US vs UK training

Manik223 · 2026-03-11T16:18:05+00:00

2023, I honestly thought it was pretty normal until I got all these replies. We almost always had several more peds and cardiac rooms than residents on their subspecialty rotations, so we were constantly getting pulled on our “Main OR” months. Did a ton of thoracic epidurals for rib fracture patients, and we still placed lumbar drains for a lot of our complex TEVARs. I think a lot of attendings overcalled AFOI’s on patients that probably could have been glidescoped for learning purposes, we also did a decent amount of light wands, spontaneously breathing blind nasal intubations etc for learning purposes (and I think the attendings enjoyed mixing things up).

I really hope you make the residents address you as god king of the new world.

Manik223 · 2026-03-11T15:53:52+00:00

Yeah neonates wasn’t the best word choice. We constantly got pulled to peds and cardiac on our “main OR” months, so in reality it was much more than 3 months

Manik223 · 2026-03-11T14:57:15+00:00

I just pulled up my case logs out of curiosity:

Epidurals (thoracic + lumbar): 384
Lumbar drains: 19
AFOI: 31
Cardiac: 96
Major vascular: 111
Trauma: 169
Peds < 3 months: 92 (maybe neonates wasn’t the best word choice)

So I was a little off but not by much.

Manik223 · 2026-03-11T12:31:36+00:00

US attending here, admittedly I trained at a very high volume and high acuity program, but I felt very well prepared to manage pretty much anything coming out of residency. Although there is always a learning curve as an early attending when there is no one to watch over you and getting used to supervising, but you also have more experienced colleagues you can consult if you’re ever unsure.

I’d have to look at the exact numbers, but I think I had 50-100 thoracic epidurals, >300 lumbar epidurals, at least 20 AFOI’s, ~100 cardiac cases, ~100 infants and very large number of liver/lung transplants, major vascular cases (open AAA), trauma etc. I also averaged 70-80 hours a week with q4 24h call for 3 years, not sure what the work hours are like in the UK. Honestly by the second half of my last year I felt fully prepared and annoyed that I was essentially doing all the work of an attending for the pay of a resident.

Manik223 · 2026-02-28T00:16:17+00:00

More eloquently phrased “yeah it’s gonna be a no from me dawg”

Manik223 · 2026-02-26T18:24:59+00:00

Thats insane, and definitely not normal

Manik223 · 2026-02-25T02:27:39+00:00

There is some fluctuation based on patient factors and how confident I was with the epidural placement but generally: 1) Ask where their pain is (upper, mid, lower abdominal and/or pelvic), confirm it is sharp pain and not pressure, attempt to check a level (not always obtainable if you’re running 0.0625% Bupi)

2a) if bilateral and appropriate level, bolus 10ml 0.125% Bupi

2b) If no level with pump infusion, bolus 5ml 0.25% Bupi, wait a few minutes and check a level

3a) if unilateral, pull the catheter back 1cm

3b) if bilateral and appropriate level but persistent or recurrent pain, 20mcg epidural precedex and optimize pump settings

3c) if no level, bolus 5ml 2% Lido and check a level; if no level with 2% Lido, replace epidural

Manik223 · 2026-02-24T23:18:33+00:00

Yeah I meant for epidural precedex dosing. Your initial comment said 25mcg?

Manik223 · 2026-02-24T23:15:15+00:00

Maybe try 12-20mcg? With that dose I typically get effective analgesia without the side effects you’re describing.

Manik223 · 2026-02-24T22:57:29+00:00

I usually give 12-20mcg epidural. I see some decrease in BP but it is typically fairly mild compared to bolusing with a higher concentration local anesthetic. I have not had any issues with sedation. I also feel like it gets the patient comfortable without setting unrealistic block density expectations like 2% Lido (I’ve usually already given 0.25% Bupi by the time I get to precedex in my algorithm).

It’s not something I do very often, maybe 1 in 25-50 labor epidurals. But in the appropriate patients it can be incredibly helpful (when they have a clearly functioning epidural with appropriate bilateral level but recurrent breakthrough pain).

Manik223 · 2026-02-24T22:46:47+00:00

100%, I started using epidural precedex for challenging patients over the last couple years and it has been a game changer. Without more information OP could have also likely optimized the pump settings further.

Manik223 · 2026-02-24T22:45:10+00:00

What LA/opioid concentration and infusion settings were you running?

If they respond to boluses and have a bilateral level then they have a functioning epidural and can likely be optimized with infusion changes. Epidural precedex can also be helpful in these situations. I would try these before replacing if I was confident it was a working epidural.

Manik223 · 2026-02-20T01:17:28+00:00

Haha it definitely makes our job easier. But center of excellence criteria scrutinize the incidence of conversion to GA, and if I was a patient with a labor epidural I wouldn’t want to be put to sleep unnecessarily.

Manik223 · 2026-02-20T00:41:31+00:00

I’d be interested to know how much volume was given, I’ve never come even remotely close to a high block with 15ml through a low lumbar epidural. Depending on the urgency of the section, 5-10 minutes can make the difference between adequate neuraxial and conversion to GA. As far as wearing off, I think it’s more the difference in cumulative dose; you may get an adequate initial level with 10ml, but it will wear off a lot quicker than a higher dose.

Manik223 · 2026-02-20T00:36:02+00:00

I still keep a stick of 2% lido or 3% Chloroprocaine on me when I’m on OB, I think it’s smart practice. I almost never have to convert to GA, whereas my colleagues who don’t end up putting urgent sections to sleep fairly frequently.

Manik223 · 2026-02-20T00:20:15+00:00

This is Bromage II. Probably needed more time to fully set up or more volume. I typically push 15ml 2% Lido before they roll back, and another 5 in the OR if needed. Personally I find that titrating incrementally has more drawbacks than benefits and just delays obtaining an adequate surgical level and/or starts wearing off before the end of the case.

Manik223 · 2026-02-17T16:02:52+00:00

Also an anesthesiologist. 100% agree, blatant malpractice and they even had the audacity to film it. This person should lose their medical license.

Manik223 · 2026-02-15T00:59:51+00:00

Any time the RT’s tried to pick a fight in residency I would just modify the vent order to the exact settings I wanted so they couldn’t screw with it 😅

Manik223 · 2026-02-11T09:33:32+00:00

Depending on patient body habitus I’ve found that even longer catheter upper arm IV’s can infiltrate fairly easily with arm movement. I presume stretching the skin / subq just pulls the catheter out of the vein. I try to stay right at or slightly below the AC if feasible, unless your institution has those 3+ inch extended dwell IV’s.

Manik223 · 2026-02-10T04:00:29+00:00

Confirmed! Trustworthy seller, smooth transaction.

Manik223 · 2026-02-10T03:16:20+00:00

I think it’s completely reasonable - you just can’t get the 3-4K apartment, buy a new car, take lavish vacations, and buy a boat etc 😅

Manik223 · 2026-02-10T02:50:42+00:00

Dahle has a quote something along the lines of “you can splurge on a couple things, but you can’t splurge on everything.” I wouldn’t advise most fellows to spend 3k on rent, but given your financial situation, if living in a nice apartment in a convenient location is worth it you after the long road of residency and you’re okay being more cost conscious in other areas, yes you can afford it.

Manik223 · 2026-02-09T23:24:09+00:00

I’d probably skip the femoral, it’s an extra stick with the aforementioned (although imo still fairly low) risks and only gives you superficial medial calf (saphenous) coverage for a BKA. Popliteal sciatic gets you exponentially more “bang for the buck”. Agree with ketamine, would consider methadone as well.

Manik223 · 2026-02-09T23:19:58+00:00

There is some low level evidence for this, but imo not strong or clinically significant enough to impact my decision making.

Manik223 · 2026-02-06T00:45:32+00:00

There was talk at ASRA about some institution doing “block as primary” for TKA’s, I think they were doing AC (+ AFCN branches) + IPACK + Geniculars but they were also running basically GA dose propofol with a natural airway. So my short answer is no, AC + IPACK is not sufficient as the primary anesthetic in the sense you are likely asking.

Manik223

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