A day in the life of... Tim Jackson
Published: May 08, 2018
I have been a consultant anaesthetist for approximately 9 years in a busy acute NHS Trust in Yorkshire. As well as completing my routine planned jobs as a consultant in theatre, putting patients to sleep for major vascular surgery, emergency theatres and other disciplines, I have developed an interest in vascular access. This has evolved, almost by accident, and what follows is a very narrative account of the ways in which vascular access has become intertwined with the rest of my working week.
Having met many folk who are involved in vascular access around the country, I am often struck by the common challenges that we all face in striving to deliver a quality service for our patients. And, although I may be a NIVAS Board member (and therefore expected to provide a perfect service and to have all the answers!) I am not immune to the frustrations inherent in this fledgling field. With this in mind, I hope that many fellow practitioners reading this will appreciate the shared experience.
A typical day for me would begin as I drive to work, contemplating the day ahead. I know that I have a patient scheduled for vascular access. I also know that my NHS Trust doesn’t always have the capacity to provide a procedure room to insert the tunnelled line required for this patient. It reminds me of conversations I keep revisiting, in true Groundhog Day style, on how to try and optimise the way we provide vascular access. I envy the nearby trusts who have a regular availability of list space, but then I reflect on the fact that there is wide variation across the country in the way in which vascular access services are provided, often associated with the quintessentially organic way that the NHS has evolved.
I know that I cannot guarantee that I will have inserted this tunnelled line by the end of the day. I try to manage my expectations as I head towards the acute theatre to join in the theatre team’s planning meeting so I can argue the case for my patient. Luckily, the surgeons who are running the acute list on the day are of the more enlightened kind, and are keen to let me into theatre first thing in the morning. It’s a win:win situation as it gives them a little more time to complete their post-take ward round before saving the world, one abscess at a time!
I arrange for someone to cover my elective list so that I can be freed up to perform the line insertion, and thankfully the day goes without event. The patient has had an extensive bowel resection and is going to need long-term total parenteral nutrition at home, so they appreciate that this device is a key step on the road to returning home. They are well, having recovered from their surgery, and have been waiting for several days for their line.
While I’m in the acute theatre, the anaesthetic Senior House Officer on call for the day catches my attention, and is happy to see me as there is an outstanding peripherally inserted central catheter referral on the list that nobody has had the availability to see over the past few days. The referral is an orthopaedic patient who needs several weeks of IV antibiotics and who could probably be discharged home on outpatient parenteral antimicrobial therapy care, so there is potential to free up a bed once the line is inserted.
Sadly, having already compromised my official job for the day, I realise I am unlikely to achieve enough flexibility in the remainder of my day. So, in the interest of not having the patient hanging on under false pretences, I decide I won’t be able to do this today, and suggest the referring healthcare professional speak to the acute anaesthetic consultant to check if they can facilitate the PICC insertion. This is the pitfall of being an anaesthetist who is known for having an interest in vascular access, but who doesn’t have a specific availability of protected time in which to do it. I’ve learnt not to be frustrated with this, every patient I help is a bonus, but I’m just one person and I can’t personally provide a service 24:7!
It does remind me that I need to continue to put more effort into developing a business case in order to develop the service that we can provide. We’ve already come so far, now that I have a team of consultant colleagues who can insert a wider range of devices; however, there’s still much to do. We need the data to support a business case to develop a service, but there’s currently no one with any spare capacity within their clinical workload who could actually obtain these data – oh the challenges of this kind of practice in the NHS today!
As the day goes on, I open my emails and catch up with the 10% that need my attention. There’s the minutes of the recent IV strategy group meeting that I was unable to attend, and I’m relieved to note that I haven’t inherited any actions in my absence – the Chair has a mischievous side and often tries to encourage attendance by dishing out work to those who are absent! There is also an incident report for a patient who suffered an axillary vein thrombosis in the same side as an internal jugular line where the tip was patently not inserted far enough on the post-insertion chest x-ray. Although this wasn’t great for the patient, it is a valuable story that I feel makes a case for reviewing the range of line lengths available in the ICU, so I send an email to the powers-that-be in order to change practice for the better. This, at least, is a change that is easy to enact!
As the day goes by, my ICU consultant colleague asks me for help with a difficult IV access in a patient who’s presented in casualty. He’s an experienced colleague whose approach to vascular access I trust, and he informs me that this patient (whom I’ve previously seen) has presented with acute metabolic problems and dehydration, and he can’t see any central veins (either jugular or femoral) on ultrasound. The patient currently has fluid resuscitation in progress via an intraosseous needle in her tibia, and she needs some more reliable IV access.
He offers to take over the care of my patient undergoing vascular surgery who is on the table at that time, if I could assess this young lady. She is transferred to theatre and is pleased to see me, asking if I could insert another subclavian line like before, as it was much more comfortable than the jugular lines she previously had hanging from her neck.
An ultrasound revealed a reasonable axillary subclavian vein, and a temporary central venous access device was duly inserted. I remark to myself once more that vascular access isn’t usually that difficult, all it takes is a little bit of specialist knowledge and some attention to detail and you can give patients a better experience than they’ve had before.
And with that ends my typical day, where my scheduled day of vascular surgical patients had not quite turned out as expected. Nevertheless, I think we managed to do a good job for a couple of patients, even if it didn’t require rocket science and even if I couldn’t help everyone that day.
I wonder, how many people reading this have similar experiences within the realms of vascular access in the NHS?
Dr Tim Jackson, Consultant in Anaesthesia and Intensive Care Medicine, Calderdale & Huddersfield NHS Foundation Trust