by 2040.

The College is committed to promotion of sustainability through our Strategic Plan 2018–2021 (rcoa.ac.uk/strategy-vision), our Sustainability Strategy 2019–2022 (rcoa.ac.uk/sustainability), and the Joint Environmental Policy Statement (bit.ly/362O2P9) with the Association of Anaesthetists.

More information about our range of work to support the environment can be found here: rcoa.ac.uk/environment-sustainability

anaesthesia 2021 goes virtualWe are excited to announce that Anaesthesia 2021, the College’s flagship conference, will now be held virtually. So why not join us from wherever you are on the 18–20 May 2021, for a packed live-streamed programme.

No matter what stage of your career, Anaesthesia 2021 has something for you. From local legends to international icons, the programme offers the chance to learn, stay informed and network with your peers.

We are very much looking forward to you joining us online in May; don’t forget to book your place by midnight on 18 March to be eligible foran early bird discount.

Visit rcoa.ac.uk/anaesthesia to book and view the programme or see further information on pages 64 and 65 of this issue.

We are keeping our fingers crossed that we will be able to visit Manchester for Anaesthesia 2022 in May next year.

honours and thank yousHave you ever wondered what type of individual might become an honorary fellow of the College? Why not read the criteria for honours, awards and prizes (rcoa.ac.uk/honours-awards-prizes) and see if you can nominate a worthy group or individual.

College honours are given in recognition of outstanding achievement, contribution and work done for the College or for the specialty of anaesthesia, relevant science, critical care medicine or pain medicine. This will have been work done in a sustained way and for a prolonged period, at national or international level, or for a defined substantial project not otherwise commissioned or rewarded.

Sometimes honours are given to non-anaesthetists for work in collaboration with us or for otherwise furthering the interests of the specialty.

Some awards and some lectureships are funded from donations which were made in memory of anaesthetists from the past, hence some of the eponymous awards.

Most importantly, our honours and awards can only ever be as inclusive and diverse as the nominations we receive so we would love to hear from you if you know of an individual or a group who you think would be worthy recipients.

Macintosh Professorships awarded to Dr Tonny Veenith and Dr Brendan McGrathThe College is delighted to announce details of two Macintosh Professorships approved by the Nominations Committee (rcoa.ac.uk/news/macintosh). Dr Tonny Veenith, Consultant in Neurocritical Care and Critical Care Medicine at Queen Elizabeth Hospital in Birmingham, and Dr Brendan McGrath, Consultant in Anaesthesia and Critical Care at Wythenshawe Hospital in Manchester, have been awarded for their outstanding contributions to academic anaesthesia and research.

Find out about this, and other College awards, by visiting our website at: rcoa.ac.uk/honours-awards-prizes

Dr Brendan McGrath

Dr Tonny Veenith

Tell us your cOVID-19 storyas part of its cOVID-19 campaign, the Policy and Public affairs team is keen to hear from Fellows and Members about their experiences. The stories will be used to highlight the important role anaesthetists are playing in responding to the pandemic. To find out more about how to have your story published, visit the college website:

rcoa.ac.uk/ covid-19-campaign

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Medical WorkforceCensus Report 2020

NEWS IN BRIEF News and information from around the college

Our Global anaesthesia: towards health equityIn partnership with the World Anaesthesia Society, the College is holding the Global anaesthesia: towards health equity event on Tuesday 16 March. Discounts are available and doctors living and working in low and middle income countries (LMICs) will be able to attend the event for free.

The event will explore key topics from a variety of disciplines to highlight and explore how to address health inequalities in a variety of different contexts. Attendees will come away with a greater understanding of the challenges and ways forward in addressing health inequality in different healthcare settings. Topics will include improving access to healthcare for marginalised communities, social determinants of health and the connectedness of ‘Global’ Health.

For LMICs to claim their free place, email global@rcoa.ac.uk to receive the discount code.

For everyone else wanting to take advantage of the 25 percent discount to attend this event – more details can be found on the event booking page: rcoa.ac.uk/events/global-anaesthesia

Medical Workforce census reportThe College has released its Medical Workforce Census Report 2020 (rcoa.ac.uk/census-2020), showing on-going and significant workforce gaps in the service. The RCoA is warning that data gathered from 97 percent of NHS hospital Boards and Trusts shows that more than one million surgical procedures will need to be delayed every year unless anaesthetic workforce numbers are increased to meet patient demand.

To address this situation, the RCoA is again calling on the government to invest in anaesthetic training places, packaged within a sustainable, long-term approach to the funding of medical training places in the UK. The RCoA is currently working to define the number of anaesthetists needed over the next five-year period and calls on the government to work with them and stakeholders to fill these anaesthetic workforce gaps, so NHS patients can receive the hospital care wherever and whenever they need it.

For further information or queries on workforce, please contact: workforce@rcoa.ac.uk

2020 National Emergency Laparotomy audit (NELa) reportThe Sixth Patient Report of the National Emergency Laparotomy Audit (rcoa.ac.uk/news/nela-2020) outlining the results, conclusions and recommendations from the audit has been published. Annual research led by the College focused on the care of over 24,800 NHS patients before, during and after emergency bowel surgery, has shown that enhanced patient care has successfully reduced the 30-day mortality rate from 11.8 percent in 2013 to 9.3 percent in 2019. But problems with other elements of patient care do still remain.

The RCoA believes that the recommendations in this report must be shared across the NHS, with hospitals, health Boards and Trusts taking on the need to reassess their care pathways for elderly patients, focusing on systematic improvements to ensure improved consistency of care. We must see organisational change before further improvements can be realised.

85% of high-risk patients admitted to critical care (80% in Year 4)

24,823 patients had emergency laparotomies in England and Wales

National 30-day mortality rate has fallen to 9.3%(11.8% in Year 1)

Improvements in care have reduced patients’ average hospital stay from 19.2 days in 2013 to 15.4 days in 2019

19.2 DAYS 15.4 DAYS

COVID-19 RESOURCESStay up-to-date with all our latest clinical resources and guidance for anaesthetists and intensivists:

icmanaesthesiacovid-19.org

NATIONAL INSTITUTE OF ACADEMIC ANAESTHESIAhealth Services research centre

Post of hSrc DirectorThis post is a three-year fixed term appointment to direct, manage, develop and deliver the aims and objectives of the NIAA Health Services Research Centre in line with its strategic plan, ethos and policies.

For more information (including the job description and person specification) and to apply, please visit our website: bit.ly/36A5yui

Further information about the HSRC is also available here: niaa-hsrc.org.uk

Closing date for applications is Friday 26 March 2021

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Dr Jan Man Wong ST3, Whipps Cross University Hospital, Barts Health NHS Trustwongjanman@gmail.com

Dr Nur Lubis Locum Consultant Anaesthetist

Leone together with a team of GPs, Emergency Department nurses and Infectious Diseases specialists in a field hospital. This experience came in handy during the COVID-19 pandemic, providing familiarity with PPE and also developing mental resilience.

The consultantHaving a consultant post at a tertiary hospital has not stopped Dr Choyce from dividing his time between working in the NHS and being an anaesthetist with Orbis providing ophthalmic anaesthesia training. Dr Choyce was initially an Orbis volunteer in 2005 before negotiating a sabbatical to spend more time with the charity. On his return, he was able to agree on a contract which allows him to be away for 12–14 weeks a year. He has completed 80 projects with Orbis worldwide.

Guest Editorial

GLOBAL ANAESTHESIA: ALWAYS A GOOD TIMEThe All-Party Parliamentary Group on Global Health highlighted the need for UK health services to support international volunteering. This is echoed in the Department of Health’s Engaging in Global Health framework.1,2 The College has been a keen supporter of these initiatives at both strategic and educational levels.After core training, I was confronted with a desire to work in developing countries and with uncertainty about the ethical standing of what I could offer. I sought advice from different individuals, and decided to go ahead with a non-clinical leadership placement in South Africa with Health Education England.3 My initial dilemma led me to team up with Dr Lubis, a veteran in global anaesthesia, to find out about the experiences of others. We spoke to six colleagues who went abroad at different stages of their careers to find out how they did it, the challenges they faced and why it had been worth it. These colleagues ranged from core trainees to practising and retired consultants.

The core traineesAfter deciding to switch to anaesthesia following her ACCS EM training, Dr Green took time off to complete the Diploma in Tropical Medicine. She found out about Friends of the Nepal Ambulance Service, a UK

charity, via contacts from the course, and subsequently volunteered. She conducted educational activities, including trauma training and simulated scenarios. Her experience made her realise the importance of constructive feedback and encouragement when teaching, which she has applied to her NHS work.

Dr Saddington spent three months in Mandalay, Myanmar, before starting her ST3 post. She taught 50 anaesthetists on the MSc programme, spent time in the ICU, and occasionally helped out in theatres. She was initially connected via one of her consultants, but has since made in-country contacts and is hoping to set up a Myanmar fellowship. She has sent another trainee to Yangon and organised the inaugural Safer Anaesthesia from Education (SAFE) Obstetric course in Myanmar. Now that she is back in training, she uses a combination of study leave, post-nights rest-days, and annual leave to enable her to deliver SAFE and Vital

Anaesthesia Simulation Training (VAST) courses worldwide. She has found her College Tutors very supportive towards her endeavours.

The senior traineesDr Pillai spent six weeks completing the RCoA Developing World Anaesthesia module in Sri Lanka in her ST4 year. She was given four weeks for the module, and used two weeks of annual leave over the summer holidays. She worked in a district general hospital covering paediatrics and adults, where she experienced different practices compared to the UK. She took her children, husband and mother – proving that having a family is not a barrier.

Dr Smith was an ST3 when there was a national call for medics for the Ebola response. As she was on a non-essential unit of training, she spoke to the College tutor and training programme director, who released her temporarily from training. She worked with the International Medical Corps in Sierra

The retired consultantUpon retirement, Dr Ravalia became involved with the World Federation of Societies of Anaesthesiologists’ Palestine Anaesthesia Teaching Mission, and is currently Head of Programme. Coming from an era where anaesthesia was less ‘high tech’, he feels he has a lot to offer. He has no intention of ‘properly retiring’.

conclusionSpeaking to like-minded colleagues has confirmed our view that this is a worthwhile and rewarding path to pursue, and that opportunities are present at any career stage. None of our colleagues mentioned the financial sacrifice of this, often voluntary, work and we also do not see this as an obstacle. It is possible to create your

own path in global anaesthesia and overcome perceived hurdles with good preparation, time management and determination.

AcknowledgementWe would like to thank the anaesthetists we interviewed for their time and for giving us an inspiring insight into their involvement in global anaesthesia.

References1 The UK’s contribution to health globally:

benefiting the country and the world. All-Party Parliamentary Group on Global Health 2015 (bit.ly/39w1Ke3).

2 Engaging in global health – the framework for voluntary engagement in global health by the UK health sector. Department of Health and Department for International Development 2014 (bit.ly/2MTJ5kL).

3 Improving Global Health through Leadership Development programme. Health Education England (bit.ly/39ARZva).

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Faculty of Intensive Care Medicine (FICM)

Dean’s updateDr Alison Pittard OBE, Dean FICMcontact@ficm.ac.uk

Faculty of Pain Medicine (FPM)

Report from the Chair of the Professional Standards CommitteeDr Paul Wilkinson, Chair FPM Professional Standards Committeecontact@fpm.ac.uk

As spring approaches, we look forward to longer days and warmer weather... maybe! Consolidating learning from 2020, we are looking to refresh our strategy for 2021 and beyond. Although activity continues on a virtual basis, we have plans for our return to ‘business as usual’, whatever this looks like.Our new curriculum was approved in December last year with implementation from August – an amazing achievement by everyone, and one which will see a reduction in the assessment burden. Having postponed our 10th anniversary celebrations last year, we are excited to continue these during 2021. The inaugural Timothy Evans Essay Prize1 was awarded in December, and our collaboration with the College of Intensive Care Medicine, Australia and New Zealand, goes from strength to strength, focusing on training and wellbeing. In other collaborative news, we recently consulted on our #BetterTogether framework with the Royal College of Emergency Medicine, on the interplay between intensive care medicine and emergency care. Our Life After Critical Illness guidance, the latest instalment from our Critical Futures initiative,2 will be published soon, resulting in a more uniform approach to patients’ needs following discharge.

Another incredible achievement of Faculty members, and others, in December was the release of a recorded single, Every breath you take (we watch over you), building upon our success with the Joint Fatigue Working Group and promoting our Voices from the Frontline3 in a slightly different way. In collaboration with a freelance choir director,4 more than 100 voices rehearsed the song virtually over two weeks, demonstrating that by working together as a team almost anything can be achieved. It was such a boost for morale and wellbeing, and a fitting end to what was undoubtedly a very difficult year.

References1 FICM10 Essay Prize – Tim Evans Award.

FICM (bit.ly/34BgVBk).

2 Critical Futures Initiative. FICM (bit.ly/3aD5sEW).

3 Voices from the Frontline of Critical Care. FICM (bit.ly/34zhSd8).

4 Kari Olsen-Porthouse: I help workplaces create and maintain harmony through group singing (libertysinger.com).

The FPM’s attention over the last six months has been firmly on COVID-19. Many projects were, temporarily, put on hold with a focus on producing essential COVID-19 guidance. From the outset, I would like to thank all members of the Professional Standards Committee who have worked tirelessly on these efforts.The response to the COVID-19 pandemic can be summarised as follows:

■ an initial national COVID-19 survey to assess the global impact of COVID-19 on pain services

■ guidance on managing the initial impact of COVID-19

■ guidance on the use of steroid injections with COVID-19

■ guidance on the safe reopening of practice

■ advice on managing consultations and commissioning adjustments in COVID-19

■ managing the impact on interdisciplinary care is covered in a further publication in collaboration with the British Pain Society.

These materials are available in the COVID-19 section of the FPM website (bit.ly/3nHWGZ4).

In addition, we will soon publish a COVID-19 national survey focused on the far-reaching changes and experiences in pain practice across the United Kingdom.

For the last 10 months, it has been very difficult to think beyond COVID-19, but we have maintained a number of significant projects. The update of Core Standards of Practice, which is a large volume providing best standards of multidisciplinary care, will shortly be completed. A further major strand of work relates to the opioid crisis. This work, undertaken with the Royal College of Surgeons of England and Royal College of General Practitioners, is close to completion and will result in a major publication on opioid management perioperatively. There is also further advice planned about reducing opioids for specialists.

There are a variety of other projects ongoing or on hold which I have not summarised here, and I apologise to those members who are involved in those projects.

The need to maintain the high standards of pain practice at a time when resources and personnel are diverted to manage the consequences of the pandemic has been highly challenging for all, but there is an emerging sense of optimism that practices may revert back to normal for good in the coming months.

... by working together as a team almost anything can be achieved

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Do’s Don’tsDo’s Don’tsDr Kirstin May Associate Specialist, Oxford University Hospitals Foundation Trustsas@rcoa.ac.uk

Dr Robbie Kerry Consultant Anaesthetist and Clinical Lead, Horton Hospital Banbury

SAS and Specialty Doctors

SHINING AT INTERVIEWFollowing our recent experiences with repeated recruitment rounds for specialty doctors and clinical fellows, we shared our top tips for getting shortlisted in the RCoA Bulletin July 2020.† We would now like to shine the spotlight on the interview process.

†bit.ly/WinShortlisting

An interview is a chance for the department to get to know a candidate beyond what is possible from paper alone. It is a chance for both sides to assess how well they may suit each other – it is important to remember this is a two way process. We are looking for a team member above all, so how well a new person would fit in is very important. It is a good idea to make contact with the department in advance of interview to ask for more information. An informal visit might be possible as well as a telephone conversation with a current post holder and/or the clinical lead. Finding out during an interview that the job is not right for you is a waste of the candidate’s and the interview panel’s time and may deprive another applicant of an opportunity. Recruitment is costly for employers and time consuming for clinicians, who are likely to conduct shortlisting and interviews in their own time. The job market is favourable for specialty-doctor candidates, with a significant

vacancy rate across the country (rcoa.ac.uk/census-2020). There is no need to take a scatter-gun approach to job hunting and apply for potentially unsuitable posts or jobs in geographical areas you would not wish to live in.

Over the last few years it has become common practice to offer remote interviews as an option, and since COVID-19 this has probably become the norm. It is customary to dress smartly in business attire. Remember first impressions count: double-check the instructions, arrive promptly, and make sure we can see your face and hear you if attending by videoconference. If you are wearing scrubs, a theatre-hat and a face mask the interviewers cannot really see you or even hear your answers clearly. It is wise to have key contact details in case of technical difficulties. If you have changed your mind about the job, please cancel.

The size of the interview panel varies and is likely to involve more interviewers for permanent posts. You are likely to be asked questions by several different individuals. As many candidates for specialty-doctor posts come from abroad, the interview is an opportunity to assess language and communication skills. If candidates have no experience of working in the NHS the interview may explore their understanding of the NHS organisational structures and how healthcare is delivered in the UK.

It is usual practice to ask set questions to make it easier to compare candidates and – through standardisation – make it as fair as possible. You are likely to be asked to outline your career to date and your future plans. Other common topics are team working, patient safety and good medical practice principles (bit.ly/2p8GWq3). We are looking for someone who is a careful listener and addresses the specific question. You may reflect the question back, to ensure you have understood what

we are asking. Specific examples to illustrate your point can be helpful, and they may come from non-clinical contexts. You may be asked clinical questions, but the interview is unlikely to resemble a clinical exam. The person specification and job description may well give you pointers towards likely questions, as they should emphasise what is important to the department and the clinical role you are applying for. If you have little experience of the interview process, asking someone for a practice ‘mock interview’ may be helpful. The interview is your chance to market yourself, so make the most of the opportunity. Towards the end of the allotted time you will usually be given a chance to ask questions yourself. If you are well informed about the job already you may not have any questions, and that is absolutely fine. You will usually hear the outcome within a few Days. If unsuccessful ask for feedback.

Want to know more about building your anaesthetic career?

Join us at our after the Final course:

rcoa.ac.uk/events/after-final-frca

■ Prepare by reading the application pack and your submission thoroughly.

■ If shortlisted, contact the department to get more information or to arrange an informal visit – speak to the clinical lead or a current post holder.

■ Follow interview booking instructions, arrive on time, and look smart.

■ Show yourself as enthusiastic, personable and honest.

■ Make good eye contact.

■ Give concise answers – we can always ask you to expand if we would like to hear more.

■ Ask for clarification if you don’t understand a question.

■ Feel free to ask questions about the job, the department or the local area.

■ Don’t be late.

■ Don’t waffle.

■ Don’t lie, exaggerate or fabricate experience.

■ Don’t ask questions that are clearly answered in the application pack or about pay.

Good luck!

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Dr Natasha Santana-Vaz ST7 Anaesthetic Registrar, University Hospitals Coventry and Warwickshirensv@doctors.org.uk

Mayer’s principles1 Coherence: remove extraneous,

distracting material.2 Signalling: highlight key points.3 Redundancy: use narration with

graphics, limit text.4 Spatial contiguity: keep linked

text and visuals physically close.5 Segmenting: present information

in segments.6 Multimedia: combine words and

pictures.

YouTube educational videos largely encompass practical skills or pre-recorded talks, with visual information delivery by independent or embedded mechanisms. During design we should consider cognitive load theory, balancing the intrinsic, germane and extraneous load elements to favour long-term memory.6

WhatsApp exemplifies constructivist educational theory with collaborative learner contributions rather than student–facilitator interactions. Small group discussions between learners can be self-maintaining and adaptable over time. The non-hierarchical environment promotes engagement, with end-to-end encryption maintaining privacy. Nevertheless, teacher monitoring is essential to minimise topic deviation and address common misunderstandings.

Video design recommendations1 Keep it brief.2 Complementary audio-visual

elements.3 Signal key concepts.4 Enthusiastic, conversational style.5 Promote active learning

with questions or interactive elements.

Twitter incorporates humanist and behaviourist theories. Natural human eagerness to learn is facilitated through post comments enabling development over time. Behavioural changes result from feedback gained through comments and retweets, with clinicians reporting that relevant research shared via social media has changed the way they do or intend to practise.7

conclusionsRemote learning within medical education is increasingly popular and important. Applications, courses and social-networking sites are powerful remote learning tools, and considering relevant educational principles improves success.

Despite needing to address issues like cyberbullying, the digital divide and quality-assurance difficulties, the use of applications, courses and social-networking sites can progress remote teaching and learning experiences. It certainly is an exciting and novel time for medical education, with wonderful opportunities to share with and learn from others all around us.

References1 Singh D, Alam F, Matava C. A critical analysis

of anesthesiology podcasts: identifying determinants of success. JMIR Med Educ 2016;2(2):e14 (DOI: 10.2196/mededu.5950).

2 Daniel D, Wolbrink T. Comparison of healthcare professionals’ motivations for using different online learning materials. Pediatr Invest 2019;3:96–101.

3 Dombrowski T et al. Flipped classroom frameworks improve efficacy in undergraduate practical courses – a quasi randomized pilot study in otorhinolaryngology. BMC Med Educ 2018;18:294.

4 Oakley B, Sejnowski T. What we learned from creating one of the world’s most popular MOOCs. NPJ Science of Learning 2019;4(7):1–7.

5 El-Bialy S, Jalali A. Go where the students are: a comparison of the use of social networking sites between medical students and medical educators. JMIR Med Educ 2015;1:7.

6 Brame C. Effective educational videos: principles and guidelines for maximizing student learning from video content. Life Sci Educ 2016;15:es6 (DOI: 10.1187/cbe.16-03-0125).

7 Maloney S et al. Translating evidence into practice via social media: a mixed-methods study. J Med Internet Res 2015;17(10):242.

Society for Education in Anaesthesia UK (SEAUK)

REMOTE LEARNING:educational principles for successThe current digital age has prompted a significant transformation within medical education. Remote learning, where student and educator are not present in a traditional classroom environment, was the exception to the norm. Recently though, its popularity has risen, with better resources empowering clinicians to balance continuing medical education requirements with multifocal demands on their time.Remote learning options include applications (‘UpToDate’, ‘Medscape’, journals, podcasts), courses (modular, webinars, seminars), and social-networking sites (YouTube, Facebook, WhatsApp, Twitter). All are powerful pedagogical tools underpinned by educational principles.

applicationsAdult learning theories, such as Knowles’ principles of andragogy, inform the use of applications, with students identifying research topics. Unfortunately not everyone finds the didactic delivery styles of UpToDate, Medscape and journals appealing.

Alternatives like podcasts suit auditory Visual Auditory Kinesthetic model learners, offering journal article discussions and exam preparation support. Shorter podcasts, including case summaries and integrating social

media, may have greater longevity.1 Unfortunately applications often lack interprofessional engagement and knowledge-acquisition assessment.

coursesRemote online courses (modular, webinars, seminars) can easily disseminate the latest specialty-specific advances. The convenience factor offered by flexible anytime, anywhere learning, coupled with the ability to study synchronously or asynchronously is great. Furthermore, incorporating online discussion allows in-depth concept exploration and encourages participation from nervous learners.2

Using online learning to complement face-to-face sessions, as in the flipped-classroom teaching model, is complementary to courses and recognised within undergraduate practical skills teaching. This model

could be applied to ultrasound-guided regional blockade and central venous catheterisation teaching, in addition to airway skills lab sessions or resuscitation courses.3

Successful massive open online courses (MOOCs) recommend using Mayer’s principles of multimedia learning to enhance efficacy. Equally applicable to webinars and seminars, the embedding of humour within material is advocated.4

Social-networking sites (SNSs)SNSs dominate learners’ social lives. Facebook has 2.6 billion monthly active users, YouTube and WhatsApp 2 billion each, and Twitter fewer at 326 million. While educators acknowledge that the use of social media enhances learning experiences, the majority do not use it within teaching. Those who do mostly post opinions or share videos via Facebook and Twitter.5

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Patient perspective

A reflection on the last three years as Chair of the

Lay CommitteeThis will be my final article as Chair of the Lay Committee, as I

demit the post in March. I am not sure where the time has gone; it has certainly flown, but on reflection I hope we have positively

developed aspects of our operation.

Carol Pellowe Chair, RCoA Lay Committee

laycomm@rcoa.ac.uk

We now have a chair-designate in post in the final months of the chair’s term which enables handover and encourages a continuous dialogue. I am delighted that Pauline Elliott applied and have every confidence in her leadership over the next term. I have a final year to serve on the committee and look forward to contributing to its work from the sideline,

Once I took up post, I was shocked to find that half of our membership was about to retire within six months. Liam, as President at the time, allowed me to retain three members for an additional 6 to 12 months to maintain the committee’s work. We have now a full complement of excellent people who work well together. The only aspect we are lacking in diversity, and this is a key focus for this year’s work. Despite the lack of face-to-face meetings, we have honed our Zoom skills, though we look forward to meeting face-to-face again. We are sharing out responsibility for coordinating replies to consultation reports and writing for the Bulletin, which improves cohesion and morale.

We joined the Lay Committee of the Academy of Medical Royal Colleges, which has enabled our focus on patient issues regarding COVID-19. In particular, we were concerned at the delays in seeing a general practitioner in some areas of the country and also at patient fears about attending hospital appointments. Working with all the medical colleges’ lay committees we feel we were able to give an enhanced voice.

Internally, we continue to contribute to all relevant College business. Anaesthesia Clinical Services Accreditation (ACSA) demands considerable time, though members enjoy the experience of seeing anaesthetics ‘for real’. I suggested a couple of important changes to how ACSA is organised, and I am delighted that they were accepted. Wherever we contribute to College business, members find that they are treated as equals and their contributions are valued. This is tremendously important and a huge encouragement to members, as they are often working on their own. Another area we are beginning to work on is pairing up members to assist with sharing workloads and understanding the whole work of the College.

Despite working in the NHS and academia since leaving school, I had a lot to learn about anaesthetics and the College. I walk regularly with two (now retired) anaesthetists, but this did not prepare me for the complexities of College business. At first, I found

Council meetings overwhelming, but I have gradually come to appreciate the areas of its business that I need to be fully cognisant of. Everyone is very friendly and keen to assist, which I have appreciated and always stress when potential lay members ask me about the bonuses.

I have appreciated the learning opportunities afforded by the College. Attending the conferences was particularly useful, and they were a good opportunity to network. Rewriting the curriculum is a huge undertaking, and the Lay Committee appreciate being involved. Members find assisting at the OSCEs very insightful, and they hopefully add a different dimension. Simulation and Equivalence add their own demands but I feel a lay view is useful.

When I first started in post, I received secretarial support from the President’s office. Soon after, responsibility for the committee was moved to Kathryn Stillman’s Directorate of Communications and External Affairs. None of the work we have done would have been possible without the guidance and advice from El Fabbrani, ably supported by Rasheda Begum. I have never had to worry about what to do and when, as they have kept me on track and provided all the necessary paperwork. So, a big thank you to them!

Despite working in the NHS and academia since leaving school, I had a lot to learn about anaesthetics and the College

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Revalidation for anaesthetists

Some data on usage of the Lifelong Learning PlatformChris Kennedy, RCoA CPD and Revalidation Co-ordinatorrevalidation@rcoa.ac.uk

Usage and performance of the Lifelong Learning Platform is kept under regular review by the College team, with a number of key areas reported on each month. A more detailed data report is produced at the end of each year and, given the unique circumstances from 2020, we would like to share some of this information with you.The Logbook, plus the functionality in the Lifelong Learning Platform focusing on anaesthetists in training, was launched in August 2018 and, up until the end of 2020, a total of 1,116,201 workplace-based assessments (WPBAs) had been completed. During 2020 it was interesting to note that May and June were the peak months for WPBAs, as can be seen from Figure 1.

Between 1 August 2018 and 31 December 2020, more than 2,865,000 Logbook entries had been added into the Lifelong Learning Platform. This time, when the data from 2020 was

examined, over 100,000 Logbook entries were added in each of the months except for March, April and May, and July.

Continuing professional development (CPD) functionality – a new and enhanced system for recording and reflecting upon completed activities, and for applying for event accreditation – was launched in November 2019, and a milestone was reached in early January 2021 with 40,000 personal activities added. This feature of the Lifelong Learning Platform was more impacted by the events of 2020, with

there being an understandable drop in CPD activities being added during April and May in particular, before a record monthly high of 5,623 activities was added in November.

The number of CPD accreditation applications also dropped during the months from April to August 2020 before a total of 315 was received from September through to the end of the year. This coincided with the introduction of ‘Virtual CPD’ as a new category, both for individual activities and for events being provided; this type can continue to get considered for accreditation if there is some form of interactive learning featured.

With the volume of accreditation applications continuing to increase during the early months of 2021, we would like to repeat our appeal for members to consider getting involved as CPD Assessors. Further information is available on the College website: rcoa.ac.uk/cpd-assessor full training is provided and your support in this role will be very welcome.

PERIOPERATIVE JOURNAL WATCHDr Yohinee rajendran and Dr Jia Liu Stevens, ST6, North central London School of anaesthesia

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.

Body habitus and dynamic surgical conditions independently impair pulmonary mechanics during robotic-assisted laparoscopic surgery: a cross-sectional studyThis is a single-centre study of 91 patients. Pulmonary mechanics were measured during four separate stages of surgery, with BMI stratified into five categories. At baseline, transpulmonary driving pressures (TDP) increased in each BMI category (1.9 ± 0.5 cmH2O; MD ± SD; P < 0.006). Pneumoperitoneum and Trendelenburg further elevated TDP (2.8 ± 0.7; 4.7 ± 1.0 cmH2O, respectively; P < 0.001) and depressed end-expiratory transpulmonary pressures (–3.4 ± 1.3;–4.5 ± 1.5 cm H2O, respectively; P < 0.001) compared with baseline. Optimal PEEP was greater than set PEEP in 79% of subjects at baseline, which was accentuated by pneumoperitoneum and Trendelenburg. The notable changes in lung mechanics with increasing BMI, at different stages of surgery may guide individualised PEEP settings.

Tharp WG et al. Anesthesiol 2020;133:750–776 (DOI: 10.1097/ALN.0000000000003442).

Brief preoperative screening for frailty and cognitive impairment predicts delirium after spine surgeryPostoperative delirium is a common complication, which affects 20–80% of older surgical patients. This is a single-centre prospective cohort study of 229 ≥ 70-year-old patients undergoing elective spinal surgery. Both the five-item FRAIL scale and cognition screening were used preoperatively. The primary outcome was delirium. 25% of the patients developed this. On multivariable analysis, frailty (scores 3–5, OR 6.6; 95% CI, 1.96–21.9; P = 0.002) vs. robust (score 0) on the FRAIL scale, lower animal fluency scores (OR 1.08; 95% CI, 1.01–1.51; P = 0.036), and more invasive surgical procedures (OR 2.69; 95% CI, 1.31–5.50; P = 0.007) vs. less invasive procedures were associated with postoperative delirium. These findings support the guidance from The American College of Surgeons and the American Geriatrics Society, where preoperative frailty screening should form part of a comprehensive pre-assessment work up in identifying high-risk patients.

Susano MJ et al. Anesthesiol 2020;133:1184–1191 (DOI: 10.1097/ALN.0000000000003523).

Association of frailty with morbidity and mortality in emergency general surgery by procedural risk levelThe effect of frailty on morbidity and mortality after elective surgery has been extensively studied. However, its contribution after emergency general surgery (EGS) is less well established. This is a cross-sectional study analysing 882,929 Medicare inpatient profiles between Jan 2007 and Dec 2015. The primary outcome measured was overall 30-day mortality after discharge. EGS was stratified as low- and high-risk dependent on surgical magnitude. Frailty was assessed using a model similar to the Rockwood Frailty Index. Frailty was significantly associated with mortality (OR, 1.64; 95%CI, 1.60–1.68). After stratification, this remained significant for high-risk (OR, 1.53; 95%CI, 1.49–1.58) and low-risk (OR, 2.05; 95%CI, 1.94–2.17) procedures. Frailty was associated with EGS related mortality, with greater risk in low-risk procedures.

Castillo-Angeles M et al. JAMA Surg. Published online 25 November 2020 (DOI: 10.1001/jamasurg.2020.5397).

Randomised controlled trial of sugammadex or neostigmine for reversal of neuromuscular block on the incidence of pulmonary complications in older adults undergoing prolonged surgeryResidual neuromuscular blockade has been associated with postoperative pulmonary complications. 200 >70-year-old patients were enrolled in an open-label, assessor-blinded RCT; patients either received 2 mg/kg sugammadex or 0.07 mg/kg neostigmine. There were no significant differences in the primary end-point of postoperative pulmonary complications (33% vs 40%; OR, 0.74; 95%CI, 0.40–1.37; P=0.30). Sugammadex decreased residual neuromuscular block (10% vs 49%; OR, 0.11, 95%CI, [0.04-0.25]; P<0.001). Phase 1 recovery time was comparable between sugammadex and neostigmine, difference –12.7 min (95% CI, –29.2–3.9], P=0.13). In an exploratory analysis, there were fewer 30-day hospital readmissions in the sugammadex group compared with the neostigmine group (5% vs 15%; OR, 0.30, 95%CI, 0.08–0.91]; P=0.03).

Togioka BM et al. Br J Anaesth 2020;124(5):553–561 (DOI: 10.1016/j.bja.2020.01.016).

Figure 1 WPBAs completed in the Lifelong Learning Platform during 2020

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22 | | 23The college is committed to developing a collaborative programme for the delivery of perioperative care across the UK: cpoc.org.uk

Dr Hilary Swales RCoA Patient Information Lead, Southamptonpatientinformation@rcoa.ac.uk

resource. We added many new resources, including the patient leaflets Sedation explained, Anaesthesia and your weight, and Your airway and breathing during anaesthesia, as well as information for carers following general anaesthesia or sedation, and information on anaesthesia for vascular/cardiac surgery (rcoa.ac.uk/patientinfo/resources). More recently we have added information on the environmental effects of anaesthesia (rcoa.ac.uk/patientinfo/environment).

We have many excellent and detailed risk leaflets (rcoa.ac.uk/patientinfo/risk-leaflets), but most patients have no desire to read all of these. We therefore designed a risk infographic (rcoa.ac.uk/patientinfo/risk-infographic) to summarise the common and serious risks associated with anaesthesia – the infographic design helping patients to visualise the information more quickly and the link to population size helping to put risk in context.

Making patients aware of the benefits of optimising health and fitness at an early stage of their patient journey can

THE PIG THAT FLIES!I’ve now been lead for patient information at the RCoA for more than five years and remain passionate about driving this forward. It was not a role I had ever looked to take on, but I am a firm believer in taking on new opportunities when they arise and in opening doors!My interest first arose when supporting friends and family through surgery and realising how little some knew about their anaesthetic and surgery prior to admission. I served on the Obstetric Anaesthetist Association’s (OAA) Information for Mothers subcommittee and saw the benefit to mothers of extending the range of resources and translations available in labour wards. Lastly I saw how much easier my life as an anaesthetist was when patients had some understanding of anaesthesia

and risks, and when I could signpost to quality resources to back up discussions in pre-assessment.

Following recent GMC guidance (bit.ly/2JQvQji), we are required to support shared decision-making and consent as fundamentals of our good

practice. The Montgomery ruling means our patients need to be informed of the risks that are particularly relevant to their lives when giving consent for procedures. High-quality patient information is therefore of ever-increasing importance.

My initial task back in 2015 was to establish a manageable committee with good lay representation – which we fondly call ‘PIG’ (the Patient Information Group: rcoa.ac.uk/pig). There followed much unseen work

developing policies and procedures. Many underestimate the difficulty of writing patient information in a way that informs but does not patronise, and in language understood by the majority. We elected to write for a reading age of 12–13 years, knowing that we were planning a specific easy-read resource

(rcoa.ac.uk/patientinfo/easyread) and that carers and accessibility software could help less able readers. Unfortunately, any resource containing the word ‘anaesthetist’ quickly pushes up the reading age! We established review of our resources by the College’s Professional Standards Advisory Group and developed ‘user testing’ of all new resources.

We were fortunate in having existing good-quality RCoA information and risk resources developed by Dr Lucy

White, which we have reviewed and updated regularly. We were keen to support these with extensive FAQs (rcoa.ac.uk/patientinfo/faqs) and a glossary (rcoa.ac.uk/patientinfo/glossary) explaining terms that many of us take for granted. You and your anaesthetic has remained our key

improve outcomes – hence Fitter Better Sooner was born! (rcoa.ac.uk/fitterbettersooner) The animation and toolkit of resources have been widely used in pre-assessment clinics and were highly commended in the 2019 BMA Patient Information Awards.

An important aim was to translate our main resources into the top 20 UK languages (including Welsh) so that they would be available to many in their first language. While working with the OAA I discovered the translation charity Translators without Borders. The College agreed to us applying to partner this excellent charity. Translations of our key resources are being loaded onto the College website as they become available (rcoa.ac.uk/patientinfo/translations). Our resources are already used in many countries – translations will doubtless extend this.

The PIG has been keen to demonstrate the quality of its resources. We joined the Patient Information Forum (PIF) (pifonline.org.uk) to advance our understanding of the production of patient information, and were delighted that they created the PIF

be the first medical royal college to be awarded that standard in February 2020.

So where next? We are keen to support environmental sustainability and to develop our resources into online resources while still supporting those who prefer a leaflet to share with family and carers. We have a fantastic range of resources, but now we need to make our members, healthcare professionals, colleagues and patients aware of their extent. The College’s social media team shares new developments and resources with a wide audience. We recently established a network to inform pre-assessment leads and healthcare professionals about new resources. We also hope to meet members at future RCoA meetings – as we did at Anaesthesia 2019 in the days when we took face-to-face communication for granted!

My six-year term is nearing an end, and the College will be looking for someone else to take over the helm as lead for patient information. It’s been hard work, none of which is specifically rewarded by the College, but it has been a hugely interesting and rewarding role that has allowed me to be fully involved with RCoA work for patients and members, yet stay largely out of ‘politics’. The role is superbly supported by a small team at the College, and I must thank Elena Fabbrani, Rasheda Begum and Mandie Kelly in particular for all their work to support PIG over the years and for keeping me largely to task!

Translations of our key resources are being loaded onto the website as they become available:rcoa.ac.uk/patientinfo/translations

Trusted Information Creator quality mark – ‘PIF tick’ (bit.ly/2MMzkS3). At inspection, our resources were indeed deemed to be of high quality, but we needed to augment policies underpinning development and are grateful now to have these in place. We were delighted to

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Translations now available online

Dr Muataz Amare Consultant Anaesthetist, Salford Royal Hospital NHS Foundation Trust and Cochrane Anaesthesia Dissemination Fellowdramare85@gmail.com

Dr Michael McEvoy Consultant Anaesthetist, The Royal Bolton Hospital and Cochrane Anaesthesia Dissemination Fellow

Professor Andrew Smith Consultant Anaesthetist, The Royal Lancaster Infirmary and Coordinating Editor, Cochrane Anaesthesia Review Group

anaesthetists in training as knowledge translatorsTrainees in anaesthesia can find it difficult to engage with research unless they are on an academic training pathway or research fellowship. Cochrane systematic reviews are of high quality but are often not as visible as more mainstream anaesthesia journals. The creation of this initiative is therefore an enormously useful opportunity both for us and for Cochrane. We therefore volunteered for the role and began to learn techniques for dissemination involving social media, responding to relevant articles in journals,1 writing blogs, and teaching. We found the role incredibly rewarding, as it provided an opportunity to publish literature, liaise with editors and answer problems from the anaesthetic community. It also fulfilled the curriculum requirements for research, management and teamwork, as well as enhancing our curricula vitae.

achievementsKnowledge translation is a challenging task which can become overwhelming and can pull in many different directions, but with support from

Cochrane and a mentoring scheme1 we have had many successes. Tasks were simplified into background activities such as using social media to promote new reviews, and more targeted special projects such as creating a special collection of evidence to inform a subspecialty group. Impact can be measured in downloads from websites, Altmetric attention scores (which overall increased by a combined 369 over the duration of the project), and the journal-impact factor of the Cochrane Database of Systematic Reviews.

Achievements have included publication of summaries of reviews, attendance at meetings to provide reviews to authors of national guidelines, creation of a special collection on regional anaesthesia to avoid aerosol-generating procedures and preserve drug supplies during COVID-19,3 and liaising with the Obstetric Anaesthetists’ Association when a drug supply issue caused concerns for caesarean sections.4

At the end of the first year, the plan is to continue the role and support new trainees with thorough succession

planning. Future work aims to focus on direct engagement with anaesthetists4 through virtual journal clubs and update sessions where the fellows can challenge anaesthetists to update their practice or audit local policy.

References1 Promoting Cochrane Evidence to the

Right Audience – Cochrane Dissemination Fellows. Cochrane Community Blog (bit.ly/2L9CRwJ).

2 Knowledge Translation. WHO (bit.ly/3s34o3z).

3 McEvoy M, Amare M, Smith A. Special Collection – Coronavirus (COVID-19): Regional anaesthesia to reduce drug use in anaesthesia and avoid aerosol generation. Cochrane Library, April 2020 (bit.ly/3bifVWQ).

4 Sng BL et al. Hyperbaric versus isobaric bupivacaine for spinal anaesthesia for caesarean section. Cochrane Database of Systematic Reviews 2016, Issue 9. (Article No: CD005143, DOI: 10.1002/14651858.CD005143.pub3) (bit.ly/3bdPFwJ).

Anaesthetists as ‘knowledge translators’ with Cochrane

The objective of evidence-based medicine is to assess the effectiveness of interventions and establish which carry the least harm. This has been the overarching aim of the Cochrane Collaboration since 1993, when it was created to produce and disseminate high-quality systematic reviews on the key questions in medicine. There has been a Cochrane Anaesthesia Review Group (CARG) since 2000.The dissemination of evidence-based information to the appropriate stakeholders should be a key aim for healthcare researchers, as any evidence that does not lead to engagement from a clinical audience is essentially ‘research waste’. CARG believes that research does not finish when a review is published, and if high-quality reviews are produced then dissemination of that evidence to clinicians is vitally important.

In 2019, Andrew Smith created the role of Clinical Dissemination Fellow to assist with this ‘knowledge translation’. The aim was to promote reviews directly to clinicians and also to inform any standards relevant to anaesthesia to ensure strong evidence was used in their development.1 Anaesthetists in training are in a strong position to do this, as they understand the clinical significance of the reviews and hence how best to influence clinical practice both locally and nationally.

how is knowledge translation changing?Traditionally, once a study has been completed the results are published, hopefully read, and potentially used in clinical practice. The authors may feel that their work is completed, but mere publication is a passive form of end-product dissemination which relies entirely on an audience finding and engaging with the literature.

Knowledge translation is defined by the World Health Organization as ‘the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health’.2 This definition shows that not only does knowledge translation involve the exchange of information, but it also includes involving end users in the creation of research questions, study design, and the use of the information. This integrated approach should therefore create more directed research and reviews which are more useful for clinicians.

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The College has tried to accommodate this. For the first time, candidates are allowed to apply for senior trainee posts without their full Primary, allowing some extra time to pass the exam. It’s easy enough to see the purpose of this, but it leads to candidates with their Primary being passed over for those without. Furthermore it does beg the question, what happens to those trainees unable to pass within the one-year grace period?

Other knock-on effects are much more immediately apparent. Those who applied to start their ST3 in February 2021 faced an unusually high competition ratio for this time of year, with 535 applicants vying for 150 jobs.2 There could be many reasons for this, including trainees returning home from being abroad, trainees’ plans to work abroad being delayed or cancelled, or even the College’s plan to extend core training to three years from the current two.

There is little that the College can do to accommodate trainees leaving or returning from travel, and this appears to be just another unfortunate impact of COVID-19. However, further clarity regarding the swap from two to three years of core training would be useful. The College has carried out gap analysis3 and produced criteria for gap jobs, but when these jobs will start and how the different training regions will

standardise them remains to be seen. Either way, core trainees on the ‘old programme’ are beginning to see these latest rounds of applications as the final ships leaving the dock.

The increased competition ratio, combined with an altered system of verifying candidates’ self-scoring, seems to have left many applicants dissatisfied and without jobs or even interviews. The next round of applications has been moved forward to early December in the hopes of creating more time to interview candidates and allow more people to be considered. However, this comes at the cost of less time for entrants to prepare their portfolios. Only time will tell exactly how effective this will be.

I, along with every other core trainee, have risen to the challenges that this pandemic presented over the last few months. We have done all that has been asked of us and, in a lot of cases, more. And yet when it comes to career progression many have been left out in the cold.

Some measures have been put in place, but I feel more could be done. Things to consider would include counting COVID-19 ARCP outcomes as separate to usual extensions, prioritising jobs for those who have already passed exams or clarifying the nature of ‘gap jobs’, possibly backdating clinical experience.

These may appear to be small things to those who have been through the selection process but, for those stuck at my level, they could make a massive difference.

There may be no ideal solution for everyone. Though attempts are being made to lessen the impact of the pandemic on our working lives, we will have to see how effective they are. Most importantly of all, I want to tell others in my position: you are not alone.

References1 COVID-19 – ARCP and Coding Information.

COPMED, 2020 (bit.ly/3pzIqnh).

2 Anaesthetics February 2021 recruitment. ANRO, 2021 (bit.ly/2YxujD4).

3 Curriculum Gap Analyses. RCoA, 2020 (rcoa.ac.uk/curriculum-gap-analyses).

Core trainees: the COVID career challenge

Many people have been negatively impacted by COVID-19. Whether they have suffered the illness themselves or experienced many of the other indirect impacts of this pandemic, it is fair to say that 2020 did not go as anyone planned. Within the healthcare industry we have had some advantages and disadvantages. We have had the reassurance that our jobs are relatively safe, even though we may not have always felt safe at our jobs.

There have also been unforeseen impacts on training. This varies from the registrars who have found themselves staffing ITU and subsequently had less specialty time, to the novices who were underexposed to anaesthetics. As a CT2 in anaesthetics, I have been part of what I feel is a forgotten tribe. I am sure I am not the only one and would like to use this platform to highlight the plight of myself and others in a similar position.

Firstly, a bit of background. I was due to finish my core training in August 2020. I passed my Primary MCQ in September and

sat my OSCE/Viva in January. I had the misfortune of failing my Viva by one mark. In the subsequent weeks after the results were released, we went into lockdown and the May resit was cancelled.

As a result of my exam situation, I have been given a six-month training extension. Somewhat interestingly, this is considered part of the official extension time as per the Conference of Postgraduate Medical Deans (COPMed).1 As with all trainees, we are normally allowed only 18 months of extension time over core and specialty training. Through no fault of my own, I have six months less to extend my traning for personal reasons, research projects or exam extensions. Whilst this does not affect ‘Out of Programme’ time, there are those who prefer to remain within programme where possible for a variety of reasons.

Core trainees on the ‘old programme’ are beginning to see these latest rounds of applications as the final ships leaving the dock

Dr Christopher Ng, Anaesthetics CT2, Buckinghamshire Healthcare Trustchristopherng@nhs.net

The college has produced a Training

Update which covers a number of areas relevant

to training, including details of how we are supporting

progression:

rcoa.ac.uk/training-update-january-2021

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Dr Richard Marks Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trustrichard.marks5@nhs.net

In the operating theatre I assessed placement of the DSE in relation to the patient (1 point), 3 points for a chair as recommended in Health and Safety Executive guidance, 1 point if I could sit down and stand up without bending or twisting, 1 point if the writing surface was in the same 90 degree quadrant as the screen, 1 point if the drugs tray could be accessed from seated without bending, twisting or stooping, and 1 point if the chair could swivel about its axis. These are the repeated movements in doing our job. This produces a maximum ‘Ergoscore’ of 14. To convert this to the risk assessment score simply means subtracting the ergoscore from 14 (see Figure 1).

The first thing to notice is that there is no theatre 13. The other obvious feature is that there is a big range of scores. Each anaesthetic room and theatre has a different layout. If there are any common features it is the lack of space in induction rooms, lack of standardisation, poor inflexible (DSE) placement, and chairs that were probably thrown out by the secretaries as unsafe.

HOW ERGONOMIC IS YOUR ANAESTHESIA WORKPLACE?The association between intervertebral disc prolapse and anaesthetists was published in this Bulletin in 2009.1 A recent Association of Anaesthetists survey revealed cervical disc prolapse in an alarming 24% of respondents.2 In our department of 103 consultants, 15 have had spinal surgery for disc prolapse.Heavy lifting, bending and stooping, twisting and turning, fixed extended postures (where one stretches out to reach awkward places), and whole-body vibration are all associated with disc prolapse. Excepting whole-body vibration, all the other activities occur frequently in my working day. The law is clear on physical activity in one’s job. Harmful actions should be minimised or avoided;3 high-risk activities should be assessed. Other than knowing what the job involves, no special skills are needed to risk-assess the workplace. I decided to give it a go.

Anaesthesia is a workstation with drug and equipment preparation, a patient interface, and a monitoring and recording environment. Understanding this, I began visiting our 17 theatres with my camera and highly ergonomic notepad.

Display screen equipment (DSE), is a marked feature in many occupations. We are ‘heavy’ display screen users.4 A

DSE must be adjustable for angle and height, with the upper edge at eye level. For viewing while seated, there must be an adjustable chair with lumbar support. For typing or writing, the surface must be angle and height adjustable.

On the assumption that work starts with hand washing, I awarded a point for each item that could be accessed from the sink without twisting, turning, bending or stooping – gloves, sharps

bin, refrigerator, and ALL the drugs cupboards. The maximum ‘Sink Association Score’ was 4. As I want to see the patient and the display screen at the same time, I allocated a point if this was possible. As a measure of space in the anaesthetic room, I rotated the trolley through 90 degrees and 1 point was awarded if one could still pass through the room without twisting or bending.

Anaesthesia is a workstation with drug and equipment preparation, a patient interface, and a monitoring and recording environment

Figure 1 Relative risk scores

Patient safety is our priority, but we should recognise that there is a substantial physical component in our work. We are not excluded from health and safety legislation, and our employer is obliged to make our working environment as safe as possible. Would you play a computer game perched on a wobbly stool with the screen behind your head? (see image, right).

References1 A pain in the neck. RCoA Bulletin 2009;58:13–14.

2 Leifer S et al. Upper limb disorders in anaesthetists – a survey of Association of Anaesthetists members. Anaesth 2019;74(3):285–291.

3 MAC Assessment Tool. HSE 2019 (hse.gov.uk/pubns/indg383.htm).

4 Work with Display Screen equipment: Health and Safety Regulations. HSE 2003 (hse.gov.uk/pubns/ck1.htm).

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Dr Josephine James Retired Consultant Anaesthetist, Birminghamjamesjo@doctors.org.uk

TimescaleThe FLT started its work at the beginning of April, and completed its duties at the end of May.

My experienceLike many retired doctors, I was eager to help out during this difficult time.

When I heard that medical students were part of the FLT, I was initially concerned that they would not be up to the task. I wondered how I would have coped at a similar stage of my career. I remember myself as a very naïve student with little life experience, and am sure I would have struggled at the same stage of training. How would these young people cope? In fact, all four doctors were impressed by their attitude. They displayed elements of professionalism and maturity way beyond their years and were a delight to work with: polite, friendly and eager to learn. The experience must have been, at times, traumatic, but they never showed this. They were asked to write their reflections of the experience, which have been published.1

are medical students different these days? I compared some demographics for my intake at a London medical school in 1970 (personal information) to those of the FLT student group who were happy to supply details. Of the 14 FLT students, 11 responded. From this comparison, it is clear that the demographics and structure of medical training have changed considerably since 1970. There are more females and a larger percentage of students selected from lower socioeconomic classes,

OUT OF OUR COMFORT ZONEWorking with medical students in a Family Liaison Team during the COVID-19 pandemic

state schools, ethnic minorities, and those with disabilities2,3,4 (see Table 1).

Many students are now selected through the Graduate Scheme; Birmingham University accepts 10% per year through this route,5 and there were four of these in the FLT, three of them qualified pharmacists.

Other aspects of medical education have also changed. Many of the students had held part-time jobs prior to starting medical school. Communication skills and health sociology are taught from very early in training, and pastoral care is much more structured. In addition, the role of the doctor in today’s society has changed markedly. All the above factors, with the improved gender balance, and rich social and cultural mix, must undoubtedly have contributed to the students’ behaviour.

conclusionI would like to thank all the members of the FLT, especially the students. This unique experience will benefit them immensely when they become doctors.

Members of the FLTDoctors: Christopher Ellis, Samia Fayek, Dominic Siggins, Josephine James

Students: Kiran Lehal, Abigail Hallum, Elena Ctori, Elizabeth Winterton, Samatar Osman, Hamna Iqbal, Lauren Kandakumar, Elena Tumulty, Ayesha Ahmed, Samuel North, Sara Bawa, Cigdem Cinar, Ahmed Somji, Niema Moazzam, Aimee Devereux

Footnote: In November, during the second wave of the pandemic, the FLT started its work again, this time without the medical students.

References1 Ellis CJ. Communication in the time

of COVID. FHJ 2020;7(3):e36–38 (bit.ly/3sjtuLR).

2 Medical students diversifying across economic and ethnic measures. Medical Schools Council, 15 January 2020 (bit.ly/39xZZgL).

3 Medical School Annual Return – Overall Student Numbers and Demographics 2017–2018. GMC (bit.ly/2Xp2r3i).

4 Royal Society of Medicine: The Medic Portal. Graduate Entry Medicine (bit.ly/3oJsvCt).

5 University of Birmingham: Medicine Application Statistics (bit.ly/2Xu1FCi).

Table 1 Comparison of the demographics of two groups of students from 1970 and 2020

Age years (average)

Gender F/M Nationality EthnicityGraduate Entry

1970 students

18.1 F 27.8% M 82.8%

British 93.5% Other 6.5%

White British 87.6% Other 12.4%

1.9%

FLT students

20 F 75% M 25%

British 100% Other 0%

White British 45.5% Other 54.5%

36.4%

Heartlands Hospital is an 800-bedded hospital, part of University Hospitals Birmingham NHS Foundation Trust. It had one of the highest numbers of COVID-19 admissions during the first wave of the pandemic, and in March 2020 it created a 32-bedded ICU to accommodate the large number. Staff were redeployed from other clinical areas to work in ICU, and University of Birmingham medical students were moved from their studies to fill the staffing gaps this created.

As the pandemic worsened, nearly all the beds became occupied by COVID-19 patients, creating a massive workload for ICU staff. Each patient’s next-of-kin (NoK) needed to be regularly updated on their progress, with time being taken to explain their condition and planned treatment procedures, and to answer questions.

As the ICU staff were so overwhelmed, a special group of doctors and medical students took on this task and became the Family Liaison Team (FLT).

how the FLT worked:The Team comprised four retired consultants who had previously worked at the trust. Their specialties were ICU, anaesthesia and infectious diseases. It

also included 16 medical students in their 3rd, 4th and 5th years. The doctors worked on a rota system; the students rotated in small teams.

The students met with ICU staff outside the clinical area after the daily ward round, and each patient was discussed at length. A student would call the NoK in less severe cases with reasonable clinical progress. The FLT doctor made the call if there were complex medical issues, deterioration, interventions planned, or challenging communication issues expected. Where death was anticipated within 24 hours the ICU staff would contact the relatives directly.

When the FLT doctor made the call, a student would either meet with them in an office, or telephone them (two

doctors had decided to work ‘remotely’ from home). The student had access to the patients’ records and each patient was discussed at length. Calls to the NoK were made by the doctor in the early afternoon; a conference call was set up between the doctor, student and NoK, enabling the student to take notes while the doctor spoke to the NoK.

TeachingTutorials on ICU care, COVID-19 and communication skills were given in early April by one of the consultants. Other teaching took place during case discussions, guided by both student and doctor. The students all had structured pastoral care.

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Active Experimentation

Abstract Conceptualisation

Concrete Experience

Reflective Observation

realistic and aligned to the curriculum): even more so if the anaesthetist in training shares with the observer the aspects of their performance that they wish to work on in advance of the activity. Fundamentally, it is the developmental conversation itself which has value, rather than the completion of the documentation, and the role of the observer is to ‘sense check’ the anaesthetist in training’s desired standards, then enable them to recognise opportunities and strategies for development, rather than to make a summative judgement of ability.

The developmental process can start anywhere in the learning cycle, but it most often begins when an experience

SUPPORTING PROGRESSThe new anaesthetics curriculum

Assessment is pivotal to embedding the philosophy that underpins the curriculum, as it shapes every aspect of the learner’s learning experience. Our key aim for assessment is to improve practice by concentrating on the educational potential of assessment, and de-emphasising the collection of evidence of achievement. Assessment within the new curriculum is weighted towards formative development where we give an account of practice to enable improvement rather than accounting for practice. The learner is expected, and should feel confident, to demonstrate a journey of progression, in which the process of improvement is appreciated in addition to achievement.

an experiential learning cycleDevelopment of any complex practice is iterative. An experiential ‘cycle’ of concrete experience, reflective observation, abstract conceptualisation, and active experimentation should underpin education (see figure). Simply ‘practising’ anaesthesia will result in changes to performance, but making that practice ‘deliberate’ by defining a clear developmental trajectory towards curricular outcomes and focusing attention where performance can be best improved will improve its effectiveness. Focused attention can only be achieved by analysing performance, an activity that can be undertaken by anaesthetists in training themselves, if they are capable of frequent, meaningful reflection, but is more effective when that reflection is facilitated by an expert.

In a ‘feedback’ conversation, the performance of the anaesthetist in training is compared to a conceptual ‘desired performance’. This implicit metric will be a composite of their own ambition, the curriculum standards, and the supervisor’s expectation. It is more important for development that any gap between the observed and the desired performance is explored, and that a plan is generated to bridge the ‘performance gap’ than it is that the performance is measured against an explicit metric. The purpose of Supervised Learning Events (SLEs) documentation should be to serve as a record of a developmental conversation.

Developmental conversationsThe term ‘feedback’ may be unhelpful, as it implies a conversation in which the performance of the anaesthetist in training is described by the supervisor, compared to the supervisor’s own implicit metric. Observations on the performance ‘gap’ are therefore defined by the supervisor, and are ‘handed down’ to the anaesthetist in training. In this construct the observation only has value if there is alignment between the perceptions and goals of both the observer and the anaesthetist in training. It is more effective to explore the anaesthetist in training’s evaluation of their performance against their own expectation, (provided that expectation is

Dr Ben Shippey Consultant Anaesthetist,

Ninewells Hospital, Dundee2020cct@rcoa.ac.uk

Dr Marie Nixon Consultant Anaesthetist,

Portsmouth Hospitals NHS Trust

2020cct@rcoa.ac.uk

Part two

is analysed. As a result of that reflective process, concepts are created which describe how performance might be enhanced in the future. The concepts are applied ‘experimentally’, in that the impact of the change is not assumed, but is observed and reflected upon. The expectation is that performance will improve through repeated cycles of experience, reflection, conceptualisation and application. SLEs should therefore be undertaken with this iterative development in mind: they should examine the performance of the

anaesthetist in training and explore the ways in which it might be improved. Features that are key to making SLEs effective are that the conversation happens soon after the observed activity; that this dialogue is aided by a credible facilitator, and that the conversation is seen as part of a continual process of development, rather than an assessment of performance at a single point in time.

Future Supervision LevelThe SLE documentation will be modified to allow the supervisor to record, if agreed, the level of supervision required if the activity were to be undertaken again immediately. Previous experience shows that a

Experiential Learning CycleKolb Da. Experiential learning: experience as the source of learning and development, 1984.

dichotomous ‘satisfactory/unsatisfactory’ judgement results in the majority of performances being judged as ‘satisfactory’, implying that supervisors struggle to define ‘unsatisfactory’ as an outcome. Conversely, a judgement of ‘level of supervision’ is relatively easy to make: while this is subjective, summative assessment based on a number of subjective opinions has acceptable validity.

It is hoped that by refocusing attention on participation in developmental conversations and moving away from SLEs as summative assessments, these conversations become a normal part of everyday practice in which teaching, learning, and assessment happen simultaneously. The intention is that training moves away from performing SLEs for the purpose of demonstrating ability, towards a more open culture where frequent, informal, formative analysis of performance is both expected and achievable, and where those powerful conversations, guided by the standards within the curriculum, serve as the scaffold to the achievement of excellence.

Further information is available via the

website at:

rcoa.ac.uk/2021-curriculum-

assessments

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The current list of workplace-based assessments will be replaced by the adoption of Entrustable Professional Activities (EPAs) for assessment of IAC and IACOA. An EPA is a discrete area of clinical practice that an anaesthetist is trusted to perform under distant supervision when they have demonstrated sufficient competence. While this is a new concept, in practice it should feel much more akin to what actually happens as part of clinical training, and it recognises the role of experienced trainers, teaching, encouraging, and discussing progress with new anaesthetists in training.

During the training period SLEs, personal activities, and MTRs are used to help the anaesthetist in training develop the knowledge and skills required and to demonstrate their progress until they reach a point where they can be entrusted to carry out that activity with more distant supervision.

Holistic Assessment of Learning Outcomes (HALOs)The 2021 curriculum sets out a range of key capabilities that are divided into clinical and non-clinical domains. HALOs provide a structured framework to reflect the evidence that the anaesthetist in training has achieved the required learning outcomes for each domain of training. The anaesthetist in training will need to demonstrate achievement of all the key capabilities in the domain. All 14 domains must be completed in order to progress to the next stage of training. The HALO can be considered analogous to CUT forms in the 2010 curriculum.

Assessors should draw upon a range of evidence, including logbook data, SLEs, MTRs, personal activities (such as courses and e-learning) and reflections, to inform their decision as to whether the learning outcomes have

UPDATING ASSESSMENTSThe new anaesthetics curriculumDr Jo Budd, Consultant Anaesthetist Hereford County HospitalDr Gethin Pugh, Consultant Anaesthetist & Intensivist; Associate Dean, Health Education and Improvement WalesDr Joe Lipton, Consultant Anaesthetist, Guy’s & St Thomas’ NHS Foundation Trust, London

The introduction of the new curriculum brings with it some important changes to assessment. Fundamental to these changes are a focus on formative assessment to guide future learning, and an aspiration to reduce the overall burden of assessment. This article describes some of the key changes to assessment and introduces some of the new components of the programme of assessment.

Formative assessmentFormative assessment is assessment for learning. Its goal is to review progress in order to offer ongoing constructive feedback with the aim of improving performance.

Supervised Learning Events (SLEs)SLEs should be used to promote professional educational discussions and guide future learning. Trainers will be familiar with the tools such as A-CEX, CBD, DOPS and ALMAT, however, these will be updated to emphasise the importance of feedback and include a revised supervision scale.

The trainer identifies the level of supervision that the anaesthetist in training requires for the activity, ie if they were to do the activity again, ‘right here, right now’. The use of a supervision scale makes more

explicit the implicit judgement of an experienced trainer when supervising trainees. Feedback should cover both the clinical and non-clinical aspects of performance, and may include direction as to what is required to progress to the next supervision level.

For some activities it may be more appropriate to assign ‘not applicable’ for the supervision level. It is important to note that there is no minimum number of SLEs required for any of the domains.

Multiple Trainer Reports (MTRs)MTRs will replace existing consultant feedback processes. The MTR reflects the greater emphasis placed on the professional judgement of trainers as part of the revised approach to assessment. Trainers have the opportunity to report on the progress of the anaesthetist in training, including areas of excellence and areas for

development. The MTR is a mandatory requirement to support progression at critical progression points of the new curriculum. The MTR is distinct from multi-source feedback (MSF), which will continue in its present form.

Summative assessmentSummative assessment is assessment of learning and results in a mark or grade – pass or fail. Its goal is to test knowledge or performance against set criteria.

Initial Assessments of Competence (IAC)The IAC and IAC for Obstetric Anaesthesia (IACOA) will continue as summative assessments of the initial training periods in anaesthesia and obstetric anaesthesia respectively. The IAC represents the first critical progression point of the new curriculum.

been met. As with the current curriculum, a single piece of evidence may inform a number of different key capabilities. The evidence from personal activities will be especially pertinent for the GPC domains.

While HALOs will normally be completed towards the end of a stage of training, anaesthetists in training should be encouraged to accumulate evidence throughout the stage. Within each domain, key capabilities that require similar evidence will be clustered together and will be reviewed by a designated trainer, in a similar process to the existing CUT form completion.

WHAT HAS NOT CHANGED?

■ Formative assessment using SLEs with the emphasis on feedback

■ A single assessment may provide evidence to satisfy multiple key capabilities across any domains.

■ SLEs are only one form of evidence used to support achievement of key capabilities.

■ Assessment of the initial phase of training in anaesthesia and obstetric anaesthesia with the IAC and IACOA.

■ The FRCA Primary exam, to be completed by the end of CT3, and the Final by the end of ST5.

■ MSF to be completed annually.

WHAT WILL CHANGE ■ A-QIPAT to support formative assessment of QI projects

■ EPAs for the assessment of IAC and IACOA

■ HALOs to collate the evidence for completion of the domains of learning at each stage

■ MTRs to replace existing consultant feedback processes.

Further information is available via the

website at:

rcoa.ac.uk/2021-curriculum-

assessments

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Dr Daphne Varveris Chair, RCoA Scotland BoardDaphne.Varveris@ggc.scot.nhs.uk

Dr Abrie Theron Chair, RCoA Wales Boardatheron@rcoa.ac.uk

■ write a letter inviting them to ‘meet’ or attend a relevant event to discuss our manifesto priorities and better understand our specialty – the Policy and Public Affairs team at the College would be delighted to help you with this

■ tell them about your experience – sharing your local case-studies as they relate to our wider ‘asks’ can powerfully show the positive difference they could make if they acted locally

■ maintain your new relationship and help us build on it – after the election, write a thank you or congratulations letter to your new or returning MSP or MS and urge them to set up a meeting with the College. Please also follow up on any commitments they make to you in person or in writing

■ ask them to promote our manifesto on social media – we can be found at @RCoANews.

A brief reminder that, as a registered charity, the RCoA is a non-party political organisation. This means that while we regularly engage with parliamentarians, we cannot endorse a political party or specific candidate.

Thank you to all of you in advance for any time you can spare to help us campaign for the priorities as set out in our manifestos. The Policy and Public Affairs team would love to hear back from you about what responses you received, which messaging worked best, and to discuss how they can support you to raise the profile of anaesthesia in your local area.

Please contact advocacy@rcoa.ac.uk with any questions or requests for support.

UPCOMING ELECTIONS IN SCOTLAND AND WALESOn 6 May, voters will head to the polls to elect representatives for the Scottish and Welsh Parliaments, the London Assembly and local councils, as well as police and crime commissioners.These upcoming elections represent many ‘firsts’. They are the first elections in the UK to be held in COVID-secure conditions, the first time that 16- and 17-year-olds can vote in Wales, and the first time that foreign nationals can vote in the Welsh and Scottish parliamentary elections.

It is also the first time that the Wales and Scotland Boards of the College have produced election manifestos, laying out their priorities for change based on what members living in Scotland and Wales are saying most needs to change.

We’d like to thank all of the many members living in Scotland and Wales who took part in this consultation exercise. Your answers, combined with widespread stakeholder engagement with our health and care partners, helped us to come up with our manifesto priorities.

Although the manifestos for Wales and Scotland are different, some similar themes emerged. Building on the work of the College’s recently published census, both manifestos address the deeply worrying ‘real gap’ in our anaesthetic workforce. They also both speak to the challenges facing NHS staff – health, wellbeing, and morale, especially for our trainees. Both also seek to complement sector work, for example supporting the Scottish and Welsh Academy manifestos where we think we can best make a difference and our voice is most needed.

If you have not had a chance to read the manifestos, you can access them via our website: rcoa.ac.uk/wales-scotland-2021

How can you act as a representative of your College during the election campaigns?Even with social distancing guidelines in force, your MSP/MS and other candidates will be using these critical weeks before election day to meet as

many constituents as they can and raise their profile. This means that they will be reaching out via online events, phoning you, or hosting virtual hustings.

This is a great opportunity to use these manifestos and represent the views of your College and colleagues. If you do plan on representing your College in a public election forum this year or engaging with candidates on a one-to-one basis, please:

■ remember to say that you are a member of the RCoA, which, with a combined membership of 23,000 fellows and members, represents the three specialties of anaesthesia, intensive care and pain medicine

■ share our manifesto with them and ask them to publicly commit to our priorities – you can tell them that if they would like more information they can get in touch with the RCoA’s Policy and Public Affairs team directly at advocacy@rcoa.ac.uk

Scottish Parliament Senedd

If you have not had a chance to read the manifestos, you can access them via our website: rcoa.ac.uk/wales-scotland-2021

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Dr Louise Bates Clinical Fellow, Centre for Perioperative Carelouise.bates2@nhs.net

Lisa Plotkin RCoA Policy Managerlplotkin@rcoa.ac.uk

In particular, we think we need to do a better job at making the case for why the NHS should prioritise perioperative care. We know we have strong evidence for the benefits of the perioperative approach to healthcare resource use and the quality of patient care, and we know that colleagues across the UK are delivering transformative outcomes for patients.

But it is becoming increasingly clear that good evidence, good case-studies, and the goodwill of individuals is not enough to make change happen at a systems level. A recently published CPOC evidence review (bit.ly/37xdePp) into perceptions of perioperative care shows that while healthcare professionals are supportive of the perioperative approach, health policymakers and healthcare managers have been largely divorced from these discussions. This is now starting to change, with both NHS England’s National Medical Director and National Clinical Director for Critical and Perioperative Care championing this issue at a national level.

But they cannot do it alone. With this Green Paper consultation, we are striving to set out our stall in a way that supports those national efforts and better resonates with parliamentarians, the wider health and care sector, and the public. We know we have a great story to tell, and – with so many newly open doors – we need to tell it now better than ever.

Get involved in CPOC’s Green PaperIn January, the Centre for Perioperative Care (CPOC) launched the first ever Green Paper consultation on perioperative care in the UK. A huge ‘thank you’ goes out to the many College members who have already signed up to be more involved and/or have participated in a consultation activity.Our Green Paper project is a nine-month programme of consultation and research aimed at addressing the short-term challenges and long-term opportunities facing the perioperative care agenda. It aims to draw together CPOC’s diverse community of partners around a shared set of priorities for change and a vision for the future of perioperative care.

Most importantly, our Green Paper will be a statement of intent from CPOC to governments across the UK about the role we all need to play to make progress on advancing this agenda and improving outcomes for patients.

The project will culminate in the publication of our perioperative care ‘Green Paper’ in the autumn. You can read more about the Green Paper’s

aims and objectives and access our current consultation documents here: bit.ly/3reXIOG

Why now?Rather than waiting for the UK government to do this, CPOC has launched its own Green Paper consultation this year for three main reasons:

Firstly, in the wake of the pandemic there is now a set window of opportunity to start doing things differently.

We believe that the principles of perioperative care provide solutions to many of the most pressing ‘COVID-19 recovery’ challenges and align with pre-pandemic aspirations laid out in national strategies, like the NHS England Long Term Plan. With this Green Paper, we

hope to capture and campaign for those solutions during this (potentially) limited time when NHS organisations may be most open to implementing, championing, and funding them.

Secondly, in keeping with this spirit of innovation, it is the right time to start thinking about not only what policy changes we want to see next year, but also about what kind of change we want to see for perioperative care in the next 10 years. We think that our CPOC community needs to lead in setting out this agenda for the longer-term future of the perioperative team before it gets set out for us.

Finally, we are carrying out this Green Paper consultation because we are some of the people who need to do things differently too.

Get involvedWe can’t deliver this Green Paper without the active participation and help of RCoA members. If you would like to get involved in this project, please consider joining our ‘informal sounding board’ of experts, patients, and policymakers. The kinds of things we’ll be looking for your help with include:

■ giving us your views as we develop our policy thinking, for example by taking surveys, feeding back on draft papers, and helping us prioritise what we explore further

■ championing our work on social media and to your personal and professional networks. We’ll be regularly updating people on this project using the hashtag #CPOCGreenPaper – retweets very welcome!

■ blogging for us to share your experiences, reflecting on new findings and informing the public about this work

■ attending workshops or events

■ submitting your work as a case-study.

If that sounds interesting, please email CPOCgreenpaper@rcoa.ac.uk. For regular updates on the Green Paper and how you can get involved, please visit the project webpage here: bit.ly/3reXIOG or subscribe to our newsletter here: bit.ly/3riND2W

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0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Strongly agree

Agree Neither agreenor disagree

Disagree Strongly disagree

43.94%

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41.67%

41.67%

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Strongly agree Agree Neither agreenor disagree

Disagree Stronglydisagree

Figure 1Responses to survey question

Figure 1Responses to survey question

related complications developing in later years. There may be a case for adoption of prehabilitation in all patients, thinking of the programme as a broader social intervention rather than purely preparing the child for the immediacy of surgery.

Our survey results certainly show that paediatric anaesthetists feel there is a need for paediatric prehabilitation, and that this should be multidisciplinary involving (among others) dieticians, physiotherapists and play therapists. Respondents felt that such a service should be embedded within the preoperative assessment process rather than merely signposting to other services. An evidence base is clearly necessary when trying to justify the business case for such a programme.

Perioperative practice was to be the theme for this year’s APAGBI annual conference, regrettably cancelled due to the COVID-19 pandemic. Clearly it is a focus of attention. Recent prehabilitation studies in adults have shown surprising and somewhat counterintuitive results. The PREVENTT trial showed that preoperative IV iron was not superior to placebo when administered to anaemic

PRIME TIME FOR PAEDIATRIC PREHABILITATIONDr Chris King, ST5, Medway NHS Foundation Trust, KentDr Samantha Black, Consultant Paediatric and Perioperative Anaesthetist, Prehabilitation Lead, Medway NHS Foundation Trust, Kentsamantha.black1@nhs.net

‘Every child having a GA for a procedure/operation should expect to receive preoperative assessment that meets the medical, physical and emotional needs of that child’

patients before major abdominal surgery.3 This reminds us of the importance of evidence-based medicine rather than merely following instinct.

We need well conducted randomised-controlled-trial data in children, targeting specific interventions with consistent outcome measures. Is it finally time for a national research project to establish an evidence base for paediatric prehabilitation?

References1 PErioperAtive CHildhood ObesitY 2019 (ICHGCP.net Identifier NCT03994419)

(bit.ly/39kUpOk).

2 Paediatric Perioperative Anxiety: Does the Little Journey App Help? (Little Journey) 2019 (ClinicalTrials.gov Identifier NCT03797716) (bit.ly/39mFPWM).

3 Richards T et al. Preoperative intravenous iron to treat anaemia before major abdominal surgery (PREVENTT): a randomised, double-blind, controlled trial. Lancet 2020;396:1353–1361.

This is the opening statement in the paediatric perioperative care section on the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) website (bit.ly/3oDXGyM).

Prehabilitation, the process of enhancing an individual’s functional capacity to enable them to withstand a forthcoming stressor, is a rapidly developing field of perioperative care. While adult prehabilitation is becoming more widely established, paediatric prehabilitation, and in particular its evidence base, trails behind considerably. We are in the midst of an obesity pandemic, with poor nutrition and sedentary lifestyles not just limited to the adult population. Surgery is a teachable moment – ‘making every contact count’ – whereby we can make lifestyle changes that could have long-term positive impact for children and families.

There is very limited published literature on the subject currently, though some studies are in progress. The PEACHY study is looking into the effect of obesity on perioperative complications in paediatric patients undergoing anaesthesia.1 Another study

in paediatric ambulatory surgery is evaluating the clinical effectiveness of a virtual reality psychological-preparation app at reducing perioperative anxiety compared to standard care.2

We canvassed all APAGBI members using an electronic survey, with 132 responses from across the UK. Responses were split between teaching hospitals (77%) and district general hospitals (23%), with over 90% of respondents of consultant grade. Just 55% of respondents worked in hospitals with paediatric consultant-led pre-assessment clinics.

Our survey question was: ‘Do you think there is a role for ‘prehabilitation’: medical optimisation of conditions such as diabetes and anaemia, dietary and exercise advice, psychological and anxiety management, and smoking cessation guidance?’ (see Figure 1).

Common themes from respondents’ comments were that current services are typically set up to address paediatric anxiety, but managing more complex co-morbidities was referred to the GP, paediatricians, or surgical team. Anaesthetists often found themselves as

co-ordinators addressing these patient needs, usually by necessity rather than design. Childhood obesity was a recurring issue, and the teachable moments during pre-assessment were often missed. One respondent had recently encountered a 14-year-old who had ‘given-up’ smoking, having been smoking since the age of 11. It would seem naïve to assume that smoking cessation advice should be limited to adult patients.

With the exception of anxiety management, respondents felt prehabilitation was unlikely to play a role in the majority of district general hospital’s ASA 1–2 daycase surgery, but there was a definite gap with respect to the more complex child. 85% of survey respondents either agreed or strongly agreed with the statement: ‘Giving perioperative advice and optimisation in the few weeks prior to surgery can improve patient outcomes in high-risk patients’.

That said, paediatric surgery represents a golden opportunity for triggering behavioural change early in a child’s formative years. The diet and active living modifications may prevent obesity-

Please also see the rcoa resources

for children, young people and carers on

our website:rcoa.ac.uk/

childrensinfo

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Dr Sneh Shah ST7 Anaesthesia, Imperial School of Anaesthesiasneh.shah@doctors.net.uk

Dr Sadie Syed Consultant Anaesthetist, Imperial College Healthcare NHS Trust

case-based scenarios, which facilitated discussion generation and enabled non-threatening participation.

A notable benefit of our traditional course was the ability of novices to build peer-to-peer relationships which would provide them with support while embarking on a complex specialty. We now had a relatively large group of novices who were essentially strangers to each other learning together virtually, and we were keen to reproduce the familiarity and intimacy of our conventional course. Following each round of polling, we used breakout rooms with a ratio of one member of faculty to a maximum of seven learners to allow small group discussions. This helped maintain the active participation of our learners, maximise understanding around the topic, and contributed to the learner’s sense of personal connection in a large virtual group. We collected weekly feedback and adjusted the format based on the previous weeks’ responses to ensure the most valuable learning experience for our novices.

Our course feedback has been overwhelmingly positive. The main modification we will make to our next course is to give learners ample time to complete the initial set of online modules. Learners reported that our course requirements had competed with the mandatory training inherent to starting work at a new trust. In the absence of COVID-19 restrictions, we would re-instate our skills workshops, which are vital not just for practical skills but also for the social contact between trainees and with trainers.

Key strengths of our digital course included the ability to accommodate a relatively limitless number of learners while retaining a personable ambience.

We actively sought to maintain learners’ interest and involvement throughout each session by creating an environment where different modes of participation were frequently required, thereby embracing the process of ‘active learning’.2 Anonymous feedback at the end of each session was displayed to help learners feel that their experience and views were a high priority, and

enabled transparency about the changes, based on majority opinion, to be made to the subsequent sessions.

We have learnt a great deal from a complete rebuild of our traditional course and believe that our model can be easily adapted by other training programmes beyond those for novice anaesthetists.

For those planning to develop their programmes, we offer some of our top tips for delivering an online learning package:

Course design needs to acknowledge the cognitive burden of participating in a virtual environment

Participants should ensure that they are using the most current version of the interactive platform and be encouraged to use a PC/laptop to allow access to all the functions of the platform

All participants must have their own screen – sharing screens reduces contributions and leads to distractions

Participants must consider online learning and participation in interactive sessions as ‘work’ – study-leave should be obtained, and professionalism maintained

A briefing email should be sent prior to the session so that both faculty and learners are aware of the plan and expectations for the session

Extra time before learners join the session should be timetabled for faculty to become familiar with the technology being used and for any questions about the session to be addressed

A non-participating moderator is needed to monitor the chat function and provide online support to learners and faculty

Breakout rooms are a useful way of creating intimacy and overcoming the anonymous nature of online learning

Tools such as Mentimeter are a well-received way of initiating interaction of participants

Actively obtain and action feedback where possible as the course progresses from session to session

References1 Syed S, Nathwani R, De Zoysa H. Novice training: moving with the times.

RCoA Bulletin 2013;79:42–45.

2 Craik FIM, Lockhart RS. Levels of Processing: A framework for memory research. JVLVB 1972;11:671–684.

FINDING NEW SUCCESS IN NOVICE TRAININGThe Imperial Novice Course, established in 2010, supports novices to achieve their Initial Assessment of Competency. Our traditional course consisted of four days of lectures and workshops, a simulation day, and a website hosting supporting resources.1 As the COVID-19 pandemic evolved, we realised that delivering our traditional face-to-face course would be impossible and that a complete redesign was essential. We describe below how we have developed a qualitatively successful online learning package.Our digitally transformed course requires learners to view podcasts and written material at a self-directed pace prior to their attendance at weekly online interactive sessions. The course material was expanded to provide a wider understanding of the essentials of anaesthetic practice, since novices this year would potentially have reduced training opportunities. The material was divided into 71 video podcasts and 46 written topics. Each topic would be stand-alone and of approximately 10 minutes duration. This would allow content to be viewed in easily digestible chunks with a low risk of screen fatigue.

We needed to upskill ourselves and our voluntary faculty to produce the podcasts. Interestingly, we had access to a greater number of faculty than previously, since material could be prerecorded. Our team learnt how to edit podcasts, which provided a buffer of forgiveness for recording errors and allowed us to ensure top quality content.

Viewing the podcasts required a high level of self-motivation from our learners. They were required to complete specified topics in advance of interactive sessions. Our learning platform (imperialnovice.com) was designed to allow us to monitor progress of our individual learners so that poor compliance or potential

issues could be rapidly identified.

Live interactive sessions were held once a week for four weeks, and we hosted more than 40 learners per session using Zoom Pro (zoom.us). Integrating Mentimeter (mentimeter.com) into the sessions allowed anonymous polling of responses during

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HELPFUL

TIPS

Overall, 84 participants representing multiple deaneries attended. Sixty-eight feedback forms were returned and complimented the excellent chairing, slick Zoom control and content variety (see Table 1). Constructive criticism suggested a shorter day, earlier publication of a full timetable and increased advertising. Considering this, we felt that our first trainee-led virtual symposium was a great success, a huge part of which was undeniably due to the enthusiasm from trainees, 26 excellent poster presentations, and an insightful keynote session on wellbeing. We would wholeheartedly encourage trainees in other regions to organise similar events, since we were able to showcase inspirational work from our region nationally, providing trainees with valuable evidence for ST3 applications. Furthermore, for the organisers, markers and symposiasts, e-SAT met points within the curriculum for ‘Innovation’; ‘Management’; ‘Academic and research’; and ‘Improvement science, safe and reliable systems’.

Reflecting on the e-SAT, what have we learnt about running a successful event? The demands of organising a national symposium from scratch were, at times, unexpected and labour intensive. One of the most valuable lessons was the importance of a dedicated, motivated team who work well together. Regular (virtual) meetings, strict adherence to deadlines, and task delegation were crucial in ensuring manageable workloads. Continuity of roles ensured tasks were completed thoroughly and accurately – for example specific committee members assigned to handling email correspondence via a coordinated pro-forma. In addition, offering an interesting and diverse programme meant that we appealed to a wider anaesthetic audience; limiting presentation lengths to five minutes maintained momentum within a strict schedule, and the ‘raise hand’ and Q&A functions encouraged audience participation without interrupting

TRAINEE-LED VIRTUAL SYMPOSIUMS: THE FOOLPROOF GUIDEPresenting your work as an anaesthetist in training brings a wealth of opportunities. Aside from CV building, it allows us to refine essential skills such as data collection and analysis, academic writing, and public speaking. Educational events also allow us to learn from our peers and to network within the anaesthetic community.The COVID-19 pandemic led to the cancellation of face-to-face events, yet quality improvement and audit continued. With training programmes ongoing, one common question emerged among junior anaesthetists: ‘How, as a trainee, can I make myself more competitive in this current environment?’

With this in mind, in June 2020 four Mersey trainees devised the first North West e-Symposium for Anaesthetic Trainees (e-SAT). The aim of this one-day virtual event was to provide a platform for non-consultant anaesthetists to present their work and specifically allow core trainees to gain evidence for a national presentation within Domain 5 or 9 of the ST3 Self-Assessment. Within 12 weeks, and with support from our Associate Head of School, the committee were able to create, advertise and deliver the e-SAT, the process of which is outlined in Figure 1.

speakers. Finally, we focused on delivering a professional event, concentrating on the appearance of our materials as well as prompt, clear communication with symposiasts and presenters. Practice run-throughs of the symposium were invaluable, allowing us to anticipate potential problems alongside building familiarity with the software.

So, for any trainees looking to organise a virtual event, our take-home tips are:

■ assess the demand: you can organise a great event, but a captive and willing audience is vital

■ practice is essential: confident platform navigation will ensure smooth running and avoid hiccups on the day

■ teamwork really does make the dream work!

Table 1 Feedback

Feedback question Strongly agree Agree Neutral

I learnt something from e-SAT 60% 38% 1%

Content was relevant to my clinical practice

62% 38% –

I would be interested in attending future virtual learning events

72% 24% 4%

I would be interested in attending another e-SAT

66% 32% 1%

Figure 1 e-SAT Logistics

Dr Leanne Gentle Clinical Fellow in Paediatric Intensive Care, Alder Hey Children’s Hospital, Liverpoolleanne.gentle@nhs.net

Dr Supanki Kamalanathan ST7 Anaesthetist, Mersey Deanery

Dr Kim Gibson ST5 Anaesthetist, Mersey Deanery

Dr Luke Dias ST7 Anaesthetist, Mersey Deanery

Dr Simon Mercer Consultant Anaesthetist, Liverpool University Hospital Trusts

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■ the need to formally demonstrate, through accreditation, the structures and processes in place to deliver a fellowship programme where fellows spend at least 80% of their fellowship in clinical neuroanaesthesia.

Similar to other accreditation schemes, such as Anaesthesia Clinical Services Accreditation (ACSA),5 fellowship programmes compare themselves to the requisite standards and provide evidence to support their responses; their applications are then peer reviewed. Areas requiring improvement are identified, along with suggestions to effect changes.

International accreditation of perioperative neuroscience fellowshipsThe International council for Perioperative Neuroscience TrainingDr S Bapat, Consultant Neuroanaesthetist, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, LondonDr F Roked, ST7 Anaesthetics and Intensive Care Medicine and former ICPNT Clinical Fellow, Queen Elizabeth Hospital, BirminghamDr D R Douglas, Clinical Fellow in Intensive Care Medicine and former ICPNT Clinical Fellow, UCLH NHS Foundation Trust, LondonDr A Luoma, Consultant Neuroanaesthetist, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London

The International Council for Perioperative Neuroscience Training (ICPNT) was established in 2019 to develop a global standard for education and training in perioperative neuroscience through a peer-review accreditation process. To date, there are 22 accredited fellowship programmes covering nine countries across five continents.1 ICPNT is currently under the remit of the Society for Neuroscience in Anesthesiology and Critical Care.2,3

The ICPNT’s mission is to ‘set educational standards, foster engagement, and supervise activities that promote high-quality subspecialty education in perioperative neuroscience and ultimately improve outcomes of patients with neurologic conditions in the peri-procedural period’. The educational curriculum covers key

aspects of perioperative neuroscience, as well as optional modules such as paediatric neuroanaesthesia. It is a comprehensive fellowship programme, with a minimum duration of one year, that ensures fellows develop the skill set essential to lead and support highly functioning perioperative neuroscience teams. The ICPNT educational

standards complement those required by the RCoA for advanced training in neuroanaesthesia.4 The main differences are:

■ an increased emphasis on neuromonitoring

■ the necessity for fellows to engage in academia

For an institution or department, the accreditation process encourages examination of and improvements to local education and training practices through peer review. Local experiences may be shared to facilitate learning by others to support the development of more robust education and training programmes. The ICPNT programme requires that the fellow is at a suitable stage in their training to benefit from, and complete, a neuroanaesthesia fellowship. The structure is flexible, thereby enabling fellows to satisfy personal development needs. To address the challenge of meeting international differences in neuroanaesthesia training, ICPNT sets a specific end-of-fellowship logbook case-number and case-mix, and defines the proportion of training time that should be spent in clinical neuroanaesthesia. The expected case-mix is broad, with an emphasis on more complex clinical scenarios. For institutions, this may be challenging due to differences in local practice as well as services provided, and more recently the reduced case numbers due to the SARS-CoV-2 pandemic.

Accredited programmes join the educational network run by the ICPNT Neuroanaesthesia Program Relations Committee. The committee organises regular global educational events, the first of which (a webinar) occurred in July 2020. This was followed more recently by a journal club with future plans including case presentations with discussion of challenging surgeries or decisions. These international events provide an opportunity for fellows to gain experience in novel neuroanaesthesia techniques as well as neurosurgical procedures not always available locally, enabling them to widen their scope of practice. They improve understanding of healthcare systems where the environment and resources are different to their own, promoting flexibility in thinking and a

broader world view. For programmes and fellows alike, this is an opportunity to promote academic and professional relations and facilitate networking among ICPNT-accredited programs.

For us, engagement with the ICPNT accreditation has been an overwhelmingly positive experience. Recent worldwide events have highlighted the importance and benefit of international co-operation and the need for cultural awareness and respect for diversity. ICPNT by its very nature offers membership to an international community, promoting cross-cultural working and insight into one another’s circumstances. It has the potential to develop future international networks and collaborations between programmes for research, quality improvement, and education. In the UK, upon successful completion of an ICPNT Fellowship Programme, fellows will have met the RCoA standards for advanced training in neuroanaesthesia, and their fellowship will be globally recognised through ICPNT certification. Ultimately, we believe this fellowship programme will help support advances in the care delivered to patients with neurological conditions.

References1 The International Council on Perioperative

Neuroscience Training (ICPNT) (icpnt.net).

2 Ferrario L, Kofke WA..Standardized Accreditation of Neuroanesthesiology Fellowship Programs Worldwide: The International Council on Perioperative Neuroscience Training (ICPNT). J Neurosurg Anesthesiol 2019;31(3):267–269 (bit.ly/35HRgXZ).

3 Society for Neuroscience in Anesthesiology and Critical Care (SNACC) (snacc.org).

4 CCT in Anaesthetics, Annex E: Advanced Level Training. RCoA, 2010 (bit.ly/2LQosW4).

5 Anaesthesia Clinical Services Accreditation (ACSA) (rcoa.ac.uk/acsa).

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Dr Ashwini KeshkamatI am a specialty doctor at Dartford and Gravesham NHS Trust in Kent, with a special interest in teaching.

I want to use my role on College Council to improve lifelong learning for all anaesthetists.

As a woman in the profession, I want to work towards even better recognition of the contributions of female anaesthetists. It is also important to address issues of equality, diversity and work-life balance for all our Fellows, Members and associate members.

I moved to the UK through the Medical Training Initiative (MTI) in 2011 after completing my anaesthetic training in Mumbai, India. Prior to this, I was awarded the gold medal at the Diplomate of National Board of Examinations. The College has helped me to achieve the DESA, FCAI and FRCA (2016).

In my role, I would like to use my overseas training background to further enhance the experience for the international medical graduates, MTI trainees and contribute to the global partnership goals of the College – especially shared learning across borders.

At present, I am also a member of the College’s SAS and Examinations Committees.

Looking to the future, I want to use our experience of the COVID-19 pandemic to promote better teamwork and positive mental wellbeing across the profession.

MEET THE NEW COUNCIL MEMBERS

‘My advice to anyone joining Council or contemplating involvement in any other aspects of College work: put yourself forward, make ‘yes’ your default answer.’– Dr Kirstin May

Dr Ramai Santhirapala I am a consultant anaesthetist and perioperative medicine lead in London at Guy’s and St Thomas’ NHS Foundation Trust.

I have a deep appreciation for the brilliance and challenges of our specialty, and I am honoured to represent you on Council.

I am committed to supporting the College in two areas: inclusivity and wellbeing.

As a South-Asian woman who spent her childhood in Sri Lanka and Nigeria, I understand the challenges of optimising professional opportunities while remaining authentic to cultural roots. Our College Council should reflect the diversity within our specialty. I want to see broader representation and I am committed to ensuring all have a voice.

A recent College survey (rcoa.ac.uk/frontline) reported the adverse effect of the COVID-19 pandemic on workforce mental health. I have been deployed to the ICU frontline and observed first-hand the rise in mental health issues among consultants and anaesthetists in training. Here, I have listened to trainee concerns surrounding disruption to their training pathways, especially for those taking exams.

I will work towards improving wellbeing of anaesthetists by addressing working and training conditions, strengthening peer-to-peer networks and facilitating access to formal support services.

The College is pleased to announce the election of new SAS and consultant Council members for the College; Dr Ashwini Keshkamat and Dr Ramai Santhirapala, respectively.

Many thanks to all the candidates for standing, and to all those who voted.

Terms of office commence in their first Council meeting on 10 March.

President Professor Ravi Mahajan, said, ‘The Council and its elections are vitally important to the College’s work. This is now their opportunity to work proactively and selflessly with their fellow College members, volunteers and staff to advance the work we are doing on behalf of our growing membership. I’d like to thank every member who took the time to nominate candidates and cast their vote.’

‘I would also like to thank all candidates for standing and presenting an excellent choice for the College.’

‘Congratulations to Ashwini and Ramai, I look forward to working with you both.’

The full election results are available from: rcoa.ac.uk/election-council-2021-results

THANKS TO DEPARTING MEMBERS The RCoA Council would like to thank Dr Kirstin May and Professor Jaideep Pandit for their hard work and dedication in their roles.

President Professor Ravi Mahajan, said, ‘Kirstin and Jaideep have played pivotal roles at the College, not only as members of Council but through their hard work and commitment across a wide range of activities, committees and groups.’

‘I would like to personally thank them for the time and dedication to the RCoA and wish them all the very best for the future.’

To read more about Kirstin May’s highlights from her role on RCoA Council, read her blog on the website (rcoa.ac.uk/blog).

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BEING AN EVENT CLINICAL CONTENT LEADa chance to shape the rcoa education programmeDr Gunjeet Dua, Consultant Anaesthetist, Guy’s and St Thomas’ Hospital, London

More than 1,700 of our fellows and members selflessly offer their time, energy and skills enthusiastically to the work of the College. These roles range from examiners and committee members, to ACSA leads and AAC Assessors. To highlight these roles further and to provide you with a true taste of what they involve, we started regular ‘Insider’s View’ interviews for the Bulletin last year.

In this issue, we have Dr Gunjeet Dua from Guy’s and St Thomas’ Hospital in London. Among her numerous initiatives she has developed and leads the TAP Academy Practice Course for Postgraduate Nurses for King’s College London, she was the lead in planning and leading multidisciplinary training for all anaesthetists and theatre staff at Guy’s and St Thomas’ Hospitals during the COVID-19 pandemic, and is the founder and course director for the renowned Guy’s Advanced Airway Course, which hosts about 350 international delegates every year.

Could you tell us a little bit about yourself. You’re involved in so many wonderful initiatives. How do you balance all of this?It’s hard, but if you want to do it, it’s possible. I’ve been keen on teaching and delivering education since my training days. I still remember the day when I approached my regional teaching lead to organise an airway workshop. It was the best day of that year when I got the go ahead. We worked hard, and those airway workshops grew into the Guy’s

International course. This year we did it virtually during the pandemic and had 6,000 delegates from 100 countries. It’s just building up from where you start, and if you like doing it you just keep on developing it further.

On the local level, I am the educational lead at Guy’s, looking after my department and the nurses and coordinating all the teaching activities. On the regional level, I coordinate the training days for our post-fellowship trainees. On an international level, I worked and organised the workshops at

the World Airway Management Meeting in Amsterdam a year back. It was a wonderful experience learning to deal and collaborate with experts all over the world. They have different experiences and are at different levels, which keeps it so exciting and energises you.

Did any of those roles that you just mentioned, prepare you for becoming a Clinical Content Lead?I was already attending events from the delegates side and teaching at some College courses, but I wanted to progress further. I would say working

aN INSIDEr’S VIEW

at those different levels, and with different budgets, made me challenge myself. Luckily I managed and it’s been wonderful since.

Has the experience as a Clinical Content Lead enhanced your personal learning or skill set?I joined the College at a very challenging time: the only certain thing was the uncertainty. I was really worried about joining a team where everything is virtual. Thankfully, the College made me feel so included. On the delivery front, education was being virtualised. It was so many see-saws to balance. Covid and non-Covid training. Getting the time right, getting the prices right, so people aren’t getting bombarded with webinars, but still we wanted to keep going on and bridging that gap in education during this time where we still can’t physically meet, bringing that interactive element in those webinars. All these things, as experienced as I was, I had not done before.

What I also learned, and really enjoyed bringing into my own education experience, was the emphasis now put on topics such as diversity, inclusiveness,

wellbeing, the environment and staying green – topics that probably had a lower profile in the past.

What important qualities do you think someone that would be interested in doing this kind of role should have?What makes you a good educator is having a passion for delivering education. You’ve got to enjoy it. It’s a lifelong learning attitude, changing with the times, quickly adapting, and with an inner goal to professionalise yourself. Committing to deliver 100% till the final curtain is drawn. It’s being there. Even sitting as delegate at your own event. There will be inevitable hiccups all along the way, and it’s only the team working together who can get through it and enjoy it. I can say that the main effort is at the planning stage, and that’s where you have to be keenly involved. And the more backup plans you can have, the more stress-free it is.

Are there any other experiences that you would like to share?At the first few meetings, I didn’t know who was who. It was just so formal. Now when I look back, I really laugh at

it. I felt like I was being interviewed and everybody was just there having a chat and planning the events.

If you could give one piece of advice to someone thinking about becoming a Clinical Content Lead, what would it be?The main advice is: do it if you love doing it. Don’t do it just because you have to or to help you progress professionally. It just won’t click then. Ask the questions: does your job planning fit into it, does your work–life balance fit into it, will your department support you?

Start at local events at your department level, and stay engaged throughout the event. If you are already doing it at your local level, learn to develop a structure with your events team. Keep an eye out for details, whether it’s a physical event or virtual. Believe that it’s substance more than style. Keep it simple for everyone, especially in the virtual world.

If you have the above personality, come join us! We are a great supportive team at the College, and we’ll make you dream big and achieve those dreams.

If you are interested in this or any role involving organising events or training, please listen to the full podcast of the interview here: rcoa.ac.uk/get-involved-gunjeet-dua For other ways to get involved with the college please visit the Get involved section of our website: rcoa.ac.uk/get-involved

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Detection of right (or left) bronchial intubation with the patient drape-covered is impossible by eyeballing chest movements, plus our anaesthetic monitors don’t help. EtCO2 does not change. If using high inspired-oxygen concentration (FiO2), SpO2 is on the flat part of the saturation curve; airway pressure may rise two or three centimetres of water but be accepted as normal. Chest X-ray, bronchoscopy, ultra-sound scanning and auscultation are the only ways of revealing bronchial intubation.

Ask operating department practitioners what percentage of anaesthetists auscultate after intubation: ‘About 10%, and always trainees; less than 10% measure tracheal cuff pressure’. I would like my asthmatic lungs auscultated regularly and cuff-pressure measured;11 the latter is six-hourly in intensive care.

References1 Wee MYK. The oesophageal detector

device. Anaesth 1988;43:27–29 (DOI: 10.1111/j.1365-2044.1988.tb05419.x).

2 Sellers WFS, Holesworth SP. Updating Wee’s Oesophageal detector. Anaesth 2003;58:615.

3 Nunn JF. The oesophageal detector device. Anaesth 1988;43:804 (DOI: 10.1111/j.1365-2044.1988.tb05779.x).

4 Birmingham PK, Cheney FW, Ward RJ. Esophageal intubation: a review of detection techniques. Anesth Analg 1986;65:886–891.

5 Sellers WFS, Jones GW. Difficult tracheal intubation. Anaesth 1986;41:93.

6 Kidd JF, Dyson A, Latto IP. Successful difficult intubation: use of the gum elastic bougie, Anaesth 1988;43:437–438.

7 Goodman LR et al. Radiological evaluation of endotracheal tube position. Am J Roentgen 1976;127:433–434 (DOI: 10.2214/ajr.127.3.433).

8 Conrardy PA et al. Alteration of endotracheal tube position. Crit Care Med 1976:4:8–12 (DOI: 10.1097/00003246-197601000-00002).

9 Heinonen J, Takki S, Tammisto T. Effect of Trendelenberg tilt and other procedures on the position of endotracheal tubes. Lancet 1969;1:850–853.

10 Owen RL, Cheney FW. Endobronchial intubation: a preventable complication. Anesthesiol 1987;67:255–257.

11 Seegobin RD, Van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs. Br Med J (Clin Res Ed) 1984;288(6422):965–968 (DOI: 10.1136/bmj.288.6422.965).

AS WE WERE...Tracheal-tube etiquetteSenior House Officers trained in 1975 were meant to straighten re-used red-rubber curved tracheal tubes to peer though the lumen so blockages with dried KY jelly, fluff and, if overseas, cockroaches or grubs were revealed and removed. With a good laryngoscope view, the upper area of the tube-cuff was placed just below the vocal cords. If the view was poor, the tube was inserted anyway, and if the lungs didn’t inflate on reservoir bag squeezing or automatic ventilation, Dr Mike Lindop at Addenbrookes’ had the solution. He recommended that the inserter took a deep breath, disconnected and blew down the tube. If the lungs inflated, it was not bronchospasm, a blocked or oesophageal tube; it had to be a breathing circuit problem and the patient would survive with expired air ventilation while you twiddled with the knobs. To be polite (germ-lessening), he suggested blowing through a surgical facemask. Lungs take hardly any puff to inflate and ‘Lindop lips’ may be demonstrated to trainees using three or more humidification filters, afterwards discarding the furthest away from the patient so nobody catches anything.

Michael Wee1,2 and then John F Nunn3 spotted that if the tube was oesophageal, then negative pressure – sucking on it with a bladder syringe (Wee) or an Ellick bladder evacuator (or

sucking by mouth!) – would collapse the oesophageal wall into the tracheal-tube tip, whereas if in the trachea, air came out. A ‘Positube’ was developed, similar to Wee’s device, and I think I may have the only extant one.

Oxygen saturation and end-tidal carbon dioxide were not routinely measured, and, even today, lack of an EtCO2 trace does not necessarily demonstrate oesophageal intubation. Profound hypotension, a failed analyser or one not plugged in will do it; you have to infer a tube is oesophageal, especially if you haven’t watched the tube pass the vocal cords. A review of detection techniques from Seattle had the first description of the UK’s gum-elastic bougie with coudé tip used as an oesophageal detector.4 The whole 60cm goes down into the stomach. Professor Fred Cheney in 1981 noticed a 30–40cm bronchial ‘hold-up’ of the bougie in the 2ml syringe-sized-generation bronchus; we attributed the idea to him and his resident in 1986.5 Peter Latto in Cardiff then researched

100 bougie insertions in 1988,6 confirming Cheney’s observation.

When 1975 tubes were in, bilateral auscultation of the chest was de rigueur, listening over the ribs in the axillae. This demonstrated the tube was somewhere within the trachea and there were no funny noises at that time. If noises (wheeze, rhonchi, crepitations) arrived later, with hand on heart one could say they were not there at the start. We were exhorted to write ‘equal breath sounds’ or similar on the chart. Movement of the tube tip is known to occur during flexion and extension of the neck,7,8 and the steep Trendelenburg tilt position raises the carina, even more so during laparoscopy. Therefore with a tube secured at the mouth, the tip slides down into the right main bronchus.9 Eighteen years after this paper, RL Owen and Professor Fred (again) in Seattle calculated that 21cm female, 23cm male at the incisors in adults is (usually) mid tracheal.10

Dr William F S Sellers Locum Anaesthetist, University Hospital Coventry and Warwickshirearchives@rcoa.ac.uk

This photograph was taken before the cOVID-19 pandemic

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NEW TO THE COLLEGEThe following appointments/re-appointments were approved (re-appointments marked with an asterisk).

regional advisor anaesthesiaBarts & the LondonDr Roger Cordery (Bart’s Heart Centre) in succession to Dr Chris Sadler

college Tutors East of EnglandDr Fiona Yau (Broomfield Hospital, Chelmsford, Essex) in succession to Dr Nina Walton,

Dr Elspeth Reid (AT) covering Dr Fiona Yau, (Broomfield Hospital)

Dr Victoria Howell (The Queen Elizabeth Hospital, Kings Lynn) in succession to Dr Stuart Greenhill

Dr Vanessa Johnston (West Suffolk NHS Foundation Trust, Bury ST Edmunds) in succession to Dr Abigail Hallett

MerseyDr Bethan Armstrong covering Dr Catherine Gerrard (Whiston Hospital, Prescot)

North WestDr Bernadette Lomas (Wythenshawe Hospital, Manchester) in succession to Dr Sophie Bishop

NorthernDr Karen Naru (Royal Victoria Infirmary, Newcastle upon Tyne) in succession to Dr Zoe Eke

OxfordDr Amy Swinson (Oxford University Hospitals) in succession to Dr Jonathan Chantler

WessexDr Lucy Marshall (University of Southampton) in succession to Dr Tsitsi Madamombe

West Midlands BirminghamDr Emma Plunkett (Queen Elizabeth Hospital Birmingham) in succession to Dr Suresh Natarajan

WalesDr Adrian Woollard (Neville Hall Hospital) in succession to Dr Edward Curtis

*Dr Michael Eales (Morriston Hospital Swansea)

certificate of completion of TrainingTo note recommendations made to the GMC for approval, that CCTs/CESR (CP)s be awarded to those set out below, who have satisfactorily completed the full period of higher specialist training in anaesthesia, or anaesthesia with intensive care medicine or pre-hospital emergency medicine where highlighted.

October

Barts & The LondonAleksandra Ignacka

BirminghamLaura Kocierz Dual ICM

East & North YorkshirePawan Pernu

East MidlandsPaul Groves Dual ICM

Manish MittalJoel Swindin Dual ICM

Sagar Tiwatane

ImperialLisa-Jean Sogbodjor

Kent, Surrey & SussexDouglas Stangoe

North Central LondonKaren FanEmma Sharkey

North WestMichael McEvoy Dual ICM

Natalie QuinnCheng Tan Dual ICM

NorthernCatherine Phoenix

OxfordJames Hardwick Dual ICM

PeninsulaAnne-Marie Bougeard

South EastIan DavisBrenda NyamaiziAdetokunbo Owolabi

WalesDaniel O’DonovanThomas Rees

WarwickshireGunasheela Kalashetty

WessexRhys Davies

West of ScotlandJoe Hawkins Dual ICM

Alastair Hurry Dual ICM

Kevin McNamara

West YorkshirePhilip Antill Dual ICM

Thomas MillerRobert Neal

November

Barts & The LondonLaura ElgieDominic Nielsen

East MidlandsLaura Carrick

ImperialCosmo Scurr PHEM

Hannah Talbot

Kent, Surrey & SussexTimothy BakerNatasha Clunies-RossAnita Thoppil

MerseyLuke Dias

North Central LondonTimothy Dawes Joint ICM

North WestMarni LechlerPriyadarshan Potla

NorthernJane Danby Dual ICM

South EastValentine Woodham

West of ScotlandGraeme Carroll

ErraTUMDue to a clerical error in the College’s database, the following anaesthetists who completed their training in the East of England were erroneously listed as having completed their training in Kent, Surrey, and Sussex in the November 2020 issue: Dr Lisa Grimes, Dr Julia Neely, Dr Meike Keil, Dr Rachael Morris and Dr Daniel Stolady. We apologise for this oversight. The online version of this issue will be corrected accordingly.

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APPOINTMENT OF MEMBERS, ASSOCIATE MEMBERS AND ASSOCIATE FELLOWSAssociate MembersDr Anish JosephDr Richard Anthony BuckleyDr Iranga Chanaka Gebalanage

Dr Salem Alaref Salem JamhourDr Divya KumarDr Dissanayake Mudiyanselage Sumudu Ruwanthi Seneviratne

AffiliateMr Mark Shaun Fernie

APPOINTMENT OF FELLOWS TO CONSULTANT AND SIMILAR POSTSThe College congratulates the following fellows on their consultant appointments:

Dr Sabina Bachtold, Frimley Health NHS Foundation Trust

Dr Jigneshbhai Patel, Queen Elizabeth Hospital, Birmingham

Dr Sioned Phillips, Frimley Health NHS Foundation Trust

Dr Marc Vilas, Forth Valley Royal Hospital, Larbert

DEATHSWith sadness, we record the death of those listed below.

Dr Noormohmed Doctor, LondonDr James Gutsell, AttleboroughDr John Mathias, LondonDr Geoffrey T Taylor, Isle of WightDr Jeremy Taylor, Surrey

To submit an obituary that will be published on our website (rcoa.ac.uk/obituaries), please email your text (500 words) to archives@rcoa.ac.uk

LETTERS TO THE EDITORIf you would like to submit a letter to the editor please email bulletin@rcoa.ac.uk

Dr helgi Johannsson

Dear Editor,

The dangers of dental drills

Drill use during dental and maxillofacial surgery is commonplace and often instills a great deal of anxiety for the awake patients on which it will be used. While accidents involving dental drills have been reported, thankfully they do not appear to be commonplace. In our hospital, eye-protective equipment is not routinely used by members of the surgical team who are not directly adjacent to the patient. However, more specifically, eye protection is very rarely used even by the operating surgeons themselves.

A previously published case report has shown that dental surgeons are at risk from fractured dental burs,1 and cases of patients aspirating dental burs are also recognised. Here I present a case of a missing dental-drill piece that highlights the potential risk to not only those directly adjacent to the patient but to all staff present in theatre at the time.

A previously fit and well ASA 1 patient had been anaesthetised, intubated and brought into theatre for a routine dental procedure. During the operation a dental drill was required. Drilling commenced without incident initially, but shortly after starting a loud ‘pop’ was heard from the drill, whereupon activity ceased. It became evident that there was no longer a bit inserted in the drill but its location was unknown. An initial examination by the maxillofacial registrar revealed no

injury to the patient and no evidence that the piece was either in or on the patient. Further searching by surgical staff around the theatre suite was also unsuccessful. The procedure continued with a new drill without complication. It was only during the next case that a member of the scrub staff looked up to find the drill-bit impaled into the ceiling of the theatre.

To this author’s knowledge, this is the first report of a dental-drill separating from the drill with enough force to embed itself into a ceiling. Hopefully, it highlights the potential risk to all members of the theatre team, not just the operating surgeons or patient. Extra vigilance should be taken to ensure that dental burs are securely locked into place before drilling commences; perhaps all members of the theatre team should be offered eye protection in the future to prevent catastrophic ocular injury.

Dr Mitchell Cole, ST6 Anaesthetics, Northern School of Anaesthesia

Reference1 Kassahun H et al. Unexpected hazards

with dental high-speed drill. Dent J (Basel) 2017;5(1):10 (bit.ly/2XILpx2).

Dear Editor,

Tea Trolley Training: a COVID-19-safe method of practical learning

In addition to the many merits detailed by Dr Corbett et al (Jan. 2020, Issue 119, p28) and Drs Gough and Pickering (May 2020, Issue 121, p56), we have found Tea Trolley Training to be a particularly effective educational tool during the COVID-19 pandemic.

Sadly, like many other hospitals, departmental educational opportunities within our institution have been greatly curtailed due to unprecedented clinical pressures and the restraints of social distancing. Our department was keen to maintain emergency front-of-neck access (eFONA) training, particularly due to the increased potential for difficult airways in COVID-19 patients with high rates of severe laryngeal oedema. Our key aim was to produce the most high-fidelity training possible due to the practical nature of the skill. A zoom meeting would certainly not be sufficient in this case!

Tea trolley training was delivered in anaesthetic rooms during operating lists, or in recovery areas at quiet times. We used crico-trainer models and the relevant airway equipment as per Difficult Airway Society guidelines.1 All models and additional kit were washed down with chlorhexidine wipes after each use, and hand gel was made available on the trolley.

Staff members participating adhered to social-distancing recommendations, wearing masks and gloves throughout the session.

Our feedback was globally positive, showing that people found the training highly useful, enjoyable and felt safe throughout. We recorded increased confidence scores in performing eFONA post-training when compared to pre-session scores. Many participants commented that undertaking training in this way also ensured good use of theatre downtime, ie, waiting on air changes in between cases, or cancelled lists due to emergencies or bed pressures.

We will continue delivering much-welcomed training sessions using this method for the duration of the pandemic and beyond.

Dr Catherine McGow, CT2a ACCS Anaesthesia, Mersey Deanery

Dr Marysia Cywinski, ST7 Anaesthesia, Mersey Deanery

Reference1 Frerk C et al. Difficult Airway Society 2015

guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827–848.

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The college has developed a toolkit that offers patients the information they need to prepare for surgery, including the important steps they can take to improve health and speed up recovery after an operation.

The Fitter Better Sooner toolkit consists of:

■ one main leaflet on preparing for surgery ■ six specific leaflets on preparing for some of the most

common surgical procedures ■ an animation which can be shown on tablets, smart

phones, laptops and TVs.

You can view the toolkit here: rcoa.ac.uk/fitterbettersooner

We have also created printable posters, flyers and stickers to help you signpost patients to the toolkit. The animation can be shown on TVs in waiting areas. You can find all these additional resources and instructions on how to download the animation in MP4 format (or request a version in PowerPoint) on our website here: rcoa.ac.uk/patientinfo/healthcare-professionals

Please share this toolkit with colleagues in both primary and secondary care settings.

It has been shown that people who improve their lifestyle in the run up to surgery are much more likely to keep up these changes after surgery.

Online events23–24 March 2021

27–28 April 2021

rcoa.ac.uk/events

BOOKNOW!

Patient Safety in Perioperative Practice20 april 2021 | Online

rcoa.ac.uk/patient-safety-periop-practice

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Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

Book your place at rcoa.ac.uk/events | 63

rcoa.ac.uk/anaesthesia

18–20 May 2021 Online

Co-badged with:

Professor Suellen WalkerGreat Ormond Street Hospital for Children, London

Dr Brendan McGrathManchester University NHS Foundation Trust

Professor Kathryn MaitlandImperial College London

Professor Niels PeekThe University of Manchester

Professor Rupert PearseQueen Mary University of London and Barts Health NHS Trust

Dr Hilary SwalesRCoA Patient Information Lead

Dr Andrew KleinRoyal Papworth Hospital NHS Foundation Trust, Cambridge

Dr Lauren OswaldChristie NHS Foundation Trust, Manchester

JOHN SNOW ORATION

MACINTOSH PROFESSORSHIP LECTURE

Early birdplaces available until 18 March – save up

to £180

POSTERCOMPETITION

PODCASTSVisit our website to hear sneak peak programme preview podcasts.

POSTER COMPETITIONPrize: £250

Deadline: Sunday 25 April 2021If you have worked on a quality improvement or research project please submit a poster for your chance to showcase your work. Full details can be found online.

Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021

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Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details. %

Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

Book your place at rcoa.ac.uk/events | 65

Regional Anaesthesia Masterclass24 March 2021 | Onlinercoa.ac.uk/events/regional-anaesthesia-masterclass

After the Final FRCA: making the most of ST5-ST721 april 2021 | Onlinercoa.ac.uk/events/after-final-frca

UPCOMING WEBINARSNew webinars are released regularly.

Please visit our website for dates, topics and speaker information.

rcoa.ac.uk/webinars

The RCoA Leadership and Management series covers a spectrum of topics designed specifically for anaesthetists that are senior trainees and consultants.

The Essentials27 May 2021 | Online

WATC H N OW >WATC H N OW >Visit our website to hear from the faculty about the

Leadership modules and the reasons to attend:rcoa.ac.uk/leadership-management-programme

Bulletin | Issue 126 | March 2021

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Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

Book your place at rcoa.ac.uk/events | 67Book your place at rcoa.ac.uk/events66 |

%

Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

Bulletin | Issue 126 | March 2021

Cardiac Disease and Anaesthesia Symposium22–23 april 2021 | OnlineCelebrating 20 years of the Cardiac SymposiumNow in its 20th year, the Cardiac Symposium remains the leading conference on Cardiac conditions and their management.

Bringing together anaesthetists, cardiologists and intensivists; the conference is a unique opportunity to hear from experts, many of whom have worked tirelessly in this field over the years, presenting a multi-disciplinary approach to give the best possible care to our patients.

■ Non-invasive cardiac evaluation. ■ Anaesthesia for grown-up congenital

heart disease patients. ■ Pulmonary hypertension case

management. ■ Pathophysiology of coronary and valvular heart disease. ■ Managing patients with heart failure. ■ Patients with left ventricle assist devices. ■ Cardiac problems in COVID-19 patients.

Key topics

Dr Helen Higham

Professor Saul Myerson

Dr Kate Grebenik

Professor Pierre Foëx

#rcoacardiacCPD credits 10

rcoa.ac.uk/events/cardiac-disease-anaesthesia-symposium

YEarS

Now in its 20th year!