F1 DOCTORS must demonstrate competence in 15 procedures in order to become eligible for full GMC registration. Here are some helpful tips on performing arterial blood gases (ABGs), blood cultures and intravenous (IV) infusions.
I remember my first attempt at an ABG as a foundation year 1 doctor. It was on a surgical ward on a patient who was short of breath. His radial pulse was strong and easily palpable. I was confident that I would be able to get this core procedure signed-off. Unfortunately, after two failed attempts, which were both witnessed by a surgical SHO, I decided that it was probably the appropriate time to escalate it to someone more senior. Unsurprisingly, the SHO obtained the sample on her first attempt. I was eventually able to get the ABG core procedure signed off on my busy respiratory rotation but the experience taught me that things may not always go to plan.
Main pointers for ABGs:
• The modified Allen’s test can be done to ensure that there is adequate blood supply through the ulnar artery.
• ABGs are very painful so always make sure that it is indicated before attempting. ABGs are very good at highlighting CO2 retention but in certain situations such as diabetic ketoacidosis, a venous gas may provide adequate information.
• Always note the amount of oxygen that the patient is on.
• Remember to expel the heparin beforehand.
• Apply pressure to the area afterwards for five minutes.
Different trusts/health boards have different equipment and this was the case for blood cultures when I was an F1. The whole process was different to what I learned as a student and, for me, it was like learning a new skill again. Although the equipment and the protocol were different, the underlying concepts were still the same. An aseptic non-touch technique was used, a sterile field was still required and all sharps needed to be discarded appropriately.
Main pointers for blood cultures:
• Always take more than one set of blood cultures. If you fail the first time, at least you won’t have to waste time to collect the equipment again.
• Always note whether the patient is on any antibiotics.
• Each trust/health board may have different equipment and different protocols but they all have the same underlying principles and purpose.
• Do not touch the skin once it has been cleaned to avoid contaminating the sterile field and the subsequent blood culture sample.
At medical school we did a lot of revision on IV fluids, especially on maintenance fluids for patients who are nil by mouth. However, as an F1, you come to realise that IV fluids can be used for a wide range of patients for a variety of reasons. Furthermore, IV infusions not only include fluids but also IV medications such as antibiotics. My IV infusion core procedure was actually signed off by a staff nurse working on the ward. As doctors, we mostly prescribe medication rather than administer it. To get this core procedure signed off, I had to shadow the nurse while she mixed her antibiotics into a 100ml bag of IV saline. I then talked through the procedure with her. Afterwards, she watched me mix the infusion and put the infusion up for the patient.
Main pointers for IV infusions:
• When prescribing IV fluids, always check the patient’s urea and electrolytes, their fluid status, past medical history and indication to guide the type of fluid you prescribe and the rate.
• Input and output monitoring can be another useful guide for prescribing IV fluids.
• When administering IV infusions, always get the infusion counter-checked.
• Always double check the patient’s name, date of birth and allergies before administering the infusion.
• When mixing IV infusions, always check the guidelines to ensure the medication is mixed with the correct fluid.
Main pointers for core procedures in general
Completing the 15 core procedures within F1 is not difficult but being organised and preparing beforehand will help. Core procedures are skills that you will use throughout your foundation programme and they are likely to come into use as you progress in your career.
Here are some pointers for core procedures in general:
• Always communicate with the patient (or simulated patient). Talking through the procedure as you proceed can help consolidate your knowledge as well as making sure that the patient understands the procedure.
• Sometimes it may not always be possible to do the procedure on a real patient during your rotations. You can always demonstrate your competency in that skill through shadowing or through a simulation session.
• The aim of core procedures is to learn, therefore don’t be disheartened if things do not go to plan. Use it as a learning experience and try to obtain feedback in order to improve in the future.
• Use the feedback that you have received when you have been signed off to further improve on your skills.
• Try to make sure that you don’t leave too many skills to the last rotation.
Dr Anli Zhou is an F2 in emergency medicine based in Bolton