The COVID-19 pandemic is nowhere near to be over but it is, probably, the right time to reflect on “the good, the bad and the ugly” changes that it has brought to RA training programmes in various centres.
In our centre, Oxford University Hospitals NHS Foundation Trust (OUHFT), RA training is an important part of the multi-specialty training provided by the Nuffield Department of Anaesthetics. The NDA, founded in 1937, is the first independent department of anaesthesia in the UK, in Europe, and in the Commonwealth (https://www.ndcn.ox.ac.uk/divisions/nda/history). Although RA has been practiced and taught in our Department for decades, the formal training module was set up in 2002, following obstetric and airway ATMs. Over the years it has become one of the most popular advanced training modules, with no shortage in applicants. From the RA ATM with 1 advanced trainee in 2003 it has grown to the RA Programme which, with careful rota planning, can accommodate up to five subspecialty trainees, internal and external, with different career objectives. Some 60 trainees have been trained since 2003, with very positive feedback, as confirmed by the recent survey. Although the priority is to provide a 6 months advanced training for “internal” specialist registrars in their two final years of their training in the Oxford School of Anaesthesia, we have also been able to offer “out of programme” 12 months training for external fellows from Malta, Australia, Ireland and other countries. Some of these trainees have already completed their training in their countries ( post CCT ), others have less straightforward career paths. The key to successful training is a flexible and individual approach to trainees’ learning objectives.
OUHFT is a busy teaching hospital with some 45 theatres on 4 sites and separate on-call rotas for different sites. The ‘base’ site for the RA training is the Nuffield Orthopaedic Centre. The NOC is a tertiary and quaternary referral centre with most theatre lists suitable for training in neuraxial or peripheral nerve blocks. According to our year-long audit of training opportunities at the NOC in 2016/17 (well before COVID-19, “BC” times), over 3,500 blocks were performed during the year in 8 theatres. This volume of blocks allowed us to accommodate 4-5 full time trainee during one training round. Operations range from straightforward hip and knees to complex limb reconstructions, joint revisions, major spine, ortho- and oncoplastic surgery. Significant number of patients are very complex – either surgically or anaesthetically, or both. High volume surgery procedures allow good audits and Quality Improvement Projects such as standardised documentation for blocks or day case spinal anaesthesia for hip replacements. Care for complex patients allow ample opportunities for Problem Based Learning Discussions and presentations/publications such as limb reconstruction surgery during COVID pandemic in a patient with a heart-lung transplant.
«During the lists a RA trainee is directly or indirectly supervised by a named Clinical Supervisor or another Consultant Anaesthetist, the level of responsibility being increased according to the trainee’s progress.»
In addition to the NOC case mix, there are opportunities to perform Regional Anaesthesia (RA) techniques on other OUHFT lists, such as Trauma, Vascular, Emergency, Transplant, and Plastic lists, as well as Obstetrics , depending on the service lists and on-call commitments.
During the lists a RA trainee is directly or indirectly supervised by a named Clinical Supervisor or another Consultant Anaesthetist, the level of responsibility being increased according to the trainee’s progress. Various workplace based assessments are completed during the course of training. Sub-speciality qualifications such as EDRA are encouraged.
Apart from the practical skills acquisition there are several non-clinical objectives which may differ for various trainees. We offer opportunities to develop organisational, management, leadership and teaching skills relevant to regional anaesthesia, perform and complete audits and QIPs, submit, present and ultimately publish a variety of projects and studies. At the beginning of the training block an individual training plan is agreed between a trainee and their Named Clinical Supervisor, the progress is reviewed during the interim and final assessments. The NCS and the trainee stay in close contact during the training block and often for a few months after, completing various projects.
Reflecting on the past year as a trainer, the words that come to my mind are “dedication”, “resilience”, “resourcefulness”, “flexibility”, “tiredness”, “anxiety”, “uncertainty”, “frustration”, “disruption”, “overload”, “perseverance”, “new normal”. We know from the recent BMA trainees’ survey that majority of trainees (74%) feel that COVID-19 had disrupted their training, many opportunities were lost and the mental toll was quite significant (The Doctor, March 2021). I wouldn’t be surprised if the GMC Training survey will also capture a significant negative impact of COVID-19 on the trainers’ wellbeing.
From the RA trainer point of view, it will be fair to say that all aspects of training in our centre were affected by COVID-19 pandemic to some extend – from skills acquisition to publishing papers, but there were also unexpected and excellent new opportunities – from presenting very unusual COVID relevant cases to developing new “hybrid” teaching models. I am grateful that two former RA trainees share their stories in this article – one is on training “hit by the 1st COVID wave”, the other – “between the waves”. From their stories it is obvious that not everything is gloom and doom, so together – trainers and trainees – we have done something good even in the most extraordinary challenging times.
As for any other procedural-based specialty, skills acquisition in RA training was inevitably affected by the reduction in elective operating during the pandemic. At the same time, interestingly, change in practices and PPE guidelines during COVID created unique training opportunities such as learning and teaching US-guided CNA in Force8/10 masks in a patient with severe scoliosis, an experience not to be forgotten (picture). I wish that more pictures were taken during this short teaching session for a future presentation, but at the time the patient safety and clinical success was a priority.
«From the RA trainer point of view, it will be fair to say that all aspects of training in our centre were affected by COVID-19 pandemic to some extend […].»
Presenting and publishing. Although many European meetings were postponed or run without abstracts presentations, on-line presentation opportunities were created “at home”. British Society of Orthopaedic Anaesthetists (BSOA) initiated a series of virtual webinars, with trainees’ presentations in November 2020. This was followed by the AAGBI WSM in January 2021. Some 15 abstracts were submitted from our RA trainees through the last 12 months (and I may have missed a couple). They were accepted and presented as poster and oral presentations, with some prizes won and great potential for several full paper publications. The full papers, however, remain “work in progress”, with a real threat that, unfortunately, in the big world of the PubMed search our hard work may remain barely noticeable. Unless of course, tired trainees and trainers will make this final push to get the work published…
Teaching/management/leadership. In the past the Oxford RA Course with Cadaveric Anatomy not only was very popular amongst attendees but also offered excellent opportunities for teaching/management/leadership skills to RA trainees. It is, sadly, not running at present, however, the pandemic has stimulated us to develop a new hybrid teaching model – a Sonoclub. This is an excellent example of being resourceful and adapting to the “new normal”. Trainees should be congratulated on taking this project on.
Finally, the pandemic has taught me to allow for unexpected changes and respect the Reinhold Niebuhr’s prayer even more: “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference”. Although it was written almost 90 years ago, at the challenging times of training during the COVID-19 pandemic I think it is very relevant. Hope all trainers and trainees will agree with me.
In-programme RA ATM Training, 6 months, Aug 2020-Feb2021
«Advanced Training Modules (ATMs) in regional anaesthesia (RA) are usually six month trainee selected placement, undertaken in the final years of training. I have just completed my RA-ATM at the Nuffield Orthopaedic Centre (NOC) in Oxford. My ATM started in August 2020, as the initial UK COVID-19 surge had fallen in the UK and elective orthopaedic lists started to return to the NOC. Theatre lists returned slowly but not to full capacity, with decrease from eight full elective lists to six by August 2020 and then unfortunately, the second wave in December 2020, led to a further fall to only two semi-urgent lists. Being conscious of the likely impact on training, I proactively sought out RA training opportunities and exposure and in the first three months of training, I managed to achieve a similar number of peripheral nerve block experience compared to my higher RA module two years earlier. I have been lucky in terms of my RA experience, as a recent RA trainee survey in the deanery has highlighted that over 50% of trainees had experienced a decrease in RA training due to COVID-19. To improve training opportunities, new and alternative avenues for training are required and I have been involved in starting up the Oxford Sonoclub, a RA teaching course, directed at deanery anaesthetic trainees. The course is trainee led with consultant supervision, with hands on sonoanatomy teaching covering the ‘Plan A’ blocks endorsed by the RA-UK, neuraxial blocks and beyond. COVID-19 had complicated the setup of the teaching programme, with need for social distancing, smaller group workshops, PPE and extra infection control precautions. Due to recent spikes in COVID-19 numbers and the lockdown, we had to cancel the face to face training, but we are adapting and trying to organise an online video library of approved ‘how to’ block YouTube links and pre-recorded block talks through our trainee website. Aside from the negative impact on training lists and opportunities, the pandemic has brought an upsurge in the access to teaching materials online, through webinars and access to international conferences. Virtual reality is the likely avenue to investigate and focus on for RA training.»
Out of programme Fellow, post CCT, Aug 2019-Jul 2020
“Hit by the first wave”
«Having completed my specialist anaesthesia training in Ireland in July 2019, I was delighted to be offered a one-year fellowship in regional anaesthesia (RA) in Oxford University Hospitals. My RA experience in Ireland was primarily during a 2-month module in the “block bay” of University Hospital Galway, and it was here that I realised I wished to pursue advanced training in RA. “Practice makes perfect” and so I sought a fellowship in RA to improve my block proficiency and confidence. As my first introduction to the NHS, I quickly realised that while there were differences, often subtle, to get to grips with, that the Nuffield Orthopaedic Centre (NOC), as a quaternary centre for orthopaedic care, was an excellent place to begin my journey in the NHS. After figuring out the system, gaining my consultant trainers’ trust and recovering from an unfortunate elbow fracture, I was able to enhance my RA experience with over 220 blocks during my time in the NOC. Little did I realise that the blocks done during that first six months would make up the bulk of my numbers for the year!
In March 2020, as COVID-19 spread throughout the UK, elective orthopaedic and plastics lists were among the 1st to go, and consequently the number of operating lists with opportunities to perform RA dropped significantly. Furthermore, trainees and fellows were allocated to ICU and emergency theatre rosters to cope with the first surge in COVID-19 admissions. While this was indeed a challenge, especially with almost weekly changes in PPE/protocols/SOPs, I was fortunate to have gained sufficient experience in RA during the first half of my fellowship to apply to trauma and emergency cases, thus avoid aerosol generating general anaesthesia. This practice applied the joint ESRA/ASRA guidelines of late March 2020, recommending RA over GA for patients with COVID-19 to reduce the risk of COVID-19 transmission. RA +/- sedation techniques allowed appropriate cases to continue without the risk of AGPs.
Uncertainty and huge changes in work practice made continuing “normal fellowship service”, such as maintaining research projects, audits, a diploma and even minimum continuing professional development, difficult to say the least. As RA Fellow I was invited to join the organising committee for the British Society of Orthopaedic Anaesthetists (BSOA) Spring Scientific Meeting, a great experience which provided insight into work that goes on behind the scenes at medical conferences! While COVID restrictions prevented the Oxford meeting in April, the format was adapted and a successful virtual event series was delivered in October-November 2020. This included a trainee oral presentation competition, involving a “talking slides” presentation followed by a “zoom” Q&A session, another great learning experience and I was delighted to be awarded 2nd Place overall.
Resilience is a term I have come to associate with doing a fellowship during a pandemic! Having submitted abstracts to European conferences that were cancelled, keeping the research momentum going has been a challenge. Projects have continued, albeit at slower pace, and thankfully some conferences, and the opportunity to present work, have resumed in a “virtual” format. A project examining the strengths and weaknesses of the Oxford RA training programme over the past 17 years was shortlisted for oral poster presentation at the Association of Anaesthetists ASM in January 2021. Furthermore, having been faculty for the neuraxial ultrasound workshop at the Oxford CPD day “pre-COVID” in December 2019, I was delighted to contribute to the innovative “sonoclub” at the NOC in December 2020, teaching (via zoom) the fundamentals of neuraxial ultrasound techniques. Adaptability has been key to continuing teaching and research in the pressurised COVID-19 environment and RA/coping/life-skills I learned during my time on fellowship in Oxford will be greater than I can ever describe on my CV!»
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