Modern anaesthesia training: is it good enough?

Anaesthetic training in the UK has recently experienced significant organizational and politically driven changes. This article examines the effects these changes may have had on the training of anaesthetists and concludes that despite the introduction of changed working patterns and reduced hours over the past decade, academic and professional standards appear to have been maintained, but at the expense of reduced confidence among some trainees. The UK system focuses heavily on achieving competence in different areas of training. While this is clearly important, it understates the added value of consolidation and experience based on repeated exposure. Trainer and trainee surveys suggest that due to perceived service pressures, and worries about patient safety or clinical governance, this important latter stage in professional development is increasingly being omitted from the training programme.

In-theatre training of anaesthetists in a teaching hospital: has it changed over 10 years?

BACKGROUND: We wished to ascertain in what way recent changes such as Modernising Medical Careers (MMC) and the implementation of the Working Time Directive (WTD) have affected clinical training and experience for anaesthetists in a teaching centre, in particular the provision of training in specialized fields of anaesthesia provided in the teaching hospital. METHODS: Data were extracted from the computerized system for every operating theatre in this Trust. This provided a continuous record of all operations undertaken, and has previously been validated as an accurate record against individual anaesthetists' personal logbooks. We compared recent data with that of 10 yr ago. RESULTS: Comparing data for 1997 and 2008 showed that registrars and post-fellowship senior registrars (SRs) in anaesthesia continue to be well supervised directly by consultants (49% and 39%) and subspeciality training has been protected in our department. Average case numbers for SRs increased from 442 to 623 yr(-1), including an increase in emergency workload and theatre cases undertaken during the evening and at night. Although average case numbers for both SRs and consultants increased, we detected a small decrease in average case numbers from 394 to 353 yr(-1) for pre-fellowship registrars. CONCLUSIONS: In spite of many pressures on training in the clinical setting, the number of cases and senior supervision in specialist modules for trainee anaesthetists in our teaching hospital has been maintained. Continuous monitoring of in-theatre supervision is one way of confirming that training is not compromised as changes occur in hospital workload.

High latent drug administration error rates associated with the introduction of the international colour coding syringe labelling system.

BACKGROUND AND OBJECTIVES: The potential for increased drug administration errors during the transition to the International Colour Coding syringe labelling system has been highlighted. The purpose of this study was to assess the potential effects before their introduction into our department. METHODS: Thirty-one anaesthetists, 19 with no previous practical experience of the new labelling system (Group 1), and 12 with previous experience (Group 2), volunteered to induce general anaesthesia for a standardized simulated patient in a designated theatre. They were presented with a scenario designed to suggest the need for a rapid sequence induction and provided with drug syringes labelled with the International Colour Coding system. All drug administrations were recorded. Active error was defined as the injection of the wrong drug. Latent error was defined as the selection of a syringe in error but stopping short of administering the drug. RESULTS: In Group 1 a total of 107 drug injections were recorded of which 1 (0.9%) was an active error and 16 (15%) involved latent errors. Eleven anaesthetists (58%) performed at least one latent error. Group 2 had an error rate of 3%, a 6.9 (1.3-26.7) fold reduction in the rate of error (P = 0.023). CONCLUSIONS: Although only one drug was given in active error, latent errors occurred in 15% of drug administrations. The only factor conferring protection against error was prior experience of the new labelling system. The period of transition to the International Colour Coding syringe labelling system represents a time of increased risk of drug administration error.

Influence of changing work patterns on training in anaesthesia: an analysis of activity in a UK teaching hospital from 1996 to 2004.

BACKGROUND: We aimed to assess the influence of reduced working hours on training in a UK teaching hospital as the specialist registrar grade was introduced in 1996, the New Deal was implemented in 2001 and the Working Time Directive (WTD) took effect for doctors in training in 2004. METHODS: We analysed data from operating theatres in our hospital looking at grade of anaesthetist, time of day, emergency category, and specialty for more than 50,000 cases. RESULTS: Although direct supervision of trainees increased from 32 to 37 to 47%, senior house officer (SHO) and specialist registrar (SpR) caseload reduced by 20 and 21%, respectively, while that of the consultants rose. CONCLUSIONS: The reduction in total operating theatre cases for our trainees was evident across the epochs analysed, case numbers fell after introduction of the New Deal as well as more recently following the WTD, particularly for SHOs who are now doing a larger proportion of their work at night. SHOs and SpRs are doing more obstetric cases than in previous times but these are regional and not general anaesthetics.

Comparison of four different emergency airway access equipment sets on a human patient simulator.

This study used a patient simulator to study the ease of use and efficacy of four currently available cricothyroidotomy sets. We assessed the success of insertion of each piece of equipment and measured the subsequent adequacy of oxygenation and ventilation. We also examined the complications encountered using each set. We found that there was a 100% success rate of achieving an adequate airway within acceptable time limits using the 'Quiktrach' and 'Melker' sets, with good airway patency and ease of ventilation. There was an unacceptably high failure rate in achieving a patent airway when using the 'Transtracheal airway catheter with ENK-flow modulator' and 'Patil's airway'. The pre-assembled and user-friendly 'Quiktrach' set provided the fastest and most effective means of oxygenation in the simulated patient requiring an emergency surgical airway.

A detailed analysis of theatre training activity in a UK teaching hospital.

We examined the placement of anaesthetists in our department over a 2 yr period. Data were collected from an in-theatre system to provide details of caseload and supervision for 34,856 operations. There was wide variation between anaesthetic sub-specialties with overall supervision levels of 35% of cases for senior house officers (SHOs) and 32% for specialist registrars (SpRs). The consultant data showed the size and areas of teaching reserve in the department. We then examined individual logbooks in order to validate our data, and departmental rotas to put these data into perspective with previous attempts to quantify trainee supervision. Supervision data derived from the rota allocations showed that 86% of SHO lists and 62% of SpR lists were scheduled to be supervised. This study has described our training activity and facilitated departmental changes, as well as highlighting the need for great care in interpreting trainee supervision data acquired from different sources, particularly when comparisons are being made.

Continuous auditory monitoring--how much information do we register?

We have studied response times of 30 anaesthetists to a standardized episode of arterial oxygen desaturation in a simulated patient, randomized to the use of either a fixed or variable pitch pulse oximeter. We wished to determine if a variable auditory signal was important in detecting adverse events. A variable pitch pulse signal had a shorter time to recognition of desaturation (P < 0.0001), with a mean response time of 32 s, compared with 129 s for the fixed pitch signal.

Multiple-choice examinations: adopting an evidence-based approach to exam technique.

Negatively marked multiple-choice questions (MCQs) are part of the assessment process in both the Primary and Final examinations for the fellowship of the Royal College of Anaesthetists. It is said that candidates who guess will lose marks in the MCQ paper. We studied candidates attending a pre-examination revision course and have shown that an evaluation of examination technique is an important part of an individual's preparation. All candidates benefited substantially from backing their educated guesses while only 3 out of 27 lost marks from backing their wild guesses. Failure to appreciate the relationship between knowledge and technique may significantly affect a candidate's performance in the examination.

Drawover vaporizers for sedation in intensive care.

OBJECTIVE: We have undertaken a laboratory study to determine whether a drawover vaporizer in the inspiratory limb of an intensive care ventilator circuit can produce safe and therapeutic concentrations of isoflurane. DESIGN: An Oxford Miniature Vaporizer (OMV) and Ohmeda TEC vaporizer were assessed over the range of inspired isoflurane concentrations, airway pressures and tidal volumes experienced in the ICU. CONCLUSIONS: The experimental findings suggest that the OMV inhaler in plenum mode can be relied upon to produce safe concentrations of isoflurane over a clinically useful range of inspired concentrations. Furthermore, it behaves predictably over the range of airway pressures likely to be encountered in the patient admitted with acute severe asthma. However, we found that the Ohmeda TEC vaporizer did not perform reliably in this setting.

A comparison of retrospective versus contemporaneous nausea scores with patient-controlled analgesia.

In the search for an effective method of reducing the incidence of postoperative nausea, a standardised system of patient assessment is required. We examined 76 patients who had undergone elective total abdominal hysterectomy and were receiving patient-controlled analgesia with morphine. Nausea scores were obtained using an 11-point rating score. Repeated contemporaneous assessments were compared with a single retrospective score made 5 days after surgery. Retrospective nausea scores were higher than those recorded contemporaneously. Maximum contemporaneous score showed greater agreement with the retrospective score than did the median, mean, or minimum contemporaneous score. Collectively, these results suggest that patients tend to remember their episodes of nausea vividly, even if these episodes were punctuated by relatively nausea-free periods. The variability between the two sets of results suggests that contemporaneous and retrospective nausea scores should not be used interchangeably.

Peripartum cardiomyopathy presenting as a cardiac arrest at induction of anaesthesia for emergency caesarean section.

Peripartum cardiomyopathy is defined as the onset of acute heart failure without demonstrable cause in the last trimester of pregnancy or within the first 6 months after delivery. It occurs in about 1 in 4000 deliveries and is often unrecognized as symptoms of normal pregnancy commonly mimic those of mild heart failure. We describe a previously asymptomatic patient who presented with a cardiac arrest at induction of general anaesthesia for emergency Caesarean section and subsequently developed acute heart failure. This case is unique both in its mode of presentation and the total absence of antecedent symptoms or signs of cardiac disease.

An unusual case of sudden desaturation following induction of anaesthesia for caesarean section.

In the following case report an episode of sudden and rapid desaturation, occurring soon after induction of anaesthesia in a fit preoxygenated obstetric patient, resulted from the use of a Manley minute volume divider which had become purged with nitrous oxide.