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Colin Graham, in his review article (March 2005 JRSM1), revisits the suggestion that all airway interventions in UK emergency departments could be managed by emergency physicians. If training of emergency physicians is standardized to six months in anaesthesia and six months in critical care, they would acquire only rudimentary skills in basic airway management and the conduct of anaesthesia. There is widespread use of the laryngeal mask airway, considerable decrease in working hours, and the need to concurrently teach anaesthesia trainees, paramedics, etc. In only six months trainees would participate in approximately 350 cases, on average performing less than 2 endotracheal intubations per week. Few of these will be in emergency circumstances.2-4
If anaesthesia experience mainly continues in emergency departments where 2 trauma patients will require rapid sequence intubation per month5 trainees cannot maintain their skills. How indeed are their consultants to revalidate as trainers? They must be able to predict and act immediately whenever there is difficulty. How will they recognize the difficult airway and call an anaesthetist early when even the most thorough examination is only 71% sensitive?6
It is one thing to intubate a patient following cardiac arrest and another to anaesthetize and intubate a patient on the brink of an arrest. Currently there is an inappropriate degree of self-confidence amongst emergency department trainees, despite their experience in emergency anaesthesia.7 So how can we best develop and maintain their skills despite infrequent exposure?
I believe the answer is to regularly repeat anaesthesia training blocks, perhaps one training list per month. In addition, written, practical, and simulator testing for recertification ensures maintenance of skills.8,9 Anaesthesia emergencies are uncommon. Therefore knowledge or clinical experience, lacking in those not formally trained, could only become apparent in very large outcome studies.10,11