Tips on core skills

Dr Sophie Ludlam offers advice on tackling three more core procedures that all trainees must perform

F1 DOCTORS must demonstrate competence in 15 procedures in order to become eligible for full GMC registration. Here are some helpful tips on performing IV infusion of blood and blood products, injection of local anaesthetic and subcutaneous injections.

IV infusion of blood and blood products

Each hospital has its own protocol for the use of blood products, so it is definitely worth familiarising yourself with this before attempting this core procedure. I remember prescribing and setting up my first unit of red blood cells for transfusion. It was for a patient who had an upper GI bleed on my ward. I assessed her cardiovascular and hydration status and she had a tachycardia and low blood pressure. I asked for two units of red cells from transfusion, but supported her with intravenous fluids in the meantime.

As students we are taught about transfusions and their reactions and this made me nervous - but don’t worry. I found a nurse who agreed to guide me through the process. If the right checks are carried out and procedures followed, the risks are minimal.

Before I carry out IV infusion of blood and blood products, I always make sure the transfusion is indicated and that I get informed consent from the patient before ordering any blood products. I also learned early on to make sure the lab has an up-to-date Group and Save sample from which to cross-match.

It’s important to always check the prescription and blood product at the patient’s bedside with their ID wristband before starting the transfusion (the nursing staff can often help with this). Similarly, I make sure patient observations are recorded throughout the transfusion to monitor for any reactions. If I’m in any doubt, then I know I can ring the transfusion lab for advice.

Injection of local anaesthetic

Using local anaesthetic can make certain procedures a much easier experience for both you as an F1 and your patient. I first used it during an attempt at a lumbar puncture, but it is also used for procedures such as chest drains and wound suturing. I talked through the procedure with the medical registrar and we decided on lignocaine as our anaesthetic of choice. Once the patient gave their consent and we had decided on our injection site, I injected the lignocaine just beneath the skin. I then injected more anaesthetic along the intended path of my spinal needle. Unfortunately, I was unsuccessful at the lumbar puncture, but despite this the patient remained pain-free throughout due to successful injection of local anaesthetic!

Before administering LA, I am always sure to check the patient’s allergy status and then warn them that it may sting a little as it is being injected. Choosing the appropriate LA and concentration for the procedure you’re performing is, of course, very important. I checked this with a senior colleague, but the British National Formulary (BNF) is also a useful resource.

In using LA, I always wait a few minutes to allow the initial local anaesthetic to work before continuing with any further injection or procedure. I then make sure to observe the patient afterwards for any side-effects such as redness of the skin – true allergy is rare. When using a syringe, I always like to withdraw the plunger a little before injecting the drug to check I haven’t accidentally hit a blood vessel and it’s safe to continue.

Subcutaneous injections

When it comes to subcutaneous injections as F1s, we are more used to prescribing the drugs than administering them. The best opportunity to gain this competency on the ward is either with the insulin-dependent diabetic patients, or those who need low molecular weight heparin (LMWH).

I remember I first asked a young lady with type I diabetes if I could administer her insulin, but she wasn’t keen – often they like to deliver their own. So I asked a nurse if I could follow her on her late afternoon drugs round and help her with her dalteparin injections. I watched her give the first one and then it was my turn. Luckily, the pens come pre-filled with their own short needles, so I could just focus on the correct site and technique of injection.

Fat distribution determines your site of injection, with the commonest sites being the abdomen and thighs. I chose to inject into the abdomen, being sure to avoid sites with evidence of overlying infection or fat breakdown. I then cleaned the skin, inserted the needle at 90 degrees and then slowly injected the LMWH, using the aseptic nontouch technique.

As with LA injections, the same principle applies when using a syringe in that I always withdraw the plunger a little before injecting to check I haven’t hit a blood vessel. Just as administering any drug, I make sure it is checked, documented and signed for correctly on the patient’s drug card.

My main pointers for core procedures in general

Although the thought of completing 15 core procedures during F1 may be daunting, they are actually things that you will do most days on the wards without even realising it. (Don’t forget to ensure you have appropriate guidance when you are carrying out any of these procedures.) Here are my top three tips for getting them signed off:

1. Do them as early as you can in F1, for two reasons:

  • If you don’t succeed at the first attempt (this is very common), you will have plenty of time to try again.
  • Continuing to practise and record further attempts at core procedures in your portfolio will show dedication to improving your clinical skills and give you a varied range of feedback – all of which will help you to be a better doctor.

2. Anyone trained in performing the procedure and giving feedback can sign you off – the nursing staff can be extremely helpful.

3. Sit down with the assessor to complete the form as soon as possible – to ensure they complete the form and give you the all-important feedback.

Dr Sophie Ludlam is an FY2 in orthopaedics at Royal Bolton Hospital