Letters To The Editor: Anaesthetic Training in Accident and Emergency

J Accid Emerg Med 2000;17:309311 emergency (A&E) departments in the United Kingdom have access to this expensive tool.
RSI is a skill that is used with short notice and requires condence and competence to perform appropriately. The cognitive and psychomotor skills needed are unlikely to be retained from a single course. RSI should therefore be taught as part of an integrated training programme. This should include prolonged exposure to intubations during an anaesthetic attachment, a short course similar to the National Emergency Airway Management Course from the USA covering core knowledge, and a process of revalidation and quality assurance. We feel that the use of simulators would not be practicable for the primary training of the large numbers of UK A&E specialists in RSI. The use of simulators could, however, play a vital part in the regular appraisal and revalidation of individual practitioners once they have completed their training programme. This revalidation of skills and the regular audit of results should form the basis for the essential quality assurance, which this programme would need. In summary, if we follow the airline pilot analogy, training occurs in the classroom and in the air, revalidation is the work of the simulator.
STEPHEN BUSH Specialist Registrar in Accident and Emergency ([email protected]) ALASDAIR GRAY Consultant in Accident and Emergency ALISTAIR MCGOWAN Consultant in Accident and Emergency Accident and Emergency Department, St Jamess University Hospital, Leeds LS9 7TF NEIL NICHOL Consultant in Accident and Emergency Ninewells Hospital, Dundee 1 Ellis C, Hughes G. Use of human patient simulation to teach emergency medicine trainees advanced airway skills. J Accid Emerg Med 1999;16:3959.
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LETTERS TO THE EDITOR

Anaesthetic training in accident and emergency EDITOR,I read with interest the comments of Boyle et al1 regarding anaesthetic training for accident and emergency (A&E) specialist registrars. They suggest that there is a denite advantage of spending six months as a true anaesthetic SHO as part of the A&E specialist registrar scheme, rather than as a supernumerary extra in theatre. As someone who initially undertook a training in anaesthesia with a view to entering higher training in A&E via this route, I would agree that it oVers much more than the opportunity to become condent and competent at advanced airway management in the relatively controlled theatre setting. Training in anaesthesia oVers the chance to gain many other skills that are extremely useful to the A&E trainee, particularly in the resuscitation setting, including the assessment and management of critically ill patients, providing ventilatory and circulatory support where necessary, the use of anaesthetic equipment, invasive haemodynamic monitoring techniques and transportation of critically ill patients. The opportunity to become procient at the various regional anaesthetic techniques and to gain an understanding of pain management is also very relevant to A&E practice. The possession of the FRCA, which requires at least 2.5 years of training in anaesthesia, is one of the established ways to enter the A&E specialist registrar grade. Surprisingly, in the current membership list of the British Association of A&E Medicine, only 60 (0.05%) members possess the DA (or old primary FRCA), with only 12 (0.01%) possessing the FRCA or equivalent.2 As our specialty continues to develop and accepts more responsibility for early advanced airway management, ventilatory and circulatory support and rapid sequence inductions, both within the A&E department and in the pre-hospital setting, I feel that we should encourage more of our junior trainees interested in a career in A&E to enter the specialist registrar grade via this route.
JOHN J ODONNELL Specialist Registrar in A&E Medicine, Royal Inrmary of Edinburgh, Lauriston Place, Edinburgh EH3 9YW ([email protected]) 1 Boyle AA, Florance R, Mackenzie R. Anaesthetic training for specialist registrars in accident and emergency. J Accid Emerg Med 2000;17:75. 2 British Association of Accident and Emergency Medicine directory 1999/2000. Blackpool: BOE Publishing.
ponade (with blood aspiration). It is able to blink and reproduce unilateral pupillary signs. A child mannequin is available, and a neonatal one is being developed. On the other hand, at present the simulated wheezing is not convincing in asthma scenarios, and the mannequin cannot simulate grand mal tting, colour change (pallor or cyanosis) or perspiration. Like the Wellington study day, the south west simulator programme for trainees is an innovative extension of traditional emergency department training. We see it as an evolving project that will be carefully evaluated from both the trainer and trainee perspective. A further use of this technology already allows online access to live training sessions broadcast from the centre via satellite (www.multimed.co.uk) to user terminals installed at nine hospital sites in the UK. We would welcome correspondence nationally and internationally.
GAVIN LLOYD South-west Regional Training Committee for Emergency Medicine ([email protected]) 1 Ellis C, Hughes G. Use of human patient simulation to teach emergency medicine trainees advanced airway skills. J Accid Emerg Med 1999;16:3959.
Emergency cranial computed tomography EDITOR,Harris et al1 apply Rothrocks criteria2 to a UK population of non-trauma patients. Their abstract concludes Simple criteria can be usefully applied to patients presenting to an A&E department in this country to target patients most likely to have clinically signicant ndings on urgent cranial computed tomography. We believe that the method and ndings of the study do not justify the change in practice implied by this conclusion. Our methodological concerns are threefold. Information gathered retrospectively from notes and request forms casts doubt over the accuracy and completeness of the symptoms and signs (particularly the symptom of nausea). The inclusion criterion is ill dened (patients who are referred for computed tomography). There is no explanation for the inclusion of nausea (it is not one of Rothrocks original criteria). There are also theoretical objections. To be useful, a clinical lter must be applied to unselected patients and include criteria that have a high inter-observer reliability. There is no logic in applying a clinical lter after the decision to investigate has been made. Furthermore, both studies acknowledge that they do not tackle the problem of subarachnoid haemorrhage in young patients presenting with isolated headache. Surely this is a major consideration in formulating any criteria for computed tomography (CT)? We applied Harris criteria to our prospective series of patients attending A&E with non-traumatic headache (248 patients). Seventy two CT scans would have been performed. The criteria would have missed three (1.2%) patients with an abnormal CT scan. Judging from the diVering rates of CT abnormality in the two studies (35% v 6%), CT rates in the UK are well below those in the USA. Given that we accept a detection rate of 1 of 80 for patients with skull fracture and GCS 15, perhaps we should be scanning more patients with non-traumatic headache not fewer.
High level simulator EDITOR,We were delighted to read of the use of a high level simulator in emergency department training.1 From January 2000, we in the south west have secured three years of funding for the use of the same METI-HPS simulator for specialist registrar training at the Bristol Simulation Centre (www.bris.ac.uk/Depts/BMSC/). Like the Wellington group, we face the challenge of creating realistic scenarios of critically ill and injured patients for the purpose of formative assessment. Clear advantages of the high level simulator over traditional advanced life support group scenario teaching include: + real time, accurate audio and visual monitoring responses to clinical and pharmacological interventions + the use of videotape assisted hot review + interactive physiology and pharmacology tuition, particularly in regards to the use of inotropes, anti-arrhythmics, sedatives, opioids and induction agents. The additional features available on the METI-HPS were perhaps a little understated in the Wellington paper. Voice simulation is standard, and has played a key part in thrombolysis study days run at the Bristol Medical Simulation Centre. The mannequin is also able to simulate needle decompression of a tension pneumothorax (with audible hiss) and successful pericardiocentesis of a cardiac tam-
Rapid sequence intubation EDITOR,All emergency medicine specialists should be competent in rapid sequence intubation (RSI). We thank the authors for their commitment to training this essential skill.1 The simulator experience with video playback could be an extremely powerful teaching aid for RSI and its potential attendant complications. Currently, only a few accident and

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J Accid Emerg Med 2000;17:309311 emergency (A&E) departments in the United Kingdom have access to this expensive tool.

LETTERS TO THE EDITOR

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