A 48 year old woman recently commenced chemotherapy for a new diagnosis of acute myeloid leukaemia. She attends the Day Bed Unit to have routine bloods checked prior to her next dose of chemotherapy. Since her last assessment, she sprained her ankle and is taking regular ibuprofen.
In the earlier stages of my training, I disliked the discomfort I felt when patients deteriorated to a level beyond my skill set. The ICM doctors who arrived at such times clutching bags of impressive sounding drugs and equipment before whipping them away with an air of proficiency impressed me. I applied for ACCS training, hoping to join their ranks. Vocalising an interest in ICM prompted a range of responses from colleagues. “Are you sure?”….
As I was saying at the odd conference before we were so all so rudely interrupted, Point of Care Ultrasound is finally coming of age in the UK. It has taken a while – the first diagnostic use of ultrasound was in the 1940s by a neurologist, a comparatively rapid pickup from the first demonstrations of Non-Destructive Testing for metals using ultrasound in 1928.
A 34 year old woman presented to the Emergency Department with a two day history of progressively worsening double vision, followed by ataxia and slurred speech. She reports a diarrhoeal illness eight days ago, though this has now resolved. She is normally fit and well and takes no regular medication.
In the second part of our podcast series on ‘Knowing Your Team’ we will be looking at the roles of physiotherapy and speech and language therapy in the management of critically ill patients. It is so inspiring, listening to how these specialists have an enormous amount to offer in both the acute and long-term rehabilitation of critical care patients.
I am standing in one of the resuscitation bays of the emergency department holding a patient’s airway open while pre-oxygenating them, as we are running through the RSI checklist…
John Wilkinson, Janet Wilkinson, Sarah Redford, Matthew Faulds
Following on from Gilly Fleming’s blog in November where she gave a fantastic update on some of the ways teaching can adapt to the challenges of the pandemic, we wanted to share with you our experience of developing a new learning tool and applying it in such an unusual time.
Welcome back to another year of FICMLearning Podcasts.
This is the first part of a podcast series we will be running to raise the profile of the critical care multidisciplinary team. We hope that this will highlight the vital contribution that each member of the critical care team makes to the complex management of patients on the intensive care unit and how effective collaboration between team members helps to ensure successful outcomes after critical illness.
We are very lucky to have a well developed and longstanding coronial service – I’ve just been listening to the FICM podcast with Derek Winter and have found out it can be dated back to at least 1194. Something not covered in the excellent podcast is how it feels to be in the stand – giving evidence, so here is a blog on my experiences.
A previously well 48 year old male, presents to ED with a 48 hour history of severe epigastric pain radiating to his back. On surgical examination he is extremely tender with guarding.
On 30th November 2020 the Faculty held its annual Clinical Leads Conference. all attendees had access to pre-recorded lectures which where then discussed in the Q and A session held on the 30th. We would now like to give access to these pre-recorded sessions and they can be access below. The recorded Q and A session is available below, we suggest watching the lectures first.
These sessions will be available until 15 January 2021.
Enhanced Care: Dean Dr Alison Pittard
ACCP Training and Accreditation – the future: Ms Rachel Pascoe, Lecturer in Nursing at University of Plymouth
Life After Critical Illness: Immediate Past-Dean, Dr Carl Waldmann, Dr Joel Meyer, Dr Andy Slack
Changes to Clinical Commissioning of Critical Care Services – The Future? Professor Jane Eddleston, Commissioning Lead
Getting it Right First Time (GIRFT). Critical Care and possible implications for your unit: Dr Anna Batchelor, GIRFT Lead
How to set up and run a Critical Care Research Nurse Team: Ms Jade Cole, Team Lead, Cardiff Critical Care Directorate, and Research
Animation Support on ICUs: Professor David Wald
Full Conference Question and Answer Sessions: recorded on Zoom 30 November 2020
I originally chose to study pharmacy after being inspired by some family-friends who owned their own community pharmacy. I studied at Nottingham University, and only changed my mindset towards hospital pharmacy at the very end of my degree and managed to secure my Pre-Registration Pharmacist year in my local district general hospital. My training was excellent, I loved the clinical aspects of the job, and I was encouraged by the team to progress my career in hospital pharmacy.
This month James Sira talks to Bev Frankland about writing a statement for the coroner, as well as preparing and giving evidence at the coroner’s inquest.
Bev is the Risk & Inquest Manager for South Tyneside and Sunderland NHS Foundation Trust. She is primarily responsible for looking after the ‘top-end’ of the investigation spectrum e.g. inquests, serious investigations and police matters. She has several years experience supporting medical staff through the process of an inquest and in these podcasts shares some key advice.
My time working in Intensive Care as an ACCS-EM trainee was one of the most influential periods of my career so far. I worked with a truly incredible team. During the lockdown period, I was able to reflect on my time in Intensive Care and my role as a woman in medicine. As part of this, I approached eight women in the Intensive Care team to share their inspiration and their perspective. It was a privilege to hear their stories. Thank you to WICM for this platform and to the women you will read about, for their time and their words.
Dr Jasmine Medhora
Laura Allan, Emergency Medicine and Intensive Care Medicine Registrar
My time working in Intensive Care as an ACCS-EM trainee was one of the most influential periods of my career so far. I worked with a truly incredible team. During the lockdown period, I was able to reflect on my time in Intensive Care and my role as a woman in medicine. As part of this, I approached eight women in the Intensive Care team to share their inspiration and their perspective. It was a privilege to hear their stories. Thank you to WICM for this platform and to the women you will read about, for their time and their words.
Dr Jasmine Medhora
Roxy Bloomfield, Consultant in Anaesthesia, Intensive Care, Prehospital and Retrieval Medicine
Were you the person who ended up leading a cardiac arrest on the ward? Did you stumble upon a car crash in the street and had to take control? Is there an area of your career you didn’t expect to have? Have you ever found yourself leading when you didn’t expect to?
My time working in Intensive Care as an ACCS-EM trainee was one of the most influential periods of my career so far. I worked with a truly incredible team. During the lockdown period, I was able to reflect on my time in Intensive Care and my role as a woman in medicine. As part of this, I approached eight women in the Intensive Care team to share their inspiration and their perspective. It was a privilege to hear their stories. Thank you to WICM for this platform and to the women you will read about, for their time and their words.
Dr Jasmine Medhora
Dr Deborah Owen, Intensive Care Medicine Registrar
My time working in Intensive Care as an ACCS-EM trainee was one of the most influential periods of my career so far. I worked with a truly incredible team. During the lockdown period, I was able to reflect on my time in Intensive Care and my role as a woman in medicine. As part of this, I approached eight women in the Intensive Care team to share their inspiration and their perspective. It was a privilege to hear their stories. Thank you to WICM for this platform and to the women you will read about, for their time and their words.
Dr Jasmine Medhora
Dr Caroline Lacey, Intensive Care Medicine Registrar
A 65 year old woman has a cardiac arrest at home. She is in VF and receives 2 DC shocks by the paramedics before return of spontaneous circulation (ROSC) is established. She is intubated at the scene and is taken to her local hospital.
My time working in Intensive Care as an ACCS-EM trainee was one of the most influential periods of my career so far. I worked with a truly incredible team. During the lockdown period, I was able to reflect on my time in Intensive Care and my role as a woman in medicine. As part of this, I approached eight women in the Intensive Care team to share their inspiration and their perspective. It was a privilege to hear their stories. Thank you to WICM for this platform and to the women you will read about, for their time and their words.
Dr Jasmine Medhora
Alice Coulson, Trainee Advanced Critical Care Practitioner
My time working in Intensive Care as an ACCS-EM trainee was one of the most influential periods of my career so far. I worked with a truly incredible team. During the lockdown period, I was able to reflect on my time in Intensive Care and my role as a woman in medicine. As part of this, I approached eight women in the Intensive Care team to share their inspiration and their perspective. It was a privilege to hear their stories. Thank you to WICM for this platform and to the women you will read about, for their time and their words.
Dr Jasmine Medhora
DrLouise Hartley, Consultant in Intensive Care Medicine
The COVID-19 pandemic is a global healthcare emergency and the NHS is facing an unprecedented crisis. During the first wave in March and April 2020, the immediate priority was understandably on clinical delivery of safe and efficient care for patients presenting with a novel disease process. This led to the suspension of many “non essential, non-covid” services, and included widespread disruption to medical education at all levels, from undergraduate to postgraduate.
My time working in Intensive Care as an ACCS-EM trainee was one of the most influential periods of my career so far. I worked with a truly incredible team. During the lockdown period, I was able to reflect on my time in Intensive Care and my role as a woman in medicine. As part of this, I approached eight women in the Intensive Care team to share their inspiration and their perspective. It was a privilege to hear their stories. Thank you to WICM for this platform and to the women you will read about, for their time and their words.
Dr Jasmine Medhora
Nicola Clark, Physician’s Associate, Intensive Care
My time working in Intensive Care as an ACCS-EM trainee was one of the most influential periods of my career so far. I worked with a truly incredible team. During the lockdown period, I was able to reflect on my time in Intensive Care and my role as a woman in medicine. As part of this, I approached eight women in the Intensive Care team to share their inspiration and their perspective. It was a privilege to hear their stories. Thank you to WICM for this platform and to the women you will read about, for their time and their words.
Dr Jasmine Medhora
DrJoanna Thirsk, Anaesthetics and Intensive Care Medicine Registrar
This month is the first in a two-part series looking at the work of the coroner. James Sira talks to Derek Winter about the role of the coroner, medical examiner, and the coroner’s inquest.
Derek is HM Senior Coroner for the City of Sunderland and was appointed as one of the two Deputy Chief Coroners of England and Wales in 2019. He has conducted a wide range of cases in the 15 years he has spent as a coroner and has modernised the Sunderland coroner service.
Most intensive care doctors will at some point in their career be required to provide a statement for or give evidence at a coroner’s inquest, and this can be a daunting experience.
It has been an odd few months… when I initially planned to write this blog it I planned to write about something somewhat different – but then along came COVID-19…
A 40 year old male was admitted to intensive care unit requiring intubation and ventilation for community acquired pneumonia. He developed acute respiratory distress syndrome (ARDS) and on day 2 commenced an atracurium infusion for worsening hypoxaemia.
Despite two sessions of prone ventilation he failed to improve and required high ventilatory pressures. On day 5 he was placed on venovenous extracorporeal membrane oxygenation. (VV ECMO).
You must be mad! The usual response from single CCT colleagues in a now increasing frequency – more exams, more portfolios, longer training, increased cost – all to start on the same pay scale.
On the 20th May 2020, the legislation relating to consent for organ donation changed to an opt out system. As critical care plays a pivotal role in the organ donation process, these two podcasts give a clinical perspective on the importance of the new legislation and how it impacts on the discussions we have with family members about consent for organ donation.
There are also some interesting anecdotes & lessons learnt from the awareness campaign and implementation strategy used in Wales when this law was first introduced in 2015.
Hello – I’m Liz Thomas – a consultant in intensive care medicine and anaesthesia and I am delighted to have taken over the role of Chair of the WICM committee from Dr Rosie Baruah. I have been on the WICM committee for almost 12 months.
You are asked to review a 25-year-old female office worker who has presented to ENT with a sore throat and a progressive dysphagia.
She is apyrexial, haemodynamically stable and fully concious. A full examination reveals extensive wounds across her thighs due to subcutaneous heroin injection.
Max and Keira’s Law came in to force on the 20th May 2020 and brought renewed hope to the thousands of people on the UK transplant waiting list. The legislation introduced ‘opt out’ as the legal basis for organ donation consent in England and is expected to lead to an additional 700 transplants a year. However, the path to getting the new legislation in place was far from smooth.
This month Matt Bromley talks to Simon Conroy about frailty and its implications for critical care. Simon is a professor of geriatric medicine in Leicester and the clinical lead for the specialised clinical frailty network.
He has a particular interest in translational research in the acute care setting and has made significant improvements in the recognition of frailty amongst older people presenting acutely to hospital and how this can be used to inform decisions about clinical management.
You are called urgently to A&E to assist with a patient who is 36 weeks pregnant with a low GCS. She collapsed in front of her husband after complaining of severe abdominal pain.
In this blog, David describes bias and how it can have a profound effect on people’s lives. Implicit or unconscious bias may be described as attitudes that affect our understanding, perceptions, actions, and decisions without us having an awareness of their effect on us.
A 63 year old man with a history of hypertension and ischaemic heart disease has been admitted to the intensive care unit with refractory hypotension due to severe sepsis. Inflammatory markers are raised and CXR has revealed a right lower and middle lobe pneumonia.
We were approaching the end of April. We had just come through a CQC inspection, COVID was in full swing on our 13 bedded unit, running 3 times our capacity having spilled out into our main theatres, anaesthetic rooms and recovery.
FFICM is a ‘high stakes’ exam taken by ICM trainees, and is mandatory before entry it stage 3 training. This article aims to give some tips and pointers to trainees who are preparing for this exam, written by an experienced FFICM examiner.
Post graduate exams are hard. They have a huge impact on the candidate’s life. It can be difficult to put the rest of your life on hold for 3 months to focus on revision, but this is unfortunately necessary. The revision should become intolerable after a few months or you are not revising hard enough.
As a dual trainee who had never jumped off the training treadmill, I was looking forward to my maternity leave. I had pictured long coffee afternoons with other new mothers, taking up baking and trying my hand at baby yoga. Heck, I had thought I was going to be so refreshed by what I thought would be a break I might even sign up to do a part-time Masters in my ‘time off’.
Andrew Jacques, John Fletcher, Manoj Wickramasinghe
Welcome back to the simulation series.
In this second part Matt Bromley, a senior intensive care medicine trainee, talks to a number of simulation enthusiasts about the practicalities of setting up and delivering simulation training on intensive care.
Andrew Jacques is a consultant in intensive care medicine in Reading and has been instrumental in developing in-situ simulation training on their intensive care unit. He is also the simulation lead for the education sub-committee of the Faculty of Intensive Care Medicine.
John Fletcher is an advanced critical care practitioner in the Leeds Teaching Hospitals NHS Trust who has many years of experience as an ICU nurse and educator. He joins their Simulation Fellow, Manoj Wickramasinghe, in talking about the development of a high-fidelity intensive care simulation course that has a strong focus on MDT involvement.
A 74 year old female with a background of hypertension presented to the emergency department with gradually increasing breathlessness and pleuritic chest pain following a recent long haul flight.
Back at the start of the year, we all watched the news with curiosity about a place called Wuhan, and a new coronavirus that was ravaging the city. We continued to watch with further interest as it made its way towards Europe.
An unresponsive 76-year-old male is admitted to the intensive care unit. He has a past medical history of bipolar affective disorder (treated with lithium and valproate), self-harm and previous suicide attempts.
Shashi Chandrashekaraiah, Sushruth Raghunath, Avinash Jha, Arif Akbar, Ikenga Samuel & Mohammed Elshamy
International Medical Graduates (IMGs) account for approximately 25% of the current UK trainee doctor workforce and are predominantly of black Asian and minority ethnic (BAME) backgrounds. There has been a lot of discussion during the current COVID-19 crisis about IMGs and their contribution to the NHS, VISA/Immigration health surcharge and the more important topic of increased mortality among BAME doctors from COVID-19.
Welcome back to the difficult decision making series of podcasts.
In this second part James Sira, a consultant in intensive care medicine, talks to Dominic Bell about how to approach decisions around admission to critical care using a framework based on a clearer understanding of futility.
Dominic has been a consultant in Intensive Care Medicine for more than twenty years. He has a degree in medical law and has been an expert witness for the Court of Protection on end of life decision making, and for the GMC on fitness to practice investigations. He has also worked as an assistant coroner and has been an expert witness for the police.
As I look through my office window at yellowing patches of summer grass, it may seem strange to talk about Christmas. But these are strange times. I remember being told that there are three stages of life – first you believe in Santa, then you don’t believe in Santa, then you are Santa.
COVID-19 has presented challenges unlike anything we have faced before. In this blog, colleagues share their experiences by describing five things they wish they had known.
A previously well 76-year-old male presents to ED having been found on the floor at home by a relative. Collateral history reveals ‘flu-like’ symptoms and headache within the last week.
On arrival he is soiled, agitated and combative with a GCS of 9/15 (E2 V2 M5). There are no obvious localising neurological signs. Pupils are equal and reactive. Temperature is 39.0.A basic delirium screen in ED is negative (urine dip and chest x-ray). As you continue assessing the patient, he has a short-lived generalised tonic-clonic seizure.
COVID-19 has presented challenges unlike anything we have faced before. In this blog, colleagues share their experiences by describing five things they wish they had known.
For those of us who contribute to patient facing research, there were signals in early March that our working lives were about to change. The safety implications related to recruitment of and sampling from patients in studies who were potentially infected with SARS-CoV-2 needed to be considered. As a result many NIHR portfolio studies, supported by their funders, decided to pause recruitment.
A 67 year old man has been admitted overnight to the intensive care unit. He presented with flu-like symptoms and a non-productive cough. His wife reported that he had been ‘seeing things’. Investigations revealed hypoxaemia, lobar consolidation, neutrophilia and a raised lactate dehydrogenase.
You suspect the patient may have Legionnaires’ disease.
COVID-19 has presented challenges unlike anything we have faced before. In this blog, colleagues share their experiences by describing five things they wish they had known.
COVID-19 has presented challenges unlike anything we have faced before. In this blog, colleagues share their experiences by describing five things they wish they had known.
COVID-19 has presented challenges unlike anything we have faced before. In this blog, colleagues share their experiences by describing five things they wish they had known.
One of the difficult jobs during this pandemic is not only our dedication and commitment to best care of our patients, but the supervision and support of those less familiar to the Critical Care environment. This may be our own trainees, but also others for whom the decision to come to our ‘space’ hasn’t necessarily been their own; and includes other specialty trainees, senior medical staff, nursing colleagues and allied health professionals.
In the first part of this series, Danny Bryden and Dale Gardiner give their views on decision making, particularly with respect to admission to critical care. They also discuss wellbeing, and the impact of COVID-19. Danny is vice dean of the FICM. Dale is a consultant in anaesthesia and ICM in Nottingham, and is the national clinical lead for organ donation with an interest in medical ethics.
A 54 year old woman with a history of hypertension presented to the emergency department with a sudden onset severe headache. Her GCS was E3 V3 M6 on arrival, but deteriorated over the next 2 hours to E3 V2 M5. A CT brain demonstrated an intracerebral haemorrhage and a CT angiogram confirmed a ruptured middle cerebral artery aneurysm. She was intubated and ventilated for transfer to the regional neurosciences unit where she underwent a successful endovascular coiling procedure the following morning. On sedation hold she is now GCS E1 VT M1.
What are the potential causes of her reduced level of consciousness?
The following is a guide to help you set up an in-situ simulation (ISS) program in the intensive care unit. It is not an exhaustive guide but drawn from my experience of establishing a program on our unit and some of the problems and solutions along the way.
The series of simulation podcasts is going to be released in two parts. This first part contains conversations with Paul Bedford and David Grant, and also includes links to some of the research and resources that they mention.
A 40 year old male was found unresponsive in the garden. Initial GCS was 9 (E3V2M4) which deteriorated to 7 (E2V2M3) on arrival to the emergency department. ECG and CT brain were both normal. An ABG demonstrated a high anion gap metabolic acidosis (pH 7.0) with an increased osmolal gap (>10mOsm/kg). In view of unexplained decreased level of consciousness along with high anion gap acidosis and high osmolal gap, ethylene glycol toxicity was considered to be the most likely diagnosis.
The final years of training can be somewhat of an emotional roller-coaster – you’re excited to finally see the ‘reward’ for all those years of hard work, but anxious about taking on a new post and responsibilities. Perhaps one of the more difficult considerations is where you want to work as a consultant, and how this will influence your career progression after training… it certainly was for me! In this blog, I wanted to share my thoughts about finding a consultant post, and why becoming a district general ICU consultant was the right choice for me.
What happens to your patients once they leave ICU?
What may be the end of the story for critical care healthcare professionals is usually the beginning of a long, difficult and sometimes very lonely journey for patients and their relatives.
Consent is the voluntary permission of a patient to be given a treatment. Consent must be obtained wherever possible before all treatments and procedures, reflecting the importance of individual patient autonomy in healthcare.
The issue of mental capacity in the critical care environment can be fraught with difficulty and can cause anxiety to staff working in these environments. It is important for all staff involved in the care of the critically ill to understand the law in relation to capacity and consent and have knowledge of the process of making a capacity assessment.
Since the invention of blogs in 1994, blogging has exponentially expanded into every sphere. There are millions of blogs on the web representing a spectrum of interests, ideas, ideologies and information sharing.
Alison Pittard, Matt Morgan, Sarah Marsh, Rosie Baruah, Segun Olusanya
This series of podcasts takes a closer look at the concept of resilience through a series of interviews focusing on challenging times. The interviews were recorded at the FICM ‘Striking the Balance’ meeting in September 2019.
In September I had the experience of speaking at 3 meetings in 3 weeks. I find speaking at meetings quite daunting and so I’ve put together 12 points as a ‘note to self’ to remind myself of what works for me.
Freddie Mercury is singing “I’m going slightly mad….” in my ear! He’s been at it all morning. I keep saying “yes” when I know I shouldn’t. My OCD is struggling to keep up with my diary. So how did I end up here?
The time has come; Striking the Balance our first ever WICM meeting on 27 September 2019, on a rather wet Friday at the Royal College of Anaesthetists. In all the excitement leading up to the event, I recall speaking to Lucy Rowan at the Faculty the day before to discuss the day and shared my rather nervous feelings about writing this blog.
A
25 year old male is admitted to critical care following a motorcycle
accident. He hit a car travelling at
60mph, was thrown over the roof and skidded 20m down the road. His injuries include a fractured pelvis,
unilateral rib fractures from 6-10 on the left, and a fractured lateral
malleolus also on the left.
As I write this, the baby is finally sleeping upstairs and I have a small window before setting off for the school and nursery run. Ah, the peace and quiet.
On the 2nd of June I had the pleasure of attending the inaugural Woman In Surgery Scottish Meeting at the Royal College of Surgeons in Edinburgh. The programme was packed full of enthusiastic and informative speakers – and one of them, Mr Mark Hughes, an ST8 in neurosurgery who I have the privilege to work with at the Western General Hospital in Edinburgh, also happened to be male!
Those of you familiar using social media may have seen #thisiswhatascientistlookslike, which aims to highlight the diversity of the people working in science, and break down the stereotypes many of us have regarding scientists.
I’ve written a blog on implicit gender bias for WICM, focusing on the problems female doctors can face as a result of the implicit bias that doctor = man, I thought it might be interesting to look at nursing, where there is a strong implicit assumption that nurse = female…
Whilst revising for the Final FFICM viva, I found myself rather frustrated with the lack of suitable material to assist and direct my revision. I promised myself (perhaps rather foolishly) that, should I pass the FFICM on my first attempt, I would make it my mission to publish an SOE revision text book.
The intercom crackled and it became difficult to decipher the words on the other end of the line. The Flight Director informed me as the Chief Medical officer that there was a medical emergency.
After two amazing years at Southampton Neuro ICU and 50,000 miles on the clock, I am moving back to London to be closer to my girls. Thinking about succession planning for my post has allowed me to enthuse to the Wessex ICM trainees about how rewarding my job has been here. So why should they consider applying for my job?
There is increased awareness amongst the medical royal colleges of the challenges of returning to work after a long period away, and the need for this to be a structured, managed process. The Faculty is developing its own Return to Work (RTW) guidance, which will be a synthesis of the guidance provided by its constituent colleges.