Andrew McKendry
Anaesthetic ST6
Location West Yorkshire
Activity
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Andrew McKendry made a comment
The biggest issue I've experienced is inertia. People have become so used to things moving so slowly that trying to keep a list moving is like steering a wayward oil tanker.
Most of my anaesthetic work is now in an "ultra-green" theatre complex - all patients swabbed negative and isolated for 14 days (now down to 7) prior to surgery. It does work...
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I very much agree that anaesthesia / peri-op need to be involved far, far sooner in the surgical pathway. How it would be done though is tricky - without surgical MDT discussion, it's hard to know what operation and which approach is to be utilised, with significant differences in resultant surgical insult. In an ideal world, everyone would get assessed, but...
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Andrew McKendry made a comment
The market based system that the NHS runs on is an utter disaster in cost-efficiency. Instead of having a central and monolithic purchasing structure, which would have one of the largest single buying powers in the world, thus driving down prices, we instead get trusts to battle each other.
The changes need to be at national, political level, and all the...
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Effective and efficient ICT comes at a headline upfront cost that the NHS is unwilling to pay for or invest in. The end result is a problematic, poorly interconnected and bug ridden mess that costs an order of magnitude more in the long run.
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Andrew McKendry made a comment
MCOP integration is, and historically has been, exceptionally poor in this patient population. I don't ever recall seeing a geriatrician involved in any acute surgical case, with the obvious exception of orthopaedics. I think a fundamental change here would reap huge benefits.
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- How do you think problems such as multimorbidity and frailty will impact on the perioperative pathways we have looked at so far?
> For one, it will be far more complicated and drawn out. Our pathways so far have focussed on one big, or several small issues. Frailty and multimorbidity is throwing everything including the kitchen sink at our carefully curated... -
Andrew McKendry made a comment
A good experience to hear of. I always find it fascinating how people come to their conclusions about end of life care; I think we always need to remain cognisant of not imposing our beliefs on others when it comes to discussing it.
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Andrew McKendry made a comment
That seemed to work very well!
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Andrew McKendry made a comment
Some hospitals are better at this than others. One common theme I've seen among some of the poorer performing ones are differing teams every day, so no-one takes true ownership of any problems that crop up, so the patient gets bumped to "optimise" and thus becomes someone else's problem.
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Andrew McKendry made a comment
I love NELA's aims, but there are always a few holes to pick.
On Key Message 2, Sterling et al's meta-analysis in 2015 showed no difference in mortality between 1 and 3 hours in terms of antibiotic administration, and infact no appreciable difference at any of the time points it looked at. I have no qualms with the idea antibiotics should be given as a...
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Andrew McKendry made a comment
Agree with pretty much all of what others have said. One thing I would add is the demographic undergoing emergency surgery is so far removed from the elective population, that there always will be a massively wide chasm between the two, no matter how well you optimise things. There are patients undergoing emergency surgery who wouldn't even come close to...
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Andrew McKendry made a comment
Leeds have been running "Think Drink" for a few years now. At morning brief, when list order is confirmed, part of the briefing is giving timing for when patients can drink clear fluds up until. It means no-one is left thirsty prior to surgery, and certainly worked well.
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Andrew McKendry made a comment
Looks slick, easy to use and useful.
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Andrew McKendry made a comment
Apps are an excellent way to get feedback, if web based, which it appears this one is. Standalone apps, however, are nowhere near as useful, as they have to be specifically found, downloaded and installed, which a lot of people won't do.
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Andrew McKendry replied to Andrew McKendry
@SamanthaC I'm not sure there's a single or right answer to it.
The idea of shared decision making gives more weight to patient choice, but, on occasions, is also guilty of treating "patients" as a monolithic block. Every patient is different in their experiences, education, culture and fear levels, and some are able to contribute to a decision, and others...
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Andrew McKendry made a comment
There's certainly been a lot of work by Professor Klein on this, especially in regards to pre-delivery anaemia in pregnant patients. Some very interesting protocols from Norwich optimising Hb in parturients effectively with significantly reduced transfusion rates as a result.
Anaemia is also poorly managed in primary care, with doses of iron being too...
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Andrew McKendry made a comment
The tying in of smoking cessation with pre-op and making it "opt out" is a stroke of genius. It's a question I see asked at our regional pre-op all the time and patients just say "no" when you ask about referral.
I remember back when I was a novice, and anaesthetist acquiring sandwiches from the hospital kitchen in the morning after seeing his patients, and...
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Andrew McKendry made a comment
Protocols can be exceeding useful for routine management of routine problems, but always need significant wiggle room. One only needs to look at the protocols that stemmed from the Rivers trial to see how wasteful or damaging protocols can be when not grounded in good science.
And while protocols are fantastic resources for the majority of patients, we...
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Andrew McKendry made a comment
•Do you think the material presented here will change your practice?
- Not significantly so. Virtually everything in this week's programme forms part of what I consider core clinical practice, and was pretty much what I was taught in med school 10-15 years ago. Periop basically formalises what most colleagues and I already do.•Will you try to adopt a more...
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Andrew McKendry made a comment
One thing CPET doesn't check is tolerance to surpassing the anaerobic threshold, which can be significantly improved upon. Some people collapse in a heap when exceeding AT, whereas other can tolerate exceeding their AT for hours on end.
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Andrew McKendry made a comment
Patient 1: 1.2%
Patient 2: Impossible to say as the relevant information is not all available. Does he have spread? Does he have any acute or subacute renal issues secondary to his cancer? Is this an acute presentation of obstruction secondary to cancer or an elective removal after routine screening?
Patient 3: She is dyspnoeic, AF, signs of renal...
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Andrew McKendry made a comment
On the whole I agree with what's said in the video, although I have issue with the statement that targeted shared decision for high risk surgery "will give you the benefit of reducing wrong patient surgery".
I personally don't see how you can link the two in the context of what else is said - who is defining what is "wrong patient" surgery, the clinician or...
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Andrew McKendry made a comment
I think it's hard to comment on this unless you've had, or know someone who had a negative experience of the points in this video. I've been a patient undergoing surgery - I expected to lose a degree of control and was happy with that. Same goes for my father who had an AVR. He's normally very "in control of his own destiny", but knew that he had to give part...
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Andrew McKendry made a comment
Not only is the patient group highly heterogeneous, but so are the hospitals providing care to a sick paediatric cohort; there has been significant centralisation of services for paediatrics and most high risk paediatric surgery takes place in tertiary centres with a much lower threshold for transfer of care. It will be difficult for smaller hospitals to...
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Andrew McKendry made a comment
Highly notable that he pointed out something many of us have noted: the absense of psychological support for high risk patients. We see how critical care follow up clinics have made a difference; maybe it's time psychologists were involved in peri-operative pathways for appropriate patients?
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Andrew McKendry made a comment
York really are at the forefront of all this and have a model we should all be aspiring to. The protocols are simple and seemingly effective.
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Andrew McKendry made a comment
1) When should a perioperative pathway of care start?
On the day the surgical team decide that an operation is to take place, or in some cases, even before then if there are significant clinical challenges to overcome to make that surgery possible2) When should it end?
- On discharge from follow up from the surgical team (eg, a follow up... -
Andrew McKendry made a comment
Certainly in my experience, the number of patients we have admitted to critical care purely on the basis of better nursing provision is high. Professor Pearse is right in saying that this patient cohort don't always need the fancy critical care treatment, it's about nursing. This is again a feature of lack of staffing on surgical wards; there doesn't seem to...
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Andrew McKendry made a comment
All laudable aims; without more funding and staff to deliver them though, care will never be optimal.
NELA is a prime example of efforts to improve periop care for emergency laparotomies, however in my experience it's become a "checklist" of what to do, rather than drive forward a notion that this is the standard of care that should be delivered to all high...
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Entirely agree. Pre-op nursing staff do pretty much nothing but pre-op. They're far more skilled than many of us anaesthetists at picking up the little issues that sometimes get missed. Pre-op operates as a team between the n/s and the anaesthetists - that's not a disadvantage in the slightest.
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Andrew McKendry made a comment
Some good points raised already.
It's interesting you say "In an effort to prevent on the day cancellations the majority of elective surgical patients now undergo nurse delivered preoperative assessment". I do wonder if the initial drive for this was for financial, as opposed to for patient care (which would have been the correct reason).
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Andrew McKendry made a comment
I'm not entirely sure how realistic a patient listed for a THR would have their operation within 3 weeks, regardless of the cancellation, which exaggerates the issues. Certainly the pre-operative care was entirely missing; where was the pre-op assessment clinic that would have picked up a myriad of issues and given time for things to be sorted? There wasn't...