Maidstone Merry Medic

Transcription

1 Maidstone Merry Medic By Mahua Bhaduri Acknowledgments to: Gurveer Saggu, Talia James, Megan Galloway, Antonine Piteau-Michelle, Alex James, Alex Lai, Jonathan Michael, Lorraine Kavasen

2 Contents 1. Introduction 2. Ward-based system 3. Useful contact numbers/ bleeps 4. Explanation of on-call and rota 5. Preparation for the weekend 6. Tests & Investigations 7. Referrals 8. Microbiology discussions 9. Stroke firm 10. Chaucer firm 11. Elderly care firm- Mercer, Jonathan- Saunders 12. Cardiology firm 13. Gastroenterology firm 14. Respiratory firm 15. UMAU firm

3 Welcome to Maidstone! Your first few weeks as a F1 can be one of the most daunting experiences! There a massive learning curve and you will feel out of your depth at times. In these situations do not hesitate to ask for help from your seniors, everyone is expecting you to! Maidstone is a great F1 hospital to start at; it is a busy but friendly DGH, all the consultants, registrars are very approachable. By the end of your foundation year 1 you will have the experience and knowledge to go into F2 confidently. We have created this guide to better prepare you for your transition from medical student to F1 medical doctor at Maidstone Hospital. Good luck! Mahua mahuabhaduri@doctors.org.uk

4 Ward Based System Ward Specialty Consultants Consultant Ward Rounds UMAU Acute Dr Keough Dr Busch/ Roe Dr Siva Daily Stroke Stroke Dr Thom/ Dr Busch Daily for the new patients, Tues am for all patients Jonathan-Saunders Ortho-geriatrics Dr Kukanasen/ Dr Noble Monday am, Thurs Mercer Elderly Care Dr Thom/ Dr Busch, Dr Kukanasen/ Dr Noble Daily for new patients Chaucer Acute/ Diabetes and Endocrine Dr J Kumar, Dr S Perera Tuesday/ Thurs John-Day Gastroenterology Dr Bird Dr M Kumar Dr Baburanjan Pye-Oliver Medical (under gastro) & surgical Dr Bird Dr M Kumar Dr Baburanjan Foster-Clarke Respiratory Dr Husain Dr Mankragod Cornwallis/ CCU Cardiology/ Surgical Dr Takeda, Dr Nunn, Dr Mishra, Dr Caulfield Consultant specific Consultant specific Dr M: Mon pm, Wed am, Fri am Dr H: Tues, Fri Consultant specific Whatman Currently over-flow ward - - Useful bleeps

5 On call bleep Odds Med Reg 1444 Biochem st on call SHO 1777 Haem Ward cover F Blood bank 24481/ Ward cover SHO 1646 CT Surg Reg at Maidstone 1600 US Surg Reg at TWH 5588 Xray Haem Reg 1667 Pain team 1414 Anaesthetic Reg 1601/ 1362 Pallative nurse 1133/ 1425 Cardio Reg 1302/ 1555/ 1714 Microbiology cons 24040/ 24048/ Porters This is an extensive but not exhaustive list of important bleeps you will need. More specific bleeps for each job can be found in the Job section of the guide. Top tip: Download the MGHswitch app for your Android phone. It has all the numbers for all the teams, department possibly needed! Password: hermitage

6 On-calls & Rota Maidstone medical on calls can be tough. Do not be afraid to ask for help and you will learn alot. You will be expected to do around 1 weekend in 4 and 1-2 weekday on calls. When you do a weekend you should have a half day that week. Weekday on-calls On a weekday there will be 3 F1s on-call, as well as 3 SHOs and one registrar. The on-call F1s are divided into: 1st on call 2nd on call Ward cover/ bleep 1500 First house officer on-call Your day will start at 9am and finish at 9.30am. The on-call will consist of patients accepted by the medical registrar either from A & E or GP referrals. At 9 am go to the UMAU office and put your name and bleep number in the pink list. The pink list is the spreadsheet where all the on call referrals are recorded. It is accessible via Q drive. The pink list will contain: patient details, their presenting complaint which should have been already written by the registrar who accepted the patient and their location. Once you have written your bleep number on the pink list and ideally introduced yourself to the registrar on call you should return to your usual ward to start your ward round. Sometimes there are patients already waiting to be clerked and in that case your registrar may want you to start clerking at 9. When you go to clerk take a medical proforma and drug chart with you. Make sure you have written your name next to their details on the pink list. The majority of the patients will be on UMAU or A & E. If they have come from A & E they usually have had history, bloods and basic imaging already done which will help speed up the process. It is important to take your time to get a concise history and examine properly as your clerking will be repeatedly referred to

7 throughout the patient s admission. It is also useful to look previous EDNs (electronic discharge notifications) and in isoft for previous clinic letters. Once you have seen the patient you should write your differentials and formulate a management plan. Even if you have little idea on what is going on with the patient it is a good practice to give it a go and often enough you will be right! Each patient you clerk will need to be post-taked by the consultant. Once you have post-taked your patient should be highlighted pink on the list and you should follow up any jobs or hand them over in handover. Apart from clerking you are also expected to attend cardiac and peri arrests. Your on call finishes 9pm but you will be expected to handover which normally takes an additional 30 minutes. Top Tip: on-calls are the best way to get your CBD and mini-cexs done for your e-portofilo. Start early to avoid the rush at the end! Second on house officer Like the first on house officer you should go to the UMAU office at 9 am to introduce yourself to the on call registrar and write your bleep on the pink list. You should then return to your daily ward and come down to clerk when you are bleeped by the on call registrar. You should attend all the cardiac and peri arrests. Your day finishes at 9.30pm like the rest of the on call team. Ward cover/ bleep 1500 Ward cover or bleep 1500 starts from 5pm and finishes at 9pm with handover until 9.30pm. When you are on ward cover you are expected to attend to all the bleeps from the medical wards including Romney. Romney is a rehab ward which is covered by GPs in day hours. You can find the 1500 bleep in the UMAU office. Ward cover

8 can be challenging at first, you can get a lot of bleeps in quick succession but you will soon learn to prioritise the calls. You are most likely to get called for things like: prescribing warfarin, IV fluids, pain relief. You may be asked to review a patient after a fall or if they are acutely unwell. If you are worried about a patient or unsure what to do you should bleep the SHO on call on bleep NB. Before finishing at the end of day it is helpful if you make sure that all the warfarins are dosed and IV fluids prescribed. It will make the shift for the ward cover F1 a lot nicer! The only thing you should handing over to the ward cover F1 at at the end of the day are scans you are awaiting to be reported, awaiting blood results and any critical unwell patient you are concerned about. Weekend On calls In the weekends there are 3 F1s, 2 SHOs and 2 registrars. One registrar is the registrar on call and the other is the discharge registrar. The F1s are divided into: 1. First on call 2. Ward-cover 3. Post-take F1 The first on call does the same job they would do in the weekdays: clerking on the medical take. The ward-cover F1 acts as the wardcover/ bleep 1500 from 9-5pm. At 9 am you should print off the green list which is the weekend handover list. This is a list of jobs that have been handed over to you by the normal day teams. They will include things like weekend review of patient s, checking bloods. The green list can be found on the Q drive in the doctor s folder. You will be bleeped by nurses throughout the day from the wards for: warfarin dosing, falls, BMs, PAR scores, spiking temperatures, IV fluids. At Maidstone we are piloting the green book which is a book where the nurses will keep a list of jobs for you rather than bleeping every time a job comes up.

9 Weekend ward cover is probably the most stressful shift you will do. It is important to keep calm, make time to eat and drink and keep an organised list. If you are asked to review a sick patient remember ABCDE and do not hesitate to bleep the SHO (1646) or reg (1777) if you are stuck. Post-take F1 works from pm. This varies on the consultant and what time they would like you to get in for. If you are on call with Dr Mankragod for example he may like to start the ward round at 7.30am to allow enough time for the jobs to get done and you can leave earlier. You should come in minutes early to organise post-take list. This is essentially the pink list from 9pm the night before - 9 am that morning. You may need to update the location of the patients as they may have moved from UMAU to the wards. Starting on UMAU, the consultant will review the patients with you and the night team. It is your job to document in the notes the posttake ward round and record any jobs. After your ward round it is your responsibility to make sure the jobs are done for all the patients. Remember to put out bloods for patients who need it the next day and update the green list with these jobs. The patients on your post-take ward round are your responsibility for the day- make sure you hand anyone over to the F1/ SHO before you leave. Finally, once you have finished all your jobs it is nice to help out the on-call team until 5.30; however it is up to your registrar s discretion when you can leave! Preparation for the weekend It is important to sort out your patients before the weekend as medical patients are not review over the weekend unless it is handed over or they become sick. Things to remember:

10 1. Rewrite all drug charts that you anticipate filling up over the weekend 2. Try to dose warfarins and write IV fluids up where possible 3. Ensure that sick patients are handed over via the green list. It is important to explain the diagnosis, current management, ceiling of care for the patients you are handing over. It is a good idea to go over the sick patient s with your SHO/ Reg before the weekend and write a clear management plan for the patients in the notes. 4. Ensure that bloods are ordered and handed over in the green list. Remember to be clear with what you are handing over, why the bloods are clinical significant and the management you would suggest. 5. Ensure that all patients who may be discharged over the weekend have their EDN completed before the weekend. Ordering Tests and Investigations isoft: isoft also known as patient centre is the computer program where you will order the majority of your investigations/ tests. You can view old clinic letters on it using the patient document viewer which is very useful on-call. You can also find important patient details including NOK telephone numbers, GP addresses. You can track where patients are in the hospital and their consultants under episode enquiry. Bloods Bloods are ordered on isoft. Find the patient you are interested in. Select order entry and you will find the tabs Doctors A&E, Doctor medicine. Select the test you need and click add order at the bottom of the screen.

11 Enter the relevant patient information which is especially important in unusual tests. Remember to change the date if you are preordering for the weekend. If there is a blood test you need that you can not see on the tabs click find and type it in. If you are taking the blood remember to ring the porters ext to take the bloods. Radiology investigations You can find most of the investigations again in isoft. The majority of X-rays can be found in the A&E, medic or orthopaedics tab. If the clinical information is clear and there is a clinical indication for the Xray these do not need to be discussed. However, radiology do not report the Xray so you will get used to interpreting them. CT scan / MRI are more difficult to get. Again you order them through isoft using the different tabs and the search button. If you are requesting a CT head it s a CT brain. CT colonogram can be requested by requesting a CT abdomen and writing CT colonogram in the clinical information. When you request a CT/ MRIs and you would like them done on the day you will have to discuss if with the radiologist. You can find them in the reporting room in Xray in hours. You are expected to give a concise history, what scans they have had before and what your team are looking for in the scans. This is scary at first but you will get better at it! NB if you are requesting a CT brain for a possible stroke and the patient fits the thrombolysis criteria. You should write Thromobolysis call in the clinical indication, this way the patient goes to the front of the list and it does not need to be discussed with the radiologist. If you are requesting a CT PA for a possible PE, you will need to search CT pulmonary emboli and write the Well s score in the clinical indication. The request will not be accepted without this. All scans out of hours will need to be discussed.

12 Endoscopy OGD, colonoscopy and flexi sig all have hand written request forms. These can be found on the Q drive >> Doctors >> F1>> useful forms These will need to be handed into endoscopy. If the endoscopy lists are not fully booked the nurses can add on inpatients without discussing it with the endoscopist. However if they are fully booked which is most of the time you will have to discuss the form with the endoscopist to see if they can fit you in. NB all Upper GI bleeds require scope within 24 hours! ERCP has a special request form again. These need to be discussed with the Gastroenterologist consultants/ registrars. An up to date INR must be done. Cardiac tests These can all be requested on isoft. A 24 hr tape is 24 hour holter. These can often take time to happen. If the request is urgent you can discuss them with the cardiac technicians on the ground floor next to the entrance of Xray.

13 Referrals For urgent referrals ring the appropriate registrar on call. For everything else you will be required to write a detailed referral for your patients. Cardiology and Gastroenterology have template referrals that can be found in Q drive >> Doctors >> F1>> useful forms. I have also left a template here for the other referrals. A good referral will be most likely attended quicker. In a referral make sure you include the following: 1. Patient details: name, DOB, hospital number, ward 2. PMHx 3. DHx 4. Presenting complaint- differential diagnoses 5. Investigations including imaging and relevant bloods 6. Why you need their expertise, what are you querying 7. Your contact details and your bleep Drop your referral down to the secretaries, most can be found in the Travers unit on the ground floor in the pink zone. Surgical referrals will need to be discussed with the on call surgical reg at Maidstone. Contact them on bleep 1600.

14 Discussions with microbiologists At Maidstone you will have a lot of discussion with the microbiologists. Anyone with a long course of antibiotics or patients who have had multiple courses of antibiotics will need to be discussed. The microbiologist can be contacted via or via switchboard. Make sure you have the patient s drug chart and bloods to hand. The microbiologist will want to know the clinical indication for the antibiotics, the clinical examination findings, any useful investigations, their bloods and what antibiotics they have had. Those on the respiratory firms will have a weekly microbiology ward round on Friday mornings with Dr Khan/ Sluga where all the patients on antibiotics will be discussed. Top tip: Use the formulary found on the MTW intranet to find out the antibiotics and dosages used for the majority of infections. You should not use antibiotics which are not on the formulary without microbiology advice.

15 Acute Stroke Unit The team Stroke Consultant this changes every month. The Stroke Consultants are Dr Thom and Dr Ellis, however Dr Ellis is currently on maternity leave so is being covered by Dr Busch. Registrar usually on the ward, however there is a stroke clinic on Thursday morning which they may go to. 2xSHO Currently a GP trainee and a locum SHO 1xFY1 One of the senior doctors will carry the thrombolysis bleep. This goes off when a stroke patient is admitted who may be eligible for thrombolysis. If the patient is thrombolysed the bleep holder will be off the ward for about hours. Sister Steph is the ward manager. She is great and will help you out if you need anything. Caroline is the Stroke Nurse specialist. She is a great source of information about anything stroke related. Any questions about management/stroke guidelines she is the one to ask! There are also lots of physiotherapists, occupational therapists and SALTs on the ward which you work with. They are all lovely, very easy to get on with and happy to help! The timetable Monday Tuesday Wednesday Thursday Friday AM 8 am monday morning meeting Full consultant w/r Ward round Ward round Ward round PM jobs 2pm MDT jobs Jobs Jobs Every morning you have a board round where the physios, OTs, a sister and the doctors briefly discuss the patients. This gives the opportunity to plan for any potential discharges and raise any concerns from overnight. Following board round we do the ward round in the morning and jobs in the afternoon. Currently we are splitting up the bays to make the ward round go quicker, but with the new doctors coming in this may change to team ward rounds. The stroke consultant will come to the ward everyday to see the new patients and anyone who may be unwell or need a review. On a Tuesday there is a full Consultant ward round. There is then an MDT meeting at 2pm. This is usually attended by the Consultant and one other member of the team. The rest of the team stay on the ward to get on with jobs. Investigations

16 The standard investigations for patients with an ischaemic stroke include: - Carotid dopplers Don t do if the patient would not be a candidate for surgery hour tape If the patient is in sinus rhythm on admission. No need if known AF. - ECHO - Fasting lipids - Thrombophillia screen in younger patients where cause for stroke is unknown. These can all be requested on isoft. Treatment: All patients with an iscahemic stroke are treated with 2 weeks of 300mg Asprin, which is then switched to 75mg Clopidogrel All will be started on a statin if not already on one. Do not prescribe prophylactic dalteparin until hrs post infarct. In haemorrhagic strokes you can usually prescribe prophylactic dalteparin after a week to ten days but this is often patient specific and I would check with the Consultant first. If a patient has a stroke whilst on warfarin, this is stopped and the stroke treated with 300mg Asprin as above. The warfarin is usually restarted 1 2 weeks post infarct. Again this is patient specific and depends on their recovery. The Consultant will usually make the decision but they may need reminding! All haemorrhagic strokes need discussion with neurosurgeons at Kings. This is usually done by the clerking doctor, but you may need to follow this up. Patients who have an unsafe swallow are initially NG fed for a week or so to see if their swallow imporoves. If not they are referred to a PEG insertion for longterm feeding. A Consultant Gastroenterologist will need to review the patient and agree to insert the PEG. To get this done you can either fill out a form or write a letter to the gastro team and drop it off to the secretaries. EDNs If possible try and stay on top of EDNs! Particularly with the long stay patients it may be worth updating the EDN as things happen so the task is not so huge when it comes to the day of discharge! All stroke patients need to have a stroke passport attached to their EDN. Most stroke patients are followed up in Stroke Clinic 8 weeks following discharge. If you have any medical patients that need follow up in clinic, clearly state on the EDN they are for the medical clinic not the stroke clinic. Stroke is a good job to start on. The patients tend to be stable and all the different members of the MDT are really friendly. I am sure you will have a great four months!

17 Chaucer Ward The Team Dr Perera/Sivva and Dr. J Kumar Endocrinology & Diabetes Team work as two separate but interchangeable teams on Chaucer and Cornwallis/Culpepper respectively. Dr. Sivva is currently working on UMAU but will be swapping with Dr. Perera at some point. Each team consists of an FY1, SHO (CMT/GP trainee), Registrar and consultant. There is additionally an SHO (FY2) who floats between whichever team needs them. Your bleep is #1513. Other useful bleeps are on the hand over sheet (currently the SHOs on Chaucer have no bleeps). Chaucer Ward consists of 4 bays and three side rooms. It is split between Dr. Perera and care of the elderly. The current agreement is that Dr. Perera should have no more than 20 patients and usually 2/3 of the patients on Chaucer. This currently consists largely of B and C bays with SR1 and 2. The situation is very dynamic as patients move bays they should not change teams for continuity of care sake. Chaucer used to be a winter ward escalation ward but is slowly reverting back to its old role of an extension of UMAU. Pretty much all of this is subject to change as the consultants change over and management have a new idea. Timetable Normal working hours Mon Fri 9 5pm. Actual working hours 8:30 6pm (depends how much a perfectionist you are). Plus medical on call shifts. Monday Tuesday Wednesday Thursday Friday 8.30am Planning/teaching meeting in D&E centre 9.00am Consultant Ward round Consultant Ward Round 12:30pm Medical Grand round lunch FY1 Teaching lunch FY1 Teaching Lunch Grand Round Lunch What to do when you arrive: Pick up the nursing hand over sheet and update your patient list with all the new patients and print out a list. Summarise all the new people. Hopefully by this point the most senior person for the day will have arrived so you can start the ward round (every now and again you ll have to do an FY1 ward round). At 10am there is a board round (at the board) with nurses OT and PT, only one doctor needs to go to this as long as you know all the patients.

18 You will deal with all sorts on Chaucer a lot needing specialist referrals. The main conditions seen are falls, confusion, CAP, asthma, COPD, cellulitis, heart failure, AKI. Falls/confusion make sure CXR, urine dip, ECG, lying/standing BP, TSH, B12 + folate and vitamin D are all done and you know the results. Asthma: make sure they have daily peak flows (prescribe on drug chart), refer to respiratory nurse. Heart failure need daily weights (prescribe on drug chart) and fluid balance. A lot of your job is referring to medical specialities As with all medical jobs It is your job to find everything for patients (don t rely on SHOs/SpRs/consultants): Previous clinic letters on isoft Cardiology examinations on Tomcat (username/password on handover sheet) Oncology letters on KOMS (need to register for username/password) Phone GP (number when you click on the I next to patients names on patientcentre) to get summary sheet of conditions/medications to fax to chaucer ( ) EDNs Usually no follow up from the medics is required. However, any outpatient appointments if needed should be written on the EDN and ask Leslie to book. Currently Leslie is employed as the ward clerk (she is usually a CSW, but despite this is very useful at chasing things). All useful numbers are on side of the nurses desk on the ward or on the hand over sheet (Q:/doctors/Dr Perera/) On Friday make sure patients have a problem list and DNAR or escalation status is written for the weekend team. Any patients to hand over to check bloods, do jobs, discharge etc over the weekend are on the green list (make sure the jobs to do are specific, not just please review). (Q:/doctors/!!Green list/). Password: mtwgreen. Add patients to the bottom of the JK section. Final piece of advice. If you don t know how to get something done just ring switch board and they can usually point you in the right direction.

19 Care of Elderly - Mercer ward 1. Timetable The week starts with an 8am meeting in the Travers Unit on Monday morning where consultants and juniors meet together and make sure adequate staffing on the elderly care wards (Jonathan saunders/stroke/mercerr) for the week. Issues and annual leave can be booked here. The rest of the week is routinely 9-5 except of course for the days which you will be on call (see the separate medical timetable for those dates). It is sensible to get to the ward a bit early and you will need to do the following: a) update the list new patients, brief hx etc b) write a patient summary for new patients in the notes recent bloods, imaging results, presenting complaint, working diagnosis. c) Make sure all the bloods needed for patients have been ordered 2. The ward round typically starts at about 9am. The SHO/Reg/you will see the stable patients, and the consultant will just come to see the new patients routinely. Once or twice a week they will also want to see all of their patients. The day for this varies. We generally divide tasks to the F1 sees the most well patients and the SHO/reg sees the most unwell. Following ward round the rest of the day will be completing the jobs generated by the ward rounds: a) EDN s (discharge summaries) you will be hassled for these. Best to do them early and if you anticipate a discharge later in the week start it then. b) Ordering scans these are done through patient centre online. c) Chasing blood results (through telepath ) d) Doing MMSEs etc etc 3. The consultants are as follows: Dr Thom, Dr Noble, Dr Busch, Dr Kukanesen. All very approachable. You will work with all of them at some point. They tend to rotate around. 4. Special investigations: a) Colonoscopy/OGD request forms are in the doctors drawer on mercer ward (outgoing F1 s will show you). In here are paper forms which must be filled out. You must then take them to the endoscopy unit. b) Referral letters generally I write a letter with a history of the patient and reason for referral. Cardiology is a proforma (but they also take a referral letter). You must then hand deliver the letter to the medical secretaries (all the in the travers unit). Surgical referral letters go to the F1 on that firm. 5. No special procedures. You will do plenty of blood taking/abgs/cannulas. Otherwise most special procedures such as pleural taps etc will be when you are on call. You will be supervised!!!! That s the main things. Good luck. Everyone is very friendly you will be fine!!!

20 Jonathan- Saunders Ward/ Orthogeris Timetable of the week: Monday to Friday 9am -5 pm (Except Mondays when you have to go for the Care of the Elderly Meeting) What is expected: In the morning: - update your handover list - Summarise new patients in their notes - Ensure bloods are out - Check with Nursing staff if there is anyone that needs to be seen urgently and see them first - WARD ROUND- some days with the Consultant, other days you may have to lead the ward round by yourself Mondays- MDT meeting anytime between pm. Your job is to write in the details of the MDT in the patients notes Afternoon: - Jobs created during the ward round need to be prioritised and completed. - Check that all relevant blood tests have been performed and if not- that someone does them urgently - Check bloods at around 3pm and correct/make plan accordingly. Update bloods folder -Update handover list -Put out bloods for the following day Team and important contact numbers: FY1 bleep: 1673 SHO bleep: 1501 Med Reg: 1444 Surgical Reg: 1600 Ensure you obtain the Consultant and your own Registrar s mobile numbers. How to order specialised investigations: Irrelevant on this ward Any preparation then should know about for practical procedures commonly done on the firm: Only the usual- cannulas, ABGs Any common things needed on EDN, typical follow up: EDNs should specify what operation has been performed, any post-operative complications, any investigations performed. Should also include AMTS and MMSE

21 Any follow up required from the GP- on JSA in particular Vitamin D replacement (Cholecalciferol for 2 months then switch to AdcalD3), fragmin duration (For NOF# fragmin is administered for 28 days), analgesia to be weaned down if necessary Things to remember for the weekend: Any patients that need to be reviewed over the weekend or have blood tests checked should be written on the weekend hand over list under Q drivedoctors weekend handover Please ensure warfarins are prescribed for the entire weekend for those on warfarin. Please ensure if patients require fluids, this is written up If blood tests need to be performed over the weekend ensure the blood forms are printed and nursing staff are informed On the Friday, ensure that patients requiring bloods on the Monday are printed out Finally any management that you think they would find useful to know: - Learn about the Investigations and treatment for the different types of anaemia - All patients that are admitted with confusion should have confusion screen bloods: Calcium, TSH, FBC, CRP, LFTs, TFTs, B12, folate, urea, renal profile - Vitamin D should be performed on all patients with fractures on this ward. If Vit D<30 Start Cholecalciferol units for 5 days, then Cholecalciferol 1600 units for 2 months, then AdcalD3 for life. Bisphosphonate must be started once Vit D replaced sufficiently (i.e 1-2 weeks after starting cholecalciferol)

22 Cardiology Typical day Starting at about 8:30 to update the list and clerk patients in for the cardiac cath lab. SHOs come in a about 8:50. Consultant/SpR ward round officially starts at 9. Some Consultants are more punctual than others. How long it lasts will depend on the number of patients and the Consultant. At some point in the day but usually after the ward round, the Consultant/SpR will go and review patients for which other teams have requested a Cardiology review. You might be expected to go along or you may be asked to stay and make a start on the jobs for the ward patients. The rest of the day will be spent finishing the jobs that have come out of the ward round including arranging imaging, reviewing results, writing discharge summaries etc. At the end of the day you will probably want to sit down with the team if possible and update the list and request bloods for the next day. You can expect to finish on time most days. On Fridays, it is courteous to try and write a more detailed ward round plan summarizing the patients background and any plan for the weekend. If a patient is likely to be discharged over the weekend, it is helpful to write their discharge summary in anticipation. It is not always possible but it is also useful to try and make sure Warfarin doses are prescribed. The team The Cardiology team is extremely friendly.. There are 4 Consultants, Bet Mishra, Laurence Nunn, Dennis Caulfield and Scott Takeda. There is a Staff Grade (Saghir) and a Cardiology SpR (Os) There are 3 SHOs but there will rarely be all of your around due to nights/on calls. There is 1 FY1. Consultants take it in turn being Consultant of the Week and being in charge of the ward patients. They also provide on call Cardiology advice out of hours and do weekend ward rounds of the CCU patients (which you are not expected to go to those). They will usually do any urgent jobs for the patients over the weekend themselves but occasionally, if you are the FY1 covering the wards, they may call you to inform you of anything outstanding, There is a Consultant/SpR ward round of CCU everyday and often of the other inpatients too. On some days

23 the juniors will be left to see the ward patients alone. Staffing levels and leave Scott Takeda is in charge of annual leave and signs all leave forms. For obvious reasons there needs to be adequate staffing levels on the ward so you need to discuss leave plans with your SHOs to ensure this happens. The easiest way to go about it is probably to create a spread sheet of everyone s leave plans and oncall commitments. You also need to be mindful of staffing levels before swapping any on calls and make sure there are always at least 2 people on the ward. Patients There are 6 patients on the Coronary Care unit, most of which will be under you sometimes there are a few medical outliers. Your other patients will mostly be on Culpepper (which is shared with the Endocrine team) and you will have a few outliers on other wards. Total number of patients is very variable. When you accompany the Consultants/SpR to see patients for which a Cardiology review has been requested by another team, make sure you clarify with them whether the plan is to give advice only or whether they wish to take over the care of this patient (in which case they become a Cardiology patient). The only way a patient becomes a Cardiology patient is if they are referred to Cardiology and Cardiology accept to take over their care. This is different to other firms which opperate a ward based system whereby all patients on their ward are under their care. Even patients on Culpepper who have been admitted with an a clearly Cardiac problem must be referred to the Cardiology team by the Endocrinology team before their care is taken over. You, as the F1 do not accept patients. This is a Consultant or SpR decision. The Catheter Lab Consultants in Cardiology divide their time between ward work, clinics and being the cath lab. The lab will do electrical cardioversions, coronary angiograms, ablations and pacemaker insertions. They also implant reveal devices which record the heart activity and you are encouraged to go and watch procedures if there is time. Pacemakers and reveal devices are usually done as a day case. Sometimes they will stay overnight. Pacemaker and reveal device patients need to be clerked in and the nurses will call you to do this. This involves going to the lab, examining the patient and writing a brief clerking. The aim is to make sure they are fit to go for the procedure. If they are going home the same day they need an outpatient prescription of antibiotics. The nurses will give you the prescription form and tell you what they need (usually amoxicillin and flucloxacillin for 5 days or clarythromycin if penicillin allergic).

24 I would recommend looking through the 'pathway' each patient has because it makes your clerking easier. Any patient having a pacemaker needs a post procedure CXR so you need to request that if they are having a CRT device or DDD device then it must be a lateral as well as an AP film. You need to make sure someone checks the X ray for a pneumothorax so if it happens late in the day, hand it over to the ward cover F1/SHO. You are not expected to be able to comment on lead placement, just exclude a pneumothorax. If the patient is having an overnight stay, they need their medications and antibiotics written up in a normal inpatient chart. Different Consultants have different preferences with regards to DVT prophylaxis after pacemaker insertions. Many Cardiology patients are also on Warfarin so the best thing is to clarify with the Consultant when this needs to be restarted and whether they want fragmin in the mean time. Cath lab procedures start at 9am so you need to have clerked them before that. You also need to make sure the list is updated (Q drive/ doctors/ Cardiology masterclass/ LIST) so in the morning, check who is on CCU and who is on Culpepper under Cardiology. Other teams request Cardiology opinions by putting in referral forms. There are blank forms on CCU and completed forms should go in the red box on CCU. Consultants will usually see the referrals after the ward round. Make sure that you know where the patients are (should be on the forms but patients get moved so check patient centre) and if you can, it's nice to print out any recent clinic letters from cardio or Echo reports. Finally: The CCU nurses write down blood results for CCU patients (ask them where). We keep a folder on CCU where we write in bloods for out other patients. If a Consultant decides an inpatient needs an angio/pacemaker/cardioversion you need to fill out a cath lab form (available on CCU/in the cath lab) and get them to sign it and then hand it in to the manager of the Cath lab. If they want to arrange a Myoview you need to go to Nuclear Medicine (in the Oncology centre) and get one of the forms and fill it out. Some complex patients eg consideration of valve surgery/consideration for bypass surgery need to be referred to St Thomas'. They are usually referred to the JCC which stands for Joint Cardiology and Cardiothoracics meeting. It happens every Wednesday at St Thomas' and you need to do the following: Fax through a referral letter with patient's history. Make sure you include their NHS number, address and GP details Also fax through Echo reports and Angio reports for those patients. The fax number for JCC is at the bottom of our list. Phone to make sure they have got it

25 Image link the Echo and Angio and anything else they ask for (so they can view the actual images). Image linking the Echo and Angios can be done by asking people in the cath lab to do it. If you need to image link CTs you need to call/ the PACS team. Make sure everything has been sent over by 3pm on Tuesdays otherwise you will miss the deadline and they will have to wait to be discussed the week after. Dr Takeda arranges fortnightly Echo meetings which are sometimes sponsored by a drug rep. Usually one or two of the juniors have to present a case and then there is a bit of a discussion. It runs from 8 9 on Tuesday mornings and you get breakfast. Dr Mishra has a clinic on Thursday mornings which an SHO does with her the SHOs usually take it in turn. Enjoy it's a great job! Gastroenterology- John Day ward Timetable: Dr Bird does a ward round on Monday and Thursdays only. All other days the Reg/SHO/F1 will do the round. All new patients admitted to the ward on these days will be under Dr Birds team. On Tuesday, Wednesday and Friday Dr Babarajan s team will accept the new patients. On the day Dr Bird does the ward round you will need to go in 30 mins earlier to ensure that you can add the new patients to the list and print out blood forms so that the phlebs can take the bloods in the morning. Monday AM- Dr Bird accepts all new patients on the ward and will do the ward round. He likes to write his own notes. Lunch (12:30-2pm) Grand Rounds PM- Ward jobs generated from the ward round Tuesday AM- ward round (No Consultant- Dr Babarajan accepts new patients) Lunch (12:30-2pm) F1 teaching PM- Ward jobs Wednesday AM- Ward Round PM- Ward Jobs Dr Bird has ERCP lists on Wednesday. You will usually be bleeped by his secretary at some point during the day. They will tell you how many patients he has on his list and where they are in the hospital. You are expected to put a cannula in and take routine bloods including clotting on these patients. You should also do a mini clerking including information on why they are having the ERCP and PMH and also complete a drug chart. Include analgesia on the drug chart should they need it later. Dr Bird will usually go and consent the patients once you have done the clerking and bloods. This is all usually done around lunchtime as his list starts around 2. You will need to complete the EDNs for these

26 patients also. Sometimes they are day cases or stay overnight. Wednesday can be quite busy if you are on your own and expected to clerk these ERCP patients also. Thursday AM- Dr Bird accepts all new patients on the ward and will do the ward round Lunch- (12:30-2pm) F1 teaching PM- Ward jobs Friday Breakfast meeting from 8:30am. F1s must make tea/coffee for all members of the team. Held in the Travers Unit opposite Gastro secretaries room. Each week a member of the team will present a case on anything they wish to present on- can be non medically related also. Sometimes a drug rep will attend also and provide breakfast. Following meeting return to the ward for Ward round Lunch Grand rounds (12:30-2pm) PM- ward work F1 Responsibilities: *Update the ward list daily *Print a new one every morning for all members of the team *Request bloods for patients the day before to be taken by the phlebs the following day *Ward jobs Team and important contact numbers: Dr Bird s secretary is called Jackie. She is very helpful. She can be found in the Travers Unit. How to order Investigations: For any CT/MRI/US request you must submit a request on patient centre but also discuss with a consultant radiologist. Make sure you know a brief history and indications for the scan requested and have an up to date creatinine. They will approve the scan request which will speed up the process. To request an OGD, you must also find an endoscopist eg Dr Bird, Dr Kumar, Dr Babarajan etc and discuss the case with them. They will agree to carryout the OGD. You then complete an OGD request form which can be found in the endoscopy department and hand it in to them. (Make sure you photocopy lots of spare request forms and keep them on the ward so you do not have to keep going to the endoscopy dept to collect them) There is an office in the endoscopy department where you can attach the form on the board. You will have to include information such as recent clotting results. Practical Skills: You will have the opportunity to perform ascitic taps and drains whilst on gastro. You usually watch a few done by the CT trainees or registrar first then carry them out yourself under supervision. After a while you can perform them without supervision if you feel competent enough. Things to remember for the weekend:

27 *If you request bloods to be checked or taken over the weekend, make sure you print all the forms out and put them in the blood forms box (saves time for weekend team) *Make sure warfarins are prescribed over the weekend *Make sure drug cards are up to date and will not require re-writing over the weekend *On the Friday always provide a summary of each patient in the ward round notes to make it easier for the weekend team should they be called to see the patient for a review *Try to provide a management plan for the weekend team to follow should anything happen to the patient over the weekend * Add sick patients to be reviewed over the weekend to the weekend handover list. People on ward cover will review them. Include as much information as possible. *If a patient is to be discharged over the weekend, ensure that the edn has been completed already Respiratory Foster Clarke ward Welcome to Foster Clark Ward, home of the respiratory teams for Dr Husain (SAH) and Dr Mankragod (RMR)! Where do I get my list of patients for the ward? Current patient list is available on NerveCentre (an application which is accessible on the desktop or web link): I recommend copying this link into your NHS draft mail folder so it can be accessed from any NHS computer as some of the computers will not have the programme on the desktop and so will need this link to access the list. Who gets the new patients? Every morning new patients are transferred to the ward and will be written in red on the board. Allocating patients can always be tricky as it can result in unequal work loads for either team but the agreed way to decide is to: 1. Check if the new patient is known to either consultant (then taken if known) 2. If not known then should be taken over by the team with fewer patients Check if known by: (Patient centre > Episode enquiry/patient Document View (clinic letters) or logging into EDN and checking if any previous discharges under that consultant) Once agreed the ward clerk (Anita) will change the names to green (for SAH) or purple (for RMR). NOTE: If a new patient is moved up to the ward on the same day as being admitted (e.g. clerked in and moved up from UMAU at 1pm), they remain under the clinical responsibility of the on-call/umau team until the next morning when they will be allocated in the usual way. This can be confusing as they may be in red on the board but if there is no CONSULTANT post-take ward-round (PTWR) entry in the clerking then they fall into this group who are not under your care for that day.

28 Lord North is our outlier ward equally split patient between two respiratory teams and do the same for the new patients as above. The same principle for taking over care applies on this ward as mentioned in the above paragraph. At 9am the staff in charge will ask you to do a 'board-round' daily The board round is a quick talk through all of the patients under your team including the new ones who you may not have had a chance to have summarised. This allows for discharges to be flagged up early and physio/ot input to be identified early. The board round takes a few minutes and is useful if you've been away and don't know the patients but can be briefed about them from a nursing/allied healthcare perspective. With the board round done, start your ward-round. How to get ready for the ward round? Once allocated new patients, prepare an entry in the notes before the patient is seen. e.g: Date Ward Round Dr M / S 87F Admitted with... PMH... Imaging / ECGs... Bloods... (WCC and CRP Dr H is keen on these!) (including most recent microbiology results, which day of antibiotics the patient is on etc.) Obs... Assessment... Plan... Doing this for every new patient seems hard at the beginning but this will help you remember your patients better, and will be a life saver when your patient is reviewed outof-hours/by another team/by another of your fellow F1s! I would recommend starting at 8:15-8:30 on the first few days to get the feel of preparing for the board/ward-round. You will gradually pick things up and be able to make your own call about the best time to turn up each morning! Other important things: If patient has cancer and/or is under oncologists please inform oncology registrar of the patient admission at the earliest opportunity through bleep or isoft patient centre. They may not necessarily do anything but it is a matter of notifying the team should there be any delay or interruption to ongoing oncology care. Respiratory nurse- Sandra, Katherine, Lung ca specialists contact details are on our contact numbers sheet on the doctors base in the ward. Ensure the list is updated every evening (if you can). Consultant Ward round days

29 Print/write latest FBC, U&Es, CRP and LFTs +/- clotting, sputum and blood cultures ready for the ward round for all the patients, print blood requests for Thursday morning and by Thursday evening have all the results printed in the folder ready for the consultant WR on Friday (do the same on Mon for Tuesday). Ensure you have latest imaging ready on the PACS for r/v + ECHO reports. Do a board round with consultant and nurse before the ward round at 9am nurses desk See unwell patients first then potential discharges and then stable patients Generally side rooms are seen at the end of the ward round for infection control. X-ray meeting Held on Monday lunchtimes (Peggy Wood Breast Centre with Dr Mills) usually lasts half hour. This meeting is useful for reviewing any imaging which is uncertain or requires consultant radiologist input. If you have any patients from the wards who have complex imaging requiring discussion then include these on the list (either yourself or notifying Margarita). This list includes patients seen in clinic and from previous admissions who are having follow-up scans. Request this list on Monday morning from Margarita (24299) and she will this to your NHS account. She is located in the Respiratory Secretaries office, Ground Floor of Travers Unit. During the meetings detail all plans and follow-up decisions agreed. F1/SHO/SpR to take outpatient CT, MRI, US forms with you and fill them after the meeting and hand over outcomes of the meeting to Margarita with imaging request forms (get them signed by SpR or Dr Husain same day). Adding patient to MDM list If patient needs to be discussed in MDM then confirm it with Dr Husain or SpR first and send patient detail to cancer co-ordinator via to Mary Rogers, mary.rogers@nhs.net and CC to Dr Husain s secretary: Margarita Clark margaritaclarke@nhs.net. Thoracic referral for r/v or further advice Patient who needs Thoracic surgery input then please d/w Miss Karen Harrison-Phipps (Thoracic surgeon at Guy s and St Thomas Hospital), Thursday AM clinic in OP at Maidstone Hospital. AND/OR Send a referral to gst-tr.thoracicsurgery@nhs.net for registrar (Bleep 1101 via their switchboard) Please link all the PACS images via mtw-tr.pacshelp@nhs.net Finally.. The respiratory firm is a notoriously difficult but rewarding rotation to be doing and by then end you will be comfortable in managing patients with BiPAP, performing ABGs, understanding chest drains and working up patients with the common respiratory diseases. Dr Husain team timetable:

30 Monday AM: Registrar ward round Collect X-ray meeting pt list from Margarita (Sec) Breast unit X-ray meeting with Dr Pippa Mills (Consultant radiologists): PM: Dr Husain + Reg OP clinic Tuesday AM/PM: Dr Husain led ward Round Bronch list Alternate week AM Wednesday AM: SHO + FY1 led ward round PM: Jobs, Dr Husain private clinic Thursday AM: Lung 8.30 AM: Registrar ward round, Dr Husain clinic PM: Jobs, Dr Husain clinic Friday AM: Dr Husain led ward round PM: Jobs Dr Mankragod team timetable: Monday AM: Ward round 2 PM: Dr Mankragod ward round Tuesday Wednesday AM: ward round AM: Dr Mankragod ward round Thursday AM: Lung 8.30 AM: Ward round PM: Jobs Friday 8 AM: Dr Mankragod ward round PM: Jobs Useful tips: Access the patient list from anywhere Access to ECHO results, Pacemaker details, 24/48hr tapes etc.