Ambulatory and Regional Anaesthesia Fellowship

Learning Program

Introduction:
This Clinical Fellowship is designed to provide the Fellow with the opportunity to gain skills and confidence with clinical regional anaesthesia. Fellowships are available for six or twelve month terms and are usually reserved for advanced trainees who have completed examination requirements for College Fellowship.

There is an emphasis on ambulatory anaesthesia and application of regional techniques to the short-stay surgical population. The majority of cases will be sourced from the elective orthopaedic lists. Additional opportunities to gain further experience will come from acute admissions and trauma cases on an ad hoc basis.

Regional Anaesthesia Faculty:
The Fellowship is based at Sir Charles Gairdner Hospital, Nedlands, WA. The following Anaesthesia Department Consultants are involved in the management of orthopaedic patients at SCGH and have an interest in the promotion of RA within the hospital:

Dr Steve Watts (Coordinator)
Dr Lindy Roberts (Director Acute Pain Service)
Dr Brien Hennessy
Dr Craig Smith
Dr Steve Myles
Dr Holger Holldack
Dr Barry Lim
Dr Mark Lennon

Prerequisites:
Fellows are expected to be proficient in the assessment and preparation of patients for surgery and in the provision of general anaesthesia. Competence in central neuraxial blockade (spinals and epidurals) prior to commencing the fellowship will be of benefit. Fellows seeking more experience with these techniques should make this clear at the commencement of the rotation.Rostering:
The Amb/Reg Fellow is allocated a set clinical program with five orthopaedic sessions per week. Additional clinical sessions are allocated to preoperative assessment and acute pain management. These sessions are in conjunction with Regional Faculty Consultants. There is one half-day set aside for non-clinical activity (research, audit, teaching) and one designated half-day off. The Fellow is not expected to work night shifts although a "long-day" (to 8pm) and weekend shifts will be rostered periodically.

Journal Club:
The Regional Faculty holds quarterly journal-clubs to discuss issues of relevance to the sub-specialty. These will be based around a case presented by the Fellow. Topics and dates will be posted in the Department.Course Content:
Below are listed topics relevant to ambulatory and regional anaesthesia that the Fellow is expected to be familiar with by the completion of the rotation. Some of the topics relate to basic clinical pharmacology that should largely be revision of previously learned material. Other topics are specific hands-on skills that can only be attained in theatre. It would be advisable to keep a log of specific blocks so that gaps can be identified prior to the end of the term.

Basic science
Local anaesthetic pharmacology
Analgesic pharmacology
Neural anatomy, cellular function
Physiology of nerve stimulation
Anatomy refresher (may include cadaver lab) o Brachial plexus
o Lumbar Plexus
o Sciatic Nerve
o Intercostal nerves
o Femoral sheath
o Epidural / Subarachnoid space

Standard regional techniques (and their complications)
Bier’s block
Interscalene block (single shot)
Femoral "3 in 1" nerve block
Fascia iliaca block
Sciatic nerve block
o LaBatt / Raj / popliteal / lateral
Axillary block
Ankle block
Spinal
Epidural advanced regional techniques (and their complications)
Axillary/interscalene catheters
Lumbar plexus block (single shot and continuous)
Sciatic infusion techniques
Supra and infraclavicular blocks
Paravertebral block
Cervical plexus block
Suprascapular block
Ultrasound guidance
Perioperative issues:
Preoperative assessment
Preparation of patients for ambulatory surgery
Informed consent for regional anaesthesia
Management of continuous regional blockade
Co-analgesic supplementation
Neural blockade in the home environment
Regional anaesthesia audit
Assessment and management of postoperative nerve dysfunction

Research:
The RA team aims to provide patients with a best-practice anaesthesia service. We are continually seeking to measure and improve our outcomes with an emphasis on quality of analgesia. The Fellow is expected to contribute towards the maintenance of the internal RA database and to assist with research projects as directed. A research assistant and statistical support are available within the Department for Fellows wishing to undertake their own projects.

Assessment:
The Amb/Reg Fellowship is essentially a rotation involving clinical experience and no formal assessment is undertaken at the completion of the rotation. The course content serves as an outline of some of the aspects of Amb/Reg practice that need to be covered to attain competence. Active discussion and feedback is encouraged.

Dr Steve Watts