I love Twitter and I love #FOAMed. I get to be a fly on the wall observing passionate and qualified debates on interesting and arguably controversial topics. In a refreshing divergence from the cricoid pressure debate, the Minh Le Cong (PHARM) and Nic Chrimes (VORTEX) public airway philosophical discussion rolled onto the topic seeded by an ‘innocent’ Tweet:
Should all med students learn how to deliver a baby or intubation?#meded
For a transcript of the discussion, have a look at the Storification from Minh: Storify – Minh Le Cong vs. Nicholas Chrimes
I had some pretty strong personal opinions about this topic and this was reinforced this week by one evaluation comment from the ACLS Competency Course I coordinate at our hospital. A second year doctor commented, ‘the airway session was probably too basic for a JHO.’ This concerned me. It is not a comment that has arisen previously and I welcome constructive critical feedback. The emphasis of airway management in our ACLS program is on competency and ideally proficiency in bag-valve-mask technique (including two-handed face mask seal technique), simple airway adjuncts and laryngeal mask airway. A discussion of indications for ETI and preparation for and assessment of successful intubation. This inflamed my concerns about emphasising teaching of rarely used, specialist skills to juniors (nursing or medical). I have observed on many occasions a junior doctor (having just completed their intern year) state something like ‘ Yeah, I can intubate, I’ve done an anaesthetic rotation’ only to grab the laryngoscope in their right hand for a second until the realisation that it won’t work that way. Thankfully they are only breaking the teeth of an airway trainer in our Sim Lab. This is not an attack on said ‘Junior doctor’ as I have heard the same comments from new ICU nurses ‘yeah I can look after a ventilated patient’.
While I am in no way qualified to dispute the technicalities of endotracheal intubation, I do know a thing or two about competency assessment, training and simulation (including critical care skills). People love to wear the glamour skills such as ETI as a badge of pride, a symbol of expertise during their medical training adolescence. The problem is, when is one competent in ETI. Is a few observed passes in anaesthetic bay competent? Is a number of intubations on an airway head in Sim Lab competent? Do we want competency in this skill or mastery?
In my working role I am involved with a great deal of the junior doctor professional development program and find it is actually a fairly well defined scope and curriculum based upon the guidelines from the Confederation of Post Graduate Medical Councils.
Skills & Procedures for PGY1 and PGY2 Competency Standards
- Venepuncture
- IV cannulation
- Preparation & administration of IV medication, injections & fluids
- Arterial puncture in an adult
- Blood culture (peripheral)
- IV infusion including the prescription of fluids
- IV infusion of blood & blood products
- Injection of local anaesthetic to skin
- Subcutaneous injection
- Intramuscular injection
- Perform & interpret an ECG
- Perform & interpret peak flow
- Urethral catheterisation in adult females & males
- Airway care including bag mask ventilation with simple adjuncts such as pharyngeal airway
- NG & feeding tube insertion
- Gynaecological speculum & pelvic examination
- Surgical knots & simple suture insertion
- Corneal & other superficial foreign body removal
- Plaster cast/splint limb immobilisation
I’ll finish with a big disclaimer. This is not intended to take a side in a Twitter discussion between professionals with far more qualified opinions than mine. I would just urge all clinical educators to beware the Unwritten Curriculum, you just might be telling juniors ‘we expect you to go and perform this procedure – you are now competent’ (not everyone will interpret teaching this way – just those lacking insight). Scary, huh?
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Spot on !
Good points, well made.
We see the same on EMST course I direct – juniors have come away stating they can ‘do FAST scan’ after a brief discussion of the FAST vs DPL vs CT abdo cases and perhaps watching a short video of FAST
The more I get older in medicine, the more I realise that we need to teach the simple things well…not the more complex. I can teach my grandma to pass an ETT on a mannikin. I cant teach her when to intubate/when not to or the nuances of a trauma RSI unless she grasps pharmacology, physiology and pathology at an advanced level – so about 10 years of medical training!
Good post, liked it
Yeah. Best case of this I’ve experienced a couple of years ago when and PGY2 was pontificating about how he always did DC Cardioversions with no sedation (grandstanding in front of some interns). I said ‘that’s nuts, what are you basing that on?’ He said ‘I’ve done heaps like that’. I couldn’t help myself, I said ‘with all due respect mate, your about 24yrs old, and have a year of internship under your belt, you’ve done nothing heaps. Check your evidence base and standard of practice, pretty sure giving analgesia at a minimum is an ethical obligation.’ Residents are the adolescents of medicine.