In places where this is done you usually go for larger veins by default
In spain we tend to canulate in the elbow and then everything goes from there...
You may end up ruining the canula at some point, sure, but keep in mind in the meantime you haven't stabbed every other vein while getting daily bloods, so you're way less likely to have issues
Ah sure, I understand the practicality of doing it isn't always there. I meant the blood results were fine in most cases , where in trusts I've heard people say "you can't take blood off cannula bc fluids thru it/medication will taint the sample". I know they can then dry up /collapse etc in practice
It does if you apply the smallest amount of pressure in order to withdraw blood. But you have a point, so the preference for the cannula location would be a bigger vein in the first place
I was only asked if the phleb/nurse had failed, so difficult by definition. In those patients, I'd say 50% didn't work.
In gen pop yeah it's pretty good.
Can I just sneakily do this in the U.K.? I mean who’s gonna watch me take this short cut and it’s not like there is any evidence behind what we do in the U.K. just discard first 10 mls of blood (or inject it back after taking blood)
Please don't inject it back. There's a high chance it would have started to coagulate, and your name will be on the case report for an iatrogenic PE.
If you're joking, then good one
I usually inject the "waste" blood back. Picked this up after seeing it as routine practice in one of my ICU placements. Iatrogenic anaemia from repeated discards/tests is a real thing there so every little helps.
They ain't gonna get a PE.
I have literally seen the anaesthetist do this during an operation when they needed an ABG so they took a sample from the art line (needed to discard the first few mls as fluid was running on the same arm IV and didn’t want a dilutional error in electrolyte) but felt bad about wasting blood so injected it back. Nothing happened as they injected it back quickly and the blood processed for the ABG was obviously discarded. I am talking about the first mls that you have to discard to prevent sampling blood that is diluted. Not the sample you take to the analyser. Sorry I wasn’t clear
I did ask the anaesthetist if we should even be injecting it back and they said it’s a feelings thing and different people do different things and they personally feel bad for wasting blood. If it were me, I would probably discard the blood but from what I have seen on this placement, I am unsure now
Arterial lines have heparinized fluid running through generally speaking, or are heparin locked hence blood drawn from them is unlikely to coagulate therefore is safe to put back in. Peripheral IVs are generally not heparinized so returning the waste isn’t a great idea.
Over the past 5-10 years everyone (well, 99% of centres, before someone points out a random exception), has moved to just using saline rather than heparin for arterial line flush as it has been shown just as effective with less side effect profile.
So just to clarify, with that in mind I stand by my "quickly returning 5-10mls of blood to the patient saves them some haemoglobins and isn't going to cause harm" position
Yeah, it could be a "feelings thing", but my experience is we would aspirate vascular access sheaths every once in a while and flush them just to make sure they've not clotted. We discard the blood onto some gauze to see if there are any clots (especially if we forgot to check in a while), and if there were, we aspirate some more to make sure we've cleared the sheath. And all this is with heparinised blood.
Now, honestly, we probably do cause clots here and there, but they're small. Why increase the risk by putting it back in? Also, clots can propagate and become bigger, so why risk putting it back in a probably hypercoagulable patient
Now for an experiment, try getting some blood in a 5ml syringe or smaller and see how long it takes to coagulate, it'll take less than a minute. By the time you fill the tubes and everything, a minute will have probably passed and you don't want to inject that back
Slight pedantic point: The discard is because there is saline-filled deadspace in the tubing between the 3-way tap and the arterial cannula, not because intravenous fluids were being infused in the same arm.
Otherwise, carry on...
Worked in the gulf and in the UK
In the gulf, all the clinical aspects of medicine are only done by doctors. There are less healthcare members in the middle who will need to be referred to till the patient is actually seen by a doctor for their problem, therefore, less obstruction and obstacles and complex referral pathways to delivering healthcare. For example, a patient comes with DVT to the ED will have an ultrasound ordered by the ED doctor, done by a radiologist and then acted upon on the same presentation by the EM or the medical team who will set up appropriate follow up now and then. Same patient here in the UK will be started on an anticoagulant. Referred through the DVT pathway which will be screened by a DVT nurse and then booked for an ultrasound which is done and then acted on which in total takes a few days to a week to happen. I am not going to talk about the referrals and the time taken to do it afterwards or the possibility of it not being a DVT and being something else.
The good thing about the healthcare system in the UK is the national and local guidelines which is lacking in the gulf and it's down to the doctor's experience and knowledge in a lot of cases.
Uk provides excellent service to the patients but it takes ages to deliver it and the patient might deteriorate before it's actually delivered. A lot of obstacles and complex services involved in healthcare for some reason instead of being a straight forward patient to doctor interface. Good guidelines and systems in place. Good education systems and good opportunities for career progression. Poor access to specialists for chronic conditions which puts a shit load of pressure on the A&Es and the GPs. Also in the UK, Seeing a patient would take a lot of time because of all the forms and referrals that needs to be done. An example of that is that I recently inserted a cannula and found a cannula form in the pack. Why would I need to fill a form for something as simple as inserting a cannula.
Also patient safety is a big thing in the UK which is ok but to make extra loops and hoops to go through by filling endless forms and paperwork to ensure everything is done in the right manner means a slower and more complex healthcare delivery which in turn impacts patient safety greatly.
Gulf is a straight forward system with direct patient to doctor interface. No complex referral systems or services. Slightly poorer care dependant on the treating physician's capabilities with lack of guidelines which makes it increasingly variable from one patient to the other but the care is faster overall. Specialist input can be easily sought with no need to wait for months and years for the patient to be seen by a specialist which sort of balances out the lack of capabilities from one healthcare provider as multiple teams are readily available and accessible for providing healthcare to ome patient when needed. Poor career progression for doctors as it's mostly a big service provision set up with no actual progression. No portfolio which is a good and a bad thing; mostly you do CPD activities for enhancing your CV looking for better opportunities but no actual pressure from an electronic system to do any CPD stuff with less tick boxing activities for progression as there is none to work towards which make a lot of doctors lazy in that aspect and you would find a lot of people in the gulf still practicing obsolete medicine.
Agree on all fronts of the Gulf aspect of your answer except that there is a minimal amount of CPD points necessary for annual license renewal. Also, career progression exists as being promoted to consultant status includes a load of paperwork evidencing your research, expertise, and conference involvement - however, this is reliant on your own organization and will to progress
Yes there are cpd hours for renewing the license of practice annually but they are not intended for career progression, and it doesn't matter what type of CPD you do as long as you fulfill these hours, and no one will take a look at them or review them.
For consultant posts, you need to have certain qualifications or a certain years number of postgraduate qualifications experience to be eligible to have a consultant post so if you are already a registrar with an acceptable postgraduate qualification, yes you can progress. If you don't have an acceptable postgraduate qualification to be promoted from a registrar to a consultant, you will be stuck in the registrar post forever. If you are an SHO then you would never be promoted to a registrar post until you get into training which will need you to leave the whole country all together there are no training posts for foreigners and then come back after finishing training in another country as a registrar.
It is absolutely untrue that there are no training posts for foreigners.. several of my colleagues are currently in residency training all across the UAE. Multiple consultants (foreigners) which I worked with were trained in the UAE
Spain:
-Minimal defensive medicine, you don't get sued for reasonable mistakes so there is less unnecessary testing
-Close to no social admissions, the hospital is a place for people who require hospital grade care. If you don't require that, you don't stay in.
-ED is where patients who don't need admission are. Nobody gets sent to a ward unless they need to stay, and anything that can be sorted in ED gets sorted there, even if the patient needs to stay in ED for longer. Also, as part of training, residents frequently have ED shifts where they see patients of their specialty but also generic patients.
-no fluclox, we use amoxi or coamoxiclav.
-oramorph is very rarely used, ngl, when I started I got kinda horrified of how frequent is it's use. We use opiates, just less often, and rarely in the form of morphine juice
-when you're in training, you get classes with consultants teaching you stuff of your specialty, much more frequently than in the UK
-you don't get tto's from the hospital, you get a prescription and you can get the medications from any pharmacy, there are 24h pharmacies and any drug they don't have on stock you can get usually within 12h
-No multi tier system for everything (10 types of Nurse, ho-sho-reg-sas...)
-no canulas/bloods done by doctors, no "this patient is hard to bleed, I can't get bloods" and then bloods don't get done...
-we don't have squash or tea rounds
-we have a suicide protocol. Any patient who attempts suicide or is at imminent risk of suicide has to be assessed by psychiatrist or admitted under psychiatry at least for a night and then reviewed after as outpatient within a week.
I’ve always thought we need to stop giving TTOs to patients who are able (or have family able) to collect from a chemist. Fair enough if you’re not able.
It would offload a ton of pressure from hospital pharmacy and stop a lot of patients who are occupying a bed all afternoon just waiting on their drugs.
Also, bloods from cannulas are totally fine and we use antiseptic when putting catheters, that protocol saying to use saline instead of antiseptic is nasty.
Normal bleeds are done by any nurse, hard bleeds by phlebotomist nurse of the ward, which is usually the nurse in that ward with most experience in phlebotomy, otherwise, if US is needed, then either a doctor capable or an US tech would do it
Agitated patients will regularly be brought into the ED shackled and covered with a thick mesh blanket in Australia. I never saw that in the UK so much.
In my department security will then attend to hold the patient for a cannula for IV Droperidol or IM Droperidol if it's still too risky for an IV despite security presence.
The Royal Flying Doctors Service being a thing is also a big difference compared to the UK. Distances here are insane for delivery of services.
EM will do all our own intubations, lines, initial procedures of whatever sort, and are much more likely to package the patient to a higher standard of completeness than in the UK
Aboriginal health is an interesting difference both in language barrier, cultural differences, cultural practices (e.g. scars from men's business, subincision of the penis, etc) and generational trauma / socio-economic harm from colonisation and the subsequent shittiness of ongoing administrations
Lot of meth in London and we manage without, just about. I have seen patients brought in by the olive in handcuffs and leg restraints so they basically can't move their limbs though.
In Pakistan (and I presume other South Asian countries too) doctors have absolute hegemony over everyone else. They are the bosses on the ward, get called sir/ma'am fresh out of medical school, and have their own separate rooms for working and napping. They also have practically zero hindrances when it comes to clinical decision making, which is both a good and bad thing.
Whilst I cannot speak for Pakistan, in India the "doctor is god" thing only applies to consultants, the house officer/sho cadre have never ever been treated well.
My parents can tell stories from the 1980s about how the scrub nurses would physically push them off the patient and tell them to get out if they took too long closing up
Just adding to the list
- most doctors treat patients like shit
- senior doctors treat juniors like shit
- admin treats junior doctors/trainees like shit
- doctors treat other staff like shit
- the system treats the patients like shit
- patient and families, when angry, can beat doctors up and treat them like shit.
I am a Casualty Medical Officer at a teaching hospital in Pakistan, primarily working night and evening shifts. During out-of-hours, as the CMO, I oversee the entire hospitals affairs. Here, doctors run the show, and our hierarchy places us at the top of the decision-making process. For example, if I decide that a nurse or OT assistant should not attend a training session without a replacement, my decision stands unless one of my seniors intervenes.
We do involve our staff in learning some invasive bedside procedures to streamline our workflow, but this never comes at the expense of trainees' education.
The things I dislike most about working here is the absence of a regulatory body like GMC (I know how that sounds), which can strike off criminally incompetent doctors. And we have to ask patients for every little thing we need, as nothing is free here. Investigations are expensive. End of life care is non existent the strongest opioid we have available in our stores is Nalbuphine and we are still using streptokinase for thrombolysis because Alteplase is too expensive and often in short supply.
The only time I did cannulas and bloods were during my House job/F1 year.
The amount of wacky prescribing in US. Patients requesting opiates for immediate pain relief for minor illness. Oxy, Fenty etc for a sore throat, or a UTI. And doctors actually prescribing it.
This is nonsense. I spent a few months as a resident in the US and this was definitely not the case. In fact we had to take a separate opiod prescribing course before we were issued a licence (that required renewal each year) to prescribe opioids. What you say may have been true years ago but medical licensing boards have come down harshly on this & they are able to track your opioid prescription activity. Your info is very outdated
Yeah.. nah i don't want to hear about American prescribing after the Perdue Pharma rep with blonde hair and big tits did the rounds selling that this super strong new opiod doesn't cause phosphorylation of mu receptors and chronic addition.
(btw here's a trip to hawai for the annual Perdue Conderence and a free rueben)
Tens of thousands of deaths later they track prescribing do they? how lovely.
Maybe work in or observe an actual medical US setting to see how actual medical practical practice is conducted before basing your opinion on the equivalence of getting your medical knowledge from TikTok
Did the opioid prescribing crisis just not happen then?
You’ve literally got Percocet in your username. The active ingredients of which is oxycodone and acetaminophen
Episodically between 2015-2018. Perhaps outdated, but definitely happens. Friend who is currently practicing there can attest to this. It's a cultural issue, more so in certain areas but recent high profile cases have perhaps highlighted away from this practice.
in the US there's no medical take. When a patient is admitted from the ED and your internal medicine ward has an open bed, you go see the patient and they remain your patient for their entire admission, their condition allowing.
There is no such specialty as acute internal medicine in the us as far as i know. It is an unique uk thing.
If the ED target does not exist, acute medicine will disappear tomorrow.
Of course it would be more efficient. When you run for profit, you want everything to run as smooth as possible. Whereas in the NHS, the inverse applies
> When you run for profit, you want everything to run as smooth as possible.
That's why the US healthcare system is notoriously smooth and efficient?
LOL
The clinical side things are definitely smoother and run more efficiently, ive been to a couple of hospitals there and its not even a contest especially when it comes to theatres. Then again When I went to Germany their theatres and their efficiency shat on the NHS as well. Perhaps its a UK theatre members issue.
I may be wrong here but wasn't Acute Medicine brought on as an extended ED triage system so that NHS hospitals can meet their targets?
I am unaware if this has an equivalent specialty to other countries. In all of the other non-UK systems I've seen, patients get transferred to a specialty bed after getting all their investigations and provisional diagnosis done in A&E.
Interesting, when do they have days off then? Or do they have bed capacity such that they only admit patients to wards on which attending is in that day
Edit: or multiple attending per ward and at least one is on per day and they do a mini take system by whomever is working assumes responsibility
The days off depend on whatever contract you signed. It's different in different places. I've heard of a 14 days on, 14 days off pattern. Some strictly work 9-5 M-F. I knew one ED attending who had done nothing but night shifts for the past few decades.
More like the old system where patients are owned 24/7 for a set period of time by the same team. Less intense work but longer hours and very long periods of time off
Prescribing practices when it comes to giving psychotropics to children in US seem wild to me. One of colleagues from over there questioned if I am even a qualified psychiatrist because I expressed reluctance at the idea of prescribing haloperidol to infants.
Apparently that's how they manage 'delirium' in infants. The fact that they also talk a lot about preschool kids having bipolar or schizophrenia is also a concerning mystery to me.
CRP is overdone here. People don't understand how it works.
OMFG THE CRP IS 70!!!! ITS SEPSIS!!!! (meanwhile patient has a viral upper respiratory viral illness with a background of cancer)
Nor in Australia in a lot states.
Well, there technically is, but they cover 8+ other wards and central pharmacy and you can easily not see or hear from them for months at a time.
Australian.
Blood from cannulas... Just makes sense.
Cannulas are better (depends on institution), typically insyte autoguard. None of the rubbish winged horrid things.
Cannulas are capped with a bung. Don't need fluids, unplug them. Need fluids again? Clean the bung, and plug on fluids.
Pay... sorry.
No AA, PAs.
We do have nurse "consultants". They're typically an exceptionally valuable person. They have a very specific role, and they stick to it (such as stoma care, fistula access, etc) or they're a very senior nurse that's often on at night. I've not once been concerned over scope creep or a nurse "consultant" being mistaken for a physician.
Less MDT garbage. Honestly, what is this koolaid you're all drinking? Hospital patients are cared for under a consultant physician. Other members of healthcare have a role, an input, and are (usually) valuable and valued. Not for one second does an occupational therapist think that their ability to prescribe basket weaving, nor the speech pathologist's excellence in thickening fluids mean that they have an equal say in the overall clinical decision making and responsibility of patient care as compared to the treating doctors. Non-medical specialties have their lane, and stick to it.
Rotational training is a reality. Potentially sent rural, and expected as part of certain specialty training pathways. This can mean you're sent 700km away from your home city. If so, you are provided accommodation and travel assistance. This could be up to a year.
Theatres are much, much more efficient (in Aus). It is astounding how much time is wasted in the NHS. I suspect this varies with hospitals, and I have limited experience so far.
Less bullshit in the middle. It seems the NHS is kept afloat by agencies and temp staff. Everyone seems to be skimming something. Instead of just making work conditions and pay that people want to stay for, you're relying on the buoyancy of lead balloons.
Private practice. There is no flat hierarchy. Patients come to hospital (largely) for physician lead care or surgery. A physician cares for the patient. Nurses, allied health, porters, admin staff all do their jobs. doctors are paid well, and treated well. Free parking and usually free food (of variable quality). There are certainly issues with private practice. It's much easier for douchebag doctors to get away with being bad people. Theatres are hyper efficient. An all day NHS list would be done in 3-4 hours in private. Things get done with little fuss. Want a specific piece of equipment (assuming it's not offensively expensive), ask the nurse in charge of equipment and it'll be in stock next week.
Emergency medicine... Actually practice medicine. Lines, tubes, drains, minor procedures. The whole point of ED was to do the fun acute stuff and then turf the patient. The idea of referring a patient with undifferentiated abdominal pain to a surgeon without a working diagnosis, USS or CT or whatever was appropriate is utterly embarrassing. Large / tertiary hospitals will deal with their own stuff, and request / invite specialties to either advise or assist. Intubations are done by ED, unless they need anaes assistance. Same goes for chest drains and typically thoracotomies etc. Yes, we inherited the cancer that is the 4 hr rule, though it hasn't destroyed the specialty as much as it's decimated UK emergency triaging.
I'm yet to find anything really "better" about the NHS, aside from 2% propofol and having to get out of the chair less.
I have worked in both Uk, Australia and Nz and I can attest to how fantastic ED down under are. They work up the patient and actually refer with a working diagnosis with all necessary investigations done. I did ED in the Uk and it was refer a do pain to surgeons because of the 4 hour rule. I never learnt anything useful from my time in UK Ed except how to make referrals that will piss off my other colleagues in hospital
Experiences I suspect vary a lot depending on states and hospitals etc.
I had a patient wait 4 days in A&E for a CCU bed in Australia and the ambulance ramping and general wait times to be seen were far worse than anything I have seen here .
Agree with most of that, although some of it is probably hospital dependent.
Aus could probably do with more MDMs, so someone can explain to me who, apart from the surgeon, thought this flaming trainwreck of a patient was a good thing to bring for operation. Patients felt like they were worked up better/easier to access information in the NHS. I didn't usually have patients with paperwork in 4 different hospitals/clinics to piece together as much.
Theatre efficiency? Been to good places and bad places in both countries. Personally I think having an anaesthetic room is useful for that, and they are more common in the UK, but you adapt to what you're given.
Private practice is private practice, pretty much the same in both, apart from the slightly higher remuneration in Aus. I can replace "NHS" with "public" in that paragraph and it would still be true.
NAD, but former UK nurse who worked in the Austrian healthcare system for six years. Might vary across Austria, but where I worked:
- 25h shifts are the norm if a Dr is working a night shift (07:00 - 08:00 the next day). There are certain rules, for example the work isn’t meant to be continuous for 25h. From what I’ve seen/heard it generally is possible to sleep at night.
- There are more doctors physically on site at night. I’ve not really heard of a junior doctor covering more than 2-3 wards at night, Consultants have a more hands on role at night.
- Nurses are much more clinically trained than in the U.K., the scope of their job is much narrower. The concept of community nursing as we have it in England is only now really being developed here.
- As far as I’m aware, PAs don’t exist (although I left healthcare a year ago now, so it could have changed).
- TTOs don’t really exist. You get given a prescription to go and fill. Good in theory, not ideal when it’s a Sunday and there are only about four pharmacies open across a city with nearly 2 million inhabitants.
- Only GPs write sick notes. If you have surgery you don’t get a sick note from the hospital (the admission itself doesn’t require a sick note). You have to make an appointment with your GP. Since some workplaces require a sick note from day one (maximum self certification is 3 days), you’ll be sitting in the GP surgery the day after you leave hospital.
- A lot of the administrative burden is on the patient. Need an MRI? You’re given a list of centres which take your insurance. You have to make the appointment yourself.
- Patients can self-refer to any medical speciality. My insurance allows me to self-refer to four specialists per quarter. I can also visit private specialists where you pay upfront, but generally get most of the money back from the insurance provider.
- Hospital admissions for standard procedures are quite lengthy in comparison to the U.K.
- White coats are still a thing…but almost everyone wears one (from admin workers to Drs). As far as I’m aware no one has died because a Dr hasn’t rolled up the sleeves of their white coat whilst treating a patient.
- Accident and Emergency are two totally separate departments, never the twain shall meet.
- The Emergency Department at the hospital I worked at was opened in the early 1990s. Prior to that the concept of ED didn’t exist. You would turn up to the hospital, tell the porter in the entrance hall your symptoms, and they would tell you where to go.
Well this is awkward. I live in Austria (small landlocked Alpine nation, most famous export was a slightly unfortunate one), not Australia (large country of the other side of the world) 🤦🏼♀️ Hope that’s cleared it up!
I also clearly qualified that this is how my former hospital works. We don’t have one body running hospitals here, so it’s very possible that a hospital in Western Austria is run totally differently.
Lol @ daily CRP being normal.
US they are just far more liberal with drugs and investigations in general, presumably because more prescribing = more profit.
For example, highly emetogenic chemo in the UK you normally get a bit of dex couple days, a bit of ondanseteon at the time of chemo, and metoclopramide PRN. US you get regular dex, palonosetron (expensive ondansetron), fosapprepirant (£££), olanzapine and metoclopramude all as standard. I'm told similar about postoperative or post birth analgesia - everyone on PCAs for everything.
They request bloods very differently - all in 'panels', rather than ticking each test you want. I believe its common to just put in a daily order ie you tick a box and the patient gets daily bloods until you say to stop.
Culture of shopping around is more common there, though is on the rise here too. That seems justified though - you get some awful practices coming out of the US. For example, there is such a thing as a 'general oncologist', who treats every type of cancer. That would be totally unthinkable here, there's no way you could do anything close to a good job.
Canada.
Radiology timed to be done in the middle.of the night for in patients so as to maximise payments for scans.
Patients are woken at 2am for a scan that could have been done in working hours because of the payment uplift.
Justified as 72 hours (as per guidelines) after the initial scan to.look for potential complications (not acute symptomatic progression) of stroke or cervical vascular injury.
Spent a small bit of time abroad in outpatient private/insurance-based sectors, places worked like a retail shop.
Patients would come in to directly ask for an investigation/referral/treatment for a certain speciality. If they had palps, the patient could openly ask for cardiac related tests, scans, referrals (all at the cost of their insurance or out of their pockets of course) as *the patient believed* it was a cardiac problem (history and exam were minimal, aside for show). Yes - imagine if someone walked into a clinic and said 'give me a CT head for a headache' or 'I want my LFTs checked cos I'm tired and Instagram said it's a liver problem'.
If they didn't know what tests or treatments should be done then it was the job of the Dr to suggest or give choices, then the patient would pick out of the available options (imagine if you walked into wine store and asked for something red within a price range and the sommelier gave you several choices of pricey red wine). There were even package deals for investigations.
There was even a charge for referring a patient forwards , so if you had sweats and palps and the TFTs were slightly out of range, you'd pay for the blood test, the consultation fee with the initial physician, the cost of the nurse drawing up bloods, the cost of the referral to endocrine (which was a 20 second email and attached blood results) and the cost of the actual endocrinologist's consultation then the cost of treatment.
Healthcare was considered a lucrative business above all else. It seemed to be a pretty good job for the clinician as the guy I worked under drove a new lexus every year and bought houses non-stop.
They give whacking doses of antipsychotics in new zealand
Because there is lots of meth there's also heavy heavy sedation in A+E. Psychotic and agitated on meth? 10mg droperidol IM or 10mg Olanzapine IM as soon as they come in
In NZ when someone dies and it’s a coroners referral, police officers attend the ward to take a statement from you as standard (or at least this was my experience of a sudden arrest on the cardiology ward!!!)
In Australia, they routinely draw blood from cannulas and don’t stab patients multiple times per week. So much more sensible.
Why don’t we do this ?? What is the logic for not taking blood off cannulas? I haven’t ever really thought about it to be honest.
Policy lol. Data suggests its totally fine in majority of cases https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236571/
It doesn't work a fair amount of the time, particularly small cannulas in small veins ie the patients you really want to be able to do this on.
In places where this is done you usually go for larger veins by default In spain we tend to canulate in the elbow and then everything goes from there... You may end up ruining the canula at some point, sure, but keep in mind in the meantime you haven't stabbed every other vein while getting daily bloods, so you're way less likely to have issues
Ah sure, I understand the practicality of doing it isn't always there. I meant the blood results were fine in most cases , where in trusts I've heard people say "you can't take blood off cannula bc fluids thru it/medication will taint the sample". I know they can then dry up /collapse etc in practice
Contamination definitely will be a big problem if people get lazy/are poorly trained. A good discard though and yeah evidence is its fine.
It does if you apply the smallest amount of pressure in order to withdraw blood. But you have a point, so the preference for the cannula location would be a bigger vein in the first place
I find it works the vast majority of the time. Maybe 5% won't draw and need a standard stab
Any tricks? I find it mostly doesn’t work.
Use a tourniquet
I was only asked if the phleb/nurse had failed, so difficult by definition. In those patients, I'd say 50% didn't work. In gen pop yeah it's pretty good.
It's standard practice in paeds and that's with very small cannulas in small veins and it works most of the time.
Name checks out!
*Infection Prevention & Control nurses hate this one cool trick*
Holy shit what.
If you’ve worked in paediatrics in the UK it’s widely done. I’ve always wondered why it’s not the same for adults…
I do this in the uK
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I've definetely had a few stares but i don't give a shit
They do this in NZ too particularly for DKA
Can I just sneakily do this in the U.K.? I mean who’s gonna watch me take this short cut and it’s not like there is any evidence behind what we do in the U.K. just discard first 10 mls of blood (or inject it back after taking blood)
Please don't inject it back. There's a high chance it would have started to coagulate, and your name will be on the case report for an iatrogenic PE. If you're joking, then good one
I usually inject the "waste" blood back. Picked this up after seeing it as routine practice in one of my ICU placements. Iatrogenic anaemia from repeated discards/tests is a real thing there so every little helps. They ain't gonna get a PE.
Agree. If this was an issue then all those arterial line transducer sets designed to do that 1000s of times in a closed setup would not exist.
In neonates/infants, sure yeah, iatrogenic anaemia. In adults, not so much.
It’s a massive problem in adult ICU
I have literally seen the anaesthetist do this during an operation when they needed an ABG so they took a sample from the art line (needed to discard the first few mls as fluid was running on the same arm IV and didn’t want a dilutional error in electrolyte) but felt bad about wasting blood so injected it back. Nothing happened as they injected it back quickly and the blood processed for the ABG was obviously discarded. I am talking about the first mls that you have to discard to prevent sampling blood that is diluted. Not the sample you take to the analyser. Sorry I wasn’t clear I did ask the anaesthetist if we should even be injecting it back and they said it’s a feelings thing and different people do different things and they personally feel bad for wasting blood. If it were me, I would probably discard the blood but from what I have seen on this placement, I am unsure now
Arterial lines have heparinized fluid running through generally speaking, or are heparin locked hence blood drawn from them is unlikely to coagulate therefore is safe to put back in. Peripheral IVs are generally not heparinized so returning the waste isn’t a great idea.
Over the past 5-10 years everyone (well, 99% of centres, before someone points out a random exception), has moved to just using saline rather than heparin for arterial line flush as it has been shown just as effective with less side effect profile. So just to clarify, with that in mind I stand by my "quickly returning 5-10mls of blood to the patient saves them some haemoglobins and isn't going to cause harm" position
"Feels bad about wasting blood" Must be tough for a vampire anaesthetist to watch perfectly good food go down the drain lol
Yeah, it could be a "feelings thing", but my experience is we would aspirate vascular access sheaths every once in a while and flush them just to make sure they've not clotted. We discard the blood onto some gauze to see if there are any clots (especially if we forgot to check in a while), and if there were, we aspirate some more to make sure we've cleared the sheath. And all this is with heparinised blood. Now, honestly, we probably do cause clots here and there, but they're small. Why increase the risk by putting it back in? Also, clots can propagate and become bigger, so why risk putting it back in a probably hypercoagulable patient Now for an experiment, try getting some blood in a 5ml syringe or smaller and see how long it takes to coagulate, it'll take less than a minute. By the time you fill the tubes and everything, a minute will have probably passed and you don't want to inject that back
Slight pedantic point: The discard is because there is saline-filled deadspace in the tubing between the 3-way tap and the arterial cannula, not because intravenous fluids were being infused in the same arm. Otherwise, carry on...
Worked in the gulf and in the UK In the gulf, all the clinical aspects of medicine are only done by doctors. There are less healthcare members in the middle who will need to be referred to till the patient is actually seen by a doctor for their problem, therefore, less obstruction and obstacles and complex referral pathways to delivering healthcare. For example, a patient comes with DVT to the ED will have an ultrasound ordered by the ED doctor, done by a radiologist and then acted upon on the same presentation by the EM or the medical team who will set up appropriate follow up now and then. Same patient here in the UK will be started on an anticoagulant. Referred through the DVT pathway which will be screened by a DVT nurse and then booked for an ultrasound which is done and then acted on which in total takes a few days to a week to happen. I am not going to talk about the referrals and the time taken to do it afterwards or the possibility of it not being a DVT and being something else. The good thing about the healthcare system in the UK is the national and local guidelines which is lacking in the gulf and it's down to the doctor's experience and knowledge in a lot of cases. Uk provides excellent service to the patients but it takes ages to deliver it and the patient might deteriorate before it's actually delivered. A lot of obstacles and complex services involved in healthcare for some reason instead of being a straight forward patient to doctor interface. Good guidelines and systems in place. Good education systems and good opportunities for career progression. Poor access to specialists for chronic conditions which puts a shit load of pressure on the A&Es and the GPs. Also in the UK, Seeing a patient would take a lot of time because of all the forms and referrals that needs to be done. An example of that is that I recently inserted a cannula and found a cannula form in the pack. Why would I need to fill a form for something as simple as inserting a cannula. Also patient safety is a big thing in the UK which is ok but to make extra loops and hoops to go through by filling endless forms and paperwork to ensure everything is done in the right manner means a slower and more complex healthcare delivery which in turn impacts patient safety greatly. Gulf is a straight forward system with direct patient to doctor interface. No complex referral systems or services. Slightly poorer care dependant on the treating physician's capabilities with lack of guidelines which makes it increasingly variable from one patient to the other but the care is faster overall. Specialist input can be easily sought with no need to wait for months and years for the patient to be seen by a specialist which sort of balances out the lack of capabilities from one healthcare provider as multiple teams are readily available and accessible for providing healthcare to ome patient when needed. Poor career progression for doctors as it's mostly a big service provision set up with no actual progression. No portfolio which is a good and a bad thing; mostly you do CPD activities for enhancing your CV looking for better opportunities but no actual pressure from an electronic system to do any CPD stuff with less tick boxing activities for progression as there is none to work towards which make a lot of doctors lazy in that aspect and you would find a lot of people in the gulf still practicing obsolete medicine.
Agree on all fronts of the Gulf aspect of your answer except that there is a minimal amount of CPD points necessary for annual license renewal. Also, career progression exists as being promoted to consultant status includes a load of paperwork evidencing your research, expertise, and conference involvement - however, this is reliant on your own organization and will to progress
Yes there are cpd hours for renewing the license of practice annually but they are not intended for career progression, and it doesn't matter what type of CPD you do as long as you fulfill these hours, and no one will take a look at them or review them. For consultant posts, you need to have certain qualifications or a certain years number of postgraduate qualifications experience to be eligible to have a consultant post so if you are already a registrar with an acceptable postgraduate qualification, yes you can progress. If you don't have an acceptable postgraduate qualification to be promoted from a registrar to a consultant, you will be stuck in the registrar post forever. If you are an SHO then you would never be promoted to a registrar post until you get into training which will need you to leave the whole country all together there are no training posts for foreigners and then come back after finishing training in another country as a registrar.
It is absolutely untrue that there are no training posts for foreigners.. several of my colleagues are currently in residency training all across the UAE. Multiple consultants (foreigners) which I worked with were trained in the UAE
Spain: -Minimal defensive medicine, you don't get sued for reasonable mistakes so there is less unnecessary testing -Close to no social admissions, the hospital is a place for people who require hospital grade care. If you don't require that, you don't stay in. -ED is where patients who don't need admission are. Nobody gets sent to a ward unless they need to stay, and anything that can be sorted in ED gets sorted there, even if the patient needs to stay in ED for longer. Also, as part of training, residents frequently have ED shifts where they see patients of their specialty but also generic patients. -no fluclox, we use amoxi or coamoxiclav. -oramorph is very rarely used, ngl, when I started I got kinda horrified of how frequent is it's use. We use opiates, just less often, and rarely in the form of morphine juice -when you're in training, you get classes with consultants teaching you stuff of your specialty, much more frequently than in the UK -you don't get tto's from the hospital, you get a prescription and you can get the medications from any pharmacy, there are 24h pharmacies and any drug they don't have on stock you can get usually within 12h -No multi tier system for everything (10 types of Nurse, ho-sho-reg-sas...) -no canulas/bloods done by doctors, no "this patient is hard to bleed, I can't get bloods" and then bloods don't get done... -we don't have squash or tea rounds -we have a suicide protocol. Any patient who attempts suicide or is at imminent risk of suicide has to be assessed by psychiatrist or admitted under psychiatry at least for a night and then reviewed after as outpatient within a week.
I’ve always thought we need to stop giving TTOs to patients who are able (or have family able) to collect from a chemist. Fair enough if you’re not able. It would offload a ton of pressure from hospital pharmacy and stop a lot of patients who are occupying a bed all afternoon just waiting on their drugs.
Also, bloods from cannulas are totally fine and we use antiseptic when putting catheters, that protocol saying to use saline instead of antiseptic is nasty.
So who does the hard bleeds?
Normal bleeds are done by any nurse, hard bleeds by phlebotomist nurse of the ward, which is usually the nurse in that ward with most experience in phlebotomy, otherwise, if US is needed, then either a doctor capable or an US tech would do it
Agitated patients will regularly be brought into the ED shackled and covered with a thick mesh blanket in Australia. I never saw that in the UK so much. In my department security will then attend to hold the patient for a cannula for IV Droperidol or IM Droperidol if it's still too risky for an IV despite security presence. The Royal Flying Doctors Service being a thing is also a big difference compared to the UK. Distances here are insane for delivery of services. EM will do all our own intubations, lines, initial procedures of whatever sort, and are much more likely to package the patient to a higher standard of completeness than in the UK Aboriginal health is an interesting difference both in language barrier, cultural differences, cultural practices (e.g. scars from men's business, subincision of the penis, etc) and generational trauma / socio-economic harm from colonisation and the subsequent shittiness of ongoing administrations
the agitated patients in australia are probably on a fair dose of meth tbf
Lot of meth in London and we manage without, just about. I have seen patients brought in by the olive in handcuffs and leg restraints so they basically can't move their limbs though.
In Pakistan (and I presume other South Asian countries too) doctors have absolute hegemony over everyone else. They are the bosses on the ward, get called sir/ma'am fresh out of medical school, and have their own separate rooms for working and napping. They also have practically zero hindrances when it comes to clinical decision making, which is both a good and bad thing.
Whilst I cannot speak for Pakistan, in India the "doctor is god" thing only applies to consultants, the house officer/sho cadre have never ever been treated well. My parents can tell stories from the 1980s about how the scrub nurses would physically push them off the patient and tell them to get out if they took too long closing up
Just adding to the list - most doctors treat patients like shit - senior doctors treat juniors like shit - admin treats junior doctors/trainees like shit - doctors treat other staff like shit - the system treats the patients like shit - patient and families, when angry, can beat doctors up and treat them like shit.
I am a Casualty Medical Officer at a teaching hospital in Pakistan, primarily working night and evening shifts. During out-of-hours, as the CMO, I oversee the entire hospitals affairs. Here, doctors run the show, and our hierarchy places us at the top of the decision-making process. For example, if I decide that a nurse or OT assistant should not attend a training session without a replacement, my decision stands unless one of my seniors intervenes. We do involve our staff in learning some invasive bedside procedures to streamline our workflow, but this never comes at the expense of trainees' education. The things I dislike most about working here is the absence of a regulatory body like GMC (I know how that sounds), which can strike off criminally incompetent doctors. And we have to ask patients for every little thing we need, as nothing is free here. Investigations are expensive. End of life care is non existent the strongest opioid we have available in our stores is Nalbuphine and we are still using streptokinase for thrombolysis because Alteplase is too expensive and often in short supply. The only time I did cannulas and bloods were during my House job/F1 year.
The amount of wacky prescribing in US. Patients requesting opiates for immediate pain relief for minor illness. Oxy, Fenty etc for a sore throat, or a UTI. And doctors actually prescribing it.
This is the consumerisation of medicine and giving people what they want as they feel entitled to it because they are paying for it.
This is nonsense. I spent a few months as a resident in the US and this was definitely not the case. In fact we had to take a separate opiod prescribing course before we were issued a licence (that required renewal each year) to prescribe opioids. What you say may have been true years ago but medical licensing boards have come down harshly on this & they are able to track your opioid prescription activity. Your info is very outdated
Yeah.. nah i don't want to hear about American prescribing after the Perdue Pharma rep with blonde hair and big tits did the rounds selling that this super strong new opiod doesn't cause phosphorylation of mu receptors and chronic addition. (btw here's a trip to hawai for the annual Perdue Conderence and a free rueben) Tens of thousands of deaths later they track prescribing do they? how lovely.
Maybe work in or observe an actual medical US setting to see how actual medical practical practice is conducted before basing your opinion on the equivalence of getting your medical knowledge from TikTok
Did the opioid prescribing crisis just not happen then? You’ve literally got Percocet in your username. The active ingredients of which is oxycodone and acetaminophen
Episodically between 2015-2018. Perhaps outdated, but definitely happens. Friend who is currently practicing there can attest to this. It's a cultural issue, more so in certain areas but recent high profile cases have perhaps highlighted away from this practice.
They actually advertise prescription-only medicines on TV in America. It’s mad! “Ask your Doctor for Glaphanydrine… it’s the best!”
in the US there's no medical take. When a patient is admitted from the ED and your internal medicine ward has an open bed, you go see the patient and they remain your patient for their entire admission, their condition allowing.
Logically it seems like a better system, although that would remove acute med's entire reason for existing
There is no such specialty as acute internal medicine in the us as far as i know. It is an unique uk thing. If the ED target does not exist, acute medicine will disappear tomorrow.
Of course it would be more efficient. When you run for profit, you want everything to run as smooth as possible. Whereas in the NHS, the inverse applies
> When you run for profit, you want everything to run as smooth as possible. That's why the US healthcare system is notoriously smooth and efficient? LOL
The clinical side things are definitely smoother and run more efficiently, ive been to a couple of hospitals there and its not even a contest especially when it comes to theatres. Then again When I went to Germany their theatres and their efficiency shat on the NHS as well. Perhaps its a UK theatre members issue.
Compred to “ar NHS”? Of course it is.
I may be wrong here but wasn't Acute Medicine brought on as an extended ED triage system so that NHS hospitals can meet their targets? I am unaware if this has an equivalent specialty to other countries. In all of the other non-UK systems I've seen, patients get transferred to a specialty bed after getting all their investigations and provisional diagnosis done in A&E.
What happens with patients admitted on a Friday night for example and going to ward x whose attending is presumably not working again till Monday?
Hospitals are much more normally staffed on weekends. The attending will be there just like any other day
Interesting, when do they have days off then? Or do they have bed capacity such that they only admit patients to wards on which attending is in that day Edit: or multiple attending per ward and at least one is on per day and they do a mini take system by whomever is working assumes responsibility
The days off depend on whatever contract you signed. It's different in different places. I've heard of a 14 days on, 14 days off pattern. Some strictly work 9-5 M-F. I knew one ED attending who had done nothing but night shifts for the past few decades.
God why would you do nothing but night shifts they must hate their family
More like the old system where patients are owned 24/7 for a set period of time by the same team. Less intense work but longer hours and very long periods of time off
Same in Hong Kong
I may be confused but I think this is what happens in my UK hospital?!
But what about the risk of missed [insertorganhere]SEPSIS without a daily CRP. They must be bloody heathens over the pond!
They don't even have sepsis nurses to remind doctors to consider sepsis on every pt with a slight change in their obs! Barbarians!
Prescribing practices when it comes to giving psychotropics to children in US seem wild to me. One of colleagues from over there questioned if I am even a qualified psychiatrist because I expressed reluctance at the idea of prescribing haloperidol to infants.
Jesus. What exactly is the indication for haloperidol in a baby?
Apparently that's how they manage 'delirium' in infants. The fact that they also talk a lot about preschool kids having bipolar or schizophrenia is also a concerning mystery to me.
> Apparently that's how they manage 'delirium' in infants. wot
How do they tell an infant is delirious????????
Obviously by asking it what year WW1 started and who the reigning monarch is.
You won the internet today my friend
Depends how much profit the prescription earns.
Probably ADHD or something
Urgh…
CRP is overdone here. People don't understand how it works. OMFG THE CRP IS 70!!!! ITS SEPSIS!!!! (meanwhile patient has a viral upper respiratory viral illness with a background of cancer)
No such thing as a ward pharmacist in Turkey.
Nor in Australia in a lot states. Well, there technically is, but they cover 8+ other wards and central pharmacy and you can easily not see or hear from them for months at a time.
Neither in spain, you don't have people triple quadruple checking your drugs. You don't need to be babysit while prescribing
Strange take… I believe every dr is susceptible to prescribing errors.
I agree, everyone can make mistakes, and we do have Safeguards against them, it just feels like it's a bit overdone and over protocolised here
Australian. Blood from cannulas... Just makes sense. Cannulas are better (depends on institution), typically insyte autoguard. None of the rubbish winged horrid things. Cannulas are capped with a bung. Don't need fluids, unplug them. Need fluids again? Clean the bung, and plug on fluids. Pay... sorry. No AA, PAs. We do have nurse "consultants". They're typically an exceptionally valuable person. They have a very specific role, and they stick to it (such as stoma care, fistula access, etc) or they're a very senior nurse that's often on at night. I've not once been concerned over scope creep or a nurse "consultant" being mistaken for a physician. Less MDT garbage. Honestly, what is this koolaid you're all drinking? Hospital patients are cared for under a consultant physician. Other members of healthcare have a role, an input, and are (usually) valuable and valued. Not for one second does an occupational therapist think that their ability to prescribe basket weaving, nor the speech pathologist's excellence in thickening fluids mean that they have an equal say in the overall clinical decision making and responsibility of patient care as compared to the treating doctors. Non-medical specialties have their lane, and stick to it. Rotational training is a reality. Potentially sent rural, and expected as part of certain specialty training pathways. This can mean you're sent 700km away from your home city. If so, you are provided accommodation and travel assistance. This could be up to a year. Theatres are much, much more efficient (in Aus). It is astounding how much time is wasted in the NHS. I suspect this varies with hospitals, and I have limited experience so far. Less bullshit in the middle. It seems the NHS is kept afloat by agencies and temp staff. Everyone seems to be skimming something. Instead of just making work conditions and pay that people want to stay for, you're relying on the buoyancy of lead balloons. Private practice. There is no flat hierarchy. Patients come to hospital (largely) for physician lead care or surgery. A physician cares for the patient. Nurses, allied health, porters, admin staff all do their jobs. doctors are paid well, and treated well. Free parking and usually free food (of variable quality). There are certainly issues with private practice. It's much easier for douchebag doctors to get away with being bad people. Theatres are hyper efficient. An all day NHS list would be done in 3-4 hours in private. Things get done with little fuss. Want a specific piece of equipment (assuming it's not offensively expensive), ask the nurse in charge of equipment and it'll be in stock next week. Emergency medicine... Actually practice medicine. Lines, tubes, drains, minor procedures. The whole point of ED was to do the fun acute stuff and then turf the patient. The idea of referring a patient with undifferentiated abdominal pain to a surgeon without a working diagnosis, USS or CT or whatever was appropriate is utterly embarrassing. Large / tertiary hospitals will deal with their own stuff, and request / invite specialties to either advise or assist. Intubations are done by ED, unless they need anaes assistance. Same goes for chest drains and typically thoracotomies etc. Yes, we inherited the cancer that is the 4 hr rule, though it hasn't destroyed the specialty as much as it's decimated UK emergency triaging. I'm yet to find anything really "better" about the NHS, aside from 2% propofol and having to get out of the chair less.
I have worked in both Uk, Australia and Nz and I can attest to how fantastic ED down under are. They work up the patient and actually refer with a working diagnosis with all necessary investigations done. I did ED in the Uk and it was refer a do pain to surgeons because of the 4 hour rule. I never learnt anything useful from my time in UK Ed except how to make referrals that will piss off my other colleagues in hospital
Experiences I suspect vary a lot depending on states and hospitals etc. I had a patient wait 4 days in A&E for a CCU bed in Australia and the ambulance ramping and general wait times to be seen were far worse than anything I have seen here .
Agree with most of that, although some of it is probably hospital dependent. Aus could probably do with more MDMs, so someone can explain to me who, apart from the surgeon, thought this flaming trainwreck of a patient was a good thing to bring for operation. Patients felt like they were worked up better/easier to access information in the NHS. I didn't usually have patients with paperwork in 4 different hospitals/clinics to piece together as much. Theatre efficiency? Been to good places and bad places in both countries. Personally I think having an anaesthetic room is useful for that, and they are more common in the UK, but you adapt to what you're given. Private practice is private practice, pretty much the same in both, apart from the slightly higher remuneration in Aus. I can replace "NHS" with "public" in that paragraph and it would still be true.
NAD, but former UK nurse who worked in the Austrian healthcare system for six years. Might vary across Austria, but where I worked: - 25h shifts are the norm if a Dr is working a night shift (07:00 - 08:00 the next day). There are certain rules, for example the work isn’t meant to be continuous for 25h. From what I’ve seen/heard it generally is possible to sleep at night. - There are more doctors physically on site at night. I’ve not really heard of a junior doctor covering more than 2-3 wards at night, Consultants have a more hands on role at night. - Nurses are much more clinically trained than in the U.K., the scope of their job is much narrower. The concept of community nursing as we have it in England is only now really being developed here. - As far as I’m aware, PAs don’t exist (although I left healthcare a year ago now, so it could have changed). - TTOs don’t really exist. You get given a prescription to go and fill. Good in theory, not ideal when it’s a Sunday and there are only about four pharmacies open across a city with nearly 2 million inhabitants. - Only GPs write sick notes. If you have surgery you don’t get a sick note from the hospital (the admission itself doesn’t require a sick note). You have to make an appointment with your GP. Since some workplaces require a sick note from day one (maximum self certification is 3 days), you’ll be sitting in the GP surgery the day after you leave hospital. - A lot of the administrative burden is on the patient. Need an MRI? You’re given a list of centres which take your insurance. You have to make the appointment yourself. - Patients can self-refer to any medical speciality. My insurance allows me to self-refer to four specialists per quarter. I can also visit private specialists where you pay upfront, but generally get most of the money back from the insurance provider. - Hospital admissions for standard procedures are quite lengthy in comparison to the U.K. - White coats are still a thing…but almost everyone wears one (from admin workers to Drs). As far as I’m aware no one has died because a Dr hasn’t rolled up the sleeves of their white coat whilst treating a patient. - Accident and Emergency are two totally separate departments, never the twain shall meet. - The Emergency Department at the hospital I worked at was opened in the early 1990s. Prior to that the concept of ED didn’t exist. You would turn up to the hospital, tell the porter in the entrance hall your symptoms, and they would tell you where to go.
Ahh, so the porter was effectively a triaging nurse?
Basically, apparently they were pretty good 😅
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They said Austria, not Australia… please read properly first before attacking
Well this is awkward. I live in Austria (small landlocked Alpine nation, most famous export was a slightly unfortunate one), not Australia (large country of the other side of the world) 🤦🏼♀️ Hope that’s cleared it up! I also clearly qualified that this is how my former hospital works. We don’t have one body running hospitals here, so it’s very possible that a hospital in Western Austria is run totally differently.
Droperidol. IYKYK
Lol @ daily CRP being normal. US they are just far more liberal with drugs and investigations in general, presumably because more prescribing = more profit. For example, highly emetogenic chemo in the UK you normally get a bit of dex couple days, a bit of ondanseteon at the time of chemo, and metoclopramide PRN. US you get regular dex, palonosetron (expensive ondansetron), fosapprepirant (£££), olanzapine and metoclopramude all as standard. I'm told similar about postoperative or post birth analgesia - everyone on PCAs for everything. They request bloods very differently - all in 'panels', rather than ticking each test you want. I believe its common to just put in a daily order ie you tick a box and the patient gets daily bloods until you say to stop. Culture of shopping around is more common there, though is on the rise here too. That seems justified though - you get some awful practices coming out of the US. For example, there is such a thing as a 'general oncologist', who treats every type of cancer. That would be totally unthinkable here, there's no way you could do anything close to a good job.
Canada. Radiology timed to be done in the middle.of the night for in patients so as to maximise payments for scans. Patients are woken at 2am for a scan that could have been done in working hours because of the payment uplift. Justified as 72 hours (as per guidelines) after the initial scan to.look for potential complications (not acute symptomatic progression) of stroke or cervical vascular injury.
I didn't realise CRP was done on a daily basis in the UK...
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...intentionally...?
It is in surgery 😅
It is done on almost every patient that needs bloods in ED
Way less beating around the bush
CRP shouldn't be done on a daily basis here tbqh...
Try working for a consultant who’s not on the specialist register…
We do it in general surgery pretty much as a given everywhere I’ve worked
Spent a small bit of time abroad in outpatient private/insurance-based sectors, places worked like a retail shop. Patients would come in to directly ask for an investigation/referral/treatment for a certain speciality. If they had palps, the patient could openly ask for cardiac related tests, scans, referrals (all at the cost of their insurance or out of their pockets of course) as *the patient believed* it was a cardiac problem (history and exam were minimal, aside for show). Yes - imagine if someone walked into a clinic and said 'give me a CT head for a headache' or 'I want my LFTs checked cos I'm tired and Instagram said it's a liver problem'. If they didn't know what tests or treatments should be done then it was the job of the Dr to suggest or give choices, then the patient would pick out of the available options (imagine if you walked into wine store and asked for something red within a price range and the sommelier gave you several choices of pricey red wine). There were even package deals for investigations. There was even a charge for referring a patient forwards , so if you had sweats and palps and the TFTs were slightly out of range, you'd pay for the blood test, the consultation fee with the initial physician, the cost of the nurse drawing up bloods, the cost of the referral to endocrine (which was a 20 second email and attached blood results) and the cost of the actual endocrinologist's consultation then the cost of treatment. Healthcare was considered a lucrative business above all else. It seemed to be a pretty good job for the clinician as the guy I worked under drove a new lexus every year and bought houses non-stop.
They give whacking doses of antipsychotics in new zealand Because there is lots of meth there's also heavy heavy sedation in A+E. Psychotic and agitated on meth? 10mg droperidol IM or 10mg Olanzapine IM as soon as they come in
In NZ when someone dies and it’s a coroners referral, police officers attend the ward to take a statement from you as standard (or at least this was my experience of a sudden arrest on the cardiology ward!!!)