Update in the european anesthesia education

Ben Gurion University of the Negev, Israel, Faculty of the International School of Instructors in Anesthesiology (ISIA), Congresul II Internaţional al Societăţii Anesteziologie Reanimatologie din Republica Moldova 27-30 august 2009Introduction In spite of the fact that each physician, all over the world, graduated a six or seven- year medical school, there is a permanent need for continuous learning, since medicine is a profession in permanent progress and each of us must assure adequate quality of patient care and also public accountability. In a bilingual book (English and Hebrew) published in 1992 (“Education and teaching in Anesthesiology in Israel) I wrote that “ society expects to see a specialist operating in the framework of modern, up to date medicine, and who is aware of the many innovations in every field”. Self learning or participation to scientific conventions and refresher courses proved to be valuable tools, but neither one can offer a real method for creating real up to date knowledge and skills. Recertification, as it is practiced nowadays in the USA, seems to be the closest framework to what the medical system is supposed to offer regarding the patient safety and modern care. But the question is how could we keep ourselves in good shape between two recertification examinations, which is held once every 10 years? Teaching means not only hard working gifted students but also, or mainly, good teachers, coaches and guides, who would be able to teach, to inspire and (why not?) to serve as role-models for their younger colleagues. These were the thoughts on which the 15-year Beer Sheva educational project was started in the early 90s. It was supposed to help closing the gap between the modern medicine practiced in the western hemisphere of the world and that part of Europe which was for almost half a century under the communist regime. The Beer Sheva project, entirely financed by the WFSA, exposed young Eastern Europe anesthesiologists to the modern aspect of our profession, by offering a direct view to daily activities of a busy up to date Israeli hospital. More than 160 young physicians took part to the project, 36 of them (22%) coming from the Republic of Moldova. The project did not include a follow up system in order to know what happened to each of those anesthesiologists who spent between one month and one year at Soroka Medical Center in Beer Sheva, but we do know that some of them became directors of anesthesia departments, chiefs of professional units, organizers of congresses and conventions. We also know that some 20-25% of them found the way to Western Europe and they are currently employed by a foreign department. We soon realized that in spite of the efforts and financial resources we could not completely close the gap between the two kinds of medicine practiced on both sides of the former Iron Curtain. The idea was to find a new way to implement modern medicine, techniques, organization and also mentality among the new generation of anesthesiologists in Europe, not only in former communist countries but also in some other regions of the continent. The permanent contact with our profession all over Europe showed very clearly that one of the feeble points of educating the new generation of specialists was the use of old method to teach new things. Once the needs for basic equipment and drugs have been solved and the access to up to date information ceased to be a problem, we felt that one has to take care of the system of teaching, the way the practical information is transferred and skills are taught. Method These thoughts created a new project, of “teaching the taecher”, an international institution (The International School for Instructors in Anesthesiology-ISIA) with the aim of preparing in a restricted number of countries, a group of instructors, who would be exposed to the modern ways of teaching theoretic and practical subjects, as well as main aspects of organizing our profession. The core of the established curriculum was to teach the new way of lecturing clinical subjects, based on description of real cases, but also including the evidence base data and basic sciences knowledge. Soon the curriculum was enriched by adding a long series of subjects related to educational skills and anesthesia organization items. The first ISIA course took place during the years of 2006-2007 , in Bratislava and Belgrade, three classes, each of one full week of presentations, skills teaching and discussions regarding various aspects of our profession. The “students” of ISIA 1 were all young anesthesia specialists from five countries (Moldova, Serbia, Slovakia, Poland and Bulgaria), four from each country, selected by their national societies of anesthesiologists. The admittance criteria were: full training in anesthesia, good commend in English and the obligation to attend all three classes (organized at intervals of six months each). But the most important point was each candidate commitment that after graduating the ISIA classes, similar national courses would be organized in their own countries. The ISIA faculty included Drs M. Dobson and Lesley Bromley, two very well known British anaesthetists, Mrs. Shirley Dobson, a very gifted specialist in the domain of education teaching, as well as some well recognized European experts in various fields of anesthesia and its domains of interest. The timetable included case presentations and discussions (prepared in concordance with the modern demands of clinical teaching), special sessions of teaching educational skills and also frontal lectures on topics related to the organization of our profession. Results All 20 students graduated the three classes of the 1st ISIA course and got a final diploma. At the end of the 3rd class all of them proved to be dedicated teachers, able to bring the knowledge obtained at ISIA to younger colleagues in their own countries. As a result, during the following 2 years similar courses have been organized in each of the participant countries and some 100 young specialists, all together, took part to these national courses organized by the ISIA 1 alumni. A possible and valuable fringe benefit of ISIA to be mentioned is that of creating a new generation of leaders in Anesthesiology, by helping the “students” to develop special personal features, like motivation, a significant degree of compulsiveness, capability to see problems of the others as well as ability to irradiate leadership. In the last two years nine out of 20 ISIA 1 alumni have been promoted in various professional and organizational positions, in all the five countries. The near future ISIA 2 is on its way. Next October twenty more students, from five more countries (Romania, Hungary, Slovenia , Macedonia and Greece) will take part to the new three-class cycle. ISIA 2 would be equally sponsored by the two international professional organizations :ESA and WFSA. The classes will be hosted in a nice Romanian resort area, with the excellent help of Prof. Daniela Filipescu from Bucharest and under the auspices of the Romanian National Society (president: Prof. S. Marinescu). One very important aspect of the next ISIA course is the fact that this time our faculty would include former ISIA 1 alumni, who would gradually take over some of the perennial faculty members tasks. It is our hope that in the future these young ISIA graduates will be able to replace the old generation of teachers and assure the continuation of this valuable project. Very recently (June 2009) the ESA-NASC committee decided to propose the creation of an “umbrella” teaching European organization, with the aim of coordinating the already existing projects in this domain, in order to avoid futile parallel activities. The new body, which would be called : THE EUROPEAN INSTITUTE FOR TEACHING ANESTHESIOLOGY (EITA) is supposed to start acting early next year and to take under its responsibility current teaching projects (like ISIA), but also initiating new ones, one example being an international center for teaching airway management skills. A British philosopher once wrote that the real difficulty in changing the course of any enterprise lies NOT in developing new ideas , BUT escaping from the old ones. The tremendous progress initiated on the European continent in the last years regarding teaching anesthesia seems to respond to this clever saying

How to attract a young physician to our profession - or the anatomy of a failure

Anesthesiology and Critical Care, Ben Gurion University of the Negev, Beer Sheva, Congresul II Internaţional al Societăţii Anesteziologie Reanimatologie din Republica Moldova 27-30 august 2009Medical literature is full of papers trying to explain the psychological drive of young people to become physicians: an interesting life experience, a profession with a meaning and an aim, which offers a social position and prestige and also a nice financial incentive. Indispensability, the desire to help people, to get respect and access to science, have been for centuries the main reasons to select medicine as a future profession. But today the situation is changing in the sense that some negative aspects of the profession (heavy work, badly structured residency track, significant decrease of respect offered by the patient and not least inadequate wages) weight more and more in taking a decision which would influence one’s whole life. In the last years Anesthesiology, one of the youngest medical specialties, became a victim of this new situation all over the world and a real shortage of professionals in this domain is felt. The well recognized shortage of anesthesiologists in many countries just worsens a situation in which demand for anesthesia services increases all the time. In spite of the fact that anesthesiologists in many countries won a respectful position in the medical community, they are still considered practitioners of a service profession, a peripheral one, not always adequately reimbursed. The aim of this presentation is to analyze the situation of this profession in Israel and also to offer colleagues from other countries an example of how things can go from bad to worse if efficient steps have not been taken in time. Anesthesiology manpower in Israel. Since the creation of the state in 1948, Israeli Anesthesiology faces a real paradox. Although the number of anesthesiologists per 100,000 (around 10-11) inhabitants is similar to that of other countries, only 12% of them graduated in an Israeli medical school and in the last years less than 1% of the Israeli alumni chose anesthesia as their future career. Among Israeli anesthesiologists younger than 40, only 8% graduated a local medical school. The discrepancy between the rather high number of anesthesiologists and the very low rate of Israeli medical schools alumni who become anesthesiologists is easily explained by the fact that 88% of the current anesthesia manpower in this country comes either from immigration (the largest part) or from those Israeli citizens who studied medicine abroad. It is worthwhile to mention that as per the year of 2006 65% of the Israeli anesthesiologists have graduated a medical school in the former Soviet Union! But, according to official data, the overall emigration to Israel significantly decreased in the first decade of this century and this became the main explanation for the current severe shortage of anesthesia workforce in this country (75% of anesthesia departments indicated a serious need for new physicians, specialists and residents too). Since a similar shortage is encountered in other countries all over the world, the situation in Israel might become even serious, due to the fact that many Israeli physicians prefer to work abroad, in more affluent countries, because of the better work conditions and payment. A survey presented by us in 2008 also showed that the state of well being among Israeli anesthesiologists does not contribute to the solution of workforce in this country. Although the well being feelings among the Israeli anesthesia residents is much better today than 20 years ago, the Israeli anesthesia specialist, in comparison to other countries and to 20 years ago feels much worse. The explanations offered for these survey results include low basic income, a need for working additional hours and look for an additional place of work in order to supplement the meager monthly income. Another survey (presented in 2008 by Dr Zeev Goldik) brought some very disappointed data about the perception of the anesthesiologist’s job in the eyes of the Israeli public. Even if the data showed some improvement in the last decade, in 2008 only 67% of the public knew that the anesthesiologist is a physician, only 33% considered the anesthesiologist in charge with patient’s life and only 50% of the responders thought that the selecting the type of anesthesia is part of the anesthesiologist’s job description. Previous attempts to ameliorate the situation. The dangerous trend of not choosing anesthesia as a future career among young Israeli physicians is well known. A paper published by us in 1977 in Israel showed that the average young physician was not eager to include anesthesia on the list of profession to be selected as a professional career. The responders indicated the flaws of the profession: a service specialty, weak contact with the patient, the negative image of the profession in the medical community, boredom and not enough financial remuneration. Unfortunately, the medical system in this country was pleased with the permanent influx of anesthesiologists coming from abroad and did not initiate a serious program for mending the situation. During the last decades of the previous century special initiatives have been taken, mainly by the professional organizations. An increase in the monthly income, creation of more professional units (neuroanesthesia, cardiac anesthesia, pediatric anesthesia, etc) accompanied by a better salary for those in charge, special grants for new residents, all these have been tried in the past but all have failed

Benefits and harms of perioperative high fraction inspired oxygen for surgical site infection prevention: a protocol for a systematic review and meta-analysis of individual patient data of randomised controlled trials.

INTRODUCTION The use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been replicated with varying success and subsequent meta-analysis are equivocal. Recent advancements in perioperative care, including the increased use of laparoscopic surgery and pneumoperitoneum and shifts in fluid and temperature management, can affect peripheral oxygen delivery and may explain the inconsistency in reproducibility. However, the published data provides insufficient detail on the participant level to test these hypotheses. The purpose of this individual participant data meta-analysis is to assess the described benefits and harms of intraoperative high FiO2compared with regular (0.21-0.40) FiO2 and its potential effect modifiers. METHODS AND ANALYSIS Two reviewers will search medical databases and online trial registries, including MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and WHO regional databases, for randomised and quasi-RCT comparing the effect of intraoperative high FiO2 (0.60-1.00) to regular FiO2 (0.21-0.40) on SSI within 90 days after surgery in adult patients. Secondary outcome will be all-cause mortality within the longest available follow-up. Investigators of the identified trials will be invited to collaborate. Data will be analysed with the one-step approach using the generalised linear mixed model framework and the statistical model appropriate for the type of outcome being analysed (logistic and cox regression, respectively), with a random treatment effect term to account for the clustering of patients within studies. The bias will be assessed using the Cochrane risk-of-bias tool for randomised trials V.2 and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation methodology. Prespecified subgroup analyses include use of mechanical ventilation, nitrous oxide, preoperative antibiotic prophylaxis, temperature (2.5 hour). ETHICS AND DISSEMINATION Ethics approval is not required. Investigators will deidentify individual participant data before it is shared. The results will be submitted to a peer-review journal. PROSPERO REGISTRATION NUMBER CRD42018090261

EIT Observations of the Extreme Ultraviolet Sun

The Extreme Ultraviolet Imaging Telescope (EIT) on board the SOHO spacecraft has been operational since 2 January 1996. EIT observes the Sun over a 45 x 45 arc min field of view in four emission line groups: Feix, x, Fexii, Fexv, and Heii. A post-launch determination of the instrument flatfield, the instrument scattering function, and the instrument aging were necessary for the reduction and analysis of the data. The observed structures and their evolution in each of the four EUV bandpasses are characteristic of the peak emission temperature of the line(s) chosen for that bandpass. Reports on the initial results of a variety of analysis projects demonstrate the range of investigations now underway: EIT provides new observations of the corona in the temperature range of 1 to 2 MK. Temperature studies of the large-scale coronal features extend previous coronagraph work with low-noise temperature maps. Temperatures of radial, extended, plume-like structures in both the polar coronal hole and in a low latitude decaying active region were found to be cooler than the surrounding material. Active region loops were investigated in detail and found to be isothermal for the low loops but hottest at the loop tops for the large loops

Closing the gap in Europe through education: a reverse mission

Universitatea Ben Gurion din Negev, Beer Sheva, Israe

Propofol-related infusion syndrome (PRIS) Propofol-related infusion syndrome (PRIS) -a review

Abstract Propofol related infusion syndrome (PRIS) is a rare and controversial clinical entity that was described in patients who got this sedative drug for long periods of time, mainly in the critical care environment, and very often in doses larger than those recommended by literature. Initially it was described in children, but soon some cases of adult patients in critical condition were published. Acute neurological conditions such as head trauma or status epilepticus are among those clinical situations that predispose to PRIS development. PRIS is characterized by severe clinical and laboratory signs, such as bradycardia, cardiac failure, hypotension not responding to vasopressors, lactic acidosis, and signs of rhabdomyolysis. It seems that administration of propofol in large doses and for long duration has a pathological influence on mitochondrial activity, but disturbances in lipid metabolism and free fatty utilization have also been incriminated as being part of the pathophysiological explanation of the syndrome. The article presents the main prophylactic measures to be taken when propofol is administered in large doses and for long periods of time, as well as proposals for management of PRIS. Since a good part of the literature questions even the existence of the syndrome, the article presents some data regarding this controversy and proposes a very careful approach to every case in which PRIS is suspected