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Have you gone live? Perfect. Well, welcome, Mike. So everyone who's in the chat. So this is Myat. He's one of our absolutely fantastic. A NP so advanced nurse practitioners and he is actually working in, I worked with him personally in upper G I surgery last year as an F one. And he, he did a lot for the team, sort of, you know, helping us with our role, sort of showing us the ropes in upper G I and it was really my 1st 1st surgical job. So I have a lot to sort of owe to m but I will leave it to him. So my, just a bit of background about him. He works in Moscow Park Hospital. He's had experience in working as a nurse for 12 years now and he's worked in upper G I for four of those years. So the longest sort of role that he's taken up, um which you'll be covering more about in the talk. But without much further ado I present Mike Richard. Fantastic. Thank you, Sherry. Thanks for having me. Um I think, um, a bit of a disclaimer beforehand, I think because obviously, um, what I'm presenting is a clinical nurse practitioner role. Um, and it, in other trusts or in other specialities, this might be slightly different. Um And, uh, yeah, and I guess that's a question and answer session later a bit. So. Right. Ok. Let's make a start. So I'm Mike. I work in Moscow Park Hospital. Um, just a bit about me. So I qualified in 2012. Um, I, um, studied at the University of Plymouth. I'm also a mature student. Um because in my previous life, I studied social work, psychology and public health in Germany, um and got a master's degree in that, um and decided not to do any for that. Um And then moved to England and did my um nursing degree. Um The reason why I went into nursing is, um because I did national service in Germany, um and worked in a nursing home, um as part of my national um service. Therefore, I had a pretty good idea of what I let myself into. Um, I then qualified, like I said, um with Plymouth in 2012 and then started working in surgery, um on a busy um G I ward, um and urology at the time, um, stayed there for about two years. Um And then I said, right, ok, I need to have some other experience and join staff bank and joined the dark side like I call it, um which is the medical site a bit. Um Just to get an understanding of actually how the different parts of the hospital work. Um because I always knew that I think going up the food chain on the ward would not be my, um my preferred choice of career. Um I always saw myself a bit more of a specialist role and therefore, um I wanted a bit of, more of a um diverse um um um yeah, bit of diverse um knowledge basically. Um I then um was lucky enough to get a job in the Middle East in Abu Dhabi in Klif in clinic. And um while they were still building the hospital, I was waiting for the job to come up. Um um basically a note to come over, I joined the interventional radiology, which um was an amazing experience. Um and not a lot of people know that in radiology are actually a very skilled nurses there. Um They do interventional radiology stuff which means um all the angiograms, angioplasties, nephrostomy, stuff like that. So you learn how to scope, you learn how to um basically um um organize the whole unit. Um You manage the unit you're in charge and do on court and stuff like that. Um So um I've done that for roughly about a year, then I went to the Middle East, stayed there for just short of a year. And um that was probably, um which set me probably up quite nicely for this role I'm doing now is because this was the first time actually a um um an employer actually took time to have a look at my current skill level at the time that was in 2016. Um So we had to do a test and um it looked at certain skill levels and including um how to um how to diagnose a patient with certain informations you had at the time. Um little videos, little snippets of blood results, stuff like that. And then you had to form a diagnosis. And um what they then did is they then looked at the test results and then they gave you specific training for the knowledge gaps you had, which was fantastic. Um And my feedback to them was actually this is the first time people have done that to me. Um NHS doesn't really do that. Um And um um made me actually realize that I probably made the right choice of going into a specialist nursing role. Um I then came back and started working for the bowel cancer screening service, which um is a fantastic service. Um Part of public health England um done that for about just over 18 months, I think. And then the job is AC MP in upper G. I came up, I knew that the job was in the pipeline for quite a while because um the job, um they put the job application or the, the funding for it. Um The business case in, in 2014 and I stayed in contact with the, um, with the clinical lead in upper G in contact throughout that time. Um, the job came up. I went for it. I didn't really think I, I'm qualified enough. Um, and, er, got the job. Um, and the amazing thing actually is that, um, it's a brand new job at the time, so I didn't have any big shoes to fill. Um, I could make the role as much as I want. They basically gave me a carte blanche. Um They said this is what we want. Um um and they wanted it roughly to have it run like our colorectal team who have got four C MP S. Um So I've modeled it a little bit on there and with slight tweaks, which works better for our team basically. Um Within the first year I've done my paca course, which is the clinic where it's the physical examination and clinical reasoning course. Um And basically you learn um how to examine patients and um how to diagnose them and basically clinical reasoning. Um And then I literally got my results and then the following week I started my N MP course in 2021 with UE um which is our um main university here um in Bristol um and completed the course within nine months. Um probably the hardest course I've done. Um apart from the nursing degree, um it's a demanding, tough course, but you learn a lot. Um but I also say to people um who hasn't done it, um say bye bye to your family for about six months. Um And then, um yeah, and I just started doing my job basically and I go through that um in a minute and then, um I recently literally just last month I finished the pe I master class um in with Gilford, um which is a pancreatic exocrine insufficiency course. Um And that was a two day course, which um was fantastic. Um And that leads quite nicely with my future plans for the job and which I'm going through in a minute. Ok. So, um setting at Sko, so we're the, um, we're the UK actually Center for Excellence for Metabolic and Biot Surgery. Um in addition to our benign upper G I Center, which means that we don't do any upper G I cancer service. We have a cancer team, a nursing team. But um, it's basically, um, and they meet once a week. Um, they're meeting, um I think tomorrow morning actually. Um and um I do liaise with them on a frequent basis, but um, any cancer related surgery need to go to Bristol because they are a tertiary center basically, but we are a um Biot center. We are the only UK um Center for Excellency. Um We've got five Biot surgeons. Um and we have got one of the um, biotic surgeons in the country, Richard WBO. Um who probably trained quite a lot of um biotic surgeons in this country actually. Um And that's he is probably the main reason why people want to come to us as well. Actually, um we've got three registrars, one senior bariatric fellow that is usually a person who is um either post CCT. So literally, they can, they have qualified as a um as a consultant and they can go for consultant jobs or someone who is at the very end of that pathway. So usually an ST seven ST eight ST nine, and wanna do a year in Biot because they wanna do Biot surgery basically. Um And then we accommodate that basically. Um, on top of that, we've got, um, 22 more junior registrars, we've got one sho um um or CT one or CT two. So, um, there are, um, and their core trainees. Um, and I normally don't, um, I make sure that I don't plan with them because their rota is actually quite, I mean, they're brutal. Um They do nights, they do on call. Um, if they have to have time off, it has to come, um, from the time they spend with their team. So hence we hardly see them. So, um, we got three F one. and like Sherry just said, Sherry was one of us, um, was one of them last year. Um And then we've got two Biot specialist nurses who are literally just do purely bariatric um um specialty. Um They know all the biopic patients. Um And then one CMP um in terms of where I fit somewhere in all of this hierarchy, um I probably fit somewhere between the sho and the F one I would say um because I don't know enough to be the sho but I know enough to be enough to put technically roughly. So it's roughly where I sit. Um And when I started the job, um I said, oh, where do you want me to sit? And they said I need to function within my team, um, on an sho level, which on a good day I probably do. Um, and I've got good days every time. Um, so, yeah, so dealing with surgical problems. So the majority of our patients, um, you can basically classify in like three different categories. Um, we've got the biliary problems which are your gallbladder problems, your, your cholangitis patients and your empyema patients who past gallbladders, um, chole patients who, um, who need to be treated quite urgently. Then we've got a chunk of patients who are, um, suffer with pancreatitis and they are probably, they're the most complex patients, um, especially the ones which are severe, I think at the moment we have probably about three or four and it's not unusual for us, unfortunately, to palliate them as well, especially if they are co morbid. And, um, the severe pancreatitis illness would not. Um, and it would basically it might be a life ending event for them, unfortunately. And then obviously, um, we've got the Biot, um, surgery mainly elective cases. Um, um, however, we do deal with emergency admissions and especially because we are the Regional center, we get quite a lot of referrals from Exeter from Y which is not part of our trust anyway, um, or even further down the line in Devon and Cornwall as well. So they send patients over to us and usually they have, um, problems like dysphasia or, um, they might have internal hernias, um, stuff like that, which we need to fix, um, slip gastric bands, um, which we need to, uh, sometimes sort out as well. And, um, therefore, um, they come to us because, um, we need to sort them out and we're probably the team actually who put them in, in the first place. So, um, so, yeah, um, an overview of a day basically. Um, so I roughly start usually about 7 30. Um, I think officially I start at eight. The problem is that the ward ones should start at eight. Um, I think the post doctors are normally supposed to start a quarter to eight and then sort the list out. But usually, um, um, it's my team. Um, and therefore, um, I need to know what's going on really. So, um, so roughly about 7 30 sometimes seven o'clock, um, I usually then do, um, update the list, print the list, check um, if you had any red tops, we've got a, um, op system here where we get electronic referrals. Um, and we see them normally within 24 hours, they come the day before we normally see them a part of our ward draw basically eight o'clock. We start the water round. Um, usually with one of our registrars or if we're on call, we normally take part only on call and then every Wednesday morning um in our hospital, we do have surgical teaching, which is fantastic resource of knowledge and your CPD basically. Um which means that um from 8 to 8 30 a member of staff within the hospital is giving us teaching basically. And that might be that uh we recently had one of the senior. Um Well, we had the um radiographer, a radiologist, um giving us an idea of um looking at CT images and stuff like that um to identify um um appendicitis pancreatitis, stuff like that. So then um any surgical techniques, um um any core trainee, um any registrar, any surgical consultant, um they take it in turns to present something for about half an hour. Um And it's usually well attended and um like I said, it's a really, really good source of CPD and for my learning fantastically as well actually, and then the world round takes depends on the numbers. And um so we are medium size hospital. We've got about 800 beds um which the majority, unfortunately, um, are medical and they do encourage on our surgical beds, um, can take up to 1 to 3 hours roughly depending how quick and how demanding the, um, the patients are. Um, we need to see and then followed by it, like I said on here, followed by the most important part of the day. I say coffee and in all fairness, I think it is really, really important within our team And the other surgical and specialties do the same after the, we've done the water round, we do sit down and have a coffee and literally wind down for about 10, 15 minutes um over coffee, go through through the list if the consultant is there. Um And or the, the reg are we actually make sure that we know what we need to do, what we need to chase what we need to ask for. Um What do we need to do with XY and Z? Um um On top of that, we obviously have a whatsapp group. Um if there's any semi urgent or non urgent things and we can post them in the group if it's something urgent um which comes up through the throughout the day then um actually one of us has to walk into theaters um and uh find someone senior and potentially pull them out, which I so far in my four years, I probably had to do a handful um had to get a senior out because I could not manage um a patient who was quite sick basically. So, so, um after we divide up the jobs, we literally let's let's do it. Um We've got a surgical building where the majority of our patients are, is 112 bedded unit, um, or single room environment, although they have converted some of the rooms now to um to double rooms. Um And the majority of our patients are usually in that building, um, which means that you don't have to walk around a lot, which is fine problem is that it's far away from the theaters and it's also far away from endoscopy and from um, radiology. So, um, then, um, and then if you're ali polar, the problem is that, um, once you're dealing with your jobs, um, you then have to also deal with all the other board jobs. So like dealing with the bleeps, um, update family members. Um, and these are jobs which can be done either by me and majority of times I do them because, um, er, I'm there probably more frequent than the F ones because the F ones have to literally do the rota as well. So they are nights, they're on weekends, they're on cover, um, they have some days off, they allowed to go on holiday, stuff like that. So I'm probably the more constant in the team. So therefore, I know the patients generally much better and therefore I'm quite happy to actually discuss things with the family members and update the, um, the patients as well. Um, if things are a bit unclear, um, update the wart nurses with plans. Um, unfortunately because, um, when we go through the warts, um, the nurses do still the drug ro most of the time and on top of that, we've got electronic prescribing. Um E PM is fantastic. Um, it does come with drawbacks. It does take longer to do your drug wrong, basically. Um, especially if you have a patient and the medication is not prescribed and that's part of the problem. And I have to, if it's one of our patients, I'd sort that out. Um But they also don't then because they do the drug still, which means they not um joining us on the ward round. And therefore, I always make sure that I go back to the nurse and say, listen, we patient X has to do XY and Z we need to do this, this and this and I think this is really important. Um um because things get missed. Um And um my communication is a big problem. Um And I've got a nice quote at the end which I actually follow through the t more or less. Um when it comes down to my communication, gets on the ward. Um and then discussion with members of the wide MDT and that's obviously it's all about. So I'm part of the, of the bigger MDT, um which means that I have to liaise with OTs physios, dieticians, war war pharmacists. Um The Pops team, um I see that one of their members is actually online haa. Um And um so they are basically the surgical geriatric team um as per nice guidelines. Um, a surgical patient who's over the age of 70 needs to be seen by a geriatrician and because of our pops team, which I always forget what it's called and I hope Anna can put it in the chat. Um They, because of Anna and her team, um, we are, we're number four in the country, um because of that and they are a fantastic source, er, resource of, um, knowledge and what we can do with patients who are co morbid 30 score of, I think five plus. Um, and then they basically give us advice and if they get stuck, they get their geriatrician involved and I look at that. Thank you. Thank you, Sherry proactive care of older person, I think. Yeah, that's probably about right actually. Um, yeah. Um, so, um I liaise with Anna and her team quite a lot. Um because we have got a degree of older patients, especially because of Somerset, I think population, I think when you look at the demographics, I think we've got 60 70% over the age of 60 I think. Um, um, and then I'll have to deal with calls from the surgical triage area. Um, and um, so we have got a, um, surgical admissions board, like most, um, most hospitals and we have got a triage area there and sometimes we asking patients to come back there or if it's an upper G I patient, um, then I get to see them. Um, and I always tell them to believe me rather than the junior because the junior again might not know the patient. And therefore I'm quite happy to see the patient and review or assess the patient. Um And then normally, uh normally around two or three o'clock, we meet with the registrars or if it's a busy theater day, um we meet in between cases and then update them. Um Usually one of us tries to update the bloods. Um We go through the patient list. Um We need to see if we um have requested any CT S MRI S ultrasounds, stuff like that or um um or if we need to chase them um to make sure that they're relatively urgent. Um uh and then go from there. Um and then when it gets down to like 56 o'clock um as um from five o'clock onwards, the surgical wards um are not supposed to bleep me anymore or the te the surgical teams, we've got a surgical ward cover from five o'clock onwards, they are supposed to bleep them. Um But if they see me lingering around, they do bleep me and then I normally, I normally sort them out. Um And it's usually because you get to know the bleep numbers, um, which, what it is and then you have a rough idea why they bleep you and then if you have a really sick patient, then I normally do answer it and, um, try to sort it out too. Um, and then, um, anything before I leave, which is outstanding, I normally hand over to the board cover, um, just to make sure that they're aware of certain patients which have the potential to deteriorate. Um or um they might need to chase um any scans or something like that, which I couldn't. So um so yeah, so that's basically my day. Um So on a daily basis, like I said, I have to collaborate with um the dieticians, the acute pain team. Um they are a really useful uh bunch of people really. Um they're, they're specialist nurses and they're working under the tutelage basically of the anesthetic team and they come and see patients who, so they come and see patients automatically when they're on P CS. Um But um I um if I'm not so sure which pain medication I should prescribe or dosage wise, then I normally give them a quick ring. Um And um based on their advice, I normally, I prescribe something. If I think they, the patient needs, needs a PCA, then I normally ask them because it should be run by them. Um I probably could prescribe it. Um But I never do because I feel like I, um, I need some advice from the specialist basically. Ok. And the junior doctors are, or the post back doctors as they are these days. Um, they do exactly the same, um, OTs physios. So that's when we do the discharge planning. Um, we've got a discharge team within our hospital and, um, they meet in the morning, go through some patients which are medically fit and see if we can get them home. Um There's various pathways they follow, um which I'm sometimes not really fully understand. Um The main one I normally hear is called D so discharge to assess someone who's going home and they're waiting for slot to go home with a care agency. Basically microbiology. Yeah. So they are um if you have obviously sick patients who are on intravenous antibiotics and they are on some weird and wonderful drugs like meropenem, uh Tazo Vancomycin. Um We normally um stay in contact with the microbiology team on a quite frequent basis, um especially when the patient gets better and you want a oral switch. Um because for meropenem, for Tazo, for Vancomycin, there is no natural oral switch. So therefore you should have a discussion with microbiology and like I said, that is the set up within our hospital and within our team. So other teams might have a slight different idea. Well, pharmacists, they are um a really useful source um especially because of for, for the biopic patients um because I have to modify most of their drugs, post surgery, radiology. So, um and endoscopy because I've worked in bul cancer screening and in, and I worked in radiology. I do know all of the interventional radiologists. Um and most of the endoscopist and therefore, um um the upper G I team is normally quite happy if we need to discuss certain scans and um they're quite happy for me to go down there, um which I believe is not commonly done in other um in other to or in other specialities. But because of my varied knowledge and um understanding, they're quite happy for me to go down there and discuss things. Um And then if they're still not happy or if the radiologist is not happy, then normally a senior goes down, then later anyway, anesthetic team, um they're part of the acute pain team. But um if I need to get someone into the emergency theater, for example, I need to speak to the on call anesthetist um to review the patient. Um and then put a booking form into theater one which is our emergency theater and then the upper G I cancer team um which are quite a small team. Actually, there's only three nurses. Um They technically sit under the um under the gastro team. Um but um one of my um consultants is usually attending one of the meetings um on a Wednesday morning. Um So if I have any patients who have cancer or they come in and we find out they have cancer. I normally refer them to the upper g cancer team. Um Vice versa. If they have patients coming back from the tertiary center and they need follow up scans, then they're actually asking me because it's a relatively new team, they're not all fully qualified in certain aspects. Um because I'm also e a trained, um which means I can regret scans and um and other things. So they're asking me to um basically do um their scans for them. And then the pop team, as I said, who are basically a good lifeline, I also share offers with them, which is quite handy. So over lunch, I normally discuss certain things with them um challenges. Um It's interesting um when it comes down is obviously the challenges are communication basically. So um and the quote from Sydney Harris um is quite um it, I think it hits the nail on the head. Um er liaising with the tertiary center is really important but you need to get, need to give the information succinct um s a really important. Um So it's um it's important that we know an SB A and that we can do it well. Um and that's where I struggle with the war nurses. Sometimes they are quite busy, something happens to one of my patients and they believe me and the SB A is substandard. Um and it's not that they don't know what to do. It's just like in the moment, in the heat of the moment patient is sick. I need to get the image information across as quickly as possible. And therefore, um, that can be a struggle. Um, but vice versa and I know I was in the same shoes when I was with them. Um, and, um, yeah, it's, um, it's a learning curve and I'm working on that. Um, as I go through that in a minute, caseload is a big issue. Um That can be, um that varies depending if we were on call or not. Um If you're normally on call, post on call on a Friday morning, we might have 30 35 patients. Um but then we might not be on call for another two weeks and towards the end of that two weeks, I might have only six or seven patients left. Um But they tend to be usually the more complex patients who um are pancreatic um or um patients who um had complications from surgery or something like this. And then the challenge is, is the expectation I put it there. So the expectation is mainly about um the biliary patients, actually, I have to say, and the pancreatitis patients. So in terms of like um for the pancreatitis patients and um I put in the um I put a reference list at the end and there's a nice guidelines for how to deal with pancreatitis patients. And from a patient and from a relative point of view, they, it looks like we're not really doing a lot and, um, medically or surgically we don't, we don't operate on them. We give them food, we give them fluids, we give them pain relief. Um, and we give them oxygen because sometimes they don't really, um, um, they, uh, uh, yeah, it's, it's tricky. Um, and, um, they're like, ok, why I'm so sick and then, especially if you don't really know why they have pancreatitis. Um, because in my teaching, um, I do understand that I do explain to them, there's 11 reasons why you might have pancreatitis and then you need to bring it down why they have pancreatitis. And it's really difficult, I think in the expectation because they don't know how long they need to stay in. If they have pancreatic pseudo or peripancreatic collection, they need to have procedures done in the tertiary center that's not down to us then. Um, so it's all these expectations. And, um, so from that point of view for our biliary patients, the problem is once we found out that they have gallstones, um, and we tell them that, ok, unfortunately, the window to do a hot lu Coly, which means that you can do a, um, you can do a gallbladder surgery, keyhole surgery within the first five days. And then after that, it's a bit more complicated and a bit more risky, then you have to wait six weeks. The problem is that we send the patient home with antibiotics and tell you right. Ok. Wait until we invite you for the surgery or how long does it take? About six weeks? Well, you're telling me poor PC, aren't you? Because obviously it's not six weeks. I know the waiting list is a mile long. Um, and they're probably right and they're worried what happens if they come back and, and they don't want to be in pain again. And so is all of these managing these expectations, which is, it's time consuming. It's difficult. Um, and that's where the holistic approach comes in a little bit, um, which I go through in a minute. Um, yeah, it's, it varies. I've got good days where I do a really, really good job with some of the patients. Um, and I've got days where either me or some members of the team are really bad at it. And, um, um, every time I do a good job I take it as a win and move on. And, um, yeah, um, luckily we're getting better at this. Um, yeah. Yeah. Is expectation is really, really difficult. Um, um, and it's not so much a patient. It's actually, um, it's the relatives more than anybody else really. So, er, holistic care. So interestingly. So, historically, the, it is quite challenging within the surgical setting. So, um, I think the common phrase I heard was that the surgeon is good looking after the whole of the patient and not the whole, so they're very good at looking after the hole they made for the surgery, but not after the, the whole of the patient in terms of like discharge planning, stuff like that. Um, and to a certain extent that's actually quite right and quite true. And, um, and they're not specifically trained for that either, I think, and that's probably where, um, the specialist nursing actually comes in. Um So like an AC P or an um or AC MP. Um I think we're very good in bridging that gap because part of our bread and butter is actually to do this because we are trained to look after patients in that way. Um And um I think it's really important because once a patient is medically fit from a patient, from a surgical point of view, my consultant potentially doesn't want to have to do anything with the patient anymore. Um quite rightly. So it becomes my problem was or the, or the post grad doctor. So it's um it's quite, it's quite interesting. So, um um and if I do that, then it frees up the F one or the SHL to do something else. Um because we're also a teaching hospital. Therefore, um I want to make sure that whoever is rotated to work with us, um that they get a good understanding, a good knowledge of upper G, I, even if they don't want it um or don't want to do surgery. Um, but hopefully they can take something out of it and then they move on to the next job and have a bit of a better understanding of what upper G I does basically. So, um if that makes sense, um to bariatric patients really, so they are a very complex group of patients to work with and to a certain extent, I'm actually quite glad that my two bariatric colleagues are dealing with them, um, presurgery because they are a patient group which have to probably wait one of the longest, therefore, one of the longest waiting lists within uh the NHS. On average, it takes six years from referral from GP to have your surgery within the NHS. Um So you can see why patients go abroad. They pay privately to have the surgery done, which does come with drawbacks because they don't get the psychological nutritional side of that. Um Because sometimes some patients think it's a quick fix, but it's still a lifetime change. And because we are a regional center for biotic surgery and we are the Center for Excellence. Um, we get a, a fair proportion of patients who have a lot of complications. The majority of patients actually, um are after surgery going home, usually the next day or day two. There's four types of surgery we offer um, a gastric band gastric sleeve gastrectomy where you um take about 75 80% of your stomach away. Um, you bypass the gastric bypass is where you bypass the, the parts of the stomach and you do some replumb basically. Um, and the band sits on top of your, um, um, it sits on the top part of your stomach and then you can squirt some water into a port basically where it can make it tighter. Um, and then the medication optimization is a huge challenge because after surgery, um because of the absorption and, and stuff and they need to have their medication modified. So patients, um uh we're using new guidelines um which is a website where you can um uh which can use for patients who have got swallowing difficultly. So need to have modified um medications, we can make them either liquid form. And the website basically tells you if you can crush your medication. Um And if not, these are your alternatives problem with that is that the alternative which they give me as an option might not be in our Musgrove Park Hospital formulary. And that's why I have a close relationship with the ward, with the ward pharmacist. Basically. Um they are generally tricky. Um and they need to stay on lifelong medication. And um when we do so we do about five biopic cases a week, we probably do less at the moment because we started robotic surgery literally a couple of weeks ago or last week. Um So we are training um our surgeons to do that. Um, and therefore, um, um, we have slightly less cases per week. However, um, um, their medication to modify takes me probably for each patient roughly about 45 minutes. And I'd rather do that than the junior doctors. And I'm not so sure if Sherry last year had to do it. Probably you did when I was off. Um, but, um, I usually tell them I do it because it's a pain. It's literally a pain. And, um, um, it's really, really difficult. Um, and because they have to wait for so long for their surgery, they're getting sicker. Um, mostly when you're off. Yeah. Um, they're getting sicker and therefore they're getting older. Therefore they have got all these other, um, comorbidities. They have type two diabetes. They are depressed, um, because they can't exercise. Um, uh, Citalopram is one of the worst medication you need to modify. Um, uh, 10 mgs of, I know it now because I do it so many times. 10 MGM Citalopram. Um, if you want to modify it, you have to put it in drops. Four drops is eight mgs, eight mg in drops is the equivalent of 10 mg in tablet form. But that is only because I'm not, it, I've done it so many times. Um, modified relief medication. I need to. Yeah, I need to get in touch with the pharmacist. I normally have a pretty good idea of what I need to do, but I normally then just quickly check with our chief pharmacists. Um, and then, yeah, they're just, yeah, it's, yeah, it's difficult. It's, it's interesting when, um, ward nurses see me on the ward sitting and they say, oh, you're just sitting there for an hour or so. And I do sit at the nursing station, I, for an hour. And that is mainly because a, I'm probably doing the medication for their Biot service. Um, on top of that, I'm updating the list um requesting a scan, asking for more bloods for tomorrow. Um And that brings me then to the CNP slash AC P role. So on the medical side, they have a lot of AC P roles um which is the advanced nurse practitioner. I, I am AC NP um which is a um clinical nurse practitioner, which means that I don't have the AC P course. Therefore, I'm not an advanced practitioner, my personal opinion. And that's just me is that when you look at the job description, OK, there's slight differences, but what I actually do is probably I do as much as the as, as a practitioner because if I get to a sick patient, I, I see the patient, I take my stethoscope, I oscillate, I listen to um bowel sounds, I make sure that I do bloods. I if and once I figure out what it roughly is I ask for additional scanning, stuff like that. And then after I've done this, I then speak to a senior and most of the time they're not around because they're theater. So therefore I have to make that decision. Um, or it's usually, then between the F one and me and we're like, sometimes the blind leading the blind and we're like, ok, I think that sounds like a good idea. We do that and then speak to the senior and then, and usually it's fine. Um What's your favorite thing about your job role? Any advice for student nurses who may want to take up your future role? Um, I do like talking to my patients. Um, interestingly, um, um, my wife is a nurse as well. She works on the surgical admissions ward. Um, she's one of the seniors there and, um, um, is, er, and I have to talk to her a lot as well, not only at home but at work. And, um, and I do like this, I do like the education side of it as well because you are suddenly the, you're the expert. Um, and that is really tricky because sometimes you don't know the answer. And I am very honest that even if I don't know the answer, like, even to the patient or to the staff nurse, I actually say to them, I don't know, however I would come back with an answer for you and I'm usually pretty good with that and I think that is part of your nursing integrity and that is really important. I think, um, I have to do a lot of NG tubes, for example, for patients who go into small bowel obstructions. Um, one thing I, I, and I teach on it, I'm the only practitioner in the hospital who actually teaches on it. Um, I do tell them so most nurses tell them. Oh, don't worry. It's fine. Procedure is not too bad. I tell them it's most, the most horrible procedure you can do to a patient who is corpus mentis because it is. And I had one in myself just for fun and it was the most horrible procedure. It's mainly because my mate at the time was a student as well and didn't know what to do as well. So, um, but it's really important that you're honest with your patient because if you lose your patient because they don't believe in you, then you've lost your patient. Um, they don't believe you anymore. Um, and it doesn't matter how good your intentions are. Um, and I think that is really important. Um, I think being the linchpin sometimes is pretty cool as well, I think. Um, uh, yeah. Um, I do like talking to my patients, um, as if you would work in muscle. Um, and if you in the surgical side, if you ask for Mike they seem to. Yeah. Yeah. He, he talks a lot, which is a good thing personally. I think so. Yeah, if that makes sense, I hope that answers your question. Um my pancreatitis patients, um they're like the bariatric patients, they can be very challenging to treat, especially if they are um if they are on the severe spectrum. Um which means they normally go into. So we've got currently, I think we've got a few who have got actually a preferred duodenum because of that. Um So that means we need to speak to our tertiary center in Bristol using the refer a patient um website, which actually is not too bad, I think for the, for the receiving hospital, it's a fantastic service for the person who is actually has to do the referral. And again, it's predominantly me. Um it's a pain because again, that will take me about at least half an hour um to do it because they want all the information, which is quite rightly because it's a comprehensive handover to and that is a little bit more than an SB bar I have to say. Um but it's um um it's a quick and good thing and they usually come back within 24 hours. If it's very urgent, we normally do a fast bleep and bleep the BR I in Bristol um and get a hold of the onco onco surgeon um to do that. Um And then severe cases involve a lot of people within the wide M BT, like I said, you need to get hold of the um BR I, so the HPV surgeon in Bristol, then you discuss with our G I radiologist, dieticians, um, OTs physios because you still need to make sure that the patient gets out of bed. Um, nurses, healthcare assistant, um, phlebotomists. Um, if there's no phlebotomy service, then, uh, we have to do it. We've got four phlebotomists for the whole hospital. Um, and there are some shortcomings occasionally. So, therefore, um, on top of then of our normal job list, we then have to be the phlebotomist on the day. Um So, yeah, and again, it setting the expectations. Um we're quite honest with our patients. Um uh some of my consultants are probably a bit more harsher than others. Um But we normally give them a realistic idea of um what they can expect basically. Ok. Um And then it's either me or the registrar or the sho or the F one can do that additional tasks. So at the moment, um So I'm in the process of trying to establish if I can get funding for an AC P. So therefore, um and or I need another person. So I'm trying to gather evidence for that. Um So that's on top of my normal day as well. Um I do a teaching for the Wars Nurses. Um and I try to do it bimonthly. Um It was supposed to be on Thursday. I had to cancel it um because um the junior doctors are on strike which I fully support. Um So that will be sometime next next month or so. Um, apart from speaking here, um I did a um the bombs, so bombs is the Biot and metabolic obesity Metabolic Surgical Society. I did a journal club with them, um, where I had to present something so I'm quite happy to speak, which is quite good. Um And because people know that they tend to come to me because I think part of the nursing profession is that some, the majority of notes are not very comfortable. I think that's probably a good word, stand in front of people and present something. Um I do it every other month. Um And because of my previous studies, I had to do it a lot anyway. Um So at the next N MP regional conference, which is next week, um I have the pleasure of talking and together with unattended actually. So, um which will be interesting. Um I'm in the middle of, of writing a standard operating procedure for our wild tubes within the hospital. Um, which I'm not keen on. I have to say the only reason I do it is because, um I think for my CV, it's probably pretty good um to say that actually it's a policy slash standard operating procedure um with my name on which can only help. Um And you can actually say I've done this and therefore it open doors to other things as well. Um And then, um I'm in negotiation at the moment with my, uh consultants to start clinics, um um how we're doing it and when we're doing it, there's no time frame set at the moment, but I recently had my appraisal and therefore, um I need to push for it a bit more. Um um We're coming towards the end t actually now. So, but all um the single biggest problem in communication is the illusion that it has taken place. Are you under a similar illusion? And that is basically my mantra at work. Um If I think that the communication did not happen, then I go back to that person and say, are you, do you understand? You sure? Are you happy? Any problem? Bleed me? No problem. And I don't mind to get bleed. It's my job. Um This quote is fantastic because when you then look at the dates or the ra incident forms, whatever you have in your local area, when you look at the problem, it always boils down to the communication and it's not only what did you think you said and what did the other person understood that is part of the problem, I think. Um um I'm a foreigner. So therefore I'm probably a bit more tuned in to that anyway. Um So always make sure that people understand what I want from them. Um And I, like I said, I tell them to beat me back because I am happy to be b bleed and to teach and stuff that sorry. Um I think that's my end here. So I've asked here any questions um if you want to get hold of me, um These are my details. Um And at the very end, I have a reference list as we supposed to be, I guess because we are professionals. I hope that was all right. That was perfect. Thank you so much, Mike for a lovely presentation that was all encompassing and thank you for clarifying the CNP versus A NP role as well. I think this is to highlight a lot of our sort of um shortcomings and sort of gaps in learning as well of each other's profession. MDT. So this is why the this series of talks is absolutely fantastic to sort of showcase one representative person from each kind of subspecialty just to come and speak about their role as well. I mean, I definitely can see, you know, how comfortable you are with talking, having had experience in the Middle East here. We've given some talks already and I think that goes a long way into educating um the, the people of the future and, and how you mentioned that, you know, you doing your role and being so familiar with upper G I in general then gives junior doctors a platform to actually go and do whatever they need to do to in order to learn and you know, satisfied the things that they need to do for their portfolios as well, which is fantastic I think if that was ok. I'm sorry, what were you saying? No, to be on to that point, I'm purely selfish actually because these are the workforce who look after me. So why wouldn't I part with my knowledge? So, um, no, no, I, I do love, um, obviously we've worked together. I do love talking. Um I do love to teach people. Um, and I think for the future workforce, this is really important. Um And um yeah, and I wish there would be more people. Yeah. Yeah, absolutely. Retention of staff. Our biggest problem, this is why, you know, everyone is going on strikes each other in solidarity for nurses, for doctors, for all our MDT professionals. Um I think my one question was sort of, I'm obviously more a medical person, so I wasn't an F one doctor who wanted to pursue surgery, but still really enjoyed my upper G I rotation. But for, for people who are coming in and want to pursue upper G I surgery, what are your tips that you, you know, you would tell them to sort of satisfy in the role or tell them to get ahead and do doing? Um I think for so for the doctors, I think it's important. Um So if they take, they come in and they tell me, oh, I'm really interested in surgery. I will make everything possible that you spend as much time in theaters as you want to. And if you tell this to our seniors. Oh, they'll be, they'll be all over you. Honestly. Like, be on the, honey. Honestly, they, because they love to teach, especially you've met Mr Mason. He is, they're all fantastic teachers and they want to part with and they are, it's really important. So you spend some time in theaters and then you figure out to actually, yeah, you then have to. What happens is you've got one of two things happen either. You think that actually it's not that what, what I think it is, the problem is that when you're an F one, you're not really, you can't really do a lot sometimes. So all you do is holding the camera, but what they sometimes let you do is to close this patient up. So you do a bit of suturing stuff like that. Um And then probably start doing your, you have to do your, um, mrcs, I think. Is that what you have to do? I think, get ahead with these things start probably with rising. Um, luckily I don't have to do this and I heard they are really expensive. Um, so, um, yeah, do things like that, um, from a nursing point. So that's absolutely fantastic advice. Um And from a nursing point of view, if you want to do that, um, make sure that you push for CPD all the time. Um, because that's how I do it. I push for CPT all the time. I asked to go to conferences. I asked to do present stuff and, and, and this is the only way you learn basically. Um So, yeah, thank you so much. Yeah, definitely. I think Mr Mason, Miss Holliman. Absolutely amazing inspirational surgeons got me here to two just to, you know, have a taste of what it's like, but that's honestly great. And thank you so much for your talk. I will upload this on our mind, the believe website with hundreds and thousands of links. Thank you so much to all the participants for joining us. There'll be a lot more participants. So if you get a few email, do let me know if it's getting too much for you and, and I can, I can help out for our way. I can. Yeah, no worries. That's fine soon. Thank you so much, Mike. That's amazing. And I look forward to your slides and publishing you on our website. That's all right. No worries. Thank you so much. Bye bye. Thank you. Thank you. Bye bye.