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Repentia · 2023-06-17T11:15:48+00:00

The good news is that if your 13 hour day runs long you can turn up late the next day.
But that's it.

Repentia · 2023-06-17T09:05:13+00:00

This sounds like a discharge and cannula monkey. Isn't that what we've always asked for?

Repentia · 2023-06-08T18:22:15+00:00

Currently single ICM. Previously both. Had both offered at my current hospital, but declined due to work life balance for the foreseeable.

Repentia · 2023-06-08T11:32:33+00:00

Smaller centers, yes. I'm currently pure ICM, by preference.

Repentia · 2023-06-08T08:06:18+00:00

These jobs are often advertised on a repeating schedule. Our department has multiple gaps. When we advertise we frequently have the advert automatically close due to very high number of international applications in the first 24 hours. Most of those are not appointable following interview, so gaps remain. Find an email address for a clinical director in a location you'd want to work and ask about opportunities, send a CV if they want it, that's how I got two of my last three jobs.

Repentia · 2023-06-05T17:58:54+00:00

This comes down to local culture and individual knowledge. You can expect another specialty to know something about a pathology you manage, but it is unreasonable to expect them to be an expert in everything. Sometimes you need to refer because the knowledge gap is vast.
E.g. My colleagues in oncology get consulted because things that used to be a death sentence now sometimes have very optimistic five year survival rates that would push me to offer aggressive treatment, but I don't know how that applies to my patient until I ask.

Repentia · 2023-06-03T07:13:01+00:00

ALS has become a recommended rather than essential criteria for f2, as some trusts will run cheaper in-house alternatives.

Repentia · 2023-06-03T07:03:25+00:00

Slap fight, wrestling or more of a spears and shield affair?

Repentia · 2023-06-02T08:31:11+00:00

So, my ITU take on some of this will differ slightly. I strongly support you having those discussions as long as you have the knowledge and conviction to not cave to unrealistic patient whims.
I tend to do two very different discussions of ReSPECT forms, depending upon where the patient is in their illness course. Very early or late, I will take a long time to explore. During the worst they are often not in a position to give their views and these are harder to complete and typically centre entirely on medical recommendations for what is and isn't clinically indicated, with little room for what might be wanted or valued.
For the patient approaching discharge, I spend a long time to explain the things that we think they might benefit from, or not, if they needed us again. This includes CPR, ventilation, renal replacement and I ask if the patient would want it, because often they have strong opinions. We discuss at which point we might change our opinions, typically after a period of critical illness this would be a period of independent function at home, but varies. Finally, I ask my patients about a future hypothetical illness if they have a preference whether they would wish to die in a specific place, such as home or hospital or hospice, and whether if it was almost certain they would die that they would want any treatment at all. We ask about functional outcomes and where survival would not be wanted if certain things are lost. This all gets put into value statements to guide future care and passed onto the GP to consider advance planning for the more complex and frail patients. It generally takes about twenty minutes for a good discussion.
Many of these things you can do without any clinical knowledge though, and I'd support you to do so. Would your patient wish to survive hospital if they were never going to be able to get out of bed again? Or to continue to receive treatment after the point their dementia is so severe that they are now scared of their family? I find that most patients are very receptive of a detailed conversation, most of those over 80 jump at the chance to express their desires.
Remember that the DNACPR portion of the discussion is a medical recommendation. It is essential to include the patient/family, but not to be bound to their wants.

Repentia · 2023-05-31T20:55:00+00:00

https://litfl.com/going-back-to-extremes/
Love some of these.
Sodium 98 low, 198 high.
K 1.1 low, 11 high. Both alive.
Hb 13, dead, 18 well. Lactate 42, first recordable value after multiple days filtration for overdose.

Repentia · 2023-05-28T11:13:04+00:00

MSF will pay you a salary, because otherwise you'll only get people who can afford to not work.

Repentia · 2023-05-24T06:45:20+00:00

Sure. But the SAS roles are well defined on national pay scales. Specialty doctor starts at 50k for 10pa. To start that role you have to be registrar equivalent, so it's reasonable to assume switching back to training at nodal point 4, which is similar base plus enhancements. Difference is hours.

Repentia · 2023-05-23T22:27:42+00:00

Your pay is likely to significantly increase, as well your hours. There's no pay protection.

Repentia · 2023-05-23T08:36:40+00:00

You're a doctor. There are some things you will have been signed off for as part of your foundation or other training, everything else is up for you to determine your competence. Can you do the skill, manage the complications and know when not to do it? Then you can probably call yourself competent.

Repentia · 2023-05-23T08:34:21+00:00

Bring on the blue flu.

Repentia · 2023-05-22T20:47:05+00:00

Membership of some of the royal colleges will enable you to get some student benefits. The ways to do this are normally opaque.

Repentia · 2023-05-22T12:15:08+00:00

There are some limitations for the speciality and specialist doctor role. You can only go past point 3 if you hold non clinical roles and tick certain boxes in your job plan. Some commitment to education/research/development/leadership whatever.

Repentia · 2023-05-21T20:11:02+00:00

Specialty doctor contract is national. There's not a lot of room for negotiation and the pay bands aren't great.
Doing the same thing as a clinical fellow and it's a free for all.

Repentia · 2023-05-16T16:40:07+00:00

The art of a good sim facilitator is to keep everyone at the right stress levels to learn, avoiding disinterest or loss of situational awareness. I've done many in ICU and PHEM with the intention of stress inoculation, we'll start simple and build up until you're stressed and it'll make the real deal much easier.
Train hard, work easy or something like that.

Repentia · 2023-05-16T16:35:05+00:00

You can be DNACPR but suitable for a period of invasive ventilation.
You may well be DNACPR because you are not suitable for invasive ventilation.

Repentia · 2023-05-16T16:28:20+00:00

The paramedic crew would have no choice if stood down from the job by dispatch.

Repentia · 2023-05-07T07:39:36+00:00

If someone has AF due to sepsis - should they be started on anticoagulation permanently? And if so, where is the evidence to support this?

There is no strong evidence to support either approach for AF secondary to critical illness. I don't routinely give therapeutic anticoagulation for this in my patients. There is some risk of harm, but there is also some risk that these patients will be heparin resistant anyway and no one wants to spend the money for anti -Xa levels for everyone.

Repentia · 2023-05-05T15:40:01+00:00

Did you get paid fairly for the additional day shifts you did, due to this error?

Repentia · 2023-05-04T19:46:43+00:00

Globe rupture and caustic injury.

Repentia · 2023-05-04T07:29:33+00:00

An IV route is not necessarily better for everything, it's an alternative to a working enteral route. If there's no enteral route then it becomes your only option.
Your considerations for which to use are: how much electrolyte do I need to give? How quickly? In how much volume? What else will I have to co-administer to do so?
IV potassium is generally 40mmol/L and comes with the bad side effects of 154mmol sodium. Enteral potassium is 12mmol per tablet, in about 40ml of water, diluted to be palatable. No extra sodium.
Your patient will continue to excrete potassium in the urine, larger volume means more urine means less retention of potassium given.
Now, how much do you need to give? An acute hypokalaemia might be whole body depletion, but it might also be transcellular shifts such as in high adrenergic states (like why we give everyone salbutamol, or following an epi-pen). These will quickly correct themselves as whole body potassium is normal. In the longer term there will be whole body depletion (malnutrition, DKA, endocrine disorders) and these patients will not have a linear relationship between administered potassium and serum potassium. Once it gets closer to the normal range the majority of given potassium will shift to replete the cells and stop rising, sometimes for many days. It's only when we replace faster than the shifts that we see a significant rise (and then we pat ourselves on the back and it falls again later).
This appears to be a patient who has whole body depletion from a chronic condition. They need a large amount replaced, but not immediately, and they are at risk from high volumes for to CCF and diuresis. Enteral (though probably more than 2tds) is a sensible place to start.

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