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Hi guys. Um just to start off with, can everyone hear me? OK. Somebody can just say in the chat, can everyone hear me? Just put like yes or no, I can hear you. OK. Yeah, great. Yeah, perfect. OK, thank you. Yeah. So um thank you guys everybody for tuning into our teaching series. Um So Conquering Residency basically is a teaching series which is based for Im GS. Um and it's made of I MG doctors. So we've all been through the process and hopefully it will be a helpful introduction for you guys into that transition back into the NHS from your respective countries. So my name is so and I graduated from Medical University M UV. Um Just a quick sort of show where, where did other people graduate from? Is it mostly M UV or do we have someone from other countries if you could just pop in the chat of where you've um graduated, that would be really helpful. Yeah, I'm ok. So I'm seeing it's mostly M EV students that's totally fine. Um So hopefully this will be like very um informative as well for you guys. It's, it's gonna be good for all I MG doctors, but because myself and um, Doctor Anisa who's doing the talk today, we both graduated from M UV. So, um, we, we've been through the exact same thing that you guys have. Um, so today's session is basically going to be sort of bread and butter of what junior doctors and residents have to do. So it's going to cover larking, looking at um, important features when you're on your on call shift. A lot, a lot of it can be quite daunting, but these things, once you pick them up, you'll, you'll learn very quickly. Um So it's just like a general introduction. We're aiming to have kind of one session every week and it'll be today is just like a miscellaneous topic, just an introduction. But we're hoping to go through a system by system approach starting with cardiology. Um And then in terms of the dates for each talk, if you guys can keep an eye on whatsapp, we'll put because obviously different doctors are working different shifts. Some people will be on call, et cetera. So um it's best to keep an eye on whatsapp. And if you follow us over on Instagram, we'll put um the dates on there as well. Um Yeah, I would appreciate if you could follow the Instagram as well at the end of today's session, um you will receive a feedback link, so it'll be on your niece's powerpoint and I will also um put it in the chart. And if you can just fill that out, then you'll automatically get um a certificate and also guys, the whole series is CPD approved. So, on the um automatic certificate that you get the CPD logo will be there. So this will really help to boost your portfolios as well. Um But you'll only get the certificate obviously, if you fill out that feedback form and we'll make sure we send that at the end. So yeah. Um that's everything from me. Um I'll hand over to a and if you guys have any questions, you can send it either during the chat or we can have like a little Q and A afterwards to just to talk in general. Um Any questions you might have. Um Yeah, we hope this is beneficial for you guys and I'll hand it over to any center. Hi guys, I just want to add two things to what someone's already mentioned. Um So yeah, we do have the group chat and it's primarily M UV students. I think our teaching series was supposed to be targeted towards M UV students since me and someone both graduated from there. Um But the team of doctors that have come together to make the teaching series, we actually have quite a few I MG doctors from other countries as well who thought it would be really beneficial for other IM GS too. Uh So for that reason, we made the account as well. Because we have more reach to people that actually need help when they're coming over to the UK and start working here. Uh, so definitely share with I MG doctors. And the second thing is with regards to the certificates, I would say keep a file of all the certificates that you get from the teaching series. Um, because when it comes around to your first appraisal, which will come around quite quickly, you can upload the certificates and show competency. Um And it will be really good to show when you have your appraise, appraisal meeting with your appraise. Um You'll just have that evidence there that you formally attended the teaching series. Um So definitely have a little file and put all your certificates as you go along. Otherwise you'll kind of lose track of them. Uh Which is what happened with me when I was doing my training for my job. Uh And then it's really hard to get hold on the certificates you need. So just have a little file, put all your certificates in there. Um So as I mentioned, the first session is kind of boring for me, but not for you guys. I'm hoping it's gonna be useful because the whole teaching session is based on larking. Um And it's coming up with management plans, whether you are on the ward or you're down in A&E. So it's basically the, the epitome of being a medic. Uh and it's really important you document very, very well because at some point during your career, you are going to have a complaint come in and it's your documentation that's going to save you. So definitely learn how to document properly. Every tiny little everything that happens in the hospital. Like if someone's refusing medication, you need to document it. If there's an issue, uh document it. If you've had a discussion with a senior about the plan and it's something that you agree with or disagree with, you still need to document it that as per registrar, this is the plan. Um So documentation is really, really important in the NHS. And in fact, when you're clocking patients, you'll realize that you spend longer with papers or if you're in a bit of a bougie hospital, the computer screen than you are with your patients, it's not the best. But um like I mentioned, documentation is really important. So it's important that you get it right the first time. So I do wish somebody taught me how to document before I started working. I kind of just went for my first shift and was introduced to a clocking sheet that I had never seen before. So hopefully you guys will already be aware of what clocking sheets look like and how to document properly in your ward rounds. And when you're asked to see a patient when you're on call. So um let's talk about the crash team. Does anyone know how many doctors are on the crash team and who they are, you could type or you could use your microphones guys. Any what? No idea for. Um So on the crash team, you will have two registrars. You've got two Hs and you've got one F one and essentially the registrars and the SH OS are split up. So you have a pair down in A&E doing the larking and then you've got a pair on the wards and then you've got the F one who's primarily on the wards because, um, they tend to have a lot more ward related jobs. Uh Recently, I've noticed a lot of F ones have started to help with the clocking, which I think is really good because uh when they get to F two, they will probably be really, really good at clocking. Um But it's not their primary role. So if you're thinking of starting as an F one, you're not usually larking, it's more ward related jobs. Um Essentially the crash team will have a handover in the morning and the night team will hand over jobs uh that are incomplete or still need chasing from patients. They have clocked during the 12 hour shift. Um If there's any MRI scans that need requesting, they will let the team know because they are consultant referrals only. And if there's someone that's really, really unwell, they'll highlight that to the crash team. And if someone's going to ITU or is already in itu they will let the team know and you'll have the same handover in the evening where the morning team will pass on the same information to the night team. Um, so as an sho you are either clocking down in A&E or you are on the wards. When you are on the wards, you're expected to support the F one. and when you're clerking, you'll always have a registrar and A&E with you in case you needed the support. If someone's really unwell on the ward and you're the sho you can always escalate to the registrar that's on the wards as well. So you always have the support that you need, uh, regardless of what grade you are and where you're working. Um Right. So with A&E that's more clerking and with ward jobs, that's more bleeps to see patients that are using. Um, and I'll talk to you a bit more about which new scores are escalated to who in the presentation. So this is what your Clocking sheet looks like. There's actually more pages, but I've had to split them up just for the powerpoint. Uh Anyone seen the clocking sheet before shang, you will have seen the parking sheet before cos you work in the same hospital as me. Yeah. So this is actually a generic clocking sheet. Um, so a lot of the things that are in this clocking sheet on, on the original clocking sheet. I had to just print out a generic one specifically for the teaching. Uh because the ones in the hospital will have patient details printed onto it. And I can't use that for confidentiality reasons. So we've got here a generic clocking sheet and at the front you can see it has the patient's details. So from this, what's the most important information, it's the age, the date and the time of arrival. So when they were admitted, the hospital number, which you use to search for any relevant information related to the patient in the systems, then the address is also really important because a lot of patients, especially Jerry's patients, they tend to come from nursing homes and there might not be a number. So you'd have to sort of Google the nursing home and find the number and give them a call. And then the other important information is the next of kin. So this can be a family member, it can be a family friend or it might just be where the patient lives if they are coming from a nursing home. And if you need to update family or next of kin, if you need to have a resuscitation discussion, for example, you might need that information, but you'll find it on the front sheet of the clocking papers. So you need to write down your name, the consultant on call uh on the front sheet. So you've clocked that patient. And then when you come to the first box, it says presenting complaint. Um So this will usually be an A&E s handover and it will be something like chest pain or shortness of breath or cough. Literally two words, three words, loss of consciousness, collapse something along those lines. So you just fill out that box. And then the history of the presenting complaint is when you go to see the patient and you take a history now with taking history, I think what you, what you'll have noticed if you've done any attachments is doing history in the UK is different to what we used to do in Bulgaria. And I think the reason is because we had a language barrier. So taking history was quite difficult in Bulgaria, whereas in the UK, English is your first language, their first language and they, you have to be really careful with the words that you use and how you're phrasing things. Um So try not to ask any leading questions because say this patient, an 85 year old came in with chest pain, you're taking history and you're asking them, does it radiate to your neck, your back, your jaws, uh down your arms. They are going to say yes and you are going to leave that room with a cardiac history. So don't ask bleeding questions, try to keep them basic generic and always rule out the other symptoms. If you're thinking of a certain diagnosis, if you want to rule out an nstemi, you want to sort of ask what other symptoms they had? Like, did they have any fevers, any vomiting? Were they diaphoretic clammy? Um Ask them to sort of describe the pain, the nature of it. Where is it radiating to again? Don't ask leading questions. I want you to ignore. The part is, has the person been more forgetful in the last 12 months? Because that's not actually there on the clock sheet. Uh, and it's related to delirium, which we'll talk about later. So you want to take a thorough history and write it down in this box. Um So usually I'll go and see the patient do all the talking and then document after and then you've got your past medical and surgical history. So I actually write this part out before I go to see the patient. So it's like reading up on the information around that patient before going to see them, you will find past medical and surgical history on the GP records. So in the UK, that's G MCR. So any of the hospital systems, if you click on the G MCR link, you'll find the past medical history for the patient. I don't think it's the best thing to rely on. And the reason is it's not always accurate, it's not always updated. So either way you need to clarify the past medical history with the patient when you go to see them, but it's good to have it written down before you go. Um And what else, I think from the past medical history, a lot of patients they don't know what medical problems they've had in the past, in which case, using the medications is really useful because the medications will tell you whether they've got hyper or hypothyroidism. Are they hypertensive? Have they had a previous Mr if they're on Doac, um, not every patient knows their past medical history. So again, you need to use a combination of the GP records, the patient and have a look at the medications as well. Um Right, with regards to smoking and alcohol, I think you guys already know that we always ask about smoking and alcohol. You need to know if they are an exsmoker. Uh, when did they stop smoking? Um, always give advice about stopping smoking and whether they would like to be referred to the smoking nurses for more advice and the smoking nurses are usually very good at giving a regime uh to off nicotine replacement for these patients. And you've got the same for alcohol as well. So why is asking about alcohol intake really important for patients that are going to be admitted? Does anyone have any idea? Great. See, she found you are amazing because we work in the same hospital. But yeah, it's because of withdrawal. So if someone's going to be admitted and they're going to be there for a while and they drink a lot of alcohol, usually they're not going to have access to the same amount of alcohol or any alcohol at all in the hospital. So they may start withdrawing. That's why it's really important when you're clocking a patient, you ask how much they drink daily or weekly. Um, and what do they drink? Because, or, or a better question is when's the last time they had a drink because they may start withdrawing if you've not asked about alcohol at all. But all of a sudden, you're being asked to see a patient who's quite aggressive, confused, agitated. It might be because they are withdrawing, they might have some tremors and you would need to start them on the withdrawal pathway. Um So that's PEX and Librium and the C A scoring system is used for patients that are on the withdrawal pathway. Uh There's also the alcohol liaison team. So the nurses that come and sort of give advice and help patients that are withdrawing. Um with regards to symptom review, this isn't actually a separate box on, on the official clocking sheets. So what we usually do is under history of presenting complaint, we'll always ask the patient about symptoms from other systems. So if for example, theoretically, this patient came in with chest pain, we've taken a cardiac history, but we've also ruled out pruritic chest pain, any respiratory system uh symptoms and the gi system for nausea, vomiting, diarrhea, melena, um abdominal pain. And you would also need to ask about any urinary symptoms. So you want to rule other things out and you can just put it in one line. No gi or urinary symptoms. But at least you have asked. Um, and I'll tell you why when we get to the end of the Clocking Sheet, does anyone have any questions so far or would you like me to continue? Thanks. Uh, fine. Ok. I'll continue, um, drug history. So, for the medications again, it's G MCR, you want to look at the repeat prescription and make sure the patients have been prescribed the medications that they are usually on at home again, do not fully rely on the GP records. You need to clarify with the patient that they do indeed take these medications. They might have some minor changes, they might tell you. Oh, actually I stopped taking the furosemide months ago. II didn't need it anymore. Or they might tell you actually that medication didn't sit right with me. It made me feel nauseated. So you need to make know of those things and change the medications accordingly. Um, another useful part of looking at the drug history on the GP records is to see if they've had any acute medications prescribed. So a lot of the time, what you'll see is patients with, for example, COPD or asthma exacerbations, they may have had a short course of steroids and antibiotics prescribed in the community by the GP, which clearly hasn't done the job and that's why they are in hospital today. So, just having a look at those and writing them down is really useful. So you want to write what they take, how many times they take it, what the dose is. Uh, it's good to have it written down on paper or if you're electronic to have it written down separately because it's easier to refer to when you are prescribing the medications on the system. Uh, so in, in my hospital we use M um it's probably the same in other hospitals, I'm not sure, but it would be electronic and you're prescribing them on the system. So it's good to just have like a copied version in front of you. Uh with regards to allergies and sensitivities. So drug allergies are also found on G MCR. So the GP records, um you shouldn't always rely on the allergies on the GP records. I think I've been saying this a lot for GP records. Uh but as the patient, if they've had a reaction to a certain drug, you need to clarify what it is and you then need to put that on the system so that all healthcare professionals have access to that information, what the allergy is and what reaction they had to. It, this is really, really important for patients with penicillin allergies because you guys probably already know penicillin is like first line for almost everything when we give antibiotics. So if they do have a penicillin allergy, it needs to be a legit issue. Uh And then other things like if they're on long term oxygen therapy, uh if they've got a peg tube in, if they've got CKD five and their dialysis patients just writing that is, it's important. Um on the GP records, you can also find if the patient has a community DNA R in place or an advanced care plan. So just noting that and writing it down somewhere on the clock and sheets, I usually write it in past medical and surgical history. Uh and the date that the DNR decision was made, uh And then I just clarify it with the patient with the patient when I go and talk to them. That's the easiest type of DNA R discussion to have because it's already in place. So it's used for feeding, especially in patients that have had a stroke and they've got swallowing issues. I hope that answers your question. There's different types of, well, we'll get to this when we talk about the stroke, but there's different options available for people that have swallowing problems and they have a smaller team that come and assess them. And ultimately, if it can't be handled with a change in diet, they might opt for a nasogastric tube or a peg tube. And another option is if someone feels like they want to have normal food, we give them the option of risk feeding, which is essentially allowing them to eat whatever they want because maybe they have a poor quality of life and whatever time they have left, they want to enjoy their food. Uh So we have risk feeding as well as an option. Um Is that ok before I move on some? Right? Yeah. Ok, perfect. Um, so normal functional status isn't on the original clocking sheets either. This is just a very in depth generic clocking sheet, but we'll ignore that for now and we'll come back to it with the social history. Uh, family history. You can always clarify with the patient, but a lot of patients, they don't really know about family history. Um, we'll move on to social history because this is probably the most important part of the clocking sheet. So in the social history, my hospital is very big on social history. They want to know the physical baseline and the cognitive baseline of patients, especially because a lot of the patients that you see, they are going to be elderly frail patients. So what we need to know is, do they live alone? Do they have their own house? Is it a flat? Do they have stairs? Are they able to go up and down the stairs or do they have a stair lift? Do they use walking aids? Um What about the bathroom? Do they use a commode? Are they able to move around independently or do they have carers come in if they have carers come in? You need to know if it's twice a day, three times a day, four times a day. And do they have district nurses come in for them? Um You also need to clarify if patients are at nursing homes and in some cases when patients are from nursing homes and they aren't able to give you history themselves because they are confused. A lot of the time they will come in confused. You need to get collateral history for the clocking sheets from the nursing home. So just check on the address. If there's a nursing home address, you might wanna give them a call just to get history and ask about the allergies, the drugs and you know, how did the patient present and why have they been sent in? Um So that's more physical baseline. And then we've got cognitive baseline, which is usually elderly patients with a background of dementia. We want to know where they are with their memory usually because if they are confused and they have an infection, they'll probably be more confused than usual. And we need to get them back to their baseline confusion. So we need to know what that baseline is and we need to establish that with whoever they are living with the next of kin or the nursing home. Uh So again, having that conversation with the next of kin or the nursing home is really important. Um You'd write that down in social history and you want to use the clinical clinical frailty scoring system which I want to show you to give them a number based on what social history you've taken. And ultimately, you're right if they are independent or dependent on ADL S and what those ADL S are. So ADL S are activities of daily living and they include things like cooking, doing the groceries and personal care. So that's what we want to ask. I've never actually asked any patients about pets or birds and any of those other issues. So I'm just going to ignore that an occupation. You don't usually always ask it, but I guess it is a good question. Um So does anyone know why the social history is the most important part of the clocking sheet? We can use it to make a decision. What type of decision do we need to make? Yeah, so we can make a decision based on the social history for discharge. You're right, because essentially if it's out of hours or overnight and it's an elderly patient that's come from a nursing home, we, we wouldn't discharge them back to the nursing home. We'd keep them in overnight for monitoring and have a morning review and then send them home. That's, that's a nice thing to do for elderly patients. Uh Whereas if they're independent and mobile, we are able to send them home at whatever time. Um But yeah, we can make a decision based on discharge. And the other thing I was thinking of is, well, I have a consultant in A&E who's very specific with social history. And he will always ask what's the ceiling of care whenever you escalate a patient to him. So for the social history, we use this to decide what the ce ceiling of care will be for a patient alongside the medical history. Um So for example, if you have a patient that lives in a nursing home, uh they're dependent on their carers four times a day, they're housebound or bedbound and they've got district nurses coming in for insulin injections, you might want to have them at ward level care. Uh So that's the ceiling of care decision based off the social history. So you then move on to your clinical examination of the patient. So make sure you've had a look at all the geeky medic videos for examining all. So I'm gonna talk about uh sea of care at some point in this presentation. So we'll get to it, but there are three types of feeling of care. Um Yeah, so make sure you have, have a look at the examinations for the different systems before you start working and you actually know how to do them. I know when I was studying a lot of it was COVID which didn't help. So on the examination part, you're just gonna document your findings. So the general appearance, I would make note of this whilst I'm going through it. Um So in general appearance, I would write things like alert and orientated to time place and person, I would then go on to describe what they look like. So um if they look pale, I have changed the slide. Can you guys see it? Can you guys see the slide about the physical exam? OK, perfect. Um OK. Yeah. So if they look pale, have a look at the oral cavity. If they've got dry mucous membranes, you wanna write things like that. If they look cyanotic, if they look breathless, you want to write all this in general appearance. I want you to ignore the confusion tests at this point. We're gonna talk about it. Uh And then in the cardiovascular system, you want to write the heart rate. So you can calculate the heart rate. I usually go by the nursing notes and I just assess the pulse for the rhythm. If it's irregularly irregular, which can happen in a lot of patients that have a background of atrial fibrillation. If they're tachycardic or bradycardic, you want to write that down, then auscultate the heart, write down the heart sounds are normal or if there's any murmurs. Is it a new murmur? Is it something that's already been established in the past? Um assess for the JVP and check the capillary refill time and if there is a delayed cap refill, what do we think of for this patient? Anyone? Yes, and possibly sepsis if they are peripherally shut down. So, assess the cap refill? And I usually like to examine the calves and put it under cardiovascular system. So if they've got pitting edema, you need to grade it as well. So just start from the ankles, go up to the shins just under the knees and then you basically just need to write, they have bilateral pitting edema or if it's unilateral and it's up to the shins or just below the knee, um, like that and then we'll move on to the respiratory system in the respiratory system. You can again manually check the respiratory rate and I'm a bit lazy. So I'll go off the nursing notes. Unless someone's quite poorly, then I'll manually check the respiratory rate. Um You want to check chest expansion and also auscultate the chest. There's usually a nice little picture of the lungs here. So you can just put some XS if there's crackles, if there's wheezing or there's reduced airway entry on one side or both sides or if the chest is clear, you can just draw an arrow through it and write clear airways are equal, there's equal airway entry bilaterally. Um And then once you've done the respiratory exam, you'll move on to the abdomen. So, bearing in mind, even if the patients come in complaining of something that's cardiac related, you still have to do all the examinations because this is their first time being seen with the general medics. So you have to do a full examination. So for the abdomen, there's usually a nice little hexagon here that represents the abdomen. And again, you want to check that the abdomen is soft, non tender or if they have any pain anywhere. Where is it? Is it right? Upper quadrant, is it left? Lower quadrant? Is it suprapubic? And if there's tenderness guarding rigidity and then just auscultate to check the bowel sounds, um, skin and locomotor isn't usually on the actual larking sheets, it says other and under other, I would just for skin, I usually put it in general appearance. And for locomotor, you'll check the tone and power, especially if they're coming in with the weakness on one side or something. Neurology or stroke related. So you want to do a full neurological exam as well. So, neurology is another box on the actual larking sheets, but I've skipped that one out because the one that was in the generic Clocking sheets, it was quite long and I didn't want you guys to look at it and be like, what is this? Um So a lot of the neurology exams, especially if it's a stroke patient, it goes directly to the stroke team. And that's why we don't get to see most of it. But if you do need to do a full neurology exam, then you need to check the tone, the power sensations, the gaze, um stroke related symptoms, visual changes, um slurring of the speech and under neurology, I would always write what their G CS is so bearing in mind if someone's acutely confused, that's automatically a 14 out of 15, instead of a 15 out of 15, have a look at the pupils write that the pupils are equal and reactive to light. So that's pearl. Um And if there's no neurology, you just wanna write no focal neurology, um then you come to your investigations. So I actually write down the investigations when I check the GP records to write down all the meds and the past medical history. So essentially try to fill in as much of the clocking sheet that you can before you go to see the patient because it gives you an idea of the background and sometimes patients are in with the same presentation as last time. Um So it helps looking at past letters, past medical letters, if they've come in with something gi related and they've had previous bleeds or they've been under the gastro team before. Uh, it's really useful to look at the past medical history and previous clinical letters to see what the doctors have already said about this. Is there an established diagnosis or is it something that's ongoing chronic? Is it someone that just needs a top up in blood transfusions? So look at previous letters, um, with blood tests, you wanna look at important things like the hemoglobin. So if there's low hemoglobin, look at the M CV, you wanna think of anemia or are we thinking of a bleed, which you need to rule out when you examine the patient, you need to ask them if they're bleeding from anywhere. Um How to act on this. I won't share because you've got blood transfusions and bleeding later on in the teaching series. Uh look at the white cell count and neutrophils and C RP for infection. Um and for use and ease if there's any electrolyte abnormalities, do they need replacing? And what's the cause urea for dehydration? Or if there's a bleed and VBG S or ABG S, most patients that come from A&E because essentially we're clocking the patients that A&E have not been able to discharge. So someone's unwell, they may need further treatment from the medics before being discharged or they might need admission and that's the reason why they've been referred. ABG S and VV GS are usually almost always done in A&E because they are quick and you can get a reading of the electrolytes and hemoglobin glucose and lactate. Um You can also work out if someone's in respiratory failure if someone's acidotic or alkalotic. So we'll cover the ABG S and GS and interpretation when we cover the resp system. Um But you need to know how to interpret those and then you've got LFT S. So when, when the FT S are raised, what would you usually think about for this patient, what's like the most common cause of deranged LFT S? Yes. So if there's the range LFT S. Of course, that's why you also want to ask about alcohol intake because that might be the reason it might not be anything clinic, anything clinical, but it might be to do with how much alcohol they're drinking. In which case, there's not much you can do to fix the LFT S. Then if there is any additional tests that have been ordered by A&E you can write these like the amylase magnesium phosphate, which are usually checked if someone's come in with their first presentation of atrial fibrillation and you want to write these down too. Another thing you can check is HBA1C to see how controlled this patient's diabetes is. Uh so you can have a look at the HBA1C as well. Uh For ECG S, yes, you do need to know how to interpret them. If you're struggling or you need extra help or you need someone to cross check it, then you can always ask the reg but definitely know how to read ECG S. Um We're going to cover ECG S in cardiology anyway, but the most essential things are an inte stemmy, although we won't see a lot of sties because if A&E catches Demi it's going straight to PCI and not to medics. Uh so an ends sty or unstable angina bundle branch blocks, atrial fibrillation, flutters, things like this you will see on the ECG. And if someone's bradycardic and you need to check for heart block, um those things you need to write for the ECG, not every patient will have had an ECG from A&E, but if they haven't had one and you think this patient needs admission, it's worth having a baseline ECG anyway, for any patient that's admitted into the hospital. So just get one done. Um with chest X rays, you need to know how to interpret them. You are not going to have a report until a while after. Uh So there's no point sitting around waiting for the report. You need to be able to click on the chest X ray and interpret that chest X ray yourself. Um So a lot of the common findings on chest x rays that you should know about as juniors, we're going to cover in the respiratory part of the teaching series, but it's mainly things like consolidations, increased opacities, any plaques or nodularities, um collapse pneumothorax, COPD and asthmatic changes that might reflect on a chest X ray. You want to have a look at those as well and just write down your findings with your chest X ray. You always want to compare it to an older chest X ray to see if it's worse or better than the previous one um for other imaging tests. So for example, if a patient has come in and it's a repeat present uh presentation, so they've had like a second bleed or something, you might want to look at what they in the previous admission and what imaging test they did then. So if it was almost two months ago, they came in with the same presentation of Melina and they had a colonoscopy, you might want to look at the results of that and write it here. If they had a CT Abdel vs, you want to write the results here. If they've had recent CT heads also write the results. So it depends on the presentation you kind of pick and choose what's important to know. Essentially as a junior you're collecting and summarizing all the information about the patient before the consultant, see the patient. So writing that is useful on our clocking sheets. It almost always asks for an echo. So we always check the most recent echo result. Uh And we'll write that here. If they have L VSD, what the ejection fraction is. Um any heart failure, we'll write it down here the results. And finally, we have the last page of the clocking sheet, which is basically the diagnosis. So it's actually not got these subheadings in on the original sheets. It's just diagnosis. And then you've got a big empty space to write what your diagnosis is and write your management plan. And I think as a junior, it's a good idea to write down what your plan is and why you think you should do that. Because when the senior picks up the patient, you've clocked to post take, they're able to see what clinical decision you made but why you made it as well. Um So one thing I've learned the hard way is when you go in and you clock a patient, it's never straightforward. You'll find five or six other problems with them. So, in your diagnosis, there's never only one diagnosis, it's always a few. So you'll be writing diagnosis or issues 1234 and it might be something like cap curb four. they might also have an AK secondary to dehydration and poor oral intake. They might also be very frail. So you want to put advanced frailty. Um So there's usually a couple of issues and you need to write all those down in your diagnosis if it's someone with chest pain, for example, and it might be that you think it's pruritic, but you're worried that it could also be an A CS. So you could write the top differential as cap or anything else that causes pruritic chest pain and you might put underneath, but rule out A CS and you might want to add into the plan to add a drop anyway. So you just need to write your differentials and then for your plan, it's the plan that you come up with. And that's essentially what the fundamentals of the teaching series is. So every presentation that we go through, um it's system based. So we'll cover the most common presentations in each system. And essentially by the end of the teaching, you'll have a set of management plans or things that you should be thinking of including in your management plans when you start seeing patients on your own, which you will be uh but it's to make sure that you guys are already aware of these things before you turn up to your first sho shift on a night and you have no idea what to do and what plans are and how to put them in place, which was basically me this time last year. Um Yeah, so just writing things like they might need bloods tomorrow. If you want to add on bloods, you could do that if you need to order a chest X ray or a CT CT S are consultant referrals. So if you do think you need to get a CT, definitely discuss it with the registrar at least um before you put in the request because it will ask you for the consultant decision before you put the request through. Um And anything else you need to do, like if they need to be seen by the cardiology team. So usually end sties need to be referred to cardiology. There's usually a referral system in place for hospitals. So whatever team you need to refer to, you're able to do that on the system and you put in an sbar handover essentially for that patient, what symptoms they've come in in with what results you have on investigation and that you need their help for further advice and management and then you leave it to that team. So for an NSTEMI, we would put in a referral to the cardiology team who will then essentially pick up that patient and see them whilst they're being admitted and decide. Do we want medical management? Is this patient going to go for angiography? Um And the rest is sort of what's done during the admission larking is more what you're doing immediately fine. And then you've got additional sheets, which is space to write down any discussions that you've had with the patient with the family uh or care home. And usually I write down if I've had a discussion about DNA RS, uh DNA RS are do not attempt resuscitation and we're going to talk about that at some point, then you just need to sign it off at the bottom and you also need to put the ceiling of care um which we'll talk about and your DNA R decision. So the clinical frailty score, it comes under social history and this is the clinic clinical frailty scale that we use in the hospitals. Um And like I've mentioned before, based off the social history that you've taken, you decide what number they are at. So for example, if someone's using walking aids and they feel breathless after walking a few steps, you might want to put mildly frail. But if someone's bed bound and they need carers four times a day, you might want to put a as the frailty score, this helps decide the ceiling of care for that patient. Sorry if there's noise in the background. Um The four at the four A test is used to assess for delirium in patients. So if someone's come in acutely confused, you need to ask them these uh these questions. This is on MD CP, but it's actually printed out on our clocking sheets. Um So you just go through it and just put, if they are agitated or sleepy. Um and they get points for that and you'll just circle it and go through it, ask them what their age is, date of birth. Do they know where they currently are? Do they know what year it is? And whether they're able to remember these things? And a common one we use is saying the month backwards and then with regards to acute change or fluctuating course, it's best to ask family members or the care home because they'll know what the patient's baseline is and whether this is just an acute deterioration and then it'll give you a score at the end to sort of figure out if they are delirious when it comes to delirium. There are two types of delirium. Do you guys think you'd be able to tell me what those are anyone? Yeah. So some patients can come in hypoactive delirium. Um And they're usually sleepy and they don't want to answer your questions and it's really difficult to take history. That's where collateral history comes in place. And it's the same with hyperactive delirium. They can be quite aggressive and they might just ask you to leave. They might not let you examine them. In which case you might wanna come back up a different time to examine them. Or usually if I'm struggling to examine someone, I'll just write it on the clocking sheets that I'm unable to take proper clinical exam. So remember that guys, this is also a diagnosis on uh the problems list that you have at the end if they are hyper or hypoactive delirium. So for example, if they have a uti you might write uti is the primary diagnosis. And then the second problem might be hyper or hypoactive delirium secondary to above meaning the uti. Um So keep that in mind. Now with DNA S and feeling of care with DNA RS, it's this purple form that's on the slide. And as an sho you are allowed to have DNA or discussions and you are allowed to sign DNA R, but they need to be countersigned by the consultant. So ultimately, every patient you see is going to be post take by a consultant. So if you've already put in a DNA R, it will be countersigned by a consultant or if it's a bit more urgent, you might want to ask your consultant to have it signed. So you just need to fill it in, write down the date of the DNA CPR decision, which is the date that you saw them. And usually you would tick the first box where it says CPR is unlikely to be successful due to. And then you'd write it down, things like age, frailty comorbidities and what comorbidities they have. Or for example, if they have a malignant cancer, you might want to write that there and that you've discussed it with the person and you also need to discuss it with family members. It's really important that you include family members in uh DNA or discussions and they need to be aware of the discussion, the patient, the decision the patient has made either if they have capacity or if they don't have capacity, you need to have a DNA R discussion with the person that's the next of kin and has power of attorney. So make sure you're aware who the next of kin is and who has the power of attorney. Um Yeah. So with DNA Rs, my consultant has a very specific way of having DNA R discussions. So I would try and write this down because having DNA R discussions is really, really difficult and it's something I struggled with initially, but I have gotten used to over time. So what we don't want to do is talk about suffering during CPR and we don't want to talk about itu or ventilation or essentially any treatment escalations that we aren't going to offer. We need to remember that our patients are dying of something progressive. And this is the reason why we're putting in a DNA R. So we want to start by saying something like I want to talk about that resuscitation thing. Essentially, most people will know what you are talking about. And they might have even thought about this quite a few times. They might have already made a decision about it and they might have already discussed this with their family members. So all you need to communicate with them is, you know, such a person is going to go at some point and you know, they're quite frail, the end is going to come eventually. And we think that when that end comes, you know, usually we want to die peacefully in our sleeps with our family around us. And when that time comes and they die, we won't be able to bring them back. It's going to be the end because of what we were saying, they're frailty cancer, infection disease for that end to happen peacefully. We need to do a form so that the people at the time would know what to do. So essentially the people ak a the healthcare professionals will respect that person's wishes to have a death with dignity. Um You want to make sure that the patient understands what you're saying and we also need to clarify that it may not happen during this admission, but this form and having it in place it helps for a long time in the future, even if they're going to go back home after this admission. So we don't just put DNA S. If we think someone is going to die in this admission, it can be for patients who are quite elderly, frail have multiple comorbidities may possibly survive this admission and go back home, but it's good to have this form in place. Um Anyway, again, we want to repeat the active management plan. We're still actively managing patients that have DNA Rs. We're just not taking them to itu we're not going to do CPR, we're not going to intubate them. Um Just let the family know you're going to complete the form. They don't need to do anything. You can offer them a leaflet and you need to document the discussion that you've had with the patient and the family. Remember if the patient lacks capacity, you are having a DNA or discussion with the next of kin and the person that has power of attorney. So the main take home from having a DNA R discussion is when the time comes and they die, we won't be able to bring them back because of the reasons that we gave. I hope that DNA R discussion is something useful to you guys and you apply it to your practice when you start working and it sort of go back to the DNR discussion. I think the session is going to be recorded so you can always have a listen to it again. Um I think if you're not comfortable with DNA R discussions, you might want to sort of observe some of the registrars and other Sh Os have them. Um And then try yourself and the starting point would be, you know, patients that have a DNA are in place in the community that I mentioned before. So if they have a DNA in place in the community, it means they've already had that resuscitation discussion with the GP. And if they, it's already there, it's established. All you need to do is clarify with the patient that you know, they have a DNA R in place in the community. And are you happy to continue with that? And are you happy for me to fill in a form in the hospital? Or sometimes they might already have a purple form in which case, they need to bring it into the hospital. If they don't have one, you can always fill in another one because it's important they have one whilst they're in hospital um with regards to sealing of care. So you've got ward based care, you've got HD U and ITU and again, you're using the social history to sort of decide what the ceiling of care would, would be alongside the medical history. If someone has a DNA R in place, they are automatically for ward based care for patients. Otherwise they are for full escalation, meaning they will go to it. There are some patients that it, even if they're young, they're quite poorly and we don't think they would survive resuscitation. In which case they might not be for full escalation, but they could go to HD. So essentially it's the same team in it that are looking after them, but they don't have the full scope of management or like full on CPR and sort of intubating. But I usually, as an sho I've never decided if someone's for HDI always, it's usually the ITU team and the consultants that decide. Um I think for me personally, it's either like a very obvious ward based care or for full escalation, it takes time to do these things. So definitely observe some of the seniors before you get an idea of what type of patients are full escalation that versus for um DNS and ward based care DNA RS and ceiling of cares. It's quite tricky to have those communications, but it is very, very important. Um You will get asked by every senior that you escalate to what the ceiling of care is. So definitely have that in mind. Uh So with the early warning score, I'm going to assume that you guys already know what the early warning score is. It's a screen for sepsis and we're going to cover it in more detail when we talk about sepsis. So it's not just sort of sepsis six as juniors. Is it like if you're clocking, you need to be able to come up with a differential and find the source of infection. You can treat them as infection of unknown source, but ultimately, you are the doctor that's going to order all of the examinations required to find what that source of infection is. And you need to be able to do a full clinical examination. If there's a wound, it might need a wound swab. Do you think it's a uti I, do you think it's chesty? Is it a chest X ray? Do they need blood cultures? What is it essentially we do blood cultures for everyone that's septic anyway, um viral swabs, whatever it is. But this is what we're going to talk about in sepsis and how we're managing sepsis like the full scope of management. So, on this slide, I've just put like the escalation for each doctor. So usually anyone that's using a seven or above is escalated to the registrar and these tend to be patients that are or would need to be on the end of life pathway or if they are full escalation and they deteriorate and they need to go to ICU. These are the type of patients the registrar will handle um also patients who are unresponsive and their G CS has dropped. I think the registrar usually gets the first call now with um Sh Os. So I keep stressing on Sh Os because it's likely that you are going to start working as Sh OS and not F ones. So Sh OS are usually escalated patients that I'm using around five and six and it tends to be management plans from the day team. So at 5 p.m. you might get a bleep from the ward team before they leave saying so and so has now fallen unwell. I've sent off a chest X ray for this patient. Please. Can you check what the chest X ray report is? And well, you need to have a look at it, decide whether they are chesty clinically examine them and start them on antibiotics. So a lot of it is stuff like that from the stroke team. You usually have like patients on the stroke ward that may have aspirated and you get called to review a chest X ray, keep them nail by mouth and usually from the cardiology ward. If there are patients that or on telemetry, if they are now on NSVT S or they've gone into fast af and you need to give them like a stat of uh bisoprolol or whatever it is. You need to know how to sort of manage those arrhythmias, which is why we've covered them in, in the teaching series. You also get a lot of patients that are having hypoglycemic episodes. It's usually diabetic patients that are on insulin. So I've personally noticed that insulin can go wrong in the hospital. Usually they are monitored and the blood sugars are written down um, but it's just important with hypoglycemic patients, you have a look at what their blood glucose has been like and you know how to manage them. So, oral glucose versus Glucagon versus Dextrose, uh depending on what their glucose levels are and holding the next dose of insulin. Uh, you get a lot of that as an sho and from the slide can you just tell who gets the most bleeps any guesses after the reg? It's usually the F one, like the F ones tend to get more bleeps because it's nitty gritty little jobs on the walls that need doing. But thank you. So, um, the registrar often gets referrals or if someone's very, very unwell, but because we have DNA Rs, um, most of the times the plans are in place and the seniors know exactly who's unwell and what they're doing. Whereas F ones get a lot of bleeps from the wards about nitty gritty little jobs that have not been done. Um And a lot of them are things like prescribing P RN analgesia. So when you clock someone, my advice is if someone's a little bit sick, give them P RN antiemetics, you know, it doesn't mean that they are going to have antiemetics three times a day, every single day. If they're saying to you, they feel a bit nauseated add on PRN cyclizine. If they are complaining of pain, there is no harm in adding on P RN analgesia. It helps it will help the nursing team a lot and it's going to help the patient. So the nursing team won't have to escalate to the F one out of hours and be like, can you please prescribe Gaviscon for our patient? Just make sure that, you know, all the cure and stuff. If the patient needs them at the moment, they should be a part of your management plans. Um If someone's now hypotensive and they need some fluids, they might escalate it to the F one. So it's usually a new score of 0 to 4. Uh Usually if someone's in pain, they might ask the F one to prescribe some analgesia. So therefore, prescribing these small P rn meds. When you clock the patient, it can help the patient, the nurse and the F one on call. If someone's desaturating, usually the nurses will already start the patient on oxygen. Uh But you need to go and clinically examine them as an F one find out why they're desaturating. If they spiking temperatures, you might need to then take blood cultures. Um A lot of the times F ones also get bleeps to take blood and do cannulas. And if they are struggling, they might escalate to the su which might be you. Um A lot of the bleeds are also someone's now acutely confused on the ward or chest pains. And if someone's had a fall, you'd need to fill out a full performer. Uh and just to clinically examine them to make sure they are. Ok. So the F one has a lot of jobs and if as an sho you're not getting very many bleeds, be nice, help the F one, give them a call. Ask them if they're ok. Ask them if they can take, if you can take some of their jobs, you're there for 12 hours. So help each other out on the team. Um This is notes that I would have written for if I'm the ward sho and I've been asked to see a patient. So that's what a TSP is. So I've kind of made up a case for this one and I've kind of put out a template of how I would write down the notes and document. So this is exactly how you need to document uh whether it's electronic or on paper, this is what you need to do. It's the format you need to follow. So definitely just copy and paste it. Um You want to write down what you've been asked to see the patient for. It's not always a new score. It can be if the patient has some chest pain or uh they're now requiring oxygen or whatever it is. You need to write that down on the right hand side, of course, write the date, the time the ward, what hospital you're at your name, your grade, your GMC number. Uh and then this should be done ideally, once you have seen the patient but write down what the patient's age is when they were admitted, what their presenting complaint was. Then the background is the comorbidities and the little triangle is just a differential diagnosis or the diagnosis that have been made in the hospital and what they're being treated for. So you can see next to each diagnosis. I've written down what they are being treated with as well. So over here we've got c it's a curve score of four and that they're on IV Koin and it's day four. It's important that you write what day of the antibiotics they're on as well. Um So yeah, it's important to write it in that way. Just write down what treatment they're on, what meds they're on. Um Not every single one of them, just the important ones. I've also written down that the patient has a DNA R in place because if this patient is unwell, if they are really, really unwell, you need to know that they are not for resuscitation. So it's good to just have it written down in front of you. Um, usually they'll have a purple form in their file and then whatever examinations they have had investigations, they've had you want to write them down. So the viral swabs are negative chest X ray. What, what did you find on there? Write down what was on there? Uh write down the most latest bloods and then write down the early warning score and for each early warning score, you need to write down the individual parameters and what they are. Um And then you want to examine the patient clinically, the chest, the abdomen, the calves do a full A two E assessment. I'm assuming you, you guys all know what an A two E assessment is. Um And for the plan, you just write down what you're going to act on. So for this case that I've made up, it's the patient that came in with shortness of breath productive cough. They're being treated for a chest infection. They've got decompensated heart failure in the background for which they were on IV furosemide. Not anymore. Uh They've got a reduced oral intake and the dehydration plus being on IV furosemide would have possibly contributed to an AKI on this patient's bloods and they're also very frail. So you can see from the early warning score that they tachy, they're tachycardic. The BP is high, they're requiring oxygen, but they don't have a temperature. So I've now examined them. The chest sounds very crackly. Calves are ok. Abdomen is snt and I've done an, a two week exam and my plan for this patient would have been to repeat bloods, send them off and have them chased. Um In this case, I don't think I would have repeated a chest X ray just because this patient would have had a very recent one. If it's someone that started to randomly desaturate whilst they're admitted in hospital. You might want to think along, think along the lines of hap and get a chest X ray. Um I can see that the patients on IV Taz and clearly they've still deteriorated so they might need to escalate their antibiotics. I can't make that decision. I would need to discuss it with microbiology and they might want to change their antibiotics to something a bit more stronger with more coverage. And I would also put them for daytime review. And if this patient's quite poorly, it sounds like they're quite poorly. You can see they've got a DNA R in place. They for ward based care, they've got multiple problems, they've got multiple comorbidities in the background. I would quite possibly if they are still poorly with strong ivs consider end of life. So I would put it in the plan. But ultimately, as an sho you can't really make that end of life decision, you can suggest it. Um And if it's something where you feel like the patient needs a more imminent decision, you might want to escalate it to the registrar who would then come and sort of decide whether the patient needs to be for end of life or do we want to try further antibiotics? Um That's if it, if you think the patient is very, very unwell and might die overnight. So this is what your notes should look like. If you've been asked to see a patient and the form that you would follow. For ward round. It's pretty much the same as when you've been asked to see the patient, but I've written it in a similar way on the right hand side. So for the ward round, you need to write the consultant's name and your name and the same information on the right hand side. And in this case, I've written that the patient is known to me. So it would save you from writing down all of the things that you have previously wrote down in earlier ward round notes. Um I would have still put a little summary of what the ongoing issues are just because it's easier to have it in front of you. If it's your first time seeing that patient on a ward round, you want to follow the format we've done on the left hand side. So write everything, the background presenting complaint. It's your 1st, 1st time seeing this patient write down the investigations done so far, um clinically examine them, write a plan. Whereas if you've seen them before, you just need to build on your previous plans. Um Again, for your early warning score, always write out all the individual parameters. I know some departments like cardiology usually just look at heart rate and BP and yes, it's nice to write less, but it's important that you write all of them. So if something goes wrong or they are unwell, everything is in front of you again, write down the most latest bloods, examine them. So your examination on ward round depends on how many times you've seen them. Essentially. If it's your first time seeing them, you want to do the full examination, if it's your fifth time seeing them and you know that this patient is medically fit for discharge and they're just awaiting placement in a nursing home, but they're now commit uh complaining of some sort of abdominal pain. You might just want to do an abdominal exam, have a discussion with them, make sure they're ok. They're getting on, say hi, um, have a look at their bedside notes, they're eating and drinking bowels opened normal stools. Um, if they're on insulin, you want to check their blood sugar levels and make sure they're stable, write all of that down and then you come up with a plan. So I'm going to mention this now because I think it's important. But with regards to bloods, you don't get a fresh set of bloods every single day. I would say order bloods when you feel like there's a clinical need to order bloods. So if someone's been spiking temperatures overnight and you've seen that in the notes or they're telling you today that they feel a little bit unwell, um, even if it's something as little as they've got some pain in their hands, like joint pain and you look at it and it looks a bit swollen and red, they could be septic secondary to that. Um So you need to order bloods, you need to make a clinical decision to order bloods and just write down the plan for the day. Um And sometimes the plan can, can be as simple as awaiting placement and continue supportive management. And other times you might need to do bloods and further examinations or things like discuss with microbiology about someone's antibiotics. And a lot of times these plans, they come consultant, the consultant, see the patient and you're writing the plan, you're acting on the plan. So it's important you understand why you're doing these things. Um Other times you as an sho sometimes as an F one as well, you do the ward round independently and you're expected to come up with the plan. Um Definitely when you're on your attachments and stuff, read through people's plans. So you get an idea of what the plans look like and read the previous one as well that really helps and that's it. I feel like that was quite long and I was talking a lot. Um But ultimately, from the powerpoint, we've discussed having good documentation um because having a complaint as a doctor is inevitable, you will have a complaint at some point. So it's important you document everything correctly, take a good history, make sure you're ruling out other systems as well. Essentially having a good history means you rule out a lot of things that you don't need to do further investigations for and you're not wasting resources. Um, I've also had a conversation with you guys about DNA and how to discuss these with patients. I've told you about the ceilings of care and in terms of further resources, I would say if you've just graduated from M UV or you've just graduated, um, I would recommend using pass med and they have specifically, I think, um, a bank of questions for medical students that the med students here in the UK use, I would flip through those in my spare time because they are case based. So when you read through them, you can apply those two situations that you see in the hospital. Um sometimes you'll see something that's exactly the same as what was in the questions and you kind of know how to act on it because you've already read through management plans and answers on passed. So it really helps using pasmed. Um What are the resources? Could I suggest? I did have another one in the back of my mind that I can't remember at the moment. So when I do remember, I'll let you guys know. Um it's scary working in the UK and it's even scarier starting out as a locum. So definitely, if you don't know the answer to anything escalate, you'll always have a senior to escalate to. And I really hope you guys have supportive seniors so that it doesn't feel like a burden escalating. So in terms of clocking a patient, the nice guidelines say it should be 40 minutes per per per patient. However, you can see that the documentation is long. Um you have to make phone calls and you have to have discussions with family members and it can take long. So some patients do take longer than others and some patients are quite fast to clock. So it just depends, I think initially, especially as a junior, you do take longer to clock. II feel like for most of the juniors at my hospital, we on average spend an hour to clock per patient. Um and then you just get better with it with time. But 40 minutes is uh the nice guidelines. Definitely some patients take longer and some patients are quite fast to clock. So there's no right answer to that question. I guess. I hope I've answered it correctly. Does anyone else have any other questions? No worries. Um Does anybody else have any other questions before we finish? Thanks, Anita. That was really good. I apologize if I was talking a lot. It is quite detailed and I try to fit in as much of the documentation stuff. Um Hi, I recognize you. Uh Thank you for attending um with regards to the teaching session or the teaching we have after this one, they're all based on clocking and being patients and coming up with management plans, which is essentially what you're doing every single day as a junior doctor. So definitely try to attend as many as you can. And hopefully now that you guys understand what clocking is, what DNA Rs are, what feeling of care is, you'll be able to get through the clinical stuff a lot easier. Um If you have any questions or you want to drop me a message on whatsapp or whatever, just feel free and that's it for today. This is it. Um Guys, I've just sent in a link for the feedback form. So if you can fill that in, there's also a QR code on a slide um that will really help us. It's just like basic questions. Um but it'll really give us an idea like where everybody is before and how helpful the sessions are. Um Obviously, we want to make it as useful for you guys as possible. So yeah, and once you complete that you'll automatically get like a generated certificate, which has obviously got the CPD logo as well because it's all been approved. So that will automatically save into your me profile as well. Um So yeah, that's another really good thing that I need some money to as for us. Um So yeah, and I think I just wanted to add on as well um To what I need, I was saying particularly about local workers. That's what I've done at the moment as well. Um Basically, when you start your shift as local, obviously, well, the first hurdle is getting one because a lot of agencies they want experience now, which is just very inconvenient, but that's what's happening now. But the ones which don't require experience somewhere, you can just forward yourself. Um, it may be the case that you end up getting the shift, which is great because your foot's in the door. But then there's also the thing of now I actually need to go to the shift and I have little like, I have no experience prior and I've graduated from a different country, entirely, totally different system. Sometimes it might be that like, depending on what agency you are, you might not have done an attachment at that hospital or you might be completely unfamiliar with that hospital. And it like, like that was, that was the case for mine. And if that's the case, I would say, like, try to advocate for some shadowing. Um whether that's like if your my first shift was a night shift, um which was terrifying obviously, but that's just what what I got. Um So I asked to basically shadow the shift before it was also like quite far. So I didn't have to stay there, but I would say take that initiative and definitely shadow previously. The main reason being you can get your login sorted because like will concur as well. A lot of the times the system is one of the biggest problems and you really do not want to be fucking around with logins. It's just gonna look really unprofessional, you know, and it's gonna delay you so much. So try to get shadowing. Sometimes some agencies are really funny. Like, it depends on what agency it is, but literally worst case, if it's like a night shift, just go a few hours earlier, at least test your logins, at least check. Ok. How do I order bloods? And you can just ask someone you are, you are definitely like a lot of the time. You won't be the only one there. Like I know for my last night, like it was surprisingly quite well supported, I guess, depends on the trust, but um you will usually hopefully always have somebody else that you can ask for help. Um I remember we were talking about management plans and stuff, obviously, as someone who's like fresh from M UV, like I had no idea like for plans, I was like, I mean, I guess like they're dry, they might need fluids. Like, honestly, it was, it was very overwhelming, but when you first go, so you'll usually, you'll go and you'll have like a handover, right? So at that point, you can introduce yourself clearly to the team and just make sure you emphasize that you're new. It's your first shift at this trust, first shift in the NHS. Um And you will probably like, require help and you'd appreciate their support, something like that just so they know, and then when when you are going bear in mind, like a lot of you will be clocking. So you might go down into um like in the area and you won't be the only one clocking. Those are the people. So at any point, if you want to ask something, you just ask them like your colleagues, hopefully there should be other people around you and you can kind of ask them like, hi, like I've done the clock. This is what I was thinking. Could you maybe make further suggestions? What do you think of my plan? Even if your plan is not even a plan, even if it's just basically like, I mean, I think they're infected, the blood markers are a bit high, something like that. Like you can just talk to them. You will never like be completely alone and literally worst case scenario and not aa had this experience as well. If there's literally nobody else, you can just ask your reg like it's OK to annoy them because you do not want to do anything unsafe on your part. So it's completely ok, just always ask if you're not sure. And when you're new, they expect you to ask, it's almost unsafe not to ask because they're gonna be like this like you should be asking questions you're new. So um yeah, I kind of wanted to add on that and it's also good if you um I guess for your own learning, like as you're seeing patients in A&E or your clocking whatever for your personal learning, maybe make like a little logbook or like a note for yourself. Like, oh this person came in with this, my management was this and then it's kind of like you can get more into that rhythm and you can get more confident in yourself. Like with locums, I feel like a lot of the time it's confidence. Um and also from M UV, like, I don't know because Anisa said like a lot of you will be familiar, but I know like for us M ev, like didn't teach us at all. But could I just could we just have like in the chat, how many of you are familiar with um A two E and like that general system? Like, have you heard it before or is it? So they like, that's quite, that's quite new to you because I know for me when I graduated, I was like, we learned it for the first time. Yeah. Yeah, we, we didn't know about it before that. Um But it's, it's an extremely important tool. Um Definitely something we could discuss like in one of the talks as well, obviously, depending on maybe you guys know about it already. Just like, have you heard of it? Yes or no. So uh add on to this because II remember what the other resource was. I wanted to suggest it's not really a resource. It's the A s course Which yeah, I hope you guys have heard about. I think you guys should definitely, definitely do the A LS course. I actually took my a course before I started um working full time as a local. I did my A LS and it boosted my confidence by like 1000. I am now. I think I feel a lot more confident being on. Um Sorry, I'm reading the messages at the same time. I think I feel a lot more confident on the wards um because of the A LS. But when you do your A LS course, they not only teach you what at ES are because I think with, with teaching series and with sort of online things, they kind of just talk about at ES but you need to see it in person. So you know how to act on it when you're in that situation. Um And that's what the A LS course is. Like, they teach you the A A to E assessment, but they also teach you how to act on um every single part of the A two assessment, which is what you need. You need to see it. Um They also teach you ABG S interpretations and acutely unwell patients and you also go through resuscitation. So it would be worth doing the A LS course first because you know what to do if someone's really unwell. And I think that's, that's the best thing as a doctor, I guess is to handle unwell patients acutely unwell patients. Yeah, the most basic expectation from an H by the reg is to act on your A to ease. That's all they expect from you. So definitely do your A S course. And then you'll also be able to be on the crash team because when you're on call and you're on the crash team, you will be one of the people that has a role in resuscitation. So you'll either be airway circulation or CPR. Uh The lead is usually the reg and you've got bloods, drugs, IV, access, scribe and Def f and you'll split them roles amongst the team and you have to do one of those roles. So doing your A LS, they actually train you what to do in each role. So they'll teach you how to put in an eye gel. They will make sure you're doing adequate chest compressions through CPR. They'll teach you how to use defib and how to safely deliver a shock. Um And essentially in your A s course, when you do your, your mini exam at the end, it's just you and your two examiners and they are your helpers, they are the other doctors in a crash call and you have to do your full a three assessment and then the patient starts crashing. Um And you have to start resuscitation. So you're the leader in the exam and it honestly, it's the, it's the most nerve wracking course I've ever done in my life. I was very, very scared to lead. But, um, it's just something you have to do and everyone has to do in the A LS and pass it at F two level. So, definitely look into the A LS course as well. It'll definitely help when you're on the wards and when you're on the crash team. Yeah. And they also have a nice chapter on ECG S if anybody doesn't like, I got like a really, I think it's quite, I don't know, I like the step wise approach they take and it was quite straightforward. Um And in the test, they asked about loads of ECG S. So you will definitely be more comfortable by these. Quite a lot of the questions are so the hospital can fund the A if you are permanently employed with the hospital. But if you're a local, you have to pay for it yourself. I was low at the time. So I paid for my A course and when I started working permanently, they offered to sort of um pay that back, but it didn't really bother me cause I paid for it a while ago. It is expensive though. It's like 600 lbs. I just did the, the one day course, like the one that you do online and then like you do the mini courses online and then you just go in person for the exam day and the training, it's uh you can do B LS. There's like a virtual B LS but ultimately it doesn't really mean anything. I think A LS is the big one. Like, that's the one that you actually have to invest in. So, if there's any that I would pay for, I would pay for an A LS. Yeah. A lot of like, um, you can shop around for A LS as well. Like some cities might have it cheaper. I know, like ours was quite expensive but there's some which will have it like more around the 400 area. So you just need to like do some digging for that. Um And yeah, yeah. And also a lot of them, a lot of job applications on track, they will ask for essential criteria. A LS. So if you, there's obviously there's bl sa L sa Ls, if you have a LS that will be valid for four years and that'll cover if they've put B LS. Well, you, you've done like more than that. So A LS just kind of covers you for everything. Um B LS, you can even do it like during attachment and it can be free as well, but it's not like a lot of local agencies will ask for B LS, but it's, it's very basic like like it's not just doctors who do it, like loads of professionals do that. Whereas A LS it's more specialized like doctors, nurses, more advanced healthcare professionals. Um And if you compare B LS and A LS, like the skills you learn from A LS are just so different. Um, that it's just like, it's not even a competition between them. Like what's more, what's more helpful? Like you do have to fork out a bit but it's, it's very worth it. If not, if nothing else for your confidence in hospital, like, at least you will know the terms and like the basics, like as a minimum. Um I think I've got one more thing to add. Um If you start working as a locum, it's basically a big smack across the face. And I actually is like, I'm not even joking. It's, it's difficult because you're just being thrown under a bus and you're expected to know what to do. Um Essentially they want to hire you because you know how to do the job, you know how the systems work. Therefore, my recommendation is do your attachment stay in that hospital, make sure you know what the hospital policies are, make sure you know how that specific hospital runs, um all their systems and eventually a job opportunity will open up. I know it can be quite draining waiting for a job. Um But it's easier that way because then you're seen as someone that actually knows how the hospital works and that's what the employers want. They want you to be someone that is able to pick up the job and just get on with it. And that's the reason why we've done the teaching series to sort of bridge the gap and help you guys just get on with the job and just pick up patients, clock them, put management plans in, understand a bit about how the NHS works, which is something that I wish someone would have done for us. But sadly, that just did not happen. Um But yeah, a clinical attachment really, really helps, definitely try that route instead of just going into it blindly cos essentially as a locum. You, you're not really supported, you're on your own. And if something goes wrong, the consultant is not gonna sort of put his foot in and try and save the day. But if you're employed permanently, they kind of give you a big fat hug and help you out of the problem. So I suggest working in one hospital and just staying there. And I think that's the best way to go about it with regards to the I MG teaching. So the whole reason why we have a separate, like an accountant on Instagram and a group chat is because initially we wanted to do this for I MG students that were coming back from Bulgaria. But we've got I MG doctors that have joined us, uh who believe it would be really useful for other Im Gs too. So you'll actually meet them in, in some of the teaching sessions later. Um So you've got IM GS that have come from Bulgaria and they've got no clinical experience whatsoever. So it's really, really difficult for us. Whereas the I MG doctors that are coming from other countries have usually studied their work. They've had clinical experience and they usually don't have an issue with picking up clinical jobs in the UK. It's more system, paperwork related issues than it is clinicals. Whereas for doctors like us, we don't really have much clinical exposure. So it's really difficult. It is really, really difficult, but we've tried to have a balanced team. So we've got Im GS from Bulgaria. Uh We've got Im GS that have worked in different countries and then come over and then we've got a lovely F one on the team as well. So we really hope you guys benefit from the series, definitely leave feedback so that we can continue improving and I hope you guys get all the help that you need um from the sessions. If anyone has any other questions, feel free to drop them. Ok, guys, if there's no further questions, I will just send the form for the sorry, the link for the form again, if you can fill that out and then hopefully we will um see you for the next session. So again, just keep an eye on whatsapp, Instagram for the date, but we are aiming to run them as I said weekly and we'll start with cardio. Um Yeah, I hope that was useful for everybody and thank you for joining us and we hope to see you next time as well guys. Definitely, um, have a look at the Instagram accounts because we'll post the dates as we get on on the account. Thanks guys for attending. Ok. Um We'll definitely drop providers on whatsapp as well, but I think it's primarily on Instagram um because we have, we all work full time, so it's really difficult trying to find the time to teach. So usually we'll just up, upload the dates as we go along. Um But definitely I'll keep that in mind. We'll definitely post on whatsapp.