TIVA Part I - Pharmacokinetic Principles and Methods of Delivery PDF

THE ROYAL COLLEGE OF ANAESTHETISTS
48/49 Russell Square London WC1B 4JY tel ++44(0)20 7813 1900 fax ++(0)20 7813 1876 website www.rcoa.ac.uk email info@rcoa.ac.uk President Professor P Hutton Vice-Presidents Dr P J Simpson & Dr D M Justins Editorial Board John Curran Peter Hutton Mandie Kelly (Editorial Officer) Gavin Kenny Rajinder Mirakhur Jane Pateman Anna-Maria Rollin (Editor) Peter Simpson
Inside Bulletin 16
The Royal College of Anaesthetists is grateful for the contribution to the production of this publication by:
763 Presidents Statement 766 GUEST EDITORIAL Apocolypse 2004? 768 National Anaesthesia Day, 8 November 2002 769 Vital work of anaesthetists goes unrecognised by most of the public 771 National Anaesthesia Day sponsors 773 AAGBI and National Anaesthesia Day 774 The Data Protection Act: A joint statement by the RCA and AAGBI 775 Non-consultant career grades
2002 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. Fellows, Members and trainees are asked to send notification of their changes of address direct to: Miss Karen Slater, Membership Officer, at The Royal College of Anaesthetists tel 020 7813 1900 fax 020 7580 6325 email subs@rcoa.ac.uk. Articles for submission, together with any declaration of interest, should be sent via email (preferred option) to: bulletin@rcoa.ac.uk, or by post (accompanied by an electronic version on a floppy PC disk, preferably written in any version of Microsoft Word), to: Mrs Mandie Kelly, Editorial Officer, The Royal College of Anaesthetists. All contributions will receive an acknowledgement. The Editor reserves the right to edit articles for reasons of space or clarity.
776 TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Total intravenous anaesthesia (TIVA) I: Pharmacokinetic principles and methods of delivery 780 TRAINEES TOPICS An experience of an overseas trainee 782 A review of Guide to the FRCA Examination: The Primary 783 RCA Education Programme 791 AUDIT AND THE EVIDENCE BASE OF ANAESTHESIA Assessing anaesthetists performance using recovery indicators 795 Centers for excellence in regional anaesthesia 797 Why study the history of anaesthesia? 799 Appeals 801 Report of meetings of Council 803 Flexible working for doctors 804 Report of the College Tutors Meeting, April 2002 805 Conscious sedation in termination of pregnancy 806 Correspondence 810 Notices
The views and opinions expressed in the Bulletin are solely those of the individual authors, and do not necessarily represent the view of The Royal College of Anaesthetists
Presidents Statement
irst of all, enormous thanks to all those who contributed data to this years census. Although one or two departments needed a little prompting, we ended up with 100% response rate which must be unique in the history of data collection. This information is of inestimable value for planning and for David Saunders who represents the College in manpower discussions with the DOH.
An update on potential changes to postgraduate training

As predicted in my last Presidents Statement, several government working papers were slipped out during Summer, notably the Statement of Policy on the new Postgraduate Medical Education and Training Board (PMETB) which will replace the Specialist Training Authority (STA), and the long awaited SHO recommendations entitled Unfinished Business. The content of the PMETB Statement on Policy1 was a great improvement on the previous Medical Education Standards Board (MESB) proposals which appeared so negative towards the role of Colleges. In the Statement it states clearly that one of the objectives of the PMETB is to consolidate and strengthen the position of the Medical Royal Colleges and Faculties as essential elements of the education and training process and also that the PMETB would base the specialty subcommittees around the specialty training committees of the Colleges. These good intentions now need to be presented to Parliament in a new Statutory Instrument (SI) that includes General Practice Training. The devil, as usual, will be in the detail and in particular, in the apportionment of powers and responsibilities between the profession and the government. It will be one of our major exercises to respond to the SI during its autumnal consultation period and make the best representations we can in the interests of patients and trainees. Unfinished Business2 resulted from an initiative of the Chief Medical Officer who set up a working group to advise him on the problems of SHO training. How our College came to be missing from the bodies listed at the back that had submitted evidence, I do not know, since Stuart Ingram toiled tirelessly on behalf of our trainees. With hard-working College Tutors, Programme Directors and Regional Advisers, SHO training in anaesthesia is well organised with a proper curriculum and assessments. Unfortunately, many SHO posts in other disciplines are not part of a planned educational programme and provide limited educational content. Some are occupied for years by stuck doctors,
1 2 3 4
much to their own detriment. Consequently, Unfinished Business was targeted not at us, but at others. Our strategy was directed firstly at making sure that our SHOs would not be disadvantaged by any proposed changes and, secondly, if possible, to use the changes to improve choice for our own specialty. Essentially, both these objectives were achieved. The document is now out for formal consultation and we will reinforce these principles during this period. What we must be careful of is the attractiveness of anaesthesia and critical care training posts to other specialties resulting in a diminution of training opportunities for career gas-persons.
Devolution, primary care trusts and the inexorable growth of uncertainty

Hardly a week goes by that I am not reminded somehow or other that the UK now has four health systems that are becoming increasingly autonomous. Some of this is good: it is to their credit that the administrations in Northern Ireland and Scotland have grasped the nettle of service rationalisation and published public consultation documents.3,4 Meanwhile, in England, the last election result at Kidderminster (now known in Whitehall as the K-word), continues to frustrate sensible debate about how best to deliver a health service. Another example of the difficulties of devolution is that although the SI relating to the PMETB will apply to the whole of the UK, it has to be introduced and approved separately by both the English and Scottish Parliaments: failure in either will result in its delay and obligatory revision. To confuse matters further, it is not clear just how well Primary Care Trusts will function now that they carry the lions share of the NHSs financial resource and are meant to take great note of local opinion. Soon, votes, or the need to obtain them for re-election will again begin to dominate the thoughts of those who need electoral support. It is a cruel anomaly for a Government that has pledged more resource to healthcare than any other in the last 50 years that the achievement of their national targets requires policies which automatically bring them into direct conflict with local pressure groups. As the devolved administrations continue to flex their muscles and the vox populi potentially becomes ever more selfish and at variance with strategic policy there must be many in the government having second thoughts about the wisdom of their recent policies.
Available at www.doh.gov.uk/medicaltrainingintheus. Available at www.doh.gov.uk/shoconsult. DHSSPS. Developing Better Services: Modernising Hospitals and Reforming Structures. Available from: www.dhsspsni.gov.uk/publications/2002/betterservices.html Future Practice: A review of the Scottish Medical Workforce. Available at www.scotland.gov.uk/publications.
Bulletin 16 The Royal College of Anaesthetists November 2002 763
Politeness, political correctness, probity and trust

True politeness to ones fellow man that intuitively recognises and respects personal differences is a gift that not everybody possesses. Both history and war teach us that such differences have been, and still are being, exploited to achieve misguided human aims. The latest edition of Good Medical Practice makes it clear that all doctors working in the UK should respect the wishes and cultural norms of all their patients. This is very important not only because of Britains multicultural society but also because it sets the standard for those who come to work here from abroad. Conversely, certain aspects of political correctness (PC) which probably started out as a vehicle for reform and the recognition of individual differences, are now becoming oppressive and counter-productive. Some political correctness is now probably offensive to those it is meant to protect. Because the College falls under the new Race Relations Act we have been required to document a policy on equal opportunities, and racial awareness and monitoring. This has been done as sensitively as possible and is now in place. Those undertaking duties for the College will in future be requested to fill in a questionnaire, but compliance is voluntary. Extremes of PC expression were collected together some years ago in the Official Politically Correct Dictionary and Handbook.5 This has some real winners (with their reference sources) such as an aircraft crash being described as a failure to maintain clearance from the ground and is an excellent source of harmless after-dinner material. One area in which medicine internationally has tried to be completely above suspicion is in the prevention of research fraud and the insistence of disclosure of financial interests.6 In 1996, the New England Journal of Medicine (NEJM) introduced a policy as follows: Because the essence of reviews and editorials is selection and interpretation of the literature, the journal expects that authors of such articles will not have any financial interest in a company (or its competitor) that makes a product discussed in the article. The upshot of this laudable policy has been that in the last two years, the NEJM was able to solicit and publish only one review in their Drug Therapy series on novel forms of treatment. In short, all the experts had an interest or conflict of interest and so were ineligible to submit manuscripts. The insistence on perfection resulted in a reduction in the flow of valuable, up to date information to the medical profession. To counter this problem, a new statement has been issued
like the one above but with the word significant inserted before financial interest.7 Guidelines as to what is significant are subsequently described as holdings in stock or patent licences or remuneration over US$10,000 per annum. The emphasis is, however, that these are guidelines and in the end, the editors will have the final say. Personally, Im pleased to see this modification introduced because in so many aspects of medical life we need to return to accepting judgement and trust rather than striving for absolutes. The theme of trust was developed elegantly by Baroness ONeill in this years Reith Lectures entitled A Question of Trust.8 Early on she developed the argument that in the public sector the focus is on performance indicators chosen for ease of measurement and control rather than because they measure accurately what the quality of performance is. She concluded that If we want a culture of public service, professionals and public servants must in the end be free to serve the public rather than their paymasters. Her comments that over zealous monitoring and the never-ending drive to transparency might actually encourage deception and reduce trust will not be welcome messages for some of our current political leaders.
The information super-highway and human rights legislation

For some time now I have been trying to develop my thoughts on the relationship between the internet and the Human Rights Act (HRA).9 As a start I tried to find a historical event that was analogous to the impact of the internet. The best that I could come up with was the invention of Johann Gutenberg, a fifteenth century dot.com entrepreneur who mass produced individual, movable letters for a printing press. This made it possible to produce written words in infinite quantity and in identical copies. True to form, he over invested and went bust, but not before his printing press was producing multiple, affordable copies of the Bible. William Caxton went to Cologne to learn this art of printing with moveable type and introduced it to England in 1478. The ability to print easily increased the facilities for the spread of antigovernment and anti-church literature and in 1529 Henry VIII required that all books had to be licensed by the Privy Council. In 1586 the Star Chamber was established to control publication of domestic and overseas news and printing presses were limited to London, Oxford and Cambridge.10 Nearly two hundred years later, The Gentlemans Magazine was still publishing House of Commons Debates under disguises such as Accounts of Proceedings in the Senate of Lilliput. The literary freedoms espoused by JS Mill in the nineteenth century which we now take
5 Beard, Cerf C. The Official Politically Correct Dictionary and Handbook; Grafton, London, 1992. 6 Davidoff et al. Sponsorship, authorship and accountability. The Lancet 2001;358:854. 7 Drazen JM, Curfman GD. Financial associations of Authors; NEJM 2002;346:1901. 8 ONeill O. A Question of Trust. The Reith Lectures 2002. Cambridge University Press, 2002. 9 Human Rights Act 1998 at www.homeoffice.gov.uk/hract/guidlist.htm. 10 Drabble M. Censorship and the Laws of the Press in The Oxford Companion to English Literature, OUP 1985:1101. 764 Bulletin 16 The Royal College of Anaesthetists November 2002
for granted were not conceded easily by English governments. So, am I just a reactionary old buffer responding true to type and standing in the way of progress when I am concerned that the HRA states in Article 10, the Freedom of Expression: Everyone has the right to freedom of expression. This right shall include the freedom to hold opinions and to receive and impart information and ideas without interference by public authority and regardless of frontiers. Well, I dont really think I am. My concern with this article of the HRA is that it is strong on rights but weak on duties. As far as I know it is not possible to expect as a right that another person will give you accurate information, or legislate that they should. It is paradoxical that the much-maligned professional codes by which we regulate our relationships with patients are (unlike the HRA) built on the cornerstones of honesty, probity and duty. The consequences of this freedom of expression for the information put on the internet are very far reaching. Over 50% of adults with internet access now search it for health information.11 The huge differences between the net and the historical situations described above are the volume of information, the absence of any checks on its accuracy and claims, the ease with which it is changed, the international nature of its transmission, the difficulty of refuting or correcting falsities and the complete absence of accountability. Outside our specialty I feel great sympathy with the oncologists who are facing a morass of anti-establishment lobbying which frequently gives false hope to patients, usually at a pre-set price. The worst of all is when authoritative journals are selectively quoted to give support to a completely unrepresentative and specious argument. Could I please ask anybody who finds a patient who has consulted a website (whether they found good or bad information) to drop us a line with the website address so that we can build up a database of those relevant to anaesthesia, critical care and pain relief.
aspects of medicine. Charles Stack piloted through a document on the care of the dying child13 and David Hatch led the GMC's review on withholding and withdrawing life-prolonging treatments.14 Both are clearly written, informative and reasoned, and give practical advice to doctors and other staff involved in the care of the dying. They should be obligatory reading for all trainees and consultants.
Are we entitled to have a say?

Modern anaesthesia is now so safe and we make it look so easy that its dangers are readily forgotten. This creates an expectation in the minds of others that enable them to make decisions without taking us into account. An example of this was the discussion surrounding caesarean section on maternal request when neither the dangers of anaesthesia nor the ethical position of the anaesthetist were considered.15 More recently, (and to their credit), surgeons have questioned the value of some surgical procedures and introduced the possibility of using sham operations (including anaesthesia) as placebo controls.16 Again, there has been no proper discussion of the risks of anaesthesia and no consideration given to the ethical position of the anaesthetist. For us, this is new territory and an area in which we need our thoughts clear before finding a sham patient on an operating list. How would you feel if that dreaded disconnection or anaphylactic reaction just happened to be then? Views on this subject would be welcomed.
National Anaesthesia Day

National Anaesthesia Day is on 8 November. Please give support in whatever way you can. John Goldstone, Juliet Davies and the team, together with our sponsors all deserve a big thank you for the work they put in to represent our specialty in the most positive way possible. Please refer to their contributions later in this issue to get up-to-date on what is happening.
Endnote
Anaesthetists make up over 15% of hospital doctors but only 3% of those who have been referred to the NCAA. They are also under-represented proportionately in GMC enquiries. This means that we run into fewer problems than others or that local mechanisms of clinical surveillance are working appropriately. Either way its good news for the specialty. On that positive note, have a happy Christmas and best wishes for the New Year.
To comfort always
Congratulations to Ian Nesbitt, a consultant in anaesthesia and intensive care from Newcastle upon Tyne for his BMJ filler entitled A lie softly spoken.12 This described the ethical conflict of compassion versus honesty in the management of a fatally injured elderly lady. I am sure that this dignified account reminded many outside our specialty of the human roles they forget we play amongst the paraphernalia of technological medicine. Two other College Fellows who recently chaired working parties also deserve praise for their contributions to the wider
Peter Hutton
11 Sastry S, Carroll P. Doctors, patients and the internet: time to grasp the nettle; Clinical Medicine 2002;2:131. 12 Nesbitt I. A lie softly spoken. British Medical Journal 2002;324:1122. 13 Paediatric Intensive Care Society, Standards for Bereavement Care 2002. 14 Withholding and withdrawing life-prolonging treatments: good practice in decision-making. Available at www.gmc-uk.org. 15 Paterson-Brown S. Should doctors perform and elective caesarean section on request? British Medical Journal 1998;317:462. 16 Ridgway PF, Darzi AW. Placebos and standardising new surgical techniques. British Medical Journal 2002;325:560.
Guest Editorial
Apocolypse 2004?
f you thought that things were bad last time I wrote an editorial on workforce issues1 they have now become very much worse. Critical Care departments throughout the UK are currently struggling to comply with the terms of the New Deal junior doctors contract which came into force on 1 December 2000. A punitive system of payment to current trainees whose posts are non-compliant with the hours-limits and/or the rest requirements of the New Deal has been put in place. For all contracts issued from 1 August 2001 for PRHOs and from 1 August 2003 for SHOs and SpRs, trusts must clearly demonstrate that posts are fully compliant with the hours limit of the New Deal or they will be in breach of contract.2 Repeated surveys have shown that a significant number of hospitals, arguably the majority, have not been able to move trainees onto a compliant contract whilst maintaining a viable service to patients. Furthermore, many departments cannot see any way in which successful implementation can ever be achieved. As if that were not enough, the legislation implementing the European Working Time Directive (EWTD), the Working Time Regulations (WTR), came into force on 1 October 1998. This is European health and safety legislation providing a mechanism by which the entire workforce, including doctors, can reduce excessive working hours.3 Certain sectors of the workforce are currently excluded from the scope of the Regulations, including deep-sea fishermen and doctors in training in the UK. A timetable for the implementation of the required 48-hour week for junior doctors is included in the Regulation: A maximum of a 58 hour working week by 1 August 2004. A maximum of a 56 hour working week by 2007. A maximum of a 48 working week by 2009. A further transitional period of three years may be allowed after application to the EC whereby the 48-hour week is not implemented until 2012 and a 52-hour week is imposed in this transitional period. It is difficult to believe that a UK government will not apply for this extension.
UK (and only in the UK) it is possible to apply for derogation (L derogatio lessening or impairment of law) from the WTRs; an individual worker states that he/she does not wish to limit the number of hours worked by them per week. In the absence of a new consultant contract, the CCSC of the BMA negotiated derogations for senior hospital doctors in a way which enabled the service to be sustained; this collective agreement was promulgated to trusts.5 It is possible also for doctors in training to apply for derogation, however it is not possible to negotiate derogation for the entire body of trainees. The UK right to derogation is due to be re-examined in 2003 at which time the privilege may well be withdrawn.
Ways forward assuming an insignificant increase in the medical workforce

The first way in which Problem 2004 could be ameliorated is by a radical rethink about the ways in which healthcare is delivered to a geographical area. This concerns the reconfiguration of local health services; the dreaded R word. In the current political climate this is unacceptable but may be the only way in which a 2004 crisis could be managed. A second way would be radically to change working practices. In anaesthesia it would be theoretically possible to utilise existing facilities more extensively by twilight and weekend working; this is presumably what was in the mind of the negotiators of the new consultant contract. Even if satisfactory terms of service could be negotiated for medical staff before 2004 experience has shown that medical staff are not usually the limiting factor in the implementation of this type of arrangement. The problems of staffing intensive care and obstetric anaesthesia remain intractable. Thirdly, an expansion of the anaesthetic workforce could be introduced by extending the duties of the non-medical members of the anaesthetic team. Even if deemed acceptable, the necessary training could not be delivered in the time frame available
Increasing the size of the medical workforce

Planned expansion The number of consultants in England will grow from about 3,800 at present to about 5,000 at the end of the decade if the currently planned expansion is maintained; this does very little to assuage the 2004 problem. Worryingly, there has been a change in the manner in which the expansion in the number of NTNs is funded. When agreement on expansion of the grade between the College and the workforce planners was reached last year it was assumed, probably naively, that this would be fully funded by new money. However, the powers-that-be have come up with a scheme whereby, for a small number of posts (the so-called floor), the money must be found by the postgraduate deans but for a much larger number of posts (the ceiling) monies must be found from other sources. This has lead to a re-mapping exercise; trusts have
The situation has become further fraught by the successful application of a group of doctors in Valencia to the European Court of Justice of the European Community. In the so-called SiMAP4 judgement, if a doctor is present and available in the workplace with a view to providing professional services, the time is to be counted as hours worked. Thus, if a trainee is asleep in an on-call room they are considered to be present and available and therefore must be deemed to be working. It will be readily seen that critical care departments who already have no idea how the New Deal is to be implemented will be faced in August 2004 by an even higher hurdle, the 58 hour week backed up by the SiMAP judgement; a last straw indeed. Consultants and other career grade doctors have been labouring under the terms of the regulations for four years. In the
766 Bulletin 16 The Royal College of Anaesthetists November 2002
been asked to look for ways in which the money for extra NTNs could be raised from existing funds such as abolishing redundant SHO posts or converting staff grade positions. It is clear that this is highly likely to be the way in which these posts are to be funded in the future. Since the round of bidding began it has become obvious that district general hospital trusts have applied for the majority of the posts. This will make available more training opportunities in SpR years 1 and 2 but, as the trusts containing the specialist units have been able to find relatively little money in the re-mapping exercise, higher specialist training will be much more difficult to deliver. More UK graduates The government have taken the commendable step of substantially increasing the numbers of students entering medical schools. In 1997, 3,749 places were available to aspiring doctors; in 2005, 5,894 places will be available. This increase in the total number of UK graduates will, of course, have no effect on the 2004 problem; the welcome increase in potential specialists will not be seen until the end of the decade. It is not clear how many graduates will wish, quite understandably, to work flexibly. It is quite possible that the increase in graduates will be mopped-up by the desire of specialists to undertake part-time work. Anaesthetists trained overseas There has been a move to recruit overseas doctors into the workforce on a temporary or permanent basis. At the time of writing this appears not to have been particularly successful in the specialty of anaesthesia and intensive care and in any case the vast numbers that would be needed to avert disaster are most unlikely to be recruited in time for the 2004 deadline. Creative accounting An apparent increase in the workforce at resident on-call level has been achieved by the creation of posts with names such as clinical fellow or trust fellow. These are often very attractive jobs as far as training goes; they exist most frequently in heavily trainee dependent for service areas such as adult and paediatric intensive care. The increase in the workforce is apparent rather than real because the main way that it is achieved is by attracting, and thereby delaying, trainees who should really be progressing through the training scheme to gain a CCST. This has the effect of lengthening an individuals training and increasing the size of the training grade pool. Thus, the on-call rotas are patched up to the detriment of the numbers of fully-trained applicants for consultant positions.
At a national level it is highly likely that ways of overturning the SiMAP judgement are being investigated. However, the average time taken for a submission to be heard by the European Court of Justice is reported as being five years. One way forward would be for trusts to seek to expand derogation to individual trainee anaesthetists; this, however could not be a compulsory procedure and would therefore be potentially expensive. Further, it is quite possible that the ability of UK employees to agree derogation will be withdrawn in 2003. It is quite clear that, as the law stands at the moment it would be open, in 2004, for an individual trainee who felt that the conditions of the WTR were not being met to take the employing trust to the European Court of Justice. In summary, when all workforce issues are considered it would appear that, whatever expansion is possible, it will not be nearly sufficient to prevent the predicted problems from occurring in 2004. It is highly unlikely that European law can be amended in the time available and it is not clear whether trainee derogation can be negotiated. It is essential therefore that each department calculate the effect of making all training posts compliant with the WTRs and the SiMAP judgement. Contingency plans must be put in place after urgent discussion with trusts. Trusts, in turn, must feed the immense problems centrally. There is no doubt that, if SiMAP cannot be renegotiated, the plans will necessitate the absolute minimum number of doctors being resident on-call. What a mess! The views in this editorial are my own and do not necessarily reflect those of College Council. Events are moving so quickly that details may be out of date by the time of publication.
David Saunders Southampton General Hospital

References 1 2 3 4 5 The College, SWAG and the National Plan. The Royal College of Anaesthetists Bulletin 3 (September 2000). HSC/1998/240 amended in respect of weekend rest requirements. Department of Trade and Industry website: http://www.dti.gov.uk/er/work_time_regs/ Sindicato de Mdicos de Asistencia Pblica. Department of Health Advance Letter (MD) 6/98 Working Time Directive: agreement for career grade doctors.
August 2004
It is fairly straightforward to calculate the number of anaesthetists required to deliver the service at its current, somewhat dire, level if all contractual and legislative conditions were to be met. Having performed the calculation, it would appear likely that, if the entire workforce, both training and career grades, were put onto a full shift system, the present service could not be maintained. As it is clear that the service must be maintained it would appear that the way forward will be through negotiation and through the courts.
National Anaesthesia Day, 8 November 2002

Dr J Goldstone, Chairman, NAD Working Group
o here we are in our third National Anaesthesia Day! It is very exciting that we have the support from so many to continue this project In particular we are very pleased to see other projects which educate the public and patients, the central aim of National Anaesthesia Day. We have had continuing support from the College and I should take the opportunity in this edition of the Bulletin to thank all those within the College who have given us time, whether that be in secretarial support, financial matters, or indeed sitting on our Working Group. The National Anaesthesia Day Working Group is unusual in its balance. Co-opted members are Terry Cluff from DatexOhmeda, Emma Crabtree from Abbott Laboratories, Simon Theobald from Aspect Medical Systems, and Liam Grottick from B.Braun. All four companies have sponsored the project this year, not only in financial terms, but with logistical and practical support. You will also see that we have co-opted Bill Kilvington, the President of the Association of Operating Department Practitioners, and Melanie van Limborgh, the acting Chairman of the Association of Theatre Nurses(NATN).Both are great supporters as members of the anaesthetic team. Melanie herself is an anaesthetic nurse and we are delighted that at the NATN meeting in Harrogate on 10 October a slot was given over to National Anaesthesia Day. Much help has been given by Andy Coughlan at Smiths Medical, who yet again this year have sponsored our website and made this so simple and easy to run. It is a mine of information and we know it is used regularly by patients, the public and particularly the press. I dont know whether it is pleasing, amazing, or probably to journalists just plain normal, to see that whatever piece we see printed in whatever publication, appears to be a cut and paste from the documents which we have made freely available on the National Anaesthesia Day web pages. The Fact Sheets in particular have formed the basis of many articles. This year we are sure the documents: Ten things patients want to know about anaesthesia and also Twenty things you didnt know about anaesthesia will be a source of more media coverage. Clew Communications (previously Second Opinion) have once again promoted National Anaesthesia Day for us and there are more marvellous presentations designed by HGV Design. We hope both will help to make yet another successful day.
So what is new this year?

This year the slant has been towards educating school children. You will know by now that the reason for this has been the results of the two MORI Surveys we have undertaken so far, as well as the MORI Poll publicised for the first time in this edition of the Bulletin. Younger people are the least well-informed of all demographic groups surveyed by MORI, identifying an underlying lack of knowledge and understanding about anaesthesia and what it involves. So this year we have tried to link the art and science of anaesthesia to the National Curriculum, and invite school children into the hospitals taking part. For the first time we are hosting an event at the Royal College consisting of lectures and displays for school students in London, and all available space in the College has been given over for this task. Once again, we are very grateful to our sponsors for their help with this event. By now you will also know about the competition for schools running on National Anaesthesia Day. The competition asks the school children participating in National Anaesthesia Day what they think a patient is most likely to want to know and what questions they think a patient will have before having an anaesthetic. The tie-breaker is to complete the slogan: Anaesthetists not only keep you asleep .... We hope to get back from the school kids yet more revealing information, just as the MORI Polls have given us. Did you honestly expect patients not to know that pain clinics even existed? Did you expect patients to know that anaesthetists play a key role in those pain clinics and in intensive care units? I think probably we all thought our patients knew what we did and will be somewhat taken aback by the results of the poll. The conclusion is that we are not informing and educating the general public well enough. The MORI poll demonstrates that the public do not understand what is going on. October saw the introduction of Patient Information Leaflets into all hospitals. We have been delighted with the Patient Information Project which is taking place in the College and the documents which have been and will be released as part of that project. They link so well into National Anaesthesia Day and its aims of educating patients. Perhaps I should finish by passing on to you below the message of support for National Anaesthesia Day from The Rt Hon Alan Millburn MP, The Secretary of State for Health. Good luck with your day. Do please let us have follow-up and thank you for your support.
Message of support for National Anaesthesia Day, 8 November 2002

Anaesthetists perform a key role in healthcare provision in this country. In the UK, all anaesthesia is administered by medically qualified anaesthetists, and with over 10,000 practitioners, they form the largest single group of hospital doctors in NHS hospital practice. A day such as National Anaesthesia Day offers the opportunity to raise awareness of the vital contribution that they have towards health. With nearly all of us needing an anaesthetic at some time in our lives, but few of us having an understanding of the variety and complexity of the modern anaesthetists role in our hospitals today, this learning event is very welcome. The focus of National Anaesthesia Day 2002 is on school children and to increase their knowledge and understanding of the work of anaesthetists. I hope that the many young people involved in events of the day are encouraged to consider future careers in the NHS, where we welcome them as part of the wide range of teams that we are developing to improve the nations health. I wish everyone involved the very best success and am sure that it will be an enjoyable and informative day.
Vital work of anaesthetists goes unrecognised by most of the public

Mr C Mihill, Clew Communications Ltd
Alan Milburn Secretary of State for Health

invitation templates to a full PowerPoint presentation, tailored to the National Curriculum. The range of visual material is impressive and the historical perspective will give depart-
AODP supports National Anaesthesia Day

We are again delighted to be associated with National Anaesthesia Day and I believe that this years event could be one of the most important yet. NAD 2002 provides a rare opportunity to bring young people into their local hospitals to demonstrate not only the role of anaesthetists and the science and technology behind anaesthesia, but also the work of the anaesthesia team as a whole. Sites that are participating in NAD 2002 will have access to a wealth of material, from school
ments the opportunity to dust off the Schimmelbusch masks, Boyles bottles and other ephemera that most departments seem to collect and which so graphically illustrate how very far we have progressed. This is the chance to invest in the future of our respective professions and I have no doubt that there will be many amongst those visiting our hospitals who will see beyond the flashing lights and technological marvels and have their eyes opened to career opportunities that, currently, all too few are aware exist.
he vital work carried out by anaesthetists outside the operating theatre such as running intensive care units or pain clinics goes largely unrecognised by the British public, a new MORI survey has found. The findings are to be released to the media to coincide with National Anaesthesia Day, on 8 November. The survey, carried out by MORI, involved interviews with 2,031 adults across Great Britain, who were asked for their knowledge about the work of anaesthetists. The respondents to these questions were able to give as many (or as few) answers as they liked, so responses add to more than 100%. Asked who they thought was responsible for running intensive care units, 54% said a ward sister or staff nurse; 38% a physician or general medical specialist; 17% a surgeon, and 15% a cardiologist. Only 8% correctly identified an anaesthetist as the person who usually runs an intensive care unit. 7% of the public thought a neurologist ran the units; 6% a radiologist and 5% a geriatrician. People were next asked what clinics in a hospital they had heard of. Ante-natal clinics were known by 93%; diabetes clinics by 83%; asthma clinics by 81% and chest clinics by 76%. Only 47% had heard of pain management clinics. Those that had heard of pain management clinics were then asked who they thought ran them. Anaesthetists emerged as the doctors deemed least likely to be in charge. The public thought that neurologists were most likely to run pain clinics (30%) followed by palliative care doctors (26%); a sister or staff nurse (24%); an occupational therapist (19%); a rheumatologist (18%); an orthopaedic surgeon (13%) and a cancer specialist (12%). Just 11% said, correctly, that anaesthetists ran the units. In terms of wider perceptions about anaesthesia, the survey found that nearly three in five British adults were aware that anaesthetists are medically qualified doctors.1
Figure 1 Public perceptions of who runs intensive care units
Figure 2 Public perceptions of who runs pain management clinics
Dr John Goldstone, Chairman of the National Anaesthesia Day working group, said the survey reflected the continuing need for information to the public about the work of anaesthetists. We need ongoing publicity, as the survey shows. This isnt wanted as some kind of self-glorifying trumpet-blowing exercise, although we should be proud of what we do, and it certainly isnt meant to heap extra work onto an already hard-pressed speciality. Patients need the information so they are in a better position to ask more informed questions about their own care. From our perspective, if there is greater public, and political, recognition of the work of anaesthetists then there is a better chance of our voice being heard when it comes to asking for extra resources, or workforce planning, or any of the other issues that the profession is concerned about. Dr Goldstone added: National Anaesthesia Day is important and we do believe it has helped to change public perceptions of our work, but we cant rely on one day a year to do this. In a sense, every day needs to be National Anaesthesia Day. There will always be new patients, new politicians, new trust managers, new civil servants, new journalists, so telling people what we do needs to be a continuing, year-round, exercise.
In comparison to a similar survey carried out in 2000, there was a significant drop in the proportion who said that anaesthetists were not medically qualified doctors, from 36% in 2000 to 29% in 2002. As in previous surveys, younger people were least likely to know that anaesthetists were medically qualified doctors. Only 45% of 15-24 year olds thought this was the case, and 37% said it was not (with 18% not giving an opinion). Looking at the implications of the latest survey, MORI says: There is evidence of a need to correct public misconceptions about anaesthetists and to raise the profile of anaesthesia generally. Overall, the findings reveal a lack of knowledge about an anaesthetists responsibility within the ICU and pain management clinic, revealing a need for communication about the role of anaesthetists as well as better understanding as to their qualifications.
Technical Note
Questions were placed on two waves of MORIs Omnibus. Three questions were asked of 2,031 adults aged 15+ between 21 and 26 February 2002. The question about anaesthetists being medically qualified doctors was asked of 1,987 adults aged 15+ between 7 and 11 March 2002. These waves interviewed nationally representative quota samples of adults throughout Great Britain. A full copy of the MORI Survey 2002 is available on the National Anaesthesia Day website (www.rcoa.ac.uk, just click on National Anaesthesia Day). For further details please contact Michele Corrado or Anna Carluccio at MORI tel 020 7347 3000.
1 It should be noted that this question was placed on a separate wave to ensure that this question did not influence responses to subsequent questions. It was not possible to place this question last as earlier questions would have impacted on responses. 770 Bulletin 16 The Royal College of Anaesthetists November 2002
Abbott Anaesthetics are delighted to be strong advocates of National Anaesthesia Day. We feel it is a particularly valuable programme as it raises both the public and political profile of anaesthetists and the anaesthetic team throughout the UK. Abbott has been supporting the anaesthetic profession for several decades now through a wide variety of educational programmes, and will continue to support the integral role of the Anaesthetist in healthcare. For more information, please contact the Professional Relations Manager, Ms E Crabtree at Abbott House, Norden Road, Maidenhead, Berkshire SL6 4XE direct tel 01628 644517
Datex-Ohmeda are world leaders in the field of anaesthesia delivery systems, and an emerging leader in critical care, with a 100 year history of ground breaking technology development. At Datex-Ohmeda we strongly support National Anaesthesia Day as a programme for creating a much greater perception amongst the general public of the great contribution that the specialty of anaesthesia, and the anaesthetist, have made to continually improving standards of surgical and critical care within the hospital environment. Our mission at Datex-Ohmeda is to help healthcare professionals improve the quality of patient care in the clinical environment. by providing integrated anaesthesia and critical care systems. Products that make the care process run smoothly through every clinical aspect, so that clinicians are free to concentrate on what attracted them to medicine in the first place providing the highest standard of focused care to every individual patient. Our commitment to education is second to none. The Datex-Ohmeda Academy, based at our Hatfield head office, offers extensive and unique clinical and technical training, accredited by The Royal College of Nursing. For more information, please contact Datex-Ohmeda Ltd, 71 Great North Road, Hatfield, Hertfordshire AL9 5EN tel 01707 263570 fax 01 707 260065
Smiths Medical is delighted to be associated with National Anaesthesia Day. In offering Anaesthetists market leading solutions in the areas of airway management, pain management, needle protection, arterial blood sampling, temperature management, patient monitoring and hospital infusion, we feel that our support for National Anaesthesia Day is a natural extension of our commitment to the anaesthetist in the workplace. For more information, please contact Smiths Medical, 765 Finchley Road, London NW11 8DS tel 020 8458 3232 fax 020 8201 9024
Aspect Medical Systems is committed to enhancing the science and art of anaesthesia, and as such are delighted to sponsor National Anaesthesia Day. Aspect developed the Bispectral Index (BIS), the first direct measure of the effects of anaesthetics and sedatives on the brain. BIS supports the anaesthetists clinical decision making, resulting in improving the quality of patient management. Most members of the public are unaware of the many clinical decisions which need to be taken by the anaesthetist during the course of surgery to ensure a safe and optimum anaesthetic. With the BIS index, anaesthetists have a unique opportunity to demonstrate that subtle, directed changes in patient management during surgery can have dramatic effects on patient outcomes days and weeks after surgery. This broader vision of anaesthesia is an enormous opportunity to substantially improve patient outcomes and establish anaesthetists as key clinicians in the hospital setting. National Anaesthesia Day is an excellent forum for the public to gain more understanding of what happens to them when they undergo an anaesthetic, and appreciation of the technology available may alleviate the fear expressed by many people that they could be awake or aware during surgery. For more information, please contact: Aspect Medical Systems B.V., Haagse Schouwweg 8b, 2332 KG Leiden, The Netherlands tel 0031 715 725 935 fax 0031 715 725 936 email amsint@aspectms.com website www.aspectmedical.com
AAGBI and National Anaesthesia Day

Once again the AAGBI is pleased to support the Royal College of Anaesthetists in celebrating this years National Anaesthesia Day, and with great enthusiasm embraces the raison dtre this year education. The AAGBIs members continue to be frustrated, as do the Colleges, at the lack of recognition afforded by the public to the work of our specialty and hopes this years National Anaesthesia Day will help to correct this. It is in the interests of all anaesthetists to support the aims of this day and to participate actively in assisting in its objectives which are to establish the concept of anaesthetists as highly specialised doctors caring for patients in all the areas of surgery, obstetrics, intensive care and pain management. We believe that the first two National Anaesthesia Days have begun this process and the MORI Polls support this view. This years aim of educating young people by showing how anaesthesia is central to the National Health Service and its targets will, it is hoped, encourage the media to publicise this event and further popularise the specialty. Anaesthesia should no longer be an arcane art but an applied science with a highly practical core. The science aspects will be familiar to young people studying the National Curriculum, but without the efforts of the National Anaesthesia Day participants these familiar areas would remain hidden. We are well aware of the importance of demystifying our specialty and that this will help to alleviate the publics worries about their future contact with our profession, and this will smooth their path and our task of providing safe care for them. Dr Michael Ward, the AAGBIs Junior Vice-President, has represented the AAGBI at the Working Group meetings, and reported back to Officers and Council. We are well aware of the enormous amount of work necessary to stage an occasion of this magnitude, both within the College and in local departments. To tie in with National Anaesthesia Day, a new AAGBI publication Infection Control in Anaesthesia will be launched on 8 November and it is hoped that this publication and the implementation of its contents, will further relieve the publics anxieties. The AAGBI extends its best wishes to all those Departments of Anaesthetics participating this year and hopes that National Anaesthesia Day 2002 will exceed its expectations.
It is with great pleasure that the National Association of Theatre Nurses supports National Anaesthesia Day. The anaesthesia team, of which anaesthetists, anaesthetic nurses, recovery nurses, pain nurses and other perioperative healthcare professionals play such a vital part, may be perceived as a less visible form of patient care compared to other specialities of nursing and medicine. So we will have to work all the harder to ensure that our input and expertise is recognised by the general public and other healthcare professionals. National Anaesthesia Day is a vital part of that recognition process and it deserves the success it will undoubtedly achieve. Anaesthetic practice faces many challenges in the changing healthcare agenda. Perioperative nursing faces many of the same challenges as well. As we move forward together it is truer than ever to say that despite the differences in our work, we share a common bond to provide good quality care to our patients. The National Association of Theatre Nurses will promote National Anaesthesia Day as part of our activities and will hope to continue to provide representation on the National Anaesthesia Day Working Group. Our congress this year will feature the launch of an Anaesthetic and Recovery Nurses Forum that will help represent and promote Anaesthetic and Recovery nursing in our membership. During the launch we will welcome a representative from the National Anaesthesia Day Working Group to highlight the objectives of National Anaesthesia Day to our delegates. Good Luck on National Anaesthesia Day!
The Data Protection Act

A joint statement by the RCA and AAGBI
he Data Protection Act 1998 came into force on 1 March 2000 and requires Data Controllers, where appropriate, to notify with the Information Commissioners Office. This replaces the previous requirement for registration under the Data Protection Act 1984. Some confusion has arisen as to how the Act affects individuals. The confusion was partially caused by information passed on in good faith by the RCA subsequently being found to be wrong. The purpose of this joint article from the AAGBI and the RCA is to clarify the current requirements of the Act as it affects anaesthetists.
If, however, the medical data recorded on computer includes, such details as treatment provided, diagnosis, type of operation, there will be a requirement to notify even if the database is kept for invoicing purposes only.
Logbooks
In the case of computerised logbooks, which comprise details of operations performed, there would be a requirement for each trainee/anaesthetist/consultant to notify the Information Commissioner as they would be the data controller in such instances. The employers notification does not cover individual doctors computerised logbooks. Even if the identification was restricted to hospital number, this would still constitute personal data (as it would be possible to identify individuals from this information) and consequently notification would be required. The opinion of the Information Commissioner is that it would be very difficult to anonymise data in electronic logbooks sufficiently to escape the requirement for individual doctors to notify. If the logbook is in a manual format, however, notification would not be necessary.
Who is a data controller

The latest advice from the Information Commissioners office is that anyone who keeps information on computer is likely to be a data controller and failure to notify can lead to penalties under the Act. The data controller, is defined by the Act as being the legal person (which can include both individuals and organisations) who determines the manner in which and the purposes for which personal data is processed. The Act however, includes a number of notification exemptions.
Patient records
If personal data pertaining to patients is held entirely in manual format, there is NO requirement to notify under the current Act. There would of course still be a requirement to comply with the data protection principles of security etc. If medical data is recorded on computer, such as details of treatment provided, diagnosis, type of operation, the key issue is who is the data controller. In the majority of cases, most of the work undertaken by consultants, NCCGs and trainees for the NHS will be covered by the entry of the organisation they work for, e.g. a hospital trust and there is thus no requirement for individual notification.
What you should do

As notification is easy, can be done on the web, and only costs 35 per annum (which is a deductible expense), it might be prudent for anyone who has records to notify. In any event each individual should consult the information available from the Information Commissioners Office www.dataprotection.gov.uk and reach their own informed decision.
Private practice
If the information retained on computer is restricted to only personal data required for Accounts and records purposes i.e. name, address and amount owed, it is likely that this will fall within the exemptions and there would not be a requirement to notify.
Non-consultant career grades

Dr J P Curran, Chairman, NCCG Committee
Summer homework
n the September 2002 issue of the Bulletin, I referred to work being done by Charlie Cooper on Professional Development for NCCGs. Charlie Cooper is the Postgraduate Deans representative on your Committee. I am pleased to say that he completed the task on schedule, despite untold hours bashing away on his home PC. (This method, by which many of my peers work, seems odd at a time when discussions suggest that all time spent training is time at work. You might think that fine, but if asked did that mean that time spent on private study at home also counted, I guess youd say no. Well, there are those who argue yes. To reduce the argument to the absurd, will we one day ask all successful candidates in examinations to attest to having studied within European Working Time Directives?). OK, I digressed a bit. The Committee made a few minor changes and Ill return to the topic later.
The census
The 2002 College census revealed 1120 NCCGs (out of a total workforce of 5981, with 363 UK based Members or Associate Members). 250 NCCGs were 55 years or older. Over all specialties NCCGs are the fastest growing group of the medical workforce (Audit Commission: Acute Hospital Portfolio: Medical Staffing 2002 (http://www.auditcommission.gov.uk/itc/acuteportfolio.shtml). Quite how many are Trust Grade seems unknown, but cant be unknowable. Dark statements that Trusts are reluctant to reveal this are all very well: have they been asked in an explicit fashion? No fewer than 39 different titles seem to describe Trust Doctors, at least showing Man's ingenuity at constructing titles from very few words. As a result of growth of NCCGs, despite an overall increase, the proportion of consultants in the overall workforce has risen little. Remember, none of this hides the stark fact that we are short of doctors. The Audit Commission Report (paragraph 15) states that there is an urgent need for progression to consultantship (whatever that might be in the future) to include time in a non-training (i.e. service) grade. Should this be a compulsory part of every anaesthetists career progression? To clarify the competencies (knowledge, skills and attitudes) needed to align non-training to training grades for such a purpose, will need time, energy and resources. To sign up someone as competent is not a formality: to attest to competence is a statement for which one is accountable. We are only just feeling comfortable about doing this for those following our CCST programme, with its defined syllabus. Reservations on the part of consultants about rapidly introducing a new system are understandable, given that presumably much of the advice we have already received from educationalists and our own colleagues cant just be jettisoned on grounds of expediency. Or at least I hope not.
More summer homework

On paper, at first sight we arent much further forward over issues that I referred to in September. However, those who read carefully Unfinished Business: proposals for reform of the Senior House Officer Grade (UB http://www.doh.gov.uk/index.htm) will find far more than the title suggests. There are at least three key bits for NCCGs. First, reform of the SHO grade is likely to time-cap specialty specific training at two to three years. Two years is what is currently required for those proceeding to intermediate and advanced training. Three years is the current minimum needed for appointment to the Staff Grade. Lets assume the programme is three years (not necessarily a safe assumption). What happens to those who do not proceed to further training? Paragraph 3.19 of UB tells us they may move temporarily into a service post outside the training structure. So far, the opportunities to return to training have been limited anyway, and UB tacitly acknowledges that the non-training grade will grow, but quite how the hope that there will be no profligate expansion on the grounds of expediency (UB 3.61) is not clear. Secondly, the goal-posts for what constitutes a CCST are being dismantled (UB proposal 18) and will presumably be defined differently for each specialty. What do we do about those NCCGs who may already fulfil whatever criteria emerge? Thirdly, acknowledging that the NHS could not run without NCCGs, a review of the role, educational support, professional development and career opportunities and pathways for NCCGs should begin in the autumn. (UB proposal 19). At least your Committee is ahead of the game on professional development, which brings us back to Charlie Coopers work. His document will go to the October Council meeting and I fervently hope will soon see the light of day. It will help in your now mandatory appraisal.
Finally
Ive chaired my last NCCG Committee. My going is logical: the development of the NCCG project needed to provide that an NCCG member of Council should chair the Committee, and Chris Rowlands will do it well. My last plea to you all is over Council elections. In early November there will be a notice in the British Medical Journal about the March 2003 elections. Consider standing. If you cant stand do at least vote.
TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Editor Professor R K Mirakhur, The Queens University of Belfast
Total intravenous anaesthesia (TIVA) I:

Pharmacokinetic principles and methods of delivery
Dr K Anderson, Lecturer and Professor G N C Kenny, Head, Department of Anaesthetics, University of Glasgow
Introduction
n the past decade the popularity of total intravenous anaesthesia (TIVA) has increased as new hypnotic and analgesic agents, with improved pharmacokinetic profiles, particularly suitable for intravenous administration, have become available. This has coincided with greater understanding of the pharmacokinetics of intravenous infusions and huge advancements in microprocessor and infusion pump technology, leading to the development of commercial infusion pumps such as the Diprifusor, which has made the administration of intravenous anaesthesia more userfriendly for the practicing anaesthetist. ination independent of renal or hepatic function and duration of infusion. In this respect, it can be considered as having a context insensitive half-life of only three to five minutes. This allows excellent titratability of analgesia over a wide range of infusion rates and blood concentrations. Consequently, it is becoming increasingly popular as a component of a total intravenous technique in day-case surgery, neurosurgery, and cardiac surgery. Its major limitation is that alternative analgesia (by longer acting opioid, nonsteroidal anti-inflammatory or local anaesthesia) needs to be in place when the infusion is discontinued.
Basic pharmacokinetics for TIVA

Pharmacokinetics is the study of what the body does to the drug, i.e. the distribution and elimination of the administered drug, together known as drug disposition. A distinction must be made between the clinical concepts of drug movement between organs and tissues that anaesthetists carry in their head, and the mathematical models that describe the observed concentration-time relationship. Mathematical concept of drug handling Pharmacokinetic models attempt to describe the relationship between dose and blood concentration with respect to time. The quoted pharmacokinetic parameters are useful for calculating the loading doses and rates of infusion necessary to maintain a steady-state plasma concentration. They do not, however, describe the concentration in any particular tissues, and as such are not organ orientated. In particular the pharmacokinetic compartments do not relate to any particular organs. The rate of change in blood concentration is calculated from the slope of the curve at any point in time (Figure 1). Hence, by separation of the different components of the curve we can describe the decline in plasma concentration in the terms of various half-lives such as distribution half-life (t12) or elimination half-life (t12). Mathematical analysis of the graph of concentration against time, for most anaesthetic drugs reveals that the decay of plasma concentratons is triexponential. Tri-exponential drugs are best described by a three-compartment model (Figure 2).
Pharmacology
The traditional triad of anaesthesia, hypnosis, analgesia and muscle relaxation, can all be achieved by intravenous techniques. However, the increasing use of the laryngeal mask airway, and the realisation that muscle relaxation is not always necessary merely to facilitate tracheal intubation, has led to the more rational use of neuromuscular blocking agents. Hypnosis Hypnosis is defined as a state of altered consciousness during which perception and memory are altered. Any intravenous anaesthetic can be used for hypnosis by infusion, however their practical value is determined by their individual characteristics. For instance, thiopentone accumulates leading to delayed recovery and etomidate is not recommended by infusion because it has been associated with increased mortality when used for prolonged sedation in the critically ill. Currently propofol is the hypnotic of choice for infusion, because of a rapid recovery profile even after prolonged infusion, and particularly because of the good quality of recovery. Analgesia Most injectable opioids have been used by infusion during anaesthesia. Alfentanil has gained some popularity for infusion, particularly in patients with renal failure. However, the new m-opioid receptor agonist remifentanil is metabolised by non-specific plasma and tissue esterases making its elim-
TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Total intravenous anaesthesia Anderson K & Kenny GNC Figure 1 Drug disposition in a two compartment model
Clearance = Elimination * Vc Clearance can be calculated as elimination from the body (Cl), or to describe the clearance from one compartment into the central compartment, Cl2, Cl3. It is mathematically related to the half life: t12oc Vc /Cl In other words, as clearance increases the half-life reduces, and as the volume of distribution increases so does the halflife. Clearance can also be used to describe how quickly the drug moves between compartments. Loading dose
Figure 2 A three compartment pharmacokinetic model, consisting of a central compartment (C1 ), and two peripheral compartments (C2 and C3). Drug is delivered into (with i.v. administration), and eliminated from the central compartment. Rate constants k12, k21, k13, k31, determine the tranfer of drug between the central and peripherall compartments. The elimination rate constant is k10
The drug is initially delivered into the central compartment, so that C1 is the initial volume of distribution (Vc). If the desired concentration for therapeutic effect (Cther) is known, it is possible to calculate the loading dose to achieve that concentration: Loading dose = Cther* Vc It can also be used to calculate the bolus dose required to rapidly increase the concentration during a continuous infusion: Bolus dose = (Cdesired-Cactual)* Vc However, in reality most anaesthetic drugs fit a 3-compartment model, hence following administration of a bolus dose the drug will be redistributed to C2 and C3, and will also be eliminated from the central compartment.
Mathematical models generate some theoretical pharmacokinetic parameters such as volume of distribution and clearance. These describe the bodys handling of the drug, and can be used to calculate the loading dose and rate of infusion necessary to maintain a steady-state plasma concentration at equilibrium. Volume of distribution (Vd) This is simply the apparent volume in which the drug is distributed. It is calculated by the formula: Vd = dose/concentration of drug Its value depends on whether it is calculated at time zero after a bolus (Vc) or at steady state after an infusion (Vss). Clearance (Cl) Clearance represents the volume of plasma from which the drug is eliminated per unit time to account for its elimination from the body. It can be calculated from the formula:
Continuous infusions To achieve a desired concentration (Cdesired), the required dose rate can be calculated: Dose rate= Cdesired*Clearance However, it will take five to six half-lives to achieve steady state. The desired concentration can be achieved more quickly if a bolus dose is followed by this infusion rate (Figure 3). But the concentration will still fall below the desired concentration for some time because of redistribution. Correlation of observed drug disposition with traditional half-lives The half-life describing drug disposition changes depending on when it is measured. For instance after a bolus dose, the reduction in concentration will be as a result of redistribution and elimination acting concurrently. While the observed initial decline in blood concentration will be close to the distribution half-life (t12), it will be closer to the
TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Total intravenous anaesthesia Anderson K & Kenny GNC Figure 3 The propofol blood concentration after a bolus followed by an infusion
plateaus at steady state. At this point it is the same as the elimination half-life, and is no longer context sensitive. The context sensitive half-time graphs provide better comparisons to the clinically observed drug disposition than the traditional pharmacokinetic parameters. The content-sensitive half-life increases for some drugs over time but is relatively constant for a drug such as as remifentanil. Varying depth of anaesthesia It can be seen that it is no simple matter to provide and maintain a desired concentration of a drug. If the anaesthetist wants to increase or decrease the depth of anaesthesia in response to patient response or surgical stimulus, it becomes even more difficult to calculate.
elimination half-life (t12) after a prolonged infusion. In short, the observed fall in blood concentration or indeed duration of clinical effect is poorly predicted by either of these half-lives. Hence these are not particularly useful terms for the practicing anaesthetist. The situation with drug infusions is more complicated. It has become clear that the observed half-life at any particular time depends on the duration that the infusion has been running, this is the context sensitive half-time (CSHT). Context sensitive half-time This is a more clinically useful term and has been defined as the time for the drug concentration to decline by 50% in the context of the duration that the infusion has been running. It is not a single figure but a range of figures which are better considered as a graph (Figure 4). This clinically relevant half-life increases with the duration of the infusion until all compartments or body tissues are in equilibrium. This reflects the peripheral compartments becoming filled with drug. The context sensitive half-time eventually
Figure 4 Context sensitive half-time. The time required for drug concentrations of thiopentone, fentanyl, alfentanil, propofol and remifentanil to decrease by half their value as a function of the duration of the infusion
Delivery of TIVA
Target controlled infusions Target Controlled Infusion (TCI), uses a real time pharmacokinetic model to calculate the bolus dose, infusion rates or indeed for how long to stop the syringe pump, to achieve a desired or target blood concentration (CT) at any point in time. TCI systems have become a powerful research tool, and systems have been developed for many drugs. However the only commercially available TCI system to date, is the Diprifusor for propofol. It uses a 3-compartment pharmacokinetic model of propofol, and some basic data about the weight of the patient, to calculate and control the infusion rates required to reach the desired CT. An increase in the target concentration entered into the pump, results in a bolus dose followed by an increased infusion rate, whereas a reduction in the target results in the infusion being suspended until the concentration reaches the target, then the pump re-starts at a lower rate (Figure 5).
Figure 5 Propofol blood concentrations and infusion rates generated by Diprifusor TCI pump when the concentration is titrated from 4 to 6 gml-1 and then back to 2 gml-1 in increments
TRAINEES FORUM: PREPARING FOR THE PRIMARY FRCA Total intravenous anaesthesia Anderson K & Kenny GNC
Comparing manual infusion and TCI When propofol was introduced in the early 1980s it became apparent that its pharmacokinetics, and in particular its recovery profile were particularly suited to infusion anaesthesia. At this time equipment to administer a computer controlled infusion was not available to most anaesthetists. Several studies have compared the use of manually controlled infusion with TCI, and while the designs have differed, the results are broadly comparable: with the TCI system induction of anaesthesia is achieved with less propofol over a longer time, insertion of laryngeal mask airway is more rapid, there is less patient movement in response to surgical stimulus, though recovery times and total propofol dose are generally greater (possibly reflecting a more appropriate anaesthetic depth). Significantly, the majority of anaesthetists prefer the TCI system. Performance of TCI systems While the TCI systems deliver propofol to achieve a target concentration entered by the anaesthetist, this is calculated based on the population pharmacokinetics with which the microprocessor is programmed. In practice, the actual measured blood concentration is likely to differ from predicted. This can be quantified as the performance of the system. For each individual observation, this is usually expressed by the term performance error; this is calculated from the difference between the measured concentration (CM) and the calculated concentration (CCALC). Performance error (%) = CM -CCALC /CCALC x100 For a population of patients, these observations are pooled, and expressed as a median absolute performance error (MDAPE). This represents the scatter or spread of measurements, also known as the precision of the system. This gives an indication of how close the calculated value is to the measured value. Another descriptor of performance is the bias of the system. This describes whether the system over-estimates (positive bias) or under estimates (negative bias) the measured concentration (Figure 6). For the Diprifusor, in healthy patients within 20% of their ideal body weight, the precision is generally 2025%, and appears consistent across most age ranges. Generally the system has minimal bias at 2g ml-1; it underestimates at lower values, and overestimates at higher values. When criticising the performance of TCI systems, anaesthetists often forget that the difference between end-tidal volatile anaesthetic partial pressure and arterial partial pressure is of a similar magnitude. End-tidal monitoring usually over-estimates arterial partial pressure by around 2025%.
Figure 6 The relationship of measured plasma concentrations (dots) with the target concentration of a TCI system (solid line) can be described in terms of precision and bias. This graph shows hypothetical measured blood concentrations for a target controlled infusion of propofol at 4gml-1
Individual variability
Pharmacokinetic variability There can be variations in the plasma concentration of drug between patients because they differ from the population pharmacokinetic model used. This pharmacokinetic variation results in a variable plasma concentration being achieved. Potential confounding factors for the pharmacokinetic data set used are sex, body weight, age and systemic disease. For propofol administered by the Diprifusor, body weight correlates well with clearance and volume of distribution, and surprisingly, this applies even in obese patients. Volume of distribution and clearance are disproportionately greater in children, with volume of distribution being increased more than clearance. Therefore children require different pharmacokinetic settings. If the adult system is used then the problem of divergence is encountered. This describes the phenomenon where the difference between the measured and target propofol concentration becomes greater the longer the infusion is running. A commercial TCI system for children is not yet available; accordingly the Diprifusor is currently not licensed for children less than 16 years. Despite the decreasing Vd associated with ageing in adults, the MDAPE is remarkably consistent across age groups. For remifentanil the important pharmacokinetic variables are sex, age and lean body mass. Accordingly these have been included in a TCI Remifentanil pump Remifusor available only for research at this time.
Pharmacodynamic variation
In addition to pharmacokinetic variation, there can be marked variation in individual patients response at the same blood concentration. This is pharmacodynamic variation. As well as affecting drug disposition and elimination, systemic disease can affect response to the drug also. For instance, there is increased sensitivity to sedative and hypnotic drugs in patients with renal, hepatic and cardiovascular disease. It appears that pharmacodynamic variation is greater than pharmacokinetic variation. Indeed for propofol it is estimated to be six to seven times greater. This explains why there is no correct concentration of propofol. Therefore, in these patients it is appropriate to start with a low target concentration and titrate to effect slowly.
Further reading Anaesthesia 1998; 53 (supplement 1):186. Padfield NL. Total Intravenous Anaesthesia. ButterworthHeinmann. ISBN 0-7506-4171-1. Glass PSA. Intravenous infusion techniques: how to do it and why we should do it. Canadian Journal of Anaesthesia 1998;45:R117127. Minto CF et al. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil: I. Model Development. Anesthesiology 1997;86:1023. Minto CF et al. Pharmacokinetics and Pharmacodynamics of Remifentanil: II. Model Application. Anesthesiology 1997;86:2433.
TRAINEES TOPICS Editor Dr M J Garfield, The Ipswich Hospital, Suffolk
The trainees topics section for this issue has been reduced in size, in order to allow more space for National Anaesthesia Day. The How the College works series will continue in the next issue. This month, there is an account by Dr Padma Rao, of her experience as an overseas trainee (and a working mother), and a review of the Colleges Primary FRCA book, by Dr Sally Wilmshurst, a recent Macintosh Prize winner.
An experience of an overseas trainee

Dr P Rao, Specialist Registrar, North Thames
t was in January 1997 that I landed in the United Kingdom to join my husband, a qualified surgeon from India who had taken up a Senior House Officer (SHO) post in one of the North London hospitals with a lot of expectations, ambitions and goals. As I walked through the narrow corridors of the hospital accommodation, my heart just sank. The tiny studio flat that we were offered was in a condition far from my expectations. The first thing that I did was to cover the furniture with throws to conceal the unsightly stains. Hours of shampooing could not get rid of the peculiar smell from the carpets. My husband soon mastered the art of balancing on a three-legged chair at the dining table. We managed to survive. (I was later delighted to know that those buildings were demolished and new ones built). By then, I was not a bad anaesthetist by any standards, even without mentioning the gold medal I had been awarded for my performance in the postgraduate exam at the state level. I managed to get a SHO post in the friendly anaesthetic department at the same hospital as my husband. Having learned to administer a safe anaesthetic within limited resources, I then faced the challenge of making appro780 Bulletin 16 The Royal College of Anaesthetists November 2002
priate use of these available resources. Not knowing exactly what was expected of me, I did almost everything I was asked to do including intravenous cannulations on the wards during the late hours. I worked relentlessly to get through the exhausting emergency lists. I soon learned to follow the instructions of seniors who had better organisational skills, if not always better clinical skills. The regulations of the College are such that most overseas trainees end up working at SHO level for at least two years before obtaining the specialist training that they are aspiring for. So did I. Exams, interviews, failure and success the cycle went on. Life outside anaesthetics was fabulous. The world seemed smaller and closer than ever. We could afford the holidays that very few people at home can even dream of, and eventually moved out of the hospital accommodation. Then came along our first child, long awaited. Eight months of motherhood away from work shook the confidence I gained over time. However, before long I was back on the track facing clinical commitments, audit projects, presentations, and the next milestone: the Final FRCA. Just as I was gearing up to it, came the news that my husband
Please send articles for submission, together with any declaration of interest, to the Editor of Trainees Topics, Dr Mark Garfield, via email (preferred option) to: mark.garfield@ipshtr.anglox.nhs.uk, or by post (accompanied by an electronic version on a floppy PC disk, preferably written in any version of Microsoft Word), to: Department of Anaesthetics, The Ipswich Hospital, Heath Road, Ipswich, Suffolk IP4 5PD. The Editor reserves the right to edit articles for reasons of space or clarity.
was selected for a two-year Fellowship programme in the United States. To complicate the situation, I was pregnant for the second time. Along with the news came sickness, which forced me to go off work a few weeks and needless to say, to defer the big exam. I landed in the United States of America seven months pregnant, with a toddler to look after, and a husband who in the coming months would show up very little at home (it would be unfair if I did not mention how helpful he was in that little time). The average length of a surgical trainees working day is 14 hours. He was expected to be on-call all the time except on the rare occasions when he left the city with prior arrangement. It was an unforgettable experience, dropping my son at the childcare centre and driving on to the hospital for the delivery. The one thing that America offered me, which I truly appreciated, was an excellent level of healthcare (of course paid for by the employers private insurance). It was sort of a move from new deal to no deal. It would have been very difficult to survive with two children but for the balance in our sterling account, and my maternity pay. The signs of stress and lack of sleep soon showed in one way or the other. Days kept rolling by quicker than I expected and it was soon time for me to return to work, now facing a need to maintain a family across the continents. The help came in the form of our parents. As they took the temporary charge of children along with my husband, I moved on to face further challenges. On 1 March 2002, I was back in London, on my own, away from the family, determined to get the FRCA. I had exactly two months before the theory exam and if I was lucky enough to pass that stage, a further eight weeks before the orals. The common suggestions made by the senior colleagues were: you need a good six month preparation for the exam, you need to be up-to-date with whats in the leading journals, you are expected to know a lot of medicine etc. One suggestion that sounded more practical to me at that stage was you
need to know basic facts about each topic in the syllabus. I worked along those lines and of course on the exam technique. I made the best use of the free time that I got as a flexible trainee (I am ever so grateful to the flexible training scheme). The theory exam definitely consisted of much more than what I considered to be basic facts. To my surprise, I was called for the orals, although I knew that it meant nothing unless one passed the whole exam. I went on a two-day course where I faced the humiliation of practice vivas. Amongst the usual comments such as it was all right, it is all there but you need to improve your technique a little bit, there was one single honest piece of feedback. At the end of a practice session one of the examiners asked me if I thought I would have passed. I had no answer but an hmmm. He added, They are there to fail you. You may have read more than I did but it doesnt help if you can not demonstrate it. It stirred up the frustration in me. I went after people for more practice vivas. On the big day I was relieved rather than ecstatic to see my number on the board. When everything was over I felt it had not been a challenge for me. The real challenge is ahead in a few days time when I will have my children with me, and experience being a single mother working unsociable hours. Today I feel I am not quite what I ought to be. Yet, I am proud to be moving on from a developing country into the developing world, with the hope that one day I will be able to make some contribution. No doubt, there will be many more qualified overseas anaesthetists seeking prestigious British training, and the system under the pressure of the new deal will undoubtedly require their contribution. It would only be prudent to make the best use of their skills without subjecting them to the unnecessary lengths of basic training. As an overseas doctor, I would like to make a few humble suggestions, which I think would benefit the system as well as the trainees, if I may do so. I think that there
should be the introduction of a mandatory course for all overseas anaesthetic trainees, where they are provided with detailed information on:
The NHS framework. Available resources and patient expectations. The role of the anaesthetist as a whole (it does differ
from country to country).
Input expected from the trainees at various levels. Importance of communication. Ethical issues.
Relaxation in the present eligibility criteria for the Primary FRCA examination, which unlike most other specialities includes one year of experience in the United Kingdom regardless of overseas experience and qualifications. However, six months experience at SHO level may be appropriate for most qualified overseas trainees before they are able to undertake the responsibilities at a registrar level, if not for appearing for Primary FRCA. I am thankful to the system that has made me a better anaesthetist and am hopeful that the process would be less taxing for future overseas trainees.
A reveiw by Dr S L Wilmshurst, SpR Anaesthesia, The Royal Preston Hospital

Guide to the FRCA Examination: The Primary, Dr P Cartwright MB ChB FRCA. Published by The Royal College of Anaesthetists, London Pp. 210. ISBN 1-900936-21-6. I wish Id had this book when I sat the Primary exam. Despite exam preparation courses, hundreds perhaps thousands, of multiple choice questions pulled from dog-eared, handed-down books and practice OSCEs, there was still a fear of the unknown. If only I could have known what sort of questions to expect, how the marking scheme worked or how the examiners were thinking. Then, when the exams are all over and the Fellowship has been awarded, its my turn to help organise practice exams and to informally grill prospective candidates. This can be just as intimidating as the real exam. Thinking up realistic questions on the spot in a busy general surgery list becomes almost impossible (except the questions from your own exam, which never seem to leave you!). Here is a book, written by the examiners themselves, which will prove invaluable to anyone involved in the primary exam from the candidates, many of whom have not sat MCQ exams since medical school, may never have taken a formal viva and may have graduated before the introduction of Objective Structured Clinical Exams into undergraduate assessment, to potential examiners such as myself. The book is divided into three broad sections. Section one provides an insight into the structure and marking of the exam sections. In particular, the structure of the OSCE is detailed including a description of the main areas to be tested anatomy, communication, data interpretation, monitoring, measurement and technical skills. There follows a description of the viva sections including the duration, subjects tested, marking and exam etiquette. In the unfortunate event of failing the exam on two occasions, a guidance interview is required and the book describes this process. Section two consists of sample multiple choice questions from the Royal Colleges own question bank, divided up into Physiology, Pharmacology and Physics as in the actual exam. There are sample OSCE stations, including very useful guidance sections on the equipment and personnel required for potential examiners who may be organising practice OSCEs. There are also 12 separate viva exams. Section three includes answers and explanations to the questions in section two. In summary, this is an excellent book which I would recommend to anyone facing the primary exam or involved in any way in preparing candidates. Roll on the Final version!
EDUCATION PROGRAMME
Please note that unless indicated otherwise, lunch is included in the registraion fee.
Basic Sciences Course for Primary FRCA 1324 January 2003 (code: A78)
Clore Management Centre, London WC1 This course is intended to complement study for the primary examination and consists of two weeks of full time lectures on those aspects of physiology, pharmacology and statistics that are of relevance to anaesthetists. Lectures will take place between 0900 and 1630 Monday to Friday. Tutorials will also be held during the course and each participant will be entitled to attend four tutorials. A separate application form is available from the Courses and Meetings Department. Please do not use the generic application form. Registration fee: 530
RCA EDUCATION PROGRAMME PLEASE PULL OUT AND KEEP
College Symposium
Anaesthesia, Science and Art 78 November 2002 (code: B05)
Institution of Electrical Engineers, London WC2 In addition to the two day programme, there is an opportunity to meet with colleagues and friends at an informal reception on the evening of 7 November. Registration fee: 330 (fee for trainees registered with the College: 250)
Course on Current Topics in Anaesthesia 2529 November 2002 (code: C11)

The Royal College of Anaesthetists, London WC1 Consisting of lectures and discussion, it is intended as both a refresher course and update on the latest techniques for consultants and NCCGs. Registration fee: 475
College Anniversary Meeting

Changing Practices 1920 March 2003 (code: C49)
Institution of Electrical Engineers, London WC2 Registration fee: 330 (fee for trainees registered with the Colllege: 250)
New Tutors Meeting

18 December 2002
The Royal College of Anaesthetists, London WC2 A one day meeting for newly appointed College Tutors. Attendance will be by invitation only.
National Anaesthesia Day Lecture 8 November 2002

The Royal College of Anaesthetists, London WC1 A schools education event to be held at the College. For details of this event and others across the UK, please see the National Anaesthesia Day web pages on www.rcoa.ac.uk
Airway Day 5 February 2003 (code: C19)

One Birdcage Walk, Westminster, London SW1 A core topic day. Registration fee: 175
Clinical Governance How to make it work for you 8 January 2003 (code: C85)
The Royal College of Anaesthetists, London WC1 This workshop is designed to give an overview of a framework for implementing Clinical Governance in clinical practice: it refers to the RAID methodology (Review, Agree, Implement, Demonstrate) as used by NHS Clinical Governance Support Team. It will involve practical examples from the experience of a number of clinical teams including: Paediatric surgery. Accident and emergency. Acute pain. Theatres.
College Symposium
CME Day 9 November 2002 (code: A76)
Institution of Electrical Engineers, London WC2 A joint meeting with the Association of Anaesthetists of Great Britain and Ireland. Registration fee: 180
How to Teach Teaching Methods 1213 February 2003 (code: C80)

Lancashire County Cricket Club, Manchester An intensive two day workshop for Consultants and senior SpRs. This workshop has limited places. Registration fee: 360
Final FRCA Course 17 February to 7 March 2003 (code: A82)

Birkbeck College, University of London, WC1 As course in September 2002. Registration fee: 680
Joint meeting on Research Methodology 14 November 2002 (code: C43)

The Royal College of Anaesthetists, London WC1 A joint meeting with the British Journal of Anaesthesia. This meeting is designed to introduce participants to the way in which good research should be conducted and presented. Limited numbers. This meeting is financially supported by the BJA. Registration fee: 60
How to Teach An Introduction to Teaching for Specialist Registrars 21 November 2002 (code: B36)
Kings College, London SE1 A meeting designed to introduce post-FRCA specialist registrars to the skills that are required to facilitate effective teaching and training. Registration fee: 110
This workshop will be useful for any anaesthetist interested in working with their clinical teams to make improvements to their service. It will provide an understanding of the principles of successful change management within the context of Clinical Governance. This workshop is limited to 50 participants and is approved for CEPD purposes. This meeting is financially supported by the NHS. Registration fee: 95
Anaesthetic Emergencies A Core Topic Day 27 March 2003 (code: A03)

Royal College of Physicians & Surgeons, Glasgow Further details to follow. Registration fee: 175
Review day for NCCG Anaesthetists 7 April 2003 (code: A12)

The Royal College of Aaesthetists, London WC1 This is a clinical study day for non-consultant career grades such as staff grades, associate specialists, and those doing a significant number of clinical assistant sessions who would like to update their knowledge on common areas of practice. The seminar is designed to allow time for discussion and group work around a number of anaesthetic and resuscitation scenarios. Those who have not had a recent opportunity to review anaesthetic practice are particularly welcome. Registration fee: 170
Training Paramedic Trainers 16 June 2003 (code: A74)

The Royal College of Anaesthetists, London WC1 A comprehensive one day seminar. Registration fee: 160
All meetings have CEPD approval on the basis of five points for a full day and three points for half a day. Retired Fellows continuing to subscribe to the College are entitled to attend meetings at half price. Please complete the generic application form or contact the Courses and Meetings Department at the College for further information. The Courses and Meetings Department Training and Examinations Directorate The Royal College of Anaesthetists 48/49 Russell Square London WC1B 4JY switchboard 020 7813 1900 ansaphone 020 7813 1888 fax 020 7636 8280 email educ@rcoa.ac.uk
Cardiopulmonary Disease and Anaesthesia

1920 June 2003 (code: C97)
Hotel Russell, London WC1 In addition to the two day programme, there is an opportunity to meet with colleagues and friends at an informal reception on the evening of 19 June. Registration fee: 330 (trainees registered with the College: 250)
How to Teach An Introduction to Teaching for Specialist Registrars 1 May 2003 (code: C18)
The Royal College of Anaesthetists, London WC1 A meeting designed to introduce post-FRCA specialist registrars to the skills that are required to facilitate effective teaching and training. Registration fee: 110
College Tutors Meeting 23 July 2003

Royal Northern School of Music, Manchester A two day meeting for all College Tutors, Programme Directors, Regional Advisers, Deputy Regional Advisers, Council Members, Bernard Johnson Advisers and the Scottish Standing Committee. Attendance will be by invitation only.
Diplomates Day 7 May 2003

Kensington Town Hall, London W8 A ceremony of presentation of diplomates for those doctors who passed their Final Exam in June 2002 and December 2002. Attendance will be by invitation only.
Basic Sciences Course for Primary FRCA 718 July 2003 (code: C12)
Birkbeck College, London This course is intended to complement study for the primary examination and consists of two weeks of full time lectures on those aspects of physiology, pharmacology and statistics that are of relevance to anaesthetists. Lectures will take place between 0900 and 1630 Monday to Friday. Tutorials will also be held during the course and each participant will be entitled to attend four tutorials. A separate application form is available from the Courses and Meetings Department. Please do not use the generic application form. Registration fee: 530
Please note that new meetings and updated programmes are available on the College website (www.rcoa.ac.uk/courses)
Sleep Apnoea 27 May 2003 (code: C84)

The Royal College of Anaesthetists, London WC1 Further details to follow. Registration fee: 175
NCCGs as Teachers 3 June 2003 (code: D10)

Venue to be advised A meeting for NCCGs interested in increasing their involvement in teaching anaesthetic trainees. Registration fee: 180
College Symposium
Best practice 67 November 2003
Institution of Electrical Engineers, London In addition to the two day programme, there is an opportunity to meet with colleagues and friends at an informal reception on the evening of 6 November. Registration fee to be advised
Course on Current Topics in Anaesthesia 913 June 2003 (code: A32)

Novotel Hotel, Birmingham Consisting of lectures and discussion, it is intended as both a refresher course and update on the latest techniques for consultants and NCCGs. Registration fee: 475
THE ROYAL COLLEGE OF ANAESTHETISTS SYMPOSIUM
Anaesthesia Science and Art

78 November 2002 (code: B05)
at the Institution of Electrical Engineers, London WC2
Thursday, 7 November
Session I General Anaesthesia 10.0510.30 Mechanisms of anaesthesia: A new physicochemical approach Dr J Sear, John Radcliffe Hospital, Oxford 10.3010.55 Awareness during anaesthesia Professor G N C Kenny, Glasgow Royal Infirmary 10.5511.20 Xenon: An advance? Dr T Marx, University Hospital Ulm, Germany Session II Vascular Anaesthesia (1) Jointly with the Vascular Anaesthesia Society 12.1012.35 Anaesthesia for endovascular surgery Dr N Edwards, Royal Hallamshire Hospital, Sheffield 12.3513.00 Anaesthesia for patients with lower limb ischaemia Dr J Thompson, Leicester Royal Infirmary Session III Vascular Anaesthesia (2) Jointly with the Vascular Anaesthesia Society 14.1514.40 General vs Regional anaesthesia: Where are we now? Dr R Griffiths, Peterborough District Hospital 14.4015.05 Perioperative cardiac protection in non-cardiac surgery Dr S Howell, Leeds General Infirmary 15.0015.30 Spinal cord protection Dr M Price, St Marys Hospital, London Session IV Dental anaesthesia 16.2016.45 Conscious sedation Professor J A W Wildsmith, Ninewells Hospital and Medical School, Dundee 16.4517.10 In-hospital dental chair anaesthesia Dr J Stanford, St Georges Hospital, London 17.2018.10 G U E S T L E C T U R E The Natural History and Management of Combined Coronary and Peripheral Vascular Disease Dr B Gersh, The Mayo Clinic, USA 18.2019.30 Reception for all participants
Friday, 8 November 2002

Session V Obstetric Anaesthesia Jointly with the Obstetric Anaesthetic Association 09.0009.25 Analgesia in labour, including CSE Dr P Clyburn, University Hospital of Wales, Cardiff 09.2509.50 Update on emergency Caesarean section Dr I Russell, Hull Royal Infirmary 09.5010.15 Anaesthetic aspects of pre-eclampsia Dr C Elton, Leicester Royal Infirmary 10.1510.40 Post-dural puncture headache Dr M Wee, Poole Hospital, Dorset Session VI Head injuries 11.3011.55 Transfer to specialist centres Dr M Smith, National Hospital for Neurology and Neurosurgery, London 11.5512.20 Cerebral protection Professor D Menon, Addenbrookes Hospital, Cambridge 12.2012.45 Anaesthesia Dr A Gupta, Addenbrookes Hospital, Cambridge 14.0014.30 D O N A L D C A M P B E L L E P O N Y M O U S PROFESSORSHIP LECTURE Post-operative cerebral hypoperfusion and heart surgery: from identification to influence on outcome Dr R P Alston, Royal Infirmary of Edinburgh Session VII Pain Relief Jointly with the Pain Society 14.3014.55 Mechanisms of pain Professor S McMahon, Kings College London 14.5515.20 New Drugs Dr C Bountra, GlaxoSmithKline, Stevenage 15.2015.45 Neuropathic pain Professor T Nurmikko, University Hospital Aintree, Liverpool 15.4516.10 Acute pain management Professor I Power, Royal Infirmary, Edinburgh
Registration fee: 330 (fee for trainees registered with the College: 250) Approved for CEPD purposes
The Royal College of Anaesthetists and British Journal of Anaesthesia
Research Methodology Meeting

The Royal College of Anaesthetists The Association of Anaesthetists of Great Britain and Ireland
14 November 2002 (code: C43)

at The Royal College of Anaesthetists, London WC1
This meeting is designed to introduce participants to the way in which good research should be conducted and presented. It will be useful for anaesthetists of any grade who are already involved in research or about to embark on a research project. Post FRCA Specialist Registrars and Lecturers will find this meeting to be particularly appropriate to their needs since knowledge of research methodology is one of the non-clinical topics which form an important part of Post FRCA training. Even if actual research is not undertaken it is considered essential for trainees to acquire an understanding of research methodology so that they are able to critically appraise research reports in the literature. The teaching sessions will address the following topics: Developing a research idea. Study design. Project management. Analysis, presentation and interpretation of data. Dissemination of results.
Continuing Medical Education Day

9 November 2002 (code: A76)
at the Institution of Electrical Engineers, Savoy Place, WC2
This years CME Day will include the following topics: The hour after Surgery. Head injuries. Diabetes. Regional blocks and DVT prophylaxis. Keep your patient warm. Fluid management. Anaesthesia and risk: informing patients. Anaphylaxis. Stridor in a child. Aspects of vascular anaesthesia. Update in thoracic anaesthesia. Anaesthesia in the elderly. Anaesthesia and liver disease. Burns. Resuscitation. Inotropes in anaesthesia what can I use next? Serious Hazards of Transfusion (SHOT): the first five years. Acute postoperative pain Registration fee: 180 Approved for CEPD purposes
Group sessions will allow participants to: Provide criticism of a published research paper. Design a clinical trial. Detect common pitfalls in analysis and interpretation of data. This meeting is supported financially by the BJA. Registration fee: 60 Approved for CEPD purposes
How to Teach
Introduction to Teaching for Specialist Registrars
21 November 2002 (code: B36)
at Kings College, London SE1
This meeting is designed to introduce Post FRCA Specialist Registrars to the skills that are required to facilitate effective teaching and training. Apart from an introductory session on how adults learn, the presentations will focus upon the practical teaching skills which a Specialist Registrar should be able to utilise in day to day practice. All the presentations will be given by experienced anaesthetists who have a major commitment to teaching. The development of teaching skills is one of the non-clinical topics that form an increasingly important part of Post FRCA training for Specialist Registrars. For anaesthetists with a special interest in medical education there are opportunities to obtain additional qualifications in medical education and the meeting will form an excellent introduction to the development of this worthwhile component of a balanced professional portfolio. The programme will address the following topics: Why learning teaching skills is important. An introduction to teaching adults. How to give a lecture. Teaching for small groups and tutorials. Teaching in the operating theatre. Teaching practical skills. Getting the most out of PowerPoint. Teaching examination skills.
Course on Current Topics in Anaesthesia

2529 November 2002 (code: C11)
at The Royal College of Anaesthetists, WC1
This course consists of a week of lectures, each of which is followed by ample time for discussion. It is intended for doctors engaged in clinical anaesthesia (ie Consultant, Specialist grade or their overseas equivalent) who feel that they may benefit from a refresher course in the latest techniques. Places will not be allocated to anaesthetists in training. The programme will cover topics under the following headings: Scientific foundations of anaesthesia and their clinical implications. Advances in anaesthesia, intensive care and pain. Local and regional anaesthetic techniques. Anaesthetic equipment and monitoring. Postoperative care. Places are limited on this popular course and you are strongly advised to apply as soon possible. Please note that preference will be given to applicants who have not attended this course recently. Registration fee: 475 Approved for CEPD purposes
Registration fee: 110 Approved for CEPD purposes
THE ROYAL COLLEGE OF ANAESTHETISTS SYMPOSIUM
Clinical Governance at Work

How to make clinical governance work for you
8 January 2003 (code: C85)
at the Royal College of Anaesthetists, London WC1

09301000 10001045 Registration and Introduction to Course What is Clinical Governance and how to use it Dr Sean OKelly, Consultant Anaesthetist, Swindon and Marlborough NHS Trust, NHS Modernisation Agency Associate
Where did clinical governance come from? The NHS as a Complex Adaptive System implications for change. Is Clinical Governance different and does it work?
10451100
Group work session Unwritten Rules Dr Sean OKelly, Consultant Anaesthetist, Swindon and Marlborough NHS Trust, NHS Modernisation Agency Associate
Exploring the reasons why making changes in the health care setting can be so difficult.
11001115 11151145
Break Barriers to Change Dr Ian Kendal, Consultant in A&E, Swindon and Marlborough NHS Trust
The human dimensions of change. Leadership, engaging stakeholders and providing support.
11451215
RAID I: Reviewing and Agreeing Dr Ian Kendal, Consultant in A&E, Swindon and Marlborough NHS Trust
How to start exploring quality issues within a service. Collecting the right information in the right way. Listening to patients. Gaining staff ownership and formulating recommendations for improving the service.
12151300
Learning from real-life experience I Course Faculty

Short presentations of lessons learnt and real life experience in several areas: Paediatric surgical services. A & E. Acute Pain Services. Theatre activity.
13001330 13301400
LUNCH RAID II: Implementing and Demonstrating Dr Sean OKelly, Consultant Anaesthetist, Swindon and Marlborough NHS Trust, NHS Modernisation Agency Associate
The art of project management. Working as a team. Effective targeted communication. Helping the service through transition. Troubleshooting.
14001445
Learning from real-life experience II Course Faculty

Short presentations of lessons learnt and real life experience in several areas: Paediatric surgical services. A & E. Acute Pain Services. Theatre activity.
14451515 15151545 15451630
Group work session: (How to make RAID work for you)

Small-group work session designed so that participants can explore the RAID model and how it might be applied within their own clinical service.
Break Evaluation and Close Dr Sean OKelly, Consultant Anaesthetist, Swindon and Marlborough NHS Trust, NHS Modernisation Agency Associate
Course Faculty Dr S OKelly (Consultant Anaesthetist, Swindon and Marlborough NHS Trust, NHS Modernisation Agency Associate), Dr I Kendal
(Consultant in A&E, Swindon and Marlborough NHS Trust), Dr B Sandhar (Consultant Anaesthetist, Royal Devon and Exeter NHS Trust), Dr J Stock (Consultant Anaesthetist, Hastings and Rother NHS Trust), Ms S Squire (Director of Education and Patient Involvement, Clinical Governance Support Team, NHS Modernisation Agency).
This workshop will be useful for any anaesthetist interested in working with their clinical teams to make improvements to their service. It will provide an understanding of the principles of successful change management within the context of Clinical Governance. Limited to 50 participants. This meeting is supported financially by the NHS.
Registration fee: 95 Approved for CEPD purposes.

Anniversary Meeting
Changing practices
1920 March 2003 (code: C49)
at the Institution of Electrical Engineers, WC2
This meeting will cover the following sessions: Wednesday, 19 March Critical care medicine Management of acute lung injury: Management of COPD. Sedation of the critically ill. Blood transfusion in the critically ill. Perioperative care (1) Pre-assessment clinics. Pre-optimisation. Management of patients with CAD. Pain management. Annual General Meeting Hewitt Lecture Thursday, 20 March The airway The difficult airway. The airway in the ICU. The airway in resuscitation. Training and anaesthesia competencies. Training and anaesthesia competencies Discussion This house believes that the use of the LMA has resulted in the deterioration of Airway Skills Peri-operative Care (2) TIVA. Changing practice with muscle relaxants. Delayed Post-operative complications. A full programme is available from the Courses and Meetings Department at the College and also on the College website www.rcoa.ac.uk/courses
COURSES AND MEETINGS Booking procedures

A generic application form for all events, except FRCA courses, is contained in every edition of the Bulletin. This is also available to download from the College website (www.rcoa.ac.uk/courses). Application forms for the Final FRCA course and Basic Sciences course for the Primary FRCA are available separately from the Courses and Meetings Department. Once a course or meeting and the relevant fee have been publicised, bookings on the generic application form will be accepted at any time. The appropriate fee must be paid at the time that the booking is made (bookings will not be accepted for events that do not show a fee). If your Hospital/Trust is paying your registration fee, please pass the completed application form to the relevant person for forwarding with payment. To ensure that bookings are processed correctly, it is essential that the booking form shows the code number, title and date of the event being booked, e.g. C81 How to Teach: Small group teaching 20 June 2002. All courses and meetings are open to all grades of anaesthetist (unless specifically stated otherwise). Bookings will be accepted on a first come first served basis. When a course or meeting is full this will be publicised on the College website. For several weeks before major meetings, details of vacancies will be available on the Courses and Meetings Department ansaphone. Fees and cancellations Payment for all College courses and meetings can be made by Sterling cheque, payable to The Royal College of Anaesthetists, Switch, or Credit Card (Mastercard/Visa/Delta). Notice of cancellations must be given in writing to the Courses and Meetings Department at the Royal College of Anaesthetists at least ten working days before the course or meeting commences in order to qualify for a refund. All refunds are made at the discretion of The Royal College of Anaesthetists and are subject to a 25 administration fee. Delegates cancelling after this date will NOT be entitled to a refund unless the Royal College of Anaesthetists considers there to be exceptional circumstances that would warrant a refund. Accommodation Local hotel information will be sent to you on receipt of your application. Application forms Completed generic application forms should be returned to: Courses and Meetings Department, Training and Examinations Directorate, The Royal College of Anaesthetists 48/49 Russell Square, London WC1B 4JY switchboard 020 7813 1900 ansaphone 020 7813 1888 fax 020 7636 8280 email educ@rcoa.ac.uk
Registration fee: 330 (250 for trainees registered

with the College)
Approved for CEPD purposes
PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS USING BLACK INK

This form is to be completed in conjunction with the programme for Courses and Meetings. If you wish to apply for more than one meeting, please photocopy this form and use one form per application. Please state below the name and code of the meeting. This form should be returned to: The Training and Examinations Directorate, Courses and Meetings Department) The Royal College of Anaesthetists, 48/49 Russell Square, London WC1B 4JY Switchboard 020 7813 1900 ansaphone 020 7813 1888 fax 020 7636 8280 email educ@rcoa.ac.uk
Name of meeting ______________________________________________________________________________________________ Registration Fee: ** CODE:
Surname: ____________________________________________ Forename 1: _____________________________________________ Forename 2: __________________________________________ College Reference No (if issued): Address line 1: _______________________________________________________________________________________________ line 2: _______________________________________________________________________________________________ line 3: _______________________________________________________________________________________________ Town/City: ___________________________________________ Country: ________________________________________________ Postcode: Date of B irth: Telephone number (including STD code): Fax number (including STD code): email address: ________________________________________________________________________________________________ Present appointment and Hospital: ________________________________________________________________________________ Dietary requirements: __________________________________________________________________________________________ Payment can be made by Sterling cheque, made payable to The Royal College of Anaesthetists, or by credit card below: Please charge my credit card: Card number: Expiry date: Issue No (Switch only): Start date (Switch only): Visa Delta MasterCard Switch Total Remittance: ______________ This address is (tick ONE only): Temporary Permanent
Cardholders signature: ________________________________ Cardholders name: _______________________________________
**Retired Fellows, paying the retired Fellows subscription rate, are permitted to attend College meetings at half price.
AUDIT AND THE EVIDENCE BASE OF ANAESTHESIA Editor Professor G N C Kenny, Glasgow Royal Infirmary
Assessing anaesthetists performance using recovery indicators

Dr S M Yentis, Consultant Anaesthetist, Chelsea and Westminster Hospital, London
Summary
here is increasing pressure on doctors to assess their performance as part of the appraisal and revalidation processes, but little guidance on how this might be achieved, especially in non-surgical specialties and those in which serious adverse outcomes are rare, such as anaesthesia. All nontrainee anaesthetists in one department agreed to take part in a pilot study, using the condition of their patients in the recovery room as a surrogate indicator of their performance. After a consultation period of three to four months, five indicators were selected and these were monitored in the recovery room for the same three-month period in two successive years. The results were fed back to the participating staff on an anonymous basis, in that they knew only their own identity. All staff performed well according to the indicators chosen and the department was satisfied that the process was a valuable one despite its deficiencies, and that a seriously under performing anaesthetist would have been detected. suitable indicator of performance may be less obvious. In anaesthesia, the requirement for monitoring performance has been accepted equally enthusiastically: A poorly performing anaesthetist is one whose performance is outside the accepted framework of practice.8 However, no specific guidance is offered as to how this might be detected. All anaesthetists are used to being blamed for all ills by those who misunderstand their specialty. Given the inescapable requirement to monitor our performance and the concern that an inappropriate model might be imposed upon us from outside our department, we decided to explore ways of monitoring our own performance.
Methods
It was clear that the basic method required was a simple audit, but the outcome measures were less clear. The proposal was first considered at regular departmental meetings, at which the various options for suitable outcomes were discussed. These included complaints and major mishaps (death or severe damage), satisfactory appraisal or revalidation, and aspects of our pre-, perand postoperative management of patients. Complaints and major mishaps are rare in most individuals practice and were thus considered to be too gross an indicator, although useful for extreme cases. We considered appraisals and revalidation to be too new and undeveloped. Pre- and perioperative practice was thought to be too varied and difficult to evaluate: assessing preoperative management posed problems with recording ward visits and their content, compounded by the variable times at which patients were admitted before surgery. Perioperative practice was also difficult to assess objectively without relying on the anaesthetic record or other observers. Although we could have audited specific procedures such as central venous cannulation or regional anaesthetic blocks, there were none suitable that were undertaken sufficiently frequently by all the anaesthetists. We then considered the postoperative period. Following patients on the postoperative wards could potentially have been useful but was rejected because of difficulties with collecting data and with separating anaesthetic factors from surgical or medical ones. The recovery room, however, had potential since it represents a window for the early effects of our practice to be visible. It was also a stable environment with staff who could perhaps be persuaded to collect the data.
Introduction
The current drive to improve and monitor the quality of clinical care has focussed increasingly on the performance of individual doctors. The Government has stated that individuals should be made ... accountable for setting, maintaining and monitoring performance standards,1 that ... doctors performance must be assessed in the context of his/her workplace2 and that systems should be in place for ... detecting and addressing poor performance.3 The General Medical Council emphasises the requirement for assessments and appraisals of your professional competence and performance,4 regular review of individual members performance5 and ... information ... to show how well the doctor is practising to demonstrate the doctors performance.6 The British Medical Association agrees: ... early identification of poor clinical performance is vital.7 The methods by which performance is to be monitored have received much less attention than the need to monitor it. In surgery, especially cardiac, outcome could perhaps be easily and directly linked to an individuals performance, even given the problems that arise from differences in individuals case mix and the possible confounding effect of other team-members. However, in many other specialties a
AUDIT AND THE EVIDENCE BASE OF ANAESTHESIA Assessing anaesthetists performance Yentis SM
Having decided to focus on the recovery room, we agreed that it was important to define the outcomes clearly; ensure that they were meaningful, not too numerous and frequent enough to be useful; assess them for each individual anaesthetist; and make sure the process was open and involved the whole department. Preliminary discussions yielded a shortlist of ten possible items which were then considered by a small group representing audit, risk management and multidisciplinary activities within the department, including representatives of the recovery room nursing staff. The five items finally selected were chosen because they represent different aspects of our practice including record-keeping, pain relief and complications: No perioperative antiemetic (our department has agreed protocols for acute pain management that require administration of an antiemetic if any long-acting opioid is given intravenously). Inadequate prescription of postoperative analgesia according to department protocols. Excessive analgesic requirements, defined as more than 10 mg morphine required intravenously in the recovery room. Prolonged stay in the recovery room, defined as longer than two hours excluding surgical or pre-existing medical factors. Unplanned admission to the intensive care unit (ICU), excluding surgical complications. The five proposed indicators were ratified formally by the department, and simple data sheets prepared for the recovery staff to fill in. Each of the indicators was marked as being present or absent for all emergency and elective adult patients who received general anaesthesia and who passed through the recovery room for the main theatres during a three-month period. Patients admitted directly from the operating theatre to the ICU were able to be included because the recovery staff routinely keep a list of all cases operated on and update it continuously throughout the day. The name and grade of the most senior anaesthetist directly involved with the case was also recorded for each patient. At the end of the three-month period, the results were analysed by the Lead Clinician of the department at the time (SMY) and circulated in graphical form to all nontraining members of the department on an anonymous basis: each knew their own code but not those of their colleagues. The accompanying note suggested that all staff should use the results to consider their own practice in view of the differing case mix between anaesthetists. The results
were also discussed at department meetings. We repeated the audit for the same three-month period the following year. The study was discussed with the Local Research Ethics Committees chairman before preparing this report, and the members of the department were given the opportunity to withhold their data from it if they wished but none did.
Results
The total number of cases for which data were recorded was 1113 for the first year and 637 for the second year, of which 720 and 374 respectively had a named non-trainee associated with their anaesthetic. From routinely collected theatre activity data, the total number of cases passing through the main theatres during these two periods were 1899 and 2038 respectively. Median (interquartile range (range)) number of cases per anaesthetist was 36 (2544 (7120)) for the first year and 19 (1224 (744)) for the second year. Incidences of the five indicators are shown in Figure 1. There was no consistent area of concern and taking into account the case mix, the department considered that the standard of care overall and for each individual was satisfactory during both study periods. We also decided that the audits were worth doing and should be repeated at regular intervals but that this should be less frequent than yearly, given the work required.
Discussion
The need to measure performance is no longer under dispute but there is concern that the outcome measures used should be both accurate and not taken out of context.9,10 The results of this study are open to both these criticisms. Our routine theatre activity data included cases done under local anaesthesia applied by surgeons, as well as those done under regional anaesthesia administered by anaesthetists. We excluded both these from our analysis since the majority of cases in the theatre suite are performed under general anaesthesia and this therefore provided greater consistency. However, the exact number of cases receiving local or regional anaesthesia is unknown for these periods. The activity data also included paediatric cases even though the majority of these were done in a paediatric operating theatre elsewhere in the hospital. Because there are different protocols for anaesthetic management of children, these cases were also excluded from the study although the number excluded is unknown. We therefore did not know how many cases might have been missed, for example when the recovery staff were particularly busy. If we had had the resources, a dedicated person could have been allocated to
collection and validation of the data, but our aim was to apply the study to the routine clinical setting. Whatever the discrepancy between the number of cases included and the true denominator, though, it is unlikely to have affected the results in a systematic fashion. We also do not know the reason for the reduction in the number of cases counted in the second study period. This might have been related to the increased workload undertaken by the department over the previous year and the difficulty faced by increasingly busy recovery staff in recording the data. Considerable changes were taking place in anaesthetic service requirements over the two study periods, including expansion of paediatric surgery, and this may have reduced the number of suitable cases passing through main theatres since much paediatric surgery takes still place there, especially out of hours. The risk that the results might be taken out of context either within or outside the hospital was accepted as being regrettable but unavoidable. In particular, the fact that no account was made for differing case mix could potentially present an individual in an undeserved unfavourable light. As a department, however, we were satisfied that had an individual apparently failed in any of the chosen indicators to a high degree, his/her case mix could and would be considered when reviewing the results. Overall, we felt that as a department, taking part in such an exercise made us stronger rather than more vulnerable. The indicators chosen might be considered rather soft outcomes, but in the absence of hard data reflecting performance and given the rarity of serious mishaps, there is no choice but to monitor surrogate markers. We considered the ones selected to be a useful mixture of various levels of practice standards including adherence to protocols, and are confident that had a member of the department been seriously under performing, we would have had a good chance of detecting this. We acknowledge, however, that apart from the concerns already mentioned this audit has other weaknesses. First, the cases included were not truly representative of our workload, for our hospital has separate obstetric, daysurgery and paediatric operating theatres and recovery areas where the majority of these cases are managed. We also did not consider other parts of the service provided by the department such as analgesia in labour, the acute and chronic pain services, resuscitation and intensive care. In addition, since the anaesthetists covered different numbers of operating lists in main theatres (ranging from one to seven per week) and these could each include two to three patients or six to seven patients depending on the surgical specialty, the denominators varied considerably between
individuals. Second, although we included trainees as a group, we did not evaluate individual trainees because of their large number and rotation patterns. Third, it is possible that staff would try harder during the study periods, thus presenting a better picture than really exists though it could be argued that this alone might be a worthwhile reason for conducting the audit. Finally, the project could be criticised as not being a true audit since we had no defined standard against which to compare the results. However, we do now have at least a baseline against which to compare future audits. Despite the above criticisms, we felt satisfied that we had taken steps to identify any anaesthetist who could be consistently under performing, and were reassured that no such person stood out. Furthermore, the above model could easily be adapted to any other clinical specialty or even to non-clinical support services though in order to succeed it should fulfil the above requirements of using indicators that are meaningful, and involve those whose performance is being assessed. In a truly open and blamefree culture, such an audit should not have to be anonymous, and indeed this was discussed at length within the department. However, although there was unanimous support for the project as a whole, a number of members felt that disclosing the identity of individual anaesthetists represented a step too far at this stage. Finally, there is the question of resources, for the whole process was both lengthy and time-consuming, and validation of the data impossible. In an ideal world we would have wished to conduct our audit annually or even continuously, though perhaps every two to four years would represent a reasonable compromise given the lack of resources available. That such an ongoing monitoring of recovery indicators is useful has been shown by Peskett in her report of a scheme supported by the Australian Council on Healthcare Standards and Australian and New Zealand College of Anaesthetists.11 Notable in this project is the provision of adequate resources and staff to ensure not only accuracy of data collection but also inclusion of many more than just five indicators. Pesketts study was published after we had embarked on our audit but we were encouraged by its methodology and results, and the fact that valuable information could be gathered when adequate support was provided. Peskett also suggests other potentially useful indicators, including unrousability to voice at 45 minutes and a core temperature of under 35C, both of which we would consider for future audits.
Acknowledgement
I am grateful to my colleagues in the Magill Department of Anaesthesia for their support and their permission to report these results, and to the staff of the recovery room who collected the data so diligently.
References 1 2 3 4 First class service. Department of Health. DoH, London; 1998. Supporting doctors, protecting patients. Department of Health. DoH, London; 1999. An organisation with a memory. Department of Health. DoH, London; 2000. Good medical practice. General Medical Council. GMC, London; 1998.
5 6 7 8 9
Maintaining good medical practice. General Medical Council. GMC, London; 1998. Revalidating doctors. General Medical Council. GMC, London; 2000. Response to Supporting doctors, protecting patients. British Medical Association. BMA, London; 1999. Good practice guide. Royal College of Anaesthetists. RCA, London; 1998. Trueland J. Surgical mortality audits to include consultants results. BMA News 2002;April 6:2.
10 Hospital Episode Statistics. Central Consultants and Specialists Committee Annual Report. British Medical Association, London, 2002;7. 11 Peskett M. Clinical indicators and other complications in the recovery room or postanaesthetic care unit. Anaesthesia 1999;54:11431149.
Figure 1 Recovery indicators recorded over two three month periods in successive years: first year (ae); second year (fj). Grey columns = proportion calculated from a single case only. Each letter refers to an individual anaesthetist except for S.Reg, Reg and SHO which refer to combined results for specialist registrar years 35, specialist registrar years 12 and senior house officer grades respectively (a) Antiemetics not given per-op when opioids given (b) Morphine > 10 mg required in Recovery
(c) Greater than two hour stay in Recovery
(d) Post-op analgesics and antiemetics not prescribed
(e) Unplanned admission to ICU
(f) Antiemetics not given per-op when opioids given
Centers of excellence in regional anaesthesia

Dr J C Walton, The National Womens Hospital, Auckland, New Zealand
ometime during the autumn of 2000 I found myself coordinating dates to attend a preceptorship at St Lukes Medical Center, New York, a designated Center of Excellence. A number of work colleagues had spent time working at Duke University, North Carolina, and had pointed me in that direction to learn more about regional techniques and their application. Duke University is also a Center of Excellence. Essentially, these centers provide intensive training programmes designed and run in the USA with a view to expanding best practice in regional anaesthesia for surgery and for post-operative pain management. As well as the two mentioned above which provide specifically for regional anaesthesia, Thomas Jefferson University Hospital (TJUH), Philadelphia, and Roswell Park Cancer Institute (RPCI), Buffalo New York, are Centers of Excellence for post-op pain management. Over time it is hoped to establish a wide network of these centers, focussing on the advanced training of clinical specialists. The programmes are aimed at practicing US anaesthesiologists, and sponsored through an unrestricted grant by Astra-Zeneca. The workshops in regional anaesthesia offer a comprehensive review of practice of peripheral nerve blocks and strategies for integrating them into anaesthetic practice. The benefits of good acute pain management services are well known, and the programmes at TJUH, and RPCI are directed at a collaborative, multi-disciplinary approach to pain control. This programme, also open to nurses, outlines design of an acute pain service, with emphasis on patient care, education and outcome research. Both programmes illustrate the cost-effectiveness of their implementation. Each programme consists of two full days of interactive learning and didactic sessions. Numbers are limited to a maximum of four. Unable to pass myself off as remotely American, I was very generously accepted onto these programmes. Timing dictated that I attended St Lukes for regional anaesthesia, and I was able to include a brief visit to TJUH. Each day we met at 6.45 am in the Ambulatory Surgical Unit, which by then was already a hive of activity. Assistant Professor Admir Hadzic and Associate Professor Jerry Vloka run the course. The structure of the two days is totally dependent on theatre schedule, but in any case all aspects of management from patient interview, through placement
(g) Greater than two hour stay in Recovery
(h) Morphine > 10 mg required in Recovery
(i) Post-op analgesics and antiemetics not prescribed
(j) Unplanned admission to ICU
of blocks and perioperative management were covered. There were also didactic sessions on choice of local anaesthetic, functional anatomy (just a little rusty!), equipment and top tips for performing each peripheral nerve block. As in the UK there is a lack of awareness among the general public regarding potential uses and benefits of regional anaesthesia where appropriate. At St Lukes ambulatory unit, on the strength of improved pain control, reduced incidence of nausea and vomiting and drowsiness, many are strongly advised to have peripheral nerve blocks with or without light general anaesthesia. Patients walk from the waiting area to the block placement area and climb onto a trolley there. There is a mobile anaesthesia cart containing everything imaginable for any block in much the same style as a spinal/epidural trolley. The patient is helped into position and given fentanyl and midazolam sedation. Although not licensed to place any of the blocks, we were each able to identify landmarks on all the patients. The limiting factor, apart from the operating list and therefore the blocks performed, was the presence of available anaesthetists, one being required for each patient. The programme at Duke enables trainees to place more blocks, as nurse anaesthetists provide immediate patient care after this. The benefits of having a well organised area in which to site the blocks showed how, at its best, regional anaesthesia could be accepted as the norm, causing minimal delay to the theatre list. Passing into theatre, the positive attitude and acceptance of the surgeons involved was clearly evident. The time taken to establish blocks was easily matched by the reduced time in induction, positioning and emergence. Extrapolating to use at home, there is obviously a need for anaesthetists to work outside the theatre in order that blocks can be ready and working prior to theatre. At TJUH for example, the anaesthetist sites the first epidural of his list. The acute pain team then sites all others required, during the pain rounds. The increased Body Mass Index (BMI) of many patients lends itself well to peripheral blocks as both pre and post op the patient is able to assist in transfer between trolley and operating table. Supplementation given during theatre varied from no further sedation, to a propofol drip controlled manually by the anaesthetist, to light general anaesthetic with LMA or intubation; surgeons are quite prepared to give further local infiltration as they go if necessary. The financial cost of pain, nausea and vomiting post op, with the need for admission is an issue in the States for both patients and doctors, and therefore early discharge from post anaesthetic care unit (PACU), and from hospital is a huge benefit. It would be very nave to regard regional anaesthesia as the panacea of anaesthesia, and to assume that setting up
such a unit is straight forward. The task of planning, gaining funding and support, providing the necessary education and expertise and maintaining the unit is immense. Professor Hadzic still struggles to convince everybody of the merits of peripheral nerve blocks, but his enthusiasm is infectious and speaking to patients after their operations it is easy to see why. Of the 14 patients we saw over the twoday period, all were extremely satisfied with their outcome, all very eager to be on their way home. Discharge protocols are clearly very different to the UK; some patients go home the morning after mastectomies (mostly done under paravertebral block). Recovery in familiar surroundings, with support in managing the dressings and removing the drain at home, helps these patients to recover more rapidly from such a major operation. Within the last year Professors Hadzic and Vloka have produced a website connected to their department (www.NYSORA.com). The New York School of Regional Anaesthesia has been designed to take the place of a textbook, as it can provide a continuous dynamic approach that keeps pace with new developments within the field. It is a highly popular and informative website that in February 2001 was receiving 35,000 hits per week, and I would recommend anyone interested in regional anaesthesia to view it. Of particular interest and very encouraging, are the comments from surgeons advocating the use of peripheral nerve blocks for their cases! I was also able to visit TJUH, and although I did not attend one of their programmes, I was given an insight into what is included. Each day begins with a detailed ward round of all patients with the entire team, which included the acute pain management service (APMS) director, Dr Eugene Viscusi, attending staff, pain and regional anaesthesia fellows, anaesthesiology resident, clinical nurse specialist, acute pain nurse, pain resource nurse, and a smattering of medical students each with a clearly defined role. The acute pain nurses split their day into three shifts of eight hours each. They perform at least one, and often two pain rounds each shift. They are able to adjust analgesia or treatment of side effects according to treatment algorithms, and for specific queries or complications they are directed in the first instance to the fellows.
Acknowledgement
I left the US with a wealth of knowledge, plenty of reading material and informative videos on peripheral nerve blocks, and am very grateful to the Centers of Excellence programmes for this. Also to St Richards Hospital in Chichester, West Sussex and The Royal College of Anaesthetists, for providing the financial support which enabled me to make this trip.
Why study the history of anaesthesia?

Dr P Juvin and Dr C Bonneville, Department of Anaesthesia and Intensive Care, Bichat-Claude Bernard Hospital, France
he aim of this paper is to consider why the history of anaesthesia and intensive care deserves to be studied by anaesthetists. Among the many lessons that the history of anaesthesia can teach anaesthetists, we have selected four, which are developed and illustrated: the need to use primary sources, the importance of research even with no immediate practical relevance, the combined role of luck and need, and the suspicion about long held dogma.
Checking the sources

The first lesson of history is about sources. Historical research shares with biomedical research a need for original data. Unfortunately, historical research is often equated with an entertaining inventory of secondary sources. Secondary sources often contain transcription errors, as well as distortions due to the copiers interpretation of past events in the light of present knowledge. The descriptions of the first deaths due to inhalational anaesthesia provide a telling example of the mistakes made by authors who fail to check their sources.1 Many descriptions by modern authors indicate that Hannah Greener was the first patient to die during anaesthesia. However, anaesthesia was incriminated in several perioperative deaths earlier. For example, on 16 February 1847, Jobert, a surgeon at the Saint Louis Hospital in Paris, reported that two of his patients had died following ether anaesthesia, probably as a result of gastric content aspiration. In November 1847, 12 deaths ascribed to ether had been reported in France. During the same period, anaesthesia was incriminated in several deaths in other countries. Hannah Greener is a striking illustration of how failing to check sources allows a mistake to spread through successive writings. This first lesson of history (i.e. methodology) is often mentioned in the scientific literature.2 Knowledge without immediate practical relevance is useful. A second lesson of history is about the dynamics of medical discovery. There are usually two phases, both equally necessary. The first is a slow process of general maturation during which the painstaking compilation of small pieces of evidence gradually builds up the mass of general knowledge. Accumulating facts, while apparently of no immediate practical benefit, allows the scientific community to reach this critical mass of knowledge. Thus, the current increase in the number of medical publications is a welcome trend, although most published studies fail to
yield immediate advances. In the field of anaesthesia, the theoretical discoveries of Lavoisier and the English chemists (Priestley, Davy, Hickman) can illustrate this point. Without knowing it, they prepared the ground for inhalational anaesthesia. Then, once the amount of accumulated knowledge reaches a critical mass, the second phase can start: a discoverer strikes out in a new direction either by bringing together scattered pieces of information or by radically changing a mode of thinking. Hippocratic medicine is an important example of how a phase of slow maturation is followed by radical changes induced by one person.3 During the fifth century BC, the Greeks had completed a phase of maturation and were beginning to find rational explanations for facts ascribed until then to divine intervention. In the field of history, Thucydides challenged Herodotus view that the procession of historical events was brought about by the intervention of the gods. Hippocrates did the same in the field of medicine. Diseases were ascribed at the time to penetration of a demonic force within the body. Hippocrates rejected this explanation and, with it, the treatments used at the time, which sought to appease the anger of the gods. He suggested a natural cause (a defluxion of cold phlegm caused by changes in the winds) and a natural treatment (administration of whatever is opposed to the disease). Thus, the Hippocratic revolution was born from the conjunction of a slow accumulation of general knowledge and the mind of a genius who was capable of decisive innovation in his chosen field. Thus, history teaches that knowledge is useful, even when it is apparently without immediate practical relevance, because it increases the amount of information available to humankind until a critical mass is reached, opening up the road to discovery.
Luck and need

That luck and need are essential ingredients in the process of discovery is a third lesson of history. The development of external cardiac massage illustrates the role of these two factors.4 In 1858, Silvester described his remarkable technique of artificial ventilation. In 1892, Maas noted that resuscitation for cardiorespiratory arrest was more effective when Silvesters method was applied vigorously and at a rate above 120 compressions per minute. It occurred to him to feel the pulse of his patients during resuscitation.
He noted that beats were perceptible at the same frequency as the chest compressions. Thus, while seeking to improve Silvesters artificial ventilation technique, Maas serendipitously discovered a means of artificially restoring blood flow. However, the time was not yet ripe for external cardiac massage. Only cases of cardiac arrest that occurred during surgery were treated at the time, and surgeons preferred the well-established method of surgical internal cardiac massage. Need was missing, and without this key catalyst for scientific, discovery external cardiac massage stayed in limbo for several decades. Eventually, the need for external cardiac massage arose from the development of electricity. Cases of electrocution started to occur among workers in electric power plants. A method of resuscitation suitable for use at the scene of these accidents was urgently needed. Luck, which had put Maas on the right track, again chose to lend a helping hand. In 1958, Knickerbocker and Kouwenhoven observed that application of electricity through externally applied electrodes was capable of restoring circulatory activity in electrocuted dogs. They noticed that, in itself, application of the electrodes to the chest, when sufficiently vigorous, produced a blood pressure increase. Subsequently, this technique of external cardiac massage was validated in 20 patients. This time, luck (the unexpected finding that isolated firm application of electrodes produced a pulse beat) was present in combination with need (for a cardiac massage technique that could be used at the scene of an accident). External cardiac massage rapidly gained the place of prominence it still enjoys today.
time-honoured and novel practices must be put into perspective. Throughout history, many physicians, trapped in the present, have stated they held an everlasting truth, which proved no more than an ephemeral illusion. When studied by medical doctors, the history of medicine including the history of anaesthesia can be a pleasant cultural hobby, of no immediate utility. However, we have shown that even such activities with no immediate utility can drive progress. History teaches us to step back to observe the turmoil generated by new ideas. Revolutions announced in loud voices and solutions claimed to be definitive have punctuated the history of humankind since its beginnings; most succumbed to the test of time. But history also teaches us to be on the lookout for the unlikely, which can generate discoveries and progress. Finally, history teaches humility: what seems certain today may prove wrong or useless tomorrow. It is never too late, even when everything seems irreversible, because in history unpredictable mutations and structural changes can occur, which revoke what seemed to be a ruling of Fate.6 Historians are watchful of the present because they are knowledgeable about the errors of the past, they are open to new territories but wary of paths that lead nowhere, and they are acutely attentive to the future because they know it holds routes of exploration that lie beyond the imagination. These would be valuable qualities in an anaesthetist. Anaesthetists should study history.
References 1 Juvin P, Desmonts JM. Premiers dcs lis lanesthsie par inhalation en France. Un exemple dabsence de vrification des rfrences bibliographiques. Annales Franaises dAnesthsie et de Ranimation 1998;17:273274. Steel CM. Read before you cite (Commentary). The Lancet 1996;348:144. Grmek MD. In: Histoire de la pense mdicale en Occident. Paris, France: Le Seuil; 1995. Juvin P, Desmonts JM. Cardiac massage: a method rescued from oblivion. Anesthesiology 1998;89:771776. Juvin P, Desmonts JM. The ancestors of inhalational anaesthesia: the soporific sponges (XIth-XVIIth Centuries). How a universally recommended medical technique was abruptly discarded. Anesthesiology 2000;93:265269. Chaunu P, Mension-Rigau E. In: Danse avec lhistoire. Paris, France: De Fallois; 1998.
The need for critical reappraisal

A fourth lesson of history is that physicians should view their knowledge with humility and perspective. History abounds in definitive conclusions and dogmatic statements that were eventually proved wrong. An example is the efficacy of soporific sponges.5 These were sponges soaked in a mixture of plant extracts with sedative (henbane and mandrake), analgesic (poppy), and paralysing (hemlock) effects. They were used from the eleventh to the sixteenth centuries to facilitate surgical procedures. Modern authors proved that sponges prepared using the original recipes were ineffective in inducing anaesthesia. Yet soporific sponges were recommended during more than 800 years by the highest scientific authorities. Because the practice was considered of established value, it was not challenged despite its lack of efficacy.3 In medicine even more than elsewhere, both
2 3 4 5
Appeals
Dr C P H Heneghan, Barrister and Member of Council
octors are often asked to sit on appeal panels these days. This is because many important decision are subject to appeal, and quite rightly so: where livelihoods or budgets are affected by decisions, there must be a way of correcting error or bias. This is what appeals are for.
Unfairness
A decision may be said to be unfair because of biased procedure. This is where the concept of natural justice comes in. There are two parts to this: that everyone may have a proper hearing; and that no-one should decide his own case. Having a proper hearing includes being allowed to give evidence, cross examine, and comment on other evidence. So evidence must be openly heard, and decisions must not be based, for example, on private conversations. Not deciding your own case means that you should not be a judge where you have an interest, i.e. where the result of the decision affects the decision maker personally. It may be that the first decision maker has not in fact been biased by his interest, but even the appearance of bias can be grounds for appeal. Incidentally, this also applies to appeal tribunals. So an appeal tribunal must not include anyone who participated in the first decision, as he may be reluctant to change it. Similarly, it would be wrong to hear an appeal if one of the first decision makers is close family, or perhaps for the chairman of a trust to hear an appeal from a decision by his own chief executive, as the two may work very closely together. Sometimes unfairness is the only permitted reason for appeal. Usually appeal against, say, exam results wont allow the marking to be questioned, but might allow alleging a question was outside the syllabus, or the room was too noisy, too hot, too cold etc. In other circumstances, however, factual decisions can also be questioned.
Structure
A decision that is being appealed against can be made by a variety of decision makers through a variety of processes. Sometimes there may be one individual, perhaps in an executive role, sometimes a group, board, committee or tribunal. So it might be that a Chief Executive or a Judge is making a decision, or a Discretionary Points Decision Making Group, a Disciplinary Tribunal, a jury, or perhaps a College committee. There may be a good deal of variation as to procedure, as sometimes there may be live witnesses and representatives, sometimes only documents are considered, sometimes documents plus argument from live representatives. A Disciplinary Tribunal will probably hear live witnesses and perhaps representations, while many committees or individuals will probably only consider documents. For ease of exposition, I shall call all the possible varieties of initial decision makers the First Decision Maker. Similarly, appeals may vary in constitution and format, from tribunals, with or without legally qualified chairmen, to grand committees, to a judge or a panel of them, up to the House of Lords and the Privy Council. I shall call them all Appeal Tribunals
Why appeal?
Of course, many want to appeal because they are unhappy with a result the we was robbed group and more of that later. Appeals may indeed be on grounds that the decision was wrong, or that it was unfairly arrived at. The decision can be said to be wrong because the wrong conclusions have been drawn from the evidence, and thus the first decision maker has got the facts wrong what would be an appeal against conviction in a criminal case or because it has decided the wrong course of action an appeal against sentence. There may also be the added dimension of the possibility of professional misconduct.
Factual error
People often tell different stories about the same events. Someone may be lying, but this is not the only reason for discrepancies. People make mistakes, or forget, some notice things that others dont, and so on. Decision makers have to work out what actually happened, and sometimes what people intended. Sometimes you can question their conclusions on appeal. When that is allowed, appeal tribunals are sometimes allowed to work out the facts for themselves, and substitute their conclusions for the original ones, and sometimes they are only allowed to tell a (different!) first decision maker to look again, as they seem to have got it wrong. It depends on the rules of each appeal system which of these is allowed.
When an appeal tribunal only has limited powers to change a first decision of fact, this is usually when a primary decision maker has been hearing live witnesses. Then part of the first decision makers assessment includes judging the credibility of witnesses, which the appeal tribunal cannot do when it has not heard them. In that case, an appeal can usually only question the decision on the facts if it was obviously virtually impossible on the only possible view of the facts.1 In that circumstance, the appeal tribunal can usually only order a rehearing, not substitute its own view. When credibility is not an issue, as for example when only documentary evidence is being considered, an appeal usually has full powers to change findings of fact.
How to decide an appeal

You may be asked, as a member of an appeal tribunal, to decide one or more of several questions: was the process fair, was the view on the facts correct, was the conclusion based on the facts correct, was the order or sentence correct? You may be allowed to order a rehearing, substitute your own findings for those of the first decision makers, or substitute your own orders. It is important to be clear which of these applies and the tribunal chairman should make that clear to you. Secondly, for any decision which you are being asked to review, you need to know the test which was meant to be applied at the first decision, and use that test to re-judge the case. Thus if someone was found to have been drunk on duty, and to have been dismissed as a result, if you are reviewing the whole matter, you will probably have to decide whether the tribunal was fairly set up and conducted, whether the appellant was on duty, whether he was drunk, whether drunkenness on duty is forbidden in his contract, and whether the offence warranted dismissal or a lesser punishment. Though it is unlikely that all of these will need to be decided, every element has to be right to uphold the outcome, and only one element has to be wrong to defeat it.
Orders
Appeal tribunals can usually change any order, sentence or instruction of a first decision maker. Thus an appeal can agree completely with what happened, and whether it was (for example) professional misconduct, but change the order resulting from it. It may think differently about whether public/patients need to be protected against recurrence, or give different weight to unblemished records, and so on. The powers of the appeal panel should be clear from its governing regulations.
Who may appeal?

While sometimes you need permission to appeal, more often it is not necessary, and anyone can appeal. Thus the mere fact that someone appeals does not mean that he has a case. An appellant may have no idea whether he has case, he may just appeal on the we was robbed principle. Equally, he may have a case, and it may be a good one. This is the central problem of appeals, that you are always tempted to think that someone who has the nerve to appeal must have some sort of case, and recognising that this is not necessarily so is the first step to giving the appeal a proper hearing.
Conclusions
Appeals tribunals should be clear what decision they are being asked to review, and what powers of review they have. Appeals may be based on unfairness of procedure, factual errors, or incorrect decisions based on the fact or any combination of those. Appeal tribunals should not allow the mere fact that a decision is being challenged to influence whether they allow or dismiss the appeal.
1 The judicial phrase is that a decision is so unreasonable that no reasonable tribunal could have made it.
Report of meetings of Council

At a meeting of Council on Wednesday, 17 July 2002, the following were recommended to the Specialist Training Authority for the award of a Certificate of Completion of Specialist Training having satisfactorily completed the full period of higher specialist training in anaesthesia:
East Anglia Dr Kenneth Grixti Dr Deborah Janet Meldrum Oxford Dr Michael William Peter Goodwin Dr Kate Felicity Barkshire Yorkshire Dr Ralph Kenrick Longhorn Dr Duncan Lee Hamilton Trent Dr Maki Hamad Dr Shalini Mathew Kurian Dr Aideen Maria Maguire North Western Dr Karen Jayne Kidner Dr David Ian Thomasson Thames - North West Dr Sandeep Shashikant Kulkarni Dr Thungo Kuwani Dr Neil Andrew Randhawa Dr Nicholas James Hogg Dr Ian Leslie White Thames North Central Dr Ruth Hurley Thames North East Dr Anne Cecilia Gregg Dr Andrew Alexander Klein Dr Lisa Penelope Mccready-Hall Dr Srinivasan Sampathkumar Thames South East Dr Emma Jane Stewart Taylor South Western Dr Jonathan Neil Ingham Dr David Graeme Pogson Dr Richard Alexander Struthers Dr Vijaya Esuvaranathan Dr Steven John Leslie Haynes Dr Susan Jane Loxdale Dr Andrew John Pittaway Dr Frances Margaret Ohiggins Dr Dalvina Elena Hanu-Cernat Dr Elizabeth Hunt Dr Simon Andrew Hester Dr Elis Owain Hughes Dr Gowry Rasi Simon Wales Dr Michael Patrick Gilbert Dr Ravi Taneja Dr Subbarayalu Balaji Scotland West Dr Susan Jane Smith Dr Lynn Margaret Carragher Dr Ross Fairgrieve Scotland East Dr Pamela Oakley Johnston Brauner Ivan (Charles) Breeze Richard Frederick (London) Buttigieg Michael (Malta) Cantlay Kaye Louise (Edinburgh) Carswell Neil Stuart (Leeds) Christelis Nicholas Dimitri (Orange Free State) Corcoran James Peter (Manchester) Cormack Caroline Rosemary Helen (Edinburgh) Coupe Michael Howard (Birmingham) Cowley Edward Julian (London) Cross Richard Andrew (Manchester) Cunningham Alison Sara (Manchester) Das Sumit (London) Davies Richard Gregory (Birmingham) Davis Anthony Henry (Liverpool) Davis Nathan (London) Davison Marc (London) Delecki Aleksandar (Dusseldorf) Demaine Karina Ann (Manchester) Dempsey Charlotte Marie (London) Desai Suneel Ramesh (Sheffield) Desikan Somi Ramachary (Madras) DeSilva Sonia Princy (Bangalore) Dodman James David (Newcastle Upon Tyne) Doherty Pamela Anne (Glasgow) Donnelly Brian James (Belfast) Dovell Tamsin Mary (Nottingham) Dunn Juliet Marie (Nottingham) Dyson Elsbeth (Cambridge) Edge Christopher John (London) Elabani Jamal Ali Madi (Al Fateh) Farley Claire Alison (Wales) Farquharson Andrew Charles Alistair (London) Flynn Paul Edward Robert (London) Forrest Kirsty Ann Thornton (Edinburgh) Gale Thomas Charles Edward (Nottingham) Galiveti Prabhu (Nagarjuna) Garstang Jonathan Edward (London) Gill Steven Phillip (Leeds) Goel Vandana (Maharshi Dayanand) Gold Stuart James (Dundee) Gooch Christopher Leeds (Glasgow) Gopal Shameer (Witwatersrand) Gordon Sarah Elizabeth (London) Grant Christopher Alexander (London) Gray Jillian Sandra (London) Halkes Matthew John (Wales) Harris Rupert William (Edinburgh) Harris Stephen John (Birmingham) Hashem Medhat Mohamed AbdelM (Cairo)
The following names were approved for the Diploma of Fellow of The Royal College of Anaesthetists (University of primary medical qualification in brackets):
Abdel-Aziz Ahmed Rashad (Ain Shams) Alawattegama Hemantha Dinuka B (London) Aldwinckle Robin James (Nottingham) Ali Nazrudeen (West Indies) Assmann Nicole Magdlena (Berlin) Augustine Albin Immanuel (Madras) Baines Duncan Alexander (Birmingham) Balasubramaniam Balaji (Mangalore) Bali Anu (Wales) Banks Amelia (London) Barber Paul Allen (London) Barker Horace Robert Mark (West Indies) Bayley Guy Langford (London) Bedford Geoffrey C (Newcastle Upon Tyne) Beed Martin Jeffrey (Nottingham) Bein Nicole Angela (Bochum) Bolton Tara June (London) Bong Choon Looi (Edinburgh) Bourke Alan James (Dublin) Boyd Timothy Hendry (Oxford)
Haslam Nathaniel (Newcastle Upon Tyne) Haynes Joanna Claire (Liverpool) Hignett Rachel Jane (Cambridge) Higney Mark Charles (Glasgow) Horner Daniel Richard Maxsted (London) Howard Jeremy Mark (London) Ilavajady Srinivasan (Bharatidisan) Inweregbu Kenneth (Leeds) Jackson Mark Alastair (Leeds) Jeyaraj Leo Muthusamy (Madurai-Kamaraj) Johnson Duncan (Aberdeen) Jones Gareth David (London) Jones Holly Bethan (Bristol) Jones Timothy Martin (Leeds) Kelly Fiona Elizabeth (London) Kendell Judith (London) Kinagi Muragesh M (Karnatak) Krieger Christine Elisabeth (Freiburg) Krishnan Paramaswamy (Nagpur) Lakshminarasimhachar Anand (Bangalore) Lam Shuk Wan (London) Larcombe Peter John (London) Lermitte Jeremy Gordon C (Southampton) Lewis Simon Michael (London) Lim Denise Joyce (London) Linnett Vanessa Claire (Newcastle Upon Tyne) Livingstone Harvey Lionel (Leeds) Lloyd Richard James (London) Lynch Gerry (NU Ireland) MacCallum Niall Sammy (London) Mackle John Ian (Glasgow) Mahalingam Talanayar Gautam (Tamil Nadu) Malhotra Surbhi (Glasgow) Marshall Philippa Mary (London) Martin Terence Elwin (London) McCormick Martin Francis (Glasgow) McGill Fiona Joy (Wales) McGrath Conor Dominic (Liverpool) McLeod Shaum Raymond (Aberdeen) McVeigh Gwendolyn Ruth (Aberdeen) Mehta Vivek (New Delhi) Menon Jayesh Ramachandra (Kerala) Mohammed Fareda (WestIndies) Monkhouse Diane (Newcastle Upon Tyne) Moon James Kenneth (Oxford) Mordani Kavita Jaikishan (Pune) Mullhi Damanjeet Kaur (Birmingham) Nadra Aida Mary (Wales) Nagaiyan Sridhar (Madras) Nene Siddharth Anil (London) Ochnio Barbara (Lekarz Szczecin (Poland)) ODonnell Aidan Mark (Edinburgh) ONeil Pauline Mary (Aberdeen) OscarFredy Sam Michael (Madras)
Padmavathy Vellore Bhaskaran (Madras) Peyyety Janaki Subhadra (Nagarjuna) Pike John Lindsay (Leeds) Pillai Paraneswaran (Kerala) Pinnell Jeremy Robert (Leeds) Polovinkine Pavel Valeryevich (Vrach Gorky) Ponnaiah Veda Hari Prabhakar (Madras) Quinn Andrew Charles (Leeds) Rajagopal Kailasam (Madras) Ramachandran Sridevi (Madras) Ramesh Vijayaraghavan (Mangalore) Ramkumar Konnur Rajasekaran (Tamil Nadu) Rao Padma Puppala (Osmania) Rattel Afra Maria Rosa (Munich) Rawlinson Sarah Charlotte (London) Reddy Roopa (London) Rees Sara Caroline (London) Reid Simon Alexander (Newcastle Upon Tyne) Roberts Eilir Arwel Wyn (Liverpool) Roberts James Hugh Medwyn (London) Roberts Richard Alun (Wales) Salisbury Jonathan (Dundee) Saluja Rupali (Delhi) Saravanan Palanikumar (Madras) Scholz Anette (Saarland) Sebastian Joseph (London) Seidel Jochen (Aachen) SenthilKumar Durairaj (Madurai-Kamaraj) Shah Tanuja (Nottingham) Shann Debra Jayne (Dundee) Sheppard Lorcan Patrick (London) Sim Lisa Mei Ling (Southampton) Sindhakar Seema Ratnakar (Madras) Singh Mreenal Nandan (Wales) Skinner Adam (Bristol) Smith Shona Catherine (Edinburgh) Snyders Stephen Paul (Cape Town) Sodhi Manisha Surainsingh (Bombay) Solan Katharine Jane (London) Spooner Kay Joanna (London) Ssenoga Abraham Kasenene (Makerere) Standley Thomas David Auger (Birmingham) Stansfield Janet Mary (London) Stevenson Carl Andrew (London) Sudhir Gopakumar (Kerala) Telfer June Mary (Edinburgh) Temple Andrew Richard (Leeds) Terblanche Marius (Stellenbosch) Thomson Rebekah Charlotte Clara (Leeds) Thornton John Patrick (NU Ireland) Tillyard Andrew Robin James (Glasgow) Tsang HooKee (Wales) Usher Stephen Mark (Wales) Vercueil Andre Etienne (Cape Town)
Walsh Dean Patrick (Otago) Walters Sarah Elizabeth (Cambridge) Walton Anna Marie (Southampton) Waters Claire Elizabeth (Sheffield) Watson Malcolm John (Glasgow) Weale Nicola Katherine (Nottingham) Whitcombe Andrew James (Leicester) White Michelle Claire (Bristol) Wiggans Stephen Mark (Birmingham) Wilkinson David Andrew C (Birmingham) Williams William A (London) WolfeBarry Juliet Alexandra (London) Woodcock Clare (Leeds) Zain Zurainah (Bristol)
At a meeting of Council held on Wednesday, 18 September 2002, Dr K Chandradeva (Kent), Dr C Duffy (Cammbridge), Dr W A McFadzean (Swansea), Dr H A E Youssef (London), Dr N Volpe (Worcestershire) were all admitted to the Fellowship ad eundem. Professor I Power (Edinburgh), Dr M Y K Wee (Bournemouth), Dr K A Price (Tyne and Wear) were all admitted as Primary FRCA Fellowship Examiners. The following were appointed Regional Advisers:
Anglia Dr N W Penfold, West Suffolk Hospital, Bury St Edmunds (in succession to Dr P D Phillips) (with effect from 14 October 2002) Northern Ireland Dr J Darling, The Ulster Hospital (in succession to Dr J Murray) (with effect from 1 October 2002)
The following were appointed Deputy Regional Advisers:

Yorkshire Dr R H Cruickshank, St Jamess University Hospital, Leeds (with effect from 8 July 2002) North Thames (Central) Dr C I Beard, Royal Free Hospital, London (in succession to Dr E M Grundy) (with effect from 1 August 2002) Dr R M Milaszkiewicz, Barnet General Hospital (newly created post) (with effect from 1 August 2002)
South Thames (East) Dr J V Sedgwick, Kings College Hospital, London (with effect from 1 August 2002) Wales Dr A C L Fraser, Glan Clwyd Hospital, Rhyl (in succession to Dr D W Thomas)
Flexible Working for Doctors

The Flexible Careers Scheme (FCS) was developed as part of the Improving Working Lives for Doctors initiative. The scheme helps doctors maintain their careers by providing more centrally funded opportunities to work part-time and have temporary career breaks. The Flexible Careers Scheme funds doctors who are able to work up to 49% of full time and in each case the scheme is adapted to individual circumstances and provides sufficient medical/clinical practice for revalidation purposes.
The following were appointed/reappointed College Tutors (re-appointments marked with an asterisk):
Northern Dr G R Enever, Royal Victoria Infirmary, Newcastle-upon Tyne (in succession to Dr V E Bythell) (with effect from 2 September 2002) North Thames (West) Dr M L Cox, Chelsea & Westminster Hospital, London (in succession to Dr M A Hayes) (with effect from 1 July 2002) South East Scotland *Dr P A Roddam, Queen Margaret Hospital, Dunfermline South Thames (East) Dr C Mallinson, St Thomas Hospital, London (in succession to Dr D N James) South Thames (West) Dr C W J Gass, St Georges Hospital, London (in succession to Dr B J Stanford) (with effect from 1 September 2002) Wales Dr T J Wall, Morriston Hospital, Swansea (second College Tutorship established) West Midlands Dr M I Bowden, Selly Oak Hospital, Birmingham (in succession to Dr J P Millns) (with effect from 1 December 2002) Dr H F Yanny, Manor Hospital, Walsall (in succession to Dr K Balachandar)
What does the Flexible Careers Scheme offer?

For doctors in the training grades the FCS provides an alternative to flexible training, although it is important to note that time spent on the scheme will not be accredited for training because doctors will be working less than 50% full time. It is however possible for doctors on the scheme to keep their NTNs. Trusts that employ doctors in the training grades on the Flexible Careers Scheme receive 100% central funding to cover their employment costs. For career grade doctors it provides a route into permanent or temporary part time work by providing centrally funding for the creation of suitable part time posts. Trusts that employ career grade doctors on the Flexible Careers Scheme receive central funding to cover up to 50% of their employment costs. For returners the scheme provides a clear re-entry pathway back into the NHS with fully funded refresher training, and the option to work full or part time during this period. After completing refresher training there is the option to return to a part time post supported by the FCS. For doctors nearing retirement it gives central funding to support them in reducing their hours in their final years of service. Trusts that employ doctors close to retirement on the Flexible Careers Scheme receive central funding to cover up to 50% of their employment costs.
Benefits of the Flexible Careers Scheme

Central funding to pump prime the creation of more flexible part time work arrangements including annualised hours, job shares etc. A fixed annual amount, currently 700, paid to the doctor, to contribute towards professional expenses. Access to the NHS pension scheme and to the same employment rights as other colleagues. An educational CPD element. An exit strategy for moving on after being on the FCS. It provides sufficient medical/clinical practice to meet the requirements for revalidation. Career grades can remain on the scheme for up to three years while doctors in the training grades can remain on the scheme for up to two years. The Flexible Careers Scheme is already helping doctors return to work after a period of absence, work more flexibly and reduce their hours close to retirement. For further information on the Flexible Careers Scheme, or to apply to join, contact NHS Professionals on 0845 60 60 345.
Report of the College Tutors Meeting, April 2002

Dr J E Peacock, College Tutor representative, The Royal College of Anaesthetists
his years meeting took place in London and focussed on some of the issues surrounding competence and trainee assessment whilst providing opportunity for the College to report to Tutors about past and future developments. As usual the programme was produced by the two tutor representatives, Mike Wilkinson and myself, following sometimes desperate requests for feedback and ideas from other tutors, regional advisors and schools. In response to specific comment about the structure of the previous years meeting, an intentional decision was made this year to include more time for discussion together with a final session wholly given over to a Question Time with the College President and representatives of College Council. The first presentation was by Dr Neil Johnson from Leicester who is now the Lead Postgraduate Dean for anaesthesia. He usefully reminded us of his role in managing NTNs and contributing to national policy as well as helping to develop both the speciality and its senior members whilst not getting involved with individual trainees or deaneries. During the discussion time which he specifically requested, he informed us that future priority in managing NTNs would be to produce capitation based equity over time with local factors taken into consideration. Concern was expressed that putting trainees where there were large numbers of patients could be seen as providing service and did not necessarily match with providing good training.
Competence and assessment

The session on Competence included a review by John Curran looking at competence and assessment with some of the difficulties surrounding the balance of training against service. The concern that junior trainees continue to gain excessive experience of obstetric analgesia and ITU because of on-call rotas at the expense of other areas of expertise reared its head again and also in Question Time. Keith Myerson addressed the distinction between professionalism and competence reminding us that attitudes and behaviour matter. Although judgements on such matters are always subjective, when confirmed by more than a single observer they can be fair and reliable. He also identified that competence is only the first step on the ladder and that individuals need to progress to proficiency and even to expertise during their career and this may be an appropriate response to the clamour to introduce reductions in training times. An amalgamated case history of a problem trainee prompted significant discussion about what to do with such an
individual and a show of hands indicated that about 75% of those present had some experience of dealing with a trainee who did not satisfy basic competence assessments and yet did not have the insight to recognise their weaknesses. Although not frequent, this may become a real problem for a tutor who should never have to deal with such an individual in isolation but with help from the school, regional advisors, the postgraduate deans office and the College. The issue of protecting patients and preventing such an individual moving around between jobs and in particular to locum agencies was also discussed; not least the mechanism of referral to the GMC as the only remaining option. The potential for disagreement between the proponents of competence-based and time-based training in the session on assessment was masterfully avoided by Neil Johnson and David Greaves. Both based their arguments and presentations on the need to produce anaesthetists who are capable of delivering safe and effective care with competence-based being based around a curriculum and a minimum amount of time in training whilst time-based training may focus initially on a log book and an inventory of key procedures which might require procedures to be counted. In updating us on the competency-based programme Stuart Ingram reminded us that the documents are not set in stone and that feedback is encouraged where the system is not working. The years 35 document is being developed and will be available in due course. During discussion Neil Johnson stated that he felt that tutors need training to fulfil their roles. As a result of this and comments during Question Time, it was agreed that a New Tutors training day would be set up with the Colleges support to try and provide this. Additional evidence for this was provided by Jonathan Edgar who had surveyed the previous meeting about tutors learning needs. Results showed 92% had received no formal training and 94% felt that there was a need for an introductory course.
Intensive care medicine

The session on intensive care training reminded us again of the need for specific modules but also that training was in critical care which had a broader remit than just intensive care. There was NOT the expectation that trainees would spend time solely on ITU; high dependency and outreach were also areas requiring critical care training. The existence of an educational supervisor on each ITU who is responsible for education with-
in that area was also identified. Great emphasis was placed on tutors and supervisors working together to provide a summative assessment of critical care modules and on avoiding duplication of work. However, both Alastair Short and Paul Lawler were explicit in expecting the supervisor to be actively involved in the critical care assessments and for them not to be devolved to anaesthesia in isolation. During the final session, questions and discussion flowed in both directions. Peter Hutton led discussion on the European Working Time Directive, the introduction of the Medical Education Standards Board and the desire of the STA to reduce the duration of SpR training. Specific questions from the floor included attached sessions, time on ITU, problems of attitude as well as more formal utilisation of clinical attachments as an introduction to UK practice.
AS WE WERE ...
From the Past
In December 1909 The Lancet commented as follows on the recent demonstrations of spinal anaesthesia by the visiting Rumanian surgeon, M Jonnesco: Spinal anaesthesia does not appear to be welcomed as warmly in Great Britain as in some of the continental countries, and we believe that the main reason is that there is less cause to be dissatisfied with the use of general anaesthesia here than there is abroad. We talk a good deal of our defaults in the matter, but we appear to be ahead of many of our neighbours. Whether it is because in these islands chloroform was first used and nitrous oxide discovered, while ether introduced by a man of the Englishspeaking race, was given a ready acceptance whether it is this inheritance or for some other reason, the fact remains that in Great Britain we have a number of medical men devoting their professional efforts entirely, or almost entirely, to the study and practice of anaesthesia. This is not the case on the continent where, in Jonnescos words, the anaesthetist is often inexperienced, and never responsible. The editorialist continued by attributing the choice between general and spinal methods also to the racial differences between British and Roumanian operators, anaesthetists, and patients, and what they were prepared to put up with. Reference Editorial Spinal anaesthesia. Lancet 1909;ii:1684.
Future meetings
The first of the New Tutors introductory meetings will take place in the College on 18 December 2002 with the second at the next tutors meeting which is in Manchester on 23 July 2003. To produce a programme which will be of interest and relevance to the audience, ideas, comments, criticisms of the reported meeting, current difficulties or uncertainties need to be forwarded to the organisers. It would be helpful to receive a more audible response than the near deafening silence which greeted Mike Wilkinsons request for ideas last year. Additionally, a Tutors Representative to replace me will need to be elected to work alongside Fiona Dodd who was elected this year. Nominations will be sought nearer the meeting but hopefully will not be left to the meeting itself this year.
David Zuck History of Anaesthesia Society
Conscious sedation in termination of pregnancy Report of the Department of Health Expert Group
This report contains findings of a DH Expert Group that was asked by the Chief Medical Officer to consider the use of the technique of conscious sedation in termination of pregnancy. The technique is not widely used for termination of pregnancy but as it is being introduced by service providers, the Group has drawn up standards relevant to the use of conscious sedation for this purpose. The report sets out recommendations for abortion service providers who wish to offer, or are already offering, conscious sedation as an alternative to a local or a general anaesthetic for early surgical abortion, to those women who meet the criteria. The report can be found at www.doh.gov.uk/sexualhealthandhiv. A copy is being sent to those NHS hospitals and approved independent sector places that perform terminations. Further hard copies can be ordered by tel 08701 555455 email doh@prolog.uk.com fax 01623 724524 or by writing to: Department of Health Publications, PO Box 777, London SE1 6XH quoting: 29269/Conscious sedation in termination of pregnancy. For further information, please contact Kay Ellis, Sexual Health and Substance Misuse on: tel 020 7972 6172 or email kay.ellis@doh.gsi.gov.uk
Correspondence
Please make your views known to us via email (preferred option) to: bulletin@rcoa.ac.uk, or by post accompanied by an electronic version on floppy PC disk, preferably written in Microsoft Word (any version), to: The Editor, c/o Mrs Mandie Kelly, Editorial Officer, The Royal College of Anaesthetists, 48/49 Russell Square, London WC1B 4JY. Please include your full name, grade and address. All contributions will receive an acknowledgement. The Editor reserves the right to edit letters for reasons of space or clarity.
Epidural injections
Madam, With regard to the recommendations on the use of epidural injections, (Bulletin14, July 2002), I would be grateful if someone could clarify the following statement from section 2, paragraph 8: Epidural injections for the treatment of back and leg pain of spinal origin should not be performed without good reason on a patient whose conscious level is depressed (as a result of anaesthesia or sedation) What constitutes good reason? It does seem to be a statement that the legal profession could argue over. On a personal note, I work in a hospital where sedation has been used for years (decades) and some of the patients are adamant that the pain of the procedure under local is too great without use of sedation (at times bordering on anaesthesia). Does the above constitute good reason? I would be grateful if you could provide some further clarification as it does have clinical risk and governance implications, and it would have a major impact on the practice of some of my colleagues and on the patients affected. I Makkison, Consultant, Derbyshire
The AMBU bag

Madam, The survey on the AMBU Bag by Dr T Sivagnanam (Bulletin 13, May 2002) was very interesting to read. Suri Seri Begawan Hospital is a District General Hospital situated at Kuala Belait, Brunei Darussalam serving a population of about 50,000 people. The operating theatre complex was renovated in 1995. With good financial support from the Ministry of Health, the Department of Anaesthetics was adequately equipped. The operating theatre complex con-
sists of two main operating theatres, one minor operating theatre and a two-bedded recovery area. Each main operating theatre has an AMBU bag prominently placed near the anaesthetic area and easily reached in an emergency. Separate individual AMBU bags are available in the minor operating theatre and the recovery area. The fully equipped resuscitation trolley is placed in the recovery area and has its own resuscitator. Thus, it is seen the operating theatre complex has five AMBU bags available at any one time. In addition, paediatric resuscitators are available. A modern anaesthetic machine is available for use in each main operating theatre. An older anaesthetic machine is on stand by and is placed within each operating theatre itself (space available). Anaesthetic machine failure can occur without any prior warning, particularly in the middle of the night. If this happens at our hospital, the anaesthetized patient will be transferred to the other (standby) machine safely and smoothly with the use of the AMBU bag and the operation can proceed. It is very important that all the anaesthetic machines in use, not forgetting the anaesthetic monitors, are regularly checked, serviced and maintained. The operating theatre mechanic with 25 years service at our hospital has done an excellent job to date. Suri Seri Begawan Hospital compares well with the Hospitals in England. S Varatharajan, Specialist Anaesthetist, Brunei
Anaesthetic skill-mix
Madam, I wholeheartedly agree with the assessment by Dr F J M Walters on Anaesthetic Skill Mix (Bulletin 14, July 2002). He has correctly stated the case for nurse anaesthetists, and has also pinpointed a major difficulty of applying their use to the UK the haphazard nature of list planning! Being freed up for tasks other than routine theatre work consultations, pre-op visits, planning meetings made me feel a more valued physician and team member in Sweden than I did in the UK. I was happy to delegate simple and routine tasks to nurses I had myself trained and whose standard of patient care I had full confidence in. Apparently this debate is still moving forward; as recently as six years ago, anaesthetists putting forward such a point of view were being equated with flat-earthers. Perhaps the worst aspect of the campaign against those who put forward such views was that even those who had successfully worked in the Swedish system (22 years in my case) were told that whatever they said about the benefits, they were wrong! wrong! wrong! (and if they wanted their careers to proceed, they should shut up). R Fletcher, retired Consultant, Cheadle Hulme
Distinction awards
Madam I read with interest Dr J S M Zorabs response to Dr J Prings letter concerning the Distinction Awards system (Bulletin 14, July 2002), and should like to comment as follows: Dr Zorab must be in receipt of at least a B Award to qualify for the various committees on which he has served. Unsurprisingly, therefore, he is vigor-
ous in his defence of the award system. I have rarely, if ever, heard it supported by a non-award holder, which hardly suggests widespread confidence in its operation. Dr Zorab is perfectly correct in saying that Dr Pring should not make accusations without hard evidence. However, as he must be well aware, the deliberations of Award Committees are confidential even secretive and such evidence would be very difficult to obtain. However, Dr Pring is entitled to voice his opinions, which I suspect are shared by a good many consultants. Dr Zorab stated that members of Award Committees work very hard to make an imperfect system work as well as possible and do their best to see that appropriate merit is awarded. Perhaps so, but then how does he explain systemic inequalities such as the disproportionately low number of awards made to female doctors, ethnic minorities, or indeed to certain specialties? Is that just part of lifes unfairness, or a manifestation of Dr Prings corruption, nepotism and oldboy networkism? Or is merit being judged by inappropriate criteria? There is a Candide-like tone to Dr Zorabs letter, suggesting that the Distinction Award system is the best arrangement possible. Yes, I agree with him that the world is unfair, but that is no reason to perpetuate a system perceived by many to be less than transparent. On balance, my sympathies lie with Dr Pring. Finally, I might add that some of the same criticisms can be directed equally against the allocation of Discretionary Points. IR Fletcher, Consultant, Newcastle upon Tyne
Consultant surgeon assessment

Madam, The title Consultant surgeon assessment of consultant anaesthetist working practice1 (Bulletin 14, July 2002) seemed to promise an interesting article on a challenging subject. Unfortunately, the author (and protagonist?) of this exercise got into a muddle from the word go.
The title speaks of working practice, and indeed, the two ratings requested from the surgeons (list organization and patient management) vaguely aim at professional performance; yet summary, introduction, and discussion all elaborate on the desire to measure working relationships. These are two entirely different spheres which one did Dr Carnie and his department try to assess? Assuming judgments on two aspects of professional performance (list organization and patient management) were sought, the two-item questionnaire was not entirely misdirected, but extremely crude. How would the surgeons measure these complex composites without looking at a multitude of well-defined subcategories and appropriate measurement tools for each of them? It all boils down to crude, entirely subjective impressions or opinions, pet-hates of the surgeon (e.g. epidurals) and possibly even hidden agendas (e.g. influence of the statement on private practice with the anaesthetist concerned). This is not assessment, and certainly is not good enough to form the basis for appraisal and revalidation! Through the back door this subjectivity might actually allow a glimpse of working relationships, but without an accurate standard of measurement it is impossible to determine whether a poor score reflects dislike between the two colleagues, poor performance on the part of the anaesthetist, or the mechanism of projection on the part of a poorly performing surgeon. Apart from inter-assessor variability, there is also the problem of disparity of surgical specialties: a cataract list is not the same as a major vascular list, hence the scores achieved by different anaesthetists are not comparable. Neither of these confounders has been addressed. Was any attempt made to validate this two-point questionnaire? Dr Carnie, too, asks this question, and comes up with four feeble answers: All the surgeons returned the questionnaire this signifies acceptance, and compliance of the surgeons, not validation of a test. A wide diversity of assessment scores was returned not so. The next part of the sentence states in parenthesis that 19 of 28 anaesthetists scored 4 or 5 in all
of their assessment, and the overall median scores were 4.7 and 5. This does not suggest the approximately natural (Gauss type) distribution that one would expect. In any case, the fact that the results are as they are does not validate a test. The majority of returns demonstrated a satisfactory performance assessment congratulations! This is a department where 27 of 28 anaesthetists are above average. Does this validate the test, or rather cast doubt on its validity? The survey was the catalyst for it may have had some beneficial effects, even if the numbers generated were completely meaningless. Meaningless raw data do not acquire more significance by mathematical manipulation (like means and medians), nor by mistakes in the process (like quoting the range of regular surgeons as 16, when Table 2 suggest that the number 6 never occurred). Any tool chosen to measure an outcome has to be demonstrated to be capable of doing so,1 before any resources are wasted on its application and decisions are based on its results. I am not convinced the questionable questionnaire passes this test. L Dimpel, Consultant Anaesthetist, University Hospital of Wales, Cardiff Reference 1 Carnie J. Consultant surgeon assessment of consultant anaesthetist working practice. The Royal College of Anaesthetists, Bulletin 14;July 2002:690692.
Tagging
Madam, In response to the question raised by your correspondent on the issue of security tags (Bulletin 15, September 2002), I am appending the advice we have received in a letter from the Medical Devices Agency dated 18 July 2002 regarding the same subject: The security tags contain low power radio transmitters, with output power in a similar range to that employed by remote car locks. The contractors have carried out some tests on hospital sites and no adverse effects were seen. Unfortunately, they were
unable to provide documented test results. Our experience of higher power sources, such as mobile phones, is that even these need to be very close to medical equipment to cause any effect. This suggests that the low power transmitters in security tags are unlikely to cause any adverse incidents. However, there will be situations where the tag is likely to be adversely affected by medical devices. For example, this is likely to occur during MRI scanning, where the intense fields used would damage the tag and might cause injury to the wearer. In these circumstances, the tag should be removed. The tag can be removed by cutting through the attaching strap. If this is done, the hospital should inform the appropriate monitoring centre, whose phone number will be found on the tag. The Agency has not received any adverse incident reports due to security tags. Should any problems occur, they should be reported to our Adverse Incident Centre for investigation. If interference from a tag is suspected, or the procedure is likely to damage it, the tag should be removed as described above. J Watts, Clinical Director, Burnley
aggregate the views of my colleagues. This process allows them to remain anonymous while preventing domination by particular individuals who might otherwise be overly influential in a group decision. Each successive questionnaire gives feedback to the respondents concerning their responses to previous iterations. This allows them to change responses completely, to maintain their previous positions, or to move toward consensus. To help guarantee a successful Delphi the following applies:
1 No single opinion is attributed to the

individual who provided it.
2 Participants must have adequate time

to generate and to rethink their original thoughtful responses.
3 Participants must have skill in written

communication.
4 Participants must be highly motivated

to address the questions.
5 The process should continue until the

group is close enough to consensus for practical purposes. Stage 1 This consists of an initial questionnaire which has the purpose of identifying broad issues (e.g. are there any areas of the draft guidelines you would like changed, added or deleted). Stage 2 Responses to the open ended questions in the first questionnaire are analysed qualitatively by sorting, categorising, and searching for common threads to construct the second questionnaire. This questionnaire asks respondents to rate the importance of each issue/item raised in the first iteration on a (3- or 5-point) scale ranging from not at all important to absolutely essential. Stage 3 The responses to the second questionnaire are analysed and communicated to the respondents in the form of a third questionnaire. The items/issues are ranked according to the items mean ratings and respondents are asked to reconsider their ratings in light of the group response. The final responses are assessed and items/issues which are rated overall as being essential to include/change/delete are adopted. This process of systematically aggregating the opinions of individual experts in developing a consensus is based on the assumption that many heads are often bet-
ter than one, an assumption supported by the argument that a group estimate can be more reliable than that of one expert. Overall the Delphi technique is very useful as it overcomes some obstacles to change. One such obstacle to innovation is fear of loss of control. By using the Delphi approach one is able to develop a data based proposal quickly and build a consensus on and ownership of a complex issue among a cross section of faculty or departmental staff to enable the idea to flourish. This is important, as relevant, innovative ideas themselves cannot bring about change. Rather, it is the relationship between innovative ideas and the political, economic, and social environment into which they are introduced that determines acceptance and growth of the innovation. The independence, credibility and high standing of participants who are responsive to local specific needs is another key element in the success of a Delphi process. This also makes it easier for results to be accepted by governing committees. MC Holt, Whangarei, New Zealand Reference 1 Stritter FT, Tresolini CP, Reeb KG. The Delphi technique in curriculum development. Teaching and Learning in Medicine 1994, Vol.6;No.2:131141.
Change methodology
Madam, I agree with Dr OKelly that change methodology is important for effective quality improvement in the provision of health care (Bulletin 14, July 2002). Whilst the described RAID (review, agree, implement and demonstrate) model of change is one method by which change can be brought about there are others. One such process that I have used with great success is that of a modified Delphi process. I have used this process in developing a unified peri-operative diabetic management guideline for use across three hospitals for both medical and surgical specialities in one Trust. I have also used this process to establish what should be included in our department handbook for house surgeons. It can also be useful for concluding issues brought up at department meetings when many views are heard but no conclusions are reached. The modified Delphi process1 that I have used is a three stage process. To achieve the desired outcome I used questionnaires in three successive iterations to
Consultants pay and prestige

Madam, A survey recently conducted in hospital aimed to find out what nurses and patients knew about consultants pay. 70 nurses and 50 patients were randomly recruited to be interviewed by house officers on a single day, this to minimize collusion or checking the answers first. They were asked how much they thought consultants earned for their NHS work and on what basis they were paid, whether salary, fee-for-service, hours worked or specialty. Over 70% of both groups did not know that consultants were paid by fixed salary. They were then asked on what basis did they think they ought to be paid and how much. Finally, if they thought that specialty should influence pay, they were asked to rank them in order, being given a list of five specialist
fields to choose from. Both groups thought consultants should be paid according to hours worked and their chosen specialty. Although there was a very wide range of figures, those suggested by nurses would produce a basic salary of over 90,000 and by patients over 100,000. When asked to put specialities in rank order, 71.5% of nurses and 70% of patients put surgeons first and both groups put anaesthetists second. Of nurses 24% and of patients 10% ranked anaesthetists first. Either National Anaesthesia Days are having an effect or we do not need to worry too much about our image. It is the physicians who should, for only 1.5% of nurses and 14% of patients put them top of the list. Sadly we cannot read too much into a small survey in a single hospital, except that it seems that this hospital has a group of anaesthetists of whom we can be proud. AK Adams, retired Consultant, Cambridge Reference Ball EL, Parekh D, Woodward A. Preconceptions of consultants NHS salaries. Annals of the Royal College of Surgeons of England (Suppl) 2002;84:233235.
so on. Yet nowhere did an anaesthetist appear to have been involved, someone who had probably cared for her on intensive care as well as providing anaesthesia for her numerous operations. Secondly, The Mail on Sunday were playing the same game in an article in their supplement You, published on 8 September 2002 not that I read this paper! In an article written by a Markie Robson-Scott, the story of a woman suffering from breast cancer was recounted. In particular, the article focused upon the members of the team involved in her treatment and recovery this included the GP, breast care nurse, breast surgeon, plastic surgeon, ward nurse, oncologist, counsellor and reflexologist. Again, not an anaesthetist in sight. The patients comments about the role of the ward nurse are particularly interesting: I had never been in hospital before, apart from when I had my babies and I was really frightened, especially it seems silly now about having an anaesthetic. I wonder if the author of this article has ever had an anaesthetic or even knows what an anaesthetist does! Such an article clearly
does nothing to improve our profile and may even undermine some of the good work done by those involved in National Anaesthesia Day. I personally find it most frustrating when I see such articles and advertisements, but I am not sure what we can do about it, or if it really is that much of an issue. Clew Communications, who are now involved with the public relations and media coverage aspects of National Anaesthesia Day (The National Anaesthesia Day Brand Bulletin 15, September 2002) clearly feel that targeting the media will play an important role in further enhancing the publics view of anaesthesia and the development of the National Anaesthesia Day brand. As such they will be targeting up to 1,000 media outlets. Perhaps those outlets I have mentioned above should be targeted in particular. In addition, perhaps the College should make representations when we feel we have been misrepresented (or not represented at all!). R Orme, SpR 4, Oxford
The Liverpool Society of Anaesthetists
Slim Volume Symposium

Evidence-based anaesthesia and critical care A slim volume?
At the Moat House Hotel, Chester 2829 November 2002
Saxon Ridley Too sck for critical care? Luciano Gattinoni Does mode of ventilation affect outcome? David B ennett Pre-optimisation: whats the evidence? David Goldhill Does outreach alter outcome? Cameron Howie Any evidence of progress in sepsis? David Saunders Suicide: are anaesthetists at greater risk? Sarah Harries Tranees in the DGH: blessing or burden? Peter Hutton Skill-mix in anaesthesia: how far should we go? Dorothee Bremerich Walking epidurals: wishful thinking? Glenn Russell GA + LA: fashion or standard? Herv Bouaziz Neuro complications: can we learn from the French? Paul Edwards LA for carotid endarterectomy: is it safer? DEBATE Children under four should be anaesthetised in a specialist centre Registration fee: 300 (Consultants) 250 (Trainees and NCCGs) Approved for ten CEPD points For further information, please contact Ms Georgina Hall, Department of Anaesthesia, Arrowe Park Hospital, Wirral, Merseyside CH49 5PE tel 0151 604 7056 fax 0151 604 7126 email georgina.hall@whnt.nhs.uk
National Anaesthesia Day

Madam, The success of National Anaesthesia Day is clear for all to see. The latest MORI Poll (available via the National Anaesthesia Day website at www.smiths-medical.com/nad) shows a greater percentage of the public think anaesthetists are medically qualified than when the same poll was carried out in 2000, and all those involved should be congratulated in giving us a greater profile. However, certain parts of the media would appear to be in need of education. Firstly, I am sure many anaesthetists will recall the recent Government-led adverts on television attempting to increase the recruitment and retention of nurses. Essentially, the storyline of the advert identified all of those individuals responsible for helping a young road accident victim recover from facial injuries three surgeons, five physiotherapists and
The Mersey School of Anaesthesia and Perioperative Medicine
Primary FRCA Basic Sciences The Mersey Selective

A COURSE TAILORED SPECIFICALLY AND ONLY FOR CANDIDATES SITTING THE P RIMARY E XAMINATION IN WINTER 2002
Monday, 10 February to Friday, 14 February 2003 Registration fee: 350
This five-day course of lectures and tutorials has been designed following extensive consultation with trainees who have recently had to face the challenge of the Primary Examination. As a result, the course will cover only those areas of the syllabus considered to require special attention and elucidation, the aim being to explain and to simplify. Please note that places are limited to 30. It is emphasised that the course will only be of real benefit to trainees who are seriously approaching the threshold of the examination. The following are verbatim extracts from the Feedback Forms of The Mersey Selective Course in June 2002:
The course has shown me the level of knowledge that I would need to acquire to pass the Primary FRCA. ... some of the lectures have clarified difficult concepts and elusive topics eg Pharmacokinetics and Statistics. I realised what I am expected to know. This was a well organised course in so much as to let me know just how much more I really needed to know prior to the exam. A lot of very difficult topics were extremely well covered. Basic principles were well explained. I did a primary science course in ... and I have to say I found this course a lot more beneficial. The idea of selecting topics is a very good one. It is an excellent course which has given me a message to work harder and made me understand certain topics .... Many difficult areas that are poorly covered in textbooks are explained very clearly and patiently, dispelling many myths and misconceptions you infer from textbooks. This course has made me realise that I do not know as much as I thought I did and the depth that is required. I commend each and every tutor for making the effort in ensuring that we understood the topics covered. Enjoyable well run course, encompassing areas not well covered or dispersed over various texts. Excellent course. It gives us direction and content. Aware of how much more we have to work. I thought the course was very well organised and covered the majority of the difficult topics from the syllabus and made me aware of what areas I need to pay particular attention to before the exam.
For further details and an application form, please contact The Mersey School (email only please) on MSA@rlbuh-tr.nwest.nhs.uk
The Association of Anaesthetists of Great Brtain and Ireland

January 2003 Winter Scientific Meeting (venue to be confirmed) June 2003 GAT Annual Scientific Meeting (venue to be confirmed) More detailed nformation can be obtained from the Association of Anaesthetists of Great Britain and Ireland, 9 Bedford Square, London WC1B 3RA tel 020 7631 1650 fax 020 7631 4352 email meetings@aagbi.org website www.aagbi.org
Election to the Board in Scotland 2002

There are two categories of vacancy in the above election which was due to take place on Monday, 2 December 2002. However, as the number of nominations equals the vacant seats, no ballot is now required.
NCCG member
Following changes to the Boards Regulations, there was one vacancy for an elected Board member. This will be known as a NonConsultant Career Grade (NCCG) vacancy and is elected by Fellows, Associate Fellows, Members and Associate Members. The NCCG candidate nominated, and now declared elected, is: ROBISON Christine (Fellow: 1984) (Date of Birth: February 1954) Edinburgh Royal Infirmary Nominated by: Dr J H McClure, Dr M R Logan and Dr V Clark
Consultant member
Bristol Medical Simulation Centre

Forthcoming courses for 2002
14 & 15 November Novice Anaesthetists Course for SHOs with three months to two years experience (120 for one day/200 for both days) 22 November SAAD First Response for Dentists (eligible under section 63) Course (20) 2 December Simulated Airway and Ventilation Emergency course for SpRs and consultants in emergency medicine, ITU and anaesthesia (150) 4 December NCCG Critical Incidents Day for non-consultant career grade anaesthetists (150) 6 December Training the Trainers for faculty starting a a simulation project (150) 12 December Medical Emergencies Course for SpRs and consultants in emergency medicine, ITU and anaesthesia (200) 18 December Paediatric Anaesthesia Critical Incident Day for occasional paediatric anaesthetists (150) 31 January 2003 Paediatric Anaesthesia Critical Incident Day for occasional paediatric anaesthetists (150) 5 February 2003 NCCG Critical Incidents Day for non-consultant career grade anaesthetists (150) 18 February 3003 Paediatric Anaesthesia Critical Incident Day for occasional paediatric anaesthetists (150) Specific departmental courses can be arranged upon request (fee negotiable) BOOK NOW! Fees include coffee, tea, biscuits and lunch. All course approved for five CEPD points (for one day) and eight points (for two days) For further information, please contact: Mr A Jones, Centre Manager, The Bristol Medical Simulation Centre, UBHT Education Centre, Level 5, Upper Maudlin Street, Bristol BS2 8AE tel 0117 342 0108 email alan@simulationuk.com and/or visit the website http://simulationuk.com which contains course details
Consultant members of the Board are elected by Fellows and Associate Fellows. Two consultant vacancies on the Board occurred in 2002. Dr Jenifer Meek came to the end of her second term and Dr I D Levack completed his first term, and so is eligible for re-election. The candidates nominated, and declared elected, are: 1 LEVACK Iain (Fellow: 1981) (Date of Birth: June 1951) Ninewells Hospital and Medical School, Dundee Nominated by: Dr D Hartmann, Dr W F D Hamilton and Dr B E M McGuire 2 MORTON Neil (Fellow: 1983) (Date of Birth: October 1955) Royal Hospital for Sick Children, Glasgow Nominated by: Dr L R McNicol, Dr J Currie and Dr J F Sinclair The above elections will be effective from Monday, 2 December 2002.
The Royal College of Anaesthetists

Paediatric Anaesthesia and Critical Care Emergency Services in Hospitals
In any hospital that receives unrestricted paediatric emergency admissions, whether through the A&E Department or by referral, it may be necessary for the on-call anaesthesia/critical care team to help with the stabilisation of sick children before their transfer to an appropriate, geographically separate, centre. This may involve intubation, ventilation, the establishment of invasive monitoring and perhaps the transfer itself. It is thus necessary that on-call anaesthesia and critical care teams in such hospitals at all times include at least one member competent in such procedures, and that both appropriate equipment and trained assistance are always available. Clinical directors should bear these factors in mind when planning their services, agreeing CEPD plans and constructing staff rotas.
Appointment of Members, Assoociate Members and Associate Fellows

The Royal College of Anaesthetists would like to congratulate the following who have been admitted following the introduction of the new membership criteria in August 2001:
New Members July 2002 Dr Yousry Adeeb Kamel Dr Frances Reid Dr Peter John Alderson August 2002 Dr Poonamallee S Sampath Dr Trevor William R Lee Dr Penelope Anne Short Dr Sally Pryor Kelway Dr Raya A-N M Hamoudat Dr Mary Engleback Dr Barbara Mary Helena Perks Dr Gamal El-Din Youssef Dr Hanumanth Rao Jonnada Dr Muhammead Qasim September 2002 Dr Sowbhagya Munishankarappa Dr Vidya Prasad Kasthala New Associate Members July 2002 Dr Musena C Nhemachena August 2002 Dr Zaffar Hassan Dr Atef Youssef G Youssef Dr Ramiz Idriz New Associate Fellows August 2002 Dr Uwe Seidenfaden The Royal College of Anaesthetists 48/49 48/49 Russell Square London WC1B 4JY tel 020 7813 1900 fax 020 7813 1876 email info@rcoa.ac.uk website www.rcoa.ac.uk College Secretary Mr Kevin Storey Deputy College Secretary and Training and Examinations Director Mr David Bowman IT Director Mr Gary Hall Professional Standards Director Ms Emilia Lightfoot Courses and Meetings Mr Amit Kotecha 020 7908 7347 Miss Chantelle Edward 020 7908 7325 ansaphone 020 7813 1888 fax 020 7636 8280 email educ@rcoa.ac.uk Educational approval for Schools and hospitals Ms Claudia Lally 020 7908 7339 Examinations Manager Mr John McCormick 020 7908 7336 Individual Trainees Mrs Gaynor Wybrow 020 7908 7341 Membership Services Miss Karen Slater 020 7908 7324 Presidents Personal Assistant Miss Trisha Bernays 020 7908 7308 Subscriptions 020 7908 7329
Deaths
The College regretfully records the deaths of the following Fellows: Dr Nigel Eastwood, Staffordshire Dr Hans G Epstein, Oxford Dr Richard S C Howell, Warwickshire Dr Erik J Leighton, Berkshire Dr William M Maidlow, Somerset Dr Donald Munro, Wakefield Dr Anthony J Pearce, Newmarket, Suffolk Dr Andrew Robinson, Leeds Dr Richard A J Williams, Suffolk
Appointment of Fellows to consultant and similar posts

The College would like to congratulate the following Fellows on their consultant appointments: Dr Susan Abdy, Queen Elizabeth Hospital, Kings Lynn, Norfolk Dr Margaret Burnstein, Addenbrookes Hospital, Cambridge Dr Catriona M N Connolly, Ninewells Hospital, Dundee Dr Christopher M Danbury, Royal Berkshire Hospital, Reading Dr Marisa Haetzman, Wishaw General Hospital, Lanarkshire Dr Isobel C Gardner, United Bristol Healthcare Trust Dr Sivaginanam Karthikeyan, University College Hospital of Wales, Cardiff Dr Nicholas J D McNeillis, Conquest Hospital, Hastings Dr Even W Moore, Arrowe Park Hospital, Upton, Wirral Dr H Finbarr ONeill, Royal Victoria Hospital, Belfast Dr Rakesh Tandon, Addenbrookes Hospital, Cambridge Dr Kyaw Tint, University ofNorth Tees, Hardwick Dr Jason D Walker, Ysbyty Gwyynedd District General Hospital, Bangor Dr Jonathan Watkiss, Guys Hospital, London The College would also like to congratulate Professor Harry Owen who has been appointed to the post of Professor at Flinders University, Adelaide, South Australia.

TIVA Part I - Pharmacokinetic Principles and Methods of Delivery PDF

Transféré par

Informations du document

Description originale:

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

TIVA Part I - Pharmacokinetic Principles and Methods of Delivery PDF

Transféré par

Droits d'auteur :

Formats disponibles

THE ROYAL COLLEGE OF ANAESTHETISTS

An update on potential changes to postgraduate training

Devolution, primary care trusts and the inexorable growth of uncertainty

Bulletin 16 The Royal College of Anaesthetists November 2002 763

Politeness, political correctness, probity and trust

The information super-highway and human rights legislation

Are we entitled to have a say?

National Anaesthesia Day

Bulletin 16 The Royal College of Anaesthetists November 2002 765

Ways forward assuming an insignificant increase in the medical workforce

Increasing the size of the medical workforce

David Saunders Southampton General Hospital

National Anaesthesia Day, 8 November 2002

So what is new this year?

768 Bulletin 16 The Royal College of Anaesthetists November 2002

Message of support for National Anaesthesia Day, 8 November 2002

Vital work of anaesthetists goes unrecognised by most of the public

Alan Milburn Secretary of State for Health

AODP supports National Anaesthesia Day

Bulletin 16 The Royal College of Anaesthetists November 2002 769

Figure 1 Public perceptions of who runs intensive care units

Figure 2 Public perceptions of who runs pain management clinics

Bulletin 16 The Royal College of Anaesthetists November 2002 771

772 Bulletin 16 The Royal College of Anaesthetists November 2002

AAGBI and National Anaesthesia Day

Bulletin 16 The Royal College of Anaesthetists November 2002 773

The Data Protection Act

Who is a data controller

What you should do

Non-consultant career grades

More summer homework

Bulletin 16 The Royal College of Anaesthetists November 2002 775

Total intravenous anaesthesia (TIVA) I:

Basic pharmacokinetics for TIVA

776 Bulletin 16 The Royal College of Anaesthetists November 2002

778 Bulletin 16 The Royal College of Anaesthetists November 2002

Bulletin 16 The Royal College of Anaesthetists November 2002 779

TRAINEES TOPICS Editor Dr M J Garfield, The Ipswich Hospital, Suffolk

An experience of an overseas trainee

Bulletin 16 The Royal College of Anaesthetists November 2002 781

A reveiw by Dr S L Wilmshurst, SpR Anaesthesia, The Royal Preston Hospital

782 Bulletin 16 The Royal College of Anaesthetists November 2002

THE ROYAL COLLEGE OF ANAESTHETISTS

RCA EDUCATION PROGRAMME PLEASE PULL OUT AND KEEP

Course on Current Topics in Anaesthesia 2529 November 2002 (code: C11)

College Anniversary Meeting

New Tutors Meeting

National Anaesthesia Day Lecture 8 November 2002

Airway Day 5 February 2003 (code: C19)

How to Teach Teaching Methods 1213 February 2003 (code: C80)

Final FRCA Course 17 February to 7 March 2003 (code: A82)

Joint meeting on Research Methodology 14 November 2002 (code: C43)

Anaesthetic Emergencies A Core Topic Day 27 March 2003 (code: A03)

Bulletin 16 The Royal College of Anaesthetists November 2002 783

Review day for NCCG Anaesthetists 7 April 2003 (code: A12)

Training Paramedic Trainers 16 June 2003 (code: A74)

RCA EDUCATION PROGRAMME PLEASE PULL OUT AND KEEP

Cardiopulmonary Disease and Anaesthesia

College Tutors Meeting 23 July 2003

Diplomates Day 7 May 2003

Sleep Apnoea 27 May 2003 (code: C84)

NCCGs as Teachers 3 June 2003 (code: D10)

Cardholders signature: Cardholders name: _______