It Is Recognised That to Gain Experience and Competence in Providing a Safe General Anaesthetic

It is recognised that to gain experience and competence in providing a safe general anaesthetic for a Category 1 Caesarean section can be difficult for a trainee new to the speciality. Discuss ways in which this difficulty can be overcome

------Anaesthetic Training Scheme ------

For the average UK anaesthetic trainee their first exposure to a labouring obstetric patient may not occur until they reach their second or sometimes third year of training. Some will possibly have anaesthetised women in the early stages of pregnancy for a termination of pregnancy at an ST1/CT1 level. Others may have anaesthetised pregnant women for a non-obstetric emergency case e.g. laparoscopic appendectomy or similar. However in many non-obstetric casesa rapid sequence induction may not have been indicated and so the exposure to this particular skill will be limited.

During the Basic Level Training of the RCoA syllabus, it is recommended that obstetric training happens as a dedicated block and that the trainee must pass the formal ‘Initial Assessment of Competence in Obstetric Anaesthesia’ (IAOC). It is usually through the receipt of this competence certificate that a trainee may join the on-call rota for obstetrics and provide anaesthesia for labouring women without direct supervision. Interestingly, given the potential rarity of the Category 1 general anaesthesia (GA) caesarean section (CS)the syllabus suggests that simulators may assist in skills such as ‘general anaesthesia for Caesarean Section’. Additionally the IAOC requires only for the trainee to‘conduct a GA for a C-Section.’ It does not mandate that this is for an elective or emergency case. As a consequence it is certainly possible for a trainee to attain the IAOC, join the on-call rota and even to progress into intermediate training without having ever given or indeed witnessed a Cat 1 GA CS.

------Obstetric Caseload ------

Before considering how to tackle the problem of the under experienced and incompetent novice trainee we must first define the problem by determining the incidence of Cat 1 GA CS and the likely exposure to these cases by a novice trainee.

There are estimated to be around 350000 obstetric cases involving anaesthesia annually in the UK and 17000 of these received a GA (5%). In total around 8000 of the 17000 obstetric GAs were for Caesarean Sections (see table). The OAA estimates the annual caseload of Cat 1caesarean sections (general or regional anaesthesia) to be around 11000 each year and in about 50% of cases a trainee will be the most senior anaesthetist present.

Accidental awareness (AAGA) Obstetric Anaesthesia; Report and Findings of the 5th National Audit Project

This means though that in 25% of cases there was a consultant present and in 25% a career grade doctor. It is probable that trainees will be present on delivery suite during the majority of consultant delivered GAs if one assumes that is unlikely a consultant is alone on delivery suite or working singlehandedly out of hours. In either scenarioa potential training opportunity exists for the novice trainee. Of course not all of theapproximately 3000 Cat 1 sections overseen by a consultant will be via a GA. Indeed it may be more likely that a consultant delivers their anaesthetic via a non-GA method such as rapid sequence spinal (Kinsella 2010) or is more proficient in using epidural top-ups in these cases. Estimates show that only 25-50% of Cat1 sections are performed under general anaesthesia (National Obstetric Audit Data). Indeed the RCoA audit recipe standard is for >50% of Cat 1 CS to be carried out with regional anaesthesia (RCoA 2012). Perhaps then the future direction of obstetric anaesthesia is away from the GA and towards RA in emergency CS.

Recent figures put the number of UK anaesthetic trainees at just over 4000. One could estimate therefore that 8000 CS under GA (of any category) equates to 1- 2 per trainee per year (allowing for those delivered by consultant or career grade with no trainee involvement). Additionally anestimated Cat 1 Caseload of 11000 with approximately 50% GA rate equates to around 5500 Cat 1 GA CS per year; about 1 per trainee per year. With either calculation it is evident that the opportunities to gain confidence in this area are limited.

------Experience vs. Competence ------

Now that we have quantified the challenge for the novice trainee we must attempt to qualitatively address the problem.What is it that so concerns a novice trainee about the Category 1 GA CS? After all it is fundamentally a rapid sequence induction and laparotomy. How or why is it different to the perforated bowel or AAA? Could the novice trainee perhaps use cases such as those to increase their overall confidence in dealing with a high-risk patient? Are there risks or characteristics specific to the obstetric case that makes it very different? It may be the risk of failure to intubate and/or ventilate. The quoted incidence of failed obstetric intubation is around 1:400 (Kinsella 2015); much higher than in the non-obstetric population. However a systematic review (Goldszmidt 2007) showed that there was no evidence that intubation is technically no more difficult (grade 3 or 4 laryngoscopy) in the obstetric population than in the non-obstetric population.One may wonder if it is the anticipated difficulty that becomes a self-perpetuating problem and anxiety for the novice trainee. Perhaps there is also concern regarding morbidity/mortality to foetus or mother. The MBRRACE report of 2015 attributed maternal death directly to anaesthesia in very few cases; in the order of 0.1 / 100 000 maternities (Cantwell 2015). Materno-foetal mortality is a catastrophic outcome when it does occur but thankfully its incidence is very low. Perhaps then the level of competence already being demonstrated by anaesthetic trainees is sufficient and safe. But how should we define competence?

‘the ability to undertake responsibilities and perform activities to a recognised standard on a regular basis. It is a combination of practical and thinking skills, experience and knowledge’ (Health & Safety Executive)

Through this definition we can see that competence e.g. giving a GA for a Cat 1 CS,develops partly through experience and that the two are not synonymous. One may have experience but not yet be competent. A novice in obstetric anaesthesia could certainly develop the required‘practical and thinking skills’ away from the high pressure environment of an obstetric theatre. This could be from private study and reflection, work done in a simulator or through case discussions with peers and senior colleagues. Despite the obvious need for theoretical knowledge, a study doneof a non-medical workforce in Finland showed that the majority ofemployees value work experience as the main source of their competence (Paloniemi 2006). So if we except that experience of the GA CS is the primary way of becoming competent in it, how many casesdoes a trainee need in order to be considered ‘competent’? And is competence the desired end point or should the novice strive for more?

In a study looking at competence in physicians performing sigmoidoscopies it was determined that 24-30 examinations were needed before they were deemed competent (Hawes 1986). The markers for competence included accurate polyp diagnosis and speed or procedure. A study of anaesthetic trainees showed that to achieve a failure rate at epidural insertion of less than 5% required around 50 attempts or ‘experiences’ (Drake 2015). On the assumption made earlier of an average exposure of1 or 2 Cat 1 GA sections each year of training then even in a 7 year programme the average trainee may only be involved in a dozen or so cases. So unless a trainee goes on to complete advanced obstetric anaesthetic training and assuming a similar number of attempts required before competence is achieved it is unlikely that a trainee will ever therefore be truly ‘competent’ in the Cat 1 GA CS.

Thegreen line on the diagram above indicates progression from Novice to Expert as a composite of training & experience. However an imbalance in these two parameters may lead to an over confident but undertrained doctor or as in the case represented by the dashed blue line, an under confident but entirely competent trainee which may represent many junior anaesthetists.

The next question would be to consider what would constitute competent performance for a GA Cat1 CS? Many would suggest a successful intubation, cardiorespiratory stability, successful extubation andmaterno-foetal survival. It may be that despite all of these criteria being achieved a trainee may remain dissatisfied with their performance. In this sense it is only through repeated exposure that confidence and competence is achieved. There is also the issue of time-related decline in confidence and competence. It may take a disproportionate amount of time to gain confidence if there is a long interval between opportunities to repeat the technique.

Inhis 2012 article, McIndoe quoted the work of Dreyfus and Dreyfus who considered learning and experience as a five stage continuum;

Novice > Advanced Beginner > Competent > Proficient > Expert

Dreyfus (1980)

Dreyfus and Dreyfus felt that a novice simply follows rules to the letter providing that they are told precisely which rules to apply. Acompetent person can quickly and independentlyassess the task at hand and then determine and apply the relevant rules. The proficient clinicianusesintuition and the ability to devise their own rules. So to combine the ideas of Dreyfus and the syllabus of the RCoA, what the IAOC is aiming to achieve is a competenttrainee who knows the rules of the Cat 1 GA CS and can apply what they know to the situation at hand. However without proficiency, should a scenario or problem arise to which they don’t have a set of rules to apply then they may get into difficulty. It is perhaps the innate awareness of this lack of proficiency that causes the novice such anxiety. Indeedthe great sage Donald Rumsfeld once wisely noted;

“as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don't know we don't know […], it is the latter category that tend to be the difficult ones” (US Dept. of Defense 2002)

------Suggestions & Solutions ------

1. Maximising Opportunities

During the early years of training it is imperative that a trainee should maximise the opportunity offered by all non-obstetric GAs in the pregnant population. Selected theatre casescan be used to perhapsrehearse a drill with the supervising consultant e.g. preparing drugs and equipment and talking through the ‘what ifs’ of a Cat 1 GA CS. One could also attempt to work as quickly and efficiently on every GA involving a pregnant woman as if it were a Cat 1 section.

Novices could aim to maximise opportunities for learning in GAs administered for Cat 2,3 and 4 sections. If a novice’s first experience of a GA for CS is in a category one case then scope for immediate learning may be limited. ‘Legitimate peripheral participation’ is a concept described by Lave and Wenger in the 1990s and explains how a novice can become an experienced member of a community. Their idea is that the novice is gradually initiated into the community by first joining in with low-risk peripheral tasks (observing a GA for a Cat 2-4 CS). They gradually become acquainted with the language and techniques of the community and their participation increases (give GA for elective CS under direct and then indirect supervision) until they become an experienced and key member of the community. With particular relevance to anaesthetic practice, they described how novices gain from directly observing the ‘practice of experts’ and that by participating in a situation a novice can reflect on development (Lave 1991).

Novices could utilise the statistic that 50% of category 1 sections are performed when a senior anaesthetist is present in theatre. However one should note that in the 2011 GMC trainee survey it was found that half of consultants admit to restricting the activity of trainees even when they had deemed the trainee competent in performing that skill. It must be the responsibility of all anaesthetists to consider when a learning opportunity presents itself and to remember that according to Dreyfus it is ultimately only through accumulation of experiences that a trainee can develop competence and proficiency. The same responsibility to identify and encourage learning opportunities is also true for senior trainees. If a senior trainee is required to deliver a GA CS out of hours it may be useful to call the SHO from ICU or emergency theatres not only for an extra pair of hands but also to increase their exposure even if they are not currently undertaking a formal block of obstetric training. Practically this could also be achieved by ‘piggybacking’ the novice’s bleep to the emergency obstetric bleep or having additional bleeps to be held by novices so that they could be alerted to potential GA cases even if working in a different theatre area.

2. Peer-to-peer learning

There could be wider use of Morbidity & Mortality and trainee peer group meetings where difficult cases are discussed. Some anaesthetic departments organise short weekly breakfast meetings overseen by a consultant where trainees are invited to bring along interesting or difficult cases for discussion and reflection. Incorporating a regular obstetric slot could exposure the very junior trainees to the sorts of dilemmas facing the on-call obstetric anaesthetist. This taps into Jean Lave’s idea of a community of practice (Lave 1991). It is imperative that new-comers to the obstetric anaesthetic community are involved as early as possible in order to become familiar and comfortable with the concepts, dilemmas and language of the specialty.

3. Simulated experiences

Studies have shown that in the cause of endotracheal intubation it required10 hours of deliberate practice in a simulator to be as effective as 15 intubations in the operating theatre (Hall 2005). One could extrapolate this idea to the simulated obstetric airway however there is far more to a Cat 1 GA CS than simply being able to intubate the trachea even though this represents a significant anxiety to the novice trainee. Nevertheless in addition to specific simulator courses for the difficult airway and can’t intubate/ventilate rescue techniques there are also specific multi-disciplinary simulator courses. Many such courses will consider obstetric and neonatal emergencies in an environment that includes midwives, obstetricians, anaesthetists and ODPs. If we consider that a successful Cat 1 CS involves complex multidisciplinary working, clear and focussed channels of communication and a wealth of human factor skills then such courses clearly have a significant role to play in training for high-impact, low-frequency scenarios.

Perhaps attendance on a simulator course could be a mandatory or at least suggested component of the IAOC. This could require investment from the OAA, RCoA or regional organisations. In larger centres the local anaesthetic department may wish to facilitate a simulator day if such facilities are available. Such courses though require time, expertise and ultimately financial investment which often limit their availability. However if the reward was increasingly satisfied, confident and competent novices then perhaps this is an investment worth making.

In order to introduce a non-simulated patient into the training environment perhaps the RCoA or OAA could attempt to produce a training video developed from a real or near-real Cat 1 GA CS case. A project of this size may require central coordination as locally produced small scale material may not be of sufficient quality or scope. One could envisage a real-time video package accessed through the e-Learning Anaesthesia (e-LA) portal where the user could view the Cat 1 CS from the perspective of all the ‘key players’ in the case; anaesthetist, surgeon, scrub staff, midwife, ODP and patient.

4. Non-Clinical Training

As I mentioned at the beginning of this article, the Cat 1 GA CS is essentially a collection of clinical skills that the obstetric novice is capable of; a rapid sequence induction, careful management of blood pressure and timely administration of certain drugs. Perhaps we should therefore shift the focus away from the clinical and towards the non-clinical skills. It is widely accepted that ‘human factors’ play a huge role in the success or failure of any clinical encounter. They potentially are crucial in the high pressure obstetric environment. The complex interpersonal dynamics between midwifery, obstetric, anaesthetic staff and the patient could lead down a path to success or failure; the recent problems at Morecombe Bay being a case in point. Perhaps some form of human factors training delivered regionally or nationally should be a mandatory part of every doctors training

5. Training fit for the future

The current NICE guidance is that the decision-to-delivery interval for a category 1 CS be less than 30 minutes (NICE 2011). We must consider that in the career of many novices or even during the training years there may be a gradual departure from the use of a RSI and GA for the Cat 1 CS. It has been showed that the top-up of a well-functioning epidural or administration of a spinal can be achieved as fast as a general anaesthetic in some cases (Dahl 2009). If the rapid sequence spinal technique garners greater support and/or epidural rates for labouring women increases to nearer the rates seen on the continent (80% in France) then the GA CS may become an even rarer event.

------Conclusion ------

The Cat 1 GA CS remains a formidable challenge to anaesthetists of all grades and levels of experience. As discussed in this article learning doesn’t stop once ‘competence’ has been achieved. Only through a process of lifelong learning can we hope become experts at our craft. It is the responsibility of all anaesthetists to help the most junior in our profession to climb onto the first rung of this ladder of learning. Through an approach that embraces current and new technologies, real and simulated patients, individual and group reflection we can hopefully make the journey as painless as possible (for the patient as well as the trainee.)

Cantwell R, Knight M, Oates M and Shakespeare J. on behalf of the MBRRACE-UK mental health chapter writinggroup. Lessons on maternal mental health. In Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, KurinczukJJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2015: p11