Surgeons' News, March 19

24

THE LONDONERS TRAINED TO DEAL WITH STAB INJURIES AND OTHER TRAUMAS

Criminal records Archives reveal tales of murder, forensic advances and literary influences

28

THE CHALLENGES OF TREATING VICTIMS OF ACID ATTACKS

MARCH 2019 rcsed.ac.uk

MARCH 2019 | VOLUME 18 | ISSUE 1

EDITOR’S WELCOME

STAYING POSITIVE Clare McNaught ponders reasons to be cheerful despite Brexit and rising crime

I

write this editorial on New Year’s Day, having stayed up uncharacteristically late to hear the chimes of Big Ben herald the start of 2019. The capital’s celebrations were designed around the theme of London is Open in an attempt to deflect the negative publicity surrounding the Brexit negotiations. The full impact of Brexit on the NHS remains uncertain, but it has undoubtedly been detrimental and demoralising to the many thousands of European Union (EU) nationals who work in the health service. They are now required to apply for permanent resident status before March 2020.

Let us hope that common sense will prevail, and that our EU colleagues are welcomed and valued for the high-quality care they deliver on a daily basis.

The New Year’s firework display incorporating the majestic Westminster architecture showcased a very positive image of London. This was in sharp contrast to the damaging crime reports that dominated the media headlines of 2018. More than 1,200 knife offences, with over 100 fatalities, were recorded in the city last year and there has been a threefold increase in the incidence of acid attacks.

In this issue of Surgeons’ News, Shehan Hettiaratchy explains how service reorganisation has helped to improve the outcome of victims of knife crime and trauma (p24). On

page 28 plastic surgeon Alexandra Murray describes the psychological and physical effects of corrosive attacks and the surgical methods used to help the victims of this heinous crime.

On the same theme, but on a much lighter note, our Surgeons’ Hall Museum team highlights the historical relationship that Edinburgh has had with the criminal fraternity in both the real and fictional world.

I was aware of the influence that surgeon Joseph Bell had on medical student Arthur Conan Doyle and the subsequent character development of the detective Sherlock Holmes.

The revelations regarding Robert Knox FRCSEd and notorious serial killers Burke and Hare is well worth the read (p40).

As surgeons, we become acquainted with patients at the worst time of their lives, whether this be through illness or accident, or because they have been a victim of crime.

With the daily escalating demands and pressures in our working environment, it is easy for us to forget how privileged we are to be able to impact so positively on the existence of our patients. My New Year resolution is to remember just that. On behalf of the team here at Surgeons’ News, may we wish you health, happiness and prosperity for 2019.

Clare McNaught editor@surgeonsnews.com

The full impact of Brexit on the NHS remains uncertain, but it has undoubtedly been detrimental to the thousands of EU nationals who work in the health service rcsed.ac.uk | 1

24

THE LONDONERS TRAINED TO DEAL WITH STAB INJURIES AND OTHER TRAUMAS

28

THE CHALLENGES OF TREATING VICTIMS OF ACID ATTACKS

42 Criminal records

MARCH 2019 rcsed.ac.uk

Archives reveal tales of murder, forensic advances and literary influences

MARCH 2019 | VOLUME 18 | ISSUE 1

40 EDITOR Clare McNaught MANAGING EDITOR/SENIOR COMMUNICATIONS OFFICER Emma Charlesworth 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

Contents

March 2019

04

AGENDA News and views from the profession; FPC conference report; NHS England's 10-year plan; training for informed consent; and more

DESIGN AND PRODUCTION

10

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

24

ACCOUNT MANAGER Sian Campbell DESIGNERS Felipe Perez, Amanda Richardson SUB EDITOR Kirsty Fortune MEDICAL SUB EDITOR Dr Arshad Makhdum PUBLISHING EXECUTIVE Claire Macaulay 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. The Royal College of Surgeons of Edinburgh permits single copying of individual articles for private study or research. Multiple copying of individual articles for teaching purposes is permitted without specific permission. For copying or reproduction for any other purpose, written permission must be sought from the Royal College of Surgeons of Edinburgh. Exceptions to the above are those institutions and non-publishing organisations that have an agreement or licence with the UK Copyright Licensing Agency or the US Copyright Clearance Center. Access to the magazine is available on the College website rcsed.ac.uk.

Cover illustration: Eleanor Shakespeare

2 | Surgeons’ News | March 2019

PRESIDENT WRITES Professor Mike Griffin explains his hopes for his time in office DOCUMENTING TRAUMA Shehan Hettiaratchy outlines how to cope with major events such as the Westminster Bridge attack

28

PLASTIC SURGERY The complexities of treating physical and mental injuries of acid attacks

30

PLANNING Lessons learned from a live major incident exercise

32

DENTAL FORENSICS Why the discipline is about much more than identifying the dead

34

CARDIOTHORACICS Undergraduates on a placement scheme share their experiences

36

FELLOWSHIPS Mike Holland encounters a range of diseases in the COSECSA nations and Andrew Healey copes with complex polytrauma

44

39

WINE INVESTMENTS The myths and the magic of the College's collection of rare vintages

40

BODY OF EVIDENCE The Museums' collections tell a vivid tale of the life and crimes of 19th-century Edinburgh

42

SURGEONS' HALL RIOTS Seven women's fight for access to medical education in the 1800s

44

TRAINEES AND STUDENTS Outreach and training activities; ASiT on the advance of trauma care; the importance of technology in delivering international research

51

DENTAL The evolving process of clinical assessment; faculty news

56

COLLEGE INFORMATION Diploma recipients; awards and grants; obituaries

62

OUT OF HOURS Graham Layer enjoys Michelinstarred fine dining and Bernard Ferrie imbibes some Brexit beverages

64

FROM THE COLLECTIONS Louise Wilkie dissects the Murder Act

2.096

Agenda The latest news from the College and profession / TRAINEES

Riding elected as trainees’ rep

M Vascular surgeon David Riding

anchester-based surgical trainee David Riding has been elected as Trainees’ Representative Member on Council, the fifth person to hold this post.

The role was introduced in 2012 to give a voice to surgical trainees at the highest level. The RCSEd is the only surgical Royal College to offer such a position.

Already a member of the Trainees’

Committee, Riding has played a key part in the #LetsRemoveIt anti-bullying campaign, striving to protect the wellbeing of all health professionals to improve teamworking and the working environment and, ultimately, to enhance patient safety and care.

Mr Riding, a vascular surgeon from Chorlton, Manchester, worked at Mbarara University Hospital, Uganda, in 2012. He is currently working towards a doctorate in venous disease at the University of Manchester.

/ AWARDS

Hunter Doig Medal awarded to Alice Hartley City Hospitals Sunderlandbased urology registrar Miss Alice Hartley has been awarded the prestigious Hunter Doig Medal in recognition of her contribution to excellence in surgery.

The College awards the Hunter Doig Medal every second year to a female Fellow or Member of the RCSEd who demonstrates career potential and ambition. Hartley is an ST5 in urology who has recently returned to clinical practice following time out for a doctorate in the molecular biology of prostate cancer.

She promotes human-factors training in surgery, and has led the RCSEd’s campaign

4 | Surgeons’ News | March 2019

to tackle undermining and bullying, #LetsRemoveIt, since 2016. Her belief that surgeons have to lead and take responsibility to challenge bullying and harassment in the surgical team underpins her role as campaign Chair.

The first Hunter Doig Medal was awarded in 2007 to recognise excellence among the College’s female membership. The medal is named after two of the College’s most notable women surgeons.

Caroline May Doig, a paediatric surgeon, was the first woman elected to the RCSEd Council in 1984.

She served three terms of

Alice Hartley (left) receives the Hunter Doig Medal from Caroline May Doig

office, and in 1991 was also the first woman to chair the General Medical Council Overseas Committee. Alice

Headwards-Hunter was the first woman to sit and pass the examinations of the RCSEd in 1920.

/ FACULTIES

New faculty gives voice to practitioners in remote locations

It is a challenge to deliver healthcare in isolated communities

The Faculty of Remote and Rural Healthcare has been established in recognition of the need for a global institution that works to ensure that everyone has access to high standards of healthcare regardless of their location.

The new faculty will develop and promote new standards for practitioners of remote and rural healthcare to ensure the highest level of excellence. In collaboration with its partners, including organisations within industry and academia, the faculty’s aim is to support the delivery of equitable, economically viable access to integrated healthcare – and thereby improve significantly the health and medical outcomes of people living and working in remote and rural areas.

Many people around the world live in isolated communities, and work in industries such as oil and gas, mining and shipping, where

/ SAFETY

Patient group to help set College safety agenda To build on the hugely successful work of the RCSEd Patient Safety Board, the College has launched a Patient Safety Group.

Chaired by Miss Anna Paisley, this multidisciplinary group is drawn from all faculties of the College and includes representatives from the wider surgical team and patients.

The group will support and coordinate existing patient safety initiatives, set a proactive safety agenda for the College and facilitate collaboration with external organisations on patient safety issues.

The RCSEd Patient Safety Board was established in 2008 following the development of the non-technical skills for surgeons (NOTSS) taxonomy. Under the successive stewardship of Professor George Youngson and Mr Simon Paterson-Brown, it worked to promote understanding of human factors in surgery.

Today, NOTSS programmes are an established part of surgical training in the UK, US, Australia, Denmark, Japan and beyond, with more than 40 NOTSS courses running in the UK alone each year.

isolation is a direct challenge to their health and wellbeing.

Developing technologies for extending the reach of medicine and care to remote and rural areas are often under-exploited and poorly deployed, given the geographic circumstances.

Compared with their urban counterparts, remote and rural inhabitants often experience lower life expectancy and worse health status.

There is a unique opportunity for individuals and organisations to affiliate with and contribute to the development of this new faculty, and become part of a diverse, global, multidisciplinary community. As the faculty develops, benefits to individuals will include access to a curriculum and assessment framework that caters for the specific needs of those working within remote and rural settings.

Theatre in the early 20th century

Rare collections now online The College’s Library and Archive has launched its new Digital Collections website (archiveandlibrary. rcsed.ac.uk), an online repository of manuscripts and photographs that span the College’s 500year history.

The website’s Surgeons Database enables users

to trace ancestors who qualified from the College from the earliest days of the barber-surgeons through to 1918. The database holds details of some of the most wellknown surgeons, including Elsie Inglis, Dr Robert Knox, Joseph Lister and James Young Simpson.

rcsed.ac.uk | 5

AGENDA

/ OVERSEAS

/ AWARDS

Malaysia office thriving

Mike Griffin with Maria McKenna and Stephen Clark

Newcastle Freeman Hospital scoops national award for its palliative care A team specialising in palliative care for heart and lung transplant patients at Newcastle’s Freeman Hospital has won a national award. The Dundas Medal is awarded by the College and

Scottish charity Palliation and the Caring Hospital (PATCH) to reflect work done to improve the provision of palliative care for patients in hospital.

Dr Maria McKenna and

The College’s office in Malaysia has continued to develop. It ran the Joint Surgical Colleges Fellowship Examination (General Surgery), held a visit from the British High Commission to collaborate on healthcare and hosted a high tea, a networking event with RCSEd Vice-President Pala Rajesh, at which the College gathered ideas for future developments for the ASEAN region.

RCSEd Malaysia is exploring new ways to interact with medical students and prospective membership of the College through a new initiative, the RCSEd Ambassadors Club, which will be rolled out this year.

Professor Stephen Clark, representing the Freeman Hospital team, were presented with the national award at the College’s diploma ceremony on Friday 9 November 2018.

/ PRESIDENTS

/ ELECTION

College unveils Michael Lavelle-Jones portrait

RCSEd surgeon voted in as ASI President

In celebration of Professor Michael Lavelle-Jones’s Presidency, he was presented with a portrait of himself at a ceremony in the Fellows’ Library. The portrait includes a picture of his wife, Christine, his Wales flag mug and the prestigious Silver Scalpel Award, which he won in 2014.

The College was delighted to host six Past Presidents at the portrait unveiling.

Dr P Raghu Ram has been elected as President of the Association of Surgeons of India (ASI) for the year 2020.

More than 7,000 surgeons from all over India took part in the poll, the highest turnout in ASI’s 80-year history.

Dr Ram, an RCSEd International Surgical Adviser and Director of KIMS-Ushalakshmi Centre for Breast Diseases, won by a huge margin of almost 2,000 votes.

Professor Michael Lavelle Jones and his portrait and, below, former presidents (left to right) Michael Lavelle-Jones, John D Orr CBE, Ian K Ritchie, David A Tolley, Sir John Temple and John A R Smith CBE

6 | Surgeons’ News | March 2019

Dr P Raghu Ram

Review Clare McNaught enjoys a comprehensive surgical tome Surgery: Core Principles and Practice John Corson and Robin Williamson (Eds) ISBN 978-9351525233 £188

/ AWARDS

Council Member wins excellent teacher prize Dr Sunil Kumar, College Council Member and Head Consultant of Surgery at Tata Main Hospital in Jamshedpur, India, received

the Excellent Teacher Award for National Board Examination by the Vice-President of India in a formal function held in New Delhi.

/ AWARDS

Nominations open for Farquharson Award 2019 Nominations are requested for the biannual 2019 Farquharson Award, which is in memory of Eric Farquharson (pictured), Surgeon and Fellow of the College, who authored Farquharson’s Textbook of Operative Surgery and is a former Vice-President of the College.

The award is offered to anyone who has made significant contributions to surgical teaching or surgical anatomy, at either undergraduate or postgraduate level. Although it was traditionally reserved for those who taught at the bedside, in theatre, in the dissecting room, or through lectures or

textbooks, the award has broadened to incorporate new methods of teaching through simulators, wet laboratories, operative videos and distance-learning programmes.

It is open to surgeons and those in allied professions who have contributed to surgical and anatomy teaching. Recipients do not have to be Fellows or Members of the College, nor do they have to be medically qualified.

The closing date is Friday 24 May 2019. A proforma for the citation can be obtained from Mrs Irene MacDonald at i.macdonald@rcsed.ac.uk

It was my pleasure to review the second edition of this internationally renowned textbook.

The editors have collaborated with multiple academic surgeons from around the world to produce a textbook that is comprehensive, easy to read and visually pleasing. The two volumes comprise more than 2,000 pages and are organised into user-friendly, colour-coded sections on all aspects of general surgery.

Volume 1 covers the principles of surgery, trauma and gastrointestinal surgery. Volume 2 deals with the specialties, including vascular, endocrine, breast and transplantation surgery.

The book is aimed primarily at the trainee surgeon, who is required to progress through core general surgical training prior to the commencement of higher specialist roles. The sections are closely aligned to the knowledge requirement of the ISCP surgical curriculum and that of the MRCS and FRCS general surgery examinations. Like many other books of this nature, the basic pathophysiology, relevant anatomy and principles of surgical treatment are clearly explained. What makes it stand out is the attempt to integrate knowledge acquisition along with clinically relevant skills. Case studies give a clinical narrative on common scenarios – for example, how to access the hostile abdomen in a patient with previous multiple laparotomies.

These help the reader develop the higher-order problem-solving skills needed in clinical practice.

Some would question the need for owning a printed textbook in the digital age. Fortunately, on purchase of the book, you can register for free online access through emedicine360.com. Once logged in, I could easily search the textbook and access the information on my iPad, making it a useful mobile educational resource.

I commend the editors and the authors for producing this quality publication, which will appeal to students, trainees and surgical educationalists throughout the world.

rcsed.ac.uk | 7

AGENDA

IN BRIEF The latest guidelines, articles and studies

Cost-effectiveness of revascularisation in patients with intermittent claudication

Data were used from the Invasive Revascularisation Or Not in Intermittent Claudication (IRONIC) RCT. A total of 158 patients with mild-to-severe intermittent claudication owing to aortoiliac or femoropopliteal disease were allocated to either BMT alone (including a structured, non-supervised exercise programme) or to revascularisation together with BMT. The mean cost per patient in the BMT group was €1,901 compared with €8,280 in the group treated with revascularisation.

Revascularisation resulted in a mean gain in QALYs of 0.16 per patient, an incremental cost-effectiveness ratio of €42,881 per QALY. Authors concluded the costeffectiveness ratio of revascularisation was within the threshold for public willingness to pay according to Swedish Guidelines, but exceeded that of UK NICE guidelines.

Djerf H, Falkenberg M, Jivegård L et al.

BJS 2018; 105: 1742–1788

Systematic review of shared decision-making in surgery

This systematic review evaluated shared decision-making (SDM) during consultations in which surgery was a treatment option. Over 32 articles, SDM was measured using nine metrics. Some 36% of 13,176 patients and surgeons perceived their consultation as SDM, as opposed to patientor surgeon-driven. Surgeons more often perceived the decision-making process as SDM than patients (44% versus 29%).

Authors concluded SDM in surgery is still in its infancy, although surgeons and patients both think of it favourably. de Mik SML, Stubenrouch FE, Balm R, Ubbink DT. BJS 2018; 105: 1721–1730

Multicentre international trial of laparoscopic lavage for Hinchey III acute diverticulitis (LLO Study) This retrospective study included 231 patients with Hinchey III acute diverticulitis who had laparoscopic lavage from 2005 to 2015. Sepsis control was achieved in 172 patients (74.5%). A recurrent episode of acute diverticulitis was registered in 46 (26.7%). Among 212 patients who had laparoscopic lavage without conversion, the morbidity rate was 33%, the reoperation rate 13.7% and the 30-day mortality rate 1.9%. Laparoscopic lavage showed a high rate of successful sepsis control in selected patients with perforated Hinchey III acute diverticulitis affected by peritonitis, with low rates of operative mortality, reoperation and stoma formation.

Binda GA, Bonino MA, Siri G et al. BJS 2018; 105: 1835–1843

Functional trajectories before and after major surgery in older adults This prospective cohort study evaluated functional trajectories of 250 patients over 70 years before and after major surgery. After surgery, four trajectories were identified: rapid (15.6%), gradual (n = 76, 30.4%), partial (n = 70, 28.0%) and little (n = 57, 22.8%) improvement. Rapid improvement was seen for 51.7% of participants with no disability before surgery, but was uncommon among those with mild disability and was not observed in the moderate and severe trajectory groups. For participants with mild to moderate disability before surgery, gradual improvement (54.8%) and partial improvement (49.3%) were most common. Most participants with severe disability (81.8%) before surgery exhibited little improvement. Outcomes were better for participants undergoing elective versus non-elective surgery.

Authors concluded that functional prognosis in the year after major surgery is highly dependent on premorbid function.

Stabenau HF, Becher RD, Gahbauer EA et al. Ann Surg 2018; 268: 911–917

Radical prostatectomy or watchful waiting in prostate cancer – 29year follow-up This study randomised 695 men with localised prostate cancer to watchful waiting or radical prostatectomy from October 1989 to February 1999 and collected follow-up data throughout 2017. Of the 347 men in the radical-prostatectomy group, 261 died. In the watchful-waiting group, 292 of the 348 men died; 71 deaths in the radical-prostatectomy group and 110 in the watchful-waiting group were due to prostate cancer (relative risk 0.55). The number needed to treat to avert one death from any cause was 8.4. Among the men who had radical prostatectomy, extracapsular extension and a Gleason score >7 were highly predictive of a risk of death from prostate cancer.

Authors concluded that men with clinically detected, localised prostate cancer and a long life expectancy benefited from radical prostatectomy, with a mean of 2.9 years of life gained.

Bill-Axelson A, Holmberg L, Garmo H et al. N Eng J Med 2018; 379: 2319–2329

Oesophago-gastric cancer

This standard covers assessing and managing oesophago-gastric cancer in adults. It describes high-quality care in priority areas for improvement.

NICE quality standard [QS176], December 2018, nice.org.uk

rcsed.ac.uk | 9

THE PRESIDENT WRITES

Safeguarding our future surgeons Professor Mike Griffin on the early days of his presidency and his hopes for his time in office

T

he handover from one president to the next often appears to happen as a seamless exercise. Following my election in June 2018, the invaluable support of my predecessor, Michael Lavelle-Jones, made the transition much less traumatic than I could have imagined. I wish to thank him for his leadership of the College, in particular his tireless work internationally and for the maintenance of our College values, which are as strong as they have ever been.

It has been an extraordinary change in my life. For the last 30 years, I have been responsible for one of the largest surgical cancer units in Europe, operating and endoscoping every week together with on-call commitments. My clinical duties have ceased and I confess to experiencing a sense of bereavement when I realised that the hands that had operated on more than 1,000 oesophagectomy patients had become redundant to a certain extent. Nevertheless, as I took over the reins as President on 9 November 2018, I quickly realised I was not going to have much time to dwell on the culmination of my clinical career.

One of my first duties as President of our College was to lay a wreath at the Remembrance Service at St Giles Cathedral in Edinburgh for the 100th anniversary of the ending of the First World War; both the procession and service were

10 | Surgeons’ News | March 2019

very emotional. The Canon spoke in his address at the service about the turmoil in Europe 100 years ago and brought our minds to the present day and the turmoil once again facing Europe with the uncertainty, confusion and concern over the UK’s exit from the European community.

My next commitment was to examine and officiate at the diploma ceremony in Sudan. This was an uplifting experience and I learned a lot from my visit regarding surgical training and healthcare problems in this country. I was concerned to hear of their health issues and sought reassurance that our commitment to providing assessment and improving standards in surgical care was viewed by the Government, surgeons and people as a positive experience.

Meeting the ambassadors of the UK and Canada, as well as having

discussions with a wider range of patients, academics and clinicians, helped me conclude that our work is making a difference to surgical care in this environment. The future in Sudan is much more uncertain than it is in Europe and our College will continue its efforts to maintain standards there and in other countries around the world.

I returned to Edinburgh and focused on the issues facing surgery in the UK. The success of our cancer unit in Newcastle had been built on hard work, teamwork and a collective feeling of goodwill, making a difference to patients in a very vulnerable position. Our College will move forward with this teamwork in mind, enabling us to innovate, teach, train and ultimately care for patients.

Development of the future surgical workforce is vital to our patients.

When I and many other surgeons were applying for senior training positions, we were often competing with 40 other outstanding applicants.

The talent is the same now, but doctors’ attitudes have changed.

We are approaching a situation where one applicant is available for one training post in many surgical specialties. Why is this? Why is our wonderfully rewarding profession being shunned by newly qualified doctors? There are many reasons, but suffice it to say it represents a huge problem, and a challenge for our profession and our College. We have to rekindle the excitement, the stimulation and the joy of caring for and curing patients

We have to rekindle the excitement and the joy of caring for and curing patients with our expertise with our surgical expertise. I wish, therefore, to focus on our surgical workforce in my time as President.

Our future surgeons are our trainees and our SAS doctors. We should not be asking individual SAS doctors what they can do for us, but what we can do to help them. We have to work as a team and we must do this not just for our College but for our patients because if we do not, who will be looking after us, the patients of the future?

Over the next three years, I will work closely with our Regional

St Giles Cathedral, Edinburgh

Advisers across the UK to engage at the start of medical training and to stimulate and excite the surgeons of the future. I am very fortunate to have an outstanding Council, boosted by our recent elections with women and men willing and very able to serve, and we should look to them to take more responsibility for our surgical specialties.

My Vice-Presidents, Rowan Parks and Pala Rajesh, will lead both at home and abroad, and have the ability to inspire and educate. Reviews of our education delivery – which will affect medical students, surgical trainees and our established consultants – are nearing completion; and reviews of our examinations structure performed

by Council Member Tim Graham are crucial to the future direction of our College strategy.

We have said goodbye to our trainees’ representative, Michael Moran, who has been a brilliant contributor to Council. I am pleased

to welcome David Riding, who has been extremely active on the Trainees’ Committee. We have also said farewell to an outstanding College stalwart, Charlie Auld, who has almost single-handedly developed the Faculty of Perioperative Care, has chaired committees with Health Education England and has been unstinting in his work for both the College and the Faculty. I am pleased that he will continue to contribute to the College activities and thank him for all the work he has done over many years.

As President I will bring passion and enthusiasm to my role. With such a superb team and Council behind me, I know that wisdom and common sense are with me in abundance. I look forward to working with and for you wherever in the world you live.

Professor Mike Griffin president@rcsed.ac.uk rcsed.ac.uk | 11

AGENDA

SURGICAL SAFETY UPDATE

Cases from the Confidential Reporting System for Surgery (CORESS) Missed zygomatic arch fracture

A patient with a fractured mandible as a result of an alleged assault had surgical treatment for the mandible fracture in a regional oral and maxillofacial unit. However, the concomitant zygoma arch fracture went unnoticed by both emergency department staff and the operating surgeons.

A blow to the side of the face may cause an obvious mandible fracture and a less obvious zygomatic arch fracture, as happened in this case.

A patient may only remember a single blow (which concusses him/her), but may have sustained other impacts, either from further blows or from indirect injuries caused by falling.

Head CTs for head injury almost always irradiate the eyes, but stop just before imaging the orbital floor and zygomas. Radiographs for mandible fractures do not always show the zygoma. Isolated fractures of the zygomatic arch may have no symptoms and can only be recognised by feeling the arch for a change in shape.

Reporter’s comments

If you see a mandibular fracture on a radiograph, you should look for one on the other side. If the patient does have a mandibular fracture (particularly of the ramus or condyle) and you don’t palpate the zygomatic arches, you may miss a second fracture.

In this case, there was too much focus on the obvious injury for which the patient was transferred and for which surgery was indicated. This eventually

12 | Surgeons’ News | March 2019

necessitated two operations rather than one. Head injury CT scans should include the orbital floors and cheekbones (the orbits have already been irradiated and the extra time/radiation dose required is negligible). However, there is a risk of overreliance on imaging rather than clinical examination. A basic focused physical examination might have revealed the zygomatic arch fracture in this case.

If patients have sustained a significant injury to the face, particularly if the history is not clear due to concussion, alcohol or multiple blows, a thorough examination with a high index of suspicion of other injuries is needed.

CORESS comments

CORESS agreed with the detailed specialist advice provided by the reporter. The clinical psychology expert on the Advisory Board referred to this as ‘anchoring’ – cognitive bias in which fixation on a primary injury or piece of information results in inadvertent neglect of other potentially significant outcomes.

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

Chest drain fatality

A patient had undergone a left lower lobectomy for lung cancer five days earlier and had a small pleural effusion. It was decided to drain this on the ward. A senior trainee attended the patient and placed a Seldinger-type drain into the chest, anteriorly in the mid-clavicular line. No ultrasound examination was undertaken to mark the location of the effusion.

It quickly became apparent that, inadvertently, the drain had been placed into the heart. The patient was immediately taken to theatre, where the drain was removed from the left ventricle. Although the patient’s initial recovery was good, he subsequently deteriorated on ITU and died one week later.

Reporter’s comments

There was failure to use British Thoracic Society guidelines and to obtain an ultrasound of the chest to localise the effusion. Knowledge of and adherence to use of the triangle of safety when inserting a chest drain might have avoided the adverse outcome in this case.

CORESS comments

The effusion should have been imaged by ultrasound and marked. After lobectomy, there may be distortion of the normal anatomy with heart shift. British Thoracic Society guidelines for chest drain placement can be found at: BTS Pleural Disease Guideline 2010:

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.

BTS Guidelines for the Management of Pleural Disease. Thorax 2003; 58 (Suppl 2): 1–59. dx.doi.org/10.1136/thx.58.suppl_2.ii53

Inappropriate oesophagectomy

A patient with a lower oesophageal lesion, with biopsies suspicious for adenocarcinoma, was referred from a peripheral hospital to the upper GI MDT. At MDT review, the term ‘suspicious’ was omitted from the pathology report.

The patient underwent a second endoscopy and biopsies, but was listed on a fast-track for surgery and underwent oesophagectomy before the biopsies had been reported. The second biopsies, which failed to confirm the presence of carcinoma, were not presented at the MDT prior to the operative procedure.

When the original histology was reviewed, it was recognised that the histological features, originally reported as suspicious, were those of reflux oesophagitis. Major life-changing surgery was therefore carried out unnecessarily.

Reporter’s comments:

This case involved both propagation of false information and proceeding without the correct information.

CORESS comments:

The surgeon based the decision to intervene on the MDT record, rather than review of the original notes and pathology. There was an urgency to meet cancer target waits, with further pressure because of the tertiary referral. At this point, the clock should have been stopped and relevant results reviewed. If investigations that will inform the process of intervention have been requested, then the results of those investigations must be reviewed prior to intervention. This case illustrates premature closure of thinking and the danger of rigid adherence to targets.

CORESS is an independent charity supported by the Federation of Surgical Specialty Associations (FSSA)

rcsed.ac.uk | 13

AGENDA

Distance no object Professor James Garden looks back on the evolution of the online Master’s courses

Flexible learning

T

he full suite of eight surgical online Master’s programmes is now delivered by the University of Edinburgh and the RCSEd under the new banner of Edinburgh Surgery Online (edinburghsurgery online.com).

It was in 2007 that surgical trainees first enrolled to the then novel MSc in Surgical Sciences, also known as the Edinburgh Surgical Sciences Qualification (ESSQ).

At the outset, it was thought that recruitment would come principally from within Great Britain and Ireland because the programme content was based on the intercollegiate MRCS curriculum. It is now evident that this and subsequent Master’s programmes have reached a much greater global audience.

This year, our 1,005th student will have secured a certificate, diploma or Master’s level qualification through one of the Edinburgh Surgery Online programmes. At the winter university graduation ceremony on 30 November 2018, the 709th Master’s student graduated, with successful candidates coming

14 | Surgeons’ News | March 2019

from Australia, Bahrain, India, Poland, Denmark and Ireland.

Of those surgical trainees who attended, we were particularly pleased to see two students, Chee Wong from Ireland and Olusegun Kehinde from Nigeria, who graduated with ChM degrees when they had previously been graduates of the MSc in Surgical Sciences.

Both students were effusive about the way in which the ChM in General Surgery has supported their learning towards independent clinical practice.

A further Australian trainee, Jarred Stevens, who has been working in the UK for the last two years, graduated with a ChM in Trauma and Orthopaedics and distinguished himself by being awarded the Sir Harold Stiles Medal as the top-performing student.

It is intriguing to look at the geographical distribution of our Master’s students. There are currently more than 500 students from around 50 countries enrolled in our Master’s programmes at any one time.

The UK may come in the top10 list of specialist surgical team

Sarah Jones (front row left), Denis Robson, Director Retired, Johnson & Johnson (middle row left), Eric Borgstein, Secretary General COSECSA (back row left), Ewen Harrison, Senior Lecturer in General Surgery UoE (back row second left) and James Garden at a COSECSA meeting

James Garden Director of Edinburgh Surgery Online, University of Edinburgh

”With a young family I enjoyed the flexibility. I don’t have to be full-time and attend classes, everything is done online, which gives the flexibility to study and work side-by-side. Although flexible, the course was comprehensive and the textbooks, resource materials and journals were available online. This was a great resource and made learning easy. I met (online) students from all over the world and was able to share experiences, difficulties and frustrations wherever they were working.

That has been very helpful!

As well as adding to your knowledge, these programmes help you to prepare for the exit fellowship exams.”

Olusegun Kehinde, MSc in Surgical Sciences and ChM in General Surgery graduate, Nigeria members – at 92 per 100,000 people – but our programmes are now proving invaluable in supporting young surgeons in those parts of the world with some of the worst access to surgeons. In the same list, Malawi is ranked in the bottom five in the world and yet our programmes have now supported 31 training surgeons since 2010. Seventeen students have now graduated from the MSc SurgSci, as many as there are surgeons in a country with a population of 19 million.

Although the global distribution of these Master’s alumni does not always follow the same pattern of RCSEd Members and Fellows, we should rejoice at the impact of the Master’s programmes on surgical

training worldwide over the last 10 years. Many of our students have had to be innovative in securing financial support to enrol in the Master’s programmes. A number of Malawian trainees have been fortunate to receive scholarship funding from Johnson & Johnson. but there is now an opportunity to recycle programme income to widen access through full funding of scholarships.

This year, the new memorandum of agreement between the RCSEd and the University of Edinburgh has ring-fenced 10% of programme income to support a full scholarship programme for trainees in low- and middle-income countries.

These newly launched Edinburgh Surgery Online Global Scholarships support 20 training surgeons in this academic year. Only applicants from the World Bank list of lowand middle-income countries are eligible, and trainees supported in this way come from East Asia, sub-Saharan Africa and Latin America. We continue to explore ways to support surgeons whose training environment may be challenging. In addition to Commonwealth Commission Scholarship funding, we have support from Women and Health Alliance International to fund a training surgeon from Benin.

The annual meeting of the College of Surgeons of East, Central and Southern Africa in Kigali, on 5–7 December 2018, again provided a tremendous opportunity to catch up with a large group of our global students and alumni. The College Membership and Fellowship should be proud of the impact this educational activity has had over the last decade in capacity-building globally. Please continue to promote these programmes at home and abroad, irrespective of which part of the world you find yourself on College business. rcsed.ac.uk | 15

XXXXXXXX

Meeting expectations Susan Hall reports on the Faculty of Perioperative Care’s fourth annual conference

F

ollowing on from two excellent, well-attended perioperative courses the previous day (Leadership and Development along with the Extended Surgical Team in Cardiothoracic Surgery), the Faculty of Perioperative Care (FPC) held its fourth annual conference at The Studio in Birmingham on 3 November 2018.

Immediate Past-President Professor Mike Lavelle-Jones undertook the last official activity of his presidency by opening the conference with a message that emphasised the College’s commitment to the development of the Faculty. He said it would continue to be led by FPC Lead Charles Auld, who has been instrumental in its development.

The atmosphere of the day was vibrant, with attendees actively

16 | Surgeons’ News | March 2019

participating in question and answer sessions, as well as the networking opportunities provided.

Particular themes highlighted by speakers were the ongoing appraisal and assessment of non-medical assistants, and the attitudes of surgeons of all grades towards these practitioners.

The sessions began with an overview of the development of educational packages for surgical first assistants (SFAs) from Julie Quick, senior lecturer at Birmingham City University. The contribution of the National Association of Theatre Nurses, now known as the Association for Perioperative Practice (AfPP), was highlighted, as was the development of university-led courses for SFAs. Moving from education to assessment of skills, I considered the methods of assessment available to

Susan Hall Fellow of the Faculty of Perioperative Care and senior lecturer at Anglia Ruskin University

SFAs in support of appraisal and the identification of continuing professional development needs.

With the expectation that there will be a parity of assessment of assisting skills across the surgical spectrum, I considered not only the resources provided by the RCSEd-endorsed AfPP SFA Competency Toolkit, but also the use of workplace-based assessment tools.

Alistair Geraghty presented the findings of a UK-wide surgical assistance survey undertaken during his time as the College’s Scottish Clinical Leadership Fellow. He identified that in a changing surgical

Considerable benefit was seen in cardiothoracic surgery, where SCPs have been a feature for over 30 years

Using both ANPs and SCPs ensures service delivery, frees up consultants’ time and allows adequate cover landscape, 61% of hospitals employed non-medical practitioners as part of the surgical team – considerable benefit was seen, particularly in cardiothoracic surgery, where surgical care practitioners (SCPs) have been a feature for over 30 years.

Orthopaedic surgery is a specialty that employs numerous non-medical practitioners in the assisting role.

However, coincidentally and unrelated to their presence or not, overall, 29% of surgeons commented that they were not satisfied with the level of assistance provided in the operating theatre. The survey also revealed an interesting dynamic whereby only 7% of consultants felt that non-medical practitioners could have an adverse effect on surgical training whereas this rose to 57% for ST3–ST5 trainees.

The expansion of surgical care teams to include Nursing and Midwifery Council and Health and Care Professions Council registrants was explored in the second morning session. Speakers from Brighton shared with delegates their knowledge of developing new patterns of working in cardiac surgery using both advanced nurse practitioners (ANPs) and SCPs. They have found that this ensures service delivery, frees up consultants’ time and allows adequate cover in both ward and theatre environments.

The underpinning theme of this presentation was that the work experience should be enjoyed. This was seen as one way to overcome poor retention of practitioners working in cardiac surgery.

Left (from left to right): FPC Fellow Susan Hall, FPC Lead Charles Auld and College Immediate PastPresident Michael Lavelle-Jones Right: Conference delegates Below: Poster winner Anna Mohammed with RCSEd VicePresident Pala Rajesh

The ‘good, bad and ugly’ of SCPs in an orthopaedic team, as seen through the eyes of surgical trainees, was explored by Bill Robertson-Smith, an SCP at Northampton General Hospital.

Charles Auld and Colin Woodard (a lead SCP) considered the assessment and appraisal of SCPs. Increasingly, the MSc in Surgical Care Practice is being seen as the qualification expected of trainee practitioners, who are required to undertake workplace-based assessments to assess competency progression during training.

This practice should be maintained once SCPs are working in an established post and form part of their annual appraisal – with evaluation by members of the multidisciplinary team seen as a ‘gold standard’.

Mr Woodard provided examples of the work being undertaken to develop an appraisal document that has the potential to contribute to patient safety and identify areas that require further training. It was argued that employers of both SFAs and SCPs should provide appropriate, reimbursed study leave in support of this.

Matters relating to consent are always of particular interest to practitioners from across the professional spectrum.

This was considered in the afternoon by Professor of Trauma and Orthopaedics Richard Montgomery, who explored legal cases brought over the past three years.

The presentations ended with an outline of the role of the General Medical Council (GMC) and explanation of the College’s antibullying campaign. The first of these was helpful for delegates, as it is anticipated that the GMC will become the regulatory body for the Medical Associate Professions of Physician Associates, Advanced Critical Care Practitioners, SCPs and Physicians’ Assistants (Anaesthesia).

The effects of bullying behaviour are stark. Alice Hartley, one of the campaign’s leads, told delegates that, for every episode of bullying, the recipient will suffer a 61% drop in his/her cognitive ability – a frightening thought, particularly when one considers the impact on patient safety.

The conference introduced a poster competition with the theme of exploring practitioners’ contribution to surgical care. Twelve posters were displayed on the day.

Each explored the impact of a non-medically qualified member of the surgical team on patient care.

The winning poster, presented by Anna Mohammed and entitled Surgical School: a Novel Approach to Patient Education, looked at the development of an educational programme for patients about to undergo robotically assisted urological procedures.

The standard of the posters was excellent and provided a forum for practitioners to showcase the research that they have been undertaking in the workplace.

Anna‘s prize, presented by College Vice-President Pala Rajesh, was a certificate and a College quaich. rcsed.ac.uk | 17

The long-term plan

I

With new funding on the horizon, Aisling Rollason from the College’s Policy and Public Affairs team examines NHS England’s proposed spending over the next decade

n June 2018, UK Prime Minister Theresa May announced an increase in NHS funding over five years starting in 2019/2020.

Alongside this, the development of a new 10-year plan for the NHS in England was also announced to determine how the extra money should be spent.

NHS planning usually takes place over a much shorter timescale, often over the course of a four- or

18 | Surgeons’ News | March 2019

five-year administration, leading to difficulty in shaping the NHS over the medium to long term.

RCSEd welcomes strategic, long-term planning for the health service, but there can be difficulties in forecasting when events such as Brexit or a new administration will affect its implementation.

Since 2009/2010, NHS funding has grown just over 1% per year in real terms in comparison to the

longer-term growth of 3.7% a year.

Funding pressures, increasingly complex and frail patients, and higher population numbers have all contributed towards an NHS that is severely under strain.

There are more than four million people on waiting lists for elective treatment in England, and the 18-week referral to treatment (RTT), consultant-led target of 92% has not been met since 2016.

AGENDA

New technologies and their impact on patient care and how big data can be harnessed to improve care require attention within the long-term plan A recent NHS Confederation report1 stated that staff recruitment and retention, increasing demand for services and provider deficits are three of the most critical challenges facing the NHS. While the announced funding can help to address these, the NHS has some difficult decisions to make regarding where money should be spent to have the maximum impact.

NHS England has stated that its clinical priorities within the plan are mental health, cancer, cardiovascular and respiratory disease, and learning disability and autism, with an additional focus on children’s services and health inequalities.

NHS England undertook consultation with a variety of stakeholders, including the Royal Colleges. RCSEd’s Policy and Public Affairs team consulted with membership at all levels to ensure the views of those on the front line were represented.

Members raised a number of issues, including the lack of focus on acute pressures in secondary care and the need for workforce, culture and education to be at the heart of a future plan for the NHS. Poor IT infrastructure and the lack of IT integration, and the ability of the NHS across the UK to share good practice and be more progressive in its approach to problem solving were also raised.

In England, the NHS has issues with recruitment, retention and valuing staff. The ability to attract, recruit, and retain suitably qualified personnel in a cost-effective manner is essential. In light of the uncertainties around Brexit and the associated economic climate, this appears likely to continue to be a fundamental challenge and may require exploration of more innovative

solutions to adapt to staffing challenges. Intrinsic to this is responding to staff feedback and recommendations relating to workplace satisfaction, staffing levels, career progression opportunities, as well as support and training needs.

The College published a report in 2017 entitled Improving the working environment for safe surgical care (available on rcsed.ac.uk).

This included a number of recommendations (many of which are applicable across the health service) with the ultimate aim of making care safer for patients, but also ensuring that the working environment in the NHS is more attractive. These recommendations include reintroducing the hospital mess, intelligent design of rotas and establishing senior support with time made for safe handovers and structured ward rounds.

Along with workforce, IT is another key area for development in the NHS over the coming years.

Currently, IT systems within the NHS are outdated and lack integration. Inadequate IT systems with multiple passwords and the inability to review multiple systems concurrently not only frustrate staff, but also lead to

In June last year, Prime Minister Theresa May announced increased funding for the NHS Further reading Letting Local Systems lead, NHS Confederation, 2018 bit.ly/Lettinglocal-systems-lead Referral to treatment (RTT) waiting times statistics for consultant-led elective care bit.ly/2Sn5wfO

inefficiency and worse patient care. In addition, the NHS is storing and utilising increasing amounts of patient data that requires robust data protection and resilience to external threats, the dangers of which we saw during the WannaCry ransomware attacks on NHS IT systems.

Priorities must include ensuring that there is intercompatibility between NHS IT systems and removing the current overreliance on paper-based systems. Currently, opportunities to use patient data to improve patient care and outcomes are being lost. The emergence of new technologies and their impact on patient care and how big data can be harnessed to improve care require attention within the long-term plan.

One of the College’s key concerns is the seeming lack of focus on the acute pressures currently being faced in secondary care within the long-term plan.

Increasing awareness and the need to invest in social care, public health and mental health is crucial, but we must ensure that secondary care and the current pressures being faced by teams across England, and the UK, are being addressed. This will remain a priority for the RCSEd’s Policy and Public Affairs team. rcsed.ac.uk | 19

AGENDA

Difficult decisions College Council Member Janet Wilson discusses informed consent and training designed to improve it

T

he Informed Consent: Sharing the Decision (ICONS) training project addresses the changes in professional behaviour demanded by the Montgomery ruling. In particular, it focuses on the obligation to consider all the alternatives available to surgical treatment, including the option not to treat.

Without considering the other options, there is no decision for the patient to make because it has already in effect been made by the surgeon. Importantly, ICONS encourages participants to refocus their consultation from the outset to ensure that patients’ values, preferences and desired outcomes are at the centre of the consent process.

The delivery of training in this fundamental, yet at times subtle, skillset was trialled in the first RCSEd open workshop in November 2018. Many of the delegates were senior surgeons and therefore well versed in consultation skills, yet the majority still fed back that the experience of ICONS would bring about systematic change in their practice.

The ICONS syllabus was derived from two preparatory workshops the College ran in January and February 2018.

The second of these closed sessions, held in Newcastle upon

Tyne, incorporated three patient participants. It was fascinating to see how the combination of patients, medics and professional actors, simulating exaggerated – even absurd – communication scenarios, could stimulate quite strong and not always consensual reactions among a multidisciplinary group of senior surgeons!

The workshops informed the scripting of four video-recorded scenarios by the Operating Theatre group (operatingtheatre.org.uk).

This is a collaboration of writers and performers, directed by Alex Elliott, who use drama to develop and deliver patient safety and communication healthcare messages to multiprofessional audiences.

The ICONS training objectives are to understand the processes that lead to good consent and the role of shared decision-making in delivering informed consent.

Specifically, after attending an ICONS training event, delegates will be better able to understand the importance and relevance of the Montgomery legislation; employ efficient methods of eliciting patient needs and preferences and values in a busy clinic; use appropriate language for well-balanced surgeon–patient interactions; communicate risk to patients in a more realistic way; respond to the common enquiry “what would you do?”; discuss options,

These outcomes concern that most privileged and confidential of all activities: our conversations in the consulting room 20 | Surgeons’ News | March 2019

Janet Wilson Professor of Otolaryngology Head and Neck Surgery at Newcastle University

including surgery; and critically appraise their own current patientinformation resources.

The latest course in Birmingham incorporated workshop stations: facilitating realistic patient engagement; language changes everything, including framing and bias; practical skills to assess and communicate risk, including anaesthetic risk; time on the outside – how patients share decisions and how we can prime patients to be activated; and information toolkits, including decision aids for patients and where to find them.

What has struck me more than anything about the ICONS project is the level of warmth and enthusiasm from all levels in surgery and among all disciplines. I think we have been particularly fortunate that both our

Immediate Past President, Professor Michael Lavelle-Jones, and our current President, Professor Michael Griffin, have been enthusiastic supporters of ICONS and regard it as a key educational skill for the modern surgeon.

Dr Anna Sorbie, an academic lawyer who kindly supports the College on both the Patient Safety Group and the Lay Advisory Group, speaks to attendees seeking a checklist, or what the GMC says we need to say.

From her legal perspective, these outcomes are not what the sad lessons of Nadine and Sam Montgomery are all about. They are about something much more fundamental and perhaps less tangible. They concern that most privileged and confidential of all

Above right: ICONS development group getting to grips with the challenges

activities we undertake as medical professionals: our conversations in the consulting room.

ICONS will never be static.

Like other non-technical skills for surgeons, it has to evolve as technology evolves and as societal expectations and frames of reference change. We are heartened that already leaders in core surgical training are looking at ways to

commission bespoke, regional variants. So, alongside training our trainees, we have hugely welcomed the more senior participants who are the trainers of tomorrow and essential if ICONS is to achieve its true potential.

The next ICONS workshop will be held on 6 November 2019 at the Edinburgh campus.

Montgomery ruling Nadine Montgomery, a woman with diabetes and a small frame, delivered her son vaginally. There were complications due to shoulder dystocia, which resulted in hypoxic insult with consequent cerebral palsy. She had not been informed of the increased risk of vaginal delivery despite asking if the baby’s size was a problem. She sued for negligence saying if she had known of the increased risk, she would have had a caesarean section.

She won her case, which established that patients should have all the information available, not what the doctor thinks they should know. rcsed.ac.uk | 21

AGENDA

Keeping the peace Rachel Spearing reports on a new workshop in Conflict Resolution Skills in Healthcare: Bullying, Undermining and Leadership

T

his workshop, co-convened with Professor Andy McCann, an expert in professional performance, was created to focus and raise awareness of bullying and undermining issues in healthcare and their impact. We wanted to make sure that people understand the issues, create awareness of the effects, and develop the skills to manage and respond to conflict.

This is the beginning of a journey to create cultural change.

I am a barrister in practice at Serjeants’ Inn Chambers in London and a consultant with leadership think tank DNA Definitive. I have 20 years’ experience in a variety of criminal, regulatory and civil scenarios that have made my skills quite novel in designing and delivering executive education for preventative practice. I’ve led cultural change through founding

the Wellbeing at the Bar programme and I am trained in Trauma Risk Management courses, which I deliver for the Foreign Office to lawyers. Through that, I was introduced to the #LetsRemoveIt campaign. We worked to put the website together and designed a workshop that demonstrates the College’s ongoing commitment to non-technical skills in surgery.

Bullying and undermining behaviour has a huge impact on people’s ability to flourish and the quality of their working life. For healthcare professionals, negative behaviour is compounded by the difficulty of the job. We know from BMA data that there are massive professional implications for patient safety and public trust. This has cost implications for the NHS, not just through absenteeism, but also through poor performance, clinical mistakes and retention.

The workshop is targeted at three key audiences: trainees, consultants

We designed a workshop that demonstrates the College’s ongoing commitment to non-technical skills in surgery 22 | Surgeons’ News | March 2019

Rachel Spearing Barrister and #LetsRemoveIt workshop convenor

and managers. There’s a focus for trainees so they can develop resilience, rights, and expectations of leadership and working life. For consultants, we have reflective practices to review the behaviour of themselves and others to give them good leadership and conflictresolution skills. This will also enable them to realise when they may be vulnerable to the risks of their own behaviour and how to spot it in others. Managers need to know their role, the legal obligations and how to respond. We want to empower and engage staff at every level to tackle these issues and for them to understand that group action needs to be taken to deal with them.

We can offer a follow-up for participants after completing the course to see how they are doing, whether they are continuing to use the tools provided by the workshop, and to see if it has made the quality of their life and practices better.

Interested in the workshop?

Visit rcsed.ac.uk/anti-bullying, email education@rcsed.ac.uk or call +44 (0)131 527 1600

BOWEL CANCER RESEARCH

Cancer appeal BCUK and the RCSEd roll out Scotland’s first fundraiser for a Colorectal Cancer Surgical Research Chair

B

owel Cancer UK (BCUK), in partnership with the RCSEd, has launched a £430,000 Improving Surgery, Saving Lives fundraising appeal to establish Scotland’s first Colorectal Cancer Surgical Research Chair.

Despite being curable, particularly if diagnosed early, bowel cancer is Scotland’s second biggest cancer killer.

This Chair will research and develop treatments, surgical standards and ways to overcome access to surgery issues due to location. The four-year Research Chair will work in partnership with a Scottish university to increase the number of surgical trials focused on bowel cancer and patient access to trials.

Professor Steve Wigmore, College Research Chair at the RCSEd, said: “We are committed to supporting the best surgical research to deliver tangible outcomes for patients.

To achieve this, we work with others to maximise our impact. Our partnership with Bowel Cancer UK marks an important milestone in our attempts to address a form of cancer that kills more than 16,000 people a year in the UK. Committing our resources to this new Research Chair will enable us to address the causes of this terrible condition and bring hope to the thousands diagnosed each year.”

Deborah Alsina MBE, Chief Executive of Bowel Cancer UK, commented: “Clinical trials are vital for taking potential treatment developments from research ideas to translating them into new drugs, diagnostic tests and surgical treatments for patients.

“Over the years, surgical clinical trials have had a huge impact on improving the outcomes for people with bowel cancer. Most recently, we have seen great advances in using drugs and surgery in combination to help shrink the

BCUK Chief Executive Deborah Alsina at the fundraising appeal

The importance of achieving this post and the outcomes to save lives can never be overestimated

Iain Kerr, patient and survivor

tumours to a size that makes surgery more likely to be effective at curing patients. Only surgical clinical trials offer us the evidence to know this is safe and effective.”

Iain Kerr, a volunteer with BCUK and former bowel-cancer patient, shared his perspective: “This Chair is important, as if somebody hadn’t done previous research on the procedure I had, I might not be here. The importance of achieving this post and the outcomes to save lives can never be overestimated.”

Donate to our campaign To achieve our ambitious aim of raising £430,000 we need your support. To donate to our campaign call 0131 527 1591 or email development@rcsed.ac.uk.

You can donate by cash, cheque or credit card. If you are a UK taxpayer, an extra 25% will be added for every pound you donate. rcsed.ac.uk | 23

MAJOR TRAUMA MAJOR TRAUMA

At the sharp end

Shehan Hettiaratchy was featured in the BBC documentary Hospital, which followed staff at St Mary’s as they treated victims of the Westminster Bridge attack.

He gives us his insight into modern trauma care in London

T

he major trauma network in England was established over the last decade and has halved mortality rates from major trauma.

It was tested last year by terror attacks and the Grenfell Tower fire, and was found to be robust and effective. With Wales and Scotland setting up similar networks this year, trauma care across the UK is on track to become the best in the world. So what’s it like to be part of the system, what makes it work and what are the challenges?

Work as a team or don’t work at all

Photograph by Ryan Mcnamara

One of the key aspects that has led to success is close teamworking. Trauma makes teams from all specialties grow together, as they have to manage severely injured patients. The concept that leadership and followership are dynamic, and that any high-performance team has a fluid hierarchy, has meant that the right decisions tend to be made. This requires a degree of humility and the need for all team members to check their egos in at the door.

It’s all about the physiology Trauma care is all about correcting the physiology, not putting injuries back together. This concept must be shared by the whole team. For the surgeon, this

24 | Surgeons’ News | March 2019

Shehan Hettiaratchy Lead Surgeon and Major Trauma Director

Shehan Hettiaratchy at work

rcsed.ac.uk | 25

MAJOR TRAUMA

If a trauma team can’t care for and look after itself, how will it be able to care for patients? involves changing mindset and operating in a different way. What can/should be done surgically will be set by the anaesthetic team, who will have the best handle on how the patient is performing physiologically. This may mean abbreviated surgery in someone who is physiologically unstable or early/immediate definitive surgery in those who are physiologically fine. The concept of timelines is no longer as relevant.

Bring your best knife to the gunfight Surgeons can only deal with major trauma effectively if they are confident in the whole range of trauma surgical techniques. They must also be flexible and willing to compromise. Repairing a popliteal artery injury may be easier with the patient prone, but if their chest is open and they can’t be turned, you will have to improvise, adapt and overcome. The surgeon must be able to work with other specialties to plan the surgical sequence and priorities.

Life at the sharp end is tough – don’t get hurt The continuous exposure to patients who have been injured in traumatic

ways can be emotionally challenging.

This can be particularly true for junior members of the team. The chance to decompress and debrief is important to allow people to process what they have seen. More significant problems may need formal counselling. A good trauma team will look after its own and all many may need is a quiet chat over a cup of tea.

The recent terror attacks had an effect on all team members, particularly the less experienced.

In addition, patients who have been injured in acts of criminality, such as knife crime, can be more difficult to deal with due to their fear, redirected anger and the severity of their injuries. After trauma deaths, especially in children, staff need to be properly debriefed and supported. If a trauma team can’t care for and look after itself, how will it be able to care compassionately for patients? Not everyone is emotionally cut out to manage the high intensity and emotional extremes of trauma; if it’s not for you, there’s no shame in that – another area of clinical practice may be better for you.

Learn from your mistakes, don’t let them destroy you

Right: Tributes near Westminster Bridge for victims of the terror attack

We all make mistakes and as trauma is a high-intensity, high-pressure situation, mistakes are inevitable.

The number and impact of mistakes must be minimised and lessons must be learned and implemented.

On a knife edge Instances of knife crime were at their highest levels in England and Wales in 2018 since their last peak in 2012, according to the Office for National Statistics, with 32,986 cases recorded.

Knife crime raises significant issues in healthcare systems. It puts demands on specialists to treat multiple wounds, typically administered to the chest and abdomen. It impacts levels of blood supplies in hospitals and puts pressure on mental health

26 | Surgeons’ News | March 2019

services who support victims after their physical recovery. Prehospital care and emergency departments provide essential care that can prevent the need for surgery, with interventional radiology increasingly used to stop bleeding.

Since the establishment of major trauma centres in 2012, the NHS in England has saved the lives of an additional 1,656

victims of stabbings, gun crime and acid attacks.

Major trauma networks were

designed by clinicians to standardise care and improve outcomes by providing specialist treatment rather than patients being taken to the nearest hospital, which may not be able to offer the same level of care. Teamwork between surgeons and allied healthcare professionals is vital to successful treatment, as positive outcomes rely on the speed and accuracy of identifying the full extent of injuries using imaging. To this end processes have been established and refined to ensure best outcomes.

A no-blame, non-judgmental culture is hard to develop, but is essential to maximise understanding and learning from any mistake. It’s important to support anyone who has made a mistake, as it can be devastating for them. Given that most errors are systemic rather than individual, the process must be handled sensitively.

Develop and live an ethos One way of pulling all of this together is to develop a team ethos, which you’ll often see in highperforming sports teams or in the military but not often in medicine.

Any ethos must be a tool that can be used daily to help make decisions and create common ground within the team. Some kind of tag line

can also be useful as a short-hand signal of the ethos. Our is ‘Dedicated trauma care, anytime, every time’ and was developed by all members of the team. Our ethos is three simple tenets: put your patient first in all you do, care for and respect your colleagues, and display compassion and humility.

Major trauma care is hard work, but incredibly rewarding.

The exposure to the challenging ways people are injured is offset by being part of a functional, close multidisciplinary team.

It provides intellectual, surgical and emotional challenges, but the payback is the privilege of helping the most severely injured patients get back to living their lives to the full.

Biography Born and raised in Hampshire, Mr Shehan Hettiaratchy graduated from Oxford University in 1994 with prizes in surgery and medicine. He trained in surgery in London, Birmingham, Australia and the US, with three specialist fellowships (micro, hand and wrist, and aesthetic surgery).

In his capacity as trauma lead at the Imperial College Healthcare NHS Trust in central and west London, he treated victims of the Grenfell Tower fire and the Westminster Bridge terror attack.

He has worked in war zones (Afghanistan, Chechnya, Kosovo) and disaster areas (the Haiti earthquake) as a British Army reservist and volunteer.

rcsed.ac.uk | 27

PLASTIC SURGERY

Acid attacks

Alexander Armstrong , Marie Song and Alexandra Murray examine the challenges of treating victims of assault from corrosive substances

28 | Surgeons’ News | March 2019

Thewriter01

high-risk boroughs, pH-testing kits are used to identify if the product is acid or alkaline and its strength – vital information when treating such injuries. One thousand acid-response kits have been developed, including the use of a rapid-response vehicle, five litres of water for irrigation and personal protective equipment. For larger-scale attacks, the fire service attends to irrigate mass casualties.8 The Crown Prosecution Service has improved the guidance around such attacks and classified corrosive substances as ‘highly dangerous weapons’, elevating their seriousness to that of violent gun and knife crime.

As a result, tougher prison sentences can be imposed.9 Major retailers have signed up to a voluntary scheme restricting the sale of corrosive products to under18s, including sulfuric acid drain cleaner, hydrochloric acid (≥10%) and sodium hydroxide (≥12%).7 One of the primary

Alexander Armstrong Plastic Surgery Registrar Marie Song Plastic Surgery Registrar Alexandra Murray Consultant Plastic Surgeon, SDU Lead and Clinical Director of Restore Burn and Wound Research Charity

goals of a corrosive-substance attack is to maim and disfigure. Offenders target the face for maximum impact.

This poses a significant surgical, reconstructive and psychological challenge. High-concentration agents invariably result in full thickness (third degree) burns that require surgical debridement. The potential for deepening of corrosive burns within the first 72 hours means staged debridement, followed by reconstruction, should be considered to optimise outcomes and reduce the risk of failed reconstruction. These injuries often involve the face, so functional and aesthetic concerns must be addressed because scarring can significantly impact, for example, the lips, causing problems with oral continence, eating and speech, with exposed mucosa and resultant ulceration. Scar contracture of the eyelids can cause cicatricial ectropion – exposing and drying the conjunctiva, an inability to close the eyes and protect the globe (resulting in painful ulceration of the cornea) and, in some cases, cause blindness.

As such, our ophthalmology colleagues need to be involved early whenever eyes are suspected to be injured.

Currently, complete replication of the normal quality of unburnt skin is not possible, so facial function and appearance can never be restored completely. However, techniques have been developed to reconstruct cosmetic subunits of the face. These subunits are divided by the natural skin creases and folds of the face, and

Products have been developed in an attempt to replicate normal skin. These aim to restore some pliability

Mid Essex Hospital Services NHS Trust/ Science Photo Library

B

urns secondary to corrosive substances are a growing problem.

Approximately 1,500 cases of acid attacks have been documented in the last year globally and instances are rising.1 There has been a threefold increase in reported attacks in the UK from 2013 to 2017.2 Statistics from the Health and Social Care Information Centre have shown a 50% increase in hospital admissions as a result of assault from corrosive substances over the last 10 years.3 The majority of cases were found in East London boroughs, accounting for 68% of attacks.2 These are areas of social deprivation and the findings are in keeping with the association of burn injuries and low socioeconomic status.4 Burns patients present with a multitude of problems that have to be addressed early. Victims of corrosive substance attacks require support in dealing with their psychological trauma and social circumstances. These issues are addressed using a multidisciplinary approach both within and outside specialist burns services.

One theory for this spike in attacks is police stop-and-search methods used to address violent knife and gun crime have resulted in an increase in criminals carrying corrosive substances. These products are easy to obtain and conceal in drink bottles with a nozzle, facilitating a jet spray to the victim. It is difficult to prove the intention to harm. The Home Office launched a project to improve legislation, policing and the ability to prosecute criminals and to address under-age sale of products.5, 6, 7 The Metropolitan Police have provided specialist officer training to improve the ability to prove intention to harm. In

include the upper and lower lips, eyelids, cheeks, nose, forehead, chin and neck.10 Engineered products have been developed in an attempt to replicate normal skin. These aim to restore some pliability and stretch – normally obliterated in the scarring process – and tend to contain an animalderived, purified collagen, decellularised dermis and glycosaminoglycans. The latter play the role of dermal hydration and elasticity. These products become vascularised like a graft and are used in either a single-stage procedure (a skin graft laid on in the same sitting) or a two-stage procedure (a delayed skin graft is used once vascularity of the substitute is achieved).11 This can be useful in any body site where full-thickness burn injury is affecting a functional area, such as hands.

Other surgical approaches may occasionally be required, particularly where vital structures or bone are exposed, including local, regional and distant tissue transfer. These procedures should be performed by teams carrying out regular flaps and microsurgery, and should ideally use

Left: William Pezzulo needed 33 surgical procedures after an acid attack Above: Chemical burns from an acid attack

References

tissue that is a best match for colour and thickness to optimise outcome.

The most complex rung of the reconstructive ladder is facial transplantation. This is superspecialised plastic surgery and has been successfully used in wellselected patients where function is severely impaired. The evidence surrounding this area is still limited and we do not yet know the long-term outcomes. Like any other organ, facial transplant from a donor requires lifelong immunosuppressive drugs to prevent rejection, which in itself poses risk. There are significant ethical challenges around these

1. Butler PE, Clarke A, Ghani S, Mannan A. Cases of chemical assault worldwide: a literature review. Burns 2007; 33: 149–154 2. Sharp rise in attacks involving corrosive fluids in London. bbc.in/2mIR01E Visited 25 November 2018 3. Health and Social Care Information Centre.

Hospital episode statistics.

England: Admitted Patient Care, 2016–2017

4. Heng JS, Clancy O, Jones I, et al. Low socioeconomic status, ethnicity and geographical location confers high risk of significant accidental burns injuries in London.

Crit Care 2014; 18 (Suppl 1): 77 5. Responsible sales of acid and corrosive substances: voluntary commitment. bit.ly/saleofacid Visited 25 November 2018 6. Acid attacks – Parliament

procedures and the donor family, as well as the recipient and their family, need intense psychotherapy before embarking on such a journey.

There is still a long way to go in reducing the impact of acid attacks, but like many complex areas in medicine, a holistic multidisciplinary approach is required to address all aspects of patient care. Robust prevention strategies need to be put in place through clinical engagement with the emergency services, the government, media and public, and this specialist group of burns patients should be managed through specialist units in the UK.

UK. bit.ly/ AcidAttachBriefing Visited 25 November 2018 7. Acid attacks: Retailers sign up to voluntary ban on acid sales. 2018. bbc. in/2qFvJNN Visited 25 November 2018 8. London police given 1,000 acid response kits after surge in attacks bit. ly/2KfpJ2Z Visited 25 November 2018 9. CPS Offensive Weapons, Knives, Bladed and Pointed

Articles. Legal Guidance, Violent Crime. bit. ly/2KPX1rb Visited 25 November 2018 10. Facial aesthetic units. bit.ly/2BIJtKY Visited 25 November 2018 11. Pham C, Greenwood J, Cleland H, Woodruff P, Maddern G. Bioengineered skin substitutes for the management of burns: a systematic review. Burns 2007; 33: 946–957

rcsed.ac.uk | 29

MAJOR INCIDENTS

Planning for the worst

NATALIE OXFORD

Stuart McKechnie shares the outcomes of a live major incident exercise at the Royal Infirmary of Edinburgh

30 | Surgeons’ News | March 2019

E

vents in London and Manchester in recent years have raised the spectre of a mass casualty incidents.

Lessons from these events have been documented to facilitate preparation in other parts of the UK, with many hospitals conducting tabletop exercises of various scenarios and their capacity to deal with them. While helpful, these are limited

Above: Events such as the Grenfell Tower fire have led many hospitals to plan for such scenarios

in their ability to foresee local logistical challenges. The Royal Infirmary of Edinburgh set out to perform a live exercise to increase preparedness for an event none of us wishes to see happen.

We put a planning team in place from the outset, consisting of the Major Incident Officer, and trauma leads from surgery, the emergency department and anaesthetics. The small group was a deliberate move

There will be an upcoming largerscale exercise as we aim to test resilience further

Stuart McKechnie Surgeon Commander with the Royal Navy and Consultant General and Trauma Surgeon at the Royal Infirmary of Edinburgh and Defence Medical Services @navysurgeon stuart.mckechnie@ nhslothian.scot. nhs.uk

We had practised many aspects individually, but this was the first opportunity to put everything together to ensure the exercise aims remained targeted, relevant and, above all, realistic. We also took advice from colleagues at the Queen Elizabeth Hospital in Birmingham, who were further along the learning curve.

This is a vital lesson in exercises of this nature, where duplication of effort and failure to learn from the experience of others risks significant inefficiency. We set key planning lessons far enough in advance to

Top and above: Royal Infirmary of Edinburgh staff take part in a live simulation of a major incident

maximise benefit and include dates for debriefs and feedback meetings in the same schedule.

We then engaged other key departments individually to ascertain their learning targets while keeping the exercise focused. These included radiology, blood bank, theatres, intensive care and the control room.

We had practised many aspects individually, such as departmental call-out plans, but this was the

first opportunity to put everything together. The exercise itself took place in a deliberate time slot to minimise any impact on day-to-day clinical care while maintaining realism. Staff resources were increased – particularly in the emergency department – to enable the exercise footprint to be as true to life as possible. Some areas, such as CT scanning, were drilled in adjacent areas to enable normal activity to continue uninterrupted while the learning objectives, such as time to a hot report, were still accurately tested.

The exercise provided the opportunity to test relatively new concepts involving the front-loading of blood and presence of blood bank liaison in the emergency department, the role of the Surgeon Commander in theatres and inter-/ intra-specialty communications.

In moulages of this nature, the learning points can be an extensive list and this instance was no different.

Many were easy fixes, but triaging had to take place to produce a targeted list to improve before the system is tested again. From a surgical point of view, these concerned the availability and subsequent resupply of surgical sets, communication between the triage surgeon in the emergency department and Surgeon Commander in theatres, and the organisation of staff resources to enable continued work through subsequent days. Parallel work in damage-control surgery and training of trauma teams will make a big impact.

A key positive from the exercise was increased engagement – tangible not just on the day, but going forward – because many more people showed a desire to contribute to the continued development of our response. The main drive of this will be an upcoming larger-scale exercise as we aim to test resilience even further and hopefully assist other hospitals as they put together their own major-incident plans. We cannot predict if and when an incident will happen, but we can be ready for it. rcsed.ac.uk | 31

Long in the tooth?

Fraser McDonald , Graham Roberts and Victoria Lucas explore how dental forensics could be useful in helping to determine people’s age

W

hen referring to forensic dentistry, many reflect on the typical aspects seen in modernday crime dramas: identifying dead bodies whose facial features have 32 | Surgeons’ News | March 2019

been destroyed, or securing or excluding suspects from the alignment of teeth found in a flesh wound. This bite-mark identification has come into serious question, with some cases disputed when investigated at a later date using DNA evidence.1 With the ever-changing

need for reconsidering new data within science and the RCSEd mission statement of ‘From here, health’, the focus of training within the College needs to re-evaluate possible areas for living forensics.

We live in a changing global economy with terms such as

DENTAL FORENSICS

Scientific publications have shown that estimation of dental age can provide support to the age of the applicant ‘internationalisation’ becoming commonplace and migration of people occurring around the world. People are now seeking new lives away from military and political persecution, and asylum seekers are often reported in national news stories. Equally, in many developing countries, staying alive with a minimal amount of food and clean water is all that concerns some populations. The concept of records of date of birth is not seen as important.

Even levels of school education cannot be used as a reflection of age. Academic progress, if delayed in some developing countries, often leads to students being placed in a younger age group so that they can consolidate their knowledge and education.

Having a country of origin, whether adopted through migration or as a birthright, implies access to the rights and privileges of that country. A validated date of birth is important for living and working in that society.

Important ages in the United Kingdom2 include the minimum age of criminal responsibility and age to consume alcohol. They rely on a genuine record of the date of birth.

While the UK has robust directives (the Births and Deaths Registration Act of 1926, superseded by the Registration of Births, Deaths and Marriages Regulations 1968, made it an offence not to register a birth), many countries do not have such requirements, so many migrants have less-stringent evidence of their age.

In these cases, we depend on methods to estimate their age. These currently include radiographic evaluation (wrist and/or teeth), the general appearance of the individual and the validity of any documentation they can provide supporting their date of birth.

Failing this, the Merton test can be applied by two specifically trained

References

1. Saks MJ et al.

Forensic bitemark identification: weak foundations, exaggerated claims.

J Law Biosci 2016; 3: 538–575 2. Jayaraman J, Roberts GJ, Wong HM, McDonald F, King NM. Ages of legal importance: Implications in relation to birth registration and age assessment practices. Med Sci Law 2015; 56: 77–82 3. Roberts G, Lucas V and McDonald F. Age estimation in the living: dental age estimation – theory and practice.

Encyclopedia of Forensic and Legal Medicine 2nd Edition; 41–69 4. Roberts G, Lucas V, McDonald F, Camilleri S, Jayaraman J, Davies D, Moze K. In our opinion. BDJ 2017; 222; 918–921

social workers. Essentially, the person responsible for determining the age of the individual must seek to elicit the general background of the applicant, including their family circumstances, history and educational background, as well as their social interaction. This has to include the applicant’s activities in the previous years. During discussion, the assessor has to establish the applicant’s credibility – always a highly subjective process.

What can go wrong if the assessment identifies the wrong age? Someone claiming to be under 18 who is actually over 18 may be housed with those who are under 18, which could be a safeguarding issue.

A case reported in The Independent newspaper in November 2018 considered an individual taking school-level examinations of a 15- to 16-year-old who is alleged to be 32 years old.

A simple way to clarify this would be a dental radiograph.3 Modern dental radiographic equipment has reduced dental exposure to a minimum, especially when compared with the ambient sources of radiation we are exposed to in our everyday life. The dental

profession has been challenged in the lack of objective data to support concerns of misusing radiographs as a form of screening.4 Scientific publications, refereed and reviewed, have shown that estimation of dental age can provide support to the age of the applicant.4 These techniques are based on a significant database of extant radiographs and, while criticism is levelled at the validity of these techniques, little practical and objective working knowledge of age assessment exists.

Clearly, we are not recommending screening – we are supporting an objective evaluation with known data to potentially protect vulnerable adults. However, the final comment must lie in any data that exist from standard general dental practice. Many new patients to practices have a radiograph to review their dental health as they enter the practice as well as their state of dental development, and this could be used to verify their age. rcsed.ac.uk | 33

CARDIOTHORACIC PLACEMENTS

Specialty focus Students from the RCSEd and Vascutek Cardiothoracic Surgery Placements for Undergraduates scheme share their experiences

T

he RCSEd Surgical Specialty Board in Cardiothoracic Surgery and Vascutek support a multicentre national programme that gives talented and motivated medical students an immersive experience of life in cardiothoracics. The scheme is designed to allow future surgeons to make an informed choice of specialty at an early stage of their surgical career. Below are three students’ reflections.

Anthony Wijaya from Cardiff University undertook a two-week placement at University Hospitals Bristol with Dr Doug West

From the first day, I watched video-assisted thoracoscopy VAT procedures in thoracic surgery.

The whole team made me feel very welcome, taking time to show me different aspects of their specialty, including ward work, clinics and surgery.

I was able to assist in some procedures. The most interesting for me was a VAT lobectomy in which I was given the opportunity to operate the camera and to use the stapler to remove a section of lung metastases.

In the second week, I spent most of my time (sometimes 12 hours a day) in cardiac surgery, watching and assisting with coronary artery bypass grafts and aortic valve replacements, which gave me an insight into what a career in cardiac surgery would involve. I saw some interesting paediatric cases, such as congenital

I operated the camera in a VATS lobectomy and used the stapler to remove a section of lung metastases 34 | Surgeons’ News | March 2019

valve replacements and a subaortic membrane resection.

The anaesthetists were very keen to teach me how to interpret transthoracic echocardiograms.

In theatre, a particularly memorable experience was when the surgeon asked me to stabilise the myocardium with my finger while he performed anastomosis of the vein graft to the coronary artery.

I spent a day in cardiac ICU with some very enthusiastic cardiac anaesthetists, who tutored me on cardiac physiology. When following the on-call registrar, I felt privileged to witness emergency insertion of a chest drain for a tension pneumothorax, and I was asked to interpret the chest radiograph.

Overall, the placement was really well organised and I would recommend it to any student interested in cardiothoracic surgery.

Omar Zibdeh from Plymouth University Peninsula School of Medicine spent two weeks at James Cook University Hospital with Mr Jonathan Ferguson

The team at James Cook were so welcoming and I was given the opportunity to assist in, perform and log more surgery in those two weeks than I had in my whole medical career thus far, including a thoracotomy and harvesting of saphenous veins. It was a steep learning curve and challenging, but it was enjoyable nonetheless. It provided the opportunity to experience the specialty authentically and evaluate it realistically as a career option. From the word go, Mr Ferguson encourages you to seek out professionals in the specialty and talk to them to learn about the good, the bad and the ugly. I had many conversations with the cardiothoracic trainees at different

My placement at James Cook reaffirmed my passion for pursuing a career in cardiothoracic surgery

stages of their career, both in and out of hospital. These conversations gave me access to knowledge of and advice about the logistics of cardiothoracic training from those who had experienced it first hand, and allowed me to make contacts with my future colleagues.

I really felt part of the team and a colleague rather than a student. This helped accelerate my growth both on a personal and professional level. I was privileged to witness state-of-theart robotic thoracic procedures, some of which had never been performed in the world before. In fact, I was given the footage of an operation to edit and narrate for publication.

I would never have obtained such an experience in medical school.

Many thanks to Mr Ferguson, the whole team at James Cook, Vascutek and the RCSEd for this opportunity of a lifetime.

Devan Dipak Limbachia from the University of Birmingham also undertook a placement for two weeks at James Cook University Hospital with Mr Jonathan Ferguson

Within the current undergraduate curriculum, there is minimal emphasis placed on cardiothoracic surgery. Opportunities like this are

a fantastic way to provide early exposure, ensuring students make realistic, well-informed career choices. My placement at James Cook University Hospital reaffirmed my passion for pursuing a career in cardiothoracic surgery.

At the beginning of the placement, I was given a very warm welcome and Mr Ferguson discussed the available options to tailor this experience to my interests. He provided me with all the resources needed to map out my two weeks, including ward rounds, theatre lists and clinics.

During the placement, I was able to scrub into many cases, performing my very first thoracotomy and saphenous-vein harvesting. The placement helped to strengthen my basic surgical skills and provided a window into several techniques used within the department. One of the highlights of the placement was being given open access to the robotic da Vinci Surgical System.

I had the pleasure of working with Mr Dunning. As a result, I was able to create an educational video based on one of the team’s robotic cases. Following on from my time at James Cook, I was fortunate to meet Mr Dunning in Birmingham, where I observed several diaphragm plications and practised on a novel surgical simulator.

I would like to extend my thanks to the RCSEd, Vascutek, Mr Ferguson and the team at James Cook University Hospital for this memorable opportunity.

BORN TO STAND OUT Terumo Aortic has integrated Bolton Medical and Vascutek with a vision to transform the treatment of aortic disease worldwide. Our unique portfolio of endovascular, surgical and hybrid technologies and services enables clinicians to meet the individual needs of each patient. Together, we are interwoven with life.

rcsed.ac.uk | 35

FELLOWSHIP

When in Africa Mike Hollands reflects on lessons learned on the Rahima Dawood Travelling Fellowship

A

s I walked on to the ward on my second day in Africa in 2017, my host, Dr Hopewell Mungani, told me how much I would enjoy seeing the first case on that day’s teaching ward round. “It’s a case of snake bite and you Australians have lots of snakes!” How could I tell him that, although we have lots of snakes, snake bites are rare in Australia and I was not the expert he imagined?

I suppose that case illustrates what it means to be the Rahima Dawood Travelling Fellow: a broad surgical knowledge and a readiness to be flexible.

The Rahima Dawood Travelling Fellowship is a joint initiative between the RCSEd and the College of Surgeons of East, Central and Southern Africa (COSECSA). The Fellowship commemorates surgeon and author Yusuf Kodwavwala Dawood’s parents and was initiated in 1987. The Fellow is expected to visit four or five of the member nations of COSECSA, teaching trainees, students and junior doctors.

The teaching format varies from nation to nation, but includes formal lectures, small group tutorials and teaching ward rounds.

Planning three weeks in Southern Africa remains a significant challenge, and I received invaluable assistance from the College staff, Mr Graham Layer, Mr George Youngson and Professor Eric Borgstein.

I began my Fellowship in Zimbabwe with my host, Professor

36 | Surgeons’ News | March 2019

Wounds or injuries in the peripheral areas of the country may take weeks to receive attention

Above: Yusuf Kodwavwala Dawood and Graham Layer Below: Malawi’s children’s hospital funded

by Madonna’s foundation

Godfrey Muguti. We knew each other from when he was a Rowan Nicks Fellow of the Royal Australasian College of Surgeons at Westmead Hospital in 1990.

After morning handover, I joined the surgical team for a teaching ward round. A registrar presented the first case comprehensively, then there was silence. The surgical team were waiting for me to start the discussion, only I had not been forewarned – I quickly caught on.

I saw cases covering breast disease, trauma, vascular disease, peptic ulcer disease and emergency surgery – no place for the super-specialist here!

Later, I presented the University of Zimbabwe Guest Lecture entitled Trauma Management in Austere Conditions.

In the evening, I was due to present my Rahima Dawood

Lecture to the Zimbabwe Medical Association, but this was postponed owing to the resignation of President Mugabe. Harare that evening was in carnival mode with thousands of people in the streets, cars everywhere and lots of noise.

My next port of call was Malawi.

I visited Blantyre – where I stayed with Professor Eric Borgstein and his wife, Sophie, at their home in the hills above the city – and Lilongwe, where my host was Dr Carlos Varela.

From Malawi, I went to Lusaka in Zambia, where I was well looked after by Dr Michael Mbambiko.

I saw a huge range of disease and I was struck by the delays associated with obtaining surgical care. Wounds or injuries in the peripheral areas of the country may take weeks to receive attention.

The boy with the snake bite is an excellent example. The child was bitten by a puff adder at night, a tourniquet was applied by his family and they visited the local healer the next morning with the tourniquet still in place. Approximately 72 hours after being bitten, the child arrived at a centre where he could receive definitive care after a long journey on public transport. He had extensive local tissue damage from the adder bite and a gangrenous hand, probably a consequence of the prolonged application of the tourniquet.

The range of disease is quite different to that of a developed country. Wounds are a significant part of the clinical load. Gall bladder and diverticular disease are rare.

In lieu, spontaneous perforation of the small bowel secondary to typhoid and sigmoid volvulus are common. The patients present late and often require a stoma.

After discharge, patients are required to purchase stoma bags and the cost is frequently prohibitive. It made me reflect on the things we take for granted in some healthcare systems.

In Malawi and Mozambique, expatriate doctors – both consultants and trainees – play an enormous part in supporting the healthcare system. Nurses are in short supply, so resident medical officers (RMOs) or medical officers do many of the tasks normally assigned to nurses, including recording patient observations, changing dressings and removing drains.

Medical officers are not synonymous with RMOs – they are not medically qualified. Instead they complete a Diploma in Clinical Medicine. They act as ward doctors, and in many hospitals as anaesthetists, undertaking some operations.

The operating theatres are often very inefficient. Surgery may be cancelled at short notice and for questionable reasons. This results in unproductive uses of theatre time, unnecessarily short operating lists and delays in elective operating.

In Blantyre, I visited the Beit CURE International Hospital – an orthopaedic hospital where the ethos is adults pay so kids can walk

– and the Mercy children’s hospital.

The latter is a new facility funded

by Madonna’s foundation, Raising Malawi. It is the vision of Professor Borgstein and will provide state-ofthe-art facilities for children. It has 50 beds and Malawi’s first paediatric intensive care unit.

From Lusaka, I flew to Maputo for the COSECSA Conference and concurrent GIEESC meeting (WHO Global Initiative for Emergency and Essential Surgical Care). I delivered the Rahima Dawood oration entitled Wound Management: Lessons from Natural Disasters, following the ceremony for the new COSECSA graduates.

COSECSA is thriving. It has been in existence for 18 years and has 12 member nations. It has more than 1,000 Fellows, over 500 trainees, more than 200 exam graduates and

Graham Layer with the COSECSA Executive

Mike Hollands Upper Gastrointestinal and Hepatobiliary surgeon at Westmead Hospital, Sydney, and Honorary Fellow, RCSEd

The operating theatres are often inefficient. Surgery may be cancelled at short notice and for questionable reasons

99 accredited hospitals. In the region covered by COSECSA, there are approximately 1,600 surgeons for over 320 million people – one for every 200,000 people. Yet there are vast discrepancies, ranging from one surgeon for every 550,000 people in Malawi and Burundi to one for every 85,000 people in Kenya. Mozambique has 250 accredited surgeons, half of whom are expatriates. Only half of its hospitals have an accredited surgeon on staff and only one quarter an accredited anaesthetist.

As the Rahima Dawood Fellow, I learnt as much as the trainees I taught. I have been actively engaged in global surgery for many years, and this trip provided me with an opportunity to reflect on the real issues for low- and middle-income countries. Things we take for granted – early presentation, basic pathology, well-trained nursing colleagues, and affordable medications and prostheses to name just a few – are in short supply. It is not just a surgical or anaesthetic staff issue, although this is obviously crucial. rcsed.ac.uk | 37

FELLOWSHIP

Guns and resus

Alban Barros D’Sa Fellow Andrew Healey explains how Cape Town’s surgeons learn how to deal with complex polytrauma

D

uring my Fellowship at Groote Schuur Hospital (GSH), Cape Town, I set out to assess how specialist trauma and liver surgeons gain their competencies and how they share their expertise in the care of victims of complex visceral polytrauma.

Access to GSH is strictly controlled by airport-style security checks, and I was struck by the abundance of notices asking people to refrain from entering with a firearm. On arrival, I was welcomed by the duty hepatobiliary and pancreatic (HPB) consultant, and visited the HPB and trauma units and integrated theatre suite of a private hospital within the University of Cape Town.

HPB Fellows complete general surgical training before applying to GSH. The HPB Fellowship consists of six months of endoscopy training and outpatient care, followed by six months of ward cover and theatre, repeated over two years. On-call is 24/7 for one week at a time, although most acute surgical issues are initially managed by the acute emergency surgical team.

The two-year trauma unit Fellowship includes at least three months in the intensive treatment unit. The remaining time is distributed according to a two-tier rota of cutting room (resus) and back room Fellows, alternating on a weekly basis. The latter manage new admissions in the postresuscitative surgery phase. The front room Fellow runs a seven-bed resus unit supported by two medical officers, with a dedicated neighbouring trauma theatre. There is a 24/7 CT facility for overnight inter-hospital transfers from centres without adequate imaging facilities. A mobile X-ray machine, previously used in the gold mines, had been modified for use as a bullet finder/bone assessor.

I met Senior Trauma Fellow Sanju, Sobnach with whom I performed several gun-shot wound (GSW) laparotomies – the average for the hospital was three per day. I observed Professor Andrew Nicol arrest haemorrhage from GSWs to the liver/duodenum and superior mesenteric vein, with no HPB assistance. This key skillset is clearly more easily attainable in highvolume centres. The unit was keen to develop conservative management

The average for the hospital was three gun-shot laparotomies per day 38 | Surgeons’ News | March 2019

Andrew Healey Consultant HPB Surgeon, Royal Infirmary of Edinburgh

of low-velocity penetrating trauma.

Professor Nicol highlighted that level-one trauma units should aim to have a <10% negative laparotomy rate; the GSH rate is 3%.

My experience in Cape Town was memorable. I was keen to explore areas of subspecialty training that could be applied to basic trauma training in areas with a low incidence of penetrating trauma. The general surgery rotation trainees benefit from six months trauma training prior to subspecialty Fellowships, while nontrauma subspecialty Fellows have a similar trauma experience to higher surgical trainees in the UK. The most important skills demonstrated in the trauma unit were decision-making and the ability to arrest haemorrhage/resuscitative surgery expertise. I think trauma training in low-volume centres will focus on recreating the stressful environment in which these skills can be achieved and assessed, and we must not dismiss such opportunities in subspecialty training.

Research Report For details of this and other research Fellowships, see the 2016–2018 Research Report, which is available at rcsed.ac.uk

INVESTMENT

Heard it through the grapevine Jean-Pierre St Mart explores the myth of the College’s wine cellar

THE WINE LIST

For connoisseurs, the College’s known prized collection includes the following rare vintages...

OLD WORLD: RED WINE Burgundy (France) Richebourg Grand Cru, Domaine de la Romaneé-Conti

VINTAGES (2002, 2007, 2012–2015)

La Tache Grand Cru Monopole, Domaine de la Romaneé–Conti

(2006–2007, 2009–2015)

Grands-Echezeaux Grand Cru, Domaine de la Romaneé-Conti

(2007–2015)

Clos de Tart Grand Cru, Monopole

(2010, 2011, 2015, 2016)

Bordeaux (France) Château Léoville Las Cases

(1996)

Château Pétrus

(2010–2017)

Château Trotanoy

(2009)

Tuscany (Italy) Lodovico Antinori, Tenuta di Biserno

(2007)

Piemonte (Italy) Barolo Monfortino Riserva, Giacomo Conterno

(2010)

Ribera Del Duero (Spain) Pingus, Dominio de Pingus

(2015–2017)

Douro-Porto (Portugal) Taylor’s Vintage Character D.W Port

2000

Graham’s Vintage Port

2007

WHITE WINE Burgundy (France) Chevalier-Montrachet Grand Cru, Domaine Leflaive

(2016)

Puligny-Montrachet Clavoillon, 1er Cru, Domaine Leflaive SPARKLING WINE Champagne (France) Salon, Blanc de Blancs Champagne Grand Cru

(2016)

(2002)

NEW WORLD RED WINE: Napa Valley (United States) Dominus, Dominus Estate

(2008, 2010, 2015)

Opus One, Opus One Winery

(2015)

Ulysses, Ulysses Vineyard

(2015)

AHEAD OF THE GAME

market.

En primeur wine is bought prior to bottling or release on to the in the Historically, this advance allowed châteaux to pay their bills especially from immediate post World War II era. However, this system soon changed efficient way of what was primarily a source of financing the next vintage to an wine merchants to secure first growths from the top estates.

T

here have been many rumours of a legendary old wine cellar hidden deep beneath the foundations of Surgeons’ Hall. It supposedly houses many rare bottles and sought-after vintages. Having a personal interest in wine (outside of my life as a hip and knee surgeon), I decided to investigate and lay to rest the myths surrounding this renowned wine collection.

An old wine cellar does exist, although one would be pushed to describe the contents as ‘fine wine’. In 1834, an area off the main kitchen was initially built to store the College’s wines. Over time, it has been used as an all-purpose storage facility, including for housing easydrinking wines at social events.

The College only truly started investing in wine in 2009 under former President David Tolley through wine merchant Corney and Barrow. Any potential profit made out of buying or selling wine en primeur goes directly to supporting the College. En primeur wine is bought prior to bottling or release onto the market. Rather than being delivered directly to the College’s own cellar, it is kept at the wine merchant’s professional storage facility. This is to ensure the wine is kept in optimum conditions to retain its maximum financial value. As with all forms of investment, nothing is guaranteed and wines purchased en primeur can depreciate as much as they can appreciate in value (such as some first growths of Bordeaux from 2009 and 2010).

The College is about to launch a scheme for its Members that will enable them to buy wine at a discount.

Any discounted wine bought through such membership incentivises the wine merchants to allow the College further access to fine wine futures for their everexpanding investment portfolio.

Wine futures investment can range from as little as £50 to potentially four-figure sums per bottle. Previous investments have been heavily weighted towards the Bordeaux and Burgundy regions due to their reputation and historically good returns. More recently, the College has expanded to acquiring Italian, Spanish and New World wines.

My investigation revealed a less-than-glamorous wine cellar within Surgeons’ Hall, but the College’s investment in fine wine is astounding. Over the past 10 years, the wine portfolio has risen by over 140% of its original value. This has reaped great financial rewards, which have been reinvested in the College.

More information Jean-Pierre St Mart blogs at thewineapprentice.com Wine merchant: corneyandbarrow.com rcsed.ac.uk | 39

MUSEUMS

Criminal collections

Surgeons’ Hall Museums Assistant Curator Louise Wilkie and College Archivist Jacqueline Cahif uncover 19th-century life and crimes in Edinburgh

M

any a 19th-century criminal tale can be found in the College heritage collections, owing to the work of past Fellows in the field of forensic medicine and their role as medical witnesses. Henry Duncan Littlejohn and William Newbigging PRCSEd are notable, as is Joseph Bell PRCSEd. Others, though, had a more dubious association with criminality.

The anatomist Dr Robert Knox FRCSEd has gained considerable notoriety for his connection to the Westport murders.

Robert Knox

There has always been disagreement on Knox’s culpability in having knowledge of the source of the medical cadavers he purchased from Edinburgh’s notorious serial killers, Burke and Hare, who murdered 16 people in a 12-month period from 1827. Generally, Knox has been cast as a villain in the drama, probably influenced by contemporary sensationalism in the print media, which had the effect of shaping later accounts.

First-hand testimony of those closest to Knox is sparse and existing accounts questionable in accuracy. A new archive acquisition from the family of Thomas Hume goes some way to filling this gap. Hume was an arts student at the University of Edinburgh and his manuscript memoirs are essentially an eye-witness account of the drama that unfolded, including interactions with ‘Daft Jamie’, one of the 16 murder victims, and his 40 | Surgeons’ News

attendance at the execution and dissection of William Burke.

Hume’s closest friends were Knox’s anatomy-school assistants, who granted him access to the anatomist’s infamous lectures. His narrations during class were particularly vivid, affecting Hume so much that he abandoned “all thought of the medical profession” as a suitable career. “No sooner did Dr Knox uncover a frightfully mutilated subject in the last stage of decomposition and putrefaction, than I sank down in a dead faint.”

Admittedly, Hume was writing later in life, and his recollections of some events were clearly affected by a hazy memory or wild tales ingrained in the popular imagination. In particular, he recalls a medical student entering Dr Knox’s dissecting rooms “to find his poor friend ‘Daft Jamie’ lying on the table for dissection!” However, there is no evidence that the corpse was ever taken to Knox.

Yet there are many instances when we can safely take his accounts at face value, most notably when he directly participated. On the night news of the murders broke, a large mob gathered “in the square of the Old Infirmary in front of Knox’s dissection rooms … determined to have their vengeance”. Hume and his friends “decided to act as a body guard in conducting Knox … safely home” and he subsequently provides an almost minute-by-minute account of this.

Hume provides new witness testimony. His on-the-ground narrative of events on 28 January 1829 when Burke “was then and

Their findings were recorded as ‘probable death by violence with a suspicion of strangling’ there condemned to the gallows, upon which I was an eyewitness of his being hung” offers new perspective, given that all other witness accounts were reported from the balconies of Edinburgh’s Parliament Square. Hume was also

It is clear Edinburgh has a unique relationship with crime and those determined to prove it Burke and Hare

Robert Christison became Medical Officer to the Crown in 1829, a title he would hold for a staggering 37 years, yet it was the trial of Burke and Hare that brought him into the public eye.

Christison, alongside Newbigging, was tasked with examining the body of Burke and Hare’s final victim, Margery Campbell. Their findings were recorded as “probable death by violence with a suspicion of strangling”. Unbeknownst to them, Hare had turned King’s evidence. Christison alone was called to give evidence and it was this testimony that not only proved murder, but also validated Hare’s evidence.

Additional injuries were found on Campbell’s body, including damage to the spine and various contusions. Christison, in conducting his experiments – which included beating cadavers to prove post-mortem bruising and by discussion with leading anatomists of the day – found these additional injuries had been inflicted after death, when the body was forced into a tea-box. This was an important development in postmortem investigations. present at the student riot over the dissection of Burke’s body. The full manuscript is online at the Digital Collections link at archiveandlibrary. rcsed.ac.uk In 19th-century Scotland, there was a rise in difficult-to-prove crimes such as poison and infanticide, and the law looked to medicine to prove such crimes in court. Originally, medical evidence had not fared well, with many a medical man left embarrassed by his experience in the witness stand. However, men such as Robert Christison and Henry Duncan Littlejohn would bring credibility to the subject.

Arthur Conan Doyle creates Sherlock Holmes

It was this investigation that was used to first introduce the reader to the most famous medical detective of all, Sherlock Holmes. In Arthur Conan Doyle’s first novel A Study in Scarlet, Holmes is described as “beating the subjects in the dissecting-rooms with a stick” to “verify how far bruises may be produced after death”.

Medical student Conan Doyle was influenced by other Edinburgh medical witnesses during his studies between 1876 and 1881. For example, Henry Duncan Littlejohn led investigations into many highprofile murder cases, which he regaled to his students. However, it is to Joseph Bell that Doyle credited the idea of Holmes. “It’s most certainly to you that I owe Sherlock Holmes,” he wrote to Bell in 1892.

Bell, another medical witness, was known for his diagnostic prowess and powers of observation. He would diagnose patients without aid or any spoken symptoms. He even has a striking physical resemblance to the literary sleuth.

It is clear Edinburgh has a unique relationship with crime and those determined to prove it, both real and fictional.

Above: Illustration of resurrectionists Right: Exhibit GD 81 from the Hume archive Left: Sherlock Holmes statue in Picardy Place, Edinburgh. It stands opposite the birthplace of Sir Arthur Conan Doyle

rcsed.ac.uk | 41

EQUALITY

Seven against Edinburgh Elaine Thomson outlines the campaign for the medical education of women between 1869 and 1873

T

he first women to have their names put on the medical register in Britain were Elizabeth Blackwell (1858) and Elizabeth Garrett Anderson (1866). Blackwell trained in New York, but the Medical Act of 1858 stipulated that no foreign degree was sufficient to qualify for inclusion on the British medical register. Garrett Anderson had qualified as a licentiate of the Society of Apothecaries in London in 1866. Once she had received her licentiate, however, this route was also speedily closed to women.

It was not until the late 1860s, when Sophia Jex-Blake began the battle for the medical education of women at Edinburgh University, that the issue of women’s right to enter the medical profession was fully confronted.

In October 1869, Sophia Jex-Blake and four other women – Edith Pechey, Isabel Thorne, Matilda Chaplin and Helen Evans – succeeded in matriculating to study medicine at Edinburgh University.

One year later, they were joined by Mary Anderson and Emily Bovell. As events unfolded, the group became known as the Septem contra Edinam, or the Seven against Edinburgh.

They faced opposition from the outset. Arguments against medical women pointed to the impropriety of having men and women taught together in the same classroom – especially in the anatomy classes and the dissecting rooms. The

Arguments against medical women pointed to the impropriety of having men and women taught together 42 | Surgeons’ News | March 2019

matter of women’s inferior intellectual ability was raised.

Jex-Blake got round the first issue by persuading the lecturers to teach the women students in separate classes.

In the spring examinations, all five medical women won prizes in botany and four of the five were in the honours list for physiology and chemistry, thereby dismissing any arguments concerning their lack of ability. Pechey came top of the class in chemistry and should have won the Hope Scholarship, a prize awarded to the student with the highest marks. The scholarship was awarded to a man, who had come second, rather than to Pechey.

In addition to this snub, the university refused to issue certificates of attendance to the women students for those classes that they had passed. The women appealed against both decisions.

Although the senate agreed to issue the certificates, they refused to re-allocate the scholarship. It was the controversy surrounding the Hope Scholarship that marked the beginning of a systematic effort to exclude women from medical education at Edinburgh University.

By early 1870, many of those who had taught the women students in separate classes at the university had, under pressure from colleagues, withdrawn their services.

The university, however, was not the only place in the city where they could attend classes in medicine.

The extra-mural medical school provided lectures to medical students to prepare them for the licentiate examinations of the Royal College of Surgeons of Edinburgh and the Royal College of Physicians.

In July 1870, all of the extra-mural lecturers agreed to accept women

into their classes. By October of that year, having passed all classes offered by the extra-mural school, the women approached the Royal Infirmary for permission to walk the wards.

The issue of mixed classes once more came to the fore. In the wards of the hospital it was argued that women would witness the most hideous diseases and illnesses, the sights, sounds and smells of which would shock and offend their delicate sensibilities. As a result, in October 1870, 16 out of the 19 members of the medical staff voted against allowing women into the Infirmary for clinical instruction.

The next event in the saga was the riot at Surgeons’ Hall. On 18 November 1870, as the medical women attempted to enter Surgeons’ Hall for an anatomy exam, they were met by “a dense mob filling up the roadway, sufficient to stop all traffic for

Wellcome Images, Margaret Todd

Pechey came top in chemistry and should have won the Hope Scholarship.

It was awarded to a man about an hour”. The gates of the Hall were slammed in the women’s faces by the half-drunken mob of male students, who proceeded to swig whisky from within while abusing the women “in the foulest possible language”.

Although the women managed to enter the lecture theatre, the mob was still awaiting them when they emerged to hurl mud and more verbal abuse. In December a memorial was submitted to the extra-mural lecturers, signed by 66 students, complaining at the presence of the female students. The College passed a resolution by 27 votes to four against mixed classes.

The remaining months of the year were spent in a legal wrangle with the Infirmary. The Infirmary electors voted against the admission of women by 100 to 98. Finally, in June 1873, the Court of Session upheld the university’s appeal against the women’s right

Top left: A 1900 portrait of Elizabeth Garrett Anderson Above: Portrait of Elizabeth Blackwell by Joseph Stanley Kozlowski, 1905 Top right: Sophia Jex-Blake (left) and Edith Pechey (right) Middle right: Hunter Doig medal winner Farhat Din (left) with Caroline May Doig, the first woman to be elected to the RCSEd Council in 1984 Bottom: The plaque to honour the Edinburgh Seven

to be examined by the medical faculty. There was now no way for the medical women to gain even a part of their degree from the University of Edinburgh. The battle for medical education in Edinburgh, which had lasted for almost four years, was over.

In 1876, the Russell Gurney Enabling Bill was introduced. Once women had obtained their medical degrees from foreign universities, the Enabling Bill made it possible for them to obtain a licentiate from one or other (or both) of the Royal Colleges at the time, thereby allowing them to practise as

surgeons or physicians in Britain. In response to this victory, Jex-Blake and a number of the medical women who had studied in Edinburgh gained their MDs in Europe, then returned home to seek the licentiate that would allow them to practise medicine in Britain. The Kings and Queens College of Physicians and Surgeons of Ireland was the first to allow women to sit the necessary exams. In May 1877, eight years after she had first attempted to enter the medical profession, Jex-Blake and four other medical women from Edinburgh had their names added to the medical register.

Fact and fiction Elaine Thomson has a PhD in the history of medicine from the University of Edinburgh. She writes medical historical crime fiction, and is the author of Beloved Poison, Dark Asylum and The Blood. Her fourth novel, Surgeons’ Hall, is out this year.

rcsed.ac.uk | 43

Trainees and students The College’s outreach and training activities TRAINING

Surgical Anatomy Workshops Spring rollout of training for senior students The College, in its commitment to future surgeons, will deliver its highly acclaimed Surgical Anatomy Workshops for senior medical students from spring 2019. The first will be held at the RCSEd and a further three will be delivered across the UK. Professor Gordon Findlater has taken over from Professor David Sinclair to continue work delivering surgical anatomy to those eager to increase their knowledge and understanding.

The workshops are designed to increase awareness of the links between anatomy and surgical practice. They begin with a talk entitled Surgery and Anatomy – Partners in Time and Space, followed by three practical sessions on the surgical anatomy of the head and neck, trunk and limbs. Delegates are split into groups and rotate around the three half-hour sessions.

The faculty uses a case-based approach, demonstrating the importance of knowledge of surgical anatomy to all aspects of surgical practice. Students have the opportunity to ask questions during these interactive sessions.

Teaching groups are kept small to ensure a high level of teaching is delivered. Teaching aims to give students an understanding of the skills and knowledge required to develop the skills of internal, three-dimensional visualisation of anatomical structures.

Knowledge gained will also help to prepare those interested in pursuing a career in surgery

44 | Surgeons’ News | March 2019

Understanding anatomy is key to good surgical practice

for the anatomical knowledge required for the MRSC. Students who attend these workshops will receive two years’ free affiliation, providing access to Acland Anatomy. For more information, contact outreach@ rcsed.ac.uk

SYMPOSIUM

RCSEd hosts student research meeting Undergraduates present laboratory-based research and clinical audits The College, in partnership with the Edinburgh School of Surgery, invited undergraduates and

foundation trainees to a Student and Foundation Research Symposium held at the RCSEd on Friday 7 December.

The meeting was a studentand foundation-led symposium involving a number of short presentations. The event provided an opportunity to present work undertaken during undergraduate and foundation training, including laboratory-based research projects and clinical audits.

Lectures on training and research were given by speakers including Trainees’ Committee Member Peter Vaughan-Shaw, Mr Alistair Geraghty, Mr Tom Drake and Professor Stephen Wigmore.

Students and foundation trainees

came from Birmingham and Manchester and as far away as Madrid.

Best oral presentation was awarded to Khadija Khamdan from the University of Manchester for her research on ‘Lymph node yield in oesophageal cancer resection and its impact on survival – the Salford experience’.

Second place went to Ben Fox from the University of Edinburgh, with ‘The accuracy of computed tomography evaluation for union of the clavicle’. Best poster presentation went to Shivali Dawda, also from Edinburgh University, for ‘Patient-specific simulation of pneumoperitoneum for laparoscopic surgical planning’.

REGIONAL SURGICAL ADVISERS IN YOUR AREA

7

10

The College’s support and advice network throughout the country

14 13 11

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

12

1

26 42

27

43 9 38

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

24 25

22 23

41

8

34

2

15

17

16

36

40

SCOTLAND

6 28 3

39 29

30

WEST OF SCOTLAND 11 Simon Gibson, Queen Elizabeth University Hospital, Glasgow

ENGLAND

5

33 35

NORTH OF SCOTLAND 7 Morag Hogg, Raigmore Hospital, Inverness 10 Lynn Stevenson, Aberdeen Royal Infirmary, Aberdeen

EAST OF SCOTLAND 14 Musheer Hussain, Ninewells Hospital, Dundee

4

21

Military RSA 8 Lt Colonel Alistair Mountain, Royal Stoke University Hospital, Stoke on Trent, 9 Surgeon Commander Adam Stannard, James Cook University Hospital, Middlesbrough

SOUTH EAST OF SCOTLAND 12 Farhat Din, Western General Hospital, Edinburgh 13 Robyn Webber, Victoria Hospital, Kirkcaldy

37

20 19 32 31 18

OXFORD 28 Giles Bond-Smith, Oxford University Hospitals NHS Trust SOUTH WEST PENINSULA 29 Jamshed Shabbir, University Hospital Bristol, Bristol 30 Neil Smart, Royal Devon & Exeter Foundation Trust, Exeter

EAST OF ENGLAND 15 Stuart Irving, Norfolk and Norwich University Hospital, Norwich 16 Roshan Lal, James Paget University Hospital, Great Yarmouth

WESSEX 31 Hunter Mclean, Queen Alexandra Hospital, Southampton 32 Arjun Takhar, University Hospital of Southampton NHS Trust

EAST MIDLANDS 17 Sridhar Rathinam, Glenfield Hospital, Leicester

WEST MIDLANDS 33 Ishan Bhoora, Cannock Chase Hospital, Staffordshire 34 Pradeep Kumar, Queens Hospital, Staffordshire 35 Ramanan Vadivelu, Royal Wolverhampton Hospital NHS Trust 36 Giles Pattison, University Hospital of Coventry and Warwickshire, Coventry

KENT, SURREY & SUSSEX 18 Mike Williams, Eastbourne District General Hospital, Eastbourne LONDON 19 Cynthia-Michelle Borg, University Hospital Lewisham 20 Ziali Sivardeen, Homerton University Hospital MERSEY 21 Janardhan Rao, Countess of Chester Hospital, Chester 22 John Taylor, University Hospital Aintree, Liverpool 23 Ravi Pydisetty, St Helen’s & Knowsley Teaching Hospitals NHS Trust NORTH WESTERN 24 Mike Woodruff, Royal Preston Hospital, Preston 25 Richard Graham, North Manchester General Hospital NORTHERN 26 Paul Gallagher, Wansbeck Hospital, Northumberland 9 Barney Green, James Cook University Hospital, Middlesbrough 27 Steven Powel, Freeman Hospital, Newcastle 9 Peng Wong, James Cook University Hospital, Middlesbrough

YORKSHIRE & HUMBER 37 David O’Regan, Leeds General Infirmary, Leeds 38 Mark Peter, Scarborough General Hospital, Scarborough

WALES

39 Sanjeev Agarwal, University Hospital Wales, Cardiff 40 Raymond Delicata, Nevill Hall Hospital, Abergavenny 41 Vaikuntam Srinivasan, Glan Clywd Hospital, Rhyl

NORTHERN IRELAND 42 Catherine Scally, Antrim Hospital 43 Colin Weir, Craigavon Area Hospital

RSA VACANCIES

Aberdeen, Birmingham, Bradford, East Midlands, Kent, Surrey & Sussex, London, North Western, Peterborough, Plymouth, Portsmouth, Severn, and West of Scotland

rcsed.ac.uk | 45

TRAINEES AND STUDENTS

The landscape of ASiT assesses the evolution of trauma care in the UK and Republic of Ireland

D

eath from trauma remains one of the major causes of mortality in the early decades of life.1 Uncontrolled haemorrhage is the leading cause of preventable death in the trauma setting and is a significant burden on healthcare internationally.2 Worldwide in 2016, there were 1,399,255 road traffic collision (RTC) deaths and 658,733 fatalities due to interpersonal violence.3 In the UK in 2016, the NHS treated 70,212 patients involved in RTCs, resulting in 1,805 deaths; and 75,471 patients presented to hospital because of interpersonal violence, with 860 deaths.4 The landscape of trauma care and trauma surgery has evolved significantly over the past decade.

Trauma care in the UK has changed dramatically since the publication of the National Confidential Enquiry into Patient Outcomes and Death report entitled Trauma: Who Cares?5 This report was undertaken to raise public awareness of the deficiencies in trauma care within the UK compared with the rest of the world.

The result was the establishment of a network-based major trauma system with 27 major trauma centres (MTCs) and numerous regional trauma units in a hub-and-spoke model. This process began in 2012 and has saved an estimated extra 1,600 lives.6 In the Republic of Ireland, the delivery and structure of trauma services is highly topical and under review and reconfiguration nationally.

Current delivery of trauma care is in an ad hoc and fragmented fashion.

At present, 26 centres provide trauma care and all of the relevant subspecialties are only available on site in one centre.7 The report 46 | Surgeonsâ&#x20AC;&#x2122; News | March 2019

As reconfiguration and trauma care advances, the approach to training also requires attention

Above: Increased use of air ambulances requires new training in transfer methods

from the National Trauma Steering Group, A Trauma System for Ireland, has outlined plans for a well-planned, coordinated trauma system consisting of two regional hub-and-spoke Trauma Networks, each with a designated MTC in Dublin and Cork.

The Trauma Steering Group report acknowledges the need for enhanced education and training in trauma and calls for the Health Service Executive to establish a formal trauma training committee and a dedicated lead for trauma education. The Royal College of Surgeons of Ireland, which delivers training to the relevant specialties, has welcomed the report.8 As reconfiguration and overall trauma care advances, the approach to training in trauma care provision also requires attention. With the development of new, structured services, novel technologies

and transfer methods (e.g. establishment of an air ambulance network), training in major trauma management must evolve. New-age major trauma surgeons must be able to manage the most complex of patients, including those requiring resuscitative endovascular balloon occlusion of the aorta and those needing activation of massive transfusion protocols based on realtime viscoelastic measurements, all in addition to performing surgical procedures. They must also be skilled in the complex human factors required to lead and integrate the care provided by a multitude of specialties in the time-sensitive, high-pressure emergency department environment and operating theatre.

Many trainees undertake highquality Fellowships within the UK and internationally. Until recently, there was a lack of a nationally recognised, General Medical Council (GMC) approved, designated training scheme for trainees wishing to be trauma surgeons. This prompted the development and introduction of the Training Interface Group

trauma training Adrianna Lincoln

(TiG) trauma Fellowship. From project conception, the Association of Surgeons in Training (ASiT) participated in and provided a valuable trainee perspective on the processes of curriculum development, GMC approval, hospital selection and appointment of the first TiG Fellows.

TiGs fall into two pathways: resuscitative surgeon and major trauma leader. The posts are advertised nationally and are open to post-exam, pre-certificate of completion of training trainees across the country. Potential Fellows can have a background in emergency medicine, anaesthesia, maxillofacial surgery, plastic surgery, orthopaedics, general surgery or vascular surgery.

The resuscitative surgeon TiG is appropriate for the latter two specialties, while the major trauma leader is open to all. The benefit

Above: A trauma trainee practises inserting a resuscitative endovascular balloon occlusion of the aorta catheter Above right: Surgeons perform surgery on a simulated casualty

of the TiG is to learn the technical skills to save lives while providing leadership of the patient from the trauma room to the rehabilitation ward. The TiG Fellowship could become an attractive model for those wishing to train as trauma surgeons in the UK. The ASiT International Surgical Conference in Belfast on 22–24 March 2019 will host a new preconference CRaSH Course (Centre for trauma Sciences, Resuscitation and Surgical Haemorrhage). This course aims to empower the delegates to be able to deal with the major trauma patient as if this is the first day in a job at a major trauma centre, then push them further to start to think about planning for a mass casualty incident – something that is often lacking in Trust induction or mandatory training for many.

References

A Thaventhiran, CA Fleming, HM Mohan, AP Williams, NR Walker, GL Humm and DM Nally, on behalf of ASiT

1. Pfeifer R, Tarkin IS, Rocos B, Pape HC. Patterns of mortality and causes of death in polytrauma patients: Has anything changed?

Injury 2009; 40(9): 907–911.

2. Cannon JW. Hemorrhagic Shock. N Engl J Med. 2018; 378(4): 370–379. Available from nejm.org/ doi/10.1056/NEJMra1705649 3. WHO. Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and by Region, 2000–2016. Geneva; 2018.

4. NHS Digital. Hospital Admitted Patient Care Activity,

The TiG trauma Fellowship is an exciting new initiative for UK trainees Prizes will be awarded for best abstracts in emergency or trauma surgery thanks to the East Midlands MTC. An exciting new event is running parallel to ASiT’s conference. The Hackathon is a multidisciplinary exercise on the theme of innovation in surgical practice. It is an opportunity for true collaboration between surgeons, scientists, engineers and others, and will bring together a diverse mix of knowledge and skills to develop questions and solutions. This innovative approach could yield really exciting results that could change clinical practice.

As trauma is a fast-evolving area of healthcare, it is important that training meets requirements and that the next generation of surgeons is inspired to pursue a career in trauma.

The TiG trauma Fellowship is an exciting new initiative for UK trainees. Similar structures may develop in the Republic of Ireland as reconfiguration of trauma services occurs.

ASiT will continue to embrace and support the delivery of high-quality trauma care and improved, focused training that will result in overall improved patient care and survival.

2016–17 [cited 19 July 2018].

Available from nhs.uk/dataand-information/publications/ statistical/hospital-admittedpatient-care-activity/2016-17 5. NCEPOD. Trauma: Who Cares?

London; 2007.

6. NHS England. More than 1,600 extra trauma victims alive today says major new study. [cited 22 October 2018]. Available from england.nhs.uk/2018/08/ more-than-1600-extra-traumavictims-alive-today-says-majornew-study

7. National Trauma Steering Group. A Trauma System for Ireland. [cited 22 October 2018].

Available from health.gov.ie/wpcontent/uploads/2018/02/Reportof-the-Trauma-Steering-Group-ATrauma-System-for-Ireland.pdf 8. Balasubramanian I, Mohan HM, Whelan RJ, McDermott F, Winter DC. Restructuring an evolving Irish trauma system: What can we learn from Europe and Australia?

Surgeon 2016; 14(1): 44–51. doi: 10.1016/j.surge.2015.08.002.

rcsed.ac.uk | 47

TRAINEES AND STUDENTS

A world of data Stephen Knight and Ewen Harrison

discuss the importance of technology in delivering international research

S

urgery offers the best chance of cure for most solid tumours amendable to resection, yet it is estimated that fewer than 25% of patients with cancer have access to safe, affordable and timely surgery.

The success or otherwise of surgery for cancer in global settings is largely unknown. Best-guess data on surgical outcomes can be simulated from computer models, but robust, uniformly collected data are often unavailable. However, the revolution in mobile technology is proceeding incredibly rapidly, particularly in low-income countries.

It is estimated that upwards of 80% of adults own a mobile phone in Ghana, Kenya and Nigeria, compared with 93% in the UK. This presents a fantastic opportunity to collect data in healthcare, both for local audit purposes and to contribute to international studies in surgery.

GlobalSurg 3 is the first international, multicentre, prospective study to assess quality and outcomes in patients undergoing surgery for three of the most common cancers (breast, gastric and colorectal). This is challenging, particularly in lowresource countries. In order to deliver this, we have developed a number of technology and communication platforms to provide collaborators with a simple and easy method to collect patient data.

The GlobalSurg Collaboration is a wide group of practising surgeons around the world aiming to perform research in surgery

Any surgical unit providing emergency or elective surgery for breast, gastric or colorectal cancer worldwide is eligible 48 | Surgeonsâ&#x20AC;&#x2122; News | March 2019

to foster local, national and international regional networks. Including more than 7,500 practising surgeons, the collaborative methodology adopted by the group has already delivered two large, high-quality studies involving 26,000 patients undergoing elective and emergency abdominal surgery. This has now been supported by the National Institute for Health Research in a consortium between the universities of Birmingham, Edinburgh and Warwick, together with international partners.

Any surgical unit providing emergency or elective surgery for breast, gastric or colorectal cancer worldwide is eligible to participate,

with consecutive patients recruited over a minimum data-collection period of four weeks. Data points relating to patient characteristics, cancer staging, operative treatment and 30-day outcomes were collected.

This methodology has been designed to avoid overburdening low-resource centres that may otherwise be unable to participate in such projects. To ensure data

Smartphones can be used to enter data in a secure manner without the requirement for a data connection quality, a detailed protocol has been produced and published online, together with translations into 12 common languages.

The Research Electronic Data Capture system is a secure, online data-collection tool that provides a user-friendly method of entering patient data points.

The interface can be designed to make specific fields visible only if certain conditions are met, such as the selection of breast cancer and postoperative seroma, so that a streamlined interface can be developed. Smartphones can be used to enter data directly in a secure manner without the requirement for a data connection at the time. We have tested this method and found it to be efficient, particularly in lowincome settings, reducing data-entry time while remaining secure.

In addition, pre-specified dataquality rules can be coded within the system, providing real-time warnings to collaborators when entering their data.

This enables the identification of potential outlier responses for specific patient records and encourages immediate checking of data quality by the local collaborator at time of entry.

For example, an on-screen alert prompting review will appear if a patient has been entered as undergoing a Hartmannâ&#x20AC;&#x2122;s procedure, but an end colostomy has not been selected in the appropriate field. Regular checks of data quality and patient records are performed centrally, with local collaborators contacted via email to review specific data points where required.

Real-time analysis of the data is always available at data.globalsurg. org/numbers, and gives national leads and local collaborators access to clear visualisations of current country registration, patient recruitment and data completion.

To date, this has allowed nearly 3,000 collaborators across more than 75 countries to monitor progress and collate data on over 9,000 patients.

To allow for secure and efficient data analysis, we pull data directly into an open-source development environment for R, a programming language for statistical computing and graphics. Data analysis is performed on the server through a web browser in a secure manner, meaning data will never be on a personal computer or USB stick, greatly reducing the risk of data compromise. The handling and organisation of data from over 9,000 patients, each with more than 80 individual variables, requires highperformance statistical software, for which R is renowned within the data-science community.

Following data cleaning and analysis, online applications can be built to allow data visualisation at a country-wide level, enabling global comparisons of outcomes and realtime interaction with large volumes of patient data. This has been used successfully for GlobalSurg 2, which examined the incidence of surgical-

Stephen Knight NIHR Clinical Research Fellow and General Surgery Registrar

Ewen Harrison Senior Lecturer in Surgery and Consultant Transplant/ HPB Surgeon

site infection following abdominal surgery, and can be found at ssi.globalsurg.org.

At our upcoming annual researchprioritisation workshop in Kigali, Rwanda, our data manager, Dr Riinu Ots, has created a similar online application to perform initial exploration of the GlobalSurg 3 data with input from our global partners. This aims to encourage collaborative discussion, focus on specific comparison between individual variables within the dataset, and identify potential avenues for further exploration and novel publications.

Our use of technology demonstrates the ability to collaborate globally and crowdsource large volumes of highquality patient data, particularly within low-resource settings. A strong community has formed around this and is setting about answering clinically important research questions. We are now expanding the application of technology, with a focus on machine learning, wearable devices and mobile technology to predict surgical outcomes worldwide. rcsed.ac.uk | 49

FEBRUARY 22 Future Surgeons Key Skills 22 One Day Membership in Orthodontics Process Course

11 NOTSS (Great Yarmouth) 13–15 Trans-anal Microscopic Surgery

29 RCSEd 18th Annual Audit & QI Symposium

6–7 The Edinburgh MRCS OSCE Preparation Course

29–30 Basic Surgical Skills (Wirral)

13 Surgical Anatomy for Perioperative Practitioners

23 Future Surgeons Key Skills (Aberdeen)

20 Simulation Based Education for Surgeons (SBES)/IST Trainers Update

30 Surgical Anatomy of the Limbs: A Study Day (MRCS Level – Wade)

23 One Day Membership in Orthodontics Process Course

21–22 Basic Surgical Skills (Birmingham)

25–27 Edinburgh Hand Course

21–22 International Conference on Surgical Education and Training (ICOSET)

30–31 The Edinburgh MRCS OSCE Preparation Course (Manchester)

28 Informed Consent: Sharing the Decision (ICONS) (Birmingham) 28–1 March Basic Surgical Skills MARCH 2 23rd Annual Conference for Dental Care Professionals 2 Surgical Anatomy of the Trunk: A Study Day (MRCS Level – Wade) 4 Thyroid and Parathyroid Masterclass (Birmingham) 7–8 Training the Trainers: Trainer Development Course (Birmingham)

23–24 The Edinburgh MRCS OSCE Preparation Course (Chennai) 28–29 The Edinburgh MRCS OSCE Preparation Course (Sri Lanka) 28–29 Complete Ear Surgery 28–29 The Edinburgh MRCS OSCE Preparation Course (Kuching) 29 NOTSS (Leeds) 29 NOTSS (Newcastle)

APRIL 1–2 Basic Surgical Skills 3 Preparation in Implant Dentistry 3–4 Definitive Surgical Trauma Skills (DSTS) 4–5 Training the Trainers: Trainer Development Course 5 Plastering Techniques for Fracture Treatment 6 Future Surgeons Key Skills (Manchester) 7 Future Surgeons Key Skills (Manchester)

13–14 The Edinburgh MRCS Preparation Course (Cardiff) 26 NOTSS (Leeds) MAY 1–3 Core Skills in Orthopaedic Surgery 3 NOTSS 11–12 Basic Surgical Skills (Isle of Man) 13–14 Basic Surgical Skills 13–14 Edinburgh Hands-on Balance Course 15–17 Advanced Trauma Life Support 22 Basic Skills in Paediatric Surgery 28–30 4th Surgical Approaches to the Spine

DENTAL

Fraser McDonald and Honorary Clinical Senior Lecturer at the University of Glasgow Toby Gillgrass share their views on clinical assessment

A window on best practice

T

here are significant changes afoot in the way we approach clinical assessment. The view is that how we have assessed, how we are currently assessing and how we will assess in the future are very different, and the process is continually evolving. The prime objective of the College in establishing robust assessment processes is to protect the public/patients by ensuring a minimal standard of competency that will help support clinical care delivery.

Within this best-practice ethos – and to develop examinations that are contemporaneous, modern and appropriate – behind-the-scenes support needs to include elements such as building infrastructure and information technology.

As part of these principles, there is a continuing requirement to review evidence to ensure we remain at the forefront of care provision (any aspiring designer or examiner is highly recommended to attend the International Advanced Assessment Course held annually in London – visit www.hpac.sg/iaac.html for more information).

For more than a decade, the College has had a link with the Royal Australasian College of Dental Surgeons. In that time, there has been a significant number of successful candidates (more than 100) of the conjoint assessment.

The conjoint examination, MOrth/MRACDS(Orth), is held twice a year – in May in Edinburgh and in November at the University of Adelaide, which has a newly opened and functioning assessment facility.

The university’s assessment facility features multifunction

Within this best-practice ethos behind-the-scenes support needs to include elements such as building infrastructure and information technology rooms that can be used for all levels of assessment, such as the Membership of Orthodontics.

It also includes a ‘communication station’ from where examiners in a soundproofed room can unobtrusively observe candidates during their specialist assessment as they interact with a volunteer actor on the other side of a one-way mirror.

Candidates have no idea that their practice is being scrutinised and the rooms clearly provide a very conducive environment to assess at specialist level.

The department at the University of Adelaide represents one example of best practice – one that is clearly an aspiration for all organisations involved in assessment.

Professor Fraser McDonald Dean, Faculty of Dental Surgery Dr Toby Gillgrass Honorary Clinical Senior Lecturer, University of Glasgow Dental School

51

Dental

News from the dental faculties

Derek, Lauren and Leonard Maguire

MEMBERSHIP

FDT’s reach extends to 16 countries The Faculty of Dental Trainers enjoys inclusive membership

The Faculty of Dental Trainers (FDT) continues to grow, with membership from 16 countries.

Applications for Fellowship and Membership from dental nurses, dental therapists, armed services, NHS and private primary care dentists, and dentists working in universities and hospitals have been successful, making the Faculty truly inclusive of the dental team.

Three members of one family from Northern Ireland joined the Faculty. Derek Maguire, his

52 | Surgeons’ News | March 2019

son, Leonard, and daughterin-law, Lauren, were awarded their memberships at a College ceremony on 31 August 2018.

Guidance on how to join is on the website to assist DCPs and dentists. All enquiries are welcome at fdt.rcsed.ac.uk APPOINTMENT

Faculty of Dental Surgery elects Vice-Dean

Helen Craddock sets out plans for her role

Helen Craddock has been elected as the new Dental ViceDean. Commenting on her

appointment, she said: “I am deeply honoured to have been elected to the role of Dental Vice-Dean. From what has been a varied and exciting career in clinical academia, dental education and general dental practice, I hope to bring elements from my experience to support the Faculty of Dental Surgery in its aspirations.

“My background gives me insight that I intend to use to support the Faculty’s aim to support all members of the dental team in developing their full potential for the benefit of patients. To this end, I intend to expand and diversify our network of Regional and International Dental Advisers to include

members of the dental team from all areas of dental practice.

I believe the Faculty of Dental Surgery should be leading the profession by providing highquality, accredited training and assessment.”

RECRUITMENT

College calls for dental examiners Convener of Dental Examinations Ian Corbett explains the role

The College is recruiting for a variety of dental examiners.

These roles offer a range of experiences and travel opportunities. Ian Corbett, Convener of Dental Examinations

Elections for Members of the Dental Council (pictured above), explained: “Having been an examiner, question bank manager, Specialist Advisory Board Chair and completed my first year as Convenor of Dental Examinations, I can tell you how rewarding an association with College examinations can be.

“Over the last year, the Dental Faculty held more than 100 examination diets in 18 different countries. From small, specialist examinations to large cohort memberships, all examinations are organised by a hard-working team of College administrators and run with anything from a single assessor to a large team of examiners.

“On appointment as an examiner, the College provides examiner training and then updates training every three years. Before examining for the first time, an examiner will attend a diet of an examination as an observer to take the opportunity to familiarise themselves with the examination process.

“Once on an examinations panel, an examiner may be invited to take part in one or more diets per year depending on availability.

“Examining can be very rewarding and at times entertaining. In addition, it offers the opportunity to travel.

“Examiners are required to provide questions, communication and clinical scenarios. The College has an extensive education department that provides support and advice on question development, and boards frequently run team question writing days. Providing questions is a requirement of

Elections to appoint three new Members of Dental Council (Dental Fellows) and the single Members’ Representative (Dental Member) will take place in June 2019. In advance of this, formal calls for nominations will be issued in March, with ballot papers expected to be issued in June. Following consideration and approval by the Dental Council in December 2018, the

the role, sharing the burden and providing fresh ideas, and it’s rewarding to see your questions appearing in an examination.

“Becoming an examiner for the College is a great way to get involved, be part of a different team, and help to promote development in our profession.”

For more information, visit the Professional Appointments section of the College website (rcsed.ac.uk).

2019 election process will predominantly be carried out online. Only the small number of Faculty Members for whom the College does not hold a valid email address will be issued with hard-copy nomination forms and ballot papers.

For more information, please email dental@rcsed.ac.uk

STANDARDS

Standards for Dental Trainers available on Faculty website FDT also sets out DeNTS taxonomy assessment tool

The FDT has completed its Standards for Dental Trainers, which are available on the Faculty website at fdt.rcsed. ac.uk. The standards include frameworks on environment,

facilitating learning, assessment, supporting and monitoring progress, professional development and professionalisation of the trainer’s role.

Meanwhile, developing the DeNTS taxonomy for assessing non-technical skills for dentists was the subject of the Second Annual Meeting of the FDT on 20 September 2018 and work on this assessment tool is continuing.

rcsed.ac.uk | 53

DENTAL

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

NORTH EAST OF SCOTLAND 1 Martin Donachie, Aberdeen Royal Infirmary

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 | March 2019

RDA VACANCIES

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

5

COLLEGE INFORMATION

DIPLOMA CEREMONIES

Congratulations to all our new Fellows and Members who were presented with diplomas in Edinburgh and Khartoum FRIDAY 5 OCTOBER 2018 EDINBURGH Admission to Fellowship Ad Hominem Dr Catherine J Calderwood, FRCOG, FRCPEd, FRCPGlasg, Chief Medical Officer for Scotland Professor Robert S D Higgins, MSHA, FACS, the William Stewart Halsted Professor, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, US Professor Maximo H Simbulan Jr, FACS, Jose Rizal School of Medicine, Xavier University, Chairman Emeritus, Maria Reyna Xavier University Hospital, Philippines Award of Fellowship Without Examination Mr Dimitrios Damaskos, Consultant General Surgeon, Royal Infirmary of Edinburgh Professor Christopher Liu OBE, Consultant Ophthalmic Surgeon, Sussex Eye Hospital, Brighton Diplomas of Fellowship in the Specialty of General Surgery Danaradja Arumugam, Dr MGR Medical University, India Sudin Varghese Daniel, University of Kerala, India Amaran Krishnan, Newcastle University Khurram Siddique, University of the Punjab, Pakistan Fadlo Rami Shaban, University of Edinburgh Maddumage Don Sujith Indeewara Wijerathne, University of Colombo, Sri Lanka Diplomas of Fellowship in the Specialty of Ophthalmology Ahmed Mahmoud Ragab Mahmoud Hussien, Alexandria University, Egypt Diploma of Fellowship in the Specialty of Otolaryngology Tanya Sreeta Banerjee, University of Manchester

56 | Surgeons’ News | March 2019

Diploma of Fellowship in the Specialty of Paediatric Surgery Evelyn Ervine, Queen's University, Belfast Diplomas of Fellowship in the Specialty of Plastic Surgery Amer Hussain, Quaid-i-Azam University, Pakistan Waseemullah Khan, Bahauddin Zakariya University, Pakistan Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Ramesh Dalwai, Rajiv Gandhi University of Health Sciences, India Rohit Gangadharan, Pondicherry University, India Gary Michael Hannant, University of London Waleed Selmy Kheder Shahoda, Cairo University, Egypt Diploma of Fellowship in the Specialty of Urology Hazel Elizabeth Smith, University of Edinburgh Joint Surgical Colleges’ Diploma of Fellowship in Trauma and Orthopaedic Surgery Armughan Azhar, University of the Punjab, Pakistan Diploma of Membership in Ophthalmology Mohammad Hasan Bokhari, University of Health, Lahore, Pakistan Diplomas of Membership in Otolaryngology Daniel Jason Lin, University of Warwick Rasads Misirovs, Riga Stradins University, Latvia Wai Thet Phyo, Yangon University, Myanmar Intercollegiate Diplomas of Membership in Surgery in General Rajendiran Ashwin, Pondicherry University, India

Niladri Banerjee, West Bengal University of Health Sciences, India Shubhendu Chakraborty, University of Dhaka, Bangladesh Prashanth Krishna Gopalaswamy, Sri Ramachandra University, India Alok Gupta, Guru Gobind Singh Indraprastha University, India Katherine Victoria Hurst, Cardiff University Zahra Ibtasar, University of Health Sciences, Lahore, Pakistan Muhammad Waqas Ilyas, University of Health Sciences, Lahore, Pakistan Allan Johnston, University of Glasgow Pushkar Prafulla Joshi, Maharashtra University of Health Sciences, India Xiang Wei Jonathan Lee, University of Southampton Talal Majeed, King Edward Medical University, Pakistan William David Maynard, University of Birmingham James Kyalo Mbuvi, University of Nairobi, Kenya Ki Shing Victor Miu, University of Leicester Abdul Kareem Mohamed Naleem, University of Sri Jayewardenepura, Sri Lanka Naufal Rizwan Ahmed Rameezuddin Ahmed, Dr MGR Medical University, India Diploma in Mountain Medicine Bill Uttley, University of Edinburgh Diploma of Membership of the Faculty of Perioperative Care Jane Louise Herbert, Edge Hill University, Manchester Award of Fellowship in Dental Surgery (Without Examination –

By Application) Manar Khalil Alhajrasi, King Abdulaziz University, Saudi Arabia Diploma of Fellowship in Restorative Dentistry Jennifer Jalili, University of London

Diploma of Membership in Endodontics Ali Abduireda Abdulla Munwah, October 6 University, Egypt Diploma of Membership in Oral and Maxillofacial Surgery Omkar Anand Shetye, Goa University, India Saad Ahmed Khokhar, Baqai Medical University, Pakistan Diplomas of Membership in Orthodontics Nina Baizura Binti Abdul Aziz, University of Malaya, Malaysia Sukhi Kaur Atwal, University of Manchester Ahmed Tarek Farouk Ahmed Soliman Aboshousha, October 6 University, Egypt

Julia Therese Mangan, National University of Ireland Lisa Wong, University of Sydney, Australia Diplomas of Membership in Primary Dental Care Edward Alexander Coakley, University of Dundee Michael John Pawley, University of Manchester Diploma of Membership in Prosthodontics Paul Gerard Grimshaw, University of Sheffield Diplomas of Membership of the Faculty of Dental Surgery James Alexander Ogden Fitton, University of Leeds

Mohammad Ghafraan Hussain, University of London Hannan Naseer Imran, Newcastle University Abeera Imran, University of Manchester Nimesh Devshi Karsondas, University of Manchester Nakul Hitesh Rajani, University of Manchester Zara Rehman, Prague University, Czech Republic Chandni Shah, University of Sheffield Amruta Rajesh Sheth, Rajiv Gandhi University of Health Sciences, India Kenneth James Speirs Strain, University of Aberdeen Diplomas of Membership of the Faculty of Dental Trainers Tze Bill Ip, University of Liverpool

Charles Nicholas Turner, University of Dundee Diploma in Orthodontic Therapy Shonagh Marie Maxwell Robertson, Edinburgh Dental Institute FRIDAY 9 NOVEMBER 2018 EDINBURGH Admission to Fellowship Ad Hominem Professor Donald E Low, FRCSC, FACS, FRCSI (Hon), FRCSEng (Hon), Head of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, US Professor Manuel Pera, Professor of Surgery, Autonoma University of Barcelona;Head, Section of Gastrointestinal Surgery, Hospital Universitario del Mar, Barcelona

The Hunter Doig Medal Ms Alice Hartley, Urology Trainee, Chair of RCSEd campaign to tackle undermining and bullying in surgery Award of Fellowship Without Examination Mr Miller Hayden Smith, FRCD, FACS, Clinical Assistant Professor, Departmenet of Surgery, Cumming School of Medicine, University of Calgary, South Calgary Oral Maxillofacial Surgery, Canada Award of Fellowship in Dental Surgery Without Examination Dr Vinay V Kumar, MDS, DMD, Department of Oral and Maxillofacial Surgery, Uppsala University Academic Hospital, Uppsala, Sweden

rcsed.ac.uk | 57

COLLEGE INFORMATION

Dr Y Naresh Shetty FDS RCSEng, Programme Director, Postgraduate Diploma in Implant Dentistry, Head of Division, Oral Diagnostic & Surgical Sciences, School of Dentistry, International Medical University, Malaysia Diplomas of Fellowship in the Specialty of General Surgery Emma Georgina Evelyn MacInnes, University of Aberdeen Maziar Navidi, University of Warwick Diploma of Fellowship in the Specialty of Otolaryngology Daniela Bondin, University of Malta Diploma of Fellowship in the Specialty of Neurosurgery Jonathan Victor Poots, Queen’s University, Belfast Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Syed Kashif Abbas, University of Health Sciences, Lahore, Pakistan Muhammad Adeel Akhtar, University of the Punjab, Pakistan Hemanta Das, University of Calcutta, India Thomas John Atthill Hunter, University of Manchester Scott David Middleton, University of Edinburgh Shanaka Ravindra Senevirathna, Kathmandu University School of Medical Sciences, Nepal Joint Surgical Colleges’ Diploma of Fellowship in Trauma and Orthopaedic Surgery Ayman Mohamed Khair Elamin Babiker, University of Gezira, Sudan Intercollegiate Diplomas of Membership in Surgery in General Fahd A Alsaleh, University of Dublin Nadzirah Hairul Anwar, Universiti Kebangsaan, Malaysia Myat Aung, Yangon University, Myanmar Sandhya Chalasani, National University of Ireland Shashanka Dhanuka, University of Madras, Chennai, India Nameer Faiz, Patna University, India Adam Daniel Gerrard, University of Liverpool Eilidh Georgia Merle Gunn, University of Dundee Erin Jayne Hankin, University of Glasgow Saqiba Jadoon, University of London Bethan Elizabeth John, Cardiff University

58 | Surgeons’ News | March 2019

Andrew Christopher KennedyDalby, University of Manchester Benjamin Paul Kent, Plymouth University Shantata Jayant Kudchadkar, Goa University, India Susan Mabel Karen McCrossan, University of Dundee Rajeev Menon, Calicut University, India Amol Mittal, University of Mumbai, India James Olivier, University of Nottingham Rebecca Sarah Stoner, University of Aberdeen Valerie Huali Tan, National University of Singapore Diplomas of Membership of the Faculty of Surgical Trainers Michael David Kipling, University of London Maziar Navidi, University of Warwick Diploma in Immediate Medical Care Laura Skyrme, University of Edinburgh The McCormack Medal (2017) Udo D Abah, University of Leeds The Dundas Medal (2018) The Freeman Hospital Specialist Palliative Care and Cardiopulmonary Transplant Team The Syme Medal (2017) Iain James Nixon, University of Glasgow Award of Fellowship in Dental Surgery (Without Examination –

By Application) Irwan Soo, National University of Malaysia Diploma of Membership in Endodontics Bushra Mateen, University of Health Sciences, Lahore, Pakistan Diploma of Tri-Collegiate Membership in Oral Surgery Rachel Anne Green, University of Dundee Diplomas of Membership in Oral and Maxillofacial Surgery Samir Chugh, Kurukshetra University, India Bobby John, Calicut University, India Latha P Rao, University of Kerala, India

Diplomas of Membership in Orthodontics Nehal Mohieeldin Mohamed Amer, Cairo University, Egypt Noha Ali Mamdouh El-Ashmawi, Cairo University, Egypt Miltiadis Makrygiannakis, The National and Kapodistrian University of Athens, Greece Shehabeddin Khaled Siala, Misr University for Science and Technology, Egypt Diplomas of Membership of the Faculty of Dental Surgery Marwa Ahmed Albasheer Abdalgaffar, University of Khartoum, Sudan Ahmed Abdulelah Hameed Al Hajyat, Pharos University, Alexandria, Egypt Zainab Faisal, Hamdard University, Pakistan Mahera Hasan, Riphah International University, Pakistan Kate Amy Jefferson, University of Dundee Saarah Nisa Juman, University of the West Indies Shahida Maqbool, University of the Punjab, Pakistan Tajinder Ropra, University of Bristol Muhammad Tariq Shahzad, University of Health Sciences Lahore, Pakistan Maria Tanveer, University of Health Sciences, Lahore, Pakistan Fatima Waqar, Khyber Medical University, Pakistan Gemma Wilson, University of Manchester SATURDAY 24 NOVEMBER 2018, KHARTOUM, SUDAN Intercollegiate Diplomas of Membership in Surgery in General Abdulgadir Elsunny Hamad Elnil Ahmed, the University of Kordofan Tasabeeh Badr Aldeen Ahmed Abdalazeez, Al Neelain University Shahed Abbas Abushama Abdelmahmoud, National Ribat University Azza Hassan Eltegani Abdelrahman, Ahfad University for Women Ahmed Hamed El Tahir Ahmed, Al Fashir University Tarig Hassan Elobid Ahmed, University of Khartoum Rowaa Mohamed Ahmed Hamid Mohamed Ahmed, Omdurman Islamic University Sara Kamal Abdelrahman Ali, University of Khartoum

Samahir Abdel Monaim Mohammed Ali, University of Gezira Lina Abd El Moneim Mohammed Ali, University of Khartoum Moaz Mohammed Ahmed Babiker, University of Bahr elGhazal Mohamed Osman Suliman Basher, Al Neelain University Eiman Ahmed Elsadig Diab, the University of Kordofan Alsarah Mutwakil Abbas Diab, Omdurman Islamic University Baligh Mohammed Salih Kubashi Elsaid, Nile Valley University Rodaina Ibrahim Ahmed Fadlelseed, Elrazi College of Medical & Technological Sciences Hala Salah Elsadig Elshiekh Giha, University of Khartoum Omer Ibrahim Ali Ibrahim, University of Khartoum Israa Hassan Abdalla Mohamed Kheir, University of Khartoum Nagla Mustafa Ibnouf Mohamed, Al Neelain University Mohamed Ali Babiker Mohamed, University of Khartoum Alaeldin Mohamed Tageldin Mohamed, El-Imam El-Mahdi University Moawia Mohamed Ibrahim Mohamed, University of Khartoum Mohammed Abbas Babiker Mohammed, University of Khartoum Samah Izzeliin Abdelmotaleb Mukhtar, University of Khartoum Ameera Yousif Khalid Omer, University of Khartoum Mohamed Elamin Mohamed Osman, Al Neelain University Amro Hussien Fageer Mohammed Osman, El-Imam ElMahdi University Walid Salah Eldin Khalifa Sayed, University of Khartoum

IN MEMORY FELLOWS Rosemary Helen MacNaughton ADAM (FRCSEd 1952) Charles James Hume LOGAN (FRCSEd 1960) Donald McINTYRE (FRCSEd 1961) Robert PICKARD (FRCSEd (without examination) 2004) Manickam THIRUMAL (FRCSEd 1994)

All the latest grants, fellowships and bursaries from the RCSEd

AWARDS & GRANTS Undergraduate Student Bursaries

The College is offering a number of 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. Proposals for work on research projects in any branch of surgery are eligible for consideration.

For an application pack, including full terms and conditions, please contact Mrs Cathy McCartney, the College’s Research and Grants Coordinator.

Closing date for applications is Wednesday 20 March 2019.

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 at fst.rcsed.ac.uk/ grants.aspx Applications should be emailed or posted to Mrs Cathy McCartney, College Research and Grants Coordinator.

Closing date for applications is Wednesday 15 May 2019.

Faculty of Dental Surgery grants for education

The Faculty of Dental Surgery of the RCSEd supports educational endeavours for individuals who are Affiliates, Members and Fellows of the Dental Faculty and/or the Faculty of Dental Trainers. Grants (up to £3,000) will be available to defray expenses for those undertaking an appropriate educational qualification.

Closing date for applications is Wednesday 12 June 2019.

Small Research Grant (up to £10,000)

The College’s research strategy highlights the following areas of research as priorities for the College to support: Surgical/dental translational research Surgical/dental health services research

esearch into surgical/dental aspects R of patient safety, simulation and non-operative technical skills Cancer research of demonstrable direct clinical relevance to the management of solid tumours.

Applications are invited from surgical trainees and recently appointed consultants who are Fellows/Members of the College in good standing.

Grants are awarded for pumppriming projects for a period of one year only. Please note that requests for running costs to support established projects will be less favourably reviewed than those for pilot work that has the potential to facilitate applications for more substantial funding in the future.

Research project submissions should satisfy one or more of the College’s four priority areas for research, as listed above. The application should include a well-defined exit strategy (i.e. how the project will be taken forward).

Closing date for applications is Wednesday 12 June 2019.

King James IV Professorships

Applications are invited from practitioners of surgery or dental surgery rcsed.ac.uk | 59

COLLEGE INFORMATION

who have made a significant contribution to the clinical and/or scientific basis of surgery. The courtesy title of Professor will be accorded to the individuals for the duration of the College year in which their lectures are delivered. Applicants must be Fellows/Members of the College in good standing.

Closing date for applications is Wednesday 12 June 2019.

Travelling Fellowships

The Cutner Travelling Fellowship in Orthopaedics Sir James Fraser Travelling Fellowship in General Surgery Alban Barros D’Sa Memorial Travelling Fellowship in General Surgery

Closing date for applications is Wednesday 12 June 2019.

Syme Medal

Applications are invited for the Syme Medal, a prestigious mark of excellence awarded to a Fellow or Member of the College in good standing on the basis of a recently submitted thesis (MD or PhD), published body of research or educational development. The research should have been published in high-quality, peerreviewed journals. Consideration will be given to the impact of work on future research or clinical practice.

The Medal is to be awarded to surgeons in training or recently appointed consultants, and is distinct from the King James IV Professorship.

With their written application, candidates must submit a CV (no more than two pages), along with a discourse of up to 1,500 words (excluding references, prior publications and papers

in press) summarising their recent research or educational development.

The essay must refer to and contain findings emanating from the candidate’s own work. A list of any prior publications and papers currently in press should be included. The names of any supervisors and collaborative workers must be acknowledged, as well as the name of the institution(s) where the work was carried out.

Appointments to the Syme Medal are made on the understanding that those elected submit a manuscript for publication in the Journal of the Royal College of Surgeons of Edinburgh and Ireland. Depending on the nature of the work and the topic, the successful candidate may be invited to present a lecture at the College.

Closing date for applications is Wednesday 12 June 2019.

Dundas Medal

The medal is in commemoration of Dr Charles Robert (Bertie) Dundas FFARCS FRCP Glasgow. Dr Dundas was a senior lecturer in the Department of Surgery (Anaesthetics) in Aberdeen and honorary consultant anaesthetist from 1975 to 1995. He died in 2014 from biliary carcinoma. He was never offered palliative care while he was ill and spent his last months waiting for chemotherapy while enduring a poor quality of life. His widow, Dr Valerie Dundas, made a donation to Palliation and the Caring Hospital (PATCH) to improve the provision of palliative care in hospital.

In recognition of Dr Dundas’ lifelong enthusiasm for teaching, research and innovation, an annual award to recognise efforts to improve the provision of

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

60 | Surgeons’ News | March 2019

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

palliative care for patients when they are in hospital is fitting. The award is open to individuals or teams (medical, nursing or paramedical) working in any hospital in the UK. It is not essential that the applicant should be an FRCSEd. The term ‘hospital’ applies to both acute and community hospitals.

Closing date for applications is Wednesday 26 June 2019.

Wong Choon Hee Medical Student Elective Travel Bursaries

The RCSEd, in association with Meducatus (meducatus.com), is pleased to offer medical students the opportunity to apply for financial support for their elective in surgery.

This award is open to medical students in the UK and the Republic of Ireland who are undertaking approved surgical electives abroad.

This award will be advertised and given out annually in September. It provides a contribution to the overall costs of travel and subsistence. Travel must be undertaken after the award is made in September.

Closing date for applications is Wednesday 3 July 2019.

Joint RCSEd/SOMS/ Shanghai Head & Neck Fellowship 2019

Applications are invited from Members/ Fellows (MRCS/FRCS) of the RCSEd and the Scottish Oral and Maxillofacial Society for a four-to-six-week Fellowship in head and neck oncology in Shanghai at the Department of Cranio-Maxillofacial Science, School of Stomatology, Ninth People’s Hospital, Shanghai Jiao Tong University. The funding is up to £4,500 to cover costs.

The level of operative experience required to benefit most from the time is equivalent to a final-year post FRCS (Intercollegiate) trainee. Other applicants will be considered on merit, but this level should be seen as a benchmark.

Application is by letter and CV (no more than four pages), along with two references, which should be sent to Mrs Cathy McCartney at c.mccartney@ rcsed.ac.uk. Further information can be obtained from Mr Roger Currie at r.currie@rcsed.ac.uk Closing date for applications is Wednesday 10 July 2019.

CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS Sushruta Professorship in Plastic Surgery

Stefan Hofer, Professor of Surgery, University of Toronto.

Transforming lives.

Breast cancer reconstruction: how we changed a procedure into an academic practice and then changed the world around us.

Dundas Medal

Maria McKenna, Consultant in Palliative Medicine, and Professor Stephen Clark, Consultant Cardiac and Transplant Surgeon, Freeman Hospital, Newcastle University.

Pump Priming Grants

Jason Wong, Consultant Plastic Surgeon/Senior Lecturer, University of Manchester.

In vivo integration of 3D printed capillary networks.

Alexander Aarvold, Consultant and Honorary Associate Professor, Paediatric Orthopaedic Surgery, University Hospitals Southampton.

Sulfur biology in skeletal development: an explorative study in developmental dysplasia of the hip.

Dan Lin, NIHR Academic Clinical Fellow (ST2) in Otolaryngology.

A preliminary investigation of IDO immune status in head and neck cancer.

Richard Holliday, Specialist Registrar (StR) in Restorative Dentistry, Newcastle University.

Effects of vapourised nicotine products on oral health: in vitro studies on oral cells, biofilms and staining.

Janice Miller, Clinical Research Fellow, University of Edinburgh.

The role of the neuromuscular junction in cancer cachexia.

Rory Piper, NIHR Academic Clinical Fellow and Neurosurgical Trainee, University of Oxford.

Detecting meningioma invasion of the optic canal: a novel tractography pilot study.

Anne Ewing, ST4 Surgical Trainee, University of Edinburgh, Western General Hospital Campus.

Human intervention study of aspirin and metformin to modify lipogenicdriven colonic epithelium targets

and identifying the relationship with crypt stem cell signalling.

The King James IV Professorship

Parwez Hossain, Consultant Ophthalmologist, University of Southampton.

Preventing blindness by application of real-time healthcare technology.

Christopher Oliver, Senior Retired Fellow, Honorary Professor Physical Activity for Health Research Centre (PAHRC), University of Edinburgh.

Improving data visualisation, information and knowledge transfer for surgeons.

Adnan Saithna, Consultant Orthopaedic Surgeon, Southport and Ormskirk NHS Hospital Trust.

ACL reconstruction in contemporary practice â&#x20AC;&#x201C; how to achieve better outcomes.

The Syme Medal

Paul Monk, Orthopaedic Surgeon, Honorary Senior Lecturer, University of Oxford.

The patellofemoral joint: form and function.

Jay Nath, ST7 General Surgery, West Midlands Deanery.

The clinical benefits and metabolic mechanisms of hypothermic machine perfusion of kidneys prior to transplantation.

Michael Hart, Specialty Registrar, Neurosurgery, Cambridge.

Network-based neurosurgery.

Sir James Fraser Travelling Fellowship in General Surgery

Christopher Johnston, Clinical Lecturer in General Surgery, University of Edinburgh.

To observe the technical aspects of combined advanced endoscopy at the Department of Hepatobiliary Surgery, Monash Medical Centre, Australia.

The Alban Barros Dâ&#x20AC;&#x2122;Sa Memorial Travelling Fellowship in General Surgery Alexander Leeper, ST6 Upper GI Surgery, Royal Infirmary, Edinburgh.

To practise general surgery in an austere environment and participate in development of a sustainable surgical service at Gahini Hospital, Rwanda.

rcsed.ac.uk | 61

OUT OF HOURS

Amazing artistry Be it grand, Michelin-starred fine dining or charmingly rustic eateries, Graham Layer appreciates good food Graham Layer Immediate Past VicePresident, RCSEd

Le Manoir aux Quat’Saisons in Oxfordshire

A

culinary icon, Le Manoir aux Quat’Saisons near Oxford holds two Michelin stars; has its own magnificent vegetable and herb garden, hotel and empire; and has the charming Raymond Blanc at its head. Its food is outstanding both in presentation and bold flavours. We enjoyed canapés with our champagne – my favourite was a parmesan crouton associated with a cone of beef carpaccio – all made by schoolchildren under the eagle eye of Head Chef Gary Jones as part of an ‘Adopt a School’ charity event.

The first course was a precision-constructed beetroot terrine with a creamy horseradish sorbet, which was clever, unique and delicious. This was followed by white crab meat muscular fibres in lime, and flavoured with a tinge of coconut and chilli. Next up, a hen’s egg over a watercress puree decorated with Jabugo ham and toasted hazelnuts.

Each ingredient was balanced and easy to taste. The main course was stunning after a refreshing sorbet: a generous mass of meticulously cut beef fillet in a fabulous red wine and chicken stock reduction with accompanying vegetables and Jacob’s ladder alliums (a new one for me).

Dessert was a classic piece of French patisserie from Head Pastry Chef Benoit Blin: an extraordinary threedimensional jigsaw of an anatomically perfect block of gateau composed of chocolate and caramel, and served with Curcuma ice cream, which had a turmeric flavour. To end, a light selection of chocolates and petits fours. This feast was exceptional.

Another famous hotel restaurant, Amangalla in Galle, Sri Lanka, served me a memorable lunch on its colonial terrace. The restaurant offers fine dining at dinner time and a lighter lunch menu served either outside or in the wood-beamed hall. We enjoyed grilled prawns decorated with banana blossom and a good combination of pineapple chilli salad, a Caesar salad with smoked chicken and bacon (but sadly no anchovies) and plentiful calamari tossed with capers, courgettes and a variant of tartare sauce. Following these, sea bass with

62 | Surgeons’ News | March 2019

peppers and squashes. Sea bass is a difficult fish to serve successfully, as peppers can easily dominate the soft, white flesh. A crab tagliatelli in an oozing lemon butter sauce with black pepper was a great success, while gnocchi was straightforward gnocchi.

I have been to a number of surgical meetings in the west of Canada recently and been recommended Forage on Robson Street in Vancouver, a trendy, somewhat rustic restaurant and bar. Its interesting service schedule intimately combined my experiences of Cambodian chaos, the generosity of a Chinese meal and Spanish tapas.

Our server was very charismatic and the whole evening was huge fun, catalysed perhaps by an excess of champagne consumed prior to reaching the establishment.

Charcuterie with five cheeses, duck croquettes, bison steak, halibut, mushroom gnocchi and various other small plates appeared randomly at the table. Haywire chardonnay from the Okanagan Valley was in plentiful supply – the wine’s name reflected well on our postprandial psyche.

Vancouver is also home to Market in the Shangri-La Hotel, part of the Jean-Georges Vongerichten empire, where we enjoyed a breakfast of muesli, eggs Benedict with smoked salmon, and classic bacon and eggs. I was keen to return and order my favourite truffle and fontina pizza, but sadly there was no opportunity on this short visit.

Relais & Chateaux restaurant The Pointe, at the Wickaninnish Inn in Tofino, Vancouver Island, is excellent.

The seafood chowder was creamy and a fantastic stimulant to the palate, followed by an unusual but successful Caesar salad implanted with marvellous seared scallops. This was a wonderful meal in relaxed surroundings.

Doubtless, it is in competition with The Great Room at Long Beach Lodge nearby. Our dinner consisted of ubiquitous buffalo – that is, bison – as a tartare; and scallops with corn, which was really innovative. This was followed by a seafood risotto, which fortunately was not a thixotropic paste – a fate that often befalls this dish. A reliable duo of lamb was served, which was then swamped by a standard-fare chocolate dessert, which could have been one-quarter of the size (and served to two).

Going solo Bernard Ferrie picks up some Brexit beverages

In Calgary to the east: Rouge – a fine-dining establishment serving a mix of European and Canadian specialties in a historic 1891 corner house. After a champagne reception in the garden, we were served foie gras parfait and a duck confit of very high standard, among other interesting accoutrements. The house was packed out – it is clearly a notable venue in this Prairies city.

I usually write about Hong Kong, as it always brings surprises, and this time Michelin Guide-listed Chinese restaurant Celestial Court was disappointing and not up to its usual standards. This was perhaps justifiable due to the previous day’s super typhoon. Hotel restaurant The Café produced an outstanding grand international buffet to suit all tastes for all the guests and staff marooned in the hotel during the typhoon.

The Jockey Club restaurant at Sha Tin surpassed itself with outstanding Chinese dishes that were instantly recognisable and much enjoyed by Western diners, while inappropriately named Elite Dining – located on the 31st floor of the iSquare tower block in Kowloon – served us a banquet featuring whole squashed and roasted baby pigs which appeared to have met their fate under a steamroller!

Dinner in Hong Kong needs to be prefaced by champagne at Felix, a cool, contemporary bar on the top floor of the Peninsula Hotel.

Finally, in Edinburgh, I was pleasantly surprised by the value and the delicious brasserie-style food served at Ivy on the Square. The prawn cocktail contained large prawns, the salad Niçoise looked as if it had originated in Provence, and the smoked salmon and crab were generous, if not the best I have enjoyed. The tuna was a particular accomplishment and a generous chicken breast Milanese topped with fried egg was a massive success. An alcoholic rum baba and the classic chocolate bombe followed, where the pouring of a hot sauce caused a captivating implosion of the chocolate sphere surrounding the ice cream.

Cut beef fillet at Le Manoir Below: large dessert portions at The Great Room

A

re we nearly there yet? No more French leave, German measles, Dutch courage and especially Brussels sprouts and dull light bulbs. All UK sourced – sort of.

Two Kents: Biddenden Gribble Bridge Dornfelder 2016 (£11, Thind Sevenoaks), a light red. Serve this smooth, fruity wine with hard cheese, Monsieur Bibendum.

No English red wine in 1973. Brexit without bubbles?

Balfour Leslie’s Reserve (£26.99, Waitrose) is dry, bottlefermented citrus green apple with pink highlights.

Two whites – English White Lily 2016 (£10, M&S).

Earl Grey tea, Victoria sponge on the vicarage lawn?

Grapefruit and lime, fragrant and floral. Lovely wine.

Chapel Down Flint Dry 2016 (£13.99, Majestic) – green apple, citrus, grass, nectarine and elderflower.

Refreshing, like freedom.

Cider? Thatchers Gold – full-flavoured, medium dry Somerset refreshing sparkle (£1.99, various). Probably drunk at Agincourt.

Two ports. Always have a plan B – i.e. a backstop.

Taylor, Fladgate & Yeatman – very British – do Taylor’s Late Bottled Vintage Port 2009 (£15, various). Ripe, sweet deliciousness. Didn’t we start drinking port when we were not talking to the French? Allies since 1386.

The second is Churchill’s Reserve Porto (£6.50, 20cl Worths) to go with Stilton or rich fruit cake. Don’t decant or recant. Sadly no space for the Churchill cocktail… Gutted, though, about the Belgian buns

and Danish pastries.

rcsed.ac.uk | 63

FROM THE COLLECTIONS

Dissecting the Murder Act Louise Wilkie traces the history of anatomy teaching from the 16th century

A

s a means of increasing the knowledge of the newly formed Incorporation of Barber Surgeons in 1505, Edinburgh Town Council agreed to supply the surgeons with the body of one condemned man a year. Edinburgh, it seems, was ahead of its time – in 1752, the Murder Act made this process official policy for all those executed in Great Britain.

The Murder Act introduced the denial of a burial as an additional form of punishment to dissuade would-be criminals. Hanging in chains was an option, but the usual punishment was public dissection.

In 1702, David Myles was convicted and hanged for incest, and became the first criminal to be publicly dissected in Scotland. In 1697, the Town Council insisted that, as a condition of receiving additional corpses, the Incorporations of Surgeons build a public anatomy theatre to hold dissections. This they did, and Archibald Pitcairne oversaw a seven-day dissection of Myles by seven of the leading surgeons of the Incorporation, with Pitcairne conducting an epilogue on the eighth day. A reproduction of the theatre, dissection and epilogue can be seen in the museum.

It was clear by the 1700s that anatomy was the key to medical studies. It would be the son of John Monro, Deacon of the Incorporation of Surgeons 1712–1714, who would cement this in medical teaching. Alexander Monro became Professor of Anatomy at Edinburgh University in 1721 and three generations of Monros would hold this chair until 1846. The University of Edinburgh opened its medical school in 1726 and Edinburgh became a world-

Dissection of a Malefactor by Adriaen van der Groes c.1700.

Presumed to be Archibald Pitcairne undertaking the dissection

Right: The College Museums have recreated an anatomical dissection theatre and the dissection of David Myles Below: A pocket book made of Burke’s skin

Many of those hanged in and around Edinburgh were delivered to Monro for dissection 64 | Surgeons’ News | March 2019

renowned centre for anatomical teaching. The university greatly benefited from the Murder Act of 1752: 110 criminals were publicly dissected in Scotland between 1752 and 1832 and a significant proportion of those hanged in Edinburgh and its surrounding areas were delivered to Monro for dissection.

The most famous criminal to be dissected in Edinburgh has to be William Burke in 1829, perhaps a fitting punishment given that all his victims met the same fate. Burke and Hare murdered 16 people and sold their bodies for dissection.

Burke was hanged on 28 January 1829 and his body dissected by Monro tertius. Due to demand from the public, the crowd, in groups of 50, was allowed entry to view the body after it had been

dissected. Stories of souvenirs were rife and one such supposed souvenir lies within the College – a pocket book made of Burke’s skin with gold letters reading ‘Burke’s Skin Pocket Book’.

The Anatomy Act of 1832 put an end to grave robbing and murderous activities by allowing the legal dissection of any unclaimed corpse but at the same time ended dissection as a punishment to crime. It also ensured that anatomists were licensed and introduced Inspectors of Anatomy to ensure the regulation of human remains.

The Homicide Act 1957 ended the death penalty for all murder except capital murder, then the Murder Act 1965 abolished all capital punishment.

The Human Tissue Acts now ensures the regulation of human tissue and Scotland still maintains an Inspector of Anatomy to oversee all use of human remains, from anatomy theatres to surgical training and education, including public display in museums.

Louise Wilkie Assistant Curator, Surgeons’ Hall Museum