Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

ACE IT! PREP FOR FY1SCHEDULE FOR THE DAY Time Topic Speaker/Speakers 6:00-6:15 pm  Introduction Abdulla/Huria 6:15 - 6:35 pm FY1 and FY2 Abdulla  rotation Ward round, On- 6:35 -7:10 pm calls and weekend Sylvia shifts Radiology scans 7:10-7:30 pm requesting and Ilias interpretation 7:30-7:50 pm Safe Prescribing Bhavdeep 7:50-8:10 pm E-portfolio + QI Sara project Pay and tax 8:10-8:30 pm Huria allowance + CPD LEARNING OUTCOMES: ROTATIONS IN FY1 AND FY2 Objective n° 1 Objective n° 2 Objective n° 3 Gain a comprehensive Learn about the variety of Recognize the role of rotations in understanding of the rotation specialties involved in the rotations assessing competencies across a schedule throughout the and how they contribute to a well- broad range of medical, surgical, foundation years, including the rounded foundation training and possibly community-based settings duration and objectives of each experience rotation Rotations - 6 in total FY1 Through undertaking supervised responsibility for 4 Month rotations Make the most of it, or don't. patient care, you’ll consolidate your skills from ward base medical school within the workplace. Following ask to hold the bleep on-calls ask to join clinic successful completion of FY1, you’ll be awarded a clinics - FY2 Foundation Year 1 Certificate of Completion ask to see referrals (FY1CC) and recommended to the GMC for full outpatient component - derm / renal registration. specialty based use the time to understand role of MDT - cardio -> angiograms/ pacemaker/ FY2 just it as reflection - role of PT OT, ANPs , Although you’ll still be supervised, you’ll have referrals care coordinators greater responsibility for patient care, and begin to resp -> bronchoscopy / NIV make management decisions as you progress link above to your horus and the HLOS towards independent practice. You’ll also contribute surg -> M&M meeting - theatre - hot to the learning and development of the wider clinic healthcare team, including nurses, medical students outpatient -> GP/ ED/ Micro and less experienced doctors. On successful completion of FY2, you’ll be awarded a Foundation Programme Certificate of Completion (FPCC). This indicates that you are beginning to demonstrate clinical effectiveness, leadership and decision making skills, which are essential for core, specialty or general practice training, and therefore are ready to begin one of these training programmes. INDUCTION Introduction to your new place of work - ranges between 1-2 days to a week - can use it to complete mandatory elearning - although you should be given allocated time for that or paid for First rotation -> get used to the workload, on-calls and rota the hours. You will be exhausted - normal - your body will adjust. Hand over and leave on time - do bloods early You should have your rota 6 weeks prior to start of rotation always always make a list have something outside of work Entitled to 2hrs per week study day - 1 day per month - use it take your break - there is ALWAYS time Entitled to taster week exposure leads to experience - that is the way of life FY2 you are on SHO rota - imposter syndrome Entitled to study leave attend your teaching - in person or teams Entitled to study budge inc. for courses like ALS people wont learn to respect your time until you learn to value your own first Will be overwhelming at the start but use it as opportunity to get There is almost always more time than you think! If you don’t have time to read the notes before assessing an unwell patient then to know your cohort and sort out the logistical aspects. they are peri-arrest and need a 2222 call. PLEASE don't sedate because someone said so can’t find guidelines ? search what you want .nhs.pdf TAB and PSG in first or second placement let you ES know you are willing to improve and want feedback help your colleagues, because it comes in circles supervisors are a mixed bag look out for your self first - you will be surprised don't let other speak rudely to you exception report don't escalate without with getting things first Supernumerary post Geriatrics/Stroke Day-to-day is mainly admin -> on-call is where Thorough WR entry - learn the style your cons. Includes paeds / anaesthetics/ ITU/ microbiology the fun is but also the stress Wants i.e. LBO/ VTE/ Abx hx / up to date issues Follow reg to arrests/ look at referrals Take the time to understand your shift pattern Your senior will go back to admission notes - so Clinics Seek opportunities to challenge yourself Admin based job should you A-E perfection Highlight who doesn't have TEP - could be an Cannula practice / central lines take time to highlight things to your audit Exam preparation consultant during ward round Ask nurses in AM who is sick Get to know your patients, shake their hands - Outside hobbies - coding gives you good indicator of muscle tone, Taster week Put bloods out for next day - things can also coordination, movement, sense of care and Locum ? AMU wait empathy Weekend review? -> why and escalation plan GP -> enjoy it - is it for you? Work within your limit Basics that most need: LSBP/ ECG/ medications review / Collateral / continence screen/ cognitive screen 4AT Understand role of PT/OT/SLT/Care coordinator GENERAL SURGERY - use it as reflective point Family discussions - know when to escalate to Escalate to surg reg first before medical senior - dont break bad news alone this including scanning patients On the list for each patient update Look at OT document for baseline function / they do excellent neuro exams Hb/WCCs/CRP and stoma/drain output, current Allot of micro discussion - know the duration of Abx, Fevers or not, HR, BP. abx given - any lines - BC - URINE mcs - ask Ortho and Urology VBG is key in post op concerns (lactate / duration Concerned or confused - ask at the trauma electrolytes) meeting Dont progress diet on your own Write - Ryles tube and its size in the plan and ?asking a question - bring all the infor - latest XR - examination findings how long to leave the tube on free drainage for Dressing on from theatre ? check the op notes ? (i.e. not a spigotted fine bone feeding tube) - left on purpose fine bore being less than 9 FR - for feeding - Take off bandages and assess what you see where to find them (those that come from ED) - upload to system if Theatre - learn how to to suture - I+Ds possible Be medical advocate - drug chart, fluid balance , Look for other injuries U/Es useful presentation - haematuria/ washout/ irrigation LEARNING OUTCOMES: WARD ROUNDS AND ON-CALLS Objective n° 1 Objective n° 2 Objective n° 3 Understand the Develop skills to effectively Learn communication techniques to documentation manage time and prioritize effectively relay important requirements and legal patient care during on-calls and information to team members and aspects of patient care ward rounds, ensuring critical other departments, enhancing during on-calls and cases are attended to promptly. coordination and patient outcomes. ward rounds, including how to record accurate and useful patient notes COMMON BLEEP SCENARIOS You may receive bleeps to You maybe asked for a falls review. If a patient's condition It typically refers to the You maybe bleeped about suddenly worsens, such as urgently review meds, drug systematic assessment of a interactions, dosages, or to patient following a fall, particularly updating anxious next of kin severe respiratory distress provide critical medications in in elderly or at-risk individuals. out of hours or to write or a sudden drop in blood emergency scenarios. You may This review aims to identify the discharge letters that have pressure, the medical team also be bleeped or handed over causes of the fall, evaluate the been missed by the day responsible for the patient patients whose investigations patient's risk of future falls, and are outstanding implement strategies to prevent team! will receive an urgent bleep recurrence. to attend immediately MEDS/INVESTIGATIONS NOK FALLS ABNORMAL OBS REVIEW UPDATE/DISCHARGE SCENARIO 1 SCENARIO 2 SCENARIO 3 A nurse bleeping about a patient: A nurse bleeping – NOK update A junior doctor handing over – Post-Op Bloods Review Hello doctor, I have just done a set of obs and one of my The family of a patient have been phoning all day for an Jonathan Becker's came in with abdominal pain and had patients has a temperature. Can you please come and update and desperately want to speak to a doctor but no appendicitis. He went for his appendicectomy today, no one has done it. Patient has a new diagnosis of complications. prescribe some paracetamol? metastasised bladder cancer with poor prognosis. Patient is currently going for CT scan for further work up and is not His post-op routine blood test results haven’t come back yet Alex McGuinness, MRN 1111111, DOB 09/08/1947 acutely unwell. but would you please just review them to make sure they Temperature 39.4 degrees. BP 89/40, HR 97, RR 24, T39.4, are fine. Sats 99% on air They are on the phone now and are very irritated. Can you Patient does look a bit unwell and is shivering quite a bit please speak to them, I can transfer you. Bloods show Ur 17, Cr 180, K+ 7.2 You cannot do bloods but the nurse in charge on the ward is trained to do cultures so can help Jonathan Beckers, MRN 8888777, DOB 09/08/1965 Obs = NEWS 0 SCENARIO 4 SCENARIO 5 A nurse bleeping – Low BP but normal for patient A nurse bleeping – Apixaban Hello doctor, I have just done some obs and my patient Gemma Morris has a BP of 92/78. Can you Hi doctor, I have a patient that has been prescribed please come and review and prescribe some fluids? apixaban but I can see that the previous dose If asked: was held. Should I give this current dose or not? Gemma Morris, MRN 2323232, DOB 30/12/79 Esther Garfield, MRN 987987, DOB 08/07/1966 Stable obs Patient has bowel obstruction She is asymptomatic but hasn’t drunk water in a while as she has been asleep up until recently. You are not worried about the patient as a whole. SCENARIO 1 Post-op Bloods SCENARIO 1 Post-op Bloods SCENARIO 1 Approach: Post-op Bloods Issues High potassium AKI Ideal plan Repeat VBG now to confirm raised K+ Review patient clinically Perform ECG (consider calcium gluconate) IV Fluids IV Insulin + glucose - 10 units Actrapid in 50ml 50% glucose over 30 mins Medication review: suspend meds such as ramipril, furosemide Repeat VBG later on Take home message When some managements are initiated, it is important to return to the patient to re-check on them OR effectively handover if it is the end of your shift SCENARIO 2 Sepsis SCENARIO 2 Sepsis SCENARIO 2 Sepsis SCENARIO 3 NOK Update SCENARIO 3 Approach NOK Update This is one that shouldn’t be dealt with by the on call team. Especially for this patient it is inappropriate for the on call team who does not know the patient to break bad news if it is not urgent. If they manage to get round to it, there is also a confidentiality issue. Consider informing family that you are not the usual day team and patient is not currently unwell so there is not urgent update from you. You will ensure to handover for regular team to give NOK a call with patient’s permission. Take home message It is important to know what jobs are NOT for the on call team SCENARIO 4 ABDOMINAL PAIN SCENARIO 4 ABDOMINAL PAIN SCENARIO 4 ABDOMINAL PAIN SCENARIO 5 Acute Desaturation SCENARIO 5 Acute Desaturation SBAR HANDOVER An SBAR approach is a good Patient details (name, DOB, hospital number) system to ensure you Patient location communicate all details in a SITUATION Headline (What is the major problem now!) S systematic way. Think about Admission details (if inpatient): date, admission reason, what the person you are treatments speaking to will want to BACKGROUND Past medical history know, and have the notes, B ± any other relevant aspects of the history drug and nursing charts available so that you can Observations answer any of their Examination findings questions. A ASSESSMENT Investigations received/pending Management so far R RECOMMENDATIONS Diagnosis/differentials Management plan and outstanding jobsWARD ROUNDS The goal is to meticulously document each patient interaction so that any member of the Multidisciplinary Team (MDT) can understand the care plan. It's beneficial to communicate this plan directly to the patient's nurse and/or the nurse in charge. This helps them coordinate care more efficiently, reducing the need for them to contact you frequently and enabling them to update families about the care plan, especially when you are occupied. You might initially find ward rounds overwhelming, often due to frequent interruptions and the rapid pace at which patients are seen. However, this should get easier with time. It’s important to seek support from your seniors and request a slower pace if needed to ensure you fully grasp and can document the care plans effectively. WARD ROUNDS When charts are available at the bedside, ensure you document the following in your notes: the National Early Warning Score (NEWS) chart, fluid intake and output chart, and blood glucose levels. Review the Medication Chart: Antibiotics Medication Reassessment VTE Prophylaxis: Physical Examination: Record the general appearance of the patient. If any findings are unclear, don’t hesitate to consult with your seniors. Impression: This section should include your diagnosis/differential diagnosis, which is a critical part of the documentation. If uncertain about what to include, seek guidance from your seniors. Note if the the patient is medically fit for discharge (MFFD), and ask if they can provide a date for discharge. Plan: Use numbered/bullet points to outline a detailed care plan. Consider the following: Review any necessary blood results. Assess dietary needs and determine if the patient should remain nil by mouth. Evaluate the need for treatment escalation or the completion of a Do Not Attempt Resuscitation (DNAR) order. Always rationalise why you are requesting a certain scan or blood test. OSCE stop WARD ROUND ENTRY SIPP may be used to remember the main sections Summary Investigations reviewed Patient assessment (questioning + charts + exam) Plan LEARNING OUTCOMES - SAFE PRESCRIBING Objective n° 1 Objective n° 2 Objective n° 3 Know how to access and utilize Understand the principles of safe Recognize common prescribing, including accurate pitfalls and errors in resources for drug information dosage calculations, considerations prescribing, and learn and guidelines to ensure up-to- for drug interactions, and patient- strategies to avoid date prescribing practices. them. specific factors (like age, weight, and comorbidities). Different types of fluid Replacement Includes two components: 1. Pre-existing fluid deficit (replace STAT) 2. Ongoing losses (replace future losses as they occur) The type of fluid replacement depends on the type of fluid lost Types of fluid lost and what they should be replaced with Maintenance include: Emergency: 1) Extracellular fluid loss (e.g. D&V, NG aspirates, stomas, burns, pancreatitis) These are the minimum requirements to Replace with a fluid similar to plasma (e.g. Give a 500ml fluid bolus of a crystalloid such as maintain a patient’s fluid level. Hartmann’s solution, or NaCl 0.9%) Hartmann’s or 0.9% sodium chloride over <15mins. 2) Classical dehydration (e.g. pyrexia, poor intake) If the patient is unstable or you are worried, consider If they are depleted or have losses (such as Should be replaced by normal maintenance fluids seeking senior help straight away with a low threshold for diarrhoea, vomiting, high output stoma, (e.g. dextrose-saline) a medical emergency call drains), these need to be added. 3) Blood loss Should be replaced with packed red cells A patient with known heart failure or elderly still be dehydrated on clinical examination. In that case, you can If the patient continues to bleed, they may also give a smaller volume of fluid over a longer time period need other blood products (e.g. FFP, platelets, e.g. 250ml over 30mins. cryoprecipitate) to actively stop the bleeding rather than simply replacing the lost red cellsAnalgesia Ladder Breakthrough Dose of Morphine: The breakthrough dose of morphine should be one-sixth to one-tenth of the daily dose of morphine. Laxatives for Opioid Use: All patients receiving opioids should be prescribed a laxative to prevent constipation. Caution with Opioids and Chronic Kidney Disease: Opioids should be used with caution in patients with chronic kidney disease. Preference for Oxycodone in Palliative Patients: In palliative patients with mild to moderate renal impairment, oxycodone is preferred over morphine. Severe Renal Impairment and Alternative Opioids: For patients with severe renal impairment, consider using alfentanil, buprenorphine, or fentanyl as alternative opioids. Metastatic Bone Pain Management: Strong opioids are effective for relieving metastatic bone pain, whereas the assertion that NSAIDs are particularly effective is not supported by studies. Strong opioids provide quick relief Remember, individual patient needs and circumstances should always guide treatment decisionsCONVERTING TO MORPHINEPRESCRIBING - END OF LIFE JJ (DOB 12 Feb 1964, Hospital number 123456) has been diagnosed with lung cancer with cerebral metastasis. After her discussion with your consultant, she would like to be for end of life care. She is allergic to eggs (rash) but no medications. She weighs 60kg. Her renal function is normal. She can, and is happy to, take oral medications as appropriate. She has been reviewed by the palliative care team. They documented in the notes: Please start subcutaneous midazolam for anxiety as required. She has been taking oral morphine liquid 10mg every 4 hours for the last 24 hours. Please change her to an appropriate dose of regular morphine modified release tablets, with an as required breakthrough dose of oral morphine liquid. She is at risk of seizures so please start Levetiracetam (trade name Keppra). She would like any evening medications at 9pm, as she goes to bed then All her previous medications should not be givenOther drug chart details completedDate chart startedChart numberWeight entered As required medication 1MidazolamDose = 1.25mg or 2.5mgRoute = S/CIndication for nurses given (e.g. anxiety)Frequency and maximum dose reasonable (e.g. 1-2 hourly, max 20mg)Signed and dated As required medication 2Morphine + oral liquid specifiedDose = 10mg (or 5ml if liquid strength also specified in medication box)Route = POIndication for nurses given (e.g. pain)Frequency and maximum dose reasonable (e.g. 4 hourly, max 60mg)Signed and dated Regular medication 1Morphine + MR tablets specifiedDose = 30mg (half total dose she has been taking daily)Route = POPrescribed at 0800 and 2100 (2200 must be crossed out, or 2100 added below and circled)Indication listedSigned and dated Regular medication 2Levetiracetam with brand name in brackets (antiepileptics in list of drugs where brand name must also be specified)Dose = 250mg (as per BNF)Route = POPrescribed once dailyIndication listedSigned and datedPRESCRIBING - PRE - OP JJ (DOB 12 Feb 1964, Hospital number 123456) Blood results: Hb 103 g/L (130-180), WCC 4.5 x10^9/L (4-11), Plt 266 x10^9/L (150-500), Na+ 137 mmol/L (133-146), K+ 4.5 mmol/L (3.5-5.4), Ur 4.5 mmol/L (2.5-7.8), Cr 92 mmol/L (59-104), Mg 0.4 mmol/L (0.8-1.0), INR 1.0 (0.8-1.2) Task: Please complete the patient’s drug and fluid prescription charts. You have clarified with your consultant and she has specified: The patient should have venous thromboembolism prophylaxis this evening but not on the day of the operation The patient should have maintenance intravenous fluids overnight as he will be nil by mouth from midnight (please prescribe 2L initially in case of delay in list) Aspirin can be resumed on day 5 post-op Any antihypertensives should not be given today or on the day of the operation Any electrolyte abnormalities must be corrected intravenously Please also write up an antiemetic and paracetamol in case the patient needs them post-op.Patient details completed correctly on both chartsFull nameHospital numberDOBAddress (drug chart only) Allergy box completed on both charts None known Signed and dated Other details completed on both chartsDate chart startedChart numberWeight entered Fluid chart 1Prescribed IV magnesium replacementFluid = 0.9% salineAdditive = 2-5g magensium sulfateVolume = 200-500ml (depending on magnesium content)Duration = 100ml/h (or total duration equivalent)Dated and signed Fluid chart 2Maintenance fluid prescribedFluid choice = 2x dextrose-saline (preferred); or 1x dextrose, 1x normal saline1L volume bags x2Additive 20mmol KCl in one or both bagsRate = approximately 1.5ml/kg/hDated and signed As required medication 1Paracetamol 1gRoute = IV or PO or IV/POIndication for nurses given (e.g. pyrexia/pain)Frequency 4-6 hourlyMax dose 4gSigned and dated As required medication 2Anti-emetic e.g. Cyclizine 50mg or Ondansetron 4mgRoute = IV or PO or IV/POIndication for nurses given (e.g. nausea/vomiting)Frequency Cyclizine 6-8 hourly, Ondansetron 4-6 hourlyMax dose Cyclizine 150mg, Ondansetron 16mgSigned and dated Regular medicationsEnoxaparin 40mg S/C or Dalteparin 5000units S/C or local hospital alternativeAnti-embolism stockings should not be given in PVD (IPCs may be considered instead)Aspirin 75mg PORamipril 5mg ONTimes correctIndications completedSpecial instructions completedAspirin suspended correctly until day 5 post-opEnoxaparin/Dalteparin suspended on day of operationRamipril suspended today and on day of operationSigned and datedDRUGSDRUGSMicroguide + Pharmacists!Good Prescribing Guide: This guide can be used to review prescribing practices across various departments in both emergency and chronic care settings. It is included as part of your Microguide LEARNING OUTCOMES: E-PORTFOLIO + QI PORJECT Objective n° 1 Objective n° 2 Objective n° 3 Learn how to Develop skills to come up with Gain familiarity with the specific e- portfolio platform used by your effectively document your own QI project that will training program, including how to learning experiences, enhance patient safety and how clinical encounters, and this will support the trainee in navigate it, update entries, and feedback to build a their future career aspirations . extract reports or summaries for comprehensive and reviews reflective e-portfolio E-PORTFOLIO Horus All Foundation Schools in England use Horus (provided by Health Education England). All foundation doctors have access to an electronic portfolio (e- Your foundation school and/or local The exact format of each e-portfolio may vary but they generally include: education provider will: Personal and Professional Development Plan (PDP) set up your user account and Meetings with your educational and clinical supervisors update it with any in-year changes Assessments (for example, change of supervisor, Supervised Learning Events (SLEs) placement dates or specialty). Reflective reports and other evidence ARCP Turas All Foundation Schools in Northern Ireland, Scotland and Wales use Turas (provided by NHS Education for Scotland) The exact format of each e-portfolio may vary but they generally include: Personal and Professional Development Plan (PDP) Meetings with your educational and clinical supervisors Assessments Supervised Learning Events (SLEs) Reflective reports and other evidence ARCP Source: UKFPOMINIMUM REQUIREMENTS FOR ARCP START & END OF PLACEMENT MEETINGS WITH CS & ES WITH SATISFACTORY OUTCOMES 01 X1 TEAM ASSESSMENT OF BEHAVIOUR (TAB) 02 03 X1 PLACEMENT SUPERVISION GROUP (PSG) 04 CURRICULUM FULLY MAPPED/COMPLETED WITH SLE’S AND AUDIT/QIP 05 SUMMARY NARRATIVE 06 REFLECTIONS 07 PERSONAL LEARNING LOG (60 HOURS) 08 FORM RWHAT YOU NEED FOR EACH ROTATION FOR THE YEAR CS meeting ES meeting START OF TAB PLACEMENT PDP PSG mini-CEX CBD DURING PLACEMENT LEARN DOPS Summary Narratives Reflection Audit/QIP END OF PLACEMENT CS meeting ES meeting SLES 01 MINI-CEX (MINI-CLINICAL EVALUATION EXERCISE) 02 DOPS (DIRECT OBSERVATION OF PROCEDURE) 03 CBD (CASE-BASED DISCUSSION) 04 LEARN (LEARNING ENCOUNTER AND REFLECTION NOTE) 05 DCT (DEVELOPING THE CLINICAL TEACHER) 06 LEADER (LEADERSHIP IN A TEAM, EFFECTIVE SERVICES, ACTING IN A TEAM, DIRECTION SETTING, ENABLING IMPROVEMENT, REFLECTION) TAB 01 MULTISOURCE FEEDBACK (MSF) TOOL 02 COLLATES FEEDBACK FROM COLLEAGUES YOU HAVE WORKED WITH 03 AIM TO COMPLETE DURING YOUR FIRST ROTATION 04 NEED A MINIMUM OF 10 RESPONSES (ACROSS MDT) 05 FIRST REQUIRES A SELF-ASSESSMENT COMPONENT AGAINST EACH DOMAIN 06 ASSESSORS HAVE 45 DAYS TO COMPLETE THE TAB ONCE IT HAS BEEN SENT OFF PSG 01 SIMILAR TO THE TAB BUT ONLY ‘SENIOR’ HCPS AND NOMINATED BY YOUR CS DOCTORS MORE SENIOR THAN F2 ABOVE) NURSES INCLUDING PRACTICE NURSES OR NURSE PRACTITIONERS (BAND 5 OR WARD PHARMACISTS ALLIED HEALTH PROFESSIONALS 02 YOUR CS IS RESPONSIBLE FOR SENDING THIS OFF 03 MAPPED TO THE FPCS IF ANY CONCERNS ARE RAISED A NEW ONE MUST BE DONE 04 PERSONAL LEARNING LOG 60 HOURS OF LEARNING TO BE LOGED - AT LEAST HALF MUST BE CORE LEARNING CORE NON-CORE SIMULATION E-LFH ACTIVTIES BMJ HUB EVENTS GRAND ROUND FOUNDATION CAREERS TEACHING EVENTS OTHER ON- SITE TEACHINGSUMMARY NARRATIVE QI PROJECT Aim: First of all you need to decide what the aim of your project is going to Measurable – ensure that there is something you can easily be. Trainees often identify things they think should change to improve measure to demonstrate any change. patient care. It can be qualitative data (descriptive) as well as Projects can also be chosen following a significant event; complaint; quantitative data (numerical data). Achievable - ensure the an area of care you feel passionate about or inspiration from other data is easily collectable and keep the aims simple. QiPs. Time defined – choose something that can be done in time The project should aim to improve patient safety or care and be ‘SMART’ Specific - do not make it too broad and chose something frame –you need to be able to complete at least two sets you are interested in. Words such as increase /reduce help to set a of data measurement. clear goal. Questions that need answering 1.What are you trying to accomplish 2.How are you going to engage the team, patients and other stakeholders. 3.Describe what baseline data or information you gathered 4.Do you have a PDSA cycleWHERE TO GET INSPIRATION Any changes needed to improve the current practises in whichever rotation you are PROJECT 1 working in, Significant events/complaints and PROJECT 3 any patient safety experiences PROJECT 2 Quality imporvement reports Any change to latest guidelines Find a project early ! Ask your consultant and/or supervisor if they can get you in touch with someone who is already conducting one Even though QI projects require a few different cycles, you can aim to perform at least one cycle!STEROID CARD ENHANCED AUDIT Steroid Card - enhanced Audit https://docs.google.com/presentation/d/1KOGxi- EoDEV2NxToLqqWMEuwravK1iRs/edit? usp=drive_link&ouid=107923345093605391179&rtpof=true&sd=true LEARNING OUTCOMES: REQUESTING AND INTERPRETING RADIOLOGY SCANS Objective n° 1 Objective n° 2 Objective n° 3 Learn the criteria and protocols Develop skills in formulating clear, Understand the process of following for requesting various types of concise, and clinically relevant up on scan requests, interpreting radiology scans. questions when requesting from results, and integrating findings into radiology team, enhancing the patient care plans. effectiveness of scans and patient management Source: Geeky Medics REQUESTING SCANS Approval involves a radiologist reviewing your imaging request to determine: Whether the scan is necessary If the chosen imaging modality is appropriate The urgency of the scan If additional imaging is required beforehand You would also need to provide important information like eGFR and any scoring systems required eg: WELLs score. Typically, you will need to contact the duty radiologist by phone for approval. Whilst they will have your request available, they will ask you to provide more details about the patient. CHECKLIST FOR REQUESTING Know why you are requesting the scan - what are you investigating for? Differentials? The urgency of the scan Any recent scans? What were the findings? Request examples - Appropriate or inappropriate? 80 yr old male presenting with acute SOB, background of Parkinson’s. CXR for ?aspiration pneumonia 45 yr old female, presenting with SOB, tachycardia and chest pain. No PMH. Wells score 7.5. D-dimer +ve. CTPA for ?PE 54 yr old male a/w fever, consultant is requesting urgent CTAP for ?infection 74 yr old presenting with pyrexia, climbing CRP (150) and WCC (18). CXR as part of septic screen. 69 year old presenting with progressive SOB over several months, now desaturating requiring 1l O2. ECG sinus tachy. BNP 2000. Echocardiogram ?HF CHEST X-RAYS The most common radiological scan you will see and request. Clinical indications for a chest x-rays: Check position of nasogastric tubes, endotracheal tubes, PICCs etc. As part of a septic screen Respiratory disease Cardiac disease Inhaled foreign object Trauma CUSTOMERS Chest x-rays are not immediately reported so it’s important you have a basic understanding of interpreting scans SYSTEMATIC APPROACH 1 - Identify the patient 2 - Orientate the film 3 - Check rotation 4 - Penetration 5 - Adequate inspiratory effort 2. Orientation PA - The size of the heart can be accurately commented on AP - flat looking clavicles, large heart and scapula overlies the image 3. Rotation Spinous processes of thoracic vertebrae must be equidistant from the medial ends of the clavicles Rotation will affect heart size, tracheal position and density of lung fluids. Well penetrated 4. Penetration The degree to which X-rays have passed through the body. Is the spine visible behind the heart? Can you see the lung fields clearly? Well penetrated X-ray: Thoracic vertebrae and bronchovascular hilar markings are just visible behind the heart. Left hemi-diaphragm visible through cardiac shadow 5. Inspiratory effort Count the ribs: 5-7 anterior ribs 7-9 posterior ribs INTERPRETING CXR’S A B C D E •Airways •Breathing •Circulation •Diaphragm •Everything Else Sometimes there may be an abnormality so obvious it needs to be mentioned firstAIRWAYS Trachea - is it central? AIRWAYS Things that push... Tension pneumothorax Large pleural effusion (High pressure in pleural space due to fluid or air). AIRWAYS Things that pull… Lobar/lung collapse Fibrosis Pneumonectomy BREATHING Note: posterior is mainly made up by inferior lobe. X-rays produce a 2D image of a 3D structure Regions seen are referred to as zonesBREATHING BREATHING Localised to the right middle zone Bilateral widespread opacities Multiple well demarcated lesions ‘patchy consolidation’ upper zones > lower zones throughout both lungs ?Pneumonia ?Miliary TB ?canon ball lesions secondary to renal cell carcinoma CIRCULATION Cardiothoracic ratio = width of the heart cannot be larger than half of the thoraxic cage. DIAPHRAGM • Look for cardiophrenic angle and costophrenic angle - is there any blunting? • Look for air under the diaphragm – an erect CXR is used to assess presence of pneumoperitoneum fundus of stomach.iaphragm is pushed up by the liver. The left by EVERYTHING ELSE Bones ECG leads Pacemaker NG tube PICC line Artificial valves ABDOMINAL XRAYS Possibly second most common x-rays you’ll come across as an FY1 ABDOMINAL XRAYS Bowels contain gas/air within the lumen - will appear black Small bowel Central Location Valvulae conniventes – folds which are seen across full width of the bowel Normal Diameter < 3cm Large bowel Peripheral Location Haustra – sacculations or pouches that protrude into lumen. These do not completely traverse the bowel Faeces - mottled/blotchy appearance due to trapped gas Normal Diameter < 6cmSMALL BOWEL <3cm for small bowelmLARGE BOWEL <6 cm for large bowel and <9 cm for caecumSMALL BOWEL OBSTRUCTION Centralised dilatation of bowel loops. >3cm diameter Visible valvularconniventes: “coiled spring appearance’ Causes: •Adhesions (surgery) •Hernias •Crohn’s strictures •Tumours •Gallstone IleusLARGE BOWEL OBSTRUCTION Distal dilatation of bowel loops >6cm diameter Visible Haustrations Causes: Colorectal Cancer Diverticulitis Volvulus (sigmoid in adults, caecal in children) VOLVULUS Twisting of bowel on its mesentery Commonly occurs at: Sigmoid Colon (75%) or Caecum (25%) High risk of: Large Bowel Obstruction (LBO) Bowel Perforation Bowel IschaemiaSIGMOID VOLVULUS Coffee bean signCAECAL VOLVULUS ‘Embryo sign’ LEARNING OUTCOMES: PAY + CPD Objective n° 1 Objective n° 2 Objective n° 3 Learn about financial planning and Understand the structure of pay Learn about what continuous scales, increments, and resources available for healthcare professional development consists additional allowances relevant to professionals, including pensions, of how you can gain CPD points your role and specialty within the benefits, and options for additional throughout your foundaiton years! income through locum work. healthcare system Gross Pay Deductions Basic Pay Income Tax Weekend National insurance Night Shift PAY AND Pensions DEDUCTIONS Locum shifts Student loans Don’t forget to claim tax relief: Some things required for work are not taxed such as GMC/BMA membership/ You can claim income tax on these.JUNIOR DOCTOR PAY SLIP GUIDE - SOURCE BMA DOCTOR’S PAY SCALE You maybe paid under or over depending on your contract K ! U t t R d e o p : m c x u E S SHIFTS AND ROTA EWTD: The working week cannot average more than 48-56 hours (this excludes night and on-call duty) There must be a day off each week There must be 11 hours of rest in a 24 hour period There must be a break in the working day if it is longer than 6 hours There is a right to have 4 weeks of paid leave per year Maximum of 4 night shifts per week with a minimum of 46 hours rest after 3 or 4 sets of nights Maximum shift length of 13 hoursEXAMPLE PAY SLIP Source BBCTAXABLE INCOME AND NATIONAL INSURANCE CONSTRIBUTION PAY CALCULATOR https://questionnaires.b ma.org.uk/jdpaybanding /index.htmlADDITIONAL PAY Accomodation GMC Rent MRCP/MRCS exam Petrol MDU Bills/ Electricity/ Water Conferences Social Expenses Courses Gym Other memberships TIPS FOR SAVING MONEY Reclaim Tax on BMA, GMC registration and royal college membership fee Make use of NHS discounts Track your income and expenses to understand your cash flow and create a budget. Categorize your spending (e.g., rent, utilities, groceries, transportation, leisure) to identify areas where you can cut back if needed (have a look at the additional pay section for more) Make a saving bank account: this will encourage you to put a certain amount of money towards saving every year. Make the most of your study budget: My foundation school offered study budget of 500 pounds which can be used for conferences and other resources Anyone working in the NHS can get access to thousands of journals via the OpenAthens account Maximise the benefits of subscriptions you are already paying for. For example, BMA members can borrow medical textbooks at low cost – this could save you a few hundred pounds when preparing for membership exams. MPS members can access courses worth over £1000 covering communication skills and dealing with complaints Childcare benefits - You can get up to £500 every 3 months (up to £2,000 a year) for each of your children to help with the costs of childcare. This goes up to £1,000 every 3 months if a child is disabled CPD POINTS CPD hours are the actual amount of time you spend participating in an activity. CPD points are a measure of the educational value of that activity and are used by professional bodies to assess your commitment to continued professional development. You can achieve this by attending courses and online learning provided by these organisations to enhance your understnading as well as boost your CV for future career application!THANK YOU!