The Royal Surrey County Hospital (RSCH) has become the regional oncological surgical referral center for much of the Surrey, Sussex, and Hampshire area in the United Kingdom, serving a population of 1.5 million patients. Many of the highly specialized surgical specialties are now established here and include ENT, Maxillofacial, Oesophagogastric, Hepatobiliary, Gastrointestinal, Colorectal, major robotic Urological and Gynecology surgery. The hospital has an international reputation in laparoscopic surgery with Enhanced Recovery in conjunction with the Minimal Access Therapy Training Unit (MATTU) center and the University of Surrey. In addition, there has been widespread adoption of invasive cardiovascular measurement (Esophageal Doppler, LiDCOrapid) and goal directed therapy by the department.
This Advanced Airway Clinical Fellow post is available for an initial 6 months (extendable for further 6 months by mutual agreement) and is suitable for senior anesthetic trainees in the final 3 years of training [UK Specialist Trainee years 5, 6, 7 or post Certificate of Completion of Training (CCT) equivalent] wishing to gain further experience in advanced airway management.
This post will focus on the following areas:
- Anesthesia for head and neck oncology. Currently there are 4 all day head and neck cancer lists per week. This includes ∼40 free flap cases per year by the maxillofacial team (Enhanced Recovery Pathway established 2013, one of the first for this patient group in the United Kingdom) as well as neck dissections, laser procedures, and laryngectomies performed by the ENT head and neck consultants.
- Anesthesia for maxillofacial surgery. In addition to the above there are 3 all day maxillofacial lists for noncancer surgery per week. The department currently performs the highest number of bimaxillary osteotomies in England. Pediatric dental services are provided, as well as on-call cover for regional maxillofacial and ENT emergencies.
- Aesthesia for ENT surgery. The hospital is also a tertiary referral center for complex nasal and sinus conditions, as well as specialist otology and general pediatric services.
- Advanced techniques are frequently employed in both emergency and elective settings: these include asleep and awake fiberoptic intubation, apneic oxygenation (Transnasal Humidified Rapid Insufflation Ventilatory Exchange or THRIVE) and High Frequency Jet Ventilation (Monsoon).
- The on-call commitment is to the obstetric service, and includes supervision/support of an Emergency Theater anesthetist.
Research and audit
The department has close links with the Postgraduate Medical School at the University of Surrey including access to the Research Design Service. Research activity in the department is well established with patients enrolled into large multicenter trials as well as local investigator-led trials predominantly regarding emergency tracheal access, cricothyroid ultrasound, enhanced recovery, cardiac output monitoring and optimization of fluid resuscitation and analgesia. Our departmental research group Surrey Perioperative Anaesthesia Critical care collaborative Research Group (SPACeR) is now a Clinical Academic Group (CAG) with the University of Surrey and Ashford and St. Peter’s NHS Foundation Trust: www.spacer.org.uk/. Several clinicians hold honorary lecturer positions at the University.
There are currently research fellows based in anesthesia and in ICU and all post holders are expected to complete a quality improvement program, audit and/or original research during their period of training. All post holders are allocated a mentor at the beginning of their post to assist with this. Presentation of completed work/case reports/audits at the annual Difficult Airway Society meeting is expected.
Recent airway projects (all poster-presented, with peer-reviewed publications referenced) include:
- Evaluation of cricothyroidotomy trainers.
- Investigation of prototype cricothyroidotomy introducer.
- “G-CUT” Ultrasound techniques for identification of cricothyroid membrane1.
- Difficult Airway trolley redesign—theaters, ICU, trauma, and obstetrics.
- Advanced airway management Procurement (Optiflow units 3, Glidescopes 5, McGraths 6, Video flexible scopes 5).
- Survey of extubation devices.
- Multicenter study of Cook Staged Extubation Set.
- Bench studies evaluating Surgicric and Surgicric 2 Cricothyroidotomy devices2–4.
- Impact of cricothyrotomy training.
- NAP4 review5.
Successful grant applications
DAS/NIAA Project Grant (£1000) Comparison of sagittal versus transverse ultrasound techniques in identifying the cricothyroid membrane in a subject with neck pathology, 2016.
SPACER Grant (£600). “G-CUT”: a simple transverse ultrasound technique for identification of the cricothyroid membrane, 2015.
HEKKS Grant (£50,000) SCReaM: Surrey Crisis Resource Management Simulation program—Stanford University collaboration, faculty training, simulation course design, set-up and delivery, 2015.
AAGBI/Anaesthesia Research Grant (£9,750) Surgicric 2: a comparative bench study with 2 established emergency cricothyrotomy techniques in a porcine model, 2014.
DAS/AAGBI Project Grant (£3,855.40) Bench study comparing 3 different emergency tracheal access devices in a porcine model, 2012.
Quality improvement/patient safety
- Airway Alert Card & Difficult Airway Database—National Pilot Project. DAS 20166.
- Establishment of Enhanced Recovery Program for Head and Neck cancer patients7.
- Enhanced Recovery pathway for ENT patients undergoing laryngectomy surgery.
- Regional Tracheal stent service.
- High Frequency Jet Ventilation service.
- Surrey Crisis Resource Management Program (SCReaM): Prompt card implementation 20168,9.
- Obstetrics Rapid Sequence Intubation preparation checklist, Emergency Rapid Sequence Intubation preparation checklist: reduce human error and promote multidisciplinary engagement 2016.
- Policy for the Management of Obstetric Failed Intubation 2016.
- Unexpected Difficult Airway management guidelines, documentation, alerts—Theaters, ICU, trauma and obstetrics.
- Case reports written up10,11.
- Audits undertaken annually.
There is a significant teaching role within the hospital including use of the simulator. Fellows are encouraged to partake as Faculty, developing teaching and debrief skills as well as managerial skills as Course Director.
- SCReaM program, Multidisciplinary Human Factors and Crisis Resource Management training—University of Surrey.
- Mandatory “Boot Camp” emergency airway teaching: Anesthetic Consultants, Trainees and Nontraining staff.
- TART (Tricky Airway Teaching) Breakfast meetings Royal College of Anaesthetists (RCOA) approved.
- “The Unexpected Difficult Airway” day—MATTU center.
- The “ODP Difficult Airway Simulation Course”—RSCH.
- Novice Anaesthetic Trainee Simulation (NATS)—University of Surrey.
- CT2 Anaesthesia Trainee Simulation (CATS)—University of Surrey.
- Student ODP Simulation 2 day course (SOS)—University of Surrey.
- Obstetric Anaesthetic Simulation (OATS)—University of Surrey.
- Managing Emergencies in Paediatric Anaesthesia (MEPA)—RSCH.
- KSS Cancer Study Day: ST trainees—RSCH
- “Anaesthesia for ENT” seminar days—Association of Anaesthetists of Great Britain & Ireland (AAGBI) London.
- Airway Day—Basic and Advanced courses RCOA, London
- Core Topics—RCOA, London.
- Difficult Airway Society UK, National.
- Guys Advanced Airway Management Course, London.
Training and assessment
We offer one such Fellow post at any one time and training and supervision is conducted by 8 Consultant Anesthetists with a specialist interest in difficult airway management.
Formal assessment is not mandated, however a Fellow in the final year of training may complete the Advanced Airway Module of the RCoA CCT in Anesthetics. According to Annexe E: Advanced Level Training (www.rcoa.ac.uk/system/files/TRG-CCT-ANNEXE.pdf) the learning outcomes of which includes the following.
Such skills can be evaluated according to the RCoA work-place–based assessments: Anesthesia Clinical Evaluation Exercise (A-CEX), Case-based Discussion (CBD), and Direct Observation of Procedural Skills (DOPS).
Current clinical fellow post holders have prospectively applied for and successfully gained recognition of these posts for training from the RCoA. This post is advertised via NHS jobs and appointed at competitive interview. We welcome those interested to contact us in advance.
An Advanced Airway Fellowship set in a friendly and forward-thinking Anaesthetic Department. The clinical training emphasis is on acquiring a strong set of advanced airway skills, and is matched with the development of mental strategies to recognize and manage potentially difficult patients. Original research and publication is positively encouraged, alongside furthering one’s presentation and teaching expertise.
Conflict of interest disclosures
The authors declare that they have no financial conflict of interest with regard to the content of this report.
1. Gosavi S, Beverly A, Foxall G, et al. “G-cut”: impact of ultrasound training session on identification of cricothyroid membrane in a high-BMI subject. Br J Anaesth 2016;117:109–110.
2. King W, Patel B. Pilot study of Surgicric I—a new device for emergency tracheal access. Anaesthesia
3. King W, Teare J, Vandrevala T, et al. Evaluation of novel Surgicric® Cricothyroidotomy device for emergency tracheal access in a porcine model. Anaesthesia
4. Chrisman L, King W, Wimble K, et al. Surgicric 2: a comparative bench study with two established emergency cricothyroidotomy techniques in a porcine model. Br J Anaesth 2016;117:236–242.
5. Curtis R. What NAP4 means to me: a trainee’s view. BJA Bulletin 2012.
7. Bater M, King W, Teare J, et al. Enhanced recovery in patients having free tissue transfer for head and neck cancer: does it make a difference? BJOMS 2017;55:1024–29.
8. King W, Lomax S, Moss D, et al. SCReaM! Surrey Crisis Resource Management Programme: introducing human factor training alongside operating theatre emergency prompt cards. Anaesthesia
News 2017; 358: 12–13.
9. King W, Lomax, S. Who should read cognitive aid prompts? Anaesthesia
10. Curtis R, Lomax S, Patel B. Use of Sugammadex and the cannot intubate/cannot ventilate scenario in patients with predicted difficult airway. Br J Anaesth 2012;109:461–462.
11. Curtis R, Lomax S, Patel B. Use of Sugammadex in a “can’t intubate, can’t ventilate” situation. Br J Anaesth 2012;108:612–614.