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Your letters

Dear Editor

The RCoA and the lost tribe of trainees - prioritisation for the Primary FRCA examination

The RCoA have recently issued revised regulations for the Primary examination [1]. COVID has constrained the number of candidates that can be examined, and therefore formal prioritisation has been adopted. Those allocated to Category A take priority over Category B; the latter, if similar selection is repeated, might be excluded for some time - in effect a lost tribe of upset and disillusioned trainees. Those with a Deanery number achieve a higher rank, and the term 'time critical' helpfully applies to those with, rather than those aspiring to, a number.

Possibly this is the first time that a Royal College has defined a differential value for candidates, and then uses that to deny examination access. All these candidates are equally eligible, pay the same examination fees, and most pay the same membership fees – note no such discrimination is taking place at the difficult and dangerous work face.

As a Chairman of Examiners for the old FICM examination, I find this prioritisation grossly unfair and unwarranted, and in days gone by I would have refused to examine knowing eligible candidates were arbitrarily excluded on a whim. Allegedly the College has sought legal opinion. Surely if such an opinion is required to decide if a system is reasonable and fair, then it is at least dubious even if not illegal.

This is allegedly affecting 60 trainees who have no redress. I call for the immediate withdrawal of this offensive prioritisation, and reinstatement of proper and fair access to the examination for all eligible candidates, or we will have an even larger lost tribe. If you are a trainee disadvantaged by this, or have trainees, I am sure that your College would be pleased to hear from you, and should be appropriately sympathetic to your problem of their making.

Neil Soni
Previously Consultant Anaesthetist, Chelsea and Westminster Hospital.

Declaration of interest: my son is taking the Primary examination, which is how I became aware of this issue.

References 

  1. Royal College of Anaesthetists. Primary and Final FRCA examination regulations, 11 December 2020. www.rcoa.ac.uk/documents/primary-final-frca-examinations-regulations/section-4-prioritisation-applications (accessed 20/1/2021).

A response 

Thank you for giving me an opportunity to respond to Dr Soni's comments. The RCoA has a statement on its website that gives a detailed account of the current situation with the FRCA exam. We will continue to provide updated information over the coming months via our usual channels.

I can confirm that no part of the prioritisation process will affect a doctor's eligibility for ST3 recruitment rounds.

Chris Carey
Chair of the RCoA Education, Training and Examinations Board

Dear Editor

Our current method of winning a debate is inherently biased

Our current method of winning a debate is inherently biased. The current convention is that the winner of the debate is the person that swings the audience to their side of the argument. We have adopted this convention because if one only voted after the debate, the accepted norm will always defeat the minority. To make progress we wouldn’t want a system that inherently favours the norm.

I was amazed by the quality of the recent Association Winter Scientific Meeting. There was a debate as to whether we should drop the FRCA examination. Both speakers presented a high quality pitch, and the swing was towards dropping the examination. However, let’s look at the psychology of this. Those with firm conviction are very unlikely to be dissuaded. Voting because of familiarity is less likely to be with firm conviction. Those that voted against the FRCA initially have rejected the norm, and will have a higher degree of conviction. Thus the current convention favours the nonconventional argument, because those voters had higher conviction from the outset. For instance, in a debate over veganism, veganism will always win because vegans won’t change their minds. Voting is undoubtedly a vehicle to enhance people’s education on both sides of an argument in an atmosphere that avoids conflict, but conversely it is not correct to say that it serves no purpose in the validation of the merit of either side. Perhaps we will stick with the current convention for the same reason we tell our children Santa Claus is real (it makes everyone happy), but I throw down the gauntlet to one of my colleagues who perhaps is a lateral thinker, psychologist and statistician to come up with a better way of evaluating the winner of a debate.

Antony Richards
Consultant Anaesthetist
Royal Oldham Hospital, Oldham

A reply

Dr Richards poses an interesting question. How do we measure the results of a debate? Who ‘won’ or ‘lost’? He alludes to a common argument, that one should not have excessive confidence in the power of rational debate. There is, some might say, no reasoning with some people.

So, what could we do better?

The question
What should we be asking? We could ask who a delegate was most convinced by, or impressed with. Should we prompt for quality of performance or content, as in more formal debating contests? We could just ask “Who do you think won?”

The fixed position and higher degree of conviction of entrenched views could be addressed by prompting open-mindedness with “Leaving aside your previous opinions….”

The sample
How do we account for the self-selecting population? Perhaps we could identify the floating voters, those without a firm position at the beginning of a debate. YouGov and other pollsters use ‘rim weighting’, also known as ‘raking’, which ensures that the marginal proportions in a sample match those of the target populations. I’m not sure that this would work in the context of a Pro/ Con debate – we are all very similar.

Timing
Do we poll immediately after a debate? Do we poll before and after? Or do we let things sink in for a bit; perhaps a delayed poll might give us a clue as to whether the rhetoric has stuck. Or were we charmed, only to change our mind later?

More questions than answers I’m afraid, but here at the Association we like a challenge. Perhaps it’s time to freshen up Pro/ Con debates, but we must retain the spirit of friendly jousting and the light-hearted bonhomie that I think the Association does best (and I acknowledge my bias).

Chris Mowatt
Chair of the Education Committee, Association of Anaesthetists

Cartoon of the front page of the journal Trainee Today


Dear Editor

Standardisation, syringe labelling and pre-filled syringes - 1

David Whitaker’s article on syringe labelling touched upon a labelling obsession that only pedantic anaesthetists can have [1]. The figure in his article shows ‘left handed’ and ‘right handed’ syringes, labelled with the sticker longitudinally along the barrel of the syringe. While this clearly shows the contents when the label is uppermost, rarely are drug trays so orderly and syringes often find their way into different orientations. Moreover, the labels often then conceal the volume markers on the barrel.

Our Figure 1A shows the label clearly when the syringe is orientated with the label uppermost; however when the label of the syringe is concealed (Figure 1B), it is entirely unclear what drug the syringe contains and thus it could be reached for in error. Although the label is not legible in its entirety in Figure 1C, the colour will alert the anaesthetist as to the class of drug; of course the label should be checked before the drug is administered.

Until pre-filled syringes are universally available, we would suggest that the safest way to label syringes is to apply the sticker around the base of the syringe so that it can be visible whatever the orientation of the syringe (Figure 1D). We all have our ‘right’ way of doing things: this is one of ours!

Standardisation, syringe labelling and pre-filled syringes Figure 1

Figure 1. 

Vanessa Skelton
Consultant Anaesthetist

Kathryn Laver
ST7 Anaesthetist
King’s College Hospital NHS Trust, London

 

Dear Editor

Standardisation, syringe labelling and pre-filled syringes - 2

I was cheered to see the standards for labelling of syringes in the recent safety issue of Anaesthesia News [1]. I would like to make two points on the instruction to place the label lengthways along the syringe barrel. The first is that I feel the label should be placed in such a way that the wording is as close as possible to the syringe graduations. This allows the clinician to view both the drug name and the volume delivered at the same time, which is an important safety consideration (Figure 2).

Standardisation, syringe labelling and pre-filled syringes Figure 2

Figure 2.

The second point addresses the complaint often made by advocates of circumferential labels: the difficulty in quickly identifying a drug when placed label down. If drug labels were manufactured so that the colour was present on both sides of the label (i.e. the label was made from coloured paper and not just printed on white paper), this would allow quick identification of the agent type even when a syringe label is turned label-down; makers of prefilled syringes often use this as an added feature.

Jason Walker
Consultant Anaesthetist
Ysbyty Gwynedd, Bangor, Wales 

Twitter: @jasondwalker

Dear Editor

Standardisation, syringe labelling and pre-filled syringes - 3

Colour coded labels are commonly used to improve safety during anaesthesia, however, this is not foolproof or devoid of scope for improvement. We note recent concerns raised over a lack of standardisation, prompting the development of a guideline by the Association of Anaesthetists [2]. In addition to this, Lo and Plaat raised concerns that syringe labels do not stick adequately to the syringe, leading to the possibility of error if a label falls off [3].

We conducted a short experiment by placing labels in different orientations on the four most commonly-used syringe sizes; these were: single circumferential; longitudinal; and two circumferential overlapping labels (Figures 3 and 4). We photographed the syringes one hour after the labels were applied.

Labels were less likely to lose adherence when placed longitudinally or doubled, compared with the single circumferential orientation, although the longitudinal labels on the 2 ml and 5 ml syringes can be seen to adhere imperfectly. This suggests that two labels placed circumferentially is the best strategy to promote label adherence, followed by the longitudinal orientation.

William Simpson
Anaesthetic CT1

John Vernon
Anaesthetic Consultant
Nottingham University Hospitals NHS Trust

AN-21-426_9-Fig-3-V2

Figure 3. Left to right: circumferential; longitudinal; doubled circumferential. Upper 2 ml; lower 5 ml. 

Standardisation, syringe labelling and pre-filled syringes Figure 4

Figure 4. Left to right: circumferential; longitudinal; doubled circumferential. Upper 10 ml; lower 20 ml

A reply

Thanks to the safety aware anaesthetists for valuable comments on my article [1]. Syringe labelling has improved, but to raise it to the next level anaesthesia, intensive care and pain medicine require all their injectable drugs to be supplied in prelabelled prefilled syringes. Prefilled syringes have additional advantages of correct contents, sterility, and rapid availability. As medication safety is a global priority, anaesthetists should be urging the speedy introduction of prefilled syringes locally in their own hospitals, nationally and internationally.

Whilst working to introduce prefilled syringes, standardising current labelling practice can still improve the situation. Dr Walker correctly says that the volume graduations on the syringe barrel should be visible, and ideally manufacturers should re-orientate the siting so that the graduations are still visible when a label is stuck uppermost along the barrel and the syringe is resting on a flat surface. Making labels from coloured paper, and also printing the drug name on both sides, would be helpful. Sticking two labels along the length of the barrel could help, as having two of everything is another good safety principle.

Drs Skelton and Laver are correct to say that drug trays are rarely kept in an orderly fashion. However this is a safety area that is directly under anaesthetists’ control and where we can most easily make a difference. After introducing a standardised ‘medication template’ (Figure 5), Grigg et al. found no medication errors in six of the next 13 months [4]. Labelling syringes circumferentially ensures that the colour can be seen, but rarely the complete name of the drug (Figure 1C and 1D).

Drs Simpson and Vernon clearly demonstrate the need for reliable label adhesive. As labels get old, the adhesive dries out and the colours fade; they should be thrown out and replaced on safety grounds.

David Whitaker Chair,
Patient Safety Committee, European Board of Anaesthesiology Manchester

References 

  1. Whitaker D. Standardisation, syringe labelling and prefilled syringes. Anaesthesia News 2021; Issue 403: 12-3. 
  2. Association of Anaesthetists. Standardisation, syringe labelling and prefilled syringes, 2021. https://anaesthetists.org/Home/Resources-publications/Anaesthesia-News-magazine/Anaesthesia-News-Digital-February-2021/Standardisation-syringe-labelling-and-prefilled-syringes (accessed 10/02/2021). 
  3. Lo Q, Plaat F. Non-sticky sticky syringe labels. Anaesthesia 2017; 72: 654. 
  4. Grigg EB, Martin LD, Ross FJ, et al. Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study. Anesthesia and Analgesia 2017; 124: 1617-25.

LabellingTable

Figure 5.

Dear Editor

A virtual mock OSCE

COVID-19 has had major impacts on medical training, including the cancellation of courses and examinations. The RCoA decided to deliver the latest round of the Primary OSCE and SOE via video-conferencing technology, a change that could be here to stay.

Having recently taken the exam ourselves, we knew that practice was vital. With courses postponed, we decided to set up a ‘virtual mock OSCE’ to provide some all-important practice for candidates. We gathered information regarding the new format, and developed 14 realistic stations and mark schemes covering the curriculum topics. Some were simpler to devise than others - how do you perform interactive resuscitation or simulation virtually? We recruited 14 examiners who kindly donated their Saturday mornings, a task made easier by the fortuitously-timed second lockdown, and advertised our OSCE to trainees. Word spread quickly, and places filled within days.

We used Zoom to run the OSCEs. Candidates and examiners were placed into ‘breakout rooms’ for seven minutes, two for a brief via the ‘shared screen’ and five for the station itself. We then reallocated candidates to the next station and, subsequently, they received individualised feedback.

Screenshot of a mock examination taking place on Zoom

Unfortunately, there were a few teething issues. Screen sharing was not always available, requiring the host to enter rooms and enable this remotely, leading to some delays. No pattern has been identified, and Zoom have been contacted for advice.

Our overall experience was positive. The feedback has been excellent and, importantly, we were able to provide this for free. We hope to resolve the technical issues, and with feedback from candidates who sat the real examination plan to make it more realistic. One thing is certain, hosting a Zoom call with multiple breakout rooms is arguably as stressful as sitting the real exam!

Shilen Shah
Clinical Teaching Fellow 

Rory Dennis
Anaesthetics Trust Grade 

Kavita Upadhyaya
Consultant Anaesthetist 

Broomfield Hospital, Chelmsford

Dear Editor

The baker's dozen of COVID proning

I suspect the following ‘tummy-time’ observations may be familiar to the legion of amateur intensivists honing their proning skills over the last year:

  1. Physiotherapists are your proning friends - they are freakishly strong, always roam in packs, and they know which direction limbs cannot and should not go. 
  2. D.I.Y. head rings that look like a crown of thorns will turn out exactly as you suspected. 
  3. You can never have enough i.v. bungs and caps. 
  4. You will always forget to disconnect the pulse oximeter just before the turn. 
  5. ICU red slide sheets really are very slidy (unlike their operating theatre cousin, the blue slide sheet). 
  6. If the BIS™ strip is hanging off the forehead before you start, it will not miraculously work after you have flipped. 
  7. The larger the body habitus, inevitably the fewer and smaller the available staff members for turning. 
  8. A disconnection in the breathing circuit on turning is seriously frowned upon.
  9. A disconnection in the bowel management system is a Never Event. 
  10. There is always a proning/ de-proning to do just before handover. 
  11. There is never more than one prone/ de-prone in a row - they are always frustratingly spaced out throughout the night. 
  12. Despite these new found proning skills, we will continue to kick up a fuss when a surgeon requests it for pilonidal sinus or varicose vein surgery. 
  13. It turns out not many people know what a Cornish pasty looks like, or if they do, they certainly wouldn't win a Hollywood handshake for their "Bake-off" creation.

Patrick Ward
Consultant Anaesthetist and Airway Lead
Chelsea & Westminster Hospital, London 

Twitter: [email protected]

Congratulations to Patrick Ward for winning April's Letter of the Month prize.

Dear Editor

Proning to prone

Dr Weller - and you too - should read Oliver Kamm’s liberating book ‘Accidence will happen’. It should free you from concerns about whether prone is an adjective alone or not. To verb is human. A different but equally liberating perspective on the use of English is ‘The Sense of Style’ by Steven Pinker.

Both books consign old-fashioned prescriptive guides written by old buffers to the trash-can where they belong. The ‘rules’ turn out to be not rules at all. In short: relax.

Yours cheerfully

Steven Cruickshank
Consultant Anaesthetist
Newcastle upon Tyne

Editor’s note

With regard to pandemic neologisms, I discovered this on Twitter: 

“I’m going to COVIDize the OR.” — Anesthesia resident. COVIDize [verb]: to prepare one’s operating room for a COVID patient. 

We are definitely not going to relax that far, even if that makes me an old buffer.