Julian Donovan
@julian_donovan
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Emergency Medicine doctor. Newsletter below:
Joined November 2015
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I've found the utter audacity to do a newsletter about stuff I learn each week.
I've done a whole 5 of them so far, the next is tomorrow.
Because the world needs another newsletter bro.
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The move toward ‘reg level’ non-medical ED staff leaves a bad taste because of the double standard with trainees.
As a new ED reg, I’ve sat 2 membership exams (a 3rd in 2 months), had to rotate through acute medicine, critical care, and anaesthetics.
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@FitFounder
Or trying to make a catchy tweet out of complexity proves lack of understanding.
I'll bear in mind your thoughts when I see my next emergency department patient.
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ST3 EM this year. But first, last year in ICM/anaesthetics was one of the best learning experiences I have had.
Some reflections on the heroes I worked with in these specialities that I will take forward:
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Does anyone in UK EM perform LP on those admitting for ?meningitis.
Seems this should be our thing to do
NICE: Perform the lumbar puncture before starting antibiotics, unless it is not safe to do so or it will cause a clinically significant delay to starting antibiotics.
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✅ ACCS Emergency Medicine - standing on the shoulders of giants. Owe this to loads of people, especially my wife ♥️
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If this is required for me to be a reg, how is it possible to get there in bypassing that? How can you be a reg if you can’t prescribe? If you can’t do safe sedation and airway management? Can’t request imaging?
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Why does UK emergency medicine have a culture of handing over intubations to anaesthetics/ITU?
With ACCS training, this seems ludicrous to me now.
Acute medics, respiratory docs who dual accredit ITU intubate.
It seems a core EM skill, and we are a global outlier here.
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@FitFounder
You're wrong.
This sentiment only applies to lifestyle related aspects of pathology, which admittedly are many.
But there's a lot more that can go wrong with your health.
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I have worked with brilliant non-medic colleagues, learn from them, and enjoy working with many of them.
But it’s the push, within the system, for equivalency with medical registrars/consultants that doesn’t make sense to me right now.
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I had to attain IAC in anaesthetics, I have a mandated number of pediatric cases to attain, complete yearly quality improvement work, evidence teaching, fulfill ultrasound competencies, yearly MDT feedback, etc etc.
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In a way, it doesn’t matter who does what. Competence is what actually matters, regardless of background. It’s not doctors vs non-doctors for me.
I just don’t think equivalency can be met unless we re-define what a reg is, otherwise it feels a double standard.
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Especially when abx can sterilise CSF in 2-4 hours for certain bacterial pathogens, leading to further diagnostic uncertainty for IP teams.
I feel we should be doing these at the front door.
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I’m conflicted about striking.
Agree we need more pay, but so does everyone.
Is it reasonable to demand full restoration when every other industry (bar professional and scientific) are lagging behind inflation?
Everything is relative, we don’t operate in a sandbox.
(1)
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Thank the lord I’ll never have to sit any FRCA exams, but for what its worth, I’ve made a fresh commitment to learning physiology with the aim of grounding myself better, starting with a series son respiratory physiology:
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@teamwghicu
bloody hell it's quite stressful seeing it on the other side even if only a video - gave me more appreciation of how distressing this must be for a lot of patients
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Anaesthetics continues to cannibalise itself.
The ST4 bottleneck has always perplexed me. All the anaesthetic trainees I worked with were impressive and dedicated. It’s just insane to not reward and utilise this kind of workforce by throttling posts.
Anaesthetists, missed out on a highly competitive ST4 post? Worry not because you can work as a clinical fellow where you earn less than a STUDENT anaesthesia associate
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2. First principles mindset.
Although enforced by FRCA, the commitment to physiology and ground-up approach to clinical practice was impressive. Rather than just learning patterns, practice was reinforced by layers of physiology, pharmacology, basic sciences…
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@blondemedSJW
Sometimes 2am in a busy ED with competing pressures and no ability to counsel further isn't the best time to do it though.
Saying there is a mass, possibilities include cancer etc is fair enough. Give a warning shot. But needs specialty team input asap.
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@bruceppdl
Bruce, it’s more a term of endearment than an earnest label. Like ‘bunch of legends’. But thanks for your invaluable input.
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How many ED's cardiovert for 'new' AF?
Haven't seen a single one (that's not got adverse features). Often just rate control or off to SDEC when alright.
Be interested to know how many routinely cardiovert of a good history of <48 h onset.
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Without a doubt, strength training = biggest return on investment across so many domains.
It mobilises your body's internal pharmacy to exquisite and unique titration for health and physical development.
Day 1
@Strength4_Life
workshop bringing home the message that everyone should be strength training... 💪🏼💪🏼
#strengthsaveslives
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@doc_matt_jacko
do agree it's not about putting tube in neck specifically, but I'd say that being able to do so, and remaining skilled at it is a more urgent skill than finishing a full clerking.
It's an acute resuscitation skill whereas a full clerking isn't.
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..which meant that, when the grey areas of medicine were inevitably encountered, you could move beyond guidelines and apply hard-earned experience and first-principles knowledge to a case.
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@lesgedge
I guess the counter-argument is that medics are also extremely busy. I think if it nails a meningococcus or viral or rule-out then it's worth doing. I'd argue getting diagnostic clarity in a suspected meningitis is worth the effort. CSF gets more ambiguous very quickly after abx
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1. Genuine curiosity.
An attitude to ask ‘why’ and explore different possibilities in order to refine the mental models they practice with. Great for discussing cases and iterating improvements as a team, eg M&M. Real commitment to the craft and to improving.
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3. Fix first approach.
Similar to EM, ICM/anaesthetics are masters at fixing problems in real-time as they unfold. The skill to commandeer acutely deranged physiology with knowledge, technical skill, and various equipment is awesome to see.
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4. Prepare for disaster.
I saw a lot of forethought go into multiple cases that required a plan A, B, C and D. This commitment to forward planning frees up mental bandwidth in the moment, keeps everyone on the same map, and provides contingencies if disaster strikes.
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5. Zoom in / zoom out thinking.
A knack for zooming into extreme levels of detail, eg in complex ITU patients, across multiple layers of a patient journey, balanced against the ability to see the big picture and move fast when required.
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I don’t buy the narrative of ‘poor us the government exploited us during the pandemic’.
We had job security. Pretty much everyone suffered.
Need to avoid the victim mentality when lots of sectors are in a similar boat. Some aren’t able to strike.
(2)
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”You will get sued for missing a diagnosis this week, you won’t for giving someone cancer in 20 years time”.
Only just found this book, but the framing of risk and decision-making
@EMManchester
puts forward is phenomenally useful. Great read so far.
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@MsBethanJ
yes really agree. very reluctant to strike. Sick of the "f
@ck
you pay me" militant activists out there. It seems necessary in face of gov response but really hope an agreement is reached before then.
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If you're diabetic, resistance training and adding lean muscle mass is one of the best things you can possible do.
Increase the reservoir for glucose utilisation, optimise long term blood glucose control.
Get hench - that's a doctor's prescription to you.
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@GaslingSarah
@MStott88
Precisely - different market forces at play here. The free market economy is where Lawyers work, whereas doctors (especially at F1) are at the mercy of centralised workforce planning and have only one employer option that is out of their control.
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@mark_tehan
True, guidelines and reality often don't align. But at least NICE etc are ostensibly based on the best we can get from the evidence, so if able to do then would be good.
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would like to know experiences of any other EM doctors from outside UK in these situations - how do you manage a busy department and also a high resource patient (eg intubated) - just higher levels staffing? in tandem with ITU? dedicated resus doc?
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@LarcombePeter
why so binary? like others have said, may be in Collab with ITU present. may be solely ED managed and packaged for ITU. may be ED undertake initial management and handover in dept. don't see why it all or nothing, surely depends on circumstances.
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@clare_eliza
@DrLuke1994
@mattbaker126
I'm honestly not trying to stir the pot here, but genuine question what's the level where a counter view is *not* 'mansplaining' and just expressing an alternate view?
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@blondemedSJW
Can have no peritonitis in perforated viscous.
Can have normal WCC in appendicitis.
Lactate often normal in ischaemic bowel.
Investigations/signs only add to a good pretest probability, they don't guarantee a diagnosis. Seen this a lot in EM.
Great catch on your case!
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Started new ST1 role yesterday.
Nurse yesterday kindly offered to let me try to take bloods as the "new medical student".
Definitely due to my youthful exuberance rather than anything else 😬
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@YavorRM
Understand the need to manage ITU beds carefully and not inappropriately escalate care in certain cases. But EM make lots of decisions on escalation, and shouldn't preclude.
Just seems odd that EM in US/Aus/Canada have embedded much more critical care incl airways.
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I know it's been out for a while, but I'm a big fan of how bold the RCEM agitated behavioural guidelines are, giving really practical, clear recommendations on drugs.
Really nice 1st, 2nd, 3rd etc line options too.
Worth a read through.
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@peaceanddoug
Can confirm that's nuts.
Every service I've worked with sends home with cannula in situ because nursing staff administering abx at home also check state of cannula etc.
Daily cannulation is worse for infection risk not to mention wrecking veins.
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Finally finished the FUSIC Heart - thanks to the countless hours generously given from the echocardiographers who put up with me. What I naively thought would take a few months became >1 year of poking around with a (ultrasound) probe in the dark.
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@armyemdoc
@mattherridge9
@JoelSymonds999
You keep them breathing and safe until the opioids have worn off. You don't tear them out of an OD that often has other substances on board. Observation, titration, and time are much safer than a sledgehammer of naloxone.
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@adk300
yes high risk for all those who intubate. Evidence doesn't show worse outcomes for non anaesthetist intubations
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@MJTB1987
that's lovely - I think this is the most realistic and ideal by having trust and good collaboration between us and ICU/anaesthetics, which I've seen variably frayed between different hospitals.
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@drbosheaGP
@IMT_latest
@RCGP_RoI
@aausgp_ireland
@CormacLucey
@irishmednews
@RealEddieHobbs
Phenomenal lack of awareness for what actually happens in an ED these days.
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@nickopotamus
cool, yes very much agree. I don't mind it as an opening gambit of "badness" ("NEWS score of 13") but needs specific clarification after.
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This is brilliant.
Although barbell training is the most titratable, systemic form of strength training, we can apply those principles to most movement patterns.
Don't put off people by insisting on gyms.
Use our imagination to bring them the benefits in any way possible.
'If a pt needs assistance for STS, that is above their 1RM.' I've never thought about it like that. Strength training is not scary and needs to be better utilised in all healthcare settings. Physios are well placed to do this. Thanks
@Strength4_Life
@CPNG_ISCP
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@jasonhoran
Do cubicle'd patients get hip blocks? Prob about the same amount of space needed as an LP? Especially with US machine
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@pulmtoilet
Can someone teach me on this - struggling to understand how they differ.
Is it that EF is more a relative measure and SV is more absolute in its measurement?
How do you differentiate the two? How is that applied clinically?
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@nickopotamus
I'd find it quite hard to triage referrals when I was the ITU SHO on call if I didn't get a run down of the obs.
Or I'm guessing you mean just giving a single news score as handover, in which case, totally agree.
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Put together a bit of an approach to acute abdominal pain in the ED. Uploaded it here since my teaching was cancelled due to COVID🤷🏼♂️
Tried to cover some things that may not have been covered at med school...
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@YavorRM
GDP on healthcare between UK/Aus/Canada is comparable, so unclear if it's a resource issue.
Issues I see:
- Yes, staffing. Some UK EDs do manage their own RSIs however. Viscous circle of reducing critical care skills possibly leading to poor retention of ED docs.
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This guy has the killer combination of profound competency and extreme likeability.
Amazing achievement Kris - to any med students needing revison materials, I can vouch for this.
I’ve written a book! 📚
Since medical school I have been putting together a textbook about the “Core” stuff for finals and I’m pleased to say it’s finally been published!
Thanks to
@CRCPress
and reviewers have given their advice on the content.
Available now!
#MedTwitter
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(5) But the erosion on Dr pay has clearly been significant over the last 10+ years. And if the roughly £1billion/yr to achieve FPR also helps NHS broadly, then fantastic.
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Had a challenging NIV case recently. Felt a bit of a knowledge gap raise its head toward me. Wrote about it. Learnt some stuff. Always keen to be corrected/informed/updated by others here.
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(3)But hard to quantify how much, lots of other factors…
- Workload
- Hours
- Rota
- Facilities
- Breaks
- Supervision
- Support
- Bullying
- Learning/development opportunities
- Flexibility
- Etc
….all play a part and need input.
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I‘m very open minded though, but these are my current thoughts that I‘m trying to work through.
Keen to hear from others.
(3)
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I think the NHS needs rescuing and huge input, seeing the madness happening in acute and secondary care with no capacity right now.
I understand making doctors feel valued so they can stay is part of that.
The NHS globally needs serious investment.
(4)
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@danny_mercer
Past two cannula calls I had:
1. When I finally got there after finding USS and all equipment, patient discharged for SDEC f/u.
2. When I got there, cannula in place by IV access team. Called me "just in case" when I asked.
Both times not told of changes until I arrived.
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Terrifying.
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@nelson_kamali
Many resus nurses I've worked with are happy with much of this. absolutely agree it's a major factor though and would need all (incl ED clinicians) at the requisite skill level
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(6) Currently, I feel more strongly about the entire NHS needing investment of more staff, resources, beds etc than I do about my own pay restoration.
But I’m aware that FPR will likely retain more Drs. Wholly in support of nursing colleagues striking.
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(2)But also have to acknowledge optics/impact of Dr strike in the context of widespread multi-sector strikes.
Reassuringly high level of public support seems present though.
Doctors clearly ↑ burned out. GMC Trainee Survey is bleak reading. I’m sure FPR part of this.
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(8) But also appreciate that pay erosion can’t continue the way it has without significant consequences (Dr’s leaving, strikes,etc).
Looking down the road, also minded that course correction needs to happen before precipitous pay erosion has even worse consequences more widely.
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Boo hoo - pouring outside. HSPU becoming more consistent, line slowly getting better.
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@OfficerCasualty
Yes, can imagine the raised eyebrows I'd get from consultants if I suggested doing this in any ED I've worked in
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@Jploughrey
@EMTAcommittee
I know people who didn't get in that set the standard for me and that I try to emulate. that speaks volumes to me that the process is inherently flawed. It can never be perfect, and challenging context for assessing, but the calibre who didn't get a place is jarring.
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@02offers
Huge issue this. Needed to source syringes from theatres for a hip block the other day. The friction when kit isn't available is massive. Pre-made packs/trolleys save so much time
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@jordanbpeterson
Jordan, I'm an emergency medicine doc and feel strongly that people should have autonomy over their bodies. The part that is harder to square is how viral transmission can have second order effects on others in a more obvious way than other behaviours. how do you square this?
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@RobertHermanMD
@PendellM
@smithECGBlog
@BrooksWalsh
@The_Nanashi_O
@DidlakeDW
@DocNikko
@FloydECGs
@ecgrhythms
@EM_RESUS
@PMcardioBot
Is there any STE in the inferior leads? Or are we looking at purely HATW in V3-V4 and STD in aVL? These are terrifyingly subtle findings in a demographic that would easily be fobbed off.
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@armyemdoc
@CCWearmouth
@JoelSymonds999
Do you have the concept of 'capacity' and 'best interests decisions' where you work?
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>1 yr progress on handstand pushup. Wager another month or two until strict full ROM. Enjoying the process but want it now.
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Prediction: 2021 is (2020 Ctl + V --> Ctl + C).
I think we need to buckle in.
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Anyone considering medical school, check out this awesome free resource to help with your decision and application 📝
Another way which can help *many many more* medical school applicants from disadvantaged backgrounds is !
Completely free website / online platform with the best resources, events & guidance for aspiring doctors.
Please share with those who could benefit.
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(1)Thanks for all the responses.
Rather than oppose strike action (or ‘gaslight’ myself), I’m trying to steelman it, precisely because it’s a big move.
Well made point by others that it’s not a zero sum game.
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@A_V_Simpson
That’s phenomenal, this is why I find prognostication such a murky area. He looks awesome
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@armyemdoc
@JoelSymonds999
1. You get equally good feedback in smaller doses.
2. Trying to stop someone without capacity absconding from the resus room DOES tie up many staff.
3. I've very rarely had someone cognisant enough to engage in a conversation like this shortly after OD. Often mixed drugs onboard
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@ICUdocX
@ICS_updates
@FICMNews
@BACCNUK
@stevemathieu75
the number of times they saved my ass with a diplomatic "did you mean to prescribe 50 grams of gentamicin for bed 7 with an eGFR of 3?'.
Invaluable.
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(3/n)
I need insulin to live. We *need* modern medicine.
These allow me to survive.
But strength training, attention to diet/sleep/stress - these allow me to thrive.
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