PRESIDENTS WRITE Mike Griffin hands over the President’s reins to Rowan Parks

A fond farewell

Professor Mike Griffin reflects on the successes and challenges of his tenure as RCSEd President and welcomes the new team of Office Bearers

y four years as

MPresident have been wonderful and I am extremely proud of everything we have achieved as a team.

I could not have done this without the support of my two Vice-

Presidents – Pala Rajesh and Rowan

Parks – Honorary Treasurer Alastair

Gibson, and Honorary Secretaries

Judy Evans and Clare McNaught.

We were a tight team and we worked together to make the changes needed to grow and develop the College. We achieved a great deal, but none of it would have been possible without the hard work and resilience of the College staff.

My term has not been without its challenges. I knew we had to change to grow. In our professions there were many people I wanted to help: trainees, women in surgery, less-thanfull-time workers and SAS doctors.

I wanted to support, nurture and develop all of them and give them the tools they need to excel. I wanted to rekindle the joy of looking after, caring for and curing patients.

When I was a young registrar it was a joy to come to work. We worked long hours, but we had places to meet, relax and be social.

Nowadays our workforce must take rests in corridors or in the cafes where their patients’ families might be at the next table. We need to try to improve the working environment if we have any hope of retaining and recruiting staff in our hospitals. I also realised that if you want to make it better for one group – women, for example – you would ultimately make it better for everyone. The brilliant ‘Let’s Remove It’ campaign to cut out bullying and undermining helped everyone. Encouraging support for less-than-full-time working helps everyone. So we developed a campaign that would be the main theme of my Triennial meeting – ‘Making it Better’ for everyone.

TRIENNIAL SUCCESS Initially to be held in June 2020, for obvious reasons it finally happened two years later. We joined up with ICOSET and it was a huge success. It was wonderful to bring surgeons and dentists together to share ideas, network and enjoy social events.

We also decided to update the brand. The one that hit the mark was the combination of the castle (for Edinburgh), 1505 (the date of our Royal Charter), the sun rising over ignorance (taken from our siglium), the globe (representing our international presence) and the unicorn, Scotland’s heraldic animal, which is also known as a powerful horse of healing.

One of my key ambitions as President was to reach the younger members of our profession. Our Membership, Marketing and Communications team created an app that could deliver all the benefits of the College in an easily digestible format. This, combined with offering free Affiliate membership to all medical and dental undergraduates, helped us to grow the early years segment of our membership pipeline and will stand us in good stead for the future.

I am also proud of our Skills Competitions, which continued during the pandemic due to the creative thinking of Angus Watson, who put the skills ‘in a box’. Each year we have increased the number of students who have taken part – this year we had 1,300 applications at the first stage.

COVID-19 RESPONSE During the pandemic I met with the Communications and Policy teams on an almost daily basis to assess the ever-moving clinical situation and lobby for what we needed to ensure that our members were looked after. I also drove a dedicated COVID-19 strand of webinars, which ran weekly

I wanted to rekindle the joy of looking after, caring for and

curing patients ''

Clockwise from top right: Mike Griffin and Craig McIlhenny, Surgical Director of FST, at ICOSET In 2019; the President in his official robes; Prince Charles visits the College; unveiling the sculpture commemorating healthcare workers during the pandemic; the President speaks at the Triennial Conference; Professor Griffin in theatre

throughout the pandemic to share information and raise issues that our clinicians were facing. We also ran webinars targeted at trainees, who were feeling very isolated during this time. Given other priorities, they were worried about their career path and the lack of proper practical craft skills and training.

Our Development and Partnerships team, under the leadership of Michael Stitt, was expanded to include International and I was delighted that Mariette Naud-Betteridge, who had managed our new Kuala Lumpur office, was appointed as Head of International. Together, the team worked with then Vice-President Pala Rajesh to bring his vision to life. This culminated in the College’s first ever International Conference in Chennai this October.

In September we welcomed HRH Tuanku Muhriz ibni Almarhum Munawir and delegation to the College to bestow the Tuanku Muhriz Travelling Fellowship on Andy Kent. Angus Watson gave a lecture on his time in Ukraine. We also presented the College International Medal 2021 to Tan Sri Dr Noor Hisham Abdullah. This was a particularly poignant visit, as it fell during the period of mourning following the death of Her Majesty Queen Elizabeth II.

With our flag at half mast, the College mourned the loss of Her Majesty by stopping all activities on the day of the funeral and greying out our communications for the period of mourning. I was honoured to be invited to the memorial service in St Giles, as the President of a Royal College whose Patron is her heir, King Charles III.

STRENGTH TO STRENGTH Our museum has been transformed over the last few years and is now one of the most important visitor venues in Edinburgh. The Library has also gone from strength to strength, increasing the number and variety of subscriptions, books and periodicals available. Surgeons Quarter faced an extremely challenging few years due to the pandemic. However, the team, under the leadership of

Scott Mitchell, quickly reacted to take advantage of the furlough scheme. He also put our hotel, Ten Hill Place, to good use during lockdown by offering rooms and a meal to all those working on the frontline who needed to live away from their family to protect them from the virus. Even Scotland’s National Clinical Director, Jason Leitch, made use of the offer.

A NEW ROYAL PATRON On 29 June we welcomed HRH Prince Charles to view the prototypes of four statues we have created as a gift to honour his father and our Patron, HRH Prince Philip. The four bronze life-size statues, entitled ‘Your Next Breath’ were created by sculptor by Kenny Hunter to commemorate the resilience and courage of healthcare workers during the pandemic.

On that day we announced that Prince Charles, now King Charles III, had become our Patron. Surrounded by paintings and images of his father, Prince Charles made an unexpected and emotional speech about how his father loved his work with the College and how he hoped to follow in his footsteps. We are honoured to have him as our Patron.

SAFE HANDS Despite the interruption of normal presidential activities due to the pandemic, I believe that together we have achieved a great deal.

We have positioned ourselves as the friendly College, welcoming everyone from the UK and across the world and making sure that we reach as many people as possible from the start of their career to their retirement.

It has been an honour and a pleasure to serve you for four years. There is much more to do, but with the new Office Bearers now in place, we are in extremely safe hands.

Professor Mike Griffin president@rcsed.ac.uk

I wanted to reach younger members of our profession ''

Investing in our people

Our new President Rowan Parks reflects on his exciting yet challenging role and vows to continue the work of his predecessors in ‘Making it Better’

t is with great pride that I have

Ibeen elected and now installed as President of our College. It is an exciting but still challenging time to take over, and I am deeply fortunate to be inheriting a great ship, stewarded by the incredible hard work of my friend and predecessor, Professor Mike Griffin.

I am only too aware of the responsibility and the commitment that comes with this crucial role. In becoming the 176th President of the

RCSEd, I am the first surgeon originally from Northern Ireland to hold this office.

In another first for the College, a father and now son have been presidents of two different Royal

Colleges in the UK and Ireland, as well as also both being President of our Surgical Specialty Association,

ASGBI. So I would like to pay tribute to my father George, a Fellow of this College since 1963 (and still in good standing). He was President of our sister college, the RCSI, from 2000 to 2002 when Sir John Temple was President of the RCSEd.

It is my role to build on the great work of those who have come before me and ensure the College continues to flourish and have influence.

It is now 517 years since our College was founded, and I believe we are just as influential and crucial to UK and international surgery as we were then. Our Edinburgh campus and facilities are second to none. We have outstanding talent here – those who have the capacity to think outside of the box and innovate. We have many jewels in our crown, including our Faculties: Dental Surgery, Surgical and Dental trainers, Perioperative Care, Pre-Hospital Care, Remote and Rural and Humanitarian Healthcare, and Sport and Exercise Medicine.

These Faculties have all grown so much in recent years and keep us at the forefront of surgery and dentistry, both in the UK and, increasingly, internationally. Our challenge is to remain ahead with these developments, not because it is in the College’s interests, but because it is in the interests of our patients and their safety, which is the reason we are here. We also need to invest in people – future Members, Fellows and College staff.

I have been fortunate to have been part of a phenomenal clinical and academic unit for almost 25 years. My colleagues at the academic HPB Surgical Unit at the Royal Infirmary of Edinburgh, under the leadership of Professor Sir David

Carter, Professor James Garden and now Professor Stephen Wigmore, have just been the most wonderful, dedicated, supportive and collegial colleagues I could ever have wished for. The unit has a global reputation and I am tremendously proud of that. I wish to pay tribute to the incredible support and teamwork shown by all of my clinical and academic colleagues that has permitted me to undertake many roles and responsibilities, not least my involvement in the College over the past 13 years and more.

The key to teamwork is valuing everyone in the team. We must continue to foster that teamwork among our College staff, currently led by Tony Oxford. Our College will move forward with this teamwork in mind, enabling us to innovate, educate, train and care for patients.

As you know, when Mike and I put together the programme for the Triennial Conference, the theme was ‘Making it Better’. Unfortunately, the pandemic meant the conference was delayed for two years, eventually being held in June this year. That theme, however, remains important and it is my intention to continue to use it as we transition into the next administration. We do want to make it better – better for surgeons, trainees, students, SAS doctors, for dentists and, ultimately, our patients.

NURTURING TRAINEES Our trainees have had it very tough over the past couple of years. Their resilience has been stretched, their training has been impacted and often their working environment has been challenging. We must ensure they are valued and nurtured. I am passionate about the education and training of the next generation of surgeons and dentists, and this will be a major focus of our endeavours over the next few years.

We must ensure their training is prioritised as we recover from the impact of the pandemic, but also manage a huge backlog of elective surgical workload. We must also rekindle in them the excitement, the satisfaction and the joy of looking after, caring for and curing patients. During the next three years I aim to work with our Regional and International Surgical Ambassadors to engage with students, trainees and younger Fellows with a commitment to support, stimulate and encourage these future surgeons.

A major focus as we enter the next few years will be on our workforce. Together with our trainees, we also need to support our SAS doctors and our non-medical workforce, as well as our consultant colleagues.

We have an outstanding Council at present, bolstered even more by our recent elections. We have a completely new Office Bearer team. I couldn’t have asked for two better Vice-Presidents – Tim Graham and Clare McNaught – who will lead both at home and abroad. Tim’s huge experience in education, training and assessment will be vitally important as we develop and expand our education and examination portfolio. Clare, our youngest ever VP and first ever female VP, will have oversight of our international portfolio. This will be crucial as we recognise that more than 40% of our College membership are based overseas. It is also great to have Robin Paton taking over as Honorary Secretary and Siong Liau as Honorary Treasurer.

What I can promise is that I will bring passion and enthusiasm to this role, and with such a superb team and Council behind me, I believe that the College can and will carry on the fabulous work of the last administration and truly make a difference for young doctors, surgeons and our patients.

Professor Rowan Parks president@rcsed.ac.uk

We must rekindle in trainees the excitement and the joy of looking after,

caring for and curing patients ''

Opposite page, Immediate Past President Professor Mike Griffin, left, and new President Rowan Parks at the Diploma Ceremonies in November

Left: Rowan Parks speaking at the Belfast Forum

SURGICAL SAFETY UPDATE

Cases from the Confidential Reporting System for Surgery (CORESS)

Air embolism in coronary artery bypass perfusion error

This case reflects a report recently submitted to CORESS. Cardiac surgery is a highly technical area in which a patient undergoing heart surgery may be placed on heart-lung bypass to ensure continued organ oxygenation while the heart is temporarily stopped. In this case, a technical error gave rise to an adverse incident when a vent tube was inadvertently placed into the perfusion circuit the wrong way round. On establishing cardiopulmonary bypass, the surgical team became aware that air had entered the heart after noting an air bubble within the cardioplegia cannula.

The visible air was cleared and the operation continued. Postoperatively, it was evident that the patient had sustained a hypoxic brain injury. The cause was identified as a significant air embolism during institution of bypass.

The patient did not regain consciousness postoperatively. Following repeated CT scanning and clinical reviews, the prognosis was felt to be extremely poor. Treatment was withdrawn and the patient died. The root causes were human error and equipment factors.

Whilst the specific clinical features of this case are not pertinent to all surgical practice, the principles of checking kit, ensuring knowledge of equipment operation prior to commencement of surgery, and of being aware of potential systems errors are relevant to all surgical practice. The Society for Cardiothoracic Surgery is aware of, and has commented on, this case.

SCPS Safety Committee findings

This was an adverse event arising out of a highly technical and niche area of surgery in which misapplication of the perfusion apparatus was involved. The equipment was checked and found to be functioning normally. Due to the design of the pumps, the risk of human error leading to an inadvertent change of flow direction to the vent pipe was real. This potential to inadvertently reverse the flow on this particular pump was demonstrated to all members of the perfusion team. It was recommended that once the heart-lung machine has been set up and existing safety checks completed, it should be switched to zero revolutions rather than placed in standby mode. This should be added to the perfusionist protocol checklist. Fluid should be aspirated into the vent line prior to its insertion (wet table test). This task should be included in normal checks undertaken by the scrub nurse. Human factors contributed to this incident.

As part of the Massive Air Embolism protocol review the SCPS recommended introduction of one-way valves to the vent suction line. Other specific recommended actions included a wet table test of all suckers as standard to avoid errors. It was felt that wet testing of vents prior to insertion would further increase the safety of these devices.

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

Double trouble

A 76-year-old male vascular patient with atrial fibrillation and a femoro-popliteal bypass graft was inadvertently prescribed both apixaban and enoxaparin together. Although the prescriptions were on different charts, it was an intentional attempt to ‘bridge’ the patient onto a direct oral anticoagulant (DOAC).

Reporter’s comments

Pharmacy advice made it clear that concomitant prescribing of two anticoagulants is contraindicated unless it is for a patient being started on warfarin for venous thromboembolism (VTE) or for an established warfarinised patient with a subtherapeutic or unstable international normalised ratio. DOACs have a rapid onset of action – hours not days. When switching from a parenteral anticoagulant to a DOAC, the first dose should be given when the next dose of low molecular weight heparin is due or on cessation of an IV unfractionated heparin infusion. The higher initiation doses for both apixaban and rivaroxaban

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are not ‘loading doses’. All DOACs have short half-lives and this is a larger dose to cover the higher period of risk, acutely after a VTE.

CORESS comments

The Advisory Board commented that electronic prescribing might have averted this issue. It was also noted that the discipline of checking all drug charts in use remains an important function of the daily ward round.

Inadvertent bladder injury at orchidopexy

An eight-year-old boy presented for bilateral second-stage orchidopexy for intra-abdominal testes. The first stage, a Fowler-Stephens procedure, whereby the testicular vessels are divided to allow hypertrophy of the accessory supply via the vas deferens (Figure 1), had been carried out several years earlier with an unusually long period between first and second stages due to COVID-19. The parents were keen for both testes to be moved to the scrotum during the same operation to avoid further anaesthetics.

The procedure was approached laparoscopically. The primary port was inserted without complication, infraumbilically, using an open technique. Insertion of two secondary ports was hampered by limited space despite using standard insufflation pressure and flows.

Both testes were seen within the abdomen. The left testis was associated with a large hernia sac and was managed through an open incision into the groin after a laparoscopic procedure on the right side. Visualisation was challenging due to the limited space so the pressure for the pneumoperitoneum was increased to 15mmHg, although the working space was still unusually small.

The testis was mobilised and then a Veress needle and ‘step’ port sheath were passed up from the scrotum into the peritoneal cavity under vision. The needle did not immediately pass into the peritoneal cavity and required some manipulation. An 11mm step port was passed up the sheath, the testis grasped via the port and brought down into the scrotum. Postoperatively, there were no immediate concerns, but the family were anxious and the child was kept in overnight. He did not pass urine and was clearly peritonitic the next morning. Bloods and imaging were in keeping with a bladder leak, which was confirmed at exploratory surgery. The edge of the bladder had been injured by the Veress needle inserted via the scrotum and there was a clear urine leak. The patient made an uneventful recovery once the bladder had been repaired.

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.

CORESS is an independent charity supported by AXA Health, the MDU and the WPA Benevolent Foundation.

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FOk A SAFER SURGICAL FUTURI

CORESS and reporter’s comments

The pressure required for the pneumoperitoneum was higher than normal and might have pushed the bladder out more laterally than usual. The Veress needle was brought up medial to the medial umbilical ligament and did not pass smoothly, providing a clue about possible mis-passage that was not picked up at the time. Bladder injury is a recognised complication of this procedure.

In future, the approach should be lateral rather than medial to the medial umbilical ligament. The bladder should be empty prior to the key manoeuvre, although the role of catheterisation in young males prior to surgery is controversial and should be dealt with on a case-by-case basis.

New CORESS app

The CORESS Reporting App, which makes reporting easy and convenient, is now available to download and use on your phone. Search for CORESS in the Apple or Google Play app stores to find out more.