Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

I know. I know. Hello everyone. Good afternoon. I hope we're all doing well. Um Can someone just write in the chat, whether you can hear me, please? Hopefully you can hear us both just waiting for a message in the chat to ensure you can, please. Can everyone hear me? Yes, we can. Ok, perfect. Fantastic. Thank you so much. So, welcome everyone to the first webinar in our series called Post Seven Syndrome. Um We wanted to do this series just because um a lot of BS SNS um content has been um directed and geared towards um Sophia and positive. So we also want um Kevin to also have uh some time in the spotlight as well. Um So we're gonna be basically discussing the transitioning process, so finish in ple and transitioning back into the NHS, going back to the UK. That's basically what this um series is about. Um Our speaker for today is Doctor Lay Osmani. He graduated this summer actually in May and he started working in the UK. Um So he's just gonna be telling us about our, about his story. Um and also just about um things that you're gonna see commonly as an FY one working with the NHS. Um and also just a little bit about B SSN. So we are a nonprofit organization and our goal is basically to support students um during their time at university in Bulgaria and also specifically support them in the integration pro uh process, going back to the UK and integrating back into the NHS. So I'm gonna hand over to Doctor Osmani. Thank you very much. Um Also if you do have questions, do just write them in the chat. Uh Doctor Osmani is just gonna be um responding as we go along just so we can have a really comprehensive. Um Oh, so yeah, take care. Thank you, Doc. Thank you, Jemima. Appreciate it. Uh Hello everyone. My name's Le um I am a junior doctor now in the UK. I graduated in Ple April this year, April 28th. Uh Some of you may know me, some of you see me. But yeah, so I'm essentially just gonna talk through what life is like from the point you finish your last exam until where I am right now. Essentially. Uh I'm gonna tell you all the truths and ins and outs and what to look out for, what to do, what not to do and any advice. Uh Obviously, I'm looking this way cos the chats here, the screens here with the presentation. So if you see me, look this way, I'm just looking at the chat. Um if any of you have questions as I'm going through it, do ask, there's quite, there's a lot of content, but there's a lot of useful information and the more you ask questions, the more you're actually going to understand, like certain aspects of it, there's a lot of like information based on like the admin stuff relating to transitioning back. But there's also information of actually working on the ward. So I think that would be helpful for all of you. Ok. So I'll start now essentially. So me, my current employment stays on what I've done so far. So as I was saying, here's me grinning awkwardly. Uh I graduated in April 2023 from Pleven. Um Since then I managed to get my GMC registration in May 2023. And by the way, later on, in these uh slides, I'll have more information on specific bits of this actual slide. Um But just for now, just a quick overview, I got my GMC in May 2023. And then I also did A I LS course in May 2023. S at the end of May, I went on a bit of a break, decided to go on holiday because six years I'm plan. Trust me, you needed a nice break after that. And then I also was accepted on to something called the Gateway program, which I'll explain in a second clinical attachments. Now, I'll explain what clinical attachments are observers honorary contracts the lot. But in July, I believe I started with a GP placement in London for about a month, went around three times a week. Um just to get some experience with patients and then in the UK, speaking to patients and quite a lot of things. I mean, GP was the only one which I could have I could find at the time, cos clinical attachments, they're not easy to find. So I started off with GP cos GP was better than nothing. And then after that, I managed to get a placement in cardiothoracic surgery at Royal Papworth Hospital, which was in October actually. And then in terms of employment, since then, I've been doing what's called an honorary contract. So I've been working as a sho in A&E I sent Heller Hospital. I did that in October and I recently finished actually. So it was two months. And in the meantime, I've also been doing fy one loing. So I've been loing. Uh there's the agency hold doctors at Barnsley Hospital, Lincoln County Hospital, um mainly in general surgery and acute medicine. And A&E I think this, this week on Friday, I'll start at another hospital called Pilgrim Hospital where I'll be working in oncology as well. Ok. Ok. So let's start from the beginning. What happens after your last exam? Um I'm sure for most of you it'll be celebrating some of you crying. Some of you just, you know, everyone will just get gassed, they'll go corner for a coffee, go ha go eat restaurant or something cos they haven't eaten all night, they've done an all nighter. Um, but essentially the first thing I recommend you should do is run to student office and request your letter of completion and certificate of good standing. No, some of you may ask like, why, why can't I just wait a day a week? Essentially. What essentially happens is as soon as you ask student office and you, it's like a mini form you fill out, um you fill it in asking to request a letter of completion, which is essentially a document from the university stating that you finished your six years. So you finished your five years and a year internship and you could, you're technically qualified under the name master physician. Um and that's the document you're going to use to register as a doctor through Epic and then on to the GMC and also a certificate of good standing, which is another, it's like a letter of recommendation from the dean just stating that you're a competent physician. You take good history, good physical examination and together that's also used for your GMC application. So why I say run, you know, essentially what happens is some people might just wait a couple of days. It takes around a week for it to for you need to sort it out essentially. Um So the sooner you do it, the sooner you'll get it. I know people waited like a couple of days and then once they waited a couple of days to get the letter of completion, student office took maybe like 23 weeks, four weeks until they came back with a letter of completion. So they couldn't sign to up to the GMC. And then people wanted to go back home before graduation ceremony. So people ended up staying in Pleven. So essentially, if you wanna quit, if you want everything to be registered, you're ready to go, you're ready to leave Pleven, come back just for graduation, then run to student office. Just be like, can I have the request a letter of completion? They'll give you a form, you sign it, you come back after a week. Cool. So that's done. You've requested the letter certificate of Good Standing now, Epic and GMC application. So first of all, we start with Epic. So Epic stands for electronic portfolio of international credentials. So Epic is used to essentially legally verify your medical credentials. So GMC use Epic as a company organization, they focus on just essentially seeing your documents, seeing your letter of completion, validating it by essentially firstly, you have a notary appointment. So a legal appointment where you swear by all this information is correct. And then legally they take the document, send it to student office, student office, verify that that's their document they've given it to you. So we can confirm that. Then they confirm it themselves and then send it back to you and then everything's confirmed. So everything's legally confirmed that you have completed the six years. So IC that's what Epic is used for the American Texas based company. I think. So what you essentially do is create an Epic account online and download what's called an Epic identification form. This form essentially just confirms your identity, like who you are, your passport details, which university you studied at all these admin stuff. So you complete the form, sign it and then send it off to Epic and that takes a couple of days. Epic confirm it. So they agree that this is your name. This is where you studied. Cool. Now you have to do a notary c interview. Let me tell you something about this interview because essentially the the system when you send this off is kind of so bugged like it's such a poor system, they use that you send it off and then you're not sure if it's sent off and then you're waiting to for an appointment cos there's one, there's an appointment where you though you could book it in advance or you request. Now, you know, some people were requesting now at May hours and nothing was happening. Some people booked it forward, but they again on that time and time slot, there's nothing forward like some of the time slots were like a month in advance for this. So we were all stressed but that's solely because of their system that they use what you do. You submit the form and then you could email Epic be like I've submitted the form, but I haven't got a notary can interview. They then send you back the an email saying we are ready for your interview. Please click the link below. So some people were getting this at like 2 a.m. three AM and also you have to be quick. You have to be on it. Like look at your emails, just wait for this email. It'll come through once that's done. Then you're ready for the interview and everything's smooth. But since then it was just that system was just a chaos cos I remember I was so stressed because it was like two days before my last exam which was internal and they're like messing around with me like your interviews. Like they're not responding to my email. I'm just like what's going on. But yeah, everyone gets the email, you just click on it and then it's a, it's like a zoom call. They have their own virtual thing. Your camera comes up and it's just a woman from Texas just confirming everything. You have to have your passport with you and you hand it like put it up against the camera with your name, date of birth and everything and put your hand up and then like you solemnly swear da da, da da da. So it's kind of a legal interview. Once you do that, it takes about 23 minutes. That's cool. That's the main bit done. So then your, your form and your interviews confirmed now your epic is created, you're ready to go. So what you need to do now, so you could do this about I'd say about a week or two weeks before. So up to the interview bit you could do about a week or two weeks before. So that once you get your letter of completion, that's when you can begin the um validation of your credentials. So for me, I did it about, I started the process about 23 weeks before my final exam, the Epic account like creating it doing this interview. And I think as soon as I got the letter of completion, you're good to go so you can upload letter of completion. Um It allows you to upload a document and per document. It's how much 100 and 3 lbs. But with the letter of completion, it's only one document. So you only pay it once. So you upload it as alternate document. You could upload a diploma. But diploma is another pathway. Nobody really uploads it through diploma. It's longer, nobody really does it. There's extra steps. So I wouldn't recommend everyone just did it as an ultimate document. Just upload the letter of completion once that's uploaded um upload it as a P DFI think I can't remember. So you just scan it and upload it as a PDF once that's uploaded. So Epic, it takes a couple of days for Epic to get it. And then it takes another couple of days for them to send it to student office. And then it takes another couple of days for student office to send it back to Epic and then it's confirmed and then you get your Epic ID account. So once everything's verified, you've got your Epic ID, your letter of completion has been legally accepted by Epic by student office. You're good to go. So then that's when you can start with your GMC application. OK? Any questions about Epic real quick, it's a bit of a confusing system that they use. But uh it's, it's straightforward. It just takes a couple of weeks and it can be a bit annoying. And then also another thing is especially when people are finishing their exams, lots of people are requesting uh letters of completions and a lot and they get a lot, the like student offices get a lot of emails about verifying it from IC. So some people had to wait like almost a month for student office to accept it. Cos there was so many students finishing. That's why I said run to student office to just get it out of the way as soon as possible. I mean, you can't wait. There's no rush in this whole application process with GMC. Everyone's gonna get their GMC, that's for sure. Um OK. So in terms of GMC application, what do you need? This is actually way more easier and straightforward than Epic. To be honest, Epic was a headache GMC was straightforward. So there's this form called the I MG 23 form. It's about 22 pages long. You won't have to fill that many. And it's a lot of just the details that you need. Like your identi and identification details, your details about your internship. I think you have to put all your dates for your internship. So like gen uh internal medicine surgery, peds, emergen emergency medicine, uh hygiene, all of those you have to put like start day and day, fill it in as in like 40 hours per week. Um And then you attach a passport picture, understandably. So your letter of completion, a certificate of good standing. So because you've done your letter of completion with Epic, you just put Epic ID account number. So your GMC will look at your Epic account and see that it's verified. So that's fine. You attach a certificate of good standing. Um So that's the Dean's recommendation that you're a good physician that you take good history. You're polite, your communications. Well, that's just needed as part of the application. Um And then also you do your O ET or Ielts. Um You could add either your O ET or Ielts a reference number, you add it in the part of the form and then I just attached mine at the end as well. Um And then once you fill in the form, the form's pretty straightforward. There's a couple of bits like you're like unsure, but with GMC, like some people were quite unsure, they just rang GMC asked a couple of questions, they, they're really helpful. So GMC is pretty straightforward. I mean, it takes about again a week. So you send your GMC application, you wait a week. GMC then replies saying you need to pay 100 and 60 lbs or 100 and 61 lbs as part of the application fee, you pay that, then you wait another week and then you should be good to go. So you'd get this email, your GMC application GMC reference number, dear doctor. We're pleased to welcome you to the UK register and then you are officially uh fully registered G uh doctor in the GMC. You do actually before they did ID identifications in person. So you actually had to go into the GMC offices in London and I think in Manchester. But now you can do it online and it's really quick, but that's part of the ID verification. But once that's done, your GMC is fully done. Congrats. Six long hard work years, six long, hard years of work have finally paid off. Uh This was us, I believe I just found one on Google images. It's hella pixelated. But yeah. Um so you finished your last exam you've done your epic. You've got your GMC. Now, all that's left is the ceremony and then a couple more admin bits, if I'm being honest, uh for example, on the right here, do not forget to legal, legally notari, I'll answer the question in a second. Do not forget to legally notarize and translate your diploma and also make sure to do a police clearance check before you leave Bulgaria. Because essentially when you're back in the UK, if you get a non tr a nontraining trust grade fy one fy two job, uh you do need a police clearance. I'm not sure about the translation of the diploma because you've already got the GMC, but especially for um for locum work, they definitely asked for your diploma in its original state and a translated version. So for sure, make sure you do that. It costs around 100 and 2011. Me and my friend were like contemplating as to whether to do it, but we were just like, let's just do it cos nobody really told us what to do after we kind of just went with what rumors were around, you know, people talk on whatsapp. Oh Make sure you do this, make sure. So we just did it, but I'm here to tell you it's definitely needed, especially if you're applying for agency work. Um Definitely do it. I think there's a, the translation place is opposite Mov near Immigration office. Um There's a place there that does it and the police clearance you'll need it takes about, I think it's like two levels to do. It takes about a day. I'd say do it like a week before you leave Bulgaria for good. Just so that you have the most up to date version. Um But yeah, make sure you definitely do these two. I know some people contemplated. Some people didn't do it but it's just to make your life easier. Like agencies will ask. Ok. Do you have a police clearance? We do need that in order to sign you up hospital trusts. N may need to make sure you have a valid like D BSC RB, check in the country you're working with working in and like studying and so make sure you do these two er question in the chart by Mohammed was any reason why GMC application might be rejected? Honestly, I have not heard a case where a GMC application has been rejected if I'm being frankly honest with you. Um I know there's cases where somebody might have missed a certain bit of the application form. So they just emailed them back saying can you please fill in the required part of the application that you missed, they fill it and they send it off. So personally, I haven't heard anyone that might have been rejected from a GMC application. Um All you really need is to pass your exam. Do the EEI have your passport letter of completion certificate of Good Standing. O et or Ielts, er, and Epic ID account number. I know there's minimum requirements for O at and Ielts. I think in Ielts you need a minimum of a seven and an average of 7.5. If you're a native speaker, I wouldn't say it's too difficult. I know you might, uh, the writing for Ielts is especially the hardest. I think the writing for both is the hardest. Um, but I know some people maybe failed it once. If you're a native speaker, you should pass first time. If you don't then you'll probably pass second time. If you're not native. It's a bit trickier. But again, it's possible, it's not hard at all. Like, it's not as difficult. It's pretty straightforward. You do need to study. So don't go in without studying. I mean, some people do and pass, but I'd recommend studying. Uh, do you? I asked which test did I do? Which you would recommend? Now it's totally up to you for me. I did O ET because it was medical based and I just don't like English tests or exams. They're just, I don't know if you asked me to write an essay on a topic in like, 15 minutes. I'm just gonna, I like to think about it. But if it's medicine you kinda, you're rapid on it. You're just used to like answering stuff really quickly. Ot is more expensive though. It's about 323 120 lbs. Uh, is it 320 or something like that? Yeah. And Ielts is like 180 or 190 or something. Um, but o et me and two friends did it in Romania. We, we tried to make it a little trip for ourselves. So it was quite worth it. It was actually very fun. Didn't feel like an exam. I mean, we studied but we just, you know, we had good memories there as well. So it didn't feel like an exam and it was just something we just got out of the way and just make sure you do it and just get out of the way cos it is annoying and you don't want it near to your final exam and then you've got graduation and then you got Epic to think about and GMC just becomes a lot. Go out the way, just do it. Um, get out your mind. It's very doable. I wouldn't stress too much. Definitely study at least two weeks on it, in my opinion. Um, there's a chance you could just study, not even study, go in and pass, but you gotta learn the structure if people were transfer students to Pleven or took a year out. The GNC need proof of previous education. Yeah, about that. I'm not too entirely sure because there wasn't too many in our year who managed, who actually moved universities but shouldn't imagine it being that difficult simply because you have a letter of completion that basically states all the exams you've done and your internship here. Um, so I don't see it being too much of an issue. I know people in the year above who transferred universities and they're doing just fine. So I sh it shouldn't be that much of an issue. And again, if, if you want to like further ask questions on the specifics, you could just ring GMC. They're proper, nice, they're proper helpful. They'll tell you everything. And in my opinion, I don't think you need to worry about that. Um uh huh. Ok. But yeah, so yeah, and then enjoy your ceremony is nice. You're with your friends, family, everyone's celebrating. Um Let me just quickly. Yeah, everyone's celebrating, you know, having a good time, everyone goes out like after for dinner, all the restaurants are booked out. So make sure you book in advance. But yeah. Ok. What's next? So you had your ceremony? You had your graduation? Everything's good. Life's good. You arrive in the UK, everyone's congratulating you for completing your medical degree. The first thing they ask is when do you start work? So what's everyone thinking? What are your next steps? Uh A sa can you take ot ielts before six years starts? Yes, I believe so. Um I think for ot it's a two year deadline. So I think you can late in fifth year and it will still be valid for GMC registration. However, I would recommend doing it later but not too late simply because if you want to apply for F two stand alone, um you need AO ET and Ielts to be valid when you're applying for it. And if you do it in like fifth year, your OT would have expired. So you'd have to do O ET again. Um But also for F two standalone, your ot ielts result has to be a bit higher. I think it's 7.5 minimum in each section and 400 minimum in each section in O ET. So if you do want to apply for F two standalone, definitely do make, do it later in fifth year, but not too, in six years. Sorry, but not too late for, I think J I did it in February and my last exam was in March. So it was a month before, um, I left it a bit late but I think it was ok in the end. Ok. So again, what are you thinking? What's your next steps? You arrive in the UK? Um What's everyone thinking? What do you do? You finish your exams? You arrive in the UK, you start work straight away. How do you start work? And you won't have any suggestion, any idea of what you do? Hm. We registering with agencies already. Yeah, essentially. Yeah. Um, you do, you should start registering with agencies already. That's true because it, it can take, uh, quite a bit. So, Kate, we program. Ok. So you come in as a fresh baby in the UK. You've just done six years. Um, but you have no UK NHS experience as a doctor now being able to get, uh, job with no UK experience. Not impossible, but definitely not favored. Especially now in this specific year I'm talking, there's quite a lot of international graduates that have come to the UK. The market is extremely saturated, like extremely, if a hospital trust sees a CV, they've done, um, they've done their degree in Bulgaria but they have no UK experience and their C VS blank, they're gonna compare it with other doctors who have done. Maybe there's doctors who've worked three years in their country but have now come to the UK. So they've got three years on you actually working as a doctor. Um, so they're going to favor them straight away. Your CV is almost like nothing to them. So it's quite unfortunate, but this is what I'm here to advise on. So you have to build your CV. There's two things you should do straight away, do A I LS or A LS course 100% that just needs to be done. Um, it, it helps. Not only because when you're on the wars, there's a cardiac arrest and you're the first doctor that you need to know what to do. Um, but you need as part of your application, part of your CV. And proves it massively. Now I LS or A LS definitely don't do both. Please don't do both. Um So, ok, so B LS, if you've done one in Bulgaria, firstly, it's a, it's something good to have, it's something good to know. Um, it's really important actually, but UK don't really accept B LS. That's not from Resource Council. UK. So in terms of application, it's pretty much pointless. However, it's still a good course to do and good course to know. So these courses you should try to do in the UK, definitely don't do I LS or A LS. Both I LS is immediate life support. A LS, advanced life support. Um I LS is about 100 and 65 lbs. A LS is about 450 lbs, so it's very expensive. Um I LS will mainly talk to you and teach you about air management, cardiac arrests. Um Whilst there's like anaphylactic shocks, asthma emergencies, choking emergencies. Um Yeah, those are the main ones I see. A LS is a bit more than that. It's like a, it's like cardiac arrest, but you're actually leading the team. So you're going to be leading the team in terms of who's doing the airway management, who's doing the IV access, who's doing the chest compressions, he's doing the defibrillator. Um It's a lot more advanced. Um Yeah. A LS is defibrillation and stuff, but so is I LSI LS is like a smaller version of a LSI LS also, there's no M CQ exam. It's just a practical exam which again is so easy. Like the people who were there, like, they didn't know anything and they just about understood, but they still passed, like, it's a pass sort of exam, but it's also very important for you to know. So make sure you do pay attention. You do read beforehand, um, from the, for the B LS and the European Resuscitation Council. It's still not accepted. Like, I don't know, the UK are very stingy. They just need their UK Resource Council certificates. That's what they prefer. And I don't think if you don't have ABL S, I'm pretty sure the trust will make you do ABL S before you start working for them, at least. Um I LSI LS is like the base base like course that you need to do as part of your CV, application for jobs. So definitely have, think about I LS if you have so cos A LS is more expensive. People don't really go for it. I didn't really go for it cos it's just too expensive at the time. I was still as like, I just finished like I had no work. So I was like, I'm not paying 500 quid when I could do A LS and probably means the same. But A LS is more advanced. A LS does put you more top of the ranking between all other doctors. Um Do people fail it. So I LS, not that I'm aware of, I mean, it'd be incredibly hard to fail. I LS like incredibly hard. Um It is informative. Make sure you do read up beforehand because you're gonna need to know all the information. They also teach you a to e assessment, which I'm going to get onto a bit later. But uh it's definitely something that you'll use throughout the water. It's very important to know. So, yeah, I LSI think it's a one day thing. I did it in London. Um uh It, it was fine chest compressions, airway management defib, you understand it, you know, which are shockable rhythms, which are non shockable rhythms. Um And what to do in case someone arrests. Um But yeah, a see chain of survival, they say they use this a lot early recognition, early CPR early defib and then post resuscitation care. All of these are essential to helping someone survive if their heart stops. Um And I think the earlier you do it, I think by much like it improves their moral, like improves their living by like 50% or something, but they're really uh active on this chain of survival. But yeah, as I said, A LS, um if you had lots of C DS and they're pretty much the same. Everyone has a A LS but one has a LS that A LS will be ranked up because it's harder. There's AMC Q exam, I think about um there's AM CMC Q exam that's about 90 MC QS and you need about 65 to pass 70 to pass. It is tough. You need to study. Um, there's also a practical exam where you have to lead a cardiac arrest. You have to tell people in the team who's doing I VA access, who's um doing chest compressions, who's doing airway management. Um, get all the medication ready, adrenaline when to use it, everything like this. Ok. So Il Sa Ls make sure you have that on lock as soon as you arrive, whichever you wanna do, it's up to you. A LS is much harder if you wanna study cos you have to study for it cos you don't wanna fail and was 450 lbs. Um, and it's also hard to book. Uh, do you not need to have done B LS to the eye? S? No, you don't. Uh You can just sign up to do, is it cost 100 and 60 lbs? You just sign up really? Um, in terms of, in relation to UK students, F ones don't do A L SF twos by the end of F twos, uh, the UK students, they would have done a LS. Um, and their trust normally pays for it. That's another reason why people don't do A LS because if you're unemployment and you go to F two, the trust normally pays for that course. So you don't have to pay for it. But if you're like, still unemployed, still searching for a job and you're desperate, then A LS will rank you up quite highly. And yeah, people can fail a LSI know a couple of people failed a, it is a tough exam. It's, it's doable. It's, it is doable. You just need to study. If you don't study, you won't pass. What would you recommend for a second year? Medic in terms of building the CV? Honestly, just enjoy your uni years. Um In terms of actual uni stuff to build your CV, it's more all the society work if you wanna do like be president or vice president of society, that helps um it helps, especially when you want to enter specialty training. But in my opinion, just enjoy uni study um and just live your best life, live your student life and make sure you do keep on top of work cos everything builds up to the end, all your knowledge builds up to the end. Uh So make sure you're on top of it. And yeah, just take part in societies, any events, workshops, if you wanna go to conferences, if you wanna um actually give a presentation to a conference, all of that's really good. Um And you could add it to your CV. Make sure you get evidence of it because some place, some trusts like want to look at it. Um OK. Moving on from Il Sa Ls. Any more questions on it. Um But essentially do one of either. I did. I LS, I've still not done A LS. I'll probably do it next when I start doing F two. And hopefully the trust pay for it goes 450 quid. Anyways. Cool. So on your CV, you've now got six years done. I LS done. It's looking much better clinical attachments, clinical attachments. Let me see. Now, I'll talk about clinical attachments. Now. Uh actually let me talk about references please before you leave Pleven, um make sure you're on good terms with, I'd say three minimum two, but three consultants preferably actually most definitely consultants who can give you a reference. Um because yeah, it has to be consult. I mean regs are fine because they're in specialty training. Towards the end, you can put them as consultants, cos you know, Bulgarian, you can have different meanings of consultants and registrars. It's like I used to, I used ophthalmology and trauma and also consultants. Um as references for that you've been, you need a three year reference that you've been a medical student and essentially all you need from them is just their email and let them know that either agencies or hospital trusts will contact them regarding a reference that you are a student in Ple, but make sure you're on good terms because sometimes you're going to be needing references for like five agencies. So you've got to send them five forms to fill in and just make them aware and make sure you're on good terms because some, you know, some professors, especially in Bulgaria, um, they're just, they just won't have it. They just, they just can't be arsed, they've got their own work. Why do they care about a student who's in the UK? Like that's why, make sure it's someone like you're on good terms with and they'll for sure give you a reference and they're nice. Um, I've also used OBS er, Ellie was really nice. Er, she gave me a couple of references as well. Um, so what you need from them is just their contact email and just letting them know agencies will contact them. You don't need to give them something to sign because um, I mean, if you sign up to agencies early, you print off their reference form, then get it signed in person, but by this time you would probably be in the UK. So it's a case of just emailing over the agency will email whoever the professor is and they'll be like, can you fill in this reference form for Doctor Osman who wants to work with us? Just let them know, let Ellie know um, or let any other professor know. Ok. Uh can you just fill in this reference form, please? Um, covering the periods from March 2020 to March 2023. That's what I did. So it covers three years, they just sign it, they stamp it and they send it back. But these can get really annoying if anything. I think these are the most annoying things when applying for jobs and local agencies. So make sure you have 23 references in my opinion. So just go to them, just be like, can I have your email? They're gonna email you? Is that ok? And mo most of them are fine. Um Most of the professors they're willing to do that. It's just, it could get annoying because if you do it for one agency call, you still haven't got a job, you apply for another agency and then you have to ask your reference again and again and it gets a bit tiring for them and you don't want that. Um would you just suggest writing it for them, to be honest, it's um it's just a tick on a tick basis like it just ticks it across. Um Can we use a consultant in the UK? Yes, if any. So when you apply for jobs in the UK, consultants in the UK is the most ideal thing. However, what are you using the reference for? Because if it, if the reference covers medical student in Bulgaria and it's a UK consultant, they could sign it off but they won't cover that UK experien er that Bulgaria experience because they're in the UK if that makes sense. Um So where the U UK references is through clinical attachments and honorary contracts. So uh do we need a reference from the doctors in Pleven. Yeah. So as I've been saying, um you need a reference from 23 doctors from Pleven just to cover the period of medical school that you've been in, in my opinion, have 23 ready. You won't need to maybe use all three, just the one or two but definitely be in touch with uh some concerns UK reference for the clinical attachment but not for BG. Yeah, exactly. So for the clinical attachments. So firstly for what is a clinical attachment? Um essentially it's just it's an observer ship. So you, you ask you email hr s across the locations. You're looking for all the hospital trust, you could either ring the hr hr team uh email them. But if you ring them, you're more likely to be successful because it is hard um to get clinical attachments. But um they are there if that makes sense, some places are willing to do it and essentially they just sign you to the hospital trust and they assign you maybe to a consultant or to a team or ward for you to go to and then you'll be there for, I'd say 4 to 6 weeks as a recommended amount in my opinion, um where you'll essentially just look over, see what they're doing, ask them questions. Um Some places you could take blood so they'll help, they'll teach you how to take blood, how to do ABG S. Um some clinical skills. Some places prefer you just to watch. Uh, I mean, I was in GP for a month because I couldn't find anything else. And it was, I was mainly doing telephone consultations. I was speaking to patients. I was learning how to communicate. Uh because that's a big thing here is communicating. I know some of us are native speakers but um there's actually a way to communicate which you kind of just learn on the job. You're not really taught it. Um So that GP was essentially doing telephone consultation. I was doing physical examinations and the GP was like looking over me, like checking how I was doing it and giving me advice after I was doing that like 23 times a week for like 46 weeks. So that was my GP placement done and I got a reference from the head like GP. Um but I wouldn't recommend doing GP simply because if you're applying for jobs which work in a hospital, in a ward, they want you to have experience on the wards. Like if you're on a GP, you're not really experiencing what you would experience in a hospital setting. So for me, because that was the only thing I could do at the time, that's what I did. However, I wouldn't recommend it at all. Um I'd go straight to hospital, just keep emailing people, keep messaging if you've got links, this is the best time to use them. Um if you know, consultants, trust me, there's a lot of nepotism in the NHS. Um But it's a good thing if you've got um people, if you know consultants who are willing to help you with clinical attachments, definitely use them, definitely email them. And that's one of the first things I'd do clinical attachment and then the A LSI LS course. Um Yeah, and this here uh let me just scroll down. Sorry. Can I use a reference from a doctor? Let's say Canada, for example, if you've done work with them, yes, if you've done work and you put it on your CV, and you could cover a reference for and for sure you can. But it depends on the w what work is done if you've done an internship, like if you've done a month internship in Canada, put that on if it's sixth year though, I wouldn't recommend anything less than that because it's what they want as of late in terms of clinical work. Are there any agencies like locum people? But for trust grade jobs? Uh Yes, I'll explain that in a second and how they differ, differ if that makes sense. But yeah, just quickly on this one. I put this here. Some people did a phlebotomy course. I personally didn't um It was like 100 and 20 quid, but also couldn't find a booking. So I was just like all about could be something to put on your CV. Uh But the main ones, Il SA L sa 100% and a clinical attachment, 100%. Um Does anybody know what honorary contract is? Because that's what I did. Uh If you saw at the beginning I did uh I've done quite recent honorary contract as an sho in A&E anyone have any idea what honorary contract is? Let me just explain it. Honorary contract. So honorary contract basically means you're working for the trust have uh you don't get paid for it. Um And you could essentially do everything except prescribe and discharge. So you're working as a doctor, but you can't prescribe and discharge and you need to be under. Um I'm just having a read on the thing. Yeah, so some honorary contracts are the honorary contract. The term itself just means a contract for you that you don't get paid for. And then obviously you could have that as an observer ship where it just states that it's an honorary contract, which means you're just there on observer ship as a clinical attachment. But in my case, I was in sho in A&E in South London on an honorary contract basis, which is essentially like a clinical attachment, but on a CV, it looks much better because you're actually working. You're not just observing, you're not just looking at F one F two S, you're actually seeing patients. Um you're requesting investigations, you're doing clinical skills, you do have supervision. That's the most important thing. Um So I was, for example, I was working in same day emergency care in A&E South London. So I would see patients. I would examine them. II wouldn't have anyone supervising me, but I'd just, you know, take history, examine them, uh, and then request investigations and then I'd report to the consultant who's working there, explain the case, uh, in SBAR format, which I'll explain, um, what I've done my plans and investigations and then he'll either go see the patient again with me or he'd agree with my plan and then I'd proceed. Uh, but that's really, it's really valuable on your CV. It's essentially what got me the agency jobs at the moment because it's quite a highly rated, um, thing like contract to do, um, especially working as a sho in A&E U. See everything. That's where I learned a lot of stuff, a lot in two months. Um, but yeah, some that ho honorary contracts to work, er, free are, are quite hard to find harder than clinical attachments. I mean, they, they cross over in terms of the meanings but, um, if you could do, like, I know someone doing an honorary contract, fy one in general surgery. So they're working in general surgery but they're not getting paid, but it's work experience. You can put that on your CV. And then other trusts they really appreciate that and they really, like, understand that counts as NHS experience. So that will get you higher in the ranks, in terms of who they want to hire and who they don't. Um So if you can, when you email trust or when you call them, just be like, is your trust, is anybody providing an honorary contract? Uh I'm a fully GMC registered um the doctor who just graduated from Bulgaria want to gain some NHS experience. Is it ok. Um And then they'll, they'll let you know and you can only do these clinical attachments honorary contracts as far as I know if you have a full regis full registration with the GMC. Um I think some places do clinical attachments without it, but I'm pretty sure you need it. OK. Roots for job application now, as I was saying, firstly, let me just start that. Uh as of now, the markets are really saturated. There are a lot of doctors, there are a lot of people trying to find work both from Bulgaria, from outside, outside of the UK in Europe International medical graduates who've done their labs. There are a lot of doctors right now. Um So the markets really saturated. Um I was speaking to, I was speaking to um I'll answer that in a second. Uh I was speaking to a sho the other day and he was just telling me how no sorry act one called trainee uh year one. He was saying that essentially every two years UK have this thing where they go really saturated in doctors and they're really unsaturated in doctors. Um, I don't know why. Exactly this is, I think after the two years all the doctors that were saturated they go into specialty. So it frees up a lot of vacancies if that makes sense. So those that were graduated in 2020 they had quite a lot of vacancy 2020 to 2022. There was a lot of vacancies. You could get a lot of doctors in 22 to 24 which we believe will start easing up. So I think by August in your year, jobs will start coming up a bit more. That's, that's what I think the idea is. But as of right now it is quite saturated. I know quite a few people are still looking for their first job. If I'm being honest, people are still looking for their first locum shift or cos it is quite difficult in this market. Um, it took a while for me to even somehow get onto the jobs that I'm doing now. Um, but let me tell you the roots. Now, if I'm being honest, someone with you will have it easier than others and everyone's going to go through a different pathway. So you, you simply cannot look at others and be like, oh, they, they managed to get, um, um, an honor above 5.5 grade. Da da da, da da. This person they got averaged 3.8 grade. No one cares. About the grade in ple, like, go for an, going for an honor is good to add to your CV. So definitely try if you can definitely try. However, it's not guaranteed that you'll get a job. This person won't guarantee. Like, there's a lot of, like, political nepotism slash luck. There's a lot of luck as well. And again, it's about building your CV. Just try to make your CV as best as possible. Then the rest is just out of your control. It's, it's just based on luck and hopefully, um, some places you're just there at the right time, essentially. Uh But in terms of what jobs you can do. So there's these things called trust grade, nontraining contracts. It's nontraining because we're not part of the UK training program. We've got the four GMC registration. So we're not in training if that makes sense, trust grade. So the trust releases jobs on track, which is uh essentially a health jobs.co.uk. They release all the jobs on there and then you apply through something called track. Um, and they offer contracts six months, one year, four months, rarely, two years, but they do offer contracts on there. It is hard to get them on there. Some people get lucky. Some people manage to have a good application and then you get offered interviews if you're successful at interview. Um, they'll give you the job, but it is tough. I'm not gonna lie. I've done quite a few applications. But so I haven't managed to get interviewed through track. Um again, the market's saturated and also you need a bit of luck. But yeah, so what you can be doing is waiting at home or doing a clinical attachment and then waiting for a track job, but I would not recommend that at all if you can work, try and that's where agencies come in. Um Initially, I was, I wasn't sure about doing agency because I heard there's, it's like unsustainable and it's a bit risky as your first job, but I just kind of went for it and II just got a post and I was quite lucky. Um, so, yeah, you could do locum. Now, as someone asked before in terms of like agencies like local people, but with trust grade jobs. So you could get long term locum posts, I think, with certain agencies where the hospital send long term posts. So from like a August to December, that's like four months locum. You've got, you fit it in with a wrote about locum rates, um, which is ideal, but again, it's really competitive and you need a bit of luck. Sometimes they just happen to pick you. It's just, um, it's just how it is. Um, and then you can get short term, maybe a couple of weeks and ad hoc agency, which is technically what I've been doing. Um, I've been working essentially maybe 34 shifts a week. I think this week, I'm working from Tuesday to Friday. But once you get booked in, once that hospital books you again because I heard somewhere it takes about like the hospital will have to pay 5000 lbs to just to book a new, a like a new doctor into their trust as a locum. So they're always hesitant, adverse, but if they're desperate for doctors, they'll book you in once they book you in, they keep booking you in and booking you in and booking you in. Um So essentially for me, it was a case of I did my GP and I did uh cardiothoracic surgery. Uh I did a clinical attachment in it was early October um for about two weeks. Um just to add it to my CV again, that helped with the agencies, but I was still struggling a bit. That's when I got onto sho honorary contract. I just happened to email the doctor, they offered it. I didn't like I didn't know what it was. I thought it was just another attachment, but I actually did the work there and I was just like damn. Um But then through that, I managed to get agency booked in because believe it or not, I've been searching through agency from about August till about October and I was getting nothing. I was absolutely getting nothing. And I'm telling you it gets depressive. Sometimes there's still people who like in my year who are still struggling to get locum shifts or any like, track is extremely hard to get because they're rare to come by and there's lots of people applying and then there's interviews and then also it's a bit tough and then locum again, er, it was tough, especially with no UK NHS experience. That's, that's the main thing. They, your new doctor, it cost about five K for you to, to be on their trust. So they're not risking it. They'd rather go to someone who's worked at a hospital before or worked in a UK hospital. They know what to do. So obviously they're gonna hire them. Um But clinical attachments help a lot. So make sure you do them and, and then once you get booked in, once you'll keep getting booked in, that's the good thing about it. Um In terms of what I did, I started cos I was so desperate for a job. I started in acute medicine as an F one but on a night on call. So it was, it was tough. I'm not gonna lie, but the majority of the shift was mainly learning how to do things on the it, like how to request scans. Ok, cool. What do I do now? Like what's clerking? What does larking even mean clerking is just taking physical, taking a history and physical examination and you have a booklet on how to fill it in and straight forward. I think it's one of the main things Borge taught us how to do. Um But yeah, that shift was larking and initiating management, but I had a good sho in reg, she was helping me. It was my first shift. It was a night shift. I was tired. It was 12 hours. Uh uh Do I need to stay on CV. OS clerk and patients prior to a reg consultant? Seeing them um on your actual CV? No, in terms of what you've done. No. Uh on your CV, it should just be, I did a honorary Sho in A&E I didn't go through however, on my agency, some of the hospitals wanted to book me, but they didn't know what honorary sho was and what my roles were. So they asked my agent to ask me to write them a quick essay of what I did. So then I listed everything. Once they got that, then they accepted my CV. Uh some people are not willing to move away from home. Like some don't want to move away from London. Ok. Another one. Um yeah, I'm not going to lie at first. You probably have to be open to being flexible. I didn't wanna leave London that much. I didn't wanna go too far. But it is tough out here. You're, you're gonna have to just compromise. I mean, the they'll have like hospitals will have accommodation or there'll be a premier in even if it's for a couple of shifts, you need to build your CV. Trust me. It's better than staying at home. You'll get depressed, you'll think. Oh, why am I not getting a job? Oh, there's people working but I'm not working. Um, you're gonna have to compromise. Another thing is, look, I know people who are from London. Um, they got a long contract in London. They accepted the application. The interviews went well. Or if they were in another, like, people in Scotland and a friend working in Scotland, he's from Scotland. Um uh It is, luck is luck. But if you get the opportunity to work somewhere, just do it. You can worry about location afterwards. Cos once you're in the system, it's much easier to get a job afterwards. Like once you're starting off is harder for some people, it will be easy. That's the thing. It is luck. Um You just do what you can keep yourself occupied. The worst thing you could do I think is just be at home and not do anything and not email around and just is depressive. I think we all go through that period and that, that's probably the hardest thing that's been about. Um working post, post Pleven. It's just in Pleven, you're used to system, you're going into sixth year, you know, you've got rotations and then you'll finish, you're in fourth year, you know, you've got internal, you've got farmer, you know, like there's a system in place. But after that, everyone, people start in sho people start in f one people will be GPS, like applying for GP training in like three months. Like everyone's on their own path, everyone's earning their own, like financial, like some people on local money, some people want trust grade money, everyone's on their own. But as long as you keep on top of things don't get stressed, obviously, keep in touch with friends. You wanna be with friends as well, like you wanna see what they're doing, like help each other out when you can. But yeah, uh someone asked, what are the interviews for? Ok. So for interviews, it's mainly the track jobs for local agency. You don't do an interview, they just book you in, you go to the shift and you work for track jobs. It's because they're offering a year contract. They wanna make sure they offer a year contract to someone like they like they think they're clinically like competent and ready to join our team. They know the values of each hospital trust. Each hospital trust has their own values before interview. You should know that values. Um And then use it as an example to something you've done. Like most of their values are like together like working as a team, inspire like care, being patient orientated. So interviews will be if you want the long term contracts within the hospital trust, so you're in their system, you're in the rotor. Um you get your own clinical supervisor, educational supervisor. Um ideally, if you want stability, track jobs, contract jobs are the best way lo jobs is. It's a lot of moving about, like last week I traveled Wednesday to Friday, Wednesday to Saturday. This week, Tuesday to Saturday. There's a lot of traveling, a lot of paperwork times sheets. There's a lot of stuff to get through. Um F two stand alone. Now, I don't know many people who have done this, this is the pathway this applied to F two, essentially UK students. When they finish F one, they get their full GMC and then they do a standalone, which is the F two. It's, it's essentially FY two where you rotate every four months in a different um different department, which is ideal like that's what we want. However, it's a bit competitive, especially cos we're IM GS. Um I think so you need, there's different um person specifications, so essential criteria that you need in order to successfully get through this. So you need, obviously you could have three month employment in NHS that counts as your English skills or you could have a high O et score or high IE LT score. Um You need to show evidence that you've done F one internship year. So that's again through references and then that's, you do it through the application and then you're long listed, you just wait, uh they've removed S JT for this year. So there's no S JT as straight to interview, I think. Um So they'll check your application, they'll either invite you to interview, they'll interview you and then each trust you could rank and think, and then I think trusts will hire whichever one they like the most or whichever one they rank the highest or how their interview went or how their application is. They rank you and then they put you on their program. Um, I don't personally know any I MG who's done the F two standalone post. I know it is difficult to do it. Um They have removed the SAT and again, there's not enough space, there's lots of doctors. I know in the news it says UK understaffed with doctors, but it's really saturating right now. I still got friends who haven't got their first shift. Um But yeah, um Gateway EU program. Cool. Um So NHS Professionals. So it's an organization which works with trusts all around the UK. Um Essentially what they do. They created this program specifically for us. Thank people. Three months. NHS does any job within the NHS count. Um Honestly, I'm not sure, but I would assume. So, I think if you work, hate C A for three months, I could get a reference or actually I'm not sure because I think it's three months as a doctor, I'd have to check on the eligibility criteria. But I think it's three months paid NHS experience as a doctor. I think if it's not as a doctor, then maybe you can get away with it. I think there's a form you, you get for a consultant to sign that you've worked there. So that's definitely something to check in the eligibility eligibility criteria. But again, with the gateway program, so essentially NHS professionals who work with all the trusts, they, they're the ones who organize all the bank shifts. Bank shifts are essentially the hospitals locum. So hospital work for themselves, rather than going through an agency to find you, they work through themselves and they work internally through doctors are who are already on contracts, but wanna do locum within the hospital. So essentially they made a program in which or eu graduates, they work with trusts in order to give them 21 year or two year contracts to work at that trust rotating like an F one like an F one F two does in the UK. And by the end of it, your crest form signs off. Now again, it's a competitive. Um You do have to do interviews for this. You do two. So you do one interview which is entry onto the program and then you do another with the trust which is similar to a track interview, um which is just essentially the consultants in the department that want to hire you. Um They have that interview with you, they ask you clinical questions, ethical questions and bits about your CV and maybe bits about the trust and its values and what and it could be anything else? Like, what do you think about the NHS, the pressure, the junior doctors striking anything like that? So essentially this program is slow. So I'd have it on the background, which is what I did in June. I signed up for it. I did my interview to get onto the programs. I'm on the program. They email me now trusts, um, which give one which are looking for doctors from Europe to be on, on their, in their hospital working on rotations um for 1 to 2 years. So you send their CV to Gateway gateway, send it to the trust. If the trust chooses you, they'll interview you and then they could hire you for a year or two. So again, this is good in terms of stability, the trust grade trap drugs, gateway, except the only thing is they're hard to get, they're not as easy, getting trust grade is not as easy for. So again, for some people, it might be easy. Some people, they might have a good application. The interviews might go well, they might get hired like it's really dependent, but in terms of personal experience, I know it's difficult. Um And locum was difficult for me until I got the post and now I just keep getting booked. Um So those are the pathways you can go. Um It's totally up to you. Everyone's on a different path. I know people working at sho level right now. I know people working at F one level right now, I know people who want to apply for GP in January, which is quite soon. So everyone's on their own path, earning their, again their own financials. Like some people are earning like crazy money. Um, as an F two locum, some people are earning trust grade money which isn't bad and obviously with the strikes and everything it's slowly increasing. Um it's manageable. How are we in comparison to the UK medical graduates? Cool. I mean, did anybody ask question, what did you say about English speaking rotations? Oh, it still has to be done, right? OK. Sorry. Uh Let me just go back. So for this F two standalone, this one here for the F two, they need to test your English language skills. Now the way they do this is through either ET Ielts or having three months NHS employment as a doctor and then you need a reference for that. So for the um O ET it has to be above 400 score in each section. And for Ielts, I think it has to be A S it has to be a eight above an average, an eight and above 7.5 to apply for GMC registration is different because for GMC registration it's above seven, an average 7.5 and above 350 score in oh et um but for this, it's a, it's like 50 score higher or like a 0.5 score higher for F two. So if you wanna do it for F two, standalone, your OTI E LT has to be higher than if you were applying for GMC registration. Uh If that makes sense. OK. Halloween in comparison. Cool. Um All right. Let's see. No worries. OK. Medical knowledge. Cool. I'll start with theoretically and I'll go with practically and I'll just ask you a couple of questions though. Theoretically. I'd say we're the same if I'm being frankly honest, I don't think there's a major difference. Uh If anything, I think maybe we're even better. Um Cool. Sorry, I was just reading Je Momma's message. Cool. Theoretically, we are the same, if not better. So again, it also depends on you. So you got internal next week and you haven't started studying and you wanna cram. Um, sure you'll cram, you'll learn some bits, but you'll forget like you should give yourself, especially in sixth year. I would recommend surgery internal. Um, I'd say obs and maybe peds is like internal but lesser, I haven't done a rotation in peds. So I'm not quite sure, but definitely surgery and internal 100% study for them. Give yourself one or two months time even if you have to, yeah, where you don't necessarily have to study too in depth and you're not stressed as much. Definitely studied because the knowledge you'll need, OK, when you come back to the UK, you'll 100% need it and shi shing, I'll get back to you in a second. Once I get to this practice, I'll tell you all the ins and outs, trust me. Um, but for the theory especially, it's good to have a base knowledge. I'm not talking, you need to learn things inside out because we're not expected to know things inside out. We want the base, we just want just the base knowledge. Um, you have for certain diseases. If you know a disease, you know what it means, you know, generally what the, what investigations are done, what generally what the management do is done for it. Ok. Um especially six years, just study internal surgery 100%. Another thing you should study pharmacology, clinical. I can't stress it enough farm. You just need to know in terms of theory in terms of w I wouldn't say we lack but, but in terms of, compared to UK students, their farmer, I'd say is slightly better than ours in terms of what to, how to manage a patient. Um Yeah, not mechanisms of actions, not really. I wouldn't say that it's more first line treatment, but again, I'll get back to you in a second. When I get to this clinical part, I talk about pharmacology a lot more in depth in terms of general theory. You have a disease, no etiology of why it's caused no clinical picture. If a patient comes to you, how, how can you tell that that patient is suffering that disease? How do you know they're having acute coronary syndromes? Are they having central chest pain? Are they having pleo chest pain? Um, is it generalized musculoskeletal pain even? Cos I've seen quite a few where they've been not misdiagnosed, but they've been, they've thought they've co come in with a heart attack, but in fact, it's just, they have just skeletal or muscular pain which is just causing a generalized chest pain. Um, could it be a chest pain because of aortic dissection? Like you need to know about these differentials and what to expect? Like, definitely have that sort of awareness and knowledge. And if you keep cramming all the time, I know I'm not, I wouldn't say I was the perfect student, but there's definitely some things I've crammed for. There's definitely some I've actually like went out of my way to set up a whole routine study inside out and internal and uh surgery was definitely some of them. Um But in terms of, again, compared to UK students, theoretically, I wouldn't say there's much of a difference at all. The only thing with them is they know what to do. They know the whole admin side of it. They know, OK, what should I do now? If they're unsure, they know what to look for, they know who to ask. They know like what to search B NF. Do you know how many people use B NF? It's crazy. Make sure you download that app. Cool. Um Oh, yeah. No, I'm, I'm staying for it because I understand what it's been like, graduating from Pleven, like I know what we graduate with the knowledge we have and like what's expected of us. And basically the aim of this is just to give you advice on what you should prioritize for your first job. Um So as I said, here, when we first start a to e assessment should be like the back of your hand. Um, and I'll have an example with the interview question and then we'll go through it and what to look for. But a assessment you learn through I LS and A LS. So that's a good thing. You'll be tested on it, you'll go through it with the person and you'll start to understand what at E assessment actually means. So don't be too stressed when you do the Il SA LS, they'll teach you it. Um, and then acute management, acute management. So it's more. So if you get bleeped by a nurse co you will, they'll be like, ok, this patients in serious pain. Can we give them pain medications? Um, ok. What they had, they had paracetamol? Ok. What's next in like Cocodamol? Have they had Cocodamol? Have they had codeine? Yes. Ok. What do you do next? There's a pain step by step management, which is in clinical form, which is why I'm saying you should learn it. Some trusts are different in terms of pain management. But there's but usually then will give Oramorph sub morph, which is just morphine, either oral, so orally or sub subcutaneous. And then usually if you, if you need to do more intense pain medic medication, you'll call a pain management review team who are more specialized and more give better advice. So you just call them and ask, oops and yeah, and then they'll help you. But at assessment and acute management. So people with chest pain, abdo pain, low G CS score confusion, um signs of sepsis, stuff like this definitely learn 100%. Um The internet is free, youtube is free. You just use it. It's, it's so when you start definitely learn that. Ok. Uh Il Sas that will cover some of the things, but those are the main ones, the rest of the job, I'm not gonna lie. We are glorified admins. So we'll do a lot of admin ward based jobs. Um especially if you're working on wards in general surgery and in general medicine like it could be renal re what happens. Cool. So essentially in the morning you come in, you prep notes, prep patients, not so you print off like all the patients what they've had done. What stage of their recovery are they in? What do they need doing? But isn't filled out, you prep it so that you know, by bed by bed, who who the patient is and just some general info on each one. So you print print that for the ward round called A 30. You go with the reg or consultant, you go see the patients so you're there with your little document sheet. You, you're right. Ok. Patient named Bet Ward. Oh no, 36 bed nine. Cool. You just listen to the consultant and he's talking, he speaks to the patient, he examines them. Da da da da. One patient will be taking notes of what the consultant is actually like examining. So if they're doing an abdominal examination, they'll write down uh they'll draw the abdomen which is like a hexagonal shape. They'll write ok, soft, non tender. If that's what if they're fine, if their abdomen is soft, nontender and then they'll just write what the consultant's saying. And just basically noting down, you need to document what has been said in that review of the patient and then another one junior doctor, which is what I tend to do is just write the plan for the day. So the consult will be like, ok, so this patient um who need a follow up chest X ray because he's coughing. So request chest X ray and you just square on it as part of like your job cos when you finish the job, you take it or you fill it in just so that you know what you're doing. Ok. So this patient requests x-ray cool. Um if all clear, ready for discharge tomorrow or if non clear prescribe antibiotics for chest infection and put a square on it if they're ready for discharge. OK. Discharge patient uh write discharge summary. Draw square, prescribe TT os draw square. And that's your jobs for that patient done. That's all the admin you're gonna do for that patient for today. But you have about it depends on the ward but some like I think one day I had 17 patients. So there was a lot of jobs to get through the through the day. Another time it was five patients and I was done by like 10 a.m. and I was just chilling waiting to see if I was getting bleeped by a nurse and you only focused on your patients. If another nurse is like, oh can you see this patient? You go to the junior doctor who's seeing that patient cos they know the patient, they know their background, they know why they're there, they know what management they're getting, they know what needs to be done. Like with you, you just focus on your jobs for the day, for that consultant for those patients. And again, as I said, request scans, chasing results, taking and sending off bloods. So they need repeat bloods nearly every day just to see how their inflammatory markers, you know their C RP um their white cells, how they're doing and if they're improving, so you'll need to take blood, send it to the department and wait for it. That's a job done. You take it. So there are some patients quick jobs. It'll just be like PT which is physiotherapy, so speak to physiotherapists, er, remove Pace Line or PA or whatever uh P line, sorry. Um, and then get ready for discharge, discharge summary. TT O is called ticket. Some, sometimes you finish by 11, sometimes one, these ward jobs, sometimes you have lots of jobs to do and you have to hand it over to the next different one. So in terms of what the jobs are? Ok. Uh Does anybody know what TT Os are? Because I didn't, I was like, what the hell is att o any idea at all? Tt Os are to take out? Exactly. Nikki meds when discharging. So when you discharge a patient, for example, if they're, uh, we might give some prophylactic antibiotic, they finish the operation. Um, you don't want them to get an infection POSTOP, but they wanna, but they're leaving the hospital. There's no reason for them to take up a bed when there could be new patients coming in who are quite ill and need a bed. Uh, cos they're gonna have an operation. So you give them the blood, uh, the, you give them sorry, the medications for them. When they discharge amoxicillin, you prescribe it on the system. Amoxicil or 500 mg, blah, blah, blah, blah. Um It's OK if you're terrible. Trust me. I didn't know any of this when I started literally nearly zero. but TT OS are act the medications that you prescribe when they leave and most of the time you'll be told what to prescribe for them. These lot need to take this drug for the next five days. So you prescribe this drug, this drug and the end date for it. That's the TT O done. So, so att O is discharge summary is like a mini letter. Um Some people have like uh it's a quick online e discharge. So you write about the clinical presentation, what they had done. They came in with a cholecystectomy or they whatever hysterectomy um patient, I don't know investigations that happened there, they underwent this, they underwent this operation and then patient has been discharged with this medication. He has been safety netted, which essentially means if they get worse or if they become ill, you have to tell the patient if you ever feel if your symptoms are getting worse, you're getting the temperature, please do come back that saves you from the job and you need to document it cos you could easily get caught out here. Um, if things aren't documented. So you need to safety net. A lot of patients. Um But yeah, discharge summary so that it's sent to the GP. So if the GP is doing follow up, they know what they've had done at the hospital. So these are the main jobs we're doing. It's all like discharge summaries chasing results. All right, let me call CT, let me call um, CT radiologist. Ok. Has this patient come in? Um, when is this patient being admitted? It's something we call, which is vetting, vetting is basically confirming that the CT is being requested for the patient and that they can come if that makes sense because you request it online call, it's been requested, but then you need to vet it. So you call CT. Hello? Um, my name is Leah. I'm one of the junior doctors on general surgery. I'm just calling about a patient. Da da da, da da requested a CT. Um I just wonder if it's going to be confirmed. They'll be like, yes. Um Does this need to be urgent or can then wait? And I'll be like, so I believe the patient had a fall and hit their head. Um Their consciousness is G CS 13 or G CS 10. Um So I'd want it urgent and then they'll be like, ok, no worries, I'll put you on a not of the list. Uh We'll get the patient out. Are they able to walk there? Are they able to take a chair? Do you want them through? Um Do you want them to come through a bed? Do you need a porter which basically the people who transfer the patient to, I'm like, oh, the patient, um they reduced G CS. So they're quite confused. They can't, can't walk preferably in a chair and then they'll be like, ok, So then that's vetted, it's been confirmed they're having act um you then go to the portal, you could write it on their list. CT patient details, they'll go to the patient, take them to CT and then they're ready to take the CT. It's a lot of admin, as I said, um in terms of the actual medicine we'll need to know is at e and assessment and acute management. The rest, all the like knowledge about disease, pancreatitis and everything you need to know it. While the consultants make the decision on what to do, you just follow them cos they're the lead and then the reg is also so don't be too stressed but do definitely know. Cool. I'm waffling a lot but I hope it's informative. Um theoretically that's, that's all good. Alright, clinically not gonna lie no better than us 100%. It is good. They know they know how to do stuff because they are taught. I think they start on second years on dummies taking blood um doing cannulas, I think no, second year they start with like normal, you know, physical auscultations stuff that we do. Ok. And maybe examinations, but from fourth year they do the invasive ones. So venna punctures ABG S VBG S which I'll get onto later. Um Cannula insertions, catheterization and NG tube insertions. They do these from fourth year each year, they have to get it ticked by the nurse and the nurse has to be there and watch them do it on a patient and they also get prep through dummies. We don't get any of that. We had like a 12 week course, I don't know if they still do it on injections and dressing techniques where we did it like once on a, on a, like a dummy, which I don't even remember. But here we are. But one thing about it is sometimes nurses can't be asked to take blood or Cannulas cos, it's just, it's just, I mean, nurses have to do it. It's not that they can't be arsed, they have to do it, but it's, if they've got a lot going on and they need to finish that, they could ask you to do it. Essentially, there's lots of opportunities for you to take blood. And to be honest, I was stressed sometimes I still get a bit, you know, a bit wheezy when they ask, but it's actually not too bad. Um, especially in the first, if you've never done it, just tell them, I feel like in Bulgaria we're just keep showing up on certain wards of this one. Pleven also teaches the students keep showing up on certain wards. See, that's good. I didn't really have that in Pleven. Like even him, I didn't really get to take bloods or anything like that. But if you can do it in Pleven do it, it's, it's, you, you're gonna have to do it. You're gonna need to know. Um, but again, once you're in the UK, you just, you just tell them, look, II haven't done blood before. Is it ok? If you teach me, like, 99% of the time they're gonna teach you, they're really nice. Like, I feel like in Bulgaria was scared to ask cos otherwise they're like, just be annoyed or have that look, you know. Um, but here everyone's helpful. Like they'll be like, yeah, for sure, no worries. But I mean, some people obviously they, they're busy, they're busy with the job. So um they'll maybe ask if we could do it later or something. But most of the times it's a five minute job, you just go, they'll teach you all the things that you need how to do it. All the little techniques. Everybody does it slightly a bit different like, OK, some people like to hold the butterfly together, clip it together and then do it like advance. Some people like to hold it like where it's like this and then they advance that way rather than just holding it like that. Everyone has their own techniques at the end of the day. It shouldn't be something you're too stressed about. And again, if you flop or if you don't get it, it's fine. It's, it's not a big deal. Lots of people can't get it, then they ask someone else, most of the nurses, they can't get it. So they come to us um we can't get it. Like, for example, there was a time it was really on early on um in one of my clinical attachments where they asked um for me to do it. But there was a med medical student there and I just wasn't comfortable with that patient. So I just asked the medical student who was like final year in like Saint George's, he just went and did it and it was like, it was top notch but like there's no ego or anything around it. If you need help, just ask them, they'll teach you, you do it, do it once, do it twice, then it's just come like, as good as anybody else on it. I mean, the main, so these are the main ones that you'll need to do. Venipuncture, ABG Cannula insertions, catheterization. NG tube insertions in G tube insertions is like is rare. But the other one, I feel like venipuncture ABG cannula are the most common then catheterize and then NG tube insurgents. I haven't done NG tube insurgent yet. Um I was planning to do it. The I was with one of the regs. He's like, have you done it? I was like, I know what to do but I haven't done it. He, I know, OK, come with me, I'll like, teach you. He's like you just finished with that job. I think I was like, I don't know, prescribing something and he's like, um and then just quickly read up on it and then talk me through it as we walk into the patient and then I'll help you. And I was like, can. But when we got there, the nurse done it. Uh sl half of it a bit of me was relief. The other part of me was like, damn, I wish I did it. But I'll have these opportunities. I know I will. And like, there's always someone who knows some things, like there's some nurses who do ng tube insertions, like nurses are sick. Make sure you're on good terms with nurses. They save your ass so much. Um, yeah, as I said, remember if they're better, they're gonna be better. They've done it, obviously, they're gonna be better. They've done it in fourth year, fifth or sixth year. They keep doing it when they're working. I mean, sometimes people miss ABG S, they're very easy to miss the artery. They're very easy. So it's not a big deal if you miss, I'd say do it twice. If you can't get it twice. Um, I'm just looking at the chart, sorry. If you can't do it twice, then just ask someone else to do it. It's completely fine. I do it two times, maybe three and then I just call it a day. If I can't do it, I can't do it. There have been times I've, there's been times, yeah, where I've actually inserted into the vein but because the, er, apparatus that they use is slightly different to another trust. There wasn't any flashback. So I thought it didn't go in the vein but it did. And then I basically poked at her three times, the needle went in, but I didn't withdraw because I didn't know that it went in. I assumed there was flashback, but this specific one there wasn't. And I was like, damn. But you live and you learn, you move on as long as you're nice to patients as well. You tell them you just be like, I'm just going to take some blood if that's ok, I'll have a go if I can't get it this time, I'll get my senior and he'll have a go. Most of the times patients will be compliant if they're not just ask someone else. Uh Apart from clinical attachments, is there any way to suggest that we can build clinical skills? As I said, the main ways either ask him ple like just go about maybe an A&E or he just go and see if there's any opportunities to take blood. That's the only thing I could think of. And then it's clinical attachments in the UK. And again, if not phlebotomy course, but in my opinion, you learn on the job. If you can't do it, even as a doctor just ask the nurse to do it or teach you, they'll teach you. Everyone's nice. Everyone's really nice. Uh Doctors, nurses, a CPS, I've met out of everyone I've met, working, like, 98% of them are nice. Some of them are just too stressed out. So they're like, I'll get back to you, but the rest are just so nice and they're willing to teach. That's the thing. Um, so, yeah, that's in terms of clinical skills again. ABG S, I've gotten used to venipunctures. I've gotten used to can, I've gotten used to catheterization. I've done like, two. Maybe since I started working. One was on a patient I couldn't do. So I had to call urology. And then they were like, oh, do you know how many people we get called? You can't do catheters and then we do it and then to find out they had a stricture, they couldn't do it and they were like, ok, I'll give it to you. Um We can't catheterize this one. So we had to do a super pubic one uh ng tube again, just that one time. But I'm sure many times it will come up. Um So that's clinical skills don't be too stressed. Just ask, they're fine. They're chill, relax, breathe, practice with a pen. I'm gonna practice a ab like what you do for an ABG in a second and one of the slides. Um But yeah, um communication cool. Now it's definitely an area even as a native. It's, it's, they have different ways of communicating in the NHS from doctor to doctor, doctor to nurse. Like not when you're speaking face to face it more when you talk about a patient, um they prefer using SBAR, does anybody know what SBAR communication is? Sbar? Communication? S pa r any guess? But most likely, I didn't know what it was. So I don't think anyone should know what it was. Maybe they might know, but essentially SAR is just, it stands for situation background assessment and then recommendation. So when you're handing over or when you're making referrals over the phone, so say you've got, for example, I want to call up um respiratory. So I have to communicate to them over the phone and I have to make it quick. People don't have time for like a five minute conversation about everyone's clinical diagnosis, their clinical picture and everything. They got about two minutes or else they gotta get on with their jobs. Now when I do talking, I like to do a lot of this, I was, I was like, I was explaining to the doctor about a patient and he was like, OK, number one, what I like to teach my students or like junior doctors is put your hands together like this. OK? So when you, so this is so when you explain to a patient, you don't do the do this because imagine you're having a phone call with them, they can't see your hands so do this and then discuss a patient. Uh Nikki said, yeah, exactly situation background assessment or investigations and recommendations. So I want a sbar, there's a patient who's I've seen in the A&E. Um, so I'm going to call them and be like, um, hello. Uh, I want to discuss a patient for you to review if that's ok. Yes. Can you tell me about the patient? So, we have a 59 year old gentleman who's presented to the, er, um, with, uh, with the chest infection requiring sepsis. Cool. That's your situation back. Ok. So as I said, 59 year old male, um, with a chest infection with clearing sepsis, he's had two days of productive cough with spiking temperature. Uh, it could be um productive cough showing white sputum. Um And then here you mentioned past medical histories. He's known co PD known asthma. Um And then you move on to assessment under assessment investigations. Um His oxygen saturations are at 84% with bilateral crackles on either side, sorry, bilateral crackle crackles on either side during auscultations, chest X ray showing um showing consolidation on the basis of both lungs. So that's your assessment done. You talked about SS ATS, you've talked about investigations. Um, you've now have to do a recommendation. So, have you started them on anything recommendation? Um, I've started on IVC Clarithromycin or whatever drug they use every trust is different. Um, can you review this patient query sepsis? We've started a sepsis six protocol as well. And they'll be like, ok, thank you very much. Uh, where's the patient location. OK. I'll come see the patient. Boom. That's how you doing. SBAR, you got really make it concise and really nice for the consultant or the reg or the other sho so that when they come, they, they, it's not five minutes, it's a two minute. They know what to do when they get there. Everything's been like simplified and ready for them if that makes sense. And I'm not gonna lie. I still struggle sometimes with Sbar cos they do it. So it's so common in UK to do it all the time. Some consultants be like, um they'll give me tips on it how to make it short and stuff. Like no one's really like, they, they're not really antagonizing in the UK, they're really quite nice and helpful. Um But yeah, breaking bad news. Um You do that, you have to do that a lot. Uh I've attended one cardiac arrest where the patient had passed away. So I had to speak to their family. Usually it's the doctors that work that are responsible for that patient. Cos I was in A&E it was me and another junior clinical fellow. He, we were both seeing the patient so we both had to speak to the family. Um Honestly, II don't, it's best if you like keep them in a good environment, you tell them everything you tell them. Um If they have any questions, if they understand what's going on, it is emotional. They're very emotional. Um But it's just one of these, you kinda, you can't prepare, like I wasn't prepared for it, but it's a conversation you have to have. And again, usually you're a professional, you're dealing with a patient, like you sympathize with the family. You tell them everything, you make sure they understand everything they ask. Any questions that they need. If you don't know a question that they ask, they'll be like, I'm not quite sure. Um, but I can ask my consultant and he could give you a better answer. Um You tell them the truth, you don't just make like stuff answers that you can't give them and then they might ask about bereavement services afterwards and then you just tell them what they need to know if it's part of being a doctor. Um, I've had to do that once or twice. Um, I mean, you break bad news generally, especially if, um, someone's coming in A&E not knowing that they have a chest infection even stuff that's treatable, very treatable. Um, your break brand news that unfortunately you've got, what we see is a chest infection on the X ray. So we're going to start you on antibiotics. This is uh, like you'll break bad news quite regularly, but in terms of the big things I've had to do it once. Um, usually I, especially in wards, I'm pretty sure the consultant does it or the reg, the juniors don't really do it because we were in A&E, it was a bit different. Um, and duty of Kor, which is basically, if you've done a mistake, you have to tell them you've done the mistake. You have to apologize, you offer a plan or what to do from now, moving forward and then obviously you answer any questions that they have or anything else. And again, you have to apologize, you have to tell them, ok, I've made a mistake. I prescribed him antibiotics. He's got this ot toxicity because of the drug because of the antibiotics that I prescribed when it should have been something else. You tell them, you apologize, you offer a solution or what the plan is. And then II haven't really had to do that, but it's something you definitely need to know. And they will ask you on interviews on this specifically sbar handovers, breaking bad duty of candor. They will ask that. Ok. Uh Moving on prescribing. Um Yeah, I'd say prescribing in terms of theoretical is the most stressful thing because like we understand when drugs are used in pharmacology and how to use it, but we don't understand when we actually need to use it. Like what do we need to do? How much do we prescribe? Luckily, most of the time your reg will tell you what to prescribe. But if it's for the simple stuff, pain management, fluid prescription um or starting them on hyperkalaemia bundle, you should know that you should be on it. Um, but there's stuff to help you. For example, if you don't know, um the antibiotic treatment for uh intraabdominal infection, you need to go on the, uh, the hospital's internet, which is their computer. You just go on Internet Explorer, it comes up with their own internet and you go on antibiotics called, you go on treatment called click on that and you go on intraabdominal infections and then it tells you the first line, the second line what to prescribe, how much to prescribe. You just prescribe it before you do. Always, always look at allergies. If you prescribe coamoxiclav to a patient with penicillin allergies, boy, and something goes wrong with a patient. It'll go back on you. Coamoxiclav has penicillin. Well, amoxicillin and Cla clinic, Claval acid. Um Amoxicillin is a penicillin. If they have a penicillin allergy and you have an anaphylactic shock, they could if they worst case if they die and then the family ask and then they form a complaint license is finished. My friend. Unfortunately. But again, there's lots of like before you prescribe, especially if it's an online thing, it'll tell you the patient is allergic. Are you sure you want to prescribe penicil? Like you'd have to go through like 23, yes or nos to prescribe without seeing like you'd have, it'd have to be bizarre for you to prescribe in that sense. Sometimes if it's written, it's a bit scarier because you're not told. But the nurses will sometimes see it or the pharmacy will flag it. They'll call up the ward be like, are you prescribed Comox Club? But this patient has penicillin allergy. Uh, do you wanna discontinue that and go with the second line? So there's a lot of that, but in case it doesn't just allergies before anything. Search for that allergic for and don't prescribe that. Cool. Um, as I said, antibiotics for infections, there's a website called Mind the Bleep, er, which I'd highly recommend for all of this for all I MG stuff for all communication, sbar, prescribing all this at E assessment. Acute management. Mind the bleep, make sure you go on it. They have good articles and good videos on acute management for pain for antibiotics for in patient and fluid prescriptions, fluid prescriptions is another one. We don't really get taught in where we were at. I can't remember learning about it that much. I know they mentioned Hartman's once I was like, what's a Hartman? Um but you have resuscitative and you have uh maintenance. If a patient doesn't eat or drink because they're having a surgery, they're gonna need fluids. So they don't get dehydrated, don't get, you know, confused all of that. They need fluids. You have to prescribe fluids. Yeah, literally what's a heart and um you have to prescribe fluids um according to their needs. Um So most of the time it's 1 L over eight hours, but there's specific calculations Um obviously, for more obese patients or for skinnier patients, the fluid, what they need fluctuates. And also you need to check their potassium and sodium levels. If for example, um as long as potassium is high, you don't really go for Harman's, you'd go for more saline solution because there's, you want to give them like more potassium when they're saturating and potassium if that makes sense. Um Some have plasma light, it also depends on the stock of the hospital. I've prescribed Harman's 1 L over eight hours for a patient who's not gonna eat. Um Then the nurse comes to me who's patient, this don't have any Hartman's. Can you prescribe plasma light, please? So I just went on discontinued Hartman's on the system prescribed plasma light boom. Um There's also resuscitated fluid which again, please mind the bleep A to e assessment will tell you about that. If someone's in hypervolemic shock, they need fluids whilst their heart's gonna rest need fluids. So you give them a bowl is 500 mL over 30 minutes. Um That's enough fluid so that they don't go into shock. If they are in heart failure, you need to give less because you give them fluid that's just gonna build up in their lungs. It's gonna build up in their peripherals. You need to give 250 ml over like 1530 minutes. Um Again, every trust has different guidelines. Some trust for chest infection, they'll prescribe one antibiotic. Some trust will prescribe another. That's why I'm saying for me, the hardest part, especially local in at different hospitals was learning what the guidelines was for that hospital, what guidelines was that hospital? All the like admin and it behind it, like some prescribe online, some don't prescribe online, some have a different system. Um So make sure you use the internet before you prescribe, I think. But once you start getting used to it, it's not that bad. You need to learn about VT E prophylaxis as well. So thromboembolism, if someone's um going into surgery and they're going to be lying on a bed for three days, four days, they have increased risk of having a DVT and then subsequently a pe so almost all trusts have this like VT E risk assessment and then you have to prescribe them, uh, prescribe them. Enoxaparin, usually 40 mg as prophylactic dose or if they, if they're bleeding, you can't prescribe them that. Um, and either you can't prescribe them or if they're on any other anticoagulants, Rivaroxaban or Clopidogrel, they're just gonna end up bleeding. So you don't give them the enoxaparin, you just give them stockings and they wear stockings instead. So that's the medical me Mechanical management. Um, and then you got the, er, the medical management, which is the enoxaparin, 40 mg, er, cos, they're lying down, they're gonna get, they can get DVTs or PE, that's one thing. So, always before you prescribe, they make you do a VT E risk assessment. It's called, um, quick question again. I'm sorry that there's Aron means, but ODP DTD SQ DS, we use these all the time. Does anybody know what these mean? Uh, put in a wild guess? It can literally be anything. No judgment cos I didn't know. And I, to be honest, it took me quite a bit just to get used to using them. Exactly. Exactly. Uh Q DS four times daily. OD once daily. Exactly. OD, once daily, you give this medication once per day. BD. So two times daily, I forgot what the B stands for. These are all Latin terms. Bi-daily, maybe, I don't know. TD, S3 times daily and Q DS four times daily. Um It's just, you need to know it. We use it all the time. All right. Prescribe omeprazole OD 20 mg, prescribe omeprazole 20 mg is the dose OD is the frequency once a day. Prescribe coamoxiclav 1.2 g. TD FSI V. Cool. You've got Coamoxiclav drug 1.2 g. That's a dose IV. So that's the method. And then T DS is how many times a day? Three times a day. So they're gonna need three times a day infusion of Coamoxiclav. Um Q DS the most common prescription. We prescribe paracetamol, 1 g, T DSI mean Q DS. Sorry. So paracetamol, 1 g. So, you know, each tablet is 500 mg. So 1 g, two tablets, paracetamol, two tablets four times a day, every four hours, every 4 to 6 hours. Um But maximum eight times. So, again, four times a day. See, but they use it all the time. So get familiar with these terms. ODB DTD SQ DSI didn't know what it was. Started getting used to them like, oh, that's not what that means. Um But yeah, so that's how we discuss, oh, should I prescribe? Um What did I prescribe that? Levofloxacin? I think I prescribed the other day 500 mg. Um And then I was like, should I do ODB D like BD? So you use these quite common to get used to this? Um Any more questions on clinical or theoretical knowledge on what we need? I, I'm gonna get into A&E assessment and I'm gonna get into ABG. So those will be soon. I think I've got a clinical scenario next. If there's no questions on this, I'll move on again. Practical. Just do what you can really in ple. I know it's quite hard but if you can just 11 day, just go in and just see if there's any blood just don't get stressed cause it's fine. You won't kill a patient. Clinical skills. You'd have to actually damage them. But it's, it's fine. It's just a little small brick. It's fine. Even practicing on your friends. How long would you say it took you to adjust or feel confident? Mm I wanna tell you, I don't know. Really, I feel like I'm always, I feel, you know, every shift almost feels like a ple exam, but that's just me being over thinker stressed. I don't know what to do. But it takes, it takes, it takes about a week or two weeks, especially if you're in a place which is consistent for you to understand the system and understand your role. And then from then on, it's just about you building your own like knowledge around it. All the prescribing all the communication you still ask questions, sho still asks questions, register, ask questions. That's a continuous thing in terms of being confident and knowing what you do. I'd say about 1 to 2 weeks, consistently, three weeks, four weeks and then you'll be good. I've been working since November, early November or late October. Um I've gotten used to the role itself but I know some trust is a bit different. I'm still asking if that makes sense. OK, let's do a quick example, Cole what they teach you essentially is called this patient. Has this disease? Told me the etiology, clinical picture investigations treatment. But when you're on the wards, you're not gonna have someone say, ok, what's the etiology? Da da da. You're not doing a history, you don't do a history there. And then especially if you're working in a ward where they're already admitted and worked on, you're gonna be called for acute things. So for example, this was an interview example as well. Um So a 72 year old male named John, this is John, smiling has under undergone a laparoscopic cholecystectomy to treat his another thing. Sorry, a quick pause here. Some words we're used to saying in Bulgaria, like encephalitis or Cephalex or Cefatriaxone or something. That's not how they pronounce it here. It's um encephalitis, cefuroxime, Ceftazidine, cefTRIAXone. They use Kef instead of Cef. And I remember CCE they're like, we're not America. We're UK, I was like, sorry, that's what, what was that micro app thingy? That's what they told me about. Oh, but that's essentially it. Right. Let's go through it again. A 72 year old male named John has under undergone a laparoscopic cholecystectomy to treat his presenting complaint of right upper quadrant pain which has shown to be caused from gallstones. He's now two days POSTOP and appears confused. He's wandering around the wards corridors, confused as to where he is. You are the on call fy one and the nurses have bleeped you to come in acutely review this patient. What do you do? So what does being on call mean? So usually, especially ward shifts, they're from 8 to 5. That's not on call, but from five. So from 8 a.m. to 5 p.m. you're working from 5 p.m. to 8 p.m. It's like you're the only junior doctor on that ward. So they'll call you for reviews. Now, this patient's confused. He's walking around the wards and it's not a good thing that he's confused. Cos normally he was competent before he's very aware of why, where he is, what he's been doing. So, you're the on call. F one and the nurses have bleeped you to see this patient in bed 15, ward 36 or whatever. What do you do? Anybody have any ideas of what are they doing? What are you doing? You're getting bleeped. You've got the phone ringing. Hello? Hello, doctor. Can you come see this patient? Um Ward 36. Uh his name is John. Da, da, da, da da. He's very confused. He's walking around the walls. He doesn't know what he's doing. He's, he's messing about with his drainage. Can you come see him, please? He's, now we've managed to get him back onto the, onto the bed. You're gonna have to go. You're the only junior doctor. If you're generally busy with an acute scenario where you believe it's more life threatening than this. You can tell the nurse. Can you bleed my registrar? I really, I focused on a, a quite important like emergency. Uh Yes. ABCD. EI don't think. No. Cool. So there is a lot of talking. So this one ABCD E you go to the patient, John. My name's low. I'm one of the junior doctors on the ward today. How are you? He replies, I am very well. Um What day is it? So he's speaking to you. He's having a conversation automatically. That's A in ABCD E that's a done. He's speaking to you. His airway is patent. Ok. So he's clearly having a conversation. You're not worried about any obstructions or anything in his airway because he's speaking to you. Um, but what if he wasn't speaking to you? What if he was like having Stridor for, he wasn't breathing, if he was having foam, like foam or fluids come out of his mouth? He has blood coming out of his mouth. That's the first thing you do and you resolve. So in this case, he's speaking so you can move on to b but if for example, he needed airway management, he needed suction. Is there. Did he have a tonsillitis? A tonsillectomy? And he's suddenly got a clot on one of the, where the tonsils were removed and it's bleeding profusely and he can't talk, that's going to kill him cos it's going to fill his lungs with fluids with blood, especially it's gonna irritate the lungs. He's gonna get pneumonia, he's gonna get sepsis. He's gonna get into cardiac respiratory arrest. So when you go through ABCD E, you do in that order, simply because that's the first thing that's gonna kill you. If your airway is compromised, it's gonna kill you first sort out a now, obviously, if you are unsure, ask for help. Um But the m I'd say the best thing you could do was do suction. You can ask the nurse. Uh Could we do suction on this patient. They'll come in with everything that you need suction. Um, and then you call for senior for help ASAP, um, especially if or if you're auscultating and you hear they have Stridor and they're struggling to breathe again. Airway management. Um There's always help, obviously, the senior help will always come. Um, if there's an on call reg, even if it's not on your ward, if it's on your ward, if you're in surgery and your reg is in theater, you could bleep a anesthesiologists reg on call reg be like I got this patient airway compromise. Can you come help me? They'll rush to you and help you. So A is done called B what is BB, by the way, anyone know what B is in ABCD E breathing? Yep, it's a breathing. Ok. Cool. So yeah, breathing. So this patient um so you've done airway, you're happy you're now uh moving on to breathing. What are you looking for in breathing in the breathing section with John? Obviously, you could do a full history about this patient, but this patient could be dying because his breathing's been there's something wrong in the breathing section. So you're acutely reviewing this patient. Uh What do you search for when breathing? So airway is patent, meaning the airways fine, you move on his airway is fine but breathing. What does that focus on? Yeah, Jemima. Exactly. Exactly. O2 sats and respiratory rate, auscultation, chest expansion. Cool. So first thing you do click on ao two saturation if they don't have one already. OK. So OK, let me give you an example. Uh John has CO PD he is on 89% oxygen. Are you gonna give him more oxygen? Does anybody know the normal ranges for oxygen saturation? So what should the normal oxygen saturation be? Honestly, I'll take any random answers cos I learned all of this when I came back. I mean, I knew a bit in Bulgaria but exactly, it's more than 94%. So above 94%. So 94% to 100% is what the normal adult their oxygen saturation. When you click on the pulse, oximetry should be. Now, the only exceptions are if they have CO PD, OK. If they have CO PD, you aim for that saturation to be between 88% and 92%. OK. So I said John had CO PD. So in fact, and he had 89% oxygen saturated. So his oxygen was actually fine. If it was 81% then I'd give him oxygen um give oxygen. Exactly. It's less for CO PD. It's 88 to 92% for CO PD and above 90.4% is fine for normal adults. But CO PD, you go for less because what happens if they're on 90% but they have CO PD and you give them oxygen and they go 94 95%. What they happen is they start developing um acidosis, respiratory acidosis, they start retaining CO2 because the lungs are already damaged because of the chronic um changes due to chronic bronchitis. And um they now develop CO PD and their respiratory function is damaged anyways, it's reduced. If you give them more oxygen, they're going to retain more carbon dioxide. And they develop this respiratory acidosis, which then it's, it could lead to a lot of things, it could lead to respiratory arrest and a whole lot of respiratory failure and you do not want that. So make sure you, firstly, when you know if they're co PD or not before you administer oxygen, I think in if you, when you do A L SA LS and you're unsure about patients um and their oxygen saturations are low, they'll always start with a mask, 15 L, non breathable mask. But when you're on the ward, when you start getting used to things, you start getting used to how much oxygen someone actually needs like 2 L, nasal cannula is fine to start off with. Um and uh what does 2 L? What does 15 L mean? That's what you might ask, which I was asking as well 15 year when it's with the mask, they, it's, they have the whole oxygen gas tank, they're getting full 15 L of oxygen. It's just going through the mask into their nose because they need it. They're acutely deteriorating the oxygen's 90% and they're non COPD, they're a normal person. They need 94 above you give them that, that's fine in emergency situations. You can adjust oxygen later as long as they're getting oxygen. But once they're like a inpatient, uh they're slightly decreasing. Say John didn't have CO PD, he's on 91% oxygen. Obviously, he needs a bit more so he needs to go above 94%. You give him a nasal cannula 2 L to start off with his 91 starts going up to 9495. So you're happy. Um If it's still 9293 give him a bit more. Maybe 34 L of oxygen starts increasing. Cool. So you've sorted out the oxygen requirements in b so his saturations are fine, his respirate cool. So you start off with inspection first inspection, chest expansion. Is it expanding? Is it paradoxal, you know, in flare chest? But that'd be extreme, you'd know. Um You start inspecting. Is there any fractured ribs? Is the bruising called auscultation? Do they have any crackles? Do they have any wheezing? Um any sort of difference in changes? Cool. So that's the inspection practical side of it. And then you go obviously, oxygen saturation and respirate is important. How fast are they breathing? Who knows the normal ranges for respiration rate, throwing random breaths per minute. How often should you be breathing per minute? Yeah, exactly. 12 to 20 breaths. Pretty much 12 to 20 is fine. Um, and then anything above tachypneic or bradypneic if it's less than 12, um, it's a really good indicator because if they're breathing fast, it's usually because there's an infection, there's a pe, you don't naturally breathe fast, maybe if you're very anxious, but that's mainly your heart beating faster. But in terms of actually tachypneic, especially if they're lying down and if they're breathing fast, there's something to look out for. Um And again, for example, if you wouldn't move on to see without sorting B out if they're tachypneic. And for example, if you auscultate, there's a consult, you hear crackles on either side, you act, then what do you need to do in terms of investigation that be chest X ray 100%. Could it be a chest infection? ABG. Now, I'll go into ABG in the next slide. But ABG is quite important investigation just as important as other bloods. ABG is very important in terms of what it shows in terms of infection, in terms of breathing, how your lungs are coping if there's any respiratory failure. Um ok, so you saw that out, you've sort out the his breathing rates five is 12 to 20. Um You're not really worried about chest infection. You can't hear any crackles cool, his breathing is fine, his airway is fine, you move on to C circulation. Um What do you do in circulation? What do you measure in circulation? I wanna know, think of basics. What would you measure in circulation in blood in like, so any random parameters that you can think of? Exactly one of them is pulse, simple feeling your pulse, any other that you can think of as simple as you can think. Exactly. Exactly. Yup. All of those are right. Um, so what we tend to start with is, start with, from the hands, feel the peripheries. Are they cold if they're cold? What does that mean? It means their perfusion is quite reduced. Are they hypervolemic is not enough blood going to their hands. Um You do a capillary refill. So as you feel first, you feel if they're cold or warm capillary refills, so you press down on their nasal buds and then you let go and then blood should come. So you turn from white to red in less than two seconds um or pale to no. Ok, in less than two seconds. Um That's normal. If it's longer, then we could think maybe they're dehydrated or maybe there's reduced, maybe they're in hypervolemic shock. So, pillar refill and feel their pulse. How is their pulse? Is it regular? Is it a weak pulse? Maybe they're not getting enough fluid? Um They, they're not f their blood isn't filled with fluid like it's very hypervolemic. So they're not, it's not a strong pulse, it's a weak pulse. Um Is it regular? Is it gonna do, do, do it? Do do do, do do you know in a FB for example, there's a beatbox in there but yeah. Um so yeah, I feel regular irregular um and then you also feel BP cool. Let me give you a scenario. Um ok, this patients BP is 100 and 25/83. Uh Are you guys stressed at all? What would you do? What would you think about with this BP? Yeah, 100 and 23. Over 80 3, 120/83. Yeah, you'd think it's normal. Yeah, I'd agree. In nearly every case it's normal. Um, well, what if I told you this patient you've checked their BP, monitor, monitoring for the past week, uh, or however long they've been in hospital for their normal baseline is 100 and 63/98. So they, they've got hypertension but their baseline, meaning their normal BP is 100 and 60/93 but they're on 1 20/80 right now. To me that's slowly leading to they could be losing blood somewhere because their BP is dropping their heart rate's increasing. Um So their heart rate, let's say is like 100 and 15. Um, what do I do? So, on a normal patient that's normal. But this patients come in with hypertension. He's known you would check his observations first of all, whenever you see a patient, you would see the obs for now. And for previously. So you notice a change in trend. Now, this patient's normally in 1 60/100 but he's now 1 20/80 is, and you're worried that it's decreasing and he's gonna turn into hypervolemic shock and this patient could deteriorate. What do you do? You give fluids or what, how much fluids do you give? What do you check? How like for example, so this patient, he needs a resuscitated fluid. So he needs fluids to make sure to increase his BP to his normal, not, not the general population is normal but his normal. So you give him, firstly, you have to check if this patient has heart failure. If he has heart failure, you don't give him too much fluid because you don't wanna overload his lungs with fluid. You have to give a small amount just so that the cells and the um in the vessels, all the fluid is there rather than it ex like excreted into the lungs and into the peripheries because of heart failure. Cool. So firstly, are they known heart failure? No, do they? What's their left ventricular function? Like you would know in their notes if their past medical history, if they have heart failure or left ventricular dysfunction, you would know it'd be written there. If it's not written call, you give them 500 mL bolus which is just like a bolus just means like a fluid challenges. Like you just give them 500 mL of, I'd go for Hartman's. Harman's is like your ideal fluid that you need. So, either Hartman's or Saline mainly, um give them 500 milli milliliters. Hartman's in um 15 minutes and then after 15 minutes check their BP. Is it improving? If it's improving? You're treating the patient, you're managing them. So you're doing well. So cool, do that. If they had heart failure, you'd give a bit less. So you get 250 mL over 30 minutes. So that way they're actually getting the fluid and it's not overloading them into the lungs. Ok. Um So yeah, so BP is important. That's what I said, check previous BP readings if they're deteriorating. Obviously, the BP decreases, the heart rate goes up. But if the heart rates are normal and you're happy and the BP is normal, you can move on. Um But again, it's just things to look out for. If the heart rate's like 120 they're tachycardic, it might be anxious, but they also might have an infection or they could have be having sepsis. So, um, treat what you can as you're moving along. So we treated airway. So airway was patent, but if it wasn't remember, suction, asked for senior nurse. So there's naso um nasopharygeal tubes and um there's a laryngeal tubes or in oral oral laryngeal tubes, there's one in the mouth, one in the nose. Um So everyone was done breathing again, we did. But as I said, remember the oxygen saturations, the chest X ray, uh beware of these things. So when you're speaking to John, you're doing these things, you're taking your um the pulse oximetry, you're auscultating them. You're acutely checking the patient, you're reviewing the patient, you're not taking history that much cos they're drowsy, they can't give you history. You go about what, you know, you're just reviewing them to make sure they're stable. That's your job, you're there to stabilize them and escalate to a senior if you're worried. Cool. So we were on circulation. As I said, BP, heart rate, pulse, capillary, refill time. If you're having chest pain, order E CG. And to be honest, I see I order bloods as well. What bloods uh let me put on the chart. These are the main ones you go for. Uh So I just post in the chart. Those are the main things that as I said, some places you could request the bloods online, some you kind of just paper, but I've only been doing it online. So it's not too bad FBC. So full blood count, urea and enzymes C RP LFT bone profile, which is like calcium, your calcium and coagulation screening. Um Those are the main ones and then obviously, if you're worried about chest pain, put chop in, if you're worried about pe, put D dime in, got it on. Um bone profile is essentially just your calcium and your adjunctive calcium levels. Uh it's just part of the routine electrolytes. So that's in your urea and electrolytes. You know the U plus E, that's very important. So you need to know sodium levels, potassium levels, calcium chloride, all of that sodium potassium, especially. So FBC, full blood count, red blood cells, hemoglobin, MC, VMC H CMC H, all of that platelets, um lymphocytes, white blood cells a lot C RP. Anybody know what C RP is. Um what's useful c reactive protein. What does that? Yeah. So c reactive protein shows inflammation. Usually it could be due to infection or pancreatitis or just inflammation of something. Usually use it for infection as a, a source of infection. Um LDH. Yeah, but that's, that's more the lactate which I'll explain in a bit. Um But c reactive protein is for inflammation which it will tell us a lot. If a patient is having an infection, the white cells are high. The C RP sometimes can be low cos it can lag a few hours. So sometimes the C RP raises after a few hours of the infection or after a day of the infection. So, and it reduces slowly as well. If a patient's improving, we look at ACR P, the C RP will start decreasing as days go as days go by. Meaning, OK, the in the infection is going away, the antibiotic's working. So it's a good indicator. You look at the trend, it's increasing, you know there's something wrong. They have an infection, they have inflammation somewhere. It's decreasing means it's working. The treatment's working, they're getting better. Are they improving? Um, so white cell count and C RP are important in terms of infection. It's really important. LFT liver functions. Sometimes you can have um, cirrhosis that would show up. But that's more chronic issue. More acute ones would be if they're having pancreatitis. But the, the pancreas is actually um compressing against the common bile duct. And suddenly they're having bilirubin getting into the liver and it's all the liver markers are in all getting raised. What if they have a condition that has chronic, would this effect result 100%? Um I had a patient the other day, alcoholic liver cirrhosis LFT S were everywhere. It's mainly the LFT S uh in terms of other chronic ones. Yeah. Not really unless they have like a myelo multiple myeloma or if they have any um he uh hemology cancers where their uh hemoglobin is low. Um Their red blood cell, white cell count is low. The platelets are low. But the thing is that's the thing with these, you, you measure the trend and you measure how they were before compared to now rather than just now, you need to get more information. Um um But yeah, in terms of chronic inflammation, um cos inflamma inflammation comes up in flares. So, yeah, it could derange the results in certain. But when you're not having a non flare episode, your white cells would only rise in case of an, of an actual inflammation or infection if that makes sense. Um It's all about looking at the trends. So yeah, I see. I would request, as I said, bloods, I do an E CG if he's having chest pain or if I'm worried about any heart attack. Am I anything? Um So yeah. Uh and no, I forgot the ABG and V BGI do at B because it's related to the lungs. A lot of it's related to the lungs. Uh I do it when I'm at the B section by the C section. Blood check, BP, heart rate, uh check if they're dehydrated, hydrated by obviously checking if they've got any swelling in the feet. If their tongue is dry, if you feel like pinch on the skin, is it like turgid or is it like loose? Is it well hydrated? Look at the tongue. Is it like, is there fissures in there? Does it look like they're dehydrated? Um So yeah, in D now, D so uh in the, what's the, what do we look for in the? Ok. Anyone know what D stands for at least. Yeah, exactly. Exactly. Disability. So here you measure the patient's consciousness. So this patient was confused. So use Glasgow coma scale, you start getting more used to using it. Um At first it's like you kinda, you could pull out your phone and just go on MD CALC, which is an app which just, you just go through it. It's just to help you out. There's no harm in that. Um, but obviously the more you do it, the more you get used to it if they're speaking to you and they're fully alert of everything. Like, if I'm talking to a normal person, like a normal conversation with a person, sorry. Um, like my friend or something, their G CS is 15 because they're responding everything. If their eyes are moving fine, if their arms are moving, their legs are moving and they're speaking to you. GC SS is automatically 15. That's just in your head. Obviously, if they're, it's when they start getting confused and that's when you start, you know, changing if their G CS is fine. Um So this patient, it's a CVB U. So alert, confused or they responding to verbal pain or are they unresponsive? So this person is confused. So he would be on the confused part of the A CPP U score. Um And then you'd measure the glucose and d why, why do we measure glucose? Obviously, pupils, you check their pupils check, are they reactive or they find no signs of stroke? The main ones to do here is GC SA CVB U and measure glucose. But why do we measure glucose? What would glucose do? Especially in this patient. Anybody have any idea for a random guess? Yeah. Yeah. And might, might hypoglycemia or hyper be related to this patient specifically in terms of what you could see in this scenario. Yeah, exactly. Um Hypo or hyper, uh a lot of it's in hypo hypoglycemia. Um It can cause confusion, disorientation, especially if they're in shock and eventually lead into a coma. So he could be confused because he might have not had anything to eat and he's taking his insulin in shock cos he's diabetic and then suddenly his glucose is 3.1 quick solution, get them to drink something. Um Usually they have these small shots of glucose. Uh Just ask the nurses, can you give him if he's happy to take orally? That's fine. If not, then you give him IV infusion of glucose, dextrose um 5%. Um uh Yeah, so that's one of the things he could be confused. So you get ABCD, you get to d realize he's confused because his glucose is low given glucose, he's fine. Everything's fine. You go back to where you are, what you were doing before you're fine. You've treated the patient, you've managed them, they're OK, they're happy. Um But yeah, that's one of the main reason we do glucose. Um E exposure. What does that mean? What do we do in e sorry, this is d drugged up. I've been talking about this but I just hope it's really informative because uh I know when I graduated, uh I would have loved to have something like this or know exactly what I'm doing. Uh e Yeah. Um He has a lot of so, yeah, temperature. You need to measure the temperature. Obviously, spike temperature. You would think infection cos that's your body's way of fighting an infection. Um So yeah, measure temperature and then inspect, inspect the body head to toe. Look, do they have any injuries? Do they have any rashes now? Ok. So this patient is allergic to penicillin. Uh, you check on the system, someone's prescribed penicillin for this patient because of an infection. He's now developed rashes. What are you thinking? Is the airway is not pay, um, obstructed yet. His airway is fine but slowly it'll start closing. So you've noticed the rashes and you've noticed he's been taking penicillin even though he has an allergy. What's the first thing you think of? Exactly? You think of an anaphylactic shock? This per this patient could be having an anaphylaxis. Um So you got a cool anaphylaxis. Very serious. Um You got a cool the crash team which is 222422222. You do it for cardiac arrests, you where you just pull the thing, pull the red button on the wall, you pull it and then they rush to you or you could call crash team and be like patients suffering an anaphylactic shock. They come to you. First thing you should do as you know, lift their legs up so that all the blood, all the volume goes centrally to the heart and then you need to give them an um adrenaline. Um The nurses will know generally. So if you're not sure about which dose they know they're trained that this patient needs um epinephrine for 100 mcg. Uh And you have to, does anybody knows where you stab him to give them the epinephrine. They asked us in the interview as well, where would you just inject it so that they get the Epinephrine? I personally haven't experienced that. Anaphylactic shock yet is intramuscular deltoid. I'd say that'd be more. I'm not sure if anybody does deltoid, but the main one is the thigh. So yeah, nicu on the thigh, Antero lateral area of the thigh. So anteriorly and a bit laterally, you stab in there, you hold, you push it, hold 10 seconds, pull it out and then they should be fine. You find out this patient isn't having an anaphylactic shock and you just stab them with Epinephrine weapons. Are you in trouble? No, they just get excited. They get very jittery. Ok. Um Generally 300 mcg won't do much. It'll save someone's life if they do have an anaphylaxis. So if you've stabbed them, suspecting a anaphylaxis and they don't have them, um, it's ok. Uh The patient will just be jittery for a bit, but it's better to be safe than sorry if that makes sense. Ok. So yeah, that's e so inspection look, did they have any cuts anywhere. Any, does it look like they have a fracture bruises? Um, any fractures on the ribs? Is there flail chest, you know, have a look and measure the temperature, uh, check for allergies and measure the temperature. So that's e um, and then, yeah, you've gone through it. Everything's fine. You could tell the patient. Ok, the patient is stable. Um, obviously cos he's confused. Something would have went wrong if he did a A to E and he's just, I don't know, he's just mucking around some people just like to muck around. So, but if you're happy with the at E document, it, move on, go back to your ward. If anything happens, the nurse will ringing you again. Um But essentially if a patient like this is confused, um most of the time if a patient is confused after surgery, it's because of a post operative infection. Have that in your head. But also in this specific case, which was given to me in an interview, this patient. So the consultant asked me, you've got what is U and E? So you and electrolytes, how would it affect confusion? So I have to talk to mum if they're dehydrated. If they're dehydrated, they could get confused. If they, if they have an infection, they could get confused sometimes they coexist. Um So make sure that's where your electrolytes urea come in as well and they'll tell you about all the sodium potassium and everything. But also, do you know the social status of this patient? This patient is actually a severe alcoholic, but because of the operation, he's had to stop and now he's having alcohol withdrawal symptoms, which one of them is confusion. So that was the case in my case. But I just told you generally just so that you know what to do in each step. I hope at e assessment was as clear as possible. I mean, if you have any questions on, at E, let me know now, before I get to ABG and VBG and then we should be done. But any more to A to e do you have somewhat of an idea of what to do? Now when in any acute scenario? A to e literally with everything, if someone's coming in A to e start with a because that will kill them first. If you're happy, keep going, keep going, stop investigate and then act upon it. If at b you're not sure with their chest, they have an infection and you get the chest X ray and it tells you there's consolidation, start them on antibiotics. You've done your management, they're not deteriorating anymore. They're just still confused. Obviously, it takes a bit for the antibiotics to work. So you, you leave them that you told the nurse, ok? They have an infection, I've given them antibiotics and they, they'll know they'll update it. Ok. That's a good question. What of sub spine do we do at a cool, um, this is more in case of trauma. Um, but as a junior doctor, I don't think you'll see trauma. But again, if a patient falls down and hits their head, first thing mobilize, immobilize the spine. Ok, the more they move it, the more in danger they are at the, the more at risk they are of hurting or damaging their spinal cord and causing paralysis. So, mobilizing the spine, make sure the cervical spine. So the neck will, um, is immobilized. Uh, they usually have neck braces in the wards. I mean, outside of, if you're on the streets and you have to do at assessment, just make sure they're not moving their neck about, especially if it's a head injury, try and mobilize it. That's why when you see always in A&E they put them in the little thing in the um, little neck brace just to ensure they don't move about damage any spinal cord or anything like that. Um But that's the main thing you do just mobilize it. Um I don't think as a junior you'll see much of this. Um, but that, but that's a good thing to point out. Uh Thanks for that question any more before I move on to ABG and VBG. No, I'm going to APG and VPG. Cool. So did I know what ABG VBG was up until August of this year? Probably not. Uh as a medical student. Are you allowed to do this is this for the ABG VBG you're talking about? Oh, in animal? Ok. If something goes on as a medical student, um, I mean, you'll have the most knowledge in that case, I don't know the legalities about it, but you can, especially if you feel comfortable enough, but primarily if you're qualified and you've done a IL SA LS course and you're a doctor, you should be doing these if someone's dropped and no one's around and you're there, obviously, you're going to help out as a medical student, you could give like some advice like stuff, you know, obviously as a senior one, I think something similar happened when I was in second year, someone had a like heart attack. But um I can only tell you about the anatomy or physiology. II didn't know anything. So obviously, I'm not going to like, they've already got staff and ambulance sorting it out. So as a second year, not really sure what I could have done. But now knowing as a doctor, if I see someone that, that he is having central chest pain, I'd ask for aspirin, 75 mg to 300 mg, probably 303 100 mg, chewable aspirin. Um and wait until an ambulance is called, but as a med student, you're just like uh what do I do? But obviously, if someone's dying in front of you start a CPR if the heart stopped, call an ambulance ASAP, ask someone where the defib is, but all of this you learn in a LS and A LS as well. That's what I'm saying. It's really good and important you have that. Er, but yeah, alright, ABG S and VBG S, arterial blood gas, venous blood gas, what are they, how do you do them? Where do you send it off? What do the results show? So what are they like in, what do you think an ABG is used for? Like when would you use it? In your opinion? Any ideas you say anything? Literally, I'll just explain it through step by step because ABG S are actually very common and especially when I was working in A&E um I would do this almost for every patient that I'd see and I see a lot in a day. Acute breathlessness. Ok. So yeah, breathlessness for sure. If the shortness of breath 100% you do an ABG exactly any acidosis, metabolic acidosis for sure. Um But again, it's more you suspect metabolic acidosis, but why would you suspect metabolic acidosis? Um How would you know a patient's metabolic acidosis clinically? You won't really know you'll find out they were in metabolic acidosis through ABG. But you won't know beforehand really unless you know, they're a type one diabetic who's suddenly in keto acidosis. Um and they're having um the breathing for the name. Um But yeah, so what are they arterial blood gas, venous blood gas? Um Patient comes in A&E short of breath, tachypneic, anything to do with the lungs where you feel like they're not getting enough oxygen. If their oxygen saturations are low, you just do it. It takes about two minutes, but it's important to know and it'll tell you even some stuff on it about glucose. Tell you some stuff about potassium. I think VBG S and ABG S are, are pretty specific on the potassium and sodium. Obviously, the bloods are very specific, but this is also like if you need a quick result, cos here, you don't have to send it off to the lab, you go to this thing here and you do it yourself, do what she's doing. You're just taking it off her. Now you're going to her finding the result it'll print off here and you rip it and you'll have this. So you do this in almost any acute scenario. Obviously, if someone's come in with a head, not a head injury, let's say they fell and hurt their leg and there's nothing else clinically, you just know that they've her the tibia or potentially broken it. So you refer to author for X ray or whatever, you won't really need the ABG VBG. But if they come in with ABDO pain, even abdo pain, chest pain, breathlessness, um tachypneic, um any signs of infection, even on the leg, you have to do a ABG tells you a lot. How do you do it? Uh Let me see if I can show you here pretend this is a needle, this is my wrist. So you ask the patient to essentially first you gain consent. I'm going to do what's called an arterial blood gas. I'll tell you the difference as well. Cos they're not exactly the same and how you do it. Obviously, in venous, you get from venous blood, so you get it from where, how you would take blood normally. But arterial, you have to hit the radial artery. Uh If you miss some people do a brachial, some people do a femoral, but that's I let the seniors do all that. I ain't trying to puncture archery and then have it go wrong. That's not me. You let the seniors do it. Um So you ask them to essentially flex their risk downwards. So you push it down. So just that. So it's like this, obviously the lying down. So you and then you palpate for the radial artery to do it on yourselves. You, it's, it's, it's like when you feel your pulse on your wrist, that's what you're doing. So essentially you palpate the radial artery all the way. So you start, let's say, from towards the hand, you're moving towards the hand, you feel the radio as you're moving towards the hand. I don't know if you can see it and up until the distal part where you could feel the pulse. So I feel the pulse here as I get closer, it's harder for me to feel the radial pulse. So you go until you s stop feeling the radial pulse as much. So you go where you can feel it clearly. And now with, with a needle, so it's a sharp needle you can see on here. It's about this. I don't know, it's quite a large needle. Firstly, it does hurt the patient. We don't use lidocaine. Nobody really uses the lidocaine for this because it's just, it'll take longer and the difference isn't that much. You're not trying to wait 5, 1015 minutes for the lidocaine to work. It's gonna hurt equally as much. I wanna say it's excruciating pain. It's very discomforting pain. It's just the initial bit where you enter the skin. So you approach it at almost a 45 degree angle and you could either face the patient and do it. So you do it downwards or you face against it. So you're like entering this way if that makes sense. Um Well, you hold the ABG like a pen. So like here, if you see on here in this picture, you hold it like that, hold it like that. Um And then you get ready to insert 45 degree angle. Um not too flat cos you, the artery is deep and not perpendicular. Or else the blood wouldn't actually enter the syringe. And with the syringe, the syringe, make sure there's a little gap here for the blood to collect. You only need about that much may or maybe a bit more like a bit, a thumb worthy of blood, arterial blood. You don't need a lot and you don't need to have the syringe all the way back here. I don't know if you can see arrow. Yeah, I think you can, you don't need the syringe all the way back here and not fully closed like a little gap here or a little halfway. So make sure you aspirate and just leave that little gap there. Ok? Before you enter, please, when you enter and you're in the artery and the blood's filling, don't pull this, don't pull it back, don't aspirate it cos it's gonna go in there anyways, cos the artery is high pressure, it's gonna go there anyways and please do not push this down. You push this down, you put air embolism could maybe mess up their hands. Necrosis, things will fall off and you have your license taken. Cool. Don't push your pool, have it ready beforehand. Once you're in, he either aspirates in or it doesn't, if it doesn't, it means you didn't hit the artery completely fine. It happens so many times everybody misses. Um, it's not as easy as it looks. Um But yeah, essentially you enter 45 degree. There's a bevel at the end of the needle, it's like the most pointy bit. Make sure it goes into the skin that way. It is easier for the needle to go in and the blood to come in, it is just, you will know what I mean when you see the needle itself. So you just enter 45 degree in and do not go too deep. Go about, um, a couple, a couple of centimeters in once it's in. Um, the blood will start aspirating into the little area here. It'll fill up once that's done. By the way, you need no tourniquet here because it's an artery, the pressure's already high, the blood's gonna get in there. You don't need that tourniquet, you just need the needle. Um, some antiseptic beforehand. Obviously, er, once you put it in as you're removing out, don't remove it out, then put gauze in it as you're moving it out as you remove the needle, put the gauze in, hold it there and even ask the patient to hold it tight for like firm for a minute or two. Once that's done, um, then you've successfully collected arterial blood gas. Uh, you take off the little level with a needle, you put that in the sharp spin and then you've got this, this little thing here. So then you go to the machine, most areas will have this machine you put it in, it'll tell you, insert, insert a sample, you insert it, it says hold two seconds, it hold it, it aspirates a tiny bit of blood into the, into the little machine. What we like to do is when we have the blood, we kind of like push just one drop out just so that the next drop is better results and it, it reduces any like alterations of the results. So remove a drop of blood and then the rest of the blood, you just put it in the machine, it will aspirate it and then it'll print it off and it'll print it off and it will come like this. Cool. I'll try to speed it up cos I've been talking a lot. Um cool. Um So you've got this call. So this is an example for a patient of what do you see here? And what are you thinking? Let me know uh just give me an idea. You could even just talk about what you see in terms of the results here or tell me what you might think is happening with this patient with these results. And I'll just explain um what you need to look out for and what these actually show and mean anyone have any idea just put in a random figure that you see here anything at all? Metabolic acidosis? OK. What made you think that exactly why not respiratory? Why not both? And is does this show you maybe a cause? Exactly. Mhm Now, is there anything else in there? So you are actually spot on, is there anything else that could indicate why this per person might b and metabolic acidosis? Anything else showing anything? So essentially, so as you said, first thing you look at is ph is it decreased or has it gone up? Yeah. So this ph H has decreased acidosis y Now two things to look for these figures here, partial pressure of CO2 O2 or your carbonate ions. These are obviously decreased than metabolic acidosis. Now, we use this for to measure respiratory acidosis as well. Um When is this patient in respiratory aci like what in the figures here will happen for this patient to be in respiratory acidosis? And what does it mean? Um Is there any difference anybody know what happens to the partial pressure of oxygen and CO2 in that case? Yeah. So essentially you have partial pressure of oxygen. Now, in any case of hypoxic events or respiratory failure, partial pressure of oxygen will decrease. So it will be reduced. Ok. If there's anything wrong with the uh l uh sorry, the lungs, um the partial pressure of oxygen will reduce. If they have pneumonia, it will reduce. Now, the partial pressure of CO 02 will either tell us if it's type one respiratory failure or type two respiratory failure. If it's type one respiratory failure, it's just the po two that's going down, it's decreasing, but this is normal. So they're just not getting enough oxygen. If they're in type two respiratory failure, it means they're retaining carbon dioxide which is very acidic to the body and it's, it can cause a lot of consequences and can lead to respiratory arrest. So it's quite a dangerous thing. But with a simple ABG, we can see if they're in respiratory failure. Type two, P CO2 will increase. This means that they're retaining CO2 in the body, which is acidotic. And we don't want that whenever you're in clinics in A&E, they'll be like, oh this person's retaining, um they're retainers, they're retaining, meaning they're CO2, they're retaining in their blood. Um The PO two will decrease, this will increase. So po two decrease CO2 P CO2 increases in type two, risk failure in type one. Po two decreases, this stays normal. So then that's when they're in respiratory acidosis and that could be due to pneumonia, it could be due to pulmonary embolism. It could be due to them having CO PD um by having an infec infection or exacerbation, which is why they're in type two R failure. RS failure can lead to respiratory arrest and then cardiac arrest. So it's always important and that's why ABG S are important for respiratory based um infections or respiratory based causes. Ok. I hope that's clear because it is very important. Um This case was metabolic. Yes, this is decreased, this is decreased. Their metabolic is about why their glucose is 6.5. Am I concerned about the glucose in this situation? They're norm they're non-diabetic as well. So am I concerned at the 6.5? Ok. Um No, for this case, not really, but DK is a very good one to have, but in this one, the glucose isn't that high for me to think DKA, um, it's not that high. Um, if so, essentially this lactate is really important. They don't teach us about lactate that. Well, in Bulgaria, in my opinion, I don't know about ABG S and lactate, but lactate is one of the most important markers on this sheet along with oxygen along with, er, base, um, lactate. Usually if it's increased, it's due to an infection. So high, one's 11.5 it's through the roof. I'm thinking if lactates increased, then acidosis, they have an infection somewhere. Um run blood cultures if they're having a high temperature tachycardic and I see this start sepsis protocol straight away. Sepsis. Six management start it straight away. Sepsis. Six, you'll learn more about it. Uh I might do another presentation on it cos it's quite important but if they're tachycardic and they have temperature, I immediately start in a sepsis six which is take uh give them oxygen. It's three gives and three takes. So you give them oxygen, give them antibiotics and give them fluids. That's the first management you do. And then you take blood cultures, you take their lactate levels here and then you also um take, you measure their urine output and input because if they're sepsis, they'll start being oligo uh ureic. Um So, yeah. So in this case, yeah, glucose, I'm not really stressed because it's only 6.5 and in infections, glucose rises a bit. So that's, to me that doesn't show much in, in fact, it just helps me think that this person doesn't have an infection because their lactate is 11.5. That's the main value here. Main value, acidotic metabolic acidosis right here. Oxygen saturating 92.5%. Again. Um, if they're having a chest infection, I'd give them oxygen if they're non, obviously, if they're non CO PD, if they're co PD, remember 88 to 92 is normal. Um And then yeah, so lactate the ones to take away from. This is lactate. Ph for sure. And obviously, HC 03 is the most important one. I reckon bicarbs. So I'll mention DK A. This is also very good to check if they're in diabetic ketoacidosis. Cos they'd be a acidotic and they'd be in less than 15 millimoles per liter. Um uh carbonate ion with a very high glucose. It'd be like a, it'd be much higher. It'd be like 11.8 17 or something. Something crazy. It'd be hyperglycemic and there'd be acidotic decay sometimes if this is normal, but they are very high, then maybe they're just hyperglycemic and not acid ketoacidosis yet. That way you manage it slightly different. So there's a lot you can tell from um ABG S VBG S. It comes with practice for me A&E I saw so many ABG S and VBG S that started becoming routine. Co before that I had no clue what the hell it was even on wards. I don't really see ABG S VBG S that often. But if you're working in A&E or acute med ABG S VBG S, it's your common go to like, it's just, it's a need. It's a must, it's quick as well. You do it in like five minutes. I've done a couple, they're not bad patient might wince like they do with a normal injection is fine. You just reassure them if you miss completely fine or someone else to do it. And then like, I couldn't do it on one patient. My senior reg did it and he couldn't do it on that. We prick him twice. That's enough because it's, it, it becomes a bit annoying for the patient. So then we, he went for the femoral artery and he did it through the femoral artery. So that's another way of doing it. Ok. Yeah. So any questions on this, I think that's it. To be honest. I know it's a long one and I took a lot of your day, but I hope it's been informative. Does anybody have any questions could be related to anything clinically or it's related to what they wanna be doing? Post, post plein It was kind of long. I didn't expect it to be that long, to be honest. But no, it was really helpful. Like, really, really, really helpful. I don't think anyone's really gone through things like this with us before. Yeah. You know what is like? So, yeah, and II didn't really have any of this before as well. Like all of it's kind of just learned on the job. Kind of like me and my friends discuss situations, like, in A&E, I feel like A&E was a ma steep, like the steepest learning curve. Like you'll just be exposed to anything you're just constantly asking. Ok. But what do I do here? What do I do here? Da da, da, da, da. Um, but it's fine if you are like in the UK, they're very nice. They're very helpful. Um, and, um, yeah, I wouldn't be stressed, as I said, in terms of theoretical knowledge, what you should prepare all the medical knowledge have a base of it. Uh Make sure you have a base knowledge. Not too intense. I feel like you're not doing a research paper on every single disease and just have a base. So you're aware when you're seeing a patient and you think of the differentials, they're chest pain. What could, are they having a heart attack? Maybe if they have pneumonia or maybe they have an aortic dissection. Um, but yeah, um, in terms of that UK, they're really helpful in terms of a job. Don't be too disheartened. If you're struggling, there's a lot of people struggling but make sure you just build your CVI feel like eventually everyone gets a job. Even if you start locum cos everyone progresses at different rates. Like some people just wanna be a GP and then have a nice solid life. Which to be honest, sounds nice at this moment. In time when you're working, it can get a bit stressful, especially acute med A&E shifts. They're quite stressful. General surgery. They're not too bad if you start in the NHS general surgery, I think would be the perfect place to start. A&E would be the steepest learning curve, but you would learn a lot um about the stroke. How long on average is it taking you and your uni friends to get jobs? Um Honestly, it completely varies. I know someone as soon as they finished, they were already on agencies. They were already working at like a week. Like I wanted a holiday. II went turkey. I had a nice time. Um I just wanted to chill and when it came to July, I started applying it and started getting more stressed cos I feel like July, they started taking everybody in for August and then from August to October, it was quiet. It was so quiet. I've never seen the market so quite unsaturated. Um However, everyone gets at different rates. I know some people know in it chest express, no clinical attachments. They managed to get a three month placement, working in general surgery or general medicine. It happens. Some people will get lucky. Some people won't uh help each other out and I'm not gonna lie. Um If you have links, it does help whether people say nepotism does exist. If you have parents, you're just lucky. What can I say? I personally don't. So it was a bit harder. I had to ask like people already working if they knew someone knew someone. Is it, it's all about networking. Um Obviously, if you have parents, if they can help you find a consultant for you to do a clinical attachment with, honestly try to do it. Some people try to speak to. Hr let the parents, the consultants speak to hr if there's any job opportunities, um all of this does happen. And obviously, why wouldn't you, if, if you've got a child who's just graduating, you want them to get a job, you're obviously going to speak to whoever you can for them to get employed. Um But if you're starting n like I, I've, I had one cousin, she helped me with the clinical attachments which helped me get a job. But in terms of getting a job trust grade, it's harder. If you do a clinical attachment, there's a good chance you could get a job through that clinical attachment, but make sure you do the clinical attachment before August. So that for August, they can interview and employ you if that makes sense. Um But if you miss it out, like I II couldn't really find anything. Like as I said, GP was my first one. Like I was emailing everyone but nobody was getting back. So you gotta call people. But yeah, um, you've got a network, you gotta find people to help you out. And, but eventually I feel like everyone gets a job. I know some people are still a bit struggling now but they're doing the clinical attachments and then the strikes as well as junior doctor strikes. Unfortunately, the agencies are still booking people. So, um, it's a good thing for us. If you haven't got a job, the strikes as soon as you put your foot in through that door, they'll book you. That's the whole point. The first booking is the most important. Like I was so stressed for maybe like three months. I'm doing, I'm working for free, I'm doing free labor, I'm treating patients. I'm still putting my license semi at risk cos you're still seeing these patients. Um But I'm not getting paid and there's no career progress in my head. I'm like, there's no career progress but the clinical attachments help you get a job. And then these locum shifts, even though I'm doing consistent locums, like hospitals are ringing to book me. And now it's me saying no, a lot more than them saying, you know, if that makes sense. And before like hospitals were like, uh she doesn't really have any clinical experience. Um like NHS experience, uh it's gonna be a bit hard. So we go for someone with NHS experience who's worked here before. But if you've um if you've done a clinical attachment, they're more at ease with you working. They're a bit sketchy, but when they're desperate, they'll book you when you, when you're booked, they keep booking you and booking you and booking you and booking you and then you have NHS experience to put on your CV. Um But I would keep references if you can clinical attachments, make sure you have references uh Pleven for your three years, make sure you find two or three just in case, make sure you're on good terms. Um And yeah, so I LS clinical attachment, your CV. And then once you start working like II can't explain it. It goes by quickly, firstly, 8 to 5 shifts, they're calm, they're so quick. Honestly, they go so by so quick cos you're constantly working, doing admin, it's the 12 hour shifts where you start feeling, especially nights. I would not recommend nights and also agencies won't really book you for night shifts if you don't have experience because it's a risk to them. It's a risk to, to you cos you're a bit more independent in that case, like in the day, there's other junior doctors, you just go to the next junior doctor. Like, can you help me? I haven't used it before. It's my first time. Can you show me they'll show you you'll know you'll learn. And like, especially in theory, I think I was in like a clinical attachment at the cardiothoracic surgery. And they were having a teaching with one registrar and like I'd say about 1015 junior doctors F two who graduated from Cambridge. And she was asking questions about tension pneumothorax and you know, in Pleven. Yeah, if you have stoic of surgery, you know, tension pneumothorax is his biggest thing. So essentially nobody knew anything about tension pneumothorax or what you would do. Um She was asking me, OK, what Cannula would you insert? Um Obviously, you don't know, you just say large bore cannula. Where would you insert a second intercostal space, mid clavicular line, chest drainage, all of these like if you do general surgery and you know, stoke have really, he asked me in the oral, he asked so many people with this question because it's very important. But none of the F twos really knew and I was unemployed. I was just like observing but they were just looking at me like, and I was just like f I'm just trying to get a job. But yeah, so theory I wouldn't stress like that because it's mainly the reg and consultants acting upon the medical knowledge. You're just there to do the admin work and acutely manage urgent situations and then knowing when to escalate, you can't do everything on your own. If your stress just escalate, call your reg be like this patient. Da da da da da explain through sbar quickly what's going on and then be like, like some cases like this, this patient is intolerant to some pain medication. What should I give? They'll be like, OK, try um sub morph 10 mg, stat, stat basically means ASAP just do one dose, just give it now. So if you don't know, just our, they'll tell you the whole point of working in the NHS. Everyone's helpful. Everyone works as a team. No one looks down upon you. Um, some people might get stressed and get a bit irritated but they won't like, like diminish or like antagonize you and think that your knowledge is bad or anything like that. They'll, they'll help you, they'll teach you and your work. So it's actually not too bad. Um But yeah, that's about it. And if you have any other questions, let me know. But yeah. So does anyone have anything else to ask uh Doctor Osmani? Um And yeah, I was just saying so basically the NHS is nothing like clever and not gonna drag you through the streets when you don't know. But don't get me wrong though. Don't get me wrong. NHS isn't like clever, but the system is very under stress and it isn't as um isn't as organized as everyone would hope it to be like when you're doing patients notes, like it's all in a folder and it's got handwritten notes and now suddenly your license can depend on it because you don't document something to like what you should have documented. Like it's, it's not as smooth as II would have expected. Like the system is still in its ropes, but in terms of the people there, they will help you. And also yeah, how you carry yourself as well, like like make sure you wanna learn these things. Like if you're unsure, just tell them if you're there stressing, not knowing what to do, the longer the patient has their ABG done, the longer the results will come in, the longer the treatment comes in like, but yeah, exactly. Every hospital is different, some electronic records but to be fair, most history and patient notes are done on paper for a lot of hospitals. Um Some are done like, well, they transition to electronic, but most I'd say about 65% is still paper, 35% electronic, but now it's transitioning a bit more. Um But yeah, and does anyone have anything else to ask, do Doctor Osman and we're just gonna wrap this up? Um Thank you so much doc really, really appreciate it like we don't, you know what it's like and and we don't get people talking us through things and sitting us down to do this. So this is really, really helpful, really, really appreciative. Um Everyone, please, please, please, I'm gonna send this again, please fill in the feedback form for Doctor Osmani if you enjoyed this talk and if it was helpful, obviously, it's gonna help him with his own portfolio as well and his own progression in the NHS. So please fill this out for him. Um And then you'll be able to get your attendance certificate as well. Um But yeah, I feel like this is probably a good place to wrap up if no one has anything else to ask. Um Are you OK to give out your Instagram details if people, yeah, it's, it's on the it should be on the um page, right? Um Yes, it's on the Instagram page. Let me, I'm just gonna write it in there. Just bear with me. Thank you. I hope it was informative because I was exactly in everyone's shoes about six months ago. So um I know everyone needs some sort of advice cos all we knew was you finish, you go to UK you start working but you kinda need the ins and outs and what to look for and what not to look for. But yeah, I think Jemima has put down my Instagram if you have any other questions or anything like that. Um You can just reach out but yeah, I think that's everything. Hope everyone had a nice talk. Thank you, Jemima. Thank you doctor. Um Yeah, please guys fill out the feedback form really, really helpful for us as well so we can get these um talks out to you and get you guys what you need and want. So, thanks everyone. Have a lovely evening. See you very soon. Um bye-bye. No, worries. Thank you, everyone. Bye-bye. Thank you. Bye bye bye. Thank you, everyone.