SSAI postgraduate training program in Critical Emergency Medicine – advanced resuscitation science and practice
“Critical care, everywhere”
The resuscitation and treatment of acutely unstable patients has historically been one of the four cardinal roles of the Nordic anaesthesiologist, along with operative anaesthesia (including perioperative medicine), intensive care medicine, and pain management. The SSAI has established advanced educational programs for each of these major roles (pillars) of anaesthesiology as well as for various subspecialist roles within anaesthesiology, such as paediatric-, obstetric-, and cardiothoracic anaesthesia. Although every anaesthesiologist is expected to have a solid foundation in caring for unstable patients through their training and practice in theatres and in the intensive care department, keeping up with the advancing science and treatment possibilities for the emergency management of critically ill and injured patients can be a daunting task. To further strengthen anesthesiologists in this role the SSAI established the advanced postgraduate training program in Critical Emergency Medicine (CrEM; previously referred to as Emergency Critical Care). CrEM deals with advanced resuscitation science and practice in a broad sense, for both trauma and acute illness, in various patient categories and settings. The training program focuses on the patient that has sustained an injury or become acutely ill outside the hospital and requires immediate medical assistance at the scene of the incident, en route to the hospital or on presentation to the emergency department.
Despite the similar nomenclature, CrEM should not be confused with the primary specialty of Emergency Medicine which is focused on the diagnosis, risk stratification, emergency treatment and disposition of any and all patients that present to the emergency department of the hospital. A small subset of these patients will be critically ill and unstable and in the Nordic countries, anaesthesiologists will be summoned to resuscitate, stabilise or otherwise manage this subset of patients. These patients are the focus of the postgraduate training in Critical Emergency Medicine.
Updated curriculum and training objectives
This is the curriculum for the two (2) year advanced training program in Critical Emergency Medicine. At the end of the program the candidate should have scientifically based clinical proficiency in assessing and treating critically ill and injured patients and stabilising them during transport to a department or facility where they can receive further care. The skillset for these tasks can also be of use in other clinical settings (for example in the intensive care department, operating suite, as well as on the wards) although this is not the primary focus of the program. The CrEM candidate should have systems level knowledge of prehospital emergency medical services including dispatch and response, protocols and quality indicators. These doctors will end up being the resident experts in such matters within their departments, leading resuscitation teams and influencing local policy and practice. Others may continue on to (or already be established in) careers in prehospital and retrieval medicine.
The overarching topics / training objectives for the program are
- Advanced resuscitation practice in the widest sense
- Emergency anaesthesia and airway management for trauma and medical emergencies including prehospital emergency anaesthesia
- Emergency care of the unstable trauma patient including initial assessment, resuscitation and stabilisation, and transportation to and within the hospital
- Emergency medical management of the critically ill patient in all patient groups and age categories, in various settings and for all causes
This will be supported by theoretical and practical training in
- Relevant emergency procedures while equipping the candidate with the
- Non-technical skills to be able to put these practical skills to use in varioussituations, especially the prehospital settings but also various other environments and team compositions
The program curriculum and training objectives (see draft HERE) give an idea of the topics and procedures which experts in CrEM are expected to be proficient in, although the level of proficiency will vary according to the specific topic or procedure and the candidate’s individual focus. For example: all will be expected to have an expert grasp of anaesthesia for unstable trauma patients and resuscitation in various settings but not all are expected to be able to undertake transport of unstable neonates in incubators or patients connected to ECMO circuits, although they should be familiar with the problems and solutions related to those settings.
Criteria for application
Applicants must be full members of the SSAI. Upon entering the program, the candidates will already have completed specialist training in anaesthesiology and intensive care medicine and should have at least two years of experience as consultant anaesthesiologists. They should have training and experience in resuscitation of both adult and paediatric patients for both medical emergencies and trauma (a minimum requirement is ALS, EPALS, and ATLS / ETC, or comparable courses). Instructor level experience in at least one such course is desirable. They should ideally also have completed training in major incidents and mass casualty management (e.g MIMMS or comparable courses). Applicants should have familiarity with the pre-hospital emergency medical services (EMS) including relevant clinical knowledge, dispatch training and procedures, level of training and competencies of prehospital practitioners, techniques for rescue and extrication, transport logistics, and local EMS system structure and funding. They should also have some experience from prehospital care (this can include research, teaching and volunteer response or ride-alongs). An interest in and professional focus on the management of critically ill and injured patients during various emergency situations is a must.
Selection is based on the SSAI Guidelines for AEP steering committees. In accordance with this guideline there is a set number of places in the program reserved for each participating country in proportion to the countries’ populations. Sixteen (16) out of 24 places in the SSAI CrEM program will be reserved by nation (SWE 6, DEN 3, FIN 3, NOR 3, ICE 1) assuming sufficient eligible candidates. Unfilled places and the remaining eight additional places will be awarded to the most eligible remaining candidates regardless of nationality.
Places will be awarded based on the steering committee’s rating of the following criteria for the applicants:
- Work experience
- Documented work in critical emergency medicine (CrEM)
- Documented work experience in the prehospital environment specifically
- Documented research activity in CrEM or related fields
- Proposed research project (interest of and applicability to CrEM)
- Motivational letter and other sections of the application
- Documented funding and guaranteed position for clinical training
- Additional criteria
- Leadership experience
- Relevant academic or pedagogical experience
The criteria will be rated by the following scale: Substandard 0; Fair 1; Good 2; Excellent 3.
Note: Only merits described in the application will be scored.
In addition to these charted scores the steering committee will aim for equality regarding nationality and gender as the stated in the SSAI Guideline.
All SSAI members, including applicants, participants, and steering committee members are expected to maintain a high standard of personal conduct and to treat members and others with respect. See also the SSAI Ethical Code of Conduct. https://ssai.info/organization/ethics/
The programme consists of the following five components meshed with the overarching training objectives described above:
- Clinical practice. During the program, the participant must work in a setting where they are regularly tasked with providing emergency care to critically ill or injured patients. This can be at institutions such as university clinics or regional general hospitals in clinical settings such as emergency rooms or trauma bays, in anaesthetic teams with regular delivery of emergency and trauma anaesthesia, intensive care units with outreach systems and a high volume of emergency admissions, or in physician staffed prehospital systems (HEMS/EMS) or some combination thereof. Because of the prehospital focus in the program, candidates should spend at least 1 month before the program in a prehospital setting and should have a regular prehospital component to their work during the 2 years (either as part of their routine clinical work or intermittently as an observer/ride-along). It is important for the participant to have a written agreement with the host department outlining their participation in the program as well as additional clinical, tutorial, and quality improvement work relevant to the programme during the two years, including time to fulfil the required tasks and assignments. Mentorship for the clinical practice will be provided by one of the SSAI CrEM faculty but the candidates are also encouraged to find a local mentor to provide direct feedback throughout the study period as well.
- Directed self study and distance learning activities. During the program the candidates are expected to cover the theoretical and practical training outlined in the training objectives (see above). The training objectives form the basis for what they are expected to know at the end of the two year program, but candidates will enter the program with varying degrees of knowledge and experience within the field and will therefore have to choose how to focus their learning in order to achieve this goal. To facilitate the learning process participants will be split into working groups which will each get several assignments of relevant topics (relating to critical emergency medicine) to address during the course. They will provide their answers in the form of short lectures or discussions shared with the whole group, some during the residential courses but others as online lectures on a regular basis between the courses. Some assignments may be presented as infographics or short narrative reviews, interactive lessons, quizzes or peer review assignments. The lectures and papers will be based on best evidence as much as possible and on best practice where evidence is lacking. Through these lectures and gathering of evidence for various and wide ranging topics, the candidates should as a group end up with a list of articles, guidelines, book chapters, podcasts and lectures helping them to cover most or all of the topics in the curriculum and training objectives. By sharing their learnings with all of the program candidates (and potentially a wider audience), the entire group is exposed to all the various topics in question, reducing the effort spent by each individual to cover the training objectives.
To further develop the CrEM program candidates are urged to add to the list of topics in the training objectives if they find relevant subjects or literature.
Examples of questions / assignment topics include:
- Cricoid pressure (pro-con debate)
- Use of ketamine for emergency anaesthesia in head injured patients
- Pre-hospital and emergency management and transport of the patient with potential spinal injuries
- Airway management strategies in pre-hospital cardiac arrest: Intubation v SGA
- Vehicular extrication (what is the evidence?): How would you extricate a patient who is unconscious after a head on collision and trapped in a 4-door hatchback? How can you facilitate the process?
- Use of blood products in severely bleeding trauma patients. What to give first and what to give then?
- Resuscitative hysterotomy: Who is it really for?
- Management of the excited delirious patient. Is ketamine always the answer?
- The bleeding parturient. Two patients. One big problem.
- Managing the obstructed difficult airway in the small child. Is there still a place for the needle cric?
- Oxygen. Is it always too much of a good thing? (Are there any studies showing hyperoxia to be better than normoxia?)
- Residential courses. The residential courses, four of them in all (Norway, Finland, Sweden, Denmark) tie the self-study and scientific projects together, allowing the candidates to meet up, build a network and share knowledge and experience. Each course is 4 days in duration and focuses on different aspects related to emergency care of the critically ill and injured patient in various settings and patient populations. Topics covered include relevant (clinical) practical skills within advanced resuscitation practice and trauma anaesthesia but also important non-technical skills such as communication, leadership, and decision making, all of which are of critical importance when working in ad-hoc teams and low resource environments. We also address emergency response systems (including prehospital dispatch and EMS) and major incidents, including management and response. Teaching includes a mix of hands-on technical skill development, case-based problem solving, scenario simulations, mini-lectures, and group discussions.
- Exchange programme. The participant will organise an exchange period with a department, clinic, or EMS/HEMS service or any combination of these in a different country. The period may be arranged as an exchange, a visit, or a locum position with a foreign clinic or service. While exchanges between Nordic countries are acceptable the candidates are also encouraged to seek experience from less familiar systems in other parts of the world. The period should ideally be at least 1 month but may be split into smaller segments of at least 1 week duration each. The participant should have a clear goal of what to achieve in the exchange period as well as a plan for how the hosts can help facilitate this. The Exchange Period must be done after the enrolment into SSAI CrEM. The candidate is expected to deliver a report from their exchange, sharing their experience and highlighting the differences and similarities between their local systems and the system in the exchange country.
- Scientific project. Each participant is required to do a scientific project which will run through the two years of the programme. The projects can be individual or in groups of up to three participants. The project will be introduced at the first residential module and during each course up to a half day will be dedicated to the discussion of scientific topics, including a discussion of the participants’ projects. Participants without a PhD are required to submit and get their research project accepted as an abstract/poster at the next biannual SSAI Scientific meeting as a minimum OR submit the project as a scientific paper to a relevant Pubmed indexed journal. Participants with a PhD can choose to act as supervisors in a project of fellow course participants, but still have to present a project at the discretion of the course’s research director. For details see description and aims of scientific module.
Upon completion of the program the participants will be granted the SSAI Diploma in Critical Emergency Medicine (CrEM). Completion is dependent on the following conditions:
- Attendance of all four residential courses
- Completion of 4 weeks in an exchange programme
- Approval of all course assignments and quizzes
- Approval of the research project
- Completion of 2 years of the clinical practice program
The SSAI programme in Emergency Critical Care is intended to be a self-sustaining, not-for-profit programme. The cost of participation in the programme amounts to:
- €10.000 which covers the educational program and residential courses (including meals and accommodation).
- Travel expenses are not included
- Payment is divided into four instalments payable before the onset of each residential module.
- Expenses for the exchange program are not included
HOW TO APPLY
The following documents must be submitted
- a cover letter, describing your motivation for applying
- CV (with a publication list) focusing on activities relevant for the program
- plan for the clinical work during the two years in the program
- an outline of a proposed SSAI CrEM Research Project
- a signed application form (download here)
- the signed SSAI CREM contract (download here)
All documents should be put together in one single pdf file. The name of the file should clearly state the name of the applicant.
The application should be sent to firstname.lastname@example.org.
October 1st, 2022.
If you have any questions regarding the application, please contact programme director, Nanna Kruse, email@example.com