Graduate teaching and training of urgent bedside management
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A presentation by Owain Thomas at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.
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Graduate teaching and training of urgent bedside management
- 1. Graduate teaching and training of urgent bedside management OWAIN THOMAS MD MA(Cantab) PhD DESA Specialist anaesthetist, Paediatric Anaesthesia and PICU, SUS Lund University Hospital, Sweden Treasurer, Swedish Society of Anaesthesia and Intensive Care (SFAI) National coordinator, 3 day course in Anaesthetic Emergencies sponsored by The Swedish Society of Junior Anaesthetists (SYA) odt@cantab.net 7/September/2017
- 4. Flin R, Maran N. Basic concepts for crew resource management and non-technical skills. Best Pract Res Clin Anaesthesiol. 2015 Mar;29(1):27-39. What is graduate training?
- 5. What is graduate training after completion of ST? Collegial feedback Formal courses Reading scientific journals and books Participation in clinical research Adapting placements after log- book / own needs Enough time to learn from colleagues Case discussion Presenting at departmental meeting Development plan Study visit E-learning Clinical work Training in a simulated environment SFAI CME Committee 2016 How can anaesthetists prepare themselves for critical situations?
- 6. May 2012 Swedish Society of Junior Anaesthetists’ Spring Meeting, Nösund October 2013 First 3 day course in Anaesthetic Emergencies in Lund
- 7. Goals of 3 day course in Anaesthetic Emergencies
- 8. Structure of 3 day course in Anaesthetic Emergencies Before the course Read the course manual Complete a factual pretest During the course -Introductory morning: background to simulation, debriefing and CRM. -8 full scale simulations + debriefing (45+45’) -Airway workshop (90’) -Short factual lectures -Social event on first evening At end of course Post-test (factual) “Flipped classroom” Factual information can be read at home before the (hopefully) high-yield learning experience“Multimodal teaching styles” Mixture of lectures – case discussions – skills workshop – simulation - debriefing “Social learning environment” Try to create optimal conditions for collegial feedback. Encourage constructive group dynamics. “Exam pressure but probably not performance in stress pressure” Controversial whether learning is impeded by using simulations as exams.
- 9. Chapters in course manual for Anaesthetic Emergencies Preparation before anaesthesia and transport Airway Cardiac disease in the non- cardiac patient Structured approach Circulatory failure Peroperative hypertension Abnormal capnography, ventilation and hypoxia Peroperative arythmia Anaesthesia and cardiac arrest Massive haemorrhage LAST MH Anaphylaxis Electrolyte diatheses Obstetric crises The intoxicated patient
- 10. Debriefing Participants formulate their own goals for improved performance when they return home: “One small improvement is better than no improvement at all” Pragmatic teaching attitude. Perhaps not applicable to medical students?
- 12. AE 118 Group A Group B Group A Group B Group A Group B 0745 Introduction OT/CR 0830 Why? Cri Simulation Simulering Simulering 0855 How? - Sim Room 2 Sim Room 1 Sim Room 2 0915 Debriefing OT - -- PWe -- 0925 Tour Cri/PW/-/- CRI/PW 1005 Coffee Simulation Simulation Simulation PW/OT Sim Room 1 Sim Room 1 Sim Room 2 PWe - PWe -- Group A Group B Cri/PW/-/- - - Simulation Simulation Sim Room 1 Sim Room 2 Simulering Simulering Simulation Simulation Sim Room 2 Sim Room 1 Sim Room 2 Sim Room 1 -- PWe -- PWe Simulation Simulation Sim Room 2 Sim Room 1 Simulering Simulering -- PWe Sim Room 2 Sim Room 1 -- PWe PW/OT Lunch Change before 1300! Posttest OT15 14 17 Coffee CRM exercise Coffee during debriefing 13 16 Check-out Feedback Coffee during debriefing Faculty meeting Check-out, feedback Faculty meeting When and where is course dinner? Faculty meeting 18 Participant timetable KS Huddinge 31/10-2/11/2017 Cri/PW 1015 Coffee Coffee Airway workshop Day 3 Coffee Check-in Circulatory collapse 1015 Coffee Day 1 Day 2 8 9 Coffee, registration Airway algorithms - 0815 Systemmatic approaches Simulation Check-in Airway workshop 10 11 1100 Own cases - 1150 Lunch Lunch12 Change before 1245! Change before 1300! 1020 CRM and tools for debriefing 2 participant groups consisting of 12 anaesthetist participants 4 nurse anaesthetist participants 2 instructor groups consisting of 1 senior anaethetist 1 anaesthetist skilled at simulation 1 technician, nurse or anaesthetist skilled at simulation 1 course leader Strict time-discipline is required Which is possible on a 3 day course Simulation is labour-intensive Which makes it expensive
- 13. “Protocollize if possible” and make small improvements frequently Standard documents and material reduce the workload before each course and can be improved. Encourage exchange of teachers / facilitators / instructors 3 day course in anaesthetic emergencies has now been held 15 times (the 16th time will be in English with faculty and participants from Sweden, Iceland and Finland).
- 14. “Flipped classroom” Factual information can be read at home before the (hopefully) high-yield learning experience “Multimodal teaching styles” Mixture of lectures – case discussions – skills workshop – simulation - debriefing “Social learning environment” Try to create optimal conditions for collegial feedback. Encourage constructive group dynamics. “Exam pressure but probably not performance in stress pressure” Controversial whether learning is impeded by using simulations as exams. “One small improvement is better than no improvement at all” Pragmatic teaching attitude. Perhaps not applicable to medical students? Strict time-discipline is required Which is possible on a 3 day course Simulation is labour-intensive Which makes it expensive “Protocollize if possible” and make frequent small improvements Standard documents and material reduce the workload before each course and can be improved. Encourage exchange of teachers / facilitators / instructors
- 15. End
Editor's Notes
- 1 what is graduate training, particularly in the context of anaesthetic emergencies. 2 How our national course in this subject came about 3 I’ll describe to you how the course is organized and try to pick out relevant aspects /points for training of medical students in the same subject. Similarities and differences between anaesthetists and nurse anaesthetists and medical students.
- -Specialist training – 5 years after full registration – is very well specified – both by LAW (Board of Health and Welfare) and recommendation by our national society’s working group for ST (KVAST). -Very clear what skills and knowledge trainees in anaethesia are meant to learn. -Problem is that the means of learning these skills is limited and regionally varied. Eg some health authorities offer an organized programme eg Gothenburg where I believe there are several steps that all trainees go through. Others – no formalized preparation for critical incidents.
- Possible to do ‘at home’ Reading, e-learning, case discussions Courses ATLS, European Trauma Course, one day simulation courses Good – how much they give depends on level of participants and what you want to learn.
- I had just come back from New Zealand where the course called Emergency Management of Anaesthetic Crises. I was also coming to the end of my specialist training -> extra interested.
- Working, cooperating and leading in crisis situations: eg LMA anaphylaxis. Airway swells up and they have a hypoxic cardiac arrest. It’s obviously important to secure the airway at the same time as CPR as soon as the the patient loses circulation. Delay noticing / realizing that CPR must be done and the discussion when the group realizes after the simulation that they had asystoli for 2 minutes might be what they facilitators decide to focus the debriefing on. Who was in charge? How could they have made sure they noticed etc. Difficulty is that creating that CRM gem might require 15 minutes of routine induction and 10 minutes of working up to it, which is not realistic if you have a class of 50 medical students to get through. (also the debriefing can take ages) + long term aims.
- Discrepancy between what instructors and participants think is important to learn.
- Discrepancy between what instructors and participants think is important to learn.
- Material is available on web site. Now: syringe labels preprinted so that preparation of cases is more efficient.