| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
| ||||||||||||||
| ||||||||||||||
|
|
|
|
||||||||||||
|
||||||||||||||
Department of Anesthesiology, Hospital for Special Surgery, New York, NY
To the Editor:
Martin et al. (1) are to be commended for their report evaluating a new teaching model for training in regional anesthesia. Based on the results of this study, they certainly achieved their stated goal "to increase resident training and exposure to peripheral nerve blocks with a resultant improvement in skill and confidence level." Indeed, the residents at Duke University Health System are the envy of many programs across the country that are struggling to offer comprehensive training in, and adequate numbers of, peripheral nerve blocks to their residents.
This system of training does come at some expense, however. We propose the first cost to be the loss of the intraoperative educational experience of a regional anesthetic. The second cost relates to the potential for damage to the doctor-patient relationship.
Placement of a peripheral or neuraxial block is only one, albeit very important, aspect in the performance of a regional anesthetic. There are other important components in the performance of a complete regional anesthetic, and by focusing only on the "block," residents may miss out on a critical part of their education.
Managing the sedation during a perfect, adequate, or inadequate block is a skill that requires experience and training. In fact, many patients feel the sedative management is as important as the block placement itself. Choosing the correct sedative and level of sedation when blocks are perfect or imperfect can be a challenge for residents, requiring experience in each setting.
Prompt and effective treatment of adverse events during performance of regional anesthetics may mean the difference between a harmless physiologic alteration and a devastating complication. These events may include cardiovascular changes such as bradycardia and hypotension under neuraxial blockade, or during shoulder surgery under interscalene block in the sitting position (2). They may be as life threatening as an airway emergency or a seizure, or as benign (but not unimportant) as movement during surgery. Recognizing the differences between mild respiratory difficulty arising from hemidiaphragmatic paresis after interscalene block (3) in a healthy individual versus severe respiratory compromise secondary to a pneumothorax or inadvertent epidural injection requires experience.
Each of these events requires skilled diagnosis and management in order to avoid disastrous outcomes as well as dissatisfied patients and surgeons. For these reasons, we believe omitting the intraoperative portion of a regional anesthetic in a majority of cases may not be in the best interests of a resident learning regional anesthesia.
In summary, learning to perform peripheral and central neural blockade is an essential component of performing complete regional anesthetics. This skill can only be perfected through repetition and a high volume of blocks under skilled and dedicated supervision. We believe the Duke model is a complete success in this regard. However, their manuscript would be more appropriately titled "A New Teaching Model for Resident Training in Peripheral Nerve Blockade." There is more to "Regional Anesthesia" than placement of the block.
References
Department of Anesthesiology, Duke University Health System, Duke North Hospital, Durham, NC
In Response:
We appreciate the comments of Ligouri et al. and wholeheartedly agree with the importance of comprehensive education in all of the aspects of regional anesthesia. Our article focused on one aspect of the regional anesthesia training our residents receive, particularly the CA-3 experience. However, the study did not describe the entirety of the Duke resident experience in regional anesthesia. As we demonstrated in the article, our CA-1 and CA-2 residents have significant experience placing regional blocks, for which they also conduct the entire intraoperative portion of the case (Median 78 spinals, 150 epidurals, and 77 peripheral nerve blocks) (1). They gain experience with appropriate intraoperative sedation, possible rescue of an inadequate block, and the management issues related to positioning and other potential surgical complications. In addition, the block resident is able to visit several rooms at intervals during the cases and determine the outcome of their regional anesthetics, associated sedation, and surgical course. Our residents receive comprehensive didactic education regarding regional anesthesia and also benefit from cadaver workshops demonstrating relevant anatomy. A Web-based education module (2) is also available online and via our perioperative information system and is used by faculty and residents to enhance the clinical experience. This module includes many of the topics Dr. Ligouri and his colleagues mention. We therefore believe that our residents are well trained in all aspects of regional anesthesia.
Another unintended but valuable result of our senior resident regional anesthesia experience is that it prepares the resident for various models of practice they may encounter after residency. One of the factors that led to widespread acceptance of the use of regional anesthesia by our surgical colleagues is the ability to achieve successful regional anesthesia without utilizing operating room time to do so. Our preoperative block area, and the model we use with our senior residents, allows for this efficiency. In addition, the senior resident develops valuable skills that will be useful as an attending anesthesiologist, such as quickly establishing a therapeutic rapport with patients, developing efficiency with time management, and assisting junior residents with their own regional anesthetics. We believe this model helps our residents with the transition to consultant-level practice of regional anesthesia following residency, while providing them with ample opportunities to achieve technical proficiency with a wide variety of regional anesthesia techniques.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
