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In my third F1 job I had a reg who had never worked in the NHS. I taught her how to do ABG's and cannula's during my first job in Acute Med. When I came round to do Geri's she had rotated there.

On our first ward round she left a patient with a GCS of 8 and a Glucose of even less, telling me to handover to the on call team. She didn't understand why people having high doses of potassium infusions needed cardiac monitoring and was just dangerous. I kept telling people but no-one listened until she called a reg for advice and he watched me manage a life threatening situation whilst she just stood there. Both of my SHO's were new to the UK so it was often left to me to talk to other specialties/patients. The nurses would communicate their concerns about patients through me because they felt it was pointless to talk to anyone else!

That was a very stressful job. I was lucky I'd done ITU beforehand which meant I had a robust system for assessing sick patients, and a team I could run to for support when I felt out of my depth, but I was out of my depth every day.

Yeah, I've had many experiences similar to yours. Probably the most memorable was being called at 3am in the night because a patient being treated for a UTI had dropped their systolic to the mid 50s. I did what I could, started the sepsis protocol and gave multiple fluid boluses to see if she would respond. 3 stat boluses later and her BP was still in the mid 50s and she was deteriorating in front of me. I called the med reg for support and flagged this patient as an ITU candidate (lactate of 8, for full escalation). His response was 'give more fluid and nebuliser'.

I did as he instructed, bar the nebs, and after 1.5l of crystalloid over 30 minutes her systolic was hovering just over 50. His response? 'more fluid and manual bp, machine could be broken you know'.

At this point I called the ITU reg, who took one look at the patient and accepted her. She was on inotropic support for days.

What concerns me is that by that point I'd been an F1 for almost a year, so I knew what needed to be done. But would the F1 following me fresh out of med school recognise that this med reg was chatting *******s?

Reply 4461

nexttime

Original post by Friar Chris

There's one who's a 'Specialty Doctor' or Associate Specialist like grade at my current hospital. She's scarily clueless but is full of her own importance, which makes it twice as bad because she pretends to know what she's doing and slaps down anyone who disagrees by throwing her rank around.On Thursday (after deciding to do a ward round of patients I'd already rounded - she doesn't work on my ward but my consultant is her supervisor so she wanted to make it look like she does something...) she had to ask me the following set of questions so that she could treat a patient. I'm using varying degrees of emoticon to represent my sheer disbelief instead of typing out my answers.

1. How do I treat C difficile enteritis?

:indiff:

2. I don't like metronidazole. So should we use some IV Vancomy-

:facepalm:

3. Oh, so PO Vancomycin?

:rolleyes:

4. Will that treat his UTI as well?

:nothing:

5. What do you mean he doesn't have C diff?

:getmecoat:

She also wanted totally unnecessary repeat bloods on people who'd had bloods the day before and had no acute derangements, MMSEs on three patients who were clearly delirious and for whom they would have no diagnostic value for the supposed dementia, and a CT Head of one of them to 'confirm' her diagnosis.

Oh, and demanded, against my protests including reporting what the patient's consultant wanted, a catheter for the poor fellow with dementia who infarcted a kidney two weeks ago but is totally well now with a stable renal function at CKD III and is passing urine very well into pots for the nurses to measure, who has already pulled out the catheter he had on admission a week ago with mild urethral trauma as a result.

Oh and then she was surprised that Flucloxacillin doesn't work for MRSA :nothing:

I'll be honest, that reads as pretty normal to me :p:

We have a LOT of clinical fellow/staff grade type positions and whilst some of them are very good... most of them really are not. Awful to work with, awful to patients.

I'm sure even the worst reg wouldn't try to delegate to a new houseman in their first few months. I hope.

Ha, sadly not. My gf had her first ward cover on call evening as a brand new FY1 without any seniors at all (mind the rota gap) and the take med reg, who was supposed to be covering, refused to leave the take. So she was managing multiple acutely unwell patients alone. The hospital also had a (highly highly dubious, in my view) rule that if a patient had a DNACPR outreach would not see them, so no support there either.

The worst I've seen (disclaimer: obviously not committing to where or when I've seen this nor what events occurred afterwards):

7 year old with vaginal tears not having swabs taken (despite being under GA in theatre for repair of said tears) because the consultant "thought it was probably an accident". He then sterilised his field with chlorhexidine, meaning no one else could take swabs for a few days either.

Young lady having a 2.5 litre PPH (confirmed by weighing of swabs and blood in the buckets) with substantial ongoing bleeding not having an MOH call or any blood products because the Hb was normal on blood gas and her blood pressure was still ok. She went on to lose another litre before it stopped, but didn't get any transfusions until the next morning. This is in a centre where they had very recently had a maternal death due to MOH.

A Pakistani lady sat on the ward with a cough and persistently febrile despite antibiotics for 2 weeks before anyone tested for TB. Which it was.

There's a European reg who's only ever done cardiology after med school. She's very good for cardiology, but knows absolutely nothing about anything else. As med reg she delegates everything to the SHO (who could be an FY2) and admits everyone she sees. By her own admission, she's just desperately clinging on until she can do pure cardiology again.

A reg who regularly wrote entire detailed examination findings in the notes having not entered the patient's room. This was a guy who got paid locum registrar rates for 9 hours/day despite regularly clocking out at 10am.

Other, more amusing examples: being asked to refer to ortho ?compartment syndrome for a pain-free patient, being asked to refer a man to medics because he "looked sweaty", and being told that if i'm busy the last thing i should leave out is the AMTS and instead I should just not examine the patient because "we don't get paid for doing that" (said with a straight face).

(edited 7 years ago)

Reply 4462

seaholme

Original post by Etomidate

I seemed to be stuck with her on the acute take overnight on more than once occasion.

I recall at about 4am when nobody could get a hold of her for hours, she re-appears in the doctors office. When asked why she's not responding to her bleeps, she claims to have not been bleeped. So we try it then and there and it transpires that she had taken the battery out to have a nap and forgot to put it back in.

Wow. Did you guys do anything about it? Not saying much either way whether you did or didn't, just that I imagine it's harder when it is a senior who is slack than it is if it's a junior who is slack. I know an F1 who did a more or less similar disappearing trick on a busy on-call and the iron fist of the trust (also known as the gentle educational hand of your 'supervisors' :P) came down hard when one of the core trainees escalated it.

Reply 4463

seaholme

Original post by Sarky

In my third F1 job I had a reg who had never worked in the NHS. I taught her how to do ABG's and cannula's during my first job in Acute Med. When I came round to do Geri's she had rotated there.

I had a weird night shift where I was summoned to translate for the Registrar from a thick eastern european accent into my southern english into the thick Welsh accent of my patient and back again. It was literally like this:

[video="youtube;yfSnaY1Wp_U"]https://www.youtube.com/watch?v=yfSnaY1Wp_U[/video]

Reply 4464

Etomidate

Original post by seaholme

All of the acute clinical leads were aware of her performance. I chipped in to provide further information. She wasn't hired again as far as I'm aware.

Reply 4465

Anonymous #2

Dear god. I have no horror issues like this...

Whenever I have needed a senior they have been able to at least tell me something sensible over the phone!

Even on ortho there was always an RMO if things had gone mega tits up.

Had a few people come up in a real heap from AMU which I have had to datix because it had been that bad but nothing quite as made as this.

Oh, other than the person someone put a poop tube for their raging diarrhoea without taking a sample for 5 days until will saw them and thought MAYBE the huge amount *in the bag MIGHT be c.diff related.

Ditto the new onset diarrhoea with CRP rise that was given loperamide...*

Reply 4466

Friar Chris

Original post by zippyRN

Chris - re your problem doc is she a Speciality Doctor ( Middle grade) or Ass Spec ( senior) ?

the bar for speciality Doctor is actually pretty low as in theory you could take one of those posts following Core Training / ST2 ( this may vary in somespecialities e.g. Anaesthetists have a 'minimum standard to be an on call middle grade' and i suspect in decoupled specialities if the decoupling is at ST2a / ST 3 you'd need to have that level of skill

She's a specialty doctor (i.e. completed CT2 and somehow passed MRCP) but for reasons largely due to her ego her ID badge says 'Associate Specialist', which is clearly ridiculous :nothing:

Reply 4467

Spencer Wells

Original post by Friar Chris

She's a specialty doctor (i.e. completed CT2 and somehow passed MRCP) but for reasons largely due to her ego her ID badge says 'Associate Specialist', which is clearly ridiculous :nothing:

I'm pretty sure that to call yourself an associate specialist you have to have a CCT

Reply 4468

Hippysnake

Original post by Spencer Wells

I'm pretty sure that to call yourself an associate specialist you have to have a CCT

If that's the case then what's the difference between an ass. specialist (huehuehue) and a consultant?

Reply 4469

overclocked

Hey guys*

Have you got any advice for cannulas? *Start f1 on Wednesday and I still seem to not be very good at them*

Reply 4470

jooby92

Anyone know what the deal is regarding going back to work after nights, on the rota someone has night shifts ending on a wednesday at 9am has the rest of wed off but on thursday is back in starting on the wards at 9am. is this allowed as it seems not very fair, on my rota i have 2 days off after my night shifts which is a bit more reasonable to get back into day routine? is there like a minimum time u should be off before having to go back to work or are u allowed to be back in on the next day?

Reply 4471

nexttime

Original post by jooby92

Its a bit of a dick move by whoever makes the rota but unfortunately not uncommon.

Reply 4472

Princess Bubbles

Original post by overclocked

Hey guys*

Have you got any advice for cannulas? *Start f1 on Wednesday and I still seem to not be very good at them*

Practice makes perfect. Try not to avoid doing them. Don't be disheartened if you don't get it first time. Try and make the patient and you comfortable. Make sure you find a good vein before attempting cannulation. Go at a very shallow angle, once you get first flash back advance a few mm before withdrawing the needle to get second flash back, then place the whole cannula into the vein. Try and put in a pink but if you can't a blue is ok. If you can't get it in, ask your SHO. If that fails, ask another FY1 etc.

Reply 4473

Sarky

Original post by Hippysnake

I guess it depends what they had done before. I'd been in the job 4 months when this person was my registrar, and I knew from the off that it was wrong. I had done Acute Med/ITU which made a big difference, but other than that I had no experience as a doctor.

I haven't had an experience like that since I'd hasten to add!*

Reply 4474

Letournel

Original post by overclocked

Hey guys*

Have you got any advice for cannulas? *Start f1 on Wednesday and I still seem to not be very good at them*

Also just a new F1 but have had some good advice from anaesthetists on placements/SSCs.

Make sure the lighting is good - patients often will have these dimmed/it may be late in the evening, just switch theirs on while you're trying.

Ensure you're comfortable - Move things around to get a comfortable spot if possible, there is nothing worse than trying to put a cannula in whilst you're back is aching.

Position the patient carefully - If possible un-rotate limbs and use gravity as your friend by asking the patient to position their arm over the side of the bed.

Don't be afraid to go searching - I think often people feel the pressure to find a vein in the first spot they try, i've found that through looking at both arms before making my mind up my hit rate has gone up.

Reply 4475

Hippysnake

Original post by overclocked

Hey guys*

Have you got any advice for cannulas? *Start f1 on Wednesday and I still seem to not be very good at them*

The best advice is to just do them. Believe me, I was **** scared of doing them in my first week. I was scared of doing bloods, cultures, everything. I tried to avoid them as much as possible.

Now it's like...meh...

And don't forget, it doesn't matter if you can't do it as long as you escalate it once you've tried. There have been several cases where I've had to escalate to the oncall anaesthetist after my whole team has tried and failed to insert a blue cannula into a difficult patient, and they come along and somehow manage to get a green into a vein you were certain wasn't there before. ******s.

Reply 4476

Etomidate

Original post by overclocked

Hey guys*

Have you got any advice for cannulas? *Start f1 on Wednesday and I still seem to not be very good at them*

The main reason people go wrong is failure to have a good look and getting yourself comfortable.

Take your time choosing a vein. Look at the back of both hands and houseman's. Tie a good torniquet, let the limb hang down for a while and get the patient to pump their hand. Then when you've spotted something straight and bouncy, give it a good tap to bring it up a bit more.

Before you go in, make sure the skin is taught and the vein is anchored. Go through the skin quickly and make your angle acute as not to go deeper than the vein.

When you get flashback, go flush with the skin and advance a tiny bit more so that the needle AND the cannula is in the vein. Then hold the needle steady and slide the cannula over the top to advance it.

I would encourage you to routinely use greens, then when a difficult cannula comes along you can smash a pink in no worries.

Anything larger than a green I would use a bit of LA assuming it's not a peri-arrest situation.

In a patient with oedema, apply pressure to push the fluid away for 30 seconds then put one in quickly.

(edited 7 years ago)

Reply 4477

Hygeia

Another trick for difficult veins - run them under warm water or stick their hands in the nitrile gloves for a little bit as that helps bring them up as well

Personally I would use LA for greens as well as anything bigger than that (having had them inserted and comparing to pinks being inserted I did notice a massive difference in the discomfort!)

(edited 7 years ago)

Reply 4478

drc123

Original post by jooby92

I have this - it's pretty rubbish. Especially when you've got a whole working week plonked onto the end of the nights.

Reply 4479

Friar Chris

Original post by Hygeia

Personally I would use LA for greens as well as anything bigger than that (having had them inserted and comparing to pinks being inserted I did notice a massive difference in the discomfort!)