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So, hello everybody. I'm Nathan. I'm one of the fy twos currently working at the royal. And anyone who's met me for more than about three minutes will probably be able to tell you that I really, really want to be an anesthetist. So I'm gonna tell you what's good about anesthesia. Why I want to do it, why I think you should consider it too. And a bit about the life of an F one in anesthetics in intensive care and how to get that all important training number at any point, the guys who have set this up will be monitoring the chat. So if you want to put something in to the chat, fantastic. Equally. If you want to be brave and switch your mic on and ask me a question, just go for it. But we will have some time for questions at the end. C presuming that my slide has moved on. This is what I plan to talk about, gonna tell you a bit about me, but not too much. I'm going to give you a bit of a case study to tell you why I think anesthetics is brilliant, then go on to talk about some of the pros but also most importantly, some of the cons of an anesthetic career, a bit about where it can take you in life and the training program. And importantly, getting in before finishing up by telling you a bit about my role as an fy doctor on the intensive care unit. So let's dive right in. I'm proud that I'm a Lester grad. I started medical school back in 2017, I graduated in 2023 after intercalating, looking at airway disorders in Children with congenital heart disease. No prizes for guessing from that. What specialty I want to do? I feel. And my f one was in Leicester. I did general medicine, general surgery that are both considered real baptism of fire jobs. And then my final post was in anesthetics in intensive care. That was perhaps one of the most joyous rotations I've ever done. I'm currently in Fy two in Geriatrics of the Royal. And again, as anyone who's met me, well, no, I have a bit of a habit for attracting trouble on unwell patients. So when thinking about what I want to do with my life, I feel that especially like anesthesia that gives you skills in managing unwell patients is pretty handy as they seem to find their way to me. So I want you to imagine just to potentiate this nie to stereotype that you're sat there drinking your lovely single orgy and organic coffee in the coffee room being generally sarcastic, fulfilling every stereotype of an anesthetist. When your bleep goes off and tells you to get down to Ed Russ and get there immediately. You meet Sandra. When you walk into the Reco Bay, she's 82. She copes well enough at home. She walks with a stick when she's outside. She had a bit of a tummy ache earlier in the day, felt a bit feverish but she didn't want to fuss. She just stayed at home, took a couple of paracetamols. Her daughter went round later, slightly more concerned than her mum was and found her lying in bed. At that point. She was barely conscious. The family called an ambulance and the ambulance crew were so concerned that they pre alerted the emergency department and blue lighted her to recess when she arrived in recess. Her new score was 17. Her respiratory rate was 23. She was needing a lot of oxygen to maintain barely adequate sats. Her heart rate was 100 and 20 you do a double take when you look at that BP and yes, that is accurate. Her BP was 43. Over 30. She was hypothermic and she was making incomprehensible moaning sounds to even a good trapezia. Squeeze. Ed do the basics. Well, they put a cannula in, give some fluid, give some meropenem and they take a VBG H BJ is pretty shocking. Her ph is only seven point naught one for anybody in phase one, I would expect the ph to be somewhere between 7.35 and 7.45. Her lactate is 7.2. Again, anything above two is concerning potassium should be 3.5 to just a shade less than six. Her potassium is only 1.9. That's well within the territory where it causes serious cardiac abnormalities. We catheterize her thinking through our sepsis six steps and we only see a tiny amount of dark urine in the tube. There's not really any urine draining out. When they go to examine her abdomen. It is rigid. It's peritonitic and it clearly hurts her enormously. When we palpate it. At this point, we get a CT scan. We have these pictures that come out of the machine. Are there any budding surgeons in the room who would like to tell me what we're looking at just to orientate you? You've got the sacrum down here, pelvic bones here. And then you've got a whole mass of bowel inside here. I will give 20 seconds to see if anyone's putting anything in the chat or otherwise, I'll just infer that nobody wants to be surgeons because they're in an anesthetists chat. Stunned silence. Ok. So this is just a cross section in the axial section of your pelvis. We can see all of this fuzziness around here is inflammation. There's something clearly inflammatory and infective going on in this pelvis. We can also here, see these couple of little bits of black, these little black dots, these represent air. The only place you should have air in your abdomen is really within your large bowel. Those are outside your large bowel. Meaning that this patient has pneumoperitoneum, their abdomen has air where it shouldn't be. And that is pretty indicative that something has perforated. So the radiology report comes back really quickly and it reads this, there is evidence of sigmoid diverticulitis with significant pericolic fat stranding. That's a radiological sign that indicates infection. There is free intraabdominal air and a significant amount of free fluid in all four quadrants of the abdomen. In keeping with generalized peritonitis impression, this patient has perforated sigmoid diverticulitis with generalized peritonitis. This is a general surgical emergency and unlike a pneumonia, for example, where you can give some intravenous antibiotics and that will be able to clear the infection in an abdominal perforation. The only way to get on top of the source of that infection is to go in operatively and wash it out and where there is surgery, there is a need for the anesthetist. So I want you to imagine yourself as an anesthetic registrar. That's probably quite far in the future, but you already have more of the skills than you think. Can anybody tell me what the medical school answer is to how you approach a very sick unwell patient? Can I answer? You are more than welcome to answer, answer away an E to E assessment. Lovely golf star. Fantastic. Now, my transitions were meant to hide some of this. So apologies to my technical ineptitude. But let's go through it to her airway. What do you see? So when you look at this lady, she sat there and she's making snoring noises. No, that sounds relatively innocuous. Cos I'm sure if you go to a hospital ward in the middle of the night, there's loads of people who are snoring. But in somebody who's this drowsy, this means that all of the tissue in their upper airway is really floppy and that is only gonna get worse as their condition progresses and they become less conscious at that point, all of that soft tissue will flop onto the glottic opening at the top of the trachea and mean that patient's airway is compromised, it is on us as the anesthetist to support that airway. And from looking at this patient whose G CS is probably less than eight, their airway is in a critical state where they're not going to be able to keep that open without artificial support for long. Then we look at her breathing and we can see that while she's maintaining sats of 93% that are pretty adequate. She's needing a lot of oxygen to do that for 6 L is quite considerable. So what you need to then be asking yourself is why might that be? So sepsis can cause lung dysfunction if you're septic, your capillaries become very leaky and your lungs just fill up like a wet sponge with lots of fluid. So that's a potential and that's almost certainly going on in Sandra's case. But the other thing we have to consider as ants is what's somebody's past medical history? Imagine having septic and compromised lungs where your lungs are already compromised because of 70 years of smoking and a diagnosis of CO PD. That patient is going to be a lot sicker than somebody who came in with the same pathology in their abdomen who was previously running marathons. So you'll hear anesthetist asking lots about social history and about performance status and exercise tolerance. And the reason for that is because we know that being able to safely climb a flight of stairs without getting out of breath is a really good indicator that you will manage a general anesthetic. Meanwhile, if even on a good day, you have to stop two or three times, getting up the flight of stairs, you're at a very high risk. So let's talk about her circulation. This lady is very tacky cardic. What did I put her heart rate at about 100 and 20. She also very hypotensive with that really scary BP. She's tachycardic because her body is trying to compensate for that hypotension that's been caused by the sepsis, but it's failing. She is very tachycardic for her 82 years and she is still not being able to maintain her BP. Now, if you go to your medical school, sim, the right thing to do to somebody who's very hypotensive is to give them some fluid. And if they don't respond to 500 mils of fluid, give them another bonus and another and another until you get to about 2 L. At which point if things aren't getting any better, the question we've got to ask ourselves is, is giving more fluid the right way to go. If we've given somebody about 2 L of fluid and their BP hasn't even budged and their heart rate hasn't started to come down. Then we're in a position called fluid refractory shock. And as anesthetist, we have tools in our pocket to manage that, that our acute medical colleagues, for example, don't, another thing I'd be thinking is here's somebody who is pretty much on the edge of life. I don't think any of us would be surprised if this patient was to die at any minute in the emergency department. Even when somebody's on a cardiac monitor down in A&E that BP cuff will only cycle every couple of minutes maximum. If we're going to be giving powerful drugs to increase somebody's BP, we need to be monitoring their heart rate and BP, not every two minutes, but on a beat to beat basis. And we'll talk about how we can do that in a second disability is here for completeness, but it's actually really important. Now, this lady is so hypo is so hypovolemic and hypotensive that she really won't be perfusing her brain very well. That's problematic for somebody of our age. But in somebody who is elderly probably has a degree of neurovascular impairment. We know that actually her brain is so much more vulnerable and even a short period of being really hypotensive massively increases her risk of delirium if and only if she survives this episode. And exposure is something that when I was at medical school, you just stuck on the end to actually help us sort of complete the algorithm. You'd have a quick glance around the patient and say, yeah, there's no bleeding, there's no rashes. Brilliant move on. The more anesthetics I've done though, the more I've realized this is the biggest thing that we do as anesthetist after the airway and the circulation a lot of the time cos our machines do the breathing for us. So she's really cold. Why does that matter? Well, that matters because all of your enzyme controlled processes in your body just don't work particularly well if you're cold. And we need to think about how we can optimize this. Has anyone come across any devices we can use in the hospital to warm people up really quickly. If you think back to any anesthetic weeks you've been on, you've probably seen them wheeled out in theater. Yeah. Ok. So be brilliant. Yeah. So for people who haven't seen these, they are effectively a machine that functions a bit like a hair dryer connected by a hose to a blanket that blows hot air onto a patient. They're really effective and they not only increase the temperature to make our monitors happy, but they also improve the efficiency of every single physiological process in the body. Now, if we look at her kidneys, we can see that she's anuric, That means that I don't need to wait for a urine to come back from the lab to tell you this patient has an AK I. We also know that her potassium is very low, that's going to be further worsening her cardiac function and increasing the risk of life threatening arrhythmias. That's something else we'll have to consider before we anesthetize her. And then the final thing comes into her abdomen. It would be really nice in a patient, this septic to be able to send her to the intensive care unit and optimize her physiology as much as possible before we put her under anesthetic. But with an abdomen that's full of a horrible mixture of pus and poo and air, that's going to be very challenging. So whilst we'll give some empirical antibiotics, we need to get this lady to the theater. Now. So let me tell you what we did. We realized that we need some help at this point because as well qualified and skilled as these tests are we only have a pair of hands. Now, I was the fy one and I went down to see the patient with the anesthetic consultant running the left. Soon after we had the itu consultant joining us, we had a number of surgeons turn in and we even had the hematologists on the phone to give us some advice about her blood results. It was truly an MDT approach. We decided that this was a lady who had a surgical pathology, who was an acceptable candidate for an operation. So we got on the phone to theaters and we got her up to theater pretty sharpish. Now, it takes a bit of time to set up a theater. If any of you have been on an anesthetic list, you know, there's an enormous amount of waiting around. So we did some bits down in the recess cubicle. We wanted to monitor her BP beat by beat and be able to take regular ABG S without constantly stabbing her wrist. So we put in an arterial line and that monitored her BP on a beat by beat basis. Now, because giving her lots of fluid had failed. We needed to give some vasopressor. Now, a quick sort of divert into nomenclature. You'll hear people talk about inotropes a lot and a common phrase I'll hear on the medical board is, well, we need to refer this patient to itu for inotrope support actually to let you into a little bit of a secret as a cyst, we use inotropes but not very frequently. What most people mean when they say inotropes is vasopressors. And vasopressors are drugs that simply work to contract the smooth muscle in your arteries to increase the BP. Inotropes work in a lot more complex way and make the heart pump harder and increase the BP that way. But the reason a septic patient benefits so much from vasopressor is because a central part of sepsis is vasodilation. So it is the only drug that we have that can completely at so not completely. So it can directly attack the core pathological process within sepsis. So we put the central line into the jugular vein in her neck and we got our favorite vasopressor called noradrenaline running. Now, when the lab results came back, it showed her inr was something horrific like 3.5. And clearly our surgical colleagues don't want to operate on somebody who's that bleedy. So we spoke to the hematologist and we gave not only some red blood cells to treat her anemia, but also we gave some products like fresh frozen plasma and cryoprecipitate to give her body that vital shot of clotting factors. It would need to be able to clot whilst the surgeons were doing their operation. At that point, we got a call from theater to say that the theater was ready. So off, we go in a long procession upstairs. Now this is where the risk of it happens. Anesthetic agents are fantastic and they're safe. But what they often do is depress the cardiovascular system. If you're perfectly fit and healthy and going for an elective operation, a degree of C vs depression isn't particularly problematic because we can easily treat that with the drugs we have and your fit and healthy body can tolerate it. Her physiology however, was already on a knife etch. And because of that, we needed to be very, very careful. We needed to give just enough drug to make her asleep and paralyzed so that she could be intubated and giving any more drug than that could precipitate a cardiac arrest. Now, as the surgeons began to open the abdomen, her BP began to drop again, we increased the amount of the vasopressor we were giving to contract her blood vessels, but she wasn't really responding to that anymore either. So, because we like fancy toys in anesthesia out came the ultrasound machine and we did a quick echo and whilst in a healthy person, the echo will show the heart vigorously beating. Her ventricles were just wobbling around like a jelly inside her pericardium. So the pumping function of her heart was impaired and that's what we call cardiogenic shock. And when I was making that very pedantic point about inotropes versus vasopressors at a little while ago, inotropes can sort out shock. That's distributive. Where are er, sorry vasopressors can sort out shock. That's distributive where your blood vessels are wide and they need some squeezing. If you have cardiogenic shock, though, you need something that directly acts on the myocardium to make it pump better. And that's where our inotropes and adrenaline is a brilliant example of one of those drugs come in because we can give those to give the heart a bit of a kick to try and get it through the procedure. We obviously recognize that this is an extremely painful condition. We gave lots of pain medication, but we use those medications that we know don't affect the cardiovascular system very much at all. Now, the surgeons do this operation that's called a Hartman's procedure to be very surgical about it. It is an emergency recto sigmoid colectomy with the formation of an end colostomy. So basically, what we do is we chop out this mankey looking infected, perforated bit of the sigmoid colon and the top of the rectum with it, we bring all of the colon that's upstream to that out at the abdominal wall as a colostomy and then we stitch or in reality, staple the bottom of the rectum closed. So that there is a rectal stump that can eventually, if the patient is well enough, be rejoined to allow them to pass stool through their bottom again. So this lady went round to intensive care where I did most of my shifts on approximately five different infusions to support her physiology when she gets round to intensive care. There's still only a couple of mils of urine in that catheter bag. She's anuric and her urea has gone from less than 10 at her baseline to about 40. She's very acidotic. All of this shows us that she has gone into an AK I three. Her kidneys have completely failed as a result of the sepsis and the long standing hypotension. So the intensive care team put an yet another line in this time in her femoral vein to take her blood out, run it through the hemofilter and put it back in. She stays on that for about five or six days. She's given antibiotics, antifungals. We slowly wean down those inotrope and vasopressor infusions that are supporting her and about three or four days into her stay, she's well enough to be woken up and now she wakes up and has very little knowledge of everything that's happened. And emotionally, this is really hard for patients because it takes a bit of time to s for it to sink in that all of these awful things have happened to you, but you weren't aware of it. By the time we get to two weeks POSTOP, she's discharged from itu to the surgical ward. She's walking, she's interacting, she can even manage her stoma by herself. She went from being at the edge of life to getting back to as close to a normal life for her as is possible. And this case really summed up to me as somebody who was involved from start to finish. I saw the patient in EDI did a couple of the basic procedures in theater. And then finally, I looked after her on the intensive care unit. After that, it was fantastic to see a patient journey where that patient wouldn't have been alive. Had it not have been for an amazing team effort. That team effort came from the anesthetists, the surgeons, the intensive care team, all of our physiotherapy colleagues who help get the patients moving and other specialties like hematology and the staff in the lab. What I love about anesthesia in critical care is it's a real team effort, but we can so often pull patients back from the brink and deliver them back to a quality of life they really value. So that's the moment where I went from a, I really want to do anesthetics to, I can only see myself doing anesthetics in the future. So that's why I tell you all this really because I want to show you the impact an anesthetist can have on somebody's life. I think there's far too much in popular culture of, oh, we're just doctors who don't like putting, talking to people. So we just put them off to sleep, do the crossword and come back in a couple of hours at the end of the operation and maybe wake them up if we feel like it. Actually, there's so much more to it than that. It's intellectual. You have to think about all of the different systems. You have to pull on knowledge you have for medical school of all of the different specialties. But you do this so that at the end of the day, a patient lives. So I've talked to you about a very personal story about why I enjoy anesthesia. And I've spoken to some of my colleagues on intensive care and in theaters about what they see as the pros of anesthetic career. And this is people from anesthetic ct ones up to consultants who've been doing it for 35 years. The thing that people kept coming back and saying is that anesthetists really are at the edge of life. We manage conditions that are acutely life threatening, using drugs that can only be used under the closely controlled conditions that are in our theaters. People also say that it's a real mix of doing so we do lots of procedures. But we also have to do a lot of thinking about things like physiology and pharmacology. And actually, that's fantastic because when you study these things in phase one, it's something you do to pass the exam. It's very rare for you in any other branch of medicine to watch your drugs. Pharmacology play out in front of your eyes. Well, if that interests you potentially in quite a nerdy way, then come over to anesthetics because there's a lot of that here. And finally, there's a lot of communication in anesthetics and intensive care. Just think about what we have to say to that lady who woke up after that enormous operation. Just think of what my pediatric colleagues have to talk to a frightened child who's coming to theater for their first operation about that's all communication skills. And that's another thing that people say is we get to support people on the best and worst days of their life. Anesthetist have a constant presence on Labor Ward watching babies being born. And I can say even having done just a few days that never gets old, but also we meet people on the worst days of their life and if we can make them a little bit more comfortable or render them unconscious to allow an intervention to take place, I think that's a good thing as you go down the line. And if you speak to registrars in any specialty, they'll tell you that you actually become more siloed and more specialized and you lose touch with a variety of other specialties in anesthesia. Clearly, we'll never be as good at gynecology as the gynecologists or surgery as the surgeons. But we do keep up with these specialties that we don't do because we anesthetize their patients. So even as an F one in anesthesia and intensive care, I learned a lot of general surgery and gynecology because I was exposed to that. And finally, you're very much as an anesthetist in demand in the hospital. If things go wrong, people are calling you for support from the poorly patient in extremist in Ed to the cannula that he's doing on a ward at 2 a.m. people will phone the anesthetist. And finally, this is something I didn't quite grasp when I decided I wanted to do anesthesia at 18. But it is a family friendly specialty. You don't often take your work home with you as an anesthetist. That means if you've got kids, if you've got relatives who you want to spend time with, you can go home after your the days and have real quality of life with them because you know that you've got very highly trained colleagues in the hospital who can handle things. Now, I've had a very tough week on geriatrics. So just before I came on to do this talk, I put these three more bonus pros and aesthetic care in number one is that you get as a novice anesthetist in CT 11 to 1 teaching from a consultant, I'll challenge you to find very many other specialties that do that. Your consultant will know what you need to learn and they'll be able to help you get there and talking to those 35 year veteran consultants, they really enjoy that. They enjoy meeting a young CT one on the first day of their anesthetic training. And even three or four months later, seeing them turning into a safe and competent early career anesthetist. That's fantastically rewarding when it's you who's undergoing that development. But it's also rewarding when you're at the other end of that train being the consultant. The final thing I learned on my, the days is that anesthetists love a good break. And it's important because it does make you work better. I've never been told in any other specialty to go and have a longer break or I haven't been away long enough, but anesthetics, they're very keen on making sure that you are well rested. And the final thing is that we do see people across the entire spectrum of life like the GPS do. And actually, we could claim that we probably see people a little bit before then because anesthesia will be involved in the care of very premature babies up to the 100 year old who's broken their hip and is coming in for a hip operation to repair that fracture. And again, it's quite hard to find that in, in other specialties, of course, it's not all rosy. And there are some quite significant cons to being an anesthetist that I don't feel are deal breakers. But I think it's important to be aware of them because it might be for you. Now, anesthetists are fundamentally a service provision specialty there is you people do not come to hospital to have an anesthetic and that means that your workload is all dependent on the cases. Other people bring to you. So you need the surgeons as much as they need you. The surgeons will decide they want to do an operation. And it's very rare for an anesthetist to cancel a case. You have to work with the workload you're given by other people and some people like that, other people find that it's frustrating that they don't have that ultimate control over patient care. If you really like setting a clear pathway for how a patient will be looked after, then I'd suggest that working as a physician or a surgeon would be a good option for you. The other thing is it's potentially lonely. It is a bit of an introvert specialty overnight. You might be the only anesthetist, particularly in the district General Hospital in that area and that can get a bit tough emotionally. But you do work with a large theater team and that might feel quite sort of intimidating to begin with because you're there in sort of as a temporary visitor in a team they've been in for many years. But I found theater teams are enormously friendly and that's needed because the hours can be pretty terrible. You will be working on social hours. You'll be doing a lot of nights and a lot of weekends because medical emergencies never stop. And finally, it's important to talk about the emotional and psychological difficulty now because anesthetists are exposed to the most unwell patients in the hospital, they'll see some of the most harrowing things. And that includes critically unwell babies and Children, many of whom survive, but some of whom do not, it's very tricky that you're seeing them and having quite a key role in their care, potentially relatively early in your career. Add on to that problems with rotation and a notoriously complicated set of exams. There's a lot of resilience required in anesthesia training, but there's also a lot of support to build that. Now, the other cons are things that I think we can't ignore. So if you go onto Reddit or what was Twitter, there's constant talk about anesthesia associates, anesthetic associates call them what you will, who are effectively a ASO medical associate professional group who are going to be registered and regulated by the GMC later this year, but deliver anesthetic care. I'm not going to go too much into the opinions on them. But I think it's fair to say it's difficult to tell how their proposed role expansion will affect training and long term consultant work. But from the consultants, I've spoken to, there is a future for doctor anesthetists. The other issue is there's a real bottleneck, particularly at the transition point between your core and higher specialist training that can slow you up a bit. It's also sometimes quite tricky to get a number to go on to CT one, but we'll talk about what you can do to optimize your chances. Now there's a few factors that completely depend on you as to whether an anesthetic career is something you might want to consider. There's limited continuity of care. Again, some people like that, some people don't. But if you love anesthesia but want to have some continuity, then you can go and work in the clinic, in the pain service. The teams you work in frequently change, that might be fantastic. Or you might prefer to have a regular team who you work with on a regular basis. The point about the patients across the age spectrum is there as well. Now, it's very unlikely that a tertiary hospital, anesthetist will be doing both 99 year old hips and preterm babies, but particularly district General Hospital, you would have to treat both adults and Children. If you don't like adults particularly or don't like Children, then that's something you won't be able to escape in your training. I've obviously spoken about this idea that you're communicating less with your patients. And I do think that's a perception that's not enormously true because the communication that we have in anesthesia with our patients whilst it's relatively short lived, there is a lot of it and it's quite intense because we're meeting somebody for the first time, 10 minutes before a life changing operation and potentially going to have to build an enormous amount of trust in that person very quickly. That's a strong communication skill in itself. And the final thing is compared to other training programs that are three or five years at seven years. Anesthesia is a relatively long program of training. Now, the competition ratios have come out for anesthetic ct one and it's more than 5 to 1 this year. So there's more than five applicants to every place. So, should you just look like these very distressed emojis on the slide and just cry and not apply? And there's a lot of nihilism and a lot of people who are friends of mine who are really good candidates haven't got jobs and it's hard and it does make you doubt whether this is something you want to do. But what I'd say is the problems with training exist in all of the specialties. And I believe that the anesthetic training program is good enough that when you get in, it will be worth the heartache of trying and potentially having to try a couple of times to get that training number because it just opens up so many paths from your basic anesthetic training lasting seven years. You can broadly go down three routes. You can go into intensive care, you can go into pain medicine. Now, everyone has to do pain modules in their anesthesia training. But they're a very small part of it. If you really enjoy managing acute and chronic pain, there's a whole subspecialty open for you. And then the thing that I enjoy most is the theater based work. So you could either be a generalist anesthetist in a district general hospital who does some orthopedics on a Monday, some pediatric ent on a Wednesday and a bit of general surgery on a Friday. Or you can go and become a subspecialist working in a tertiary hospital doing cardiothoracic neurosurgery or pediatric spinal. And there's also some of these other sort of avenues to any medical career that you can do alongside anesthetists being aist. One of our deputy medical directors, er, Tim Bourne at U HL is an anesthetist by background. So there's lots of, er, sort of avenues for leadership, particularly in the big academic centers, there's research to be done and I'm sure you've all met anesthetists who are fantastic educators. So education is something that's in all anesthetist job plan. But it's actually some people do choose to take it forward and make a lot of their job about education. That's something I'm really interested in doing. Now. I don't want to just read off this list of these anesthetic subs specialties. But I want to sort of say that anesthetists work in all of these branches and as a consultant and actually, even earlier than that, as a trainee, you can build your career to suit your interests. People encourage you to have an interest and say, actually I haven't seen much H PB in many liver resections. So I'd really be interested in seeing and doing more of those and that will be facilitated. You can even go on to do specialist fellowships in things like neuroanesthesia, cardiothoracic and peds. If that's where you want to see your career going, every anesthetist leaves the training program competent to be a safe day on consultant in a general post. But that's not the end of your education journey. And you can go and make your career as general or a specialist as you like. And that's really nice. So, I've talked to you about the joy of anesthesia, the pros and cons and a little bit about why you should try for a training number. So if you get that training number, how does your training program work? So this is a diagram from the Royal College of Anesthetist taking you from where you all are at the moment as medical students through F one F two where I am at the moment. And then this application phase for core specialty training. And that would be either a CCS that stands for the acute care, common stem or core anesthesia. The applications for that opening every October and I'm just starting my application this month. So you get into training and your first and your training sort of looks like this. There's three stages, stage one lasts for three years, stage two and three are two years each and they go to make a seven year training program and all. So CT one up to ST seven and then you meet this point called CCT, that is the certificate of completion of training, that's where you complete your training program. And the GMC recognize you on the specialist register as somebody who can become a consultant. So let's break this down into what the early stages of an anesthetic career look like because whilst it's really good at your stage to look at what the consultant's job role is simply because you'll be doing that for a very long time in your career. It's also important for you to see what the training program looks like and whether that would be a fit for your personality. So stage one training is about laying the groundwork for your futures in these test. You are getting those basic anesthesia skills, learning to intubate really well, learning to bag mask, a patient and to make sensible anesthetic drug choices, to monitor your patients effectively and to deal with critical emergencies. This means that you can deliver a basic safe general anesthetic you can put in a spin or you can do an epidural and those are the foundational skills without which you can't go on to develop specialist practice. You'll also be introduced to pediatric anesthesia at this stage. So even in your first few months, you will be assigned to pediatric lists and you will in district general hospitals encounter Children who come onto the generic emergency list. Now, perhaps the most important thing you learn as a stage one trainee is to develop a sense of worry and that is worry in a good way of you look at a patient and you assess them and you can identify risk factors to say they might be complex. Let's get the boss in. Let's get the consultant in. Let's use all of the skills we have to mitigate that risk. By the time you get to being act three, like one of my good friends is at the moment, even if you can't consciously say why you have that feeling, you can develop a bit of a bad feeling about a case and anesthetic consultants are sufficiently supportive that you can call one in and go. I just don't feel good about that. Could you come and help me? Now, in stage one, you'll also do quite a bit of obstetrics and some intensive care about six months. Now, nobody can mention anesthesia without mentioning the exam. You have to sit your primary F RCA fellowship at the college of anesthetist exam before the end of CT three to move on into higher specialist training. Now, your 1st 3 to 6 months of the anesthetic training program is your I AC. So the initial assessment of competence, that's a bit like a pilot, gaining their wings to be able to fly solo, you have to be able to preassess patients formulate nice basic plans and deliver those simple anesthetics to patients who aren't particularly complex in a safe manner and being safe involves you demonstrating in a simulation scenario that you can manage time critical and high stakes emergencies like the inability to intubate someone or anaphylaxis. After that, you can go on call in a big center like Leicester on call will mean being act one where there's always a registrar around to ask for help. Or you could be in a smaller hospital like Kettering where you're the only anesthesist on for theaters and people are much more distant if you were to need help. There is a similar thing for obstetric anesthesia and you need that initial assessment of competence in obs anesthesia to be able to go on call for labor ward. And that's got some extra competencies like putting in epidurals and doing spinals in there. It's quite nice. I think how it's broken down so that you can have the confidence that your bosses know that you can do what you need to do to be able to safely go on call. Now you're a registrar at CT three, but the real proper edges are CST four and ST five where you consolidate those co scales but also get blocks of exposure to subspecialties. So you'll have a pediatric block, a cardiac block and a neuroanesthesia block. You'll also do some more obstetrics and some more ICU and you'll be assigned to lists like orthopedic ones to gain some experience in nerve blocks and regional anesthesia. Now, before the end of ST five, you will set your final F RCA. It's a feared exam. It's hard, but the light at the end of the tunnel is once you are done with that, that's the exams done for anesthetic training. There's not an exit exam like there is in a lot of medical specialties such as respiratory, for example. So after ST five, once you've got your final, you've actually got another couple of years to really hone your skills as the E test without worrying about exams. And that's quite nice. So that's what those final couple of years are really, they're there to consolidate, not only your anesthetic skills, but also your leadership and management skills. ST sixes and sevens unless they act as what's called the second on. So you are the most senior anesthetist overnight in the Royal. And the job of the second on is to support all of the more junior registrars and sh os in theaters in obstetrics and in itu if they were to get stuck, and that's a great role because they can benefit from the expertise of a much more senior trainee. But actually, it means that the ST six or seven can develop those leadership skills. They'll need to be a consultant. There'll also be a part of your final couple of years if I just go back here where you can develop a specific interest, and you can say actually, I'd really like to be a pediatric Kines. So you can go and do a six month period of peds at a children's hospital, for example, and your training program will facilitate that. The other thing that's quite worth talking about is the fact that a large proportion of the intensive care workforce are of course anesthetists. And you can work as an intensive care doctor in a small hospital without going down the dual specialty route. But more and more now you do need the dual specialty in order to be able to be on the itu rota. So you will become a consultant in both anesthesia and intensive care medicine. And this opens up a real range of new jobs. If you enjoy the itu parts of your anesthetic training, you might think actually, yeah, let's go for doing a bit more. There's a problem though, your training is extended by at least a year, often more. If you co anesthetics training, you have trainee and you haven't gone through A CCS, then you might need to go back and do an extra 12 months of internal medicine and going back and becoming a medical sho working at F two CT one level. When you're an anesthetic reg in your day job can be quite a hard transition to make. And finally, you have to be a bit of a glutton for punishment to do this because you've got another set of exams. Now, the ICU exams and the anesthesia exams do have a lot of common ground. So the anesthetists find this ICM exam slightly easier than people who are coming to intensive care from specialties like Ed or Renal because a lot of the physics that's in the exam is also in the F RCA anesthesia exam. So whether you'd like to do some itu is potentially relevant earlier than you'd think. So, when you apply for core anesthesia, you'll notice there's two options, there's core anesthesia and there also is the acute care common stem open brackets, anesthesia, closed brackets. Now, I'd like you to think of a CCS as core anesthetics. That's a three year program with a year of acute medicine and ed bolted onto the front of it. As Act two, you'd then do six months of anesthetics and six months of intensive care. That would mean that poten that as Act Two, you would gain the initial assessment of competence and the ability to go on call for anesthetics at the point you would in ct one, if you were going down the core pathway so effectively, if you're an A CCS anesthesia trainee, you'll do things a year later than your peers who start core anesthesia at the same time. So the advantage of A CCS is that it gives you experience of acute medicine and the emergency department that is helpful because any experience makes you a more rounded clinician. And what it also does is it means that if you want to do some intensive care that CT one year gives you enough post foundation experience of medicine that you can go straight into ICU dual training. The disadvantage to core anesthesia is that you'd have to do that medical top up as a registrar. Of course, if you think you just want to be a theater anesthetist and I think I want to be a theater anesthetist, I'll be applying to Court cos I'd rather get to what I want to be doing early. But the other thing is that some areas the West Midlands have most of their posts as A CCS. Meanwhile, here in the East Midlands, most of the posts are core anesthesia. So if you've got a location in mind, you're probably best off just taking what's offered in that area. So I've talked about what you do in your training program. So now's the crux that you probably all come for what secret source is there to getting a training number. So you have to apply in a very convoluted system. So there's usually two rounds of applications in a year, one to start in August at the same time as all of the new doctors and everyone rotates and one that you apply for to start in February. Now, the competition ratios are getting harder, it's becoming more competitive, but getting a spot is possible. It's about 500 spots every year. So most people, particularly if they're applying directly from F two will apply in this sort of October November time that's coming up on oral. That will be familiar to those of you in final year because you will be using that to apply for your F one jobs once you've applied. And as long as you've met the basic criteria and these are as basic as having a medical degree being registered with the GMC being either an F two or having the equivalent of completing foundation training. And then you'll be invited to sit this exam called the M SRA. That's the medical specialty recruitment assessment that everybody beyond the level of read or above seems to call the M RSA every year however much people correct them. So what is it? It's an exam in two parts, you spend 95 minutes looking at a range of professional dilemmas and these are like the old fashioned situational judgment test questions where you are given a scenario of your consultant comes to work and they look like they've been drinking and they've maybe got some white powder on their tie. What do you do about this? And they assess your ability to act professionally and manage difficult situations. I'd argue with the amount of this sort of stuff that's done at Leicester being a Lester grad gives you a lot of advantages here. But just think back to some of those professional dilemmas questions you've done on university days, that's pretty much what's being asked here. And then the other part of the exam that's shorter but is pretty much equally weighted is the clinical problem solving section that are questions that are SBA S done at a foundation level just to assess your clinical knowledge, I'm currently preparing for that using passed all the question banks are available and that set of questions is pretty much at a finals level finals potentially with a little bit of extra postgraduate learning on top, but it's very, very manageable. You don't have to be super academic and super smart to ace the M SRA you just have to practice and ranking for interviews in anesthesia is completely dependent on the M SRA portfolio has been completely removed. So when you get to interview, if you get a spot, you'll be invited to log in to a online meeting where there will be two separate stations, there will be two, hopefully not two stern faced examiners at the end of Team Zoom, choose your platform and they will be chatting with you in two different stations. Now, one of them is a clinical scenario where quite like a med school Oscar, you'll have five minutes to read the scenario and 15 minutes in which they'll ask you questions and what they'll be assessing is your clinical reasoning. So how do you manage what will probably be a medical emergency, but they'll also assess your teamwork and and ability to work under pressure. So it's, I've not done the interview yet and you're not allowed to talk about what's in the interview when you've done it. But things that are emergencies come up a lot here and they're interested in, not only you knowing the answer, but you're also understanding how teams work and how you can interact with your colleagues to achieve a good outcome for the patients. And then you'll have a general interview lasting about fif lasting 15 minutes where two different examiners will ask you to sort of tell them why you want to be an anesthetist to talk about how you've demonstrated commitment, especially in the past, how you've reflected and learnt from mistakes and examples of your communication skills being good. That's very similar actually to what would have been asked of you in your interviews that you sat to get into medical school at the start. What I suppose I'm trying to say is that you have the skills. It's just about building the confidence and doing enough practice to ace it. So this change to remove the portfolio a couple of years ago really did knock a few people and I'm one of them because I've put quite a bit of time into developing my portfolio and lots of people were left asking why. But actually the reason why is that when you get to your interview, when you're asked to talk about things, having good examples from what you've done before, make you seem like somebody who's really committed to getting into anesthesia and anesthetists tend to really like enthusiasm. So the M SRA is not only a gateway to interview, but it even now forms part of the scoring for the interview. So you get your interview slot and you then want to be able to stand up. And these are a few ways that I think any of you can relatively easily get yourself a suite of things that will allow you to stand out and interview. So they love to assess commitment specialty and that sort of has two domains. Number one is experience. So you can go on an elective if you can get a foundation job in anesthesia or intensive care, brilliant. But if you can't, you can go on a taste a week or even three taste a days, that's good. Attending talks like this helps too. I hope because one of the things they'll assess you on is how well you understand the structure of anesthetic training and the life of an anesthetist doing audits is a good thing to talk about, particularly if it's anesthetically related. But also particularly if you couldn't change the practice of as a result of your audit, getting involved in big antimicrobial audits where we say, oh, people are adhering to the antimicrobial guidelines. This percentage of the time is never really gonna change anything. I'm doing an audit at the moment looking at how often people use local anesthetic to do ABG S. No one uses local anesthetics to ABG S. So I'm gonna find that the compliance with the best practice is really low and then I'll be able to do a probably quite easy intervention. Make a few posters, reaudit it, then even if only a few more people do ABG S with local, then that's had a significant effect on people's practice. The reason I say that is you have to be a little bit savvy and a little bit clever with what you put your effort into because if you put your effort into doing the right sort of a, it, it can really pay dividends for you. No, the anesthetic recruiters, the best piece of advice I've ever been given is they're not trying to recruit an anesthetic sho or a registrar. They're trying to recruit a post F two doctor who they can make into an anesthetic sho registrar and subsequently consultant. They want you to be a nice enough person that they'd want you to be a consultant colleague going forward. But equally, they want you to have the unders standing of your own limitations and the ability to learn. So if you've got some skills courses, you've been on ultrasound skills courses are a fantastic example of this or some evidence from your portfolio that you've learned how to do this new procedure. That's music to the ears of an anesthetic consultant because they think this is somebody who we can train up and we can make into one of us in a few years time. I can't guarantee any questions, but I'd be prepared to put a decent chunk of money on the fact that they're going to ask you to talk about a time when you messed up and what you learnt from it. So let me tell you what mine is. I was on itu it was my first ever night shift on it. UI was exhausted. I hadn't really slept very well. I cannulated somebody and I left a tourniquet on their arm after I cannulated them and it stayed there for a couple of minutes before the nurse noticed and took it off. It wasn't particularly pleasant because people kept going and saying, oh, you know, you've done this, we're gonna day it XY and Z but actually no harm was done. But it did allow me to learn. It allowed me to learn the importance of allowing your colleagues like the nurses to speak up and being approachable enough that they can approach you with concerns. It also led me to look a lot about the effects of fatigue on your working. And that's made me a lot more cognizant of how my performance changes when I'm fatigued. I hope you'd agree. That's quite a good answer. And the reason that's hopefully a good answer is it shows that you've learnt, it shows that you're humble, but it is also something that's not too awful that they're gonna go. Oh dear, they did that. So you're meeting four people, four humans and they'll also give you a global rating score. So things like your passion, being polite, seeming keen and interested will actually help in your interview and they will contribute towards how they think of you. That's very highly ranked in terms of how they um so how you score points for your interview now for the final 10 minutes or so, I'd like to talk about what I did as an F one on intensive care because I think it's an amazing entry point into anesthesia. If you are somebody who is either dead set on it or is a bit on the fence, I did my time at the royal and this is what our average day would look like. So we'd start with handover where we'd talk about all the patients take handover from the night team. We'd also talk about patients from around the hospital who were on it. U's Radar. Maybe they were a step down who were sick or maybe they were somebody who'd been discussed to potentially come to the unit. Then you split the patients up and you go off to see your patients on your own and you make a plan. You might have two or three patients depending on how busy the unit is and you'll review them, you'll review all of their bloods, all of the massive a one intensive care obs chart. And you'll put that together into a problem list and a plan that when the consultants come round, you'll present to the consultants, the consultants will then give you feedback on the plan and together as a team, you will come up with a plan for the rest of the day. What's fantastic about that is that you are learning in a really supportive environment because you're forced to make a plan of your own. But you've also got the safety of that, the consultant will change it to prevent anything bad from happening. And there's nothing more satisfying than the first time you see a patient, particularly relatively complex one and the consultant makes no change to your plan. That is a day that you feel like you've won and then the rest of the day is doing the jobs and there's some brilliant jobs in intensive care. You can go and see referrals, there might be procedures to do or even transfers. And the thing that I think is underrated is being able to discuss things with your colleagues. Hi, this is Nathan from Itu gets a fantastic response on the end of the phone that you don't always get if it's Hi, this is Nathan, one of the geriatric Sh Os. There's a lot of respect for Itu around the hospital and that means that people are very happy to talk to you. I've rung surgical consultants from the intensive care unit to say this patient is really unwell. We really appreciate your input and people tend to come and it's fantastic at building your confidence of speaking to very senior doctors. That is something that's quite hard to get as an F one I found now I'm a bit of a nerd and I like doing procedures, particularly doing procedures with ultrasound. So I thought I'd talk you through a few of the things I did on my time in intensive care and in anesthesia. So up here we've got a central line. I put a good few of those in, they're a cornerstone of itu practice and allow us to give all of our fancy drugs. So we like them very much. I also by the end of my rotation was able to put these little things, the arterial lines in independently, in intensive care. They are very good at supervising, but they were also very good at saying actually we've supervised you. Now, the next step in you developing your skills is to go and do these procedures under distant Super reg and a consultant around. If things go wrong to ask for help or if you struggle, but they're not there directly watching over you. So by the time I finished as an F one in intensive care at the royal, I was able to do arterial lines and these little things called midlines independently. I did picc lines mostly independently, but I just had somebody else around to help support the patient cos it's an involved and fiddly procedure. Then there's the skills that are a little bit more dangerous and you will always be supervised with doing central lines. You're poking a very sharp needle very close to the carotid artery. People are gonna want to watch you doing that and intubation, that's something I love doing is something that you have to be very careful with. It can potentially have very nasty consequences if done wrong. So people will support you and supervise you. But if you go into your anesthetic job, your intensive care job, say I really would like to learn and develop those skills. People will put real effort in to come and teach you. I'd have registrars come up to me and saying, hi, mate. You said you wanted to do a lines, didn't you? This person needs an, a line or oh, this person's probably gonna need a central line. I'd go there today. If I were you and that camaraderie you build with colleagues even quite a lot more senior than you is something that's unmatched in any other specialty I've worked in. Now, there's a few cool things that you get to do. So you sometimes get to go out on the back of an ambulance and transfer patients. You could tag along with one of your registrars whilst they transfer a sick neo patient down the 46 to Queens and Nottingham to have a craniotomy. Or you might even be offered the fantastic opportunity of going on a solo transfer. And the first time I was going on a solo transfer, I thought right, I've made it now. This is gonna be fun. Actually, we were just taking a very well patient who was being stepped down to a ward at the Glenfield over to the Glenfield. But it was quite nice because it allows you to develop all of the skills in sort of coordinating the transfer, making sure you have enough oxygen, making sure you have emergency medications with you liaising with the ambulance crew at A OS who are the people who organize the transfer ambulances so that you can gain those sort of soft skills before you're having to transfer somebody who's very unwell and it helps the ITU team out cos they don't have to release somebody with airway skills to take Doris who can have a lovely chat about her seven cats over to the Glenfield. Then the other nice thing is that if your regs are seeing patients down in recess, they're more than happy to take you down to recess with them. And there you can learn a lot about doing an A to ea lot of times I've gone down to recess with a reg and they've said, do you want to do the A to e and sometimes that evolves? So I saw a nearer case down in, in recess where the registrar went. Do you want to do the art line? Now? You've done the A to a cool, I'll do that. Then it was come and mass bag this patient. You're up at the head end now. So why don't you intubate them there's very few places where your colleagues are that invested in your development. And it's absolutely lovely because you get to make friends with the registrars and they're actually deriving a lot of pleasure from teaching you. And a niece is really good at that. And then finally, this is the place that I enjoy the most, mainly because there were some really lovely theater staff at the Royal Hill. Give you cake. But theater is where my heart lies really in anesthesia. I enjoy being in theater. I enjoy the variety and I enjoy the alw the fact that you always have that potential for acuity and acuity is the one thing that really attracts me to anesthesia. And I think that brings the talk full circle in the everything that I've enjoyed in medicine finds its way back to theater and critically unwell patients at some point. So the experiences I've got even in other specialties have just reinforced to me that I really, really want to be an anesthetist. And I hope that any of you listening today who've maybe been sat on the fence will be thinking, yeah, this actually seems a really good option. And if you were really sure that you wanted to be an, I hope that I've perhaps given you more to be excited about. I haven't scared you off completely. So that's what we've talked about. We've talked about quite a lot and I'm not a million years over the amount of time. I said I'd speak for so given we started sort of 10 minutes behind schedule. I'm more than happy to take questions for the next 10 minutes or so. I know no one really likes asking questions on these things. So, whilst you're more than welcome to ask, now, that's my email address. You're more than welcome to um drop me an email. So, thank you very much. I'll stop sharing my slides now.