Acute Care Common Stem - Emergency Medicine (ACCS EM)

A personal reflection on my first two years in Severn Postgraduate Medical Education

James McDonald CT2 ACCS EM

Thinking back, as I approach the end of my CT2 year in the Severn PGME, I am amazed at how far my skills and knowledge have progressed since starting ACCS in August 2010. This has been largely due to the excellent training opportunities and rationalisation of the ACCS EM curriculum provided by the Severn School of ACCS. What follows are a few thoughts – basically the things which seem important to me - reflecting on my experience as a Severn ACCS EM trainee. Further information on the ACCS programme, the region, the curriculum, the assessment process, courses and training days is available on the Severn School of ACCS website and this is not repeated here in detail.

Two years ago, as a Foundation Year 2 doctor, having the confidence and ability to, for example, team lead a major trauma, independently administer regional anaesthesia and reduce fractures, manage the initial resuscitation of critically unwell medical patients, look after twelve patients on a night shift in the Intensive Care Unit or perform a rapid sequence induction seemed like a very remote and daunting prospect. Although almost all ACCS EM trainees will have some experience in Emergency Medicine (EM), Acute Medicine (AM), Intensive Care Medicine (ICM) and Anaesthetics it is unlikely that any will have experience in all specialities and certainly not to the depth provided in the ACCS. It is both this incredibly broad experience base, and the fact that it is a well thought out and purpose designed training programme, that sets ACCS  in Severn apart from other core training programmes. Successful completion of ACCS EM results in the acquisition of all the competences required, by the College of Emergency Medicine (CEM), to enter higher training in Emergency Medicine – but perhaps more importantly the tools to do the job with confidence, ability and therefore enjoyment.

My reasons for wishing to pursue a career in Emergency Medicine include the usual desire for fast pace and variety of presentations, availability of  practical procedures, a team working enviroment and opportunities for teaching but also a personal need for a training programme offering genuine and realistically achievable career prospects. Recruitment to ACCS EM in Severn is well matched to the number of higher training places in the region and as such completion of ACCS EM leads to the very real prospect of career progression in what is, currently, an expanding speciality. The region itself is exceptional in terms of both the variety of hospital (and therefore training opportunities) and for the quality of lifestyle offered. Rotations include District General Hospitals, giving exposure to higher levels of responsibility, larger centres offering specialist services such as neurosurgery and cardiothoracic surgery and tertiary centres such as the Children’s Hospital in Bristol. The region therefore covers almost all specialities in which you will need to gain experience when referring patients for definitive specialist treatment. For example, during my EM module I was involved in discussing and referring at least two sub arachnoid haemorrhages and a thoracic aortic dissection. Further detailed information on individual towns and cities is available on the Severn ACCS website although I feel it is important to note that it is a realistic possibility to commute to all locations from a single home.

One of the main strengths of ACCS EM in Severn, for me, has been the recognition of just how daunting starting posts in EM, ICM and Anaesthetics is for most trainees. Each of these specialities has a specific introductory training course, provided by Severn PGME, for ACCS trainees. The ‘New to ICM’ and ‘Novice Anaesthetist’ courses are based at the Bristol Simulation Centre and, although available to candidates nationally, are funded by Severn PGME for ACCS trainees. Like the ICM and anaesthetic courses the Introduction to Emergency Medicine day is timed to coincide with start dates for novice trainees. These courses recognise the common anxieties experienced by trainees and, for me, were a huge confidence booster in covering topics including managing displaced airways in ventilated ITU patients, inotropes and vasopressors, anaesthetic emergencies and common ED presentations including trauma and severe sepsis with multiple organ failure. All commonly performed practical procedures, for example placing central lines, chest drains, fracture reduction and suturing are also covered.

A further, one day per month, regional programme runs for EM which focuses on the Membership of the College of Emergency Medicine exam (MCEM) which must be passed in order to complete ACCS EM. Again I think that this illustrates the point that ACCS EM in Severn is a well thought out and organised core training programme. My EM experience in Bath also included a full two day induction programme and a structured weekly (two hours of protected time) in house teaching programme. This covered core knowledge and skills required when working in the Emergency Department (ED) such as ECG interpretation and the management of Acute Coronary Syndromes which further increased my confidence and ability to work effectively in my role a senior house officer (SHO) in ED.

There can be no denying that successful completion of ACCS EM requires a high level of commitment and a lot of hard work. Most placements involve working a full shift rota which is demanding in itself. In addition to this there is a requirement to be up to date in the three main advanced life support courses, attend other courses related to personal interest, pass MCEM by the end of CT3, carry out additional ‘projects’ and to complete what initially seems like a vast and unfathomable Work Place Based Assessment (WBPA) process including the usual mix of Direct Observation of Procedural Skills (DOPS), Mini Clinical Evaluation Exercises (MCEX) and case Based Discussions (CBD).

Initially, reviewing the CEM ACCS curriculum and E-portfolio was both daunting and confusing for me – a feeling I know I shared with the majority of my peers - and did not seem to provide any structure for working through the large number (over 110) of assessments required. My life, over the last two years, has been made immeasurably more straightforward by the Severn School of ACCS’ work in both recognising and rationalising this issue by producing the ‘ARCP Workbook’ and the ‘ACCS Anaesthetic Training Record for Non Career Anaesthetists’ (both available on the website). The ‘ARCP Workbook’ clearly sets out, and gives a place to record, the number and type of all assessments required to achieve a successful outcome at the Annual Review of Competence and Progress (ARCP) along with guidance on when to complete them. The anaesthetic record similarly rationalises the curriculum for achieving the Initial Assessment of Competence in anaesthesia and all other requirements for signing off this module in the ARCP Workbook. These documents then create a central, structured, record of assessments and allow the CEM E-Portfolio to be used simply as an electronic record of the individual assessments. Overall this makes a seemingly impossible task manageable and takes away the very real possibility of reaching the end of a year only to discover that required assessments have been missed.

In summary I feel that the ACCS EM programme, provided by the Severn School, has enabled me to progress in skills and knowledge relevant to EM to a level far beyond my initial expectations. This has basically been achieved by following the structured and well thought out pathway laid down by the School. Although I do not have any first hand experience of ACCS EM in other regions, I would highly recommend Severn PGME for both its success in rationalising and organising this excellent, although somewhat unwieldy, core training programme in to what is effectively a vocational course, the excellent availability of courses and focussed teaching along with the unbeatable location for both experience and lifestyle.