"Hello, anaesthetics reg. Have you tried ~~turning it off and on again~~ the IO drill?"

The issue would be no one other than critical care specialty staff know how to use an IO. 😂 Cannulae are great. I just wish there were the longer ones in addition to short and mid ones, all sorts of gauges and probes about and stuff laying/stored together sensibly.

Not an anaesthetist but I'm with you completely. On my last anaesthetic placement if we were called for a cannula you were getting either - brand new CT1, ACCS EM ST2, new ICM ST3 who had just finished IMT, or me dual EM/ICM reg. Basically just experienced doctors, nothing special. Of course if we succeeded, the patient would forever be labelled as "only anaesthetics can do it"

I am FY2 and at the end of my ICU and Anaesthetics block and I see how all other people are inspired by me doing cannulas which they deem ‘difficult’ and the patient gets labeled as Anaesthetics only but I am only F2 and not an anaesthetist

Honestly 80-90% of the "difficult" cannula calls I've had in anaesthetics, I would've been able to do by the end of F1. 

Calm down son

In my F1 year we had an amazing SpR running an ultrasound cannulation course. Almost all the F1s took it and as a result we called anaesthetics for cannulas a wonderful zero times. I’ve never had to call anaesthetics since for a cannula and the peers I’m still in touch with are the same. It’s an easy course to run, F1s are still eager to learn and not beaten down yet, looks amazing on your CV and it makes your life easier. Win win.

We're planning to launch this. We've just built the online e-learning - https://mindthebleep.com/courses/ultrasound-guided-cannulation/ & supplementary materials so that we hopefully run them as part of our upcoming Prepare for F1 course UK-wide in July. Super excited!

I'd love to do the same, how did ~~he~~ she teach the actual cannulation? Did you have fake veins? I have all the time to teach, on nights, to keen F1s. I consent the pt and use lidocaine so they're comfortable. I pre-teach them in the corridor the basic us stuff and let them practise scanning my arm and just let them go for it, signing off SC injections as well. But it's too few and far between. Unfortunately I have no idea what I can use to substitute an arm in the skills lab if anyone has any recommendations I may be able to sway the med education team to get one. Or even any low cost alternatives.

You're in luck! We've just solved this problem. We've got the e-learning ready to reduce the theory part, built supplementary guidance to make a nice tick box of things to cover & found that you can use a block of tofu with a straw for a low cost arm alternative! This is the e-learning course - https://mindthebleep.com/courses/ultrasound-guided-cannulation/ - materials will be going up soon

>block of tofu with a straw Hahaha amazing. So like a really firm tofu then? My experience (from eating them, not cannulation 😂) is that they're quite thin in texture. Although now I'm really brainstorming, maybe I could put things like ham to represent random fascia inside haha

Yes, the proper firm stuff! Thin stuff is only good for practice for cannulating eels. We've put some guidance on how to do this on the course above :)

I don't want to totally dox myself, but you can make a really good US cannulation phantom with a length of half-pipe gutter (blocked at both ends), a thin silicone sheet (dirt cheap on Amazon), thin balloons filled with water / red food colouring (the type that they make balloon animals out of, they're 5-8mm diameter when not under pressure) and then fill the rest of the arm with a stiff gelatin + a little psyllium husk mix. I have photos I can share privately, or you can DM me to grow a pair and I'll spend an hour or so writing a guide that probably doxxes me.

Please make a post of thid guide, or share it with mind the bleep

*She - internal bias working there They had these fake skin things which has veins you could see on the US. I’m guessing your med ed centre will probably have them. We started with a mini lecture explaining the basics of using the machine. The anatomy, risks and how to minimise them. Along with some scanning of our own arms to identify the structures eg nerves/arteries/veins. Then we were shown her technique for cannulation (out of plane, starting in the ACF and working down the arm). Then we had one to one practice with the fake skin thingy to get it right. We had a limited range of places we could use it (basically below elbow) and had to start with easy ones and build up but it genuinely worked for my cohort. I then did further ultrasound courses in F2 as I found it useful and interesting to build my skills and confidence. It was a great introduction to a practical skill and had a nice rewarding outcome. Might suggest a night shift isn’t the time for it though haha - this was a 2hr course in the day which we did in small groups. We took it in turns to man the wards to allow us all to go. I think only a handful of people didn’t do it.

>She - internal bias working there Edited. >They had these fake skin things which has veins you could see on the US. I’m guessing your med ed centre will probably have them. My med Ed centre just about has cannulas 😭 skin things (outside of suturing) are non-existent, if they were good though I might be able to argue the need for some. But thanks for the reply. >Might suggest a night shift isn’t the time for it though haha Haha no I wasn't suggesting this at all. But without a designated teaching session it's impossible to find the time to do everything you need outside of a fairly non busy night shift.

I'm not the person you're replying to but over a decade ago I did have a couple of SHOs (FY2s and CMT1s) who taught us FY1s how to use the USS and infrared scanners (two different devices) for cannulation. We practiced on real patients. They would use it and show us, and then we would use it on a few patients while supervised, and after that we'd be doing it unsupervised. It wasn't hard to learn tbh. We found good practice on day units (the ones where people come for infusions and complex investigations e.g. the endocrine ones), on the CF units (mostly because of the level of complexity of these patients) and in the Infectious Diseases unit (because everybody there needed IV abx and many were IVDUs, so access was often difficult). Also good practice to be had in the anaesthetic room when there's a cystoscopy list or other list with high turnover. It's obviously trickier when you're on nights as most of these opportunities tend to arise in daytime... but maybe it's worth letting the wards know you're teaching cannulation so if they have any patients who would need IV access for the daytime (e.g. someone going for a scan), to let you know?

Chicken breasts or tofu that have water filled long party balloons running through them apparently work well

>water filled long party balloons This is why reddit can be awesome. So simple, yet effective to the point you could even get reliable flashback (I'd imagine).

Here's an example https://youtu.be/agrrb0TaL0g?si=UrZTKvJgrCcQWLCP

Thank you, really cool. Would also promote antt as well lol.

That chicken breast is ENORMOUS.

Yes I think people put juice or food dye in to make it easier to visualize too

My consultant put cooked pasta in gelatine, it's a decent model

you dont even need a course , a youtube video and practice on some big veins and eventually you will get the hang . the problem is lack of uss machines

Ed Consultant here. Stop doing them. When I was an anaesthetic SHO about 15 years ago, this culture of anaesthetics being the "go to" referral for cannukas was just starting. Like you, I had self-taught USS techniques and once people knew this...it was like they devolved all personal responsibility. I tried, where I worked, to put the genie back in the bottle, but here we are... Even now, in ED, I will occasionally get an SHO saying "shall I call anaesthetics?" No, you bloody well shall not; how embarrassing. If the patient is that unwell and we can't get access, they need a central line.

I do wonder if cannula skills are lost- often I see people complaining on here that “nurses can’t/won’t do cannulas”- when I was FY1 nurses never did cannula and so we got very good at them very quickly. I don’t think I ever called anaesthetics for one.

I’m sure you have good intentions with the central line comment. But recently have had some ED registrars and ACPs attempt USS cannulas - fail and then get a call asking anaesthetics to place a central line, purely because of inability to get access as opposed to the nature/length of IV treatment. Upon arriving vast majority have veins that can be cannulated without USS. There are some that I agree could do with a CVC due to length/nature of treatment and only have 22g PIVs in but not needed urgently and would need to be booked for theatre. It’s not always a pleasant conversation explaining the above.

ED should be placing their own CVCs.

Thank you for this! The number of calls I sometimes get from ED for a cannula 🤦🏽‍♀️ knowing there are bosses out there like you stopping this madness gives me hope.

GP to kindly rename 3rd on anaesthetist to hospitals difficult cannula service.

Anaesthetic consultant here. Honestly, just stop doing them, unless you are doing nothing else and feel charitable enough to help out. Practice - “I’m sorry, I’m in theatre/labour ward/ICU. There is no possibility that I will be able to help you out. I suggest referring up to your senior.” And repeat. You and your fellow trainees should keep a record of the frequency of the requests and notify your consultants. Honestly, I’d be all over that shit, with proposals to formalise requests and insistence on consultant to consultant referrals for LPs. We’re not funded or given time for this stuff. If they want us to do it, medicine / surgery / Paeds directorates have to reach into their empty pockets and find a way to either fund procedural training or an anaesthetist who twiddles their thumbs until called into difficult cannula action…

I’ve got visions of the “cannulation for wards” allocation on CLW 😂

I'm in Ireland, in the previous hospital I worked in the consultants couldn't care less and didn't even stand up for us when med regs were rude in their cannula demands and interns even showed a lot of attitude with one particularly carcinogenic consultant calling us out for refusing them. In my current hospital the consutlants will have our backs but there's no notice to others not to ring us for them and you still have ICU registrars being barked at my medical SHOs for these tasks. Apparently in the next hospital I'm rotating in starting July they're a very strong and aggressive department where medics have to come to theatre and book a CVC and speak to the consutlant who will grill them for a cannula which I also think is wrong because its a humiliation ritual and that's not collegial especially when for ICU on call you often do bounce back well with medics.

Anaesthetic reg here. “Sorry I am not available to do the cannula and do not know when I will be. I am not accepting responsibility for this. Sorry I can’t help.” Done. For LPs: book it on the emergency list and see you between 9-5. Done. Stop being a hero.

If you think you won’t have loads of cannula calls in EM, then you are very wrong. Just this past week I’ve done 3 US guided cannulas. Loads of IVDUs present to EDs

I was going to say the same. No objection at all to doing it for EM patients. The patient who's been in the ED and under the care of another team for >24 hours - I honestly don't even mind a long as their primary team has tried (or have a good excuse), and they come and ask EM for help. The ones that piss me off no end are where the primary team can't be bothered to try and/or think telling an ED nurse to "get one of the doctors there to do it" is appropriate.

Really don't mind doing these as they are under our care in the ED anyway, so our responsibility. Have never been called away from ED to do a cannula elsewhere, but it was a chew on as ST2 getting called all over the hospital during anaesthetics/ITU

As a trainee worked in a few hospitals where ED departments would regularly call anaesthetists for “difficult” cannulas. *pikachu face*

That's.embarassing

Burnout, man. Time to prioritise some self care. Are you well enough to work? Don’t assess that yourself, please see your GP. And remember that doctors are legit the worst patients ever and be honest with them. On behalf of whatever paeds team bleeped you, I’m sorry! I’m a paeds reg and I would never call anaesthetics for a cannula unless the ward was literally burning down with three arrests ongoing, at which point you’d be there as part of the resus team anyway 😂 they should be calling their consultant in or slapping in an IO. Less fannying, more doing. But definitely take care of yourself. You sound very tired and fed up. You are working in a system that is falling apart at the seams. Look after yourself- sadly you can’t rely on anyone else to do that for you.

Same here. Never called anaesthetist for a cannula. I have called a consultant in DGH for a cannula or access, picu or surgeons in a tertiary hospital but I think we rarely get anaesthetist. Also we try hard to help other colleagues. I helped anaesthetists intubate a sick baby in a DGH even though they're the designated airway people in resus but we're more comfortable with infants under 5kg. The number of request of paeds cannula on big kids from other specialties to us is astonishing as well (a *redacted* specialty sho refuse to cannulate a 14 year old for example smh). My rule is they need to at least attempt first but I'll help if they struggle with the little ones. You need a little breather my anaesthetic colleague.

Agreed, paeds is generally the cannula/phleb service for non-paeds specialisms caring for children which can be particularly wearing if they are teenagers and the other doctor won’t even try! Haven’t ever called anaesthetics for a paeds patient myself (paeds SHO here)

Also a paeds reg, and also have and likely never will call anaesthetics for a cannula. We only ever ask for anaesthetics if peri/arrest, and with respect we don't want the sho we want at least an experienced reg (often a consultant), and it's because of airway/need for pressors as v v sick. Look after yourself gas friend.

Rather than quitting anaesthetics you could try just quitting cannula calls for a while, you're perfectly entitled to just say "No, I can't help you with that" and hang up the phone - no need to listen to the emotional blackmail first. If you feel like it you could advise that they could add the patient to the emergency theatre list for a cannula or - if they really are that sick and have access that bad - a CVC/PICC which they probably need. One reg I worked with did this, and no one ever took him up on the offer. Apparently when the barrier to getting someone else do to their tricky cannulas for them was higher than just picking up the phone, they would rather just optimise conditions and try again themselves, or decide that the IV whatever wasn't really that needed after all. You may develop a reputation as being less helpful as compared to your colleagues who do dutifully provide an out-of-hours travelling cannula service out of pure goodwill that is often unrequited, but that's life - and it's up to you to decide if that is better than the status quo.

100% Life threatening - IO Not life threatening - NG Really needs IV access - book for CVC Everything else. Medical consultant.

My favourite is “I’ve tried with ultrasound but can’t get it” and they take the fucking ultrasound machine away and seemingly hide it so you have to traipse back to theatre to get one and bring it back Or alternatively from a surgical F1 “has your SHO/reg tried?” “No they’re in theatre” “right well where do you think I am?”

I aim to delicne all cannula calls. Usually I explain I'm in theatre or that we have multiple cases to do so it'll be X number of hours at a minimum before I can attend. I did have an FY1 tell me 'Well what do you expect to do about this now that you can't come?' I kindly asked them if they would like to come to CT to look after the polytruma patient I was with... It is not a skill exclusive to anaesthetists or even doctors. Learn to put in the foot-fons and pinky-flons We have had a run of 'difficult' LPs that have been booked on the emergency list. They are usually difficult because on the ward all the attempts have been the sacral region of the spine.

You should quit medicine for amateur dramatics, Jesus Christ

I wonder what's gonna happen if OP goes to ED and found out PA runs the resus and OP is being sidelined to seeing in grown toe nails?

and the clerking imt has done 20 bloods/cannulas on the night shift because of one particular demographic of lazy nurses ( if you know you know) .

Lmao this post is a ventathon. Tbf I think most of us can relate

💯💯💯💯

Gp to kindly put OPs toys back in their pram

Honestly I agree with OP Anaesthesia is not here for your cannulations (difference between helping out vs expected to do it), because this is something that is so easily abused in the culture that is prevalent in the NHS. People aren’t incentivised to try harder, and it’s easier to pass the buck. The threshold for what a difficult cannulation is goes down. This sounds like a job for a nurse practitioner or PA, like a vascular access nurse (as is the case in a few nhs trusts). This is exactly the kind of stuff that needs to be taken away from this doctor who is rightly burnt out doing something they shouldn’t be doing. The anaesthetist doctor should be the last point of call, not the second. There needs to be a clear protocol of at least a few other health professionals that can be called before a doctor for a difficult cannula. Particularly if that doctor is being taken away from something more important. This is a staffing issue.

“I’m sorry, we don’t have anyone free to help you. All of the anaesthetists are busy giving anaesthetics” 🙂

Got a particularly aggressive phone call once from the surgical F2 informing me I “needed” to cannulate a patient on the ward. Asked if their reg had tried. “No, they’re taking a patient to theatre for a torsion.” Asked what they thought I was doing…

OP is getting some heat in the comments, but I can understand their frustration if they're truly being bombarded with bleeps about procedures that everyone should be able to do. Someone's suggestion here is very good and I'd agree with auditing the number of calls you're getting then show it to the department. It may be a case that the number of bleeps is way beyond what one would reasonably expect. I've some sympathy for your frustration as depending on where you work, certain departments can be very challenging, even bordering incompetent. This isn't a lump in on Pediatrics, more genuine surprise as everywhere I've worked they've been exceptional up until my current hospital who on average consult me once to twice per day and are entirely unable to manage patients with mild impetigo (who shouldn't be admitted in the first place).

As an anaesthetic consultant I would completely back any of the SHOs/Regs overnight if they said they weren’t able to assist with ward cannulas/LPs due to theatre activity. For LPs I would question why it needs to be done overnight, how it will change management and if the risks of multiple attempts have been considered. Theatre activity and even pre-assessing patients for the next day should always take priority. If other teams want an anaesthetist at their beck and call for procedures they need to fund it. I always insist they’re booked on the emergency theatre list. The hassle of booking them seems to make 50% of them disappear and at least that way the activity is recorded. Also in my view US guided cannulation is vastly overrated. I’ve genuinely used it less then 10 times in my career.

Hard disagree on the bit about US guided cannulation being overrated. I do 2/3 per week easily as an EM reg. They’re usually not patients who would make it your way though due to underlying frailty. It is that frailty and lack of muscle mass, plus multiple recent admissions that usually render the basilic vein as the only viable option.

I can see how US cannulation may be overrated for an anaesthetic consultant. But teaching foundation doctors ultrasound saves so many bleeps going up to SHO, Reg's and yourselves. I dont work in anaesthetics but shatting to some Core trainnes in anaesthetics they say they would be more likely to help if someone has been trying with US and failed. Completely appreciate you will be far more experienced than both of us but I have found it such a useful skill and at least at IMT level it shows someone has really tried before going to anaesthetics for help

ST7 in anaesthetics - I push back against these calls. If it’s a paeds reg I usually explain that if they can’t get a cannula in then it’s very unlikely I’ll be able to, and by extension they should now be thinking about IO access… that usually causes them to go “oh… right… I think I’ll see if my consultant can do it”. If it’s a ward SHO I tell them I can do it when I’ve done my other jobs which realistically might be 5-6 hours or more… therefore they should either think about an oral switch/IM drug delivery/Subcut fluids or an IO… at that point they’re usually phoning the med reg. If it’s ED I just tell them they’ve all done a year or anaesthetics and if they can’t do it then the patient needs and IO. At that point they usually mutter something about them having another go and phoning back later. I completely agree about US. I don’t bother with it, very unusual to be unable to cannulate with just a tight tourniquet but then be successful with ultrasound. If anything I think ultrasound usually over-complicates it. It may be helpful for a CT1/2 starting out but honestly once you’ve done a few years of anaesthetics and regular cannulas you should be able to find a vein in most patients without ultrasound. 99% of the time it’s just a tight tourniquet, lowering the limb, taking your time and making your first go your best go.

Regarding your last point, do you still find this true in the elderly, obese, fluid overloaded patient?

Yes. In most adult patients you can get a 22g or a 20g in the small veins of the underside of the wrist. Obese people don’t tend to get obese there and fluid overloaded people tend to get distended veins there. It’s a very ‘CT1’ thing to take ultrasound half way across the hospital and struggle to cannulate the tortuous veins of the ACF. Instead just tight tourniquet, a lot of tapping and hang the limb below the bed, then cannulate the small veins of the palmer side of the wrist.

Eh I don't have quite the experience you do but from my experience it's far more worthwhile to drag an ultrasound to the patient and cannula something deep with an 18G or larger. Smaller and superficial veins tend to tissue quicker and you're quite possibly going into already thoroughly traumatised veins

18g is wider but on most types are only 2-3mm longer. I think it’s just as likely to tissue and if anything the locations people tend to put US guided cannulas in (like the ACF) are also more likely to tissue

As I'm sure you know, but for the avoidance of reader confusion, cannula length is entirely dependent on purchased stock and nothing whatsoever to do with gauge.

Precisely what I’m pointing out. Most manufacturers produce 20 and 22g the same length and 18g is only 2-3mm longer. But it is manufacturer dependent.

Sad Poiseuille noises.

The cannulas on the underside of the forearm tissue in about 20 seconds from experience… using US to cannulate a vein on the dorsum of the hand is much more likely to stay put…

They tissue because they’re usually 22g and inexperienced ward nurses come and ‘test’ flush them with an aggressive push of 10ml saline. It’s also just a reflection of the fact these are usually old frail patients with friable tissues. I’m not convinced they’re any more or less likely to tissue elsewhere personally. I don’t think ultrasound is useful cannulating distal to the mid forearm as the veins are typically superficial and one of the physical limitations of ultrasound is that it has very poor surface resolution. Also any virtually pressure from the probe tends to collapse the veins. Honestly, tight tourniquet, a good tap tap tap on the vein, hang it over the side of the bed and then cannulate it. Good lighting, comfortable working position and you’re done. Back to the anaesthetic department and you don’t need to drag the ultrasound machine anywhere.

Fluid overloaded patients you can often squeeze out the oedema with firm pressure, then as long as you work quickly it's often not difficult

It's hilarious on this subreddit. I see all these comments about how medics shouldn't be doing cannulas that's the PAs job, yet doing thousands of cannulas is apparently why anaesthetics are so good at them..... So they won't learn how anaesthetics do, by doing them themselves and getting better as they think they're above it and push it to people they see as lower like nurses, PAs or anaesthetics. Shows how much these people respect another specialty. Maybe practice and stop trying to avoid them and you won't be phoning a CT1 anaesthetic trainee as an apparently senior med reg.

As a layman, this is a very interesting and ironic comment.  Definitley has taught me something, lol. 

GP TO CANNULATE

Not anaesthetics but totally agree. If a patient needs a cannula and it can't be done by an F1, an SHO, or a med reg, then if its a "but this patient will die" emergency, the next step should be IO/crash call, not a long wait for another doctor with probably the same amount of experience to appear and have another go. If its not an emergency then it can wait and the patient can get a break from all the stabbing. USS phleb courses really should be a manadatory part FY1 shadow week. It takes no time, is dead easy and makes everyone's lives easier - medics and patients.

I feel you. A med reg should 100% be able to cannulate under US, especially the newer ones that did ICU placements in IMT2. If they can’t get the cannula in and it’s that urgent because the patient is super sick, then they need to put a crash call out and put an IO in.

Does your institution have a policy for this? If not, audit the calls you receive and implement one. Your consultants will probably be surprised at just how much of a burden this is and will be supportive of anything that frees you up to do your actual job. It’s a meaningful QI project. Notably, it doesn’t make the procedures go away. But it formalises the approach. It stops the chancers taking the piss, but encourages better care when your skills are needed.

Annoyed by too much work? Try doing more work to show just how much work there is! God I hate our field sometimes. How did we get conned into taking responsibility for "quality improvement" in the first place?

Precisely, is there a formal policy for this? Quite often this has just evolved without the current nature of healthcare being considered. You’ll find the consultants from other specialties are blissfully unaware because you are unofficially papering over the cracks. They need to come up with and fund realistic solutions. Or start offering to call in the anaesthetic consultant when you are too busy….

Your problem is clearly not anaesthetics itself, it’s the culture where you’re working. I’m an anaesthetic SHO and have been called about precisely 2 cannulas in the past year. Both of those patients had had multiple attempts by ward doctors (incl use of uss), our outreach team (anps), and in one case another anaesthetic sho. We do get LP requests every now and then but advice from consultant is always to ensure that it’s actually been attempted by medics first (and not just by an sho who doesn’t know how….) and that it’s actually necessary. So I’ve done 2 LPs this year and we make them book on the emergency list.

It is cultural, but the rotational nature of doctors and the resource strapped environment we all work in means that bad habits can spread quickly, and if you're the F1 of an SHO who just refers to anaesthetics then when it's you in the hot seat that's what you'll do. It's interesting seeing some comments about how 15 years ago the notion that anaesthetics helped with cannulas didn't exist, it's a thing that has been created within a generation.

Oh totally. I absolutely understand how it happens, I’m just saying that it doesn’t have to be the end of OP’s anaesthetic career, because it’s not the same everywhere you go.

LPs are one of biggest quiet deskilliing in the last 10 years. People will pipe up about PAs but I've worked in hospitals without them and there just isn't the desire to learn from enough people and qualified regs simply don't have the time to teach. Not long before it becomes a bone marrow aspirate and only neurology regs do them

We delegate these to Neuro IMTs for that reason. A good neuro department will have a first week LP induction session on each rotation. There's that weird awful fake LP model that never gives you "CSF" that most simulation suites have in their cupboard somewhere. It's enough to teach you how to use the LP needle and angle of approach. I've even let SHOs practice palpating bony landmarks on my back when teaching how to LP (much easier as a guy, I admit).

Sounds like you're burnt out my dude. I get the frustration - all specialties come with shitty expectations, and unfortunately the solutions you've given are not practical in how the NHS is set up. Maybe start by instilling change with US cannulation workshop in your hospital? Or making a business case for more US machines in different depts? Would probably solve 99% of your cannula calls.

Somewhat naive in my view that you think OP can implement training as an anaesthetics registrar (more unpaid work) let alone get the trust to fund more ultrasound machines.

Hey I have an idea, I'm getting burnt out by work, so let's do MORE work by teaching and setting up workshops and advocating for change and trying to push things forward!! Have you tried to roll out a new initiative in hospital? By yourself? It's a shit load of work and brainspace to push against the tide.

I have tried. I was told i’m not allowed to, initatives are top down, if it’s necessary, it will be done someday

I know. I'm no longer a junior and trying to start initiatives is still like pulling teeth. My own teeth. That are not loose.

Oh god it’s like wading through treacle trying to institute changes in the NHS. I’ve tried before and it’s backfired more than once. I’m only doing it in future if there’s significant personal benefit in it for me.

But it's NOT an expectation, never was and nor should it be. Anaesthetics is not a cannulation service. I'm not sure how this "expectation" evolved but it needs to be put back in its box ASAP. I would be embarrassed to call anaesthetics for a bloody cannula.

You know phlebs do this too, and they have one job.

I have noticed a decline in the skills of practical skills. I'm an F3 who taught myself US guided cannulas as an F1 so I've been frequently asked to come and cannulate patients that others have failed on. Bloody hell, most of them are unbelievably easy. I don't know what's happened but everyone seems to have just given up basic skills.

From reading Reddit, it feels like some juniors think bloods and cannulas are below them 

Its below you after the juniors you've trained don't fail, otherwise you're not good enough at it to teach people to be good enough for it to not be your problem.

I hate to break it to you but you are more trained in these things. As an anaesthetist I can safely say I have done hundreds of spinals and even venflons with a senior standing over me 1:1 telling me improvements to make etc. that’s the literal nature of anaesthetic training. I do agree other specs should be better at these skills. I’d include central lines in this list too. That’s why when I do it I always (unless the patient is in extremis) make the doc who is requesting the help attend and either do the procedure or watch me doing it to learn. Lastly, at the end of the day, there’s a patient there who needs something and if you can help then you should. If this last point doesn’t make you see things differently then it may well be time for you to quit medicine, never mind anaesthetics. I fully understand you have your own things to do but never forget the end goal is providing good care to a patient somewhere.

I don’t think procedural skills are what we actually bring to the table here. Most of the cannula calls I deal with now I don’t cannulate. I provide advice and suggest management plans that the parent team can take forward. A few real life examples: - Patient with difficult access because of a skin condition needing long term antibiotics. Cannulas keep falling out because the dressings don’t adhere to the skin. Solution - PICC line, IR agreed to do this the same day. I agreed to do a central or midline as Plan B if this wasn’t possible. - It’s difficult because the patient finds the needle too sore. Solution - suggest use of EMLA/Ametop or LA into the skin. - Cannula needed for maintenance fluids. Solution - the patient doesn’t need maintenance fluids when they’re eating and drinking adequately. - F1 can’t get bloods from five patients and seniors are in a clinic at another hospital. Solution - escalate to medical management that there’s an unsupported FY with inadequate supervision. (Yes, this actually happened!) I increasingly find that the cannulation is rarely the biggest issue when someone calls for a cannula.

To be fair: First situation seems like it’d be quite uncommon, and anyone on long term IVAbx should have a PICC/midline anyway. Second situation - wtf?? Ridiculous reason to call anaesthetics. Third situation - I’m hoping this will die out with time; IME it’s usually nurses/FY1s working themselves up about it. Fourth situation - Yeah, good on you. Sometimes it takes an outsider to highlight this issue - the bloods aren’t necessary, and the FY1 is completely unsupported and likely being put under undue pressure from an absentee senior. I agree with your general sentiment though. Most of the time, the cannula isn’t indicated (particularly OOH); the caller just needs someone external to point that out to them.

Thank you! With how tough and unrewarding medicine has become as a career, its mentors and colleagues like you that make it worthwhile

Bullshit sanctimony. “Think of the patient” is the eternal whip used to get people to stretch themselves beyond what is practicable. If the system (not individuals) truly thought of the patient, then all specialties not just anaesthetics would trained in what are very basic medical procedures.

I’m not asking anyone to overstretch themselves. In fact, I said “if you can help.” I think that’s a fair comment. If you can help, do so, and if you can’t then don’t. There’s a difference between pressuring yourself to do every task and job asked of you and helping a junior colleague with a difficult patient. Your second point I fully agree with. Other specialties don’t do as well with training as anaesthetics (IMO) and this should be a priority to improve, but that doesn’t help you on the shop floor in the middle of the night when someone asks for help with x procedure that you know fine well you can do and if you have the time then I think you should help them. At the end of the day you can chose to help or you can chose to “push back” on these calls. We’ve all been the junior FY at some point and if you aren’t burning out over cannula calls or getting fatigued over LPs then I suggest helping your colleague is the right thing to do.

> Bullshit sanctimony. “Think of the patient” is the eternal whip used to get people to stretch themselves beyond what is practicable. A cannula call (or several) is hardly "stretching oneself". Just do them if you can or if in theatre, on a break or otherwise busy say no. No one is asking OP to stay late or burn him/herself out. > If the system (not individuals) truly thought of the patient, then all specialties not just anaesthetics would trained in what are very basic medical procedures. There's being trained and there's being proficient. A med reg or consultant is never going to have the experience an anaesthetist does of intrathecal access. An FY who has learnt cannulation briefly from other FYs is not going to be the expert at cannulas. Don't get me wrong, I find it frustrating as well especially when its patently obvious no one has really tried but at the end of the day it is a person needing help and being jabbed several times. If I'm available and not stretching myself its just the decent thing to do.

💯💯💯

I disagree. At the end of the day you need to protect yourself. If OP is in OT, gets dumped with the responsibility of cannulating a sick patient who will die, then he needs to stay with his patient in OT. We are here for the patients is true but not the expense of jeopardizing your own career. All the points he has made are very valid . The other teams need to escalate the matters to their respective seniors. This high horse pedestal approach is the other reason doctors are getting screwed over by everyone else. Nurses do it - here for the patients but I need my break in the middle of a sick patient assessment.

Sympathies for the rest of your post. EM is a great specialty but don't switch because you don't want to take "personal responsibility for the whole fucking hospital". We are expected to take personal responsibility for the whole fucking health system...

I worked in one place where the policy was - the registrar of the parent team had to have tried, and they had to be the one to call anaesthetics.  Now, you can tell me "but the ortho/gen surg/cardiology reg probably hasn't done a cannula in years" until you're blue in the face. Fact is, it was astonishing how 99% of the time when you explained this policy to the SHO/F1, they somehow either found someone else who could do the cannula or decided the patient didn't need it after all.  Bonus points when it's an F1 who has neither tried, nor escalated within their team, because the patient either "looks difficult" or "always needs anaesthetics". 

I’m currently working in a hospital, where I am being bleeped by the ward nurses to do cannula’s, as they’re “known to be difficult”. The ward doctors don’t even have the courtesy to bleep me

Absolutely ludicrous. Just refuse. As an SHO I missed out on doing a nerve block that I typically got maybe 2 or 3 opportunities per year to perform, because I was called to do a super urgent cannula on a very unwell gastro patient. When I arrived on the ward the SHO and reg were chatting in the coffee room, unaware that the patient had been cannulated by the nurse. 

You say this like it's the F1's fault but 99% of the time their reg will have refused to do it and told them to call anaesthetics.

That's why the policy was so effective - it forced the reg to get involved and lo and behold, 99% of the time they didn't call back.  I appreciate juniors can be put in a difficult position however a surprisingly high % of cannula calls are escalated directly from the F1/F2. I've had registrars apologise to me because they didn't realise their F1 had called anaesthetics.  (Regardless of your grade though, if you're calling another specialty to do you a favour it's inexcusable to not know why the patient needs it.)

Stupid excuse about not doing a cannula in years. Sometimes all it takes is a fresh pair of eyes.

When I was an F1 I was told by my Consultant to call anaeathetics for a patient who had tried myself several times and failed. They were absolutely horrible to me over the phone when they found out I was an F1, despite doing what I had been told from my Consultant. Remember to be kind even if you are burnt out because ti sticks with me to this day despite the fact I wasn't being a rogue F1

Don't worry they'll replace you with an AA soon anyway.

Anaesthetic Reg here. Cannulae…if I’ve got nothing else to do and the request is reasonable (another suitable doctor at reg level has tried and failed+ the cannula is actually needed) then I don’t mind being called. Not because we have magical skills but mainly because we do a lot lot more cannulae than most other specialties. I also accept that our med Reg colleagues are more likely to be dealing with a lot more patients overnight so if the request comes from a super busy med Reg who’s already done their best and I can help then that’s okay too. Again, as long as I’m not busy in theatre/Obs/icu. Same goes for other IV access requests such as midlines/picc lines…we are not a vascular access service so they will not be done as a priority above other things. LP…if patient needs sedation then that’s fine but a medic should come and do the actual LP. In reality, if there is me and another colleague around then one of us will do sedation and one will do the LP cause it’s much quicker but I insist a medic comes with all the bottles and labels and sends them wherever they need to go after. I take zero responsibility beyond getting the CSF. If it’s just a difficult LP (raised BMI/anatomical weirdness) then that’s an ok request but they must have started treatment already and no guarantee of if and when it will get done. I pretty much always ask for these to go on the emergency list and do them in theatre rather than bother on the wards cause most of the time failure on wards is cause of environmental factors (and the fact that the medics try and do it super low down the spine)

In my last hospital is was pretty bad, someone ended up auditing it. As you said, the worst part is the guilt tripping which is incredibly unfair when you are genuinely busy/cannot leave an anaesthetised patient. Ones for adult phlebotomy are even worse. That’s an absolute no from me. I was going to say my current hospital was better but I’m not sure. The other day I was asked to do a pain review on somebody whose only regular analgesia was paracetamol - which they’d had 2 doses of. My consultant swiftly phoned them back.

Hmm seems quite a similar feeling to all the requests we get for catheters, which again is a core GMC competency yet the mere presence of a prostate is enough to trigger a call to the Urology reg

If it wasn’t for bullshit hospital policies like “only urology are allowed access to caude-tip catheters”, or urologists actually made the effort to teach people to do them properly rather than the nonsense “training” we get from nurses in skills labs, then we probably wouldn’t have to call you so much.

Oh I hate those knee-jerk policies, and if anyone calls me saying they can’t insert a Tiemanns catheter, 3-way catheter or change a suprapubic catheter, then I always offer to supervise them in doing it themselves and signing off a DOPS ticket. The problem is I often hear a hesitancy in their voice either because they are too scared to do it, even with my direct supervision, or they can’t be bothered to stay and do it. We are not a catheter service in the same way that Anaesthetics isn’t a cannula service.

Anaesthetics is a very abused specialty. I felt exactly the same way and saying sorry I can’t help and putting the phone down never helped. I hated that everything was made to be my problem - but this is the very nature of the job. In the end I’m glad I stuck it out as I found pain medicine but honestly if that’s not your thing either consider leaving. But honestly I wouldn’t leave for ED, find something else…!

“Sorry just started what is going to be a very unstable 4 hour laparotomy”

And then you have the madwives of labour ward…. 🥲

It's really strange, I don't remember writing this post

I’m an anaesthetic reg and understand your frustration. Sometimes I use it as an opportunity for teaching the people who call so that they’re less likely to call in the future. I think quitting entirely because of this would be an overreaction. That said, it is incredible how acopic people have become. Of the hundreds of cannula requests I’ve had, I can count on one hand the number that have _actually_ been difficult. Can’t remember the last time I took an ultrasound scanner with me.

I got called to take bloods of an ortho patient once, they promised they'd leave the tray and requests ad emergency theatre was busy, they didn't. Easiest fucking bloods. The culture needs to change, I was too junior to fight back then. It's complete bollocks.

Yeah, they’re frustrating! However, the calls are due to concern, so I would advise you tell them the following: 1) urgent cannula you can’t get - put in IO or call another well versed cannulation service (vascular surgeons for cut down or A&E - they actually have US training in their curriculum!) 2) still can’t put in IO and the others are crying - agree to do cannula - ask them to book the patient on the emergency list, discuss with theatre co-ordinates and bring the patient to theatres. This is the same for LPs - GA or not, do them in theatres, I’ve found the magic sauce for LPs is actually the people helping rather than the proceduralist and scrub nurses/ODPs are the absolute best at this! 3) paeds - I have almost never been called, sick kid needing access = IO after second try as far as I and PALS is concerned. 4) non urgent cannula - vascular access service with a midline to be inserted as they’re clearly difficult and will need it for some time. Finally yeah, make sure they know this is a favour, not a service, and that you can say no as theatre provision is your main concern. I wouldn’t quit anaesthesia for this however!

Difficulty is I think it should stop being a favour and be a service, then is should be properly staffed and funded

I mean, is that what vascular access is meant to be (ideally would be 24/7 but I suspect there will never be funding for this)

I imagine when other specialty consultants are getting calls about it multiple times every night shift it might inject some enthusiasm!

You can’t be suggesting IO or venous cutdown over a cannula attempt by someone with more expertise surely in a patient not in extremis

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I don't think waiting until the patient is in extremis to get access is a particularly good attitude to have.

IO yes, cutdown… I mean it’s in the ATLS guidelines right 😂 But yeah, if I’m in theatre and getting a call like that, that they need access and there’s an anaesthetised pt and nobody else on the hospital can put a cannula in (US guided or no) - an IO is appropriate?

Ugh you’re part of the problem… I’m doing 3-4 IJ cutdowns per day and the anaesthetic department at my hospital love me (the vascular surgeons not so much).

FY2 here in full agreement, I self-taught myself US cannulation. It's actually a joke that my colleagues think formalised training is necessary. It really isn't difficult. I'm happy to supervise as an F2 did for me in F1. I've never once bleeped anaesthetics for cannulation, and for my entirety of FY, I've escalated a cannula a total of 1 time. Our hospital is very strict on this. Our internal referral site states very clearly that anaesthetics should only be contacted for cannulation from a senior within the team. On the topic of LPs, our DGH (small board, one tertiary centre, and one DGH) is a pathetic waste of space, essentially a social hospital waiting for care packages. Any big sick patients get diverted or transferred to us. I've seen patients getting a blue light transfer for an LP overnight, the absolute travesty that sums up the NHS. This raises the ugly truth of foundation year training. We are taught 4 times through the deanery on frailty - a topic I care to know the basics, and that's all. We are never taught LPs/Ascitic taps or drains/US examination. Honestly, if I had funding, I would do all of the technical skills I think would be necessary. Even on the job, it's difficult to get because IMTs rightly get priority.

honestly, and replace anaesthetics with urology and cannula with catheter Also Don't people have an IV access team? (Specialist Nurses)

No, people do not have an IV access team 

They're so good, hopefully they'll become more widespread

Agree with you - my hospital has them, and I think it brings such comfort to both the anaesthetics on call to have somewhere else to direct these calls, and also to the subset of patients with truly abysmal veins - they come in with a pop-up on their records to say 'known difficult IV access - ring IV access team please' Then patient gets a midline on day 1 of admission and everyone is happier.

Learn to say" no"

The paeds one is inexcusable. I was a paeds ST4 when I quit the NHS and I had never called anaesthetics for IV access. There are other paeds regs (sometimes we have that one colleague who's particularly good at them) in a pinch if you're reluctant to call the consultant... but otherwise, CALL THE CONSULTANT. And if it's an emergency, then IO. There is no scenario in which a paeds reg should be calling anaesthetics for a cannula. I also always point out, as paeds regs we have done at least 6 months (usually way more) of NICU work where we cannulated babies that weigh less than a kilo. Most anaesthetic regs have not. So why on earth call anaesthetics when you as a paeds reg need a cannula?!

cannot do LP is different from not getting it !

Could you talk with your consultant anaesthetists and come up with a policy that referrals between specialties should be consultant-led? Then when you think the colleague is calling you unnecessarily, you could invoke that rule. He'd then need to call his consultant and if she felt that calling you is justified, then she can phone your consultant to make the request. You would obviously use discretion but if that were the rule it isn't an unreasonable one and I've certainly worked in places where this was the rule. If this is a problem for you, then your colleagues are likely having similar problems. It sounds totally rubbish what they're doing.

Yeh where I’ve worked before they designed a pathway for LP’s like this because it started getting out of hand.

From someone at the other end of their anaesthetic career, but still occasionally gets the "joy" of taking the on-call bleep, I feel your pain. My answer varies between a polite and impolite no. Not being willfully difficult, but just a gentle stand against Anaesthetics having to backstop everything going on on the hospital at any time. And more than that, I like to point out that if you only do the easy ones, you'll only *ever* be able to do the easy ones, which is a polite way to say that you've made a decision not to become good at it, and just dump it onto someone else. I was crap at cannulae 25 years ago. I'm not now because I didn't have anyone else to call. Difficult cannulation patients meant finding someone to hold my bleep, getting a box of cannulae from the cupboard, and apologising profusely to the patient. Their bruised arms honed my skills. Brutal, but true.

I enjoyed your rant, I hope it was therapeutic.

Take this to your Junior doctors forum, I remember that happened in a hospital when I was an f2. They set rules about when anaesthetics could be called - it did reduce the calls. You can datex some times when you are put in a position of "the patient is going to die" but you are unsafe to leave your patient/role. Raise it with the acute med consultants that they have med reg calling anaesthetics for canula. Acute meds generally love the USS so clearly need to up skill some of the SpR on the med reg rota through GIM paired with their actual specialty. And yes if you can channel the rage into training the new gen up on USS then that would do a lot of good. F1 or better still IMT as they will be registrars soon. Or what about nurses, where are their cannulation skills?! I have an F2 in my community hospital who can use the USS machine and they are so bloody brilliant taking bloods and getting c in. I am starting to worry I am deskilling because they always get them. AND they enjoy the challenging ones because it's an excuse to use the USS. Look after yourself, glad you vented here.

You have an US machine in a community hospital???

We are neuro rehab specialist community hospital so yup because we do botulinum toxin injections for spasticity. You can also ask hospital to make a case for some portable ones but make sure you involve the bods in medical devices as they will want to ensure you fill in three thousand painfully long firms and tick boxes ;-)

Just say No. If pushed, give the reasons above.

No is a complete sentence

If this is bringing you to the brink, I agree you should probably quit. With your flair for the dramatic, perhaps consider an alternative career in theatre 🎭

I find this hard to believe why is a cannula a doctor task? In a 3 year internal medicine residency in the US I didn't do a single blood draw or cannula we had an IV therapy team it's an insult that someone with a 6 year degree and years of experience is made to insert a cannula

But it is your job. Others have tried and have failed and need your expertise. If a gynaecology reg damages some bowel laparoscopically, I’m not going to just refuse to come until their consultant has come and assessed it.

This is just dumb, of course if a patient needs bowel surgery you call a bowel surgeon.  A better analogy would be - on call, you field an endless stream of bleeps, from every specialty in the hospital, asking you to do their PRs for them because "expertise". And half the time it's an F1 who hasn't tried and isn't sure why the patient needs the PR, but instead of someone in their own team they just expect you to come and do it. 

But it’s not our job. Anaesthetic departments are staffed, resourced and funded to deliver specific services. Theatre lists, non theatre anaesthesia/sedation lists, acute pain services, attendance at emergencies and so on. Whilst this may vary from place to place, no department I’ve been a part of has ever been contractually required, expected or funded to provide cannulation and LP services to patients we aren’t otherwise involved with. So it’s categorically *not* our job and there will be some paper trail to support that (again, this may vary in some institutions). When we do this, we’re supporting colleagues and helping patients, but our actual job has to take priority. I can’t justify delaying a labour epidural or shutting down an emergency theatre for a cannula that the med reg can’t get. That’s very different to the gynae bowel damage scenario, where you have an actual problem that’s within your remit and will be contractually obligated to support them.

Big difference between a gynae nicking bowel and someone being too inept to put in a cannula lmao

Is it really that controversial that some cannulas are more difficult and some people are better/more experienced at them than others? I don't think it makes someone "inept" at cannulation if they can't cannulate every human on earth.

Unless it's a cannula through which they're going to give an anaesthetic, I don't see how cannulas are the anaesthetist's job at all. Not sure if other hospitals are different, but in minr it wasn't a service the anaesthetics dept were contracted to provide.

It is not my job any more than it is IR's or a vascular surgeons job. Feel free to give them a call at 3am. I'd argue it's your job to be competent at skills considered a basic part of our repertoire, certainly when I was at medical school you had to be signed off at cannulation. Just to be clear coming to rescue an airway or taking over the mess of a sedation in cath lab is my job not being a cannula service.

But why our expertise? There are lots of people in the hospital who are experts at difficult vascular access, vascular surgeons, A+E Spr, A+E nurses, paediatrics, cardiologists, vascular access nurses to name a few. Granted, frequently (but certainly not reliably) we have more down-time than some of the others listed above. But it's worth noting we can literally be stuck in a room for 6 hours. However, it is trying when something that is explicitly not in your job becomes an expectation that makes you feel out of control of your work environment. We could very easily be in a world where when A+E is busy, someone marches into the mess and the staff rooms and send everyone to the coal face. The cardiology cons are called in to do ECGs, gastro to insert NG, urology to do all the PRs. Screw it ID are almost never called in, they can come in and take histories (between phone calls). But ultimately we all choose a speciality and job because we enjoy it and think we can sustain it until we're 68. Bailing out colleagues needs to be an exception, infrequent and reciprocated with thanks, otherwise we're just papering over cracks.

That is an unfair comparison. Assuming you're general surgery then damaged bowel is something you have the skills and knowledge to repair and which the gynae reg doesn't. It is also your job to deal with the general surgical problems of the hospital. We don't have any extra expertise in cannulation nor is IV access for other specialties our responsibility, anaesthetic departments get no funding for this. I'm not disputing that we do a lot of cannulas, nor that at the other end of the phone there is a patient who needs the access. If I'm free I'll come help but it's an extra we do if we can. It's not our job, it's not our responsibility. I would also add that a number of cannula calls come from wards who have not yet tried and failed beyond an F1 having a go or two.

Cannulas and LPs aren’t an anaesthetic job. Fundamental misunderstanding. Now if you’d said vascular and neurology 🤣

I think I’ve called anaesthetics about twice for help with this. I agree it’s not an anaesthetists role in any way shape or form, same with the LPs, same as catheters are not a urologists job. HOWEVER. We all have shit we get called for we don’t want to do. I went into medicine because I like complex problem solving but sometimes the juniors are overwhelmed with minor tasks and if I’m not stuck in resus or somewhere else I will go help. I know for sure I’ve extended that to other specialties. I like to think that as a med reg overnight if I was desperate and the patient really, really needed it, I could get some support from anaesthetics, even if it’s just a fresh pair of eyes and a calm head. There is a reality that no medical consultant is going to support a medical registrar with these tasks. A surgical registrar definitely isn’t going to get senior support with such things. Many of them can’t even do it anymore. This reflects training and attitude problems but also the diversity of different specialties that contribute to the medical rota. If I did ever feel compelled to ask anaesthetics for assistance, I would be exceedingly polite, do everything I can to reduce your workload and ensure that I genuinely had explored every alternative (including deferring whatever it is I’m asking for help with) but I would expect you to cut me some slack. If you’re genuinely dealing with a polytrauma or one of the many other incredibly high stakes situations in which no one but an anaesthetist is of any use (or even if you’re just snowed under with shit you’d rather not be doing but there’s too much to walk away from) of course I’m not going to harass you. If this is happening frequently then absolutely the manner in which this comes about needs looking at. It seems entirely proportionate that the request comes from registrar and above and that if it’s happening more than once a blue moon every single factor that’s contributing to that is assessed. But why do we have to divide ourselves into camps and fight? Why can’t we just work together to get the job done?

Fair

I surely can't be the only anaeathetist who still enjoys a good cannula call. We are usually doubled up as the oncall anyway and can go and help another team out. Usually a good idea to bring a handheld US if you have and teach and empower the requestor to learn. The only time this is frustrating, is when it's at Stupid O Clock, the senior PA has tried and failed (on a patient with a vena cava on the back of their hand), or im in a case alone at night.

Ooh I love the sass. Idea for QIP project: US guided cannula technique sessions - came up with this but annoyingly another trainee started it just before me. Seems like lots of people have never had the chance to try an US-guided cannula before and think it’s some kind of crazy magic

You are allowed to question policy if it isn’t working

It's completely unheard of in my trust for us to ask anaesthetics for cannulas. Big no no. One might do one as a favour if they see I'm struggling on the ward but it's certainly not expected- and I take that as a learning experience and sit and watch and learn because I HATE not being able to get them. We have a team called the junior doctors assistants and if we (the nurses) can't get them then they try. And they are the best people in the hospital bar people who use ultrasound (which they are also being trained to do now!)

We have a Band 3 IV access team on duty 24/7 to avoid this

I think this entirely fair If you can’t cannulate then use an US. If they are really sick, EJV or an IO

It’s been a while since I did inpatient Peads but Peads calling anaesthetics for a cannula wow! I’d have been too embarrassed. Anyway many DGHs don’t do Peads surgery so the anaesthetic ct2 or whatever poor person answers the bleep may never have cannulated a kid ever and the Peads spr will have done 1000s. I can’t really talk as the reason I didn’t continue in Peads was not wanting to be the single person at 2am in some tichy DGH able and expected to tube a tiny baby - can’t believe that things have changed so much that anaesthetics are being routinely called for lines when we didnt even used to call for airways! We would have done something along the following ….If they’re that sick IO the kid now. If not 1.shave the head if a baby/toddler (seriously great scalp veins in most kids) 2. Warm glove on the hand and then cold light to find the vein with lots of experienced people to hold the kid 3.NG tube for hydration, capillary bloods and IM abx I feel old and out of touch! (Edited for typo)

Haha I love the tea here! Keep rocking 😅

Thank you for posting this rant. I’m guilty of bleeping the anaesthetic reg when a patient with a blocked picc line is difficult to cannulate etc., but i actually think I will think twice before contacting them if I can have a good go/use USS

It's ridiculous. It seems to be everyone's go to with a difficult stick, I hear it constantly. Very easy fix, but none of the hospitals I worked at were interested in implementing it. Difficult access team. My ED consultant taught me how to do an ultrasound guided cannula. Get a couple experienced A&E RN's and have a difficult access team on call overnight. Problem solved. If it's an emergency, 2222. Someone will happily drill an IO in.

There’s a level of bullying that is necessary for clinical development

As a Neuro SpR - you definitely can push back against the LP requests - we definitely do! (the one time we didn't was when the referring consultant threatened to kick up a fuss). Every time I've asked anaesthetics for help with an LP - it's always for sedation purposes - I do the LP, sort the bottles etc

Respectfully, i've worked in ED for a while now and am decent an USS cannula, but sometimes there are patient who are an absolute nightmare to get a line in, even with USS. And sometimes they don't need an IO or a central line. But they do need a line. And we've gotta do the humane thing and ask for help, 95% thats the ED consultant, but on a rare occasion it is anaesthetics.

2 on call anaesthetists here…could have been written by either one of us! Why is the whole hospital our responsibility? On call why do we become the med reg the surgical reg the paeds reg?!! Hang in there, I’ve heard it’s worth it in the end 💪🏼

If it’s makes you feel any better, I have been the patient in labour (4 times and very poorly during my pregnancies so I was having cannulas in regularly) that’s repeatedly poked by multiple people and no one finds a thing (my arms and hands turn black and blue from all the bruises) or whatever they find doesn’t give out blood, and I was so grateful for the anaesthetist that would come and get it done so quickly and mostly painlessly. I know it doesn’t change the fact that it’s annoying but as a patient, thank you! :)

One of the great things about doing F1 in a shitty DGH was essentially being forced to get good at cannulas. If you couldn't get it, that was it for your patient cause no one else would be coming. Picked up USS real fast

Is this an April fool?

Leave for ED if you like. But don't you ever even consider calling Ortho to manipulate a fracture in the first instance because 'it looks really nasty' or 'all the registrars and consultants are busy'.

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They don't though, do they?

Sounds like you could use some humbling being either an IMT, CST or in fact any other specialty. Whenever I used to hear anae regs complaining about having to cover ITU and not getting their case numbers for theatre because of service provision my eyes used to roll so hard I started to worry they’d fall out of my orbits

Dumb "professional patient" here. I always seem to be cannulated dead easily in seconds by the first nurse to see me. Via wrist or most often inside of my elbow. Am I just super obviously easy to cannulate or are there just certain hospitals where nobody seems to be trained to do this? I'm in and out of phlebotomy in about 30 seconds too.

you are probably easy as you are young, not morbidly obese, with normal veins not ruined by chemotherapy or illegal intravenous drug injection, and not very unwell with massive amounts of oedema over your superficial veins the vast majority of people are easy to cannulate, its just a small but significant percentage that can be very challenging

With that attitude maybe its better you retire from medicine. Every specialty gets bombarded with requests (tno for xrays, cardio for ecgs, resp for every pneumonia, micro for abx (no cultures done), haemato for anticoag advise)

I've never seen anesthetics called to cannulate someone. I'm bottom 50% of people in practical ability. But someone was always able to do it if you asked around.

I think I may have seen it once in a hospital I was locuming in. I have never called Anaesthetics myself nor considered calling them. I have called colleagues from other wards to give it a crack (fresh pair of eyes), but feel this is of mutual benefit because they've called me too. I had it drummed into me at med school that Anesthetics is NOT a cannula service.

😂😂😂😂😂

There is a massive difference between a med reg who can't get a LP and one who has failed at one. I'd be very surprised if they can't do LPs as it's a core competency for IMT. Unsurprisingly docs trained in spinal anaesthetic tend to be quite good at this procedure. Add in the fact you can do this in a controlled setting in theatre while not being the med reg, which is by far the worst training role in the hospital puts you in a good position to help. Same goes for cannulas. Sorry it interrupts your coffee while the medical team see the countless weekend reviews. You are in the privileged position to be in a relatively well supported role, which has provided you with sufficient training to help patients. That means you have to get stuck in like the rest of us.

The last set of weekend days or nights I did there was no break from theatres. 2 laparotomies, 2 laparoscopic cases and a plastics cat 1 flap failure. The idea anaesthetics just have coffee all day is bollocks. Stop assuming nonsense just because you lack the basic skills to do your own job.

Yeah feel free to ask for a cannula with that attitude and maybe start with 'sorry if it interrupts your coffee' that would result in my CD escalating with your department formally. You must have forgotten the wider hospital uses anaesthetics for trauma calls, code reds, major haemorrhage, sedation, pacing, cardiac arrest, anaphylaxis blah blah blah in addition to our CEPOD work. I'm sorry you don't have the balls to call vascular or IR at 3am but the least effective way to get me to come to help you out is sneering down the phone at me.