Surgeons' News, June 2018 by Think Publishing

HIGHLIGHTS FROM THE COLLEGE’S FLAGSHIP TRIENNIAL CONFERENCE

BEHIND THE SCENES OF BBC TWO’S SURGEONS: AT THE EDGE OF LIFE

JUNE 2018 rcsed.ac.uk

First, do no harm

The importance of learning from mistakes and avoiding a blame culture

WELCOME

FROM THE EDITOR Clare McNaught on standing ovations, surgical harm and TV documentaries

very once in a while you hear a lecture at a medical conference that is truly inspirational. I was privileged to be in the audience when Professor Sir Ian Kennedy QC delivered the keynote lecture at the College’s Triennial Conference. Feeding on the profession’s anxiety about the Bawa-Garba case, Sir Ian made it clear that it was time to radically rethink the role of criminal law and medical manslaughter to deal with doctors who have made mistakes. His eloquent argument around separating the need to compensate victims of harm from establishing culpability earned him an ovation seldom observed at such events. He was openly critical of the blame culture that pervades through government and encouraged a more honest approach to learning from errors. We can only hope that Jeremy Hunt’s rapid review of medical manslaughter is the first step towards a fairer system to protect patients and health professionals alike. In a similar vein, the feature articles in this issue of Surgeons’ News are related to surgical harm.

We hope Hunt’s review of medical manslaughter is the first step toward a fairer system

I would argue that none of us gets up in the morning with anything less than surgical perfection in our mind, but sometimes operations don’t go as planned. Most complications occur to individual patients, such as a bile-duct injury during a routine cholecystectomy. On page 32, Lord Owen gives us a fascinating historical perspective on the potentially devastating effect such a surgical error had on the decision-making of Prime Minister Anthony Eden. In recent years, the phenomenon of mass surgical harm, usually through the use of novel prosthetic implants, has come to light. We discuss this issue on page 24. On page 30, we highlight the psychological and physical cost of opiate addiction for chronic post-surgical pain. Despite all this, surgeons remain one of the most respected and trusted groups of medical professionals. People are fascinated by our vocation and this has driven a number of fly-on-the-wall documentaries in which camera teams have been allowed access to the operating theatre environment. We learn from Sat Parmar on page 20 what it is like to be involved in a television production, and discuss the positive and negative aspects of such programmes for the profession. For what it’s worth, I still prefer the anonymity of the surgical mask and the sanctity of the quiet operating room. Clare McNaught editor@surgeonsnews.com rcsed.ac.uk | 1

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HIGHLIGHTS FROM THE COLLEGE’S FLAGSHIP TRIENNIAL CONFERENCE

BEHIND THE SCENES OF BBC TWO’S SURGEONS: AT THE EDGE OF LIFE

JUNE 2018 rcsed.ac.uk

First, do no harm

The importance of learning from mistakes and avoiding a blame culture

PUBLISHED BY The Royal College of Surgeons of Edinburgh Nicolson Street Edinburgh EH8 9DW Registered Charity No. SC005317 contributions@surgeonsnews.com Tel: +44 (0)131 527 1600 For editorial enquiries contact editor@surgeonsnews.com Tel: +44 (0)131 527 1691 DESIGN AND PRODUCTION

Think Publishing Ltd Suite 2.3 Red Tree Business Suites 33 Dalmarnock Road Glasgow G40 4LA Tel: +44 (0)141 375 0504 www.thinkpublishing.co.uk ACCOUNT MANAGER Sian Campbell DESIGN Andrew Bell SUB EDITOR Kirsty Fortune MEDICAL SUB EDITOR Dr Arshad Makhdum EDITORIAL ASSISTANTS Jonathan McIntosh and Emma Wilson ACCOUNT DIRECTOR Helen Cassidy helen.cassidy@thinkpublishing.co.uk GROUP ACCOUNT DIRECTOR John Innes john.innes@thinkpublishing.co.uk PRINTED BY Acorn Web Offset Ltd, Yorkshire, UK ISSN 1750-7995 The views expressed in Surgeons’ News are not necessarily those of the editorial team or the Royal College of Surgeons of Edinburgh. Information printed in this edition of Surgeons’ News is believed to be correct at the time of going to press. Cover illustration: Eleanor Shakespeare

2 | Surgeons’ News | June 2018

Contents June 2018

04 10 16 18

AGENDA News and views from the profession THE PRESIDENT WRITES Michael Lavelle-Jones reports

BACK TO WORK The difficulties of returning to training after a leave of absence

JAMES COOK PLACEMENT Shruti Jayakumar on her cardiothoracic journey

PRE-HOSPITAL CARE FPHC celebrates its inaugural Scientific Conference

TV STARS Why an OMFS team and patient featured in a BBC Two documentary

SPECIALTY A review of upper gastrointestinal surgery in Hong Kong

UROGYNAECOLOGY The pelvic mesh controversy and its effect on colorectal surgery

TRAINEES AND STUDENTS Why we need a no-blame culture; training in Hong Kong; news and updates; courses

COSMETIC SURGERY Why communication is key to managing patients' expectations

PAIN MANAGEMENT What can we do to deal with the rise in postoperative opioid addiction?

DENTAL Fraser McDonald applauds volunteers in Vietnam; Dental Skills Competition winners

BOOK EXTRACT Lord David Owen reveals the impact botched surgery had on Anthony Eden

COLLEGE INFORMATION Diploma recipients; awards and grants; obituaries; RSA network

OUT OF HOURS Tasty treats from Malta to Myanmar

BULLYING Report from the #LetsRemoveIt conference in Birmingham

62 64

TRIENNIAL CONFERENCE Highlights of the flagship meeting

FROM THE COLLECTIONS Recognition for women in surgery

KEYSTONE PICTURES USA/ALAMY STOCK PHOTO

EDITOR Clare McNaught

JO U

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CITATION REP AL O N R

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Agenda The latest news from the College and profession

/ EVENT

Oldest UK Royal College honours female pioneers

n 8 March 2018, International Women’s Day, the RCSEd unveiled a commemorative plaque in memory of the first seven women to be admitted to a degree programme at any British university. The plaque commemorates Sophia Jex-Blake, Isabel Thorne, Edith Pechey, Matilda Chaplin, Helen Evans, Mary Anderson and Emily Bovell. Known collectively as the ‘Edinburgh Seven’, the women had to fight for the right to train and practise as doctors and were accepted to study medicine at the University of Edinburgh in 1869. 4 | Surgeons’ News | June 2018

At the time, their actions were extraordinary enough to attract criticism from all areas of society, and they were harassed and bullied during their studies. A defining moment in the campaign of the Edinburgh Seven was the Surgeons’ Hall Riot, which took place on 18 November 1870. It attracted widespread publicity and created a groundswell of support for the women’s campaign. The plaque was unveiled by Caroline Doig, a retired paediatric surgeon and the first woman to be elected to the RCSEd Council. Ms Doig served three terms of office and was also the first woman Chair of a major committee – the General Medical Council in 1991.

Hunter Doig Medal winner Farhat Din with Caroline Doig, the first woman elected to the RCSEd Council

Ms Doig said: “I was the first woman appointed to the Council of the RCSEd in 1984. Today, the College celebrates the role of women in all its committees and activities, and its growing female membership has reached more than 5,000 surgical and dental professionals worldwide. I am delighted there are now so many women pursuing a career in surgery and it is an honour to unveil this commemorative plaque on International Women’s Day.” The huge part played by women in the surgical world is increasingly recognised in healthcare, as shown by the success of global social media campaigns #ILookLikeASurgeon and #WomeninMedicine.

/ AWARD

First Dundas Medal awarded to Glasgow Palliative Care Team The first recipients of the Dundas Medal, recognising excellence in provision of palliative care in a UK hospital setting, is the Hospital Specialist Palliative Care Team at the Queen Elizabeth University Hospital (QEUH) in Glasgow. The medal, launched by Scottish charity Palliation and the Caring Hospital (PATCH) and the RCSEd in April 2017, rewards efforts to improve palliative care for patients in hospital. Alistair McKeown, Consultant in Palliative Medicine, QEUH, said: “We are delighted to be awarded the Dundas Medal, and are grateful to both PATCH and

the Royal College of Surgeons of Edinburgh for their recognition of our service. “Our team helps patients and families across all wards in QEUH, not just at end of life, but also in optimising quality of life over days, weeks, months and years, irrespective of the diagnosis.” The medal was established in memory of Dr Charles Robert (Bertie) Dundas, a consultant anaesthetist at the Aberdeen Royal Infirmary and a clinical senior lecturer at the University of Aberdeen for more than 30 years. He died in 2014 from hepatobiliary cancer.

Alistair McKeown and Fiona Kerr receive the Dundas Medal from RCSEd President Michael Lavelle-Jones

/ TRAINING

ROGER GAISFORD/ALAMY STOCK PHOTO

RCSEd hosts Shape of Training in Scotland

Secretary of State for Health and Sport Shona Robison (standing) speaking in the Scottish Parliament

In February, the College hosted Secretary of State for Health and Sport Shona Robison at the launch of a new programme to improve surgical training in Scotland, which included a commitment to invest nearly £157,000 in simulation training in Scotland. The Shape of Medical Training Review was established to consider how medical training could better meet the needs of patients and service providers over the next 30 years. The subsequent UK Shape of Training Steering Group Report, which was published in August 2017, made several recommendations as to how the training of doctors should change in relation to postgraduate medical curricula and training pathways in the UK.

rcsed.ac.uk | 5

AGENDA

/ GLOBAL

Access to surgery in Malawi

Trainees with the Malawi Surgical Initiative

Review Doctors in Denial: The Forgotten Women in the ‘Unfortunate Experiment’ Ronald W Jones ISBN 978-0947522438 £23.50 This book documents the events surrounding ‘the unfortunate experiment’ on women with cervical and vulval carcinoma in situ (CIS) during the 1970s in New Zealand. Professor Herbert Green did not believe that CIS was a pre-malignant condition and embarked on an observational study of women with CIS without their consent. Many women subsequently developed cancer and died. What is most disturbing about this scandal is that it took almost two decades to expose the harm that Professor Green had inflicted on these vulnerable patients. The author, Ronald W Jones, with two of his senior colleagues, at great personal cost, challenged Professor Green’s results in a scientific paper. This subsequently led to a public inquiry.

6 | Surgeons’ News | June 2018

The RCSEd has announced a partnership with the University of North Carolina to fund the training of extra surgeons in Malawi through the Malawi Surgical Initiative. Malawi has a population of more than 18 million people and currently has fewer than 50 trained surgeons. The goal of the Malawian Surgical Initiative is to train Malawians in their own country so that they are more likely to stay and practise there. The programme has been running for several years and has so far trained 16 Malawian residents.

The new partnership with the RCSEd will fund the training of an additional resident each year. “In the US, it’s easy to say that training one more surgeon per year is merely a drop in the bucket but, in Malawi, training an additional surgeon per year really changes things,” said Anthony Charles, MD, MPH, Head of the Malawi Surgical Initiative. “Looking forward 20 years, this partnership will allow for 15 additional surgeons to be working in Malawi, with five more still in training. That’s a gamechanger for the country.”

Clare McNaught reads about an event in the 1970s and reflects on its relevance in the current environment It would be easy to think that this would never happen in the modern health service, but the workplace culture and behaviours that are eloquently described in this book resonate with those recently documented in the case against breast-cancer surgeon Ian Paterson. Green was a good teacher who was respected by his colleagues. However, he was physically and intellectually intimidating, and was often described as a “bully who was impatient, arrogant and rude”. Early internal investigations into his practice were ignored, as departmental status and professional loyalty were put before patient safety. Doctors in Denial is a timely reminder to us all that we must continue to challenge the professional behaviours that are detrimental to patient safety. I highly recommend this book and suggest that it should be on the essential reading list for those who work in the healthservice environment.

For more information on the College’s anti-bullying and undermining resources, visit rcsed.ac.uk/bullying and join the conversation on Twitter using #LetsRemoveIt

Consultant Lindsey Chisholm hit the headlines for trekking eight miles to work through heavy snow to operate on a cancer patient

Surgical sound bites A star of the scalpel to rival George Clooney?

What motivated you to travel in those conditions?

After a struggle to reach home in the snow, I knew I wouldn’t be able to drive to work at the Royal Alexandra Hospital in Paisley the next day. My anaesthetist and I agreed we should do everything possible to get to work. Even if she could not get in, I knew my colleague on duty for emergencies would be glad of help with the ward rounds and other duties for our inpatients. I have good clothing and equipment for winter mountaineering, so I prepared everything that evening and set my alarm early. What are your interests outside surgery?

I enjoy hillwalking and ski touring. Having the equipment and knowledge required for walking safely in the Scottish mountains in winter meant an urban walk in snow, using a route I know well, was likely to be safe. What attracted you to a career in surgery?

As a medical student, I studied alongside several inspirational surgical registrars and a consultant surgeon who was a fantastic teacher. Seeing what a difference they made to patients’ lives, how much they enjoyed their work and their team ethos made surgery an attractive career.

It’s hard to think of anything I would enjoy more. I am lucky to work with great colleagues in a friendly hospital. I really enjoy my work with my Foundation doctors (I am a Foundation Programme Director). What advice do you have for other surgeons or those considering a career in surgery?

Take every opportunity to get into theatre. When senior surgeons and registrars see you are interested, they will be much more likely to show you interesting cases, involve you in audit and research projects, and be available for advice and support. The College has a network of Regional Surgical Advisers who are always happy to be contacted by aspiring surgeons. What are your hopes for the future of the NHS?

I hope it can be sustained as a comprehensive provider of healthcare to the UK population, readily accessible at the time of need.

Janet: Have you been watching the recent spate of TV documentaries about surgeons? John: Yes, but I don’t understand why they did not approach me to be involved – I mean, with my good looks and winning personality, I could give George Clooney a run for his money. Janet: Do you own a mirror? You look more like my grandmother than George! But, seriously, do you think it is a good thing to showcase patients and surgeons on TV? John: I think it has shown a very positive side of surgery and, let’s be honest, with all the negative publicity we have had over the last year, it has been a welcome relief. Janet: I agree, but I am concerned about the potential negative side. I have already had patients asking for referral to the QE in Birmingham for routine surgery just because the facilities look more modern! John: I see what you mean. I remember a few years ago that the Royal College of Nursing made a complaint against one of the popular fictional TV surgical shows for giving an unrealistic view of the NHS. On balance, I still think the benefits outweigh the risks, but I can promise you one thing. Janet: What’s that? John: If I was the star, the viewing figures would be off the charts! Send us your ideas for sound bite topics: editor@surgeonsnews.com

If you could change anything in your career, what would it be? rcsed.ac.uk | 7

The latest guidelines, articles and studies

IN BRIEF Aspirin or rivaroxaban for VTE prophylaxis after hip or knee arthroplasty

This multicentre trial gave 3,424 patients once-daily oral rivaroxaban (10mg) until postoperative day five, then randomly assigned them to continue rivaroxaban or switched them to aspirin (81mg daily) for an additional nine days after total knee arthroplasty, or for 30 days after total hip arthroplasty. Venous thromboembolism occurred in 11 of 1,707 patients (0.64%) in the aspirin group and in 12 of 1,717 patients (0.70%) in the rivaroxaban group. Clinically important bleeding occurred in 22 patients (1.29%) in the aspirin group and in 17 (0.99%) in the rivaroxaban group. Authors concluded that extended prophylaxis with aspirin was not significantly different from rivaroxaban in the prevention of symptomatic venous thromboembolism. Anderson DR, Dunbar M, Murnaghan J. N Engl J Med 2018; 378: 699–707

Operating list composition and surgical performance

This study evaluated the effect of operating-list composition on operating time, with a linear mixed-effects model involving 255,757 procedures and a matched analysis of 48,632 pairs of procedures. Repeating the same procedure in a list resulted in a time saving of 0.98% for each increase in list position. Switching between procedures increased the duration by an average of 6.48%. The overall reduction in operating time from completing the second procedure straight after the first was 6.18%. This pattern of results was consistent across procedure method and complexity. Authors concluded that there is a robust relationship between operatinglist composition and the duration of

operation. An evidence-based approach to structuring a theatre list could reduce the total operating time. Pike TW, Mushtaq F, Mann RP et al. Br J Surg March 2018

There is no weekend effect in hip-fracture surgery: a comprehensive analysis of outcomes

Of 1,326 consecutive patients undergoing acute hip-fracture surgery identified from a prospective database, 368 patients were admitted over a weekend and 411 patients had their operation during a weekend. Overall 30-day mortality was 7.6%, and the 90-day and oneyear mortality was 15.3% and 26.8%, respectively. There were no significant differences in any outcomes based on the day of admission or the day of surgery. Multivariate analysis for 30-day mortality demonstrated the following variables to be significant predictors: urea levels, age, admission source, surgical delay of more than 48 hours, male gender, previous stroke, acute chest infection and chronic liver disease. Authors concluded that there is no significant weekend effect in hip-fracture surgery and mortality is affected by patient co-morbidities and delay to surgery. Sheikh HQ, Aqil A, Hossain FS, Kapoor H. The Surgeon 2018 (in press)

Preoperative oral carbohydrate load versus placebo in major elective abdominal surgery (PROCY): a randomised, placebo-controlled, multicentre, phase III trial

This trial randomised 880 non-diabetic adult patients undergoing elective major abdominal surgery to a CHO (preoperative oral intake of 800ml of water containing

100g of CHO) or placebo group (intake of 800ml of water). The blood glucose level was measured every four hours for four days. Insulin was administered when the blood glucose level was >180mg/ dL. Postoperative infection occurred in 16.3% of CHO-group patients and 16.0% of placebo-group patients. Insulin was needed in eight (2.4%) CHO-group patients and 53 (16.0%) placebo-group patients. Authors concluded that oral preoperative CHO load is effective for avoiding a blood glucose level >180mg/ dL, but without affecting the risk of postoperative infection complications. Gianotti L, Biffi R, Sandini M et al. Ann Surg 2018; 267: 623–630

National trends in readmission following inpatient surgery in the Hospital Readmissions Reduction Program era

The aim of this study was to investigate whether the Hospital Readmissions Reduction Program, a national US initiative that introduced financial penalties for high readmission rates for certain medical conditions, had a ‘spillover’ effect on surgical conditions. Using national Medicare data, this study identified 17,423,106 patients undergoing a range of procedures during the past decade; risk-adjusted rates of readmission across the eight procedures declined from 12.2% to 8.6%. The hospitals with the greatest reductions in medical readmissions also had the greatest drop in surgical readmissions. Authors concluded that surgical readmission rates have fallen during the past decade and rates of decline have increased during the Hospital Readmissions Reduction Program period. Mehtsun WT, Papanicolas I, Zheng J et al. Ann Surg 2018; 267: 599–605

rcsed.ac.uk | 9

AGENDA

THE PRESIDENT WRITES Michael Lavelle-Jones reflects on two thought-provoking conferences and some impressive digital outreach

n recent weeks, I have had the chance to reflect on the impact of our College’s Triennial Conference held at the end of March. The theme, ‘The Modern Surgical Team: The Future of Surgery’, generated huge interest and Conference Convenor Rowan Parks and his team are to be congratulated for putting together such a thought-provoking programme, which was well received by the audience and beyond. I cannot overlook the power of social media, with #TriConf18 making 2,750,000 impressions worldwide – a considerable outreach! There is much that we can all learn (and did learn) from the high levels of efficiency and team working in the military services as described by the keynote speaker, Brigadier Tim Hodgetts, and as outlined in the trauma care session. There were many common themes, with good communication and team training clearly the bedrock on which an effective service can be delivered. Going forward, embracing and valuing the contribution of extendedrole nurse practitioners and the professions allied to medicine will be pivotal if we are to deliver a quality service in the NHS. The Faculty of Perioperative Care (FPC), which we established in 2016, lays down a marker of the College’s engagement with this group of professionals. Be sure to save the date for the FPC’s fourth annual conference with the theme ‘The Perioperative Practitioner: Working Within One’s Scope of Practice’, which will be in Birmingham on 3 November 2018. 10 | Surgeons’ News | June 2018

Timing is everything and our conference followed hot on the heels of the judgement on Dr Hadiza Bawa-Garba, who was struck off after the GMC won a High Court appeal against an earlier medical practitioners tribunal ruling that had led to a 12-month suspension following her conviction of gross negligence manslaughter. This judgement has unsettled – and angered – the medical profession in the UK, especially with regard to issues surrounding reflective practice, although this is only one of many issues in this case. Professor Sir Ian Kennedy QC, keynote speaker at the Triennial Conference and a leading professor of health law and ethics, tackled the issues raised in the Bawa-Garba case regarding criminal law and medical manslaughter head on. His position was reported widely, and consequently he has been able to contribute his experience and insight into this complex issue to the review of gross negligence manslaughter in healthcare that is being chaired by Sir Norman Williams. More than 700 surgeons in training

attended the ASiT Conference in April, held for the first time in Edinburgh. The theme of this year’s conference, ‘Nurturing Excellence’, is hugely relevant to us all, whether we are trainers or trainees (and we are still looking for a better, less pejorative descriptor here!). Helen Mohan is to be congratulated on putting together such a perceptive conference programme, which left few stones unturned. As usual, the President’s Q&A session was well subscribed, and highlighted the concerns about the costs of training, the potential impact of extendedrole nurse practitioners on surgical training opportunities in the UK and the difficulties of balancing training needs with service delivery. There are no easy answers to these searching questions, but I hope we

We can all learn from the high levels of efficiency in the military services provided some reassurance that the surgical colleges in the UK and in Ireland recognise and are fully engaged with these issues. A session on the Improving Surgical Training project and the imminent introduction of the pilot scheme in the UK provoked the greatest response from the audience, and there are clear and understandable concerns that two parallel systems in training have the potential to disadvantage one group against the other. Gareth Griffiths, the Joint Committee on Surgical

From left: RCSEd Vice-Presidents Graham Layer and John Duncan with President Michael Lavelle-Jones

Training Chair, is well aware of the potential risks and I am persuaded by his argument that the close monitoring that will be in place will provide the necessary protection. An international dimension to training was provided by Hilary Sanfey, past Vice-President of the American College of Surgeons and a recent Ad Hominem Fellow at our College. Hilary brought her wealth of experience as a leader of education and training in the US at many levels. Among the numerous points of interest she raised was the level of experience attained by US residents in training, who have difficulties in achieving some competencies despite working longer hours. Interestingly, training assessment in the US seems likely to go down the Entrustable Professional

Activities (see President’s Report 2017/2018) route on which the new Competencies in Practice outcomebased assessment of training in the UK is modelled. A highlight for me was the Silver Scalpel lecture, and last year’s award winner Rachel Hargest sharply reminded us that in training we should be striving for excellence rather than settling for competence – a clear and thoughtful message. Finally, I must extend my congratulations to Stella Vig, a consultant vascular and general surgeon from Croydon University Hospital, who was a worthy winner of this year’s award. Michael Lavelle-Jones president@rcsed.ac.uk rcsed.ac.uk | 11

AGENDA

SURGICAL SAFETY UPDATE More cases from the Confidential Reporting System for Surgery Not a new twist on an old tale

The case was repair of an orbital floor on a patient with mechanical restriction of up-gaze following a blow-out fracture caused by an alleged assault. The preformed orbital implant fitted nicely and it was held in place with a single screw on the inferior orbital rim. In recovery, the patient coughed and started to develop proptosis. The subcuticular skin suture was removed from the mid-tarsal incision, some haematoma was evacuated and the patient returned to theatre. In theatre, the blood was seen to be coming from below the orbital implant, but when removal of the screw was attempted, no screwdriver fitting the screw could be found. Other sets from the same manufacturer, a proprietary ‘universal’ screw-removing kit and similar screwdrivers from other kits were tried, but none fitted. Eventually, the screw was knocked out with a small hammer, the bleeding arrested, the implant replaced and secured with a screw from one of the many opened kits that were now available to me.

Reporter’s comments

Whenever any ‘new’ plating kit is supplied, the standard package should include two separately wrapped screwdrivers – one to use in a case like this, and another labelled and kept separately to extract the screw if necessary subsequently.

12 | Surgeons’ News | June 2018

This ‘double-screwdriver’ rule should increase to four screwdrivers if the screws are transmucosal (intermaxillary fixation screws, screw-fixed arch bars) and the patient may attend the outpatient clinic for them to be removed. The manufacturer had four different crosshead screws in decreasing size, and the one I used was the smallest and the only one of this type in the hospital. The screwdriver originally used from the set was no longer sterile and could not be sterilised on site.

CORESS comments

This was a systems failure. All kit necessary for a procedure should be checked for availability (and functionality) prior to an operation. The National Safety Standards for Interventional Procedures emphasise this. Surgeons would be well advised to have a backup plan in case a procedure does not proceed as intended.

Ureteric stent misplacement

A 62-year-old man underwent a difficult anterior resection for a carcinoma of the low sigmoid colon. During mobilisation of the colon, it was noted that the left ureter had suffered a partial thermal injury due to diathermy. The on-call urologist was called to inspect the ureter and, at the request of the consultant colorectal surgeon, agreed to place a ureteric stent into the injured ureter at

the end of the procedure. On completion of a protracted procedure, the urologist was called back, but a handover had taken place and, although correctly briefed, a new on-call urologist attended. Unfortunately, the stent was placed into the right ureter. A week later, the patient returned to theatre for drainage of a pelvic abscess, at which time it was noted that the stent was in the wrong ureter. The right ureteric stent was removed and a further stent was correctly positioned in the left ureter. The patient subsequently made an uneventful recovery.

Reporter’s comments

Stent placement was done as an emergency, and the usual safety precautions of radiology review and marking of the correct side did not take place. No ‘stop’ period was undertaken before stent placement. There appears to have been miscommunication between the colorectal and urological teams, and the first stent was placed into the right ureter on the understanding by the urologists that this was the injured structure. The colorectal team had unscrubbed and, despite observing the procedure, did not comment on the stent placement. The remaining scrub team also failed to alert the surgeons to the side discrepancy.

CORESS comments

This case is a Never Event and raises several issues. It is well recognised that poor communication may give rise to problems when teams change. Scrupulous handover and communication of important information is vital. If one senior surgeon initially responsible for the case was present throughout, that surgeon (the colorectal consultant) should have overseen all aspects of the case and should take responsibility for the wrongsided intervention, even if the stent placement was not within the realm of their specialty. A team pause and joint confirmation that the stent was to be placed

Frank CT Smith Programme Director on behalf of the CORESS Advisory Board coress.org.uk

We are grateful to those who have provided the material for these reports. The online reporting form is on our website coress.org. uk, which also includes previous Feedback Reports. Published cases will be acknowledged by a Certificate of Contribution, which may be included in the contributor’s record of continuing professional development.

appropriately might have prevented this incident. Team briefings should empower other members of the team to speak up if an incorrect manoeuvre is recognised, and the sign-out check was a further opportunity to remedy the situation.

Retention of a rectus sheath catheter

On the basis of literature suggesting a benefit in postoperative analgesia, bilateral rectus sheath catheters for postoperative local anaesthetic infusion were placed, prior to laparotomy closure, following abdominal surgery. At postoperative day four, the left-sided catheter was removed without incident, but the right-sided catheter remained obstinately stuck. The patient had to return to theatre for re-exploration, whereupon the catheter was found, securely fixed, in the knot of the mass closure suture.

Reporter’s comments

This was the first time this technique had been adopted, on the basis of a literature review. The surgeon, who was placing the catheter at the anaesthetist’s behest, had received no training in the technique. There were no institutional protocols for catheter insertion. Retrospectively, trapping the catheter in the mass closure suture knot seems an obvious risk.

CORESS comments

Sound anatomical knowledge and grounding in the physiological and pharmacological principles of postoperative pain relief are basic tools of a surgeon’s trade. So performing this procedure seems to have been reasonable. Nonetheless, when undertaking any procedure for the first time, it is advisable to plan appropriately and, if possible, have some formal training or experienced mentorship during the procedure. This is particularly apposite in an increasingly litigious culture.

rcsed.ac.uk | 13

In safe hands

Tom Weiser introduces the ESSQ’s forthcoming online Masters of Science programme in Patient Safety and Clinical Human Factors

uality and safety are recognised as key components of a safe, effective and cost-efficient health system. The need to have a workforce with knowledge and skills in the application of clinical human factors science to healthcare has become a strategic priority for every health board, authority and trust. It is timely that the University of Edinburgh and the RCSEd will launch an online Masters of Science programme in Patient Safety and Clinical Human Factors this September. This will enable all medical disciplines, and nursing and paramedical staff, to distinguish themselves, not just as advocates of patient safety, but as experts and future leaders in the field. This unique MSc is designed to complement on-the-job training and experience. It will be delivered through clinical case scenarios of common adverse events, interactive discussion forums and a dissertation on quality improvement. Advances in healthcare over previous decades have increased life expectancy, but patients often have multiple comorbidities along with increasing choices and treatment options. Old models of healthcare delivery are being challenged by changes to work hours, staffing and training, and new models of care delivery are increasingly integrated across health and social care. Other high-reliability organisations such as civil aviation and nuclear power have used human factors science to underpin their approach to safety. They use scientific approaches to increasing safety within their systems by understanding the limitations of human

Key to patient safety is the application of clinical human factors science in a healthcare setting

The MSc will fill a gap in the curriculum of all healthcare professionals 14 | Surgeons’ News | June 2018

performance and the impact of equipment, tasks, teams and environment on human behaviour. Much of this science also applies to healthcare, and the specialties of surgery and anaesthesia have traditionally been at the forefront of such work. The ‘end results system’, developed by Ernest Codman, a surgeon at the Massachusetts General Hospital in Boston more than a century ago, was one of the earliest systematic attempts to measure and evaluate the safety of clinical care. He pioneered the first morbidity and mortality conference to evaluate the causes of errors and disseminate knowledge on the prevention of harm. Yet for his efforts he was rejected by his peers and forced off the faculty. Anaesthetists took up the banner in the 1980s, establishing a systematic approach to understanding and reducing harm to patients. The earliest efforts were in large part based on human factors – the anaesthetic machine was engineered to be safe, standardised and redundant, and to prevent the propagation of errors such as lethal hypoxic gas mixtures. This three-year, part-time MSc programme in Patient Safety and Clinical Human Factors will be the eighth Masters programme under the Edinburgh Surgery Online brand, but it will be delivered by a multidisciplinary group of experts supported by dedicated eFacilitators and administrative staff. The eFacilitators support the community of learners, but can monitor engagement and assessment while the administrators ensure the smooth daily running of the programme. The programme utilises asynchronous discussion boards through a bespoke virtual learning environment and leverages self-directed learning mechanisms and theory. While the RCSEd has long promoted assessment of patient safety and non-technical skills, this MSc aims to support all healthcare professionals in using evidence-

AGENDA

based tools and techniques to improve the reliability and safety of everyday healthcare systems and processes. The first year will provide a broad introduction to how harm comes to patients and a detailed understanding of the specialty of clinical human factors. Specific topics will focus on the individual skills that are involved in good patient care. The second year will cover team skills and how good teamwork influences patient outcomes. Students will explore key concepts around learning from adverse events and the teaching of safety, as well as the concept of measuring and monitoring for safety. By the end of this year, they will have a thorough understanding of how patients are harmed, the reasons behind such events and how they can improve overall patient care, both individually and as part of a team. These two years provide students with the necessary knowledge and tools to develop their own initiative for quality improvement or research into patient safety. In the final year students will focus on an independent research project or subject of in-depth study under the guidance of supervisors local to them, online tutors and mentors. For those anxious about doing an MSc through online learning, an introductory module will support them and familiarise them with the learning methodology. Recent patient safety initiatives in the UK have generated interest and identified the need for leaders with experience in this field, so this unique programme will be of considerable interest. A global student audience will add to the richness of the learning community. Patient safety is poorly recognised in developing countries but initiatives by bodies such as the World Health Organization and the Lancet Commission on Global Surgery have highlighted a real need. Such attention and critical work have driven the endeavours of organisations such as Lifebox, a charity devoted to improving surgical safety globally. With the increased attention to, understanding about, and importance of patient safety initiatives and the impact of human factors on patient harm, the MSc in Patient Safety and Clinical Human Factors will fill a major gap in the traditional curriculum of all healthcare professionals. Follow the latest news on Twitter @edinsurg_online

Meet the team Simon Paterson-Brown Programme Director for the MSc in Patient Safety and Clinical Human Factors and Consultant General Surgeon at the Royal Infirmary, Edinburgh; Honorary Senior Lecturer at the University of Edinburgh @spbsurgery

Nikki Maran Consultant Anaesthetist at the Royal Infirmary, Edinburgh; Honorary Senior Lecturer at the University of Edinburgh; and Associate Medical Director for Patient Safety and Quality at NHS Lothian Tom Weiser Associate Professor of Surgery, Stanford University; Visiting Professor at the University of Edinburgh; and Trustee of Lifebox. He was part of the World Health Organizationâ&#x20AC;&#x2122;s Safe Surgery Saves Lives Program @TGWeiser Anaesthetic machines are crucial components of patient safety

Dr Shelly Jeffcott Year 1 tutor for the MSc programme in Patient Safety and Clinical Human Factors, and Strategy Implementation and Quality Improvement Manager at the Scottish Ambulance Service Dr Domenica Coxon Academic eFacilitator for the MSc programme in Patient Safety and Clinical Human Factors

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AGENDA

Triennial Conference Conference Convenor and College Council Member Professor Rowan Parks reviews the RCSEd’s inaugural Triennial Conference on ‘The Modern Surgical Team’

uilding on the success of events such as the Lister Centenary Conference in 2012 and a number of annual President’s meetings, the College’s Council decided to move to a two-day congress that would be held once during the threeyear term of office of each President – the Triennial Conference. Our current President, Professor Michael Lavelle-Jones, wanted this meeting to include the whole surgical team and involve all of the faculties associated with the College. The theme of the inaugural conference, ‘The Modern Surgical Team: The Future of Surgery’, reflected this and the programme was designed with contributions from the Faculty of Perioperative Care, the Faculty of Sports and Exercise Medicine, the Faculty of Surgical Trainers, the Faculty of Dental Surgery and the Faculty of Pre-Hospital Care.

It was encouraging to have almost 200 delegates attend the meeting, including members of the wider surgical team – consultants, trainees, SAS and a diverse group of perioperative practitioners – all engaged in learning about the importance of integrated practice to provide optimal outcomes for our surgical patients. Beyond this were many others who engaged during and after the conference on social media, with 2.7 million impressions made and more than 700,000 unique users on Twitter alone, enabling the College to speak to its nearly 25,000-strong UK and international membership and beyond, fulfilling our remit for inclusivity. The opening plenary session was unforgettable. Brigadier Tim Hodgetts CBE gave an excellent talk on the 10 top tips for building and sustaining a successful team. This was followed by Professor Sir Ian Kennedy QC, who delivered an

Rowan Parks Professor of Surgical Sciences, Honorary Consultant Surgeon and RCSEd Council Member

16 | Surgeons’ News | June 2018

outstanding McKeown Lecture on the lessons from the Ian Paterson case. Many who heard this talk, including some very senior Fellows of the College, stated that this was the best lecture they had ever heard during their careers. “There is another way,” Sir Ian told delegates, and pointed to institutional failings, management failings, colleague failings and the failings of the surgeon himself. Sir Ian described him as a bully and someone who belittled and ignored his colleagues. Paterson was not a team player and the lessons outlined by Sir Ian chimed very closely with the College’s anti-bullying and undermining #LetsRemoveIt campaign.

Day one also included sessions on intraoperative decision-making, with excellent contributions from our international guests, Dr CarolAnne Moulton and mountaineer Jelle Staleman, and on the workforce required for the future surgical team, including contributions from a surgical care practitioner, SASgrade doctor Victoria Dobie (who is SAS Representative on Council) and ASiT President Helen Mohan. This highlighted the importance of recognising the roles of all members

Above: Sir Ian Kennedy QC (left) with Professor Michael LavelleJones Left: Delegates enjoy a ceilidh Top right (from left to right): Simon Paterson-Brown, Craig McIlhenny, George Youngson, Carole-Anne Moulton and Jelle Staleman

The Conference was truly a flagship event that created a real buzz around the College

of the team, and emphasised the importance of maintaining high standards of training and team development. Another thought-provoking session was led by Dr Jocelyn Cornwell from the Point of Care Foundation on Schwartz Rounds: an intervention to support emotional and psychological wellbeing in the modern multiprofessional surgical team. Finalists in the Surgical Innovation Competition presented to an expert panel in a session coordinated by Council Member Roger Currie. A wide range of interesting ideas were pitched and Alex Young, a trauma and orthopaedic trainee, was named the competition winner for his submission ‘Virti: immersive technology to assess decision-making under pressure and distribute provider content’. The delegates’ dinner was hosted in the Playfair Hall, followed by a wonderful ceilidh in the Deacon Suite. Novices and experts joined together to enjoy plenty of laughs as toes were stepped on, calories were burned, and memories were captured in photos and on video. The importance of the multiprofessional team was again emphasised on day two as colleagues from the Royal College of Emergency Medicine and Royal College of Anaesthetists contributed to sessions on the role of the team in trauma care and perioperative practice to improve patient outcomes. Feedback on these sessions highlighted that the speakers provided extremely useful practical suggestions and advice that delegates planned to implement in their own institutions.

Parallel sessions considered the health and safety of the team in theatre and beyond, and insights into challenging the traditional model of care with input from dentistry, advanced physiotherapy and surgical assistants. At the start of the conference, we heard of the harrowing effects of poor team culture, but finished on a real high with contributions from the British Olympic Medical Team, NASA and Scottish Rugby Union on the importance of communication within the team. The 2018 RCSEd Triennial Conference was truly a flagship event that created a real buzz around the College campus, brought together colleagues from across the globe, provided a wonderful opportunity for networking, making new friends and renewing old acquaintances and, ultimately, reminded us all of the key issues that affect those who are part of the modern surgical team. Videos of the presentations are available to the College’s membership on our website at rcsed.ac.uk

Save the date for the FST’s ICOSET 2019 conference in Edinburgh on 21–22 March 2019. Visit fst.rcsed.ac.uk for more information

rcsed.ac.uk | 17

A tale of two specialties Shruti Jayakumar deepens her love of cardiothoracic surgery on a placement to James Cook University Hospital, Middlesbrough

efore I became a medical student, I chanced upon a coronary artery bypass graft operation while on work experience at a hospital. In one corner of the operating theatre, the 18 | Surgeons’ News | June 2018

anaesthetist studied the patient’s arterial blood gases while preparing a transfusion; at the other end of the room, the perfusionist attentively altered the pump flows as blood trickled through the cardiopulmonary bypass circuit.

Shruti Jayakumar Medical Student

At the very centre of the room lay the patient, with the spotlight of the surgical lights beaming on her and her chest open, exposing her beating heart – a centrepiece of the sterile surgical room. However, I was transfixed by the surgeon who was

JAMES COOK PLACEMENT

grafting a delicate coronary artery. From that moment I was hooked and wanted to experience more. Bounding into clinical years of medical school with sheer excitement and passion for cardiothoracic surgery, I expressed my desire to be a cardiothoracic surgeon, but this elicited only a disheartening response from my colleagues and seniors as they chimed the same tune: “Cardiac surgery is a dying profession and has reached its limits. Become an interventional cardiologist instead.” An encounter with Mr Jonathan Ferguson at a conference led me to apply for the RCSEd Cardiothoracic Surgery Placement in Middlesbrough. Part of the application involved writing about why I wanted to be a cardiothoracic surgeon, which prompted a period of reflection. With this came a newfound sense of admiration for the specialty – one that had made remarkable progress over the last 50 years and continues to push boundaries every day. Arriving in Middlesbrough, those opinions were quickly reinforced. Whether it was observing Mr Enoch Akowuah replacing a mitral valve endoscopically or Mr Joel Dunning operating the da Vinci robot to remove a deep-seated tumour through a sleeve lobectomy, I was inspired by the novel techniques being developed – a direct result of a constant desire to improve patient care and outcomes. I was relieved to discover that those who had told me cardiothoracic surgery was dying were wrong. I saw the breadth of diseases that cardiothoracic surgery treated, ranging from routine valve replacements and lobectomies to complex root repairs, thymectomies and diaphragmatic plications – it was not all coronary disease! Moreover, there were multifarious ways of performing each procedure and each surgery was carefully tailored to the individual patient.

Within the first few days I had ample opportunity to scrub up and assist in cases. I was able to perform thoracotomies, sternotomies, insert chest drains and harvest saphenous veins. This finally gave me a chance to visualise and apply the anatomy I had spent gruelling years learning and memorising at medical school. It was even more exhilarating than I had imagined. Although it may have partly been the novelty, the finesse of the surgeries was something I knew I would never get bored of. Having been a keen artist growing up, many parallels could be drawn between the intricate, practical nature of painting and surgery. Cardiothoracic surgery is the perfect canvas for fine and delicate skills, with a varied palette of diseases and subspecialties. While the programme taught me surgery, I also learnt something much more important. Watching consultant–patient interactions provided me with principles and values that I will carry with me as a doctor for the rest of my life. Mr Ferguson made himself readily available to the patients to soothe their worries and answer their questions prior to surgery. He often saw his patients the night before their surgery to reassure them and answer any last-minute questions, and always called up the next of kin after every case to let them know the outcome. I witnessed surgeons going far beyond their basic job description. It dawned on me what it really means to be a surgeon: that being given consent to operate was a privilege and surgery is more than holding a scalpel. I recall walking into Mr Ferguson’s office to ask: “What can I do to make myself a great surgeon?” Rather than telling me to practise more knot-tying, attend more courses or observe more cases, he told me to ask the nursing staff the same question. Surprised but intrigued, I dutifully went around collecting answers from all the scrub and ward nurses who

Cardiothoracic surgery is the perfect canvas for fine and delicate skills, with a varied palette of diseases and subspecialties

A machine invented at St Vincent’s Hospital (Sydney, Australia) that keeps the heart pumping after explantation

crossed my path. One thing was clear: behind every surgeon is a large team, and the best surgeons are those who promote cohesiveness among their colleagues, both in and out of theatre. Throughout my placement, Mr Ferguson was available to answer questions and provide guidance. When he recognised my interest in transplantation, he put me in touch with Professor Kumud Dhital, a transplant surgeon at St Vincent’s Hospital in Sydney, with whom he had trained. At St Vincent’s Hospital, I once again witnessed cutting-edge innovation in cardiac surgery and the development of new solutions to overcome previous limitations to surgery. Here, they had invented a special machine to keep a heart pumping after explantation, enabling donation after cardiac death and allowing the heart to be transported long distances. I was transfixed by the ‘rig’, which enables the heart to beat in a box. Nationwide retrievals with the rig are complex and a logistical nightmare, requiring chartered planes and police escorts to transport the organs in minimal time – although the resourceful transplant coordinators make it look easy. My experience in Middlesbrough has made an indelible mark on my cardiothoracic career. It provided me with the mentorship and guidance to thrive as a doctor, opportunities to learn surgical techniques and inspiration to undertake research. I would highly recommend applying for this programme to cultivate your potential and learn about this incredible specialty in a nurturing and cutting-edge environment. rcsed.ac.uk | 19

OMFS surgeon Sat Parmar and TV producer Jamie Seal talk to Siân Evans about the BBC Two documentary series Surgeons: At the Edge of Life

IMAGES COURTESY OF BBC AND DRAGONFLY TV

“Pushing the boundaries of oral and maxillofacial surgery is all about teamwork”

SURGEONS: AT THE EDGE OF LIFE

he team of highly skilled oral and maxillofacial surgeons (OMFSs) and prosthetics experts at University Hospitals Birmingham (UHB) is among the busiest in the country. UHB is also the Royal Centre for Defence Medicine for the UK, so nearly every British soldier injured abroad is transferred there for treatment. It was no surprise, then, to OMFS Sat Parmar that the UHB communications team asked him and his colleagues if they would take part in filming for the BBC Two series Surgeons: At the Edge of Life. Made by Dragonfly TV, it aired in early January to an audience of nearly three million viewers. “We are often approached because we are experienced in working with TV producers and crews. In 2012, Channel 5 cameras followed us in theatre and recorded the work of the maxillofacial prosthetic department in Making Faces, a four-part documentary,” says Parmar. Dragonfly TV series producer Jamie Seal, who has been in the business for 15 years, was not initially attracted to the idea of making another medical series in what he saw as a saturated market. However, he explains: “When I drilled down to the detail, I thought the world of surgeons hadn’t been explored and I was intrigued by installing a camera rig in an operating theatre.” He set out to make something that was “fresh, not derivative, and that was a celebration of the NHS – no ambulances and flashing lights, but innovation and skill”. Seal had to work out how to send riggers into the operating theatre to set up the 10 cameras when the environment is governed by infection control: “We had nine or 10 cameras running at any time, which was worth doing because the end result gave the audience a unique perspective,” he explains.

The Longest Day

In the first episode of the series, The Longest Day, specialist OMFSs Parmar and Tim Martin carried out a nine-hour operation to remove a fast-growing cancerous tumour from a 53-year-old patient’s face and performed reconstructive surgery. Teresa Dallas had been diagnosed only four weeks earlier, and without the radical procedure to remove the upper jaw and right eye she would die within months. Seal says meeting Teresa Dallas was “a daunting prospect knowing how to be sensitive and empathetic. More often than not people want the opportunity to talk through their circumstances with someone impartial.” “I can sit back and die or make the best of it,” Dallas tells the TV camera crew as she makes the decision to go ahead with surgery and they begin to follow her journey to recovery. As Parmar says in the documentary: “The face is really unique because it’s the thing we probably all value the most, so it’s critical for the patient’s quality of life that we make the reconstruction work.” Parmar and Martin used 3D imaging to plan how to remove the tumour and to ensure they reconstructed

OMFS surgeons Tim Martin and Sat Parmar with Yasmin Poonawala, a Consultant Anaesthetist Image courtesy of BBC and Dragonfly TV

her face precisely. They were all too aware that while removing the tumour would save her life, it would be devastating if she was left disfigured. After removing the tumour, the team filled in the cavity left in her face and reconstructed her jaw using a section of bone and muscle from her hip. The UHB maxillofacial prosthetics team went on to create a prosthetic eye to complete the reconstruction process. Parmar and Martin have worked together as a team for 14 years and, as Martin says, they’re “a bit like husband and wife”. Both have complete faith in the other’s skills. How do the surgeons cope with such a marathon operation? Parmar tells the film crew: “The problem with these long operations is they’re extremely physically and mentally tiring. How do I cope with it? I’m not exactly sure.” Musing, though, the first thing he thinks of is how well the team work together.

The face is emotive The UHB communications department often chooses the oral and maxillofacial team when approached by production companies to film in the hospital. Parmar says this is because “we deal with the face and it’s very emotive”. He explains: “This type of surgery is only made possible because of the team of experts we have here at UHB who have such a wide range of skills. These include the theatre team, anaesthetists, ITU and ward staff, dietetics, outpatients’ nurses, maxillofacial prosthetists, Macmillan cancer nurses, speech and language therapists, and dieticians. It’s all about teamwork.”

Biography: Satyesh Chimanlal Parmar Sat Parmar was appointed as an oral and maxillofacial/head and neck/reconstructive surgeon at the University Hospital of Birmingham in 2003. He is one of the directors of the European Head and Neck Course and the Head and Neck Oncology for Surgeons courses. Parmar is also a board member at the European Head and Neck Society. He is a Council member for the British Association of Head and Neck Oncologists and 2019 President elect for the British Association of Oral and Maxillofacial Surgeons. He was the chair of AOCMF (a multi-specialty group of surgeons) for the UK and a former European Board member for the AO Foundation. He carries out most aspects of general oral and maxillofacial surgery, but his subspecialist interest is salivary gland/head and neck cancer and reconstruction. He also has an interest in implant rehabilitation for patients with head and neck cancer.

rcsed.ac.uk | 21

SURGEONS: AT THE EDGE OF LIFE

Martin adds: “The operations Sat and I carry out in Birmingham clearly demonstrate the high level of skill needed by an OMFS, and this is representative of what oral and maxillofacial surgeons do across the country.”

You have to trust the producer The UHB surgeons don’t always agree to work with a production company and film crew, and Parmar has a clear agenda. “As surgeons, we don’t say yes to every approach from a TV company. The key thing with any programme is that you get a feel for what the producer is like. Do you like them and can you work with them? This is important because there’s no editorial control, so you have to trust what the producer does. The key thing for us is that we need someone who will portray things honestly for the patient, the hospital and the specialty. I want to expose the human side of surgeons.” Seal agrees. “Trust is key. It’s down to honesty when you switch on the camera.” Explaining why it’s important for him as a surgeon to take part in this kind of documentary, Parmar says: “I want people to understand what oral and maxillofacial surgery is. Many think we are just dentists who take out wisdom teeth. They don’t understand the scope of the specialty – and this includes many in the medical and nursing professions. I also want to raise the profile of UHB, where I’ve been working since 2003. “There is a great variation in treatments offered in different parts of the country, so the documentary allows patients to see what’s on offer – and demand it. Most importantly, I want the series to highlight the ups and downs patients go through during treatment.”

In a nutshell l The BBC Two documentary Surgeons: At the Edge of Life series one was shown in January 2018. The BBC is planning to film a second series at UHB next year. For more information, go to bbc.co.uk/ programmes/b09m60v6 l Dragonfly Film & Television Ltd: dragonfly.tv l Sat Parmar’s special interests are: implants; oncology; oral and dento-alveolar surgery; paediatric; reconstruction; salivary; skin surgery; trauma; private practice, medico-legal, appraisal; recertification; revalidation; running courses in OMFS; assigned educational supervisor; audit; and clinical research. l University Hospitals Birmingham is made up of four hospitals, including the Queen Elizabeth Hospital Birmingham where OMFSs Sat Parmar and Tim Martin are based. The Royal Centre for Defence Medicine is at UHB, and the oral and maxillofacial department also works on military cases: www.uhb.nhs.uk

22 | Surgeons’ News | June 2018

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Oral and maxillofacial surgeon Tim Martin: “The operations Sat and I carry out in Birmingham demonstrate the high level of skill needed by an OMFS” Images courtesy of BBC and Dragonfly TV

Behind the scenes Dragonfly TV started filming in May 2017, with the final interviews completed in November, just two months before the documentary aired. The TV crew spent seven days filming conversations with patient Dallas, the surgeons and the team. What viewers did not see are the multiple stories that were filmed before selecting only one to air. Parmar and Martin are always aware that patients who volunteer to take part in a documentary and are about to undergo life-changing surgery are emotionally and physically vulnerable, and they must always be able to step aside if they need to. Parmar explains: “We suggest cases to the producer and we ensure that the patients can back out if they want to at any time. It’s important that the patients also get a feel for the producer so they can decide whether they can trust them. It’s amazing how nearly every patient we ask if they want to take part in the documentary says yes.”

Trust is key. It’s down to honesty when you switch on the camera

On camera The day the camera crew filmed Dallas’s life-saving surgery, there were 131 other operations taking place across UHB’s 42 theatres – out of the three million operations carried out by the NHS in the UK annually. Only one camera operator was allowed into theatre, but remotely controlled cameras were placed throughout the operating room to capture every movement. To film Dallas’s operation, there were four cameras in each corner of the theatre and one 360° camera in the ceiling. “All the theatre team wore microphones and Tim and I wore GoPro cameras on our heads for the closeup shots of the operation to pick up everything that happened in theatre,” says Parmar. As Seal explains: “A hospital drama has never been shot like this before. Teresa’s procedure was complicated. The moment of real tension was when Sat and Tim were joining up the artery and vein in her face. That was a point of jeopardy and I was incredibly nervous watching in the gallery.” Revealing what it’s like in theatre when filming takes place, Parmar says: “Once the day starts, people are on autopilot and you forget the crew are there. We stay as normal as possible. Usually we have really loud music playing in theatre to ease the tension – our preference is loud dance music – but we can’t do that during filming.” Parmar admits he gets butterflies before he goes into theatre. “It is about what you’re putting the patient through, and you hope and pray it goes to plan. I always get butterflies, while Tim is calmer and just goes in and does his best. Once I start, though, I’m relaxed. It’s not so much about the operation – you’ve developed a relationship with the patient and their family. It’s a massive thing because they’ve put their lives in your hands and you just want to do your best,” he says. He adds that when the pressure is on, the team is “patient-focused, but we also act naturally, like when I asked for a step, one of the nurses joked: ‘You mean a step ladder?’ (Due to my height.) Our humour comes through”.

[Jamie Seal] set out to make something that was ‘fresh, not derivative, and that was a celebration of the NHS – no ambulances and flashing lights, but innovation and skill’ skills from both dentistry and medicine degrees. We are privileged in the NHS that we can provide the stateof-the-art treatment for head and neck cancer that’s comparable with the best centres in the world, and this is all done free of charge.” What does the future hold for Parmar? As a Fellow of the British Association of Oral and Maxillofacial Surgeons (BAOMS), he says that the Council has done a lot to progress the specialty: “I would like to make my contribution to this and that is why I stood to be a Council member and am also lucky enough to have been elected President for 2019.”

The latest news

President elect of BAOMS Sat Parmar holds up a prosthetic facial implant Image courtesy of BBC and Dragonfly TV

Seal is incredibly proud of the series: “I walked away from the project in awe of those surgeons and their technical skills, and we were able to counter the myth that surgeons are bombastic!” He adds: “The hospital wanted to create a show that would get young people interested in becoming surgeons – and the viewing market share among 16- to 34-yearolds increased by 58% when the show aired, which is really pleasing.” Dallas is doing well after her operation and has completed her radiotherapy. “She doesn’t want her prosthetic eye and is happy with her appearance. She looks well,” Parmar concludes.

What’s special about oral and maxillofacial? Parmar qualified in dentistry from Leeds in 1986 and in medicine in 1995. A career choice of oral and maxillofacial surgery is demanding in terms of time and money, but the rewards are extraordinary. He chose to specialise in oral and maxillofacial surgery for specific reasons. He explains: “We deal with a variety of age groups, from babies through to elderly people, and a variety of issues from trauma, congenital deformity, facial trauma and cancer. Maxillofacial surgery is hugely interesting and challenging and, most importantly, very rewarding – I am able to make a real difference to patients’ quality of life. It allows me to combine both my training as a dentist and as a doctor. “A dual qualification in dentistry and medicine is quite rightly an essential prerequisite for a career in oral and maxillofacial surgery. The profession uses many rcsed.ac.uk | 23

IKON/DARREN HOPES

Moving on with mesh

24 | Surgeonsâ&#x20AC;&#x2122; News | June 2018

UROGYNAECOLOGY

Mark Mercer-Jones and Andy Williams discuss the story behind the mesh urogynaecology controversy and the effects on colorectal surgery

he use of mesh in the female pelvis for control of prolapse and urinary incontinence is causing controversy globally. Synthetic mesh has been used since the 1950s within the abdomen to help reduce recurrence of pelvic organ prolapse (POP) (vaginal and rectal). The current mesh controversy principally concerns mesh inserted transvaginally. However, the use of mesh in colorectal prolapse surgery has now been called into question. The word ‘mesh’ has become synonymous with danger and complications, in part because of the media – in particular, social media – interest. This article discusses the story behind the mesh controversy related to urogynaecology and how the debacle has affected colorectal surgery, especially ventral mesh rectopexy (VMR).

Mark MercerJones is a Consultant Colorectal Surgeon and Honorary Secretary for The Pelvic Floor Society Andy Williams is Chairman of The Pelvic Floor Society

Mesh is used to treat the prolapse of pelvic organs and stress urinary incontinence

Background In 1996, the US Food and Drug Administration (FDA) licensed the use of mesh to treat stress urinary incontinence (SUI) and, in 2002, the use of transvaginal mesh for POP. An industry-driven surge in use (in particular, transvaginal mesh placement) led to an increase in adverse events reported by both clinicians and patients. Chronic pain, erosion and sexual dysfunction were some of the effects reported. In 2008, the FDA issued a public health notification on serious complications caused by the transvaginal placement of mesh in women treated for POP and SUI.1 In 2016, the FDA issued a final order to mesh manufacturers and the public to reclassify these devices from class II (moderate risk) to class III (high risk). The use of transvaginal mesh in the US has fallen by 40–60% since.2 In Scotland in 2014, a group of women affected by mesh-related complications – the Scottish Mesh Survivors campaign – gave evidence to the Holyrood Petitions Committee. As a result, the Scottish Minister for Health wrote to Scottish health boards requesting a suspension of the use of mesh for POP and SUI pending an official enquiry. In 2017, the Scottish Independent Review of the use, safety and efficacy of transvaginal mesh implants in the treatment of POP and SUI in women was published.3 In the conclusions, the Chairman stated that: 1. There should be patient-centred care with adequate patient choice and shared decision-making

The Scottish Minister for Health requested a suspension of the use of mesh for POP and SUI pending an enquiry

supported by robust clinical governance arrangements involving a multidisciplinary team (MDT) approach. 2. Evidence of working in a MDT together with audit as well as the mandatory recording and reporting of adverse events should be a necessary part of a consultant’s appraisal and revalidation. 3. There should be informed consent. 4. Recording databases should be improved to a national level with the creation of new data codes that would allow better NHS capture. 5. Transvaginal meshes should not be offered routinely. In the UK in 2014, the Medicines and Healthcare Products Regulatory Agency also published its conclusions on the evidence of the benefits and safety of vaginal mesh implants.4 These concluded that vaginal mesh implants were safe and effective for the majority of women and, if used correctly, they could help alleviate POP and SUI. In addition, the benefits of mesh outweighed the risks. Contrary to these conclusions, the European Commission published a report led by its Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) in 2015.5 It stated that the implantation of any mesh via the vaginal route should be considered only in complex cases – in particular after a failed primary repair –and that mesh use in SUI was acceptable. A Cochrane Review in 20166 on transvaginal mesh concurred with the SCENIHR conclusions. In 2017, the National Institute for Health and Care Excellence (NICE) published updated interventional guidance (IPG 599) on the transvaginal mesh repair of anterior or posterior vaginal wall prolapse.7 NICE concluded that there were serious safety issues, as well as concerns over efficacy. NICE advised that such rcsed.ac.uk | 25

UROGYNAECOLOGY

surgery should be offered only in the context of research. In 2017, the Australian Therapeutic Goods Administration, closely followed by New Zealand, banned the use of transvaginal mesh for POP. In the US, there are currently more than 100,000 lawsuits against mesh manufacturers – in 2017, one plaintiff alone received $57m.

localities. It is accepted that although the risk of adverse events is generally very low, high-volume surgeons who take on redo surgery and receive tertiary referrals may see an increased complication rate. When mesh complications occur, they can be devastating for patients and their families. TPFS is committed to ensuring that in such cases adequately trained teams in recognised tertiary centres will provide best available care.

Mesh use in VMR The Pelvic Floor Society (TPFS) is an affiliate of the Association of Coloproctology of Great Britain and Ireland. It was formed to set and raise standards in pelvic-floor surgery and to update members on the advances of the specialty. TPFS collaborates with other organisations focused on the pelvic floor, including the United Kingdom Continence Society and British Society of Urogynaecology. As a responsible society, and in light of ongoing concerns by the media and public groups surrounding the use of mesh in patients with POP and SUI, TPFS recently published a position statement on mesh use in VMR8 (see below). It highlighted the actions being pursued by TPFS regarding clinical governance and VMR. TPFS recognises that there has also been media attention surrounding adverse events following VMR performed in some UK

NICE concluded that there were safety issues, as well as concerns over efficacy

References

The Pelvic Floor Society states that there is lower mesh morbidity for VMR than transvaginal procedures

1. fda.gov/downloads/medicaldevices/safety/ alertsandnotices/ucm26276.pdf 2. Daly J, Frazer M. Decline and Fall, lessons learned from the troubled history of transvaginal mesh kits. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; O&G Magazine 2014; 16(1) 3. The Scottish Independent Review of the use, safety and efficacy of transvaginal mesh implants in the treatment of stress urinary incontinence and pelvic organ prolapse in women: final report. gov.scot/ Publications/2017/03/3336 4. ec.europa.eu/health/scientific_committees/emerging/ docs/scenihr_o_049.pdf 5. ec.europa.eu/health/sites/health/files/scientific_ committees/emerging/docs/scenihr_o_049.pdf 6. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Marjoribanks J. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse. Cochrane Database Syst Rev 2016; 2: CD012079 7. nice.org.uk/guidance/ipg599 8. Position statement by the Pelvic Floor Society on behalf of the Association of Coloproctology of Great Britain and Ireland on the use of mesh in ventral mesh rectopexy Colorectal Dis. 2017; DOI 10.111/codi.13893

Summary recommendations from the Pelvic Floor Society’s position statement on mesh use in VMR l Available evidence suggests that mesh morbidity for VMR is far lower than that seen in transvaginal procedures (the main subject of current concern) and lower than that observed following other abdominopelvic procedures for urogenital prolapse – e.g. laparoscopic sacrocolpopexy. l VMR should be performed by adequately trained surgeons who work within a MDT framework. It is mandatory to discuss all patients considered for surgery at a MDT meeting. l Clinical outcomes of surgery and any complications resulting from surgery should be recorded in the TPFS-hosted national database (registry)

26 | Surgeons’ News | June 2018

available for this purpose; in addition, all patients should be considered for entry into ongoing and planned UK/European randomised studies where this is feasible. l A move towards accreditation of units performing VMR will improve performance and outcomes in the long term. l Pre-VMR-enhanced checklists and patient-information booklets are being developed, and these will help surgeons and patients. l There is weak observational evidence that the technical aspects of the procedure can be optimised to reduce morbidity rates. These include choice of suture material and the use of biologic rather than synthetic mesh.

Face the facts

very medical practitioner should be familiar with the adage ‘Primum nil nocere’: ‘First, do no harm’. Balancing the benefits of a procedure against the risks of harm is a challenge in all areas of practice, but is particularly demanding in non-essential,

28 | Surgeons’ News | June 2018

Surgeons must give patients an idea of the realistic outcomes of cosmetic procedures

especially cosmetic, surgery. In an area of practice in which patients may report harm as physical or psychological hurt, the management of expectation is a critical skill. While there is a burgeoning non-surgical ‘market’ driven by little more than lifestyle choices, the number of patients undergoing

surgery is not increasing enormously. Contrary to popular belief, few patients have cosmetic surgery out of vanity or as a frivolous decision. Many patients have an element of functional need and an enormous number have an element of psychological need. Many aesthetic procedures are considerable

SHUTTERSTOCK

Jeyaram Srinivasan, Nigel Mercer and Simon Withey explain the importance of managing patients’ expectations of cosmetic surgery

technical challenges at the best of times. However, if a technical exercise, such as rhinoplasty, is associated more with a perceived psychological benefit than with a simple physical change, things can rapidly go wrong, particularly if communications focus on the technical aspects of surgery alone. The surgical community and societal attitudes have added to the trivialisation and commercialisation of surgery. It has been convenient for some people to minimise the risks and implications of surgery for financial gain. As a result, patients do not appreciate risks and, unless the surgeon educates them, enter the operating theatre ignorant of the risks. The commercial practice of using non-surgical ‘advisers’ for screening consultations, parts of the consent process and to support challenging decisions such as choice of implant sizes might help sign up patients for surgery, but it does not make for an informed patient and does nothing to align expectations. A pernicious consequence of commercialisation of aesthetic surgery is that patients may have expectations more in line with a high-street transaction than a medical procedure. A purchase from a shop is returned if it’s the wrong size or colour, or if the customer changes their mind. Similar attitudes are emerging in surgical practice and it is vital to rid patients of such mistaken beliefs. A technically talented cosmetic surgeon will develop a wide range of skills, many of which will closely mirror those in other surgical disciplines. However, if that surgeon is to avoid dissatisfied patients, there are other areas in which they would be advised to become proficient. Excellent communication skills are vital to all surgeons. In this area of practice, it is critical that the surgeon understands why the patient is sitting in the consultation room and what they expect from surgery. It is also important that the surgeon presents both sides of the discussion to the determined and excited patient who may otherwise happily turn a deaf

Jeyaram Srinivasan Consultant Plastic Surgeon, Preston; Chair, British Association of Aesthetic Plastic Surgeons (BAAPS) Educational Sub Committee; and former RCSEd Regional Surgical Adviser Nigel Mercer Consultant Plastic Surgeon, Bristol; Past President, BAAPS; and Past President, BAPRAS Simon Withey Consultant Plastic Surgeon, London; and President, BAAPS

ear to talk of risk. The surgeon must be capable of managing those patients who, despite best efforts, end up dissatisfied. The PIP breast implant scandal in 2012 led to many women worrying about the safety of their breast implants. It also highlighted some of the failings of the cosmetic surgery industry. Sir Bruce Keogh’s efforts to address this ‘unregulated industry’ led to the establishment of the Cosmetic Surgery Interspecialty Committee, which incorporated all the involved surgical specialties. It was tasked with improving professionalism and reducing harm to patients. One of the most important recommendations was to establish a unified Certification Scheme, available to those with a proven background of training and firsthand experience of practice. Through the Keogh review, it became clear that many cases of dissatisfaction resulted from poor patient choice, or from poor communication, rather than from poor technical performance. As a consequence, it was felt that a valuable risk-reduction mechanism would involve a masterclass on communication and non-technical risk. The current version of the Professional Masterclass is a twoday course. The first day focuses on the value of good communication techniques and managing patient expectations. It includes simulation with actors, practical tips, reflection and group discussion. Many candidates feel the ‘red heat’ of dealing with an angry, complaining ‘patient’ in front of their peers and find this part of the course valuable. The second day covers the non-technical skills required in

Patients may have functional and psychological needs for cosmetic surgery

managing a patient wishing to have cosmetic surgery. Participants reflect, interact and discuss various challenging elements of cosmetic practice, including the psychological basis of appearance-related anxiety and dissatisfaction. Delegates hear the experiences of medical experts. This course is a useful way of reviewing practices and reflecting on areas in which the individual delegate, and their patients, may be exposed to risk. Practical solutions are given to help surgeons reduce this risk and improve the safety of their patients. The Certification Scheme is voluntary and is open to surgeons on the GMC specialist register who wish to perform cosmeticsurgery procedures appropriate to their specialty registration. Initial applications must be supported by clinical and professional evidence collected over a six-year period. It is envisaged that ‘renewal’ of this certification, which will be undertaken every five years, will fall in line with the GMC revalidation. A broad approach to raising standards and reducing risk in cosmetic surgery will lead to greater levels of patient satisfaction and will benefit both the profession and individual surgeons.

It is critical that the surgeon understands why the patient is sitting in the consultation room and what they expect from the surgery rcsed.ac.uk | 29

A bitter pill

Dr Jane Quinlan examines the rapid rise in postoperative opioid dependence in the US and the UK, and how to deal with it

he opioid crisis in the US, where the prescribing of strong opioids for people suffering from chronic pain has led to catastrophic levels of addiction and death, has rippled over to the UK, where there was a 400% increase in opioid prescribing between 2000 and 2010. It is now accepted that opioids are appropriate and effective analgesics for patients with acute or cancerrelated pain arising from identified tissue damage due to trauma, surgery or tumour progression, but they are ineffective and, frankly, dangerous for those with chronic pain. After surgery, inflammatory processes settle and tissue damage heals, such that the acute pain subsides and, by three months but usually far earlier, ceases. If pain persists beyond three months postoperatively, it represents a transition to a chronic pain state known as chronic postsurgical pain (CPSP).

30 | Surgeonsâ&#x20AC;&#x2122; News | June 2018

Chronic pain, defined by the International Association for the Study of Pain as pain that persists for more than three months, serves no useful purpose and represents a dysfunction of the pain system, where pain is genuinely experienced but in the absence of tissue damage. Here, opioids are not effective and expose patients to an increased risk of dependence and death, together with known side-effects such as constipation, daytime somnolence, poor night-time sleep and opioidinduced hyperalgesia (increased pain sensitivity). As opioid prescribing for chronic pain decreases, are hospital prescriptions of postoperative opioids inadvertently driving longterm opioid use in the community? A 2012 study1 reviewed 109 patients undergoing various procedures, including mastectomy, thoracotomy, total knee and total hip replacement. All patients were discharged on opioids and, 150 days

Dr Jane Quinlan FRCA FFPMRCA Consultant in Anaesthesia and Pain Management, Oxford University Hospitals Trust, OUH Trust Lead for Pain and Honorary Senior Clinical Lecturer, University of Oxford

postoperatively, long after acute pain would have settled, 6% continued to take opioids. These patients did not describe more pain than their opioid-free counterparts, neither at the time of surgery nor at the time of interview, but were more likely to have taken opioids in the past, or had preoperatively described depression or expressed a higher self-perceived risk of addiction. Clarke and colleagues2 reviewed a large post-surgical population of 39,000 patients aged 66 or older undergoing major surgery. Of these, more than 19,000 (49.2%) were discharged with an opioid and 1,229 (3.1%) continued to receive opioids for more than 90 days postoperatively. The risk factors for prolonged opioid use included thoracic surgery, comorbidities such as diabetes, heart failure or pulmonary disease, or polypharmacy with benzodiazepines, SSRIs or ACE inhibitors. This study used a cut-off at three months, around the

SHUTTERSTOCK

PAIN MANAGEMENT

time that acute pain may transition to CPSP, which is particularly common after thoracotomy. The high-risk comorbidities may indicate contraindications to other analgesics, such as non-steroidal antiinflammatory drugs, such that there is more reliance on opioids, and the co-prescription of benzodiazepines and SSRIs may reflect depression and anxiety as in the Carroll study, but it is difficult to conclude that accurately with a population-based analysis. In the US, databases of privately insured patients have been interrogated to assess persistent opioid use after surgery. One study of 36,000 patients confirmed earlier estimates that around 6% of patients continue to take postoperative opioids beyond three to six months.3 The nature of surgery – minor or major – appeared to have little impact on this figure, but risk factors included smoking, alcohol and substance misuse disorders, anxiety, depression and pre-existing chronic pain. Interestingly, the dose of discharge opioid prescribed had little impact on long-term use. A similar large study by Brat and colleagues4 used ICD-9 codes to demonstrate a formal diagnosis of opioid misuse or overdose in post-surgical patients. In their dataset of half a million patients, misuse was identified in 0.6%, with 0.2% developing opioid misuse within the first year after surgery. These lower prevalence values reflect the more stringent criteria of misuse compared with other studies. Importantly, each repeat prescription increased the rate of misuse by 40%, while each additional week of opioid use increased the rate by 20%. Again, the initial discharge dose was a weaker predictor of abuse compared with psychological factors. Opioid prescribing upon hospital discharge varies widely among clinicians. Makary and colleagues at Johns Hopkins Hospital5 investigated doctors’ prescribing patterns for patients undergoing laparoscopic cholecystectomy. They found that the number of opioid tablets prescribed ranged from 0 to over 50 tablets, with only 20% of doctors prescribing what the team would have expected (up to 10 tablets). A similar study identified overprescribing after partial

References 1. Carroll I, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg 2012 2. Clarke H, et al. Rates and risk factors for prolonged opioid use after major surgery. BMJ 2014 3. Brummett CM, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg 2017 4. Brat GA, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse. BMJ 2018 5. Makary MA, et al. Overprescribing is major contributor to opioid crisis. BMJ 2017 6. Hill MV, et al. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg 2017 7. Macintyre PE, et al. Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain. Anaes Int Care 2014 8. Nooromid MJ, et al. Discharge prescription patterns of opioid and nonopioid analgesics after common surgical procedures. Pain Rep 2018 9. Peters ML, et al. Somatic and psychologic predictors of longterm unfavorable outcome after surgical intervention. Ann Surg 2007 10. Lavand’homme P. Transition from acute to chronic pain after surgery. Pain 2017 11. Alam A, et al. Long-term analgesic use after low-risk surgery. Arch Intern Med 2012 Full references available online

mastectomy,6 where the range of number of prescribed tablets (each equivalent to 5mg oxycodone or approximately 10mg morphine) was 0–50 with a mean and median of 20 pills. Interestingly, 75% of women took none of their prescribed opioids. Indeed, in many studies of major surgery, the number of tablets prescribed at discharge often failed to mirror opioid use in the previous 24 hours, with patients given opioids to take home despite having needed none the day before.7 This overprescribing leaves a large pool of unused and unneeded opioid medications in the community, as most patients who have leftover medication choose to keep rather than dispose of them. These opioids may be diverted, misused or may contribute to the unintentional poisoning of children if the drugs are not stored safely.7 The tablets are then available for inappropriate self-medication of other unassociated pains, or may be used to cope with stress, anxiety and depression – known as chemical coping – which would explain the higher incidence of persistent opioid use in those with pre-existing psychological comorbidities.7 Patients are now discharged earlier than ever after major surgery having followed enhanced recovery pathways and achieved functional goals. However, their acute pain will continue beyond discharge, necessitating wise prescribing to address the patient’s shortterm needs while reducing the risk of transition to long-term opioid use. Hill and colleagues6 used their data to estimate the optimal number of pills for each of the surgical procedures studied, based on doses used by 80% of their patients; Nooromid et al.8 highlighted suboptimal practice when they found that 94% of patients received a discharge prescription for opioids, but only 15.5% were co-prescribed non-opioid medication. Thus, overprescribing of opioids can lead to unintended persistent opioid use in vulnerable groups or

the accumulation of unused drugs in the community. Conversely, underprescribing of analgesia leads to patient distress, limited mobility (particularly pertinent after joint replacement surgery), poor global recovery,9 and the possibility of transition to chronic post-surgical pain,10 together with increased contact with primary care providers or emergency departments if patients find their pain unmanageable. Looking to the future, we need more procedure-specific information about how long pain continues after discharge and at what severity to gauge how best to provide pain management once patients arrive home. This will then inform best practice guidelines with the ‘ideal’ amount of opioid for discharge prescribing, given together with non-opioids. It would appear that high doses of opioids don’t themselves significantly increase the risk of persistent opioid use providing they are swiftly weaned as pain subsides, so a short course of moderate to high opioid doses would maximise analgesia and minimise the risk of misuse.4 The use of a reverse WHO pain ladder to reflect the reduction of acute pain with time encourages deprescribing and a step down from strong to weak opioids and then to their cessation.7 Weak opioids themselves can initiate prolonged opioid use, with a significant number of patients transitioning to stronger opioids over time.11 Identification of patients who exhibit risk factors for prolonged opioid use allows more careful monitoring, while good communication with primary care doctors will highlight the risks of each repeat prescription and should trigger further inquiry for those who may continue to request opioids. Just as the pendulum had swung too far in overprescribing opioids for chronic pain, we must avoid bringing opioid prescribing to a shuddering halt for those with acute pain after major surgery for whom they are effective and necessary for a full recovery, but for a limited time only.

Each repeat prescription increased the rate of opioid misuse by 40% rcsed.ac.uk | 31

In this extract from his book, Lord David Owen examines the far-reaching consequences of a medical blunder on the life and politics of Anthony Eden

PICTORIAL PRESS LTD/ALAMY STOCK PHOTO

In sickness and in power

BOOK EXTRACT

Lord David Owen This article is based on Chapter 3 of David Owen’s book In Sickness and in Power: Illness in Heads of Government, Military and Business Leaders since 1900. Lord Owen trained as a doctor at St Thomas’s Hospital where he was a neurological registrar. He was MP for Plymouth for 26 years and served in Labour governments as Navy Minister, Health Minister and Foreign Secretary. He was leader of the SDP from 1983 to 1987 and 1988 to 1990. He sits in the House of Lords as an independent social democrat.

t was a misfortune not just for Foreign Secretary Anthony Eden, but for international diplomacy in the ensuing years, that on 12 April 1953 in the London Clinic, what should have been a routine operation, a cholecystectomy, went badly wrong. Sir Horace Evans, Eden’s physician, had recommended three surgeons, all with expertise in biliary tract surgery. Fatefully, Eden rejected them, choosing instead the 60-year-old John Hume, a general surgeon who had “removed my appendix when I was younger and I’ll go to him”.1 Constant reminders about the importance of the patient meant Hume was so agitated that the first operation had to be put on hold for nearly an hour to allow him to compose himself. After what happened in that operation, Hume felt he could not lead a second operation, which was led instead by Guy Blackburn, Hume’s assistant at the first. This operation has been described as “even more tense than the first, and Eden was within a whisker of death at several stages of the lengthy and traumatic process”.2 Eden’s official biographer claimed that Eden’s biliary duct was accidentally cut in the first operation and Eden was told that “the knife slipped”.3 Another source was

blunter, describing what happened in one or other of the operations as a “schoolboy howler” of surgery in which “inadvertently [they] tied the bile duct as it comes out of the liver”, 4 resulting in the obstructive problems in the biliary tract. Evans had asked Richard Cattell, a world-renowned expert in this field of surgery and who was by chance in London lecturing, to see Eden. Cattell insisted that Eden should travel to Boston for a third operation and Evans agreed, but first both men had to convince Churchill at No 10. On 23 June 1953, Cattell found a high injury of the common hepatic duct close to the right hepatic artery. He performed a complicated surgical procedure on Eden. On the same day, back home, Churchill suffered a very serious stroke and there followed a conspiracy of silence with Fleet Street not printing a word about how severe Churchill’s illness was. Eden, meanwhile, recovered from his operation and resumed his responsibilities as Foreign Secretary. He was “then well until 1954 when he experienced fevers and chills on one occasion and in 1955 on three occasions. None was severe or prolonged”5 and Evans “wouldn’t hear of Anthony not being well enough to become PM”.6 Churchill finally stepped down on 6 April 1955. Determined to call an early election, Eden did so and won in May with an increased majority in the House of Commons, up from 17 to 58 MPs, confirming what opinion polls had shown – that Eden was one of the most popular politicians of his era. On 6 February 1956, Eden wrote to his wife Clarissa [Lady Avon] from Government House, Ottawa: “I am well, but was very tired yesterday, so stayed in bed all day.” That is not the behaviour of a fit man. Lack of sleep and tiredness are too often underplayed when trying to assess the effect of people’s health on their decision-making. In March, in a rancorous debate in the House of Commons, Eden lost his temper, leading to calls for him to “Resign!”.

In a rancorous debate in the House of Commons, Eden lost his temper, leading to calls for him to ‘Resign!’

On 26 July, the anniversary of King Farouk’s abdication, in a passionate speech in Manshiya Square in Alexandria, [Egyptian President] Gamal Abdel Nasser announced the nationalisation of the Suez Canal Company. Nationalisation, to Eden, was a direct threat to British interests and he publicly declared that Nasser should not be allowed “to have his thumb on our windpipe”. He made it clear he was ready to use British Armed Forces to lift the threat of Egyptian interference with the flow of ships along the Suez Canal. Britain had ruled Egypt from 1882 until 1922 and had strongly influenced its monarchy right up to King Farouk’s overthrow by Nasser in 1952. Free passage along the Suez Canal was regarded by Eden and his generation as Britain’s lifeline. Eden began to develop a personal animosity to Nasser, having met him once in Cairo when Foreign Secretary. Yet Eden had shown courage in facing the reality of decolonisation and negotiating the Suez Canal Base Agreement, with the last British troops leaving Port Said on 13 June 1956. Anthony Nutting, then a junior Foreign Office minister, describes one of Eden’s outbursts, with him shouting down the phone: “What’s all this nonsense about isolating Nasser or ‘neutralising’ him as you call it? I want him destroyed, can’t you understand? I want him removed and if you and the Foreign Office don’t agree, then you’d better come to the Cabinet and explain why.” There are many accounts of Eden’s irritability – Lord Moran in a diary entry wrote: “The political world is full of Eden’s moods at No 10.” Churchill saw that toppling Nasser would involve attacking Cairo. But the Cabinet believed that it would not be long before Nasser fell. The British chiefs of staff did not emerge well from the whole crisis, showing neither cohesion nor decisiveness. Admiral Lord Mountbatten was against the whole venture. On 17 August, Eden wrote to Churchill: “I am sorry to have been away on Monday, but I needed a few hours off. I am very fit now.” He also said: “Most important of all, the Americans seem very firmly lined up with us on inter-nationalisation” of the Suez Canal. Yet Eisenhower rcsed.ac.uk | 33

In Eisenhower’s words: ‘I’ve just never seen great powers make such a … botch of things’ never hid from Eden his opposition to the use of force. On 3 September, he wrote to Eden: “I must tell you frankly that American public opinion flatly rejects the use of force. I really do not see how a successful result could be achieved by forcible means.” Eden’s own diary entries are virtually non-existent during the Suez crisis, although his engagement diary shows that he consulted Evans or other doctors on at least 10 occasions between the Suez Canal nationalisation and the end of October. One of the few entries, for 21 August, reads: Felt rather wretched after a poor night. Awoke 3.30am onwards with pain. Had to take pethidine in the end. Appropriately the doctors came. Kling was more optimistic than Horace. We are to try a slightly different regime. Agreed no final decision until a holiday has given me a chance to decide in good health. Yet despite having taken pethidine, Eden chaired a Cabinet meeting at noon and had other meetings in the afternoon before seeing his doctors again later that day. On 7 September he commented: After fair night. Sleep at least uninterrupted, but not long, 5 hours. A week later Eden’s diary records: There were two difficult days in the House. I was quite exhausted by the end of the debate. Eden’s fever of 5 October struck just as the Suez crisis was coming to a head. Two days earlier Eden had told the Cabinet that there was “a risk that the Soviet Union might conclude a pact of mutual assistance with Egypt; if that happened, it would become much more hazardous to attempt a settlement of this dispute by force”. Eden spent two nights in hospital on 6 and 7 October when his temperature rose to 40°C and he had a rigor. On Monday 8 October, Rab Butler chaired the Egypt Committee in the Prime Minister’s absence. But by Saturday of that week Eden was well enough to speak in the traditional leader’s slot on the last day of the Conservative Party Conference at Llandudno. The party faithful loved 34 | Surgeons’ News | June 2018

Gamal Abdel Nasser announced the nationalisation of the Suez Canal in July 1956

the passage in which he said: “We have always said that with us force is the last resort, but cannot be excluded. We have refused to say that in no circumstances would we ever use force. No responsible government could ever give such a pledge.” On the evening of 13 October, Eden was told that the French had delivered 75 of the latest Mystère fighter aircraft to Israel without obtaining British and American clearance as the procedures of the Tripartite Agreement required. On Sunday 14 October, Eden held what turned out to be a fateful meeting with French Prime Minister Guy Mollet’s emissaries, including General Maurice Challe, a deputy chief of staff of the French Air Force, who revealed the plan based on a conspiracy with Israel. The normally cautious, pro-Arab Eden might have been expected on his past record to have ruled out involving Israel from the moment he first heard of it. Nutting, previously very close to Eden, asked in his book: “How and why was this mortal decision arrived at? And how and why did the man, whose whole political career had been founded on his genius for negotiation, act so wildly out of character?” A war

started in dishonour ended, not altogether surprisingly, in disaster and the man responsible, Eden, was in no fit condition to make such a decision. It was a diplomatic debacle. In Eisenhower’s words: “I’ve just never seen great powers make such a complete mess and botch of things.” It was also a wholly unrealistic view of Eden’s that any cover-up could be kept from American intelligence for much longer than a few weeks at best, more likely a few hours. In 2004, the distinguished journalist Lord Deedes, who had been a minister in Eden’s government, said on television that during the Suez crisis Eden “under prescription had, as many did, and still do, barbiturates, I think, to assist rest and sleep etc. and amphetamines sometimes for a little bit of a pick-up” and agreed that these were what are called “uppers and downers”. Deedes’s account was true and contradicts the genuine though mistaken view of Eden’s widow that he was not taking uppers and downers. The historian Hugh Thomas alleges that Eden told an adviser that he was practically living on Benzedrine, although Lady Avon says he was taking it only in the last fortnight before he resigned. In January 2005, Lady Avon, who had said at the time that she felt as though “the Suez Canal was flowing through her drawing room”, kindly allowed me access to her husband’s still-closed medical records in Birmingham University’s Special Collections Archives. There I found an

PICTORIAL PRESS LTD/ALAMY STOCK PHOTO/SHUTTERSTOCK

BOOK EXTRACT

important letter, hitherto unremarked on, which Evans had written on 15 January 1957. It was an open letter to any doctor who might have to treat Eden while he visited New Zealand shortly after his resignation as Prime Minister. Evans wrote: There have been during the past six months several unexplained feverish attacks which could have been virus infections, but the most suspect was an attack of a severe rigor, which came on suddenly without any other symptoms.7 Though it has been thought in the past that all these feverish attacks were incidental, it could be that some, certainly those with rigors, indicate a transient ascending infection in the liver ducts. It is known from recent investigations that there is a back-flow into the common bile duct, there being no valve at its outlet. On the other hand, at the last X-ray examination there was no evidence of any dilation in any part of the biliary tract. Evans then describes Eden’s treatment: His general health during the past year has been maintained with extensive vitamin therapy – sodium amytal gr 3 and seconal enseal gr 1.5 every night and often a tablet of Drinamyl every morning. These treatments have only become really essential during the past six months. Before his rest in Jamaica, the general condition was one of extreme over-strain with general physical nerve exhaustion, and at this time he seemed to be helped by rest, some increase in the sedation and Vitamin B12 therapy. Medical evidence had now been found that confirmed Eden was taking dextro-amphetamine, a stimulant that, combined with

amylobarbitone, a sedative, is contained in Drinamyl, often referred to as ‘purple hearts’. Some of the minor side effects of one Drinamyl each morning, restlessness and irritability, had developed in Eden by July 1956. It seems that the dose was increased after the medical episode on 21 August and possibly again in October, and contributed to his collapse in November. We do not know exactly how many tablets a day Eden was taking, particularly between 5 October and 19 November, when his doctors became deeply concerned about his health, recommending he take a holiday in Jamaica. Malcolm Lader, a professor of clinical pharmacology at King’s College London, in an interview on the 50th anniversary of Suez, said that people taking Drinamyl become “disinhibited” and start acting out of character. With larger doses, he said, they can become paranoid and their judgement “becomes even more impaired – at the most extreme, they can lose contact with reality”.8 Doctors well know that even the most careful of patients during times of stress feel some initial comfort in upping their dosage of amphetamines to give them a temporary boost of energy and they may not tell anyone, doctors or close relatives, that they are doing this. We also know that Eden took pethidine

Eden believed that free passage through the Suez Canal was essential to Britain

Medical evidence had been found that confirmed Eden was taking dextro-amphetamine

tablets for pain and there are reports of “his own self-medication involving injections by his personal detective”.9 Eden’s continued attempt to cover up the collusion with Israel and France diminished his standing, and when he said in the House of Commons on 20 December that “there was not foreknowledge that Israel would attack Egypt”, it was a lie. Flagrant lying to the House of Commons was something that Eden had never previously done in more than 32 years as an MP. It was totally out of character and it hastened his departure. In informing his Cabinet colleagues on 9 January 1957 of his resignation, Eden made no attempt to hide his dependence on stimulants. He openly refers to his having considerably increased his amphetamines, which he calls stimulants, since July. In relation to three crucial decisions – to collude with Israel, to mislead the American President and to lie to the House of Commons – his judgement was seriously impaired and his illness and treatment made the major contribution to that impairment. References 1. Kune G. Anthony Eden’s bile duct: portrait of an ailing leader. ANZ J Surg 2003; 73: 341–345 2. Thorpe DR. Eden: The Life and Times of Anthony Eden, First Earl of Avon 1897–1977. Chatto & Windus, London; 2003; 384–386 3. Rhodes James R. Anthony Eden. Weidenfeld & Nicolson, London; 1986; 362–364 4. Sir Christopher Booth, speaking on Case History: Anthony Eden. BBC Radio 4; 1998 5. Braasch JW. Anthony Eden’s (Lord Avon) biliary tract saga. Ann Surg; 2003; 238: 772–775)* 6. Eden C. Clarissa Eden: A Memoir – From Churchill to Eden. Ed. Cate Haste. Weidenfeld & Nicolson, London; 2007; 183 7. This is a reference to the attack on 5 October when he stayed two nights in hospital. 8. Interview with Professor Malcolm Lader, The Sunday Programme, GMTV; 5 November 2006 9. L’Etang H. Ailing Leaders in Power 1914–1994. Royal Society of Medicine Press, London; 1995; 10 *Braasch had operated on Eden in 1970 and had communicated with Cattell, who had undertaken the third operation – an end-toside hepatico-jejunostomy using a rubber Y-tube as a stent – in June 1953. Also, Cattell did the fourth operation on Eden in America in April 1957. Both men were associated with the Lahey Clinic in Massachusetts and this surgical retrospection is the closest we will probably ever get to what exactly happened.

rcsed.ac.uk | 35

BULLYING

‘It starts with us and how we value and respect those we work with’ Siân Evans reports from the #LetsRemoveIt conference on NHS-wide initiatives to tackle undermining and bullying

he most visited page on the College’s #LetsRemoveIt website is ‘Are you a bully?’ This was the interesting and challenging finding revealed by RCSEd President Professor Michael LavelleJones when he opened ‘Tackling Undermining and Bullying in the NHS’, a packed one-day event in Birmingham hosted by the RCSEd #LetsRemoveIt and Royal College of Obstetricians and Gynaecologists (RCOG). Questioning our own behaviour is the first step towards the culture change in the health service we all want to see, and perhaps the website data indicates that a move towards behavioural change is happening. RCOG Vice-President Alison Wright welcomed colleagues by telling them that the College had had to do a lot of work in obstetrics and gynaecology over many years. She explained how human factors and culture could adversely affect patients’ safety, and why “we keep on reviewing what we’re doing, and this is why this meeting is important”. Since the June 2017 launch of the #LetsRemoveIt campaign in the wake of the Ian Paterson case, the RCSEd has continued to develop resources and key partnerships, has moved the

discussion outside the medical colleges to the whole NHS workforce and has ensured the issues are debated openly, however difficult they are to confront. The College’s membership survey had already established a clear link between bullying and undermining behaviour and patient safety. It revealed the worrying statistics that nearly 40% of respondents said they had been victims of bullying behaviour and a similar number said they had witnessed it. Evidence of the negative impact of such behaviour on the effectiveness of health professionals gets stronger every year. It has been estimated that bullying costs the NHS £13.75bn annually, and that it causes 71% of medical errors and 27% of perioperative deaths. At the launch of the #LetsRemoveIt campaign, Professor Lavelle-Jones made the College’s position absolutely clear: “We must change the culture in which such a surgeon can remain unchallenged, with the team around them perhaps aware of some of the issues, but too scared to speak up. Bullying harms your profession and your patients #LetsRemoveIt.” The #LetsRemoveIt conference in Birmingham is an example of the College both working in a constructive partnership with

The #LetsRemoveIt campaign is aimed at stamping out bullying and help professionals speak out against poor behaviour

RCOG and taking the discussion and learning out across the NHS. The scale of the health service interest and commitment to tackling the adverse impact of bullying was such that the event was effectively sold out, and this was evident in the breadth of the workforce represented at senior level. Colleagues came from other royal colleges, such as the Royal College of Nursing, the Royal College of Midwives and the Royal College of General Practitioners, as well as from educators such as the deaneries and Health Education England. Human resource and medical directors, trust chief executives, the Care Quality Commission and the British Medical Association employment advisers all wanted to take part in the debate. They were joined by representatives from speciality associations such as the British Association of Oral and Maxillofacial Surgeons and the Vascular Society, as well as many individual consultants and others working in the NHS. The aim of the #LetsRemoveIt day was to use the energy and commitment of this group of NHS professionals to find ways of working together and to develop practical strategies to remove the harmful effects of bullying behaviour.

Bullying harms your profession and your patients. 36 | Surgeons’ News | June 2018

I am. What is speaking up about? It’s about your colleagues, it’s also about leadership and learning.” She explained doctors were examined on their competence but not their conduct, and called for doctors to be tested on both in the future.

Rudeness leads to poor performance

Malcolm Wright, NHS Grampian Chief Executive and Churchill Fellow 2017, used his experience of antibullying strategies in other countries to confirm this: “Bullying and harassment is a persistent problem in the NHS, and it has a detrimental effect on patient care and the ability of staff to do their jobs.”

SHUTTERSTOCK

Speaking up Whistleblowing is vital to reveal where problems lie and what action to take, but individuals need support to make this happen without adversely affecting their careers.

It is estimated that bullying costs the NHS £13.75bn annually, and that it causes 71% of medical errors That’s why Freeedom to Speak Up Guardians are now in every health trust in England acting as an interface between staff and boards. Dr Henrietta Hughes, who leads the team of nationwide Guardians, said: “I’m appalled and ashamed at what’s happening in the NHS today, and this is why I’m doing the job

According to Dr Chris Turner, civility saves lives – and as the lead for the Civility Saves Lives project, the consultant in emergency medicine knows what he’s talking about. This links to Dr Hughes’ point that how we behave in the workplace is important to the health of staff and patients. “We don’t deliver healthcare on our own, we do it in teams,” Dr Turner explained. “And how we interact with each other is key if we are a competent team.” His presentation was hard-hitting. He said that there is a 61% reduction in cognitive ability in people who experience rudeness. And an even starker statistic is that nurses’ ability to calculate is reduced by 50% if a colleague is rude to them. This means that bullying, harassment and undermining behaviour is likely to have even more disastrous consequences on how we perform in the workplace and on our own morale. Leading the workshop talking about the complexity of bullying, Dr Elizabeth Nassem illustrated this point clearly: “Bullying changes how the individual sees themselves. One act can cause fear and distress.” Even teasing to one person might be experienced as bullying by the recipient. “It’s difficult to admit you’re a victim,” she said. “We need to give people a chance to exercise agency.”

The final word The last words go to Dr Turner: “It starts with us all, the senior people in this room. What we value and how we respect the people we work with – clinical and non-clinical.” For more information on the #LetsRemoveIt campaign and to access resources, visit rcsed. ac.uk/bullying rcsed.ac.uk | 37

TRAINING

Returning to training after a period of absence can be daunting. Jenny Banks and Hannah Knight look at the initiatives aimed at smoothing the path back into training and two ‘returners’ talk about their experiences

Making up for lost time

38 | Surgeons’ News | June 2018

programme for returning surgeons in training – a comprehensive package to include networking and support events, bespoke individual sessions on cadaver training and a dedicated deanery administrator to oversee those out of programme and working less than full time. The deanery enjoyed its first Jenny Banks of the ‘Return to Work’ half days is a General in February, supported by the Surgical RCSEd. This was well received and Trainee in the those on both sides of the training Southwest partnership had the opportunity Peninsula to air concerns and receive Deanery and practical advice on a personal level. a member of Presenting on the new initiative on the College’s the day, Miss Andreea Lupu, STr7 in Trainees’ trauma and orthopaedics, summed Committee. up its importance perfectly: “After She has two a year out, we want to get back into young boys, work and do what we feel good at, and is currently and we are worth the time and effort training less to make that possible.” than full time. Steered by the Trainees Committee, the College hopes to use the experiences of the Northern

References

1. Skills fade literature review. GMC. 2014 Accessed January 2018. gmc-uk. org/about/ research/26013.asp 2. Supported Return to Training. HEE. 2017. Accessed January 2018. https://hee.nhs. uk/sites/default/ files/documents/ Supported%20 Return%20to%20 Training.pdf

Deanery pilot to support similar initiatives across the UK. In the words of RCSEd President Professor Michael Lavelle-Jones: “Returning to work after a period of absence, for whatever reason, is a particular challenge. Will I cope? How will I make up for lost time? How will I be viewed by my peers and my consultant colleagues? Will the relationships be changed forever? All questions that spring to mind. Well, you will cope and normality will return. I can speak from experience having had a mid-career break of five months to recover from a major surgical intervention and its complications. The secret is to plan your return, set expectations with all concerned and not to expect to perform full throttle from day one. I fully endorse the work done by Alice Hartley and the Northern Deanery as a practical way forward. It seems to me to be an ideal blueprint to roll out across the rest of the UK.”

There will be difficulties in getting back into the ‘swing of it’

SHUTTERSTOCK

any trainees will take a period out of training during their career. In fact, at any one point, approximately 10% of doctors are on approved time out. Some will take time out for the ever-expanding array of fellowships designed to develop skills allied to various surgical specialties, others will take time out for caring responsibilities and some will want to broaden their horizons with a period overseas. Those less fortunate may have significant time off for sickness, or perhaps even suspension from practice. Whatever the reason, and regardless of the length of time out of training, there is evidence to suggest that there will be difficulties, both real and imagined, in getting back into the ‘swing of it’.1 Following the 2016 Acas negotiations on junior doctors’ contracts, the Government promised to improve experiences for all junior doctors via the ‘Enhancing Junior Doctors’ Working Lives’ programme. As part of this, Health Education England committed to remove disadvantages for anyone choosing to take time out of training. What followed was a report of experiences and challenges faced, along with a pledge of £10m to facilitate making things better by way of funding Supported Return to Training (SuppoRTT) programmes.2 The Northern Deanery, led by Alice Hartley, urology trainee and former RCSEd Trainees’ Committee Member of Council, is already making headway by designing a tailored

FAMILY FORTUNES Hannah Knight is a general surgical trainee in the south west of England. Mum to three energetic boys, she is a seasoned returner WHAT HELPED YOU IN THE PROCESS OF RETURNING TO SURGICAL TRAINING? Having a good relationship with the team you are returning to is helpful, but not always possible (twice I had to start at a new Trust after maternity leave). It is a good idea to spend the odd day with the team you will be working with in a supernumerary role before you start back. In maternity leave, you are entitled to paid keeping-in-touch days and I would advise using these. A new Trust can set up an honorary contract and it is useful to get some theatre time for your confidence. It is appropriate to ask for supervision with operating initially. However, you will soon realise that you don’t lose your skills and it all comes back pretty quickly. Plenty of us have done it and you can usually find a sympathetic ear to reflect (rant) at if you need it, particularly if there’s a glass of wine involved.

TOO MUCH TOO SOON Rob Bethune, colorectal surgeon at the Royal Devon and Exeter Hospital, did a 12-month Chief Medical Officers Fellowship, taking time out of his higher surgical training. His work included the creation of several Quality Improvement programmes for trainees across the south west of England HOW DID YOU FIND THE RETURN TO TRAINING AFTER THE FELLOWSHIP ENDED? It was complicated and I found it really difficult. First, there was the adjustment back to clinical practice – this was not too bad. The hardest thing was carrying on the work I had done the year before. I was a full-time surgical registrar, but had loads of Quality Improvement (QI) projects carrying over, and started new ones based on my experience from the last year. I also had one day a week working at the Health Foundation (this had been agreed with the Head of the School of Surgery and my education supervisor). The conflict between what was expected of me as a registrar and doing the QI work created

significant problems. It was the only time in my training that I received some negative feedback from my supervisors – basically because I was not around as much as they thought I should be. I suspect less-than-full-time trainees experience similar problems. It got so bad that I had to go off work for two months and then when I came

back I dropped a whole load of the extra work I was doing, as well as the day a week for the Health Foundation.

WHAT ADVICE CAN YOU OFFER TO THOSE DOING THE SAME? Really, really think about what you are going to do when you return. I did not have a problem with the surgery, but it was a real problem juggling the extra stuff. I wonder if it would have been better if I had formally gone back to work part-time, which might have made it easier with my consultants. Seek advice from others who have been in a similar position. Perhaps meet with occupational health who could then keep an eye on you and protect you from yourself. rcsed.ac.uk | 39

FACULTY OF PRE-HOSPITAL CARE

Much to celebrate Caroline Leech reports on the Faculty of Pre-Hospital Care’s inaugural Scientific Conference

he Faculty of PreHospital Care (FPHC) Scientific Conference on 11 and 12 January was opened by RCSEd Vice-President Professor John Duncan OBE. He said: “For 21 years, the Faculty has championed pre-hospital care using a multiprofessional, inclusive approach. It has set a range of clinical standards, developed courses and qualifications, and brought pre-hospital emergency medicine to specialty status with the GMC.” These remarkable achievements were celebrated at the conference, which was a showcase of high-quality clinical care. The two-day lecture programme with 19 expert speakers incorporated the latest scientific evidence and expert opinion from all fields of pre-hospital emergency medicine, including medical and trauma topics, sports medicine, mountain medicine, rural and retrieval medicine, motorsport, military and civilian pre-hospital care. The event attracted more than 170 international delegates from multi-

40 | Surgeons’ News | June 2018

Caroline Leech is an Emergency Medicine and Pre-Hospital Emergency Medicine Consultant and organiser of the conference

Poster competition winners Thomas Shanahan and Emma-Jane Jones with Chairman Professor David Lockey (right)

disciplinary backgrounds, including paramedics, doctors, nurses, medical students, first responders, remote medics and other emergency services workers. Dr Gareth Clegg, Consultant in Emergency Medicine at Edinburgh Royal Infirmary, opened the first lecture with a presentation on the Sandpiper Wildcat project. Data revealed that people who live in rural Scotland were 32% less likely to survive out-of-hospital cardiac arrest (OOHCA) to hospital discharge and that having three or more ambulance crew at a cardiac arrest improves outcome. This led to a successful project delivering strategically located first responders with life support skills and an automated external defibrillator to cardiac arrest patients in rural Scotland, as well as a national strategy for OOHCA in Scotland with the aim of saving an additional 1,000 lives by 2020 with enhanced bystander CPR training, co-responding and a data linkage project. The importance of bystander CPR was re-emphasised to the audience in two other talks, one from Professor Sanjay Sharma about sudden cardiac death in athletes, where half the deaths are in patients

aged 18 years or younger. Screening is complex and expensive because there is a very low prevalence of positive findings in the broad population. The other was impact brain apnoea as a forgotten cause of cardiovascular collapse following head trauma. David Menzies, Consultant in Emergency Medicine from Dublin, described a case series of 12 patients from motorbike road racing who had apnoea after collision and none had severe structural brain injury at follow-up. Early bystander CPR was essential in these patients to allow survival. Other expert speakers included Professor Hans Morten Lossius, Secretary General of the Norwegian Air Ambulance, who presented on pre-hospital stroke thrombolysis in Norway; and Dr Matt Thomas, who asked delegates to consider the risks of hyperoxia, which can lead to lung atelectasis, oxidative cell damage and vasoconstriction to critical organs. We commonly give 15L or 100% oxygen in the prehospital environment when we should probably be titrating to SaO2 94–98%. Professor Richard Lyon updated the audience on management of crush injury following his experience with UK-International

SOUNDBITES To hear a taster of the conference, you can listen to the popular podcasting team ‘The Resus Room’, who interviewed several of the speakers and published a summary podcast at theresusroom.co.uk/fphcscientific-conference. Tweets from the conference can be viewed via the hashtag #FPHC18, which had five million impressions on Twitter. Anyone interested in pre-hospital care is invited to attend the next FPHC event: the BASICS and FPHC Joint Annual Conference to be held in Edinburgh on 16 and 17 November 2018. Further details can be found on the website fphc.rcsed. ac.uk or on Twitter via @FPHCEd.

Search and Rescue (UK-ISAR) and building collapse from earthquakes. Tourniquet application is no longer recommended for crush injury in the absence of major haemorrhage. Management concentrates on early resuscitation using crystalloids, administration of calcium for ECG abnormalities and consideration of sodium bicarbonate. Dr Stacey Webster presented military work demonstrating that half of patients who had received pre-hospital blood products were hypocalcaemic on arrival and an ionized calcium level of <1.0 mmol/L is associated with increased mortality. The evidence suggests we should be giving calcium chloride after only two units of blood to maintain calcium levels. Scientists from DSTL Porton Down presented research that may influence updates in resuscitation. In animal models of hypovolaemic cardiac arrest, closed chestcompressions were associated with

Delegates enjoy a drinks reception

Data revealed that having three or more ambulance crew at a cardiac arrest improves outcome

worse outcome than fluid-only resuscitation. Blood alone appeared to have better outcomes than crystalloid alone. The difficulty in the pre-hospital environment is the diagnosis of hypovolaemia in traumatic arrest and differentials such as hypoxic arrest or brainimpact apnoea, which might benefit from chest compressions. The FPHC runs regular consensus days on a variety of topics. This includes a systematic review of the literature, expert opinion if no evidence exists and then discussion with all relevant stakeholder groups and organisations. At the conference, the information was presented for the consensus meetings on obstetric trauma, burns, external haemorrhage and spinalimmobilisation documents. The audience were interested to hear the recommendations that tourniquets can be applied over two bones (e.g. tibia/fibula) for catastrophic haemorrhage and not just a single bone (e.g. femur). The draft new recommendations on spinal immobilisation incorporate principles of ‘self extrication as able’, ‘self support’, ‘careful handling and movement mitigation’, and ‘transport in a position of comfort

plus support if required’ rather than strict definitions on the use of immobilisation equipment. On day one, 22 entries in the FPHC Poster Competition were displayed. Medical students Thomas Shanahan and Emma-Jane Jones won first prize for their work on ‘Does longer transport time influence mortality and functional status at discharge in trauma patients?’. The runner-up poster was Dr James Raitt’s ‘Using key performance indicators to drive quality improvement in pre-hospital emergency anaesthesia: the Thames Valley Air Ambulance approach’. The conference coincided with the 21st anniversary of the FPHC. To celebrate, there was a drinks reception in the Playfair Hall. Delegates networked with their international colleagues and enjoyed live music from String Quartet Glasgow. Closing the conference, Chairman of the FPHC Professor David Lockey noted that the event had attracted a young and enthusiastic group of delegates and high-quality speakers. He believes that making this conference a regular event will do a great deal to promote multiprofessional pre-hospital care and a bright future for the Faculty. rcsed.ac.uk | 41

SPECIALTY: UPPER GASTROINTESTINAL

Unique UGI challenges

pper gastrointestinal (UGI) surgery is an exciting subspecialty full of diversity and challenges in Hong Kong. Subspecialty services are primarily provided by the 17 public hospitals run by the Hospital Authority. The two university-affiliated hospitals, 42 | Surgeonsâ&#x20AC;&#x2122; News | June 2018

Peptic ulcer, one of the many conditions treated by surgeons in Hong Kong

the Chinese University of Hong Kong and Hong Kong University, provide tertiary services for more complex conditions. The uniqueness of Hong Kong lies in its diversity: it is where East meets West. This is reflected in the wide spectrum of disease we see, from oesophageal and stomach cancers to obesity. Most units

need to deal with emergencies and elective UGI conditions as well. According to the Surgical Outcomes Monitoring and Improvement Program (SOMIP), there were 432 patients with perforated peptic ulcers, 463 patients with gastric cancers, 110 patients with oesophageal cancers and 164 obese patients operated on between July 2016 and June

SHUTTERSTOCK

Professor Anthony Teoh and colleagues report on the scope of services and training in the UGI subspecialty in Hong Kong

2017 in the hospitals under the Hospital Authority. In terms of emergency conditions, perforated peptic ulcers are prevalent in the city and are generally repaired laparoscopically. Boerhaave syndrome is occasionally encountered and the condition is increasingly managed with nonsurgical methods. Bleeding ulcers are seen on a daily basis and most of the patients are treated by endoscopic haemostasis by surgeons or gastroenterologists. Only 35 patients required emergency surgery for haemostasis of uncontrolled bleeders in 2017. As expected, this subgroup of patients requiring surgery is highly biased because they are often old and frail with multiple pre-morbid conditions and thus the operative mortality rate is often high (up to 50%). As for elective surgeries, oncological surgery for the stomach and oesophagus used to be the main caseload for the subspecialty. Adenocarcinomas accounted for the majority of gastric cancers requiring surgery and 72.6% of these were distal tumours. Some 55.3% of the operations were performed laparoscopically, with the remaining procedures done by open or robotic approaches. The mortality rate was 0.4% and morbidity rate was 23.3%. Squamous cell carcinomas accounted for almost 90% of oesophageal cancers and 73.6% involved video-assisted thoracoscopic mobilisation of the thoracic oesophagus. The mortality rate was 0.9% and the morbidity rate was 57.3%. In recent years, more units have started development of bariatric surgery and we have seen a rise in the numbers of operations performed. In 2009, 15 patients received laparoscopic sleeve gastrectomy in one unit in Hong Kong and the numbers increased to 163 patients last year, with nine centres performing these operations. Of the operations, 82.2% were laparoscopic sleeve gastrectomies and 14.7% were laparoscopic gastric bypasses. For other benign conditions, such as gastro-oesophageal reflux and

Robotic gastrectomy for gastric cancer in Hong Kong

Anthony Yuen Bun Teoh and his colleagues, Shannon Melissa Chan, Enders Kwok Wai Ng and Paul Bo San Lai work at the Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR

hiatal hernias, surgery is performed less commonly. Another unique aspect of UGI surgery in Hong Kong is that surgeons play a key part in providing UGI endoscopic services. Advanced endoscopic procedures are incorporated into different stages of workflow, from diagnosis and treatment to management of complications. For cancer management, magnifying endoscopy is increasingly practised for screening for UGI neoplasia. Endoscopic ultrasound is performed for the staging of stomach and oesophageal cancers in some centres. Advanced mucosal resectional techniques, such as endoscopic mucosal resection or endoscopic submucosal dissection, are increasingly performed by surgeons for early cancers. In a review published in the Hong Kong Medical Journal, endoscopic resections of superficial UGI lesions were performed for 187 lesions in 168 patients between January 2010 and June 2013. Endoscopic mucosal resection was performed in 34 (18.2%) lesions and endoscopic submucosal dissection in 153 (81.8%) lesions. The 30-day morbidity rate was 14.4%. Two-

year overall survival and diseasespecific survival was 90.6% and 100%, respectively, for superficial UGI neoplastic lesions. techniques, such as peroral endoscopic myotomy, endoscopic retrograde cholangiopancreatography and endosonography-guided drainage procedures, are also being practised in some centres.

Subspecialty training Most surgical trainees have the opportunity to do a six-month rotation in UGI surgery during their higher surgical training in general surgery. During the rotation, they have general exposure to various aspects of UGI surgery, depending on the unit they are attached to. Subspecialty training begins after Fellowship examination. Structured training in all aspects of UGI surgery are provided by accredited units in Hong Kong to young Fellows interested in the subspecialty. It is a two-year programme and most specialists also arrange a three- to four-month attachment to renowned UGI units worldwide to widen their exposure and enhance the international exchange of ideas and collaborative research.

A unique aspect of UGI surgery in Hong Kong is that surgeons play a key part in providing UGI endoscopic services from performance of mucosal resections to endosonography-guided drainages rcsed.ac.uk | 43

TRAINEES AND STUDENTS

Let fairness take flight Adopting the aviation industry’s no-blame model could help our profession learn from mistakes

he General Medical Council (GMC) versus Dr Hadiza Bawa-Garba case (2018) has generated huge concern among doctors worldwide. The High Court convicted Dr Hadiza Bawa-Garba of gross negligence manslaughter for the avoidable death of Jack Adcock, aged six, who died from septic shock in the context of multiple systemic failings.1 This involved a scenario all too familiar to doctors working in the NHS: filling ever-present rota gaps in addition to your normal job; inexperienced junior colleagues; hospital IT frailties; and, in this case, a lack of immediate senior support and unclear communication regarding the patient’s care between members of staff. These factors collectively resulted in the saddest of outcomes: a child’s life lost. The blame levelled at an individual in 44 | Surgeons’ News | June 2018

By G Hogg, S Hafiz, A Williams and H Mohan on behalf of ASiT Council References available online

the context of multiple systems errors has struck fear into the heart of the medical profession. There is a widespread murmur that “it could have been me”. The case has caused huge anxiety among trainees, exposing their potential vulnerabilities during times of difficulty, such as returning from maternity or other extended leave without adequate support. This case demonstrates long-standing concerns about the potential use of e-portfolios and trainee reflections in litigation and GMC hearings. Although the Medical Protection Society issued a statement reporting that reflections were not directly used in this case,2 it is well known that other cases have used trainee reflections against the trainee and there is a suggestion that in this case the reflective portfolio was used indirectly. The GMC encourages reflective writing engagement following

adverse events to help with personal development and critical thinking. The Bawa-Garba case has highlighted that there is no formal protection of this important patientsafety tool.3 While the Chair of the GMC, Professor Terence Stephenson, has stated that the GMC will not ask doctors to provide evidence of reflection in their investigations,4 there is no formal guarantee of this. Reflective practice has become such a contentious issue that it is our view, and one echoed by Dr Chaand Nagpaul, Chair of the British Medical Association,5 that it is now even more likely to be used by prosecution lawyers to construe an incriminating case and portray a confession of guilt. Reflection allows doctors to analyse a clinical event and demonstrate insight into their clinical failings or successes. It provides trainees with the opportunity to self-critique and strive to improve their practice and, more importantly, learn from error to improve their patients’ safety. Fear of recrimination from written reflections will limit the potential learning opportunities that the practice is meant to provide. Following the High Court hearing for Dr Bawa-Garba, a poll of more than 900 doctors on doctors.net.uk found 92% of respondents were less likely to be open about reflecting on mistakes made during their practice.1 Failure to protect the use of reflective practice, and doctors who are engaging in a system to learn

from their mistakes, places doctors and patients at risk. ASiT continues to voice this concern to the Academy of Medical Royal Colleges and the GMC6 because it is clear there is a paucity of sufficient practical advice for doctors about the role of e-portfolio reflection to allow the use of this learning tool with any confidence. The numbers of doctors being prosecuted for gross negligence manslaughter is rising, which is terrifying for clinicians. Knockon effects include making doctors practise more defensively, so they feel exposed and vulnerable while they try to practise safe medicine in overtly under-resourced front-line environments. Jeremy Hunt, and his senior clinical adviser, Professor Sir Norman Williams, former President of the Royal College of Surgeons of England, are leading a rapid review to provide clarity into gross negligence manslaughter in healthcare and ordinary basic human error. This is aimed at helping medical professionals understand where they stand with respect to criminal liability and professional misconduct.3 There is precedent outside the jurisdiction of the UK for finding

The aviation industry encourages transparency so that mistakes can be recognised and learned from

Fear of recrimination from written reflections will limit the potential learning opportunities the practice is meant to provide

that an individual cannot be judged based on one adverse event without consideration of their practice as a whole and the environment in which they were working. The judgement in the case of Professor Martin Corbally versus the Irish Medical Council (IMC) found that the IMC had failed to follow fair procedures, responding disproportionately to the complaint made against the consultant paediatric surgeon. The ruling stated that the surgeon should be judged not on the outcome of one case in which there were systemic failings that fell below professional standards, but in the context of his whole career7 and the wider situation in which the serious error occurred. This is in contrast to the finding in the Bawa-Garba case. If reflection were used properly, trainees would be able to highlight issues with the â&#x20AC;&#x2DC;wider situationâ&#x20AC;&#x2122; and use them to drive change. Parallels are frequently drawn between surgery and the aviation profession. Every major aviation incident is followed by a full root-cause analysis into system failures with the aim of providing recommendations for prevention in the future. The aviation industry operates in a no-blame culture, whereas doctors are submerged in a blame culture, jeopardising learning opportunities, with extensive years of litigation.8,9 Openness and transparency are now protected in aviation, with crew encouraged to

report their mistakes so that they and others can learn from them. It is recognised that reflection on major aviation disasters introduces bias. Investigators retrospectively judge incidents where, with the passage of time, facts are now far simpler than perceived by the pilot at the time. Hindsight bias results in appointing too much mental and physical ability to the pilots to manage at the time of the emergency than is humanly possible.8,9 The GMC has highlighted that its future work will involve in-depth exploration of how gross negligence manslaughter is applied to medical practice and to reflection. Ongoing systemic failures and pressures that healthcare professionals are working under can no longer be ignored. Where there has often been an expectation for the on-call clinician to report unsafe working conditions, there needs to be a shared responsibility among all healthcare staff to raise and report concerns. Further guidance on reflections and the formal protection of reflection should aim to support doctors to be open about their mistakes and resist the general inclination not to engage in reflection with the hope that the medical profession can foster a truly no-blame culture following in the footsteps of the aviation industry. Only by protecting our ability to learn from error will we enshrine patient safety and improve practice. rcsed.ac.uk | 45

On course in Hong Kong Charing Chong looks at the training opportunities offered by the College of Surgeons of Hong Kong

he College of Surgeons of Hong Kong was incorporated in June 1989 with the aim of providing continuing medical education and conducting postgraduate training, examination and accreditation for surgeons in Hong Kong. The Collegeâ&#x20AC;&#x2122;s surgical pathway is shown in the diagram on the next page. 46 | Surgeonsâ&#x20AC;&#x2122; News | June 2018

Basic surgical training Basic surgical training in Hong Kong takes at least two years after internship. In this period, basic surgical trainees (BSTs) must register with one of the four Surgical Colleges of Hong Kong and the Hong Kong Intercollegiate Board of Surgical Colleges (HKICBSC). The latter comprises the College of Surgeons of Hong Kong (CSHK), Hong Kong College

A Basic Surgical Skills course

of Emergency Medicine, Hong Kong College of Orthopaedic Surgeons and Hong Kong College of Otorhinolaryngologists. BSTs must complete a two-year rotation, which consists of one year of core training in general and emergency surgery, and another year in two or three specialties or subspecialties or another year of training in a surgical specialty related to their intended higher training (e.g. neuro, cardiothoracic, paediatric, urology, plastic, otorhinolaryngology or orthopaedic surgery). The declaration of specialty interest is entirely on a voluntary basis. Trainees who do not declare any interest will be regarded as declaring in general surgery. This is to facilitate and maximise the training opportunities for trainees, instead of imposing restrictions. There are continuous competencies assessments throughout basic training. These include the Mini-Clinical Evaluation Exercise (Mini-CEX), Direct Observation of Procedural Skills in Surgery (Surgical DOPS) and Direct Observation of Procedural Skills in Endoscopy (Endoscopic DOPS). Trainees are assessed by an associate consultant or above of the same or other hospital.

Higher surgical training On completion of their basic training, trainees must fulfil the following requirements for entry to higher training: 1. Complete the basic rotational training with satisfactory assessments and log-book record 2. All modular training (if any) as provided by each specialty during rotation 3. Fulfil the training points of individual Colleges for each sixmonth rotation 4. Complete all competency assessment forms by senior trainers 5. Complete all mandatory courses for BSTs 6. Pass Part 1 and Part 2 of the HKICBSC examination 7. Pass Part 3 of the HKICBSC examination and any specialty part.

TRAINEES AND STUDENTS

Trainees in higher surgical training follow a structured programme of training and assessment laid down by the CSHK. There are six specialties in surgery and all have the same basic surgical training. The CSHK recognises these specialties to be so distinct from each other that independent training programmes are recommended. These specialties are: l Cardiothoracic surgery (training duration: five years) l General surgery (training duration: four years) l Neurosurgery (training duration: five years) l Paediatric surgery (training duration: four years) l Plastic surgery (training duration: four years) l Urology (training duration: four years). On completion of higher surgical training and passing the Joint Specialty Fellowship Examination, higher surgical trainees (HSTS) are eligible to apply for Fellowship of the CSHK and the Hong Kong Academy of Medicine.

Training courses The CSHK has also organised the following training courses for trainees at different levels: l Basic Surgical Skills This two-day course is jointly organised by the Hospital Authority in Hong Kong, CSHK and RCSEd. It is a mandatory course for BSTs and is designed to instil core surgical skills at the very start of a surgeon’s training. l Clinical Core Competence This five-module mandatory course for BSTs covers both acute surgical and orthopaedic conditions, and perioperative care. l Critical Care This two-day course for HSTS is jointly organised by the RCSEd and CSHK. It provides instruction in the practical management of critically ill surgical patients. l Non-Technical Skills for Surgeons (NOTSS) and Safer Operative Surgery (SOS) NOTSS aims to enhance the standard and quality of training and assessment in non-technical

The surgical pathway of the College of Surgeons of Hong Kong

Intern One year at public hospital

BST training Two years

Pass the MHKICBSC Part 1, 2 & 3 Exam

Eligible to apply for Membership of the Colleges and HST in: l GS l NS l CTS l Plastic surg l Paed surg l Urol

* A&E trainees must register as a HKICBSC’s BST if they wish to have their A&E training recognised by HKICBSC

Charing Chong Assistant Professor in the Department of Surgery at the Chinese University of Hong Kong

skills. SOS aims to enhance the standard and quality of surgery for high-performing teams.

Examinations To identify those surgeons in training who have a broad knowledge of surgery in general or in different specialties, the CSHK has established and organised a variety of examinations. There are currently two levels of examinations. The Hong Kong Intercollegiate Board of Surgical Colleges Membership (MHKICBSC) Examination The CSHK established its own membership examination in 2008, which is now internationally recognised. Organised by the HKICBSC, the exam is in three parts: l Part 1: Applied Basic Sciences Multiple Choice question paper l Part 2: Clinical Problem Solving Extended Matching question paper l Part 3: Objective Structured Clinical Examination (OSCE). Fellowship Examination (Exit Exam) The CSHK is conducting the Joint Specialty Fellowship Examination (Exit Exam) with the RCSEd in cardiothoracic surgery, general surgery, neurosurgery, paediatric surgery and urology.

The training curriculum of BSTs as well as HSTs of all specialties will be reviewed regularly

The Conjoint Examination with the RCSEd in plastic surgery will be conducted soon. HSTs in general surgery, paediatric surgery, plastic surgery and urology are required to do a four-year training programme. However, they can take the Fellowship Examination in their respective specialties after three-anda-half years of higher surgical training. HSTs in neurosurgery and cardiothoracic surgery are required to do a five-year training programme, but they can make their first attempt at the Fellowship Examination after four years of higher surgical training. Subject to the specialties’ own examination format, the Fellowship Examination consists of a viva voce, clinical and written exams. On successful completion of all requirements of the training programme and the Fellowship Examination, the trainees will be elected for dual Fellowships comprising the Fellowship of the CSHK and the Fellowship of the RCSEd (except plastic surgery). They would also be eligible to be nominated for the Fellowship of the Hong Kong Academy of Medicine. It was agreed that the training curriculum of BSTs as well as HSTs of all specialties should be reviewed regularly. A task force to review the training curriculum was formed under CSHK with representatives from all specialty boards. The aim is to deliver a holistic training programme, and to ensure a fair, valid and reliable assessment of trainees. rcsed.ac.uk | 47

TRAINEES AND STUDENTS

/ COMPETITION

Winners at Audit Symposium

he RCSEd 17th Annual Audit Symposium was held on Wednesday 21 March at the College’s Quincentenary Conference Centre. This symposium gives trainees at all levels the opportunity to attend and present their audit and QI work, with the College inviting trainees to submit their abstracts for presentation at this event. The prestigious Surgeons in Training Medal session winner was Rosanna Wright with her abstract ‘Cost improvements in nasendoscopy use in a large NHS Trust’. The poster winner was Andrew Hannah with his abstract ‘A complete audit cycle of the effectiveness of an Enhanced Recovery Programme (ERP) in primary lower limb arthroplasty’.

Surgeons in Training Medal winner Rosanna Wright (left) receives her award from RCSEd Vice-President Professor John Duncan OBE

The other winners from the session included: l General surgery: Robert Young. ‘A waiting game: patient waiting times in emergency surgery clinics’. l Trauma and orthopaedic: Alham Oureshi. ‘Warfarin reversal in neck of femur fracture patients’. l Specialties and common interest: Eleanor Zimmermann. ‘Radiation safety compliance: a closed loop audit of thyroid shield usage in urology’. l General surgery: Kevin McGarry. ‘Induction teaching increases subjective and objective suturing

ability and wound management competence – a Trust-wide quality improvement project’. l Trauma and orthopaedic: Karen Anne Vejsberg. ‘Preoperative fasting in elective orthopaedic surgery’. l Specialties and common interest: Grace Kennedy. ‘Introducing extended venous thromboembolism (VTE) prophylaxis for high-risk vascular patients undergoing lowerlimb amputation – a quality improvement project’. College Vice-President Professor John Duncan presented the awards.

/ TRAINING

Cardiothoracic placements The College has developed a number of cardiothoracic surgery placements for undergraduates. Applications were received from 19 students across the UK, and placements have been awarded to six of them. Cindy Rodrigues Cleto (fourth year, Liverpool University) is going to Papworth Hospital and Anthony Wijaya (third year, Cardiff University) to Bristol Royal Infirmary. James Cook Hospital Middlesborough is taking Akshaya Rajangam (third year, King’s College London), Devan Limbachia (fifth year, University of Birmingham),

48 | Surgeons’ News | June 2018

Omar Zibdeh (fifth, University of Plymouth, intercollating at Newcastle University) and Saumil Shah (fourth year, Hull York Medical School). Akshaya Rajangam said: “I am excited to be able to explore this specialty further. I hope to gain a better understanding of the specialty as well as a better insight into the patient care and research developments within the field.”

Future placements will be announced on the College’s website, rcsed.ac.uk, in autumn/winter 2018

/ EVENT

ASiT Conference hailed a success

he Association of Surgeons in Training (ASiT) Conference was held on 6–8 April 2018 at the Edinburgh International Conference Centre. Promoting the necessity for training to advance the profession, a wealth of abstracts were presented at the conference; they were also considered for publication in the International Journal of Surgery. The RCSEd held a prize draw on the day. The winner, College Affiliate and RCSEd Northern Ireland Advocacy Network Member Martin King (FY2), explained the importance of the conference and RCSEd’s involvement: “The NHS is one of the most important institutions we have in our country. While it faces huge pressures, opportunities for training should not be lost. The future of the NHS and surgical care will require high-quality trainees and transformation of services should encourage trainees

The Edinburgh International Conference Centre

to avail of experiences where and when they present. Ultimately, trainees want to be the best they can be to offer world-class care to our patients. I am grateful to the RCSEd for awarding me winner of its competition during ASiT 2018.” RCSEd Trainees’ Committee Member Katie Hurst highlighted the benefits of the conference for the wider College: “There were some fantastic speakers, with topics ranging from the IST pilot to trauma fellowships, the trials and tribulations of training to nurturing excellence. It was also great to have so many questions regarding our MRCS lecture series, the College’s ever-growing Outreach team in Birmingham, multiple skills workshops and courses, and the College’s active Trainees’ Committee. We hope to see many of those in attendance as Affiliates or Members of the RCSEd in the future.” ASiT’s next conference will take place in Belfast on 22–24 March 2019.

/ COMPETITION

Virti enterpriselearning system takes first prize On 22 March, the College held the Surgical Innovation Competition as part of its Triennial Conference. Five trainees were selected to present their ideas for innovative improvements in surgery, surgical education, training and technology. Alex Young, a trauma and orthopaedic surgeon by training, won the competition with his submission ‘Virti: Immersive technology to assess decision-making under pressure and distribute provider content’. Young said: “It was a surprise and a privilege to win. Our company has won a few awards but this one was extra special for me as I sat my MRCS at the College and also hold a Masters in Surgical Science through the Edinburgh Surgical Sciences Qualification. The College is at the forefront of innovation. We are excited to see what opportunities arise from the award as we look to improve patient safety and help scale realistic training opportunities through the Virti platform.” Competition convenor and RCSEd Council Member Roger Currie said: “The competition was a groundbreaking initiative for the College and we were impressed by the number and quality of the applications submitted for presentation. The quality of the final was very high with a well-deserved winner, Alex Young, who we look forward to working with.” rcsed.ac.uk | 49

DATES FOR YOUR DIARY The latest surgical and dental events, seminars and courses JULY 5 Non-Technical Skills for Surgeons (Portsmouth) 8–9 Basic Surgical Skills (Dervan, India) 10 Preparation for the Diploma in Implant Dentistry (Manchester) 13–14 Basic Surgical Skills (Dervan, India) 14–15 Basic Surgical Skills (Manchester)

AUGUST 1–3 Trans-anal Endoscopic Microsurgery Course SEPTEMBER 2–4 Aberdeen MRCS Mock OSCE 4–5 Basic Surgical Skills 6–7 Anatomy for MRCS OSCE 6–7 Basic Surgical Skills (Hong Kong) 8–9 The Edinburgh MRCS OSCE Preparation Course 10 Basic Microsurgical Skills

11–12 Basic Surgical Skills (Hong Kong) 13–14 Basic Surgical Skills (Hong Kong) 14–15 Basic Surgical Skills (Wirral) 15–16 The Edinburgh MRCS Preparation Course (Manchester) 20–21 Basic Surgical Skills (Hong Kong) 20–21 Care of the Critically Ill Surgical Patient 24 Basic Surgical Skills (Eindhoven, Netherlands)

24–25 Advanced Techniques in Endoscopic Nasal and Sinus Surgery 26–27 Major Trauma Emergency Orthopaedic Surgery Programme (MaTEOS) 27–28 Basic Surgical Skills (Hong Kong) 27–28 Training the Trainers (Birmingham) 28 Future Surgeons: Key Skills

For further information, visit rcsed.ac.uk/events-courses, email education@rcsed.ac.uk or telephone +44 (0)131 527 1600. Unless otherwise indicated, events are in Edinburgh

DENTAL

Fraser McDonald examines the effects of a project in Asia on the region’s oral health

Volunteers cut the caries count

t is a great privilege to be allowed to compare provision of primary dental care in Asia with those services in the United Kingdom (politicians note the use of the phrase United Kingdom) from a clinician’s perspective. Australia has a long-standing relationship with Vietnam and, as a consequence, Australians provide many altruistic acts of support to the Vietnamese people. In one project, the Australia Vietnam Volunteers Resource Group has linked up with an orphanage and a Centre for Social Protection in the Long Hai region, east of Ho Chi Minh City. In the short time we, as a team of four, spent with the children and staff of both organisations, it became clear how well organised both centres are and how they support those who are potentially disadvantaged in society. The goal: to have mature individuals capable of being independent within society. The orphanage, in particular, cared for the children to a very high standard. Our input as a dental team in 2018 was a significantly different experience, I am sure, than that of the initial team. Previous ‘one stop’ visits had begun to raise awareness of the need for sound dental health. What became apparent during the visit, and in discussion with our Vietnamese/English speaking students, was that any source of calories for the young patients were consumed to keep them alive. Even if this consisted of high-energy condensed milk, with its high levels of refined sugar, it was essential for the children’s survival. This had obvious effects on primary dentition, but it was better that the children lived than starved to death or succumbed to infections. Once they had reached a certain age, the children moved to a traditional Vietnamese diet, which is very healthy and nutritious, and without refined sugars. This seemed to stop carious attack dead in its tracks and, although the teeth were very discoloured, infection and soft decay were minimal. We reviewed about 100 children, on a purely observational basis, some with challenging blood-borne infections, and it became apparent that healthy

Once they had reached a certain age, the children moved to a traditional Vietnamese diet, which is very healthy and nutritious, and without refined sugars. This seemed to stop carious attack dead in its tracks teeth came from the correct use of a toothbrush for an appropriate time interval and supported by a sound, noncariogenic diet. Most notable was the development of an acceptable orthodontic result when badly stained primary teeth were not removed in a ‘textbook’ elimination of diseased tissue. Equally, fluoride-containing toothpastes for different stages of development (supported by generous donations from GSK) also helped to ensure relatively sound dentition. The principle of the carrot rather than the stick seemed to work, with the children and the carers motivated by rewards. Certainly, this link between Australia and Vietnam has given underprivileged children a good start in life and those involved in the programme should be congratulated. So why is it that in the UK we still see so many children who need teeth extracted under general anaesthesia when we’ve known about caries, diet and oral hygiene for decades? Does the policy for dental healthcare have the correct balance in the UK? We live in a ‘First World’ country. Or do we? I couldn’t possibly comment. Professor Fraser McDonald Dean, Faculty of Dental Surgery

www.rcsed.ac.uk rcsed.ac.uk || 51

DENTAL

Challenge champion Newcastle University student Joe Reid is crowned Dental Skills Competition winner

un by the College and Dentsply Sirona, the Dental Skills Competition to discover the UK’s best undergraduate dentist reached its climax at the Grand Final in Edinburgh on Thursday 8 March 2018. Newcastle University student Joe Reid won the competition after a punishing series of tests that were designed to push the finalists’ skills to the maximum. Reid said: “There are a lot of talented people here so I’m quite surprised to have won.” He added: “It was a novel experience. You don’t really compete with each other at dental school and you don’t see the quality of other people’s work. There were also a lot of different challenges today that we don’t normally come across. “The best part of the competition was spending time with people from other dental schools who you wouldn’t normally meet.” The finalists from the first round of 18 UK and Irish dental schools, in which more than 400 final-year students took part, had to complete a series of challenges devised to test a wide range of clinical skills in dentistry. Brian Nattress, Convener of the Dental Skills Competition and member of the College’s Dental Council, said: “This year’s dental skills contest was expanded to include more dental schools from the UK and Ireland. The added competition captured every student’s enthusiasm and drive by placing them in a

52 | Surgeons’ News | June 2018

Professor Fraser McDonald (right) congratulates Joe Reid

competitive situation against more of the best final-year students. “The final was extremely exciting, but also very challenging. Not only did the students have to show strong skills, they had to work in a high-pressure environment. I felt honoured to see the students in action and witness the great sense of camaraderie as they competed alongside colleagues from other dental schools in the Grand Final.”

Second place was awarded to Rowan Glossop from the University of Central Lancashire, with third place going to Ammar Zaki from the University of Liverpool. Gerry Campbell, Vice-President and General Manager UK, Dentsply Sirona, said: “We are honoured and delighted to continue our partnership with the RCSEd to celebrate the talented dental clinicians of tomorrow. “This competition continues to

The competition is designed to showcase the great dental talent of the UK and Ireland’s undergraduate dentists and develop the best skills

bring out the best in students and this year we added key elements of the latest techniques in digital dentistry. Through our continued commitment to providing innovative solutions for better, faster, safer dentistry and our expansive education programme, it is our desire and privilege to support dental professionals throughout their careers.” The competition is designed to showcase the great dental talent of the UK and Ireland’s undergraduate dentists and to develop the very best skills and support for future dental surgeons. Professor Fraser McDonald, Dean of the Dental Faculty at the RCSEd, said: “Hearty congratulations to our winner, Joe Reid, and everyone who took part in this year’s competition. One of the key aims of the Dental Faculty is to set and quality-assure the highest standards for the dental profession and recognise that with the award of Membership and Fellowship.” He added: “The Dental Skills Competition

Above: Finalists from the UK and Ireland gather in Edinburgh Below: The three winners, left to right, third-placed Ammar Zaki, winner Joe Reid and second-placed Rowan Glossop

has proved to be an exciting, rewarding and challenging way of ensuring that those standards are challenged and updated annually, with students benefiting from competing against each other and networking between themselves. “As students, it is hoped they will learn the value of networks, if only to see problems are challenges that are common to all. The RCSEd is keen to complement the basic dental skills delivered at the undergraduate level in the UK and Ireland, and to help develop self-improvement in post-graduation dentistry.”

rcsed.ac.uk | 53

DENTAL

REGIONAL DENTAL ADVISERS IN YOUR AREA The Faculty of Dental Surgery’s support and advice network throughout the UK and Ireland SCOTLAND

NORTH EAST OF SCOTLAND 1 Martin Donachie, Aberdeen Royal Infirmary

TAYSIDE 2 Pauline Maillou, Dundee Dental School 2

WEST OF SCOTLAND 3 Kurt Busuttil-Naudi, Glasgow Dental Hospital and School

ENGLAND

EAST OF ENGLAND 4 Simon Wardle, James Paget University Hospital, Great Yarmouth KENT, SURREY & SUSSEX 5 Lindsay Winchester, Queen Victoria Hospital, East Grinstead

NORTH WEST OF ENGLAND 6 Callum Youngson, School of Dentistry, Liverpool

NORTH LONDON 7 Phil Taylor, Barts and the London School of Medicine and Dentistry, London

NORTH EAST LONDON 8 Nick Lewis, UCL Eastman Dental Institute, London NORTH WEST LONDON 9 Sumithra Hewage, Northwick Park Hospital, Harrow 10 Kashif Hafeez, City of London Dental School, BPP University

4 11 10 7 9 8

OXFORD 11 Mary McKnight, John Radcliffe Hospital, Oxford SOUTH YORKSHIRE/EAST MIDLANDS 12 Philip Benson, Charles Clifford Dental Hospital, Sheffield

13 14

SOUTH WEST OF ENGLAND 13 Pamela Ellis, Dorset County Hospital, Dorset PENINSULA 14 Ewen McColl, Peninsula Dental School, Plymouth YORKSHIRE 15 Brian Nattress, Leeds Dental Institute, Leeds

NORTHERN IRELAND

16 Gerald McKenna, Queen’s University Belfast

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RDA VACANCIES

Dundee Liverpool London Manchester North West of England Republic of Ireland Wales

COLLEGE INFORMATION

All the latest grants, Fellowships and bursaries from the RCSEd

AWARDS & GRANTS Syme Medal

James Syme (1799–1870) was a leading surgeon of his day and an enthusiastic teacher and surgical innovator. He was also the mentor of Joseph Lister. The Syme Medal is a prestigious mark of excellence awarded by the College to a Fellow or Member of the College in good standing on the basis of a recently submitted thesis (MD or PhD), published body of research or educational development. Research should have been published in highquality, peer-reviewed journals. Consideration will be given to the impact of work on future research or clinical practice. The Medal is to be awarded to Surgeons in Training or recently appointed consultants, and is distinct from the King James IV Professorship. With their written application, candidates must submit a CV (no more than two pages) along with a discourse of up to 1,500 words (excluding references, prior publications and papers in press) summarising their recent research or educational development. The essay must refer to and contain findings emanating from the candidate’s own work. A list of prior publications and papers currently

56 | Surgeons’ News | June 2018

in press should be included. The names of any supervisors and collaborative workers must be acknowledged, as well as the name of the institution(s) where the work was carried out. Appointments to the Syme Medal are made on the understanding that those elected submit a manuscript for publication in the Journal of the Royal College of Surgeons of Edinburgh and Ireland. Depending on the nature of the work and the topic, the successful

candidate may be invited to present a lecture at the College. Closing date for applications is Wednesday 6 June 2018.

Small Research Grants (up to £10,000)

The College’s Research Strategy highlights the following areas of research as priorities for the College to support:

FOR MORE INFORMATION ABOUT THE COLLEGE’S AWARDS AND GRANTS, CONTACT: Cathy McCartney, Research and Grants Coordinator Development Office The Royal College of Surgeons of Edinburgh Nicolson Street, Edinburgh EH8 9DW Tel: +44 (0)131 527 1618 Email: c.mccartney@rcsed.ac.uk For further information, visit rcsed.ac.uk/professional-support-

development-resources/grants-jobsand-placements/research-travel-andaward-opportunities The RCSEd collects personal data from you during the application process for awards and grants. We will not share this information with any third parties, and your data will be used solely for processing and administrating applications.

Surgical/dental translational research Surgical/dental health services research Research into surgical/dental aspects of patient safety, simulation and nonoperative technical skills Cancer research of demonstrable direct clinical relevance to the management of solid tumours. Applications are invited from surgical trainees and recently appointed consultants who are Fellows/Members of the College in good standing. Grants are awarded for pump priming projects for a period of one year only. Please note that requests for running costs to support established projects will be less favourably reviewed than those for pilot work that has the potential to facilitate applications for more substantial funding in the future. Research project submissions should satisfy one or more of the College’s four priority areas for research, as listed above. The application should also include a well-defined exit strategy (that is, how the project will be taken forward). Closing date for applications is Wednesday 6 June 2018.

King James IV Professorships

Applications are invited from practitioners of surgery or dental surgery who have made a significant contribution to the clinical and/or scientific basis of surgery. The courtesy title of Professor will be accorded to the individuals for the duration of the College year in which their lectures are delivered. Applicants must be Fellows/Members of the College in good standing. Closing date for applications is Wednesday 6 June 2018.

Travelling Fellowships

l The Cutner Travelling Fellowship in

Orthopaedics

l Sir James Fraser Travelling Fellowship

in General Surgery l Alban Barros D’Sa Memorial Travelling Fellowship in General Surgery Closing date for applications is Wednesday 6 June 2018.

Faculty of Dental Surgery Grants for Education

The Faculty of Dental Surgery of the RCSEd supports educational endeavours for individuals who are Affiliates, Members and Fellows of the Dental Faculty and/or the Faculty of Dental

Trainers. Grants (up to £3,000) will be available to defray expenses for those undertaking an appropriate educational qualification. Closing date for applications is Wednesday 6 June 2018.

Joint RCSEd/SOMS/ Shanghai Head & Neck Fellowship 2018

Applications are invited from Members/ Fellows (MRCS/FRCS) of the RCSEd and the Scottish Oral and Maxillofacial Society for a four- to six-week Fellowship in head and neck oncology in Shanghai at the department of Cranio-Maxillofacial Science, School of Stomatology, Ninth People’s Hospital, Shanghai Jiao Tong University. The funding is up to £3,000 to cover costs. The level of operative experience required to benefit most from the time is equivalent to a final-year post FRCS (Intercollegiate) trainee. Other applicants will be considered on merit, but this level should be seen as a benchmark. Application is by letter and CV (no more than four pages), along with two references, which should be sent to Mrs Cathy McCartney at c.mccartney@ rcsed.ac.uk. Further information about the Fellowship can be obtained from Mr Roger Currie at r.currie@rcsed.ac.uk Closing date for applications is Wednesday 27 June 2018.

Dundas Medal

The medal is in commemoration of Dr Charles Robert (Bertie) Dundas FFARCS FRCP Glasgow. Dr Dundas was a senior lecturer at the Department of Surgery (Anaesthetics) in Aberdeen and honorary consultant anaesthetist from 1975 to 1995. He died in 2014 from biliary carcinoma. He was never offered palliative care while he was ill and spent his last months waiting for chemotherapy while enduring a poor quality of life. His widow, Dr Valerie Dundas, made a donation to Palliation and the Caring Hospital (PATCH) to improve the provision of palliative care in hospital. In recognition of Dr Dundas’s lifelong enthusiasm for teaching, research and innovation, an annual award to recognise efforts to improve the provision of palliative care for patients when they are in hospital is fitting. The award is open to individuals or teams (medical, nursing or paramedical) working in any hospital in the UK. It is not essential that

the applicant should be an FRCSEd. The term ‘hospital’ applies to both acute and community hospitals. Closing date for applications is Wednesday 4 July 2018.

Wong Choon Hee Medical Student Elective Travel Bursaries The RCSEd, in association with Meducatus (meducatus.com), is pleased to offer medical students the opportunity to apply for financial support towards their elective in surgery. This award is open to medical students in the UK and the Republic of Ireland who are undertaking approved surgical electives abroad. This award will be advertised and given out annually in September. It provides a contribution towards the overall costs of travel and subsistence. Travel must be undertaken after the award is made in September. Closing date for applications is Wednesday 4 July 2018.

CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS Educational Dental Grant

Ms Hannah Crane, Academic Unit of Oral and Maxillofacial Pathology, the School of Clinical Dentistry, Sheffield. Edge Hill University, PGCert Teaching and Learning in Clinical Practice. Mr Mohammed Dungarwalla, Queen Victoria Hospital, East Grinstead. Postgraduate Certificate in Medical Education, Newcastle University.

Africa Bursary

Mr Mark Wodward, University of Manchester – Kamuzu Central Hospital, Lilongwe, Malawi; Somerset Hospital, Cape Town, South Africa. Mr Jamie Mawhinney, Balliol College, Oxford – Beit CURE Hospital, Lusaka, Zambia. Mr Rhys Dore, University of Oxford – The World Medical Fund, Nkhotakota, Malawi. Mr David Stewart, Newcastle University – Kelele Lodge Solidario in Kumwenya School, Kimya District, Uganda.

rcsed.ac.uk | 57

COLLEGE INFORMATION

DIPLOMA CEREMONIES Congratulations to all our new Fellows and Members who were presented with diplomas at ceremonies in Edinburgh FRIDAY 2 FEBRUARY 2018 Award of Honorary Fellowship Professor William P Saunders, FDS RCSEd, FDS RCPSGlasg, FDS RCSEng, Immediate Past Dean of the Faculty of Dental Surgery, RCSEd, Emeritus Professor, University of Dundee Admission to Fellowship Ad Hominem Datuk Dr Noor Hisham Abdullah, MD, MS, MD Hons (Newcastle upon Tyne), FAMM (Malaysia), FRCP (Lond), FAFPM (Malaysia), FICD, MD Hons (MSU, Malaysia), Director General of Health, Ministry of Health Malaysia Award of Fellowship in Dental Surgery Without Examination Dr Anil Sukumaran, FICD, FDS RCPSGlasg, Professor, College of Dentistry, Prince Sattam Bin Abdulaziz University, Saudia Arabia Diplomas of Fellowship in the Specialty of Cardiothoracic Surgery Nathan Matthew Burnside, Queen’s University, Belfast Vinay P Rao, Bangalore University, India Diplomas of Fellowship in the Specialty of Neurosurgery Su Lone Lim, Universiti Sains, Malaysia Geoffrey Adrian Tipper, National University of Ireland Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Mark Ian Blomfield, University of Sheffield Jayachandran Saraswathy Jayadeep, University of Kerala, India Hui-Ling Kerr, University of London Jakub Kozdryk, University of Gdansk, Poland

58 | Surgeons’ News | June 2018

Paul Ross Middleton, University of Aberdeen Diploma of Fellowship in the Specialty of Plastic Surgery Sandra Ellen McAllister, Queen’s University Belfast Diplomas of Fellowship in the Specialty of Otolaryngology Natasha Amiraraghi, University of Dundee Helen Louise Beer, University of Liverpool Laura Elleanor Jackson, University of Birmingham Bun Yin Winson Wong, University of Leeds Diplomas of Fellowship in the Specialty of Urology Jaya Simha Abbaraju, Dr NTR University of Health Sciences, India Asadullah Aslam, University of Health Sciences, Lahore, Pakistan Faran Kiani, Quaid-i-Azam University, Pakistan Andrew David Moon, Newcastle University Harkaren Randhawa, University of Liverpool Alexander Peter Rawlinson, University of Manchester Diploma of Fellowship in Immediate Medical Care Richard Jonathan Howes, University of Edinburgh Diploma of Fellowship of the Faculty of Surgical Trainers Adrian Michael Harris, Newcastle University Presentation of the Dundas Medal Alastair McKeown and Fiona Kerr, on behalf of Queen Elizabeth University Hospital Specialist Palliative Care Team

Intercollegiate Diplomas of Membership in Surgery in General Atif Ayuob, University of Health Sciences Lahore, Pakistan Gbolabo Opeyemi Balogun, Medical University of Silesia, Poland Mairiosa Biddle, University of London Philippa Burnell, University of Birmingham Elizabeth Cassar, University of Malta Pradeep Chand Chandran, Kursk State Medical University, Russia Han Hong Chong, University of Manchester Ezra Kai Sing Ding, Charles University, Prague, Czech Republic Ahmed Abdelkhalek Ramadan Elshiekh, Suez Canal University, Egypt Ashraf Ahmed Mohamed Ahmed Fadul, University of Khartoum, Sudan Eugene Mingjin Gan, National University of Singapore Musaab Adam Eltahir Hamdoon , University of Medical Science and Technology, Sudan Muhammad Usman Javed, University of Health Sciences Lahore, Pakistan Andrei Adrian Kozan, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania Grace Hui Chin Lim, University of Glasgow Milindu Chanaka Makandura, University of Colombo, Sri Lanka Georgios Mamarelis, University of Patras, Greece Nicola Claire McKinley, Queen’s University Belfast Ruth Scicluna, University of Malta Vetri Chelvan Selvaraj, Dr MGR Medical University,India Jun Yi Soh, University of Warwick Matthew William Trail, University of Edinburgh Dinesh Thirunavukarasu, Sri Ramachandra University, India

Siang Yew Yeo, University of Malaya, Malaysia Diploma of Membership of the Faculty of Surgical Trainers Sandra Ellen McAllister, Queenâ&#x20AC;&#x2122;s University Belfast Diploma of Membership in Orthodontics Andrew Ian Hunter, University of Liverpool Diploma of Membership in Primary Dental Care Mark Thomas Bradley, University of Glasgow Diploma of Membership in Special Care Dentistry Claire Curtin, National University of Ireland

Diplomas of Membership of the Faculty of Dental Surgery Laura Elizabeth Birch, University of Bristol Nusaybah Elsherif, University of Dublin Alexander Gardner, University of Dundee Lena Malaty, Alexandria University, Egypt Faiza Zahoor Qureshi, University of Leeds Ehab Naiem Zaky Tanyous, Cairo University, Egypt Parul Vats, Ambedkar University Delhi, India Lauren Webster, University of Manchester Usman Riaz, University of Manchester Diploma of Membership of the Faculty of Dental Trainers Stephen James Bonsor, University of Edinburgh Lorna Anne Laidlaw, University of Glasgow

Diploma in Implant Dentistry Usman Riaz, University of Manchester Diplomas in Orthodontic Therapy Rachael Elizabeth Fletcher, School of Dentistry, University of Central Lancashire Rebecca Jane Ford, School of Dentistry, University of Central Lancashire Stacey White, School of Dentistry, University of Central Lancashire FRIDAY 16 MARCH 2018 Admission to Fellowship Ad Hominem Professor Rami Joseph Abboud BEng, MSc, PhD, FRCSEng (Hon), Professor of Education in Biomechanics, Department of Trauma and Orthopaedic Surgery, University of Dundee

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COLLEGE INFORMATION

Professor Hilary Sanfey FRCSIrel, FRCSEng, FACS, Immediate Past First Vice-President, American College of Surgeons, Professor of Surgery and Vice-Chair for Education, Southern Illinois University School of Medicine, Springfield, Illinois, US Professor Erin Daniel Wright FRCSC, Department of Surgery, Division of Otolaryngology – Head and Neck Surgery, University of Alberta, US Award of Fellowship Without Examination Professor Asit Baran Adhikary, FICS, FRCSEng, Chairman and Chief of Special Unit, Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Mr Michael Charles Wyatt FRACS, Robin Ling Exeter Hip Fellow 2015 Award of Fellowship in Dental Surgery Without Examination Mr Hany Adel Nasry FDS (Rest Dent) RCPSGlasg, Consultant in Restorative Dentistry, the Pennine Acute Hospitals NHS Trust Diplomas of Fellowship in the Specialty of General Surgery Lucy Rany Khan, University of Edinburgh Alan David Meldrum, University of Aberdeen Ismail Heyder Mohamed, University of Leicester Matthew Sammut, University of Malta Dorin Ziyaie, University of Dundee Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Brijesh Ayyaswamy, University of Kerala, India Daniel Joan Morell, University of Leeds Diploma of Joint Specialty Fellowship in Orthopaedic Surgery Pillai Anand, National University of Singapore Diploma of Fellowship in the Specialty of Paediatric Surgery Neetu Kumar, Goa University, India Joint Surgical Colleges’ Diplomas of Fellowship in General Surgery Faisal Siddiqi, University of Karachi, Pakistan Kotambail Venkatesha Udupa, Kuvempu University, India

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The Henry Wade Medal For the highest-placed graduate ChM in Urology 2017 Sachin Yallappa, Rajiv Gandhi University of Health Sciences, India The Sir Arthur Conan Doyle Medal For the highest-placed graduate ChM in Clinical Ophthalmology 2017 Blanca Flores Sánchez, Benemérita Universidad Autónoma de Puebla, Mexico The James Pringle Hogarth Medal For the highest-placed graduate ChM in Vascular and Endovascular 2017 Matthew Philip Thomas, Leeds University Intercollegiate Diplomas of Membership in Surgery in General Augustina Eriefe Anetor, University of Benin, Nigeria Maria Zara Boland, University of London Dimitris Challoumas, Cardiff University Salim Chetitah, University of Oran, Algeria Abu Ali Farmidi, University of Dhaka, Bangladesh Peter Timothy Glen, University of Edinburgh Allan Hall, University of Glasgow Ramachandran Nair Harishankar, Mahatma Gandhi University, India Lianne Jane Harrison, Newcastle University Andrew Daniel Hart-Pinto, University of Liverpool George David Bryant Holland, Plymouth University Mansoor Husain, University of Khartoum, Sudan Sundeep Jain, University of Rajasthan, India Stacey Jessica Jones, University of Birmingham Kenneth Kin-Hoo Koo, University of Manchester Anne Marie Molinari, Aix-Marseille University, France Chekwas Ukefi Obasi, University of Lagos, Nigeria Paul Stirling, University of Manchester Shahbaz Ali Tariq, Dow University of Health Sciences, Pakistan Tomas Urbonas, Saint Petersburg State University, Russia Anuhya Vusirikala, University of Leicester Diploma of Membership of the Faculty of Surgical Trainers Qaisar Akhlaq Choudry, University of Prague, Czech Republic Diploma of Membership in Orthodontics Asim Abdulrahman Almarhoumi, King Abdulaziz University, Saudi Arabia

Diploma of Membership in Paediatric Dentistry Mary-Frances McLaughlin Skene, University of Dundee Diploma of Membership in Primary Dental Care Jennifer Wetherall, University of Dundee Diploma of Membership in Prosthodontics Emilie Marie Abraham, University of Sheffield Diplomas of Membership of the Faculty of Dental Surgery Rhea Chouhan, University of Sheffield Lisa Marie Durning, University of Manchester Diplomas of Fellowship of the Faculty of Dental Trainers Jayne Elizabeth Harrison, University of Wales Margaret Katherine Ross, Glasgow Dental Hospital and School David William Mark Young, University of London Diplomas in Orthodontic Therapy Kelly Jade Armstrong, King’s Health Partners, London Laura Ann Cockerham, King’s Health Partners, London Neena Raj Karra, DCP School, Bristol Dental Hospital

IN MEMORY SURGICAL FELLOWS Robert James ABERNETHY (FRCSEd 1966) Robin Michael BASKER (FRCSEd(Ad Hom) 2000) Robert Alexander BRADWELL (FRCSEd 1966) Ian Patrick CAST (FRCSEd 1966) William Robertson CHATFIELD (FRCSEd 1968) Dick Anthony Walker HOPKINSON (FRCSEd 1967) George KALNINS (FRCSEd 1971) John MACINTYRE (FRCSEd 1971) Arnold George Dominic MARAN (FRCSEd 1963 FDS

RCSEd(Hon) 1994) John Gordon NAPIER (FRCSEd 1948) Anil Chitta Prasanna RAJAPAKSA (FRCSEd 1970) George John Alexander WILSON (FRCSEd 1956) DENTAL FELLOWS David Gavin Miller GREIG (FDS RCSEd 1979) Alastair Roy MACGREGOR (FDS RCSEd 1955) Dorota Karolina RATLEDGE (FDS RCSEd 1990) Joseph Duncan RUMBLE (FDS RCSEd 1972) James George STEELE (FDS RCSEd(Ad Hom) 2011)

REGIONAL SURGICAL ADVISERS IN YOUR AREA

The College’s support and advice network throughout the country

12 11 9

Council Member with Responsibility for Regional Surgical Advisers 1 Roger Currie, Crosshouse Hospital, Kilmarnock Surgical Director of the Advisory Network 2 Steven Backhouse, Princess of Wales Hospital, Bridgend, Wales

24 38 39 25

Deputy Surgical Director of the Advisory Network 3 Mike Silva, Churchill Hospital, Oxford

Advisory Network Group Members 4 Stuart Clark, Manchester Royal Infirmary 5 David Exon, Leicester Royal Infirmary 6 Vijay Santhanam, Addenbrooke’s Hospital, Cambridge 7 Sean Kelly, Raigmore Hospital, Inverness

22 4 37

SCOTLAND

NORTH OF SCOTLAND 7 Morag Hogg, Raigmore Hospital, Inverness 8 Lynn Stevenson, Aberdeen Royal Infirmary, Aberdeen

5 15

30 31 36 2

WEST OF SCOTLAND 9 Simon Gibson, Queen Elizabeth University Hospital, Glasgow

13 14

6 26 3

35 17 18

SOUTH EAST OF SCOTLAND 10 Farhat Din, Western General Hospital, Edinburgh 11 Robyn Webber, Victoria Hospital, Kirkcaldy

28 16

EAST OF SCOTLAND 12 Musheer Hussain, Ninewells Hospital, Dundee

ENGLAND

EAST OF ENGLAND 13 Stuart Irving, Norfolk and Norwich University Hospital, Norwich 14 Roshan Lal, James Paget University Hospital, Great Yarmouth EAST MIDLANDS 15 Sridhar Rathinam, Glenfield Hospital, Leicester KENT, SURREY & SUSSEX 16 Mike Williams, Eastbourne District General Hospital, Eastbourne LONDON 17 Cynthia-Michelle Borg, University Hospital Lewisham 18 Ziali Sivardeen, Homerton University Hospital MERSEY 19 Janardhan Rao, Countess of Chester Hospital, Chester 20 John Taylor, University Hospital Aintree, Liverpool 21 Ravi Pydisetty, St Helen’s & Knowsley Teaching Hospitals NHS Trust NORTH WESTERN 22 Mike Woodruff, Royal Preston Hospital, Preston 23 Richard Graham, North Manchester General Hospital NORTHERN 24 Paul Gallagher, Wansbeck Hospital, Northumberland 25 Barney Green, James Cook University Hospital, Middlesbrough 25 Peng Wong, James Cook University Hospital, Middlesbrough OXFORD 26 Giles Bond-Smith, Oxford University Hospitals NHS Trust

SOUTH WEST PENINSULA 27 Neil Smart, Royal Devon & Exeter Foundation Trust, Exeter WESSEX 28 Arjun Takhar, University Hospital of Southampton NHS Trust WEST MIDLANDS 29 Ishan Bhoora, Cannock Chase Hospital, Staffordshire 30 Pradeep Kumar, Queens Hospital, Staffordshire 31 Ramanan Vadivelu, Royal Wolverhampton Hospital NHS Trust 32 Giles Pattison, University Hospital of Coventry and Warwickshire, Coventry YORKSHIRE & HUMBER 33 David O’Regan, Leeds General Infirmary, Leeds 34 Mark Peter, Scarborough General Hospital, Scarborough

WALES

35 Sanjeev Agarwal, University Hospital Wales, Cardiff 36 Raymond Delicata, Nevill Hall Hospital, Abergavenny 37 Vaikuntam Srinivasan, Glan Clywd Hospital, Rhyl

NORTHERN IRELAND 38 Catherine Scally, Antrim Hospital 39 Colin Weir, Craigavon Area Hospital

RSA VACANCIES

Aberdeen, Birmingham, Bradford, East Midlands, Kent, Surrey & Sussex, London, Newcastle, Oxford, Peterborough, Plymouth, Portsmouth, Preston, Severn, Wessex, and West of Scotland

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OUT OF HOURS

Le Planteur in Yangon, Myanmar

From paradise to prison, Graham Layer gives his take on eateries around the world

The inside story

Graham Layer RCSEd Vice-President

e Planteur by the lakeside in Yangon, Myanmar, is simply stunning. It is within a beautiful building with fabulous interior decor and a floodlit garden terrace leading down to the water’s edge. Its fine dining cuisine is based on Western European culture with an oriental flair and is delicious. Service is impeccable, the bill for the food is high and for wines even higher. The wine cellar is filled with Petrus representing every year for the last five decades to name drop just one of the invested chateaux. Four of us dined lakeside, beginning with nibbles and amuse bouches. Tender scallops, beef, lamb and colourful desserts followed, stimulating copious salivation and the desire for more. What a cultural contrast to sampling seafood restaurants in Ngapali in Rakhine State, Myanmar, for fresh gargantuan tempura prawns, soft squid, lobsters and various white flaky fish, all on the same plate. Pleasant View Islet was my favourite, but it is only accessible at lower tides. Two Brothers and Ngapali Kitchen are remarkably similar, but the first wins by a short lobster head. For fresh seafood, I still think Sagres and Campo di Mare in Maputo, Mozambique, take the biscuit if you happen to be exploring in such an unusual place, which is where I travelled for the pre-Christmas COSECSA meeting. With the opening of the College’s International Office in Kuala Lumpur with which I was much involved, it is likely that many of you may be visiting our KL hub and Myanmar. I recommend the no-fuss bistro Alexis in trendy Bangsar Baru, which is a perfect casual dining destination.

62 | Surgeons’ News | June 2018

It serves fresh hot food and pasta with an Asian twist at excellent prices with wines, and is entirely reliable. My benchmark carbonara pasta was tasty and interesting with beef bacon and plentiful parmesan. Malta is a popular holiday venue and a resuscitated destination for the College. De Mondion is to be found on the top floor of Xara Palace, in the ‘silent city’ of Mdina. Surrounded by history and by glorious floodlighting at night, it made for a memorable evening. We started with wonderful Maltese bread and homemade white butter, which was perfectly creamy, served with a tasty cube of neck of pork. This was followed by crispy guinea fowl breast with both globe and Jerusalem artichokes, and outstanding lobster cannelloni on a cauliflower puree surmounted by a lobster tail and a squid ink wafer. This lobster dish is insurmountable. The rack of encrusted pink lamb and the wagyu beef ribeye with salsify in a miso sauce were perfectly cooked and accompanied by baby turnips and bok choi. We declined the dessert menu, but succumbed to affogatos and piles of chocolate petits fours. Service was exemplary in a room decorated with delightful modern landscapes between the windows looking out from on high over the Maltese landscape below. A superb venue. I had Sunday lunch in Valletta at the Panorama Restaurant with a view of the Grand Harbour. Although the menu is misleading, it’s a good venue for the hungry, with plentiful portions. The amuse bouche was octopus salad and zucchini soup, followed by tasty starters of pheasant pasta and fried goat cheese in trendy panko crumbs with fig jam.

The main course was unusual: a chunky salmon and sea bass roulade with a strange cross-sectional appearance of multiple incidentalomas. Having the fish skins embalmed within was a mistake. The sliced steak with a rocket salad was stringy and needed a sauce rather than just parmesan squames hiding what was underneath. Back now to the home nations and The Wee Restaurant is found after spiraling under the various Forth Bridges in charming wind-blown North Queensferry, Fife. It is not to be confused with its new offspring in the city of Edinburgh itself, because this is the original infamous Wee. A small, comfortable dining room; a warm oasis with a friendly team serving a varied menu for all tastes. Crispy soft egg and seared scallops were perfect. Other seafood was good, too – cod fillet resting on crab linguine. Mussels I think I still prefer in a simple wine, cream, herb and garlic sauce, rather than the heavyweight parmesan and bacon style that is emerging. Their own bread is excellent. Fischer’s is part of the Wolseley, Colony Room, Delaunay empire and is said to be an Eastern European Grand Cafe. Well it is not grand, but quite small and compressed and the cuisine is certainly Austrian and middle European. It resides in charming Marylebone High Street, London, so an extra nought on the price of items is almost expected. Celebrity viewing was on the menu, which added a certain je ne sais quoi to the cured herrings and fiery hot copper pans filled with various hashes topped with eggs (bacon grosti). Schnitzel and sausages with sauerkraut were more classical, but not the usual over-generous plate size. To close, I nervously entered the realms of HMP Cardiff, Wales: The Clink restaurant, staffed entirely by reforming inmates. I had a substantial carbohydrate-heavy Saturday lunch in a somewhat austere environment. The food was presented well, but there was too much on the plates – I had pork psoas muscle embedded in a black pudding mash and realised why contemporary nouvelle cuisine had escaped. This was after a massive bland seafood terrine and before a ginger cheesecake (the star of the show). The others had a smoked duck starter, but were disappointed and then moved on to bream and venison. The whole experience inside was memorable and you need passports to do it, but it could be upgraded very easily.

Fiesta time! Bernard Ferrie toasts South America

ou’ll never get to heaven in an old Ford car, but this is a different fiesta. Argentina and Chile produce many excellent wines, but what about the rest of South America? A geography lesson from M&S…

A Brazilian trio to start. Coconova Brut (£10), a Sauvignon Blanc, Chenin Blanc, Verdejo blend from Vale do São Francisco in the north – melon, nectarine and almond. A fine bottle of bubbly. Rio Carnival (£9.50) sparkling Glera. Samba, Carnival and Copacabana rolled into one. Glera a new grape on the block, stone fruit and citrus. Simple but refreshing.

Delicious seafood at The Wee Restaurant

Araucaria Riesling Pinot Grigio mix 2015 (£9.50). Tasted a lot of Riesling recently, but not a lot of PG – except in tea bags. Apple, pear, greengage and spice from the Campanha region. Pleasant, crisp and dry.

Mexico next: Quetzal Malbec 2015 (£9). Chardonnay, Chenin Blanc – nachos with guacamole, carne con chilli of course. Fresh dry tropical fruit flavours. The quetzal bird a symbol of wealth for the Aztecs.

Bolivia: Campos de Solano Malbec Tannat 2016 (£11) from Tarija in the south – plums and kirsch, bold, powerful and full bodied, enjoyed with the final part of the Calcutta Cup. One to savour and remember. The rugby was good as well.

Uruguay: Pisano Cisplatino Tannat 2015 (£9.50). Fantastic melodious name. Plum, herb, spice, blackberry and raspberry. A true find indeed.

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FROM THE COLLECTIONS

REPRESENTING WOMEN IN SURGERY The Museums bring females to the fore with exhibits from Betty Slesser to add to the collections

he College may be more than 500 years old, but women don’t feature in its history until 1888 when Emma Littlewood was awarded the Triple Qualification. The first female Fellowship went to Alice Headwards-Hunter in 1920, the first woman to hold office was Caroline Doig in 1984 and the first female Dean of Dentistry, Professor Dorothy Geddes, was appointed in 1992. As women have been admitted to the surgical field only in the last 140 years, it is only natural that the collections reflect this, with most exhibits associated with male surgeons. Moving forward, however, the museum would like to ensure that the history of women in surgery is well represented. The museum has received a collection of instruments, memorabilia and slides belonging to Betty Slesser FRCSEd (1918–2010). She graduated in 1941 and became a House Surgeon at Edinburgh Royal Infirmary. Miss Slesser recalled at a ‘Women in Surgery’ meeting at the college in 1995 that: “My first post was House Surgeon to Dr Ewart Martin in the Ear, Nose and Throat Department at Edinburgh Royal Infirmary. At this time, women were not allowed to hold junior house jobs in the Infirmary, with the exception of the Specialist Departments and, of course, at the Simpson. An exception was Sheila Sherlock, who won the Ettles Scholarship in my year.’’ In 1942, Slesser became House Surgeon to the Prince of Wales Hospital in Plymouth at a time when it was being heavily bombed, later moving to Sheffield where she worked as First Assistant to the Surgical Professorial Unit with Sir Ernest Finch. Here, she gained valuable experience and developed an interest in thoracic surgery. In 1945, she became a Fellow of the RCSEd and went on to be one of the first women to specialise in thoracic surgery. In 1951, she was appointed Consultant Thoracic Surgeon to the Thoracic Unit in Leicester, where she worked until her retirement. Miss Slesser recounted: “In those days, it was mandatory for women attending

The museum would like to ensure that the history of women in surgery is well represented 64 | Surgeons’ News | June 2018

Betty Slesser’s equipment and slides are among the exhibits showcasing women in surgery

an interview to wear a hat. In August 1951, I applied for the post of Consultant Thoracic Surgeon to the Thoracic Unit in Leicester. At the interview, I was sitting outside the door of the interview room, when the members of the Committee were piling in, my chief, Mr Fawcett, last. Seeing me, he said ‘Where did you get that bloody awful hat?’ Nevertheless, I got the appointment.” The personal surgical objects of Betty Slesser will help the museum tell the story both of one woman’s journey and of the overall situation for women in surgery in the mid-20th century. Other displays in the museum showcase four groundbreaking women: Gertrude Herzfeld, the second woman to be awarded a Fellowship and the first practising female surgeon in Scotland; Elsie Inglis, who founded the maternity hospital in Edinburgh in 1901 and the Scottish Women’s Hospitals during the First World War; Dr Edith Dawson, a distinguished pathologist who came to work at the museum in 1961 and greatly enhanced the histological collections; and Dr Anne Bryson Sutherland, one of the first female plastic surgeons in Britain and the first President of the British Association of Plastic Surgeons. The objects on show representing the careers and stories of these pioneering women include medals, awards, portraits, pictures, instruments and specimens. The museum is collecting objects relating to women in surgery. If you wish to donate or have any queries, please contact the Assistant Curator. All contact details can be found on the museum website. Louise Wilkie Assistant Curator, Surgeons’ Hall Museum