New Starter Guide

New Starter Guide by Andrew Song

Contents

• Contents
• Welcome to your anaesthetic placement!
• Where to begin?
• What is required for your training portfolio to complete the IAC?
• Portfolios
• EPA 1& 2 explained
• EPA 1: Perform anaesthetic assessment
• EPA2: provide general anaesthesia for ASA1/2 patients having uncomplicated elective or emergency surgery at supervision level 2b.
• The IAC assessment day
• Learning in Anaesthesia Training
• The first few days
• Week 1 – 4
• Week 5 – 8
• Week 9 – 12
• What happens after completing the IAC

Welcome to your anaesthetic placement!

Starting any new specialty is always a confusing time, particularly with Anaesthetics as everyone’s previous exposure and knowledge will be different. Your first 3 months, or “Novice Period” as it is sometimes termed, will be spent working towards the Initial Assessment of Competencies (IAC), set out by the Royal College of Anaesthetists (RCoA). This will be explained in more detail later in this guide, and there are plenty of resources available which will be signposted in this guide.

Trainees will come from a range of training pathways. Each will have their own specific areas of interest, but the end goal remains the same for all. There will be varying levels of anaesthetic experience amongst individual trainees as well, which will then impact on the speed at which people progress. Do not be put off by other people’s progression, focus on your own learning needs and development.

This guide will aim to cover the EPA 1 and 2 requirements, as well as demonstrating how to evidence attainment for portfolio purposes. This is outlined in the RCoA IAC workbook (search online for the latest edition), but hopefully this guide will have some helpful pointers that is not covered in the workbook.

The other section of the guide aims to provide people new to anaesthesia with advice on how to maximise learning in a working day, as well as a rough timeline to work against. It is not meant to be prescriptive, and your experiences will vary from one hospital to another. This is only a guide, please take the bits that you find helpful and ignore the rest.

Where to begin?

The anaesthetic journey

When you first begin anaesthetics, the learning curve can be very steep and feel slightly overwhelming. It can therefore be useful to breakdown the different tasks required into a stepwise approach. Below is a breakdown of the individual steps you perform for each patient undergoing a general anaesthetic. There may be more steps in more complex patients, but these are the basics.

RCOA have developed a “Novice Guide” which provides a bit more detail into each of these areas and is certainly worth a read.

Novice Guide

An interactive guide for novice trainees.

rcoa.ac.uk

There are also books available covering training in anaesthesia. Previous cohorts have suggested “How to survive anaesthesia” which can be found on Amazon. Bear in mind that these books may well be based on an older curriculum and may be outdated by the time you get them.

What is required for your training portfolio to complete the IAC?

In order to achieve the standards for IAC, there will be 2 sections that need to be evidenced in your portfolio:

1. Portfolio evidence to demonstrate achievement of all the key capabilities that make up learning outcomes of EPA 1 & EPA 2. This will be explained in more detail later in this guide
2. Logbook summary of cases and anaesthesia type. For ACCS trainees there needs to be evidence of procedural sedation as SLE and logbook.

One you have achieved enough evidence and completed your clinical time (3 months equivalent), your Educational Supervisor (ES) will initiate a Multi-trainer report tool (MTR). This is essentially consultant feedback that your ES will gather. They will also ask you to initiate two things:

• A Holistic Assessment of Learning Outcomes (HALO) form for EPA1 and 2 to be sent to your ES to sign
• The IAC Certificate to be sent to your ES and the local College Tutor to sit

The RCoA IAC workbook provides a process map for IAC in Appendix 1.

https://www.rcoa.ac.uk/sites/default/files/documents/2022-09/EPA-1-2-2022 v1.2.pdf

Portfolios

Depending on your base specialty, you will likely be using one of several portfolio systems.

For Core Anaesthesia, ACCS-anaesthesia and ICM trainees:

The RCoA use a platform called Lifelong Learning (LLP). Once you have registered with the RCoA you will be given access. The platform will have links to all workplace-based assessments and relevant. It also has a logbook incorporated, to log both anaesthetic cases as well as during your Intensive Care placements. For those on the ACCS pathway it also has specific ACCS titled assessments.

Many anaesthetist trainees will be familiar with this, and the college provides tutorials on using LLP on their website:

https://rcoa.ac.uk/training-careers/lifelong-learning/help-support

Also see our lifelong learning page:

Lifelong Learning Platform

For ACCS non-anaesthetic trainees:

You will using your base specialty portfolio system. None of these will be familiar with most anaesthetists as it was only introduced recently. However, all the WBAs you will need are available to select with the same titles as set out by the RCoA. It will then be up to you to populate appropriately.

You will need a separate anaesthesia logbook. There are lots available as apps. Many people have used the Anaesthetic App (https://anaesthetics.app/) which was developed by a previous trainee, and is in-line with RCoA requirements. It’s also free! Summaries can be generated and exported as files which you can upload.

For those on other pathways or anything other questions regarding portfolios, please consult with either your Educational Supervisor or the College Tutor for advice.

EPA 1& 2 explained

Some definitions:

Initial assessment of competence (IAC) demonstrates the fundamental knowledge skills and attitudes to provide safe anaesthetic care.

This is assessed by you achieving Entrustable Professional Activities 1 &2 at supervision (entrustment) level 2b.

Achieving IAC is mandatory in core anaesthetic & ACCS rotation through anaesthetics

The novice period of training lasts until IAC is achieved and is usually 3 months. Until this point you will always be supervised by someone more senior.

Supervision (Entrustment) levels:

• 1 – direct supervisor involvement, physically present in theatre throughout
• 2A – supervisor in theatre suite available to guide aspects of activity through monitoring at regular intervals
• 2B – Supervisor within hospital for queries and able to provide prompt direction/assistance
• 3 – Supervisor on call from home for queries and able to provide direction via phone or non-immediate attendance
• 4- Able to manage independently with no supervisor involvement.

EPA 1: Perform an anaesthetic preoperative assessment

EPA 2: Provide general anaesthesia for ASA I/II patients having uncomplicated surgery

Evidence in portfolio used to assess:

• Supervised Learning Events (SLE): ACex (Anaesthesia Clinical Evaluation Exercise), DOPS, CBD
• Logbook (use LLP or other)
• Reflection – on clinical and non-clinical activities
• Personal activities – tutorials/e-learning/reading/courses/simulation
• Multiple Trainer Report (MTR) for IAC period (this is consultant feedback, not an MSF)

EPA 1: Perform anaesthetic assessment

Learning outcomes outlined in EPA workbook

• Takes a focused history, performs appropriate physical examinations, and interprets relevant investigations.
• Describes the features of the history and examination which confer increased anaesthetic risk and communicates these to senior colleagues, including:
• severe comorbidity (ASA ≥ III)
• previous anaesthetic complications
• anticipated or known difficult airway.
• Explains how a patient’s past medical, surgical, and anaesthetic history influences the safe conduct of anaesthesia.
• Communicates the anaesthetic plan to patients in an understandable way, including counselling on commonly occurring risks and addressing patient concerns.
• Demonstrates understanding of the limitations and scope of practice of a novice anaesthetist

Limitations

• Advanced knowledge of perioperative risk stratification and optimisation is not expected at this stage of training.
• Novice anaesthetists are not expected to possess in-depth knowledge of the anaesthetic techniques used for major surgical procedures, nor should they be expected to take consent for procedures in which they are not trained.

Suggested topics to evidence in portfolio: all amenable to SLEs DOPS/ACEX/CBD

1. Taking preop assessment history & examination
2. Establishing rapport with patient and communication techniques
3. Performing airway assessment
4. Discussing ASA classification, other risk calculators
5. Discussing comorbidity: obesity, asthma, URTI, diabetes, anaemia, ischaemic heart disease, GORD, psychoactive or non-prescribed/non-therapeutic drug use
6. Discuss starvation policy
7. Explaining anaesthetic care and gaining consent for both GA and regional

Suggestions for personal activities to evidence:

1. New starter tutorials
2. E-learning from Novice guide/eLA anaesthethesia modules
3. Reading – DAS resources www.das.uk.com Tayside airway mastery (go to DAS website and use search box), Oxford handbook of Anaesthesia.
4. Reading – Patient Information Resources tab on RCoA website- on anaesthesia and risks;
5. Reading – CPOC guidelines and risk assessment tools. www.cpoc.org.uk – Guidelines and resources tab
6. Reading – trust guidelines on perioperative diabetes, anaemia, medication management, fasting guidelines
7. Reading – SOBA app/website www.sobauk.co.uk

Suggestions for reflection:

1. Discussions not captured by, or building on an SLE
2. Difficult or challenging cases – clinical or communication aspects.

EPA2: provide general anaesthesia for ASA1/2 patients having uncomplicated elective or emergency surgery at supervision level 2b.

Learning outcomes and areas of knowledge:

EPA 2 is the provision of general anaesthesia for ASA I/II patients having uncomplicated surgery. In practice this prepares Anaesthetists in training to provide anaesthesia for low risk patients having unplanned, urgent or emergency surgery, while carrying out their on-call duties.

Limitations

• Does not include the unsupervised management of previously fit patients with significant physiological derangement such as septic shock or acute blood loss.
• Anaesthetists in training who have been awarded the IAC are not expected to be the sole anaesthetist responsible for elective operating lists

Suggested topics:

Non-italic font is text copied from the Workbook document Italics indicate additional suggestions on examples of topics for SLE/discussion with trainer. You do need to know about all the items in bold type You do NOT need to provide evidence for every individual point One SLE can cover several areas. For Core Anaesthetic Trainees, remember to map relevant items to Stage 1 (Core) anaesthetic curriculum

• Pre-operative preparation
• Relates knowledge underpinning EPA 1 (Anaesthetic Pre-operative Assessment) to safe perioperative care planning
• Understands the scope of practice as an inexperienced practitioner and seeks help appropriately
• Recalls starvation policies for administration of general anaesthesia
• Demonstrates working knowledge of commonly used anaesthetic equipment, including the anaesthetic machine, standard monitoring and airway equipment
• Anaesthetic Machine Check
• ECG/BP/SpO2 monitoring, NMB monitors, BIS
• Multi-gas analysis/capnograph
• Tables & trollies
• Vapourisers, infusion pumps
• Demonstrates working knowledge of the commonly used anaesthetic drugs (preparation / dose / effects / side-effects / cautions):
• Induction agents
• Antiemetics
• Muscle relaxants/reversal agents
• Sympathomimetics/anticholinergics
• Volatile anaesthetic agents
• Analgesics
• Intra-operative Care
• Performs airway management including the following techniques:
• Mask ventilation
• Supraglottic airway insertion
• Endotracheal intubation using direct and video laryngoscopy
• Performs a Rapid Sequence Induction
• Conducts anaesthesia with controlled and spontaneous ventilation
• Managing induction
• Modes of ventilation, settings and displays of anaesthetic machine ventilator
• Maintenance phase with volatile
• Maintenance phase with TIVA
• Manage whole case from start to finish
• Understands the physiological effects of general anaesthesia
• There are physiological effects of drugs and physiological effects of mechanical processes - why does BP fall on induction and on IPPV? Why do we not use Fi02 21%? Why is ETCO2 not equal to paCO2?
• Manages the risks posed to patients when positioning them for surgery, in particular related to pressure areas, peripheral nerves and other delicate structures
• Transferring patient in theatre - from trolley to table and table to bed
• Risks and physiological effects of lithotomy, prone, lateral positions, head down
• Protecting pressure areas and delicate structures
• Follows infection prevention and control procedures in the operating theatre
• Antibiotic guidelines, PPE, ANTT,
• Ventilation of theatre/ Aerosol clearance times
• Scrubbing up technique
• Manages tracheal extubation, including common complications occurring during emergence from anaesthesia; e.g.
• laryngeal spasm
• Coughing & breath holding
• Desaturation
• Inadequate NMB reversal
• Post-operative Care
• Gives a clear patient handover to recovery team
• Manages issues arising in recovery including acute postoperative pain, and the use of rescue opiates in recovery
• PONV
• O2 therapy
• Managing Emergencies & Simulation
• Discuss and rehearse the AAGBI Quick Reference Handbook ‘Unknowns’
• Regurgitation under Anaesthesia
• Anaphylaxis
• Malignant Hyperpyrexia
• ALS algorithms
• Demonstrates the routine for dealing with a failed intubation on a manikin as per DAS Guidelines
• Demonstrates understanding and capability in Anaesthetic Non-technical Skills
• WHO checklist team brief & sign in process
• Medication safety
• Controlled Drug management and disposal
• Preparing the anaesthetic room

Suggestions for Personal activities

1. New starter tutorials
2. Departmental education forum and meetings
3. Locally arranged simulation sessions
4. Reading – DAS resources, Tayside airway mastery, Oxford handbook
5. E-learning from Novice guide/eLA anaesthethesia modules
6. Prevention of future deaths resources on RCoA website (under Patient safety tab) – capnography/human factors.
7. QRH app/document

Managing a whole case from start to finish – encompasses all components of EPA 1 and EPA 2 so is what you should aim to have evidence of for a variety of anaesthetic techniques by the end of the novice period at supervision level 2b.

Other SLEs should demonstrate progression – don’t wait until you feel you can “get a 2b” for something before doing any SLEs!

SLEs – a few notes

• No minimum numbers required but should be used in a formative way to demonstrate reflection on learning and progress by the trainee.
• For ACCS Trainees evidence of procedural sedation is required
• For EPA1&2 the vast majority of the SLEs should be assessed by consultants.
• SLEs are low stakes formative assessments. There is no pass/fail.
• SLEs should be regular part of training
• Reflection on the event, subsequent discussion and feedback from the assessor are the most important components of the SLE.
• Areas for learning should ideally be identified prior to starting the list/clinic/ward round and the SLE request discussed in advance with the trainer.
• Requesting SLE completion retrospectively is considered poor practice and should be avoided.
• The trainee should reflect on the learning event.
• The trainer should observe the practice of the trainee and give immediate verbal feedback as well as suggestions for future development and progression. They should indicate a supervision level that the trainee requires for the activity if it were to be repeated there and then, i.e. what supervision level they deem you need for this activity from now on, not what your supervision was for the activity whilst it was being observed (this is something you might need to re-iterate to and clarify with the consultant)
• Trainers should comment on clinical and non-clinical aspects of performance such as professionalism, teamwork, communication.
• Ideally the SLE should be documented on the LLP contemporaneously. If the online form cannot be completed at this time, then the trainee will send an electronic request to the trainer. This should be completed as soon as possible. Verbal feedback should always take place at the time of the activity.
• The trainee should link the SLE to key capabilities in relevant domains.

The IAC assessment day

Towards the end of the 3-month period there will be an OSCE style assessment day that forms part of the IAC sign-off process.

Previously this was run at 2 sites, however because of the pandemic this has been run more locally. The four stations shouldn’t take more than an hour to get through in total.

This is not a formative assessment; there are no marks or grades. Similarly, do not worry if you cannot make the day (due to sickness or emergencies or any other reason), this day does not determine the overall outcome of your IAC sign-off. Anything you miss can be re-arranged locally.

Nothing about these stations will be any different to what you have been doing on a daily basis. There are no trick questions, and there should not be any surprises or complex problems for you to deal with.

Your Educational supervisor and College Tutor will be informed of your progress.

Tips

This is not a medical school OSCE; you will not “fail” if you forget to alcogel your hands. However, you will be expected to maintain a professional attitude throughout, as you would if you were assessing a real patient for example.

You may be asked to check a machine you are unfamiliar with, which can cause some anxiety for people. This will be taken into consideration; what is more important is that you demonstrate the process and can logically work through the AABGI checklist. You are perfectly entitled to say “I’m not familiar with this machine, but the first thing I want to do is…..”

Like any OSCE, practice beforehand will make you appear slicker and more confident. This is particularly true for the RSI and failed intubation station. The communication and verbalisation of your actions will be scrutinised more than your actual actions, so make sure you know the DAS guidelines well.

Learning in Anaesthesia Training

As mentioned earlier, everyone will have a different starting point and speed of development. Even people with previous experience will feel lost and slightly aimless during the first few weeks.

The timeline outlined below simply acts as a guide to help keep track of your learning, with potential milestones to try and attain leading towards your IAC. In general, there are always potential practical aims to do for cases, and theory topics you can discuss with your consultant of the day during the case. This is only a guide and not a prescriptive learning tool, and by no means exhaustive. Practical procedures will depend on the cases and lists you are assigned. If you are not getting appropriate exposure to certain procedures, you can discuss this with your supervisor to target your learning more.

General Tips

Working with different consultants – there is no “right” anaesthetic for a procedure as long as it is safe. You will see variations in practice between different consultants, which can be very confusing at times but is good exposure to the different options of anaesthesia available. Take away what you wish to incorporate into your own practice.

You will be with another (often more senior) trainee as well as a consultant, so you are not alone. It also provides the opportunity to see first-hand what challenges you may encounter when you pass the IAC and are put on the on-call rota.

There will be occasions when a complex patient or critical incident occurs that you may feel like you are not contributing much and are just standing on the side. This is also ok and expected so do not take this personally. However, try not to be a passive observer, you are still a qualified doctor and can be extremely helpful. Even if you are observing, pay attention to how people communicate during these events and management of human factors, which are highly important skills to have in anaesthetics alongside the clinical stuff!

The first few days

The anaesthetic department will have an induction. Like all inductions you will have a lot of information thrown at you, but the following are things to focus on.

1. Familiarise yourself with locations in the hospital
1. Location of the various theatre complexes
2. Location of pre-operative admission unit (if your hospital has one)
3. Any other areas that you may be working in (e.g. Endoscopy, Interventional radiology)
2. Getting set up on your hospital Rota system
1. Most places will use CLWrota, which details which theatre and which consultant you will be with that day

You will not be expected to see any patients in your first few days, but it is good practice to familiarise yourself with how your centre runs elective lists, as well as watching the consultants prepare for the day.

Do not be afraid to make introductions and state that you are a new starter. This will aid your supervising consultant in planning their day as well as relevant topics of discussion with you.

You will usually be assigned to a theatre list for the whole day, or to one list in the morning and one in the afternoon. During the list you will be with a consultant, and very rarely with another trainee. This means it will be direct 1 to 1 supervision, which makes for great learning opportunities.

Week 1 – 4

Theory

Focus on outcomes from EPA 1, but there will be lots of overlap with EPA 2

• Learning how to perform a general a pre-operative assessment as outlined by the SLEs
• Learning how to perform airway assessment – for both bag mask valve ventilation as well as potential intubation difficulty
• Begin to understand how the pre-operative assessment, airway assessment and procedure the patient is having influences anaesthetic technique, airway choice and conduct of anaesthesia
• Learning about emergency drugs – how to prepare them and what they do
• Atropine vs Glycopyrrate
• Metaraminol
• Ephedrine
• Learning about common anaesthetic drugs you will come across
• Induction agents - Propofol
• Induction opiates – fentanyl, Alfentanil, Remifentanil
• Muscle relaxants – Sux, Atracurium, Rocuronium

Tips

You will have a series of introductory lectures regarding pharmacology and physiology, as well as clinical aspects of anaesthesia. Use these as potential discussion points during your list. A lot of the theory will probably not make much sense at the start; understanding will build over time with repeated use and discussions.

You are not consigned to one list all day. Feel free to move around different theatres and use the start of cases as opportunities for airway experience. Take the initiative and let the other consultants in your theatre suite know in the morning.

Direct Laryngoscopy is difficult to both teach and learn at the start. Consider using a video-laryngoscope when first learning intubations, as both you and your supervising consultant can see what is happening easier and provide more directed instructions.

The vast majority of hospitals use the same anaesthetic machines and equipment, but this may vary in different sites and theatre suites. This can be quite confusing at the start so don’t worry about it, but in general do not use a piece of equipment if you don’t know how to use it!

Week 5 – 8

Theory to discuss

Tips

There will be a temptation to try and do more practically, or run cases independently. You will come to find that there is more to consider logistically than you imagine, so do not feel rushed to do so.

Ask to give the drugs during induction. As a novice you will often be assigned to manage the airway, and whilst it is important to maintain airway management exposure, first-hand experience with anaesthetic drug delivery is equally important. At this stage you should know enough to be able to dose and time delivery of these drugs during the induction phase.

Certain topics may start to become less relevant depending on your base specialty. Tailor your discussions so that it is more relevant to your learning needs, e.g. if you are an ED trainee you can ask about considerations when performing an RSI in a resus setting, or procedural sedation and options for those.

Week 9 – 12

By this point you will have made good progress with the following:

• Perform pre-operative assessment for ASA 1, 2 or 3 patients
• Safely manage patients intraoperatively with haemodynamic and ventilation goals
• Safely manage emergence and extubate an uncomplicated patient safely
• Perform full machine check according to AABGI standards

Your IAC will be either in week 11 or 12. These weeks should be focused on completing anything missing from your portfolio and consolidating knowledge.

What happens after completing the IAC

Do not worry if at 3 months the portfolio stuff has not been completed. As long as your educational supervisor has indicated you have met the standards you have completed the IAC.

Depending on where you are placed, after completing the IAC many hospitals will start you on the general anaesthetic on-call rota. This again may feel very daunting, but have confidence in your training so far. There will always be another more senior anaesthetist in the hospital, and an on-call consultant who will be expected to come in out of hours if you ask them to.

Do not become over-confident and feel you can tackle any airway and anaesthetic problems after your IAC. It is only an initial assessment, there is much more you can do and learn about no matter what your base specialty is.