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Should be live now. Jennifer. Hi, everyone. Um, well, just hopefully get a few more people coming in. Um, my name is Jen and we've got Claire here and Lucas. Um, and we're from NSTS and this is our first series of the new academic year. Um, and it's an fy survival guide, um, which is aimed for all those who are a bit nervous about starting, um, new Fy jobs. Um So hopefully this is here to help you out. Um So this is a little bit more about what the series is going to look like over the next month, every Tuesday and Thursday at 7 p.m. there will be a different talk. Um, and it's, there's similarities to things that we've done before if you've been following us for a while. Um, but we've taken on board your feedback and we've tried to focus on all those areas that you guys have found most useful in the past and also to cover some more topics that, um, you've been asking for. Um, so today we're gonna start with how to get through your on calls. We've previously done series on this before. And so I'm gonna do a whistle stop tour on all the things that, um, I wish I knew when I was starting my first fy one job and then hopefully some practical tips and advice to help you feel more confident when you start work. So, a little bit more about me, um, I have been an education officer on a sts since it started in 2020. Um, I'm now I'm education need this year. Um, so when I, when we started NSTS, it was in COVID Times and I had currently been kept on eight months of a general general surgical job with urology on um which I felt very unprepared for and I don't know, um depending on which medical school you go to, you get different levels of training, but I definitely felt less prepared for surgical calls than I did for my medical ones. Um I was at Leeds Medical School which was actually quite good in preparing us their clinical years and, but we set this up to try and help bridge the gap. Um I did my F one and F two in West Yorkshire. Um I stayed around after Leeds and then I've just done an F three and an F four was in London and then I went to Australia working in emergency and now I'm just back starting ong training. Um And if you have any questions about any of those things, um I can always drop my email in the chart at the end. I'm happy to talk about anything that might be useful. So hopefully we've got most people um joining now and so we'll go over what we're gonna aim to cover today. Um So the main learning objective for today is to understand what your role is as an fy one and how those responsibilities might change when you're then on call, a lot of your on call, um revolves around getting a bleak. So that's gonna be a lot of what we're gonna focus on today. Um And especially knowing how to obtain information from those bleak to make you work as efficiently and safely as possible. The five main areas I think are really important to cover, um are prescribing, assessing and making, assessing a patient and making a good management plan. Um Thinking about your documentation and how that might change depending when you're on call versus when you're chasing somebody around a ward round. Um I'm gonna briefly talk about discharges because although it's not specifically an on call job, it does make up a loss of your workload. Um And then talking about how to prioritize and how tips for managing the high workload throughout all of these, we'll be focusing on how to communicate whether that's before during or after an on call, especially about handing over and, and when to escalate. And then at the very end, I'm just gonna give you some of my tips about how I reduce my stress and anxiety around on calls and nights to try and enjoy work as much as possible. If you've got any questions throughout, just feel free to drop them in the chat. Lucas and Claire will be monitoring it. Um And we'll try and pick them up as we go. So, gonna start with a poll which is just to get a brief idea as to um where everybody is in their training. Um Hopefully you can all see this poll as it comes up in the chat. So I'm other, I got to do my own fun. Um, ok, so a lot of majority kind of final year medical students and one which is perfect. So you're all in the right place. Um, so briefly just to talk about what is the role of an F one and I think it feels really overwhelming when you start because it's a big jump between becoming a medical student. So when you'll start off as a doctor, um, but mainly the role of an fy one is to learn, you've never done this job before and you should be being taught how to do it. It doesn't always feel like that's the case. Um, when it, you know, when it does feel overwhelming. Um, and I think especially people get nervous about on calls because you feel like you're more on your own. So, um, you know, inevitably if you've not done something before, you shouldn't be expected to do it without being taught how to do it. So this is hopefully gonna give you the confidence to find out where you can get some help, get a mechanism for um communicating with people to get the help that you need. And also next lecture on Thursday is going to be about escalating as well. So don't get into it too much. Um But inevitably it's, it's a learning job and it's a learning curve. Um And someone said to me that it's not necessarily that the job gets easier, but you get better at the job and learning kind of what you, what you can do and how you can become more efficient. So, as I mentioned before, bleeds and they seem quite antiquated and it seems like there should be a better system for contacting you. Um But alas not yet. So, um normally you just get a bleep when you're on call. Some hospitals, give them to you if you're um if you know, if you're not on the ward, so you might have them on a standard day, but often it's just a bleak that you get given when you're on call and you're covering a large area. It should just be used for sick patients in urgent tasks. Um So it should be when, um when you know, when it's needed. So you shouldn't be getting beeped all the time, but it is sometimes a way of communicating with you if you're not based in the same place Um So because of that, um depending on where you work, some hospitals have um kind of like systems in place like hospital at night to help somebody monitor your bleeds or find other people to help you. So you don't get flooded. Um But often it is just you and your bleep. Um So it's good to have a mechanism for dealing with them. You don't normally hold a crash b as an fy one, but uh the hospital I worked in you did. So um it's also just knowing that how to deal with running to an emergency. Um And sometimes you don't want to be the first person. There is an F by one but things that you can do to help um in an emergency, like scribe or observe just to feel more comfortable in an emergency situation. Um They are also useful to get information from other teams. I'm just gonna mention it here. So I don't forget to, but there's an amazing app called Induction, um which you should be able to download specifically for your hospital, which has all of the beats that you should ever need. It's also really important that at the beginning of your shift, you write down which what beeps your seniors are on so that you know, who to contact and for help or where to seek advice from, from other specialties as well. So when you get a bleed, it's really important to have a framework for getting all of the information that you need from the person on the other end of the phone. Um The best way I think is to make sure that you write everything down and have a structure to do list as you go. Um The things that you need to make sure that you're writing down so that you don't have to call back and say I've got to find out who the patient is that you're contacting me about is the patient information and where they are. And if you can put all the relevant details down, it's useful. Um But that can also help you prioritize how urgent it is that you need to attend this task or attend that patient. So it's just good to be as organized as possible. Always have a pen and paper on you. So to start talking a pen and paper and in uh if you have something toder on your phone, can everybody rank the following task? So imagine that you're on your first on call shift and the rotors being unlucky for you. And your first on call is in night shift. The first half an hour you get the following six bleeds coming in quick succession. Number one. Can you prescribe fluids? Number two. Can a patient go home? Number C number three, see um a patient has just dropped their sats and they're feeling short of breath. Number D. Can you come and put a cannula in someone needs some antibiotics. Um, e is the patients in pain. Can you give them some morphine and finally, a patient's family is here and can you come and speak to them? So I'll just give you a second to go through and think what is, you know, what would you run to first basically, or what would you try and prioritize? Hopefully, that's enough time. So let's just discuss basically. There's no right answer, which is the worst kind of answer. But um ultimately, you need to know more information about all of these cases to know how best to prioritize roughly. I put them in um this order because this is what jumps into my mind as being most worrying. So patient c the one that's just dropped their sats and they're feeling short of breath. I'm pretty worried that um their observations aren't normal and something acute might be happening. So I would definitely want to go and review that patient. The patient that's in pain is also concerning for me because if someone's asking me to prescribe morphine, um I need to know why they're needing such a high level of analgesia. Have they had um other uh like paracetamol and simple analgesia before. Is this new pain? Has something changed? Again, I'm gonna want to know more information. Then I've just mentioned about prescribing fluids. Again, you want to know more. Is this patient hypotensive? Do they need a fluid bolus? Are they, do they need to be resuscitated or is it just standard fluids? And because prescribing fluids is so much, so much of my um surgical on cause is about prescribing fluids. I've got some more detail coming up in the next few slides. Number four, putting in a cannula, um a patient might be septic or unwell, so that might be important. Um But there also might be somebody else that is able to put in that cannula to help your workload. So there might be a nurse on the board that could kindly do it if you're really busy or um clinical support. If you're lucky at night, then the last two, I put them at the end, not because they're not important. Um but they're maybe slightly less urgent and maybe slightly less urgent when you're on call. Um It is really important to update family members as you go. But if you don't know that family, you might not be the best person to speak to them because it might not be an efficient use of your time to read through somebody's notes to get an idea to update them on something that you're not sure about. So it might be um more important to get a senior who's been involved in their case before or even the consultant the next day to try and speak to them also discharges as I mentioned before, shouldn't necessarily be an on call job. Um But often they can be and if they don't get done in the day. It, you know, you can get chased by um, the management team to make sure there's flow and things. So it is really important to have, um, you know, have that in the back of your mind that you might be expected to discharge letters out of hours to help the next day. So, as I've mentioned in all of those, they are very common beliefs that you can get whether that's skills like um like blood and catheters prescribing, needing to review an unwell patient. And how do you know if they're unwell from the examples that we've just spoken about? And then as I mentioned, doing discharge letters and speaking to family members, especially in the day, that can be much more common. So really, we need a framework so that you can get all of the information so that you can do the following. You need to be able to prioritize a list of jobs. You might need to have enough information. If you can complete that task virtually and think if it's safe to prescribe virtually, you might need more information just so that you can reassure, you know, somebody on the other end of the phone, what does or doesn't need to be done that they might be able to do themselves. You need enough information in case you can delegate that where it might be safe for another person at the MDT to do that job, you need to know if you need to review them. And if that needs to be urgent, you need to know enough if it's not suitable for you to be reviewing them and you need to escalate immediately to a senior to do a review. But also you need to be able to manage expectations with whoever's on the phone that if you're really busy, you might need to say, look, I've got to do XY and Z first. Um but I'm gonna get there within, you know, the next half hour or the next hour. So here I've got an example of how to have that phone conversation in order to make sure that you're getting all of the information that you need and also how to kind of alert yourself any red flags that you could be worried about when you're on the phone. You sometimes get, as I sometimes say, when I'm on the phone, a whole host of information and it's very difficult to um break it up into importance. So it's always acceptable to ask. Is there any chance you can give this to me in an SB a format? So that's like your situation, your background assessment and then your recommendations. Um And that is universal across the MDT. So just mention someone any chance, you know, you could go through the situation in their background, that's completely fine to do. And that can help you establish the presenting complaint, the working diagnosis, any treatment or surgery they've had so far. But also just remember to take down things like the hospital number, really useful questions I find to ask on the phone is, are um, does this patient look unwell to you? You know, or what are you worried about? Those can be two things that can help you assess how urgently you might need to go and see the patient always asking um the patient what their news is and their pain score. You know, if their news is zero and their pain is zero might be less concerning and, and you might be able to put that later in your to do list. It's useful to know who's calling and where from just in case you need to call them back. Um And also why is it happening at this time? Um These sound a bit aggressive as I've written them down, but it's, it's, it's getting a, you know, good polite way of asking these questions just to make sure that you know who's calling you and what ward they're from. Yeah, as I say, if you need to go back and this is an amazing thing if you can do it and if you can think ahead um about what might be useful for you to have done before you get there. Members of the team who are on the ward might be able to help you. So for instance, if you've been called to see a patient who's got some chest pain. And you could say before I arrive there, any chance anyone can do an ECG or if you're going to see somebody that, you know, you've never met before and you say before I arrive, please, could you just have their notes out ready by the patient so I can quickly read through before I review them and even just asking for an update, set of observations or um, getting a medication chart out, any of these things are useful and that can help you be so much more efficient as you're working. And so that you don't need to get there and realize maybe that needs to happen before you can do anything. So again, I think I've mentioned all of these things, but these are just things to think about um to help you extract all of that information. Ok? So any questions from that first part that bleeds, this might all be information that you know, already. But um I also found it very useful just while I'm structuring my ankles to go through. So hopefully, that's good. I'll move on in terms of any questions. Sorry. No, I was just about to say that there was no questions. Ok? Oh, thanks cla well, good. Right. So I'm now gonna talk about prescribing. Um I put this in here because I think when I started, it was something that I found, um you know, quite a lot of my anxiety about starting work about prescribing because as a medical student, no matter how many times you practice you, it's not your name that goes to it. So I think it's really good to have a framework to prescribe safely. So a lot of the time you get asked over the phone to just prescribe, and it's really important to have a context for why you're prescribing and um who that patient is and basically the indication. So I'm gonna talk about fluids when you're prescribing fluids, do you a check the patient details indication and then prescribe remotely to continue the same fluid regi regime that the patients had before and continue on? Or do you be review the hydration status in person? Do an assessment, check their BP and urine output, ensure fluids are relevant to the indication. And then if you're very thorough, check their E and S on um ice and then look at the fluid guidelines to make sure they're getting all of their electrolytes. So let me just do my p there we go. Ok. Ok. Ok. So the answer is that you will inevitably do both of these things. You know, which answer feels most right in your mind, which is in an ideal world. Everyone that you prescribe fluids to, you will do a thorough hydration status. You will look at all of their observations, you will check their skin to see their skin to and you will, you know, you want to be able to do a few things in real life. It's not always gonna happen and you will run, you know, you'll be running around, someone will need fluids and you'll prescribe remotely the same three bags that the patients had for the last 24 hours. All I would say is that, um, you, we need to, we, we all need to be careful when we do a because it can be very, very tempting on a busy surgical job and it can be really easy to fall into bad habits with fluids prescribing. Um It's still a medication and it's still sometimes can be damaging. So I think it's really important to have a structure so that, you know, when it's safe to do A but also, you know, when you need to do B So I'm gonna talk about it in a bit more detail to help you establish when you would do A and when you would do B first, as I mentioned before, why does this patient need fluids? Are they maintenance fluids? Do they have a low urine output? A low BP in which do they need some? Um Do they need kind of uh resuscitation? Are they nail by mouth and have they had an obstruction? And do they have a rose tube in, are they on patient control analgesia? And it's always really, really important to check and in doubt and if you're ever in doubt, then I would review um and I think that goes to say that at the beginning, you will be doing a lot of views because if you're unsure, you should be reviewing a patient and you know, helping to establish what needs to be done as you become more experienced. You will know, oh, I don't think I need to go and see that patient because I know this will be fine or I have more confidence, this will be fine as you start out. You do just end up reviewing everybody as you should because you're slightly more concerned. Um If they're preoperative versus they're just on maintenance fluid, they might need a different regime from what they've already, what they're already on. And so the problem with just prescribing what they've had already is that you don't know who prescribed what they had already. So it's just really important to think and check for yourself. So how are they taking fluids in? Are they nil by mouth or can they actually start to drink? Now? Um if they can have oral fluids, then they should be trying to encourage oral intake because it is much better for the patient. It's really important to check fluid balance charts. They should be everywhere on your surgical wards, but they can be electronic or on paper and, and sometimes in the nursing notes. So it's just good to make sure that if a patient is on fluids, we're checking their input and their output. It's good practice to prescribe for 24 hours, um, to make sure that they get everything that they need over that 24 hours. If it's not all coming in through the same bag. And also, despite most surgical patients being fit in well for surgery, it's good to check if they have things like heart failure, any preexisting medical conditions, poor kidney function, especially in urology patients and cancer patients. Um, it can be important that we're not making things worse. Finally, just talking about um what to prescribe. And I found this quite hard when I started work and you can look at that on the nice guidelines. There's an amazing flow chart. Um And every hospital inevitably falls into its own norms. A lot of surgical consultants know what they like and they don't like so different consultants will want their patients to be on different fluids. Um But it's, it's, it's important not to just be prescribing two packs of heart, especially without checking the patient's potassium because Hartman does have potassium in it. Um However, having just said that if a patient has high output stoma, they might need more potassium um to account for losses. Um And everything about that patient should be taken into consideration um in order to make sure that they are getting the right flows what they need. And I've driven this point home a lot, but it was something I was anxious about when I started work that's useful. I hope. Um so some more generic prescribing tips as I mentioned before. Just be really wary when you're being asked just to prescribe. Um, if you're ever in doubt, um, have a low threshold when you start as we all should have for just doing an a to assessment and that's for things like pain or any new symptoms. Um, if someone's vomiting and you're asked to prescribe ants, I think if you are uncertain as to why this patient needs this medication, it's good to review both electronic and remote and, um, paper prescribing lead way to prescribing errors. Um, electronic prescribing tends to be better for checking if they've had something um, already or to avoid double prescribing for PR N. Um, however, it is easy to make mistakes with doses because a lot of it is automated. So just double check, especially when you're tired or on nights, always check for allergies, especially when I'm prescribing over the phone. It's an, um, you know, it's something that we will do, but it's easy to forget to ask and check um, how it's being given and how often it's needed. I on a night shift will still get out of the BNF or trust guidelines. Um, because I know I'm much more likely to make a mistake when I'm tired. And so if you're ever feeling like you are really, really busy or you're thinking about multiple things, just get out um, on your app on your phone or get your trust guidelines out to make sure that you're not prescribing it blind and because it can help you feel more confident as well. There are some other lectures that we've given in the past on our website, about more details I've now gone into as well and about analgesia anti and laxatives. So, um I can always sign post those if that is useful. Finally. Um There are loads of people to help you. So even if you know, if you've tried your senior year and you're not sure, um there are normally pharmacists available. Um The pain anesthetics are good. Um And there are specialist nursing teams for diabetes or palliative care. Um Don't ever feel afraid to ask and that would also come in on first lecture and it's really useful when you're handing over to um if you're not sure about something or you know that they're gonna be going on a ward and with the morning team just to um ask for somebody to check with the senior so that you don't come back onto that night shift and have the same problem being asked to you about the antibiotics or their gentamicin if it's still needed to be IB or another really important thing is to document changes, we will be going into documentation a bit more. Um But when you're writing a discharge letter, if you don't have a documentation, uh if there's no documentation for why medication has changed, um It's really hard to explain to the GP. So just make sure when you're changing your medication, document it as well. Um And I think I mentioned that before, but don't ever feel pressured to prescribe if you're uncertain, check review and get help because inevitably it's, you know, when you're starting out, you do feel worried about some things and it's always right to be safe. Ok? Um going on to assessing and making a management plan. So say that you're feeling worried about everything like I was when I started and um you end up going to assess your patients. I've just gone through here a structured framework of how to efficiently assess somebody. Um So that you know what to do when you go to review someone for the first time on your own. So when you first arrive on the ward, I think the most useful thing sometimes is to just go and see the patient quickly before you do anything. I will then don't even need to introduce yourself. Just have a look at them from the end of the bed and you can quickly establish if that patient is well or if they're unwell, if they're unwell, you might need to go to them urgently or call for some help. But if they are well, you have time, so you can go and have a look in their notes, you can establish their age, what they've come in with if they've already had some surgery or treatment and also just get an idea about the escalation status. You can check in with the nurse that will know that patient better than you about if they've got any concerns. Um And that can be really, really helpful to have to know where you need to start. If you then have a bit more time, you can go onto the computer. Most trusts have multiple different systems to find all of your information and but opening their recent observations chart looking at when they last had observations going on ice, checking their blood and any recent results. Um and going on E mes and to look at, you know, if they're using a lot more analgesia than expected. So you can write this all at the note before you actually go in to see them. Then you go in and you can take a structured history, speak to that patient. I just a pain in this example, but it's really good to have a framework. You can go through something like Socrates and do some for associated symptoms that you might not have met this patient before. So it might be useful to get a collateral history, especially if they look a bit delirious or you don't know if they can normally mobilize. Um And you can establish if anything new is changing. Um It is useful to check their relevant past medical history as well because what they're complaining of now might not be relevant to what they came into hospital with. Um So it's useful for you to have as much knowledge as you can whenever I'm on call, no matter who I'm seeing, I do an A to E and even if they're not unwell or, you know, acutely unwell, I think this gives you the best framework to not miss out anything. And, and it's a really easy way to document it in the notes. So this is a very simplified version. But I know from if they're talking to me, the Airways patent, I can then go on to breathing. I can have a look, listen and feel of their lungs. I can check their respiratory rate and their saturations. If I'm happy, then I can move on to see. Um I can check their heart rate and their BP, they might have a cannula in, they might be getting fluids, they might need some more bloods to be taken, but I can do a fluid assessment and check their urine output um and the capillary refill time. Um All of these things can help me establish if there's any other concerns at this stage. For me and D and disability always check their G CS. Has that changed? Has it dropped? Um have a feel of their abdomen, check their blood sugar if it's relevant. Um And then e check their temperature, look for any signs of bleeding or swelling or rashes. Um And I think if you manage to do all of those things. Roughly with everybody that you see, it should throw up any red flags. And even if you've just got somebody to do the repeat observations, you can fit that all into your A two E and have an up to date idea of what might be going on with this patient. And um it's just, I think a good framework. I might miss some things out but you get the chance. OK? This is a bit of a busy slide, but this is just an example because I was talking about fluids before and how I would roughly go through it. So if I was being asked to prescribe fluids, this is obviously maybe a little bit overkill. If somebody's just on maintenance fluids, you don't need to do all of these things. But it's just to illustrate my point of having a framework. So in their history, check notes and the plan, what fluids they're supposed to be on, check their allergies and their bloods, check their input output or speak to the nursing team, speak to the patient. Um You know, you worry that they're drowsy. Are they not drinking despite not being ill by mouth, any lower urinary tract symptoms? Do they feel thirsty? Does their not look thirsty? You can do your A two E and I mi missed out on that A two E actually, which I've written it here, check their catheter or for any drains. So that can also be um indicated with their output. Main observations for your fluids is, you know, you worry about your low BP and a high heart rate. Um if they're dehydrated or worried about bleeding and think about all, maybe more concerning one. or maybe this is just that they're a bit clinically dry or they have other things going on. But that ultimately from doing your history and your examination, you should be able to consider and throw your neck really wide for as many differentials as you can think of. Partly because it's good learning practice. Um, and then think about how am I going to establish between these differentials and what investigations might help you to do this ultimately. Um That is how you start to make a plan. This is another thing that I think when you are reviewing somebody on your own as an F one for the first time, it can be overwhelming, making a management plan for the first time. And so this is just and a brief idea of how to go about doing it. Firstly, you can say that someone's in pain, you can give them analgesia or if they're vomiting, you can give them an antiemetic. You are, you know, qualified to provide symptom management. You might be thinking right? This patient might need some more investigations, they might need to repeat observations in an hour to see if things are getting better or getting worse. We might consider doing bloods for looking signs of infections. We might think you might start to think, oh, they need some more imaging or other special tests. And that might be where you would probably discuss with your senior. And think, do you think this is, um, you know, necessary having that list of differentials in your mind is a really good practice to start thinking about what could be happening. I think it's good and I think seniors really appreciate it if you go to them saying this is what I've done. This is what I found. I think it could be most likely this and this, but it could be this, this and this, my plan would be ABC. What do you think? Does that sound? OK. What would you do differently? And it just gets you into the practice of making those plans but doing it in a safe environment and I just think it's a good way to learn. Um It's sometimes hard to when you don't know, you don't feel like you know what you're doing. Um But it's just um I think seniors really appreciate you trying as well. Next, I think it's important to say to get your plan. For instance, if you have given a patient paracetamol because they're in pain, it's important to write in your plan. Give him paracetamol, recheck pain score in an hour. If pain score not improved may need to escalate or recontact me because that might change if it goes away with simple paracetamol, you might be satisfied if it doesn't, you might need to do either give them more analgesia or think about doing more investigations. So it's just useful to safety net, your plan, um and helps your nursing colleagues as well to know what, um what you, what you're thinking and what you need to do. So that leads us nicely onto documentation. Um It is good to get into good habits early and it also, although it feels sad to say it helps cover you if anything goes wrong and helps you feel better about um leaving work if you know that you've documented everything to the best of your ability. So making a good entry in the notes, um I have just put things and I think this is nothing new to anyone, but I've just put um as a reminder, everything that is good to put as a good entry in your notes. So your date and time your name, why you're asked to see the patient if you can a brief history um of what's going on, what you're going to see them with when they're acutely deteriorating, write out your HIV assessment, any investigations they've already had and what the results were. This is where you can write your impression and however many differentials you like you're allowed to be wrong because you're an F one or F two or me as an ST one. But it just shows that you're throwing your neck wide and thinking about loads of different options and then you can write your good, logical, safe management plan based on your impression. And if you're not sure. And I think, I, I mean, definitely in obstetrics, I discuss most of my management plans with my seniors and I will just write my discussion with my senior and any adjustments to my plan that they've made. It's really, really vital that you leave your number, um in case the board needs you again. Um Or if somebody wants to question something for better, worse about something that you've written, they need to be able to contact you. Ok? So that's like an ideal entry. And if you can get into a good habit, it, it, it is good and this is very different to when you're running around on a ward round, which sometimes might be on an on call when you're chasing a consult ground, trying to document everything that they're saying as they're flying around patients 100 miles an hour. And I just wanted to put this here so that you can establish the difference between how you might document on a ward round if you're a patient independently. And, and this framework really has helped me, you know, time and time again again, the situation you want to put all of those details, if you can prep the note that's very helpful because then you can work out the date of the operation and how many number of days they are postoperatively and then going through this soap format. So if you manage to get down how the patient thinks they're doing, how the patient looks to you or what the consultant or how they look to the consultant, two different things, the generic assessment. So the new score and the consultant examination and getting in the plan if you manage to get those things down, I think it's a pretty good. So um I just thought I put this in here as a useful way of documenting this up. Ok. Oh yeah. And if you can get the discharge plan in at this time, that can help later when you come on to discharge letter? Ok. Another thing I'll briefly say we're having a radiology talk, but if the consultant would like some imaging, just ask why in that moment and try and document it because when you're requesting an image later down the line, um it's really, really important to know why the patient needs that imaging. Ok. Um I, I'm gonna go on to discharge letters. Any questions at the moment? Oh, and I've just seen one. Sorry, so sorry. Mine wasn't on my list. Does it help to get your history from referring GP over the phone, including their clinical investigations, differentials before you see their patient? So, um thank you very much for this question. Um I guess it depends on where you are. Um So if you're on call in the hospital. Um, you might not, especially overnight, you might not have that opportunity. I think if you're struggling to get information about the patient, for instance, what medications that they normally take, or if you think it might be relevant to something, if you're able to call the G GP, it can be really useful and to see what they've already had. And especially if the two systems aren't linked. So mostly on ice, you can see investigations that have been done in the community. Um but not always where it is useful, sometimes speak to the GP is if you're in A&E that's not really related to right now. But if the GP is referring a patient in, I guess if they might refer, refer them straight to the surgical assessment unit, they sometimes send them in with a letter. But if there's anything querying, then, yeah, I think that's completely now it very understandable to um call the GP if you can get in touch with them and not stay on hold. I hope that's helpful. Right. Discharge letters as I mentioned before, not always the most urgent task on call. Um but sometimes it can be necessary for flow or if the day has been really busy to help patients get home, I think as an F one and going forward, it makes up a huge amount of your workload. And so it's really good to have a structure and understand why you're writing thousands of discharge letters. I think something that I didn't really realize I would have to do would be to write letters to patients. I didn't know. Um, and especially when you're on call, you can often get asked to write patient, write letters to patients that you don't know. Um I think in community they maybe sometimes think that we only have a discharge patients that we've personally known and, and I can imagine as a GP it does get very frustrating to have minimal information on a discharge letter. So just try and go through everything in the patient's notes to the best of your ability within the time that you have. So your role within the discharge process, they're sometimes called TT OS um is that there should be an electronic letter template that you would be shown when you start work, all of these things, but not necessarily gonna go through is basically what you're aiming to put into that electronic template. And it should have boxes for you to fill in most of these after you've done this, it doesn't end there. It normally then goes on to the nursing team and they write all of their specialist um comments about the nursing stay. And if they need to do any community nursing referrals, it then goes for an MDT review where the physio might have to check that the patient is safe and mobile to go home. And then occupational therapy might have to check the home is suitable for that patient to go into. Um, and that can also sometimes cause delays and after all of these things have happened, it goes to the pharmacy and, um, you often get, I mean, I've had it before and I'm sure others have the streed bleep or did you write this person's tt and that's because something doesn't match up. Um, and that can be basically where there've been changes to the patients inpatient medications versus what they were on before they came in or there are just errors as you've been transferring over medications. Um, pharmacy is normally really good and patient about going through it with you, but just checking why there've been changes and have to highlight them. Normally helps this process with the controlled drugs. You'll need to write out the TT S with what numbers and words and this can sometimes cause delay again. So just I'm gonna briefly mention it here and hopefully that will help this process, but it is, it is sometimes quite a painful one and then the patient can go home. So a little bit more about the letter information again. Um, I'm gonna kind of fly through this because this all should be in the proforma. Um, but it's just basically to have a framework that so that the GP and the patient when they've been kind of sometimes having a lot of information thrown at them and a lot going on in hospital understands exactly what's happened to them while they've been an inpatient. Really importantly, it's important to highlight any outstanding results you're still waiting for and any repeat tests that might be needed. So for instance, if someone's dropped their HB, but they're still safe to go home, they might need to repeat HB in two weeks. And again, highlighting any treatment that they've had medication, it is hard. And that's why I mentioned before about in your documentation of changing prescriptions, try and make it clear why things have happened because that can help whoever's writing the discharge letter to know if that's something that needs to stay changed as an inpatient or can be reverted back when they go home. Um The other thing is VTE, so that's your venous thromboembolism check. So your prophylaxis, if they've had major surgery, they might need to be on BT prophylaxis for more than six weeks. The POSTOP note will tell you and consultants will specifically highlight that in their notes can also be important for patients who are already on their own anticoagulants to know when to restart them. And also knowing how to refer to Warfarin Clinic and that can help get patients in NRS back up and running. Um And they're just other things that always catch you out at this stage. Um Again, um sometimes resuscitation often can change when you're in hospital, big operations or cancer patients on surgical wards. These conversations do happen and need to be documented even if you've not had them yourself with that patient. And the GP needs to know about that significant other events. You know, if there's been any problems with their care, any complaints, this could be a useful place just so that the patient recognizes it, being noted. Follow up is hugely important. So your letter should go to the ward clerk who can book in for the patient to have their outpatient follow up after big operations. Um And it, you just might need to check how that's organized within the department that you work in. It's good practice to write if you know who went and where they uh um follow up is with and they might need um x-ray looking on the system already so that they can have an x-ray before they come into clinic for orthopedic patients. Commonly, or they might need to repeat bloods before their clinic appointments as well. Commonly on surgical jobs, patients might be required to have an outpatient colonoscopy. Um And you need to know when that's gonna be and they sometimes need to take their bowel prep home with them. And more importantly, specific instructions on how to take their bowel prep. Um So these are just other specific things I think quite good to be aware of. Finally, again, actions for your GP, I imagine GPS get hundreds of these letters, all of different, varying. Um what should we say? Detail levels of detail? So if you can highlight what you really want to happen. It just means that your GP knows and that you don't put all of this effort into then not being able to find the information. So I hope that was, that was a whistle stop to on TT Os. Um But I just think as it's such a huge part of your workload and it kind of comes into your uncles, I think it's important to um, together just a couple more questions. Um I've just seen in the part in the chat, um, does on call shift cover the night shift. Yes, I associate nights with on calls so an on call shift tends to be when you hold the bleep. Um And your day on call might be a long day. Um Different hospitals very slightly but like a 12 hour day, 8 to 8. Um And the night shift again, you'll be handing your bleep over to that night person when they come at 8 p.m. and then you'll be handing it back to the long, long day on call person the next day. Um So yeah, I tend to say you're on call during the night as well, hope that's useful. Um And then, um just a bit more about including the refer is collateral data as part of your clark thing. I think as long as you document where the information is from and um what's happening, um I think it's completely understandable to, yeah, all of the information you get as part of a collateral history, especially if that's from the, or the GP. I believe that's fine. I hope that answer your question too. Right. I'm gonna just now to finish, talk about prioritizing and how to manage the workload when it gets busy. So we started at the beginning with this jobs that you get in very quick succession. Does anyone feel any better about what you want to do with all of these? Do you have a bit more of an idea? Hopefully about how you would manage each of these or who you would go to, um, for help? Oh, that's hopefully a bit better. Um, I think it's still completely acceptable to feel overwhelmed. I think if I got all of these six jobs to do in the first half an hour, despite having been working for five years, I still would feel overwhelmed. So I think it's, I think it's um, understandable, but I just wanted to go through what to do when you do feel overwhelmed and how to get some help if you need it. So these are probably some of my, I mean, there's loads of tips but these are some of my top tips that I have found really help me when I'm on call if it's your first ever shift. Um, or even if it's not, I sometimes find it's useful to go around at the beginning of my shift and leave a piece of paper at each of the main nurses desks. Um, someone taught me this tip of an F one and I still do it to this day. So if you leave a blank piece of paper and at the top you just say any non urgent task and then leave your name and you'll bleep and the, and tell the nurse in charge or the nurses around that you've done this, what this can help you do is um instead of getting bleeds every time someone might need maintenance fluids or um you know, uh something that might need a sick note when they go home tomorrow, this just helps um non urgent tasks be written down by the nursing team as they find them and you can walk around then and when you're next at that ward, if you've got the time you can go through that list of non urgent jobs and get that done. So you're not just getting bleeped repetitively for things that you think. Oh, this isn't so important right now and I've got a really unwell patient. Um And also I think it really helps me familiarize myself with my environment when I'm in a new hospital. So going to each of the wards at the beginning of your shift just helps you work out how you get everywhere where you can take the stairs or you might need to take a lift and helps you avoid getting lost. If you're running somewhere in emergency or walking quickly. And it's a great opportunity as well for introducing yourself and your stage. So if you can let the nurses know. Look, I'm Jen. I am um, a new F one and this is my first ever on call and now you've met me, I'm gonna try my best, but I'm still working out how things in this hospital work. It's just a good, a good idea to let the team around, you know what level you're at and what competencies you're at. And also if people can help you, then they're a bit more like you to, if they know that you're scared and you're new. And I think this next lecture is hopefully gonna help you more. But getting an understanding of who can help you when you're on call and you've got this sleep and you're walking around the hospital by yourself. It can feel like you're on your own. But actually there is a whole MDT PA uh MDT looking after the same patient as you 24 7. And that's a really, really reassuring fact. Um So there are so many people that can help you and you should never really feel on your own. And it's also a good idea to make your seniors aware of what your competencies are and also where there might be learning opportunities. So say, you know, the last time you put in a catheter was in your fourth year of medical school and you've not done one in ages. And you're now on a urology ward, just let your sho know, by the way, I'm a little bit nervous about difficult catheters. And would you mind if you've got a time come and watch me and give me feedback when I do the first one and then I will feel more competent and I won't have to call you and I can't do any of them and whatever skill that is, I think, um, you know, it's just useful to flag where your competencies are and completely normal cannot stress how important it can be to keep your list organized. Um I think obviously can't just redo your list every hour because you'll have so many pieces of paper, it will all end into tears. But if you try and go through it, at least once in the middle of the day, it's a really good practice. Um, at the same time to go and have something to eat and something to drink and go for a week. And it's really common when you start that, you feel like you've got so much to do, you can't have a break unless there are really, really on my patients. And you've got super unlucky. There is always 15, half, 15 minutes to half an hour where you can go and sit down and have something to eat in the middle of your day and have, have as much water as you can get on board. Because you will work so much more efficiently and effectively. If you can give yourself a break. And at that moment, you know, you can go through your list, you can cross out all of those things that you've done and feel great about yourself. And you might realize, which is what often happens to me is that just feeling overwhelmed that I have a lot to do is causing me more stress than what is actually required. Um And when you cut through that mental load and you realize, oh, I've actually only got three things that I can do in this moment or like one thing three is quite a lot and you will feel calmer and more positive towards the second half of your shift. So they are my top tips again, Thursday, the lecture on Thursday, we'll hopefully go tomorrow about asking for help. But briefly, I just wanted to say that if you're not managing your workload and you've got four unwell patients that you don't know who to go to first, you should be calling your senior, either sh or your registrar. Um And even just letting them know is one thing, but also they can help you prioritize, you know, they are more experienced than you and they should be able to help you navigate who might be suitable for you to see and they can go and see. It's never too early to get senior help when you start and you might feel like you're escalating loads initially. But I think that's, if you're being safe, it's not a negative thing at all. Um If you need urgent help, your surgical room registrar is there if they're in theater or they're unavailable, you always have the medical registrar as well who is used to getting called by surgical F 12, I'm sure. And they can often give you really, really good advice if your patient is using highly and you can't get in touch with anybody. There will be a critical care outreach team and that is normally ICU nurses or they do monitor hospital patients who are unwell. And again, you can't call these people too soon. They're such a good resource and most hospitals will have them, obviously, you'll have your crash be. So people are really unwell and your 222 twos or your um like emergency bes and never feel afraid to put one out just to get more hands and to help you as well. Sorry, I heard that too slow. We're nearly there. Now I just gonna talk about handing over. So handing over is a really useful process to share information, obviously, but also for you before you go home. Um It means that you can leave work, feeling happy that someone else can manage everything and that you don't need to worry about it anymore. Um But also you want to make sure that your handover is effective. So it's useful to if you have a moment to organize it before. So, you know what information you need to pass on and you can make that really clear to the person who you're handing over to. Um, if there's any m patients, you should highlight them, even if there's not anything that they need to do for them specifically, just good practice to make sure they know you might deteriorate any tasks that are outstanding as well that you've not been able to achieve or if not achieve to do. If you've been busy, there might be investigations or bloods or, um, imaging that you've ordered that might need chasing. Um, and it's also a really good opportunity just to reflect yourself to think. Is there anything or anyone that I'm worried about from my shift? Um, and it's just a good opportunity, even if it's not the person you're handing over to your other f one friend who is taking over, there might be an sho registrar that you can just say, can I just briefly discuss this with you before I go home? Um, and that can just help get it off your mind so that you feel good going home. SAR is always useful. Um If you're in doubt, if you're calling anyone, if you're handing over anything and you don't know where to start with too much information, just write those four letters on your sheet and go through them one by one and it would always be clearer. So I rebound these when I was doing this talk and I think they're great and I'm gonna try and use them more. So this is just a really useful framework. If you are feeling anxious or worried about work and leaving work and struggling to switch off, just five or six things that you can do as you go home, take a moment to think about your day. It might have been horrendously hectic. You might have had so much fun because you were running around the hospital feeling great at your job. But either way, take a moment, acknowledge something that was hard and accept that it was really difficult, but then try and leave it there. Consider things that went well. Three things. Maybe you smashed and got a cannula in first time. Maybe you had made a nurse friend and you had a laugh or maybe a patient was really grateful for something that you did. That will always be good thing throughout your day and just hold them in your mind. Check on your colleagues, maybe at handover or if you've got friends working the same day, just check. Are they ok? Then think about you. Are you ok? Is there anyone that you need to speak to if you feel like you're struggling? Um which is completely fine and normal and understandable after you've done that, get into the habit of throwing your handover sheet in the confidential waste bin on your way out, switch off and go home. It's time to rest and recharge because you'll probably be back tomorrow and it's really important so that you can feel good when you get home. So, um, hopefully that's something that you can all bring into your practice that is helpful. Finally, I think we're nearly at the end now. Um, it is stressful sometimes. Um, and especially when you're starting new, all this has just been changed over and I think we will celebrate getting through a month of a new job because it can be hard and, and something that I learned recently from one of the ST six who I'm working with is that she finds it really useful to reflect, not only on the things that go wrong, but also on the things that go right, because it makes you enjoy work a lot more and we all are gonna make mistakes, part of the job and you feel like they're high stakes, but it's learning how to deal with those mistakes, reflect on them and get feedback and, you know, have a framework for making mistakes that will really, really help sleep is hard. They didn't tell you about that when you start working and you have to do all of these nights, try and get in some sleep before your first night shift. I think that's just like a golden rule, even if it's for an hour or two IV class and podcast can help as well. And on your night, do something before and after to treat yourself and make sure you do, you know good things on your zero days that can help you um rest and recover and do anything that makes you feel good and just to help you get some balance because it can sometimes feel a little bit overwhelming. So hopefully we feel like we've been through all of these things um today and it's been useful for managing, feeling a bit better about starting work and especially starting your own calls. Thank you so much. Um Any questions um I can go through them as we speak. And also if you want to give us feedback, um This is a QR code, I'll also pop to feedback um link in the chat. Basically, your feedback as much as it's lovely to know for me how you found today, it's so useful for this organization. NSTS was set up for you guys. So if there's anything you want to learn or if there's anything that you feel like might be useful for you, we would love to find the right people to help put on these lectures for you. So if there's anything at all that you would like, um it's really in the feedback as well. Um I am just going to answer these questions. Um Oh, I heard some seniors get very angry if you ask the supervision. Is this true? So people get angry and I think that's true of any workplace. I think it is, um, inappropriate. People get angry when you ask for supervision, especially as an F one. and it makes me a bit sad if people aren't happy to supervise you. I think it's the rare, I think it's rare rather than, um, the rule. I mean, but then be like common. Um, and also about how you ask, I think as an F one people understand and naturally you will need supervision because they would rather that you do something safely than don't do it at all. Um But so that would be my answer to that question is that nobody should get angry with you. You ask supervision in my opinion. And, and then we said, well, if you're not comfortable with performing certain skills alone yet, I think that and it is hard to ask for help. Don't get me wrong. I think sometimes it's not within our comfort zone to feel incompetent. You feel incompetent or you feel like you should know how to do something, but you are learning on this job and everybody has been in the situation of starting a new job and doing a new skill. You need to be able to recognize your limitations and you need to be able to learn, but you shouldn't feel uncomfortable with doing something that's out of your competency. And ultimately patient safety is the priority. And if somebody isn't comfortable supervising you and you say, look, I don't feel comfortable doing this. I think it's about how you communicate back to your seniors. Um And for instance, you know, I'm currently starting to do c-sections independently. And so, and like, sometimes I look at it and think, no, I do not feel comfortable doing this because I can't see what I'm doing. And I feel like, oh maybe is this me being incompetent, but it's really important to recognize your limitations. So nothing goes wrong. Um And it's you get better at asking for help and also having confidence to ask for help is, is important. OK. Um I just have one more thing to say um briefly, which is that, oh, sorry, there's more um feedback here. I think that's the same as before. Um follow us on our um our website should be updated for our new year. So you should be able to find all of our old content on that. Uh um um our curriculum or on medal if those series be done on me before, we're on Facebook, Instagram and Twitter for that. Um And also we're still recruiting. So we have um we're aiming to get regional leads in every medical school and every foundation trust um to seminate information, but also to find out what people want to be taught about. So if you're interested, these are still the vacancies that we have and here's a QR code you can use to um put in an application and our logistics officer will get back to you. So if you want to get involved in teaching or, um, helping to publicize the work that we're doing, um, feel free to get involved. Um, I think that's everything. Oh, just one more question. Um, and then I think we are on time and if you're going, if you're only going to the hospital library after work, can you chase that results from blood tests? You ordered and notify on GP clinicians to act up. And so that's very thorough. Um And you can chase things if you would like to for your own interest. And if they patients that you've been interested in and the next day, all I would say is that when you know, we work a lot and when you finish work, I think it's a good idea to finish and appreciate that handing over. There's always gonna be somebody in the hospital 24 hours a day. So, um you, you don't need to basically, if you've forgotten to hand over something, we've all done it where we call the ward and say I've got to tell you these bloods need chasing that's fine. But ultimately, there is somebody there 24 hours a day. And when you're, we have the beauty that we can leave, work at work, we don't need to take it home with us. So I would, I would advise against just so that you get a bit of a break yourself and oh Yes, sorry let me put my email in the chat so if you have any questions then you can email me just that. Um yeah cool that's me. Ok, I'm gonna pop it back on our feedback slide for two more minutes and I hope you enjoyed it. Thank you all so much for coming.