Alex Nevard
@AlexNevard
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Doctor in Emergency Medicine. if there is a choice between taking something I said as offensive or another way, I meant the other way!
United Kingdom
Joined July 2012
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Was told by an Occy Health nurse I may not be able to start med school due to my eyesight.
And by a opthalmology Dr that I'll probably be OK to do public health.
I think about this sometimes, like tonight, when I'll be the Consultant in charge of a Major Trauma Centre A&E
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Working this Sunday, made it to the canteen by 2pm : all that's left is chips and gravy
Working today, made it to the canteen by 5pm for tea : closed.
I know food is not the sum total of wellbeing but if your staff work 24/7 surely decent food 24/7 or even 12/7 is a must
#NHS
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Just seen the effect of early CPR and AED use.
Bloke sat up and talking in the resus room after a VF arrest
2 members of the public saved his life.
Amazing stuff
#8minutestosavealife
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Yesterday one of our locum SHOs who hasn't worked with me much asked if I was Alex or Dr Nevard.
Respect right? But this is EM and I explained how the hierarchy is different.
So he now refers to me as M'lord
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I wonder if my American EM cousins would find it odd that a UK EM doc could go their entire career and have never seen a patient with a gun shot wound.
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Still amazing that Victoria in Oz had minimum nurse to patient ratios in law.
Imagine a medical ward in the UK with 1:4 nursing ratio, so a 32 bed ward it's 8 nurses. 9 including the co-ordinator. Protected in law. That'd be brilliant
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Bit late to the party but just watched "This is going to hurt" on BBC.
Totally unrealistic nonsense.
What SHO gets a locker?
Other than that honest, haunting watching.
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Discussions with ID
"Malaria seems likely, but has the patient eaten antelope recently? Or consumed a bat while in a cave? Do they live within 759 yards of an abattoir?Have they ever had improper thoughts about a camel? Have you cultured their tears?"
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Getting rid of paper leaflets and replacing them with QR codes leading to online resources is another way we inadvertently encourage health inequality.
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Radiologists shouldn't decline scans. Happy for them to advise on better modalities but if they're not responsible for the patient they shouldn't get to make the call
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If building a hospital in the future labour ward should be on the ground floor.
Else you end up with a very tense transfer in the lift from ED. And possibly a child called Otis.
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Poor prognostic indicators for the shift you are about to have in the ED.
More police cars than ambulances in the parking bays
HEMs are in the coffee shop queue.
You've received a text asking for locums on the shift you're working.
Any others?
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New daily puzzle:
It's like Heardle but it's random bits of NHS equipment beeping and you have to diagnose the problem based on the sound
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The med student on placement today hasn't heard of Mr Brightside by the killers.
I don't feel old, I feel disappointed.
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Got a really sick patient in last night after an incident at a Nandos!
They were peri-peri arrest
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Hello, thankyou for attending the ED with your emergency, I've treated you and now your safe to go home!
To discuss its long term management you need to see a specialist.
No of course I can't arrange it! See your GP, try and describe what I've said and they'll refer you.
Bye
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Deep within NHS e-learning is a video on what to do in the event of a chemical attack.
Nuggets such as: strip the patient off and scrub them with kitchen roll.
Information I thought I'd never use.
Until today
When my triplets, unsupervised, discovered a full tub of sudocrem
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FRCEM CA ✅
FRCEM SAQ ✅
FRCEM OSCE ✅
And as of today
FRCEM QIP ✅
Which means as of today I'm Alex Nevard FRCEM. And to quote my wife
"Thank fuck for that"
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I am so, so excited to start my new job on Monday in the traditional NHS way.
With a 9.5hr online corporate induction
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Depressing maths: from next month 80% of my standard take home pay goes on childcare so I can come to work to do my job.
Childcare is ludicrously expensive, even for higher earners.
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We are inadvertantly going to teach an entire co-hort of foundation doctors that doing a D-Dimer on a febrike elderly patient is a good idea.
And I look forward to the glorious future this will bring
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So yesterday I X-ray'd my third tensioning pneumothorax. Of the 5 tensions I have seen I have X-ray'd 3 of them.
I think it's a myth that you can't X-ray a tension.
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Alex's understanding of hyponaetreamia.
If it is wet, dry it.
If it is dry, wet it.
Do everything slowly
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Nhs Jobs: Please list all you previous jobs?
Me: Like all of them? Every rotation for the last 11 years?
Nhs Jobs: All Jobs, everything, ever....
Me: Everything? Even pot washing at 13?
NHS Jobs: EVERYTHING! With Dates, Photos, References, DNA, Blood, Sweat! EVERYTHING!
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Just in case mainstream media missed it, there is a 72-hour strike of the "junior" medical workforce today.
It appears the weather is getting better coverage.
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Most EDs I've worked in have gotten rid of 12 hours shifts for Drs.
Why do we still make our nursing staff work 13hr days?
Seems hypocritical - Drs can get tired but nurses must struggle on?
#teamED
#nursingrotas
#EDsafety
#patientsafety
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When your 90yr old neighbour hears you missed your birthday with family due to lock down so sends her daughter round with Sunday roast and cake.
People can be so bleeding lovely.
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My sister in law is a lawyer, when she moved jobs she was given 3 months to settle in, get used to things before really starting.
Tonight up and down the country Drs will be let loose in a brand new speciality, with new systems and new procedures.
Mad isn't it?
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What they say: "You've passed
#ARCP
by the skin of your teeth"
What they mean: "Next year do more work and not just the bare minimum"
What I hear "You put in the exact amount of effort required for the desired outcome, why change?"
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A general reminder for anyone who may need to hear it.
Confidence is not correlated with competence
People who complete tasks faster than you do not necessarily do them better.
You are often judging yourself far harder than everyone else is.
You're probably doing great
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I'm not an expert in much, but I do have quite a lot of experience in treating exertional heat illness.
Below my experience learning distilled into a Twitter thread.
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Substantive job as a Consultant in Emergency Medicine secured*
@MyiED
couldn't be happier. Thankyou to all the amazing people who got me here! Can't wait for the next stage of the adventure.
*subject to references, you know who you are!
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@coralieandrea
@DrLindaDykes
@tiredmedstuden2
I am medically trained and I believe that to be a pomegranate
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Love med student twitter today:
Partly: Got deanery I wanted: London deanery North of Thames but south of the Co-op on Camden Road
Also: Got the deanery I wanted: All of Wales!
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Putting a patient on cardiac monitoring is an utterly pointless endevour if you lack the staff to monitor the cardiac monitor.
When I want to admit to a bed with cardiac monitoring what I think I really mean is I want to admit to a bed which is monitored
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OK, idea for getting out of medicine
#4754
Buy a farm, it will also have a farm shop/tea room.
Then staff it by offering OOPEs to other medics who've always dreamed of farming/cafe opening/Pro baking life.
DM for applications
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Emergency department Compartment syndrome - EDCS
Where there are no beds to go, no ambulances left to take people home and a complete lack of space to see people in but patients continue to book in.
Pressure rises
Pain ensues
Peak incidence in *winter
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How is silver trauma not the hardest bit of emergency medicine?
Fall from standing, hits chest, it hurts, nothing else does, CXR shows new effusion ?blood.
CT shows pleural effusion but BTW: Acute 3 column spinal #. Pt has no pain or neurology.
It's crazy, scan everything!
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The more major trauma I get to see, the more I distrust blood pressure as a marker of hypovolaemia
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First late on call shift as an EM consultant tonight.
Time to break out what I refer to as the NHS gif
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If the FRCEM OSCE ressembled reality:
You have 6 minutes to perform fundoscopy on the patient, please describe your findings.
No ophthalmoscope is provided and you must find a working machine in the department.
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If I had a pound for everytime someone diagnoses a UTI in an older person based on a cliche I'd be able to retire soon.
Not sure if more common is:
Pt smells of urine
Or
Last time they presented like this they were given antibiotics for a uti and got better.
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Tip for new CT2s in ACCS.
13 Is a perfectly good respiratory rate on a ventilator. I suggest trying it tomorrow and seeing who it triggers.
Sorry, I meant trying it tomorrow and seeing what happens
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Resuscitation: A broad term, relating to a number of procedures, interventions and treatments.
CPR a very defined treatment indicated in a very specific circumstance.
And that is why it is a DNACPR, not a DNAR, stop making conversations harder, use the right term.
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Embedding allied health professionals in ED (physio, OT, Social worker) to work alongside clinical team 24/7 has to be a solution to getting patients home safely from ED.
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Today, during a low risk chest pain history threw in
"How's your mental health"
And tbh got more useful information from that than any other question.
Anyone else do it? Might be one I add to the armoury
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That message was about as clear as mud. But to the idiot who came in to A&E high on MDMA last night after attending an illegal rave in a field I THINK you're still not allowed to do that.
Probably
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Anyone work in or know of a UK ED that routinely runs a toxicology screen for people concerned they've been spiked?
Spent a lot of last night managing expectations of what we do about it in A&E
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FRCEM OSCE passed .
Final post grad exam (Number 9) passed.
Time for some bubbles
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Nothing in this story will suprise anyone working in acute care.
In fact, I caught myself thinking, 6 hours for a bed, that's not bad. Which shows how far we've fallen and how distorted our views have become.
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I think we need to get better about talking and exploring about dementia.
Especially about how end stage dementia isn't just memory loss
And Especially Especially about how stopping eating is part of the progression of disease and not a need for acute admissions
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The best thing about night shifts that start at 11pm is you still get some of the afternoon and evening to do your own thing*
*Sleeps solidly till 10pm, runs out of house eating a jam sandwich, arrives just in time for handover
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After nearly 11 years of being an NHS trainee without a locker, I now get a desk with 3 (Three) drawers!
What the hell am I meant to store in them now my nomadic phase is over? I'd suggest a big box of tissues but I feel my office mates would make inapprorpiate jokes
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Hypothesis: One could post a picture of a normal ECG to
#MedTwitter
, and at least one person would ask for the patient to go to the cath lab
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It's really tough at work at the moment, it's all about the small wins. Like when the dermatology reg writes
"I agree with Dr Nevard's assessment of the rash"
Honestly 2023 may have peaked.
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If you were going to describe Emergency Medicine right now as a gif, which would you chose?
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Be a new registrar, work a lot of nights due to rota gaps.
Ask my educational supervisor how I'm doing.
"I don't know, but you'll hear if you make a mistake"
Felt so valued.
What experience in the workplace radicalized you?
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Apparently there is a stage in your life where it is no longer acceptable to wrap present using micropore tape.
I was unaware of this transitional time but my wife tells me I've reached it.
Also how expensive is sellotape? FFS
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Ballot posted, vote cast.
I mean, I didn't post it, but like all good consultants, I delegated.
#FixConsultantPay
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@jamie_wallis
@Parody_RCGP
Dear Dr Wallis,
We recently received your tweet "annoy a GP in one tweet."" Unfortunately, we are unable to accept this tweet as it isn't submitted on the correct proforma. Please re submit using the correct form, and we will be able to consider your tweet and its request.
Bw
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Starting an EM merchandise line.
T-shirts with 'A normal Hb doesn't mean there is no bleeding'
Anyone keen?
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Some people bemoan f2 rotation.
“They don’t know anything”. Bemoan some staff.
I enjoy it: loads of opportunities to teach new skills and ingrain good habits, like last night
“Who closes head wounds?* asked the f2.
“You do” I replied and with a bit of support he did.
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I'm not sure a long-term solution to
'Poor quality referrals'
Is to make a more senior person make the referral.
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So there was talk on the news this morning about Harrogate convention centre getting turned into a hospital.
Can you imagine the Betty's sponsered tea trolley?
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I consider myself an optimistic person.
But if the first 24mg of lorazepsm doesn't sedate the patient, 4mg more is unlikely to solve the problem.
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What I find really interesting with self rostering is what people will volunteer for.
I you rostered ppl 2 weekends back to back, days on one weekend nights on the other with lates inbetween there would be uproar.
Let them chose it and it's fine.
Treating ppl like adults?Never
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Based on a lengthy post off of another SoMe platform.
We probably need to do more to explain to people how good ACPs are, how hard they work for the title and the role and how they're an embedded part of the workforce.
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Thought Christmas had come early when I got given 4 new (like brand new) sets of scrubs, complete with trust logo and embroided job title
I am now a 'special registrar'
I'm sure no one will take the pics...
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Machete wounds.
Used to think of machetes as "big knives" recent experience has told me it is better to think of them as a "sharp hammer"
Impressive sofr tissue injuries coupled with fractured bones, especially skulls.
Threshold for imaging has dropped considerably
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Didn't barristers negotiate their pay deal by just holding a strike without an end date?
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So putting in an arterial line without putting blood everywhere isn't a skill I've maintained.
"Shall we add haemorrhagic shock to the differential"
Cheers boss
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I have woken up from nights delirious but with a game changing idea.
Why don't we have Pip/Taz infused CT contrast.
Imagine the time saving, no more choosing between ABXs or going to CT. No more figuring our if the high lactate is sepsis or aorta.
I await my OBE
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Does anyone else narrate their poor DIY/Household decisions in their head in the form of a trauma call?
33yr old male, electricution and fall from 6ft
Balancing chair on bed to change light bulb when wife walked in and said "What are you doing in the dark?"
Injuries are....
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Why have we decided that the MSRA exam paper is a good way to decide who'll be a good EM Doctor or radiologist or neurosurgeon?
The questions sound so broad that no one is left happy. Is it just another arbitrary selection device?
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@arcl
@JonnyGucks
"Can you tell me which medical school you went to, so I can write to them and tell them they obviously failed in any kind of training and have failed the medical profession by allowing you to graduate"
Exact wording may vary.
Jokes on her though, we both went To Leeds
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You've got 40 minutes to cover all of frailty in EM. What learning points do you go for?
I've tried
Trauma: fall from standing is significant. Pain is different. 'Simple' rib injuries kill
Escalation of care discussion in every pt
Delirium = PINCH ME+ 4AT and not UTI + CTH
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Using toilets in the NHS, does this pull cord turn the light on or sound the crash buzzer?
Anyone else go in the dark for fear of getting it wrong?
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Rule of procedures:
Assembling kit will always take 3x longer than doing the procedure.
If it doesn't you've forgotten a bit of kit.
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Emergency medicine is just statistics with stethoscopes
Knowing how a test works, who to apply it to and what the result means underpins our entire practise.
But it's never taught like that
I wonder why
Can someone set up a likelehood ratio website for common test
#EUSEM19
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Wife is doing IMT interviews upstairs today.
Am I allowed to burst in halfway through one and ask her to do an urgent discharge summary?
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The one bonus of working Christmas is that I can't be asked to come in to cover sickness over Christmas.
Check mate Omicron
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When your medic wife is on a virtual study day next door and the lecturer says "I don't want to A&E bash but..."
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We shouldn't call it Geriatric Emergency Medicine, (GEM)
We should call it Frailty Emergency Medicine. FEM).
Partly because it's more correct, Partly to mess with people who did PHEM.
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I know EM is stupid busy at the moment but I really love my job.
In the last 2 days I've got to poke people with big needles in the chest, give people ketamine and electrocute them. Along with loads of other cool stuff
I don't know where else I'd get to do that and I love it.
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The way this reads is that a frail delirious patient was intubated. And then some stuff happened
ICU Stories:
70 yo patient, nursing home resident, w hx of dementia / atrial flutter (on anticoag) / hypothyroidism / gout / decub ulcers (among others) is brought to the ED for "altered mental status" and right gaze deviation. Afebrile, normotensive, hr 80s, sat 96% on room air
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Dear Doctor: We have an urgent O&G SHO gap and wondered if you may be available to cover?
I can think of no one, literally no one who would benefit from me covering that job...
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If you asked NHS staff at 3am what the most nutritious thing they could find or buy to eat is what do you reckon the response would be?
£6.50 for a coffee and a sandwich in my hospital.
Enough to sustain a doctor for a 12 hour shift?
@NHSEngland
@NHSScotland
@scotgov
@GOVUK
why are you continuing to extort doctors?
Meals for NHS staff should be free, or heavily subsidised. They should be healthy, and 24/7
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So today
@MyiED
turned to a
#selfrostering
system for all it's ST4+s supported by
@healthrota
That's 30 registrars accross 3 emergency departments all now choosing how they work.
So far all is well and good, though I feel I have aged making it happen...
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Anyone who needs an ultrasound guided cannula should get a midline.
Thoughts?
US easy to get hold of in ED. Hard to get hold of on wards etc
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There's loads more but in summary:
Suspect EHI in collapsed athletes
Do not trust peripheral temperatures
Active cooling
Don't use dantrolene
Consider having an active cooling plan in hospital
Don't be suprised by how unwell these patients can look
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@oli_m_sims
See the tweet that would get me cancelled is we should up skill paramedics to do all PHEM stuff and keep Doctors out of their lane entirely.
NB not quite that clear cut but general point stands
*Repost as unskill vs upskill is a big typo
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This question has been answered again and again. On Twitter, on reddit, in exit interviews, in GMC & HEE surveys. Reposts and Repeats ad nauseum.
The better question is, why haven't we done anything about it?
The NHS is a huge employer, but so many people feel badly treated. Why?
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My firm belief that the next generation of antibiotics won't come from a research lab or a rare plant found deep in the Amazon.
Instead i believe they'll come from one of the many abandoned, MRSA inoculated, coffee cultured, keep kups dotted around an A&E near you.
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I think the "A-E approach" is a good starting approach to an unwell patient.
But I don't think it teaches how to come up with a diagnosis or treat beyond nital observations.
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Went for an ultrasound today. The assistant brought me into an empty, clean cubicle and set up so the consultant could walk in and just do the scan.
Super efficient.
Imagine if we had that in EM.
Imagine
A whole cubicle!
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