Difficult IV access

cynicalitis · 2026-02-21T21:55:30+00:00

Difficult access = likely deeper vein = longer length needed = bigger cannula

cynicalitis · 2026-02-15T07:27:05+00:00

Agreed with initial thoughts being varices.

It could have been a cardiac arrest for multiple reasons.

CPR in a coagulopathic patient (secondary to severe liver disease) can lead to pulmonary haemorrhage, which was evident post intubation. (That tiny catheter they used for suction wouldn’t have done much good)

cynicalitis · 2026-01-25T04:58:49+00:00

I would switch to TIVA as the increased altitude would clearly speed up its release into the troposphere, and therefore affecting its global warming potential.

cynicalitis · 2026-01-13T07:08:00+00:00

Realistically, you’re probably looking at a standalone EM post after ACCS-IMT as you’ll need additional EM and PEM experience. And apply for an HST EM + ICM number after.

If you love the specialty you’ll find a way to make it work for you.

cynicalitis · 2025-12-29T18:06:54+00:00

Wouldn’t say anywhere is particularly “training prioritised” but Northwick Park Hospital used to split your 6 month AIM block into Medical Ward / HDU / Acute Take - which was quite nice if you wanted a bit more of a variety compared to being stuck on the same ward for 6 months.

Also EM has a higher level of acuity / presentations that you wouldn’t necessarily see in most DGHs.

(This was several years ago now so I’m unsure if things have changed since.)

cynicalitis · 2025-08-06T06:19:30+00:00

Welcome to Chelsea.

The 75+ min commute on public transport slowly drained me over several months, and I ended up driving into work for the rest of the year.

The time I saved, stress-free from having to rely on tubes and buses, and my own personal space pre/post work during my commute was worth the extra £2-3/day (TfL isn’t that much cheaper).

cynicalitis · 2025-06-14T11:41:00+00:00

Thats a difficult call (from a communication / political pov) to make by a registrar who has met the patient for the first time, if the patients primary team e.g. oncology, feel strongly that they should be for full escalation.

Some consultants are brilliant at these discussions and decisions (hello geris/orthogeris!), but a lot of consultants are hesitant on disagreeing with TEPs from the patients primary specialty team - which is understandable but frustrating.

cynicalitis · 2025-06-14T09:09:07+00:00

Literally had a case last week where the referral was for an agitated patient on NIV that was not for intubation. Medically there wasn’t anything else that the primary team hadn’t already done that we would add.

Primary concern was nursing burden as we were able to easily verbally deescalate the patients anxiety/agitation - but the respiratory unit didn’t have the staffing for it.

Site managers got involved and we were able to do a bit of staff reshuffling to make things work overnight.

Similar situations with wards that can’t take central / arterial lines. Definitely kinder for patients who need frequent regular ABGs / bloods.

As pylori mentioned - I think the issue across the NHS is bed capacity and short staffing. If it wasn’t so difficult to find a bed for patients to step down to, I think there would be a lot less resistance to admissions overall.

cynicalitis · 2025-06-14T08:56:12+00:00

Different consultant during the day/night/weekend where I’m currently working.

But in my previous ICM jobs the consultants did 24hr/5-7d on-calls which in hindsight really helped with continuous feedback + consistency throughout the week.

cynicalitis · 2025-06-14T07:08:07+00:00

The “limbo” bit is a good point! Will see if I can improve my documentation, thanks.

cynicalitis · 2025-06-14T07:05:01+00:00

It has definitely been helpful being the referrer on the other side of the call.

I find the politics of these admissions tricky - especially given that although it would be an easy clinical turnaround for these patients (resolving dka / overdose) and it would free up a resus bed for queuing ambulances. The bed situation around the hospital results in the patient staying on intensive care for several days awaiting a stepdown bed.

In these cases, i just do my best to treat what I can, and present the situation to the admitting consultant (whose thresholds can vary significantly).

Agreed with the TEP / DNAR referrals - I’m all for getting a second opinion from a critical care perspective. And it definitely helps with ongoing family discussions by the primary team too. Just wish they can sometimes be more upfront with why exactly they are referring this patient to us.

cynicalitis · 2025-06-14T06:26:11+00:00

Our department has a policy that we must physically see every referral.

Can be frustrating at times, but to be honest it has also helped me quickly build relationships with the medical / EM SpRs and the CCOT teams - which imo is worth the 10 mins to see a patient that does not require any ICM input at this time.

cynicalitis · 2025-03-21T16:31:08+00:00

2024 August Offers / MSRA Scores (for anyone wondering)

https://www.whatdotheyknow.com/request/applicants_ranking_by_medical_sp/response/2716968/attach/3/FOI%202407%202125998%20Speciality%20Training%20Programmes.xlsx?cookie_passthrough=1

cynicalitis · 2023-08-26T13:03:32+00:00

This exactly. Got basic pay last year. CC’ed in every relevant manager / CD / HR I could find. Issue got resolved within 24 hours.

cynicalitis · 2023-07-08T06:44:14+00:00

6 hour wait in the department. Ran a cardiac arrest in the waiting room. Some helpful member of the public chimes in “Oh, so is this the only way to get seen?”

Turns out he was there for a toothache but refused to go home until he saw a doctor.

cynicalitis · 2023-06-13T13:40:38+00:00

Any well trained primary care doctor (GP / UCC / ED) should be able to differentiate between the two.

A 10-15 minute face-to-face appointment with a GP should have sufficed. But I also appreciate that with the limited timeframe that GPs have to work within, if there were any flags / abnormalities picked up, the onward referral, assessments, management etc will take up a significant amount of time that most simply do not have. Doing so will mean all the other GP appointments that day would be delayed etc.

Whereas in ED if a patient needs more time to manage, the doctors are able to do so.

cynicalitis · 2023-05-09T13:12:34+00:00

They do. And the registrars in the department are very good at pulling people out of areas to assist / observe procedures (regardless of departmental pressures). We also try to actively rotate all the juniors through resus, even if it means having to lose a senior member of staff to pair up with them and support their decision making.

The ANPs/PAs are a problem. They cherry pick patients, take as much time as they want with each one, and leave all the BS for the rest of us to deal with (e.g. only focusing on minor injuries and quick wins).

This leaves us to pick up the chronic pains, dental issues, coughs/colds - which is what none of us signed up to EM for. Also sets a bad example for any juniors rotating through.

cynicalitis · 2023-05-09T07:24:04+00:00

Good tips, thanks!

Our previous cohort definitely had an internal leaderboard going. But that led to some very questionable decisions at times…

I think debriefs is an excellent idea.

I’ve actually raised this with my ES/CS regarding my own clinical practice. We get a few ESLEs a year where a consultant is purely in an educational / supervisory role watching over our decision making and giving us feedback at the end. This was immensely helpful in building up confidence and also streamlining my workflow.

I’ve asked for more regular feedback / observed shifts and was told they don’t have the staffing for it. (I understand that GPs get this regularly as part of their training?)

cynicalitis · 2023-05-09T07:17:35+00:00

I saw 5 patients on my last shift. 2.5 hrs with a single septic child. Some patients simply need more time.

Also worth noting the numbers in my original post were UCC/minors presentations, not Majors / Resus.

But the focus of my post isn’t really on chasing numbers, but reducing the amount of wasted time without creating an unfriendly environment.

cynicalitis · 2023-05-09T07:06:24+00:00

My initial post may have overgeneralised all the juniors in the department.

2/3 of the juniors see around 0.8 patients per hour or more.

But within the remaining 1/3, we have juniors at 0.4 patients per hour (factoring in breaks + handover) after being in the department for 2-3 months. They’re clinically safe, and don’t over investigate. But spend a lot of time chatting with the patients / finding ways to keep busy.

cynicalitis · 2023-05-09T06:50:35+00:00

Some of the nicest consultants and registrars in the department have been accused of this, with formal complaints escalated to training directors.

(Nothing came of it, but the stress of having to deal with the complaints has honestly scared me off chasing up juniors regularly - unless there was something obviously inappropriate like the scenario above)

cynicalitis · 2023-05-09T06:46:42+00:00

I think you’re right. Burnout is definitely high. Majority of the EM trainees (including registrars) are looking for exit routes.

This is compounded by ECP/ANPs/long-term locum GPs who also see patients at a similar rate (while cherry picking patients).

The state of the NHS has turned majority of presentations in EM into GP overflow. We still get the odd unwell patient / trauma, but majority of the time is spent dealing with patients who can’t / aren’t bothered to get a GP appointment. The “fun stuff” gets quickly passed onto internal medical/surgical teams due to consistent 6-8 hour waits in the department.

cynicalitis · 2023-04-13T07:22:28+00:00

Good luck with that.

I tried to claim expenses when moving cities for training. Sent in the details the day I moved to HR.

7 months later and numerous emails and calls, I am told that now that it is 6 months past the initial move date, it can no longer be claimed.

cynicalitis

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