If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
Electronic Letters to:
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E-letters: Electronic letters published:
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Novice anesthetists and their airway skills
- Rakhee L Kotak (7 December 2006)
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A reply from the authors
- Caroline H Whymark, A Moores, A MacLeod (10 November 2006)
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SHO Airway skills- a way forward
- jatin devraj dedhia (27 October 2006)
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A reply to 'A Scottish National Prospective Study of airway management skills in new-start SHOs'
- Attam Jeet Singh (19 October 2006)
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Re: Airway management skills - face mask anaesthesia
- Tony Hodgetts (19 October 2006)
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LIGHT AT THE END OF THE LARYNGOSCOPE - VIDEO KILLS THE RADIO STAR?
- DERRICK D CLARENCE (13 October 2006)
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Airway management skills - face mask anaesthesia
- Vinay Ratnalikar (13 October 2006)
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Rakhee L Kotak, Senior House Officer, Anaesthetics
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Editor- I read with great interest Whymark and colleagues’ paper on airway skills in new-start Senior House Officers. Having only started in Anaesthesia eighteen months ago, I decided to have a look at my own logbook numbers during the first three months of my training. They were very similar to those described in the study. There is obviously more than one reason for the decline in the number of cases we carry out as trainees. Most emergency cases are carried out during dedicated day-time lists, and the European Working Time directive means that we spend much less time at work than our more senior colleagues did. Of the cases that we are involved in, the majority are inevitably associated with the use of the laryngeal mask airway (LMA). This device is increasingly being used for all types of surgery, even Caesarian Sections! It has been given prime position of importance in the most recent Advanced Life Support Guidelines, and is now found in most resuscitation areas. I do agree with many of the authors’ points. Despite the LMA’s ever- increasing popularity, facemask anaesthesia remains an important skill. If there are two anaesthetists present, it is well worth practicing one’s facemask skills. New-start SHOs should also be encouraged to move between theatres to maximize their opportunities. Three questions spring to mind: 1. Should it become common practice for new-start SHOs to join the on -call rota with a more experienced colleague? 2. Does simulation training have a part to play in the acquisition of airway skills? 3. With plans for the introduction of Anaesthetic Practitioners, what measures will be taken to ensure that the training needs of new-start SHOs are met? Conflict of Interest:None declared |
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Caroline H Whymark, Consultant Anaesthetist , A Moores, A MacLeod
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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" 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 face mask 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 maximise 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. Conflict of Interest:None declared |
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jatin devraj dedhia, SpR
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The Prospective Study of airway management skills in new – start SHOs by Whymark et al. is interesting. According to RCOA bulletin 2002, poor quality of airway management was not felt to be confined to the trainee grade, but sloppy airway management techniques by consultants were also apparent. SHO competency document recognises basic airway management as a core skill assessed in first 3 months of training. Unless the novice can demonstrate this, he/she should not be practising without direct supervision. The LMAs has more or less replaced facemask as a standard tool for basic airway management. The low number of facemask cases is cause for concern. This skill unlike LMA is difficult to acquire. Use of LMAs is increasing leading to fewer opportunities to practise the art of intubation. With the EWTD, trainees are spending less time in theatre. The total number of cases done by a trainee has fallen by approximately 10-20%. With the use of ultrasound guided regional anaesthesia more and more cases are being done under regional anaesthesia further decreasing the chances to learn airway skills. Time is also spent in other areas like obstetrics, pain management and ITU where intubations is a low volume activity. In our institute, there are not many cases being done under mask. The novice SHO who works under supervision, does not do any night shifts so that he/she is available all times during the week when most of the supervised work goes on. The authors reported a significant numbers of cases (23%) done under mask. This may be due to training targeted at learning specific airway skills. Departments of anaesthesia should concenterate on increasing experience of facemasks only cases without compromising experience with LMA. Trainees can be made to move between theatre initially, but this will be at the expense of inability to learn the conduct of anaesthesia which is equally important. In our recent experience as novices, the supervising consultant would choose an airway management technique, within limits of course, to suite the trainee such that mask anaesthesia (and writing the chart at the same time!) would be undertaken for a case that would normally attract the use of an LMA. The majority of the cases done under mask anaesthesia in our trust are termination of pregnancies which are done by staff grades or SpRs. We have consultants with special interest in airway management who run a one day difficult airway course for our trainees. They also conduct a half a day study sessions where one gets a chance to learn airway skills on simulators and practise using fibre-optic bronchoscopes. Attending ALS, ATLS, EPLS or specific airway management courses could be a way forward. In our institute the trainees have lost their study budget. With the financial situation with most NHS trust being similar more trusts are going to decrease their study budget. This will put financial burden on most trainees, who would like to save their money to attend exam courses rather than spending it elsewhere. With Obesity an ever increasing problem, we will see more and more cases of difficult airway. Competency assessment of trainees without competency training seems flawed. This can be achieved by the following 1) Each trust should have designated doctor with special interest in airway management. This person should take specific responsibility for teaching airway skills and report critical incidents. 2) Production of teaching aid ( CD/ DVD ) to illustrate key points in basic airway management. 3) Use of simulators may be a good method of teaching unusual problems. 4) Target training to achieve airway skills in the initial months for novice SHOs. 5) Practice difficult intubation drills while in obstetric modules. Dr. Jatin Dedhia SpR in Anaesthesia University Hospitals of Leicester NHS Trust Conflict of Interest:None declared |
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Attam Jeet Singh, Anaesthetist
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I read with interest the study by Whymark and Moores on the management of the airway by novice SHOs. It, predictably, confirms my impression that currently novice SHOs are not being adequately educated in the art of airway management. In the study, the lack of expertise in basic airway skills is correlated with quantity and is reiterated that this does not relate to competency. However, exposure is the fundamental method by which most procedures are taught within the medical sphere and should not be disregarded. Given that inexperience in basic anaesthetic skills is evident amongst SHOs , what can be done about it? Firstly, novice SHOs need far greater direction. They should be rotated through theatre lists that allow the junior anaesthetist to practice their skills. Initially, they should be paired with senior consultants who would be able to guide them in a more orthodox manner; gradually they should be pushed towards emergency lists, eventually following a rota which enables them to do the on call shifts, possibly a week of 12pm-8pm shifts. From my own personal experience, I learnt a great deal more whilst on call than at any other time. With the reduction in working hours, careful thought has to be given to the traditional 3 months supernumerary period. I think a far more experience based trial period has to be employed. This would ensure a minimum exposure number and maintain a standard necessary to be achieved prior to commencement of unsupervised anaesthesia. The provision of suitable time and finance for novice anaesthetists to attend day release simulator courses is crucial. They will not only be exposed to critical incidents in a very controlled environment but also be able to discuss with other similarly inexperienced anaesthetists the problems they are facing. It is well known that the anaesthetic training scheme is far more structured and well-organized than any other medical speciality, however this should not lead to complacency and technical hitches need to be ‘ironed out’ early on to prevent them from escalating further on down the line. Conflict of Interest:None declared |
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Tony Hodgetts, Consultant Anaesthetist QEQM Hospital, Margate
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The article by Whymark et al raises many interesting issues regarding airway management training. A quick survey of the 2 new start SHOs in our department showed that both had not performed any exclusively face mask anesthetics 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 LMA insertion and 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 face mask 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 intubation. Conflict of Interest:None declared |
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DERRICK D CLARENCE, SPR ANAESTHESIA
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Dear Editor, I read the article on the Scottish National Prospective Study of airway management skills 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(manufactured by STORTZ) and I must say that its 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 trainees’ shoulder with bated breath as he tried to ensure that the best possible view has been obtained. Its 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 its an excellent teaching aid and has been known to reduce the learning curve for intubation. Thank you, Yours faithfully, Derrick Clarence Specialist Registrar Walsall Manor Hospital derrickclarence@hotmail.com References 1) The Report of the National Confidential Enquiry into Perioperative Deaths 1996/1997. Gray AJG, Hoile RW, Ingram GS, Sherry K. London: NCEPOD, 1998. I have included this reference as it recommends that all surgical hospitals should have a fibre- optic intubating laryngoscope. Not a far cry from the videolaryngoscope. 2) Kaplan MB, Ward DS, Berci G. A new video laryngoscope- an aid to intubation and teaching. Journal Clinical Anaesthesia.2002; 14(8): 620-6. 3) Weiss M, Schwarz U, Dillier CM, Gerber AC. Video- intuboscopic monitoring of tracheal intubation in pediatric patients. Canadian Journal Anaesthesia. 2000 December; 47(12):1202-6. Conflict of Interest:None declared |
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Vinay Ratnalikar
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Editor- I read this article on airway management skills with interest. I agree with the authors that face mask anaesthesia should be given a high priority when training new-start SHOs. But I found a significant difference in the usage of face mask 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 face mask 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. Conflict of Interest:None declared |
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