Since the January issue of the Annals, the following letters have been published on our website <http://www.rcseng.ac.uk/publications/eletters/>:
letter . 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
letter Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
We are disappointed to read the comments by Wraight regarding the role of surgical care practitioners (SCPs). His grievances are not reflected by the Papworth experience. At our institution there are four basic surgical training rotational SHOs and two specialist SHOs, supported by eight SCPs including two trainees. The SCPs participate fully in clinical team activities, assisting on ward rounds and chasing blood results in addition to operating responsibilities.
The philosophy of our SCPs is to aid in the training of junior surgeons rather than to compete with them. For the more junior SHO, the SCP has time to teach basic surgical skills during saphenous vein harvesting, offering valuable advice and feedback on technique. Furthermore, the SCP can free up the more experienced SHOs from leg duties, allowing them to venture up the table and participate in chest opening, mammary artery harvesting and cannulation for cardiopulmonary bypass. A recent study of all cardiac surgery SHOs in England showed that most found the presence of SCPs to be beneficial.1
SCPs have become an integral part of Papworth, fulfilling both service and training roles. Within a suitable regulatory framework,2 we believe SCPs can be of benefit to surgical trainees and enhance learning opportunities.
References
- 1.Shrivastava V. Surgical assistants affect SHO training in cardiac surgery. Ann R Coll Surg Engl (Suppl) 2004;86:238–241. [Google Scholar]
- 2.de Cossart L. SCPs – Healthcare-Lite, response. Ann R Coll Surg Engl (Suppl) 2005;87:326. [Google Scholar]
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
I am pleased that Papworth Hospital has developed an effective model for surgical care practitioners (SCPs) and I am sure others have done similarly. However, seeing the extent of the draft syllabus for SCPs1 and the sexing up by the Department of Health,2 I am not sure that everyone is coming at this from the same perspective.
Perhaps I should clarify my position. I have no objection to and, indeed, I fully support the concept of ‘physicians' assistants’, where paramedical staff assist on ward rounds, cannulate, take blood, arrange investigations and follow up results, for example.
My delineation is that to wield a scalpel and a suture (or any physician equivalents) one should have a medical degree and the breadth of knowledge and understanding that such confers. It is illegal for someone without a veterinary degree to operate on an animal. An NHS Modernisation Agency Report3 and a currently unpublished paper of mine would suggest that patients would like the same standard of care for humans.
With regard to Shrivastava et al's endorsement of SCPs,4 the conclusions cited are not so sound. Their data actually suggest that SHOs are put off a career in cardiothoracic surgery after working with SCPs for six months (41% wishing to continue with SCPs vs 61% without SCPs). Moreover, while they offer that SHOs with SCPs may be more frequently involved in initiating cardiopulmonary bypass and other procedures, it is not recorded in what capacity (surgeon or assistant) and the data do not even come close to statistical significance (p=0.3–0.8). Instead, SHOs with SCPs only performed half the number of saphenous vein harvests. For SHOs, particularly those not wishing to continue in cardiothoracics, one would have to wonder if single-handedly harvesting veins is not actually the more useful experience. Contrary to Drury et al, I cannot deduce from these data that SCPs are beneficial to SHOs.
I was taught saphenous vein harvesting by my consultant surgeon and registrars, so benefiting from their years of varied surgical experience. I still got to the ‘top of the table’ once I had completed the procedure or by swapping periodically with the registrars and the surgical consultant. At what stage will Mr Nashef allow his more experienced SCPs to venture up the table? And what then would happen to his SHOs' and SpRs' training? If he will not let SCPs to the top end of the table, how is an arbitrary delineation of above or below the pelvis any more valid than mine?
SCPs are only needed to operate if there are not enough doctors. Every time an SCP does this is a time that a junior doctor does not. We should not let all these educational opportunities go begging when we are in the extraordinary times of training jobs being abolished and doctors being unemployed.5 Why, really, is this happening? No one has yet managed to convince me of anything other than that, for now, it is cheaper. In the long run as doctors, patients and nurses we may pay dearly in many subtler ways.
References
- 1.Department of Health. The Curriculum Framework for the Surgical Care Practitioner. London: DoH; 2005. Mar, [Google Scholar]
- 2.Department of Health. Patients to get quicker care as American ‘ER’ style roles come to the NHS. London: DoH press release; 2005. Nov 4, ref 2005/0382. [Google Scholar]
- 3.NHS Modernisation Agency. Public Perceptions of Surgical Practitioners. London: Department of Health; 2004. Jul, [Google Scholar]
- 4.Shrivastava V. Surgical assistants affect SHO training in cardiac surgery. Ann R Coll Surg Engl (Suppl) 2004;86:238–241. [Google Scholar]
- 5.BMJ Careers, theme issue: What can you do if you are out of work? BMJ Careers. 2005. Oct 22,
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
I have followed the discussions regarding surgical training and the impact of surgical care practitioners (SCPs) with interest.1 Clearly, there are strong arguments for SCPs. Perhaps the most significant of these is ‘increasing NHS workforce problems and growing healthcare demand’.2
It is an unfortunate fact that the European Working Time Directive and Modernising Medical Careers are significantly reducing the availability of junior doctors to fulfil these demands. Training non-healthcare professionals to take on the role of surgical trainees is an ingenious and cost-effective solution to this problem of increasing demand with limited supply.
I am, however, quite surprised that the roles given to these non-healthcare professionals are those of operative surgery (the one area where surgical trainees are significantly missing out) and on of the more demanding areas of a trainee's work.
Here is a golden opportunity to use non-healthcare professionals to relieve surgical SHOs and PRHOs of the tedious repetitive chores generated by the daily ward round and free them up to get to theatre. Juniors could then begin the surgical training, which they can currently only start at SpR level. More time could be spent with their consultant trainers rather than with the nursing staff on the ward.
We have all heard the stories of how many appendicectomies, varicose vein procedures and hernia repairs our consultant surgeons performed when they were PRHOs. The money being used to provide SCPs should be used to provide ward-based ‘physicians' assistants’ to carry out ward work. This would free surgical trainees to make better use of their limited hours, by going to theatre and operating, as our consultants once did.
References
- 1.Costa M. Undermining surgical training. Ann R Coll Surg Engl (Suppl) 2005;87:144. [Google Scholar]
- 2.de Cossart L. SCPs – Healthcare-Lite, response. Ann R Coll Surg Engl (Suppl) 2005;87:326. [Google Scholar]
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
I fully agree that surgical assistants on the ward and in theatre offer invaluable assistance to surgeons and improve patient care. In contrast, surgical care practitioners (SCPs), as defined in Mrs de Cossart's article,1 will reduce the exposure of surgical trainees to the detriment of their training. Furthermore, the shortage of experienced theatre staff in many hospitals will only be made worse if senior nurses and operating department practitioners leave to become SCPs. It worries (and annoys) me that senior members of the College dismiss these issues and the genuine concerns of surgical trainees.
Reference
- 1.de Cossart L. Curriculum development for surgical care practitioners. Ann R Coll Surg Engl (Suppl) 2004;86:354–355. [Google Scholar]
letter Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
I thoroughly enjoyed the recent article describing the medical aspects of the death of Admiral Nelson at the battle of Trafalgar. It was interesting to note that the cause of death was given as profound hypotension as a consequence of blood loss and, importantly, spinal shock. This statement reflects the confusion that surrounds the definitions of spinal shock and neurogenic shock.
While there is no doubt that Admiral Nelson had spinal shock, which is the complete lack of function of the spinal cord demonstrated by a lack of reflexes and limb flaccidity following a cord injury (in this instance the passage of the musket round), this did not cause his hypotension. The cause of this was neurogenic shock, which is a cardiovascular phenomenon consisting of a loss of vasomotor tone and the loss of sympathetic innervation to the heart following a disruption of the sympathetic pathways in the spinal cord. Of course, hypovolaemic and neurogenic shock occur together in the presence of haemorrhage and cord damage, as in the case of Admiral Nelson.
The differences between spinal shock and neurogenic shock are important for the treatment of spinal cord injury. The management of the hypotension in the initial stages is part of the resuscitation of the patient. The recovery from spinal shock, as demonstrated by the return of spinal reflexes such as the bulbocavernosus reflex, indicate that the degree of cord damage can be quantified from assessing what remains of cord function.
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
I found the October 2005 issue of the Bulletin commemorating the death of Lord Nelson fascinating. May I applaud the authors for their thorough account of his remarkable life. I am amazed by the extensive details recorded of Lord Nelson's fatal injury despite the heat of battle. The ballistics data, while interesting, reinforces the need for military surgeons to ‘treat the wound, not the weapon’ with even a low velocity round being capable of causing significant injury.
It should be considered that the cause of death was a tension pneumothorax rather than prolonged hypovolaemic and spinal shock. Tension pneumothorax would also have caused hypotension and account for his ‘laboured breathing’ and ‘fighting for air’. This hypothesis is supported by the postmortem examination not revealing significant bleeding in the chest cavity.
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
Admiral Nelson's eye injury sustained at the siege of Calvi on 12 July 1794 remains something of a mystery after more than 200 years. This may seem surprising considering the minutely detailed descriptions of his other war wounds available.
In letters written during July and August of the same year, he speaks of wounds to his face and right eye caused by fragments of stone struck from ‘the works’ at Calvi by a shot and complains of being ‘nearly deprived of sight’ of the right eye.
Two Hurt Certificates were raised on board HMS Victory in August 1794, referring to the loss of an eye, and a further Hurt Certificate was signed by the Private Court of the Examiners, the Royal College of Surgeons, in October 1794. This latter certificate described the results of his eye wound as ‘equal to the loss of an eye’.
Doubtless, a more detailed description of any internal injury to the eye would have been impossible at the time since Helmholtz did not invent the ophthalmoscope until 1850. All the available evidence carefully assessed by Surgeon Captain TC Barras RN shows that, although blinded in the right eye, Nelson did not lose the eye nor did he wear an eyepatch. He almost certainly had a pterygium on the nasal aspect of both corneas affecting his vision, for which he wore a skip - but that is another story.
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
We thank Messrs Gardner, Gilliam and Rintoul for their interest in our article concerning the death of Lord Nelson.
As to the presence of a tension pneumothorax, while possible (as a pre-terminal event), we feel it unlikely since he lived for three and a half hours and remained reasonably lucid until the end and Beatty clearly had no recourse to insert a bronchotomy tube. Although there were repeated references to severe pain, significant dyspnoea was not noted until he asked to be turned onto his right side, with some dyspnoea in his last 15–20 minutes, after Hardy had left him. There may well have been less blood in the thorax as a consequence of his profound hypotension.
The term ‘spinal shock’ was admittedly loosely applied to cover neurogenic shock and the neurological sequelae of spinal transection. The term ‘shock’ perhaps should not be used with reference to the neurological element of spinal cord injury since it reflects altered cardiovascular status.
The principal new message is that disruption of Nelson's autonomic nervous system at T6 level made it impossible for him to adequately compensate any longer for haemorrhage.
The award of a pension for the loss of vision in one eye was not awarded by the College until 1797.
letter Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
I agree with Mr Langton and Mr Edwards that surgery is more than becoming a surgical technician and when I chose surgery as a career it was more of an apprenticeship-based system. Time has moved on since then and the current and future models of training are based around shortened, more focused training with competency-based assessment. With this future in mind, it is essential that the programmes have posts in place such as the vascular department at the Bristol Royal Infirmary, which can offer high quality training.
Ann R Coll Surg Engl. 2006 Mar;88(2):143. doi: 10.1308/003588406X95057
We read with interest the paper by Williams et al regarding the improvement in operative training since the introduction of the Calman plan. The paper does go some way to demonstrating that an adequate number of supervised operations can be undertaken in vascular surgery during a shortened training period, fulfilling the Vascular Surgery Society recommendations for number of completed procedures. These can no doubt be logged and presented as evidence when the efficacy of training is questioned.
The problem with this approach is, of course, that it encourages the view that surgery is about technical procedures alone – a view that seems to be strongly but incorrectly held by both government and hospital managers.
Ultimately, as any experienced surgeon knows, surgery is about decisions and judgement, both in and, importantly, out of the operating theatre. While we would agree that the main technical skills can be learned in a relatively short period, possibly three years as the authors suggest, appropriate judgement, ability to manage the ‘sudden and unexpected’ and in-depth insights into clinical problems take rather longer to develop. These attributes continue to evolve as one progresses from being a surgical trainee to a consultant surgeon and in the years that follow.
We agree that patient expectations have increased in recent years. We would suggest that the public expects the trained surgical consultant to have attributes and abilities that extend well beyond the level of a ‘surgical technician’. These skills cannot be gained without a prolonged period of training and hands-on experience. Achieving such skills is clearly essential if the public is to be provided with adequately and appropriately trained consultant surgeons in the future.