Paediatric intensive care training

Tomlinson summarises the problems surrounding the initial care of critically ill children in non-specialised hospitals (Tomlinson. Anaesthesia 2003; 58: 309). However, although the suggestions he makes to enhance the abilities of trusts to provide the required high standards of care are sensible, we believe that a lack of ‘joined-up thinking’ in the training of new consultant anaesthetists may continue to undermine attempts to achieve these standards. The clinical exposure of current trainees is now very different from that of existing consultants trained in the ‘pre-Calman/New Deal’ era. Gone are the endless nights and weekends working on-call, during which exposure to various paediatric emergencies could be anticipated, particularly if duty responsibilities involved simultaneous anaesthesia and ICU cover. Greater centralisation of paediatric intensive care to Lead Centres means that in many acute trusts, the care of sick children is now increasingly limited to a relatively brief time interval prior to the arrival of a retrieval team. The opportunities for trainees to learn from unplanned contact with sick children have therefore diminished significantly. Had these changes been accompanied by modifications in training programmes to ensure that all anaesthesia trainees gained clinical experience in a Lead Centre paediatric intensive care unit (PICU), then their adverse effects might be minimised. Regrettably, however, it appears that the secondment of trainees to PICUs appears to be at best patchy, and in some regions such training is only facilitated for aspiring paediatric anaesthetists or intensivists. A further disincentive is that time spent in paediatric intensive care may not even be ‘recognised’ for the mandatory period of training in critical care. Given that the majority of future district general hospital (DGH) consultants for any region are likely to be products of the School of Anaesthesia based in the regional tertiary centre, any failure to invest in their training carries important future implications for the local care of critically ill children. This raises important questions about the logic of training in anaesthesia. Although training in paediatric anaesthesia teaches core skills in airway management, assisted ventilation, pharmacology and fluid management, this does not necessarily confer confidence in the management of potentially unstable critically ill children, particularly if training has been limited to the minimum of 3 months in predominantly elective patients. Paradoxically, significant amounts of time are still allocated to training in elective and emergency cardiac and neurosurgical procedures, yet most consultant anaesthetists working in non-specialist centres are very unlikely to provide anaesthesia for cardiopulmonary bypass surgery or for a craniotomy. By contrast, however, there is a high likelihood that these same consultants will be involved with the care of children either for elective procedures or for emergencies. As the long-term outcome for critically ill children (if managed well) is considerably better than for adult patients with cardiovascular disease or neurological trauma, why is there so little emphasis on training in paediatric intensive care? Perhaps it is time to re-examine the priorities for training in anaesthesia. In order to give the future generation the best chance of survival, we must ensure that consultants have the opportunity first to acquire the necessary skills, as well as developing strategies to maintain them.