Airways skills in new-start SHOs
Swansea, UK
E-mail: getvin{at}doctors.org.uk
Editor—I read this article on the airway management skills of novice senior house officers (SHOs)1 with interest. I agree with the authors that facemask anaesthesia should be given a high priority when training new-start SHOs. But I found a significant difference in the usage of facemask between the figures mentioned in this article (23%) compared to that in our hospital (5.17%). It would be helpful to us as well as to other departments to know typically in what type of operations the trainees in your region are using facemask anaesthesia in order to increase airway training opportunities.
I feel your overall analysis of airway management techniques is commendable and I share your concerns about decreasing opportunities in airway management.
Walsall, UK
E-mail: derrickclarence{at}hotmail.com
Editor—I read the article on the Scottish National Prospective Study of airway management skills1 with interest. To my surprise, there was no reference to the videolaryngoscope as a teaching aid to intubations. We are fortunate in our hospital to have one and I must say that it's an illuminating experience even for seasoned anaesthetists. From a training point of view, no more does a consultant have to perform contortions over a fumbling trainee's shoulder with bated breath as he tries to ensure that the best possible view has been obtained. It is there on the screen for all to see.
I recommend using it for better supervision with real-time instructions, as each step of the intubation can be observed and commented upon, thus getting the maximum out of each opportunity to intubate. Furthermore, every attempt can be recorded as an image, and the trainee can review the effect of his/her manipulation of the airway.
The only drawback from the trainee's point of view being that the videolaryngoscope provides a wider more panoramic view of the larynx, thus not fully replicating the more difficult, dim, restricted view that is available with the standard laryngoscope. Despite all this, it is an excellent teaching aid and has been known to reduce the learning curve for intubation.
Margate, UK
E-mail: tony.hodgetts{at}ekht.nhs.uk
Editor—The article by Whymark and colleagues1 raises many interesting issues regarding airway management training.
A quick survey of the two new start SHOs in our department showed that both had not performed any exclusively facemask anaesthetics in their first 3 months. From my own log book, I performed less than 10 in my first 3 months of training. How significant is this as our SHOs perform bag mask ventilation on a daily basis, prior to laryngeal mask airway (LMA
) insertion and tracheal intubation? It is a common criticism that (over)use of the LMA means trainees perform less intubations and I welcome the recommendation that trainees should be preferentially attached to lists where facemask anaesthesia and intubations occur. Trainees moving between theatres will also increase the number of intubations performed, but it is important not to forget the issue of extubation, another core skill for all anaesthetists and as important as tracheal intubation.
Kilmarnock and Glasgow, UK
* E-mail: cwhymark{at}doctors.org.uk
Editor—We were interested to read the comments made in response to our study ‘A Scottish National Prospective Study of airway management skills in new-start SHOs’1 and welcome the opportunity to respond to them.
Firstly, to address Dr Ratnalikar: as this was a study of trainees all over Scotland, it is not possible to comment on the type of cases being done using a facemask only in many of the workplaces included in the study. However, in our own institutions, trainees are directed to day case minor gynaecological, urological, and orthopaedic surgery to gain experience using a facemask. Some of these cases are opportunistic learning exercises, and a senior anaesthetist working alone may elect to use an LMA in place of the facemask, but can identify a training opportunity when a trainee is present.
Secondly, in response to Dr Clarence: there are many types of video-assisted aids to laryngoscopy available today. While some may have a place in clinical practice, particularly when the more difficult airway is encountered, we firmly believe that new-start trainees should master basic skills such as facemask holding and direct laryngoscopy before progressing to experiment with such adjuncts.
Thirdly, we agree with Dr Hodgetts that although trainees can move between theatres to maximize intubations performed, this is at the expense of learning the conduct of anaesthesia and the management of emergence and extubation. This period is vitally important and can be the source of many critical incidents if not managed correctly. Our personal experience is also that some Consultants find it disruptive to running a list and teaching trainees if they are popping in and out of theatre repeatedly.
Footnotes
LMA® is the property of Intavent Ltd. 
Reference
1 Whymark C, Moores A, MacLeod AD. (2006) A Scottish national prospective study of airway management skills in new-start SHOs. Br J Anesth 97:473–5.
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