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OK, I think we'll get started. Um So just to introduce myself again. So my name is Carrie and I'm an F one in Taunton Hospital. Um, and I'm gonna be doing the start of this talk. Um And then Jake is gonna be doing um, the latter half. Um And today we're just gonna be focusing on managing on call shifts, um to make it as useful as possible for you. It would be really helpful if people could be as interruptive, um as they can be. Um I think it just helps you guys get the most out of it. So that would be really helpful. Um So it's some of our objectives that we're gonna do today. So we're gonna start off by trying to understand the structure of the on call shift. Um And kind of how you as an F one fit into hospital rotors and things like that. Um We're then gonna try and learn um, a bit about, um, handovers how to give them how to receive them, um, things to ask and stuff like that. Um And then Jake is gonna go through how to organize and prioritize your jobs. Um And then just finally kind of um on call tasks and recapping kind of a to e and, and the important kind of um things about seeing a sick patient on an on call shift. Um So like I said, start with the structure of the on call shift. So um hopefully this is a, a bit of a helpful diagram just to kind of um demonstrate how it normally works. It obviously is very different depending on the hospital that you're in. Um And also whether you're on a surgery or a medicine block, um or A&E or whatever, but, um this is generally kind of how it works. So, um, you might start at kind of eight or 9 a.m. Um The day team will be on until around 5 p.m. and then at five, you'll hand over to the on call team. Um, you'll have a bleep that you can bleep and then from five until normally around 9 p.m. it is in our hospital. Um, the on call team will be on and will do on call tasks. And then at 9 p.m. there's another handover which is a bit more of a formal handover of people sit down and um discuss things to hand over and to the night team and then the night team will carry on until 9 a.m. Um So in terms of um how it works, so you'd, if you were on call, um, usually you at 9 a.m. when you go to your, the start of your, your shift, you would collect the on call bleep, um, which you might carry all day and that might be kind of an arrest bleep or something like that. Um, and then you'd go to your, your ward, your normal ward during the day from 9 to 5 and do normal day activities. Unless there's a card harassment, you have to go to that. Um, and then at five you, you'll start getting bleeped. Um, and that's when you kind of make a list of your own call jobs. Um, and then five till nine you'd be doing those. Um And then at nine you go to hand over and you hand over to the night. Hopefully that all makes sense. Um I'm sure you guys all know that, but sometimes as a med student, it's easy to only go to certain parts of the day and not see the whole structure of the whole day. So, um I just thought we'd cover that quickly. Um So this is our first bit of interaction, hopefully. So we just thought we'd ask you what you felt, kind of the difference was between what you as an on call person should be doing versus what you as a day team should be doing and what should be appropriate for both. Um If people could send some suggestions about what they think, um kind of, we'll start with the on call team, what sort of things should the on call team be doing, um, when they're out of hours, there's no wrong answer. So any suggestions are really good. Ok, so I'll start saying some things, but please send some suggestions into the chat, um, if you can think of anything. So the main things kind of when you're on call that you're gonna be bleeped about all the jobs that you need to be doing is, um, so to start off with, normally you're gonna have a list of things that the day team will have handed over to you. So whether that's just people to be aware of, um often they'll just say this person's been really sick today if this happens overnight, this is the plan. So for example, they're not for further management, they should be made under life if they deteriorate or please discuss with ID, if they worsen kind of things like that, um which you might not have to do anything or you might have to do quite a lot. So, um those are normally on your list. Um Other things might be um they might ask you to chase some blood results. Um Normally those should only be kind of urgent bloods um for things like maybe a high potassium that they're repeating to see if it's gone down. Um chasing kind of inflammatory markers to see whether they need to be on antibiotics or chasing scans as well. So if they, if they know that there's going to be a chest X ray done overnight or an urgent CT or something like that. And then that might be your job as the on call team to, to chase those results. Um One of the things that's quite helpful to know and initially starting F one often you, your handover list is so huge because people haven't quite figured out what to hand over and what not to hand over yet. And then as you get to the end of F one people have all kind of sussed out a bit more. Um And on course, come become a little bit easier in terms of the jobs you get handed over. Um But one anecdote that I could tell you is that like at the beginning of F one, everyone used to hand over to chase MRI scans and sometimes those MRI scans have been waiting to happen for a week or so already. Um And they don't do MRI S overnight. So there is no point as an on call person for you to write that on your list. So it's things like that that can be really helpful to know um kind of from the onset, but it's also things you sort of learn as you go along. Um But yeah. Um so some other things you might do. Um Yeah, so um Ails just said e task receive from day team. Yeah. So um kind of tasks that are left over to do. Um But usually only for sick patients, you shouldn't be doing kind of routine jobs on your own call. Um, you might get called to do Cannulas or catheters that really need to be done. Um, often nurses are so good at Cannulas at the moment and catheters. But, um, actually as an F one you, you sort of feel like you're deskilling in those skills but you often get sent to the ones that are really hard, which isn't always helpful. Um And as an F one, I definitely before starting F one, I was so worried that what do I do if I can't get a handle in or can't take blood? There is always someone you can escalate to. Um, and it's not worth worrying about it because it happens all the time and it's not a big deal. Um, other things you might do is you might kind of prescribe urgent medications. Um, you might clock new patients that come in. Um, or, and kind of, the main thing will be, you might get bleeped by nursing staff about people who have become acutely unwell. So people who start new people who newly confused people who fall and, um, need a full review, things like that. Um So these are just on the next slide here. Um And also another thing that we've put on there is just about updating families. So that isn't something that you're going to be doing as an on call person that shouldn't be a job at all. The only circumstance where you should be kind of updating patients and their, and their relatives about things is if they're deteriorating and they're really unwell, um, you shouldn't be handed, be able to kind of give a next of kin update or anything like that. Um, so responsibilities for the day team. Can anyone send any suggestions? So, it's sort of, yeah. Yeah. Clocking new patients definitely. Um, especially on AM U shifts or um on kind of surgery shifts as well. Often you're involved in the clocking team. Um So that's definitely something you do in the day. And that's kind of one that goes into both. Um, although often out of hours sometimes your your seniors and jo kind of clock people um in things like on specialties like surgery. Um but yeah, new patients is a good one. It's sort of just the opposite of what we've put on call teams. So things like um doing a ward draw, reviewing stable patients, um writing discharge letters, requesting or reviewing kind of non urgent stuff. So scans and bloods and investigations, um you might be prescribing or changing people's medications, um which are kind of non urgent ones. Um and then updating families and um relatives um for patients that are on your ward. Um So yeah, those are the kind of main difference. Yeah, those are all one of the deal that so perfect. Um So now we're just gonna touch briefly on handovers. Um, so first off, we'll just chat a wee bit about receiving handovers. Um, so when you're on call F one, you've got your whole day, you've got your bleep on you. You picked it up at 9 a.m. you've done your whole day. It's 5 p.m. My main advice would be to try to leave the ward that you're on, especially if you're on a ward with, that's quite busy and you often get interrupted with little minor jobs that are not urgent and it can be really helpful to kind of leave that ward and try and like go sit somewhere, that's where you, you won't get disturbed. So like for example, the mass is a good place to sit um in our hospital anyway, and you can sit there with a piece of paper where you're not gonna be disturbed and you can just receive the handovers and your mind is focused on that rather than maybe finishing off jobs on the ward or getting interrupted by nursing staff during like you trying to answer your bleep, things like that. Um So yeah, try and get off the ward that you're on. Um because inevitably there will be things for you to do. Um Then yeah, so you'll sit down um try, what I normally do is I get a blank piece of paper kind of um fold it so that you've got kind of, I normally make like eight squares with a blank piece of paper so that I can write each hand over on each square. Um, and then it just makes it a bit more organized for you to look at. Um, and we'll chat a bit about what information that you might want to gather. But, um, yeah, that can be a helpful way to sort it out. Um, and does anyone know how you actually answer? I believe. II don't actually know the answer is whether it's different in each hospital. So I know how it works in our hospital, but it very well might be different in each hospital. Um But that is a really important thing to figure out when you have your child week, um and write it down in your phone note. So you don't forget when you're stressed on your first day and you can't remember. Um But knowing how to answer a beep is really important. Um So in our hospital, um the number will come through on the bleep and you just, you just ring it back as an extension. So it will be like four numbers. Um But yeah, um So in terms of what information you want to gather, um So do people want to write down a few things about if someone was to bleep you, um what kind of things are you gonna be asking them and writing down? So the first thing you sort of want to do is get, um, often it can be helpful just to have a headline if you're um if you're receiving a handover, if someone just says sort of, I'm phoning you because I need advice because this patient, I'm worried about them. They're sick or I'm phoning because I need you to talk to this patient, like just the headline is helpful. Um And then normally write down kind of patient name, the M RN. Um And then what, where they are, what bed number they are. Um And yeah, those are the crucial things to write down. It can be really gusting when you've got a handover and you don't have the MRI and then you, you can't do the job. So um try to remember to get the important things down. Um for each handover you get um then it depends very much on what they're asking you to do. But if we take the example of someone's sick on the ward, um getting a good handover is so important and can really, really reduce your workload, doesn't F one as well? Um So kind of asking first off, why are you worried? Kind of um why are you phoning? So they might say, oh, they using high? So, ok, what's their news? Um So you write that down so you can see what part of their news is, is kind of off. Um You might want to know a bit about their background. So, so why have they come into hospital? Um what's happened since then? Um Why are they suddenly deteriorated, like what's changed and then what's their past medical history? So do they have any medical conditions that might be particularly helpful if someone, for example, has a bit of a, a low BP or something? Um And you wanna know how much of fluid can I prescribe this person? So can I prescribe them 500 bolus, for example, not if they've got really bad heart failure. So things like that can be really helpful to just add to the mix and it might give you an idea of what's going on as well. Um You might wanna know things like what drugs they're on. And one thing that can be really helpful to know is their tap status as well. So if someone's really, really sick, um knowing what their tap is, is really helpful, not only for you in that moment, um clearly if they deteriorate further, but also for when you're handing over to the night team, for example, um often if somebody's been really sick on the wards, you've gone to see them, you've tried to do everything you can and you're handing them to the night team. Like, please review again in half an hour to see if they're improving or not. Um Especially if there's like a critical care outreach team or something in your hospital, they will often only see patients who are for recess. So, behind a room, I ask you, oh, what, what's the T status for the patient if they were deteriorate and knowing that is, is really helpful and important. Um So, yeah, those are just some of the things that we've mentioned. Um So in terms of giving handovers, um, that's obviously also very important and as the on call person, as well as receiving them at five, you're then gonna have to give them to the night team when you hand over at nine. often this can feel really difficult at the beginning. I definitely struggled cos I think especially if it's very busy on call, getting your head around people within like the space of 10 minutes is really difficult. So the questions that people ask you, like, what's the past medical history? Sometimes you, you just don't remember and things like that, but writing it down your handover sheet can be really helpful, especially for those people that you've seen that you're worried about that you want to hand over to the right team with important tasks for you and stuff. Having that information is really helpful. Um So yeah, the, the situations where you might be handing over is to the night team, for example, or if you're escalating to seniors or if you're doing referrals um kind of over the phone as well, uh Depending on your hospital. Um So how do you send a bleep that again, I think is probably different in each hospital, but something you definitely should figure out in your shadowing week. Um, so in our hospital you dial in 811 and then you put in the extension number you want to bleep and then you put the extension number that you're on so that they can phone you back. Um, and that's how you send a bleep. But, um, yeah, figuring that out in week one is really important. Um, does anybody know of any ways that you can do an effective handover? Um Any tools that you get taught a lot about in med school? Hopefully you guys remember. It's like an acronym, anyone can think. Yes. Yeah. So Sbar um So hopefully I've got, yeah here. So this can be super helpful, especially at the beginning just to like get your head around how you hand over and or how you present patients. Um It can be really overwhelming. You've got all this information about someone you've done a really thorough history and you're just trying to figure out what your actual question and the important things are. Um at the beginning, it can even be helpful. I know that some people, if they were doing phone referrals would write this down before. Um Obviously that's really time consuming. Um and probably not advised for the whole of F one and going forward. But at the beginning, it can be, if it's reassuring for you to be able to do that, then you can always write SBAR and just figure out what you want to say. Um So yeah, this is a really helpful way to hand over. So you introduce yourself, say who you are, you say what the situation is. So, um I've been asked to go and see this patient because they're using of six and I would like you to come and help and review the patient, for example, um background. So in the background, you can say they've come in because they've got a cap, um they've been treated on oral amoxicillin and now they're using high with increased respiratory rate and oxygen requirement and then assessment I've gone to assess them. I think that they need um I think that they're working hard with their breathing, their saturations are low, so I've increased their oxygen. Um I think it's worsening of the pneumonia and then you could say I've ordered them a chest X ray for a view. I'm thinking of escalating the antibiotics and increase their oxygen. Um Is there anything else you want me to do? So it can be a really helpful way to just kind of lay out what you've done, what you've assessed what you've done and whether they can help you or whether they have any more advice for you, it can be really helpful. There's kind of key words that you can say in your hand over for people who might be reluctant to come and help. If you say I'm really worried about them, I feel out of my depth. You're more likely to get a senior to come and review someone than if you say, oh, like they, they're like sick, but I think it's fine, like, but please review them, they're probably less likely to come. So there's, there's ways to kind of navigate the system to try and get help as fast as you can, but it might be just that you want advice. So saying at the beginning, whether you want advice, whether you want um a senior review or what you want is really helpful. Um So who you can ask for help? So, in the hospital, um there's obviously various people who can come and you can escalate to um if you're worried about a patient, do you guys wanna list any people that you can escalate to? There's obviously gonna be various teams in various hospitals that are um that are available, but generally there's broad kind of types of teams. Ok? So the people that um we've written down here, so um there's different levels of, of support that you're gonna need. Um So it depends on the situation. So if you're going to see someone, you're a bit worried about them, they're not acutely kind of, you're not, they're not crashing in front of you. And obviously that takes time to kind of figure out and at the beginning if you're at all concerned, oh gosh, is this person rapidly deteriorating? I would always say go for the for the Met calls and the arrest calls. Um, don't sit on it thinking, oh, it might just be me overthinking it and that they look sicker than, I think they're sicker than they are. Like, initially, no one's gonna blame you for, for override, for kind of going too high and putting out a per arrest for someone who might not need it but not doing it is a, is a big, no, no. So, always better to do it. Um But yeah, if someone's acutely acutely unwell, you're gonna be putting out those peri arrests, the Met calls um in some hospitals, you just have arrest calls and you just put those out for people who are very unstable. Um The other people you can. Yeah, so, so just put registrar. So yeah, so um your reg or your sho often there's kind of a change of command. So it depends on your shift. If you've got an sho I would suggest that you go to your sho first and the sho can then come in a review and decide. Ok. Does this need we involvement? Um Sometimes you don't have an sho and you just have a wedge. So you just then go straight to the we um very rarely as an F one you're gonna be escalating to a consultant, to be honest. Um That would only be in a very rare situation if you can't get hold of anyone. And um even then I think there's people you can get a hold of. Um There's sometimes teams like, so we have a critical care outreach team in Taunton um who are really, really helpful um and will come and see people who are using high and come and give advice and they are a team of nurses who are super, super experienced. Um really hold your hand through people who are sick. So they're really helpful to bleep um and even get advice from them or get a review. Um Nurses are also really helpful. Um They often are so more experienced than you as F ones and will, will know better about kind of sometimes if you're just kind of stunned by a really unwell patient, they might prompt you. Do you want me to put a call out or do you want me to call someone else? Um like a reg or something? Um And they, they could be super helpful and um definitely utilize your this as um So I think that was all I was gonna go through and I'm, I'm gonna pass on to Jake now. Um But keep sending any questions that you have and I'll try and answer them as we're going through. Uh Hi, everyone. Thanks Carrie. Um So I'm doing the second half of this talk. Um So I'll just carry on. I'm one of the F ones at Musgrove which is S Hospital as well as Carrie said earlier. Um So next bit is about organizing jobs. Um So just before we go to the next slide. Has anyone got any strategies that they've seen used or have used themselves for kind of, I think we talked about earlier, how you might go about making an example of how to make a list and we'll look at that in a second. Has anyone got any ways or any strategies that they've seen to how they construct a list? Um What kind of information is on the list, any symbols um or systems used? John Curry Press Sly Curry, thanks. Um So here's a couple of examples of lists. Um So I think Harri mentioned earlier about folding a piece of paper into eight and making like little square. So that's the example on the right hand side of the screen um where you can fit kind of bit of information about different patients. So the way that that person structured it is in the top left, they put who they're on shift with what the contacts are, um which I would advise that you do kind of in your early stages to make sure you've got kind of the if you're on a medical on call, the medical registrar bleep, the medical sho bleep if you're on a surgical shift, same thing. But for the surgical team and then they put kind of patient details, top left of each of the eight boxes and then a bit of information about them and then the the jobs alongside them, I think what you notice on both lists is that they've got, um, little boxes next to all of the jobs. So, a really common system that a lot of people use in medicine is that the, the blank box and then the half colored box to say that either something has been started or something's been requested. Um, so things like bloods, um, you can say that they've been requested and sent and then the, you color half the box in and then the other half you can color in once they're back and you check them, um, same kind of principles or scans, things like T ta s and discharge summaries, you might half cut the box if you've started it or you've requested the medication and then you need to sign it off and say it's all done. Um I think the important thing for jobless is everyone does it slightly differently. I know that I like to do three columns which is name, um, hospital number, date of birth where the patient is in the hospital, um, in my first column on my, a four sheet and then my second column is a bit of background information and my third column is the jobs. Um, you'll find your own system, but kind of have a bit of a play around as a student if you're doing any practice on calls or amount of hours type things just to see how you get on. Um, one thing that I will say is that you need a, a way to kind of sit um suggest to yourself what are the high priority things? It might be that you have a normal black pen which you write in the notes with. And then you have like, I don't know, a red pen or a lot of people use like the multi colored pens and they can put like big red boxes on their list for things that are urgent. Um And that's one way of doing that or you can write it in kind of the four boxes like in the picture on the left. Um where you think of things like bloods, imaging referrals and miscellaneous and you might have one for acute reviews, which is normally gonna be your top priority. Um Other point for this is about location. So when you're taking handovers um to make your list for your on call, make sure that you get at least an uh patient's full name, their hospital number and ideally their date of birth, you want two identifier if possible and then you want to know where they are on the caveat that the patient could move um during your on call. So just make sure that you've got a way to find them ie their hospital number that you could look them up. Um Were they can move from, say AM U to one of the other medical wards. Uh Next slide please. Um The next eyes a little exercise about prioritization. So in the chat, um this is a list of jobs which should come through on the on call. Um So can I have some suggestions of what order you might do the tasks in that are on the screen? Um So A is chasing blood results from the day B is prescribing pain relief for a patient post cholecystectomy. Um C is an 83 year old that's using a six for a low BP. Um That's a new, new six patient um from like a stable news to or something like that. Um D is reviewing an 86 year old man on Warfarin who's fallen but is otherwise, well, e is prescribing maintenance fluids for someone that's been near by mouth for six hours and f is for, is prescribing medication for a patient normally on antihistamine, which is missing from their drug chart. Um What kind of things would you want to be doing first? I'll take any suggestions. No, right or wrong answers center Paul. Wow. Um I've sent a poll. So if you don't want to put your answers on the chat, I know a few people have already um answer the poll instead and we'll just see what we get. Cool. So we've got a few answers. Um I'll be honest, there's, there's not a, a, an exact science or correct answer to this. Um And it's really hard when you've got one sentence to know exactly what to do first. A lot of people have gone to see which I think I would probably do first as well. Um And what I mean by that is if I was handed over that I would be asking a few more questions about, um, everything that they're nosing for what the kind of background is. Are they someone that's postoperative and they've had ABP drop and there's risks that they're bleeding or are they someone that is scoring a new six because they have a low BP that runs at 93 systolic and it's now dropped to 89 systolic. So therefore, the new score has increased um because they've entered the scoring for two, scoring for three rather than for two. But I think the, the top priority for any on call is to see un acutely unwell patients and the easiest way that they're generally escalated to you is through the nursing staff, through the observations. Um So I think that what I would do here is I would probably go for C first. Um And then people have said B and A so things that are particularly important out of hours are um kind of just de dealing with things that are easy to deal with. So if you've got electronic prescribing, um and you can kind of view enough information about the patient that's prescribing. Case B about pain relief, you can see what they're on already, what they've been having. Um That's quite an easy job to do within a matter of minutes. Check their renal function, check that they're not having lots and lots of more and more of a really high doses or, you know, check they're on regular paracetamol, really simple things that you can do within minutes. And it's the same to f, um, if you've got access to the patient's larking and you can see that it's written in the larking, then that's very easy and quick to prescribe. So things like prescribing are quite simple. The same concept for e you've got a chat and that's been known by mouth. You can see on the electronic system that he's not had fluids. Um That's nice and easy to sort out um in terms of the order that I'd probably do things in myself. So, and like I said, it's not an exact science or correct answer to this, but I'd probably do C first um I'd try and get the urgent prescribing. So the man that's near by mouth, um more at risk than AK I and B because you don't particularly want to sleep with someone in pain for a long time, then I would probably look to go and see the chap that's fallen over on Warfarin with no injuries. Um D then I would probably try and do the prescribing in f and then I would probably chase the blood results. Um Caveats, all of that is if you're handed over an urgent blood result, things like troponins that, you know, usually come back in about an hour's time. You can obviously factor that into your list as well. Um So we and everyone that put c um there next slide, please. Um So the next bit of, so now we talked about jobs and a bit about priority. Um We're talking a little bit about common on call jobs. Um So we kind of talked about examples with Carrie already about what you might be expected to do. Um Everyone's got their own system for things like interpreting EC GS, interpreting bloods. Um And if you haven't, I would encourage you to kind of make sure that you're perfecting things like looking at your EC GS, looking at your chest X rays, looking at your bloods, cos that is the bread and butter of what you'll be doing out of hours. Um Make sure, you know, going into it. I know that obviously nursing staff nowadays are really highly skilled. Um And it would be really unusual to come across a team that wouldn't know how to do an E CG blood or urine dip, but just make sure you kind of understand the process just in case. Um during your shadowing, you need to make sure that all of your it logins work. I can't stress that enough. Um There's loads of things to find out in the shadowing period. It's really overwhelming, but things to get sorted are the logins because if your login doesn't work on the first day, it's gonna make your first day even worse, um, than starting a new job without having ever done it before. Um, there's lots of really good resources online. I'm sure you come across these, doing like things for finals and OSS, but live in the past saying really good for E CG and G library, both really good websites. Um, Radiology Masterclass. If you haven't had teaching on chest x rays in medical school, which I'd be shocked. Um, you have got a really good system there if you've not quite developed your own system. Um, gee medics is just great about everything. Um, whether that's kind of interpreting LPST, interpreting as taps, interpreting anything, I'm sure there's a geeky medics article out there somewhere. If not, there's a video, um, caveat again to all of this. You're not on your own, you're in F one, you've got medical shos ssh Os registrars and all specialties that can interpret investigations with you and you'll, you'll develop confidence going into the job, you'll think. Oh my God, I've got to interpret EC GS. Um, and what's important with EC GS kind of out of hours is that you're ruling out really sinister things. So things like semi Nstemi, um, heart blocks, um af flutter, um tachycardias kind of S VT S and broad complex tachycardias and bradycardias, all of which are relatively easy to spot as long as you can spot those and know how to escalate them. I think that's the most important thing and if someone comes along and goes, no, you're wrong. Ok. Fine. Move on and learn from it. Um, next slide. Thanks. Um, in terms of out of hours prescribing, really important to be aware of um kind of common things. I know that we did some topics a few weeks ago, prescribing part A and part B which you can go back and watch if you want to, which covers all of these topics. Um Common things you'll be asked to prescribe is analgesia laxatives patients not opening their bowels, um fluids, especially on surgery. So you might be asked to do quite a few fluid reviews out of hours that may, may not include AK I reviews and electrolyte reviews as well. Um Normally Warfarin dosing if possible should be done by the Ward Day teams. Um I would really strongly encourage you to if you're managing patients on Warfarin to try and do that to prevent the out of hours team having to do that. But over weekends, things like that, you will have to occasionally do warfarin dosing. I've only done it a handful of times. Um But most forms have a really good performer um which you can use BT prophylaxis should be done as part of the clerking. Um But it may become a bit more relevant in your surgical jobs, um be aware of emergency drugs. So the main ones to be aware of are use of adrenaline in both cardiac arrest and anaphylaxis. Um and use of things like amiodarone um atropine, which is all things that you will learn as part of A LS, which I know a lot of people tend to do quite early on in F one as well. Next slide, please. Um Oh, that's not projected very well at all. So this is um something that you may be doing out of hours. So there's two elements to the, to the on calls and that is ward cover, which is a lot of what we've talked about or you may be doing medical clerking or surgical clerking, which is seeing new patients direct um from ed um taking a more thorough history, doing an examination and then coming up with your impression um or your differential diagnosis and your plan. Um This is a kind of fictional clerking which um we put together for a 85 year old called Beryl Williams. Um And you can see that it's really nicely laid out by the medical f one who's clerked them. So first sheet is a really nice run through of exactly what the percent complaint is. Um I think it's really helpful if you always put the age and the gender on um all of your clerking on the on like the first bit. I think that's so helpful for context for anyone that comes and reads it. So that's my top tip for that. Um And then you've got past medical history, social history, um, review of systems. Uh, the drugs are in there. Are there drugs in there somewhere? Maybe not. Hm. No known drug allergies, at least that was helpful. And then there's a big examination on page three and then kind of impression and plan on page four. So clerking is, um, a really fun part of the job, I think. Um, I've done four months on the acute medical unit and that was where I learnt a lot about my knowledge, my medical knowledge. Um And you do really feel like you're doing actual doctoring rather than writing discharge, summaries and um kind of the day to day ward out mini bits. Um So this is a really good example of clerking. You'd all have done clerking as part of medical school, medical training. Um The key, the key tips are like I say age and gender at the top. Um a really clear concise presenting complaint. Um really good to have uh solid um past medical history as part of the clerking because that is often what everyone will refer back to. I work in a respiratory ward now and I still refer back to the past medical history and the social history taken from the medical clerking to inform a lot of kind of my work and my decisions on a day to day basis. Your impression in the early stages of F one really doesn't need to be very advanced. Um And often the impression is not that hard to come up with. If they come in dry, they're dehydrated, they've come in confused. There's like an element of delirium. Um If they've got crackles on their chest, you've got differentials for that and it's just try and keep things simple. You don't need to diagnose everything um on first review and they'll be seen by consultants on the Post Ward round. Anyway. Um I'm a big fan of the plan, which it's not projected very well in this, these slides. But um the plan here is really clear. Um So I'll just run through it. So they've said IV antibiotics, IV fluids, medical admission, BT prophylaxis, te regular meds increased frusemide dose, ecg, echocardiogram, fluid and food chart, bowel chart, post war PTO T daily weights, I think. Um, a 14 point plan is, is great, but I don't feel that all of your patients need to have a 14 point plan. Um, a lot of things that are mentioned in this plan are kind of things that will happen anyway. So regular meds should happen regardless. That doesn't really need to be in the plan, post ward round. That should happen regardless, doesn't need to be in the plan. Um But it's good to kind of guide people as to where they are as part of their admission. Um And the other important point is to say are VT prophylaxis and hep should be a standard thing done on admissions, whether that's under medicine, surgery, pediatrics, and gynae blah, blah, blah, blah, you name it whatever admission, um, all patients need to be assessed for risk of VTE. So you normally, most trusts have a performer where you look at risk of thrombosis versus risk of bleeding. And you make a decision as to whether that's indicated or not. And that'll be usually either, um, Clexane or delta par. Um is what the patient will get um at night and at e discussion so often. So in Somerset, we call them T ES treatment escalation plans. I know that a lot of the country uses the respect forms, which is exactly the same thing DNA CPR forms and escalation planning to things like critical care um hospital transfer, whether they're for noninvasive ventilation. I think it's really good even as an F one to try and start having these conversations, if you've got someone that's 85 come in um with an extensive background that this patient's got, are they realistically going to be a candidate for um chest compressions, defibrillation? Um And, and are they going to survive to live a reasonable quality of life? Probably not. Um So it's just really important to bear, bear that in mind. And I think your seniors will thank you even if you don't have the complete conversation. Um I think to start getting the patient to start thinking about that is, is really important. Um Is there any questions about clerking with the surgical larking, medical clerking? Other thing to say is um for all patients that come in, you're gonna prescribe the regular medication. I would also prescribe kind of P RN pain relief P RN antiemetics if they've got any signs of being nauseous. Um And it's a, it's a good idea um initially to try and get the nurses to do standard observations and get things like a weight and a height recorded on the system. It's just really helpful for people that are prescribing the next day and during the admission and if they come in with something like heart failure, you've got a baseline for, for their weight as well. Uh Next slide, please. Um We've talked about this. Um So we're, this is a managing on call session. So communication with relatives is actually fairly minimal, um, out of hours. Um As bad as that sounds. Unfortunately, doctors are the minority in hospitals out of hours and therefore there's not the time to do kind of lengthy relative updates. Um What you will need to get used to doing out of hours is breaking bad news potentially to relatives. So if you've got a patient that's come in and they continue to deteriorate, um you may be asked to ring the family and kind of explain that they need to come in. Um And often they, they will ask why and you need to be able to adopt your skills to break bad news. Um Has anyone got any systems or any acronyms that they use from medical school? Um, for breaking bad knees just while I carry on talking, um, other things that often you will do, you might have to gather collateral histories. Um So if you've got a patient admitted from a nursing home, you might have to ring the nursing home and go. What's their baseline? Obviously, you've said that they're kind of newly confused. What kind of um level would we like to get them back to before we can look at discharge planning? Um And in a kind of similar fashion, if someone's coming in confused or they haven't got capacity to talk about their escalation um status, you may need to um complete a tech discussion with the next of kin or a respect form discussion with the next of kin. Um Going back to bad news. I really like the Spikes model which is widely taught across all um medical schools in the UK, at least. Um if you've not heard of the Spikes breaking bad news model, just pop it into Google after the talk. Um and have a bit of a read up about that, even if you don't use that for every conversation you have, I think your principles are really helpful. Um as it says there, there's obvious principles um communicating with relatives if the patient has got capacity um obtained consent. If not, it's kind of a best interest thing and actually talking to their next of kin is generally not frowned upon. Um And this is, this has taken a little bit as well from the spikes model. So spikes um stands for setting perception, I can't remember now, settings, perception, um invitation, uh invitation. Uh I look it up a sec perception, knowledge, emotions, and um s for strategy or summary. Um So what you want to know from relatives is what they already know. So that's their perception and then you can kind of fill in the gaps from there. And summary is always important to give someone something to focus on going forward and um kind of what the next steps are next. Um So this is the last bit of the talk. So if you're called out about someone that's unwell, I'm sure you've all kind of done lots of simulation at medical school about reviewing um unwell patients. Um You'll often get a handover from either your colleague um or nursing staff that you've maybe not met before. Um If you were asked to review someone that's unwell, I would make that your, your higher priority job. Um go along to where they are, look at the obs and any um information that's immediately available. Um If you've got time, look at the medical notes. So this is where I go back to what I was saying about the clerking. If someone's got a really good clerking with most of the information there already, half the work's done for you. And then you can look at kind of their background, their social status, their escalation status all from the glaring and then look at the last couple of all round entries, which usually will have a nice summary of issues at the top about what's going on. Then you can assess your patient, sorry, use the at E framework, which we'll just run through quickly in a moment. I'm sure most of you have heard of that. Um, and then you can come up with any further impression. You know, if, if there's someone that's on the ward and they've got a pneumonia and then they've got an increase of rate. They're desaturating your I pressure might be, oh, their mucus plugging. They need some nebs. Um, or if they're having temperature spikes, they might be worsening on oral antibiotics. They might need to go to IV antibiotics and that can be your impression. It doesn't need to be anything um, significant. If you see someone and you look at their bloods and they're getting much worse, but clinically quite stable, your impression could be like worsening biochemically or on blood, but clinically stable and then your management plan will usually match that and you're responsible for implementing your management plan out of hours. So if you've said an or to IV switch, you need to prescribe the IV antibiotics. Um, if you've kind of stabilize the patient um And you don't need to put out a an emergency call. Um Maybe that you need to hand them over for a review in a few hours time um to one of the night doctors and then you can make sure that you document all of this. And I would really emphasize documenting the management quite clearly um a for your colleagues that might have to review them overnight. What specific things are they coming to review? What parameters are we looking at? And also for the nursing staff to follow if you know their news goes to above six, again, contact whoever out of hours, I think just make it easy for everyone where possible. Um because a lot of people can panic. Um doctors, nurses, allied health professionals, um when it comes to unwell patients next slide, please. So we talked about A two E um quickly. So I this is a, a nice summary slide. If anyone kind of wants a, a picture of this or whatever just to keep in their keep in their phone. Um A being the airway, when you examine, you're making sure it's patent. Um And if it's not, it's the first thing you need to intervene with to normally use airway adjuncts. So you might use an O PA and or or airway or a nasopharyngeal airway all the way down to things like an eye gel or a laryngeal mask, airway breathing. Um If you're happy with the airway if they're talking, it's patent um is important to say breathing. Um looking at respirate work of breathing saturations, chest sounds um that's external and listening with a stethoscope. So if you can hear things like wheeze or stridor from the end of the bed, um that'll give you some clues. Um Potential interventions will be booking a chest x-ray COVID swab even now we're getting patients through on the medical ward that are COVID positive. Um ABG if they are desaturating a new answer and accurate level of their arterial oxygenation, um ABG or VBG really helpful in kind of the unwell patient per arrest situation for looking at um easy things like electrolytes, lactate glucose um and a point of care hemoglobin, which isn't always the most accurate. We will give you a a rough idea. Um We go to see which is heart cardiac. Um You look at all of the things related to the heart, heart rate, BP, pulse, listen to heart sounds. You might wanna get an E CG um which you can compare if you've got a patient with new chest pain, no shortness of breath. Um Even if they're kind of newly drowsy palpitations, anything like that, ecg um noninvasive, really easy, really cheap. Um D for disability, um which is looking mainly around neurology. So you want to know, calculate the patient's G CS, be able to do that really competently for your out of hours for either sur surgery and medicine. Um, look at their pupils, check the glucose on the BBg or with a finger prick, make sure they are at normal temperature. They're not spiking a temperature. Um, you may need to give any medications to kind of counteract things like low glucose. Um, you can give paracetamol or Ibuprofen for high temperatures. Um, and then e for, um, well exposure, um, or examination. So look everywhere, look at the abdomen, look at their back, look at their legs, make sure there's no signs of bleeding. Um Look at their carbs, make sure they are soft, make sure there's no risk of things like DVT. Um A patient with leg pain. You think about things like compartment syndrome, acute limb ischemia. Um Yeah. So if you've not heard of the at E approach, um there will be lots of videos online and there's a really good one from the Recess Council um who run the I LS and A LS courses, which is about eight minutes on youtube. If you, if you wanted to go and watch that, just to get an idea of how that works in practice as well. Um And I think that brings us to the end of um kind of the presentation. So the summary for managing your own calls um is that on calls are for really urgent tasks that can't wait until the next day. So that's urgent bloods, acutely unwell patients, um scans that are going to change management out of hours, um, which is usually chest x rays and CT scans CT heads. Um, before you start your own call, you need to find out all of the key information, including when you're working, what you're covering where you need to go for handover in the morning and also where you need to go for handover 12 hours later in the evening. You need to know how to be people. You need to know who's on your team, who's on your side, who you can contact. Often trusts have like whatsapp groups or you can make your own whatsapp group. Um If you're happy to kind of share your details, which is sometimes it's a bit quicker to um get information um and get people's phone numbers, et cetera and make sure you know how to access your trust guidelines um for common things, things like DK A hyperkalemia, any electrolyte abnormalities. Um There are some useful apps for B and F which I think you'll probably all have anyway, um Pocket doctor, which I think you can't get any more. Unfortunately. Um I, I've got it and it's really, really helpful, but I don't think you can get it anymore um from the App Store. It, so it used to be a couple of quid. There's another one. Let me get the name of it. Sorry. Um Foundation Doctor Hamburg, really helpful. That's about 34 quid. Um Well, worth spending your money on Rx guidelines. If your trust uses them induction, which is now called um, Switch at Curi or something. Um It's a yellow app with an S um, has all the numbers for every hospital in the country. It's not an official app, but really, really helpful. I would strongly, strongly, strongly recommend you get that one MD CALC. Really good. But if you don't have that, you can Google it, um, shift planner if you want to record your rotor in a nice way. Um on your phone rather than use the hospital system, um We talked about sbar as a way to give and receive handovers. Um The importance of finding your own way to make your jobs list and finding your own way to prioritize your tasks. Um If you are not familiar with common prescriptions, go back and watch our prescribing part A and part B sessions which are um from April. Um and that will give you an idea of prescribing analgesia laxatives, et cetera. Um If you've got an unwell patient A to E approach, can't go wrong if you're not familiar with A to E by now. Um Like I said a few minutes ago, recess Council A to E or ABCD E assessment on youtube. Um Really important thing is to put yourself first in all of these shifts. The on call shifts are long. Um They're really tiring, make time for your break. Um There will, there will be moments where you can have a break. Um, go and sit down, have some food, um, carry a water bottle with you is another good piece of advice. Um And actually there's some of the most enjoyable shifts um, that you might do as an F one. especially if you're in a kind of surgical or medical ward based specialty. Um, you get to do a lot more independent thinking, a lot more independent assessment. Um And a lot more of what you're trained for. Really? So, um, thanks for coming attending tonight. We've just put a feedback form link in the chat. We'd be really grateful if you could fill that in. Obviously, if anyone's got any questions, um, we'll be around a few minutes to answer them. Thank you very much.