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Out Of Programme Training Placement Reports

Dr Helen Oliver NTN LDN/091/20 /! Before embarking on my career in Anaesthesia in 2007, I spent 5 years as an Emergency Medicine Trainee in Austra ia and the !" #orking in arge, busy $e%e & trauma centres #here I de%e oped a particu ar interest in acute trauma management and the cha enge of pre'hospita medicine( I a so spent time in )e# *ea and #orking as a +ki ,atro Medic #hich further de%e oped my interest in remote and rura trauma management and casua ty e%acuation procedures by #orking c ose y #ith the +ki ,atro team in an area #ith practica y no secondary hea thcare ser%ices( -o o#ing the .M/ recognition in Apri 20&& of pre'hospita medicine as a sub'specia ty of Anaesthesia, I decided I #ou d ike to pursue this as a consu tant career option post //T( I therefore took the opportunity to e0pand my e0perience in this area by app ying for posts in Austra ia re e%ant to this specia ty(

1" !ritical !are an# Retrieval Registrar $it% &reater '(#ne( )rea Helicopter *mergenc( +e#ical 'ervice" 9 mont% post ,mont%s OOPT. mont%s OOP*/"
I app ied for this post as it promised to pro%ide me #ith an e0ce ent standing in pre'hospita and retrie%a medicine( It is the argest retrie%a ser%ice in )+1 ser%icing an area of 2&2,000 s3 mi es and a popu ation of 7(4 mi ion( It #ou d a so e0pose me to aspects of pre'hospita care I #ou d not encounter #ith ser%ices in the !", in particu ar #i derness search and rescue, offshore missions, agricu tura accidents, anima en%enomation and comp e0 inter' hospita critica care transfers( The aim of the post is to pro%ide high 3ua ity c inica care to the acute y i and in5ured patients both in the pre'hospita en%ironment and during inter'hospita transfers, and to support the ambu ance road treatment and transport system #ith a comprehensi%e aeromedica and medica retrie%a ser%ice consisting of he icopter, road ambu ance and fi0ed #ing response( Initia training consisted of an intensi%e 2 #eek course comprising 2 #eeks of medica training 6& #eek pre'hospita , & #eek inter'hospita 7 and & #eek a%iation training( The medica training courses comprised ectures, interacti%e sma group seminars, practica ski s sessions and simu ated scenarios( The a%iation training focused on genera he icopter safety, fami iarity #ith interna component of the aircrafts, #inch training, ho%er e0it8entry and he icopter under#ater escape training( -urther training courses took p ace during the p acement, inc uding 9ertica :escue and En%ironmenta A#areness training, /anyon :escue training, !rban +earch and :escue /ategory & training( These took p ace in %arious out of hospita en%ironments and further prepared us for the %ariety of situations #e may be faced #ith( They #ere %ery different from the urban en%ironments of !" ,;EM and inc uded absei ing do#n a rock face to treat a

<patient= on a c iff edge and treating and e%acuating a patient through a #ater'fi ed canyon( >ngoing training throughout the p acement consisted of month y competency rene#a s of he icopter #inch procedures and 2 month y rene#a of :+I and ad%anced air#ay competencies( Educationa opportunities #ere fre3uent #ith fortnight y c inica go%ernance meetings and dai y case discussions #ith the on site consu tant( I participated in case presentations at se%era /.? meetings and a forma presentation at one /.? and assisted in data co ection for audits comparing the rate of success of aryngoscopy by paramedics and physicians, and difficu t air#ay predictors in the pre'hospita setting( :egistrars #ere based at Banksto#n Airport in +ydney@s south'#est and #orked a fu shift rota of &2 hour shifts either resident or on ca from home co%ering the he icopters or road ambu ance( The basic co%er consisted of 2 doctors on base from 07(20'&4(20 and &4(20'07(20 to co%er the 2 he icopters a%ai ab e, #ith & doctor on base from &2(00'2A(00 to co%er a road ambu ance #hich attended primaries or urgent transfers c ose to the base( There #as a fourth doctor on ca from home bet#een 07(00'&4(00 and &4(00' 07(00 to co%er semi'urgent road transfers and fi0ed #ing missions( A fifth doctor #as on ca from home for a 2A hour period to co%er any additiona missions that occurred #hen a other staff #ere occupied or to undertake engthy missions such as E/M> or IAB, transfers #ith a consu tant( A on ca s from home had a mandatory one hour response time( :egistrars #ou d a so co%er the 1o ongong base for 2A hour periods staffing the he icopter and road ambu ance a%ai ab e there( A missions #ere carried out independent y #ithout direct super%ision, a +enior :etrie%a /onsu tant #as a%ai ab e 2A hours a day to pro%ide phone ad%ice and support, and #as on site during office hours to discuss cases and pro%ide further training8teaching sessions( A casesheets #ere re%ie#ed by the +:/ and regu ar case discussions occurred #hi e on base( ,atient case mi0 #as %aried, about one third being pre'hospita trauma patients re3uiring %arying e%e s of inter%ention at scene to stabi iBe them for transport to hospita , from the administration of opioid pain re ief or ketamine sedation for e0trication or sp inting of fractures to rapid se3uence induction of anaesthesia to faci itate intubation and %enti ation( T#o thirds of patients #ere inter'hospita transfers usua y re3uiring transport from a sma rura hospita to a faci ity #ith Intensi%e /are capabi ities for a %ariety of medica , neurosurgica and surgica causes( These patients often re3uired stabi iBing prior to transport #ith inter%entions such as insertion of in%asi%e monitoring and centra %enous access, initiation of inotropic support and intubation and %enti ation( >ther missions inc uded +earch and :escue missions for persons reported ost in bush and or at sea, the e0trication of patients #ith minor in5uries from difficu t en%ironments such as mountainous or bush and areas or coasta and ocean en%ironments( These patients often re3uired itt e medica inter%ention other than treatment of any mi d hypothermia, dehydration or an0ietyC The age range treated #as 2 ' DDyrs and A+A & ' A 6pre'hospita pts #ere main y A+A &'2, inter'hospita main y 2'A7(

?uring my p acement I gained e0tensi%e training and e0perience in the management of trauma in the out'of hospita setting, performed 2 pre'hospita :+Is, A inter'hospita :+Is and 2 #inch e0trications( I became fami iar #ith the use of ketamine for sedation in the pre'hospita setting and became much more comfortab e #orking in the comp e0 en%ironment of a trauma scene, #ith the impro%ement of my communication and cre# resource management ski s( The inter'hospita transfers pro%ided me #ith e0perience of stabi iBing and mo%ing the critica y i patient and the abi ity to de i%er a the inter%entions that an Intensi%e /are faci ity #ou d pro%ide in the cha enging setting of a transfer( My o%era e0perience inc uded EA cases 622 pre'hospita , A& inter' hospita 7( The main do#nside to the p acement #as the inconsistency of #ork oad per shift, some shifts #ou d pass #ithout missions, #hich cou d be frustrating, #hereas others #ou d be continuous y busy and e0hausting( The concern that I might become de'ski ed due to the inconsistency of the 5ob #as a ayed by the continuous teaching pro%ided by the on site consu tants and the regu ar updating of the air#ay currencies, and I gained many ne# ski s such as u trasound techni3ues to diagnose pneumothora0, TTE and -A+T and confidence in a %ariety of surgica techni3ues such as cricothyroidotomy, atera canthotomy and thoracostomy( A my ob5ecti%es for the p acement #ere met and e0ceeded and I #ou d recommend the p acement for pro%iding an e0ce ent grounding in pre'hospita and retrie%a medicine(

2" Provisional 0ello$ in )naest%etics at 't &eorge Hospital. '(#ne(" - mont% post ,- mont%s OOPT/"
The +t .eorge ;ospita is a arge metropo itan hospita of appro0imate y A00 beds, ocated in the +outh Eastern and I a#arra Area ;ea th +er%ice of +ydney, )+1, and ocated south of the city( It is a tertiary referra hospita for trauma and obstetrics and a teaching hospita of the !ni%ersity of )e# +outh 1a es( This post is designed as a bridging post bet#een registrar training and consu tant practice #ith the fo o#ing aimsF &( To gain further c inica anaesthesia e0perience at a more senior e%e , #ith the goa of achie%ing independent practice( 2( To gain further e0perience #ith subspecia ty anaesthesia( 2( To gain e0perience in other aspects of c inica practice such as research, teaching and triage( ?uties of the post #ere pre'assessing patients coming for routine surgery in c inic, anaesthetising patients for surgery, pain management, abour #ard epidura s, pro%iding anaesthesia for emergency patients, assessment and management of other patients coming to surgery such as maternity, trauma and I/! patients( As the ?uty Anaesthetist I #as responsib e for the performance of triage on patients a#aiting surgery, the booking and

schedu ing of emergency theatre cases and administrati%e processes in the theatre suite( >ther duties inc uded the teaching and super%ision of 5unior trainees or residents and undergraduate teaching( An orientation program #as pro%ided by the +t .eorge ;ospita for ne# medica staff #hich identified key re ationships, po icies and procedures( In addition, members of staff in the Anaesthetic department, both administrati%e and c inica , #ere a%ai ab e to orientate me to departmenta key re ationships, po icies and procedures( ?epartmenta teaching consisted of #eek y morning meetings and regu ar registrar teaching #hich #e #ere encouraged to both attend and present at( The #ork pattern consisted of four &0 hour shifts a #eek #ith one day as a non'c inica day to de%e op practice in teaching, audit or research, and #eekend shifts co%ering the emergency theatre #ith a 5unior registrar( >ne of the #eek y shifts #as undertaken as the ?uty Anaesthetist, #hich in%o %ed running of the emergency theatre, co'ordinating the routine theatre ists for the day and being on ca to attend #ard emergencies, trauma ca s etc( I chose to pursue teaching as my non'c inica responsibi ity( >ne of the teaching opportunities inc uded attending the Basic Air#ays :esuscitation +trategies 6BA:+7 instructor course, a course de%ised by the / inica ?irector of the Anaesthetic ?epartment to pro%ide an esca ating response for nurses and medica staff in%o %ed in the management of patients #ith potentia y compromised air#ays( >nce comp eted, I then undertook the teaching of the BA:+ course to se%era sma groups of 5unior doctors throughout the p acement( I a so had the opportunity to teach on a fu day course for nursing staff co%ering the management of emergencies in the reco%ery #ard and he d teaching sessions for medica students and 5unior registrars approaching their -A)*/A 6-:/A e3ui%a ent7 e0ams( 1ithin hours, direct super%ision #as pro%ided by a consu tant anaesthetist, super%ision #as most common y on a one to one basis, or on a one to t#o e%e if c inica conditions #ere suitab e to this e%e of super%ision( If the ,ro%isiona -e o# #as running their o#n ist, the direct super%isor #as the ?uty Anaesthetist #ho #as a%ai ab e #ithin the theatre comp e0( >ut of hours, super%ision #as pro%ided by 2 consu tant anaesthetists on ca , #ho #ere either #ithin the operating suite or a%ai ab e by te ephone contact, as directed by the case oad and comp e0ity of the surgery( Educationa +uper%isors #ere assigned to each ,ro%isiona -e o# #ith meetings arranged at the beginning, midd e and end of the p acement to discuss earning ob5ecti%es and needs and ensure these #ere met during the p acement( The case mi0 inc udes a the ma5or surgica specia ties, a though there #as not a arge paediatric surgica ser%ice at The +t .eorge ;ospita , and routine hand and orthopaedic surgery are not performed at +t .eorge( I recei%ed e0posure to a #ide range of cases and #as ab e to de%e op my autonomous practice #ith the support of the consu tant body( My o%era e0perience consisted of 2EA cases #ith a good range of specia ties( I co%ered &02 cases in .enera 8.ynae8!ro ogy, #hich inc uded cytoreducti%e surgery ists 6something I had not pre%ious y been e0posed to in the !"7, 2D cases in Trauma and >rthopaedics, 2A /ases in /ardiothoracics, 20 cases in

>bstetrics 6the $abour #ard did not ha%e a separate theatre so a emergency8e ecti%e surgeries #ou d come to main theatres7, &2 )eurosurgica cases, &5 9ascu ar and , astics cases and 2 E)T8Ma0'fac cases( A ma5or difference #ith the !" is that an anaesthetist is present to manage the sedation of a patients undergoing gastroscopy8co onoscopy, so by undertaking these ists I gained %a uab e e0posure to this fie d( +edation #as a so pro%ided for regu ar bone'marro# biopsy, E/T and cardio%ersion ists and I obtained a tota of 5& cases( I a so gained %a uab e air#ay e0perience #ith a tota of D fibre'optic intubations, 2 of #hich #ere indirect y super%ised #hich enab ed me increase my confidence and ski in this re ati%e y rare y performed but %ery important procedure( I #ou d recommend this post as a %a uab e e0perience in obtaining further e0posure to a #ide range of specia ties #ith the opportunity to de%e op independent practice, management ski s and educationa interests(