Royal Free Hospital (ICU)

In general, this is felt to be a good training post which provides the ITU experience required by a Respiratory trainee. Trainees should expect a good mix of surgical and complex medical cases on this unit. As with the other ITU posts, it is felt that 6 months is too long and the required competencies could be achieved in 3 – 4 months. However, this could then potentially be a good time to prepare for SCE or to work on projects.

There are a good mix of consultants with medical, anaesthetic and pure intensive care backgrounds. To some extent, the consultants appreciate the presence of medical/respiratory trainees especially for their thoracic ultrasound and bronchoscopy skills. Other than that, most of the time, the Respiratory trainees are mainly like the junior clinical fellows/SHOs. The respiratory knowledge and expertise may not be appreciated at times. The rota-coordinator and clinical lead, Dr Jenny Price, is well-known to be very accommodating to trainees’ requests for leave and swaps. She is forward-thinking and very flexible which makes the experience here better despite the shortfalls mentioned above. She is in-charge of induction and makes the respiratory trainees feel welcome.

The latest CQC rating for critical care here was “good“. The nurses here are generally helpful and approachable. There are 4 separate units within the department (which includes both ITU and HDU care):

• ITU East (Level 4 ITU) – 14 beds
• ITU West (Level 4 ITU) – 9 beds
• ITU South (Level 4 ITU) – 11 beds
• 2 North A (Level 2) – 10 – 12 beds

2 Respiratory trainees will be posted here at each time for 6 months and both are the only respiratory SpRs on the unit.

Consultant speciality interests

• Dr Banwari Agarwal – Anaesthetic, Research, Clinical/Educational Supervisor for Respiratory Trainees
• Dr Nicolas Barnett – Anaesthetic
• Dr Sarah Bigham – Anaesthetic, Clinical Lead
• Dr Jim Buckley – Infectious diseases, Education and training
• Dr Mark De Neef – Intensive Care
• Dr Dhadwal Kulwant – Anaesthetic
• Dr Jennifer Price – Anaesthetic, Clinical Lead, Education and training, Rota-coordinator
• Dr Mike Spiro – Anaesthetic, Research
• Dr Agnieszka Walecka – Anaesthetic, QIP/Audit Lead
• Dr Stephen Ward – Anaesthetic
• Dr Mark Carrington – Anaesthetic, Risk Lead
• Dr Prashanth Nandhabalan – Anaesthetic
• Dr Amit Adlakha – Respiratory
• Dr Nasirul Ekbal – Renal
• Dr Yadhunanthanan Rajalingam – Anaesthetic
• Dr Tamara Banerjee – Anaesthetic
• Dr Nazri Unni – Intensive Care

Typical Rota Pattern for Respiratory Trainees

Week	Mon	Tue	Wed	Thu	Fri	Sat	Sun
1	N	N	N	N
2				SD	LD	LD	LD
3			LD	LD	LD
4	SD	SD	SD	SD	SD
5	LD	LD			N	N	N
6			SD	SD	SD
7			N	N	N
8	LD	LD				SD	SD
9			LD	LD	LD

There are 4 different groups on the main rota – senior anaesthetic trainees (Rota A), junior anaesthetic trainees (Rota B), ED/medics – SpRs and IMTs (Rota C) and junior clinical fellows/F2s (Rota D). All the different groups have different work schedules and therefore different banding/supplements.

The weekly rota will be made up of a mix of these different skillsets covering each individual ITU unit.

• Day:
  • Consultant: 1 for each unit (1 of them will be on-call)
  • ITU SpR (covered by Rota A and B): 1 long day and 1 short day trainees (Float – external reviews, help with transfers and procedures)
  • Within ITU: At least 1 long day and 1 short day trainees/fellows for each unit (particularly the weekend, more staff during the week days)
  • Royal Free ITU also has a non-airway trained advanced nurse practitioner who could do the same job as the trainees/fellows
• Night:
  • Consultant: 1 non-resident on-call (low threshold to come in)
  • ITU SpR (covered by Rota A and B): 1 trainee (Float – external reviews, help with transfers and procedures, normally helps with ITU East night review)
  • Within ITU: at least 1 trainee/fellow for each unit

Respiratory trainees do not work outside the unit and mainly work internally unlike the anaesthetic trainees, who work both internally and also externally as ITU SpRs) as respiratory trainees are not airway-trained. When working internally, the anaesthetic trainees do the same job as all the other trainees/junior fellows.

On very rare occasions, Dr Jenny Price, may roster a respiratory trainee to work with the float SpR on a short day to review medical referrals externally when there are more than enough staff covering the internal units.

Work Routine

Day Routine (Mon – Sun)
Time
8 am – 8.15 am	Departmental briefing
8.15 am – 9 am	Individual unit handover
9 am – 12/1 pm	Morning consultant WR
LUNCH	LUNCH
2 – 5 pm	Micro meeting (for 60 mins), jobs and family discussions
5 – 6/7pm	Evening consultant WR
7 – 8 pm	Jobs and list preparation

Night Routine (Mon – Sun)
Time
8 – 9 pm	Individual unit handover
9 pm – 7.30 am	Junior WR and jobs
7.30 – 8 am	List preparation
8 – 8.15 am	Departmental briefing
8.15 – 9 am	Individual unit handover

• Teaching/Meetings:
  • Tuesday: Radiology meeting (AM)
  • Wednesday: Case of the Week discussion (Lunch)
  • Thursday: ITU Consultant-led teaching (Lunch), Grand Round (Lunch)
  • Friday: Journal Club (Lunch)
• During the day, it is well supported and heavily led by the consultants who would also help with referrals to specialties and family discussions. Nights are much less supervised but the ITU float SpR is normally helpful and supportive. The consultant would come in if required to review and manage sick patients.
• Other than ward rounds and reviews, trainees/fellows are expected to do the admission paper work and drug charts for patients newly admitted to the unit. The consultant should always review the new patients as soon as possible unless the patients are admitted overnight.
• Other than ward round and family discussion documentations, specialty/consultant reviews, observations/vital signs and drug charts are still paper-based on this ITU.
• There are no clinic opportunities unless you take the initiative to apply for study leave and arrange to attend respiratory clinics.
• There is opportunity to attend the weekly ITU MDT to discuss difficult cases.

Educational/Clinical Supervisor

• Dr Agarwal is very approachable and supportive. He will be happy to sign off some liver-related GIM competencies, central line insertion and of course, the ITU competency. Sign-off of other GIM competencies may not be well-received.

Bronchoscopy

• This is a common procedure within the department particularly during the COVID surge.
• The consultants are generally quite happy for you to perform the procedure independently (if you are already fully competent) with an airway-trained trainee to manage the airway (ET tube, tracheostomy) and sedation.
• The procedure is mainly done for airway toileting and washing/lavage for microbiological analysis.
• The procedure is mainly performed with an AmbuScope.

Estimated number of bronchoscopy procedures in 6 months per trainee: 11 – 20

Estimated number of endo-/transbronchial biopsies/brushings in 6 months per trainee: 0

Thoracic US and pleural procedures

• There is at least one ultrasound machine in every unit.
• We are not aware of any level 2 thoracic ultrasound trained consultant in this department. Hence, it is unlikely that this post allows for Level 1 sign off.
• Respiratory trainees should ideally be Level 1 thoracic US competent to be able to feel useful at times.
• For pleural effusions, the consultants are happy for Seldinger chest drains to be inserted by Respiratory trainees independently (if previously signed off as competent).
• For pneumothoraces, the department advocates surgical chest drain insertion. If respiratory trainees are not well-versed in this, this could possibly be a good place to learn the insertion of surgical chest drain.
• The policy within the department emphasizes that specialty-related procedures should be performed by the specialists themselves with the exception of simple bronschoscopy, e.g. ascitic drains can only be inserted by hepatologists, pleural procedures can only be inserted by chest physicians unless the respiratory trainees on their ITU block are around on that particularly shift.
• There are no opportunities for pleural biopsy, medical thoracoscopy, indwelling pleural catheter insertion and talc pleurodesis on this rotation.

Estimated number of thoracic US in 6 months per trainee: 10 – 25

Estimated number of pleural aspirations in 6 months per trainee: 1 – 5

Estimated number of chest drain insertions in 6 months per trainee: 1 – 10 (including surgical chest drain insertion)

Vascular access procedures

• There are a lot of consultants and senior anaesthetic/ITU trainees around to teach/observe and sign off the central line insertion competency (if you have not already).
• The advanced nurse practitioner and junior fellows are always keen to carry out the procedures if you are snowed under with jobs.

Estimated number of central line/Vascath insertion in 6 months per trainee: 11 – 20

Estimated number of arterial line insertions in 6 months per trainee: 1 -10

Estimated number of midline/PICC insertions in 6 months per trainee: 0 (this is performed by the vascular access team)

NIV

• Adequate experience of management of acute NIV. On rare occasions, NIV/CPAP is started on ITU for patients previously on high flow nasal oxygen. This is particularly relevant during the COVID surge.
• Otherwise, NIV would have usually been initiated externally before transfer to ITU.
• The other occasion is when extubated patients are started on NIV but this is normally supervised by the consultants/senior anaesthetic trainees with you observing on the side.
• In terms of management of established acute NIV, the consultants are quite happy for respiratory trainees to adjust settings as appropriate.

Estimated number of adequate involvement in management/initiation of NIV in 6 months per trainee: 10 – 15 (mainly management of NIV rather than initiation)

Teaching

• Simulation facilities available on the unit (which can be accessed by you)
• Journal club presentation
• On-the-job teaching of junior fellows/F2s and medical students
• Due to the flexibility of the rota co-ordinator, trainees are almost always able to attend courses and training days, sometimes even with last minute requests.

Quality improvement

• Consultants will not actively push respiratory trainees to get involved in QIP and audits but will be very welcoming and supportive if you are interested.
• There are a lot of QIPs happening that are normally run by the junior clinical fellows that you can help with or equally, you can start a project if you wish, just speak to Dr Agnieszka Walecka and she will guide you accordingly.

Management/leadership

• Limited opportunities unless trainees take the initiative to run the Wednesday teaching programme (this is normally run by the junior fellows).

Research

• Prof Marc Lipman and Prof John Hurst are active in research and are often on the lookout for trainees to join them in standalone projects or fellowships. The Free is also a site for a number of pleural trials – speak to Dr James Goldring for more information.
• ITU at the Free are involved in many national/international research projects and patient recruitments. There are a few research nurses based on the unit to speak to about these projects.
• Dr Mike Spiro also has a lot of COVID-related research projects going on which you can participate. If you wish to write up on something related to COVID-19, he is quite happy for you to use their huge database as long as your article acknowledges everyone involved in the building of the database as authors.

Specialist training opportunities

• Hepatology/Gastroenterology – the Free is well-known for its liver unit. Trainees will see numerous chronic liver failure and liver transplant patients on ITU which could potentially lead to liver-related GIM competencies being signed off. Trainees should also expect adequate exposure to endoscopy being performed on the unit.
• Respiratory –
  • COPD/asthma/OSA/OHS: common to see cases requiring NIV/intubation and ventilation on the unit.
  • Atypical chest infections: very common, sometimes TB and lung abscesses cases as well. The micro ward round is a good place to learn about indications and limitations of different antimicrobials and bacterial/fungal activity. Most of the microbiologists are very friendly and keen to teach.
  • Pleural disease: common to see pleural effusions (rarely empyema) and pneumothoraces (particularly in COVID-19 patients).
  • You would also rarely see pulmonary hypertension (as the Free also has a pulmonary hypertension unit run by the cardiologists) and ILD cases.
  • Rehabilitation: opportunities to work with the ITU physiotherapists and speech and language therapists on respiratory wean ward rounds (including tracheostomy wean).
• Infections – opportunities to see HIV patients with complicated infections, severe fungal, PCP and C. diff infections, pseudomonas and VRE colonisations, occasionally Burkholderia infections.
• Airway management – opportunities to perform intubation are quite rare as they mostly happen outside the unit or during emergency. There are anaesthetic/ED SHOs around who should take precedence in doing the procedure as well. Having said that, if this is something you are interested in, the consultants will be happy to facilitate. There is adequate experience in tracheostomy management (not insertion) including emergency management particularly during the COVID surge.
• Ventilator management – towards the end of the rotation, you will be comfortable at adjusting the settings, using different ventilatory manoeuvres, recognising ventilatory failure and sometimes, switching to different ventilatory modes.
• Sedation and vasopressors – adequate experience with the different agents but will almost always be guided by consultants and senior anaesthetic/ITU trainees.
• Renal – adequate experience in management of fluid balance (including understanding of hyperchloraemic acidosis) and renal replacement therapy, e.g. haemofiltration. Trainees will see transfers from other ITUs which do not provide renal replacement therapy.
• Surgery –
  • post-operative management of abdominal aortic aneurysm repair and other vascular operations
  • post-operative management of complex hepatobiliary surgical cases
  • post-renal transplant management
  • post-bowel surgery and splenectomy management.
• Cardiology – management of post-cardiac arrest cases, post-angiography complicated ischaemic heart disease/MI cases and cardiogenic shock.
• Endocrinology – opportunities to manage severe diabetes-related emergencies and severe hyponatraemia.
• Neurology – it is common to manage seizures on the unit, neuromuscular disorders with ventilatory failure and status-epilepticus cases, rarely Guillain-Barré syndrome cases as well.
• Rheumatology – the unit frequently recognises the hyperinflammatory condition, hemophagocytic lymphohistiocytosis (HLH) and trainees will be able to learn to look for and manage the condition.
• Haematology – plenty of opportunities to learn about the management of anticoagulation and clotting disorders.
• Palliative care – adequate experience in this which has subtle differences to the palliative care provided on the wards.
• This unit rarely manages trauma patients. ENT services are based at Barnet Hospital.
• This unit does not provide specialist neurosurgical and cardiothoracic/lung transplant intensive care medicine services.

Stage of training best suited to this rotation

• ST4 – 5
• More senior trainees may find this post frustrating as trainees are mostly found doing the same things as the junior fellows.
• ST3 without competent bronchoscopy and thoracic ultrasound skills may find the post unsatisfactory, as they are not always able to provide the respiratory expertise that the consultants find particularly useful.

Recent trainee comments:

“I would recommend this post to other Respiratory SpRs: strongly agree.”

“A good post to gain experience of ICU for Respiratory trainees, but 6/12 is too long!”

“Good medical ITU experience with excellent support. Rota is very relaxed with plenty of zero days compared to respiratory/GIM, easy to attend training/study days – good time to sit exam/work on projects.”