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welcome Teo Electrify of the on How to Have your Uncle, Surgical Siris, Lebanon Siris And today back by what we demand we've got then who's on the doctors that I've worked in the past? And he did a previous lecture. And in this series and today he's been talking to us about discharges and then how to make the most of our mg t and so think nurses doesn't people joining. But I had a pretty bad and you couldn't, um and she said so So, uh, I have one. Like Gen said, My name is Ben. Um, on done quite a few surgical jobs through my F one F two s. I was really pleased to come help out in these lectures on preparing for your surgical on course. So that's something that we'll probably quite nervous about before we start whack. And so this lecture is gonna be on, um, how to do a concise discharge summary. Um, those are the jobs that I've been through. So done eight months of tea and a on I'm on my general surgery. Blah choir cover urology. Andi, Um, orthopedics as well. General is an F one. You tend to do more award based job. So this lectures focus more on that. And then when you get after 11 surgery, you often get more involved in the clocking. In the surgery side of things. Say this lecture. I'm going to get through discharged letters and then the second section go through how to make referrals on the main people that would be making for us to three. A day to day job will be radiology, and then we want to talk about generally house do especially your fell and then come across like you know what you're talking about. Um, and then we'll finish off briefly by just touching on some of the key members of the MG t that you work with in surgical jobs on how they tend to work. So I'm going to start with a sort of a case again that will work through on sort of talked about discharge letter says we go. If everyone gets their chat box open, we'll do some, um, some interactive slides. It's okay. Just try and keep it interesting. So you're on the weekends on cool is the F one on its one PM the afternoon you've been bleached for about the 15th time today. I am so doctor, this patient needs an urgent discharge. Letter is transport on the way? So they tell you down the phone. Mrs Axes and eight year old lady. She's two weeks after having a right hip done, and she's going back to her care home. Eso If you just open the chat box, what's going through your head when you see when you've got the situation in front of you, how you're gonna what questions do you need to ask to try and prioritize how urgent this job is? What do you think about the care home? What what might need to know? What about the transport? What about the patient? What, you want to ask the nurses about the letter as to just stop trying? Pop. Something's in the chat box. A. So what? You what? We going through your head at the moment? And then we'll get a three. What? I'd approach this in the way that I do it. On what thoughts I would be having say, I've got the chapped box open. Say, fire away any little thoughts? Yeah, brilliant. So Joe said any recent consultant review so That's a really good point. So, essentially, who said she could go home? Is the care home set up? Yeah. Brilliant. Say, have they have? Do they know that they're accepting her back? On what level? Um, ability of accepting this patient back up on issue, medically fit. Brilliant. Thanks. And say meeting on this is how I try Approach this scenario. And so the first three questions that I want to ask yourself is one canister patient, actually. Go home so that that is going to be the yes or no of whether you actually need to do this job or whether you can save time And if she can go home. Who has said that? Has there been a recent war drowned that's documented that she can go home if x ones that, um, at, um or is there a POSTOP note that gives clear instructions as to when this patient is able to leave the hospital? And then if someone hasn't said that they could go, are you comfortable making the decision? Isn't half one about whether this patient could be discharged in most jobs? I would say probably No. You'd want to at least have us a chair or ranch. Either have seen the patient or be discussed with over the phone as to whether they can go home. Um, but for some patients, Northrop edicts, it usually is. Dance. The F ones decide if it's that the weekend if it's a young patient and it's clear from the POSTOP note that they can go home if, for example, they're using their crutches. Okay, you know, a young 30 old who's broken the ankle, that would be fine. And and then what? You need to ask to prioritize this task. So when's the transport coming? I How much time do I have until I need this letter ready? Um, and is there any way that we can delay this? Things that you can think of is whether they care him has a cut off time, so sometimes care homes will accept patients up to about six PM So essentially, if you say you leave in our for transport, you've got four hours to sort out this job. And so if that was the case, it wouldn't be super urgent. And then how long is this last going to take you? Has anyone started prepping the actual information Has anyone started prepping the medicines that she's going to go home on on the most important question when this pharmacy open until I e. If this woman needs something important to go home with, like her VT prophylaxis, are we gonna be able to give it to her? And then just a night like this is something that you will get bugged about a lot in your working day on It can feel like it's not. A very important task is you'll be dealing with lots of other, more clinically urgent situations. But for the nurses, they get a massive, massive amount of pressure from bed managers on D site managers in the matrons to try and clear beds because patient flow is really important. But just always bear in mind like no matter how much pressure you get, you're the one that's making the decision where your time goes. So if you think that there's a job that's more urgent or patient that needs your help before distrust letter Haitian safety is always more important. So there is no such thing as an urgent discharge letter in my mind. But just be clear to the nurses. If you have got other things going on, what you're eating a to the wart is gonna be So you check the names and you see that the consultant for this Mrs exercised She could go home tomorrow to her care home if she's being weaned off oxygen on physiotherapist so happy for her on her mobilization. Um, and she's to complete seven days total antibiotics for hospital acquired pneumonia. So you check through with the nurses. She's being off oxygen for a whole day, the physio happy and that she's not desaturating when she's moving and on the home has a five PM cut off and no one has started the letter s So what's your e t a. The's your current jobs. So from all your bleeps before in the day you've been on the off a war drowned. You've been under urology ward around wherever you've been doing, you've got five things to do. A six year old, he's got 15 minutes of 10, 10 central crushing chest pain. You got some routine bloods that the flaps have missed on there. Ward flat ground in the morning for general surgery gone. Urgent scan that needs requesting query. Perforation. You've got this letter on. Most important, you've got your lunch. So 80 have a think. What tasks might you do from each of these jobs first? And what might you leave later on and and just pop in the chap? What sort of order? Your thinking. I don't necessarily have to order all of them if you don't want. Maybe just which, you know which of the couple would you start with? Which might you leave till later on? If you think you're putting anything that others might disagree with, Why, why you do that? Say, first one and we've got chest pain. Herget, scan the letter lunch, and then the routine bloods. Yeah. And then similarly, chest pain in the urgent scan first. And then it's like a different order. The letters gone to the back for that one with your lunch. Uh, later on. Yeah, to scam request first, the c G. Oh, yeah, organized is so I mean, not that it's necessarily the only way to do it, but the way the art approach is on call would be to, you know, I mean, you have received these bleeps already. Stared hope that for that chest pain patient would already be asking the nurses to do an e c G. That's probably the most important thing because that's going to guide your management for that patient. Then requesting a CTPE should be fairly quick, and so I'd probably do that quickly and then let the general surgical team know that you're busy with this'll a d with chest pain. Review the chest pain patient on. Then this is where this off non. Urgent T t a thing comes in. If you can find time to fit your luncheon on call, just always take your lunch because before you know before o'clock and you just wouldn't be working effectively. So take your lunch, do this letter. But sometimes the pharmacies praising you might want to send the medicines off before you have your lunch on and then think of those routine bloods that have been missed. Will they alter management? If then if they're ms today, you know, is there? Is there a blood test that needs to be done to decide if something come off antibiotics? If so, that probably needs to be done. But if someone just put them out and you can't see why, and there's no clear indication then I'd put them out for the day after. So you've done on your urgent tasks and you're on the way to go see Mrs X and her t t a. So discharge letter or T T O to take away to take out usually is Elektronik and most trusts, and it will be sort of pre made performer that you just fill in. So they'll be different types, so usually be like an admitted patient performer. And some specialties will have their own cause. The only different boxes to be filled in on. And sometimes you can get away with doing a much shorter letter. If someone's only come in for, say, a day case surgery. And within that letter, you usually have sections like their history of state. So what's happened? What investigations and results have happened from the admission what they've had done, what's being treated with operations, that they had any medication changes that we've done? Is that Mets on admission, what they're like VT like they're prophylaxis Plan is for blood clots. Any follow up plan any actions that the GP needs to be aware off any significant events that have happened and what their research status is. Um, and we gave you a Z a bit more detail later, but just to get an idea of what actually happens to a letter. So once you've done all your sections, um, and also at the moment whether whether they've had cave it, whether they've had a negative cable result etcetera on some care homes, actually one another swab just before that sent to check that they're negative. So once you've done your bets, usually goes to the nurses and now fill in sections that might be relevant for care home, such a very nutrition that swallow what their abilities like, um, from a nursing point of view and any, you know, community nursing referrals that might be needed for going dressings and then goes to other members of the MG T, like the physio and the eighties. And then the most important people that it goes to from our end is the pharmacist. Um, you'll often have completed a letter, you know, two hours ago and think you're out of it and you've done the job and then you'll get a bleed two hours later. Hello? Did you write this lady's letter and you're like, Oh, God, yes, What have I done wrong? Um, but they're really good safety that they find things that you might not have thought off or, you know in crack days is if you've been prescribing in a hurry, Um, they then dispense all those medicines and deliver them to the wards on any controlled drugs. So that's any drugs that has to be signed for on signed out of a cupboard and out of a book. And we need to be really careful with discharging patients with these medicines on day. It's really important to check in your hospital what the protocol is for, say, discharging a German orthopedic patient with oxycodone or morphine. Often they'll be a limit on the quantity that they can have, and there's often specific quantities for each drug that you can supply, so you'll need to know. Often, pharmacy will put a list up. You know how many meals the bottles are for morphine, because you need to know what to put on the letter on, and then generally it's a paper copy that you have to sign your life away on with your name the date on the patient address normally has to be in view to make sure it's for the right patient. And then when all of that is done, they get discharged. So, um, what's actually put on the letter? Essentially the way that I think it is. Imagine that your GP and you receiving this letter? What do you actually want to know? Um, she didn't want loads of, you know, massive detailed explanations of what's happened. You want their presents complaint on the date that they came in the hospital. Any past medical history, which is really useful for us is juniors. Looking back at previous letters to try and get an idea of what someone's past medical history is, I'm that actual history presents complaint on then any inpatient issues, and I find it easiest. Just list each of these issues, like Issue one broken Hip on the state of the issue, say whether it's ongoing, whether it's improved and what treatment it had's on whether there's anything else that the GP needs to do for that. Any investigations and results so dangerous copy in order. Blood tests only put in blood tests that are important for the GP to know, um, such as, you know, they had an a k i on their using. These went off. And so you want the GP to repeat them? You'd want that listed in the investigation section and then any important scan results that led to them having, you know, fear two operations on Ben. Anything outstanding so that any blood tests that haven't come back yet, especially in district Hospital, some fancy blood tests like fecal calprotectin and things like that bill, they might get sent off to another hospital. They might not be back before the patient's discharged. Um, and any blood test or investigation need repeating on. If so, who's going to do that? When is it gonna happen? Generally, if it's after two weeks, it's fine to ask the GP to do things. But if you're asking the GPS to do bloods within a week, it's just it's not feasible. Sometimes the GPS won't see the letter for ages, so it's not very safe to leave up to the GP on. Then in the treatment section, Clear like what they had done, You know what date and then the medication, which usually takes the longest first have a look at what they came in on. Um, have we stopped anything since they've come in, have restarted anything new, or have you changed? Any doses of any of the medicines that they were on already on Diffuse have started a new indications. What have you started it for? That's really important. Otherwise the GPS just have no idea. On how long is it going to go? One for? On Don't forget any VT after surgery. So just a example. I won't read it all out because that really boring. Um, but this is what on Mrs Exes discharge letter would have looked like. So what? She came in with her background. Her history presents complaint. And then I've just split her issues into issue One issue, too. So it's really quick for the GP to read. Write. She broke a hip. This happened on. This is what's going on from that. She can feel the weight better on it as she is able. Oh, she was a chest infection because, you know, she develops not strong requirement. She's off the oxygen. Now it's resolving, and she's safe to go home and then in the investigation section. Uh, you know what her chest X ray showed on the fact that in her medicines we've stopped one of her BP tablets because she had a postural drop like that's quite six things and just shows the GP what's been going on Next, The V T plans really important in surgery, especially s. So make sure you check the POSTOP note that will often give you the instructions if you can actually read them. If someone's nonweightbearing, for example, after North Pedic operation, commonly on ankles on bail, need six weeks to go home with, or any major abdomen pelvis operations, you know any big receptions for cancer that often need six weeks as well on just to think when you're going through the medicines. If they came in on anti coagulation, Um, when we restarted after the operation, has the surgeon actually put in, You know, re start on day one or two if dressing clear like you need clearance truck shins is genius to go off. And if it's not clear that something that you need to sort of raised on the ward around to make sure and your seniors you're aware that you're not sure what's happening. Warfrin clinic is different in every hospital. Some hospitals, they have warfarin pharmacists. And so your job is done for you. They'll actually arrange, and they arranged a blood test monitoring. If someone's discharged, they'll arrange getting them back into Warfrin clinic for monitoring. And just in the days on and in some hospitals, it's up to you and the doctors, Um, and you have to send off a formal reports after their admission to the clinic to say what they've had done. You know what? That I now was through that admission, and that's just something to bear in mind as well. And follow up. This should be found either on the POSTOP note or sometimes it would just be mentioned on a random walk around that the consultant is under. You know, I'll follow up my clinic in in six weeks after their discharge, so sometimes it takes a bit of digging, and and again when when you start a new hospital or on a new wards, or even in a new specialty within that ward, you know, how was it organized? Is there a clipboard that you need to put stickers on? Is it an email toe a clinic or is. Does the Ward Clark pick up from the letter and it's all sorted for you and and then just simple questions. Who went and where is following up this patient on? Is there any requirements? For example, a lot of theophylline pedic follow ups will have an X ray when they arrive for their follow up to check that the fracture is still stable and and whether they're, you know, plaster or beat, or something can come off if they need any repeat bloods. I've been caught out with this before. Sometimes they need it for bottom form to take back to the hospital. So don't forget that on dissimilar for further imaging, you know how our GYN is it needed, and is there any preparation needed for it on then actions for GP, so this will probably be mentioned as you go along. But it's there's usually a box in the TT that just clearly says, What do you want this GP to do on? I usually say, Could GP kindly is at least like makes it sound like you're trying to be nice on on things that the GPS often asked to do is repeat bloods. If there's being any AKI or, you know, severe kidney issues. And if there's been any significant change, you know, to the patient's status or, you know, they're now moving to a nursing home because they can't Copaxone with that broken hip, Please be aware this patient is now being careful, you know, in the nursing home on again, just outline, create, be any any medication changes. I'm also seen it in this section is quite useful. You can ask the the GP to clarify something safe if you're unsure why someone's on a certain medication and the patient isn't sure as well. You know, some people come in on anti platelets and none of us can work out why. So it's often a useful just pop in that section. If you haven't been able to get through to the GP on the phone, you know why. Please going to clarify the indication for X ones that on and then coming towards the end of the letter any significant events that happened during admission, So this would be if they're resuscitation. Status has changed. If you've discussed that with them and they're now not for recess. And if you have done that, who have you discussed it with from the family? Is the is the patient in the family aware on? Is that to go until the end of life? Or do you want the GP to review that and at certain time point and then any other significant events, like complaints or anything else that's happened in hospital? You know, like an inpatient fall that's lead to a fracture would be quite a significant event. Endurance. Just make sure that was highlighted on the letter and any investigations that had gone into place for that. So back to Mrs X. That would be what her discharge letter would look like. And every trust will have their own protocol for VT. So when you start surgical jobs, I'd recommend, you know, just asking your seniors. Do we have a protocol for V. T A prophylaxis after operations and just, you know, make sure it's printed out some of the doctor's office because you will tie every single time you write a letter. You'll have to look up, um, until you know, by heart on and then her follow up so reteam hip hemiarthroplasty is don't get any follow up it'll, but because of her chest infection, should want to need to repeat chest X ray in six weeks on. That's usually orthopedics has shared care. S O N E L V Patients are usually cared for joint me by an orthopedic surgeon, andan, or for geriatrician medical consultant. And it's usually the medical consultants that would follow up on any medical issues that have happened during admission on then The actions for GP section on the significant events bet so just a bit of a summary on the sort of discharge letter section that's the first bit done is you can make your life and all your colleagues life so much easier if you're if you're ready and preempt all of these decisions on ward rounds. So if you're seeing a patient on down, you know, one of their medicines has been withheld by the clock and doctor, and it's, you know, day five of the admission and they still not had any of the anti hypertensives. You know, we we're restarting it, or do we want to stop it and let the GP try and restart it if they think it's appropriate? And if they're on antibiotics. Surgeons love prescribing antibiotics without any end date. So almost everyone that comes in through e. D. For general surgery just seems to end up on amoxicillin much night zone gentamicin like it's actual candy on. There will not be it duration on that it would just be indefinite. So just make sure we're asking things like, you know, you can just go to a world if they were discharged, How long would you want the course to be for on different started any new medicines as an inpatient? Do we want the GP to continue this on? Do you want any follow up? So just try and ask those and walk around and make your life easier If you have easy shifts, Um, you often get suggested to prop the TTS. If you do make sure you say really clearly what date you've packed it on. The fact that it was prepped. We had a numerous cases on our orthopedics world where perhaps teachers for patients hey, weren't ready to go home, but we were just getting ahead of the game to crap on. Some of the nurses actually took upon themselves to decide that, because the teacher had been prepped, we decided that the patient could be discharged on. The consultant came in the next morning and just found that two of the patients had left the hospital and being discharged to a nursing bed in like a rehab hospital on. They were mad because this patient officer was not mentally hospital. Say, if you are prepping, just be really clear on always keep in mind is that you know the nurses will be hounding. You feel letters, but at the end of the day, patient safety is much more important. So and before we move on, Teo, the rest of the talk does anyone have any questions about and very exciting world of discharge letters? And, um, but my last talking Abdo pain and vomiting was a bit more exciting, but you will actually spend most of your life doing secretarial jobs like this instead and right, so that's any questions that moment. But fire away later, and we can always do questions at the end. If anyone does have anything to us say next, we're going to radiology referrals on the members of the MG T. I'm so radiology. I just sort of wants to go through simply, You know what actually happens when you put a radiology request in and what you need to do. So some words that will be floating around and you went round stuff. What's happening? Well, at least I didn't because I wasn't particularly, uh, active student at partaking and everything. And requesting means that you put a request in for a scan. Vetting means that you put a request in, but you need to get a radiologist s 01 of the doctors to actually look at your request and say, Yeah, you can have that scan or no, I don't think that's appropriate. Accepted means they have accepted your request and they said they'd do the scan, but they haven't said when they haven't said, you know, how we they're gonna arrange that rejected means that someone has looked at that request and thought that's not appropriate. Sometimes they'll reject it with a message, like know, appropriate. Please consider this or sometimes they were, just reject it out right. Often, this is things like and say in general surgery for patient has had an MRI C p m. You know, to assess for gall stones and whether they're gonna try and do any intervention on a consultant will sometimes request an ultrasound after this, which is a bit of a rude movies that's really not gonna add much that will often get rejected without an explanation. So if it does, just phone up and ask why? Um and just say your consultants asked for it, and then once you've got an appointment, that's when it's being booked in. Um so to go into a request is almost like a Mini s bar. So you know what the patient's age is, what they came in with and what they're currently complaining off. If they're different things, any recent operations or treatments on, then how the patient is at that moment. You know what your examination findings are they really unstable? Do you need a portable X ray because they're on 15 liters non rebreathe, and they're really struggling. You wouldn't want to send them down to the department. Onda. Most important things put in his wife this scan. So why is this scan going to tell you the answer? And if so, what do you want it to tell you? So what? Your differentials, um, is it urgent. Have you discussed it with one of your seniors? That's a common question as well. If they see a request from F ones, just flying in for CT abdomen, pelvis is or you know CT hips toe assess Fall on the ward. They'll want to know whether you're registered. Know about it, Um, and then they'll be sections for your name, great and bleed number and then just a native full radiographers, and they organized the scans and perform the scan. So if there's any scam that you need out of ours such a chest X ray, that's a simple scan, so you don't need it vetting, but you need to chase it up. Then that would be the radiographers that you would sleep or contacts to try and arrange out of hours or urgent scans. And and they're useful to go to If you want to chase appointments for scans or, you know, if you booked an outpatient X Y Z that have they got the request? Do you need to do anything else and a few things that will catch you out when you start? If people going for any scans with contrast the radiographers and radiologists like a pink cannula in the a C F. The contrast to go through on that's because they need the contrast to go in relatively quickly in one bolus into a large vein in order to get the correct imaging on and Siris for, like CT. So I'm a rise. If someone's using these are particularly bad or they've you know they got a K I. They've got CKD. Different trust will have cut off levels for creatinine or E J f. R is to when they'll let let the request go through without a discussion on, you know, say once the grass needs 150 and you need to discuss that with the radiologist because you're really risking worst thing of their kidney function. And is the scan actually gonna give you enough benefit to do that risk on? That won't be your decision. That would be between, you know, if a consultant on the radio radiologist often if if they're borderline, the radiologist will advise doing sort of IV bolus need a pre and post contrast. So, you know, 500 more bag before and after, if their hearts okay, um, broke, so we'll have a practice. This is one of the cases that I used in my last teaching session on abdomen pain, and so I'll leave the information up. Um, if you were here a couple of weeks ago, you might recognize this history. If not, that's all the information. So you're on call and you've reviewed this 59 year old man who's presenting with worsening abduct pain over the last four hours. He's five days after a big operation for cancer. Um, you've started initial management. You've let your Reg know he's agreed that you think I have. This could be an anastomosis leak or perforation. Um, he's busy in theater, but he wants you to order an urgent CT abdomen. Pelvis. Um, you can either just write it down on a piece of paper or, you know, type down on your phone or just think through in your head What? You're right. Or if you want to share with others what you think it puts right in the chat box. I just give you about a minute, minute and a half or so. Just have a look through that information. Try and draw out what you think. The most important parts put in on public in the chat box, and I'm gonna have a set of juice. Okay, Office. It be easier when you're doing on a system, because I'll be usually set boxes to fill in. Um, so I have a thing. What? Put in the main information box? Are there any investigations that that want to know about, um, on? Do you need to find anyone to discuss the request stuff? And I hate That's an introduction to your request, as it is at the moment, that might get rejected. You might have an angry radiologist on the fame. Okay. Yeah, drive. No one wants to share. Well, that probably I'm giving you enough time. Hey, big guy. J. Bradley. Thanks. Day. Um, fine, Uncle Radio just yet. You want anergic ct for 59 year old? Now he's postop hemicolectomy. A different diagnosis for legal perforation is creatinine. And that you discussed with Reg. That's pretty good. So that's that's all the main things that need to put in the request. Um, on d. Um I mean, I didn't do this in a rash. Say, I've got a few more words in line, but you've got all the saving it paints points j. So this would be a request for 59 year old who came in. Um, he's presenting with worsening severe abdominal pain in these five days after operation. It's really important to that in there, but he's he's septic. So his observations a really unstable on you. Worried about her partner Abdomen. You discussed it with your Reg, who's advised. Just do a CT PE to rule out a week or perforation on. Do you want to kind of persuade them that he if you know, as long as he is that he is stable enough to come down to CT to have the scan done on? But you know, you could say something like he's received a fluid bolus, and if his BP was a bit battered, want to put that in to show that he probably is stable enough to go down? And because you're getting IV contrast, it will flag on us for a creatinine. And the date that this Waas on different trust will have cutoffs is, too. When that crass he needs to be your name, your grade and your bleep number. Make sure you call the radio just to get vetted on. Then check if they would like you to contact the CT department to talk to the radiographers and CT scanners to make a, you know, case for getting this done urgently on then. Most importantly, let the nurses know what the plan is because there would be ones organizing the transfer. Say that's been about radiology, and we'll do questions for radiology referrals and MDT right at the end and especially your Pharaoh's again. They take up a lot of your time on call and on the day to day war job, and it'll be different in every single trust that you go to. And when you start a new job, you have. You go back to basics, so find out how it's done and how it's done for different situations. So often. There's Elektronik systems for some trusts, and it's just a template form that you send off some trust, have paper referral forms for non urgent you know, referrals. Some will have emails instead, some will have phones, bleeps, go three switchboard for urgent or non urgent things. They just find out how it works in your trust, but generally in any referral you want to, you know? Think who, What, When, Where, Why and how So, who you referring to? Do you want the acid Joe to make a referral to, you know, surgery? Do you want the register? Come and help you with the catheter you can't do from urology. Do you need the consultant microbiologist? Cause it's out of hours and they're the only person that's working Core. Can you refer to you and the nurse specialist or, you know, the Azor mental health? Like which best teacher one on, then within. You can refer so sometimes out of ours. In some trusts as an f one, you won't be allowed to phone the microbiology consultant on call on. Now they'll say that it has to be a registrar, which is ridiculous because your ritual no less than you about the patient because you're the one that we have been seeing them and then just be really clear about what you want. Do you want advice? You want to take every care you want them to arrange? Follow up Howard gently. Do you want it? Where do you want it as an inpatient and outpatient? Why you referring again? One of the most important things on. And if you're not sure, ask your senior And if they can't tell you maybe think Do we actually need to be referring this patient and and then just, you know, some things, like, you know, how do you know when it's been received? Is it something you know? For example, my trust friend oscopy? We do on pink cards that gets sent there on they get lost all the time, so we tend to phone day after and just check that the pink guards being received on whether they've got a date for the endoscopy. And if you're doing telephone referrals, there's obviously all really important things to think about. But they're usually the best way to present. Your information will be in an S before math. So, situation, background your assessment and recommendation what you want from them and try and get infected early on. You know, if you're referring, you know this. You know, if you're feeling that chest pain, ladies, cardiology, you wouldn't start with this lady came in two weeks ago and broke her hip. She has had an operation on. Then she got a chest infection. You know, they've already lost interest. So you want to start with, like I've got 89 year old lady with possible question hypertension He's presenting with 10 out of 10 central crushing chest pain like That's like they're like, Okay, cool. I need to pay attention now just make sure you give them, like the most important information for their specialty. First, to try and get them interested in what Your A fairing So just it's about the mg t next. So, obviously, in a lot of surgical jobs, the physios and eighty's are like, absolutely crucial in both recovering from operations on discharge, planning on patient flow. Um, you know, so physio will, you know, make sure they're comparing patient's current mobility status after operations to what their baseline waas, whether it's safe for where we're planning to discharge them to. If it's no, Do we need Teo? Give them extra care at home? Or do they need to go somewhere else, such as an interim, you know, rehab facility? Or do they need to go to a care home for full cars? Um, generally, most hospitals, they'll have a way of grading ability, so it's usually independent. Stick stick plus one plus two and then Zimmer, plus one plus two wheelchair bedbound and in orthopedics jobs. Thie. You know the most conversation that you have disease will be what patient's weight bearing status is. This should be on the POSTOP note. If it's not, make sure you ask him or grounds. Just preempt it because you will get asked by the physios. And they will be annoyed because they cannot do that job until they know whether a patient is to touch weightbearing. So they just put they can use their leg just tapping their toes down to balance. But I can't put weight through it or whether they're weight bears tolerated so they can put weight through their leg and the only as pain allows while the fractures healing. Or if they're fairly weight banks, they just want around. And if it's not documented on, you're really busy. And, uh, physio asks you, you know, you can ask, you can apologize and just say, you know, it has not been documented anywhere. But could you please fill in the consultant cause I'm busy like they're they're well able to faint consultants, um, and then occupational therapist office. You work in conjunction with them as to any adaptations or equipment for the home, whether it will delay discharge and can they wait somewhere else on Do things like, You know, kitchen assessment and things like that and the surgical nurses and other people in the ward of really, really helpful, Especially when you first start a new job because there's so much more experienced than we are. And so they're helpful for a lot of things going I/O of a patient. So dressings, drips, drains. What, what's draining? Where from, how much is normal, what color is normal and catheters on any lines there in, You know, pick a central line is a PICC line, but is only for TPN. Even I had a lady today who I got asked Cannulate and I turned up to cannulate her, and she's got a PICC line in. So I was like, Why, why we cannulated this lady? But it turns out they were saving both of those lumens. Even that was Julian purely for TPN on peripheral canula for antibiotics. On that, any use that as a last resort, so she needs to can access a swell on do other people that could be re help from awards. As the Ward Clark's of really useful in some hospitals, they will literally just read your letter and arrange all the follow up for you. And it's having any computer problems. If you having problems chasing scans, they'll often know the shortcuts to get through to, you know, their power. Jenny in the scanning department that they've known each other for 30 years so Jenny can get that scan for you on If you're clocking Who patients come in under under which consultant under which specialty and where the Raiders are like they're just brilliant and then equally as helpful. If you can find someone to do, it would be a healthcare assistance or nursing staff for things like blood cannulas or E C gs. And that's only if you can find someone that will do that for you. Often they claim they don't have the training. Um, and then, honestly, the godsend for your life will be the phlebotomists good for what's misconceived hours of your day, and most hospitals will have a phlebotomy ward rounds once or twice a day. So in the morning in the afternoon, I'm they're usually requested today before and print stuff into a folder of clipboard to tell for bottom issue. Know who wants you need bloods and what they need to know what bottles to get. Um, on day, one thing to mention I've had, you know, friends on surgical jobs. Before that have the culture of the hospital will be every single patient gets a blood test every day on a surgical job, which is just ridiculous because you know that that cannot be needed at the end of those blood tests are gonna hold to management every single day. So if you are on wardrobes on, actually quite scary to sort of stand up to a senior or question of management plan, But just having the back of your mind, will it all to management? And can you ask? Oh, you know, they've had a blood test today. Could we maybe check that CRP in two days time instead of, you know, they don't like needles or something. And any unsuccessful bloods from the phlebotomist will come to you. But how do you know? Sometimes they just leave it on the back on the side, and you will honestly find that you try to chase these blood tests at two or three o'clock in the afternoon, and you find out that there are five blood tests today on sometimes that'll urgent. So you end up doing a last minute phlebotomy rounds, and everyone just has to grab a blood and go, and it can be really frustrating. But they they do work really hard, and they often have really strict rules as to where they can take blood from. So, for example, if someone's got fluids running and bathe a CFC on, they're not trained to take from the hands. They won't be able to take those blood tests, and that's phlebotomy, and they tend to be in hours then clinical support workers tend to be quite highly trained at lots of other skills as well, such as cannulas on BCGs and they often on a bleed out of ours for surgical jobs. And the nurses will go to them first. For you know, blood tests that in any doing such a gentamicin level, or can't even it's failed so often out of ours, you tend to just get the you know, cannulas they they can't manage, Um and then don't forget if you're unsure what blood bottle to do for you know, a random cancer marker for your consultants asked for an award rounds just fame, clinical sciences and ask them what they want on. If any tests aren't back or you're not sure whether they've Bean received in the lab on that often really good people to get a T on, then this will catch everyone out. But group and saves are so time consuming, but obviously for a really important reason that you don't want the wrong person to get the wrong blood. So most trusts. They have to be 100 straight onto the bottle with no stickers, obits of paper, no spelling mistakes. They have absolutely no only way they will not let you go down and change him. You're writing on the bottle if know if they've never had a blood transfusion before, they'll need a first sample taken by one bleeder on a second sample taken by someone different. So you can't just put both out for the phlebotomy team. You know, one of the doctors will have to do it, and samples tend to stay a relevant for seven days, and after that they'll expire. So if if someone does need a blood test, don't just prescribe it. Unless you're sure that they've got a recent group and save just phone blood bank and ask, you know, do we need any more? Because sometimes if they've had three units of blood from the most recent creeping save, because that can introduce new antibodies from donors and they'll want a repeat sample, even though it has been one within seven days. So it will catch you out one point. But just just try and fame Blood bank early on, if you've got any doubt and microbiology again, really, really useful, very helpful when there's a complex, you know, microbiology situation going on. So if someone's had lots of previous culture sent or you know you're treating interrupt on the sepsis, but they've also got a chest infection or you know Alpha faction or something in the guidelines aren't clear, they're really useful to go through. They tend to be in May, stressed through through a switchboard or help line. Um, and it's in ours. That'll be registrars and consultants. And then out of ours, there's usually introduced staff. I'm microbiologist, known for sometimes being a bit sort of hard of junior's down the phone. Um, so just try and make your your case for phoning as informative of possible. So make sure before you found you, you've kind of got in your head and aspirin ready. You've got the nights out. You've got any relevant investigations up on the computer so that you're ready. Toe. Have a detailed chat with him, Bob Patient and trusts I've worked in say, I worked in leads last year and Harrogate this year used micro guide, which is really good up. Um, Andi. It takes you through each body system, or it takes you through different sepsis guidelines and tells you which antibiotics to do as the all swaps. It's really, really good. And if it's not clear, heavy infection has come from, just make sure you've sent off the relevant things before. Cause Micro will ask you to do. It's a blood cultures year and cultures you've smoked any wounds or anything that has passed coming out of it. You've done a chest X ray, and then later down the line, they may advise you for, you know, searching for more weird and wonderful things like endocarditis or meningitis and things like that. Um, another group of people who are very lovely. Usually the cancer service team they often compromise comprise off specialist counts, nurses that usually available for sleep or telephone advice. Often they know the patients from the community, so you know they'll be the lung cancer specialist nurses who would have been looking after patients for a number of months or years. And they tend to know the patient's well before they even come in the hospital. Um, on, depending on the trust, nothing that they'll come around into war, drowns and reviews to stay in touch with the plan and similarly on college in hematology. And you will get some weird mindful for a full blood counts back in your day. And he told you, consultants will just know what to do on your way to say feigned them and and then often for any cancer is there's usually just a referral form for an MD T. So where you think that if there's a primary cancer that's come, you just refer that to that specialty. So I you found a lung nodule on the CT abdomen, pelvis, thorax, and I've just found it in the lung referred to the lung MDT. And if there's if it's unclear where the primary is, so you're not sure where that's cancers come from or it's in two places at once, and it's the first time anyone's found it. You often referred to the cancer of Unknown Primary or the Cup team. And then obviously, when patients come to being discharged, the cancer services of Brilliant, that for following up the patients and making sure they've got, you know, clinic slots or a telephone appointment done. Um, Andi palliative care. And one thing I want to just sort of drive home with this is that they're no only there for patients that you've deemed to be a the end of their life. Obviously, that's what they are brilliant, that managing they come in from all angles on the really good at providing advice for symptom. You know, comfort, control. Um, and often when you start, it can be quite scary. And to be looking at the the amount of morphine that some was being prescribed. And if you get asked, you know, if you're in trust that has paper drug just, you know, rewrite the drug chart. and, you know, I sent someone home today and has to a community palliative care of pharaoh drug chart. And it had 150 mg of morphine in the driver just for a day. And, you know, you read anything. Actually, they mean 15 or you know, that can't be right. But, you know, they do work with really big doses. So there really useful to get advice from early on and and often they'll come around and do wardrobes either with the nurses or joint with the consultants to check that everything is being managed well by the home team on Def Family's Got any issues? That was a really good It's off. You know, chatting with the families and the patients is to wear that, prefer to die. So if that is in the hospital, because they feel more comfortable there have we thought of everything that we can to keep them dignified and comfortable, You know, if we got the Messiah dream have re stopped doing, you know, routine things like blood pressure's, that's heart rate. You know, that's not going to really change anything that we do. We changed that to comfort survey shins, so you know, instead of going and doing with that, obviously ask you in pain. A me thirsty, you know. Do you want any mouth care with this Forbes Things like that on down, Obviously, the anticipate treatment sins which just treat each of the different symptoms like morphine for pain. Um, and as long for agitation usually trusts. If you're like enough to have an Elektronik medication system will just have a protocol that you take. And it has all of the relevant medicines on it for the specific kidney function, as that's really useful to look out for on defense is home. You know, they having community palliative, careful out there. They need any nurses to go in like they're teaching. I did today. Do they need some anticipatory medicines prescribed or syringe drive of prescribing on defense Hospice? You know, they're really good organizing how to get in there on last night. Least don't forget the family. I'm especially at the moment. I mean, visiting was getting a bit better in our trust, but I know some hospitals are still being quite strict with visiting hours. It's been so difficult for them to you know, it just picture how their family member is doing without seeing them on bats. Made conversations over the phone about patients that are dying or, you know, difficult medical decisions that have been made. It's been really difficult families, too, you know, to accept that because, you know, the last time based on them, um, you know, she was out of Tesco doing her food shop. Where is at the moment she's, you know, unresponsive. GCS four on I'm trying to tell them that, you know, were withdrawing a care, withdrawing antibiotics, and we think that she's approaching end of her life. So that's being quite difficult in terms of family updates generally, and they'll just find the ward and the nurses will give them an update on def. Nothing's changed. It's just ongoing day to day care. You know, the things that families once know about most is, you know, other eating, other drinking, they sleeping, Have they got any pain? And we won't particularly sometimes know that if we have not done the walk around that day for that patient. So the nurse is a much better place to give those sort of updates, and but if anything has changed significantly, in their plan or how they're doing like their state. If they're becoming a stable, deteriorating and all, they have a significant event that the found we need to know about such as a full, you know, or or worse. Or death, you know, actually, probably come from a doctor rather than the nurses on through your ass. One and you will get, I think, before I start stuff one, I thought, Well, I I wouldn't possibly need to be having, you know, DNA our discussions with families or telling them bath news or new diagnoses. But I think it's actually become more confident through the year. You just learn so quickly on you will be in situations where you're breaking really quite bad news to families or, you know, explaining the diagnoses. But always have in the back of your mind, especially explaining scan results with new you know, lesions on everyone's question will be well, Is this cancer? If you don't think you can answer the questions or you know that you don't have enough knowledge to answer questions, just make sure you relate that to your register and just let them know that you're not comfortable doing it And the I didn't get the family so but for some reason, just for the last bit of a lecture. So if you ask her for someone, make sure you know why. So you can do the request. Otherwise, you look like an idiot later on for radiology. Just think you need to vet the scan and keep an eye about whether it's been accepted in some small trust. It sometimes honestly easier. Trying to find a radiologist could be like trying to find a needle in haystack. Just go to the department and try and hunt down. Um, with the phlebotomy war drowns. Just be organized. You'll save so much time. If you look through your list in the evening and think, Who needs bloods tomorrow, you know, is anyone's hemoglobin dropping as anyone got low potassium and they're on replacement. You know, if anyone on gentamicin, they should have used these every day. So just trying to think through who might need blood tests and save yourself some time on. Then try and hook people with your Aspar early on on. Be ready for questions. Um, one thing that you will find, especially when you start and perhaps less confident is that you will get some very, you know, angry dickheads on the phone and just giving you grief for trying to refer a patient. But try not to take it personally like no one should go to work and get like, screamed up but just becoming confident. You know, you've been asked to refer this patient's then by your senior given if you don't think it's right, you've been asked to. I'm you know, So you know, my consultant has asked on thinks that this is a valid referral, all your referring because you believe it's in their best interests. Um, so you know, just try and bring it back to the patient, and it's quite hard for someone. Stay angry at you if you just bring it back to you know Well, I can understand why frustrated, But you know, at the end of the day, this lady needs her CT because, you know, it's the safest thing for her on. But yeah, the MCT is one of the best things about working hospital, like it's so sociable yet to meet so many people. And yeah, they're just amazing. Say use them well on your job will be fun and say, Well, take any questions from any part of the lecture on. And that's the feedback link for this lecture, which the QR code. And so I just ate in the chat box, and I think John will probably help me if there's been any on the Q and A sections Well, which was going through bits and bobs past it. Ben, thank you again for such a useful lecture on, but I don't think I ever had any teaching about the charge letters before I started work. And so it's just so use one. It makes up such a massive proportion of your time and be back guys while we're doing Q and A, he could just, um, do you take your coat? It's so useful for the whole of the Webinar series, and also for men whose fantastic on D so And we can also kind of cake to these webinars the things that you might find really useful in the future on so that be granted. So there's a couple of questions on the Q and A on that. Then cancer we could discuss together on the Testim is if their blood that need to be chasing in two weeks of discharge. Who should borrow them up, if not the GP? And so, if you are sending bloods off within two weeks, you need to just check most bloods that will be requested under a consultant name. So you have a bean admitted under on. It's usually consultants job. You know, they're not. They're not just on the words they have office time, and they should get any blood tests that coming back through. It's normally a consultant, but just check some. Some departments work by having a day, for example, in pediatrics at the bottom of our word handover sheets that we have to type every day in my life. You would put any patients that were discharged with anything outstanding at the bottom, and it would be the genius in the next couple of shifts GT to check that job on. Write the date. The bed checked it. So we just stay on top of looking at it s o B. Different in every job, but usually the consultant. Fantastic. Thank you. Um, so a couple of questions about radiology So is telling a radiologist that you're consultant asked you to order a scan, usually enough justification if pushed. Um, now, if you, um I mean, that's why I fall back on. But if the radio just really believes that it's no inappropriate scan, they will just it will just say no. In that case, try and avoid getting stuck in the middle so that there's been situations before where you know, you will end up going back and forth and you're basically carrying messages from your consultants to the radiologist and back again. Try and be really clear from the beginning. If it's a difficult request to your consultant, this is in rejected by radiology on. But I think this needs to this need a consultant to consultant hand over. If you want the scan, they're really not happy to do it on. I've tried my best, you know, And then and then just leave it to your consultant. If they still really want it, they update all sorts out. Absolutely. Yeah, I think I think that's very sense. But also just and radi ologists our doctors so so important to have us bar and respect them Sometimes over the computer, you forget he was being do know that if you're not introduction of select everybody, um DT has been said should have respect, But many of them, you know, we'll mention, you know, ordering a scan in requesting a scan. You're speaking to a colleague. So it's really important to remember those factors when having these conversations on. Yeah, if you are unable to kind of get that information across, speak to your seniors. Prior to that, I would just say to make sure that your request is really solid. There was another question I have slipped raise up kind of accordingly. But if you need to get a scan, will you receive in education saying that it was not um oh, you expect to know what? Um, when you need to let us can Sometimes they say if it's out of hours on D S. O say, today I had a lady who pulled a mg tube out at like four o'clock, which is the worst time for it. Nghe about put a new Nghe been couldn't get aspirate, so because I couldn't get aspirate, she needs to go for a chest X ray and, because it was approaching out of ours, had it being after 4 30. And my trust, When you try and request that scan, it will flag up and say, this is out of hours. You need to bleed the uncle radiologist. So sometimes it will tell you that you need to do something else. But often you're just expected to know for your trust that if you want an urgent CT scan, don't just leave it sitting there out of hours. You need to get vetted by the radiologist. Yeah, fantastic. And a few about. In fact, if you have less um, cannulas. So when is a job to do labs and cannulas? When is it the nurses? How we expected to do bloods and get the cannulas when others with more experience have been able to on similar on the same If you even asked, the nurse asked you to form a cannula that she she or they fell to insert. But you also struggle. Who would you go to really? So they're all about kind of kind of like cannulas. This really depends on the culture of your hospital on do what services air in place and at what times. So for example, where I am at the main man we'll start with blood, so that's easier in ours. Blood scopes the flaps first. If the floods fail, it comes to the doctors. That is because in our trust, there is a culture that the nurses do not do. Blood testing cannulas some of them will be trained on if you get to know them well and you treat them with respect. On def, they see that you're busy. They will offer to help you out. But in the culture of my hospital moment is that Canada's and Bloods are doctor's job on. The nurses will do it if they've got time to be helpful. In some trusts, nurses are amazing, and if the floods fail, it will go to the nurses. And if the nurse is on those blood trained, they'll do it. And if not, it will fail. It will come to you, and in terms of how it escalates it does. It is ridiculous when you first start that a phlebotomist who does 50 blood tests a day has missed, and it comes to you the F one that has done maybe 10 in the last, like you know, two weeks. But you'll just you'll get better quite quickly because all of the heart blood tests will come to you. So all of your practice is on really difficult patients, and you will you will just get better. If if you fail as an F one on the ward's, I generally would say Escalate to and usually have got an essay, Joe. One who's is slightly more experienced. And it's not to say that they'll necessarily be better at taking blood thin. You, you know, blood taking is is a scale, but often a bit of luck is needed. So generally at least two or three of you to try award level, you know, within the F one and S H O before escalating to usually, um, anesthetics, Reg on call or critical care outreach, You know, if you find them and you explain, we've had, you know, three or four attempts on the ward there really difficult to bleed. We need this blood test for this reason. Please, Can you help? They're usually fairly happy to come, and they will ask if anyone is ultrasound trained on whether someone has had a day with an ultrasound that's really useful to get trained, and if you can and because if you can say that someone had a guy with the ultrasound, then they have they have no electricity and, um they will need to come and help you on the cannulas of canyons, a fairly similar phlebotomist send. Most trusts won't do a cannula, but for example, in leads on the acute clocking floors, the phlebotomy team would do a cannula. But only at one time in the day is it only in the morning? Onda cannulas tend to be a doctor's job, but again, nurses are trained in it and then they will help you up. Yeah, completely agree. I would 100 since say as well just say and don't shy away from them. It feels so overwhelming when you start work because they feel like a new scale. But the more you do good, more, you get better, get confident. And it does just take a few weeks of months for you to be already secure and that they're the little winds in the job in the practical aspects suggest sometimes on the really good about it. So yeah, no better feeling, then getting a cannula. But like five people before I come out of that room and you feel like you've got a crown on. You're just like I got it. But yet it's, um, think so. I think just ask up to get some training. I think it depends on your medical school that leads. We're very lucky, and we got ultrasound trained on. But stick around when the anesthetic team, if you can have time for them to come when they use an ultrasound to see enough to be bring Austin D show you get involved on. Your learning is in your hands so on. But I think you can attend courses at your hospital within your trust. Just maybe ask that when you start your job or ask in medical school helping on, then last question, which just take those over eight o'clock. If we refer to a different specialty over the phone, we have to document this has happened in the notes, or is that not needed? Yeah, on. It needs documenting, usually in the notes, especially if you've got, you know, telephone referral, because there's no documentation that that's happened and just document, you know, discussed with cardiology, they advised, Stop one anti platelet. You know just what the outcome of it. Some some trust, sterile Elektronik. And so if you've sent in Elektronik referral form that will appear on the patient's documents as you know, referral to, you know, liaison, mental health on, then that will get updated within the system. So you don't really need to say that you've done it. If there's documentation of it from the Fairless off. Yeah, document document, Doctor Man, you could have no such thing is maybe sometimes too much. But document everything, done that. So help with your colleagues, the next uncle. And there's a trail of of weapons going on. What's being done on. So it's really, really useful. Okay, I think that brings us to our end again. Thank you so much better than anybody who hasn't had time to do the feedback. Please, just going to cure code now on. But just to say all of these lectures are recorded and then put on our website for you to go back, take your time a bird and watch again and, ah, the the next session is on Thursday. That's all about surgical prescribing on doing that one. So if you want to come along and learn about some surgical prescribing. Come and join in the sun. And but other than that, I think that's the end. So have a good evening, everybody, and see you on Thursday. Bye.