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👋 Happy Friday. Here’s what we got:
🤔 Solving Streetings Napkin Maths
❤🔥 It’s Cuffin’ Season(In The ICU)
🤝 A Handovian Live Event?
🧠 QuickBits: Other Top Stories of The Week
If you want to read any previous editions of The Handover, you can on our website.
NHS UPDATE
🤔 Solving Streetings Napkin Maths…
There’s always drama in the build-up to a strike.
Letters, videos, tweets… It’s Love Island: Westminster edition.
TLDR:
Latest talks between the BMA and Wes Streeting have fizzled out like a damp firework. Resident doctors in England will still be striking 14th to 19th November.
But don’t go: Read on, dearest Handovian.
For your viewing pleasure, this time the drama was chef’s kiss perfect.
The Government’s Big Beautiful Offer
So, on Wednesday, Wes pops out of the woodwork like a slightly panicked fairy godmother, waving a 💫Magical Jobs Wand🪄.
Behold! A new Final Offer.
Dropping about a week after his last final offer.
(words used to have meaning smh)
He sent a letter to the BMA, a letter to resident doctors, plus a full-on heartfelt video nobody asked for. Reminiscent of double texting an ex.
So what’s the offer
Another 1,000 speciality training jobs
Paying Royal College and exam fees
Some tweaks to LTFT pay premia
A mysterious new “alternative training pathway”
A consultation on the prioritisation of UK graduates
And “better implementation of contractual entitlements” (???)
Exciting. Or maybe not. Let’s apply our medical brains.
Napkin Maths Time
We’ve gone from zero ⏩ 1000 ⏩ 2000 extra jobs in like 8 weeks.
Where are they coming from? Even with Wes’ Magical Jobs Wand, Jobs can’t be conjured. They require training capacity, supervisors, and actual rota slots.
That doesn’t materialise in a week. So either:
These jobs are being relabelled (i.e., converting existing non-training locally employed roles to training roles)
They’ll just be jobs with diluted training, which is… not a training job. That’s just called work.
That conveniently round number was definitely born on the back of a Greggs napkin. Costed? Nope. Which specialities? Where? Logistics? Nahh.
Also, if Wes can just conjure jobs out of thin air, why’s he doing it after thousands of doctors missed out this year? 🤔🤔🤔
Royal college fees are a nice gesture, but we did the maths (on a Pret napkin because we’re classy), for a GP trainee, it would work out to £50 extra a month if you squint.
BMA response: “No x.”
No spicy BMA video explainer, but a strongly worded letter told Wes where to stick it.
Main problem? No pay increase.
Also, why is fixing staffing now a bargaining chip instead of the government’s actual job?
Wes wants “partnership,” but last week he recommended a 2.5% pay uplift next year. That’s still less than inflation.
Media strategy?
With an offer like this, was the plan actually to be rejected all along?
It feels more narrative management than negotiation tbh. Make a showy offer and force doctors to say “no” for the public headlines.
And I really did like that heartfelt video. Can’t say I don’t feel betrayed.
All the same, strikes are still on
What do we think of the new offer?
Still Striking?
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*guarantee is (unsurprisingly) subject to T&C’s. Read here
RESEARCH UPDATE
❤🔥 It’s Cuffin’ Season(In The ICU)
Close your eyes and picture the ICU.
A sea of critically ill patients on opioids
More lines and waveforms than a dodgy crypto chart.
Your seniors' words of wisdom echo:
“Don’t touch anything that costs more than your tuition”
You feel more useless than a mannequin in River Island :/
But what if there’s a new job on the horizon for juniors?
And I’m not talking about your tenth blood draw of the shift or trying to charm the printer into functioning with an emergency CT request. Nope. This one’s retro.
Time to dust off the ol’ sphygmomanometer, because apparently it’s Cuffin’ Season, baby.
Traditionally, sticking a catheter into someone’s artery has been a bit of a flex in the ICU. Real-time blood pressure! Instant blood draws!
But unfortunately, there’s not much randomised data backing this whole routine.
So new study published in NEJM this week asked this question: Do we jab you now, or jab you later?
More formally: Do patients with shock actually need early arterial catheterisation? Or can we just use the classic blood pressure cuff like it's 1881?
To answer this, researchers randomised 1010 adults admitted to the ICU with acute circulatory failure (think persistent hypotension + signs of poor perfusion) to one of two pathways:
Cuff first (noninvasive) strategy: no arterial catheter unless pre-defined safety criteria were met (e.g. cuff couldn’t read BP, need for ECMO or imminent high-risk surgery). N=506.
Early A-line (invasive) strategy: arterial catheter inserted within 4 hours. N=504.
The primary outcome measure: mortality at day 28 (from any cause).
And check it out:
In a nutshell, using a BP cuff was non-inferior to an arterial line.
But how often did cuff patients need an A-line later? About 14.7% (so ~85% avoided an arterial line altogether 😯)
And what about complications?
Haematomas / bleeding at insertion site: 1.0% (cuff) vs 8.2% (A-line).
Arterial punctures for blood sampling (per 1000 ICU days): 742 (cuff) vs 269 (A-line)
Arterial-related bloodstream infections (per 1000 ICU days): 1 (cuff) vs 3 (A-line)
Device pain/discomfort lasting ≥1 day: 13.1% (cuff) vs 9.0% (A-line) among patients able to report (22.8% vs 15.4%).
TLDR: fewer invasive complications and infections, but more venepunctures and a slightly higher proportion reporting discomfort for the non-invasive group.
But of course, don’t neglect the fine print:
Open-label design (no blinding) could bias some secondary outcomes and care processes.
Not all patients were able to self-report pain/discomfort assessments
Few trauma / post-op patients and no BMI >40 (plus study conducted in swanky French ICUs) limit the application to all patient groups.
Variation in how and if clinicians used full A-line data might have affected results.
Still, the cuff is cheaper, less stabby. And in this trial, associated with fewer complications and infections.
To the ICU docs crashing out at the thought of losing beautiful continuous waveform data, don’t get your knickers in a twist just yet. The A-line is still there for the truly needy.
But for supernumerary F1s, your hero moment has arrived. Put down Hinge, it’s time to cuff some patients instead❤🔥
(The Handover doesn’t endorse patient-doctor relationships)
QUICKBIT: OTHER NEWS YOU SHOULD KNOW
There’s finally an official statement on the exam scandal that birthed The Handover.
In case you missed it: back in Sept 2023, 283 doctors were incorrectly told they’d passed the MRCP Part 2. The Royal College of Physicians admitted the error 17 months later. So these group have to do the exam all over again 💔 They just dropped a 40-page document explaining the error.
Apparently, it was a data mishap where a dummy answer key (‘A’ for everything) wasn’t deleted. This meant both right and wrong answers were marked correct on most questions. Oops. It also explained it was a bureaucratic fault and got everyone in the RCP to apologise. Still very peak for those affected.
NICE has 360’d on its decision against the cancer drug abiraterone in its latest draft guidance. They had previously rejected recommending it due to the NHS being too broke to afford it… Sorry, “cost-effectiveness grounds”. Completely coincidentally, the price of the drug has come down significantly since rejecting it in 2021. It works with ADT and steroids, beats placebo, but hasn’t been tested against rivals like enzalutamide. Still, 4,000 men are expected to benefit.
This study in NEJM suggests that a subset of individuals who qualify for radiotherapy post-breast removal may not need it. This trial included 1,607 women of varying TMNO staging who underwent mastectomy + axillary surgery + anti-cancer therapy. Then randomly assigned to either a radiotherapy group or no-radiotherapy group. The 10-year survival between the two groups was insignificant. Although the risk of recurrence was greater in the no-radio group. View journal poster here
OpenAI’s finally realised people were asking their AI for medical advice. So now, instead of pretending to be a doctor, it’ll just tell you to actually go see one. Revolutionary stuff. So now patients with chest pain will return to Dr Google for their STEMI self-diagnosis(the world is healing)
This is a really well-written piece by Dr Kamyab. Thought it was worth sharing.
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Fun Fact: You may think the state of Catatonia is strictly hypokinetic(frozen and mute), but it can also be hyperkinetic, too. This means someone who’s not sleeping, constantly moving around and resistant to all instructions/uncooperative(“negativism”).
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