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Right, good evening everyone. Um My name is Doctor Hakim Yusuf. I'm one of the uh ICU an Anesthesia consultants at Glenfield Hospital. And I'm also one of the consultants. And the aim of this uh presentation is to just to give a broad overview of what being an intensivist is like. Um And and what the management of patients in, in an intensive care unit entails so broadly speaking, what we do in intensive care really spans these three domains. Um We provide organ support, we provide very intense monitoring, that's where the intensive care comes from. The monitoring is very intense. Um We provide specific treatment for certain conditions um to ensure uh recovery of um organ dysfunction. And actually, if you look at everything we do in itu it, it spans these three domains. Now, what is an ICU um in, in, in a, in a UK sort of centric way? Um An ICU is describing an area in the hospital that is quite self sufficient and actually in the UK um specifications of what an ICU is, is described pretty much like a hospital within a hospital because the mode of operation of an ICU is very, very different from the rest of the hospital. Now, in terms of definition, like I mentioned, the um the the the treatment modalities for patients in ICU um is more intense. But in simple terms, in terms of identifying um patients who um have this level of, of, of increased um intensity of treatment and monitoring the patient to nurse ratio is often used. And in the UK, if you're needing up to two to each one or less, um patient nurse ratio, 2 to 1 or 1 to 1 or sometimes 1 to 2 patient ratio, you are in intensive care. And so recently, there has been a, a bit of a conversation about are you an intensive care patient? If you're physically in ICU or whether if wherever you are, if you're receiving this level of intense monitoring and and treatment, then you are considered intensive care patients. And for research purposes, we actually use the latter where even if you're not in intensive care, but if you're requiring intense level of support, monitoring and, and treatment, then you're considered an intensive care patient. If you, this is very UK centric. Um if you go abroad, it's very, very different and in, in, in the US severity of you, illness is often used, used a a as a definition and in some um hospital setting systems in the US, they actually use a physical location to denote people uh patients who are in intensive care. So why would you need intensive care if you need intensive care as a severe manifestation of any disease, any disease whatsoever can bring you into intensive care. So, one of the most common um syndrome uh complexes that brings you into the intensive care is sepsis and infection. But anything else can bring you into intensive care. But you find the patients in the with any of these pathologies who are coming to intensive care have this presenting and manifested in the most severe and extreme form and hence why there's need for intense therapy. So th this is a common thing and, and actually, if we look back at this diagnosis, uh the the the pathologist I listed here, um all these pathologies cause can cause this, this syndrome which in in puritanical terms, systemic inflammatory responses does not exist anymore. But we do know that in response to um illness, people develop uh uh belong to three different phenotypes. Um One is called a hyperinflammatory phenotype, which we often see in ICU and it can lead to endo dysfunction. As you can see, um patients become highly inflamed and the inflammation and the inflammation is actually a native compensatory response to an insult and it beats to ward off the insult and protect the vital organs. But unfortunately, in a maladapted state, this leads to the deficiency of um oxygen supply to some vital organs which can lead to multi organ failure and death. And actually one of the things we tend to do. One of the places we tend to step in in ICU is at the point of preventing multiorgan failure, um or preventing death. Um but the more you go down this sort of pathway, the higher your chances of death. So we often try to try and catch them at this point between systemic inflammation and multiorgan system failure. Because once they have established multiorgan system failure, it can be very difficult to get them back to, to health. The other thing you would find with any of the pathologies you found is that it is is a direct insult on major organs and you can have major or organ failure. Um And I've listened the the the major organs here that we, we tend to support in the ICU. The truth is um is that there's a surrogate for supporting all major organs and that is supporting the cardiovascular system. Once you support the cardiovascular system and ensure a patient has adequate cardiac output with adequate oxygen delivery. In that cardiac output, you are supporting that system, but sometimes you need to add some more support because obviously there's been a direct insult on that major organ in the function of that major organ. And you probably sometimes have to add in support to replace um the function of that organ so that the organ, the organ can re recover and repair itself, which is kind of what? Um and, and this is all within the remit of what we do in intensive care. So in terms of monitoring, as I told you, the the monitoring is very, very detailed. If you go on the ward, you might get a patient with um an E CG um a SA probe and a BP uh which is a basic sort of monitoring technique. But as you can see on here, our patients have more um monitoring modality. So you have an E CG. Yeah, we we have direct arterial blood gas monitoring, you know, central venous pressure in in cardiac patients, you have pulmonary artery pressure, saturations and anti CO2. And here you can see a patient's cardiocarpus has been calculated using the cardiocarpa monitor, temperature and uh and respiratory rate. Now, all this information is synthesized and monitored. So we the thing about intensive care patients is that it's not about how they are. Now, it's how the trajectory has led until now, has that trajectory been one of an improvement or one of a deterioration or a static picture. Now, um and those are the things we bear into mind in terms of how we ramp up support or ramp up treatment. Um And so you find the intent, I've listed quite a lot of modalities o on here that are not shown on the screen including intraabdominal pressure monitoring, re pressure monitor, which you find in your ICU. And in my ICU, you find um echocardiography is a very, very um prominent modality which you use in combination with a pulmonary artery catheter in, in in monitoring patients. Um So what thing about monitoring and, and what I want to demonstrate with this slide is a pulmon artery catheter. Um It is um one key point about monitoring on ITU in two modes of monitoring patients in ITU. There are um continuous monitoring modalities which give you b to be monitoring of a patient's state which is really good. It means it means that you can easily pick up dynamic changes in the patient's clinical state and infer from those dynamic changes. But you have static uh monitoring modality as well. They are only giving you monitoring um sort of insights into that patient at certain points. And if you want to find out about any changes to the patient, you have to repeat the modality. Um and such um often context is key. Um the pulmonary catheter gives you B to B continue monitoring but it also the cardio monitoring you get on, it is static, it doesn't do it continuously. Although there are new devices in the market that do it for you that just continuously monitor cardio. But at intervals. But it's important to ensure that if you're seeing a a the thing about patients in intensive care, the state is so dynamic that it changes sometimes minute by minute, hour by hour and you often have to repeat your monitoring modality so that what you're examining and seeing clinically fit to what the patient's hemodynamics or current clinical status at the moment. And that should be reflected in the monitor modality. There's no point using AAA monitor result two hours ago to try and assess a patient now because that patient might have to be a totally different patient in two hours. That's how intense and how dynamic intensive care patients are. Whereas you might have seen on the ward, you might have done a, a blood a test yesterday. And um you can still use that test to assess a patient today because largely those patients are very, very slow to change in their clinical state. So that's very, very important uh concept to, to, to understand. So I'm just going to run through um a, a few of the things we do to monitor the systems and tell you why they are um management for different systems. So sedation, one thing there's a hallmark of intensive care is is sedation and, and you might find in common knowledge, it called an induced coma. Um And we, we do that for two reasons and I've listed a few hypnotics and and analgesics we use, we tend to use hypnotics and analgesics in combination to kind of create a a very deep sedation, sometimes general anesthesia. I mean, for two reasons, one is to ensure the patient can be still enough to cope with all the interventions that we put on them. As you can imagine, patient has got a pulmonary catheter, has got a urinary catheter arterial line, central line. Um and you are trying to ventilate them to be able to ensure all these interventions can be applied um properly. You have to sedate them with good analgesia to keep them still. That's the first thing. But also secondly, in a patient with neurological disease, sedation is actually a way of protecting the brain uh cause when they're sedated, the cerebral oxygen demand is low enough to prevent any secondary brain injury. You can't do anything about the primary insult, but all you want to do is reduce secondary brain injury. And so sedation is one key way we do that. Certainly in my hospital, when we are, we are a cardiac arrest center and we, we receive all the other calls for cardiac arrest, all Leicestershire and Rh and after we stabilize them from a cardiovascular point of view, the next key thing is to provide cerebral protection cause they are all these patients are prone to hypoxic brain injury. And so sedation is one way in which we control that to control the oxygen demand so that if, if we can do that so that we can actually protect the brain from further ischemia. Um in terms of cardiovascular support, now, irrespective of any ICU you work in um cardiovascular support and respiratory support are the mainstay of intensive care because like I mentioned, if you provide good cardiovascular and respiratory support, you're going to support all the other organs. And actually, one of the first things to try to adapt or ma adapt to illness is a cardiovascular system and the respiratory system. Um so it starts from the basics like what you do in the ward, fluid resuscitation. But in addition, like I mentioned in my, in the E slide, I'm not showing a systemic inflammatory response in pneumonia. The goals go the, the the hallmarks of that is si significant vasodilatation and sometimes you have suppression of myocardial function. So we use inotropes and vasopressors to to to support the heart. But as you can imagine, um when you're using these devices, you actually need to closely monitor the patient to decide what, what to kind of guide how you use these inotropes. Hence why we use pulmonary catheters and we use um echocardiography and other devices to monitor the cardiovascular system very closely. Now, when you come to some ICU like like mine with a cardic ICU. If you're not getting anywhere with inotropes and vasopressors, then we can start to use things like mechanical support. And what mechanical support tries to do is to replace the function or reduce the burden of work for the heart in supplying the body with blood and oxygen. And that's what um the, the, the the device I have listed there, intraortic balloon pump, um an impella or echo do which we we do at Glenfield Hospital. Now just explain what the balloon pump does. So the balloon pump I is a pump that is inserted through one of the femoral arteries and it, it lies in the aorta just beyond the uh origin of the le uh left subclavian artery. Um And what it does is when the heart is filling up, it inflates. Um and by inflating, it increases the diastolic pressure. And when it does that, it increases chron perfusion to the heart, but also increases perfusion to all the major organs both approximately and distally. But the important thing to the cardi support is when it deflates, it causes a drop in pressure in the immediate sort of uh arc of the aorta and which drops the pressure against which the va has to contract against. So it improves cardara by doing that because it reduces the afterload to the heart, the work the heart has to do. Um the we we the the impala is a device is basically an atrial pump um with one end in the left ventricle and it pumps blood from the left ventricle into the aorta to get blood around the body. Um So these are cardiac um monitoring devices. Now, in terms of respiratory uh respiratory support devices, um we start from um A as a as you can see with everything there, there is AAA basic form of support and we escalate support depending on how the patient is is faring. Um So patients can start with just getting supplemental oxygen, which is what you do on the ward. But if that's not working, we can go into noninvasive support, which you can provide without sedation. Um And when patients are not tolerating that I'm going into, into invasive support and a point of invasive support, you have to sedate them because you have to put it in the, in their, in their, in their air way or if they've got tracheostomy, they can be awake and, and they supportive. Now, other things with the intensive careful respiratory system is we do frequent airway toilet and bronchoscopy because when patients are intubated and sedated, their natural defenses and natural mucus reaction is impaired. So they tend to accumulate phlegm um and that needs to be sucked out. Uh and in it when it's, it's it's in and copies come out, you, you probably need to use a fiberoptic bronchoscopy to get it out when patients are slightly awake. Um chest physical therapy can work and patients can be given things like cough assists and, and, and, and, and chest physical therapy to help them. Expect your um ECMO is, is a mode of uh of uh it, it it is at the top end of, of respiratory support uh because this takes over the function of the lungs and you have really minimal lung function and this is for patients who have really severe lung disease. Uh and, and we used uh ECMO quite significantly during the flu pandemics and the COVID-19 pandemics of people presented with severe respiratory failure. I'll just show you what ECMO is all about. So this is the heart. Um This is how we do it. In Glenfield. There are different ways of doing it, but I'm not gonna go into, into a lot of detail, but basically in, in Glenfield, we put one ca one cannula in uh it's a very big cannula that sits in the IVC. Um and blood is taken up from the IVC and the S VC and pumps straight out into the tricho right into the right ventricle. And the blood is pumped taken up as deoxygenated and it goes through a circuit like this, there's a pump. Um and it's the oxygenator, the blood is also warmed within the oxygenator and oxygen is passed through and CO2 is blown out and then it has returned back into the patient. Um And, and, and this replaces the function of the lungs, um almost entirely and this allows you to rest the lungs and not ventilate the lungs very, very vigorously um until it recovers. Um And this is what the neck mo circuit looks like in, in, in real life. Um This is, this is the console that has the flow meter and that's the oxygenator there. You can see this is oxygenated blood going back to the patient and this is the oxygenated blood coming from the patient into the pump here. One thing we also do very frequently in intensive care is provide renal support. So you, if you've worked on a, on, on a renal ward or in a dialysis ward, you would be very uh accustomed to patients requiring dialysis for chronic renal failure. But it in intensive care, as you can imagine this cyst the syndrome of uh sys systemic severe inflammation can also cause renal dysfunction and it can either be prerenal dysfunction or it can be intrarenal dysfunction. Um And so sometimes um y you have to support the renal system. Now, most times like I mentioned before, by supporting the cardiovascular system, you by su by default, support the renal system. But sometimes when the damage is established, you have to support the renal system um in a bit for it to provide it time to recover. And we use renal replacement therapy similar to dialysis, but in, in, in itu we tend to use more continuous hemodiafiltration or ultrafiltration. Um The other. So um sort of indication for renal support you find in intensive care is poisoning. So certain drugs can be filtered out by um by using the re uh renal replacement therapy. Um A, a key example is tricyclic antidepressants. Um They, they can be filtered out through a renal replacement, the therapy when they've been taken um in, in large quantities. This is just a what a CVA circuit. It's, it's an extra peal circuit. Um You, you'd find this, uh you don't need to be in a special ICU to get a CVH. It's in most ICU S um it's, it's one of the, but, and, and this is one of the devices. Once you're connected to it, you're considered what we call it. A, a level three patient. That's a patient who's N 1 to 1. Um And, and that's a cartridge that does the ultrafiltration. Uh And these bags, one is the ultrafiltrate bag and then one is the exudate bag which has to be changed every time. Um Yeah, so gastro intentional support. Um The, the, the the the gut is, is a victim of the cardiovascular system quite a lot and also um the respiratory system. And so optimizing them, optimize the gut. However, one thing that's really important about the gut is that um it's the gut uh is, is very, very long and it is an immune, uh immune, uh immune, immune functional organ that provides a huge uh im im immune benefit to the patient. And the only way you can get the gut to work is if you feed it. Um And so um you find some intensive care person need advanced feeding regimens on intensive care or parenteral feeding. Um Now the key, the thing about feeding patients in intensive care is a big um area and, and, and there's a lot of controversy. Um and the one thing about intensive care patient is is that nutritionally intensive care patients who lose muscle, whether you give them super normal levels of protein and, and food or not. They are. Um, unfortunately, being a critically ill patients are very on physiologic state and patients tend to lose muscle and lose, um, and, and become hypercatabolic. Uh, even though that's the case, it's still important to feed them because, because they're losing muscle and a hypercatabolism without feeding them, they lose the very muscles they need to get better and recover. Um And so you want to minimize that um muscle loss as much as possible. Um If, if you go to a specialist liver unit, um the the uh extraoral device called the Mars Liver support device, which tends to um function like the kidneys in excreting waste products of liver metabolism in patients with severe liver dysfunction, usually in the pretransplant or immediate posttransplant phase. Now, one of the things we do for the brain in terms of neurological support, uh like I mentioned earlier, we do sedation. One thing we also do is actively cool patients. Um And about years ago, we've um there's been a lot of stories, um you might have heard of stories of people um who have been um in, in very temperate areas and, and, and accidentally falling into IC Lakes and developed cardiac arrest for hours and hours and, but the temperatures cooled down to about 1716 degrees, the lowest, the person with the lowest temperatures about 16.9 degrees. And then despite the fact that they've been in cardic arrest for hours. But because they've been that cold um when they were warmed up and they got return of circulation, they had intact cerebral function. And so we know hypothermia protects it has cerebral protective effect. Um And however, in the clinical space, what we found, especially in patients who have colic arrest is that preventing hyper is actually more beneficial than hypothermia cause hyperthermia for a while in its in its own has side effects such as infection. Um and immunoplex that confers on the patient. Uh We're very keen on maintaining normal glycemia in intensive care. Um And we usually follow a tight, a tighter regimen compared to what you might be used to on the wards, usually ABM between six and 10. Um If you go to a neuro icu sort of in our region, it's in Nottingham. Um You find patients in intensive care with external ventricular drains to reduce the intracranial pressure. And patients who had really significant um strokes might have a decompressive craniotomy to reduce pressure on the brain. Now, one of the most active sites of microbiology surveillance in the hospital is intensive care because we use a lot of antibiotics and we use a lot of rarely used antibiotics around the hospital. Because of the nature of our patients, we cluster patients with very rare diseases and also rare macro organisms. Um and actually um the UK standard for provision of intensive care stipulates you have a microbiology ward run every day. Now, not every itu as um I read you achieve that aspiration. However, um it just underlines how important um uh how, how prevalent the use of antibiotics is intensive care. And because of two reasons, it because all not be only because of what they bring to intensive care is also what they acquire intensive care. So we have these such as ventilator associated pneumonia. Um and uh lyme related to sepsis that can occur intensive care requiring for antibiotics. And and it's it's a well known site for development of antibiotic resistance. So, microbiology is actually very, very well policed and well um managed uh um a specialty in intensive care and and as an intensivist, your knowledge of microbiology is really, really important because the the sooner you institute the right type of anti antibiotics in your patients, the better the outcomes. So thi this is often swept on in the carpet. A lot of times when we talk about these other measures and this these other measures that I put as other measures are so important. This is talk looking at how you coordinate management of patients in intensive care with a wider multidisciplinary team. Um We often work in big teams, multidisciplinary teams comprised of not just intensivist but also physical therapists, nurses, specialist nurses, dieticians, speech and language, the therapists, we have occupational therapists. Um And uh in, in the postoperative phase, we run post ICU clinics with psychologists. Um we have the uh occupational therapists there. Um and, and physiotherapist as well. We have uh critical care pharmacist. As you can imagine, the Poly pharmacy on the intensive care is a lot, we use a lot of drugs. Our patients are on a lot of drugs. Um And as the doctor, it's sometimes really difficult to kind of really pick out and pick on um what might be interacting in the wrong way. So just having someone who's looking and picking out on the appropriate use of medication is really key. So our critical care physio therapists are really useful resource uh on the unit um for keeping us uh for ensuring that um our use of poly pharmacy uh remains uh safe for patients. Um And they, they, they join us in the ward round. So we have really senior physical therapists uh uh pharmacists on the unit. Um And so if you can see, there's usually a big multidisciplinary team which as an intensity you would lead and, but you, you need to coordinate uh a lot of opinions and, and, and, and management advice from your team for the patient's best interest. And, and, and that is a really, really important part of being an intensivist. And there's no I in team, you've got to be um a team player. Often you are a team leader when you are an intensivist, you're leading the team. Um But you've got to acknowledge the fact that the strength of the team is in harnessing everybody's potential uh a and, and positive input and galvanizing that into uh positive input for the patient. And by so doing what you do is you maximize each and every team members strengths in, in helping the patient, but also minimizing each and everybody's weaknesses because because we've come together a team, your weaknesses are neutralized. But um you, you need to create a permissive environment for everybody to express themselves as, as a team member. So if you like working in a team um of, of multiprofessional, um not just within the unit, but also with other specialties. Cause as an intensivist, you will interface with every specialty in the hospital and such specialties, we want to create an uh a relationship with you because you are looking after the sickest patients in the hospital. So um if you can maintain a, a very cordial relationship with, with, with multiple specialties and multiple teams and, and, and create a harmonious team to look after patients, intensive carers for you. Now, how do you become an intensivist? So I just put just for, for, for you guys, because I know some of you might be thinking, well, how do you get into intensive care? And this has changed over the years and, and, and this is kind of the, the current one I've actually superimposed it cos cos uh uh um I'd it with the academic training as well. Um Just to illustrate it really well. So when you come out of medical school, you do your normal sort of foundation program training. Um And if you, if you're really keen, you could ensure that you get to do an ICM rotation within your foundation training, or you could do a taste section in foundation in intensive care during your foundation training. Um And then you apply. Um Now the thing is you can apply into different um core medical um training pathways. You can apply into A CCS, which is well suited because if you apply into A CCS, it's kind of streamlines, you straight into intensive care training, but you could also apply into core anesthetic training or you can apply into core medical training. But as you can see if you apply into core anesthetic training or core medical training in core anesthetic training, you wouldn't get to do the emergency medicine, six months and A&E and acute me six months as an A CCS. So you need some top up training before you start your higher level training. If you did um core medical training, you wouldn't have done the twelve-month anesthetic training required. So you will probably need to do a top up before you enter your specialty training with um ICM. Now, after your core training, as long as you have either the full M RCP or your M CM, that membership of the College of Emergency Medicine or the primary RC exam, you can apply into higher special train. Now, when your plan has higher specialty training, ST four is often considered a six month ICM and six months, any block. Now this is for you to help you compensate for the blocks you didn't do in your core training. So a lot of people use this to compensate. And then once you do that, um you, you finish that block, you get into er, ST five where you rotate through different ICU uh special subspecialty types. You do pediatric ICU, cardiac ICU, nearer ICU and three months could be any ICU of your choice. You could, for instance, if you're really interested in being a cardiac intensivist, you could decide to spend six months in cardiac ICU just to get more cardiac ICU experience or if you want to get a self specialty experience, like um there's some people who uh would want to uh use this three months to learn more about say maybe bronchoscopy or, or echocardiography and they could spend it in that. Um Now this is the point where you do your, your, what we call the exit exam, the FF ICM final exam. And once you've passed it, you then go on to your special schools here. A special skis here is a year where you go and subspecialise, you go and look at a, a part of in that you really are interested in. And this is where if you, you want to do more cardio and ICM you could do that, you could do more neuro ICM or you want to do liver intensive care, you could go and do that or um if you are combining intensive care with another specialty, for instance, what a lot of people do is combine intensive care with anesthesia at this level, which is what's called the, the, the now called the dual CCT on this special skills. Here you go and do anesthesia. Um And once you've done that, you come back and then um do 12 months of ICU at ST seven level and then you finished your training. Um and then you can apply for consulting jobs. Now, you can see the post there if you want to be an academic because a academia in intensive care is really, really interesting, intensive care is one of those specialties around the world where the most amount of publications are published because we're dealing with the sickest patients with the highest mortality in the hospital. So there's a lot of research geared towards helping to improve the outcomes. Um So if, if, if you come into this as a, as an academic, it, you can, you can do a specialized F one and then apply to an ACF. And then once you apply to your ACF um during your ACF, the first part of your ACF is to put together an application for a phd um training program, uh A phd Fellowship. And once you successfully get APD Fellowship so do your phd here. It could take up to three years and once you've done your phd, now you have three options for doing your phd. You can do it and do it as part of your higher training program. Which, what it does, it lengthens your higher training program or you could take a break to go and do your phd and, and get it done. Um, or what some people do is, um start the higher training program and some about after the special skills. Yeah. Um take some time off, do the phd and come back now there's no right or wrong. Um And once you've done a phd um towards the end when you finish, you get a clinical lecturer and then you get a consultant job which um pairs you as both an academic and as a clinician offering you appointments by with the university. Um and your clinical uh you have an honorary clinical appointment with the hospital so that by and large, hard to train to be intensive care. Now, if you're doing a pure intensive care training without adding it with another training, it's, it's, it gets up to SC seven. But if you're adding, if you're doing it in conjunction with another special sort of respiratory medicine or, or or anesthesia, it lengthens this to 8.5 years. So the training becomes more and you do annual reviews which we called A R CPS with intensive care and your base specialty throughout until you finish. Now, I hope I haven't scared you all off about the intensive care. It's really rewarding specialty. It's very interesting. Um It's a specialty is always evolving. Um It has close links with technology and data science and, and I see the future, we create a lot of data in intensive care. So the future in intensive care evolving into in increased involvement of technology and data science and, and artificial intelligence. Um And so, um it's, it's a really rewarding specialty, it gets busy. Um And in fact that we, we look after the sickest patients means um we, we often have to deal with a lot of um loss uh with, with patients. Um but it is rewarding as well because we do um um help a lot of patients. And um uh we, we, we actually turned some patients around who are really near a death store. And I think that for most people who do intensive care is the reason why they do it. It's just that chance that you could help someone who might have died if you didn't intervene. Thank you very much, I'll take any questions or any comments. Um I suppose th thank you so much. Um Doctor you for coming. I suppose one thing at mine and sure on stage, what would you recommend someone just about to apply their found to their foundation is um how would you, what do you recommend doing with our time and making a good application for with how competitive anesthesia. And I, and I suppose intense care is, uh, that's a good question. Um So I think one of the things I would recommend is to start engaging in sort of co curricular and non curricular activities associated with intensive care. So, using your SSE S and using um um any opportunities to get involved in um teaching, training, research, uh or audit. Also, uh one thing at your level that often helps is um having um a very well versed involvement in any of the resuscitation training. So A LS APL S ATL S, um it's also a very good grounder um to get into, into intensive care, you find most people who apply to intensive care are A LS ATL S or APL S, either instructors or providers before they apply. Cause it kind of gives you a good cause. Basically we advanced resuscitation. But if we, you know, after you've done initial resuscitation, we, we take it on even further. The other thing um that tends to help is to show your interest. Um we have a conference, there's so many intensive care conferences. In fact, I think you of your third years who have worked with me, I have attended one of my conferences to prevent a poster. Um which, which is amazing. I mean, that's something you could do, you know, be involved in a, in a, in a project and present as a poster, all our conferences have medical student levies, which are really cheap than what the uh the, the uh full train doctor pay. Um And they increase in the membership. So you could be involved in projects and present those projects um at, at conferences or posters. And if it's good enough, you present as, as a, as a, as a oral presentation. Um And the other thing that helps II would say uh is that when you are sort of at foundation level, um It, it's actually quite nice to um have a feel of intensive care by either doing a rotation in intensive care if you can, if your rotation allows it or do a taster session. And remember you can do more than one taster session, you can do as many taste sessions as possible. Um just to get a feel of it that gives you two advantages. One, it, it, it exposes specialty, but also allows you to mix and mingle with senior trainees in the specialty and consultants and you can actually get one to sort of mentor you. Um and, and, and, and, and lead you along in terms of how best to uh interface with the specialty. Now, at the level of core training competition for training is not a level of core training, core training is actually quite easy to get to as a CCS acute acute medicine, um core medical training or um co anesthetic training, that's easy to get to, it's when you get to the ST four, that is where the competition lies. So um now the truth is people who have started early, so people in medical school who started the process early tend to compete better at that point as someone who made up their mind in court training to the intensive care, because you would have this log of evidence that shows that right from medical school, you've been very interested in this and you've been doing things towards that. So my biggest advice is if you can start early, if you've decided you can start early, start doing things, things like this, for instance, being a member of the society is a big thing. It's something you writing, it shows a track record that you are interested in this and you're doing projects and you're, you're getting involved and you've been to one of our conferences, you know, these are things that we, we, we're standing in good stead at that point. Now, at core training, you would do a lot more obviously to, to um like you, you try and be a AA a AAA um um try, try and get to be a, a uh um instructor, one of the um A LS APL S courses, but I've gone to conferences more, done some more audits or have a poster um um to show your interest in, in the specialty. The other thing that um it doesn't really hold as much before, but you used to, but I kind of really helps because it helps to have a good medical background doing to do intensive care. So if for instance, you're coming in intensive care and you're using the, the primary F RCA routes to apply to three and you also have M RCP that gives you double points because um because it means you have really good medical background coming into it and you find a lot of intensivist have uh a medical, I have MRI did my full M RCP coming into. Yeah, I came to the anesthetic route. If you coming through the medical route is not so important because the medic having that medical background is really helpful um coming in. So you know, a host of things, but I would say, I mean, talk for you guys starting early is a good, often, really, really good and, and the earlier you start, the more you'll have on your CV when it comes to the time to compete. Thank you. I think there is a question in the chart as well. Yeah. Yeah. So what's a typical working day schedule in the ICU both in register and consultant level? Is it one of the more variety based specialties or would you say it is heavily focused on a small range of cases? Right. So this is there, there isn't a homogeneous way to work in ICU. It's very different depending on the hospital, but it also depends on the type of ICU you work in. So what tends to happen is that? Um so I'll give you two examples. You could be an intensivist that works only as an intensivist or an intensivist that works um as an intensive as something else. If you work only as an intensivist, what happens is you have your week, you have a week where you are in charge of unit. Um And that week you spend most of that week on unit. The good thing about that is it provides continuity of care. So you'll be looking after a patient on Monday, you'll be able to form plans, evolve those plans through the week. Now, depending on the intensive care you work in, when you have your week, you only work 8 to 8 to 6 or 8 to 5 and then someone else does the night cause the night is just basically to keep up with your plans. But, but like in our ICU, what we do is that when it's your week on Monday, you work the whole day, including the night and Tuesday morning and get rest Tuesday afternoon and then work Wednesday the whole day. So you still work the whole week, but you do some of the nights on calls as well for that week. So it just depends on the starving. But generally you get a week where you have the, you are looking after the unit now because it's an intense week because the way we are, we have your plan to work is with your plan to work in PA S that week eats up a lot of your pa sa typical cost of contract is 10 PA S with 7.5 pa attributed to direct clinical care. So then you now have a second week in your second week. When you're not doing ICU at all, you may spend the entire week not doing anything. Now what I mean, not doing anything means that you're not doing anything clinical, you could do another thing. So if you have another special, like II do anesthetic. So in my non ICU week, I would do one or two anesthetic lists, but I'm also the research leader. So II cover that I um II work in the University of Leicester. So II that's also accounted for and you do your S pa work. So and I work on a one in eight rota. So I have my week one in eight times, but the other times of the week, I do other stuff. Now, if you're a single ICM train uh person, all you do is ICU in the weeks where you're not doing ICU, you're not clinical, you may do on call, but you have nonclinical rules to, to establish and things like research audit um um um management. So we have a lot of management um sort of input in se part of hospital infection control, um quality and safety transfusion that we, we help to manage because we utilize a lot of this platform. So it makes sense for us to have an input in all of that. So for a consultant, that's how it works out for a registrar, what it works out that you have normal days. So you have normal days, 8 to 5 when you work on the unit and you have on calls and the way the on calls work is that the on calls are 8 to 8 daytime and 8 to 8 night time. So, uh, and we did, we used to do seven hour, seven week days when I was a trainer, but now it's divided into four and three. So week one, you may work 8 to 6 on the unit, normal day, Monday to Friday and be off on the weekend. Week two, you will do an on call, um, Monday and finish on Friday and have the weekend off week three. You do a night, Monday and finish Friday morning and then, um, uh, you get the, the weekend off and then week four, you would work Monday, Tuesday, Wednesday, Thursday, get Friday. Uh, no, Monday, Tuesday, Wednesday, get Thursday off and then start nights on Friday. And so that's how we kind of cover the shift. Now, depending on the rotor, you're in, most rotors have a minimum of one in eight. Um So you have that cycle occur that four week cycle I just described occur eight times now, in between all you just do is normal, normal days. Ok. Um, so it's no less intense than being a registrar on A&E or, or in on a medical ward. It's the same thing. However, um, what you'll find is that, um, depending on your level of seniority, um, cos this is asking the second part of the question. Is it, is it variety based or is it heavily focused in a range of cases? Depending on the IC you work in, you'll find that um your, your, your demand for the demand for your services is varied across the hospital. It's often very, very varied. Um It's hardly ever focused even I work in a cardi ICU but my ICU has other patients on it. Uh sort of HPV vascular patients, everybody who and uh even even respiratory patients from CDU will call you to help you look after the patients. So it's often very, very, very, you have to work in an ultra specialist ICU to just have a narrow focus of cases for so for instance, maybe a liver transplant unit, the only looks after liver transplant patients, then you may just look after liver transplant patients. But in most ICU, it's quite very, it's quite var, there's a variety of stuff and if you're someone who doesn't just want to do one thing all the time, want to have a variety of input. Um ICU is for you because you could be looking after in bed one, a severe patient, a patient with severe asthma who's very bronchospastic on all the asthma medication. And in bed two, you're looking after patients with a hypocalcemic crisis. So, you know, you've got respiratory in bed one, you've got endocrine in bed two and in bed three, you're looking after a patient who has just taken tricyclic overdose with acute renal failure. And in bed four, you've got a patient in heart failure. So you can see how it's spread across different specialties. Um You know, so if, if that's what you would like something. Yeah, and you're looking after these patients in a very severe end of the spectrum, then ICU is for you cause that's what I it your your day is likely to be like um another question for me. So what got you interested in ICU? And I suppose anesthetics as well being a dual uh consultant. Um I uh so I II was one of the very first, I was in, in, in it was the very first quarter of trainees to do a foundation program. And I came out of medical school thinking I wanted to be a surgeon. Um and I wanted to be a cardiac surgeon initially, but that during that period, um cardiac surgeons were actually very finding find it very difficult to get work. And I remember one of my consultants was a cardiac surgeon who had retrained to be a general surgeon. Um But also I kind of, I've always wanted to, uh the way I think about specializing is you're either a doer or a thinker and then immediately you have a cluster in between. And I've always thought of myself as someone who was, who wanted to do a bit of doing and thinking. Um um, and I find other surgical specialties too much doing and I think some medical special, too much thinking. So that was one of the things that the what II attended a AAA career day in Newcastle because I was in the Northern Dry. Um And, and there was a big talk about intensive care and it, it s to me that look, you know, there's a lot of thinking, you, you, you've got to be very knowledgeable, but there's also a lot of doing, there's a lot of intervention, it's highly interventional. So that drew me to it. And the next thing I did was to do a taster session. So I did a taster session in my hospital in Darlington. Um And II really loved it. Went to theaters, did an ICU. I thought it was, it was great. Um And that initially drew me into it. Um But I kind of felt that you needed a lot of medicine. So I actually applied through the A CCS route um and did acute medicine and got my M RCP and then got into anesthetic. Now, when I got into anesthetic, I really wasn't sure II knew I was going to do the intensive care. I knew when to, but I didn't know what kind of intensives were gonna be. But in 2010, the first flu pandemic hit the UK and I was in, with hospital in Manchester, which was an emo center and that was it for me. I just felt this is where I wanna work and that was, I, we were really busy in that during that period, looking after flu patients and stuff and they were all on ECMO and things. And II think I hit the bug. II was hit by the bug then and I followed that path to do um cardiac intensive care and cardiac anesthesia. So if you're doing a thinker, it's very good for you. It's very good doing a thinking job. You do a lot of doing and a lot of thinking. And I suppose. So that's what got you in. What is your most favorite thing about your job right now? The fact that every day is very different, every day. I don't have a prescriptive uh pattern of work. It is very, very varied. That's what I love the most um about it. What I'm doing week A, you'll be very difficult when I'm doing week B and week C. So I II have a very, very drug plan because I do intensive care. I do ECMO and I do um cardiothoracic vascular and HV anesthesia. So week, a Monday week A I could be doing cardiac anesthesia week. B if we're doing um thoracic anesthesia, third day, I could be doing ECMO. Um and we do all forms of ECMO, ECMO for carder failure, echo for respiratory failure. It could be any and one good thing about ECMO is that ECMO is like being a detective is like, ok, you know, and it's like not being a detective but ok, you know, you've had the, so I don't mean this in a bad way but, you know, you, you, you've got a, there's been a, there's been a crime and, and the local PD have been doing this stuff and then the FBI come in. So as an echo, you're probably like the FBI cos they've done all the basic investigation and you now have to come and think outside the box and ok, you've done what's normal. This guy has not got better, what else could be going on? I do weird and funny things and do funny medicine and honestly, that's intriguing for me and I think that's sort of the geeky side of myself where you, you know, you laser specialties and say, look, we've done all the basic tests. Now, we need to start looking beyond and we find really interesting and funny things on, on patients on echo, which is very interesting. But also there's a practical aspect of, of, of, of doing procedures, um cannul in patients for ECMO tracheostomies, putting lines in chest drains. Um you know, um and advanced monitoring techniques um sort of near infrared spectrometry um peak catheters. Um um And also that, that for me, kind of gives you a lot of skill. I think the last thing I'd say is that um when you look after the sort of patients, uh we look at, I look after you can look after most patients because you, you, you've kind of, you've kind of taken things to the point where you can appreciate the whole spectrum of care. So I mean, for instance, II, give you an example today is a very good example. I um I II went to the maternity ward in, in L ri um to visit the patient and one of the nurses on the ward um cos I'm fully accredited in doing echocardiography because I need it for my job and they need an echo, an E an echo in a patients who had a per partum cardiomyopathy. And they said they had to wait till Monday and she saw me and said that's the key, that's the key. He, he works at Glenfield, he can do echo. Um and, and that for me it was uh II, II was happy I could help but I had the skill to help because of the kind of job I did, you know, so I was able to help them. I did the echo. And so, oh yeah, she's got heart failure. You need to get her to playing fill and stuff. But if I wasn't there, she would have had to wait till Monday. So there are the kind of things that kind of make, I think makes me enjoy my job is the fact that ii, over the years I've gained quite a lot of skills that make me quite self sufficient in looking after any patient who is critically ill. So, yeah, I can thank you for that doctor. Um, so I can see that you're very interested in your work and you're enjoying work. But I guess a lot of students do wonder what's the work life balance like for, for intensive care. I know you've got other roles that you take part in as well. But how would you say is your work life balance? So that's a, that's a good point. Um We have some and I'm gonna be very honest about um I mean, this, this is a natural an UK NHS issue is that we have AAA skills and, and, and and personal gap in, in, in, in the balance between service and people who provide the service. Um So there's a demand from the system for you to do more. Um And um so it is a busy job. Um It's important to have something to take you away from work. You, you need to have a balance. Um I'll be honest with you after the COVID-19 pandemic, a lot of intensivist had issues, mental health issues because it was so intense and the demand was so high and we actually had a lot of attrition. Um, people who had a lot of staff leave intensive care, especially on the nurse inside. Anyway, medics decided to step down and do less intensive care. So, if you're gonna do intensive care, um you need to have a good work life balance. I mean, for me, I balance it out by um, I, I have weeks where, because of the way my job plan is, I cluster all my work in three weeks and I have a week where I do absolutely nothing and do just things that I like. Good to go on holiday. Don't ever forget that, you know, take your holidays. Uh, don't say, oh, because the service is suffering, you're not gonna take your holidays, take your holidays, have a balance, something that balances you off. It could be anything but come back refreshed. The system allows you for that. That's why we do of weeks. So you clu all your work. So you have time to step away. And actually you find sometimes, um, when you step away for even just a week or two, when you come back, you, you, you come back very refreshed. You're, you're more functional at work. So that's an important thing. It is an intensive job. And one thing I would also recommend is to be able to identify, to be, to have that self insight and knowing when you've reached your limits and pull away. And a GMC requires you to be able to do that in, in any specialty, but more so in intensive care. Um, it's very, very important because you're looking after really sick patients. So by and now just to summarize what you said, um, I mean, for me, it is, it is cutting off. II don't have Stockholm Syndrome, which is where you, you're at home, you've just finished the shift and you're still checking electronic records to see what happened with the patient. I left at six o'clock. I don't do that. I, I've handed I do a really good handover to my colleagues and cut off and then I give myself time off. I make sure I take my holidays. I play football and I love traveling and I use that to sort of balance things out and it gives you room to do that. Um And that's the only way you can do the specialty for a long time. Um The last thing I'll say is that as you get older um in the specialty, there is also a provision to kind of help you reduce the intensity of work you do so that it becomes more tolerable later on because doing this intestinal work in your late fifties and sixties might not be tolerable. So you can scale it down, you can reduce your working hours, you can reduce the intensity work you do, you can use the type of intensive work you do, for example, in, in, in U HL. Um we have two big ICU S, we have a small IC of the general, which is less intense and more um sort of less, less busy. Um So what we have some about all the consultants have left their jobs in the big ICU S and gone to the small ICU just to kind of make the job a bit more tolerable. So there are things that you can do to kind of keep the balance. Um, but overall you'll find, um, a lot of intensivist, um, with a good balance in their work life, um, uh, sort of schedule, have a very rewarding career throughout. Think of that. Any other questions? Well, thank you. I think that might be it for now. Um, would you be ok if we put the recording up for people who might have missed being able to come? Yes, definitely. That's fine. And we'll send feedback forms when we've got the. So if you fill out the feedback form, you'll get a certificate and then we'll send that to you as well. And ok, no worries. Thank you very much for inviting me. Thank you for your time. Thank you. Have a good evening. You too. You too. Bye bye.