Northeast Anaesthetic Learning Group

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Northeast Anaesthetic Learning Group

  1. 1. Northeast Anaesthetic Learning GroupSpecialist Registrar Scheme
  2. 2. Index1. Overview of registrar experience 22. Obstetrics 133. Critical Care Medicine 244. ENT, Maxillo-Facial, Dental and Plastic Surgery 365. Acute and Chronic Pain 556. Eye Surgery 687. Day Surgery 748. Neuro-Anaesthesia 779. Thoracic and Cardiac Anaesthesia 8610. Anaesthesia for Vascular Surgery 9911. Paediatric Anaesthesia 104 2
  3. 3. 1. Registrar experienceSpeciality Block Duration of ExperienceFirst year Specialist Registrar Final Fellowship YearObstetric unit 4 weeksIntensive care unit 4 weeksMaxillo-facial surgery 4 weeksPaediatric Anaesthesia 4 weeksUrology 4 weeksCardiac 4 weeksNeuro 4 weeksENT / Eyes 4 weeksGeneral Surgery 4 weeksChronic & Acute Pain 4 weeksSpecific Teaching Modules:Examination training practical and theoretical. 1 monthExamination leave 2 weeksSecond year Specialist Registrar Optional experience YearGeneral anesthetic practice 3 monthsSpecialised Anaesthetic Practice eg ITU 3 monthsResearch - Day time release 6 monthsSpecial experience alternative 1 yearThird year Specialist Registrar General experience YearPaediatric Anaesthesia [ inc. neonates] 3 monthsCardiac & Thoracic Anaesthesia 2 monthsNeuro - Anaesthesia 2 monthsAcute & Chronic Pain 2 monthObstetric Anaesthesia 1 monthITU / Trauma / Transfer 2 monthsSpeciality BlockSpecial Experience module A 6 monthsSpecial Experience module B 6 months 3
  4. 4. Year 3First year Specialist RegistrarLearning plan Clinical Skills List Competent: Advanced ITU / Complex obstetric cases Learning: Complex monitoring methods - Skilled in: Awareness / evoked potentials etc Major complex anaesthetic areas - emergency anaesthesia Cardiac & Neuro & Neonates elective anaesthesia for major surgery Theoretical Skills List ACLS / ACLS + APLS Skilled in: self awareness - clinically & academically Comprehensive obstetric care in the evaluation of current advances in anaesthetic practice Acute & Chronic pain control in the preparation for the final FRCA General Intensive care Competent: in developing CME in teaching small groups Invasive procedures and non-theatre based anaesthesia in the assessment of SHOsyears 1 & 2 Learning: administration & management issues involvment in the Rota organisation Communication Skills List: Skilled: Clinical scenario presentation Verbal & written presentation Presentation skills for Vivas Competent: Small group teaching and assessment leading tutorials Learning: to teach anaesthetic skills & knowledge to experienced SHOs to develop appraisal skills Local Assessment: Pass the final FRCA examination Completed successfully the ACLS / APLS / ATLS Completion of the Diploma course 4
  5. 5. First year Specialist RegistrarClinical Experience Objectives of Training: To become a skilled member of the 2nd On-Call rota. To become skilled in emergency anaesthesia To maintain skills in caring for the unconscious patient To maintain skills in IV access, and airway control To maintain skills in providing effective pain control To become skilled in providing epidural / spinal anaesthesia To become competent in providing anaesthetic care for ASA 4+ patients To learn cardiac & neuro anaesthesia Specific Clinical Experience The exposure to all sub-specialities of anaesthesia before the attempt at the final FRCA is necessary - providing that adequate theoretical and clinical teaching has been achieved. The content of these modules can easily be met by longer / shorter blocks, and there is no reason for them not to be combined. The experience in ITU, obstetrics, cardiac, neuro and paediatric anaesthesia must be in blocks. The remaining half of the timetable can be flexibly organised and monitored by means of the logbook.If a modular system is chosen the relative lengths of experience should be:Speciality Block Duration of ModuleObstetric unit 4 weeksIntensive care unit 4 weeksMaxillo-facial surgery 4 weeksPaediatric Anaesthesia 4 weeksUrology 4 weeksCardiac 4 weeksNeuro 4 weeksENT / Eyes 4 weeksGeneral Surgery 4 weeksChronic & Acute Pain 4 weeksSpecific Teaching Modules1 Examination training - practical & theoretical - 1 month2 Examination leave 2 weeksNB: No more than 70% of the week can be dedicated to these formal guidelines.Allowance for holidays, study leave and post On-call time is mandatory. 5
  6. 6. Year 4Second year Specialist Registrar (Optional experience year)Learning planTrainees may present a wide variety of programmes for approval as options. 1. A remedial programme aimed at the FRCA or some deficiency. 2. Appropriate experience of another speciality. 3. Appropriate research experience. 4. Appropriate experience in another centre. Clinical Skills List Consolidation of clinical skills & the development of special interests. Skilled in delegation of tasks to the appropriate on call colleague. Development of additional skills in specialised techniques eg echocardiography. Theoretical Skills List Consolidation of educational skills & the development of research skills Further attempts at the final FRCA if necessary Develop an understanding of educational & basic scientific research Undertake a project [6 months] Communication Skills List: Able to lead and direct effectively Developing skills in changing established practice Local Assessment: RITA 6
  7. 7. Second year Specialist RegistrarClinical Experience Objectives of Training: To maintain all transferable skills To become competent in the management of medically compromised patients To learn research methodology, and teaching methodology To seek experience in another region or overseas. Specific Clinical Experience - This year may be necessary for remedial attempts at the final FRCA, but for the majority of trainees it should be used to provide for their individual development in anaesthesia and to allow ‘time out’ for research, or the completion of a Diploma Course for example. The content of these modules can easily be met by longer / shorter blocks, and there is no reason for them not to be combined. Trainees can offer any plan of work for consideration.If a modular system is chosen the relative lengths of experience should be:Speciality Block Duration of ExperienceGeneral anaesthetic practice 3 monthsSpecialised Anaesthetic Practice eg ITU 3 monthsResearch - Day time release 6 monthsSpecific Teaching Modules12NB: No more than 70% of the week can be dedicated to these formal guidelines.Allowance for holidays, study leave and post On-call time is mandatory. 7
  8. 8. Year 5Third year Specialist RegistrarLearning plan Clinical Skills List Consolidation of clinical skills Experience of the major anaesthetic sub-specialities Theoretical Skills List Skilled: Continuing self assessment & education Competent: Developing management skills Learning: Financial / contracting issues Communication Skills List: Skilled: Teaching transferable skills Individualised education of colleagues & other trainees Competent: Self presentation Local Assessment: Appraisal by Regional Panel Membership of a speciality association 8
  9. 9. Third year Specialist Registrar (‘General Experience’ Year)Clinical Experience Objectives of Training: To maintain and consolidate all transferable skills To become skilled in the management of medically compromised patients To become skilled in the management of an anaesthetic department To become skilled in training and teaching To become competent in negotiation skills Specific Clinical Experience - This year should provide, within a stable time and geographical frame, experience in all of the major specialitites of anaesthesia. The time allocated to each area reflects the wieghting of the Regional Working Party for General Specialist training - the time to develop high level skills is provided in the year 4. The arrangement of this year must be modular.If a modular system is chosen the relative lengths of experience should be:Speciality Block Duration of ModulePaediatric Anaesthesia [ inc. neonates] 3 monthsCardiac & Thoracic Anaesthesia 2 monthsNeuro - Anaesthesia 2 monthsAcute & Chronic Pain 2 monthObstetric Anaesthesia 1 monthITU / Trauma / Transfer 2 monthsNB: No more than 70% of the week can be dedicated to these formal guidelines.Allowance for holidays, study leave and post On-call time is mandatory. 9
  10. 10. Year 6Fourth year Specialist Registrar (Special experience year)Learning plan Clinical Skills List Highly skilled in two [ rarely one] speciality areas Theoretical Skills List Completely able in CME Expertise in medical education - able to start a small teaching unit Communication Skills List: Skilled in negotiation politically aware Skilled in interview & pre-interview presentation Local Assessment: CCST Appointable to a small teaching hospital Appointable to a Post CCST Fellowship in a major speciality 10
  11. 11. Fourth year Specialist Registrar (‘Special Experience’ Year)Clinical Experience Objectives of Training: To maintain and consolidate all transferable skills To become highly skilled in the management of two areas of specialised anaesthetic practice. To become skilled in the management of an anaesthetic department To become skilled in training and teaching To become skilled in interview techniques - for either Post CCST fellowships or NHS Consultant Posts To become competent in negotiation skillsSpecific Clinical Experience -This year should provide, within a stable time and geographical frame, experience in two of the majorspecialitites of anaesthesia [ for some specialty areas - ITU and Cardiac anaesthesia - a full year based in allof the regions units will be needed. However, the CCST requirements relating to dual registration of trainingtime must be taken into account when planning these long modules].Speciality Block Duration of ModuleSpecial Experience module A 6 monthsSpecial Experience module B 6 monthsNB: No more than 70% of the week can be dedicated to these formal guidelines.Allowance for holidays, study leave and post On-call time is mandatory. 11
  12. 12. Further training for those intending a career in Obstetric Anaesthesia.1. Optional year Those interested could take either all or part of their optional year in a course ofstudy which relates to obstetric anaesthetic practice. Possible options are: 1. Experience as an SHO in an obstetric or neonatal post. 2. Experience in a suitable unit elsewhere in the UK or overseas. 3. Research relating to obstetric anaesthesia. 4. Teaching or management training with emphasis on obstetrics.A trainee could present a proposal of any sort for consideration.2. Special experience year. The trainee would spend up to six months in obstetric anaesthetic practice.They would present a proposal to a supervisor who would oversee their training throughout this period.Further training for those intending a career in Intensive Care.1. Optional year Those interested could take either all or part of their optional year in a course ofstudy which relates to intensive care practice. Possible options are: 1. Experience as an SHO in an appropriate post. 2. Experience in a suitable unit elsewhere in the UK or overseas. 3. Research relating to intensive care. 4. Teaching or management training with emphasis on the ITU.A trainee could present a proposal of any sort for consideration.2. Special experience year. The trainee would spend up to six months in intensive care. They wouldpresent a proposal to a supervisor who would oversee their training throughout this period. The trainee couldspend a year in a specialised ITU post. 12
  13. 13. 2. Obstetric Anaesthesia and Analgesia 13
  14. 14. Specific obstetric anaesthetic ExperienceFor all trainees:Second three months 1 week10-18 months 6 weeks1st year Specialist Registrar 4 weeks3rd year Specialist Registrar 4 weeksFor specialist obstetric anaesthetists:Research opportunity etc. 1 year4th year Specialist Registrar 6 monthsThe practice of specialist obstetric anaesthesia is taught by a series of full time secondments combined withrepeated experience of obstetric practice in the course of day to day work. It is important that some of theuncommitted day time work throughout training is spent on obstetric anaesthesia and that there iscontinuous experience of on call work in the maternity unit.Special experience blocks:During special experience blocks the equivalent to a whole working week should be devoted to the maternityunit so that the trainee can become part of the maternity team.Second three months:A week of obstetric observation is provided at this point so that trainees learn something of the place ofobstetric anaesthetic in the tasks of the anaesthetic department.6-18 months:The six week attachment to the obstetric unit should be provided at this time. By the end of this attachmentthe trainee should be competent to provide anaesthetic cover for the maternity unit. He or she will continueto be on call for obstetric units as required throughout their training. Emphasis should be placed on continuityof care, planning of obstetric care and the team approach to care in childbirth.1st year Specialist Registrar:A four week attachment allows the trainee to have more experience of continuity in maternity care. Specificlearning objectives are directed towards the management of obstetric complications.3rd year Specialist Registrar:In this attachment trainees complete their training in the management of high dependency and critical care inobstetrics. They should also consider the issues of organising and managing an obstetric anaestheticservice.Trainees proposing a speciality interest in obstetric anaesthesia will undertake further attachments in thefinal registrar year.Units offering experience:SHO attachments can be to any recognised obstetric unit.The first year Specialist Registrar attachment must be to a unit which runs a separate continuous obstetriccall service, has more than 1500 deliveries per annum and offers an on demand obstetric analgesia service.Such units should also have a lead obstetric anaesthetic consultant with sessions devoted to the service,hold combined morbidity meetings and keep obstetric audit records.The third year Specialist Registrar attachment must be to a unit with over 3000 deliveries per annum andspecialised critical care facilities for obstetrics. Special care facilities should include the routine care ofseverely ill neonates.Training for those expressing a speciality interest in obstetrics will continue under the supervision of anamed obstetric anaesthetic specialist. 14
  15. 15. First year SHOSecond three months 1 week - IntroductionObstetric Learning Plan Theoretical Knowledge Learning: Normal labour Pain relief in labour Anaesthesia for caesarean section Communication Skills List Learning: The role of maternal choice in obstetric analgesia. History taking Examinations Discussion of options - pain relief in labour for Caesarean section Consent Local Assessment Informal feedback 15
  16. 16. First year SHOSecond three months 1 weekObstetric Clinical experience Specific Clinical Experience One weeks introduction to obstetric anaesthesia Objectives of Training Introduction to obstetric analgesic practice Introduction to anaesthesia for caesarean section 16
  17. 17. Second year SHO10-18 months 6 weeksObstetric Learning Plan Theoretical Knowledge Learning: The mechanisms of pain in relation to labour. Relevant anatomy of the pelvis and perineum. Nerve supply of abdomen, pelvis and perineum. Anatomy of the vertebral column, spinal cord and meninges. Indications and contraindications of epidural anaesthesia. The effect of epidural anaesthesia on the mother, the labour and the baby. Epidural anaesthesia in abnormal delivery (breech, malpresentations, previous section, trial of labour). The anatomy and functions of the placenta. Gas exchange across the placenta, double Bohr and Haldane effects, foetal haemoglobin. The changes in maternal physiology with pregnancy. Changes in foetal circulation at birth. The effects of drugs on the foetus. The patho-physiology of PIH and eclampsia. Understand the mechanism of action of oxytocics and prostaglandin. Fetal monitoring in labour. Anaesthesia in early pregnancy. Medical diseases complicating pregnancy. Antenatal assessment of the pregnant woman. Anaesthesia for operative obstetrics. Emergencies in obstetrics. Maternal morbidity and mortality. Neonatal resuscitation. Communication Skills List Learning: How to discuss anaesthetic management in pregnancy with patients. Working with midwives as independent professionals. The team approach to management of labour. Keeping proper obstetric analgesia records. Local Assessment Able to establish an epidural for management of pain in an uncomplicated labour. Able to give a safe anaesthetic for caesarean section, both GA and Regional. Assessment of communication skills. Ability to keep good quality records. 17
  18. 18. SHO6-18 months 6 weeksObstetric Clinical Experience Specific Clinical Experience - Six weeks experience in an obstetric unit with over 1500 deliveries per annum. Must have a designated anaesthetist in charge of obstetric anaesthesia. Must have at least 5 consultant sessions allocated to obstetrics. Must run an on request obstetric epidural service. Practical exposure to neonatal resuscitation if no previous experience in this area.The trainee will begin obstetric anaesthetic first on call during this six week secondment. He or she will thencontinue to be on call forobstetrics as required throughout their training.The substantial part of this training time must be during consultant obstetric anaesthetist sessions. Objectives of Training Ability to manage pain relief in labour. Administration of general and regional anaesthesia for obstetric routine and emergency cases. To become competent to be 1st on call for obstetrics. 18
  19. 19. Third Year TraineeFirst year Specialist Registrar 4 weeksObstetric Learning Plan Clinical Skills List Skilled in: All aspects of planning and managing pain relief in labour. Regional anaesthesia for labour and operative obstetrics. Management of complications of regional anaesthesia in obstetrics. Management of anaesthesia for Caesarean section, regional and general. Spinal anaesthesia. Anaesthesia for operative vaginal delivery. Anaesthesia for retained placenta. Competent in: Managing ante-partum haemorrhage. Managing post partum haemorrhage. The management of patients with PIH/pre-eclampsia Coping with intercurrent maternal disease. Understanding the problems of the at risk baby. Severe obstetric haemorrhage. Obstetric anaesthetic management of multiple birth. Learning: High dependency care in obstetrics. Dealing with the high risk patient (mother and baby) Neonatal resuscitation. Diagnosis and management of severe pre-eclampsia. Communication Skills List Skilled: How to discuss anaesthetic management in pregnancy with patients. Working with midwives as independent professionals. The team approach to management of labour. Keeping proper obstetric analgesia records. Competent: Presentation of a case study. Presentation to multi-disciplinary meeting. Personal Time Management and Prioritisation. Local Assessment Formal feedback from consultants. 19
  20. 20. Third year TraineeFirst Year Specialist Registrar 4 weeksObstetric Clinical experience Specific Clinical Experience - Module Four weeks experience with responsibilities developing from those of the previous year. At least one of the main attachments should be in a unit with more than 3000 deliveries per year. Objectives of Training To become a competent member of the team for obstetric care. To recognise and manage common complications and exercise proper judgement in asking for help. To consolidate management of obstetric anaesthesia. To be able to supervise and teach a less experienced trainees. 20
  21. 21. Fifth year TraineeThird Year Specialist Registrar 4 weeksObstetric Learning Plan Theoretical Knowledge Skilled in: The anatomy, physiology, pathology and pharmacology of labour. Competent: Use of audit. Learning: The pathophysiology of major complications in obstetrics. Legal aspects of record keeping. Clinical Skills List Skilled in: Obstetric anaesthetic care. Management of pain in labour. Competent in: Management of major complications of childbirth. Management of obstetric high dependency. Management of severe pre-eclampsia and eclampsia. Resuscitation and preparation for transfer of critically ill mother. Learning: Intensive care of the obstetric patient including transfer. Life threatening liver, kidney and heart failure in pregnancy. Communication Skills List Skilled in: As aspects of communicating with obstetric patients. All aspects of communicating with obstetric are team. Competent: Communicating with relatives when things are going wrong. Record keeping and audit. Learning: How to organise systems and protocols for team care. Completing the cycle in obstetric anaesthetic audit. Role of obstetric anaesthetist in antenatal education. Dealing with complaints. Local Assessment Informal feedback with consultants. 21
  22. 22. Fifth year TraineeThird year Specialist Registrar 4 weeksClinical experience Specific Clinical Experience - The placement should be in a centre with tertiary referrals for obstetrics and high level Special Care facilities for babies. Obstetric of Training To be a skilled member of the obstetric care team. To learn how to run an obstetric anaesthetic in a large and small obstetric unit. Management of patients in obstetric high dependency. Management of obstetric patients in ITU. 22
  23. 23. Further training for those intending a career in Obstetric AnaesthesiaSecond Year RegistrarThose interested could apply to pursue an optional course of study during part or all of their SpR 2 year.Possible options are:Experience as an SHO in an obstetric or neonatal post.Experience in a suitable unit elsewhere in the UK or overseas.Research relating to obstetric anaesthesia.Teaching of management training with emphasis on obstetrics.Management of obstetric anaesthetic service.A trainee could present a proposal of any sort for consideration.Fourth Year SpRThe trainee would spend up to six months in obstetric anaesthetic practice. They would present a proposalto a supervisor who would oversee their training throughout this period. 23
  24. 24. 3. Critical Care Medicine 24
  25. 25. Specific Intensive Care ExperienceFor all trainees:Second three months 3 weeks7-9 months 4 weeks10-18 months 4 weeks18-24 months 6 weeks1st Year Specialist Registrar 4 weeks3rd Year Specialist Registrar 8 weeksFor specialist Intensivists:Research opportunity etc. 1 year4th Year Specialist Registrar 6 months or 1 yearThe practice of Intensive Care Medicine is taught by a series of full time secondments combined withintermittent periods of on-call attachments during other periods.Specialist Experience BlocksSecond Three MonthsThis is primarily an orientation period. The trainee will be expected to accompany an SHO working on theUnit to learn something of the day to day functioning of an Intensive Care Unit. In addition, he willaccompany the member of the ICU team who attends cardiac arrest and trauma calls to observe andpractice immediate care of the critically ill patient. There will be a strong emphasise on formal teaching,aiming to complement training in general anaesthesia as much as possible.The general learning objectives for this attachment are:-To learn to recognise and assess the sick patientTo be competent at immediate care provisionMonths 7-9During this attachment the trainee will start to become an active member of the ICU team. Though still noton the on call team, he will function as the day resident for the ICU, working closely with a more senior SHO.The trainee will be responsible for the maintenance of the medical records for specific patients and will beresponsible for ensuring hand-over of these patients to the on-call team. This attachment will involve thepresentation of a case (with discussion) at a departmental meeting.The general learning objectives for this period areTo learn the management of the elective postoperative patientTo learn skills required to function as “on-call” resident for ICUMonths 10-18The trainee will commence ICU on-call during this attachment and will play a more active role on the ICUduring the day, including the informal teaching of junior SHO’s. In addition, he will carry the cardiac arrestbleep and will be available for trauma calls and ward referrals. Assessment of this module will involve acritical review of recent ICU literature at a departmental journal club. The general learning objectives of thisblock are:To learn management of the emergency post-operative patientTo learn the management of a patient with single organ failureTo learn advanced Intensive Care techniques 25
  26. 26. Months 18-24This 6 week attachment is an opportunity for the SHO to consolidate his ICU teaching and experience. Hewill be a fully functional member of the ICU team during both day and night. It is suggested that eachtrainee should consider preparing a piece of work for submission for the NEICS Trainees Prize. This couldbe done individually or as a group. The general learning objectives for this attachment are:To learn to recognise the patient for whom ICU admission is beneficial.To learn management of the multi-organ failure patient.To be introduced to the principles of management of the critically ill child or obstetric patientTo be introduced to the management of death/withdrawal of active therapy.SpR Year 1This is a 4 week attachment which will precede the final FRCA. Though he will function as ICU resident on-call at night, the trainee will be encouraged to accept more responsible duties during the day. He will beexpected to start taking the working ward round in the morning under the supervision of an ICU consultant -the assessment of this module will take the form of managing a working ward round. In addition, wardreferrals will be made through him and he will be encouraged to assess and manage the patient prior toadmission to the ICU (with appropriate levels of supervision). He will carry the trauma bleep and will beactively involved in the management of the patient during the golden hour. The general learning objectivesof this attachment are:To learn the management of the multi-trauma patient.To learn the principles of ethics and the law in the ICU.To learn the principles of man-power management.To learn the principles of the routine running of an ICU.SpR Year 3During this 2 month attachment to the ICU, the trainee will be expected to learn about the provision ofIntensive Care services within the hospital. He will receive teaching on aspects of management andbudgeting skills and will be encouraged to demonstrate manpower management and delegation skills. Hewill play a more supervisory role on the ICU and will now be 2nd on call for the ICU at night. In addition, thetrainee will be encouraged to play an active role in the teaching and training of SHOs and SpR 1 trainees.Assessment of this module involves the management of a teaching ward round and preparation of an itemfor submission for the NEICS Trainees Prize - again this can be an individual piece of work or the result of agroup investigation. The general learning objectives for this attachment are:To learn the management of the teaching ward round.2. To learn the principles of management and financial issues. 26
  27. 27. First Year SHO (4-6 months) - 3 Week PeriodLearning plan for Intensive Care Medicine Clinical Skills List: Competent in: Immediate care of the critically ill patient (i.e. first 20 mins) A B C skills ACLS treatment algorithms Learning: Recognition and assessment of the sick patient Interpretation of clinical data: ABG, biochemistry, haematology (including acquired coagulopathy), CXR, ECG Obtaining and maintaining a safe airway in the ICU patient. Fluid balance and sedation/analgesia in ICU patients Theoretical Skills List: Learning: Physiology and Pharmacology as relevant to ITU: Cardiovascular Sedation and Analgesia Respiratory Oxygen therapy Renal Neuromuscular blocking agents Invasive monitoring - normal values and waveforms Communication Skills Competent in: Hand-over of the uncomplicated ICU patient to colleagues Maintenance of good, accurate ICU clinical records Learning: Case presentation Communication with other health-care professionals Local Assessment No formal assessment apart from feed-back interview at end of attachment 27
  28. 28. Second Year SHO (7-9 months) - 4 Week PeriodLearning Plan Clinical Skills List Skilled in: Immediate care of the critically ill patient (first 20 mins) Interpretation of clinical data Aseptic technique Maintenance of good clinical records Competent in: Recognition and assessment of the sick patient Insertion of arterial catheters Fluid balance and sedation/analgesia in ICU patients Learning: Management of the elective (uncomplicated) post-operative patient Establishing an airway - oro-tracheal versus naso-tracheal Commencing mechanical ventilation Setting up and checking an ICU ventilator, syringe pumps and volumetric devices Recognition of the need for advanced investigations e.g. CT scan, ultrasound etc. The use of blood and blood products on ICU Insertion of central venous catheters Chest drain insertion, vascular access catheters (inc. TPN lines) Theoretical Skills List Competent in: Basic Physiology and Pharmacology as relevant to ITU Invasive monitoring - normal values and waveforms Learning: Further physiology and pharmacology Hepatic Inotropes - indication for use Neurological Infection control and antibiotic policies Temperature control Nutrition - enteral and TPN Pathophysiology in ICU - an introduction to single-organ failure respiratory failure cardiac failure renal failure Invasive monitoring - abnormal values and waveforms Modes of ventilation - IPPV, SIMV, Pressure Controlled, PEEP, CPAP Monitoring of respiratory mechanics during mechanical ventilation Scoring systems and their place in the ICU Communication Skills List Skilled in: Hand-over to colleagues of uncomplicated patients Maintenance of good accurate clinical records Competent in: Hand-over to colleagues of complex patients Case presentation Learning: Patient and relative interviews. Local Assessment: Case presentation to departmental meeting. 28
  29. 29. Second Year SHO (10-18 months) - 4 Weeks PeriodLearning Plan Intensive Care Medicine Clinical Skills List Skilled in: Immediate care of the critically ill patient (first 20 mins) Recognition and assessment of the sick patient Interpretation of clinical data Insertion of arterial catheters Fluid balance and sedation/analgesia in ICU patients Competent in: Management of the elective (uncomplicated) post-operative patient Establishing an airway - oro-tracheal versus naso-tracheal Insertion of central venous catheters Commencing mechanical ventilation Setting up and checking an ICU ventilator, syringe pumps and volumetric devices Recognition of the need for advanced investigations e.g. CT scan, ultrasound etc. The use of blood and blood products on ICU Chest drain insertion, vascular access catheters (inc. TPN lines) Learning: Management of the emergency post-operative patient Management of the single organ failure patient Preparation for and management of the intra-hospital transfer of a critically ill patient Advanced airway management - mini-tracheostomy, percutaneous tracheostomy Insertion and use of pulmonary flotation catheters Indications for and insertion of trans-venous pacemaker wires Management of post-resuscitation phase - including cerebral protection Weaning from mechanical ventilation Theoretical Skills List Skilled in: Physiology and Pharmacology as relevant to ITU Invasive monitoring - normal values and waveforms Competent in: Pathophysiology in ICU - single-organ failure Modes of ventilation - IPPV, SIMV, CPAP, PEEP. Invasive monitoring - abnormal values and waveforms Monitoring of respiratory mechanics during mechanical ventilation Scoring systems and their place in the ICU Learning: Pathophysiology in ICU - single-organ failure continued: Neurological failure including encephalopathies Coagulopathies Hepatic failure Pathophysiology: multi-organ failure Sepsis syndrome/septic shock ARDS Inotropes - application Organ support techniques - CVVH, CVVHD, IABP, ECMO Advanced modes of ventilation- pressure controlled, pressure support, inverse ratio, BIPAP/APRV, HFJV. Ethical and legal issues as relevant to ICU - introduction Communication Skills List Skilled in: Patient hand-over to colleagues. Case presentation. Maintenance of good accurate clinical records Competent in: Patient/relative interviews. Communication with other health-care professionals Learning: Teaching Stage I ICU trainees Local Assessment Critical review of paper(s) from recent ITU literature 29
  30. 30. Second Year SHO (18-24 months) - 6 Week PeriodLearning Plan Intensive Care Medicine Clinical Skills List Skilled in: Immediate care of the critically ill patient (first 20 mins) Recognition and assessment of the sick patient Management of the elective (uncomplicated) post-operative patient Establishing an airway - oro-tracheal versus naso-tracheal Commencing mechanical ventilation Interpretation of clinical data Recognition of the need for advanced investigations e.g. CT scan, ultrasound etc. Insertion of arterial and central venous catheters Fluid balance and sedation/analgesia in ICU patients Setting up and checking an ICU ventilator, syringe pumps and volumetric devices The use of blood and blood products on ICU Chest drain insertion, vascular access catheters (inc. TPN lines) Competent in: Management of the emergency post-operative patient Management of the single organ failure patient Preparation for and management of the intra-hospital transfer of a critically ill patient Insertion and use of pulmonary flotation catheters Indications for and insertion of trans-venous pacemaker wires Management of post-resuscitation phase - including cerebral protection Learning: Recognition of the patient who will benefit from ICU admission Recognition of the patient for whom further ICU management is futile Management of the multi-organ failure patient Management of the brain dead organ donor Management of the near-drowning, drug and substance overdose patient Preparation for and management of the inter-hospital transfer of a critically ill patient Advanced airway management - mini-tracheostomy, percutaneous tracheostomy Weaning from mechanical ventilation 30
  31. 31. Theoretical Skills ListSkilled in:Physiology and Pharmacology as relevant to ITUInvasive monitoring - normal values and waveforms, abnormal values and waveformsPathophysiology in ICU - single-organ failureModes of ventilation - IPPV, SIMV, , CPAP, PEEP.Monitoring of respiratory mechanics during mechanical ventilationScoring systems and their place in the ICUCompetent in:Pathophysiology - multi-organ failureInotropes - applicationOrgan support techniques - CVVH, CVVHD, IABP, ECMOAdvanced modes of ventilation- pressure controlled, pressure support, inverse ratio,BIPAP/APRV, HFJV.Learning:Physiology, pathophysiology and pharmacology in paediatric and obstetric ICU practiceEthical and legal issues as relevant to ICUIndications for Brain Death TestingHazards of electrical and other equipment on the ICU.Communication Skills ListSkilled in:Patient hand-over to colleaguesCase presentationMaintenance of good accurate clinical recordsPatient/relative interviewsCommunication with other health-care professionalsCompetent in:Teaching Stage I traineesLearningCommunication with relatives - breaking bad newsCommunication with Coroners Officers and other official bodies.Local AssessmentEntry for the NEICS Trainees Prize (or equivalent) 31
  32. 32. First Year Specialist Registrar- 12 Weeks in 3 PeriodsLearning Plan Intensive Care Medicine Clinical Skills List Skilled in: Recognition and assessment of the sick patient Management of the elective (uncomplicated) post-operative patient Management of the emergency post-operative patient Management of the single organ failure patient Establishing an airway - oro-tracheal versus naso-tracheal Commencing mechanical ventilation Interpretation of clinical data Recognition of the need for advanced investigations e.g. CT scan, ultrasound etc. Insertion of arterial and central venous catheters Insertion and use of pulmonary flotation catheters Fluid balance and sedation/analgesia in ICU patients Setting up and checking an ICU ventilator, syringe pumps and volumetric devices The use of blood and blood products on ICU Chest drain insertion, vascular access catheters (inc. TPN lines) Indications for and insertion of trans-venous pacemaker wires Management of post-resuscitation phase - including cerebral protection Competent in: Recognition of the patient who will benefit from ICU admission Preparation for and management of the inter-hospital transfer of a critically ill patient Recognition of the patient for whom further ICU management is futile Management of the brain dead organ donor Management of the near-drowning, drug and substance overdose patient Weaning from mechanical ventilation Learning: Management of the multi-organ failure patient Management of the sick child and the critically ill obstetric patient (in combination with training in obstetric and paediatric anaesthesia) Management of the post-operative cardiothoracic patient (in combination with training in cardiothoracic anaesthesia) Management of the multi-trauma patient principles, initial assessment and immediate management, including triage identification and immediate treatment of life threatening injuries neurological assessment, role of ICP monitoring and management of raised ICP assessment and management of burns and their physiological consequences recognition and management of fat embolism Diagnostic and therapeutic fibreoptic bronchoscopy 32
  33. 33. Theoretical Skills ListSkilled in:Physiology and Pharmacology as relevant to ITUInvasive monitoring - normal values and waveforms, abnormal values and waveformsPathophysiology in ICU - single-organ failureModes of ventilation - IPPV, SIMV, CPAP, PEEP.Advanced modes of ventilation- pressure controlled pressure support, inverse ratio,BIPAP/APRV, HFJV.Monitoring of respiratory mechanics during mechanical ventilationInotropes - applicationOrgan support techniques - CVVH, CVVHD, IABP, ECMOScoring systems and their place in the ICUCompetent in:Pathophysiology - multi-organ failureIndications for Brain Death TestingLearning:Physiology, pathophysiology and pharmacology in paediatric practice, obstetrics.Ethical and legal issues as relevant to ICU.Communication Skills ListSkilled in:Patient hand-over to colleaguesCase presentationMaintenance of good accurate clinical recordsPatient/relative interviewsCommunication with other health-care professionalsTeaching Stage I traineesCompetent in:Communication with relatives - breaking bad newsCommunication with Coroners Officers and other official bodiesLearning:Management of the working ward roundManpower managementLocal AssessmentSuccess in the FRCAManagement of a working ward round 33
  34. 34. Third Year Specialist Registrar (General Experience Year) - 8 Weeks PeriodLearning Plan Intensive Care Medicine Clinical Skills List Skilled in: Recognition and assessment of the sick patient Recognition of the patient who will benefit from ICU admission Recognition of the patient for whom further ICU management is futile Management of the elective (uncomplicated) post-operative patient Management of the emergency post-operative patient Management of the single organ failure patient Management of the near-drowning, drug and substance overdose patient Establishing an airway - oro-tracheal versus naso-tracheal Commencing mechanical ventilation Interpretation of clinical data Recognition of the need for advanced investigations e.g. CT scan, ultrasound etc. Insertion of arterial and central venous catheters Insertion and use of pulmonary flotation catheters Fluid balance and sedation/analgesia in ICU patients The use of blood and blood products on ICU Chest drain insertion, vascular access catheters (inc. TPN lines) Indications for and insertion of trans-venous pacemaker wires Setting up and checking an ICU ventilator, syringe pumps and volumetric devices Preparation for and management of the intra-hospital transfer of a critically ill patient Management of post-resuscitation phase - including cerebral protection Competent in: Management of the multi-organ failure patient Brain death testing Weaning from mechanical ventilation Learning: Management of the sick child and the critically ill obstetric patient (in combination with training in obstetric and paediatric anaesthesia) Management of the post-operative cardiothoracic patient (in combination with training in cardiothoracic anaesthesia) Management of the multi-trauma patient principles, initial assessment and immediate management, including triage identification and immediate treatment of life threatening injuries neurological assessment, role of ICP monitoring and management of raised ICP assessment and management of burns and their physiological consequences recognition and management of fat embolism Diagnostic and therapeutic fibreoptic bronchoscopy Management of the brain dead organ donor 34
  35. 35. Theoretical Skills ListSkilled in:Physiology and Pharmacology as relevant to ITUInvasive monitoring - normal values and waveforms, abnormal values and waveformsPathophysiology in ICU - single-organ failure and multi-organ failureModes of ventilation - IPPV, SIMV, CPAP, PEEP.Advanced modes of ventilation- pressure controlled, pressure support, inverse ratio,BIPAP/APRV, HFJV.Monitoring of respiratory mechanics during mechanical ventilationInotropes - applicationOrgan support techniques - CVVH, CVVHD, IABP, ECMOScoring systems and their place in the ICUPhysiology, pathophysiology and pharmacology in paediatric practice, obstetricsIndications for Brain Death TestingHazards of electrical and other equipment on the ICULearning:Ethical and legal issues as relevant to ICUManagement and budgeting skills on the ICUCommunication Skills ListSkilled in:Patient hand-over to colleaguesCase presentationMaintenance of good accurate clinical recordsPatient/relative interviewsCommunication with other health-care professionalsCommunication with relatives - breaking bad news, withdrawing treatmentCommunication with Coroners Officers and other official bodiesTeaching Stage I traineesCompetent in:Management of the working ward roundLearning:Manpower management, delegation skillsManagement of the teaching ward roundAssessmentEntry for the NEICS Trainees PrizeManagement of a Teaching ward roundOrganisation of a departmental journal club meeting, including presentation 35
  36. 36. 4. Anaesthesia for ENT, Maxillo-Facial, Oral, Dental and Plastic surgery 36
  37. 37. Training in anaesthesia for ENT, maxillo-facial, oral, dental and plastic surgical sub-specialities.These specialities have been grouped together because they are complementary and in many regardsrequire similar and complementary skills. Initial training places emphasis on complex airway managementskills; later training focuses on speciality operations and apparatus.At the SHO level it is suggested that these specialities are taught in dedicated blocks. This is so thatconsistent experience of airway and paediatric skills can be obtained. It must be stressed however thatsome of the general experience in the form of non teaching lists which the trainee does at other times shouldbe in these areas and will form part of their learning plan.It is particularly important that trainees understand the treatment of emergencies in these areas and whilstthe basic principles can be taught in theatre during routine lists experience will arise during on call time.Theatre teaching should therefore prepare the trainee to be able to handle dire emergencies.Formal training has been limited to the first three years of the training scheme as it is felt that a working skillshould have developed in all curriculum areas by that time. Extensive reinforcement and revision shouldcontinue throughout the last three years of training.Specific experience for ENT, Maxillo-facial, Plastic, Oral and Dental anaesthesia.SHO 1-3 Months 1 week ENTSHO 3-6 Months 4 weeks Combined ENT/Oral/Max-FacSHO 9-18 Months 4 weeks combined ENT/Max-Fac/PlasticSHO 18-24 Months 4 weeks Combined Plastic/Oral/Max-FacSHO 18-24 Months 2 weeks DentalSpR 1 Year 3 4 weeks ENT 37
  38. 38. First Year SHO Learning planENT / Maxillo-facial / oral / dental / plasticsFirst three monthsOne weeks observation and practice of ENT anaesthesiaThe trainee should be allocated to ENT lists which are largely concerned with short operations needingshared airway techniques. ENT lists include a number of children and this period of is important in thepaediatric anaesthesia training programme. Clinical Skills List Learning: Oral and nasal intubation. Spontaneous breathing intubated patients. How to deal with paediatric patients. Managing recovery when the airway is contaminated. Positioning for shared access surgery. Monitoring the patient when there is no access to the head during surgery. Theoretical Skills List Learning: The use of specialised endo-tracheal tubes. Design features of specialised tubes. Communication Skills List Learning: Talking to children. Local Assessment Informal 38
  39. 39. First year SHO Clinical ExperienceENT / Maxillo-facial / Oral/ Dental/ PlasticsFirst Three MonthsOne weeks observation and practice of ENT anaesthesia Objectives of training To learn about the problems of sharing the airway with the surgeon. To learn how to protect the contaminated airway throughout surgery and recovery. To begin learning about the special problems of paediatric anaesthesia. Specific Clinical Experience Anaesthesia for operations such as: tonsillectomy, adenoidectomy, SMR, laryngoscopy etc. Adult and paediatric patients Supervision: Trainees should work with direct senior supervision, preferably by consultants. 39
  40. 40. First Year SHO Learning planSecond three monthsENT / Maxillo-facial / oral / dental / plasticsFour weeks combined ENT, Maxillo-facial, Oral and Dental AnaesthesiaThe principal objective of this period of training is to learn how to manage a variety of patients for operationsin and around the airway. A good balance of specialities should be seen to ensure a comprehensive training. Clinical Skills List Learning: Skills of nasal intubation. Shared airway management. The surgical repertoire of these subspecialties including tonsillectomy, adenoids, polyps, SMR,grommets. Spontaneous breathing intubated patients. How to deal with paediatric patients. Managing recovery when the airway is contaminated. Positioning for shared access surgery. Monitoring the patient when there is no access to the head during surgery. Theoretical Skills List Learning: Shared airway problems. The use of specialised endo-tracheal tubes: armoured, Rae, tubes for laser surgery, etc.. Design features of specialised tubes. Communication Skills List Learning: Talking to children. Local Assessment Informal 40
  41. 41. First Year SHO Clinical ExperienceSecond three monthsENT / Maxillo-facial / Oral / Dental / PlasticsFour weeks combined ENT, Oral and Dental Anaesthesia Objectives of Training To learn about the problems of sharing the airway with the surgeon. To learn about the pre-operative assessment of patients for shared airway surgery. To learn how to protect the contaminated airway throughout surgery and recovery. To begin learning about the special problems of paediatric anaesthesia. To learn about post-operative pain relief in ENT and dental surgery. To learn about the complications of ENT and dental surgery. To learn about day and ambulatory surgery. Specific Clinical Experience A balance of ENT, oral and dental surgery. Supervision: Trainees should continue to be supervised directly wherever new techniques are encountered. 41
  42. 42. Second Year SHO Learning planNine to eighteen monthsENT / Maxillo-facial / Oral / Dental / PlasticsFour weeks combined experienceThis period of experience is intended to build upon the previous periods from the point of view of airwaymanagement. In ENT the experience should develop into aural surgery and there should be an emphasis onemergency surgery in maxillo-facial and plastics. There should be experience of major head and necksurgery. Clinical Skills List Competent : The problems of sharing the airway with the surgeon. The pre-operative assessment of patients for shared airway surgery. How to protect the contaminated airway throughout surgery and recovery. Post-operative pain relief in ENT and dental surgery. Learning: Endotracheal intubation in difficult circumstances. Indications for tracheostomy. The complications of ENT and dental surgery. Day and ambulatory surgery. Anaesthesia for aural surgery. Beginning to learn about major head and neck surgery. An introduction to major surgery on the airway: laryngectomy etc.. Control of blood pressure for major head and neck surgery. Less common procedures including laser surgery, micro-laryngeal surgery, aural surgery. Special considerations for plastic surgery. Anaesthesia for facial fractures. Theoretical Skills List Competent: In understanding the medical and surgical background of these surgical specialities. ENT emergencies: bleeding in the airway, obstruction, inhaled foreign bodies. Learning: Safety in laser surgery. Techniques of hypotensive anaesthesia. Communication Skills List Competent: In discussing surgical requirements with operators In case presentation. Written and verbal communication of anaesthetic material. Local Assessment List assessment in a speciality area 42
  43. 43. Second Year SHO Clinical ExperienceNine to eighteen monthsENT / Maxillo-facial / Oral / Dental / PlasticsFour weeks combined experience Objectives of Training To develop competent pre-operative anaesthetic assessment of patients for major subspecialty surgery of the head and neck. To develop an understanding of special techniques including deliberate hypotension. To develop competence as part of the on call team dealing with facial and jaw injuries. To develop more advanced airway skills in patients with difficult airway access. To learn blind intubation skills. To begin to use the fibre-optic laryngoscope. To learn to anaesthetise for tracheostomy. To develop skills in obtaining airway control in patients with upper airway obstruction. To develop skills in anaesthesia for micro-laryngeal surgery. To develop skills in ambulant dental anaesthesia. To begin to anaesthetise ENT emergencies. Specific Clinical Experience This module should be presented as a block of intensive experience in these areas of head and neck surgery. It is intended that a firm foundation is laid down and that intermittent experience in these areas will continue between specific specialityattachments. Supervision: During this period the level of supervision of the trainee should be gradually reduced. Help should still however always be available at close call. 43
  44. 44. Second Year SHO Learning planEighteen months to two yearsENT / Maxillo-facial / Oral/ Dental/ PlasticsMaxillo-facial / PlasticsFour weeks combined experience Clinical Skills List Skilled : The problems of sharing the airway with the surgeon. The pre-operative assessment of patients for shared airway surgery. How to protect the contaminated airway throughout surgery and recovery. Post-operative pain relief in plastic and maxillo-facial surgery. Learning: Care of the very difficult airway. Use of the fibre-optic laryngoscope. Managing major reconstructive surgery. Assessing and managing major blood loss. Theoretical Skills List Competent: In understanding the medical and surgical background of these surgical specialities. Learning: Detailed anatomy of the airway, nose, pharynx, larynx, trachea and bronchi. Communication Skills List Competent: In understanding the surgical background to these specialities. Deciding how to manage airway access. Learning: Understanding the scope of major head and neck interventions. Local Assessment List assessment in a speciality area Essay topics 44
  45. 45. Second Year SHO Clinical ExperienceEighteen months to two yearsENT / Maxillo-facial / Oral/ Dental/ PlasticsMaxillo-facial / PlasticsFour weeks combined experience Objectives of Training To develop competent pre-operative anaesthetic assessment of patients for major subspecialty surgery of the head and neck. To develop an understanding of special techniques including deliberate hypotension. To develop competence as part of the on call team dealing with facial and jaw injuries. To develop more advanced airway skills in patients with difficult airway access. To develop skills in obtaining airway control in patients with upper airway obstruction. Specific Clinical Experience This block continues head and neck and plastic surgical experience. Particular attention should be paid to major reconstructive surgery. Use of the fibre-optic laryngoscope should be taught. The trainee should be undertaking ENT emergencies if the hospital has them. Supervision: During this period the level of supervision of the trainee should be gradually reduced. Help should still however always be available at close call. 45
  46. 46. Second Year SHO Learning planEighteen months to two yearsENT / Maxillo-facial / Oral/ Dental/ PlasticsDental anaesthesiaTwo weeks experience Clinical Skills List Learning : The problems of sharing the airway with the surgeon intubated and un-intubated. The pre-operative assessment of patients for dental surgery. How to protect the contaminated airway throughout surgery and recovery. ET tube, laryngeal mask, nasal mask, nasal airway. Post-operative pain relief in dental surgery. Assessment and selection of patients for ambulant surgery. Techniques for chair side dental anaesthesia. Paediatric anaesthesia for ambulant dentistry. Complications of dental anaesthesia. The patient with truisms Theoretical Skills List Competent: In understanding the medical and surgical background of these surgical specialities. Learning: Detailed anatomy of the airway and teeth. Dental operative repertoire. Communication Skills List Competent: In discussing surgical requirements with operators . In talking to children in surgery situations. Assessment of day and ambulatory surgery. In case presentation. Written and verbal communication of anaesthetic material. Local Assessment Informal 46
  47. 47. Second Year SHO Clinical ExperienceEighteen months to two yearsENT / Maxillo-facial / Oral/ Dental/ PlasticsDental AnaesthesiaTwo weeks experience Objectives of Training To develop competent pre-operative anaesthetic assessment of patients for dental surgery including day stay and ambulant surgery. To learn how to give chair side anaesthetics for dental extractions. To understand anaesthesia outside the routine operating theatre environment. Specific Clinical Experience Allocation should be to a variety of dental lists ranging from in patient oral surgery to ambulant dentistry in the clinic and surgery setting. Dental emergencies. Abscess, trismus, acute dental pain. Supervision: During this period the level of supervision of the trainee should be gradually reduced. Help should still however always be available at close call. 47
  48. 48. First Year Registrar Learning planENT / Maxillo-facial / Oral/ Dental/ PlasticsFour weeks ENT experience.This first year registrar training can either be offered as separate blocks or as a single 12 week period. Thebalance of experience would then have to be carefully followed by means of the log book. Clinical Skills List Skilled in: The problems of sharing the airway with the surgeon. The pre-operative assessment of patients for shared airway surgery. How to protect the contaminated airway throughout surgery and recovery. Post-operative pain relief in plastic and maxillo-facial surgery. Learning: Care of the very difficult airway. Use of the fibre-optic laryngoscope. Managing major reconstructive and cancer surgery. Assessing and managing major blood loss. Laser surgery. Venturi and high frequency jet ventilation. Rigid bronchoscopy. Hypotensive anaesthesia. Theoretical Skills List Competent in: Airway management planning. Learning: How to deal with upper airway obstruction. Inhaled foreign body, epiglotitis, croup. Pharmacology and physiology of hypotensive surgery. Therapy of massive blood loss. Communication Skills List Skilled: Confers well with surgeons regarding appropriate anaesthesia. Learning: The team approach to major head and neck surgery. 48
  49. 49. First Year Registrar Clinical ExperienceENT / Maxillo-facial / Oral/ Dental/ PlasticsFour weeks ENT Objectives of Training To consolidate previous airway skills and to develop competence in more major interventions. To gain experience in new areas such as middle ear and laryngeal surgery. To extend generic skills in dealing with major surgery. Specific Clinical experience This experience must be offered as a block so that the trainee can concentrate on the special features of ophthalmology and ENT. It would however be appropriate to offer a 12 week block with combined experience in maxillo-facial, plastics and dental anaesthesia. Anaesthesia for common ENT procedures. Tonsillectomy, adenoids, nasal polyps etc.. Anaesthesia for rigid bronchoscopy and oesophagoscopy. Anaesthesia for mastoid surgery, tympanoplasty etc.. Anaesthesia for middle ear operations. Anaesthesia for laser surgery. Major head and neck surgery including laryngectomy. ENT emergencies. Foreign body in the airway. Bleeding in the airway. Upper respiratory obstruction. 49
  50. 50. First Year Registrar Learning planENT / Maxillo-facial / Oral/ Dental/ PlasticsSix weeks oral and maxillo-facial anaesthesia Clinical Skills List Competent in: Care of the airway in shared airway procedures. Planning appropriate anaesthetic techniques. Chair side dental anaesthesia. Learning: Major head and neck trauma management. Anaesthesia for fixing facial fractures. Assessment of the brain injured patient. Planning major head and neck surgery. Fibre-optic laryngoscopy. Anaesthesia for major dental procedures. Chair side dentistry. Theoretical Skills List Learning: ATLS trauma team management of patients with airway and facial injury. The history of chair side dentistry and the controversies that surround it. Communication Skills List Learning: To co-operate in a team for major head and neck surgery. To co-operate in a team for treatment of the patient with head and neck injuries. 50
  51. 51. First Year Registrar Clinical ExperienceENT / Maxillo-facial / Oral/ Dental/ PlasticsSix weeks oral and maxillo-facial anaesthesia Objectives of Training To develop skills in maxillo-facial, oral and dental surgery. Specific Clinical Experience There should be equivalent exposure to each speciality. This secondment can be combined to make a twelve week block. There should be adequate experience of chair side dentistry. 51
  52. 52. First Year Registrar Learning planENT / Maxillo-facial / Oral/ Dental/ PlasticsTwo weeks plastic surgery anaesthesia Clinical Skills List Learning: Anaesthesia for plastic surgery. The range of plastic surgery. Assessment of the burned patient. Anaesthesia for burns surgery. The emergency care of the burned patient. Airway management in burns. Injuries due to explosion. Theoretical Skills List Learning: The respiratory effect of burns. Carbon monoxide poisoning. Fluid management in burned patients ATLS management in the burned patient. Infection control in burns. Communication Skills List Learning: The problem of the severely burned patient. Talking to patients with mutilating injuries and burns. 52
  53. 53. First Year Registrar Clinical ExperienceENT / Maxillo-facial / Oral/ Dental/ PlasticsTwo weeks plastic surgery anaesthesia Objectives of training To learn the full range of plastic surgical procedures. Malignant disease, reconstructive, cosmetic and the treatment of burns. Techniques and management plans learnt in other areas will be transferred to plastic surgery. Special attention will be paid to the management of burns. Specific Clinical Experience Appropriate attachment to plastic surgical lists should be combined with some experience of a burns unit which will usually be in a supernumerary role. 53
  54. 54. Second, Third and Fourth Year Registrar Learning plan and Clinical Experience.ENT / Maxillo-facial / Oral/ Dental/ PlasticsSecond year registrar general and optional experienceA number of options are open to trainees during this year. Most trainees will have at least part of their yeardedicated to general training and during this period they will have regular experience related to thesespecialities. It is essential that varied experience takes place at this time.Research could be conducted in one of these speciality areas.Third year registrar general experience year.There are no specific secondments to these specialities during this general experience year but ad hoc workboth routine and emergency will continue.Fourth year registrar special experience year.During the final year trainees can opt for special experience in one or more of these specialities if they areexpressing a special interest for a consultant post. A supervisor would organise a suitable work plan with thetrainee. 54
  55. 55. 5. Pain Management 55
  56. 56. Training in Pain ManagementLearning about the management of acute pain and in particular post-operative pain begins immediately inthe SHO training curriculum. The logical use of analgesia services in recovery units and the role of acutepain teams must be taught. Where available some experience of the work of a chronic pain consultantshould be included in the week by week allocation prior to the formal 4 week secondment in the secondyear.There are subsequent block secondments to pain management services. Those wishing to develop a specialinterest will need to opt for additional experience.Units offering training in acute and chronic pain managementSHO’s should have experience of post-operative pain management in acute pain teams which include aConsultant in charge and pain team nurses. Where a unit with SHO training has no analgesia service asecondment to such a service should be made.Chronic pain management must take place in a unit with access to:1. Dedicated consultant sessions.2. An adequate workload.3. Adequate allied and ancillary staff.4. Facilities for: imaging laboratory services specialist clinical psychology service occupational therapy and rehabilitation facilities neurophysiological investigation5. Opportunities for research. 56
  57. 57. Experience in Acute and Chronic Pain ManagementGrade StageSHO Learning Acute pain and post- 1-3 Months operative pain relief throughout this period 9-18 months Chronic pain module 4 weeksSpR SpR 1 & 2 4 weeks acute and chronic pain. SpR 3 2 months acute and chronic pain. SpR 4 6 months optional special experience. 57
  58. 58. First Year SHO Learning planAcute and Chronic Pain ManagementThe first nine months Clinical Skills List Learning: Post-operative pain relief. Use of opioids by i.m., i.v. and s.c. routes. Use of PCA. Use of regional anaesthesia for post-op pain relief. Use of epidural opioid infusions/PCA. Use of simple analgesics / NSAID’s. Treatment of post-operative nausea and vomiting (PONV). Theoretical Skills List Learning: Pharmacology as applied to the management of pain. Physiology and pharmacology of PONV. Pharmacology of local anaesthetics. The role of the acute pain service. Communication Skills List Learning: Discussion of post-operative pain relief with patients when pre-op visiting. Communicating information relating to operative and post-operative pain relief to recovery ward staff. Ability to write clear directions for post-operative pain relief plan. Local Assessment None 58
  59. 59. First year SHO Learning PlanAcute and chronic pain managementNine to eighteen monthsFour weeks chronic pain management Clinical Skills List Skilled in: Use of opioids by i.m., i.v. and s.c. routes. Use of PCA. Use of simple analgesics/NSAID’s Treatment of PONV. Competent in: Use of regional anaesthesia for post-operative pain relief. Learning: Planning the management of the patient. The use of diagnostic aids. Use of epidural opioid infusions/PCA. Principles of symptom control in Palliative Care. The clinical assessment and multi-dimensional measurement of pain, disability and quality of life. Use of diagnostic and therapeutic nerve blocks. Theoretical Skills List Competent in: Pharmacology as applied to pain management. Physiology and pharmacology of PONV. Physiology and pharmacology of local anaesthetics. Role of the acute pain service. Learning: The epidemiology and sociology of pain. An understanding of all aspects of terminal illness. Use of opioids in terminally ill patients (tolerance, ceiling, adjuvants). Introduction to chronic non-malignant pain syndromes e.g. reflex sympathetic dystrophy, phantom limb pain, post herpetic neuralgia. Use of TENS. Use of “central” analgesics ( TCA’s, anticonvulsant ). Physiology of acute pain pathways. Anatomy relating to pain. Communication Skills List Competent in: Hand-over of patients to recovery ward staff. Writing clear directions for post-operative pain management. Learning: Assessment of psychological and psychiatric contributes to pain. The use of psychological methods. The use of behavioural methods of pain management. Pre-operative assessment and discussion with patient regarding use of opioid epidural infusions and PCA.. Local Assessment Able to plan appropriate post-operative pain relief. Able to deal with PONV in a systematic fashion. 59
  60. 60. First year SHO Clinical ExperienceAcute and chronic pain managementNine to eighteen monthsFour weeks chronic pain management Objectives of Training An introduction to the speciality of pain management. Understanding the scope of the speciality. Understanding the work pattern of the pain specialist. The role of non medical professionals in the management of pain. Specific Clinical Experience 4 weeks secondment full time to a suitable pain clinic and associated services. 60
  61. 61. First year Specialist Registrar Learning PlanAcute and chronic pain managementFour weeks acute and chronic pain managementThis secondment should be in a continuous block. Clinical Skills List Skilled in: Use of opioids by i.m., i.v. and s.c. routes. Use of PCA. Use of simple analgesics/NSAID’s Treatment of PONV. Use of regional anaesthesia for post operative pain relief. Competent in: Use of epidural opioids/PCA. Principles of palliative care with opioids. Learning: Planning the management of the patient. The use of diagnostic aids. The clinical assessment and multi-dimensional measurement of pain, disability and quality of life. Treatment of reflex sympathetic dystrophy. Early recognition, Intra venous regional sympathetic block, physiotherapy. Management of phantom limb pain. Use of TENS in chronic non malignant pain. Treatment of low back pain. The role of neural blockade. The indications for and role of neuro-ablative procedures. The role of surgery. Theoretical Skills List Skilled in: Pharmacology of opioids. Physiology and pharmacology of PONV. Physiology and pharmacology of local anaesthetics. Role of the acute pain service. Competent in: The epidemiology and sociology of pain. An understanding of all aspects of terminal illness. Use of opioids in terminally ill patients (tolerance, ceiling, adjuvants). Introduction to chronic non-malignant pain syndromes e.g. reflex sympathetic dystrophy, phantom limb pain, post herpetic neuralgia. Use of TENS. Use of “central” analgesics ( TCA’s, anticonvulsant ). Physiology of acute pain pathways. Anatomy relating to pain. Learning: The role of the pain management unit. Multidisciplinary approach to pain management. Psychology of chronic pain behaviour. The role of individual team members (clinical psychologist, physiotherapist, pain specialist) Specific anaesthetic blocks in the treatment of pain. Lumbar sympathectomy, stellate ganglion block. 61
  62. 62. Communication Skills ListSkilled in:Hand-over of patients to recovery ward staff.Writing clear directions for post-operative pain management.Competent in:Pre-operative assessment and discussion with patient regarding use of opioid epiduralinfusions and PCA..The use of psychological methods.Learning:Taking an adequate pain history, carrying out appropriate examination.Talking to patients and their relatives with chronic and terminal painful conditions.The place of complimentary medicine.Local AssessmentManaging an acute pain round with clinical nurse specialist.Informal feedback with pain specialist. 62
  63. 63. First year Specialist Registrar Clinical ExperienceAcute and chronic pain managementFour weeks acute and chronic pain management Objectives of Training To consolidate previous acute pain learning. To develop practical and theoretical skills in chronic pain management. To understand the team approach to pain therapy. To learn to communicate well with patients about their pain. Specific Clinical experience Four weeks experience of work within a pain team. Participating fully in all aspects of the work. The opportunity to observe specific practical procedures: peripheral and central nerve blocks epidural and subarachnoid injections injection into and around joints intrapleural techniques neurolytic techniques as applied to peripheral nerves and nerves in the epidural and subarachnoid spaces. thermocoagulation cryotherapy percutaneous techniques of sympathetic blockade intravenous regional sympathetic blockade stimulation produced analgesia relaxation techniques implantation of pumps and catheters neurosurgical techniques used in pain relief ionisation therapy and chemotherapy in pain management 63
  64. 64. Third year Specialist Registrar Learning PlanAcute and chronic pain managementEight weeks acute and chronic pain management Clinical Skills List Skilled in: Use of opioids by i.m., i.v. and s.c. routes. Use of PCA. Use of simple analgesics/NSAID’s Treatment of PONV. Use of regional anaesthesia for post operative pain relief. Use of epidural opioids/PCA. Principles of palliative care with opioids. Competent in: Planning the management of the patient. The use of diagnostic aids. The clinical assessment and multi-dimensional measurement of pain, disability and quality of life. Use of TENS in chronic non malignant pain. The role of neural blockade. The indications for and role of neuro-ablative procedures. The role of surgery. Treatment of reflex sympathetic dystrophy. Early recognition, Intra venous regional sympathetic block, physiotherapy. Management of phantom limb pain. Use of TENS in chronic non malignant pain. Treatment of low back pain. Learning: Organisation of pain management unit/clinic. Organisation of pain management programme. Organisation of palliative care in home/hospital/hospice settings. Assessment of pain in children. Theoretical Skills List Skilled in: Pharmacology of opioids. Physiology and pharmacology of PONV. Physiology and pharmacology of local anaesthetics. Role of the acute pain service. Use of opioids in terminally ill patients. Physiology and pharmacology of pain pathways. Awareness of chronic non malignant pain syndromes. Use of TENS. Competent in: The role of the pain management unit. Multidisciplinary approach to pain management. Psychology of chronic pain behaviour. The role of individual team members (clinical psychologist, physiotherapist, pain specialist) Specific anaesthetic blocks in the treatment of pain. Lumbar sympathectomy, stellate ganglion block. Learning: Specific anaesthetic blocks in relief of pain. 64
  65. 65. Communication Skills ListSkilled in:Hand-over of patients to recovery ward staff.Writing clear directions for post-operative pain management.Pre-operative assessment and discussion with patient regarding use of opioid epiduralinfusions and PCA.Competent in:Explaining to patients.Talking to patients with chronic and terminal painful conditions.Learning:Skills involved in management of more difficult patients. e.g. angry patients, seriouslydepressed patients.Talking to dying patients and their relatives.Local AssessmentInformal feedback with pain specialist. 65
  66. 66. Third year Specialist Registrar Clinical ExperienceAcute and chronic pain managementEight weeks acute and chronic pain management Objectives of Training To understand the organisation and management of pain services. To develop skills of acute and chronic pain management. To develop skills in palliative care. To understand whether to opt for additional training in pain management. Specific Clinical Experience Two months continuous secondment to a pain management service. Experience in wards , out patients, home and hospice. Experience of specific practical procedures: peripheral and central nerve blocks epidural and subarachnoid injections injection into and around joints intrapleural techniques neurolytic techniques as applied to peripheral nerves and nerves in the epidural and subarachnoid spaces. thermocoagulation cryotherapy percutaneous techniques of sympathetic blockade intravenous regional sympathetic blockade stimulation produced analgesia relaxation techniques implantation of pumps and catheters neurosurgical techniques used in pain relief ionisation therapy and chemotherapy in pain management 66
  67. 67. Second and Fourth Year Registrar Learning plan and Clinical Experience.Acute and Chronic Pain ManagementSecond year registrar general and optional experienceA number of options are open to trainees during this year. Most trainees will have at least part of their yeardedicated to general training and during this period they could have regular experience relating to painmanagement. It is essential that varied experience takes place at this time.Research could be conducted in one of these speciality areas.Fourth year registrar special experience year.During the final year trainees can opt for special experience in one or more of these specialities if they areexpressing a special interest for a consultant post. A supervisor would organise a suitable work plan with thetrainee. It would be expected that all trainees wishing to take up a consultant post with a special interest insome area of pain would undergo six months further training in pain. 67
  68. 68. 6. Anaesthesia for Eye Surgery 68
  69. 69. Experience of Anaesthesia for Eye SurgerySecond Year SHO (9 - 18 Months) 4 WeeksFirst Year Specialist Registrar 4 WeeksThere are two periods of experience identified in the anaesthetic curriculum; during the second year as anSHO and as a first year registrar. These periods are intended for intensive training in anaesthesia for thisspecialty in order to fully understand the particular difficulties.In addition ophthalmic surgery should be regularly included in the trainees work schedule in non allocatedtime. Trainees may feel that more experience would be advantageous to them and can organise this duringoptional period as second and fourth year registrars. 69
  70. 70. Second Year SHOLearning Plan for Anaesthesia for Eye Surgery at 9-18 months4 Weeks secondment Clinical Skills List Learning: Anaesthesia for squint surgery. Anaesthesia for cataract surgery. Anaesthesia for other techniques not including vitreo-retinal surgery. Observation of vitreo-retinal surgery. Observation of local anaesthetic techniques. Dealing with microscopes and specialised eye operating machinery. Theoretical Skills List Learning: Anatomy, techniques and complications relating to ocular regional anaesthesia Control of intra-ocular pressure. Occulo-cardiac reflex. Ophthalmic pharmacology as related to anaesthesia. Deciding between general and local anaesthesia for eye surgery. Anaesthesia for ocular emergencies. penetrating eye injuries. Nitrous oxide free anaesthesia for vitreo-retinal surgery. Ocular disease in generalised systemic disease. Diabetes etc.. Safety issues relating to lasers. Communication Skills List Learning: Talking to children. Discussing anaesthetic choice of local or general anaesthesia. Anaesthesia in remote sites Local Assessment Feedback from consultants. Possible Eye list assessment 70
  71. 71. Second Year SHOClinical Experience of Eye Surgery at 9-18 months4 Weeks Secondment Objectives of Training To learn about the repertoire of ophthalmic surgery To learn how to give anaesthetics for eye operations of simple and intermediate difficulty. To observe more complex operations. To understand the problems of anaesthesia for children. To understand the problems of anaesthesia for the elderly. To appreciate the effect of related systemic and intercurrent disease on the management of patients for eye surgery. To observe and begin learning regional anaesthesia for ophthalmic surgery. Specific Clinical Experience Four weeks experience of eye surgery. This may be a continuous secondment or be managed as day by day allocation. If the latter course is chosen attention must be paid to providing continuity of learning. 71
  72. 72. First Year RegistrarLearning Plan for Anaesthesia for Eye Surgery4 Weeks secondment Clinical Skills List Skilled: Anaesthesia for squint surgery. Anaesthesia for cataract surgery. Anaesthesia for other techniques not including vitreo-retinal surgery. Competent: Regional anaesthesia for eye surgery. Paediatric anaesthesia for eye surgery. Per-operative management of diabetes. Learning: Anaesthesia for vitreo-retinal surgery. Ocular blocks. Management of intra-ocular pressure. Eye syndromes. Theoretical Skills List Skilled: Anatomy, techniques and complications relating to ocular regional anaesthesia Control of intra-ocular pressure. Occulo-cardiac reflex. Ophthalmic pharmacology as related to anaesthesia. Deciding between general and local anaesthesia for eye surgery. Safety and lasers. Learning Anaesthesia for ocular emergencies. penetrating eye injuries. Nitrous oxide free anaesthesia for vitreo-retinal surgery. Ocular disease in generalised systemic disease. Diabetes etc.. Communication Skills List Competent: Talking to children. Discussing anaesthetic choice of local or general anaesthesia. Anaesthesia in remote sites Learning: Planning surgery for more complex patients. Surgery for the very elderly. Local Assessment Feedback from consultants. 72
  73. 73. First Year RegistrarClinical Experience of Eye Surgery4 Weeks Secondment combined with ENT Objectives of Training To learn how to anaesthetise for more complex operations. To learn about vitreo-retinal surgery. To understand the problems of anaesthesia for children. To understand the problems of anaesthesia for the elderly. To appreciate the effect of related systemic and intercurrent disease on the management of patients for eye surgery. To become skilled in regional anaesthesia for ophthalmic surgery. Specific Clinical Experience Four weeks experience of eye surgery. This secondment is shared with ENT. This may be a continuous secondment or be managed as day by day allocation. If the latter course is chosen attention must be paid to providing continuity of learning. 73
  74. 74. 7. Anaesthesia for Day Surgery 74
  75. 75. Learning Anaesthesia for Day SurgeryTrainees will learn about day patient surgery and surgery for ambulant patients in the course of their variousexperiences of speciality anaesthesia. No special provision is made to allocate trainees to blocks of daysurgery work.It is however expected that attention will be paid to the basic principles of anaesthesia for day surgery. 75

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