The times they are a-changin

Anaesthesia Blog, July 2016.

“The Times They Are a-Changin'” was a song written by Bob Dylan and released as the title track of his 1964 album of the same name. Ever since its release, the song has been influential to people’s views on society, with critics noting the general yet universal lyrics as contributing to the song’s lasting message of change, which seems particularly apt with Brexit and a new Prime Minister imminent. This month’s blog is also about change, and I particularly wish to highlight a Special Article on Pensions, Tax and the Anaesthetist. Over the last few years, a series of changes have been made to our pensions as doctors, and in April 2016 the biggest of these was introduced, with very little fanfare. Many of my local colleagues have not heard about the latest changes, and those that have are confused as to their effects on their pension. This article in the journal explains very clearly the changes that have been made and their effect on our expected pension income, and the choices we now have. There is no doubt that a good pension at the end of many years of hard work is one of the greatest incentives to working in the NHS, but can we still expect that and is there anything we can do to maintain our expected benefits? The changes to pension laws will increasingly affect workforce planning and may lead to even more experienced anaesthetists leaving the NHS – I urge you to read this and digest and discuss the implications.

I have noticed that there has been a marked change in attitudes to sedation over the last few years, and more and more of my non-anaesthetic colleagues want us anaesthetists to sedate their patients instead of anaesthetising them, because they perceive this to be better (though it is not always clear who for). The evidence comparing sedation and general anaesthesia is surprisingly sparse, but this retrospective propensity-matched cohort study in my centre demonstrated, much to our amazement, that sedation for high-risk patients with aortic stenosis undergoing transcatheter valve replacement actually had a number of significant advantages compared with GA, and our practice has now completely changed as a result, with more patients on a list, patients going home much sooner and everyone (patients and cardiologists/surgeons) much happier. An unexpected consequence is that the surgeons now think every patient should have sedation instead of GA, so the debate is set to continue for some time. I hope to see more trials comparing sedation with GA in the future.

Another interesting article in this month’s journal may herald a change in the local anaesthetic solution we use for regional anaesthesia. The authors compared liposomal bupivacaine with plain bupivacaine, and they found that the liposomal formulation provided up to 72 hours of analgesia when used for transversus abdominis plane (TAP) blocks. I think this is a very interesting development and I am sure we are going to read a lot more about liposomal local anaesthetic solutions in the near future.

Finally, there have definitely been changes to the way we teach medicine and anaesthesia, and particularly with respect to the use of simulators. Manufacturers have striven to develop advanced and technologically impressive simulation platforms, and a lot of surgeons now learn using cadavers, but this article compares a simple home-made meat model with cadaveric teaching for ultrasound-guided sciatic nerve block. Surprisingly, the cheap and simple home-made model was better for teaching novices than the cadaveric method, which will interest those running regional anaesthesia teaching courses and anyone teaching their trainees how to put in a nerve block. It seems simple is best under such circumstances.

I hope this month’s Anaesthesia will stimulate you to embrace change in your practice, and remember “Human happiness may rely on our ability to conquer a natural fear of upsetting the status quo”  (A. L. Kennedy).


Andrew Klein