REVIEW URRENT C OPINION
Developing a trauma curriculum for anesthesiology residents and fellows Joshua M. Tobin
Purpose of review The board certification process for qualification by the American Board of Anesthesiology is undergoing significant review. A basic sciences examination has been added to the process and the traditional oral examination is evolving into a combined oral interview and practical skills assessment. These recent developments, as well as the growing body of evidence regarding the resuscitation of trauma patients, call for a revision in the curriculum beyond the documentation of participation in the anesthetics of 20 trauma patients. Recent findings The implications of the 80-h work week are beginning to be appreciated. The development of a new trauma curriculum must take this significant change in residency training into account while incorporating modern educational theory (e.g. simulation) and new data on the resuscitation of trauma patients. Summary Currently, the curriculum for trauma anesthesia requires only that residents participate in the anesthetics of 20 trauma patients. There is no plan for, and little literature regarding, a more extensive educational program. This offers a unique opportunity to innovate a novel curriculum in the anesthesiology residency. The American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness has designed a curriculum that can serve as a template for this important step forward in anesthesiology education. Keywords 80-h work week, resuscitation, simulation, trauma
INTRODUCTION Trauma is the third leading cause of death in the USA and is a disease which every anesthesiologist will encounter in their practice. A trauma patient may suffer multisystem injuries in a motor vehicle collision and be treated at a level I trauma center, or may be an elderly patient at a community hospital who fell and now has a fractured hip in need of repair. Regardless of the cause, it is imperative that anesthesiologists be appropriately trained to manage trauma. Whereas the American Board of Anesthesiology currently requires that residents manage 20 trauma patients, a more refined approach to trauma education is warranted by the scope of this public health threat and the role that the anesthesiologist plays as resuscitation consultant. Fortunately, the existing residency in anesthesiology prepares physicians well in concepts fundamental to the management of all trauma patients. Airway management, placement of large bore vascular access, interpretation of invasive hemodynamic monitoring data, blood product resuscitation and www.co-anesthesiology.com
management of hemodynamic instability are core competencies in the broader practice of anesthesiology. An appreciation for trauma-specific concepts (e.g. brain injury, proper ratio of red cell to plasma transfusions, considerations for the elderly trauma patient) refines the anesthetic plan for trauma and is the goal of the trauma anesthesiology curriculum.
THE 80-HOUR WORK WEEK Any discussion of a resident curriculum in trauma anesthesiology must include a discussion of the
David Geffen School of Medicine at UCLA, Department of Anesthesiology/Division of Critical Care, Los Angeles, California, USA Correspondence to Joshua M. Tobin, MD, Assistant Professor, David Geffen School of Medicine at UCLA, Department of Anesthesiology/ Division of Critical Care, 757 Westwood Plaza Suite 3325, Los Angeles, CA 90095-7403, USA. Tel: +1 310 206 7496; fax: +1 310 825 2236; e-mail: [email protected], [email protected] Curr Opin Anesthesiol 2014, 27:240–245 DOI:10.1097/ACO.0000000000000020 Volume 27 Number 2 April 2014
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Trauma curriculum for anesthesiology residents and fellows Tobin
KEY POINTS Recent changes in resident education, specifically the 80-h work week, must be taken into account when developing a trauma curriculum. Modern educational theory and tools such as simulation are important in the education of residents for high-risk clinical scenarios such as trauma. The new anesthesiology board certification process will call upon mastery of a variety of instructional formats, including resident lectures, clinical rotations and independent study. Core tasks in trauma anesthesiology recently defined by the Committee on Trauma and Emergency Preparedness can refine the goals of the trauma curriculum. New data including airway management techniques, blood component resuscitation and pharmacologic management of trauma require a revision in the current residency curriculum for trauma.
‘80-h work week’. Resident work hour restrictions were enacted on 1 July 2003 to address concerns that over-worked, sleep-deprived residents were not able to learn their craft, or to effectively care for patients. The ‘80-h work week’ was instituted to remedy these issues. In a landmark study, Landrigan et al. [1] evaluated intern performance during 2203 patient-days involving 634 admissions and found a higher rate of serious medical errors, and serious errors in the ICU, among interns who worked for 24-h shifts on an every-third-night call schedule. This had a significant influence on institution of work-hour restrictions. A before-and-after retrospective analysis of the effects of work-hour restrictions on the mortality of trauma patients in the National Trauma Data Bank found an overall decrease in mortality in trauma patients after the institution of work-hour restrictions [2]. Specifically, mortality was 4.46% after work-hour restrictions and 4.64% before work-hour restrictions. Interestingly, at university hospitals, mortality decreased from 5.15 to 5.03%, whereas at nonteaching hospitals, mortality increased from 3.37 to 3.85%. Whereas it would seem that decreasing work hours would be a common sense approach to resolving these issues, some data suggest that errors actually increase with restricted work hours. At a level I trauma center, death and complication rates were compared over two 24-month periods, before and after the 80-h work week. There was no difference in total or preventable death rates; however, the rates of total complication, preventable
complication and nonpreventable complication were higher in the post-80-h work week group [3]. A similar before-and-after review found an increase in medical complications and diagnostic test delays after resident work-hour restrictions; however, there was no increase in serious outcome (e.g. in-hospital mortality, transfer to ICU, discharge disposition, length of stay) [4]. This effect has been postulated to be due to the increased numbers of turnovers and sign-outs that occur in the restricted work-hour model. Unfortunately, it would be difficult at this point to conduct a prospective evaluation of the effects of restricted work hours.
COMPETENCY Ultimately, the curriculum for trauma anesthesiology must respect work-hour restrictions while providing the opportunity for residents to develop competency in the care of severely injured patients. Competency, however, is often difficult to define. It is sometimes described as ‘I know it when I see it’. In an effort to make the evaluation of competency more objective, the Accreditation Council for Graduate Medical Education (ACGME) has categorized competencies into six areas: knowledge, patient care, professionalism, communication and interpersonal skills, practice-based learning, and improvement and systems-based practice (please see below). This emphasizes a focus on ‘competency-based’ learning in residency rather than the more traditional ‘time-based’ system. ACGME core competencies: (1) (2) (3) (4) (5) (6)
knowledge; patient care; professionalism; communication and interpersonal skills; practice-based learning and improvement; and systems-based practice.
Miller’s [5] model of medical competence describes four distinct levels in a pyramidal model. The base of the pyramid is the knowledge level, where a student ‘knows’ the material. The next higher level describes a competent student who ‘knows how’ a process works, followed by a student who is able to perform as expected and is able to ‘show how’ to perform a task. At the apex of the competency pyramid is a trainee able to act independently (e.g. a student who ‘does’). A senior colleague of this author once described a similar stratification of four distinct levels of competency. The ‘unconsciously nonproficient’ physician ‘does not know what they do not know’ and is dangerous. A ‘consciously nonproficient’ physician
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Trauma and transfusion
is aware of their limitations. Although not dangerous, they are not yet competent to act independently. Not uncommonly this is seen in junior residents. A ‘consciously proficient’ physician, typically a more senior resident or board certified attending, is safe and capable. Mastery of the specialty transcends to a level of ‘unconscious proficiency’. Senior attending anesthesiologists will, occasionally, reach this level and wonder ‘why everyone else finds this so difficult’. Unfortunately, the unconsciously nonproficient physician and the unconsciously proficient physician are often impossible to distinguish, underscoring the need for an objective means of evaluation.
SEE ONE, HEAR ONE, DO ONE? In order to accurately evaluate competency the individual learning styles of students must be taken into consideration. Fleming’s Visual, Aural, Kinesthetic/Visual, Aural, Read, Kinesthetic model of learning divides students into those with visual, auditory and tactile learning styles. Visual learners think in pictures; they ‘see it’. They tend to benefit from visual cues such as diagrams, hand-outs, graphics, and prefer to ‘be left alone with the book’. Auditory learners are dependent on hearing and speaking to assimilate and process information; they ‘hear it’. Some suggest that they benefit from music in the background while studying and can be seen ‘talking out the answer’ during an examination. They tend to benefit from aural cues found in lecture and discussion formats. Tactile learners, also known as kinesthetic learners, depend on touching and moving to master new material; they ‘do it’. They tend to benefit from active experimentation and ‘hands-on’ experience. In the end, anesthesiology residents will have some component of all three styles of learning and would theoretically benefit from what has been described as the ‘meshing hypothesis’ or what may be called in medicine a ‘multimodal approach’. Unfortunately, improved performance in testing has not been correlated with prospective identification of different learning styles [6,7]. It remains a challenge to identify the best method for teaching each individual student. The new anesthesiology board certification process will involve a basic sciences evaluation during the Clinical Anesthesia-Year 1 (CA-1) year, as well as a clinical sciences examination after residency is completed. The traditional oral examination is soon to be supplanted by a combined oral interview and tactile skills demonstration, the format of which remains under development. Such an examination will call upon mastery of a variety of instructional formats, including resident lectures, clinical rotations and independent study. 242
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Mastery of basic concepts provides a fundamental knowledge base. Evaluation of this knowledge base via standardized methods (e.g. multiple-choice question-based examinations) screens those who have attained a basic level of understanding from those who have not. Multiple-choice questions (MCQs) efficiently test large numbers of students on a broad range of topics. There are, however, important limitations to the MCQ format. One investigation used Moore’s expanded outcomes framework to evaluate examinations during the first 2 years of instruction at an American medical school [8]. Level 3A questions were categorized as those requiring only ‘recall’ and rote memorization; level 3B questions required ‘application’ of knowledge to reach a conclusion or make a calculation; and level 4 questions evaluated ‘competence’ by requiring the student to demonstrate that they are ‘able to show how to do what the educational activity intended them to be able to do’. Notably, level 3A questions can sometimes be answered without reading the entire question; a regrettable feature of some ‘clinical vignettes’. The study found that the emphasis in the first year of medical education is on acquisition of knowledge facts, with 86% of examinations testing mostly declarative knowledge (recall). Fourteen percent of examinations contained content evaluated as procedural (application) questions. No examinations had any competence-level questions. The second year of medical school demonstrated an increase in procedural questions, with 85% of examinations evaluating procedural knowledge (application), 15% assessing declarative knowledge (recall) and no examinations containing competence-level questions. Allied health educators have noted a similar phenomenon. In an evaluation of over 2000 questions in a nursing multiple-choice test bank, 47% of questions were written at the knowledge level, and 6.5% were written at the analysis level [9]. Whereas mastery of a fundamental knowledge base is an important building block in education, these formats of evaluation are largely limited to assessment of information recall. Acquisition of the skill set necessary to practice anesthesiology involves proficiency in tactile procedures (e.g. intubation), understanding of scientific concepts (e.g. pharmacology) and synthesis of creative solutions (e.g. development of an anesthetic plan). Development of a curriculum that can teach and assess these skill sets is the objective of an effective educational plan.
SIMULATION Simulation has emerged as an important educational adjunct. Simulation involves presentation Volume 27 Number 2 April 2014
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Trauma curriculum for anesthesiology residents and fellows Tobin
of idealized scenarios in which routine, but potentially hazardous, activities are recreated and critiqued. The aviation industry was a leader in this training technique and anesthesiologists were the first in the medical community to embrace this methodology. One of the great advantages of simulation is the ability to recreate an environment for team interaction without hazarding the safety of a patient. Leadership styles can be evaluated and lines of communication can be established in real time. As early as 1969, Abrahamson described the use of computer-based simulation for assessment of anesthesiology resident’s skill at intubation. In 1988, Gaba and DeAnda [10] described their experience with a more comprehensive anesthesia simulator. They recreated an operating room environment in an effort to shift the simulation toward a more ‘hands-on’ experience. A simulation director and systems operator conducted the session via predesigned scripts. Twenty-two anesthesiology residents and medical students who had completed an anesthesiology clerkship participated in these scripted scenarios. Feedback was solicited via a questionnaire. Seventeen questionnaires were returned and offered generally favorable comments. The realism of the mannequin was noted as an area for improvement. Whereas questionnaires solicited from subordinate residents and medical students are subject to significant error, simulation was accurately identified as a technique for realistic training on potentially highrisk procedures. Ultimately, however, simulation is a training tool. Whereas simulation can improve communication and adherence to advanced cardiac life support protocols, few studies have demonstrated a direct improvement in clinical outcomes [11]. Nevertheless, the utility of simulation in anesthesiology education and certification is drawing increasing interest. Ziv et al. [12] described the use of simulation in an Objective Structures Clinical Examination (OSCE), as part of an anesthesiology certification process. The OSCE method involves a structured evaluation to assess adherence to guidelines agreed upon by exert consensus. The Israeli experience used five simulation-based stations, including one each in trauma management and resuscitation. They concluded that, ‘there is no doubt that incorporating simulation and OSCE for testing and evaluation should play a formative (training) and a summative (testing) role, involving the anesthesiology board’. The advantages of simulation include the obvious ability to master procedures before attempting them on a live patient, as well as other advantages including the ability to simulate infrequent
emergencies (e.g. cardiac arrest, malignant hyperthermia). The ability to critique the scenario via video replay after the exercise is another important advantage. It is vital, however, to recognize the limitation of this training method. Differences in technique and approach must be appreciated. For instance, the placement of central venous access in the internal jugular vein reinforces medial direction of the needle (e.g. toward the carotid) during simulation under ultrasound guidance. In clinical practice, however, the needle is more frequently directed laterally, toward the ipsilateral nipple. Whereas simulation offers a valuable lesson in reinforcing the psycho-motor skills necessary for the practice of anesthesiology, it is incumbent upon the simulation evaluator/instructor to have an appreciation for the limitations of simulation.
CORE TASKS The ultimate goal of the trauma curriculum is to teach the fundamental concepts necessary for the practice of trauma anesthesiology. Identification of these core tasks is central to that instruction and development of a core curriculum is contingent upon a clear definition of trauma anesthesiology. Trauma patients can present with neurologic injury, airway compromise, hemodynamic instability, trauma-related renal failure, the need for complex blood product resuscitation and the systemic inflammatory response syndrome (SIRS). Management may include mechanical ventilatory support, placement of invasive monitoring and interpretation of that data, initiation of renal replacement therapy, ultrasonographic assessment of injury and regional pain control techniques. Trauma calls upon the full intellectual and procedural skill set of the anesthesiologist and represents the most challenging patient population that we treat. A wealth of recent data on the resuscitation of critically ill patients has changed the fashion in which trauma patients are resuscitated. Recent review articles have called attention to the role that the anesthesiologist plays in the resuscitation of trauma patients [13 ]. Data on the use of etomidate in emergency intubation, for example, continue to add substance to the dialog on the ideal medication for induction of trauma patients [14 ]. A broader understanding of the immune response in trauma may lead to a ‘Grand Unified Theory’ of critical illness [15 ,16 ]. Monitoring of coagulopathy with newer modalities such as thromboelastography and rotational elastometry [17 ] may lead to a targeted approach to resuscitation including coagulation factor concentrates and tranexamic acid [18 ,19 ].
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Trauma and transfusion
A greater appreciation for trauma anesthesiology has encouraged interest in the publication of texts on the subject [20 ]. This growing fund of knowledge must be presented to the anesthesiology resident in a well defined curriculum. Varon and McCunn [21 ] recently highlighted the need for a trauma anesthesia curriculum to treat this complex patient population in the July 2012 ASA Newsletter. They noted the threat to the public health that trauma poses as the leading cause of death in young Americans, and third cause of death overall. They further observed that anesthesiologists are rarely involved in the initial resuscitation of patients in the trauma bay and advocated a more active role for anesthesiologists in this initial resuscitative phase, adding that such a role would strengthen the anesthesiologist’s claim as perioperative physician. This author would add that anesthesiologists have unquestioned experience in the management of hemodynamic instability. Given that anesthesiologists will manage these hemodynamically unstable patients in the operating room shortly after their trauma bay evaluations, they must be involved in that initial resuscitation. As noted above, the anesthesiology Residency Review Committee (RRC) requires only 20 trauma cases without defining specific educational objectives. A new body of literature has evolved regarding the resuscitation of trauma patients, due largely to the experience of military physicians after a decade of continuous combat. The RRC requirements have not, however, kept pace with this expanding knowledge base. Interestingly, the RRC includes in the definition of trauma cases victims of biological warfare (perhaps better categorized as critical care or infectious disease patients). This calls attention to the need for a re-evaluation of the trauma curriculum. The American Society of Anesthesiology’s Committee on Trauma and Emergency Preparedness (COTEP) recently designed a trauma anesthesiology curriculum arranged around the six core competencies of the ACGME (please see below) [22 ,23 ]. Summary of the COTEP Trauma Curriculum: &&
&&
&&
&&
(1) CA-1 and 2 cognitive objectives (a) Understand core principles of trauma care including (i) Epidemiology, prehospital care, initial evaluation and management, team approach, airway management, vascular cannulation, resuscitation, massive transfusion, general anesthesia, regional anesthesia, monitoring, ultrasound, 244
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postoperative care, chemical and radiologic exposure (b) Identify anesthetic considerations for patients with blunt or penetrating injuries including (i) Traumatic brain injury, spinal cord injury, ocular and maxillofacial trauma, chest trauma, abdominal trauma, musculoskeletal trauma (c) Describe the anesthetic management for special populations including (i) Burns, pediatric, geriatric, pregnant Psychomotor objectives (a) Completely evaluate trauma patient (b) Provide airway management (c) Develop anesthetic plan (d) Set up OR for trauma case (e) Maintain anesthetic record (f) Develop basic communication skills with the OR team and patient family (g) Perform procedures including: (i) Endotracheal intubation, tracheal tube introducer, arterial line cannulation, central venous cannulation, position patient, insert orogastric tube, regional blocks (h) Perform postop evaluation and QA Affective objectives (a) Demonstrate sensitivity to patient’s cultural background (b) Demonstrate commitment to medical record confidentiality (c) Practice cost-effective care and display respectful care (d) Participate in morning report and in trauma conference (e) Work effectively with team and know when to call for help (f) Consider patient safety (g) Display willingness to acknowledge mistakes and accept criticism (h) Consider patient ‘flow’ through hospital system (i) Complete appropriate evaluations; and (2) CA-3 cognitive objectives (a) Appraise core principles of trauma care as above (b) Analyze anesthetic considerations for patients with blunt or penetrating injuries as above (c) Design the anesthetic management for special populations as above Psychomotor objectives, in addition to above: (a) Serve as trauma anesthesia team leader (b) Provide anesthesiology consultation in ED/trauma bay Volume 27 Number 2 April 2014
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Trauma curriculum for anesthesiology residents and fellows Tobin
(c) Display effective communication skills with the OR team and patient family (d) Perform procedures in addition to above: (i) Surgical airways, induction/maintenance/emergence of general anesthesia, pain relief including epidural anesthesia (e) Manage patients in the post anesthesia care unit Affective objectives, in addition to above: (a) Supervise CA-1 and 2 residents under the direction of the attending anesthesiologist; and (b) Document and present complications in morning report. Their approach emphasizes a systems-based method with specific goals for learners. Two distinct curricula are identified. One curriculum was designed for junior residents (CA-1 and 2) and another for senior residents (CA-3). Cognitive, psychomotor and affective objectives are identified in an effort to provide ‘total care’ for trauma patients. Attention to the core tasks fundamental to the practice of trauma anesthesia can be combined with established supplementary curricula [e.g. the Advanced Trauma Life Support (ATLS) course and Fundamentals of Critical Care Support (FCCS) course] to provide breadth and depth to the trauma anesthesia curriculum. Adherence to these well defined instructional benchmarks will serve as an important step toward formalizing the trauma curriculum.
CONCLUSION Simply documenting participation in 20 trauma cases is insufficient to demonstrate qualification to independently manage a trauma anesthetic. A more discrete assessment of trauma-specific core tasks must address the six ACGME-identified competencies, while taking into consideration the limitations of work-hour restrictions. Modern educational theory can be applied to the instructional process, and training techniques such as simulation can enrich the learning experience. A revised curriculum in trauma anesthesiology demonstrates the anesthetic community’s commitment to the public health and is our duty to the future of our specialty. Acknowledgements No funding or sponsorship was received. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351:1838–1848. 2. Morrison CA, Wyatt MM, Carrick MM. Impact of the 80-h work week on mortality and morbidity in trauma patients: an analysis of the National Trauma Data Bank. J Surg Res 2009; 154:157–162; Epub 2008/07/29. 3. Salim A, Teixeira PG, Chan L, et al. Impact of the 80-h workweek on patient care at a level I trauma center. Arch Surg 2007; 142:708–712. [discussion 12-4] 4. Laine C, Goldman L, Soukup JR, Hayes JG. The impact of a regulation restricting medical house staff working hours on the quality of patient care. J Am Med Assoc 1993; 269:374–378. 5. Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990; 65 (9 Suppl):S63–S67. 6. Pashler H, McDanile M, Rohrer D, Bjork R. Learning styles: concepts and evidence. Psychol Sci Public Interest 2009; 9:105–119. 7. Rohrer D, Pashler H. Learning styles: where’s the evidence? Med Educ 2012; 46:634–635. 8. Vanderbilt AA, Feldman M, Wood IK. Assessment in undergraduate medical education: a review of course exams. Med Educ Online 2013; 18:1–5. 9. Masters JC, Hulsmeyer BS, Pike ME, et al. Assessment of multiple-choice questions in selected test banks accompanying text books used in nursing education. J Nurs Educ 2001; 40:25–32. 10. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology 1988; 69:387–394. 11. Okuda Y, Bryson EO, DeMaria S Jr, et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med 2009; 76:330–343. 12. Ziv A, Rubin O, Sidi A, Berkenstadt H. Credentialing and certifying with simulation. Anesthesiol Clin 2007; 25:261–269. 13. Tobin JM, Varon AJ. Review article: update in trauma anesthesiology: peri& operative resuscitation management. Anesth Analg 2012; 115:1326–1333. Synopsis of recent advances in trauma resuscitation 14. Banh KV, James S, Hendey GW, et al. Single-dose etomidate for intubation in & the trauma patient. J Emerg Med 2012; 43:e277–e282. Limiting use of etomidate has no effect on mortality but did increase episodes of hypotension 15. Marik PE, Flemmer M. The immune response to surgery and trauma: implica& tions for treatment. J Trauma Acute Care Surg 2012; 73:801–808. Traumatic injury is followed by the systemic inflammatory response syndrome. 16. Asehnoune K, Roquilly A, Abraham E. Innate immune dysfunction in trauma & patients: from pathophysiology to treatment. Anesthesiology 2012; 117:411– 416. Depression of cell-mediated immune function following trauma is associated with worse outcome 17. Sankarankutty A, Nascimento B, Teodoro da Luz L, Rizoli S. TEG(R) and & ROTEM(R) in trauma: similar test but different results? World J Emerg Surg 2012; 7 (Suppl 1):S3. Both thromboelastography and rotational thromboelastometry can diagnose coagulopathy and guide therapy in trauma. 18. Fries D. The early use of fibrinogen, prothrombin complex concentrate, and & recombinant-activated factor VIIa in massive bleeding. Transfusion 2013; 53 (Suppl 1):91S–95S. Targeted resuscitation of trauma patients with coagulation factor concentrates based on point-of-care testing may be more effective than ratio-driven therapy. 19. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of & Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg 2012; 147:113–139. Tranexamic acid improves coagulation and survival in wartime trauma patients requiring massive transfusion. 20. Varon AJ, Smith CE. Essentials of trauma anesthesia. Cambridge: Cambridge && University Press; 2012. A concise review of the full spectrum of the practice of trauma anaesthesiology. 21. Varon AJ, McCunn M. The need for a trauma anesthesia curriculum: first steps. && Am Soc Anesthesiol Newslett 2012; 76:38–39. The authors call attention to the need for a well defined trauma anesthesiology curriculum. 22. Committee for Trauma and Emergency Preparedness (COTEP). Curriculum && for CA-1 and CA-2 residents. http://www.asahq.org/For-Members/AboutASA/ASA-Committees/Committee-on-Trauma-and-Emergency-Prepared ness. aspx. [Accessed 21 July 2013] A template for trauma anesthesiology education of junior residents. 23. Committee for Trauma and Emergency Preparedness (COTEP). Curriculum && for CA-3 residents 2013. http://www.asahq.org/For-Members/About-ASA/ ASA-Committees/Committee-on-Trauma-and-Emergency-Preparedness. aspx. [Accessed 21 July 2013] A template for trauma anesthesiology education of senior residents.
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Developing a trauma curriculum for anesthesiology residents and fellows Joshua M. Tobin
Purpose of review The board certification process for qualification by the American Board of Anesthesiology is undergoing significant review. A basic sciences examination has been added to the process and the traditional oral examination is evolving into a combined oral interview and practical skills assessment. These recent developments, as well as the growing body of evidence regarding the resuscitation of trauma patients, call for a revision in the curriculum beyond the documentation of participation in the anesthetics of 20 trauma patients. Recent findings The implications of the 80-h work week are beginning to be appreciated. The development of a new trauma curriculum must take this significant change in residency training into account while incorporating modern educational theory (e.g. simulation) and new data on the resuscitation of trauma patients. Summary Currently, the curriculum for trauma anesthesia requires only that residents participate in the anesthetics of 20 trauma patients. There is no plan for, and little literature regarding, a more extensive educational program. This offers a unique opportunity to innovate a novel curriculum in the anesthesiology residency. The American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness has designed a curriculum that can serve as a template for this important step forward in anesthesiology education. Keywords 80-h work week, resuscitation, simulation, trauma
INTRODUCTION Trauma is the third leading cause of death in the USA and is a disease which every anesthesiologist will encounter in their practice. A trauma patient may suffer multisystem injuries in a motor vehicle collision and be treated at a level I trauma center, or may be an elderly patient at a community hospital who fell and now has a fractured hip in need of repair. Regardless of the cause, it is imperative that anesthesiologists be appropriately trained to manage trauma. Whereas the American Board of Anesthesiology currently requires that residents manage 20 trauma patients, a more refined approach to trauma education is warranted by the scope of this public health threat and the role that the anesthesiologist plays as resuscitation consultant. Fortunately, the existing residency in anesthesiology prepares physicians well in concepts fundamental to the management of all trauma patients. Airway management, placement of large bore vascular access, interpretation of invasive hemodynamic monitoring data, blood product resuscitation and www.co-anesthesiology.com
management of hemodynamic instability are core competencies in the broader practice of anesthesiology. An appreciation for trauma-specific concepts (e.g. brain injury, proper ratio of red cell to plasma transfusions, considerations for the elderly trauma patient) refines the anesthetic plan for trauma and is the goal of the trauma anesthesiology curriculum.
THE 80-HOUR WORK WEEK Any discussion of a resident curriculum in trauma anesthesiology must include a discussion of the
David Geffen School of Medicine at UCLA, Department of Anesthesiology/Division of Critical Care, Los Angeles, California, USA Correspondence to Joshua M. Tobin, MD, Assistant Professor, David Geffen School of Medicine at UCLA, Department of Anesthesiology/ Division of Critical Care, 757 Westwood Plaza Suite 3325, Los Angeles, CA 90095-7403, USA. Tel: +1 310 206 7496; fax: +1 310 825 2236; e-mail: [email protected], [email protected] Curr Opin Anesthesiol 2014, 27:240–245 DOI:10.1097/ACO.0000000000000020 Volume 27 Number 2 April 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Trauma curriculum for anesthesiology residents and fellows Tobin
KEY POINTS Recent changes in resident education, specifically the 80-h work week, must be taken into account when developing a trauma curriculum. Modern educational theory and tools such as simulation are important in the education of residents for high-risk clinical scenarios such as trauma. The new anesthesiology board certification process will call upon mastery of a variety of instructional formats, including resident lectures, clinical rotations and independent study. Core tasks in trauma anesthesiology recently defined by the Committee on Trauma and Emergency Preparedness can refine the goals of the trauma curriculum. New data including airway management techniques, blood component resuscitation and pharmacologic management of trauma require a revision in the current residency curriculum for trauma.
‘80-h work week’. Resident work hour restrictions were enacted on 1 July 2003 to address concerns that over-worked, sleep-deprived residents were not able to learn their craft, or to effectively care for patients. The ‘80-h work week’ was instituted to remedy these issues. In a landmark study, Landrigan et al. [1] evaluated intern performance during 2203 patient-days involving 634 admissions and found a higher rate of serious medical errors, and serious errors in the ICU, among interns who worked for 24-h shifts on an every-third-night call schedule. This had a significant influence on institution of work-hour restrictions. A before-and-after retrospective analysis of the effects of work-hour restrictions on the mortality of trauma patients in the National Trauma Data Bank found an overall decrease in mortality in trauma patients after the institution of work-hour restrictions [2]. Specifically, mortality was 4.46% after work-hour restrictions and 4.64% before work-hour restrictions. Interestingly, at university hospitals, mortality decreased from 5.15 to 5.03%, whereas at nonteaching hospitals, mortality increased from 3.37 to 3.85%. Whereas it would seem that decreasing work hours would be a common sense approach to resolving these issues, some data suggest that errors actually increase with restricted work hours. At a level I trauma center, death and complication rates were compared over two 24-month periods, before and after the 80-h work week. There was no difference in total or preventable death rates; however, the rates of total complication, preventable
complication and nonpreventable complication were higher in the post-80-h work week group [3]. A similar before-and-after review found an increase in medical complications and diagnostic test delays after resident work-hour restrictions; however, there was no increase in serious outcome (e.g. in-hospital mortality, transfer to ICU, discharge disposition, length of stay) [4]. This effect has been postulated to be due to the increased numbers of turnovers and sign-outs that occur in the restricted work-hour model. Unfortunately, it would be difficult at this point to conduct a prospective evaluation of the effects of restricted work hours.
COMPETENCY Ultimately, the curriculum for trauma anesthesiology must respect work-hour restrictions while providing the opportunity for residents to develop competency in the care of severely injured patients. Competency, however, is often difficult to define. It is sometimes described as ‘I know it when I see it’. In an effort to make the evaluation of competency more objective, the Accreditation Council for Graduate Medical Education (ACGME) has categorized competencies into six areas: knowledge, patient care, professionalism, communication and interpersonal skills, practice-based learning, and improvement and systems-based practice (please see below). This emphasizes a focus on ‘competency-based’ learning in residency rather than the more traditional ‘time-based’ system. ACGME core competencies: (1) (2) (3) (4) (5) (6)
knowledge; patient care; professionalism; communication and interpersonal skills; practice-based learning and improvement; and systems-based practice.
Miller’s [5] model of medical competence describes four distinct levels in a pyramidal model. The base of the pyramid is the knowledge level, where a student ‘knows’ the material. The next higher level describes a competent student who ‘knows how’ a process works, followed by a student who is able to perform as expected and is able to ‘show how’ to perform a task. At the apex of the competency pyramid is a trainee able to act independently (e.g. a student who ‘does’). A senior colleague of this author once described a similar stratification of four distinct levels of competency. The ‘unconsciously nonproficient’ physician ‘does not know what they do not know’ and is dangerous. A ‘consciously nonproficient’ physician
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is aware of their limitations. Although not dangerous, they are not yet competent to act independently. Not uncommonly this is seen in junior residents. A ‘consciously proficient’ physician, typically a more senior resident or board certified attending, is safe and capable. Mastery of the specialty transcends to a level of ‘unconscious proficiency’. Senior attending anesthesiologists will, occasionally, reach this level and wonder ‘why everyone else finds this so difficult’. Unfortunately, the unconsciously nonproficient physician and the unconsciously proficient physician are often impossible to distinguish, underscoring the need for an objective means of evaluation.
SEE ONE, HEAR ONE, DO ONE? In order to accurately evaluate competency the individual learning styles of students must be taken into consideration. Fleming’s Visual, Aural, Kinesthetic/Visual, Aural, Read, Kinesthetic model of learning divides students into those with visual, auditory and tactile learning styles. Visual learners think in pictures; they ‘see it’. They tend to benefit from visual cues such as diagrams, hand-outs, graphics, and prefer to ‘be left alone with the book’. Auditory learners are dependent on hearing and speaking to assimilate and process information; they ‘hear it’. Some suggest that they benefit from music in the background while studying and can be seen ‘talking out the answer’ during an examination. They tend to benefit from aural cues found in lecture and discussion formats. Tactile learners, also known as kinesthetic learners, depend on touching and moving to master new material; they ‘do it’. They tend to benefit from active experimentation and ‘hands-on’ experience. In the end, anesthesiology residents will have some component of all three styles of learning and would theoretically benefit from what has been described as the ‘meshing hypothesis’ or what may be called in medicine a ‘multimodal approach’. Unfortunately, improved performance in testing has not been correlated with prospective identification of different learning styles [6,7]. It remains a challenge to identify the best method for teaching each individual student. The new anesthesiology board certification process will involve a basic sciences evaluation during the Clinical Anesthesia-Year 1 (CA-1) year, as well as a clinical sciences examination after residency is completed. The traditional oral examination is soon to be supplanted by a combined oral interview and tactile skills demonstration, the format of which remains under development. Such an examination will call upon mastery of a variety of instructional formats, including resident lectures, clinical rotations and independent study. 242
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Mastery of basic concepts provides a fundamental knowledge base. Evaluation of this knowledge base via standardized methods (e.g. multiple-choice question-based examinations) screens those who have attained a basic level of understanding from those who have not. Multiple-choice questions (MCQs) efficiently test large numbers of students on a broad range of topics. There are, however, important limitations to the MCQ format. One investigation used Moore’s expanded outcomes framework to evaluate examinations during the first 2 years of instruction at an American medical school [8]. Level 3A questions were categorized as those requiring only ‘recall’ and rote memorization; level 3B questions required ‘application’ of knowledge to reach a conclusion or make a calculation; and level 4 questions evaluated ‘competence’ by requiring the student to demonstrate that they are ‘able to show how to do what the educational activity intended them to be able to do’. Notably, level 3A questions can sometimes be answered without reading the entire question; a regrettable feature of some ‘clinical vignettes’. The study found that the emphasis in the first year of medical education is on acquisition of knowledge facts, with 86% of examinations testing mostly declarative knowledge (recall). Fourteen percent of examinations contained content evaluated as procedural (application) questions. No examinations had any competence-level questions. The second year of medical school demonstrated an increase in procedural questions, with 85% of examinations evaluating procedural knowledge (application), 15% assessing declarative knowledge (recall) and no examinations containing competence-level questions. Allied health educators have noted a similar phenomenon. In an evaluation of over 2000 questions in a nursing multiple-choice test bank, 47% of questions were written at the knowledge level, and 6.5% were written at the analysis level [9]. Whereas mastery of a fundamental knowledge base is an important building block in education, these formats of evaluation are largely limited to assessment of information recall. Acquisition of the skill set necessary to practice anesthesiology involves proficiency in tactile procedures (e.g. intubation), understanding of scientific concepts (e.g. pharmacology) and synthesis of creative solutions (e.g. development of an anesthetic plan). Development of a curriculum that can teach and assess these skill sets is the objective of an effective educational plan.
SIMULATION Simulation has emerged as an important educational adjunct. Simulation involves presentation Volume 27 Number 2 April 2014
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Trauma curriculum for anesthesiology residents and fellows Tobin
of idealized scenarios in which routine, but potentially hazardous, activities are recreated and critiqued. The aviation industry was a leader in this training technique and anesthesiologists were the first in the medical community to embrace this methodology. One of the great advantages of simulation is the ability to recreate an environment for team interaction without hazarding the safety of a patient. Leadership styles can be evaluated and lines of communication can be established in real time. As early as 1969, Abrahamson described the use of computer-based simulation for assessment of anesthesiology resident’s skill at intubation. In 1988, Gaba and DeAnda [10] described their experience with a more comprehensive anesthesia simulator. They recreated an operating room environment in an effort to shift the simulation toward a more ‘hands-on’ experience. A simulation director and systems operator conducted the session via predesigned scripts. Twenty-two anesthesiology residents and medical students who had completed an anesthesiology clerkship participated in these scripted scenarios. Feedback was solicited via a questionnaire. Seventeen questionnaires were returned and offered generally favorable comments. The realism of the mannequin was noted as an area for improvement. Whereas questionnaires solicited from subordinate residents and medical students are subject to significant error, simulation was accurately identified as a technique for realistic training on potentially highrisk procedures. Ultimately, however, simulation is a training tool. Whereas simulation can improve communication and adherence to advanced cardiac life support protocols, few studies have demonstrated a direct improvement in clinical outcomes [11]. Nevertheless, the utility of simulation in anesthesiology education and certification is drawing increasing interest. Ziv et al. [12] described the use of simulation in an Objective Structures Clinical Examination (OSCE), as part of an anesthesiology certification process. The OSCE method involves a structured evaluation to assess adherence to guidelines agreed upon by exert consensus. The Israeli experience used five simulation-based stations, including one each in trauma management and resuscitation. They concluded that, ‘there is no doubt that incorporating simulation and OSCE for testing and evaluation should play a formative (training) and a summative (testing) role, involving the anesthesiology board’. The advantages of simulation include the obvious ability to master procedures before attempting them on a live patient, as well as other advantages including the ability to simulate infrequent
emergencies (e.g. cardiac arrest, malignant hyperthermia). The ability to critique the scenario via video replay after the exercise is another important advantage. It is vital, however, to recognize the limitation of this training method. Differences in technique and approach must be appreciated. For instance, the placement of central venous access in the internal jugular vein reinforces medial direction of the needle (e.g. toward the carotid) during simulation under ultrasound guidance. In clinical practice, however, the needle is more frequently directed laterally, toward the ipsilateral nipple. Whereas simulation offers a valuable lesson in reinforcing the psycho-motor skills necessary for the practice of anesthesiology, it is incumbent upon the simulation evaluator/instructor to have an appreciation for the limitations of simulation.
CORE TASKS The ultimate goal of the trauma curriculum is to teach the fundamental concepts necessary for the practice of trauma anesthesiology. Identification of these core tasks is central to that instruction and development of a core curriculum is contingent upon a clear definition of trauma anesthesiology. Trauma patients can present with neurologic injury, airway compromise, hemodynamic instability, trauma-related renal failure, the need for complex blood product resuscitation and the systemic inflammatory response syndrome (SIRS). Management may include mechanical ventilatory support, placement of invasive monitoring and interpretation of that data, initiation of renal replacement therapy, ultrasonographic assessment of injury and regional pain control techniques. Trauma calls upon the full intellectual and procedural skill set of the anesthesiologist and represents the most challenging patient population that we treat. A wealth of recent data on the resuscitation of critically ill patients has changed the fashion in which trauma patients are resuscitated. Recent review articles have called attention to the role that the anesthesiologist plays in the resuscitation of trauma patients [13 ]. Data on the use of etomidate in emergency intubation, for example, continue to add substance to the dialog on the ideal medication for induction of trauma patients [14 ]. A broader understanding of the immune response in trauma may lead to a ‘Grand Unified Theory’ of critical illness [15 ,16 ]. Monitoring of coagulopathy with newer modalities such as thromboelastography and rotational elastometry [17 ] may lead to a targeted approach to resuscitation including coagulation factor concentrates and tranexamic acid [18 ,19 ].
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A greater appreciation for trauma anesthesiology has encouraged interest in the publication of texts on the subject [20 ]. This growing fund of knowledge must be presented to the anesthesiology resident in a well defined curriculum. Varon and McCunn [21 ] recently highlighted the need for a trauma anesthesia curriculum to treat this complex patient population in the July 2012 ASA Newsletter. They noted the threat to the public health that trauma poses as the leading cause of death in young Americans, and third cause of death overall. They further observed that anesthesiologists are rarely involved in the initial resuscitation of patients in the trauma bay and advocated a more active role for anesthesiologists in this initial resuscitative phase, adding that such a role would strengthen the anesthesiologist’s claim as perioperative physician. This author would add that anesthesiologists have unquestioned experience in the management of hemodynamic instability. Given that anesthesiologists will manage these hemodynamically unstable patients in the operating room shortly after their trauma bay evaluations, they must be involved in that initial resuscitation. As noted above, the anesthesiology Residency Review Committee (RRC) requires only 20 trauma cases without defining specific educational objectives. A new body of literature has evolved regarding the resuscitation of trauma patients, due largely to the experience of military physicians after a decade of continuous combat. The RRC requirements have not, however, kept pace with this expanding knowledge base. Interestingly, the RRC includes in the definition of trauma cases victims of biological warfare (perhaps better categorized as critical care or infectious disease patients). This calls attention to the need for a re-evaluation of the trauma curriculum. The American Society of Anesthesiology’s Committee on Trauma and Emergency Preparedness (COTEP) recently designed a trauma anesthesiology curriculum arranged around the six core competencies of the ACGME (please see below) [22 ,23 ]. Summary of the COTEP Trauma Curriculum: &&
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(1) CA-1 and 2 cognitive objectives (a) Understand core principles of trauma care including (i) Epidemiology, prehospital care, initial evaluation and management, team approach, airway management, vascular cannulation, resuscitation, massive transfusion, general anesthesia, regional anesthesia, monitoring, ultrasound, 244
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postoperative care, chemical and radiologic exposure (b) Identify anesthetic considerations for patients with blunt or penetrating injuries including (i) Traumatic brain injury, spinal cord injury, ocular and maxillofacial trauma, chest trauma, abdominal trauma, musculoskeletal trauma (c) Describe the anesthetic management for special populations including (i) Burns, pediatric, geriatric, pregnant Psychomotor objectives (a) Completely evaluate trauma patient (b) Provide airway management (c) Develop anesthetic plan (d) Set up OR for trauma case (e) Maintain anesthetic record (f) Develop basic communication skills with the OR team and patient family (g) Perform procedures including: (i) Endotracheal intubation, tracheal tube introducer, arterial line cannulation, central venous cannulation, position patient, insert orogastric tube, regional blocks (h) Perform postop evaluation and QA Affective objectives (a) Demonstrate sensitivity to patient’s cultural background (b) Demonstrate commitment to medical record confidentiality (c) Practice cost-effective care and display respectful care (d) Participate in morning report and in trauma conference (e) Work effectively with team and know when to call for help (f) Consider patient safety (g) Display willingness to acknowledge mistakes and accept criticism (h) Consider patient ‘flow’ through hospital system (i) Complete appropriate evaluations; and (2) CA-3 cognitive objectives (a) Appraise core principles of trauma care as above (b) Analyze anesthetic considerations for patients with blunt or penetrating injuries as above (c) Design the anesthetic management for special populations as above Psychomotor objectives, in addition to above: (a) Serve as trauma anesthesia team leader (b) Provide anesthesiology consultation in ED/trauma bay Volume 27 Number 2 April 2014
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Trauma curriculum for anesthesiology residents and fellows Tobin
(c) Display effective communication skills with the OR team and patient family (d) Perform procedures in addition to above: (i) Surgical airways, induction/maintenance/emergence of general anesthesia, pain relief including epidural anesthesia (e) Manage patients in the post anesthesia care unit Affective objectives, in addition to above: (a) Supervise CA-1 and 2 residents under the direction of the attending anesthesiologist; and (b) Document and present complications in morning report. Their approach emphasizes a systems-based method with specific goals for learners. Two distinct curricula are identified. One curriculum was designed for junior residents (CA-1 and 2) and another for senior residents (CA-3). Cognitive, psychomotor and affective objectives are identified in an effort to provide ‘total care’ for trauma patients. Attention to the core tasks fundamental to the practice of trauma anesthesia can be combined with established supplementary curricula [e.g. the Advanced Trauma Life Support (ATLS) course and Fundamentals of Critical Care Support (FCCS) course] to provide breadth and depth to the trauma anesthesia curriculum. Adherence to these well defined instructional benchmarks will serve as an important step toward formalizing the trauma curriculum.
CONCLUSION Simply documenting participation in 20 trauma cases is insufficient to demonstrate qualification to independently manage a trauma anesthetic. A more discrete assessment of trauma-specific core tasks must address the six ACGME-identified competencies, while taking into consideration the limitations of work-hour restrictions. Modern educational theory can be applied to the instructional process, and training techniques such as simulation can enrich the learning experience. A revised curriculum in trauma anesthesiology demonstrates the anesthetic community’s commitment to the public health and is our duty to the future of our specialty. Acknowledgements No funding or sponsorship was received. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351:1838–1848. 2. Morrison CA, Wyatt MM, Carrick MM. Impact of the 80-h work week on mortality and morbidity in trauma patients: an analysis of the National Trauma Data Bank. J Surg Res 2009; 154:157–162; Epub 2008/07/29. 3. Salim A, Teixeira PG, Chan L, et al. Impact of the 80-h workweek on patient care at a level I trauma center. Arch Surg 2007; 142:708–712. [discussion 12-4] 4. Laine C, Goldman L, Soukup JR, Hayes JG. The impact of a regulation restricting medical house staff working hours on the quality of patient care. J Am Med Assoc 1993; 269:374–378. 5. Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990; 65 (9 Suppl):S63–S67. 6. Pashler H, McDanile M, Rohrer D, Bjork R. Learning styles: concepts and evidence. Psychol Sci Public Interest 2009; 9:105–119. 7. Rohrer D, Pashler H. Learning styles: where’s the evidence? Med Educ 2012; 46:634–635. 8. Vanderbilt AA, Feldman M, Wood IK. Assessment in undergraduate medical education: a review of course exams. Med Educ Online 2013; 18:1–5. 9. Masters JC, Hulsmeyer BS, Pike ME, et al. Assessment of multiple-choice questions in selected test banks accompanying text books used in nursing education. J Nurs Educ 2001; 40:25–32. 10. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology 1988; 69:387–394. 11. Okuda Y, Bryson EO, DeMaria S Jr, et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med 2009; 76:330–343. 12. Ziv A, Rubin O, Sidi A, Berkenstadt H. Credentialing and certifying with simulation. Anesthesiol Clin 2007; 25:261–269. 13. Tobin JM, Varon AJ. Review article: update in trauma anesthesiology: peri& operative resuscitation management. Anesth Analg 2012; 115:1326–1333. Synopsis of recent advances in trauma resuscitation 14. Banh KV, James S, Hendey GW, et al. Single-dose etomidate for intubation in & the trauma patient. J Emerg Med 2012; 43:e277–e282. Limiting use of etomidate has no effect on mortality but did increase episodes of hypotension 15. Marik PE, Flemmer M. The immune response to surgery and trauma: implica& tions for treatment. J Trauma Acute Care Surg 2012; 73:801–808. Traumatic injury is followed by the systemic inflammatory response syndrome. 16. Asehnoune K, Roquilly A, Abraham E. Innate immune dysfunction in trauma & patients: from pathophysiology to treatment. Anesthesiology 2012; 117:411– 416. Depression of cell-mediated immune function following trauma is associated with worse outcome 17. Sankarankutty A, Nascimento B, Teodoro da Luz L, Rizoli S. TEG(R) and & ROTEM(R) in trauma: similar test but different results? World J Emerg Surg 2012; 7 (Suppl 1):S3. Both thromboelastography and rotational thromboelastometry can diagnose coagulopathy and guide therapy in trauma. 18. Fries D. The early use of fibrinogen, prothrombin complex concentrate, and & recombinant-activated factor VIIa in massive bleeding. Transfusion 2013; 53 (Suppl 1):91S–95S. Targeted resuscitation of trauma patients with coagulation factor concentrates based on point-of-care testing may be more effective than ratio-driven therapy. 19. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of & Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg 2012; 147:113–139. Tranexamic acid improves coagulation and survival in wartime trauma patients requiring massive transfusion. 20. Varon AJ, Smith CE. Essentials of trauma anesthesia. Cambridge: Cambridge && University Press; 2012. A concise review of the full spectrum of the practice of trauma anaesthesiology. 21. Varon AJ, McCunn M. The need for a trauma anesthesia curriculum: first steps. && Am Soc Anesthesiol Newslett 2012; 76:38–39. The authors call attention to the need for a well defined trauma anesthesiology curriculum. 22. Committee for Trauma and Emergency Preparedness (COTEP). Curriculum && for CA-1 and CA-2 residents. http://www.asahq.org/For-Members/AboutASA/ASA-Committees/Committee-on-Trauma-and-Emergency-Prepared ness. aspx. [Accessed 21 July 2013] A template for trauma anesthesiology education of junior residents. 23. Committee for Trauma and Emergency Preparedness (COTEP). Curriculum && for CA-3 residents 2013. http://www.asahq.org/For-Members/About-ASA/ ASA-Committees/Committee-on-Trauma-and-Emergency-Preparedness. aspx. [Accessed 21 July 2013] A template for trauma anesthesiology education of senior residents.
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