Surgeons' News, December 2017

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YOUNGER FELLOWS’ FORUM TACKLES TEAM BUILDING AND BULLYING

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SAFETY FIRST: THE POWER OF EXCEPTION REPORTING FOR JUNIOR DOCTORS

DECEMBER 2017 rcsed.ac.uk

When terror strikes

How prepared are the public and hospitals for mass-casualty attacks?

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WELCOME

FROM THE EDITOR Clare McNaught on preparing for major incidents, and the problems of recruitment and retention

I

write this editorial just days after the senseless mass shooting in Las Vegas where 59 innocent people lost their lives. Unfortunately, 2017 has been the year of the terror attack, five of which occurred here in the UK. Despite my horror at these events, I have been overwhelmed by the stories of the survivors who risked their own lives to save others and the remarkable response of the emergency services, who worked relentlessly in often hostile conditions to rescue as many people as possible.

In this issue, Stuart Clark, Naomi Davis and Ken Dunn describe how lessons from the Paris and other attacks were disseminated through a mass-casualty training exercise just weeks before the bombing at the Manchester Arena. This preparation ensured that victims were distributed to hospitals with the correct facilities and in volumes that enabled calm, high-quality care. The need to coordinate the treatment of children and their parents in the same unit was highlighted as a future priority.

In response to these attacks, the College has supported the launch

Lessons from the Paris attacks were disseminated through a training exercise

of the citizenAID app, which empowers the general population to perform lifesaving first aid during mass-casualty incidents after ensuring their own safety. On page 30, Brigadier Tim Hodgetts explains how the app was developed by incorporating the best evidence from military and civilian multiplecasualty events.

The profession of surgery is facing a crisis in recruitment and retention in the UK. At the inaugural Younger Fellows’ Forum, the reasons for this were explored and the overwhelming theme was the loss of team structure and spirit. As trainers, it is our responsibility to nurture the next generation, and provide them with an environment that supports them to develop their clinical skills and enables them to take personal responsibility for patient care. The new online ISCP trainer portfolio launched at the Faculty of Surgical Trainers meeting in October will help us to develop our training skills and keep a clear record of all our activities, which can be used towards our GMC revalidation.

The festive season is fast approaching and many of us will have a short welcome break from the rigours of professional surgical and dental life. On behalf of everyone at Surgeons’ News, we wish you success and prosperity in 2018.

Clare McNaught editor@surgeonsnews.com rcsed.ac.uk | 1

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26

YOUNGER FELLOWS’ FORUM TACKLES TEAM BUILDING AND BULLYING

48

SAFETY FIRST: THE POWER OF EXCEPTION REPORTING FOR JUNIOR DOCTORS

DECEMBER 2017 rcsed.ac.uk

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DECEMBER 2017 |

VOLUME 16 |

ISSUE 4

When terror strikes

How prepared are the public and hospitals for mass-casualty attacks?

EDITOR Clare McNaught 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, Felipe Perez 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 | December 2017

Contents

December 2017

04

AGENDA News and views from the profession, including anti-bullying and innovation initiatives and looking ahead to the Triennial Conference

10 19

THE PRESIDENT WRITES College activities around the globe HISTORY Malta's long relationship with the Scottish Triple examination

24 how Manchester hospitals coped with casualties of the Arena bombing

40

WORKPLACE SUPPORT How Schwartz Rounds can help foster compassion in healthcare

42

TRAINEES AND STUDENTS A fellowship in Melbourne; robotics at the Orsi; the benefits of cognitive simulation; why exception reporting has 'teeth'; skills events

20

AIR POLLUTION Artefacts that shed a light on pollution in Dickensian times

22

FST CONFERENCE Highlights from this year's Faculty of Surgical Trainers meeting

24

TRAINING How the ISCP/FST Trainer Portfolio will improve the quality of training

51

26

RCSED YOUNGER FELLOWS From bullying to recruitment, College Fellows in the early years of practice put the world to rights

DENTAL Postgraduate education after Brexit; welcoming the new Dean; skills competition; 100th Member for FDT

56

30

COLLEGE INFORMATION RSAs in your area; awards and grants; diploma recipients; obituaries

MAJOR INCIDENTS With terror attacks on the increase, Brigadier Tim Hodgetts outlines how the citizenAID app can train the public to save lives; and Stuart Clark, Naomi Davis and Ken Dunn reveal

62 64

OUT OF HOURS Taste sensations and glorious grapes FROM THE COLLECTIONS X-ray vision into WWI injuries

The RCSEd Triennial Conference The Modern Surgical Team: the Future of Surgery Thursday 22 and Friday 23 March 2018, Edinburgh You are invited to join the President of the Royal College of Surgeons of Edinburgh at the College’s flagship Triennial Conference 2018.

The Modern Surgical Team: the Future of Surgery is for everyone involved in surgical practice, care and delivery. It will examine major themes that affect everyone who works as part of the surgical team, addressing important questions, such as: What will the surgical workforce look like in the future?

training and technology. There will be opportunities to learn from and network with a wide range of experts in different fields. Our speakers include: Sir Ian Kennedy QC, Chair of the Independent Parliamentary Standards Authority and leader of the enquiry into the activities of Ian Paterson Brigadier Tim Hodgetts, Medical Director of the Royal Centre for Defence Medicine Mr Craig McIlhenny, Director of the Faculty of Surgical Trainers

What is the answer to the NHS staffing crisis?

How will we train future generations of surgeons?

How can we make good decisions under pressure, and what can we do when things go wrong?

How much do we really know about the safety of cutting-edge surgical devices?

What role will perioperative practitioners play in the future of the surgical team and what impact will this have on surgical training?

We will focus on the hot topics and emerging issues of the day, and explore innovation in surgical education,

Professor Rhona Flin, Emeritus Professor at the University of Aberdeen School of Psychology, and Psychological Advisor to NASA, the nuclear industry and the Cabinet Office Ms Helen Mohan, President of the Association of Surgeons in Training and General Surgery SpR, Ireland The full programme is online and registration is now open. Please check the website for more information, triennialconference.rcsed.ac.uk.

For any further queries, please contact education@ rcsed.ac.uk or telephone +44 0131 668 9209

Nicolson Street Edinburgh EH8 9DW +44 (0) 131 527 1600 rcsed.ac.uk Registered Charity No. SC005317

AGENDA

Agenda The latest news from the College and profession Bullying can have a devastating effect on medical professionals

/ CAMPAIGN

#LetsRemoveIt e-module goes live

T

he RCSEd has rolled out an e-module as part of the #LetsRemoveIt anti-bullying and undermining campaign, which was launched in June. The e-module is designed to inform participants about what constitutes bullying and undermining behaviour in the workplace and provides the tools needed to respond to this type of behaviour.

Alice Hartley, former Trainee Member on RCSEd’s Council and group leader for the campaign, said: “The College has a zero tolerance approach to bullying, undermining and harassment, and categorically condemns this in all circumstances. We hope this online resource will offer guidance not only to those in surgery and dentistry, but to all health professionals to help inform and encourage a change in culture in the workforce.”

/ COMPETITION

Video contest targets bullying As part of the College’s antibullying campaign, this year’s video competition invites medical students, doctors and trainees to create a video that highlights how undermining and bullying affect colleagues as well as patient safety.

All entrants will receive one year’s affiliation with the RCSEd Affiliate Network. The winner(s) can attend an RCSEd course (to the value of £150) or the RCSEd Triennial Conference (The Modern Surgical Team: the Future of Surgery), with travel and accommodation included. The competition closes on 8 January 2018.

For details and to enter, visit videocompetition. rcsed.ac.uk or contact outreach@rcsed.ac.uk 4 | Surgeons’ News | December 2017

This year’s video competition focuses on bullying and undermining behaviour

/ STUDENTS

RCSEd welcomes increase in number of medical school places

Prospective medical students visit the College

Following the announcement earlier this year of an expansion in the number of medical school places, the President of the RCSEd, Professor Michael Lavelle Jones, said: “As the problems the NHS is experiencing in

recruiting and retaining medical professionals is well known, the College welcomes this increase in medical school places and nursing numbers.

“We particularly welcome the aim of opening up places to

students from disadvantaged backgrounds and increasing trainee numbers in those locations that have experienced recruitment difficulties.

“However, given the lengthy period of time it takes to train

doctors to consultant level, we caution against this expansion being seen as a ‘quick fix’ for the NHS. It must be seen as part of an overall package of measures to improve NHS services in the medium and long term.”

/ RESOURCES

/ TRAINEES

College competition promotes innovation

Library rolls out e-book collection

The College is committed to encouraging and supporting the surgical workforce to continue to push boundaries, and to lead and inspire innovation in all areas for the benefit of everyone.

As part of the 2018 Triennial Conference, RCSEd is asking trainees from ST3 to ST8 to put forward their ideas for innovations in surgery, surgical education, training and technology within the NHS. The top entrants will be invited to the conference to present their ideas to a panel, which will include College President Professor Michael Lavelle-Jones, who will

The College library has launched new electronic books, which are accessible to all RCSEd Fellows and Members from anywhere in the world. The collection includes titles from a range of specialties. The system enables users to search for particular titles, authors and subjects as well as within books, and to make notes and citations.

choose the overall winner. Other highscoring entrants will be able to display their ideas as e-posters at the conference, and an overall winner will be chosen from this group too.

This is a national competition and certificates will be awarded to all successful entrants for training portfolios.

The closing date for entries is Monday 8 January 2018.

For details and to enter, visit triennialconference.rcsed.ac.uk or contact outreach@rcsed.ac.uk

Visit the library’s website at www.library.rcsed.ac.uk for more information

rcsed.ac.uk | 5

AGENDA

/ EVENT

Gibson and Wilson elected to Council

The Rewards programme includes holidays

/ MEMBERSHIP

T

Additional membership benefits

Mr Gibson is a Consultant Spinal Surgeon

Professor Wilson is Professor of Otalaryngology

he College is pleased to announce that Mr Alastair Gibson and Professor Janet Wilson have been elected to the RCSEd Council.

Mr Gibson, a Consultant Spinal Surgeon practising in Edinburgh, has been re-elected for a further five-year term having first been elected

to Council in 2012. This is Professor Janet Wilson’s first term with the Council. Professor Wilson is Professor of Otolaryngology, Head and Neck Surgery at Newcastle University and Honorary Consultant at Freeman Hospital, Newcastle upon Tyne. Mr Gibson and Professor Wilson took up their positions at the College’s Annual General Meeting on Friday 17 November 2017.

/ EVENT

BSHM congress honours women in medicine The role of women in medicine and Scotland’s contribution to medicine were among the key themes of the British Society for the History of Medicine’s biennial congress held at the RCSEd in September.

Highlights included the story of Thomas Latta, the Leith doctor who first introduced intravenous saline solution in 1832 to treat patients in a cholera epidemic, and a look back at women in medicine, coinciding with the centenary of the death of Edinburgh pioneer Elsie Inglis.

6 | Surgeons’ News | December 2017

Elsie Inglis

A wide variety of extra benefits are now available to Fellows and Members as part of the new RCSEd Rewards programme. Offers include holidays, luxury products, experience days, financial services and much more.

You can access the dedicated website via the Membership Services pages of the College website, rcsed.ac.uk.

/ REFORM

NI Colleges call for reform Medical Royal Colleges in Northern Ireland have come together to call for urgent action on reform of health and social care following recent announcements of budget cuts for the Health and Social Care Trusts.

“As healthcare professionals, patients’ health and wellbeing is our priority.

Healthcare reform has been delayed for too long and, as a result, our health and social care system is deteriorating and patient care is suffering. On behalf of medical professionals across Northern Ireland, we call on political leaders to hear our concerns and take urgent action to address them.”

Majid Mukadam MBE on life as a transplant specialist at Queen Elizabeth Hospital in Birmingham

Surgical sound bites Falling prey to fake news in the medical press

What attracted you to a career in surgery?

The fact that it is challenging and has an instant impact. It gives a chance of cure and relieves pain.

I was inspired by the passion, dedication and work ethic of a couple of senior surgeons, and my love for anatomical dissection strengthened my resolve to take up surgery.

If you could change anything in your career, what would it be?

It’s been an incredible journey so far. However, I have always wanted to do formal laboratory/ animal-based research, but couldn’t get involved due to the way my career evolved.

What motivates you to stay professionally active?

The desire to improve myself, keep up to date with advances and enhance patient care keeps me active. I’m always keen to introduce technology that will improve patient outcomes, despite facing funding obstacles.

Presently, I am working on obtaining an organ care system for the heart that will help to increase the number of transplants done in Birmingham.

What advice would you give a person considering a career in surgery?

To only consider it if they are passionate about surgery, to avoid it if they think it is lucrative, and to be prepared to work hard and strive to make a difference. To

always take surgical decisions with patients’ best interests and safety at heart rather than career aspirations. They should also be prepared to accept change and embrace new technology.

What are your interests outside surgery?

I volunteer with many organisations to increase awareness of health issues, particularly transplantation and organ donation in the BAME/Asian community.

There is a lot of ignorance and misconceptions about this issue, leading to low consent rates despite a greater need for transplants in this community.

I like cricket and love to walk in natural surroundings, be it in the Highlands or along the coast of the Arabian Sea. I like to read detective books and biographies.

I’m currently reading Roger Moore’s having finished Warren Buffett’s – it’s great to learn from these personalities.

Where is your favourite place?

My ancestral home in India called Kolthare – along the Arabian Sea in Maharashtra.

How would colleagues describe you?

As quiet, dedicated, helpful, having a good sense of humour, non-confrontational, witty and approachable.

Some call me Mr Dependable.

John: At last, the surgical community has recognised my academic genius. Over the last month I have received multiple requests from editors of surgical journals to submit articles for publication.

Janet: Sorry, John, the emeritus chair might have to wait! It is likely you are caught up in the predatory scam of fake online open-access publication.

John: What do you mean? I thought openaccess journals helped disseminate access to information more widely. Are they all fraudulent?

Janet: No, not at all, but scholarly publishing is a lucrative multi-billion pound industry that can be exploited. Some of the journals do not adhere to the quality publishing standards set by organisations such as the International Committee of Medical Journal Editors. They solicit manuscripts, have poor peer-review processes and often have hidden publication costs, which the authors have to pay.

John: Is anything being done to stop this?

Janet: Yes – in the US, the Federal Trade Commission has taken out legal proceedings against a number of companies. Social media sites, such as Facebook, have also started to clamp down on the publication of fake medical news, particularly those stories targeted at vulnerable cancer patients.

John: So, are you telling me I am a victim of fake news just like President Trump?

Janet: Yes, but look on the bright side – at least you can’t be impeached for your ineptitude!

Send us your ideas for sound bite topics: editor@surgeonsnews.com

rcsed.ac.uk | 7

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UC201603639e EN © 2016 Medtronic. All rights reserved.

The latest guidelines, articles and studies

IN BRIEF Wide variation and overprescription of opioids after elective surgery

This study evaluated 7,651 adults undergoing 25 common elective procedures from the American College of Surgeons National Surgical Quality Improvement Program data. It has been recommended that a maximum of seven days, or 200mg oral morphine equivalents (OME), should be prescribed at discharge in opioid-naïve patients. At discharge, 93.9% received opioid prescriptions, with a median of 375 OME (interquartile range 225–750). Analysis of the 5,756 (75.2%) opioid-naïve patients showed that most received >200 OME (80.9%).

Authors concluded that most patients were overprescribed opioids. These data will guide practices to optimise opioid prescribing after surgery.

Thiels C, Anderson S, Ubl D et al.

Ann Surg 2017; 266: 564–573

Laparoscopic surgery for adhesive small-bowel obstruction is associated with a higher risk of bowel injury

This population-based study evaluated 8,584 patients who had surgery for adhesional bowel obstruction. Patients undergoing laparoscopic procedures were younger with fewer comorbid conditions. The rate of laparoscopic surgery increased more than threefold during the study period (4.3%–14.3%).

The prevalence of bowel intervention was 53.5% versus 43.4% in laparoscopic versus open procedures (P < 0.0001, odds ratio 1.6). Authors concluded that

laparoscopic procedures for adhesive small-bowel obstruction are associated with a greater likelihood of intervention for bowel injury and/or repair. This might be due to challenges with laparoscopic approaches in patients with a distended small bowel. Authors recommend that surgeons should approach laparoscopic lysis of adhesions with a higher level of awareness and use strategies to mitigate this risk.

Behman R, Nathens A, Byrne J et al.

Ann Surg 2017; 266; 489–498

Effect of axillary dissection versus no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Trial

In this trial, 891 women with clinical T1 or T2 invasive breast cancer and one or two sentinel lymph nodes containing metastases were randomised to breastconserving therapy and sentinel lymph node dissection (SLND) alone or axillary lymph node dissection (ALND). The 10year overall survival rate was 86.3% in the SLND alone group and 83.6% in the ALND group (non-inferiority P =0.02). The 10-year disease-free survival rate was 80.2% in the SLND alone group and 78.2% in the ALND group (P =0.32). Authors concluded that for these patients 10-year overall survival for those treated with SLND alone was non-inferior to overall survival for those treated with ALND. Giuliano AE, Ballman KV, McCall L, et al.

JAMA 2017; 318: 918–926

Endometriosis: diagnosis and management This NICE guideline covers diagnosing and managing endometriosis. It aims to raise awareness of the symptoms of endometriosis, and to provide clear advice on what action to take when women with signs and symptoms first present in healthcare settings. It also provides advice on the range of treatments available.

NICE guideline [NG73], September 2017, www.nice.org.uk

#colorectalsurgery

A Twitter social media campaign promoting the hashtag #colorectalsurgery was launched and promoted across a 180-day interval. The number of tweets using #colorectalsurgery grew rapidly following the launch. #colorectalsurgery was used in 15,708 tweets, which resulted in 65,398,696 impressions and involved 1,863 individual Twitter accounts. Increased volumes of #colorectalsurgery tweets were noted in association with the timing of three major international colorectal surgical conferences. Authors concluded that online global communities formed via healthcare-related hashtags, such as #colorectalsurgery, unify social media posts, scientists, surgeons and authors who have an interest in the specialty.

Brady RRW, Chapman SJ, Atallah S et al.

Br J Surg 2017; 104: 1470–1476

Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: the DREAMS Trial

This trial randomised 1,350 patients undergoing elective open or laparoscopic bowel surgery to additional 8mg IV dexamethasone (n=674) or standard care (n=676) at induction of anaesthesia.

Vomiting within 24 hours of surgery occurred in 172 (25.5%) participants in the dexamethasone arm and 223 (33.0%) allocated standard care. Reduction in on-demand antiemetics remained up to 72 hours. There was no increase in complications. Authors concluded that the addition of a single dose of 8mg IV dexamethasone at induction of anaesthesia significantly reduces both the incidence of postoperative nausea and vomiting at 24 hours, and the need for rescue antiemetics for up to 72 hours in these patients.

DREAMS Trial Collaborators and West Midlands Research Collaborative; BMJ 2017; 357: j1455 rcsed.ac.uk | 9

AGENDA

THE PRESIDENT WRITES Michael Lavelle-Jones on the College’s activities around the globe

W

hen I arrived in Scotland more than 20 years ago, I was reminded that summer here is a ‘retrospective event’, usually judged – somewhat unkindly – on the evidence of two successive days of sunshine. Living in Edinburgh at the College during my presidency has revealed another yardstick by which summer can be judged – the Edinburgh International Festival and the Festival Fringe.

The College is situated at the heart of all these activities and provides many venues for Festival events during August. This is a happy coincidence, as August is traditionally a quiet month for core College and intercollegiate activities when annual leave and vacation time make progress on many fronts frustratingly slow. It does, however, provide me with the opportunity to spend time travelling on the College’s behalf. This year was no exception, and it was a privilege to spend time in Singapore, Malaysia, Southern India and Sri Lanka.

In Singapore, it was my pleasure to welcome 72 new Members and Fellows, drawn from more than 10 countries in the ASEAN region, to our College at one of our international diploma ceremonies.

Many had travelled a considerable distance with their families to attend the event. There is no doubt that, despite the necessary differences in our clinical practices and workplaces, membership of the

10 | Surgeons’ News | December 2017

oldest surgical college is a highly valued credential.

Earlier this year at the College of Surgeons, Academy of Medicine of Malaysia Scientific Conference in Kuching, Sarawak, I was reminded of the part played by our College supporting the development of surgical practice in Sarawak (which was a British Crown Colony at the time) when Sir James Fraser spent five years there from 1953, working for the Government Health Service.

Some years later, in 1982, he became President of our College. My visit to Kuching coincided with a most successful diet of our membership examination and I would like to express my thanks to all concerned.

Staying in the region, I was reminded of the sheer size of the Association of Surgeons of India when I took part in the Tamil Nadu and Pondicherry Chapter meeting in Coimbatore, Tamil Nadu, which drew more than 1,000 registrants for a three-day regional event.

I look forward to meeting more Indian Fellows and Members at the 2017 Annual Conference in Jaipur this December titled ‘Making Surgery Safer for Patients and Surgeons’.

From Coimbatore in Southern India, it was a small hop to Sri Lanka, where we partnered with the College of Surgeons of Sri Lanka Annual Academic Sessions in conjunction with the South Asian Association for Regional Co-operation Surgical Care Society. This year’s meeting, which marks the seventh year of our partnership with the Sri Lankan College’s flagship annual event,

was titled ‘Surgical care – Optime Maxime’ and challenged us all to provide maximum benefit with minimum risk for all of our patients and bore much in common with the Choosing Wisely initiatives that we are engaged with in the UK. The event drew a strong international faculty and audience, and is clearly emerging as a major scientific and clinical forum within the region.

Closer to home this autumn/ winter, Professor Michael Griffin and Mr Gareth Griffiths will take up their Chairmanships of the Joint Committee on Intercollegiate Examinations (JCIE) and the Joint Committee on Surgical Training (JCST), respectively. I am sure you will join me in wishing them well in these challenging posts, where the landscape is in a constant state of flux.

That rapid progress is being made was brought home to me when I heard Gareth Griffiths lay out some of the changes we can expect in the coming 12 months in relation to assessment and, critically, how we are going to define those progress points that guide a trainee towards autonomous practice.

In the last issue of Surgeons’ News, I drew attention to two new GMC documents, Excellence

by Design and the

The College is close to the hub of the Edinburgh International Festival and Fringe

General Professional Capabilities Framework, launched earlier this year.

Together, these shape the framework of future surgical training.

Embedded within Excellence

by Design was the concept of an ‘outcomes-based curriculum’ as a measure of a surgeon in training’s ability to carry out the relatively small number of high-level activities (e.g. an Outpatient Clinic or Managing the Emergency Take) which are the key components of the job of being a surgeon. This new framework for capabilities originated in Holland and has been adopted widely in the US, Australasia and elsewhere, and has the benefit of being a descriptor of a trainee’s ability to work rather than a series of separate workplacebased assessments.

Medical and surgical specialties in the UK will use the term Capabilities in Practice (CiPs) to describe these outcomes and, through them, a trainee’s progress and level of professional ability in the workplace.

It seems likely that CiPs will replace

Embedded within Excellence by Design is the concept of ‘entrustable professional activities (EPAs)’ as a measure of a surgeon in training’s ability some elements of the existing WPBAs with an emphasis moving away from a granular series of multiple assessments each looking at a narrow range of competencies to a more global assessment of capability in the workplace. The timeframe for the launch is tight (over the next 12 months in some surgical specialties, I understand) and the devil will be in the detail. It is, however, clearly the direction of travel and CiPs will be featured at length in a forthcoming edition of Surgeons’ News.

One of the highlights of the College’s calendar is our conjoint scientific meeting with the College of Surgeons of Hong Kong. This year’s meeting, held at the Hong Kong Academy of Medicine Jockey

Club Building, Aberdeen, was a great success. The theme, ‘Controversies in Surgery’, provoked a vigorous debate set against the background of state-of-the-art surgical practice drawn from Hong Kong, mainland China and Japan.

I was struck particularly by the high volume of work experienced by some centres, especially in mainland China, where a UK lifetime of subspecialty experience could be accrued in the space of a year. For those UK surgeons in training who might undertake a period of out-of-programme experience, there are potentially huge rewards.

Michael Lavelle-Jones president@rcsed.ac.uk rcsed.ac.uk | 11

AGENDA

SURGICAL SAFETY UPDATE More cases from the Confidential Reporting System for Surgery TAMIS troubles

Transanal minimally invasive surgery (TAMIS) is a new technique to treat early rectal cancer and benign polyps in the rectum. A 75-year-old patient with past history of DVT, treated with warfarin, was found to have a high-grade dysplastic rectal polyp on colonoscopy, although histology was equivocal. CT and MRI were inconclusive, suggesting that this might be a T1 tumour. The patient underwent TAMIS at which an R1 (positive margin, leaving residual cancer) resection was performed. Subsequent histology suggested a more advanced tumour. An anterior resection was therefore undertaken, which was made complicated by scarring from previous surgery. The patient developed a leak and recurrence, with tumour seeding, requiring extralevator abdominoperineal excision.

Reporter’s comments

The first biopsy suggested high-grade dysplasia, but provided an inadequate sample. CT and MRI were inconclusive for T staging on full-thickness TAMIS excision. In retrospect, it appeared that the stage was at least T2. Proceeding to anterior resection as an initial definitive treatment might have been more appropriate under these circumstances.

CORESS comments

This is a technical case in transanal surgery. The key to success in these procedures lies in accurate patient selection and staging. Preoperative staging is of paramount importance in decision-making.

Tumour biopsies have low accuracy and histological discrepancies are well recognised. ERUS and MRI also have acknowledged inter-observer variability. Digital examination may often provide the most helpful and reliable information.

Delayed diagnosis

A 65-year-old woman presented to the emergency department with abdominal pain. An erect CXR, to exclude free gas, was ordered by the ED doctor, but on someone else’s electronic log-in. The CXR, which indicated a right paratracheal soft-tissue mass, was reported three days later by the middle-grade radiology registrar. By this time, the patient had already been discharged with a four-week follow-up appointment.

The CXR report was only verified by the consultant radiologist a further four days later, who commented: ”Differential diagnosis is lymphadenopathy or azygous

12 | Surgeons’ News | December 2017

vein – CT scan recommended.” The report was not given an ‘amber’ designation, which would have resulted in the report being expedited to the consultant responsible for the patient.

The patient’s consultant received the CXR report four weeks after the patient’s admission. He reviewed the discharge summary, which had documented a four-week follow-up appointment, and opted to wait for the outpatient review before booking a CT scan.

Unfortunately, the patient missed that appointment and was booked for a further appointment, seven weeks later.

In the interim, the patient was admitted as an emergency to the surgical admissions unit, at which time the missed CXR report was reviewed. Urgent CT scan was finally obtained 10 weeks after the initial CXR, which had first highlighted the anomaly. CT confirmed necrotising lung carcinoma.

Reporter’s comments

Several factors contributed to the excessive delay in diagnosis: l Inappropriate use of someone else’s log-in to request the original CXR and no review by the doctor ordering the investigation. l Delays in reporting and verification of the CXR report. l Failure to categorise the clinical information as important (amber), which would have resulted in direct notification of the responsible consultant. l Decision by the responsible consultant to await patient review before ordering the CT scan. l Missed outpatient appointment and delay in organising a further appointment.

CORESS comments

There were significant system errors in this case in which there was not a clear pathway to flag up important radiological findings and to act on them. It was the inherent responsibility of the consultant radiologist to ensure that the appropriate clinician had been informed, and of the consultant responsible for the patient to act on this information. Although the outcome for the patient may have been no different, the quality of the patient’s care was impaired by these system failures.

Laparoscopic confusion

As part of a planned theatre serial upgrade, new high-definition (HD) laparoscopic equipment was ordered and introduced into the first of our colorectal

operating theatres. An HD stack was complemented by a slimline HD scope connected through a unique coupling. After initial usage, the scopes were sent to CSSD and sterilised. Unfortunately, the new scopes were not labelled or differentiated from the older equipment. At the next theatre list, both laparoscopic theatres ended up with incompatible scopes and stacks, resulting in delays with anaesthetised patients on table, before the appropriate pieces of equipment were reunited.

abscess. A laparotomy was performed and the bag containing necrotic gallbladder and gallstones was removed. The patient required a 10-day hospital stay before she was fit for discharge.

Reporter’s comments

Reporter’s comments

At the end-of-list team debrief all concerned parties were informed and the scopes were separated and labelled distinctly. All staff should be briefed on new equipment when it is introduced into the operating environment. Had this been done pre-emptively, the confusion and disruption to the operating list would not have arisen.

CORESS comments

All operative equipment should be checked prior to anaesthetising the patient. This should form part of the pre-operative briefing and equipment check. There is a danger of similar problems arising if formal checklists are not followed effectively.

Retained specimen bag during laparoscopic cholecystectomy

I was undertaking an emergency laparoscopic cholecystectomy in the late evening on a patient with acute cholecystitis. I encountered difficulties removing the gallbladder and phoned my consultant for assistance. He came in from home, excised the gallbladder and placed it in a BertTM bag. We achieved haemostasis and he then left the table to write the operation note, leaving me to complete the procedure.

The laparoscopic incisions were closed and the patient was discharged two days later.

Two weeks later, the patient was readmitted with abdominal pain and fever. CT scan demonstrated the BertTM bag above the liver and a right subphrenic

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.

This incident arose because of communal failings on behalf of both surgeons and the scrub team. The trainee could not see the bag containing the specimen in the operating field when he re-took control of the procedure and was distracted by the other tasks involved in completing the operation. The consultant was unaware that the trainee had not removed the BertTM bag with the gallbladder at the end of the operation and did not check, although, in anticipation, had written an operation note documenting this. The BertTM bag had not been included in the count and scrub staff did not comment on its retention. A pathology form was written out, but a specimen was never sent, and this was not highlighted to the surgical team at the time.

CORESS comments

This is the second, almost identical account, of a retained gallbladder, a Never Event, in recent CORESS cases (see case 228). All objects or equipment introduced into a body cavity should be included in an operative count and counted out on completion of the procedure. The operating team have a joint responsibility to ensure avoidance of retained foreign objects and this is covered concisely in the National Safety Standards for Interventional Procedures (NatSSIPs). The team brief aids communication between team members and all staff should feel empowered to express concern about aspects of patient safety. When control is handed from one individual to another during an operation (as in flight instruction), the first surgeon should ensure that the second surgeon understands the task in hand and knows what components remain to be completed. ‘Read-back confirmation’ might help to ensure this. The WHO signout at the end of the procedure should have picked up this specific oversight, but remains a woefully neglected part of the checklist.

rcsed.ac.uk | 13

AGENDA

THE EYES HAVE IT Dr Heather Ellis puts Edinburgh’s online Ophthalmology Masters degrees under the loupe and finds they get student votes from around the world

F

or the Ophthalmology Masters team at the University of Edinburgh, 2017 has been a very busy and special year.

Our inaugural cohort of the three-year, interprofessional MSc in Primary Care Ophthalmology by online distance learning, one of the ESSQ suite of Masters programmes for the surgical specialties, graduated in July at a grand ceremony at the university’s newly refurbished McEwan Hall. The graduates enjoyed a reception with their families and guests at the RCSEd, our partner institution.

The MSc in Primary Care Ophthalmology provides flexible interprofessional learning – delivered entirely online – for postregistration optometrists, medics, trainees and other eye healthcare professionals, including ophthalmic nurses and orthoptists, from the UK and overseas.

Our inaugural Sir David Brewster Medal in Primary Care Ophthalmology went to the MSc’s top-performing student, Lyndsay Brown.

Brown, an independent (nonmedical) prescriber optometrist in Edinburgh, and four of her optometrist colleagues who graduated simultaneously, received part sponsorship from NHS Education for Scotland’s (NES) Optometry Directorate. This was to enable them to undertake their MSc as part of the NES drive to upskill the profession in Scotland to meet the Scottish Government’s directive to shift the balance of ophthalmic care into the community to reduce unnecessary referrals of

14 | Surgeons’ News | December 2017

Professor Dhillon

REFERENCE

Pronin S, Brown L, Megaw R, Tatham AJ. Measurement of intraocular pressure by patients with glaucoma. JAMA Ophthalmol 2017; 135: 1–7

non-sight-threatening conditions to overstretched hospital eye services.

Brown’s Masters project investigated the effectiveness of educating glaucoma patients in self-tonometry and was supervised

by Dr Andrew Tatham, a Consultant Ophthalmologist specialising in glaucoma at NHS Lothian’s Princess Alexandra Eye Pavilion who co-leads some of the MSc PCO modules.

Brown has also had her first article published online in JAMA Ophthalmology as joint first author.1

Future leaders Our inaugural cohort of students on our two-year, part-time ChM (Master of Surgery) in Clinical Ophthalmology will graduate on 1 December 2017. The top-performing student, Dr Blanca Flores Sanchez from Mexico, will become the first ever recipient of our Sir Arthur Conan Doyle Medal in Clinical Ophthalmology in a RCSEd diploma ceremony in spring 2018.

The ChM in Clinical Ophthalmology is aimed at future

Scholarships

The MSc graduates with Faculty, including (front row from second from left) Dr Domenica Coxon, Academic eFacilitator, Professor Baljean Dhillon, NES Chair of Clinical Ophthalmology and MSc PCO Programme Director, and Dr Heather Ellis

leaders in ophthalmology who are developing secondary and tertiary hospital eye service provision, require subspecialty training and would benefit from close mentoring in research methodology to deliver clinical research relevant to their local and national communities.

The ChM, which is delivered online, supports, supplements and advances clinical learning, develops clinical research skills and provides a platform for mentoring ophthalmologists in training. All they need is access to a computer and an internet connection to study from anywhere in the world, and a minimum of 10 to 15 hours per week to commit to their studies. The ChM’s online distance learners have full access to the University of Edinburgh’s

considerable online library and resources, including e-journals.

The general and subspecialty content follows the Fellowship in Ophthalmology curricula of the RCSEd and Royal College of Ophthalmologists in the UK and Ireland. The learning objectives are mapped to competencies required of Dr Heather UK trainees sitting exit examinations Ellis for the Certificate of Completion of Course Specialist Training.

Organiser, The ChM’s international teaching Academic Faculty has the experience and eFacilitator expertise to deliver clinically and Personal relevant content. The Faculty is Tutor for mindful of the varied culture, climate the two and geographic contexts in which Ophthalmology students practise ophthalmology, Masters and the limitations in resources in programmes some settings. This has shaped the way in which didactic and discursive topics are prioritised and practised within the ChM’s virtual learning The Faculty is mindful environment, and is one of the unique features of the course. of the varied culture, climate

and geographic contexts in which students practise ophthalmology

ESSQ online Masters programmes for the surgical specialties: www.essqchm. rcsed.ac.uk

The David E I Pyott Master of Surgery in Clinical Ophthalmology Scholarship supports specialist surgical and medical ophthalmology training for those from developing countries undertaking the ChM. Thanks to Mr David Pyott’s generous donation of £250,000 in 2016 through his David E I Pyott Foundation to his Scottish alma mater, the University of Edinburgh, six scholarship awards will be available in the 2018/19 academic session to eligible doctors starting on the University of Edinburgh’s ChM in Clinical Ophthalmology. There are already 12 fully funded Pyott scholars studying for the ChM, the first six of whom are expected to graduate in December 2018.

Doctors from Africa, South Asia, Caribbean Islands, Pacific Islands, and Central and South America are eligible for these scholarship awards, which cover all tuition fees for the two-year programme, as well as broadband internet access and a laptop.

The awards are administered by the University of Edinburgh and applications for 2018/19 will close at the end of July 2018. Applicants must meet the eligibility criteria of the university for admittance to the ChM.

For further information, email heather.ellis@ed.ac. uk or visit www.ed.ac.uk/ ophthalmology/masters

From left: Baljean Dhillon, David Pyott and Dr J F Cullen

rcsed.ac.uk | 15

AGENDA

ONWARDS AND UPWARDS

Rowan Parks outlines the agenda for the College’s Triennial Conference, 22–23 March 2018

16 | Surgeons’ News | December 2017

S

urgery has always been at the vanguard of innovation, change and development in healthcare. Surgical teams continue to pioneer new techniques and new thinking, and respond to the challenges and opportunities that face all who work in healthcare by asking questions and working together to find solutions.

In the world of surgery today, these questions recognise that the surgeon does not operate in isolation. We are part of a bigger team, which continues to change and grow. The challenges facing this team are set against a backdrop of increasing pressures on the NHS as a whole, so the questions we must all ask ourselves include: What is the answer to the NHS staffing crisis?

What will the surgical workforce look like in the future?

What part will perioperative practitioners play in the future of the surgical team?

What will all this mean for how we train future generations of surgeons?

We will be exploring these questions, and more, at the College’s flagship Triennial Conference, titled The Modern Surgical Team: the Future of Surgery, in March 2018.

The programme will feature a number of plenary and parallel sessions. Keynote speakers will include Sir Ian Kennedy QC, who led the enquiry into the breast surgeon Mr Ian Paterson and will consider the importance of teamworking and risks of working in isolation, and Brigadier Tim Hodgetts, who will speak on the importance of teamwork from a military perspective. There will also be sessions on intraoperative decision making, the workforce required for the future surgical team, the role of the team in trauma care, health

Rowan Parks Member of Council and Convener of the Triennial Conference

We are delighted to have so many outstanding experts talking about their experiences and perspectives on teamwork

and safety of the team in theatre and beyond, training the team, and effective communication within the team, delivered by authorities in their fields from the worlds of surgery, healthcare and sport.

We are delighted to have so many outstanding experts talking about their experiences and perspectives on teamwork, including Dr Mike Loosemore, Head of Performance Services and Chief Medical Officer for Team GB at the 2018 Olympic Winter Games, and Dr James Robson, Scottish Rugby Chief Medical Officer and Scotland team doctor. We also look forward to contributions from the Royal College of Emergency Medicine and are delighted to be running a joint symposium with the Royal College of Anaesthetists on perioperative medicine, working together to improve patient outcomes.

The programme includes the final of the RCSEd Surgical Innovation Competition. This is aimed at trainees from ST3 to ST8 who will be asked to put forward their ideas for innovation in surgery, surgical education, training and technology within the NHS. The top entries will be invited to the conference to present their ideas to a panel, including the College President, who will choose the overall winner. Other high-scoring entrants will be invited to display their ideas as posters at the conference. We will showcase the winning presentations and posters from the College’s Audit Symposium, which will be held the day before the conference.

A further novel initiative will be a workshop led by The Point of Care Foundation regarding Schwartz Rounds. They are similar to grand rounds but focus on the emotional and psychological aspects of caring for others rather than clinical matters.

There will be opportunities to tour the College campus and Museums, take part in social activities and meet friends and colleagues – old and new.

I look forward to seeing you there.

Find out more and book your place at triennialconference. rcsed.ac.uk rcsed.ac.uk | 17

AGENDA

THE HENRY WADE PROJECT How the Museums are widening access to the collections by putting them online

S

ince the inception of the internet, libraries and archives have had to reassess the use of their collections and make them accessible in different ways.

The College, with its collection of rare books, clinical publications and archive documents, has had some success in these areas, but is now looking to widen access to its collections while conserving them for future use. The Henry Wade Project seeks to do this by creating a database of Fellows and Members from our 16th-century origins, digitising a selection of our rare books and archive collections, and making them available to all online.

The project has four elements: A picture library consisting of digital copies of photographs, surgical videos and artworks.

Top: Illustration showing muscles of the body’s trunk, from John Bell’s engravings explaining the anatomy of the bones, muscles and joints, 1794 Below: Horizontal section through the abdomen from Emil Ponfick’s Topographical Atlas of MedicoSurgical Diagnosis, 1900–1905

A searchable and continuously updated database of College Fellows and Members, with dates of admission and accumulated biographical information.

Digital reproductions of rare books and manuscripts.

A newly digitised archive collection encompassing a full catalogue of the College’s accumulated gifts and deposits.

The Henry Wade collection is an example of one we are keen to conserve and digitise. As well as being an outstanding military and peacetime surgeon and RCSEd President, Wade was one of the College’s most active conservators, and a prolific collector and recorder of information. His photographs from 1914 to 1917 record home service and his activity in Egypt during the First World War. He also describes the cultural life of Egypt and the military hospitals he attended.

We have also uncovered numerous documents on military surgery that offer insights into the treatment of patients in conflicts from the Napoleonic Wars to World War II.

The ‘living obituary’ element of the project will amalgamate four databases into one publicly accessible resource under the control of the library. It will provide biographies on Fellows and Members living and deceased.

The College library holds one of the most varied and colourful collections of anatomical and rare medical books in the world.

Although some of these have been published online or displayed in other collections, we feel this specific collection will make an impact on a wide audience, promoting research as well as other avenues of activity.

The Henry Wade Project will widen our audiences by digitising many of our artefacts and putting them online. The College aims to raise £500,000 overall for this project, which will last three years.

The money is expected to come from external grant-funding bodies such as the Wellcome Trust and the Heritage Lottery Fund. With sufficient funding, the project will begin in March 2018.

Henry Wade was one of the College’s most active conservators, and a prolific collector and recorder of information 18 | Surgeons’ News | December 2017

HISTORY

BUILDING BRIDGES Gordon Caruana Dingli traces Malta’s relationship with the Scottish Triple exam

T

he Triple Qualification examination of the three Scottish medical and surgical colleges was established and approved by the General Medical Council (GMC) in 1884. It enabled students who received their medical education outside universities to receive a registrable qualification.

The existing extra-mural lecturers and private anatomy schools consolidated into a formal School of Medicine of the Royal Colleges in 1895, which persisted until 1945.

The Scottish Triple has helped students who failed university final examinations, and it has enabled foreign students and graduates who faced various political problems to re-qualify with a UK qualification, including Jews in the 1930s, South Rhodesians after independence in 1965 and Maltese in the late 1980s.

A School of Anatomy and Surgery was established in Malta by the Knights of St John in 1676 and a Faculty of Medicine and Surgery was founded in 1771. Medical education followed British standards during the British period and continued after independence in 1964. Most Maltese specialists trained in the UK and many Maltese surgeons are Fellows of the RCSEd. In 1977, the Medical Association of Malta was at loggerheads with the socialist Maltese Government led

by Dom Mintoff. The dispute began when the Government insisted on binding housemen to serve in government hospitals for two years post-registration. The situation escalated when the Government tampered with the functions of the Medical Council. Striking Maltese doctors were locked out of state hospitals and foreign doctors were recruited to run the service. The strike persisted until a change in government in 1987.

In July 1977, the GMC suspended recognition of Malta’s medical degree on the grounds that clinical teaching and hospital practice had been adversely affected. The Maltese Government introduced reforms in university education and large numbers of students enrolled at the medical school, but graduates could not proceed to the UK for postgraduate training. There was a

Gordon Caruana Dingli Acting Chairman of the Department of Surgery at Mater Dei Hospital, Malta, and President of the Medical Association of Malta

The Scottish Triple examination gives foreign students and graduates the chance to obtain a UK qualification

need for young doctors to become specialists and some trained in the US, Italy, France, Australia, Belgium and Germany, but many preferred to train in the UK. The GMC granted recognition of the Maltese degree on 1 May 1986, but this left a large number of doctors who graduated between 1977 and 1986 unrecognised. A solution was reached in October 1987 with the GMC and the University of Newcastle-upon-Tyne. In January 1988, four professors from the university visited Malta to assess the standard of doctors who had graduated between 1979 and 1986.

Maltese doctors were allowed to enrol with the University of Newcastle-upon-Tyne, where they followed a rigorous, purposely designed year-long course in various disciplines of medicine, surgery, and obstetrics and gynaecology before sitting for the Scottish Triple examination. They then underwent the statutory year of pre-registration in a recognised hospital before becoming eligible for full registration with the GMC to enable them to start specialty training.

In October 1988, the first batch of eight doctors proceeded to Newcastle, where they sat the Scottish Triple examination after a year. The second batch of six went to Newcastle in June 1990 and sat the examination after six months. Eventually, 11 of these doctors became consultants, including the author.

In July 1977, the GMC suspended recognition of Malta’s medical degree rcsed.ac.uk | 19

AIR POLLUTION

EVIDENCE OF A POLLUTED HISTORY

M

ost people, if asked, would be of the opinion that air pollution is worse now than in the past but, perhaps surprisingly, they would be wrong. Electricity and gas were not available in homes until the early to mid-20th century, so before that households burned candles, oil, wood and coal for light and heat, often with poor ventilation and inadequate flues. This resulted in the air inside homes being loaded with soot particles derived from these different forms of combustion.

The nuisance effect of this polluted indoor environment in staining and damaging curtains, furniture and fittings was well known.

With regards to outdoor air, John Evelyn in his pamphlet Fumifugium in the 17th century described the highly smoke-polluted nature of London air, and James Johnson in his pamphlet Change of Air said in 1837 that London had a “dense canopy of smoke that spread itself over her countless streets and squares, enveloping a million and a half human beings in murky vapour”.

The problem was due in large part to the domestic burning of coal, which had increased tenfold over the course of the 18th century.

Although the advent of electrical and

20 | Surgeons’ News | December 2017

gas power for lighting and heating eventually alleviated the problem indoors, domestic burning of coal continued to increase, exacerbating the outdoor pollution problem. This eventually led to the infamous smogs of the early and mid-20th century.

One of these, the great London smog of December 1952, caused more than 12,000 deaths and led directly to the Clean Air Act of 1956.

This legislation introduced ‘smoke control areas’ in towns and cities, where only smokeless fuels could be used, and encouraged cleaner sources of heat such as electricity and gas. The net result was to reduce the amount of smoke emanating from household fires.

In the early 19th century, people breathed in smoke particles and a proportion of these particles accumulated in the lungs. The anatomists who first carried out regular autopsies in the 18th and 19th centuries noted that as people aged their lungs became blacker in colour.

A debate ensued in which various suggestions were advanced for the origin of this black matter.

This debate should have ended in 1813 when George Pearson, a Yorkshireman

George Pearson correctly identified darkening of the lungs as being due to soot inhalation

and graduate of Edinburgh University Medical School, wrote a seminal paper describing his research. In his paper, Pearson mentions the oft-discussed darkening of the lungs with age: “As hath been repeatedly observed, the lungs generally become more dark coloured proportionately to their age.”

Pearson then made the remarkably prescient suggestion that the darkening of the lungs is due to “sooty matter taken in with the air at respiration and accumulated in proportion to the duration of life”.

He did not base this supposition on guesswork.

Being a skilled chemist, he collected the black pigment from some lungs at

SHUTTERSTOCK

Artefacts at the College’s Museums reveal the lung damage caused by urban air in previous centuries. Ken Donaldson and Chris Henry report

The great London smog of December 1952 caused more than 12,000 deaths and led directly to the Clean Air Act of 1956

Ken Donaldson Senior Research Fellow, Surgeons’ Hall Museums Chris Henry Director of Heritage, Surgeons’ Hall Museums

Domestic coalburning caused heavy pollution in urban areas in the 19th century

Paraffin section of lung tissue stained with haematoxylin and eosin. A central blood vessel is seen towards the top left and the surrounding lung tissue is heavily impregnated with black soot

autopsy and analysed it. He found it to be pure carbon, or soot, and it was on this that he based his hypothesis.

There then ensued about 50 years of argument with two main explanations being put forward. The first was that the black pigment was derived from blood. The second was that elemental carbon could be precipitated in lung tissue when the expulsion of carbon dioxide during exhalation went wrong.

A major stumbling block to acceptance of Pearson’s view, which we now know was the correct one, was Rudolf Virchow, the single most influential figure in the development of modern pathology. It was only in 1868, when Virchow finally accepted that the black matter was inhaled soot, that Pearson’s theory was given the seal of approval.

The College’s Museums have a collection of lungs from around the time Pearson was carrying out his work. To assess just how sooty lungs were at that time, a lung sample collected in 1840 was identified, and a block taken for histology and assessment of toxic heavy metals found in soot. The image (bottom left) shows the extent of black soot accumulation in the pink lung tissue of this normal individual. The dustiness of the lung is more like the appearance we would now associate with being a coal miner, underlining just how much soot there was in the air. The lung tissue was also heavily contaminated with toxic metals such as lead and mercury, and research is continuing into the source and consequences of this level of air pollution.

This study provides a window into the heavily polluted conditions a normal person would have encountered in Dickensian times. rcsed.ac.uk | 21

CONFERENCE

LEARNING W CURVES Craig McIlhenny reports on changes in the training landscape with highlights from this year’s Faculty of Surgical Trainers meeting 22 | Surgeons’ News | December 2017

ith 150 attendees on the day, the sixth Faculty of Surgical Trainers (FST) conference confirmed that ‘Time for Training’ is firmly on the agenda for all surgical trainers and trainees. The conference, supported by Medtronic, was held in The Studio in Birmingham, literally a stone’s throw from the centre of town and the train station.

Delegates came from all over the UK and from as far afield as Australia, including Professor Stephen Tobin, Dean of Education at the Australian College of Surgeons.

Changes in the current training landscape are imminent, driven by the new GMC guidelines enshrined in Excellence by Design. This will govern how training curricula are delivered, with a move towards even more competency-based, high-level outcomes being the defined endpoint of training. In addition, the Improving

The IST project will commence within a year and is designed to improve the delivery of surgical training

Surgical Training (IST) project will commence within a year and is designed to improve the delivery of surgical training. Professionalisation of trainers, with more time allocated to training in their job plans, is a key workstream of this project and one in which I, as FST Surgical Director, have a key role.

Both of these changes formed a large part of the excellent speaker presentations at the conference as well as the lively and informed discussion in the morning and afternoon sessions. David Wilkinson, lead Dean for surgery at Health Education England, delivered the keynote address and outlined what he hoped the IST project would achieve in terms of improving training. Professor John Lund gave his perspective on the project, looking at what this might mean from an SAC viewpoint. Then, Professor Jennifer Cleland and I gave the educational viewpoint.

Above, from left to right: Stella Vig, Dermot O’Riordan Helen Mohan and Craig McIlhenny Inset left: RCSEd Vice-President John Duncan gives the prize for best oral presentation to Ronnie Davies Top right: Delegates at the conference in Birmingham, which attracted 150 attendees

The panel discussion that followed highlighted the largely positive light in which trainers see the IST project, and allayed concerns raised by both trainees and trainers. Everyone left better informed and with a new enthusiasm for the project.

Earlier in the day, the conference had explored the availability of time for training outside of the IST project, with perspectives from management, trainer and trainee delivered by Dermot O’Riordan, Stella Vig and Helen Mohan. Again, a very positive message emerged regarding the importance of having time set aside for training, and how it is vital that this time is clearly identified and protected for both trainer and trainee.

The 2017 conference expanded on last year’s event by delivering more workshop sessions, with choices of non-technical skills, improved training in theatre and delivery of better feedback just some of those available. Due to the high regard in which these workshops are held and the degree of positive feedback, the FST will continue to expand its workshop delivery at the annual conference.

The end of the day was an opportunity for showcasing surgical education research. The Faculty considers the promotion of surgical education research of utmost importance, and the session was chaired

by FST Deputy Director Alexander Phillips. The first two presentations highlighted the quality of the winners of the combined FST/ASME research grant, with presentations by last year’s winner and the proposal from this year’s winner. This was followed by our free paper session. We had a record number of abstract submissions in 2017, which was demonstrated by the quality of both poster and oral presentations.

RCSEd Vice-President John Duncan presented the prizes for best oral and poster presentation to Ronnie Davies and Anna Porter.

Craig McIlhenny FST Surgical Director rcsed.ac.uk | 23

TRAINING

On the record How the new ISCP/FST Trainer Portfolio is designed to support the Faculty of Surgical Trainers’ standards and improve training

I

24 | Surgeons’ News | December 2017

By Craig McIlhenny, Maria Bussey, Gareth Griffiths and William Allum

The new Trainer Portfolio will collate trainer activity and map it to the FST Standards for Surgical Trainers The Trainer Profile will be the first section available.

This consists of an overview of the named trainer role(s) you hold, and sections for you to complete detailing the clinical areas in which you can offer training. In addition to clinical training, there will be a section asking about what training you can deliver that aligns with the Generic Professional Capabilities (GPCs). This framework has been introduced by the GMC to specifically target concerns raised through its fitness-to-practise process and through public enquiries into high-profile problems within the NHS. The GPCs reinforce the professionalism of medical practitioners through professional values and behaviour, health promotion, leadership, teamworking, patient safety, quality improvement, safeguarding vulnerable groups, education, training and assessing clinical research.

SHUTTERSTOCK

f you hold a named trainer role (clinical supervisor or educational supervisor), you will by now be familiar with the requirement for trainer recognition by the General Medical Council (GMC). Currently, this process of ongoing recognition is based on the Academy of Medical Educators’ (AoME) seven domains of competence that are generic rather than surgeryspecific. Recognising that a surgery-specific model would be more desirable and acceptable, the Faculty of Surgical Trainers (FST) refined the AoME standards into the FST Standards for Surgical Trainers. These standards map directly to the AoME standards, so that they meet GMC requirements, but in a manner specific to surgical training.

The underlying intention behind the GMC’s requirements is to improve training. The ISCP/FST Trainer Portfolio supports this intention. It is not designed simply for trainers to tick off a requirement, but to stimulate them to think about the training they deliver and, in so doing, improve it.

As a trainer, you already spend a considerable amount of time and effort using the Intercollegiate Surgical Curriculum Programme (ISCP) for the benefit of your trainees, enabling them to record and show evidence of their progress through the training programme. However, until now, there has been no section of the ISCP dedicated to you as a trainer. The advent of GMC trainer recognition means trainers must also record and show evidence of their own progress and activity.

To fulfil this need, the ISCP and FST have collaborated on a project to design the new Trainer Portfolio, which will collate trainer activity and map it to the FST Standards for Surgical Trainers.

The Portfolio is divided into seven sections to enable simple recording and display of your activity: l Trainer Profile l Trainee Feedback l Peer Trainer Feedback l Assessment Summary l Reflective Notes l Document Library l Trainer Dashboard

These tools will allow feedback from your trainees, asking specific questions based on the FST Standards

Within the Trainer Profile you will also be able to record any other training roles or positions you hold, such as Training Programme Director, membership of training committees and any external teaching and training you do. Everything you enter into the Trainer Profile will be mapped to the relevant FST Standard.

The Portfolio will have interactive Peer Trainer and Trainee Feedback tools built in. To develop as trainers, it is important that we receive constructive feedback on our performance, just as our constructive feedback to our trainees is vital for improving their performance.

These tools will allow feedback from your trainees and other trainers, asking specific questions based on the FST Standards and inviting free comments to make the feedback as useful as possible. Anonymised data from these feedback tools will be converted into personalised feedback summaries when a minimum of five questionnaires have been received and automatically mapped to the relevant domains of the FST Standards.

As a user of ISCP, you will be very familiar with filling in workplace-based assessments for your trainees,

FURTHER READING

1. Academy of Medical Educators (2010): A framework for the professional development of postgraduate medical supervisors.

London, AoME 2. Faculty of Surgical Trainers (2014): Standards for surgical trainers. Edinburgh, FST 3. General Medical Council (2017): Generic professional capabilities framework.

London, GMC 4. General Medical Council (2012): Recognising and approving trainers: the implementation plan. London, GMC

and the Portfolio will automatically record and show evidence of this work, again mapping to the relevant domains of the FST Standards, in the Assessment Summary section. This will minimise any additional work in recording this activity separately.

The Portfolio will give you the opportunity to enter a series of guided Reflective Notes. If there are areas of the FST Standards against which you have no specific evidence, you can complete a Reflective Note against that framework area to provide evidence, thus minimising any areas of weakness within the Portfolio.

Suggestions will be included describing the type of work you may wish to reflect on for each of the framework areas within the Standards.

The Document Library in the Portfolio is where you will be able to collect any evidence of training activity or educational continuing professional development (CPD), such as course certificates or certificates for acting as course faculty. When uploading these documents, you will be prompted to map them to the correct FST Standards domain, so that this activity is captured accurately and easily.

The Portfolio will generate output that, at its simplest, will consist of a grid (the Trainer Dashboard) showing all the domains and framework areas, indicating those against which you have entered evidence. This will provide an easy-to-understand summary that, along with the detail from your Portfolio, you will be able to download as a PDF file, which you can then include in your own appraisal system to use with your appraiser as the basis for continuing recognition as a trainer with the GMC. It is important to remember that the Portfolio is simply an enhanced tool to enable you to collect and collate evidence of your training activity.

The Portfolio itself does not make any judgement on the strength or quality of evidence you have recorded within it. Guidance from the Faculty of Surgical Trainers suggests that we should aim to produce evidence for every standard over a fiveyear revalidation cycle, and we should aim to produce evidence within each of the seven domains in every year. Judgement of the quality of the evidence collected and decisions about ongoing recognition status lie with the appraiser.

The Portfolio is designed with the surgical trainer in mind. It should provide an easy route for the provision of the evidence required for ongoing trainer recognition.

It should sit easily beside whatever system your trust or health board currently uses for appraisal. For it to be successful it will require surgeons to use it and provide feedback on how it performs. Most importantly, we hope it will contribute to improving the quality of training by helping us understand what it takes to carry out this very important role well. rcsed.ac.uk | 25

YOUNGER FELLOWS’ FORUM

IT’S GOOD TO TALK

From bullying to team building, there was much to discuss at the inaugural RCSEd Younger Fellows’ Forum, writes Peter Driscoll and, right, Mark Peter reports on a group discussion on recruitment and retention

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n a new and exciting venture for the College, on 15 and 16 June 2017 the RCSEd Younger Fellows’ Forum took place at Carden Park Hotel, just outside Chester in beautiful countryside. Eighteen young Fellows of the College from all surgical specialties were joined by the President and several members of both the College Council and the RCSEd Younger Fellows’ Committee with the remit of exploring the real issues affecting Fellows in their early years of practice, while learning from others in high-pressure roles.

The Forum was fully funded by the College, with delegates chosen from written applications, illustrating how the College wants to involve younger Fellows in its future role in surgery.

Clare McNaught, Chair of the RCSEd Younger Fellows’ Committee, opened the meeting, after which there was a discussion led by the delegates on the challenges faced in consultant practice. Unsurprisingly perhaps, little of this involved actual surgery, but instead hinged on issues such as complications, complaints and colleagues, as well

26 | Surgeons’ News | December 2017

Peter Driscoll and Mark Peter Co-Convenors and founding members of the RCSEd Younger Fellows’ group

as maintaining health and happiness, both in and away from work.

The Forum was truly inspired by a talk by Captain Karl Ley, Bomb Disposal Training Officer, who recounted stories of the Falklands, Northern Ireland, Iraq and Afghanistan. We quickly realised that even in the highestpressure moments of our surgical practice, at least we were not being shot at.

After a break for lunch, delegates and faculty were organised into three groups for a competitive teambuilding exercise. It was encouraging to see each group immediately forming a cohesive team to take the tasks forward, even though we had mostly never met before.

Any perceived barriers were broken down with delegates quickly forgetting (well, almost) that ‘Mike’ happened to be the President of the College.

Simon Paterson-Brown talked about building a successful surgical team, highlighting the critical role of non-technical skills in and out of theatre. The Forum went on to develop these skills over dinner.

IN CONVERSATION Mark Peter chaired a debate on how to persuade people to make a career in surgery WHY ARE PEOPLE NOT APPLYING FOR SURGERY? EDWARD: I think the structure of surgical training is difficult: if you don’t get in at the start of core training, you’re into another pathway and it seems difficult to change your mind and swap.

ANDREW: A lot of juniors are going to Australia and New Zealand – they used to go for a year or two, but now many are staying out there.

PETER: When I trained, we did three-month stints in surgical specialties in medical school, so you had real hands-on experience of what surgery is about.

You got into theatre, looked after the patients, helped with the houseman. Now medical students get very little of that – they don’t see the fun stuff because they’re not in the post for long enough.

We had an early start on 16 June with yoga for many, in parallel with a small group discussion on the theme of recruitment and retention in surgery, run by coconvenor Mark Peter and myself, identifying interesting themes reported elsewhere (see right). Next, we were inspired by GP Dr Alistair Sutcliffe, the first man to successfully conquer the seven highest peaks of the seven continents (the Seven Summit Challenge). Through his reminiscences and photographs, he left the Forum speechless as he recounted his near-death experiences both at altitude and closer to home.

This was followed by discussion of current issues that were felt to deserve the attention of the College, with notes taken by the President himself.

After only a day and a half, delegates left the inaugural Younger Fellows’ Forum having put the world to rights and with a real sense that the College cared about them, both as individuals and as the future standard bearers for the RCSEd. More importantly perhaps, delegates and faculty parted knowing that the enthusiasm and drive that brought each of us into the profession is alive and well in our young Fellows. Surgery is in safe hands.

The second Younger Fellows’ Forum is planned for 2019 and is open to all applicants in their first 10 years of Fellowship.

The discussion hinged on issues such as complications, complaints and colleagues

Younger Fellows are working hard to change surgical culture and to prevent bullying

RAJIV: I also think there’s a change in the role of each stage within training and that perhaps puts a lot of people off. Speaking to CT1s [Core Training Year 1], a lot of them actually applied for an ENT [ear, nose and throat] job, rather than going for a general surgery job. When I ask why, they say they don’t want to be clerking patients in A&E at 3am when they’re 36 and have a family.

LISHA: I get the feeling there’s been political pressure on trainees at university, that they’re being incentivised to go into general practice and being discouraged from going into hospital medicine and surgery.

MARK: I think that’s right: the government is pushing very hard for public health, psychiatry, mental health and GPs. About 10 years ago, we were trying to adopt a Scandinavian model of workforce planning, but it’s quite hard to predict in the UK for various reasons.

LISHA: In Europe they used to have a similar system. It was ranked on how well you did in your exams and the top scorers got into surgery.

MARK: There are still very high-calibre individuals applying for surgery, which I saw when interviewing for core surgical training earlier in the year. Now, though, people who would have applied 10 years ago are thinking of a variety of careers, and a lot of them are outside medicine.

rcsed.ac.uk | 27

YOUNGER FELLOWS’ FORUM

Maybe we should formalise the taster sessions, like a three-course taster menu in a Michelin-starred restaurant

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ANDREW: We have a CT who was devastated recently because he has to do six months of orthopaedics and he wants to do plastics. I tried to impress on him how valuable this will be. There is this sort of rush to get into a specialty. I think if people don’t try it, it is not an informed decision of that chosen specialty – they don’t have other options to think: “Well, actually, I did enjoy my time in orthopaedics.”

MARK: When I organise taster days at F1 level, I make sure they follow all three tiers. At core training level, I tell them to follow the ‘mundane stuff’ – doing ward rounds, organising scans, organising lists – because that’s where you’ll see what the ‘bad’ bit is like. Then follow the registrar when they’re on call so you see the variety of stuff they do, then follow the consultant. The feedback is always really good, because they feel more involved and they get an insight into why people are stressed, upset or tired.

EDWARD: So maybe we should formalise the taster sessions, like a three-course taster menu in a Michelin-starred restaurant.

LISHA: I don’t think we do counselling very well for our medical students. We don’t ask: “What do you want to do? Why do you want to do that? What do you perceive your life is going to be like in the next 10, 20, 30 years? What do you want your work/ life balance to be? Do you want a family? Do you want to be resident and on call?” If you actually drill down to what they want out of life, it’s very different at the age of 24 to what it will be at 30, 40, 50. What they need to think about is what it’s going to

be like at those stages because that’s what they’re going to do for 30 years.

Forum delegates had the opportunity to listen to inspirational speakers

ANDREW: But there is a sort of arrogance in surgery sometimes where we think the cream of medical school will automatically come to your specialty because it’s the best and you don’t realise you actually have to sell your specialty in the same way the trainees have to sell themselves to you. I don’t think you can just say: “They will come because we’re the best.”

HOW CAN WE MAKE SURGERY MORE ATTRACTIVE? RAJIV: For me, I think it’s all about making [trainees] feel like they belong at a very early level. I spent some time at the Cleveland Clinic in Miami and seeing their team dynamics was great. They did ward rounds together and they all sat down for breakfast together afterwards, and then they went off to theatre with the intern.

LISHA: I think it’s very difficult to bring the team structure back again, because the way we work – 48 hours and leave – makes it incredibly hard to do that. However, there are still ways of making people feel included. As consultants, we do a week on call, so every morning you meet the team. In the office, we sit down as a team and go through our list of patients, and then go around as a team.

When we have new people, we ask them to stand up in our monthly meeting and show some pictures of themselves and things they do outside medicine, so then we know who they are, their aspirations, what their life’s like.

28 | Surgeons’ News | December 2017

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4 5

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PETER: But the whole concept of the team really has been eroded. There’s this idea that we’re all part of one big team. If you’re an employer with 5,000 people, that’s not a big team, that’s a huge number of individuals.

EDWARD: I think this is a theme that keeps coming back around the table, isn’t it? That’s what we remember.

So we need to promote teams, even if it’s just an article saying five key things you can do for your team.

SUMMARY The table felt that NHS morale is at a nadir. Undoubtedly this has affected recruitment and retention into perceived ‘difficult’ specialties, as well as contributing to the rate of burnout we are seeing. However, we felt there are things we can do as a College to help.

Reinvigorating the team spirit, incentivising good team morale and training people to foster good team behaviour were some of the suggestions.

Perhaps even a formal College supported role of team builder? A team that plays well together, works well together, and it may just help others realise what a rewarding and fulfilling career surgery is.

THE PANEL 1 LISHA

McCLELLAND

2 In groups, delegates took part in teambuilding exercises

ROBERT WHITFIELD

3 PETER DRISCOLL 4 ANDREW DIVER

5 6

MARK PETER (PANEL CHAIR) EDWARD FLOOK RAJIV

7 DAVE

We need to promote teams, even if it’s just an article saying five key things you can do for your team rcsed.ac.uk | 29

MAJOR INCIDENTS

A PRODUCT OF OUR TIME Brigadier Tim Hodgetts explains the citizenAID initiative, designed to help the public save lives after shooting, bombing or stabbing attacks

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n November 2016, the RCSEd gave its support to the launch of the citizenAID initiative to improve public resilience to save lives in the aftermath of a deliberate attack. This was to prove a timely intervention, given the series of subsequent attacks in the UK throughout 2017. This article provides the history behind the citizenAID initiative, its early implementation, and the plans for spreading the message of preparedness nationally and internationally.

It is perhaps difficult to accept that terrorist attacks in the UK have become frequent enough to demand that as individuals we prepare for the unlikely but not impossible event we are caught up in one. In parallel, healthcare professionals must recognise that we have a responsibility to support dissemination of information and

30 | Surgeons’ News | December 2017

Brigadier Tim Hodgetts CBE Co-founder, citizenAID

The citizenAID app gives stepby-step guidance on dealing with emergencies

skills that improve public health through effective immediate action when confronted with serious injury.

Public health has undoubtedly benefited from a sustained campaign to teach how to manage an ischaemic cardiac arrest. But if we are to instil within a similar critical mass of the public the culture of a consistent and effective response to serious injury, it demands a compressed timeline. The threat is existential. Can we really wait for this capability to build over the next 10 or 20 years?

War provides a rich ground for medical advances. It is a paradox, but one that has been exploited repeatedly throughout history. In the ensuing peace, advances spread to civilian practice. Recent conflicts in Iraq and Afghanistan are no different in this respect. A host of advances in the management of the critically injured have already been transferred to pre-hospital and hospital care within both the UK NHS and thirdsector medical charities.

What has been missing in the context of deliberate attack is transfer of military medical knowhow and skills to those who are at the scene when the incident occurs.

Professional help from healthcare responders will be predictably delayed when there is an active security threat. The only people who can make a difference, in particular to arrest life-threatening external bleeding, are those who are already there. The public. This is the rationale for citizenAID. The concepts that underpin citizenAID are grounded in the reality of experience of managing multiplecasualty incidents and have been

tested over the last 20 years. The catalyst can be traced to the terrorist bombing of Musgrave Park Hospital, Belfast, in 1991. This was one of the principal motivational drivers behind the development of the Major Incident Medical Management and Support (MIMMS) course, which established itself progressively as a national and international standard from 1993.

The seven ‘all hazard’ principles of MIMMS (Command, Safety, Communication, Assessment, Triage, Treatment, Transport) were distilled in 1998 to create an even simpler approach for every British soldier within ‘battlefield casualty drills’.

This is ‘Control then ACT’ (Assess, Communicate, Triage), which is accompanied by a series of treatment drills that have been serially refined through operational experience, but the structural approach has endured. It has become the first step in the military chain of trauma care

that has proven exceptional and unprecedented clinical outcomes, and has assured the importance of a systematic approach to multiple casualties within military culture.

This deep experience is transferred within citizenAID. The national police programme for reaction to a firearms or knife attack is known as Project Griffin and began in 2004. It has passed on valuable preparation advice to ‘Run, Hide, Tell’ in such incidents to a swathe of industry, with more recent communications campaigns more overtly drawing the general public’s attention to the advice. The National Counter Terrorism Security Office is now spearheading a campaign

citizenAID aims to empower the general public with a generic response to attack

to deliver the message to children aged 11–16 years in the ACT for Youth initiative (Action Counters Terrorism). In parallel, the British Transport Police have a prominent campaign to encourage the public to report anything suspicious on the rail network using 61016 as a dedicated text number – ‘See it, Say it, Sorted’ can be heard every few minutes at all railway stations. citizenAID is wider than these focused campaigns in a number of ways. It aims to empower the general public with a generic response to any threat that causes multiple casualties from a deliberate attack.

The first version of the free public app, released at the beginning of 2017, allows selection from ‘Suspect bomb’, ‘Exploded bomb’, ‘Knife attack’ and ‘Active shooter’.

Events in mainland Europe and UK have overtaken these as the only threats, where terrorists have used vehicles as weapons and criminals

In light of changes in terrorist tactics, citizenAID is being updated to include vehicle-as-aweapon attack

have used acid. An upgrade to the app, to be released this year, will include guidance for ‘Vehicle as a Weapon’ (VAAW) and ‘Acid attack’, noting that the principles of action for VAAW follow the same Control then ACT architecture.

A film simulating a bomb at a station and showing the citizenAID system in use by ordinary people has been sponsored by the College. Its release was timely as it was posted online just three weeks before the Manchester Arena bomb on 22 May 2017, which killed 22 people. It has not been possible to assess the impact of this film on the public response to the injured in Manchester, or of the app that was released earlier in the year, but it has certainly highlighted the relevance. The public’s initiative to improvise treatment equipment was widely reported and this is a feature of citizenAID. In July 2017, citizenAID trialled materials for schools, supported by rcsed.ac.uk | 31

MAJOR INCIDENTS

Birmingham City Council. Almost 500 teachers were familiarised with the knowledge base, the app and the skills to improvise treatment to stop life-threatening bleeding.

Overwhelmingly positive feedback was received that identified 100% of teachers both supported the content and the use of cartoons to express the messaging to children. Of the teachers responding to the real-time electronic survey, 66% were from primary schools.

The materials for primary schools are presented as two allegories – a cat loose in a school of mice (a book with accompanying nursery rhymes) and an escaped lion. Whether educating adults or children the sequence of actions is exactly the same – run, hide, tell and, when safe to do so, treat.

For primary school children, first-aid treatment is shown being delivered by adults. The intent is to provide age-contextualised material to educate without creating alarm or anxiety (as the slogan goes: ‘to be prepared, not scared’). The counternarrative is that deliberate attacks are so rare they do not warrant teaching children. The response is we already educate children how to react if there is a fire at school and to ‘stranger danger’: this is one additional step to safeguarding them. The immediate actions are also relevant to the wider context of ‘anyone trying to hurt you’. citizenAID has had some substantial early success. Within 48 hours of the launch of the free app, it was trending as the number one download on

The failure to use a tourniquet when it is justified cannot be mitigated, as it will likely result in an early avoidable death Google Play and iTunes. Publicity through national TV and radio, including following major incidents, have led to enormous spikes of activity on the website. This tells us that the public is interested in the information and wants to be empowered.

The international interest has been humbling and internationalisation has begun, although the early priority remains to provide the resilience to our UK audience first. A Level 2 Ofqual-approved course has been established, to be delivered through existing providers of first-aid training.

New equipment has been designed, including a patented device to convert clothing into a tourniquet, creating a solution that is genuinely affordable for the public.

It might appear that implementing such change is easy, but it is not. It has taken tremendous commitment from a small group of clinicians working with a philanthropic objective to improve public preparedness and patient outcomes.

It has demanded cross-government department and institutional liaison: the issue does not sit simply with health, security, resilience or education, but with shared stakeholder interests across these areas. There has been no central funding to achieve the outputs, with

The citizenAID initiative uses cartoons to help educate the public on the best course of action after an attack

the enabling financial support coming from charitable donations.

Sir Basil Liddell-Hart, an interwar strategist, wrote: “The only thing harder than getting a new idea in, is getting an old one out”. While he was writing about the context of the military mindset, this rings true for implementing disruptive change in any field. The argument regarding the use of tourniquets in first aid has resurfaced, despite the categorical proven evidence of effect from both the UK and US on recent operations.

In many people’s minds, the inverted logic for using a tourniquet – ‘if you apply a tourniquet for the wrong reason, it can do harm’ – still dominates the ‘if you apply a tourniquet for the right reason, it will save life’ logic. This potentially disenfranchises the very group of patients citizenAID is trying to save – those with devastating limb trauma from blast and gunshot. Poor clinical decision-making can, however, be mitigated by good training and distributed advice. The failure to use a tourniquet when it is justified (lifethreatening limb bleeding that cannot be controlled by other means) cannot be mitigated, as it will likely result in an early avoidable death before access to professional healthcare. At some stage, continued inertia to this fact will become neglect. citizenAID is a product of our time.

It would be difficult to imagine that the same traction for development would have been possible even as recently as 2016. Sadly, as is often the case, it has taken a series of tragedies for the relevance to be accepted ‘at home’ and for it to be a high enough priority to become institutionalised.

It will remain a challenge to sustain awareness of citizenAID in the public eye and build on this early success to ensure preparedness for the next event. We will be adaptable to any emerging trends so the clinical advice is applicable in all likely situations. citizenAID is grateful to the RCSEd for its vision and ‘early adopter’ support for the initiative. We still have much to do. The public and our future patients deserve it. We look forward to doing this together.

Don’t miss Brigadier Hodgetts’ Triennial Conference keynote ‘Teamwork: Building and Sustaining Successful Teams’

32 | Surgeons’ News | December 2017

rcsed.ac.uk | 33

MAJOR INCIDENTS

MANCHESTER ARENA BOMB Stuart Clark reports on the response to the terrorist attack and how the medical teams were able to act quickly and effectively

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hen a suicide bomber detonated his device after an Ariana Grande concert at the Manchester Arena in May, killing 22 and injuring many more, trauma teams were ready, thanks to the Manchester Trauma Collaboration.

Established in 2012 to rationalise the trauma service of Greater Manchester, the collaboration undertook regular exercises, planning and testing for mass casualty events, drawing on the specialist services of various hospitals in the area. In March 2017, an exercise concentrated on the dispersal of mass casualties, rehearsing the lessons learnt from the Paris attacks. Many involved in this exercise were on call on 22 May 2017, when their planning was put to the test. The first call was received at 10.32pm and a major incident declared at 10.46pm.

The on-scene triage and distribution worked well, with

34 | Surgeons’ News | December 2017

Stuart Clark RCSEd Council Member and Oral and Maxillofacial Surgeon

An Ariana Grande concert was targeted by a suicide bomber

patients dispersed directly to the appropriate hospital. This had significant benefits for patient care, reducing secondary transfer, as well as attempting to rationalise the flow of a large influx of major casualties.

Receiving hospitals did not need the precise details of casualty numbers, but estimates were useful in assisting with precious resources such as blood products.

Some 160 casualties went to hospital, with others receiving treatment on their return home outside the Greater Manchester area.

All the hospitals created capacity very rapidly with the clearance of the emergency department (ED), reception wards and critical care.

Capacity is determined by surgical and critical care capacity rather than the ED’s capacity to treat.

Trauma management is dynamic, with repeat triage on arrival at the ED being important.

Eighty-seven casualties were admitted to hospitals throughout Manchester, with Manchester Royal Infirmary and Royal Manchester Children’s Hospital taking the most.

Twenty-eight people were admitted to critical care.

The concert attracted many children, and one of the significant learning points was the need to keep parents and children together, both at the casualty clearing station and hospital. If large numbers of children are among the casualties, it may be appropriate to consider the use of adult critical care facilities for children over the age of 12.

WhatsApp groups were rapidly set up. This provided an excellent and secure means of communication

between teams within the hospital, and helped take some of the stress out of the situation.

Throughout the night, in several hospitals across Greater Manchester, multiple operating theatres opened with staff keen to offer their services.

As the military have found, this surgery of damage limitation should be kept to one hour and is in tandem with damage-limitation resuscitation.

It was essential to keep staff in reserve to take over the following morning. This continuity of care must be strongly emphasised in any planning so that the relieving staff do not feel like ‘second-class citizens’ just because they were not used in the initial response.

There was great pressure on the blood transfusion service, with blood mobilised rapidly from around the country. In future incidents, there should be an early alert to this service and haematologists, with porters dedicated to keeping multiple units of O-negative blood in the ED. The blood demand was ongoing in the days following the Manchester

attack, with hundreds of hours of reconstructive surgery performed.

This surgery impacts on the hospital for at least two weeks after an event and is longer than anticipated. It may be appropriate for the major trauma centre to consider diverting regional trauma to other centres while this is going on.

The wounds in Manchester were of a ballistic blast pattern, often with significant tissue loss and foreign bodies. These injuries may appear benign after primary wound debridement and removal of shrapnel, but they are complex, requiring whole-body CT and multiple debridement procedures over the following days. It was thought important to undertake thorough tertiary surveys due to multiple soft-tissue wounds. In addition, imaging requires a second review because of the complexity of blast injuries, which have unusual injury patterns and, potentially, unusual infections.

The removal of shrapnel can be difficult, and involves good

In future incidents, there should be alerts to the service and haematologists, with porters dedicated to keeping multiple units of O-negative blood in ED decision making to assess the risks and benefits considering the composition of the foreign body.

Such surgery does not take place during the damage-limitation phase.

The shrapnel that is removed is also considered to be forensic evidence.

Definitive internal fixation was initially avoided, with external fixation being the mainstay of fracture stabilisation for orthopaedics and oral and maxillofacial surgery.

Despite all the planning, some processes had to be introduced that may not have been previously considered – for example, all casualties had an audiology assessment when medical teams realised that the shockwave

The on-scene triage teams took patients directly to the appropriate hospitals to avoid secondary transfer

from the blast could have affected their hearing.

The psychological impact of such an incident can be massive.

Psychological care should start in the ED with coverage for all groups, including injured adults, children, uninjured children of parents who are injured and staff. The parents and relatives of staff need help managing media and social media, and children are the most vulnerable of all. Injured parents should be kept with injured children if at all possible – parents do not want to have reconstructive surgery on the same day as their child.

Throughout the crisis, the clinical and support staff of the hospitals throughout Greater Manchester stepped up to respond to an extreme event. This reaction was not isolated to the NHS, with medical supply companies contacting clinicians offering ‘whatever you want’ in an effort to assist. Spontaneous, unsolicited deliveries of pizzas, sandwiches and snacks were also greatly appreciated. rcsed.ac.uk | 35

MAJOR INCIDENTS

‘EVERYTHING WAS INCREDIBLY CALM’ Naomi Davis explains how the Royal Manchester Children’s Hospital coped in the aftermath of the Manchester Arena attack

36 | Surgeons’ News | December 2017

Naomi Davis Consultant Paediatric Orthopaedic Surgeon, Royal Manchester Children’s Hospital, and Clinical Lead, North West Children’s Major Trauma Network

Patients and staff appreciated the visits by HM The Queen and other VIPs. Management of these would be best done by a designated team not involved in immediate patient management.

8am. However, every neurosurgical consultant was required that night.

I arrived at the hospital at midnight and everything was incredibly calm. The Paediatric Emergency Department was full of people, but it was quiet and ordered.

Colleagues who had been through Operation Socrates were there and it was good to join them. Trauma teams were set up to receive the injured and follow them through from PED, via CT and up to either PICU or theatre.

Our paediatricians were working hard to clear beds, manage medical emergencies and in-patients.

The on-call CAMHS team were in supporting families and have been by our sides ever since. Our management colleagues set up the communication routes through silver and gold command, reunited parents and children and supported the clinical work. Nursing staff, radiologists, porters, cleaners, ministers, the whole hospital team were focused, quiet, working.

Neurosurgeons were buddy working so there were at least two around every patient to make the decision-making process really fast PICUs are used to receiving patients somewhat better prepared than they were that night, but they quickly arranged trolleys of the equipment they needed to manage each patient.

One of our consultant anaesthetists, with a group of middle grades, did a ward round on the admitted children in the middle of the night, picking up emerging problems and arranging timely transfer to ICU or into theatre.

At least two surgeons were in every theatre, making decisions quickly and all of our patients had their initial surgery before the following evening.

Over the next two weeks, we had acute MDTs in theatre at 8am and 4pm every day to plan treatment and surgery. Our microbiology, haematology and rehabilitation teams were closely involved. Daily rehabilitation MDTs discussed everything from hearing tests, wheelchairs and which children would be OK to go to the ‘I Love Manchester’ concert.

Bomb-related injuries are now rare in the UK and the encouraging advice from the ballistics expert surgical team from Birmingham really helped.

Lives were saved that night.

I’ve seen the NHS at its best and it’s truly amazing.

PETER BYRNE/AFP/GETTY IMAGES

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hile nothing could have fully prepared the emergency services in Manchester for the impact of the events on the night of 22 May 2017, considerable planning had been done since the Paris attacks, under the auspices of NHS England. This planning undoubtedly made a difference to the care we were, and still are, delivering to the victims of the attack and to our staff.

Like all hospitals, we have a major incident plan and we practise it.

Damage control surgery courses, that teach wound washout without closure, rapid external fixation and short surgery times have been rolled out. These also train in some of the command mechanisms used by the military to triage and manage patient flows.

We had a patient distribution plan within the Greater Manchester Major Trauma Service and had practised it just six weeks before the incident with a city-wide table-top exercise – Operation Socrates. From this we learnt how to clear beds on the wards and ICU, understood how many theatres, anaesthetists and surgeons we might have available and how to manage teams to maintain care, not just for the first few hours but over the coming days.

Personally, I also learnt that although there is a great temptation to get the first child admitted with an open fracture into an available theatre, that might mean that operating on a child with a time-dependent head injury is critically delayed.

When the Arena Major Incident was declared, we called half of most of the specialty teams in that night with the others ready to take over at

Going forward We should be mindful that the next attack won’t be the same and some of the lessons from the London attacks are different from ours.

On a practical level, we have made some minor changes to our major incident plan and how we identify patients as they come in.

We should remember medical, nursing and other trainees who may be involved in care but, due to differing rotas, may not be able to access all the post-incident debriefs and support.

The effect of social media needs to be managed. While on the one hand it did assist in identifying some patients, there have been incidents of the information being used unfortunately and guidance is in preparation.

There is now a central store for external fixators in the country,

available within five hours for emergency use.

We were able to nurse injured parents next to their children as we are co-located with the Manchester Royal Infirmary and they could easily be taken down the corridor for their surgery. We timed child and parent surgery so that everyone felt they were able to appropriately support their family members. Other children’s hospitals are looking into their capacity for a similar arrangement if required.

The Greater Manchester Academic Centre for Acute Care and Trauma with TARN are collating data to help to inform future responses.

There is ongoing ‘legacy’ work on rehabilitation with the Greater Manchester Health and Social Care Partnership, who supported early

There is now a national supply of external fixators

discharge, community therapies and return to education. The Partnership is working with us to shape what we hope is the future for gold standard rehabilitation for all ages.

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MAJOR INCIDENTS

‘DON’T THINK IT WILL NOT HAPPEN’ Ken Dunn looks at how an IRA bomb helped plastic surgeons prepare for multiple-casualty events

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n my first year as a consultant in 1996 I was on call at the time of the IRA Manchester bombing. The organisation of the plastic surgery cover across the Manchester EDs at that time by my senior colleague Peter Davenport taught us important lessons in how to react to such an event. Our subsequent preparation for a major incident as a burns and plastic surgery department was based on his approach and what we gleaned from the Paris attacks debriefing organised in Birmingham.

The understanding that most, if not all, casualties would require plastic surgery input caused us in late 2016 to arrange meetings with neighbouring plastic surgery departments in Liverpool, the Christie Hospital and Preston to put in place mutual support arrangements across northwest England.

On 22 May one of the two consultants on call for burns and plastic surgery in the city called me in while she was on her way to the Children’s Hospital leaving her colleague at UHSM. I joined him at 1am and started calling consultant plastic surgeons in to attend every ED expected to receive injuries according to the Manchester plan.

All sites were attended by two plastic surgeons by 4am and information started to flow via an already established WhatsApp group.

The surgeons left at home to pick up in the morning from the overnight teams attended promptly the next

A tipping point would have been reached quite soon had the event been larger 38 | Surgeons’ News | December 2017

Ken Dunn Consultant Burn and Plastic Surgeon, University Hospital South Manchester

Experience with smaller-scale explosives events proved beneficial following the Manchester Arena bombing

day while offers of help arrived from colleagues near and far. We made use of them in the subsequent days to help cover the four major sites where the injured were being treated and where they had to remain.

As a result of the extraordinary accuracy of the initial triage at scene very few secondary transfers were needed. However coordinating surgical teams across all sites required a huge amount of organisational effort, communication and flexibility by my orthopaedic and plastic surgery colleagues who picked this all up from day one.

In terms of the injuries themselves, it proved not so much about having experience with bomb-blast injuries but understanding the principles of their management and being regularly involved in the management of other forms of complex trauma.

In burns and plastic surgery, patients frequently arrive following smallerscale explosive events and with complex contaminated wounds.

Early involvement of surgeons with this form of experience was pivotal in establishing effective surgical plans. The support of our military colleagues from Birmingham in the days after the event was helpful and

reassuring given their experience with high-energy injuries.

The debriefs that have taken place have highlighted a number of important and unanticipated shortfalls in our planning, which we are currently correcting. A significant matter for us during the initial response was finding out which surgeons were in or around Manchester and available on the night of the event. Communication across the city between surgical teams and knowing where the patients are who require specialist input and when their next theatre visit would or should be was a major challenge of coordination.

Similarly the length of time a service such as ours took to return to what could be regarded as normal activity across our 12 sites was far longer than that anticipated by our hospital or indeed any of the resilience plans in place. This includes the need for staff being able to normalise after such an event so they can return to routine activity without feeling ‘deflated’, for want of a better word. This took time, support and understanding.

The plans we had worked well for the size of the event but there is a general realisation that a tipping point would have been reached quite soon had the event been larger. We are aware that these lessons are acknowledged and very much hope will be taken on board in future plans.

My advice to all medical practitioners is, do not think it will not happen on your patch.

Assume it will and plan for it in detail. Hopefully you will not need it, but if you do, the one thing you can count on is that NHS staff will respond above and beyond your expectations.

DATES FOR YOUR DIARY The latest surgical and dental events, seminars and courses NOVEMBER 15 Musculoskeletal Course for GPs/GPSTs (Birmingham) 15 Leadership and Development (Birmingham) 17 Future Surgeons: Critical Care 18 Future Surgeons Key Skills (Aberdeen) 20–21 Core Skills in Urology Modules III and IV 22 Preparation for the Diploma in Implant Dentistry (London) 25–26 Future Surgeons: Key Skills (Liverpool) 28 NOTSS (London Royal Marsden) 30– Facial Aesthetic Surgery: Dissection Course for Surgeons 1 Dec 30 NOTSS (Dundee) DECEMBER 7–8 Basic Surgical Skills 12 PINTS (Birmingham) 15 Core Skills in Vascular Surgery 15 Plastering Techniques for Fracture Treatment (Leeds)

JANUARY 7–9 Aberdeen MRCS Mock OSCE 11–12 Anatomy for MRCS OSCE 13–14 The Edinburgh MRCS OSCE Preparation Course 13–14 Basic Surgical Skills (Manchester) 18–19 Basic Surgical Skills 24 Preparation for the Diploma in Implant Dentistry (London) 25–26 VDP Study Day 29–30 The Edinburgh Head and Neck Course – Module I 31–1, The Edinburgh Head and Neck Course – Module II 2 Feb FEBRUARY 1–2 Neuroradiology Workshop for Neurosurgeons 7–9 ATLS 16 Future Surgeons: Key Skills (Edinburgh) MARCH 22–23 RCSEd Triennial Conference

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

WORKPLACE SUPPORT

SHARING AND CARING

With the College on a mission to change the culture of bullying and undermining in the profession, Aggie Rice explains how Schwartz Rounds could help

40 | Surgeons’ News | December 2017

Aggie Rice Schwartz Programme Manager, The Point of Care Foundation

Before his death, Schwartz left a legacy for the establishment of the Schwartz Center in Boston to help foster compassion in healthcare. The Schwartz Center for Compassionate Healthcare has supported more than 400 organisations in the US, and in Canada, Australia and New Zealand more recently, to introduce Schwartz Rounds (Rounds).

The Rounds programme is run in the UK and Ireland by The Point of Care Foundation, an independent not-for-profit organisation with a mission to humanise healthcare.

Underpinning our work is the premise that in order to be able to provide compassionate care, staff need to feel they are being listened to and supported. We do this by assisting them to set up and sustain Schwartz Rounds in their organisations.

Rounds, which are underpinned by robust research evidence, provide an opportunity for staff from all disciplines to reflect on the emotional aspects of their work.

In a monthly structured forum facilitated by trained members from the organisation running Rounds, clinical and non-clinical staff come together to discuss the emotional and social impact of working in healthcare. Rounds follow a standard model to ensure they can be replicated across settings.

Experiences are shared from the perspective of the panel member –

Rounds provide an opportunity to reflect on the emotional aspects of your work not the patient – and the emphasis is on the emotional impact of working in healthcare. For the remainder of the hour, trained facilitators lead an open discussion. The key skill is for the facilitators to steer the discussion in such a way that it remains reflective and does not become a space to solve problems.

The power of sharing stories can play a huge part in normalising emotions among staff, allowing them to move from a place of isolation to one of shared understanding, reducing the sense of difference and breaking down barriers among individuals, teams and across the organisation as a whole. The stories told can empower both narrator and listener, providing a platform to change narratives.

Healthcare environments are increasingly fragmented – teams are less defined and it is ever more difficult to have a sense of how individual contributions connect with the complete patient journey.

Furthermore, surgery is often reported as a specialty where unhelpful cultures and high rates of

IKON IMAGES/OTTO DETTMER

I

n 1994, Boston health attorney Ken Schwartz was diagnosed with terminal lung cancer. During his treatment, although grateful and impressed with the skills and knowledge of those providing his care, he acknowledged that it was the simple acts of kindness from his caregivers, not the drugs or surgeries, which made the “unbearable bearable”.

In an article for the Boston Globe, Schwartz wrote: “I cannot emphasise enough how meaningful it was to me when caregivers revealed something about themselves that made a personal connection to my plight.

It made me feel much less lonely.

The rule books, I’m sure, frown on such intimate engagement between caregiver and patient. But maybe it’s time to rewrite them.”

stress and bullying are particularly prevalent. Bringing together individuals to share stories can engender a sense of connectedness.

After a Round at Alder Hey, Consultant Paediatric Surgeon and Clinical Lead for Schwartz Rounds Joanne Mitford said: “It was so powerful to see this senior surgeon become a human being to the multidisciplinary audience and see the recognition and validation in everyone’s eyes along with the occasional tear … I already knew my surgical colleagues feel things deeply, and what I saw was my operational and executive colleagues suddenly connect with that. And that started to make some of our conversations feel different.”

Panellists and audience members in Rounds report an increased insight into the realities of others’ daily work and life, which can have a huge impact on relationships among individuals, and within and between teams.

In a recent Round, a surgeon talked about his tendency to create distance between him and his patients during the end stages of their lives. After seeing the patients regularly and forming relationships with them, being by their side as they died felt too difficult. He felt sadness and guilt at not feeling strong enough to do this, but in order to get through the day, he needed the distance. He became very tearful. There was a lot of support from the audience and they too shared feeling something similar. A nurse said to the panellist: “I wish I could sit on your shoulder and help you to be with your patients in those difficult moments.”

A Cardiac Surgeon and Schwartz Clinical Lead at Royal Brompton and Harefield summarises the value of Rounds: “Surgeons who are

involved in front-line care where there is a significant operative mortality (cardiac, vascular, neuro) have to learn to live with their chosen speciality.

The reality may and often does only become apparent when they become consultants and take on full responsibility for their patients.

Then it is necessary to develop a virtual carapace in order that the disappointing results of their (and everyone else’s) efforts on patient A on Monday do not affect their approach and treatment of patient B on Tuesday or Wednesday.

“To the outsider, this may look as if they have a cold, clinical approach to patients and others. Actually, this is usually far from the truth. My experience of doing Schwartz Rounds with surgeons as presenters is that afterwards I receive comments from nurses and other AHPs such as ‘I didn’t realise that he is human after all!’ And it is invariably a ‘he’.”

Hearing stories and sharing feelings of guilt, infallibility, hurt and vulnerability can challenge patterns of undermining and bullying. In having the opportunity to see the person behind the professional, relationships can often shift from belligerence to understanding.

For more information, or if you would like to get Schwartz Rounds running in your organisation, please get in touch on aggierice@ pointofcarefoundation.org.uk

Sharing feelings of guilt, infallibility, hurt and vulnerability can challenge patterns of undermining and bullying. Relationships can shift from belligerence to understanding rcsed.ac.uk | 41

TRAINEES AND STUDENTS

AUSSIE RULES

Alastair Lamb reports on learning new skills on a robotic surgery fellowship in Melbourne

T

he Peter MacCallum Cancer Centre (Peter Mac) is part of the Victorian Comprehensive Cancer Centre in central Melbourne. According to the National Cancer Institute in the US, a comprehensive cancer centre encompasses scientists and doctors working together in basic laboratory research, clinical trials and multicentre collaborations enrolling patients from all over the country, alongside pan-specialty cancer treatment.1 Peter Mac is the only comprehensive cancer centre in the southern hemisphere and, 42 | Surgeons’ News | December 2017

Alastair Lamb Senior Fellow in Robotic Surgery, Nuffield Dept of Surgical Sciences, University of Oxford

until 2011, was the only public hospital in Australia to offer robotic surgery.2 Peter Mac was founded in 1949 and named after a Scottish-born oncologist who was then Chair of Pathology in Melbourne and cofounder of the Anti-Cancer Council in Victoria. The hospital moved to its current home in June 2016: the $1.2bn facility was opened by US Vice-President Joe Biden during his visit as part of his ‘Moonshot’ anticancer programme. I was among the first cohort of staff to work at the new hospital and was involved in the big move, experiencing first hand the Herculean task of moving an entire cancer hospital two miles across a large city in one day.

Peter Mac offers a full range of surgical, radiotherapy and chemotherapeutic modalities, and

treats 31,000 public and private patients every year, including 10,000 new patients. The genitourinary oncology team spans each of these modalities and includes a fourconsultant urology unit within the Division of Cancer Surgery: Mr Jeremy Goad, Associate Professor Nathan Lawrentschuk, Mr Daniel Moon and Associate Professor Declan Murphy.

The team performs approximately 110 robot-assisted radical prostatectomies (RARPs) a year at Peter Mac, 40 robot-assisted partial nephrectomies (RAPNs), 25 assorted pelvic exenterations as part of a multi-specialty team, 120 transperineal biopsies, and an assortment of retroperitoneal lymph node dissections and partial bladder/ prostate procedures, alongside other diagnostic cancer work.

Melbourne as a city

Urology in Melbourne Although this was a robotic surgery fellowship based predominantly at Peter Mac, there was plenty of opportunity to experience the wider scope of urology across the city. This included the full range of trauma and emergency urology during monthly on-call sessions at Royal Melbourne Hospital, the main University of Melbourne teaching hospital, which has almost 600 beds and is linked to Peter Mac by a footbridge.

I made occasional visits to other teaching hospitals, such as the Austin Hospital in Heidelberg and Monash Hospital in Clayton, for interesting major cases or for collaborative research visits.

I also spent some time assisting the Peter Mac consultants, as well

The $1.2bn new state-of-the-art home of the Peter MacCallum Cancer Centre in Melbourne

Peter Mac offers a full range of surgical, radiotherapy and chemotherapeutic modalities, treating 31,000 patients a year

It’s not hard to see why Melbourne was voted the most liveable city in the world.18 We loved that we could cycle almost anywhere in the city.

Add in the tram network and we rarely had need for the car. Sport is high on the list of things to see in Melbourne, with the main sports grounds for cricket, Australian rules football, tennis and rugby only 12 minutes’ walk from Federation Square, the centre of Melbourne.

The one downside is the weather. Although we arrived in 42°C heat, the following day was 18°C – quite a contrast! Apparently it depends on whether the wind is blowing from the north (across the baking-hot central outback) or from the south (across the Antarctic ocean).

No praise of Melbourne would be complete without mention of the food and coffee. We loved our trips to backstreet independent coffee houses such as Seven Seeds on Berkeley Street, no-nonsense Italian fare on Lygon Street, parmigiana at Mrs Parma’s on Little Bourke Street, or our special treat to Vue de monde, truly exquisite fine dining in the Rialto building.

as Professor Tony Costello at the private-sector hospitals, including Epworth Hospital, a large, fully comprehensive 531-bed hospital in Richmond, and Cabrini Hospital, a smaller Catholic hospital in Malvern.

There is an interesting split between private and public healthcare in Melbourne. Some 75% of RARPs are performed in the private sector in this city. Most consultants spend over half their time in private-sector sessions with visiting medical officer privileges at one or more public hospitals.

The public sector is funded across the Medicare system, but state governments take responsibility for provision at a local level.

National elections took place during our year there and Medicare formed the basis of much discussion, as happens in the UK with the NHS. We were interested to see that the Medicare budget annually in Australia is $150bn. The most recent NHS budget (2015/2016) was £120bn. The population of Australia

Support

Although the fellowship was a salaried post, the wages were insufficient to cover the cost of moving the family around the world and living in Melbourne for a year. I am, therefore, tremendously grateful to The Urology Foundation and particularly to Mr Dennis Cope, whose generosity through the inaugural John Fitzpatrick Travel Scholarship made this fellowship possible. I also received a fellowship award from the RCSEd, courtesy of the John Steyn family, for which I am also grateful.

rcsed.ac.uk | 43

It was the combined open cases that also make Peter Mac urology a fantastic place to train is 23 million compared with 64 million in the UK. Given a generous exchange rate of two dollars to the pound and comparative coverage for the NHS of 95% versus 50% for Medicare, this means Australia spends three times as much per capita on public healthcare as the UK. Either the Australians care a lot more about their health than we do or we get very good value for money in the UK (if we accept a comparable service with equivalent outcomes).

References Available online

Hard skills The primary purpose of the fellowship was to gain surgical skills, particularly in robotics. I had put in 70 hours on the robot console and had performed nine complete RARPs before going to Melbourne.

However, I was put through the Melbourne deconstruction protocol (much in the fashion of a first term at Royal Military Academy Sandhurst!4), with my technique being developed through focused modular training, videos and with a further 100 hours on the robot, including 19 complete robotic cases.

These included five independent RAPNs, an operation I had never performed before. As for my RARPs,

44 | Surgeons’ News | December 2017

Alastair Lamb (left) with a surgical colleague in Melbourne

it was truly a privilege to learn from some of the best robotic surgeons in the world, and to have my technique refined and challenged. Impressively, these surgeons continue to change their techniques, modifying several steps of the procedure in the light of published evidence from other centres around the world.

The index procedures in this unit are certainly the RARP and RAPN, and it was pleasing to have completed all or part of 79 of these robotic procedures. However, it was the combined open cases that also make Peter Mac urology a fantastic place to train, and the 25 open procedures, mainly pelvic but some upper tract, were an unexpected bonus for the year.

Alongside this, and unusually, one of the prostatectomists, Daniel Moon, is also proficient in placement of artificial urinary sphincters. This procedure is normally carried out by reconstructive surgeons, but should probably form part of our skillset given the incidence of iatrogenic incontinence after RARP. This was another unexpected skill to learn during the year, although I am not independently proficient yet.

I also took responsibility for a number of non-specialist operating lists and so notched up several transurethral procedures, as well as providing a stent service for other oncology teams in the hospital with patients who, for example, had obstructed kidneys due to locally advanced colorectal or gynaecological malignancies or metastatic breast cancer.

This was also a productive year for research. While continuing to work on papers from Cambridge in both clinical prostate cancer5,6 and basic science7–12, I had the opportunity to collaborate on a number of interesting clinical pieces, helping to submit abstracts to EAU, AUA and BAUS. I also put together nine abstracts for the annual Peter Mac research day. We published a systematic review on salvage robotic prostatectomy13, two reviews on PSMA scanning,14 three opinion pieces15–17 and have two further manuscripts under consideration/submission. One of these presents urological complications after TPE, a report

PROCEDURES PERFORMED PROCEDURE

#

RARP (part)

67

RARP (complete)

14

RARP (assisted)

127

RAPN (part)

11

RAPN (complete)

5

RAPN (assisted)

31

Robotic nephr.

1

Lap radical nephr.

1

Open partial nephr.

1

Open radical nephr.

4

Cystectomies

6

Ileal conduit

11

Radical orchidect.

9

RPLND

2

AUS (male)

5

TURP

13

TURBT

21

Stents

66

Transperineal Bx

68

RARP: robot-assisted radical prostatectomy RAPN: robot-assisted partial nephrectomy RPND: retroperitoneal lymph node dissection AUS: artificial urinary sphincter TURP: transurethral resection of the prostate TURBT: transurethral resection of a bladder tumour

on two decades of pelvic exenteration from Peter Mac, possibly the largest of its kind in the world. The other addresses the trends in RARP management in Australia over the past decade.

This means 13 articles for the year published, three under consideration and two more awaiting submission.

Moreover, I had the opportunity to forge links with some important scientific research partners based at Monash University and Peter Mac. These will be important collaborators in the work I hope to undertake as a clinician scientist.

TRAINEES AND STUDENTS

THE DA VINCI CODE Skills Competition winner Chris Barr shares his robotics experiences at the Orsi

D

uring my final year at Bristol medical school, I was fortunate to win the RCSEd National Surgical Skills Competition. The prize, sponsored by Medtronic, took me to the Orsi Academy in Ghent.

The Orsi is an institute focused on training in minimally invasive surgical techniques. It offers handson training using the tried-andtested da Vinci robotic systems.

Twinned with the OLV Hospital in Aalst, it provides clinical as well as laboratory-based training. Robotic techniques are growing, and have been established in pelvic surgery for some time. By introducing an extra ‘wrist’ within the instrument, a magnified 3D view and finely controlled robotic movements, it opens up the variety of procedures that can be performed compared with laparoscopic techniques.

At the Orsi, I undertook an abridged course on introduction to robotics surgery in urology. The

Top: Chris Barr gets to grips with the da Vinci console Below: The robotics training lab at the Orsi Academy

experience started with observing a live robotic prostatectomy followed by laboratory-based training.

In the laboratory, we looked at setting up the patient console ready for surgery. It was fascinating to see the complexity of the engineering and how simply it ‘docked’ on to the patient. There was much discussion on port placement and collision prevention, where robot arms touch, which could lead to damage.

I was excited to start using the surgeons’ console to control the robot. I noticed straightaway how intuitive the console is. The 3D cameras help with visualisation and the finger controls are relatively simple to operate. The machine does a lot for you, controlling the degrees of motion. When you move your hands and grip, the instruments do the same within the 3D field of view.

You get much finer control than with laparoscopic instruments. However, the skill lies in mastering the entire system, not just the grips.

The console controls the camera, diathermy and cutting instruments.

There are four arms to the machine – one for the camera and three instrument arms – so one can work

as a retractor, and two active ones.

Mastering how to use them all effectively, using the range of the instruments, camera and preventing excessive force, is tricky.

The experience was excellent.

We covered a lot, using models and simulations, and finished with an urethrovesical anastomosis using an animal cadaveric model.

To see the electronics, visualisation and engineering within the machines, and how they assist the surgeon, was incredible. Robotic surgery is going to grow and experiencing basic training so early in my career has really sparked my interest. Above all, it was great fun. Thanks to all involved and in particular, the sponsors, Medtronic, Professor Dr Alex Mottrie for the clinical experience and Kevin Bauwens, the chief Orsi trainer on my course.

It was fascinating to see the complexity of the engineering and how it ‘docked’ on to the patient rcsed.ac.uk | 45

TRAINEES AND STUDENTS

MENTAL REHEARSAL Just as athletes visualise a race, surgeons can improve performance by thinking through a procedure.

ASiT examines the benefits of cognitive simulation

S

uccessful surgical practice depends on safe judgement and a mastery of technical skills.1 Total case volume and independent operating as a trainee have diminished due to a combination of a reduction in working hours, loss of the apprenticeship model and the publication of surgeon-specific outcomes, among other factors.2–3 There is, therefore, an increasing need to maximise the impact of training opportunities that arise, for example, augmentation and enhancement using simulation.

SIMULATION: THE WIDER PICTURE Much of the original simulation work for the development of clinical skills within the medical profession was undertaken within the domains of anaesthetics, critical care and acute medicine. Initially the principles of crew resource management, using combinations of classroom and simulator sessions to help develop non-technical skills, were implemented.

Latterly, several high-fidelity patient simulators have been devised for the development of both technical and non-technical skills.

McGaghie et al. (2010) undertook a review of the role of simulation-based medical education, highlighting a total of 12 potential uses: feedback; deliberate practice; curriculum integration; outcome measurement; simulation fidelity; skills acquisition and maintenance; mastery learning; transfer to practice; team training; high-stakes testing; instructor training; and educational and professional context.4 Simulation has also been used to both teach and assess non-technical skills in other members of the multidisciplinary team.

Although no replacement for hands-on surgical case volume, simulation can augment exposure to both the technical and non-technical aspects of real-life surgery.

Widespread incorporation of simulation into surgical training has been limited, however, by variability in access to high-quality, high-fidelity, affordable simulation facilities.5–7 While the benefits of simulation training are clear, these difficulties in delivery have severely restricted uptake, especially in health systems in which resources are limited.

46 | Surgeons’ News | December 2017

COGNITIVE SIMULATION: WHAT IS IT? Cognitive simulation is a technique based on mental practice to rehearse procedures. Advantages of this simulation technique include the absence of any requirement for expensive equipment or a simulation suite and its potential to be performed anywhere, at any time. The concept of formal cognitive simulation arose out of the technique of visualisation, and was developed in sports such as athletics and motorsports before its application in the acquisition of surgical skills.

Techniques are designed to enhance what many surgeons have done instinctively for decades by prerunning individual steps of an operation in their head prior to performing the procedure. Undoubtedly, the ability to create a vivid image using multiple sensory modalities, including visual, tactile, auditory, kinaesthetic and olfactory senses, significantly augments the user’s experience. Thus, by practising defined techniques regularly, cognitive simulation has been shown to shorten a trainee’s learning curve and enhance their performance and acquisition of new skills. It can also be used to manage stressful situations in the operating theatre. While cognitive simulation cannot be considered a replacement for repetitive physical practice, its use has been consistently shown to be beneficial to practice in randomised trials8,9, particularly in combination with physical practice.10

PARALLELS WITH COACHING Evidence from sport suggests that cognitive simulation could be combined with technical simulation in order to shorten the learning curve and potentially enhance surgical performance. This technique is supported by Atul Gawande (surgeon, writer and researcher), who has advocated that surgeons should have coaches, similar to those of high-performance athletes.11 Therefore, coaching the mental aspects of surgery, including pre-preparation, focus, management of stress, complications and external factors, using techniques such as cognitive simulation, should be considered on a par with teaching the physical competencies of surgery. Importantly, much like some of these physical aspects, the ability to mentally create realistic vivid experiences does not come naturally to

performance. All respondents who used cognitive simulation techniques said they intended to continue to use them in their future practice, and 89% suggested they would apply the skills learned outside of medicine.

everyone and, as such, may require a significant amount of practice to master specific techniques.

So, can it be taught? ASiT conducted two consecutive one-day cognitive simulation skills courses as a pilot.

The courses were delivered by Dr Uttam Shiralkar, a surgical performance coach. Fifty delegates (66% female) attended, spanning the full spectrum of training levels. Only 27% of delegates had any prior knowledge of cognitive simulation and none had used cognitive simulation in the context of learning surgical skills or had attended a formal course before. Six delegates (12%) had previously used cognitive simulation techniques within the context of music and sport.

The common themes in the cohort’s self-identified learning objectives were self-improvement and enhancement of practical skills. There was a 96% overall satisfaction with the course, with 88% of respondents agreeing the course would impact positively on their practice. At a six-week post-course follow-up, responses were received from 14 (27%) delegates. Almost twothirds (64%) had used cognitive simulation techniques learned on the course, mostly in the context of preparing for an operative experience. Respondents had tried the full breadth of sensory modalities, with visual most commonly used (89%) and olfactory least used (33%). Of the respondents using the techniques, 56% felt they had had a positive impact on their immediate subsequent

Cognitive simulation has been embraced by a broad array of high-performance athletes

THE FUTURE OF COGNITIVE SIMULATION Cognitive simulation has been embraced by a broad array of high-performance athletes who use the technique to enhance their individual performance.

Evidence suggests that these techniques are transferable to surgical skills. Therefore, there is a need to educate surgical trainees in cognitive simulation and incorporate its development into modern curricula and national training programmes.

ASiT has a well-established course, with high-quality feedback from more than 50 trainees of all levels across multiple specialties. Using this successful pilot, ASiT will continue to provide this course to its members as part of its educational portfolio, acknowledging the importance of these techniques in the professional development of highly functioning surgeons. We commend the development of these skills to surgical trainees.

Piriyah Sinclair, Adam Peckham-Cooper, Paul A Sutton, Henry Ferguson, Heman Joshi, Uttam Shiralker, Helen Mohan and Andrew Beamish on behalf of ASiT Council Visualisation techniques used by athletes are transferable to surgery

References

1. Bosk C. Forgive and remember: managing medical failure (University of Chicago, 1979) 2. Parsons BA et al. Surgical training: the impact of changes in curriculum and experience. J Surg Educ 2011; 68: 44–51 3. Radford PD et al., on behalf of the Council of ASiT. Publication of surgeon specific outcome data: a review of implementation, controversies and the potential impact on surgical training. https://www.asit. org/resources/archivedarticles-documents/ publication-of-surgeonspecific-outcome-data/ res1029 4. McGaghie WC et al. A critical review of simulationbased medical education research: 2003–2009. Med Ed 2010; 44: 50–63 5. Gurusamy KS et al. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev 2009 Jan; (1):CD006575

6. Sutherland LM et al.

Surgical simulation: a systematic review. Ann Surg 2006; 243: 291–300 7. Simulation in surgical training. A statement from ASiT. Nov 2011. http://www.asit.org/assets/ documents/Simulation_in_ Surgical_Training___ASiT_ Statement.pdf 8. Immenroth M et al.

Mental training in surgical education – a randomised controlled trial. Ann Surg 2007; 245: 385–391 9. Arora S et al. Mental practice enhances surgical technical skills, a randomised controlled study. Ann Surg 2011; 253: 265–270 10. Durand M et al. The effects of combining mental and physical practice on motor skill acquisition.

Hong Kong J Sports Med Sports Sci 1997; 4: 36–41 11. Gawande A. Personal best. http://www.newyorker. com/magazine/2011/10/03/ personal-best – last accessed 06/07/17

rcsed.ac.uk | 47

TRAINEES AND STUDENTS

Beth Lineham investigates exception reporting, part of the new junior doctor contract

A

ll doctors in training in England are now on the new junior doctor contract. One of its widely reported benefits is the opportunity for exception reporting, which is designed to ensure the safety and training of junior doctors.

There have been many discussions about exception reporting in the press and in doctors’ messes around the country, but what does it actually mean for our members?

I interviewed Andrew Robson, a consultant ENT surgeon and guardian of safe working hours for the North Cumbria NHS trust, to find out how this is working in practice and how junior doctors can get the most out of the new system.

As per the new contract, each junior doctor will have a work 48 | Surgeons’ News | December 2017

schedule in place for every job. The schedule details their day-to-day activities, including the shift pattern, breaks and training opportunities that should be taking place. The trust will provide generalised work schedules and these should be personalised with the agreement of the junior doctor and their clinical supervisor. If a junior has specific training needs, the schedule can be tailored to give more experience in a certain area.

An ‘exception’ is defined as any deviation from a work schedule, including staying late, not getting enough breaks, having to do ward work when you were scheduled for theatre or not being released for teaching. Any and all deviations from the schedule should be reported.

Robson says: “Each report should be relatively low level, but cumulatively they should make a big difference. The idea is that it should be continuous, formative, almost in the background. The reality is that people are taking it more seriously than that and think that they are

going to be penalised if they do exception reports, because they may be accused of being inefficient, or of playing the system to get extra payment. By no means is that the case and that’s not what trusts want. Trusts and guardians want to identify what the problems are, so they can see what the implications are for resources and patient safety. The more exception reports we have the better, because we’ll start seeing trends and be able to identify problems.”

Exception reporting is an alternative to older-style monitoring.

“Monitoring uptake is pretty poor,” says Robson. “And it’s a blunt instrument that happens once every six months. It’s all happened by then, whereas exception reporting is supposed to be a live process.”

Unfortunately, this is not taking place as much as it should be. “In the last six months, our trust has only had about 30 exception reports.

They’ve been under-reporting for various reasons. And that’s fine, it’s up to them. But if you’re working

IKON IMAGES/ALAMY STOCK PHOTO

FINGER ON THE PULSE

an extra hour three times a week, there are two impacts: it should be recognised, either in time off or payment; and it’s illegal to be working over the 48 hours average, 72 hours in any one week. So those reports should come in. But, equally, you can see why people say they can’t be bothered to put in an exception report for one hour here or there. But some have, and we just give them an extra hour off at some stage for time off in lieu.”

There are a few reasons why people may not want to put in exception reports. One, as discussed, is that people don’t think their report is exceptional enough. Another is that in surgical specialties, time off in lieu is not desirable if it comes at the expense of theatre training time.

“Of course, if you have time off in lieu and you miss a theatre list, you could then put an exception report in that you missed an educational opportunity! That’s where it needs to be done at a departmental level so you can have a sensible solution,” says Robson.

Beth Lineham Member of the RCSEd Trainees Committee

The expectation is that exception reporting leads to a flexible discussion, with solutions decided between trainee and supervisor and, therefore, allows a less paternalistic approach to rotas. The process of undergoing exception reporting should also be simple.

“An exception report takes about five minutes to fill in. The reports go to the clinical supervisor and are copied to the guardian of safe working if it’s an hours of safe working issue, or the director of medical education if it’s an educational issue,” explains Robson.

Guardians also have a new and powerful link with the trust boards.

Robson says: “The guardian has a duty to report to the trust board every quarter and the board has a duty to listen to the guardian’s report. The trust board is getting more relevant

The more exception reports we have the better, because we’ll be able to identify problems

information about junior doctors’ working conditions than ever before.

I’ve been to the trust board two or three times now and it’s illuminating how they listen to you. So the guardian has a lot of responsibility, but a lot of power as well, because if the trust board doesn’t listen, you can go to the CQC and HCE. I think that is positive both for juniors and for senior doctors, as boards have never had this exposure to what really happens on the ground.”

It’s difficult to say at this early stage how successful exception reporting will be, and whether putting in an exception report will become a standard task for a junior doctor. Over the coming months and years, we will see how exception reporting is working and how it fits in with the rest of the new contract.

Certainly, it will only be successful if we are all working together and putting in reports.

Robson concludes: “We need to encourage people to report.

It’s actually quite an important, necessary system that has teeth.” rcsed.ac.uk | 49

TRAINEES AND STUDENTS

SYMPOSIUM A HUGE SUCCESS

Students learn new techniques at Oxford event

O

n Saturday 14 October, the RCSEd along with the Hugh Cairns Surgical Society (HCSS, a student-led body), held the fourth Oxford Surgical Skills Symposium at the John Radcliffe Hospital, Oxford.

The event aimed to give delegates hands-on experience of a variety of surgical skills not routinely covered in the current curricula, as well as the opportunity to meet faculty from

Delegates at two of the six one-hour workstations

a range of surgical specialties with a view to promoting career choices in the field.

Delegates ranged from senior medical students to core trainees from all over the UK. The symposium consisted of six onehour workstations covering trauma, urology, laparoscopy simulation, suturing and electrocautery, cardiothoracic surgery and bowel anastomosis.

Consultant surgeons and senior surgical trainees led each workshop.

/ EVENT

One of the greatest achievements of this year’s symposium was the ratio of faculty to delegates: more than 40 faculty taught 72 delegates.

At the end of the day, RCSEd President Professor Michael LavelleJones presented the prizes for the winner and runners-up of the laparoscopy competition, and one for the ‘most promising surgeon’ of the day.

Rhiannon Baldwin President of HCSS

BASE: Skills for Aspiring Surgeons In October, the Edinburgh Student Surgical Society hosted an information evening with hands-on workshops to inform and inspire medical students considering a career in surgery.

The BASE: Skills for Aspiring Surgeons

event was held in conjunction with the Clinical Anatomy Scheme for Edinburgh and was supported by the RCSEd and University of Edinburgh Innovation Initiative.

Professor David Sinclair gave a keynote

50 | Surgeons’ News | December 2017

lecture on ‘Spaces and Spread – The Surgical Anatomy of Fascia’, and the students participated in workshops exploring basic surgical skills and emergency scenarios.

Thank you to Jen Reid and Eilidh Bruce for convening the event.

Skills workshop

DENTAL

Survival of the fittest Fraser McDonald looks at the future of postgraduate dental education in a post-Brexit world

B

rexit is high on the political agenda and the extent to which it will influence daily life in the UK is as yet unknown. In this, my first commentary as Dental Dean, I would like to focus on Brexit and what it might mean for the Edinburgh College and the Dental Faculty. The RCSEd has witnessed tremendous political change in its 500 years, but its role in setting high standards for the practice of surgery and dentistry throughout the UK and beyond is unchanged. The European Union has existed for a few decades and one of its founding principles is the free movement of the workforce (particularly the highly skilled) across the continent. Although this has numerous benefits, it has brought many challenges, particularly in relation to the standardisation of training and qualifications of a mobile international workforce.

The College has an impeccable reputation for education and assessment. A number of European training centres in Holland, Malta and Latvia have engaged with the College to ensure all our common assessment processes are standardised and reproducible. The Dutch have taken part in an interregnum of the Membership in Orthodontics alternating between Edinburgh and Amsterdam in the summer assessment process, while the Maltese training programme links fully with the Orthodontic assessment process. The Latvian school has established a centre for more northern areas of Europe. Unfortunately, some of the 28 countries in the European Union do not even have a nationally agreed postgraduate assessment process and others, notably Spain and Austria, have no dental specialist list status.

This issue becomes even more complex when we consider the tools we use to assess

competency, such as work-based assessments, which have been widely implemented across the UK. When used in other countries, have they been formatted and standardised to reflect dental practice and the needs of the local populations? In addition, the varying processes of clinical governance across Europe create additional barriers to quality assuring training. For example, the Tri-Collegiate Paediatric Dentistry assessment has ‘A clinical governance project’. For most UK-based schools, this is essentially an audit. But what does mainland Europe understand of the term ‘clinical audit’ and which standards are used as the baseline of the audits?

Closer to home, the situation in the UK is far from ideal. The Deaneries (now the Local Education and Training Boards) have sought to manage specialist training locally (despite the requirements of education agencies to request nationally agreed frameworks), yet their current backdrop appears to be ‘rationalising’ the administrative team support – aka staff reductions.

Anyone who has experienced this ‘local’ control will be able to identify the personality-driven agendas of both administrators and teaching establishments that do not allow for standardisation.

Assessment processes in higher education establishments are different to Royal College assessment processes, with even a simple matter of a percentage ‘pass mark’ for a candidate varying significantly at postgraduate level. Some of the higher degrees do not even reflect a percentage pass, but merely a pass or fail of a conglomerate of marks.

Is the future gloomy? Not at all, but we are going to have to think very differently about postgraduate clinical training, including team developments.

The influences of reducing governmental budgets, sterling versus euro values changing, and the workforce coming through with very different demands and debts, things cannot and will not stay the same. Change for change’s sake? No, change for survival not extinction. Someone once said ‘diversity is the engine of evolution’. Let’s hope so.

Professor Fraser McDonald Dean, Faculty of Dental Surgery

We are going to have to think very differently about postgraduate clinical training www.rcsed.ac.uk rcsed.ac.uk || 51

DENTAL

/ COMPETITION

Skills challenge extends to Ireland

T

he College’s Dental Skills Competition is running again in 2017/18 in conjunction with Dentsply Sirona.

For the first time, it will also take place in Ireland.

Now in its fourth year, the competition enables final-year dental students to showcase their clinical skills, with the best student from each heat winning a travel and accommodation package to compete in the grand final in Edinburgh on 8 March 2018.

All participants in the competition will receive two years’ Affiliate Membership with the College, 52 | Surgeons’ News | December 2017

Students are subject to a suite of tests in the Dental Skills Competition

discounted priority places on the Part 1 and Part 2 MFDS Exam Preparatory Courses run by the RCSEd in Birmingham, Leeds and Edinburgh, and a certificate of participation. Prizes will be awarded to the winner and runnersup in each heat.

Heats have already taken place at Queen Mary University of London, University of Sheffield, University of Aberdeen and University of Central Lancashire. Heat dates for the University of Leeds and Trinity College Dublin will be announced on the website shortly.

For more information, visit rcsed.ac.uk

HEAT DATES LOCATION

DATE

Cork University

27 Nov 17

Birmingham University

27 Nov 17

Plymouth University

29 Nov 17

Manchester University

30 Nov 17

Newcastle University

6 Dec 17

University of Bristol

6 Dec 17

Queen’s Belfast

7 Dec 17

University of Glasgow

12 Dec 17

University of Liverpool

12 Dec 17

Cardiff University

13 Dec 17

University of Dundee

15 Dec 17

University of Aberdeen

17 Jan 18

King’s College London

29 Jan 18

/ EVENT / TRIENNIAL DINNER

FAREWELL TO OUTGOING DEAN On Thursday 5 October 2017, the Faculty of Dental Surgery held its Triennial Dinner at Edinburgh’s Signet Library to say farewell to outgoing Dean of the Faculty, Professor

William Saunders. Professor Saunders used the opportunity to thank all those who supported him during his tenure and to welcome the new Dean, Professor Fraser McDonald.

First annual FDT meeting The Faculty of Dental Trainers hosted its first conference in October in conjunction with the Faculty of Surgical Trainers and sponsored by Dentsply Sirona. Held at The Studio in Birmingham, the conference served as the faculty’s first annual meeting and addressed the theme of ‘Time to Train’. Delegates attended sessions on finding the time to undertake training and getting recognition for trainers. Workshops on the day looked at developing the Faculty’s Standards for Dental Trainers, and how non-technical skills such as leadership, decision making and communication might be developed for dentistry.

/ FACULTY OF DENTAL TRAINERS

FDT celebrates 100th Member

Outgoing Dean Professor Saunders (right) and his successor, Professor Fraser McDonald

Professor Michael Lavelle-Jones (left), Professor Saunders and Christine Lavelle-Jones

Professor Saunders with Professor John Duncan, RCSEd Vice-President

After launching just over 12 months ago, the Faculty of Dental Trainers (FDT) has already welcomed its 100th Member: Consultant in Special Care Dentistry Najla Nizarali.

The FDT was established by the College to promote the role of dental trainers and to recognise achievements and excellence, and ultimately to enhance the quality of patient care.

Nizarali (below) said: “I believe a high standard of training and education is fundamental in producing excellent clinicians and high-quality patient care… Through this Faculty, I hope we will be able to bring together both recognised and less-recognised dental trainers, so that ideas can be shared and excellence promoted.

Not only does this advance our profession and subspecialties, it provides a forum to recognise achievement and share learning points.”

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

1

TAYSIDE 2 Pauline Maillou, Dundee Dental School 2

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

3

ENGLAND

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

16

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

15

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

6

12

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

54 | Surgeons’ News | December 2017

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North of England South East Scotland North Wales Cardiff Republic of Ireland For details, contact: outreach@rcsed.ac.uk

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COLLEGE INFORMATION

DIPLOMA CEREMONIES Congratulations to all our new Fellows and Members who were presented with diplomas at ceremonies in Singapore, Edinburgh and Hong Kong SATURDAY 5 AUGUST 2017

SINGAPORE

Diplomas of Fellowship in the Specialty of General Surgery Siok Siong Ching, National University of Ireland Natascha Ekawati Putri, National University of Singapore Yirong Sim, University of Cambridge Bin Chet Toh, University of Dundee Diploma of Joint Specialty Fellowship in General Surgery Parthiepan Ariyathurai, University of Jaffna, Sri Lanka Diplomas of Joint Specialty Fellowship in Orthopaedic Surgery Heng An Lin, National University of Singapore Pang Hung Wu, National University of Singapore Diploma of Fellowship in the Specialty of Otolaryngology Dinakar Pramechander, Dr MGR Medical University, India Diploma of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Ravindra Puttaswamaiah, Bangalore University, India Diploma of Fellowship in the Specialty of Urology Muhammad Tahir Bashir Malik, University of the Punjab, Pakistan Diplomas of Membership in Otolaryngology Kanivannen Arasu, University of North Sumatra, Indonesia Shweta Pawar, Rajiv Gandhi University of Health Sciences, India

56 | Surgeonsâ&#x20AC;&#x2122; News | December 2017

Kai Jun Tey, Asian Institute of Medical Science & Technology, Malaysia Intercollegiate Diplomas of Membership in Surgery in General Veronica Siton Alcantara, University of the Philippines Kollegal Huchaiah Amruth, Rajiv Gandhi University of Health Sciences, India Sian Ying Heidi Chang, National University of Singapore Yen Chuan Chen, Universiti Sains Malaysia Si Yuan Chew, National University of Singapore Zhen Wei Choo, University of Queensland, Australia Andrew Chia Chen Chou, National University of Singapore Yu Lin Whitney Chua, University of Melbourne, Australia Koy Min Chue, National University of Singapore Diana Melissa Bt Dualim, Universiti Kebangsaan, Malaysia Eng Tah Goh, Universiti Malaysia Sarawak Vipin Gupta, Guru Gobind Singh Indraprastha University, India Abdul Fattah Bin Abdul Hamid, Universiti Putra Malaysia Win Sabai Phyu Han, University of Yangon, Myanmar Durvesh Lachman Jethwani, Asian Institute of Medical Science & Technology, Malaysia Don Thong Siang Koh, University of London Li Yan Lim, National University of Singapore May Honey Ohn, University of Yangon, Myanmar Yizhi Kingsfield Ong, University of Birmingham Ming Wu Warren Ong, National University of Singapore

Benjamin Ruimin Poh, Monash University, Australia H Sakthivel, Jawaharlal Institute of Postgraduate Medical Education & Research, India Lasitha Bhagya Samarakoon, University of Colombo, Sri Lanka Andrew Arjun Sayampanathan, National University of Singapore Mohd Mujtaba Shahbaz, Sri Devaraj Urs Medical College, India Kan Chan Siang, Universiti Kebangsaan, Malaysia Paramasivam Sivamayuran, University of Jaffna, Sri Lanka Zi Han Tan, Universiti Malaysia Sabah Wei Sheng Tan, International Medical University, Malaysia Yen Zhir Tay, I M Sechenov First Moscow State Medical University, Russia Rajeswaran Vimalarajan, University of Jaffna, Sri Lanka Panchalingam Vivekandan, Jawaharlal Institute of Postgraduate Medical Education & Research, India Zhan Xia, Zhejiang University, China Diplomas of Membership in Orthodontics Omer Hafeez Kaleem, University of Health Sciences Lahore, Pakistan Siti Hajjar Binti Nasir, Universiti Sains Malaysia Rajinderpal Singh, Manipal University, India Szu Hui Tiu, University of Malaya, Malaysia Diplomas of Membership in Paediatric Dentistry Hiu Fong Sarah Lai, National University of Singapore Sri Kavi Subramaniam, Gadjah Mada University, Indonesia Ruixiang Yee, National University of Singapore

Diploma of Membership in Periodontics Xian Jun Edwin Goh, National University of Singapore Diploma of Membership in Prosthodontics Hui Qi Sheralyn Quek, National University of Singapore Diplomas of Membership of the Faculty of Dental Surgery Amani Binti Amran, University of Jordan Wooi Cheat Chu, Volgograd State Medical University, Russia Marisa Kiong, University of Malaya, Malaysia Zheng Dong Koon, University of Malaya, Malaysia Jane Ning Shing Lau, Manipal University, India Juo Pei Lee, Nitte University, India Sylvia Sze Wei Lim, Asian Institute of Medical Science & Technology, Malaysia Chin Kai Lim, Asian Institute of Medical Science & Technology, Malaysia Puthanveettile Manoj Kumar, University of Mysore, India Ye Han Sam, University of Otago, New Zealand Woon Ling Saw, University of Malaya, Malaysia Siti Khadijah Shuhaimy Basha, University of Malaya, Malaysia Wen Sann Sim, Asian Institute of Medical Science & Technology, Malaysia Sri Kavi Subramaniam, Gadjah Mada University, Indonesia Kuan Ming Tan, University of Malaya, Malaysia P U Abdul Wahab, Rajiv Gandhi University of Health Sciences, India Eugene Zhen Herr Yeoh, Universiti Kebangsaan, Malaysia

FRIDAY 1 SEPTEMBER 2017

EDINBURGH

Honorary Fellowship in Dental Surgery Professor James L Gutmann, Professor Emeritus, Restorative Sciences/Endodontics, Texas A&M University College of Dentistry, US Fellowship in Dental Surgery Ad Hominem Professor Pedro Diz Dios, Head of Special Needs Dentistry and Consultant in Stomatology, Santiago de Compostela University, Spain Fellowship Ad Hominem Professor Tian Wei FCS(HK)(Hon), President and Chief Professor at the Department of Spine Surgery, Jishuitan Hospital and Professor, Peking University/Tsinghua University, China Fellowship Without Examination Dr Suresh Keshavamurthy FACS, Assistant Professor of Surgery, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, US Professor M P Sreejayan FRCSGlasg, Additional Professor of Surgery & Medical Superintendent, Government Medical College, Calicut, Kerala, India Fellowship in Dental Surgery Without Examination Dr Anil K Kohli FDS RCSGlasg FDS RCSEng, Endodontist and Dental Surgeon, New Delhi, India Dr Hari Parkash FDS RCSGlasg FDS RCSEng, Dental Education Consultant Diplomas of Fellowship in the Specialty of Cardiothoracic Surgery Ricardo Boix Garibo, University of Valencia, Spain Karen Lynsey Booth, University of Glasgow Diplomas of Fellowship in the Specialty of General Surgery Pawan Kumar Dhruva Rao, University of Mysore, India Beatrix Cornelia Elsberger, University of Regensburg, Germany Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Anuj Jaiswal, University of Delhi, India

Anwar-ul-Hassan Khan, University of Sindh, Pakistan Christopher Kevin James O’Neill, Queen’s University Belfast Pratham Surya, Karnatak University, India Kar Hao Teoh, University of Edinburgh Diplomas of Fellowship in the Specialty of Urology Alexander Laird, University of Edinburgh Kannan Shanmuga Sigamani, Dr MGR Medical University, India Diploma of Fellowship in Immediate Medical Care (Without Examination) Richard Lee, IHCD Paramedic, Oxford Ambulance NHS trust The McCormack Medal Awarded annually to the candidate attaining the highest mark in the Intercollegiate Specialty Examination in Cardiothoracic Surgery.

Vanessa Rogers, University of London Syme Medals for 2016 Awarded to successful applicants who are Fellows or Members of the College, who have completed studying for a higher degree and are working to progress an academic career.

Neil Johns, University of East Anglia Christopher John Cyril Johnston, University of London Diploma of Membership in Ophthalmology Noor Bakht Nizamani, Liaquat University of Medical Health Sciences, Pakistan Syed Raza Ali Zaidi, Quaid-i-Azam University, Pakistan Intercollegiate Diploma of Membership in Surgery in General Mohammed Mirghani Saadeldin Abdin, Al Zaiem Al Azhari University, Sudan Meraj Akhtar, Aligarh Muslim University, India Hussein Abdalla Mohammed Ali, University of Gezira, Sudan Hannah Anderson, Queen’s University Belfast Danielle Alice Banfield, Imperial College London Syed Ishtiyaq Hussain Bukhari, University of Kashmir, India

Charles Frederick Wiktor Carder, University of Bristol Verena Wai-Yue Chu, University of Manchester Elliott Cochrane, University of Leeds Anna Craig-McQuaide, University of London Thomas Stephen Curl-Roper, University of Manchester Gemma Elizabeth Dovey, University of Brighton and University of Sussex Robin Ian Gordon, University of Dundee Nigel Tapiwa Mabvuure, University of Brighton and University of Sussex Ruchir Paresh Mashar, University of Oxford Sean Kane Mizzi, University of Malta Abu Bakar Md Mostafa, University of Dacca, Bangladesh Nigel Yong Boon Ng, University of Aberdeen Nadia Saffaf, University of Leicester Achala Salinda Samarasinghe, University of Peradeniya, Sri Lanka Ewan Alexander Semple, University of Aberdeen Catherine Hannah Sproson, University of Sheffield Jade Elizabeth Whing, University of Manchester Saadia Zulfiqar, University of Health Sciences Lahore, Pakistan Diploma in Membership of the Faculty of Surgical Trainers Kingsley Chinedu Ekwueme, University of Ibadan, Nigeria Diploma in Remote and Offshore Medicine Jonathon MacKay, Maritime School of Paramedicine, Canada Diploma of Fellowship in Dental Surgery in the Specialty of Orthodontics Timothy Edward McEvoy Jones, University of Bristol Diploma of Fellowship in Dental Surgery Without Examination (by application) Nayef H Felemban, King Saud University, Saudi Arabia Diplomas of Fellowship of the Faculty of Dental Trainers Julia Jane Armstrong, National Examining Board for Dental Nurses Geraldine Louise Birks, National Examining Board for Dental Nurses Grant Thomson McIntyre, University of Glasgow

Diploma of Membership in Orthodontics Fatemah Jamal Al Qattan, University of Dublin Diploma of Membership in Paediatric Dentistry Anas Ali Salami, Ajman University, United Arab Emirates Diplomas of Membership of the Faculty of Dental Surgery Nikesh Farmah, University of Manchester Mohamed Mustafa Hania, University of Dublin Jay Joshi, University of London Shaira Karim Kassam, University of Leeds Ruth Elizabeth Lambeth, University of Bristol Aoife O’Donnell, University of Liverpool Andrew Travers, University of Liverpool Diploma in Implant Dentistry Michael Lamont Holdaway, University of Otago, New Zealand Diplomas in Orthodontic Therapy Victoria Emily Atkinson, DCP School, Bristol Dental Hospital Joan Roberta Donnell, School of Dentistry, University of Central Lancashire Amanda Jane Fordham, DCP School, Bristol Dental Hospital Sarah Jane Hall, DCP School, Bristol Dental Hospital Katie Lea Hulme, DCP School, Bristol Dental Hospital Victoria Young, DCP School, Bristol Dental Hospital SATURDAY 23 SEPTEMBER 2017

HONG KONG

CONJOINT DIPLOMA CONFERMENT CEREMONY Faculty of Dental Surgery International Medal Awarded to dentists or others who have made a distinguished contribution to the Faculty, College and Dentistry internationally.

Dr John Y K Ling Joint Specialty Fellowship Examination in General Surgery Jendana Chanyaputhipong, University of Dublin Hing-Fong Cheung, University of Hong Kong

rcsed.ac.uk | 57

COLLEGE INFORMATION

Jennifer Hiu-Fung Chiu, Chinese University of Hong Kong Kam-Wah Cho, Chinese University of Hong Kong Winston Wan-Wui Hwang, Chinese University of Hong Kong Philip Ming-Ho Kam, University of Hong Kong Vincent Cham-Yat Lau, Chinese University of Hong Kong Harry Hing-Yin Lee, University of Hong Kong Clarence Chi-Chuen Mak, Chinese University of Hong Kong Joanna Chung-Kiu Mak, University of Hong Kong Yin-Yu Siu, Chinese University of Hong Kong Julian Shun Tsang, Royal College of Surgeons in Ireland Chun-Lam Wong, University of Hong Kong Yu-Yan Wong, University of Hong Kong Xiaobo Xu, Zhejiang University, China Siu-Man Yip, Chinese University of Hong Kong Joint Surgical Colleges’ Fellowship Examination In General Surgery Karkala Pulikeri Uday Prabhu, Rajiv Gandhi University of Health Sciences, India Joint Specialty Fellowship Examination in Neurosurgery Allan Ngo-lun Chan, University of Hong Kong Kwan-ho Chow, Chinese University of Hong Kong Alberto Chi-ho Chu, University of Hong Kong Lok-yan Ho, University of Hong Kong Ming-him Yuen, University of Hong Kong Joint Specialty Fellowship Examination In Paediatric Surgery Judy Wing-suet Hung, University of Dublin Hei-yi Wong, Chinese University of Hong Kong Fellowship of the Faculty of Surgical Trainers Oon-cheong Ooi, National University of Ireland Fellowship in Dental Surgery Without Examination by Application Min Gu, Wuhan University, China

58 | Surgeons’ News | December 2017

IN MEMORY SURGICAL FELLOWS Rajinder Nath AUPLISH (FRCSEd 1970) Farid Uddin BAQAI (FRCSEd 1965) Vinayak Ramchandra BHALERAO (FRCSEd 1971) Robert BUCHAN (FRCSEd 1968) Walter Neville DUGMORE (FRCSEd 1962) Paul FOGGITT (FRCSEd 1964) Solomon LEVITT (FRCSEd 1956) John McCAIG (FRCSEd 1991)

Membership in Oral and Maxillofacial Surgery Dion Tik-shun Li, Boston University, US Membership in Orthodontics Wing-sze Chan, University of Hong Kong Ling-ling Tsai, University of the East, Philippines Membership in Paediatric Dentistry Selina Tak-wing Chau, University of Hong Kong Yanlin Du, Sun Yat-sen University, China Kin-man Fong, University of Hong Kong Ahmad Faisal Bin Ismail, University of Malaya, Malaysia Membership in Periodontics Cheuk-kuen Cheng, University of Hong Kong Hin-nam Liu, University of Hong Kong Membership in Faculty of Dental Surgery Yung-dick Chan, University of Hong Kong Jennifer Yu-lam Yau, University of Hong Kong Shun-shing Yip, University of Hong Kong Diploma in Implant Dentistry Mike Tat-leung Cheung, University of Hong Kong Membership in Ophthalmology Sui-chun Chu, University of Hong Kong Tiffany Lok-man Yeung, Chinese University of Hong Kong

Donald Norwood MENZIES (FRCSEd 1958) Kenneth Leslie George MILLS (FRCSEd 1961) Fawzy Helmy MORCOS (FRCSEd 1968) Ian David PORTEOUS (FRCSEd 1973) TAN Wee Jin (FRCSEd 1997) Arthur Davey Omope WRIGHT (FRCSEd 1973) FACULTY OF PRE-HOSPITAL CARE FELLOW Peter Arthur JOINER (FIMC RCSEd 2001)

Membership in Surgery in General Ka-kin Chan, Chinese University of Hong Kong Jenny Sau-ying Chan, Chinese University of Hong Kong Timothy Tin-chak Chan, University of Hong Kong Ka-yu Cheng, University of Hong Kong Henry Chow, Chinese University of Hong Kong Chi-heng Fung, University of Hong Kong Tsit-lai Ho, Chinese University of Hong Kong Dorothy Sze-wing Hung, Chinese University of Hong Kong Lai-ying Leung, Chinese University of Hong Kong Yuen-ki Leung, Chinese University of Hong Kong Tsz-yan Li, Chinese University of Hong Kong Jackson Siew-wen Ling, Universiti Malaysia Sarawak, Malaysia Christy Wing-hin Mak, Chinese University of Hong Kong Hiu-wing Mok, Chinese University of Hong Kong Chat-fong Ng, University of Hong Kong Sally Wing-yan Ng, Chinese University of Hong Kong Galen Hon-leong Sha, Nizhny Novgorod State Medical Academy, Russia Yee-han Shum, Royal College of Surgeons in Ireland Anil Sundaram, University of Kerala, India Tai-huen Tam, Chinese University of Hong Kong Shong-sheng Tan, Universiti Malaysia Sarawak, Malaysia

Jingliang Tang, Central South University, China Jinming Tang, Peking University, China Rayvel Tze-tao Tang, Chinese University of Hong Kong Yu-tai Tong, University of Hong Kong Cheuk-wah Wong, University of Hong Kong Hoi-lung Wong, Jinan University, China Wai-hung Yeung, University of Hong Kong Yuen-yi Yip, University of Hong Kong Adrian Ho-kun Yu, Chinese University of Hong Kong GB Ong Medal 2016 The GB Ong Medal is awarded to the most outstanding candidate for the Joint Specialty Fellowship Examination in General Surgery.

Dr Hon-ting Lok Muthusamy Medal 2013 Awarded to the candidate who has achieved the highest mark in the Part A of the FRCSEd Ophthalmology examination at their first attempt and gone on to pass their Part B examination, again at their first attempt.

Dr Brian Churk-yat Li Conjoint MORTH RCSEd/FCDSHK (INT) MEDAL FOR 2016 Awarded to the most meritorious candidate in the Conjoint MORTH RCSEd/FCDSHK(Int) Examination within one year.

Dr Wing-sze Chan Conjoint MRD Medal for 2016 Awarded to the most meritorious candidate in the Conjoint MRD RCSEd/FCDSHK (Int) Restorative Dentistry Examination within one year.

Dr Hin-nam Liu John Smith Medal 2016 Awarded to the candidate who achieves the highest mark from all diets of the Part 1 Membership of the Faculty of Dental Surgery Examination held within one year.

Dr Yung-dick Chan China Medal 2017 Awarded to the person who presented the most outstanding free paper at the Joint Scientific Congress.

Dr Shirley Yuk-wah Liu

REGIONAL SURGICAL ADVISERS IN YOUR AREA

7

8

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

10

1

24 38 39 25

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

34

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

33

22 4 37

20

21

23

19

SCOTLAND

29

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

5 15

30 31

2

14

32

36

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

13 6

26 3 35 17 18

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

28

27

16

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

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

WALES

NORTH WESTERN 22 Mike Woodruff, Royal Preston Hospital, Preston 23 Richard Graham, North Manchester General Hospital

NORTHERN IRELAND

NORTHERN 24 Paul Gallagher, Wansbeck Hospital, Northumberland 25 Barney Green, James Cook University Hospital, Middlesbrough 25 Peng Wong, James Cook University Hospital, Middlesbrough

RSA VACANCIES

OXFORD 26 Giles Bond-Smith, Oxford University Hospitals NHS Trust

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

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

Aberdeen Birmingham Brighton/Eastbourne Bristol Leicester

London Newcastle Nottingham Southampton

rcsed.ac.uk | 59

COLLEGE INFORMATION

All the latest grants, Fellowships and bursaries from the RCSEd

AWARDS & GRANTS Bursaries for Affiliate Medical Student Elective Placements in Africa 2017

Bursaries are available to undergraduate affiliates of the RCSEd enrolled at UK universities who plan to carry out their elective placements in Africa. The elective does not necessarily need to be in a surgical unit, but priority may be given to students demonstrating a special interest in surgery.

Usually, each bursary is in the region of £500, which can be used towards travel and accommodation costs, or other expenses involved with the placement.

Closing date for applications is Wednesday 10 January 2018.

Ethicon Foundation Fund Travel Grants

Grants are awarded towards travel overseas to gain further training or experience and are restricted to the cost of one return airfare only. Travel for the sole purpose of attending a scientific meeting will not be supported.

Requests for retrospective awards will not be considered.

Closing date for applications is Wednesday 14 February 2018.

60 | Surgeons’ News | December 2017

RCSEd Medical Student Elective Travel Bursaries

Undergraduate Student Bursaries

Closing date for applications is Wednesday 14 February 2018.

Closing date for applications is Wednesday 21 March 2018.

The RCSEd is pleased to offer medical students the opportunity to apply for a travel bursary towards their elective in surgery. The award provides a contribution to the overall costs of travel and subsistence.

The bursaries, to the value of £250, are open to medical students in the UK and Ireland who are affiliates of the RCSEd and who are undertaking approved surgical electives overseas.

The RCSEd is offering bursaries to undergraduate students of medicine or dentistry to enable them to work for elective or vacation periods in universities, medical schools, NHS laboratories or research institutes in the UK and Ireland.

Proposals for work on research projects in any branch of surgery are eligible for consideration. Students must be affiliates of the RCSEd.

FOR MORE INFORMATION ABOUT THE COLLEGE’S AWARDS AND GRANTS, CONTACT: Cathy McCartney, Awards and Grants Administrator The Royal College of Surgeons of Edinburgh Nicolson Street, Edinburgh EH8 9DW Tel: +44 (0)131 527 1618 Email: c.mccartney@rcsed.ac.uk Only Fellows, Members and Affiliates in good standing are eligible to apply.

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 the purpose of processing and administrating applications.

Faculty of Surgical Trainers/ ASME Educational Research Grant

Applications for the joint Faculty of Surgical Trainers (FST)/ASME small educational research grant(s) are invited from surgical trainees and consultants, who are members of the FST and/or ASME. Grants are awarded for projects for a period of one year only and funding will be for grant applications up to £3,000.

For full details and to apply, download the guidance notes and application form from the FST website (fst.rcsed.ac.uk/ grants.aspx).

Email or post applications to Cathy McCartney (see box, bottom left).

The closing date for applications is Wednesday 16 May 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 (SOMS) 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.

CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS Joint MRC/RCSEd Clinical Research Fellowship

Iestyn Shapey, Clinical Research Fellow, University of Manchester.

Insulin therapy in pancreas and islet transplantation.

Joint RCSEd/SOMS/ Shanghai Head and Neck Fellowship

Shofiq Islam, Specialist Registrar, Oral & Maxillofacial Surgery, East Midlands. 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, China.

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

Wong Choon Hee Bursary

Adam Bhanji, Manchester University Medical School. Dental Care and Oral Maxillofacial Care. Mercy Ship, Cameroon, North Africa.

Gwyneth Jensen, Queen Mary University of London. Burns and Plastic Surgery department at Kirtipur Hospital and Lalgadh Leprosy Hospital, Nepal.

Jack Kingdon, Kings College London.

General/Trauma Surgery at Tygerberg Hospital and Orthopaedic Surgery at Groote Shuur Hospital, South Africa.

Roxanne Tajbakhsh, University of Leeds. Universita del Piemonte Orientale, Novara, Italy, and Cook County Trauma and Burn Unit, Chicago, US. references, which should be sent to Mrs Cathy McCartney at c.mccartney@ rcsed.ac.uk. Further information can be obtained from Mr Roger Currie at r.currie@rcsed.ac.uk Closing date for applications is Wednesday 20 June 2018.

RCSED 17TH ANNUAL AUDIT & QI SYMPOSIUM

21 March 2018 • Abstracts Invited • Closing date: 8 January 2018 The College is pleased to invite trainees to submit abstracts for its annual Audit and Quality Improvement (QI) Symposium, which will take place in Edinburgh on 21 March 2018.

Successful submissions will result in an invitation to trainees to present their work at this event, with session chairs giving feedback.

This annual College event gives trainees, at all levels, the opportunity to submit abstracts for consideration for oral or poster presentation.

There will also be a poster presentation session.

Abstracts should be submitted via the College website by 8 January 2018.

rcsed.ac.uk | 61

OUT OF HOURS

Avocado and shrimp salad at The Dempsey Cookhouse and Bar, Singapore

From a Bombay cafe in Edinburgh to a London steakhouse in Sri Lanka, Graham Layer scours the globe for innovative taste sensations

Trading places

F

Graham Layer RCSEd Vice-President

irst to Edinburgh and a new arrival from London. which has appeared all over the place in the south. I tend to Dishoom Bombay Cafe is now in St Andrew’s stick to pad Thai noodles with prawns, egg and chicken, and Square, with décor worth seeing and a warmsatay with mounds of crunchy peanut sauce. spirited ambience. The staff are in contact Norn has had rave reviews since it first opened in Leith, electronically, which is necessary, Edinburgh. It is a minimalist fine dining restaurant as the restaurant covers several with curious tasting menus, which vary depending floors, with a gastric-hopper waiting bay in on the availability of local ingredients sourced the basement, which is the bar. Irritatingly, only from “sustainable, ethical and passionate” there are no reservations taken, but all that suppliers. I had imagined a warm fireside-type is forgotten when you pass through the environment with a whisky haze, but no: pylorus and enter the restaurant. Whatever contemporary tables and noisy, twangy music. you say to your waiter, the food is spicy hot, So what about the Scottish cuisine? Four of but delicious, and challenges the intestinal us chose the seven-course menu with an mucosa. Portions are large and two of us additional special and drank plentiful white shared starters and main courses, which wine. This was shaken in a decanter until it were actually enough for three. Spicy frothed, and was an unusual and entertaining lamb chops had a barbecued crust so experience –it was said to release all sorts were a little impenetrable, but koliwada of pharmacological goodies. Our food was prawns were soft, potent and a massive complex and mostly based on colourful hit. Signature chicken tikka chunks vegetables with the occasional fish were somewhat dry, but the wonderful and lamb, and served by the chefs. It calamari made up for this with its was essentially unmemorable, but was Truffle profiteroles at ‘drizzle’. Multiple giant prawns appeared presented with exquisite attention to detail.

The Olive Tree in a masala dish and the garlic naans were fine, And now abroad, I recommend The Dempsey but not the best. This was all washed down Cookhouse and Bar in Singapore, which has with beers and a large dish of deliciously cooling yoghurt, opened in what was the old British barracks and is now a which I was forced to order! steamy enclave of multiple restaurants and arty shops. Chef Another ‘yoghurt essential’ restaurant and part of a new Jean-Georges Vongerichten’s menu was terrific. Three chain, The Giggling Squid is a noisy but realistic Thai, of us shared three starters, which included foie gras with

62 | Surgeons’ News | December 2017

rhubarb and strawberry jam, and avocado and shrimp salad with a champagne dressing. We followed with my favourite truffle and fontina cheese pizza. Tagliatelle with clams was perfect, as was the breaded veal fillet with rocket. Dessert was salted caramel ice cream sundae with peanuts, and was naughty but comforting. Meringue and ice cream was equally delicious. The whole atmosphere was excellent and the place was rightly packed out.

The London Grill in Colombo, Sri Lanka, is a near-perfect replica of an old-fashioned steakhouse in London and serves really decent food. Lobster bisque is constructed tableside and flambéed, and the black cherry pancakes, also flambéed, were fabulous. The steak with dauphinoise potatoes or frites was respectable.

And in London there is, of course, Fortnum and Mason’s on Piccadilly, where a champagne afternoon tea remains a classic, and is served perfectly by efficient and friendly staff. This treat consists of various courses of fantastic finger sandwiches with perfect taste balance, wonderful scones with all the creamy trimmings, the three-tiered cake stand, endless tea and a glass or so of chilled champagne. You are then invited to choose a dessert to take home in the iconic turquoise F&M bag – pear tart was magnificent.

The Olive Tree in Bath offers a superb tasting menu of five or seven courses. It serves innovative and sensible food that is both delicious and fascinating. An amuse-bouche of profiteroles actually made with truffles and mackerel tartare presented on a crispy salmon skin wafer began the excellent evening. Seared trout with an avocado salad followed, with asparagus, parmesan and Iberico ham rounding off the artistic and generous starters. A fish course of sea bass with fennel and olive tapenade was flavourful and did not need the fresh orange. The meat course of lamb cutlets with ewes’ cheese was a magnificent combination together with a pea purée and onions, but I thought the girolles were unnecessary. We all then shared panacotta with white chocolate, basil and strawberries, and a peanut parfait decorated with salted caramel and chocolate; both dishes were well balanced and surprisingly not sweet. Chocolate petits fours completed the excellent event.

Riesling rules Bernard Ferrie revisits this popular and tasty grape

S

o many good Rieslings are available from around the world, hence another tasting session for this geographically widespread grape.

Mineralstein Riesling 2015 (£10, M&S) by Step in Pfalz.

Citrus, peach etc tasting notes exactly as it says on the tin. A combination of fruit from limestone and sandstone soils. Lovely with meat-free pasta. Also from Pfalz, Kendermann’s Special E 2015 (£7.49, Waitrose) – lemon, lime and pineapple scented.

Afternoon tea at Fortnum and Mason’s, London

Darting Estate Dürkheimer Riesling Kabinett Trocken (£10.50, M&S). Try saying that to an overbearing wine waiter. A heavyweight mouthful at 14%, so not for lunch unless siesta included. Green apples, hints of melon and orange – fresh, dry and lively. Siesta still on the cards.

Cave de Beblenheim Kleinfels 2014 (£9.99, Waitrose).

A very typical Alsace. Dry, rich, floral aromas with mineral character. Good with pork and apple sauce – aromatic and citrus flavours.

Baily & Baily Folio 2014 Clare Valley Australia (£8.39, Waitrose). Lime flavoured with a long finish.

Baden Edition Fritz Keller 2015 (£5.99, Aldi). Elegant, dry, fruity – keep in the cellar, drink in the bath and admire the Bauhaus Museum label. Fritz also owns a Michelinstarred eatery. Excellent-value wine.

Lo Abarca 2016 (£10, M&S) from San Antonio Valley Chile. Lovely, dry, full-flavoured – lime, apricot and jasmine. The pick of the bunch.

These are subtle, versatile wines to be savoured. Palate overloaded in the festive season? A Riesling prescription beats bicarb and paracetamol any day.

rcsed.ac.uk | 63

FROM THE COLLECTIONS

X-POSED! The College collection that gives a vivid insight into the injuries of World War I

T

he Museums have acquired a series of First World War glass x-ray plates from Bellahouston Auxiliary Hospital in Glasgow dating from 1918 to 1919. NHS Fife donated the x-rays after they were discovered in Victoria Hospital, Kirkcaldy, in 2014.

Bellahouston House in Glasgow was converted into a military hospital during the First World War and operated by the Scottish National Red Cross. There are 22 dated x-rays, 12 of which come with official army medical forms requesting the x-ray, listing the name, regiment and rank of the soldier, with each form signed by a medical officer and radiographer. There is often a delay of a number of days from when the x-ray was ordered to when it was performed, indicating the sheer number of patients the hospital was dealing with.

The First World War brought a large number of high-velocity weapons that caused severe damage to the human body. Exploding shells distributed metal shrapnel, which was the leading cause of death on the Western Front, and machine gun bullets caused significant damage to bone. These x-rays highlight this type of injury, with severe fractures to the arm, legs and feet.

X-rays were invented in 1895 and by the outbreak of the First World War were becoming standard practice in British hospitals. They became a vital tool for surgeons at home and at the front. X-rays were used to locate shrapnel and bullets in wounded men, so surgery could be precise and done quickly to prevent infection. Infection from muddied pieces of shrapnel and torn clothing embedded in the wound was the biggest killer during the war.

From top: An x-ray showing a defect of the fibula with a crude attempt at repair and an x-ray indicating some shrapnel remaining Below: An official army medical form

Prior to 1916, the death rate from fractured femurs was 80%.

Robert Jones (1857–1933), Director of Military Orthopaedics in 1916, introduced the Thomas Splint, designed by his uncle, Hugh Owen Thomas (1834–1891), to the Western Front. This appliance, along with x-rays and improved methods of evacuation and treatment, helped to reverse this figure to an 80% survival rate.

The x-ray pictured at the top shows a segmental defect of the tibia, which surgeons have tried to heal by sliding a piece of bone down into the gap, holding it in place with two cerclage wires wound around the bone. A second x-ray taken one month later shows no obvious signs of healing. The x-ray pictured above shows a segmental defect of the fibula and possibly some shrapnel remaining. The 22 x-rays offer a fascinating insight into the war-wounded of the First World War, adding to the College’s impressive military surgery collections.

Louise Wilkie Assistant Curator, Surgeons’ Hall Museums

WWI brought high-velocity weapons that caused severe damage to the human body 64 | Surgeons’ News | December 2017

Cuschieri Skills Centre, Dundee Institute for Healthcare Simulation The Cuschieri Skills Centre, Postgraduate Teaching School & Clinical Skills Centre, Undergraduate Teaching School have now merged and become the Dundee Institute for Healthcare Simulation. Our aim is to deliver the highest quality Skills Courses to local and International Medical Personnel of all levels.

Post Graduate Courses include Anaesthetics, ENT, Gastroenterology, General Practice, General Surgery, Gynaecology, Immersive Simulation, Non-technical Skills, Plastic Surgery, Radiology, Urology, Vascular & Veterinary Surgery.

Visit our website for all course information and to register for courses https://cuschieri.dundee.ac.uk/course-calendar

To stay up to date with the latest dates please follow us on LinkedIn and Twitter

COURSE CALENDAR 04-Dec-2017

Consultant Temporal Bone Dissection Course

05 - 07 Dec 2017

Essentials and Intermediate Laparoscopic Skills for Gynaecological Trainees

08-Dec-2017

Hysteroscopy, Hysteroscopic Surgery and Endometrial Ablation Course

11 - 13 Dec 2017

Intermediate Skills for Laparoscopic Surgeons

18 - 19 Dec 2017

ST3 Interview Course for General and Vascular Surgery

10 - 12 Jan 2018

Basic Skills in Upper Gastrointestinal (UGI) Endoscopy

22 - 23 Jan 2018

Essential Surgical Skills Course for Postgraduates

01 - 02 Feb 2018

Progressive Skills in Veterinary Laparoscopy and Thoracoscopy Course

05 - 06 Feb 2018

Training the Colonoscopy Trainers

08 or 09 Feb 2018

Temporal Bone (1 day)

22 - 23 Feb 2018

ST3 Interview Course for General and Vascular Surgery

12 - 13 Mar 2018

BAUS Sections of Endourology and Oncology Laparoscopic Training Course

26 - 28 Mar 2018

Basic Skills in Upper Gastrointestinal (UGI) Endoscopy

Dundee Institute for Healthcare Simulation Cuschieri Skills Centre, University of Dundee Level 5, Ninewells Hospital DUNDEE, DD1 9SY Phone: +44(0)1382 383400

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