RA Training during COVID-19: Tuen Mun Hospital, Hong Kong

It is my pleasure to share the regional anaesthesia training in our hospital cluster with anaesthetists in Europe.  I am a specialist in both anaesthesiology and pain medicine with subspecialisation in interventional pain medicine and regional anaesthesia. I graduated in the University of Hong Kong and ran through my specialist training in the Hong Kong College of Anaesthesiologists (HKCA) and the Australian and New Zealand College of Anaesthetists with subsequent overseas training in interventional pain management in National Seoul University Hospital in South Korea, interdisciplinary pain management in Sydney and paediatric pain management in Melbourne. I also obtained my Fellow in Interventional Pain Practice (FIPP) diploma from the World Institute of Pain in Budapest later on.  My special endeavours are ultrasound-guided regional anaesthesia and interventional pain management.

The locations of our hospitals

For those who are unfamiliar with Hong Kong, it is a small but highly dense city of about 7.5-8 million inhabitants and is located to the east of the Pearl River estuary on the southern coast of China.  In our locality, public hospitals are managed by Hospital Authority (something like NHS in the UK) and are grouped into 7 hospital clusters. Tuen Mun Hospital (TMH), as a tertiary referral centre, belongs to the New Territories West Cluster (NTWC) which has two other smaller acute hospitals – Pok Oi Hospital (focusing on surgery of intermediate magnitude) and Tin Shui Wai Hospital (focusing on ambulatory service and day surgery). TMH was founded in 1990, followed by Pok Oi Hospital in the late 2007 and Tin Shui Wai Hospital in 2019. TMH is one of the largest public hospitals locally with around 2000 beds while the other two hospitals offer an addition of 1000 beds. Our hospital cluster is serving about 1.15 million people in our territory.  Both anaesthesia and pain services of these 3 hospitals are run by the same Department. Apart from being the training centres of both anaesthesia and pain medicine in the HKCA, our hospitals also serve as teaching hospitals for medical students in the anaesthesia module from the Chinese University of Hong Kong(CUHK).  Across the whole hospital cluster, we have 26 operation theatres in total and there are an average of 18000 operations with anaesthetist involvement annually. An operation theatre extension block is also approaching its completion and will provide 20 extra theatres in the short future.

TMH and other satellite hospitals in NTWC significantly contribute to the total caseload of regional blocks and non-labour epidurals in Hong Kong. We have roughly 1900 nerve blocks (~73 blocks/theatre/year) performed annually while we approximately do 400-500 epidurals/combined spinal epidurals (CSE) a year.  About 300 labour epidurals are performed in obstetrics every year. In particular, our caseloads in plexus blocks and CSE are comparable to the total cases done in all other public hospitals in Hong Kong. This caseload makes our facility quite unique and appealing to anaesthetic trainees in our locality and many of them would be rotated to our hospital cluster to learn about regional blocks and epidurals.

Supervising an anaesthetic trainee to perform knee articular branch block with the assistance of AR goggles

Furthermore, our Department is enthusiastic in trying new regional blocks and  adopting relevant evidence-based medicine to heighten our quality of care, for example, routine TAP blocks for all hepatectomy cases, bilateral erector spinae plane catheters for pelvic exenteration with ileal conduit and various motor-sparing blocks for appropriate orthopaedic operations. For fragility hip fracture, we have reintroduced the continuous spinal anaesthesia technique which is a disappearing art somehow in recent years and this has helped many challenging frail patients go through their operations smoothly. One of our satellite hospitals has also been chosen as the pilot hospital for smart hospital project in our locality.   We are implementing various new technologies into our anaesthetic and operating theatre services.  With the enlightenment by Professor Nakamoto from Kansai University in Osaka, we have started to use augmented reality (AR) to perform USG-guided pain interventions and regional blocks while we are further polishing it in a hope to maximise its clinical benefits to us.

Demonstration to a junior anaesthetic trainee

Regarding our in-house training, we have standardised tutorials to teach trainees about local anaesthetic pharmacology and technical aspects of regional anaesthesia regularly, as well as the perioperative conduct of regional block. However, traditional transition of skills and technical pearls by apprenticeship is still a crucial part of our RA training.  There is routine specialist supervision for trainees who perform any regional block until they become provisional fellows.  For those young specialists who want to advance the block skills such as articular branch block, lumbar plexus block and pericapsular hip neurolysis, supervision from senior specialists experienced in regional anaesthesia will be easily accessible. A dedicated regional block team is being formed with dedicated block rooms.  It will be led by senior specialists experienced in regional anaesthesia and the other membership will include junior specialists and trainees with the possible inclusion of block nurse. We hope this will enhance the skill acquisition for trainees in the regional block module and facilitate further skill advancement of junior specialists. While we have been formulating a regional anaesthesia fellowship training program for overseas fellows, we encourage our new specialists to seek for overseas training opportunities with substantial financial supports from both our hospital and the Hospital Authority.

To be fair, the COVID pandemics has inevitably affected all aspects of RA training to a certain extent in our hospitals – from skills acquisition, teaching to research. The initial impact was a caseload drop by around 20% in the early COVID waves in 2020.  It was even up to 50% in some other hospital clusters. We had to armour ourselves with N95 masks and PPE gears for all airway manipulations.  Medical student teaching and intern attachment were all cancelled.  Yet, in order to minimise airway manipulation and opioid use, we actually opted for more regional anaesthesia and central neuraxial anaesthesia whenever possible and this practice continued in late 2020 and 2021 when our service was resumed. Only a light plane of sedation was usually offered to avoid unnecessary airway manipulation after thorough communications with our patients beforehand.   This turned out to be an unexpected opportunity for our trainees to get exposed to various regional block techniques earlier in their careers.

Supervising a junior trainee to perform an axillary brachial plexus block

Previously, our anaesthesia trainees would get familiarised with central neuraxial block first before learning more sophisticated regional blocks.  Nowadays, we have adjusted our training schedule to allow junior trainees to acquire the common regional block techniques in the first few months of training, such as femoral triangle block, axillary brachial plexus block and TAP block.  In the past, while we had periodic Continuous Medical Education (CME) meetings on regional anaesthesia, it might not be logistically easy to allow too many colleagues to attend overseas conferences physically.  The COVID pandemic has actually pushed all of us to the era of hybrid or virtual conference more quickly and this subsequently allows colleagues to update their knowledge more easily.  We can also consolidate the new knowledge by watching the playbacks too.  Nonetheless, I have to say most of us prefer physical conferences much more as we have missed a lot of opportunities to form bonds and friendship with anaesthesiologists worldwide, as well as enjoying the cultures and beautiful sceneries of different countries.

Research wise, all research activities were suspended in the initial COVID-19 lockdowns but we could luckily resume all the research work afterwards after adapting to the “new normal”.  Yet, it was never an easy task for all colleagues who conducted research activities under the extra stress from COVID-19. Luckily, some of the research work has been completed and successfully published, such as the posterior hip pericapsular neurolysis in inoperable hip fracture in RAPM and the PADDI trial in NEJM.

Airway manipulations by our anaesthetic trainees in the COVID era

Apart from our in-house training, HKCA also plays an essential role in regional anaesthesia training in Hong Kong. In our recently revised anaesthesia training curriculum, regional anaesthesia has become a dedicated training module that all anaesthesia trainees in Hong Kong have to complete in order to fulfil the training requirement. The module consists of general knowledge about safe perioperative conduct of regional anaesthesia, applied pharmacology and technical skills while the training will be conducted in a work-based assessment format. Regional anaesthesia and the relevant anatomy are also regularly examined in our fellowship examination in the formats of hands-on Objective Structured Clinical Examination (OSCE), Multiple Choice Questions (MCQs), Viva and Short Answered Questions (SAQ). Additionally, an ultrasound-guided regional anaesthesia (USRA) training course with mini-lecture and hands-on workshop is held quarterly for all anaesthesia trainees to ensure all of them have an adequate exposure and training in regional anaesthesia even though their working hospitals may not routinely advocate such a practice.  In the COVID era, nevertheless, our training course has been interrupted during lockdown while we still managed to organise 2-3 courses a year in 2020 and 2021. Strict infection control precautions were applied, such as routine temperature measurement, social distancing of at least 1.5 meters apart between attendees and universal masking. Assessment on regional anaesthesia in the fellowship examination has also been switched to the virtual platform and the hands-on ultrasound demonstration by candidate has been sacrificed unavoidably.

The small group hands-on workshop in our USRA training course by HKCA in the non-COVID time. Now, it is cut to 4 people per group.

We used to have quite a few popular international conferences in regional anaesthesia and pain medicine held in Hong Kong, for instance, the International Symposium on Spine and Paravertebral Sonography (ISSPS) organised by Professor Manoj Karmakar from the CUHK. It was cancelled in 2020 and we only managed to organise a virtual education series in the 2^nd half of 2021.  The COVID pandemic has stripped us of the hands-on opportunity to learn from various experts from all over the world in ISSPS.  Another one is the Multidisciplinary Musculoskeletal Ultrasound Congress on Pain Medicine (MSKUSPM) organised by Dr Carina Li from Multidisciplinary International Association of Musculoskeletal Pain (MIA) and Hong Kong Pain Society. Apart from the hands-on ultrasound workshops, there are precious opportunities for anaesthetists and pain physicians to explore the anatomy of various nerves and relevant structures in the cadaver workshops under the guidance of world-class experts such as Professor Philip Peng and Professor Samer Narouze. All these have been stripped away by the COVID-19. We only managed to organise a local physical symposium in a smaller scale without any workshop in 2021.

The setup of mini-lecture with social distancing in the USRA training course by HKCA in the COVID era

With the past experience of SARS in 2003, the old generation of anaesthesiologists might somehow have more psychological experiences to tackle the COVID-19 pandemic.  Yet, no one would have expected the pandemic would last for more than 2 years. Here, resilience and adaptation to the “new normal” are of paramount importance to all of us. Literally, COVID-19 reflects two sides of the same coin to me.  Yes, it has given us a lot of troubles and inconvenience. Yet, it in turn has provided us some new learning experiences and has directed us to perform more regional anaesthesia as the sole anaesthetic technique in various operations.  Without doubt, I truly hope the pandemic can end soon so that we can travel to attend conferences and meet friends physically. Let’s stay safe and strong.