11 October 2008

No more intravenous cannulation

In some hospitals junior doctors are no longer allowed to carry out intravenous cannulation. Some have asked why the deaneries are not protesting about this? Dr Grumble has some bad news. There may be infection control reasons for these initiatives but this sort of thing actually comes from the deaneries. Dr Grumble became aware of these proposals recently and protested loudly. He protested to a senior personage in the deanery. He argued that putting in an intravenous cannula could be a life-saving procedure and that it was not a bad idea for the most junior doctors to get a lot of practice at it. So what do you think the response was? Did the senior personage show some sympathy for the Grumble view? Not a bit of it. She tore poor whimpering Grumble to shreds in a most dismissive way. They are powerful these people. Very powerful. She told Dr Grumble that he was old fashioned and out of touch with the way things are going. Junior doctors were not to be rushing around doing chores at the behest of tyrannical consultants. There was an unpleasant implication there about how she seemed to think Dr Grumble behaved. Now Dr Grumble would agree that junior doctors should not just be doing chores. But his junior doctors are still rushing around doing mostly purely administrative tasks. Those are the tasks that should be taken away from them. The things that could be done by a reliable clerk. But stopping them acquiring life-saving skills is plainly crackers. But nobody listens to Dr Grumble. He's not tyrannical enough. You can't argue with the deaneries. They have an agenda.


Elaine said...


It just gets worse and worse.

And just when you think it can't get any worse, it gets worse again.

Anonymous said...

Boggles the mind, doesn't it?

Have I told you the one about how, when Mrs Dr Aust was the anaesthetics SHO doing night on-call for O&G anaesthesia (major Univ teaching hosp etc etc), she got phoned one night to ask if she would nip over to a medical ward and put in a central line? The on-call for medicine anaesthetics bod was busy seeing to a crisis somewhere.

Mrs PhD pointed out she was meant to be covering O&G for Obstetrics emergencies, and asked if the med reg couldn't do it.

"Err...she says she's never done one unsupervised"

"Well, what about the medical consultant on-call?"

"Err...we've just rung him at home and he said he'd never done one unsupervised either".

True story... but perhaps likely to be more commonplace as the years roll by.

Mrs Dr A always says that putting in the Venflon is one of the things juniors should practise the most - partly because practise makes perfect; partly because (as Dr G says) you never know when you'll need to be able to do it in a crisis; and partly because putting them in is always good insurance as (again) you never know when you might need the one you put in just in case.

Dr Grumble said...

An entirely plausible story. It's possible that the consultant was quite old rather than young. Dr Grumble can remember when he was one of the very few, perhaps only, people in a medium sized district general hospital who could use a Seldinger wire. And its taken decades since then for ultrasound to be used in this setting. You are very much a victim of the times you are brought up in.

The Shrink said...

Junior doctors who can't cannulate?

Utter, utter madness.

I trained in an age where I had to site venflons, central lines, undertake suprpubic aspirate in paeds, pop in chest drains, intubate on crash calls and undertake numerous procedures in A&E.

It was valuable in so so many ways. You'd really, really think that educational folk would grasp that the expertise, competence, confidence, mastery of doctory skills and procedural processes would be valued.

It's not just about the intervention, there's also the consultation, explanation, valid consent, preparation, collaborative work with nurses, technique, documentation, teaching students/others. All that's ommitted through that whole gubbins being shifted to someone else.

Isn't there then a paucity or deficit in teaching?

Surely the Deanery should be clammering for more more more, not eschewing such practice?

As I said, it's utter, utter madness.

Anonymous said...

I know the feeling. I'm an FY1/house officer and we're in discussions with our consultants and management about getting appropriate experience and being compliant with EWTD rules.

General consensus from medically trained staff, including consultants, is we would like to keep FY1's on nights and weekends to learn to deal with emergencies and experience real independent decision making. To make this easier during the day we would like clerk(s) to do the routine stuff like organising scans, chasing results, walking ten miles round the hospital with referral letters, etc. That would keep down our hours during the day by minimising the amount of admin we have to do. It would also maximise our time to gain proper clinical experience.

Only problem, nobody has managed to persuade management that it's a good idea. They want more nurse practitioners to start covering weekends and increase cover at night. Leaving us doctors mostly 8/9 - 5.30, Mon - Fri.

The debate is ongoing...

Dr Grumble said...

You don't really have to be a shrink to know it's madness but, having said that, Dr Grumble was just beginning to wonder whether he was the mad one. The dangerous thing about all of this is that if people go on and on saying that you are out of touch and old fashioned there is a risk that eventually you may begin to believe them.

Dr Grumble said...

Yes, anonymous FY1. That's another bit of nonsense that has come from the deaneries. The idea is that F1 doctors know F all so they should be around when the consultants are around so that they can get taught. But the reality is that the F doctors don't have time to be taught much because they are scurrying around the hospital because of inadequate clerical and other support. And the likes of Dr Grumble are actually scurrying around often for much the same reason.

Somehow things don't happen in the day the same way that they do out of hours and the idea that you can learn without an element of being thrown in at the deep end is a rotten one. But when you are in the deep end you do need somebody around with some water wings in case you need them. And that somebody could be a more senior junior doctor. But staffing levels out of hours are too skeletal to allow that sort of support any more.

Underlying this is the misguided idea that training is all that is really needed rather than experiential learning. Meanwhile nurses who are not trained in diagnosis are cherry picking the work that should be a doctor's job. But curiously they never seem to scurry around and help with the chores. That, it seems, is not a nursing role. Their work is always unhurried and paced.

And when you grow up and have to work at night you will find it an even more lonely place than it was in Grumble's day. Not only will there be little support but you will have been ill prepared because you will not have been exposed to such work as an F1.

Worst of all, those at the coal face are all in agreement about what is wrong. Juniors have blamed consultants for the changes but few of us ever had any say in what has happened and those of us that did speak up were ruthlessly put down.

Dr Michael Anderson said...

Ah, so this is why, as the on-call anaesthetic SHO, I'm getting more and more of the "can you come and put a venflon in this patient because we can't do it" calls.

Thanks for explaining Dr G, suddenly everything is clearer.

Dr Grumble said...

Your post didn't escape Dr Grumble's attention, Michael.

The Shrink said...

" . . . people go on and on saying that you are out of touch and old fashioned . . . "

Ah, I aspire to such a position!

To be seen as out of touch with the currently malign zeitgeist of NHS reorganisation is laudable.

Why not fashion oneself on the older Age of Stability where, " . . . the local consultants were experienced and wise in the way of medicine, having completed a gruelling apprenticeship that usually finished when appointed around 12-13 years after qualification."

To not touch the current pernicious machinations, to adhere to older (and effective, and valued) ideals, that's got to be a good place for a senior clinician to be. Thus, I aspire to be out of touch and old fashioned!

Garth Marenghi said...

Dr G,

the worst thing about this is shown by some of the comments about cannulation on DNUK,

to complete the FY1 year one only needs to get one cannula insertion signed off, there is the beauty of competency based training encouraging the lowest of the low in terms of standards,

it shouldn't have to be a bloody competency, I didn't do my PRHO year that long ago and I could cannulate over 99% of things after a few months,

I think I can remember as a first year SHO I only had one person all year that I couldn't cannulate and they ended up needing a central line,

anyways, FY training really is the pits and there is so much chat and paperwork but the trainees simply don't get the hands on experience they need

Anonymous said...

I entirely agree, but is there anything in the Foundation programme that could not be learned at medical school?

The GMC shredded the undergraduate curriculum some years ago, hence the need for the Foundation programme. With the Foundation programme being shredded is it any surprise that specialist trainees cannot do procedures?

Dr Phil

No One said...


Anonymous said...

I'm the anonymous FY1 from 11 Oct... Just now we still work a few nights - I'll have two weeks of nights in this four month rotation. I found it really valuable, there is always a middle grade in hospital who is willing to help. I learnt a lot because in the middle of the night the main patients who are difficult to deal with are in the high dependency unit or children's ward. So what we did was the middle grade and I attended together, I took the lead in assessment and management and the middle grade supported/taught as appropriate. It was a fantastic experience, especially since there was more support than during the day because the seniors weren't always holed up in theatre/clinic/meetings! Everyone involved "at the coalface" thinks it's a very good system.

The main problems are that we are horrendously non-compliant with our 48 hour rota and that some of the night nurse practitioners (NNP) are starting to sulk that all we ask them to do is take blood, put in venflons and chase blood/x ray reports. They also don't like that the ward based nursing staff bypass them when a patient turns sick to call us instead. But that's because we're allowed to prescribe and authorise investigation requests that the they can't. So calling a NNP slows down patient care, because they assess them then call us to "tell" us what to do. Except we don't want to sign these requests until we've actually seen/assessed the patient ourselves. Saying "but the NNP told me to" will not be an acceptable defence in court if everything goes wrong.

Anyway, that's enough of a rant. I better go try to get some sleep... Because I'm on nights at the moment!

Anonymous said...

i have just been reading your blog Dr Grumble, and i can quite honestly say i am disgusted in what you said about nurses. As you probably guessed by now I am a nurse and i can tell you that your comment about nurses was totally inappropriate and uncalled for. I dont understand how you can possibly say that our work is unhurried and paced. Also we are cherry picking your work.
Maybe instead of writing your little blog maybe you should actually thinka bout what nurses actually do for you, other members off staff and the patients.
I am truely disgusted in the fact that you commented that we dont do chores, sorry but can i ask you waht chores you do?
you should respect you nursing staff as at the end of the day, they are there all the time and nurses are your support.
what would you do without them?

Dr Grumble said...

Dr G's comments clearly do not apply to you anonymous but there are some 9 to 5 nurses that have nicely ring-fenced their work and dictate to the doctors who do the chores.

It's great if you do not approve of this. It is not just Dr G who finds the lack of real nursing a problem.

Dr Grumble said...

The press are now latching on to the fall in nursing standards. It never used to be like this.

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