Qs Flashcards
Why anaesthetics
NGO work - DTMH
ICU fellow -> look forward to work and completed fusic heart, minimal anaesthetics time
-Interestingcases
Hut ICU with anaesthetics - really get on with them and ICU
-> 1 on 1 learning
-> Varied specialties and interesting cases
-> MDT
-> Leadership
-> physiology + pharmacology
Love understanding how and why things work
Hard worker -> 6 papers with 2 more on go + MRCP
Have personal qualities that fit
Get on well with anaesthetists
What makes good anaesthietst
Practical skills + humility -> Calm emergencies -> leader -> teamwork -> communication -> teacher
Keep calm in emergencies – have both formal and informal feedback to this- comes with more experience worrying less about missing things .
o Gone from being very anxious when paeds cases come in -> now have intubated and booked a PALS course
-Team work – both as leader or as part of the team, taking stress off leader with EG airway management while arrest goes on.
o Group effort to keep theatres smooth – helping each other with work load, tricky spinals, getting breaks. Second anaesthetist present for intubations
-> Leader
->
Communication skills – recently commended for how well speak with patients families after performing supervised ward rounds
o Difference with UK / maori – big extended families with health illiteracy who want to know more about you as a person. Longer talks and updates
. Teacher – love the 1 on 1 teaching and career advice
- Leadership – now attend ICU reviews / trauma calls and lead arrests
Practical skills +humility
Really noticed the difference this job, not missed a CVC / arterial line in 6 months
o Working on intubations – log of 30
o Big improvements in BVM
Mask seal eg beards, facial fracture
Obesity
Age >55
No teeth
Snoring / OSA, Stiff neck
- Able to take advice from specialties, but also be confident in own clinical decisions
ANZCA 7
Struggles with anaesthetics
- Exams are hard – luckily I love learning facts, especially how and why things work
-MRCP /DTMH / Papers - Frustrated with inefficiency of acute list eg surgeons present
- Waste of valuble healthcare resource and realised system issue - eg they have WR. - Managed to use time for myself - audit / revision but doesnt solve main issue
What is integrety? example when you’ve shown it?
Having consistent character, maintaining morals throughout life and true to values
Poorly lead paeds arrest in ED
– often away or performing tasks Eg failed IO and Echo when known no output and others available. Speaking to their boss but not sharing with room. Info from regional peads unit to stop but had to continue while we found the ED consultant
. The emotional toll of witnessing a poorly executed resuscitation attempt made it challenging to articulate my thoughts and concerns effectively.
-DIdnt want to upset reg either
-, I recognize the importance of overcoming such reservations and contributing to the debrief process, as it serves as a crucial platform for shared learning and improvement.
provide support and facilitate constructive feedback to the ED department. This experience underscored the significance of advocating for change through established channels, fostering collaboration between different departments for the betterment of patient
What makes a good leader? Leadership examples
- Self aware and demonstrate emotional intelligence, reliable and honest.
- Ecellent communicators and decision makers.
- Team workers
-Knowing team members by name and knowing them – smaller team
Go spear fishing with a bunch of nurses / HCAs
-Being courteous and supportive
Also recognise when people are struggling and being supportive
Importance of debrief – happens after every situation in ICU
-Ask for advice and help when needed
Always listen to members of team, otherwise they wont trust you
- Never be critical or micromanage
o Delegate effieicntly Match roles to skill sets – key is knowing who is on your team but also give people good Learning when is a good time for people to eg be first airway assistant
Climbing – Part of being a leader is helping people feel comfortable and safe in unfamiliar environments. They have to really trust you – with their life!
Teaching examples
Involved in teaching SHOs central / arterial lines, sometimes can be hard to not want to just take over – also have to recognise when this is appropriate
Chlamydia - schools north east England
Beau soleil - Private billionaires
Bolus - 9 months - able to demonstrate improvement
-In person presentation at AMEE - international
Personal weaknessess
Have to know, get frustrated at myself when cant make the diagnosis and know theres something missing.
- Goal orientated, struggle when I don’t manage what I expect of myself – when climbing
- Mood can suffer with injuries
Why scotland
- Worked there for 3 years, Only place id want to live. Closest friends live Glasgow and Edinburgh
- Have now lived in Peru completing diploma of tropical medicine and NZ working as ICU / currently cardio reg and sure Scotland is the best country on earth. People music, culture, outdoors.
What have you learned about worklife balance
- Learnt in ED about prioritising workload as a unending stream of potiential jobs
o Have to decide when to take a break - Improtance in ICU really looking after the team – often Consultant + charge nurse all coffee together after ward round to discuss plans
- Involved in many things outside medicine – love learning new things ( currently banjo)
o Climbing key goals and - Use Annual leve throughout rotation not in 1 block
Anaesthetics training pathway
Stage 1: Core Training (CT) 1, 2 & 3 ( or CT4 in ACCS)
- complete the Primary FRCA (includes MCQs, viva & OSCE).
- Initial competence in Airway and obstetric anaesthesia
- 6 months ICU
- ARCPs each year
Stage 2: Specialty Training (ST) 4 & 5 – Can dual or single train
- pass the Final FRCA (MCQs, short answer questions & viva)
- Evidence of completing all 14 domains
Stage 3: Specialty Training (ST) 6 & 7
- Focus on specialty interests Eg ICU / Pre hospital medicine / specialist anaesthesia
- Pain / regional / obstetrics / ICU
Approaching stress and burnout
- Acknowledge: Important issue in anaesthesia which affects wellbeing and performance of collegues which ultimately affects patient care
- Identification of warning signs: Got better at spotting early signs eg decreased enthusiasm, fatigue or behavioural changes
- Open communication: Fostering environment where people feel safe to exrpress concerns though informal chats, team meetings or more formal discussions with supervisors.
- Active listening: find time to understand colleague experiences and better understand unique stressors to help me offer more targeted support. Eg HO with issues on discharges / job prioritisation
- Access to resources: Counselling services and wellness- I had no idea what was on offer
o Ive seen clinical team here after 2nd unsuccessful paeds arrest. - Team approach: making sure people who need to be aware are
- Work life balance: Really important for me
Personally I usually find time toi climb + music + friends cooking, good time to talk
Out of depth
Langlands
Made sure to communicate thoughts with limited team
Reverted back to basic principles
Reg finally arrived and was quite overwhelmed – handed over and took a step back
Able to decompress and chat – organised to meet my supervisor and wrote a long reflection
Finished with completing a debrief
Disagreement with seniors
Briefly seen patient in resus - Recent status + aspiration intubated paramedics. Called about a patient in ICU then returned to find ED reg planning a chest drain.
o Acute desat 79% on 100% FIO2 no AE L side in ED with new mediastinal shift to left – ED consultant had told reg to place a chest drain but I didn’t.
o PACE –
Probe – discussed situation with them
Ask – about their choice of management – felt the reg couldn’t give clear indication for drain
Challenge – didn’t fit clinically with a pneumothorax or rapid effusion
Emergency – called my consultant who was in building who came down with bronchoscope
o Felt really nerve racking to disagree with a senior in a time pressured acute situation even though I was sure it was to do with plugging off or the ETT being in right main bronchus.
Ever been involved in a complaint
Duty of candor
Situation - asked for a glass of water. While going was asked to see a sick patient and completely forgot.
- Remembered an hour later and came to apologise with water. But theyd asked someone else already.
- The daughter was ‘promptly share all relevant information about patients…with others involved in their care, within and across teams’ (paragraph 65a)
‘[share] information with patients about the progress of their care, who is responsible for which aspect of their care, and the name of the lead clinician or team with overall responsibility for their care’ (paragraph 65b).
There is also more detail on what to do when finishing a shift or transferring a patient’s care:
‘you must be confident that information necessary for ongoing care has been shared’ (paragraph 65c)
‘you must check, where practical, that a named clinician or team has taken over responsibility when your role in a patient’s care has ended’ (paragraph 65c and 65d).
Duties around delegation have been clarified. The person delegating a task must:
‘give [any person you delegate to] clear instructions and encourage them to ask questions and seek support or supervision if they need it’ (paragraph 66).
The person being delegated to must:
‘prioritise patient safety and seek help, even if…[they’ve] already agreed to carry out the task independently’ if they’re not confident they can carry out the task safely (paragraph 67). irritated with me and I felt I’d lost some of their trust. Although this wasn’t a pressing clinical issue, it is easy to forget how scary and unpleasant time in ICU is for both patients and families. It was a simple issue for them which they couldn’t address easily by themselves – and shouldn’t have to
- I empathised and validated their concerns
- Explained wellbeing was an utmost concern of mine
- Made sure to keep integrity and admit mistake upfront, a lapse on my part
- Reflect, felt really bad about it but feel I was forgiven overall
- If similar situations occur and waylayed with more pressing tasks could have easily asked another member of the team to get the water while I went to review a patient.
When performing critical procedures eg Airway -> wont have the time luxury eg if scope out of battery
Difficult communication
Professional Dilema SPIES
- Seeking more info - how has this occurred, why are they unwell
o Had been unwell day before parents raised concerns– mostly ignored
o Sugars had been high and not actioned - Patients – how are they, are they safe, offer apology / complaints procedure
o Really unwell
o Offered apologies and advised re complaints should they need to - Initiative – How can it be fixed – who else needs to be updated Team/ consultat
o resuscitated - Escalation – consultant, management and clinical governance
o Informed both ICU and medical consultants
o Filled datix -> investigation resulted in extra education of sugar management on ward
o Also patient found out to be T1DM - Support – Patient and family, Staff – may all need counciling and instruction to prevent occurring
acknowledging mistakes, fostering open communication, and actively participating in the collective learning process are integral to delivering high-quality healthcare.
Why ACCS
Enjoy trauma and keen to do 6 months more in ED -> ended up carrying trauma page then asked to do revision of article
Difference between audit and QI
Audit – compare current practice against recognised standard
QI – Reviewing current practice and finding ways to improve
- Often come from issue you personally find
- Have previously made mistake of just starting audit on blood culture availability
- – didn’t have standard and so turned into QI which then ended up winning best in NHS Lanarkshire
o Plan Do Check Act cycle
o Managed to complete 2 full cycle with changes. No one had responsibility
o 1. Add to medial nursing handover -> limited benefit. 2. Discussed with porters / micro staff
Example of QI
o Plan Do Check Act cycle
o Managed to complete 2 full cycle with changes. No one had responsibility
o 1. Add to medial nursing handover -> limited benefit. 2. Discussed with porters / micro staff
Example of audit youve done
– SR opiod prescriptions
o Those on SR prior -> any changes with FU planned
o Those started during admission
Reason for opiates Eg cancer pain
Plan for follow up with Pain service / GP
- Have fed back to local working group and pain team
- Plan to present at anaesthetics meeting
National anaesthetic audits
- Usually studying rare but potentially serious complications related to anaesthesia
- NAP 3 – spinals referenced globally
- Have collaborators for each audit not just RcoA
[o Difficult airway society for Major complications of airway management
o British society for allergy and immunology for allergic reactions
o Resusitation council for peri operative arrest
o Association of anaesthetists for accidental awareness ]
- NAP 7 Most recent – perioperative arrests
o Better outcomes than other hospital arrests – especially bradycardic
o More common in old frail patients
o Lack of DNACPR
o Possibly too muvh PROP/ remi TIVA in old frail patients
o Interesting point – anaesthetists confident managing arrests but not in aftermath and eg discussion with NOK
o Lack of support for anaesthetists following arrests even if paeds / obstetric
Different to my experience in NZ
Consultant crying - counciling service
Scenario about communication
Family water forget
HO struggling with discharges and workload
Missed DKA
Problem solving example
Mediatinal shift in ED
Exampoles of team work
Arrests - using team well
Busy on calls - using HO and Charge nurse + consultant
Structure of healthcare in scotland
- Devolved in 1999
- Own minister for health – Neil gray,
- NHS Scotland spit into territorial health boards
o Each responsibe for managing own health services (actute, primary care, mental health)
o Also a few special boards –Eg Scotish Ambulance service, National education Scotland, NHS 24 (telephone triage)
Recent article read
Catecholamines and PTSD – Raised noradrenaline levels
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6288600/
What is clical governence - how do you participate
- System within a hospital which makes sure that both the hospital and the individual staff are all doing the right thing toprovide quality and safe care for patients
- Personal – maintaining skills and professional development
o Only doing things I’m trained and approved to do
o Report errors and incidents - Team
o Performing structured handovers
o attending M&M meets
o Teaching more junior staff - Hospital
o Completing QI and audits
Main problems facing anaesthesia
- Current turbulence in NHS
o Strikes – need the government to listen to clinicians and what they need clinically and personally to continue budling a health system which works for the benefit of both patients and healthcare workers.
o Need to feel clinical leadership at both a local and national level
o Importance of looking ahead of me at how registrars and consultants are teated – as I get older and experienced need to see I will be appropriately valued both physically and psychologically
Issues with pension taxes forcing doctors to retire, retire and return contracts.
o Current consultant gaps – pandemic further stretched this especially with backlog of infections
o Need entire NHS workforce to feel valued not just anaesthetics – including the finantial renumeration – deal accepted with negotiations between Scottish junor doctors committee and government. 12.4%
Importance of this to avoid strikes which are a last resort
Cant really put a monetary price on wellbeing
- Retention
o 20% consultants plan to leave nhs in 5 years
o 1/3 plan to work less than full time
■ not feeling valued or well supported, including relationships with colleagues and managers
■ wanting to pursue leisure interests and spend time with family
■ concerns about taxes or pensions
■ bureaucracy and leadership issues
■ improving mental wellbeing, reducing stress or burnout
■ could not sustain workload or being on-call
■ lack of flexibility, reduced hours, breaks or leave ■
lack of autonomy and respect
o How to prevent this
■ being able to work flexibly and less than full-time to have better work-life balance
■ reduced or no on-call work
■ contract flexibility
■ being able to adjust clinical practice or the environment to account for physical changes with age
■ having supportive colleagues and managers that are respectful and appreciative
■ advice about pay, pension and taxation issues
o
UK population growing in size and complexity – increased frailty, backlog of operations
Mistake example
Wrong length central line – packs pre made up and usually had 15cm in.
Able to pull back and re suture
Sat with patient + family and explained what happened, felt very sheepish – all very understanding
-Helpful I had gained a good raport with them from previously in the night
Filled out datix
Discussed with charge nurse about the central line box – Now have separate laveled ones
Discussed with clinical supervisor
Horrible gut renching sensation when you realise you did something wrong. Issue compounded by being on a night shift and performing a task I’d gotten used to as routine with kit all pre prepared. Reminded me that even with skills you become more comfortable in its important to have your own personal systems and checks.
In the future as I become more competent in other areas such as intubation – where an equipment error could be more immediately detrimental to patients.
Remember how importance good report
Example of bad day at work
Situation – first weekend covering CCU – ended up quite a complex situation
Task – quite busy managing a patient who needed to go for a PCI and another in complete heart block on isoprenaline who was trying to self discharge with known schitzophrenia.
Number of admissions waiting to be seen
Consultant in cath lab
House officer who was new to the job andthier first ever weekeend could tell they were struggling to cope with workload and job prioritisation. Calling me lots often about non urgent issues such as slightly worse renal function.
Action – Made a capacity assessment and sectioned patient.
Managed the stemi patient
Spoke to CCU charge nurse to explain delays in seeing new patinets and asked for their opinion as to who could wait and who needed to be seen – lucky as all were stable
Picked up house officer and went to pick up lunch – able to have a good conversation them in the doctors canteen. Asked how they were feeling and realised they had felt a little exposed and also spending around an hour or more on each discharge summary as they didn’t want to miss antthing out.
Initially went over their jobs list and crossed off some tasks. Helped prioritise others and work out which would be for other members of teams.
Next day met for breakfast in one of the CCU offices for breakfast, brought in coffee and croissants. They told me more about how they are scared of missing something and that was why they spent so long going through stuff. Made a plan to catch up before lunch to go over job list. Went over a template for discharge summaries – Eg NSTEMIs, (One already existed for TAVIs )
Result – They had a much smoother day, came and found me at the end to say how helpful having our conversation was about giving them some confidence in themselves and what was expected of them. Also that they felt they could ask me anything
Reflection – Making sure I recognise stress in all team members. Initially thought they were just being slow. I don’t think the result would have been so positive if I hadn’t made the time during a busy day to talk.
If similar happened again I would try and make the initial conversation in private – even in a high workload day its important to take some time out and be in a place where people feel comfortable to share. Not places with other people around even if only doctors.
Approach to errors
Look me up
