A simulation-based study evaluating the preparedness of interns' post-anaesthesia rotation in managing a failed obstetric intubation scenario: Is our training good enough?

BACKGROUND: Difficult or failed intubation of obstetric patients may be up to 8 times higher than in general surgical patients. A decline in obstetric intubation opportunities may be a contributing factor, resulting in reduced training opportunities for junior doctors, who therefore do not acquire airway management skills. OBJECTIVES: To assess post-anaesthesia rotation interns' preparedness to manage a difficult/failed obstetric airway scenario. METHODS: We recruited 49 interns, obtained informed consent and individually assessed them on a simulation-based scenario using a high-fidelity manikin. Two independent assessors scored participants using a checklist assessment and a global rating scale. After the simulation-based scenario, participants completed a questionnaire on their internship training, rated the simulation experience and received debriefing. The borderline regression method was used to determine the checklist pass mark. RESULTS: Analysis showed that 40% of interns passed. Correlation between assessors was strong for checklist scores and global ratings. The main reasons for failing were repeated attempts at intubation and failure to optimise the intubating position or conditions. There was concern regarding the infrequent use of a supraglottic airway device as a rescue. Twenty-eight interns had performed <5 general obstetric anaesthetic procedures. CONCLUSIONS: There are concerns regarding adequate anaesthetic preparation for interns to manage a difficult/failed intubation scenario in a full-term pregnancy. Despite the Essential Steps in Managing Obstetric Emergencies (ESMOE) airway module training, which all interns should receive, a high rate of success was not achieved in this study. Simulation-based training and assessment may be a valuable tool to improve intern training and preparedness.

Defining fitness for purpose in South African anaesthesiologists using a Delphi technique to assess the CanMEDS framework

Background: Training of South African anaesthesiologists is based on the Canadian Medical Education Directives for Specialists (CanMEDS). However, the applicability of CanMEDS in this context has not been assessed. An expert panel participated in a Delphi process to create an appropriate expanded list of CanMEDS competencies that may be used in the future to assess fitness for purpose of local graduates. Methods: This descriptive study comprised a representative panel of 16 experts surveyed electronically over three rounds to assess the importance of the existing CanMEDS roles and enabling competencies and suggested additions deemed applicable locally. The primary outcome was the creation of a list of competencies applicable to South Africa. Results: There was a 100% response rate for all three rounds. Based on the existing seven CanMEDS meta-competencies (Medical Expert, Collaborator, Communicator, Leader, Scholar, Professional and Health Advocate), respondents scored the importance of 89 enabling competencies and 19 additional competencies. Seven CanMEDS enabling competencies did not achieve consensus and were excluded. Nineteen new enabling competencies and two new meta-competencies (Humaneness, Context Awareness) achieved consensus and were added. Median ratings of importance of meta-competencies showed highest scores for Medical Expert and Collaborator and lowest scores for Health Advocate. Weighting of meta-competencies revealed highest scores for Medical Expert and Professional with all others equally weighted. Conclusion: This study has formulated an adapted CanMEDS list of enabling competencies with the addition of the two new metacompetencies of Context Awareness and Humaneness for use in South African anaesthesiology. This provides a means with which future graduates may be assessed for fitness for purpose

Errors and clinical supervision of intubation attempts by the inexperienced

Background: Tracheal intubation is an essential skill for anaesthetists and other disciplines that require emergency establishment of a secure airway. Early attempts in patients often meet with failure. Existing publications focus mainly on trainees in emergency settings and highlight the role of experience in success; most recommend prior simulation training. Common factors identified as contributing to difficulty have been difficult airways, emergencies and rapid sequence induction. Early intubation skill development in patients with anticipated straightforward airways in a controlled environment has received little attention. Objectives: This qualitative observational study aimed to identify common difficulties associated with a supervised intubation process by inexperienced personnel in the relatively stress-free conditions of elective surgical procedures in the operating theatre. Methods: Following institutional and ethical approval, participants, supervisors, anaesthetic assistants and patients consented to observation and video-recording of supervised intubations in a Durban teaching hospital. Anonymity and confidentiality were assured. Contemporaneous observations were recorded in theatre, and video-recordings were subsequently reviewed for content. Errors, and interactions between supervisor, assistant and participant, and associated outcomes, were identified. Results: Twenty participants (medical interns and medical, paramedical and nursing students) performing 72 intubations were observed. All participants had prior training using manikins or simulators. There were 61 successful intubations and 11 unsuccessful attempts. Factors associated with failure included unfamiliarity with airway, equipment or process. Process errors included inadequate head positioning, laryngoscope handling and tracheal tube manipulation. Anaesthetic assistants contributed to difficulties in some cases. Supervisor support was either verbal, physical or both. Less experienced supervisors tended to intervene earlier. There was a significant trend for success associated with the reported number of prior successful intubations. A successful intubation within the study was, however, no guarantee of subsequent success. Conclusion: Despite prior simulation training, many participants demonstrated lack of familiarity with the airway, intubation process and equipment. While improved simulation training might partly address these issues, supervision of early clinical intubation attempts needs to be redirected from the process of intubation itself to the process of intubation skills acquisition. A first step would be to ensure that all supervisors and assistants are trained for the latter goal, anticipating common errors and providing standardised conditions for success. The use of video-recording of the events is an invaluable aid to observation and interpretation, and is recommended as an adjunct to further studies of mechanical skills transfer

MMed cohort supervision: A path out of the swamp?

The authors present the case for collaborative cohort supervision (CCM), including both master's students and novice supervisors, as a possible way to rapidly increase the number of supervisors needed to address the recent implementation of a compulsory research component to specialist registration with the Health Professions Council of South Africa. Different models of CCM are discussed and possible pitfalls highlighted.

Information yield from routine pre-operative chest radiography and electrocardiography.

Studies in First-World settings suggest that routine pre-operative investigations are of minimal usefulness. A retrospective study of 797 case records determined the yield of significant information from routine chest radiography and ECG in a provincial general hospital serving a broad socio-economic sector. The results were in agreement with those of other studies, viz. that routine investigation may be worthwhile only in older patients. Routine chest radiographs showed an overall positive yield of 6%; 17% in those over 60 years but only 2% in those under 60 years. Routine ECGs showed a positive yield of 7% overall; 7.4% in those older than 40 years and 4.5% in those under 40 years. Investigations indicated by history or physical examination had a significantly greater yield: 34% for chest radiography and 31% for ECGs. Positive results of indicated investigations were more evenly spread across the age groups. The pre-eminence of clinical skills in determining which patients require special investigations is reaffirmed.

Midazolam, a new intravenous induction agent for anaesthesia.

In an open non-comparative clinical trial 64 patients older than 18 years with American Society of Anesthesiologists ratings of I and II were studied. Under standardized conditions of premedication, anaesthesia was induced by injecting midazolam (Ro 21-3981) 0,15 or 0,3 mg/kg body weight intravenously. After endotracheal intubation with suxamethonium 1 mg/kg, anaesthesia was maintained with nitrous oxide in oxygen and enflurane or halothane. There were statistically significant cardiovascular changes during and/or after intubation but there were no clinical consequences. Midazolam allows rapid induction of and recovery from anaesthesia. There was no retrograde amnesia and high proportion of the patients assessed the induction of anaesthesia as favourable. The local tolerance was very good. Midazolam seems to be a good alternative for induction of balanced anaesthesia.