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According to the studies of Kopacz, confidence
is the most important factor in using regional anaesthesia
(RA) effectively1. This confidence is only gained
by experience and training. Even for epidural and spinal anaesthesia
it appears that Residents in Anesthesia require between 45
and 90 attempts before they become really proficient2. Although
similar data for peripheral nerve blocks are lacking, Brown
estimated that even more peripheral nerve blocks might need
to be performed to achieve proficiency3. With more advanced
techniques, such as the placement of catheters for the management
of acute pain, some anaesthesiologists may never become proficient
due to a lack of training and experience and their patients
may never enjoy the benefits of these techniques. Brown3 believes
that we have reached a plateau in the practice of RA due to
four fundamental factors limiting further progress. These
factors are: 1) the lack of RA equipment (now being addressed
by Arrow International – StimuCath; BBraun – Contiplex;
Pajunk – Plexilong and Sterimed - Alphaplex), 2) predictable
variation in the duration of action local anaesthetic agents
– especially long-lasting agents, 3) regional anaesthetic
training (partially addressed by this type of proposed workshop)
and 4) practice (outcome) measurement.
Teaching institutions often lack the specific expertise,
time or opportunities to teach RA. Even physicians who train
at
centers enthusiastic about RA use these techniques on less
than 30% of the cases in their in practices3. This lack
of
confidence and teaching opportunities, together with the
ethical constraints of having human beings on the receiving
end of
a needle held by untrained and inexperienced hands, often
leads to abandonment of RA techniques. As a result, anesthesiologists
often follow the less effective methods of systemic
analgesics or (at best) single shot RA for the management
of intra- and
post-operative pain.
Dr A P Boezaart initiated this training method at the University
of Stellenbosch in South Africa. It was very successful and
involves a teaching programme that furnishes anaesthesiologists
with the necessary skills and confidence to perform these
blocks without having to put patients at risk. Cadaver-based
human anatomy forms the first cornerstone pillar of the “whet-lab/workshop”
training. The main principles of simulator training are then
used when anesthetized pigs are used for the second pillar,
namely repetitive placement of needles and catheters onto
nerves and nerve plexuses and for special techniques such
as epidural catheterization and retrobulbar injection. The
third and final pillar of the workshop is a multimedia presentation
(including demonstrations on healthy volunteers) and an interactive
session where all the techniques are discussed with attendees.
The basic philosophy of the program is that, in order to be
of value, the training program is designed to be:
- Based on human anatomy
- Hands-on
- Repetitive
- Applicable to human practice
Everybody who is currently proficient
in Regional Anesthesia learned the skills on human patients
and by making mistakes and having failures. On the sharp
end
of the needle is, however, always a real human being and,
although mistakes and failures are, with proper supervision,
being limited to an absolute minimum, they do occur. Through
repeated failure in a stressful environment with real patients
in clinical practice, trainees either persist and continue
to make mistakes until they have developed the necessary
skills
(at the cost of their patients), or they give up on Regional
Anesthesia and in doing so deprive their patients of this
valuable way of managing their acute pain.
The aim of this program is to offer trainees the opportunity
to practice the initial blocks and catheter placements and
to develop their initial skills in a stress free environment
where mistakes and failures do not matter. Once proficient,
trainees should be much more confident about safely introducing
these techniques into their clinical practice on humans.
The
latter has been the experience of the University of Stellenbosch
program. One example is a trainee who practiced 27 epidural
catheter placements at one animal workshop session before
he regarded himself as proficient – an opinion that
was shared with the course leader. Participants who attended
the
workshops had no problems doing epidural and perineural
catheterizations on human patients thereafter.
Continue to the Program>>>
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