Anaesthetics
Introduction
Welcome to the Department of Anaesthesia at the Countess of Chester Hospital.
Please make sure that the College Tutor (C/Tut) or Donna/Kate/Toni (Departmental Secretaries) have your details; address, email address, home and mobile phone numbers - fill out the Personal Details form and return it in the 1st instance to the College Tutor.
These notes are intended to introduce you to the hospital, clarify the departmental structure and familiarise you with policies and guidelines that exist for your own help and protection. No version will be completely correct at all times, and we rely on you, the users, to highlight any inconsistencies and make constructive suggestions. This can be done by pointing things out to the College Tutor, or by annotating any handouts you receive and returning it to us at any time or when you leave.
Contributions and acknowledgements
Dr Anne Troy
Departmental Structure
The department is part of the Surgical Directorate in Planned Care, and in addition to providing anaesthetic services to the Trust, also runs the Intensive Care Unit and the Pain Service. There is now a new combined ITU/HDU with ITU and HDU consultant cover all day and on call cover.
Department Members
27 Consultant Anaesthetists
3 Associate Specialists:
Dr Fiona Macrae Appraiser
Dr Munir Khan Obstetrics
Dr T ‘Vishy’ Viswanathan Chronic Pain
7 SASG ‘Speciality Grade’ anaesthetists Drs: Jamie Fanning (FTPD), Anita Jhamatt, Manal Salit, Caroline Stamper-Clarke, Michaela Duskova, Rob Schofield(simulation), and Tariq Ahmed
1 Regional Anaesthesia Fellow
1 Vascular Fellow
8 SpRs & 8 SHOs (we don’t have the full complement and usually ~2-4 short)
Currently 1 acute pain nurse-
2 Secretaries- Donna and Toni and 1 pain secretary- Kate
Consultant Anaesthetists’ Roles (these often change or are added to)
Dr Simon Bricker Lead Clinician for Obstetric Anaesthesia
Dr Nicola Campbell Obstetric Anaesthesia
Dr Mary Cardwell Lead Clinician
Dr David Castillo Audit Lead
Dr Lyndsay Cheater FICM Tutor
Dr David Childs Chronic Pain
Dr Dominic Cliff Acute Pain/day to day rotamaster
Dr Amit Dawar Sim lead
Dr Ewen Forrest Anaesthetic Pre-Assessment also RA
Dr Rebecca Gale ITU/RHD co-ordinator/
Dr Iestyn Harrod Pre-assessment/ rota master for 1/2/3 on call
Dr Sian Hill Consultant on-call rota co-ordinator; M&M lead.
Dr Paul Jameson Paediatric Anaesthesia lead
Dr Andrew Logan Chronic Pain
Dr Jeena Mathew Chronic pain
Dr Patrick Mullen Vascular/critical incidents
Dr Richard Nelson ITU
Dr N Rajadurai Acute/Chronic Pain
Dr Simon Ridler Regional/(incoming) RCOA College Tutor
Dr Nicole Robin Lead clinician for Critical Care/ICM research lead
Dr Santokh Singh Outreach/ITU
Dr Sean Tighe Trauma ITU AAGBI council
Dr Kate Tizard ITU/ Transfer lead
Dr Anne Troy (outgoing) RCOA College Tutor/airway lead
Dr Lawrence Wilson ITU
Dr Eoin Young ITU/equipment lead
Dr Woei Lin Yap Peri-operative medicine
Teaching
There are numerous formal educational opportunities within the department: Rolling Half Days (RHD) occur ~ twice each month; an intensive tutorial programme for brand new CT1 starters in anaesthesia during their 1st eight weeks; Primary FRCA tutorials every Wednesday am; Journal Club on alternate weekday lunchtimes; ICM or USS regional anaesthesia tutorials alternate Wednesdays and some ad-hoc lunchtime presentations also. The format of the RHD is a mixture of formal lectures, case presentations, audit and mortality/morbidity discussions. All members of the department on-duty are expected to attend.
New starters in Anaesthesia
If this is your first year of training in anaesthesia you will spend at least three months being closely supervised, you will need to pass several formal assessments before you can work independently and participate in the on-call rota. It is mandatory that you have your Initial Assessment of Competency Certificate (in Anaesthesia) signed off/obtained before starting on the on-call rota as 1st on-call anaesthetist. You will also need to complete the transfer course (as you cannot do intra-hospital transfers without, you will need to complete on line and in house training for this prior to going on call)
Training
CT1 and CT2 trainees will have appraisals with their Educational Supervisor at the beginning of their attachment, halfway through and twice towards their year- end (the earlier one is pre-ARCP). As part of this process you will be given feedback on your performance from the consultants. Appraisal is a two-way process and you will have an opportunity to give some feedback on various aspects of training in the Department. There will be a formal Annual Review of Competency Progression (ARCP) held by the Deanery.
The main aim of core training is to obtain the competencies to progress to specialty training and pass the Primary FRCA. You will be emailed the approved list of courses organised through HENW. During the first & second years of training there is a regular day release course which will cover most of the basic science part of the syllabus (BASICS 1 & 2) – these dates must be applied for and booked as formal study leave.
During the second year (or first year if you wish), there are pre-exam preparation courses which you need to book leave for. When you are approaching taking the Primary Oral and OSCE exams, you should arrange practice vivas for yourselves within the Department – via your educational supervisor in the first instance.
Study leave guidelines will be emailed to you. The following courses are part of your leave budget
• Novice Laryngoscopy Course (CT1)
• BASICS – Core Trainees Primary Preparation Course (12 days)
• BASICS + – Core Trainees Primary Preparation Course (2 Days)
• The EASE Course - Emergencies in Anaesthesia (CT1)
• Transfer Training Course
• Mersey Introduction to Critical Care Course
• Difficult Airway Course for Core Trainees
• BASICS 2 (2 Days)
• Basic Obstetric Anaesthesia Course
• Mersey School of Anaesthesia Primary FRCA MCQ Course (5 days)
• Mersey School of Anaesthesia Primary OSCE/VIVA Course (5 days)
• Introduction to Ultrasound Course (Half day) (CT2)
• Human Factors Workshop (Half day) (CT2)
• Pain Workshop (Half Day)
.
ST training: We endeavour to provide training modules for ST trainees to meet the RCoA requirements for training. Please let your Ed/Sup know which modules you would like to complete whilst in Chester. Please note that those on the new 2010 curriculum will need sufficient WPBA’s plus ~20 sessions (or equivalent) in most modules for competency sign off. New ST trainees attend MAFIT Classes 1,2 or 3 depending on whether they are preparing for the written Final FRCA exam or the SOE component.. Oral examination practice will be provided by the department for all trainees successful in the FRCA written exam – again, arrange this through your educational supervisor.
*Please note that Study Leave must be applied for (6 weeks in advance) when planning to attend BASICS 1&2, Mon/Tues School, other courses.*
Life support courses
If you wish to go on a course either outside the region or on a topic not directly relevant to your stage of training, funding/leave may not be forthcoming as it is inevitably limited. Please feel free to discuss attendance at other life support courses (ATLS, ALS, APLS) with your educational supervisor.
On call arrangements
At present there are 3 tiers of on call. The on call commitment is a full shift and you will provide cover for your colleagues on annual/study leave. In addition you will be expected to cover for your colleagues at short notice due to sick leave, whenever this is possible. This will be compensated for by either time back or extra duty payments.
First on call (bleep 2605)
The first on is usually a CT 1 or 2 trainee, but occasionally an ST3-7 or SAS/specialty grade doctor. You are responsible for urgent/emergency surgical cases for a shift of 12 hours. Changeover times are 08.00 (in Theatre 5 usually) and 20.00, when you will meet your predecessor, have a handover and take the cardiac arrest bleep from him/her. You are a part of the cardiac arrest team and also the trauma team. If you are busy in theatre, then the second on is also part of the team and will also attend if able (see below). If you cannot attend then please let the arrest location know this. It should be unusual for you to be in theatre after midnight unaccompanied by the second on call or a consultant. When not in theatre out of hours, you are part of the resident anaesthetic team and will share responsibility for covering the Intensive Care Unit and Maternity depending upon the level of your experience.
Should you have cases that are to be left until the morning, and it is not an unreasonable time for visiting patients on the wards you should see patients for the person to follow you on call. This will permit a prompt start to emergency cases in the morning. This is particularly important at weekends.
Second on call (bleep 2606)
This is usually an ST3 or above, but may be a CT2 trainee on their ICM basic training. This on call is a full shift commencing at 08.00h or 20.00h. Please meet with your colleague on the ITU and handover there.
You are responsible for supervising or assisting the first on call, covering the ITU (with a consultant in the daytime). You are also part of the cardiac arrest team and trauma team (see 1st on-call notes), and because you are less likely to be tied up in emergency theatre, you are the first in line to attend. Should you be tied up then get an assistant to reply to your bleep saying that you cannot go.
When you are 1St on call, 2nd on call or 3rd on-call, your anaesthetic colleagues that are not working in theatre or other areas -they may be available to assist you as part of the resident anaesthetic team. If you are actively involved in A/E cases (resuscitation, trauma, transfer to CT etc.) then please use an anaesthetic chart – there is a supply in A/E anaesthetic machine.
Intubation checklists are used for intubations in outside areas and there is also an emergency drugs bag in itu and theatre 5- please ensure you use these.
Third on call (bleep 2374)
This is usually an SASG/ST3-7 but can be the CT2 when obstetric competencies are completed and deemed ready to go on call. You cover the labour ward out of hours and handover 8am and 8:00pm. When covering maternity in day time hours, (including week-ends) part of your duties is to see the post-operative and epidural patients from the previous day if not already seen. If quiet, please help out in theatre or in ITU when these areas busy and if busy- please ask for help from your 1st/2nd on call colleagues.
Consultant (available via switchboard or in nominated theatre)
There will be a ‘anaesthetic consultant on-call’ for ITU and general side from 17.30h until 09.00h. During weekday working hours there will be 2 ITU consultants, a consultant in Maternity (not always), and for all other problems an underlined consultant, who is accompanied by a trainee, and therefore available to troubleshoot. Please see the section on ‘cases to discuss with consultants’, as well as the section on ‘the management of children’.
Pre- and post-op visiting
A pre-operative assessment for anaesthesia is a mandatory standard. You should also visit patients post-operatively particularly after major surgery to assess the efficacy of your analgesia regimen and fluid balance etc. This practice is likely to improve the quality of early post-operative care, as also heightens awareness of patients/surgical/nursing colleagues as to our valuable role in peri-operative care, and improves continuity of patient care.
Time Keeping
Time keeping is important and you should be in the anaesthetic room at least 15 minutes before the start time of the list to check the anaesthetic machines, prepare the drugs, and contribute to the pre-list ‘WHO Safety Brief’.
Rotas
The on-call rota is produced about six weeks in advance ideally, and the weekly rota is finalised one week in advance. Advance notice of leave is required to allow the rota to work; annual leave or study leave should be booked at least 6 weeks in advance. If you want to swap an on-call day/evening/weekend, then it is expected that the on-call block will be swapped rather than a single day. Swaps must be approved by the rota coordinator and please discuss with the rota master as well.
Annual Leave
Completed annual leave forms should be submitted to the day to day rota supervisor for approval (please put in tray on Donna’s desk in office). The departmental diary has returned to use. Please fill in the usual forms and put your name in the diary in the appropriate slot. If your name does not appear on the CLW rota and you think it should please let Dr Cliff know (and Donna)as it may be an oversight. There is a limit to how many trainees on each tier of on-call cover may be away at any one time. Exceptions will be made when possible. ***Annual leave should be taken pro rata to the length of time you spend in Chester
Study Leave
Applications for study leave should be made to the rota organiser (Dr Cliff & your educational supervisor and are now on line via HENW. Please ensure that your name is entered in to the diary, a form filled in and left in the office tray and 6 weeks notice is given for any leave
Sick Leave
Should you be ill, please inform Donna/Toni or /Kate, as soon as possible on Ext 5461 or 5404 during normal working hours. Out of hours a message to the first or second on call is mandatory, (in addition to a recorded message to Donna/Kate) as this is more likely to get through to the morning underlined consultant who will then arrange to have your duties covered. A return to work interview will be held on return to work. If you fail to do this within 2 weeks of sick leave you will then need to do this with the Lead Clinician. Sick leave is taken seriously by the lead employer and by this Trust to ensure the appropriate support is in place.
Bleeps
As all have mobiles we have stopped the use of personal bleeps. For the “1st-on” “2nd-on” and “3rd on” anaesthetist there are separate on-call bleeps which are also cardiac arrest pagers. You are responsible for attending cardiac arrests until handing these to your successor at shift end. A cardiac arrest test call is made every morning at 09.15h. If you are required to go on a patient transfer give your bleep to another anaesthetist. At night this might be the Consultant on call.
When to Get Help
Policies do exist for two important related issues – when to discuss cases with consultants, and who should manage paediatric cases.
Discussion of cases with consultants
Any case with which you are unhappy or have concerns should be discussed with the underlined consultant on the rota during normal hours or with the on-call consultant out of hours. All cases with the following factors should definitely be discussed with the responsible consultant and the discussion documented on the anaesthetic chart.
General factors
ASA 3 or greater
Child aged 11 or under
Emergency patients by CEPOD classification (those going to theatre for simultaneous resuscitation and operation)
Anaesthetic factors
Difficult airway anticipated or encountered.
Requirement for practical skills you do not yet possess.
Surgical Factors
Any case anticipated to last more than 3 hours (or which actually does)
Heavy blood loss
Severe Sepsis or Septic Shock cases
Who should anaesthetise children?
Aged 5 or below
The consultant should be present in the theatre area throughout the anaesthetic. An exception to this is permitted when the senior trainee on-call has completed their higher/advanced training ie (ST6 or ST7 in anaesthesia)module in paediatric anaesthesia.
Aged 11 or below
The consultant will need to be informed and to be available while the anaesthetic is occurring.
Aged over 11
Referral pattern is as for adults.
Please bear these guidelines in mind towards the end of the afternoon. It is appropriate to give the on-call consultant warning if the child cannot be anaesthetised during normal hours so that a suitable time for all concerned may be arranged.
How to get help
Cardiac arrest
In the event of a cardiac arrest in theatre when you are the sole available anaesthetist, then institute Basic/Advanced Life Support with the assistance of the surgeon & anaesthetic assistant, and instruct a theatre nurse to put out a Theatre Cardiac Arrest Call by activating the red emergency call for help device in the anaesthetic room/theatre. This will result in help arriving from other theatres very quickly. Out of hours, or depending on circumstances sometimes within normal weekday working hours, it may also be appropriate to put out a hospital cardiac arrest call (see below) Sending for urgent help from other theatres, or indeed the hospital cardiac arrest team, is the quickest way to obtain further pairs of hands, and in no way implies you lack the ability to deal with the problem. When time permits, a consultant anaesthetist must be informed, if not already a responder to the call for help.
To declare a hospital cardiac arrest
Dial 2222 and give details of location and problem to the switchboard operator.
To declare a paediatric cardiac arrest
Dial 2222 and be sure to declare that this is a paediatric arrest.
Theatre problem
The underlined consultant is clearly displayed on the week’s rota. This consultant will be accompanied, and is therefore available for emergency attendance if a trainee is experiencing difficulties in theatre, or wishes to have someone more experienced assist him/her at any point during a case. If simple advice is required, feel free to approach the nearest consultant to your theatre, but he or she may have to point you towards the underlined consultant if attendance is necessary.
Ward problem
Problems relating to pre-operative assessment and preparation of a patient may be discussed with any available consultant, but the underlined consultant will frequently be in the best position to help. He/She is the AAGBI ‘Named Consultant’, unless you someone else has agreed to take/share responsibility for that case. If a patient is likely to need intensive care or HDU care, with or without an operation, discuss with the consultant covering HDU or ITU, AND the underlined consultant before taking the patient to theatre. It might save time if you can determine the HDU bed state before doing this.
HDU/Intensive care problem: Please discuss with the ITU consultant in ITU.
Responding to a hospital cardiac arrest call
Both the first on-call and the second on-call are part of the arrest team. It is recognised that frequently the first on-call will be in theatre and so unavailable. The second on-call is then expected to attend. When the second-on is unavailable ask your ODP to inform switchboard that you are occupied. Depending on what you are doing, it may be appropriate to send an ODP if your patient is stable. Remember, if more hands are needed, then alert the on-call consultant at an early stage or the underlined consultant during normal working hours. A consultant will normally be able to attend from home within 30 minutes, but in early morning hours this may take a little longer.