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Hi. Can everybody hear us? I don't click live if you can um hear me if you can hear doctor shitty. Just drop a message. Let us know that you can hear us. OK? We'll wait a few more, like two more minutes and then we'll start. Ok, let's get started. Hi guys. Um Welcome to the third installment of the BSS Pleven Post Pleven Syndrome series. Uh Thank you for joining us tonight. This series is targeted at Pleven students who um to provide them info and guidance on transitioning out of Pleven as medical student um and to becoming doctors in the real world. So before I introduce our speaker, I'm just gonna give you a brief overview of what B SSN is. So B SSN is an organization that was started by a former student uh Yusuf, Doctor Yusuf who studied in Bulgaria as well. Um He created it to connect the international students in Bulgaria together to help them with uh reaching out to each other, getting support and guidance, uh especially on transitioning back into the NHS as Interna International Medical Graduate. It's a different process for us entirely than home students. So that's what we do here at, through our various events, we help you prepare to uh get back into the workplace to start in working in the NHS as doctors. Um So if you have any suggestions, any questions, um anything at all, then please reach out to us in your, in the university or you can reach us via our socials. So that's a little on the n now, um We will start with doctor S so doctor S is a recent graduate of Mup. Um Now he's an F one doctor working at Royal Shrewsbury Hospital. So today he'll talk to you about his, his transition back into Manchester. Thank you, doctor see over to you. Hi, Judith. Thank you very much for that wonderful introduction. And um thank you to B SSN for having me um today. Um Just to clarify. Can you hear me properly? Can everyone hear me? Yeah, I can hear you. Ok, good. Um So today I've been asked to talk about um basically my journey to the UK um as a graduate from Bulgaria and how, how that journey was, how the transition was. Um So I'm just gonna talk to you about everything basically, you know, on the pro here it says Fy one F I two. So your job role of Fy one Fy two um GMC registration lo just the entire shebang basically. Um So a bit about my journey like moisture beef. Um I was a medical student in Bulgaria So I graduated from Medical University of Plein in April 2023 last year. Um after completing six years at the university there. Um Now, before I graduated, I'd go to my GMC registration and my GMC license. So that was just something to not got, got my GMC license in um March of 2023. Um After graduation, I did um and I LS course by the Resuscitation Council and then went on to Secure Clinical Attachment at the Northern General Hospital in Sheffield under the Cardiothoracic Department. I was there for two months basically from the first of June until about um the ninth of August. So I did a clinical attachment with them. Um and then from there procedure to do some locum shifts, eventually I got a long term working contract which extended from August about mid of August. So about the 15th of August until the sixth of December. And then I started a new trust grade post with a contract of 18 months covering F one and F two started on the, on the seventh or sixth of December. And that's what I'm currently doing right now. So that's that trust grade place at Roy Shrewsbury Hospital. Um So um yeah, so if you have any questions as I go along, this, just let me know, feel free to message in the, in the chat. I can see that on my right here. So what am I gonna talk to you about? Today. Then I'm basically going to talk about GMC registration cos I know that's what most people want to initially hear about. What do I do next after I graduate from university in Bulgaria? Um What are my next steps? What, what do I have to do? Um I'm going to tell her it be multiple because that's where I graduated from. Um However, I'm pretty sure this applies to most universities in Bulgaria. And then I went to talk about clinical attachment, um how to secure one, how I secured my one. Um Also just talk about generally how the transition is from a student to a doctor and from medical practice in Bulgaria to medical practice in the UK. I think those are the two main aspects that get people a bit concerned and worried. Um I'm gonna talk about your role as an fy one fy two doctor. Um what your typical jobs would be was expected of you. Um or a typical day might look like, uh you know, depending on what shift you're doing some classical scenarios um and patient managements that you might have to face um as an fy one fy two doctor. And then finally, I'm gonna talk about the different routes of employment, different ways of securing a job um within the NHS, talking about luring jobs and bank jobs, talking about your trust grade posts, locally employed, um post, talking about the KF PA, you've got something interesting there. I'm sure some of you might know about it, some of you might know. Um and then I'll talk about gateway doctors, which is also um a recent initiative that the N HSP has organized to help doctors transition from Bulgaria um to the UK. So moving on now, talking about GMC registration, um I think something very important here, it stop. You can't start your process of GMC registration until you've got all the important documents and um you know that you need to apply for your G to registration. So first of all, you need to complete your final exams at your relative university. So I completed my exams at 11, I think in early March say around the 10th of March possibly. Um And so I had about about a month to the actual graduation um ceremony to kind of get all my documents prepared and get myself applying for the GMC. But fortunately, I'd been able to actually secure my GMC registration and license even before graduation. So I'm gonna just talk to you about how I did that. The other thing was the Ielts and O ETS exams. Now, you can do this before your last exam. You can do this after your last exam. Depends on where you are. Um where you sit, there are advantages to doing it before your last exam. Um Typically employing your last exam would come in around March, April time. So one of the advantages of doing your Ielts before your last exam would be that you're able to apply for the UK FP O program and we'll talk about that. Um, moving forward. But, um, so just, just a bit, a bit on the, on the IE LTO A. So these are your English exams, um, that the GMC requires you to get a certain level, um, before they're able to accept you as a doctor on the register on the register. Um, So I've just highlighted there. I don't know if you can see it properly, but in the box, in those two boxes over there, you've got, these are screenshots I took from the GMC website um yesterday or today. So these say um for the Ielts, if you're sitting in the Ielts, you need a minimum of 7.5 as an average and a seven in each area. And if you do your ATS and you need a minimum of a grade B, which I think is um equivalent to, I think 400 marks. So I think just double check that, but you need a minimum grade in each testing area. So speaking, listening, reading and writing and that's, that's the same areas for Ielts. Now, personally I did Ielts because I just found it to be more accessible to myself um to do, to do the O ETS. You have to go to um Romania, I think from Bulgaria to go do it which or go back to the UK and do it, which for me wasn't really an option by then because I had exams and I wanted to get it done before my final exam. So I decided to do mine in the UK. Um, in Bulgaria. I did it in the test center in Sophia and Bulgaria. Um, I'd, I'd initially booked mine for the 15th of February. Um, but then that got canceled because there wasn't enough people. So I booked it in one in Velika, Turnovo in Bulgaria. But that wasn't, um There wasn't enough people signed up for it apparently or something. And then it got canceled and then I got told to move my location or test dates. So I just changed the location to the capital Sophia. Why I know there will be a lot of people there to do it, um changed it to Sophia and then did it for on second or something of, of March. Um I prepared for it for like a month. Um I think my focus mainly was on the writing aspect because I found that um a lot of people that I've spoken to from the year above me and from my colleagues, I found that to be the most difficult part. Um and the easiest part to, to fail on. And when I say fail, I don't mean, you know, I just mean, you don't reach the GMC requirements cos that's your target anyways. So, um the writing part was the part that most people were kind of focused on um speaking, listening, reading, it was good to practice on them. Watch some youtube videos on them, but they were relatively easier if, if English was your native language. Um compared to the writing part because the writing is very much a formal writing. Cos you're doing the academic um academic ielts. So the writing part was, was quite um you know, important to focus on them. No, you have to do the academic Ielts and you have to do the medical o ETS with the OE TSI had a lot of friends that did O ETS rather than doing the ielts. And to be honest, I don't think there was a difference in terms of difficulty. I think they kind of found that like, from what I've, what I heard it was pretty much the same, however, because it was medi medically based, uh, they seemed to feel like it was a lot more easier for them because the medical students and it's medical based, I think you have to write like, discharge letters in it as well, which made it quite useful, um, when it came to your job in the UK, I suppose. But, um, it was, it was, it was, it was good. Um, it, it doesn't matter which one you do as long as you, you meet your targets, the GMC requirements, you meet those, then it doesn't really matter which one you do. Um, the Ielts is very much generalized. So there was an, it's not, it's not medically focused, you can get asked about, you can get asked to write on, you know, the, the, the planet's business. My, my ear's question was about business. Um, you can get out by anything really. So I guess this, that's some of the, one of the reasons why people might not want to do. Ielts. Um, as compared to O ETS where it really doesn't matter between you. If you're the kind of person that reads a lot, then Ielts will probably be easier for you compared to O ETS. But it doesn't really matter. You just, just gauge which is easier for yourself and then go with that. Um And if you have any questions again, feel free to ask. Um Now after you graduate, after, after you finish your last exams, you need to get um, a letter of completion and a certificate of good standing from the student office. And I'm, I'm gonna be talking to the graduates from the, the, the graduates from ple. Now those have, are graduation from Cle this year. Um Congratulations. Honestly. Um It, I know it's been a long, long, long, long journey. So you want to get things done as, as quick as possible, as smoothly as possible, um Depending on where your goals are. And then some people would like to um take some time out and that's fine. What you don't want to do still is having to you know, go back to Bulgaria to go get your letter of completion. And so you get a good standing if you've left Bulgaria already and just keep going back and forth. So as soon as you finished your final exam, I remember what we did was we literally finished our final exams, went straight to student office and requested a letter of completion and a certificate of good standing and a letter of completion is basically um your document of graduation before you actually get your diploma. And the GMC accepts that um as as an equivalent to to your diploma in the time being and your certificate of good standing is also needed to verify um that you've been a student at that university. Now, obviously you see on the slide that you need some documents prior to being able to apply for your letter of completion and get a good standing and these include your passport photos. Um But I think you need about three or four a copy of your book ID and a copy of your passport, um your international passport, um Lily Library, um clearance and your stage diary. No, some of these you can do even before your last exam. So a passport photo, you can get those, get those ready, get your, get your copy of your booking ID, your passport ready. The lively clearance. I think you need um you need to have done your final exams and then you go to the student office, they give you a little ticket um and then take that to the library and the library scans your library card and checks if you have any books or any fees you're owing. And I think you pay maybe five left and once that's cleared, you can just that, that can be done in literally less than an hour. Um You get that, get that done, you go back to the student office, hand it in along with your other documents, your stage diary, ideally, you want to um photocopy that you want to get a photocopy. So you have a copy for yourself, cos you're going to be giving the original to the student office. So once you get all of those hand it in into the student office, they verify that you've passed your final exam and then it'll take about a week for you to get your letter completion and your certificate with standard. Now watch your waiting for that. There's some other things you can do. So you can, you can then begin your GMC process while you're waiting for that. So in that week that you're waiting for a letter of completion and a certificate of good standing, you could go on to create an epic account. Now, Epic is the platform that GMC uses to verify that you're a, you've graduated from this university actually, and you've actually been a valid medical student there. Now, you create your epic account you have to pay, I think 100 and $30. Once you pay that, it takes about three working days to a week for them to create your account and send you like your login informations and then you have to like change your login details or whatever. Um takes three days to a week, which is why I said whilst you're waiting for your letter of completion and certificate of good standing in that week, you can start on your Epic account. However, you can also create your Epic Accounts even before your final exams. Um There's nothing stopping you from doing that. But I think if you're the kind of person that just wants to focus in on something and get the ball rolling, you can do, you can do it in the week. You're waiting for a letter of completion. Now, once your account has been created, you get given a an Epic identity form which you don't need to get verified, but not to reca which is another organization that is directly linked to Epic. And what they do is it's, it's an, it's over like um digital, it's digitally based. You don't have to go in person for the verification. They would just basically need your passport and they will need you to sign this identity form literally physically on the system and it's just a click of a button, but there's gonna be an individual there that is having a conversation with you get you to put your password up right next to your face. Um, and then they'll just verify that they've seen you and then you need to click sign and that would, that would be verified for you. Now, the not become appointment, however, can be quite tedious to get. Um, sometimes you have to book it. It can take a week, it can take two weeks depending on slots. Sometimes it can be a thing of, and it happened quite spontaneously and you get an email saying if you're available now, then. Um ok. Um And it could happen in five minutes and just like that. So it's quite varied. Um I think mine initially did, it took maybe 23 days to actually get an appointment. But as soon as, as soon as there was an appointment available, I just got the email going. If you're available right now, you can log in and get sign in and that email will come in in the morning usually. Um And sometimes as soon as you submit the application, they'll send you an email saying if you're available, then please log on and follow this link. And the system is quite, it's quite logical there, there's, there's like links available and if you're not able to access the link, then you'd also, you can just email them back. It's usually an individual rather than the company messaging you. It's an individual from the company. They like assign a person to you, so you would, you would just email them back going. Oh, you know, I've got this email, the link is not working. I'm not quite sure what to do and the person will just have a conversation with you and tell you what to do and send you a new link if needed. Um And once, once you've got done that and that's been verified. Now you're, you're ready to begin the next process which is to then upload your letter of completion. So let's say this takes you about two weeks to get to that notary account points, your left completion should be ready by now because that usually takes a week with a letter of completion. It's important, very important that you, you have a look at it, read what's been written on it. Usually it's a template that a student office has created for every student. Um However, they will change your name, change your date of birth, change your country of origin based on your passport that you've submitted to the the the university at your point of application. No, if, if for some reason they had gotten your name wrong, spell it wrong. Um Put your date of birth in wrong or put your your country of origin in wrong and you didn't realize and then you go on on Epic and you upload this letter of completion onto there and then suddenly your details don't match, it's going to get rejected and that's gonna delay you, that's gonna pull you back. Your entire application process is gonna delay everything again. Cos you're going to have to go back to student office, get them to reprint a letter of completion which then needs to be signed by the dean. And you know how that goes to the appointment takes forever. So it just becomes a thing where you're stuck within, you know, stuck between letter of completion and trying to upload it onto Epic. Um So as soon as soon as you submit to your application for, for um student office, obviously they go, they've got a copy of your passport. So ideally there shouldn't be any errors. But what you can do is also just maybe write your name on a piece of paper along with your application, your full name, date of birth and your your country, just write it there as well on a piece of paper, just attach it to your, to your application for, for the letter of completion. Just so. No, Erythema. Um and your, your, your, your transition is quite smooth. Um Anyways, let's say you've got your letter of completion. Perfect. Um Nothing you know, questionable on that. Then you can upload that onto Epic's platform. Now, what Epic will do is once you've uploaded it onto the platform, you have to pay a fee of $100 for that. You pay that fee and then they will send your letter of completion to student office to verify. And once, once they send that to student office, student office, then clicks a button to say yes, we did insu we, we, we issued this letter of completion. So this student, they graduated from our university, they've completed their exams, we verified that they are, they are, they're, they're now doctors basically. And then that gets them back to Epic. And then you get um a reference number from Epic that then goes onto your application form for the JMC. Um Now with getting your letter of completion verified by student office again, it's another, it's another journey just because um student office can be quite slow sometimes um but sometimes very efficient as well. Um It just depends on your communication with them, I suppose, you know, for some students, they, they got the epic verification done the same day they sent it out. So they sent it today and in two hours it was verified and sorted and that was because they went into the student office and said, I've just sent my epic verification by the way. Um So just so you're aware and they, they say, oh OK, cool, we'll have a look. Um And that's be probably also because they've, they've started the process quite early. And so there wasn't like a build up of students sending the epic cation all at once because once that begins to happen, student office begins to get um overwhelmed. And so it just becomes a thing of, let's say they, they decide to do 20 or 30 today. If you're not part of that 20 they decided to do today and say hits the weekend, then you're gonna have to wait till next to the next Monday for that to get sorted for you. Um, and so it all depends on where you do it. Um, how quick student office is, is as well. They also get quite busy with, with, you know, a lot of other, other jobs they're having to do um as part of the student office. So that's just something that can take, I think maximum a week, a week and a half. However, they'll, they'll sort it out for you because they're trying to get, make your transition easy. Um In some cases, it might get a bit more delayed than that just because you ended up realizing your letter of completion was wrong. And then Epic was like, oh, you know, this is wrong, you know, and then you just have to go through the entire process again. This makes it difficult. Now, let's say everything has gone smoothly up to up to this point. You've got to your reference number, you can then proceed to create a GMC account. Once you create a GMC account, you get your GMC number, but it's a provisional number. It's not, it's not linked to, it's basically an account number that becomes your GMC number. So you get the account number. That's essentially going to become a GMC number. Um You log on to the GMC website which you can see here, you log on to gyms website. Um There's a, there's a point there that says, um, application give me two seconds. I'm just gonna read this question. So once accepted by Epic, how long do you have, have between the time and when you must register with the GMC? Um, from what I understand, I don't think there's any timeline or expiration date as such. Um Well, you might need to just double check that because I didn't really kind of wait to find out. I just kind of did my thing as soon as um what I do know from what I remember is once you've created your GMC account, I think you have three months to apply um to actually apply for the GMC. So if you create your account and you, you don't apply for registration in three months, that account gets closed and you have to create a new account. So within three months of creating a James account, you need to apply for the GMC. Now that could change. But as soon as soon as you've logged on, they'll, they'll tell you and the GMC has like a whole guide on the website where it, it'll tell you the amount of time you've got before, before your GNC account gets closed. Are you having to create a new account? Um And then you like reference ID and everything. So I would, I would suggest, you know, once, if you're going to create a GMC account, try and apply for your GMC with that account you've created. Um I don't know what the implications of your account being closed will be. I don't think that, I don't think it's a thing where you can't recreate an account, but you're just gonna have to read the website and just find out a bit more on that. Um But in terms of the time frame, how long between when you get your, your epic education, can you register? I don't think there's, there's a time frame because I, I'm pretty sure um for my cohort of graduates, there were students that probably just got the GMC license, say August and we graduated in April. So April to August May, June, July, August. So about three months again, I mean, by August, everyone is trying to get, everyone is trying to get the, the GMC registration by then by August. There are people that go a bit later than that September um October. But I don't think it was a thing where your epic expired as such because that's been verified by the, by the university. Um However, I'd say again, just to read an epic on the epic website CFM G website. Um just to clarify. Um Just so you don't say you're being strategic and you're thinking, OK, I'm go, I want to take some time off before starting work. There's nothing wrong with getting your GMC license or registration and taking some time off. There's nothing wrong with that but say you have that. Oh, you know, II don't I want, I want to get my GMC registration and then start work then um you can, you can take time off and then to get gym to registration. But again, it's just a thing of making sure you've got that Epic sorted. And within the timeline that is, that is um agreeable. You're gonna have to confirm the timeline on, on the E CFM G website. Although I don't think there is any as such. Um in terms of what you do next, once you've got gotten your reference number from Epic. Now, initially, we all thought we could apply um online via the GMC website to apply on the GMC website for our GMC registration because it gives you the option there, apply online now for your GMC registration. However, that doesn't work for us because we are International medical grads. So a couple of us run up the GMC and we, we've had guidance from our previous uh predecessors of graduates when we run up the JMC. And we were just like, OK, we, we're graduating from PLE we've got our epic verification, we're trying to apply it online, but it's not really working. What do we do? Um And then they would just say, what's your GMC? What's your GMC account? So, you know, if you're trying to apply, you, you, you already have a GMC account. What's your GMC account number? They'll check what email is associated with that. They'll send you this I MG 23 form. Now, the 23 there doesn't stand for the year you're graduating. Um, the year before me, he used the I MG 23 form. I'm pretty sure the year before that he used the I MG 23 form. The name can change. I'm not saying it can't. Um But um I think it's called the G 23 form just because that's the code given by the GMC. Um But again, with all these things, just double check, you can ring up the GMC once you're getting closer to that time and they'll send you the, sorry, the other thing is this form does get updated. However, um, so you don't, I don't use the form from last year just purely because someone from your previous year sent it to you if they send it to you or, or, or you, you down, you can actually download it online. Um You can download it online and you can see what the template looks like. Um But just kind of verify with the GMC or get them to send you the up to date form. Um You know that you need it for that year. I want to send that to you. Um The form is pretty self explanatory on how to fill it out something you need. However, for that form now, before you can apply for the GMC is you need to have done your ielts. So you need your letter of completion verified by Epic. You need your Epic number. You need your certificate of good standing for the GMC. You never, you didn't, you don't need that to get, you don't need that verified by, by Epic. So don't, don't upload it onto Epic because they'll, they'll charge you an extra $100 and you don't need that verified at all. You just need a letter of completion, but you need your certificate of good standing for your GMC application. Um You need your ielts um number, results, number, your O et results number provided that you've hit the target requirements for GMC and you need your passport, um your international passport. I think you might also need some passport photos um as well. All of which you can just attach and send as a PDF via email back to GMC. And then once you, once you send that in, they'll have a look through the entire form, verify that you're good to go. Then they'll send you um a payment um link for you to pay as an A MGI think they usually offer a discount. So I think it was maybe about 100 and 50 lbs, possibly um 100 and 60 lbs, something like that. But uh obviously it'll change from time to time um So that would probably be a new update fee that JMC would, would let you know about. But anyway, they'll, they'll send you that link um, for the payment. Once you've paid, they'll confirm that you've paid, send you a receipt and then you need to do an ID check and they'll tell you to. Now. Um, initially ID, so when I was II got to this point of payment by say mid April like April the 15th or something. And now she's waiting for my ID check and graduation was in like a week's time. Um And so what happened was II didn't want to go back to the UK and then come back to Bulgaria for graduation because GMC would give you um a slot online to, to book your ID IV check. Initially ID ID check was was in person. So you have to fly to the UK, go down to London or wherever your nearest headquarters is. I think there's one in Manchester as well. Fly to the UK, go there, have an in person meeting with all your documents. They don't ask you anything medical. It's just literally an ID check. Give us your, show us your passport, show us your um and everything to ask for your diploma or anything like that, just your passport. Um but they then began to roll out um digital ID checks. So those it was very sudden, I think I had booked my physical um ID check for like the second of May. And then we just got an email from GMC saying we're now rolling out digital ID checks. Um Here is a link for the application to download onto your phone. I think it was called digit ID di di Identity or something. You download the application and there's like a youtube tutorial video of how to use the application. And once, once you just go through the application, you can, and you can essentially do your ID check on the spot like this. Um You just literally upload a picture of your passport, not upload but like scan it with your camera. Um come and scans your face and then somebody buy a Pfizer from the other side and, and that's it, you know, and then you get your welcome to JMC email. Um You get a welcome to the GMC email with your GMC number, which was that account number that you've created. Um And then you get asked to book a welcome to UK practice workshop, which I would 100% recommend that you do. Um I think it can be in person or it can be online. I did mine online. It, it goes on for about 12 hours, I think something like that. It's, it's, it's the entire day I think if I'm not mistaken. Um I'm not quite sure but it, it goes on for quite a while, but it's, it's a good um like an induction into the UK practicing UK system. Um Yeah, and then you can just look yourself up on the JMC register to search your name in there just to give yourself that satisfaction and seeing your name on the JMC register, just taking a screenshot of something, send it out to your family member and your loved ones and whoever's gonna be happy for you. Um Yeah, don't send it to you anyway but yeah. Um that's, that's that for G MS registration. Are there any questions um on that? Is there anything else you would like for me to clarify? Oh yeah, so with the, with the C RB check which is basically um your police check. Um all you need is your BO ID. You go to the a copy of ID, I think for some people I think you needed your birth certificate as well. I can't remember giving my birth certificate at all. Well, there are some people saying you needed a copy of your birth. Um your birth certificate. I think, I don't think that's for the UK students. I think that's for maybe other students like from other countries. Um UK students. I can't remember what else needed to show our birth certificate. Well, you just go there, you apply for it. I think it's like five labs and then you get a certificate of police clearance. Um You guys have a certificate of police clearance and you, you will need it when you're about to apply for any jobs in the UK because they will ask for it if you're about to apply for, um, your locum work about to apply for 12 grade work. They always ask for a police check from the country you're graduating from as well as a DPS check in the UK. So you definitely need it and you should also get it translated cos it comes in Bulgarian, get it translated and verified notarized. Um And just you, you have to submit the Bulgarian and the English and you've got a question here. Can you work as an NH as an NHS HC A whilst having a GMC registration? I think you can. Um I think one of my colleagues um from that graduate with me in my uh I think what is an AC A for a bit before it was able to secure um a job as a doctor? Um So I think, I think, I think you definitely can um as long as you don't try and function as a doctor um whilst you're, whilst you're on a ta because that's not what you're employed for. So don't, don't go there uh about full registration and then you're trying to prescribe medications, you're in complete violation of your job role of your gym to license. So if you're gonna function as an AC, a then function as an AC a not as a doctor. Um But ideally you want to, I mean, if, if you're, if you're trying to work as an AC A because you think I want more clinical experience and I want to get more um just chemical work. I think a clinical attachment might be more beneficial rather than working at an A ta. Um obviously as an AC A you're taking, you're doing ABS um BMS, blood glucose, things like this, which is good, it is good practice. Um but you don't get, you don't get to see much of what the doctors are doing. Like the thought process of the doctors because, but I mean, it can be very enthusiastic and like stand around the doctors all the time whenever they come during the ward rounds and just kind of like, what are they doing? How are they doing? You know, but if your, if your role as an AC A kicks in, you need to go attend to a patient. You can't, you can't then be following the doctors about cos as an ac a your primary um position is you're associated with the nurses. You're, you're, you're working with the nurses, you're um primarily not with the doctors. Um If you're wanting that doctor experience, you can, you can do a clinical attachment, an observer, um an honorary contract which is similar to a clinical attachment, but apparently they're a bit more hands on. Um Which office, I'm just reading a question quickly. Which office did you do? Did you get your C RP checked on? So it's it's, it's like the, it's not at the municipality. Um, it's like, in Plein, it was opposite the, the, the, um, Best Buy building where the gym is, it was opposite there. Um, I don't know if has, has closed or the gym is closed but it was opposite there and you have to, you have to go into, it's like a police station but also like a bunch of legal offices there and that's where you had to go to, um, before you entered the building, you had to do like a, put a scan, a full scan of, of your body for weapons and whatever it was it was, it was right next to the building, um, opposite the town center and opposite the, the Best Buy building. Um, so coming back to this HC A business, um, now if you're, if you're trying to be an AC A because f for like monetary reasons, you don't want to just have no job, you want to have a job earning some money whilst you're waiting to get your, your job as a doctor. And you think, ok, ac A would be the best like medical thing for me to do closest medical thing for me to do then fair enough. OK? You're also, you're also considering the money as well. Fair enough. Um, but if you're, if you're just like, I want to do an AAA job because I think medical experience, then I wouldn't, I wouldn't recommend that I would recommend you do like a clinical attachment um as well and you can do both do an HC a job and do a clinical attachment at the same time. Um But you'd have to, you'd have to give some dedication to your clinical attachment. I would 100% recommend a clinical attachment. Um However, you can, you can go into a medical job without a clinical attachment, but it's extremely difficult. Um maybe nine out of out of 10, you will not get a uh a job without a clinical attachment of some sort, some sort of clinical experience as doctor or shadowing a doctor. I don't know if ac a jobs will, will be as, as significant on your CD um as a clinical attachment, I can't say for certain, but I do, I do know a friend of mine who had done what is an H TA and then got working jobs um and then got trust grade jobs. Um and I know a lot of a lot of people. So what it is is if you've been doing an ac a job at a hospital beforehand, consistently stay over the last two years, you've been working as an AC a, then you've most likely built connections and built um a network there such that when it comes to asking for a clinical attack, and you could also ask cos they know you, you know the system somewhat. Well, you do not know the system still as an ac a, like you do not know how the, unless you've been really keeping a closed eye, you don't know how the hospital systems itself works for doctors. As an AC A, you don't have access to any of those as a clinical attachment. Um doctor, you will have access to those and you'll be able to use them first hand, but as an AC A you generally wouldn't. Um So, um you would definitely, I would definitely say so if, if you've done an H TA job at a, at a specific hospital, you can then speak to them and get a clinical attachment and then you can also then convert your clinical attention into an employment. So you can go through that kind of bladder um transitioning from one job to the other. Um Sometimes people do go from AC A and then when it's, when there's a job avail availability, then they become doctors there. Um But I don't think that that happens as often, to be honest, I think you do need some sort of clean for the just to show that um you've, you've, um you've, you've, you've gotten some clinical experience as a doctor. Um Jonathan is you still have, you still have to apply for the job. Um And you still have to do an interview for the job. And if you're found lacking in that interview, you won't get the job regardless of whether you've done the AC a work with them regardless of whether you've done the clinical attachment with them. And I'll, I'll tell you that from my first time experience that you will. If, even if you've done a clinical attachment, you were the best clinical attachment doctor there. If you, if you're found lacking in your interview, you will not get a job. Even if they know you, that's just, and the person that you've worked with would never be your p be your interviewer. It'll, it'll always be someone that you've probably never met. Yeah. But the, if you have found lacking on your interview, you will not get a job. It doesn't, it doesn't guarantee you a job but it gives, it puts you in a good position to apply for no. Um say going from Plein to the UK, going from student to doctor, going from the Bulgarian Medical practice to the UK medical practice. All of this is very, very stressful. Um the student to doctor transition I think is something maybe a lot of people don't mention and something once you, when you, when you begin to experience it, it, it hits you like a train. Um that's straight into doctor transition from my experience anyways, I my first week. So my first month as a doctor, not as a clinical attachment because even as a clinical attachment, doctor, you, you're not getting that, that first hand feeling of a doctor, you're, you're close but you're not quite there yet cos you don't have the full responsibilities of a doctor, but your first month as a doctor, it's crazy. And I'm not saying this is just from my experience, I've spoken to a bunch of registrars, a bunch of registrars from medicine and surgery. A bunch of, um, UK medical graduates, a bunch of Bulgarian medical graduates that I've worked with. It's talking to a lot of people. The first month is chaos regardless. right? It's, it's just, it just feels like chaos. Um Now, obviously, we all vary in like our maturity levels and our experience levels. So if you've worked in the NHS for, for a while, you've been doing an ac a job or you've worked as a, as a nurse for quite a while, there may be a level of confidence, might be a bit different. But still I II do believe that that transition from a student to a doctor is unmatched like the stress levels off the charts. Um And no one prepares you for that really. You, it's just a thing that you just have to, you just get used, you get used to being stressed, you'll get used to the stress of um because as a student, especially the student from Bulgaria, the the practice is different. It's completely different. I remember when I started my clinical attachment and I was told to um go speak to a patient. I kid you not, I initially almost like speaking Bulgarian depression trying to get clinic, um medical history, um clinical history from that. I was, I almost started just like doing the, the what we doing in Bulgaria, like speaking to them in Bulgaria. And then I just kind of snapped out of them as I walk because you get used to that practice. You don't see many English speaking patients. I mean, you do see a few but not a lot in your practice as a medical student in Bulgaria. So initially, I was a, I was about to start speaking in Bulgarian and then I was like, it took me a second to kind of think what, what are the questions we ask in English? Um cos in Bulgarian, it becomes a routine. You get used to speaking, speaking in Bulgarian. That mean that she becomes what, what, what do we ask in English? Um That, that took me a back, you know, um and the my clinical attachment, just your clinical practice. You don't get to the clinical skills that you need um for that f one post. But you can, you can um I mean, now I, you get like clinical sessions in, in, in Ple where they've designed this course to kind of help you with clinical skills, which is good. Um And there's a lot of effort from like societies in ple to kind of help students um hone their skills a bit more. But what you can do whilst you're in employment and what I did was I would go to the orthopedic clinic or you can go to whatever clinic wherever you've built a good report with your registrar, your consultant there. Um Your lecturers, your teachers go there during your free times. Just kind of say, you know, I'd like to learn how to take some bloods. I'd like to learn how to, um just where the clinical skills i, on the next slide, I'll show you some of the clinical skills you need to kind of learn a list of it from the, from the NHS. Um So it's, it's not an easy trans transition at all. There's a lot of, a lot of things to get used to, a lot of things that will be shocking that post ple syndrome would really kick in, really kick in. That impostor syndrome will really kick in. Um like the stress of not getting a job is one stress on its own, you know? Oh my God. I ha I've graduated, I'm the other doctor. I don't have a job. I'm sat at home or I'm working at wherever you're gonna be working at, you know, but it's not your goal because your, your goal was to be a doctor and work as a doctor. So you're, you're stressing about getting a job, you know, then you're also stressing whilst when you do get the job, you're also stressing. Am I doing this job properly? You're constantly thinking, you know, for the first month you're thinking about your GMC license you're thinking about, oh, have I made a mistake on this? Have I made a mistake on that? Did I prescribe my medication wrong? You know, because it, it begins to like dawn on you that you're dealing with, with patients now you're responsible for them. Um And on a medical job, which is very different to a surgical job. On a medical job, you're having to talk a lot more to patients, family and actually like interact with patients, family and just see this, these are actual people. Um which as a medical student, if you're a very textbook kind of medical student, you've just like read a bunch of pathologies and a bunch of, you've never really like implemented it into practice and, and there's a lot of other things to take into consideration when dealing with the patient rather than just the diagnosis of the patient. You know, you have to talk about this, like, was this patient, how was his patient before they came to the hospital in terms of, did they live alone? Did they live a family where they've been abused? You know, was, is there any safety, safety um safety cautions? Um What, what, what are the family preferences for them? You know, DNA CPR, you know, a lot of things, other things you need to kind of consider, for example, like death verification. We we never got ta to verify death in, in Bulgaria as far as I'm aware, you know, that's something you love. Um, I mean, forensic medicine, you do some reading on it. Well, it's never, I think where they've said go with this doctor and go and verify that, you know, not even on the forensic level, by the way, just like I've gone to see this patient. How do I verify that this patient is dead? What do I need to document? And this patient has passed away. How do I speak to the family? What, what, what, what are my limitations when it comes to speaking to family? Who do I think is best to speak to family about certain things? Because I don't have the knowledge of that. There's, there's so much going on dot It's, it's, it can be overwhelming. Um My first two months do my clinical attachment. I was overwhelmed completely. Um But I kept going in every day, volunteered for night shifts and I'll talk a bit more about clinical attachment when it comes to it. But what can you do to kind of build to help you with the anxiety, to help you with that feeling of being lost? What, what can you do to kind of just level level the field a bit more to put yourself in a better position to get a job so you can stop stressing about getting a job, put yourself in a better position to actually do your job properly so you can stop stressing about whether you've done your job properly or not. So what, what the things you know, you can do. And after all of this, you know, there will still be some sort of a certain level of stress, but you've minimized it to as much as you possibly can. So what can you do again? I've mentioned this then. Welcome to UK Practice. Once you've got to your GMC registration, make sure you book it and attend it because the GMC also notifies whatever trust you're working in that. Um You've um that you've done the Welcome to UK Practice. So that's one thing, study. Um GKI Medics, I've got some applications there on the, on the, on the powerpoint that I use on a daily basis, but it's also a good source of just medical knowledge in general. I'll talk a bit more about them as well. Uh You know, later on, but geeky medics very important. Um I would recommend that 100% um a lot of your practices in F One, you'll learn a lot of things from GKI Medics, the hand, the handbook app. Again, very, very, very essential. You just have to study a lot, study a lot and just like learn some new things. Um you know, just gain as much knowledge as you can I LS or A LS. This will boost your confidence a lot. This will also um increase your chances of getting a drop by like a lot you can do a clinical attachment because everyone else will do a clinical attachment deployment. Your, you have an A LS on your job, job application. Suddenly your, your chances of getting a job like skyrockets is different to everyone else. A Ns and I Ns prefer getting A Ns but it's more expensive. It's a lot more expensive. I think it's about which form does is 600 lbs and I LS is between 100 to 200 lbs. A less is your immediate life support a less is your advance life support? A goes in a lot more depth and like knowledge compared to your I LS with an A LS, you can lead a cardiac arrest. Um Quote, you can lead it with an I LS. You can't um Well, you with an I LS, you know, the basics of what's going on um to survive a cardio arrest score, which is important. Um Personally, I did, I did the B LS in Bulgaria and then did the I LS in the UK. And then I'm looking to do the A LS later because I couldn't afford the A LS at the time. So I did the I LS which is good, gave me a good basic um base foundation. Um So you can do the Il SA Ls by the Resuscitation Council. That's important. Don't just, don't just do a random I LS organized by a random organization. You, it will make no difference if it's not by the Resuscitation Council. Verify and you're go going to get a certification from the Resuscitation Council. Otherwise you've, you've wasted money. So don't do anything else other than one that is done by the Resuscitation Council of the UK. When it comes to I LS and E LS, my B LS was done by the European Council which had a branch in Bulgaria and that was also fine. Um Did it make a difference on my application? I don't know, I just, I put it on, it was never like a, a requirement for a job. They never said minimum of ABL S, they would usually say a desirable criteria of an ALS. Um Some like KF PA website mentions the I LS. Um but ABL S is never almost mentioned because the hospital will always train you on ABL regardless. Um But for me, it was a good, it was a good base to kind of like um understand a bit more about CPR and a cardiac arrest call. I'm just gonna look at this question quickly. What do you think about doing a flat toy course or is it not really worth it since you can be taught that on the job? Um I wouldn't say it's not worth it because learning on the job sometimes can be. Um was the what difficult um If you're learning on a clinical attachment? Ok. Fair enough, you will learn on the job regardless. There are things you will learn on the job. Well, there's things that's like expected of you then maybe for your first couple of weeks, it's fine to, to keep saying, oh, I don't know how to do, like a teaching. But after, after a certain period of time you, you're expected to know how to do it and in, in some situations, let's say you've, you've picked up a al and shift as an F two doctor because you can, because you graduated from Bulgaria, you've picked up a shifts as an F two doctor and it's your first shift and now you picked up a night shift and then it's like you get bleeped by the nurses. Oh, you know, this patient's cannula come out, could you please coming up was cannulated patient in some trusts they have, um, phlebotomists overnight fleb to help them with that. And some nurses are able to do that. But sometimes they, they've tried and they're not able to, and the next person they turn to the doctor and then you go, oh, II don't know how to do it. Oh, I've never done one before. You know, it's, it doesn't, it doesn't look good. I, it, they'll, they'll understand and they'll, they'll encourage you and teach you. It depends on where your self esteem is at. Really. If you got a self esteem that is willing to like plummet a bit and you can recover. Ben. Sure. Um, it's fine. But what I did was II did all all of my like learning and stuff. I had done some learning in the UK in Bulgaria. Like when I went to the orthopedic department and shadowed them and they told me the cannula told me how to take blood, taught me how to intubate and stuff like this. Um But on my clinical attachment, I kind of just asked, like, can you teach me how to do this? Can you show me how to do this? Because as a clinical attachment, it's like a, it's like a buffer period where you're allowed to learn as much as you can. And what I did was I focused on clinical skills a lot. Um And so II II learned how to take bloods properly, how to cannulate a patient properly. So by the time I started my job when I was asked to cannulate, and they were like, are you, are you, you know, are you alright cannulated cos your, your registrars on top will also ask you because they sometimes they don't really expect too much from you because especially the way you're just starting off, they understand and they'll be, are you, are you confident enough? Are you all right with cannulated? If you're not come with me, I'll show you um but some registry, it also depends on the person on the registrar or on the registrar. If the registrar is very much, you can't cannulate. You know, I if it's one of those not, not so supportive registrars slash sh os because they're overwhelmed themselves, the goal of other, other jobs to do. And so they're expecting the bare minimum of you cannulated that patient. And then you're just like, I can't do it. I don't know how to do it. Then it's kind of like some of them will, will not be happy. Some of them will be very happy to show you and be like, how come then let's show you and they'll tell you see one, do one teach one, right? You're saying it now, I'm not gonna teach you again. You're gonna do the next one and I'm gonna watch you do it and then you're gonna teach somebody else. So you're gonna teach a medical student or something and that's how it goes. Um So is it worth doing it if it's going to help you with your confidence? And if you're, if you're, if you're willing to go into a job, if you're not willing to go into your job, feeling completely useless, then it will help you. Definitely, I would, I would say do it. I did look into it but I got to know the experience I needed for my clinical attachment when it came to some clinical um stuff. So I didn't think I needed it if you feel like you need it and, and also you have to pay for it. So that's pay, take into consideration if you think I can get this experience from a clinical attachment, then focus on getting the expression and clinical assessment. Um And once you get into employment as well, you can also do do these courses that the hospital will offer itself. The hospital itself will offer courses. I would encourage junior doctors to join them whenever they can and those are usually free as well. Um So you could do those, but that's, that's again, it's up to you if you're willing to feel helpless and useless somewhat in, in your first couple of weeks as a doctor. Um again, that impostor syndrome will keep coming back to you. But if you built at least that base level of confidence with certain clinical skills, you know, it, it takes the edge off a bit. Oh Can you take, can you take some urgent bloods for this patient? Take a VBG, take an ABG. Can you, can you do, can you, can that patient, can you put a cafer in because they're giving her attention? If you've not done one before, you can ask, I've never done one before. They'll be o they'll lay you off for, for like the first week on the job after that, if, but even still, then I say that. But after that, if there's always something new to learn and there's always something new you've never done before, like taking bloods from a, from a, from a line from a central line. If you've never done it before, you can always ask, can you show me this one or if you see if you see a nurse going to catheterize the patient suddenly and you haven't got anything urgent to do. Just can I tag along quickly just to have a look and see and see how it's done. Um Just to build my, you know, clinical skills and just learn, you just go there and just observe quickly and, and that'll be it. Um Sorry, would you recommend doing the A LS if you can afford it before getting a job? Um Yeah, I think so. Um However, some things in the air you might not really understand because you've not really worked or you've not really like seen clinical practice. So if you've not seen clinical practice and you've not really worked and you might not really understand some of the things in A S, you'll learn it, but only when you've s when you've seen clinical practice, would it make more sense? Um Personally, I would recommend an A LS. However, an A LS will increase your chances of getting a job by a lot. Um Great will greatly increase the chances of getting a job honestly. Um No, I've got, I've got, I've got that did clinical attachment, you know, and the moment they did an A LS, it was like the magic everything suddenly they got jobs like instantaneously the next day, literally offered the job the next couple of days after they put the, put the A LS on the CV. It, it was, it was, it was amazing. It was, it was the, it was a change in, it was literally the, the limiting factor. So, um, if you go on A LS, it's honestly a flex. If you're doing, if you're on the Ed and you're on, call in the Ed and they ask, you know, cos it whenever you're on, call on medicine and in the Ed, you're always part of the, um, the crash court team. So you, you're going to ca cardiac arrest calls. They'll ask you, have you done your A LS? If you've done it, then you can potentially lead the, the arrest score. Obviously, a registrar will be there to kind of talk you through the process and teach you as well. Um And if you're not confident leading, you can just say and, but, but you've done that e all this Oscar and it, it's, it's like a flex. It's a thing, it's a good thing. So, um I just read online about being able to maybe reimburse some of the money back if you do it whilst working as a doctor. So if you got trust, if you got a trust grade posts, um your, your hospital, sometimes even funds it for you. You don't have to pay anything for it. They'll fund your A LS course completely for you. So what, what I was advised was do the I LS and then get a job, get some money. If you're in a working job before you, before you move to a local F two job, if you're doing an F one try and do your A LS, if you're planning on doing an F two job, then do your A LS. Um, if you get a trust grade job, then they will recommend you to the A and they'll pay for you, they'll pay for you. The consultant I shadowed on my clinical attachment at General Hospital just said to me, do the LS get a job and then do the A S that, that was what he recommended to me. And so I would, I would say the same um during the, during the I LS doesn't limit stop you from getting a job. However, an A increases your chances of as well. So that's something else to weigh. Do you know how much Flap courses are? Um online? I've seen some for about 100 and 60. I think. What do you, to be honest, the UK Resuscitation Council doesn't do that. I don't think it's just random hospitals and random organizations that do them. Um I think with the flap courses honestly, um if you can, if you can do a clinical attachment, if you're working at an AC A, you're not allowed to take blood A, you definitely not, I don't think, but you can learn as an AC A you can, you can observe and watch and see them to see how they're doing. Um And also you can work as a medical assistant, which also gives you experience of taking bloods of the medical assistant. Um And your job is just blood and cannulation. So that's also something. But if, if you want that background knowledge of how it's actually done before, I actually do it, then I guess a flap course could help. But if you can observe a bunch of people do it, I don't see why you need a flap course as such. I mean, they, they maybe teach you in a bit more detail, but these are all things your doctors can teach you in the hospital what you need to know. Um So again, back to this, what can you do to help take off that stress? Take off that edge. We said welcome to UK Practice study I LS slash A LS. See your clinical attachment attend inductions. Um Whenever if you do get a job, there's always an induction program that they do for. You don't, don't, don't d do not be absent at tender. Ok. Make sure you're tender um network of people, you know, do some locum shifts. I would not recommend jumping into a locum shift if you don't have any clinical experience. This is my personal recommendation. I would not say to you jump into a shift if you have no clinical experience whatsoever. Some people have done it, it's worked for them. Most people have done it. The most people that I have done it that I know of have been overwhelmed. You need to have seen something, you need to have seen how the hospital works somewhat. If you've not seen how the NHS hospital works at all, you just graduated, you've never been in the, in the hospital, in, in the UK and you jump into a lurking shift. You're playing yourself like you're, you're setting yourself up for probably the worst shift of your life. Um, you will, you will feel extremely overwhelmed, extremely lost, extremely anxious. And if you're extremely confident person, you'll make some stupid mistakes that could potentially cost you quite a lot. So you need to be very careful. I'd say be very, very careful if you're gonna do a locum shift, at least, even if it's just for a day or you just, I mean, whene whenever you take locum shifts, they'll say, oh, you know, your first day is a, like an induction. But if you go, if you pick up a shift like during strikes or something where you needed as part of the team, the team doesn't really, wouldn't really just want you to be there as an induction doctor on the day. Um, like they want you to actually do stuff if you're there. They're like, take bloods, like I don't have to take bloods, write a discharge letter. I don't have to write a discharge letter. Um, pull those on the ward rounds and documents in the, in the, in the patient's notes. I don't have to document um what like you, you, you will look silly. So at least at the very least understand what's going on and I'll, I'll try and build like some, some sort of foundation for you with, with the next couple of slides when it comes to like your job as an F one doctor, just to give you some understanding and hopefully that, that gets you to AAA certain point. But you need to, you need to learn how to do certain things um documenting at the very release document. You know, you don't want your registrar there just telling you every single thing to write, put the date down today's date, the time, my name, like you don't want them to just keep like telling you every single thing to write on the on you, you need to be able to also like read, understand what's going on in this situation and document things at the very least you need to be able to document discharge letters. Um or if you, if you don't even know what that is, I wouldn't recommend just jumping into a looking shift. It is what I'm saying. Some people have and they found it extremely difficult and it knocks the ex um self esteem a lot more and that imposter syndrome is like skyrocketing. Well, if you, if it sounds like, you know, enough experience in a clinical setting, then of of of of course you can jump into it. N not nothing delaying you. Um There's a question as a local. Can you use the facilities at the hospital such as ski skills room? Yeah. Yeah, of course. Um You definitely can, you can use, you can use you, you, you have access to the hospital. Um some hospitals however, um will will um it depends on how long your contract is there some hospitals have the facility, the skills rooms open for whenever you want to use it. Some hos you have to book in advance, give them your email, set a time and date for them to set up the equipment for you and then you'll have a, an instructor there to teach you. Um during my clinical attachment, I was given access to the skills room as well. Um I just had to go there, tell them when I want to come in, give them my email and we just arranged a time and date and I could go in there and use it whenever I liked. Um Some might not have a skills room that's also something so bear in mind. Um But generally they do general. Um So yeah, usually you, you you've got access to everything. Um now, so that's that for this, we're moving on to the next thing which is the clinical attachment. So, like I mentioned after I graduated, I did my I LS and then I was able to secure a clinical attachment, um which is basically when you, you're observed by the same time you can give him more hands on. Um So there's observer, there's a clinical attachment, they're all used very inter interchange interchangeably. So I've never say think attack and uh honorary contract. You, you're not getting paid for either of them, some of them you have to pay. Um But what, what, what you're doing is basically working with a team. You're working with the F ones, the nurses, the F two S, the Sh OS, the registrars, the consultants, you're working with everyone, the Plebs, you're basically observing how things are done on a day to day basis on different shifts in the hospital. Um Some s generally your clinical attachment, you, you, you to come in like 8 to 5 or 9 to 5, you can volunteer to go in on night shifts, which I did, I went in on night shifts. I went in to just, you know, I get a feel of that before getting a proper job. So what you want to do with your, your, your primary aim with your clinical attachment is to bring yourself up to speed as much as possible with the NHS, right. I'd recommend a minimum of two weeks. Ideally, um one of the consultant told me like most F one doctors get used to or get confident with the system in four weeks. So about a month. So ideally a month to two months. I do two months um uh from graduation. So I did mine from June, July and then seven days or so in August. Um And you, you literally learn how things work firsthand. Like you just see how everything is done now. Still, it doesn't compare to actually, when you start your job because on your job, you're actually doing these things with your thinking attachment. You're, you're, you're observing, they might tell you to do one or two here and there. You don't really, you're just doing it. But with, with ad, with your job, there's, there's, you know, clinical assessment, someone else is signing you off. Once you do things on your job, you're signing yourself off, you're doing you. Um So it's, it's, it is different to your job. Still. There's a, there's a huge difference to when you start a job but it, it gives you a very good foundation. Um So on the, on the, on the, on this table here, this is a list of core procedures for F ones. This is a list of Corpo procedures for F ones to do. Um I'm going to answer that question very soon. So this is a list of core procedures for F OS to do. Um You've got here. So this is found on, on online, it's an NHS website. If you type in procedures for N HF for F ones, you get this list and basically what you want to do in your clinical attachment is learn how to do all or most of these things, um s as much as possible. So you've got bene puncture, basically taking bloods and things like this. IV cannulation. These two things you're gonna do almost every day as an F one F two doctor, um, prepare and administer IV medications and injections. Um, primarily nurses do this. Um, but you can learn from them, just see how it's done, but very rarely as an F one F two, you have to do this from my experience. Anyways, the nurses usually do it um arterial puncture in an adult. So if, if that's like an ABG, then you definitely, you, you're gonna be doing that, no doubts. Um 100% blood cultures, you definitely gonna do that. So you need to learn these things. Um There are certain rules for blood culture that is very different. So just taking normal bloods, there's certain ways you have to go with a bottle, certain aseptic measures you have to put in place to make sure you don't contaminate the blood cultures because your aim is to grow bacteria. But if you've influenced the bacteria on there, then you're basically contaminating the patient's results. Um IV infusions again, you don't get, you don't do this much as an F one doctor, but it's good to learn how it's done to see how it's done. Um blood and blood products. That's also quite a good one to learn how it's done but you don't do it. The nurses will do this for you. Um, but you just need to kind of learn some of the basic rules around it. So with fluid prescription, it's kind of learn when, what kind of fluid to use when, why you're using those fluids, blood as well. What, which blood products are you given? When? Why also like at what rate do you give those blood products and those fluids, you know, um local anesthetic injections. So these are just things you just kind of try and learn per perform and interpret an E CG. Um So what I did was basically, I made a list which is mainly this as well as some other things I wanted to learn. And on my clinical attachment, I just found a very helpful F one slash F two doctor. So Michael was on the cardiothoracic department and on cardiothoracic at Northern General Hospital, they don't have any, any F ones, they usually have FH OS and F twos. So it felt like I was thrown in the deep end really. Um it was very intense because your F two doctors have had at least one year of experience. Some of them were F three, some of them were Sh OS to divide at least like one year of experience in the NHS. And so they knew they knew how things were, how things functioned. And as a clinical attachment doctor at a time, I was very keen, trying to like, help with the jobs, which is good. They like, they love that for me. But at the same time it began, it began to become a thing of, oh, can you do this? And then if I was like, II don't know how to do that yet, you know, there was just, just like looks and there's like a particular one of the doctors there that was very much expecting me. So work as a doctor with them, although I wasn't getting paid and I was trying, trying to learn and that's what I was doing the clinical attachment for. But the she was pretty much expecting me to do everything and know how to do everything, you know. Um and obviously you get asked certain questions that maybe you don't know, I can't remember and it, it, it, it became quite stressful. Um But if you find, if you find a really helpful um people there and they're very supportive, then that's really good. You just seize the opportunity to learn as much as you can um as well as seek employment opportunities. So once you begin to learn the hospital, the hospital system, wherever you're doing a clinical attachment and you've been with them for like a month, the registrars, the nurses, everyone is keeping an eye out, they're just looking at you, they're observing how you work, they're observing, how keen you are, how determined you are your personality, they're observing everything and if a job position was to open and you applied for the position, they're likely to like, they're also likely to recommend you to the consultant and say if there's a local position open, um this this this fella this person knows the system already, he knows how to work. Um we can potentially offer him the position. And once you apply for that looking job, you can get it. Um because the, you know, the system, you can also then apply for the hospital's bank. So each hospital trust has a bank of doctors that can come in whenever, whenever there's a there's a slot available for work. And once they know, you know, the system, you can go on to the bank and they can book you on to different shifts in different departments there. So that's why the uh clinical is important. Now, um there's a question here, how important is the clinical attachment as opposed to having clinical experience for applying for a job? If you have clinical experience? Are you able to prove it um on your on your job application? They don't really your, your entire, your entire aim of your clinical attachment is to get clinical experience. If you have the clinical experience and you're able to prove it on your CV. And during your interview, you're also able to like show that you have that clinical experience, then you don't really need a clinical attachment at that point because your, the the aim of a clinical ast is to get a clinical experience. Um So how, how do you go about getting a clinical attachment? No, it's, it's, it's difficult, it's actually very, very difficult to get into attachment. Um I know a lot of my colleagues that have not been able to um it's been extremely difficult. The, the easiest way is if you, if you've networked well enough and you know, a consultant, uh a trust or something, you can email the consultant and ask, can you can, I, can I under your tutor? Can I work, you know, do a clinical attachment on and just observe, I've graduated, I've got my James license. Am I able to do that? And if it's somebody that's willing, they'll accept and you have to apply to, to the trust. But then the consultant is there to vouch for you and that makes things a lot smoother, some trust. It doesn't matter. There's gonna be a waiting list regardless. Um If you don't know any consultants, then what you're gonna have to do then is go on to different NHS trust websites and just try and find the list of consultants on their and their emails and also the hr email and the um work workforce slash whoever is in charge of the clinical attachments at the hospital and just like email, all of them, just email, email, email, email and just be like, I'm a, I'm a new graduate, a doctor. From Bulgaria. I've got my full license and trying to get a legal attachment. Um Would you be able to help some consultants will reply to you? They develop up rejections, they develop up just no one replying to your notes at all. Um There will be a lot of rejections. There will be a lot of, unfortunately, you know, we can't right now, we have a waiting list of so so so and some of them will say, ok, we'll put you on our waiting list and it'll take maybe two months to six months or a week to two weeks or six weeks. And I'll just tell you what dates are good for you, things like this. Um But obviously you need to start early if you're looking to do a clinical attachment in, say you guys graduated in May, you're looking to start attachment as soon as you graduate in May start applying now. Um Really? So that by the time May comes slash June, you've got, you've got something secure already. You're just waiting to go into it and just like do your clinical attachment. Um but a clinical assesment does not guarantee a job. That's something else you need to understand just because you've done a click and attachment doesn't mean the jobs are now begin to fall on your laps. And like this is it, you can do a clinical attachment and still not get a job and it's just because it's become very difficult to secure a job. Now. Um Looking shifts are like extremely saturated, the local market is extremely saturated. There's just a lot of doctors just trying to get a job. Um And so there's a lot of competition. A lot of F threes also trying to get jobs. Um F four S, you know, everyone is competing for the same job. So it's just become extremely saturated. Now, it's so difficult to get look and shift during strikes, it becomes easier because the trust grade doctors are striking. And so looking doctors have more room to wiggle in. But um otherwise there's, you know, it's really out of your control. It's just down to like fortune and prayers and blessings at some point. Um You know, and also it can be a thing of where you're just like securing odd shifts. So I did my clinical attachment by the end of my clinical attachment, I successfully enrolled onto the, the bank for Northern General Hospital and I was able to then apply um for shifts. And so they had booked me for like night sh J just night shifts, right? Because that was when they didn't have a lot of doctors, they're booking for just night shifts every weekend for three months. So from August to like a eight to like December just night shifts and just weekends and that's not conducive, it's not, it's not ideal. I mean, you'll take it because you need a job at least but it's, it's not ideal, it's not, it's not what, what you want to be doing after you just graduated. You want to, you want to be in a, in a full time job, um Learning your chances of learning on a night shift are a lot less. Your chances of making a mistake on the night shift are a lot more. Nah, are just horrendous in general just because de Reuter, there's a lot less doctors on the night shift. Um So II did my first couple of night shifts after I've completed my um clinical attachment, I did, I did like two sets of night shifts stress. It was, it was stressful. Um But surprisingly, II personally thought I did well, a lot better than I thought I would have. Um which makes sense cos I had done too much of clinical attachment at that hospital. I knew the system, I knew how things worked. Um Essentially I've been working there for two months and now it's time to get paid um and get a bit more responsibility on my shoulders. Um So it was, it was um it was an experience because there were still things that I didn't know how to do that. Although during the clinical assessment, they mentioned it so many times, but when it came to actually like doing it, it just became very much. But well, I don't, I actually don't know how to do this. Like they mentioned it so many times but just didn't learn it like, um because they'll explain, they'll explain the concept to you. But if you don't actually l like, go into the details of how it's done, you won't, you won't actually learn it until you actually need to do it. Um And at that point, you're going to back to your registry mail, like I've never done this before actually. Um So can you show me? So my role, my role, uh, not in general, you know, for those couple of night shifts was quite intense because it was my first couple of shifts and it was doing night shifts, but it was, it was a good experience. Um, because it built, it built a solid foundation moving forward to like my other jobs. I'm just gonna look at this question quickly. So for bank jobs now they are asking for a minimum of six months and it just experience. Um, no, I'm guessing that's probably depending on your trust. I'll be honest, depending on the trust you're applying to because not all trust requires six months from my experience. I know doctors that register to brand jobs and they've had no experience or they've had six weeks of cr or two weeks of cleaning with them. Um And so they know the system if you know the system of the trust, six months of NHS experience minimum. Um, I don't think it's depends on the role if you're trying to apply. No, II it depends on the trust. Really. I don't, I don't think it's a, been a six months experience. I definitely know doctors that, that have gone on with three weeks of clinical attachment and they, they're on the bank because sometimes the bank will also give an interview. Some bank um jobs will have an interview before registering you and if you pass your interview then your own. Um yeah, just look around, ask around check what hospitals require six months and what which ones don't and then apply, apply to the ones today if you don't have the six months and then when you go the six months apply to the ones to do. I tried the NHS Bank website. I think it's called NHS. Oh, well, that's a different thing. So the NHS Bank website, um just gives you like a list of bank jobs across the country, I think. Um with the bank, I'm talking about, I'm talking about like literally you're talking to the rota coordinators in the system and you're speaking to, you're speaking to like the hr you're speaking to the departments of a specific trust, not um not from any chest side. So you're speaking to specific trusts. You, you've gone to the trust website, you found the HR number, you've spoken to them. You said I'm a doctor. I'd like to join, join The Point. They've then transferred you to another thing and then you've spoken to someone there and they've said OK, this is how it works. This is what we need you to, to have in terms of experience is what we need from you. I would like you to come in and shadow for a couple of days or a couple of weeks before we can actually register you on. And so you need to go like, speak to people, OK? You need to go like speak to people, sorry about that. You need to go and like speak to people um within hr and like, you know, I have a conversation with them and then they'll tell you what requirements is needed and um applying directly to the bank and trust. Um but you could also apply on like trade jobs or bank jobs and they, they would probably have like minimum requirements. But even if you apply to them without the minimum requirements, um sometimes if there, if you, you could be short listed, shortlisted for an interview and if you do well on that interview, then you're gonna be registered, registered onto the bank from my experience. That's why I'm anyway um any questions on clinical attachments before we move on to actual your role as um an F one F two doctor. And if you have any questions by the end as well, feel free to ask. Um Yeah, is that ok? Can I move on here? Great. So your role as an Fy one fy two doctor? So this is what you're trying to get familiar with when you do your clinical attachment, you're trying to understand what is it that II would be doing as an fy one slash fy two doctor. Um And I think knowing some of these things right now, we'll probably prepare your mind somewhat. So what the NHS is like and what the, what your job is gonna be like as a doctor in the NHS. And um just better prepare you really maybe take that edge off that nervousness off a bit. So, and this is just about the transition from a student to a doctor. But as it's chosen in Bulgaria, you don't do any of these things at all. You don't document um A two ES OK. You, you, you take patient history but when have you ever done an at E um that's something in A LS and an A LS will teach you very well how to go through your A two ES um A proper handover. Um If you don't know what handover is, it's basically when you're speaking, you're trying to um get another doctor or another clinician to be aware of the patient. Are you trying to seek advice regarding the patient or trying to get another doctor to review a patient for you? That's what a handover is or you're trying to get somebody else to do certain jobs that you've not been able to do where your shift has now ended and you need them to, to do that job. Um and they are completely, that's completely fine. This is an entire process in the NHS that that is done. So your, your role as an F one will include um assessing patients. Ok. Um And this would be when patients are like critically unwell or acutely unwell, you have to assess these patients um in a proper organized manner and you'd have to do some things, some treatment offer some treatments and escalate and by escalate. Yeah, you'll hear this word fly by a lot, escalate, escalate. It basically just means speak to the appropriate person that can then review this patient and give a more um advanced treatment. Um a a better review a more, you know, just f further, further treatment and management of these patients. So first I'm gonna talk about documentation and then I'll come back to the A two ES cos on the next slide, I have a few more things there for you to understand A two es better. So I'm gonna talk about documentation. So your typical day would include a ward round. So on a normal 8 to 5 shift or 9 to 5 shift on medicine or surgery would include ward rounds. So you get to work in the morning 8 a.m. or nine and you will go round with your consultant or registrar and you see patients in different beds and you would need to write down what you've observed from these patients will how the patients are doing some results of these patients. You need to write down what you think the patient's progress is and then you need to make a plan of treatment and management for this patient. So you see direct. So sl ap this is the ge generic format. You need to have your documentation in S stands for subjective, O stands for objective, A stands for assessment, and P stands for plan now, somewhere in between your A and your P, there's an I standing for impression which could sometimes be the diagnosis or the current progression of the patient. So on the top right there, that P piece of paper that says continuation sheet. If you're not able to see properly, please, I would advise that you zoom in. So this is a generic um well drowned um documentation that I just picked up on the website. So you have your patient Tom Riddle. If you're a Harry Potter fan, you would know Tom Riddle. It's from Harry Potter. So this is not real patient and Fy one Potter obviously. So this is a Harry Potter based um ward round notes. So anyways, you have the patient name, surname, hospital number, consultant, date of birth, all of that um You need to make sure before you document anything on a piece of paper, you have the patient's sticker name and identity on there, do not document because sometimes you will forget. And if you don't have the patient's ID on there, then who does it, who does this pertain to everything you've written? Who is the fault? What patient does that refer to? And that is a, is an error if you don't do that because then we don't know which patient it's for, is it, is it, is it actually for this patient or is it not? So you need to make sure you always have the patient's sticker under, you know, and then there's no stickers in the patient's notes, then you write it down there by yourself, write a patient's name, the hospital number, date of birth, gender slash sex and then consultant. OK. Now, um before you start writing, make sure to write the date, OK? The dates which that is happening on and the time which you see that patient. OK? Sometimes you're recommended to also write the ward you're on. So you can just write like ward 25 or ward 36 or ward 20 whatever ward you're on, just write like a w and then the number of the ward on there, ok? And then the title, the first thing you write the wr you see that stands for Ward Drugs, you can physically write Ward drugs, OK? Or you can write a wr it doesn't matter. So you write the w the w what the title of the, the documentation is, what's the documentation for war DRS? And then you'll write the name of the leading consultant and if they're good consultant, you write the name of the leading registrar. So in this case, the registrar spr stands for registrar specialty registrar, Snape whatever your registrar's name is, if it's consultant and registrar, then you write the consultant's name first doctor. So, so, so, so, so, so you can put in brackets, consultant and then write plus the registrar's name, Doctor Xyz. Mister XYZ brackets. And then ideally you should write your name up there as well. Fy one Fy two. Doctor Xyz. Ok. You'll write your name there as well. Now, the next thing you then write is the patient's diagnosis. OK. Now, the written here problems, sometimes you see it some documentations, it's just written as a triangle and that just stands for diagnosis. OK? Now this patient it's POSTOP day 10. OK? For BCC on. No, I'm not quite sure what that, what that is. It could be why, but I think that's like maybe a cancer maybe. Um but you'd right, how many days POSTOP if the patient is POSTOP op, you can write POSTOP day five for a left um carotid endarterectomy or for appendicectomy, for example, POSTOP day 10, postappendicectomy. OK. And you can also write the date which they had the appendicectomy. The other thing you can also write is um it like here, the patient also has a uti you mentioned it that day two of antibiotics, delirium. So, so like that if on the medicine ward, they will write a slash W which basically means admitted with. So this patient was admitted with shortness of breath, cough, chest x ray findings. You include that once you've written diagnosis, you include that there. Um, chest x-ray findings showed um left lumbar pneumonia or something. Um And you just include on the diagnosis area as well, left or lower respiratory tract infection. Ok. Community acquired pneumonia, hospital acquired pneumonia. That's your first line. So diagnosis the second bit you want to go into then is um a bit more carrying on with your objectives. So you're talking about now, the new score, we'll talk about a new score in the next slide. But a new score is essentially a national early warning score and it's used to basically gauge a patient's status um and it's, it's, it's good to, to um indicate when a patient is deteriorating. So on your news call, you usually it ranges from 0 to 20 0 being good. No concerns 20 being e extremely bad. Um U usually whenever a patient is using a three on a single parameter, you will get asked to see this patient. Um The parameters include saturations. So oxygen saturations, um BP, heart rate, um BP, heart rate, oxygen, heart, um saturations, temperature, and um respiratory. Sometimes they also include the blood glucose on that. Um Now typically, if your patient is a news of A zero, which means there's no nothing sometimes depending on how much time you have, you can just write down all the um the, the respective numbers, meaning the like what the stat is, what the BP is. You can write all of it all of it down. If you don't have time, then you're, you're fine just writing news of A zero, which means the patient's ob observation was stable. But ideally what you want to do is go on the observations chart and you see like a um like a graph showing the trend. Just have a look. Was this patient spike in any temperatures overnight? Cos if there were then potentially there was an infection flare up. Um did a BP drop overnight and were any medications held overnight? And this is where you also have a look at the previous plans from the previous documentation. So you have a look at what was any night team review. What was the plan there? What did they do? What did you guys do the day before that as well? And you just have to write the, write that on the, on the on your plan. You can say history noted or input from 19 noted and you just write that on your, on your um documentation. What you also want to document is the bloods blood results. And you also have to make sure you include the dates depending on your time. You know, some consultants might want you to document everything the entire entire blood blood results but I think that's rare. Um Most times they just want you to document what is um what is abnormal or like inflammatory markers. So your white cell count, your C RP. OK. Your electrolytes are very important. Now, obviously, this question is written here using a HB B12 LFT ST FT S calcium folate N A DNA D means no um abnormalities detected at all. Yeah. So they've written NE D there meaning they've had a look at everything and NE D basically means there's nothing to be concerned about there. However, if there are things concerning, you just need to make sure you document those and just check what the previous results were. So in this case, the white cell count was 18, was, is eight, was previously 18. So it's dropped down. So this patient is getting better. C RP is 50 was previous to 16. So that's gone up. So what's going on there? The inflamma? Well, the inflammatory markers is going up. So these are the things you just have to like evaluate the G fr is 69. So that's getting better. Um And you just go through the electrolytes, do not miss out electrolytes. Cos they're quite important. Potassium. Uh So Jim very important because if you miss us out, if you miss your potassium out and your p your patient has the potassium of seven. For example, do you, who knows the normal range of potassium roughing? No more injury? Potassium is going to be, well, you'll get used to it on the, on the, on your blood results. There's usually a reference range. Yes. So 3.5 to 5.3 roughly is what the range would be. Thank you very much for that guys. So 3.5 to 5.3 roughly is what the range would be. So if you've, if you've not looked at the user needs, unless the results went back when you're about to start your ward drops, that's fine. Just mention there awaiting blood results awaiting XYZ and then you go back during the day and just make sure you chase those results and have a look at those results and just check if there's anything you need to do so that you're not missing anything out. So generally you want to just chase your patient's blood results throughout the day and by chase, I mean, follow up the results and check where they are, ok? A lot of people will tell you chase results, which just basically means follow up the results and check what they are. So you chase this result and just have a look. Um if there's anything abnormal there, if you're not quite sure what to do, just put it past your registrar's, you know, e or your sho se just be like, oh, this is high. Do you think we need to do anything for that? Cos maybe you don't have the experience here, you know, and then they'll tell you, oh yeah, give XYZ or don't that nothing needed to be done and then you can just maybe even document that or just say, I'll just leave it. But it's important that you document. Why is documentation very important in all these cases? No, it's, it's more of a medical legal thing as well. Yes. If a patient was to die and let, let, let's let, let's not go even to that extreme yet. Let's say a patient was to sue. I'll make a complaint to the hospital and then require um demand some investigations as to whether their care was optimal or not or was it good enough care or not? The only thing you have is your documentation. Nothing else because you're going to forget you, you see so many patients throughout the day, throughout the year, throughout the month and you just see so many people. You don't, you can't remember each and every one person, ok? And the documentation is, is what shows what you've done. Ok? Now as an F one F two, you're very, very protected. Um If something, if a patient wants to sue your consultant will be dealing with it mostly, but you need to have your consultants back, it's important because they're your mentor, you need to have your consultants back as well as your back. Because if, if, if it is the case where something has gone wrong and there's no documentation as to whether it was picked up or not, then sure your conductor won't take a lot of heat, but you're going to have a meeting as well and they'll see you down and have a chat with fiance. This patient was looked after in 2021 and now it's 2024. You're not gonna be like you've seen so many patients between those times. Right? If P was looking at you in 2021 no, it's 2024. There was nothing documented. Yeah. And you can't really say anything other than you know, if you say, oh yes, I did, I did do XYZ. Well, you didn't document that. You did it. So it there's no proof that happened. OK? It's important that you, you document things very important. So the next thing we do here is so coming back to that. So subjective. OK. So we've talked about the objective things like your blood results. You also include any um imaging results on there. You just document that on there as well. And now this part where it says patient sat out, sat out in chair looks well in itself um on ongoing delirium, right? And things the patient will say to you. These are all subjective things, OK? The patient looks comfortable looks all right. You know, patient said, didn't have any diarrhea, the patient denied any diarrhea, right? Patient denies pain, we documented those you just write those there. Uh patient is starting chair looks swollen So has cough, doesn't have cough short of breath, not short of breath on oxygen, on oxygen. As a catheter doesn't have a catheter, things like this. And then your assessment is your own and e there your, um, on examination. So you see that two lungs with a, with a strike through it. Ok. So I've included some chest diagrams here. So whenever you see two lungs a strike through, it just basically means the chest is clear. We've auscultated this patient's chest and we've listened and the chest is clear. Normal breath, breath, sounds, breath sounds, you know, vesicular sounds normal air entry. If there's crackles, if it's bilateral, you can pull crosses on there. If it's only on the left, you can pull crosses on the left lung, it was on the right, you can pull crosses on the right lung. And then I always just mention as well what it is those crosses represent cos I can put crosses and it represents a wheeze and for you to represent crackles. So just just men just still write it there. Um Just reduced air entry as well. You can do that diagram over there, reduced air entry or absence entry. Now, for the for the for the abdomen, you withdraw a dime like a accident, diamond kind of thing. Now, it's important whenever you see a patient, you always listen to the lungs and you always show the abdomen as well as the carbs. Um for any signs of DVT. OK. So the abdomen, we do a like a diamond shaped thing. If there's a line through it basically means the abdomen is soft, nontender, no organomegaly, nothing concern. OK? If there's, if there's um surgical scars, you can draw them on the abdomen, maybe draw a different diamond as well and just pull where the surgical scar is and just label its surgical scar. If there's a point of tenderness, you can put it there as well on the diamond right area cause tenderness, OK? And you can also just put area of tenderness and if they, if they're tender all over, you can literally shade out the entire diamond and just put generally generally tender. The I don't know why that sound is so bad. You can just put generally tender um all over as well. OK? Now, um in terms of what does this sound good control? Sorry. Oh OK. Interesting. I don't know where that sound came from. Apologies for that. So once you've, once you've done your examination, so the HS 12 that you see there is basically saying heart sounds heard. So on this next diagram, it also mentions what it is. Heart sounds, one and two heard. Zero basically means no added um heart sounds. So your s your um if there were any murmurs you'd mentioned them, OK? Now any other things you observed or on your examination you saw. So if the patient came in with a nose wound and this patient wants BCC on nose. So, nose wound, um, you have a look at the nose wound. Um It's healing. Is it healing well? So any wound? So, I was on vascular surgery for my first l shifts. Um, following my shift at um my clinic, my couple shifts at Northern General Hospital, I did vascular sur um surgery, long term locum um at Royal Free Hospital from about the 15th of August to the sixth of December. I was on vascular surgery and we would always examine patients wounds like throughout the week. And you always have to mention the, you know, wound examine. Sometimes we'll have to draw, draw the, the stump or the, the leg ulcer. You just draw a rough diagram just to show what it is. Ok? Um This for at on here, she is um mental assessment, a quick abbr abbreviated mental assessment or mental test. Ok. And you're just checking that the patient knows their, their name, date of birth, their age where they are, um, things like this and if they're not oriented. So here, the patient doesn't know where they are or what year it is, but the patient knows the age and the date of birth and you just kind of document that as well. Ok. Anything else you need to document here? Um, your depression is POSTOP, you're probably going to be looking at wound sites, checking for any signs of hematoma, any signs of bleeding. If there's a drain in place, you're right there. Drain in place. You see how much the drain has gone, um, drained out. If there's a catheter in place, you see a catheter in place, you state the color of the urine, you state how much urine has been drained out. Because why are we staying the color if there's hematuria or, um, py urea, it's important to know as well. Um, what else that's chest drains? Um He also wants to be checking sometimes a patient's weight is important. So on my, on my cardiothoracic department thing, we used to check patients weights because of heart failure, patients will have extensive edema. And so we put them on like diuretics and we just need to check if they're improve it and the weight will improve with time. So we just need to also document those things. Um So after all of that impression, ok, impression is basically your, your consultant. Sometimes you be yourself if you the only wanna examine your patient, but it's basically what your diagnosis slash, what you think the patient's progression is. So if you've, if you've seen a patient for the first time, if you have a bunch of differential diagnosis, those would be your impression. Ok. So you've seen a patient with cough and productive sputum and shortness of breath. If your impressions are like um pneumonia, you write that impressions, one pneumonia, second, pe third, um co PD asthma, it says, but you just write it down there as your impressions. Ok? And then you write the plan. Now, the plan is basically what we're going to do for this patient today. Now, from our, from our clinical findings and everything we've seen. Ok, what are we going to do if the patient is fit for discharge? You right. MFF D medically fit for discharge? If it's not, you don't put it down, make sure to clarify, do not write medically fit for discharge for a patient who is not medically fit for discharge because you're discharging a patient that's unwell still. Ok. Always clarify. Now, um the plan here, they've written, continue oral antibiotics. PT slash ot input basically means physiotherapy slash occupational therapy. Um when you have patients um in hospital before discharging them, sometimes they're required to see the physios. So just see how they're progressing. So if you've, if you've removed a lung from a patient like or, or some sections from a lung from of a patient, how is the breathing? Now, you know, do they need, do they need breathing exercises and chest PIAs before they can actually go home? If you've just, you know, treated the patient for, for arthritis, are they able to mobilize? Well? Now, pss will be the one to discharge the patient from their perspective. If they think the patient is not yet um fine to go home because of mobility issues. From a medical perspective, the patient can be fit to go home. But from a physios perspective, if they're not, they're gonna be in the hospital until the physios are fine for them to go home or they can transfer them to a different hospital for a rehab bed. Ok. So, um or they can go to a care home or a nursing home, whatever their, their discharge plan will be. The third plan here is geriatric geriatric um input, which basically is this patient needs to be referred to the geriatric. OK? Depending on your hospital, the referral process can be very different, very varied. OK? And those are things you learn on the job. OK? These are, these are the kind of things you learn on the job in terms of how the s hospital system works for referrals. OK? Um And that's what you, you know, you, you, you refer this to geriatrics, you'll have a conversation and your sbar handover will come in place here because now you're referring this patient to a different specialty for them to review the patient and you have to go through a proper sbar which we'll talk about. Um OK. And follow up O PD. This is so this is an outpatient follow up for this patient in six weeks. So whenever this patient is discharged, when you're writing the discharge letter for this patient, these patients needs to be followed up in the clinic that consultants clinic in six weeks. It's important to put this here although the patient is not going home today, but bear in mind if you're not the one discharging this patient. And let's say you've changed your rotation or you're not at work that day. And another colleague of yours is discharging the patient. If you're not documenting this, they don't know the plan and they're going to miss it out on the discharge letter and that's not good. So you just got to document it. And so whenever you're flickering through the notes to write a discharge letter, you can just include a discharge letter patient to be seen in the outpatient clinic in six weeks. Um And usually the, the nursing team and the discharge team will, will organize that meeting, but you, your job is just to include it on the discharge letter. Ok. And here complex complex discharge planning. Um I don't know what CH stands for there, but PC stands for package of care. So in this, in this case, this patient, um um this patient is awaiting some discharge needs certain things in place before they can go home. So for example, they need carriers at home in place before they can go home or they need uh uh mobility boots because they've had, they've had a to taken off or they need a wheelchair because now you've taken a lim a limb off. Do they live alone if they live alone? And are they able to live alone once you discharge them? No, so that's not gonna happen. We need to find a care home that will take them. So that's what a package of care would consist of things like that. Um, and then it says the use and one of 52 basically means one week. So six or 52 means six weeks. If he said one of seven, it means seven days. Ok. Five of seven, I mean one of seven mean a day, one day, five of seven mean five days, ok? Because it's 57 days in a week. So seven days starts for the week 52 stands for the um seven stands for the days. 52 stands for the number of weeks. So six of 52 stands for six weeks, one of 52 stands for one week. So using these in one week, post discharge DC. OK? So this is roughly what your documentation would look like. Very important. Whenever you finish documenting, you sign, you write your um your position, fy one, your name, you put your GM the number and you put your bleak number if you've got a bleed. Ok. Very important. Sometimes you get a stamp and you just stamp it on. Now, that's if you're doing a paper documentation. If you're doing a um digital documentation where you're typing things in, you just type it in, you type in those details. Sometimes the system will automatically know who's logged on and who's documenting and you wouldn't need to type anything, it would just be automatically there that this was the person that documented this um thing. So that's generally what your your ward draw do, documentations will look like. OK? Um In terms of the plans, your consultant slash slash registrar, registrar will generally tell you what the plan is and you just have to write it down. So a lot of your work is like admin documentation paper kind of work. OK? About 50% of your work is that you're just doing documentations, referrals, things like this, OK? Um If you were doing an on call shift and you were asked to clock a patient, clocking a patient basically means your taking a patient history essentially to put it to put it simply um like we do in Bulgaria, you're taking any patient history, OK? It's just important that you go through a set of forms, OK? You need to go through presenting complaints. OK? So if you look at this documentation here, the one closest to the words, OK? You start with your presenting complaints, OK? What the patient is coming with? Why? Why, why are they here? OK. What, what's the main presenting issue? Why are they, why have they come to hospital to see a doctor? And then once you're done presenting complaints, you just a couple of words, it can just be shortness of breath, a cough, bleeding from the back side, apr bleed. This would be a presenting complaint and then history of presenting complaints. Ok. So you start with presenting complaint and history of presenting complaints would be what's how, what's happened here, how has this happened? What led up to this, to this situation? Ok. Now, if your patient is coming with abdominal pain, you need to go through your um Socrates, which is on the right hand, as you can see sight onset character, radiation, association, timing, exacerbation severity. Ok? You would generally ask the patient these questions. Now, you usually get like a clock in performer like a form where you just have to fill it out in. Sometimes you don't and you'd have to just know what, what you're doing. So we said presenting complaints, history of presenting complaints. Then we go to past medical history, which also would include the past surgical history. OK? And you just document that. What, what surgeries have they had before? What were the previous diagnosis? What was the diagnosis that they got? Have they ever had a stroke in the past? Are they diabetic? Have they, have they had an appendicectomy? Things like this? You just document all of those? Ok. We move to social history. Do they smoke? Do they drink? Did they live alone? They live in a house? Do they live in a bungalow? Things like this are important when it comes to discharging the patients as well? Ok. So do they live at home? Do they live alone if they live alone? Do they have carers coming in, things like this. It's just important to just like note that some clerking documents will have those there for you already. And you just have to like tick boxes, tick boxes, some of them don't. Ok. We also have to talk about the medication history, drug history important to always ask for drug allergies. Ok? Because if you don't know what the, what the patient is allergic to, then just confirm if you have any allergies at all. If the patient says no, you're right. Um, no known drug allergies. So NK da no known drug allergies. Ok. And if you're on any medications, you document everything. Ok. Do not write there, please see patients, patients list of documentations or please see ex don't, don't be referring people to go see other places you have to document on there because bear in mind your consultant is going to read through this document and based on that, he's going to want something quick to decide. Is this patient gonna stay in the hospital or is this patient gonna go home? Do I need to change any medications? And if you've written on that, please see the patient's list of medications. So you want your, you want your consultant to come in and then it's read through your documents and then it's going, oh, I need to go ask the patient now to give me the patient's list when you can just have documented it. Ok. Your, your consultant would be very appreciative of you. I would really appreciate your work if you've done that, if you've documented these things and it just makes life easier. It makes the patient's care a lot better or smoother as well. So it's important that you, you, you document things properly, you write the dosage, you write, how often to take it. So, here I have written OD basically means once daily BD, twice daily TBS, three times a day. Q DS, four times a day. P RN as required. Ok? Sometimes you'll have AQ DS and P RN together. So four times a day as required, basically maximum of four times a day. Ok? No more than four times a day, but they do not have to take it compulsorily, four times a day. They can take it whenever it is needed, but a maximum of four times a day. Ok. So these are things you need to kind of watch out for. So once you've gone through your past medical history, your presenting complaint, history of presenting complaint, past medical history, social history, drug history, you then need to examine the patient. Ok? You go through all the systems, ok? Um respiratory system, cardiovascular system, um gi T urin urinary system, um musculoskeletal and um neuro. Ok. So with your respiratory system, you're checking for shortness of breath, you listen to the lungs with your auscultate. All right. Um You're checking um um respiratory rates, things like this. You go through that with shortness of breath, listen for any crackles, any wheezes, document everything down. Um You move on to the cardiovascular. You listen to the heart check for radial pulses bilaterally they p palpable. You check for the capillary refill time. You can check for the central um central um Roi central capillary refill, I think as well, peripheral full time and central time you can check those um BP. So sometimes these things like BP, respiratory heart rate, the nurses might have already done that for you. Ok? So you just kind of look through that as well and just document it as well. But you can also just do something quick whilst you're there. But if you don't have enough time to be taking the BP, the nurses have done it, you don't need to do it again. Um And this is in a nonacute situation where you're just like clocking a patient, a patient is coming and you're just talking to them trying to get as much information as possible needed to create a plan of management for this patient. Ok. That's your aim. So you'd go in and say hi, my name is so and so doctor um I'm one of the fy one doctors, I'm just gonna ask you a few questions just to kind of gather a bit more information and understand a bit better why you've come in today and then my consultant slash registrar will come in and see you and we'll, we'll make a plan as to what's best for your treatment and management. Ok. And you just gather as much information as possible. So you, you, you go to, um, so you've done cardiovascular, you go to gi t you palpate abdomen. Ok. Is it soft or the tender anywhere? If they are tender somewhere? You explore? Why the tendon there since? When have they been tender? Is that a new tendon? Is that old? You do all that exploration? You, you just check? Ok. Have they had, when, when last did they open the bowels? When last, if they did they vomit, when last did they, you know, was there blood in the, in the bowels? Was it diarrhea? Was it normal? You asked these questions? You most um urinary system will last day? We are they, are they incontinent? Um Are they in retention if they had catheter in the past long term? Have they got a catheter in? Some patients will come in with a catheter? Um, that may have been blocked. Do they get any burning when they, we things like this? Um Neuro you will basically do like a quick neuro examination. Um You can also do a facial nerve, I mean, um cranial nerve examination. You just get your situation. If there's anything that you're concerned about cranial nerves for, then you can do a cranial nerve examination. If you don't know how to do one you go on. Um go on. Gee medics, they've got an amazing resource there for you to learn how to do it, watch the video, read it, read how they, how it's done and then just keep practicing on it. Um Yeah, you just over time, by the way, you, you, you, you will learn to just kind of go through this a lot quicker. But when you start off, it starts off quite slow and steady, which is fine. No one is going to say, why are you being so slow or why are you being so um why are you going into so much detail? Because you need to go into that much detail. You need to, you, you're, you're being careful. A careful doctor is a good doctor. You know, you're, you're careful, you're, you're, you're precise, you're thorough. That's good. We don't want, you don't want to be rushing things and then miss something and then it's like because then you'll blame you. You can blame worthy if you've missed the fact that this patient has got a kidney stone or they've got a catheter in and the catheter is blocked and you completely missed the fact you completely missed it. And the patient has come in complaining of abdominal pain, but they've got a catheter in and it's blocked and you trust and even even mention it, then you've missed like a key finding. So you need to, you're, you're better off going slow and steady rather than rushing things and then missing a whole bunch of things. Um So once you've gone to your urinary system, you go um neuro you can do some, you ask them just, you know, focal focal neuro stuff. You check for sensory sensations, um check for um motor function as well, sensory and motor function, you know, things like ask them to hold your hand, push down on your hand, lift up things like this, you check how you, how the neuro um thing is done. Um Gki medics again, helps you very well. You learn that very easily on Gki medics. Um and then musculoskeletal, any joint pain, any muscular pain, any ranges of movement that they're not able to do that is new to them or no. Um If you got fish will droop, then obviously you want to do a new, you know, ask them with dad a drug in the past or is this a new thing? Things like this? You just need to ask um check the pupil reflexes. Um And if there's any lesions on the body in general, you just document it down, you just note it down scaring or there's a rash here, things like this. Um Yeah, so it's, it's quite important that you go through things thoroughly and on your clocking as well. You need to just kind of um document the bloods as well, the blood results. So it will take you a while to clock a patient. It's not something where you see a patient and 10 minutes, 15 minutes you're done. Oh, with experience, maybe because basically what you would have done is you would have sat down beforehand and read this patient's file. Ok. Gone online and check the patient's history and checked the, the medication history and checked everything online before even going to see the patient. And then when you go to see the patient, you're just kind of confirming things online and they're just asking for any new things that maybe wasn't online documented. Um And that way it will, it will become a lot quicker. But for starters, you're probably gonna find it very slow and tedious and that's fine. No one's gonna blame you for being slow. Ok? Maybe they might, they might encourage you to pick up the pace and maybe over time, but just give yourself time. Don't rush things, give yourself time to, to, to grow and develop as a doctor. Um Don't panic and say, oh, I'm, I'm, I'm, I'm slow, you know, doesn't matter. You're, you're, you're good is where you are, you're not slow. Ok. So just, just carry on with that. Um And that'll be a clock in once you've class, the patient, typically your registrar consultant will then see that patient with you. So on, on my surgical rotation, it was me and my regis my registrar. Usually that will see the patient together after I've blocked them. Um You see the patient with your registrar again and you just document on behalf of your registrar. Sometimes the registrar will document by themselves and we just need to support with like any, anything that needs action in straight away. Like, oh, can we do an ABG on them? Can we do whatever? And then now as a part of your clerking, it's important as well that you write your impression. So your differential diagnosis important to write with that because your consultant slash registry will ask you, what do you think? What do you think is going on? It doesn't matter if it's wrong at all. It's a learning thing you learn and if it's right, you build your confidence. If it's wrong, you've learned something new, you've learned, you've, you can't go wrong. So just write your impression. If it's wrong, it's wrong. OK? Most often or not, sometimes your registrar is even wrong. And w when you know your registrar might require an appendicitis and you check your CT scan and CT scan will show no appendicitis just um diabetic colitis. But that could have been a part of it. Differentials. OK. So it's just you write a bunch of differentials I think is right. Write a plan that I think is appropriate. OK? From what you think um in your plan, you can write senior review, which means the registrar is gonna come and see this patient a convert to see the patient VT E important. OK. You always need to do your VT ES guys. Um You, you get told this as well when you start your jobs anywhere but your VT E which is your venous thrombo, um Thromboembolic embolic prophylaxis, right? Very important to prevent things like DVT and um blood clots and things like this. OK, as well. I forgot to mention when you examine the patients always palpate the calves, check for any calve tenderness or any swelling in the calves or things like this. Um Regardless, I know II was on vascular surgery. Um And so we, we had to do it a lot. But regardless, even on medicine now that I'm on medicine, I'm on geriatric medicine. You still have to do it regardless. Ok? Always, always check for calf tenderness. It's important because it's the easiest thing to miss. Um So your VT E, there's a VT E assessment form that you do. Um It's quite simple. You just tick things, you check your patient history and just tick things up there and based on whatever you tick, it will tell you what is needed for the patient, but you've done it, your consultants will love you for doing it um because they get a lot of hassle from the hospital management if it's not done, so you need to do it. Um And then prescribe whatever is needed as per DVT protocol in your trust. Um And then you can just write whatever investigations you think will be necessary. So if you think a patient who needs a chest X ray. Write it down if you think a patient will need a CT write it down. Um You don't necessarily need to take action on any of it. Some consultants will tell you just write down your plan. Don't take an action. I'll see the patient. Once I've seen the patient, then we can start deciding because you can think, oh, you know, the patient, the patient tells you I was coughing up blood and you're, you're thinking, oh you know this patient or the patient says you, I was vomiting blood. For example, I had this once, you know, patient says to me your heart, I vomited blood and I was there thinking, ok, we're gonna need an O GD, you know, to rule out any upper gi bleed things like this. And then my registrar went and saw the patient and the patient was just like, yeah, I was brushing my teeth and then there was some blood. So if it was the case that I had um you know, requested the, the O GD and everything, it's gonna be a scenario and now I have to go cancel it and things like this. But on my impression I wrote it down because that was what I thought was needed. After my registrar, I saw them, it wasn't needed anymore. It was just nothing happened to it. We didn't do it simple but you're you, you're not in the wrong for putting it down on your, on your plan, you follow the right thing, you followed the right protocol. Good for you. You've done good, you know, based on what you found, which is why it's important to be as thorough as possible. Um, so that would be generally what your clocking would be like. That's what clocking is. It's basically you taking patient history and having a differential diagnosis and then a plan of what you think you did and always, always sign GMC number and your role. Ok, you're writing a JMC number. So it's easy for people to, to know who's done this and stuff like that. Yeah, because handwriting sometimes is horrible. Um, and if there's anything that needs to be clarified or any investigations that are ongoing that needed, that needs your input, then they can just track, they can just like track you and speak to you. Um, it doesn't, you, you shouldn't be initially, you might be nervous about it and think, oh my God, my G GMC. Well, you're putting your GMC down, try and do, try and do things properly. Ok. Um, as much as you can. And sometimes honestly on days when you're, you're short staffed and there's nothing you can't, you can't, um, you can't do everything. Ok? Your, your, your documentation wouldn't be as good. You might even miss out all the bloods and stuff because your consultant has said, oh, don't worry about it. Let's just go through it because we've got a lot to do today. Um, it'd be good if at some point during the day you've got time to go back and just kind of like, document these things down. But the day can get really busy and you don't even get to do it at all and it's not your fault, it's not something for you to blame yourself about. It's just the way the system is. Um, you know, you're understaffed, you're, you're working so hard, there's only so much you can do. You're only a human at, at the end of the day. Um You just do your best. However, it's good to do your best, your best. Um when it comes to documentation because is the habits you form from the start that will, that will build your, your future. Honestly. Um I was in a, I was in like a teaching session once with one of our consultants and he said it was, he received an email six years later after a patient's care and they had the patient had made a complaint six years later. OK? And then when, when the documentation came, because he has formed the habits of documenting certain things whenever, whenever he sees a patient. So he, he, he was just confident enough to like, that's not right. There's no way I would have done that because he has formed the, the habits from this get go. And he knew for a fact that there's no way he would have done it. And when the documentation came, obviously, there's a odd chance that you got sidetracked and you got busy and he didn't do it. But when the documentation came, believe it or not, he had done whatever it was and the patient had no basis for the, for the complaints anymore. Ok. So you do your job proper properly now, so that you don't have to keep looking over your shoulder in the future. It's quite important. So documentation is a very, very important thing. Um As an F one F two, you just document and throughout your career, you keep documented, documented, documented, documented through because the nurses also document and that's important if a nurse comes to you and says something documented down, if it's considered the patient, I think it is important, documented because the nurse has probably documented that I have spoken to this doctor about it. So you also need to say nurse came and said so so and so to me and this is what I did as a result of it. OK. II discussed with my registrar and my registrar said this, this, this it's important to just document things because if your, if your documentation doesn't mention it or the nurse's documentation mentions it. Yeah. So it's important if you, if you've had any discussions with any other doctors, for example, you, you asked you asked for a cardiologist to come and see a patient and they came and they saw the patient and then the cardiologist spoke to you, but they didn't document anything, although they should you document whatever you spoke about. And if, even if they've documented stuff and the cardiologist said, do, do, do do this, this, this, this just, just also document what, what was handed over to you by the cardiologist because sometimes maybe they didn't document it. Or if you got a phone call from um microbiology, for example, regarding some blood cultures that you had sent off and the microbiologist called and said, oh, we grew so and so bacteria, I would recommend that you prescribe some antibiotics but check the G fr of the patient. Da da da da da just always like document that conversation. I spoke with a microbiologist. Doctor Xyz at so, so, so time and they've said this is what they recommend. And so I did that if you, if you, if you don't document something, you just do it and then something happens and then they're like, why did you do it? Oh, I spoke to the microbiologist who I'm not quite sure when I'm not quite sure. Well, you didn't document anything about it. So no one. And if they, if they did track down the microbiologist, they can easily say no, I didn't. But if you documented things down then then there's a, there's a, there's a line to trace. OK. So it's quite important that you document everything down um if you speak to family, which your job will involve a lot of speaking to family members, especially in medicine. On my surgery rotation, I didn't speak to family members as much, but on medicine, especially I'm on geriatric medicine at the moment. Like I mentioned, it's like a part of our, we almost like a daily thing to be fair that you have to do. You have to update the patient's next of kin. I ask the patient first before you update it next of kin. Um because sometimes the patient might not want the nexus kin to be updated. So just confirm with the patient, am I right updating the Nexus Kin? If they say, oh no, I'll do it myself. Then let's just document patients stated will do the updating themselves. But if the patient is fine with it and you call the next of kin also when you, that's a whole different thing. But when you speak to the next of kids, don't just jump straight into like, oh yeah, I'm calling about this patient. You mentioned the patient's name, the hospital number. You've mentioned everything and then suddenly, oh, that's my mum. I'm gonna give her the phone and you, you've just, you've just breached confidentiality at that point. So whenever you call a next screen, confirm who they are or who you're speaking to ask them about the patient's date of birth or something, just to confirm that they know the patient. Um date of birth or address is black. Can you just, just to double check, can you just confirm this patient's name and date of birth date of birth and address for me, please? And once to confirm that, then you would then proceed to like, tell me what you know so far, don't just jump into po another information because then you're telling them what they're already knowing. You're wasting your own time, you're wasting their time. Tell me what, you know, so far, if they've updated you to the point where they're know, you, then you can just pick up from there and be like, oh yeah. So, so things have progressed from there and we did XYZ um as an F one, there's certain conversations you're not allowed to have. Um for example, a CPR conversation, you're not allowed to have a conversation alone because there are certain things that, that need to be made clear that you don't have the experience or knowledge for and your registrar slash consultant should be there. So if you're there with the consultant slash registrar, you learn how it's done, doesn't mean you can do it, you should do it alone because your job role doesn't allow for you to do it alone. Um And if you're not sure what you're allowed, you're allowed to do ask. So like for example, prescriptions of like take out drugs, we generally are because we've got full GMC licenses. Well, a typical f from the UK is not allowed to. Well, we are because we've got a GMC license full Gentry registrations. So you can like um technically speaking, you're allowed to prescribe medication for patients to take home. But things like that just clarify and just ask. Ok. And before you prescribe me anything as well, confirm, you can just double check with your registrar, such consultant, consultant. What the dose is, what, what would, what exactly they would like and just check for any drug allergies before you do anything of that sort? And just again, document things. Documentation is very important. Ok. Is that, is that fine? Any questions about documentation? I know I know this lecture is quite long. Um I'm gonna try and maybe speed up over the next couple of slides. But if you got any questions, am I still audible? And I mean, I've spoken for quite a while. Um Can you just let me know please if I'm still audible and I'm not just talking into the wind? Ok. Um So do you have, do you have any questions at the moment? Ok. So I'm going to move on then to um the other part of your job. So we've talked about documenting which is like one half of your job and a lot of just paperwork and documenting and prescribing medications and things like this. Um The other part of the job then would be seeing patients, assessing patients. Ok. So, um now coming back to this. I mentioned earlier the news score, the national early warning score news. OK, like I mentioned it's 0 to 20 um as per most hospital protocols, if a patient is scoring three on a single parameter. So either if they're scoring three for the respiratory rate or for the saturations or for the for the s for the BP, for the pulse rate, for temperature for for new confusion. All right, it is as by most hospital protocols that the nurses escalate that patient to a doctor, ie the nurses get a doctor to review the patient. Ok. I've heard people say if from a news up to a five F ones are allowed to go to it above a five, ideally it should be an A or registrar. I'll be honest with you. Um most times you've probably seen news of higher than that. Ok. You see your news up to 78. But if you fill out of your depth at all, always, even if it's a news two and you feel out of your depth, speak to your senior registrar sho and if you're the sho speak to your registrar straight away, speak to them. It's OK. Ok. No one. No, you're being safe. That's important. Ok. Patients safety is the most important thing as your job because that's, that's, that's your definition of a doctor. You're looking after the patient. Ok. So patient safety, if you feel out of your depth at any point in time, speak to a senior and just seek, seek an opinion, seek, seek a recommendation from them. Ok. So you've got this news, a news chart in your hospitals, sometimes they're usually digital unless your hospital is very um, they've not upgraded yet and it's all paper based. In which case, the nurses will circle what the observations are. OK. The HC A, the nurses usually do the observations and then documents and, and put it onto a system or documents onto a chart. And so whenever you're, you're asked to see a patient at, asked to see a TSP, OK, you will see in this document, documentation that they've written a TSP, which basically means us to see a patient and the reason is raised temperatures and increased work of breathing. This is what typical documentation will look like to start off with. OK. The patient has written the, the doctor, the Fy one Smith. Um And, and I also mentioned that the mother is present and the, the sun or someone else is present. OK? If you're seen, if you've seen a question of the opposite gender, I forgot to mention this when you're clocking. If you've seen a question of the opposite gender, always get um A uh cha OK, especially if you can do any sort of examination on them, get a chaperone. Very important. OK? And just document chaperone XYZ what's in what's present, write the chaperone's name. OK. So generally speaking, um on your news score. You've got, you've got a news of zero. Is everything been between in that, in that white box on your news table. So the respiratory rate is between 12 and 20. The SP O2 is greater than 96 on air if they're scale two. Does anyone know the difference between scale one and scale two? Yeah. Feel free to just comment in a box if you know the difference but or why, why we put scale two for some patients and we put scale one for some patients? OK. Yes. For C for COPD patients. Yes, that's correct. But why, why for COPD patients? What is it about being co PD that makes you ESI 2001 9? OK. Yes. Lower requirements. But why that, that's what scale two. So a scale a scale two is lower. We, we're, we're basically setting down the patient's oxygen requirements to a lower um sats um patients starts to lo to lower. OK. So we lower O2 sats usually normal 8088 to 92. So the normal stats we're, we're, we're aiming for is above 96. All right. Well, we're bringing it down to 88 to 92. Why is that? Oh, well. OK. So um in the last lecture, um I believe my one of my colleagues layout layout had said um I mentioned about ABG S and respiratory failure and type two respiratory failure and things like this. So, on, on an ABG, you'd to, to diagnose this, you'd, you'd be looking for the carbon dioxide um CO2 retainers basically. So if your, if your, if, if the patient is a CO2 retainer, which means your pressure, pressure of um CO2 is high, then they'll be, they'll be classed as CO2 retainers and it'll, it'll be a type two respiratory failure. In which case, we will then be conceiving them. And if they've got a back of CO PD, for example, they would be bringing down the O2 sats requirements or um aims, the saturation aims to like 88 to 92% rather than what it would normally be of metaphor or above. OK. So we'll bring it down to 88 to 92% which means if this patient was scoring was, was saturating at 90. For example, for them, the new score will still be a zero. But if a patient who was on normal scale one was saturating at 92% the new score automatically jumps up to a two. OK? And they'll be requiring oxygen. OK. So that's important to always check if the patient is on scale two or scale one. If they're on scale two and it starts a 90 then you're not really bothered. But if they're scale one on the start of 990 then you're very, very concerned. OK. That's scoring three. You're extremely concerned. Why is the start dropped? So it's important to nurse develop that. If the pressure is on oxygen, they automatically begin to score two. All right. If you put the pressure on any sort of oxygen, even if it's just an elite of oxygen, it automatically begins to score too. Ok. Systolic BP between 100 and 11 to 219 is the news of a news of A zero. I don't, I don't agree with that actually. Um, it would usually climb up as well over time. Like if your BP is beginning to raise, I guess they might not score on here. He seen a score of a of a three is a 220. Well, this new score is in 100 and 11 to 219. You also need to just kind of um, have a look as well at the trend of this patient's, it might be a news of a zero, but you need to also just check the, the normal, the patient's normal range on the chart, ok? If the patient is and the patient's normal BP is usually about 120 and then suddenly it's 190. I do not believe this new score would be a zero. My, my, from my experience, I don't think so. Um, if the BP is suddenly 190 if the new score to zero, the, the nurses will still call you regardless because that's a very high BP for that patient. Ok. So this 111 to, to 219. Um I'll have a look again actually for that, but sometimes the nurses will call you even if the new score is normal, the nurses will tell you to come and review your patient. For example, if your patient had a fall, that doesn't go on the news at all, but they've had a fall. You need to assess them for the fall if the patient is bleeding, um, it might not necessarily go on the news at all unless the BP is now beginning to drop and they're going into hypothalamic shock or something. But you need to assist that patient. If the patient is having melena um Hema hematemesis, anything like this might not be indicated on the news does not mean you don't go and see the patient. Ok? You still go and see that patient. The patient is still requiring a review. Ok. Very important. And because uh you know, patients having a temperature spike does not mean, oh, it's just temperature, they need a review still because temperature could indicate an infection. You need to, you need to just go through it. So how, how do we, how do we review a patient? Um So something I like to do generally speaking if, if let's say let's say we were sat down, I was, I was, I had my bleep with me. I got bleeped, you know, hello doctor. Um I have a patient who is four in a five on the new score. And I would like you to re review the patient, please. Obviously, as soon as you hear a five, you know, ok, this is, this is serious. It's important. What would, what would be silly of you to do at that point? If you just then be like, ok, and hang up the phone? Because then you've, you, they've told you using a five, you just said ok, are you hung up the phone? You've not asked for the patient's name? You don't even know you've not sought, you've not, you know, sought any sort of information. And then now you're having to like call back the p the the nurse and be like, oh sorry, who, who is it? Why? What's going? So as soon as they tell you're using a five, OK, who's the patient? What's the hospital number? And just have a piece of paper, you write everything down, seek as much information as you can? So I'd like to go through this thing called the spies method. OK? If you, if you look at that, this spy method will also help you for your interviews. So whenever they give you clinical scenarios in your interview, if you follow this method, you can't go wrong. Really spy. So you basically on spy, the patient spies, right? The first s stands for seek information. OK? So you, you, the nurse is on the phone with you, you seek as much information as possible. Why? Why? Because most of these patients, sometimes if you're on call, you've never met the patient before. You have no clue about the patient. You're just like the patient is new to you. So the nurse will have some basic information in their handover list that they can give to you. So, OK, why, why? OK. Why are they scoring, what are the observations at the moment? Because sometimes they've not recorded the observations onto the system, but they've got it written down before they record it just OK, can you give me the, the, the current observations? You write those down? OK, let's say the BP is low. You already from just writing that you can see some of the problems with the patient and then you just seek more, more information. OK? Why was this patient brought to the hospital? OK. Why, why, why, why are they in the hospital? Why are they admitted under us? Why are they a surgical patient or why are they a medical patient? Oh, you know the patient was brought in because of uti and, and the patient had a um kidney stone ablation and da da da, da, da da. OK, you get, you're beginning to get a better picture of what was going on and you just seek as much information as you think is necessary for yourself. So first I information you're see is on the phone. OK? You've, you've, you've asked the patient for a few things. If it's chest pain, for example, you can just tell the nurses. Ok. Can we get an ECG please before I come down? Ok. What you, what you shouldn't do is rush to things. There's a sense of urgency but you don't rush, ok? You need to be calm and collected, you need to understand what's going on. You don't just rush into a thing not knowing anything about a patient and then suddenly you're in shock because you don't, you have no clue what's going on. Ok. So you've sought some information from the patient, from the nurse, you've told her to maybe do an E CG, um maybe get some things that you can use to take bloods ready, some, some cannula instruments, some um some um you know, injections and stuff just, just kind of like obviously be polite about it. Don't just be like, can we do the E CG or just very kind? Uh Would you, would you be able please to help me with um just gather some equipment to take some blood and maybe um can we also get an E CG just so that when I get there, be able to move a bit faster? And you've, you've done that now whilst the patient, whilst the nurse is doing all of that for you, you know, kindly you can seek more information, go on onto the hospital system. So we're going now to, to pee right, seeking more information and slightly into patient safety. So just gather a bit more information and if there's not enough information for you on the system, then maybe head towards the, the ward where the patient is at, take the patient's notes, ok? Regardless of how urgent things might seem and how dire decision, unless it's the cardiac arrest, in which case, you're being caught to a cardiac arrest call where you have to like, you know, do an arrest or if it's, if it's, you know, but otherwise try to just seek information, understand what's going on first. Sit down, take five minutes like that's all uh like 5, 10 minutes. Just understand cos it can be a thing where this person has scored three for this exact same reason, three hours ago before your shift began. And you can just have a look at what they done. For example, the patient had heart failure if he didn't seek information and now the BP is low and you just thought, oh, blood pressure is low. I don't know if I have heart failure, I'm just gonna give them some fluids. You don't know anything about the patient and you just went and overloaded them with fluid and now you've just worsened the heart failure and the person is on Furozin and you've given them, you're just giving them some more fluids to just counteract your, the treatment that they're ongoing like you. So what you want to do is seek some information OK, just read through the patient's not briefly. Why are they here? Ok. WW what's brought them in? What are the diagnosis, what are they being treated for? What could be the potential cause of the issue? Right? Now, you've gotten some information now it comes to patient safety. Ok. You have a look at the chart now that you've documented whatever, just have a look and see, ok, look at the trends and the observations, OK? These patients was never like this before. This is new. OK? So you just patient safety and then you go and actually take some initiative. What can I do to actually ensure that this patient is safe and, and managed to the best of my ability and this is where you go and see the patient. OK? So now this is your initiative aspect and you assess the patient, OK? If you, if if even before assessing the patient, you're a bit like weary, there's nothing wrong with you just dropping a quick chat, a quick message right to your, to your registrar because most times you have your registrar, your registrar feel like I'm gonna go see this patient quickly. I'm gonna go assess this patient, but just so you're aware, OK, that something is going on. Ok? If, if you feel like you're completely out of your debt and you're not quite sure, but always, always, always, you have to go assess the patient and do your A two ES OK? You have to because that's what you're going to, you're going to document that again and it's going to help you understand it better about the patient's safety and understand what's going on with the patient, ok? But also you can document things for the, for the, for the next team to understand as well what's going on with the patient. So we go a two ES, ok? I'm sure most of you at this point should be familiar with A two ES, OK? Airway breathing, circulation, disability and exposure. So you go to the patient, you've, you've done your, your PPE S, you've put on your gloves apron if needed. Ideally, you should as well put on your gloves, put on your apron, notice with everything I'm doing right now. We're approaching things systematically. We're not rushing into things, ok? We're not rushing cos when you rush is when you make mistakes, there is a sense of urgency still, but we're not rushing, we're taking our time and we're doing things effectively and you know, gradually in a system systematic manner. So you go to the patient, you a two ES airway breathing, circulation, disability exposure in your airway. You check in if the airway patient's airway is patent, ok? If the patient's error wasn't patent, I just thought the nurses would probably let you know straight away like, you know, patient is choking in which case it's a, a bit of like peri arrest, you need to go Yy, you're not, you're not like you. So you have enough information. The patient's safety now is what is very urgent. Ok? So you also need to kind of like weigh the urgency of the situation and look at what is like emergent and what is urgent. Ok. Emergency is different from urgency. It's just kind of have that in the back of your mind, ok? If it's an emergency situation, you're going to the patient, you're, you're, you're going straight up. Ok? And your, your registrar is probably also being called and you know, the crash team is also probably being caught and if it's very emergent, they, they'll probably even wouldn't even call you at all, you'll probably go straight to your registrar and no, even they won't even bleep you, you're not even on the radar for those kind of situations. Ok? Especially when it goes to like 89, 10 of news, they probably won't even contact you. So don't, don't be stressed. Ok? If they're not contacting you, your registrar will probably then contact you and be like, I'm going to see a patient. Basically, you're going in there to support your registrar because you're working as a team, you're going to support your registrar with the other things like taking blood and stuff like this while you, while your registrar is doing some, some of the bigger picture things as well. Ok. So you go there and everybody, every doctor does this, ok? Registrar consultant. Everyone goes through the at es some, a bit faster than others because now they, they, they're a bit more, you know, you used to doing it. Ok. So airway, you check if the patients airway is patent, this can be as simple as just talking to them, which you have to do anyways, you introduce yourself and you gain consent. Hi, my name is Doctor Xyz. Um, the nurses have said there's some concerns regarding your BP. How are you feeling? Um I'm, I'm, I'm, I'm not, I'm not too bad. Um I feel, I feel all right in myself. They're talking, ok, the airways pa they breathing everything, they're talking fine. You know, the airway is patient at that point. If the patient is like, but then, you know, ok, this patient's airway is compromised, we need to, then they can't, they're not able to like, you know, breathe the, the airways compromised at that point, it's not patent. So you have to then, you know, go through what you can do. So if the airway is not patent, head, head tilt, head tilt and chin lift, ok. I would at that point generally as well, we just get, if I'm having to do something like that where I'm concerned about the airway, um patient is potentially peri arrest as well. So you, you're just, you're getting the, you're getting the team involved. Ok? Again, everyone involved, if, if you're doing that, you're getting your, if you can't contact him at the time because you're, you're, you're, you're busy with the head chair, chair, chair lift, get the nurses to help assist you and get your, your registrars and maybe the crash court team and things like this involved to just help secure a better area for the patient. Ok. So you get people involved early if you, if at any point you feel lost patient safety. Ok? Always remember that. So let's say you check the airways patent, you go, you go to breathing, OK. Inspection, you look at the patient's chest. Are they just look at the patient generally? Are they short of breath? Is there any sort of like cyanosis? Are they panting? Is there any increased work of breathing? Ok. Is, is the is the chest moving symmetrically is the trachea deviated? You know, listen to the lungs. What's the respiratory rate like if can you on the lungs? Can you hear auscultating? Can you hear any wheezes any crackles any anything like this? You know, depending on your findings that you might want to do an APG chest X ray? OK. A as well. You can also ask the nurses kindly to do another set of observations on the patient. So take another readings of like the respiratory rate, heart rate, all these things whilst you're examining the patient as well. Just so you have the numbers. Now, the other thing with the A two ES is um any interventions that are needed at specific points, you do them. So if you've got a patient with, wheeze, you may, you perhaps want to give them some sabutal nebulizers on the spot and just ask to get the drug shot, prescribe it, get them to administer it to the patient as, as you're moving on to the sea. Ok? Because you just have to like the, the, the, the, the aim is to as soon as you pick up an issue, you're given an intervention to help. Ok? Again, if you feel at any point out of your depth, always just contact somebody senior to help you, ok? If you don't feel confident enough yet to assess a patient on your own, then tag along with people when they're going to assess patients and just see how it's done, ok? It's, it's all, it's all a matter of time. You keep building that confidence of the time, ok? Which is why I was saying earlier on, I wouldn't just recommend you jump to a locum shift if you, if you feel like you don't have that much of an experience in the clinical setting because if you don't, if you don't have that confidence yet, which again, we are all built by the way, it's not something where it's like you're born with the confidence or the confidence is always there. You, we build it over time, ok? So in your breathing, you're looking for things like that, you auscultate the chest you check for respiratory rate, you check for the ho two sat. So you're probably doing an ABG. You probably need to request an A chest X ray. Um You move on to circulation now with things like requesting a chest X ray, you can do the ABG but with things like requesting a chest x-ray, um you can also request it on the spot or you could, you could, you could request it along with other requests as well. Ok. Cos bear in mind if you're doing an ABG, you're gonna go get the equipment, you're gonna start doing the ABG, you've not moved on to circulation, you might be missing something important in circulation as well. These are things like investigations. You might need to just leave at to the end of your A two ES as well sometimes. So if you've gone through your A two ES and you've picked up some concerning things, then you can come and do your ABG S and take bloods and do the chest X ray and stuff like this. Because if you're, if you're busy there trying to do the ABG and you've not, you've not um taken the ABG, you're struggling but the patient is bleeding out. Well. Oh, I was, I was focused on b just trying to do my ABG. You have to just think about it logically as well and just like go through things, ok? It's important that you go through it as well. You've spotted the, you spotted the issue. If there's nothing, if it's something like an ABG bloods, they're gonna be sent off. I'll take him into a machine to go read, assess your patient as well and then come back and do this thing. Uh like after you assess them, do do these things to follow um circulation. Ok. Um So you check for BP, capillary refill to check the pulses, the the, you know, have you check by, you also want to do an E CG potentially uh with the with the case of chest pain of the heart is like ridiculously high, you check, you're going to do an E CG um looking for any AF um or any stemmy, you know, any signs of myocardial infarction, things like this. Um You also want to auscultate, listen to the heart and the heart murmurs and things like this. Heart sounds. Um If they're bleeding, obviously, you want to stop bleeding, you also want to gain like IV access and things like this. Um If your BP is low, you will want to start thinking about fluids, but you also just have to bear in mind things like heart failure because sometimes you can fluid overload the patient and worsen the heart failure. Uh You might just need a senior, a more senior um decision review. It's mostly a person to make that decision for you. Um Just because you're not quite sure if because sometimes the BP can drop for different reasons. Not just because uh there can be a bunch of reasons why her BP would drop, drop. Ok? And fluids is not necessarily always indicated. Ok. Sometimes the BP will pick up by itself. Patient could have different conditions that can cause BP to come down. Ok. So it's important to always have a look at that. Ok. Something you want to do. Sometimes if your patient is in sepsis, you want to always give them like a urinary catheter and ask the nurses kindly to have an input output chart where basically they, they, they measure how much the patient is drinking or taking in or how much fluid is going into the patient or how much fluid is leaving the patient. Ok. Also very important. Um So you got, you got ABC, you go to disability, which is your d now your checking is a little confused. Um if they're responsive to pain or if they're responsive to verbal stim or if they're unresponsive at all. Ok. These are all things that are on the scale and you just need to like kind of ask about, OK? OK. But they're just things that are on the scale and you just kind of need to ask about as well. Quite important. Um You also want to check your P pills and see how the patient's pupils are. If they're equally reactive to light, just have a look at that as well, depending on your findings, um you in, you escalate as appropriate. Um G CS. Ok? You do a G CS on them and always don't forget to check the blood glucose because sometimes if blood glucose is low, patients can go kind of, you know, unresponsive and just very fatigued and tired and if it's too high as well, there can be issues there as well, then you need to kind of so you don't miss out the blood glucose. Um and then de is exposure. So you do like a head to toe assessment. Ok. Of the patient, that's very important head to toe assessment. It's just looking for any sort of injuries and just noticing anything that is there, you know, palpating the abdomen, checking the urinary catheter, checking the drain, checking for any bleeding, palpating the calves. Is it swollen? Is it tender potentially a DVT just checking things like that? Generally speaking, checking for any rashes, any any external signs of infection? Um, some patients might not. So as part of the part of the exposure is if for example, there was a b next to the patient that had some vomit in there, you just kind of look at it and just see if it's, is it, what kind of vomit is it? When did it vomit? Is there blood in the vomit? Things like this? It's part of the exposure. Um have a look at the patient's back as well. Cos sometimes patients might have diapers on and have pr bleeds and you completely miss it, which is not great. Ok. So you also wanna make sure you're, you're thorough your exposure, just having a look at the patient from head to toe. Ok. Just notice anything, anything, any findings there and also the temperature, any temperature spikes, you're probably thinking you want to do blood cultures, if you've not already had blood cultures, if you've had blood cultures and they've known to do the spike in like from time to time, recent, like over the past two hours and had blood pressures like last, last hour or something, then you just wanna maybe give them some anti drugs like paracetamol or something. Um But yeah, so you go through the, you go through your A two es OK? You, you give your interventions as appropriate within your capacity, OK? There are apps out there that that would teach you and you can learn and study and I'll show those apps on the, on the next slide and those resources when you learn when to escalate what you can do before you escalate. OK? When you speak to your senior and when you know the things you can put in place before you speak to your senior, I mean, if at any point you feel like I don't know what's going on, speak to your senior honestly, they, they're not gonna, they're not gonna beat you up, they'll just simply ask you um what's going on. They'll ask you, they'll ask you what's going on. Um, they'll simply ask you what's going on. They'll ask you, have you, have you examined the patient? Ok, if you've examined the patient and you just tell them what you found on your examinations, then they'll just simply like, ok, if they think they need to come and review the patient, they'll come and review the patient. If they think it's something they can just tell you what to do, they will tell you what to do and you were just kind of um action, whatever it is they recommended for you from there. Ok? So there's nothing to stress about. But what's important is that you've, you've done your part, ok? You don't, the bare minimum is, is to go see the patient seek as much information because when you're speaking to your senior, you don't want them coming there and then starting to seek seek information as well. Just after, after, I mean, sometimes they would anyway, just because they want to confirm certain things that you might have missed out. But at least you've given them some basic foundation information that I need. Ok? And the way you're escalating is quite important to go through this sbar, ok? For it makes things easier for, for doctors to kind of like understand what's going on. So it's situation background assessment and recommendation. I'm sure this is not the first time you guys have heard of this, um, over time with practice you'll get used to it and you'll be able to, like, um, use it a lot quicker, a lot better. Um, but you, a typical thing would just be like, you ca, you call up, let's say you call up your registrar reg and you just be like, hi. My name is Sid. I'm the F one on call today. Um, I'm just calling regarding a patient who I've just gone and assessed. Um, I'm quite concerned um, about the BP, um, this patient. So I've, I've, I've, I've said the situation, I, what I'm concerned about. Ok, this patient, um, was admitted five days ago, um, because of, um, and acs heart failure patient at least five days ago due to heart failure. Um, she's currently being managed with some XYZ. She also has pneumonia. She's been made with this antibiotic. Um, she's currently on, on some medications or he's currently on, on some medications. Um, I've gone and seen the patient, I've assessed the patient and on my assessment, the patient seems alright and like this, they seem ok in themselves, they're talking, they're alert. So you go through your A two es they're alert, the alerts. Um, um, the breathing is fine. The spiritual rate, you tell them the numbers, you just tell them your findings. So you got your A, you got your b tell them to see what you found there, which is where your BP concerns come into place, you tell them the sees, you tell them the d you go through your, he basically, um, and then once you've gone through that, you, you don't say, you know, I've done XYZ. Um, but the BP has not improved. I'm not quite sure what else to do because this patient has got a history of heart failure and I wouldn't want to over fluid, fluid, overload the patient, I think. Um So I was just wondering, do you think I can give another set of fluids or do you think? Well, what would you recommend to do? And then the doctor can either be like, ok. Have you done XYZ? Oh, actually, I've not done that. Ok. Can we do XYZ or if you've done XYZ? Ok. That's good. Um Well, what were the results in those things? Cos you might have missed out some things in your asthma, you tell them the results and then it will just be a thing of, ok, I'll come and see the patient or they can just be a, ok, give another bolus of fluid and then we will observe the patient further and let me know how they improve and that would just be ok. We'll give another point of fluid and you've got a, you've got a plan and you just have to document, I've spoken with my registrar and this was the plan that was given and this is what I've done. Ok. And that'll be it, ok? And you just go through that and that would be your typical day. Some days you might get um patients using like two or three patients using at the same time most often or not, you would get that, ok? Two or three patients using at the same time. That's not, that's not like a rare finding. That's something that happens a lot and you just need to kind of prioritize, ok? Which is, which is more urgent. If at any point you feel ov you feel overwhelmed and you have a team just let the team know. Oh, I've been told about this patient on this ward. I'm see, I'm going to go to see a different patient. Could you perhaps please review that other patient? Um and just give them the patient's detail, give them AAA rough handover and then they'll go assess the patient. Um If you feel like there's too much going on, there's too many patients, there's too many things going on and you need, you need for five minutes to breathe. There's nothing wrong with that, ok? Nothing is gonna happen. Things are not gonna happen any faster because you've taken five minutes or any slower because you've taken five minutes, ok? If, if you just need that five minutes to just kind of you get nervous and you just need to breathe, take five minutes, man. Honestly, um you're better off for it rather than going there and just shaking out and knowing what to do or, you know, being too tired, just take the five minutes. I always take your breaks. Ok. And let the team know when you're going on your break. And your registrars will always tell you take a break and they feel ill. They'll tell you, I'll go see the picture. You take a break feet all day, take a break, I'll sort it out. Ok? And then if you, if you feel comfortable with that, you can go on the break. If you don't feel comfort, you can just let the guy will support you and, you know, let's, I'll, I'll come and you with that. Um, or you take the break and then you just follow up with them and say, is there anything that needs that needs doing, um, from L? So it's always important to just like support the team and just show them that you're willing to like help. Um, and they will love you for it honestly. Um, so that's important. So that's the last part of your spine is to support how can you support the team or it is important to support the team? Ok. Um, so generally other things you do throughout the day is like prescribing medications, um, always use your B NF if you don't know the dose, if you don't know the whatever use the B NF, ask your consultant, I'll do clarify with your registrar. What dose it is that once? Ok. And also just check with um check with your, with the your local trust guidelines for what is done for certain situations. So for example, if you have come to acquired pneumonia, what are the micro, what are the antibiotics this trust uses for this patient? Ok. On your internet, which is basically your trust website. There's always a guidance for everything. Sometimes it may be difficult to find purely because some hospital systems are not as easy to access as others. But there's usually a choice guidance for you guideline for you to use. Um So I always check your trust guidelines. Very important. OK? Because II, one of my registrars, for example, who if he's not sure about something, it will, it will literally say, say to the to whoever is seeking the information, let me find out on the truth guidelines for you and we will go and find out and once he's found the information he needs, it will then speak to them and give them the answer. You don't have to know everything over time, you get used to the trust guidelines because you've seen, you've seen the, you've seen the situation over and over and over again and now you know what to do. But if you don't know what to do, just go on the trust guideline, have a look at it, have a quick read of it. And then based on whatever information you've gathered, you then give um a solution to the, to the, to the concern or the query? Ok. So your job's documentation assessing patients. Ok. Prescribing medications, always check for drug allergies. Always check the patient's G fr in certain antibiotics. You don't want to be given the wrong antibiotics. Ok? You don't want to be given too high of a dose or too low of a dose or too high of a frequency or too low of a frequency. Just keep checking what the guidelines say. Um at some point you get used to it and you maybe memorize some things but give yourself time and then you have the guidelines for a reason. You have the PNF for a reason, check it. OK? Use it because if anything happens, where did you get this dose from? Oh from the B NF? Oh really? OK. That's fine. Where did you get this medication from? From the trust guidelines? OK. What did you guys? Oh from my head. Why didn't you use the trust guidelines? Why didn't you use the PNF? OK. That would be the query. So you need to use those things. Ok. So you've been prescribing a lot, your clinical skills, you will learn on the job as well, but it's always good to have a good solid, a basic foundation for clinical skills just because um sometimes it might uh it might affect your self esteem. Um Men mental health as well if you feel like you're just standing about and not really know what to do. But, um, if it's something where you're, you know how to do it and you've tried and you couldn't, you couldn't do it. Like, for example, insert, insert a catheter. You tried and you weren't able to, that's fine. Just, just let the team know. Oh, I've tried, I wasn't able to, can somebody else tried because I've not been able to, or, or I tried cannulation. A patient. I wasn't able to cannulate a patient. It's fine. No one's gonna be like, oh my God, you can't cannulate no cos everyone tries. Sometimes the registrar tried to cannulate and wouldn't be able to get it. Sometimes you catheterize a patient that registrars cannot, it's fine. It doesn't, it doesn't, it doesn't mean you like, it can boost your self esteem and make you feel great, which is good. But that's, that's about it. It doesn't mean they're any worse or you're, you're any better than them and such, it just means you've got it in and that, that was a sick one that you did that makes you feel good. Um But it's always good to have like to just know some of the clinical skills, but you'll learn, you'll learn really, like if you can't do something you just like, can you show me and they're usually very helpful? Ok. The team is usually very helpful. Now, obviously, if you've been on that team for two months and you've been asking them to show you to cannulate for those two months. They, you probably end up going um be referred to go to like a cannulation course, advise to go to a cannulation course um to that, which is also fine. There's nothing wrong with that. It's all to build your, your yourself as a, as a doctor. Um And so you just give yourself room for grief. Don't, don't overly stress about things. There's always support, even if, even when you're understaffed, there's always somebody to speak to, they might not, they might not um attend to you as urgently as you might have liked, but there will always be that support there for you. Um Just I sorry, I'm just gonna grab my charger just because my device is a bit low. Just a minute. Yeah. So they will only be that support. So it's nothing for you to be overly stressed out about. Um some of the other jobs that you might do is take um give like do referrals for patients, speak to next of kin duty of candor. So this is when if there's an error that happened. So for example, we gave the wrong antibiotics. Um and now the patient has some side effects. So even if they don't have any side effects, the the wrong antibiotics have been given and it's caused some sort of effect on the patient, you know, an error, then you would have to inform the patient apologize on behalf of the team. Um offer any, you know, any remedies that would, would, you know, help, that would help with the situation. And then you just have to explain the short term and long term effects of what's happened to the patient. Um Now how do you use this? You can use GKI medics on GKI medics. There's literally videos of how to have conversations. It's they make it ridiculously easy for you. Honestly, guys, GKI medics, how do I speak to a patient's family is on there? How do I break bad news? It's on there. How do I, how do I confirm certified death? It's on there. Everything is on G Metics. Honestly, it's an amazing platform. So don't shy away from geeky metics in your time, just kind of read through things on there. Um And you with cardiac arrest calls before, before you call to the cardiac arrest usually um there's a team briefing of who wants to do what if in the case of a cardiac arrest? Ok. And they would have assigned for your role if you don't have a SS are you, you're just basic on LS they will assign for your role. Still, it can be to get to get some blood during the arrest. It can be to do the CPR during the arrest arrest. If you're not comfortable with the defib, they, they won't give it to you. It's whatever you're comfortable with is what they'll tell you to do. Ok? And really once you've attended one or two cardiac arrests? You see how it is? I know there might be an initial panic. Oh my God. I don't know what I'm doing. I don't know how I'm gonna push the patient. I feel so nervous. Um, if you've done ABL S and an I LS, you know what to do in a situation of a Perret and how to initiate the entire process of CPR. Ok. So I would recommend doing an S at the very least, OK? If not an A LS and an is at the very least, there's no, there's no harm in doing both. There's no harm in doing an LS and then an A S later. OK? Um But once you've been in one or two cardiac arrest calls, then you kind of see how the team does it and how everything flows and you become more confident with it with everything at work is the more you do a certain thing, the more confident you are with it and you just get used to it. OK? You get used to it. So just to summarize on this, on this page, whenever you're asked to see a patient, you know, go through the spy method, seek information, think of the consider the patient safety, take some initiative, escalate it appropriate and support your team. OK? The new score is the national warning score that is important to um determine and indicate when the patient is deteriorating. However, it doesn't always flag up certain pathologies like Melina pr bleed, um hematemesis. Um F four doesn't necessarily always flag it up. So it doesn't mean those patients don't need review. Sometimes they're probably more, more urgent than in using patients. Ok? If you have a patient who has had apr bleed three or four times in the night and you have a patient using a one for temperature or you know about three for temperature, You probably want to go see that, that pr bleed patient because something can be going wrong and they might need to have some investigations straight away for some bloods taken cause the HP might have drop a lot, ok? So you need to just, you become very good at prioritizing jobs, ok? Um, on a typical day, um, let's say after you're done with your ward rounds and you've seen like 15 to 20 patients, for example, you might have a blood of a bunch of bloods to do a bunch of investigations, to request a bunch of departments to refer patients to a bunch of family members to speak to it as appropriate. If, if it's not below, above your, your role, um, you just have a bunch of things to do. You split it along across your team. If you've got a team of 23 people, some people will take some different jobs. You guys just assign different jobs to different people and then you just crack on with your jobs till the end of the day. If by the end of the day, you've not been able able to finish your jobs, you will simply just hand over to the night team and just say, please, can you do XYZ, please? Can you do XYZ? And you tell them, you know, with the sbar hand over um system, you just hand over to the night team, tell them what to do what you, what you, what you would like them to do. And then sometimes the night will hand over back during the day cos they weren't able to do it overnight and it wasn't urgent on their list of urgencies. So you'll get handed over the same job back again the next day, which is fine. It happens. It's actually how the system works. There's nothing wrong with that. Um And yeah, you just get used to things over time. OK? Um Some useful resources, I've taken some screenshots here. OK? Now this at a TSP has to see patients and the reason this book has basically this is the content has a classical fy one presentation. So you're gonna face your time with an F one F two and it tells you how to manage the situations, what to do when to escalate, how to escalate. Basically. OK. This o this book I have with me, pocket uncle I take with me every day. It's always in my pocket. It's a very small book it fits in my scrubs pocket and covers a few topics. If at any point I would be called to see a patient. I'm not quite sure what the protocol is and just to refresh my memory of the protocol, I'll have a read of that book quickly. Um, I also have this app, the handbook app. Ok. This handbook app you can tailor to whatever trust you're working at. Ok. And basically on the app, I do these three screenshots from the app. So you've got like assessment and management. If you click on the assessment, you've got like assessments with different kind of presentations. So abdominal pain, whatever, I've clicked on hyperkalemia here. So a patient with high potassium, ok? It tells you what to do. So if your po potassium is high, you can easily, you do an A CG. If it's less than six, you just monitor the patient if it's 66.4 and there's no ECG changes. You consi you consider a cardiac monitor, ok? Consider cardiac monitoring or you can also give some interventions like 10 units of a rapid insulin in 250 mils of um glucose, 50% glucose. So this is a an intervention and you can do that by yourself. It's not necessarily even speaking to a senior. Ok? But once you've done these things, you then just discuss with your senior, let the senior be aware that this is what's happened. This is what I've done so far. And your senior from their experience will probably either be like, that's been great, well done. Good job. Nothing more to do, just observe or? Ok, that's good. You've done really well, actually also do XYZ. Ok. Now that's from a scene that is obviously very kind and said you've done really well. Some seniors might just be like, you know, why, why haven't you done stuff? Well, generally speaking, to be honest, everyone is very supportive and very kind because they've all been in your shoes and they know what it's like. Ok, so they'll be very, generally, very kind to you and just be like, ok, you've done really well and they might just ask you some questions. Like, what else are we going to be looking for? What do you think they get you to think of it? If you don't know the answer, they'll tell you the answer and they'll just, there'll be a learning point for you. No, no hustle about it. Ok. Um Yeah, so these resources I would recommend the B NF have that downloaded on your phone. I think now you need an NHS email to be able to use the B NF. Um So as soon as you get a job, try and get an NHS email, but you can access the B NF online with the app. I think you need an NHS email for, if I'm not mistaken, I might be mistaken, but online you can access it however the B NF is not just to show you the doses of medications. The B NF also tells you what to use for different conditions. You, it has a section that says like a list of different conditions. And if you just type in whatever condition it is there, it tells you the treatment. First line, second line, third line, according to the UK guidelines and the nice guidelines. And so the B NF is an amazing resource to use micro guide. You can tailor to your specific trust and it's basically a bunch of antibiotics um that are given in different situations and what the trust guidelines are for different antibiotics. Um and different conditions for pneumonia, for B sepsis, for abdominal infections. It's got everything on there. So definitely you need to get that geeky medics. Amazing. II can't even explain anymore because I've emphasized that so much uh MD CALC very important to couple certain um parameters for patients. Well, school things like this um child masks or things like that. The, the med car is very nice um creating clearance. So those sort of things induction switch is basically again, you can tailor to your trust and it basically um gives you a list of all the different contact details for different per personnels at the hospital. So if you need to contact the urology F one or Urology registrar, for example, on your medicine, you go on induction switch, you're typing urology, registrar there. A tailored to your trust. Ok. You select your trust in there and it will give you the bleep number and you can just ring up the bleep and you can contact the person. It's very nice osmosis. I'm sure most of you are aware of it. Just medical knowledge and bos same thing. BMG Medic. Um Best Practice. This is a subscription based app, I believe. Um, and it's basically gives you guidelines for different scenarios and how to manage it. It's an amazing app as well. I've not used it much though because I've not subscribed to be honest, but a lot of um a lot of my registrars have recommended it and a lot of them have also said that um they go to it whenever there is a, there's a need, you know, there's a question that no question. It's also quite important that you, you also always use your internet guidelines. OK? Which is a very important your trust guidelines, your trust will also have its own B NF. Quite interesting. It's usually called like we B NF. And it's your trust B NF. It's generally not different to the normal B NF, but it'll have like more details that are more specific to your trust and those you can download the app for that, that's usually on your trust, the internet. Um So that's generated for resources. Um You can try using nice guidelines but the website is so difficult to navigate. Um a lot of my registrants also say they find it quite difficult to notate. Um, but there's another website. If I remember the name, I'll put it in the group chat. Um, that, that follows the nice guidelines but it's a lot simpler to, um, to follow. Uh, um, I'll contact B SSN if I remember and I'll maybe get them to just kind of recommend it to everyone. But, yeah, it's, it's amazing. Um, yeah. So this is some of the resources. What else? I'm sorry. This is carried on for so long. Yeah, so you a typical writer, I think just a summary you can have day on calls, night on calls, twilight shifts. Those are the different timings of them. Um Sometimes your, your uncle covers would just be ward based and you wouldn't have to go into um, you wouldn't be clerking any patients. You would just be taking care of any problems on the wards. Um But these are typical shifts. It varies from trust to trust. Um It's never the same to trust from what I've seen anyways. Like some trust will have um twilights from, especially the twilights from three to half 11. Some will have it from 12 to 4. It just varies very differently from trust to trust. Um And then finally route of employment. So hopefully by now I'll give you some basics of what your job is gonna be like as an F one F two. And I've told you how you can secure your gym to registration, some of the things that can help you make your CVA lot better. Um So now it comes down to how can I get a job? Really? How can I get into an employment? I've mentioned, I mentioned clinical attachment before. Your clinical attachment can potentially lead you to a looking job, a trust grade job or a bank job. Ok? Depending on what the situation is. Um you just have to keep seeking job opportunities. Um And you just have to keep applying on track jobs. Now, the KF FP ofit standalone program is basically the Health Education England program for IM GS. The UK students joined an F one F two program. But because we're international graduating, we've graduated with a full license to practice. We just, we are allowed to technically join just F two. OK. Now I've taken a screenshot here. This is a very updated screenshot maybe from to yesterday. Um It stays right there the next opening times for the UK FP O2 for 2024. This year, it's Tuesday the ninth of January and it closes on the 23rd of January 2024. So if it's something you want to apply to, I would strongly recommend you go on the foundation program, NHS website and you look into this a bit more. OK? It's basically if you've not done your ielts, you might, or o ETS, you might be at a disadvantage because you're not gonna get long listed for the program. You need to have your ielts slash O ETS to be able to apply or to be low, you can apply, but you won't be long listed. However, if you're able to book your ielts within this timeframe and then apply before this deadline, then you might put yourself in a better position to apply for this um the application process. Basically, once you apply, you get long listed and then you get us to do your situational judgment tests. Once you've done the situational judgment tests, the highest ranking people will then be shortlisted for an interview and then you'll have your interview. Once you've had your interview, then you can offer and then you get us to pick whoever regions it is. You, you work, you would like to work in and then from there you just get posted well with the UK FBO program. You don't need to sign a quest form. OK? You'll be going through with the UK program um form or whatever it is they use with all the other routes of employment. You will need to send a Crest form which is uh just to certify that you've met the competences for Fy one, Fy two. OK? Primarily I two really. So with locum jobs, I've put some images of like locum agencies. I was with whole doctors. They helped me find my first locum shifts after my clinical attachment at not general um and they were actually, I went through them for the bank for clinical in general as well. And I used them for my first local shifts at the vascular on, on the vascular surgery at Roche's Hospital. And I used them for, I was with them for the three months or four months since August to December. And so they've been very helpful. Um, something important about though is before you leave. Plein, try and get references. Ok? Because if you don't have references from your uni those who delay your note and work quite a lot, like you need to build some report with some doctors there and just try and ask them if you can use them as references. It's quite important. Um Otherwise you usually need a reference from Bulgaria, but if you're not able to, then a clinical attachment reference does really well. Ok? Because that's a UK reference and if it's a good reference, then it looks really good on your, on your uh your application for local jobs. Ok. The local market now is ridiculous. Um Very saturated. It's just, it's, it's exhausting reading. Um You get, you get the odd like weekend shifts here and there. If you're very fortunate, you get long term long term working shifts, my initial shifts, uh Shrewsbury was just a weekend shift. I went there and you know, they were, they were quite impressed, my consultants were quite impressed with my work. I'm a registrars as Well, and they, they literally said to me, we would like to extend, extend your contract and then they extended it for a month and then by the end of the month, they just extended it again for, for, for the following two months to December. So you see what I'm saying, if you're going to work where they can make sure, you know what you're doing and you're able to impress them because it could be a potential way for you to get a job. Um, if you're able to perform and meet up to the standards. And I believe I was only able to do that because I was, II had done two months of clinical attachment at the Northern General Hospital um under cardiothoracic and those two months were paid off during the two months. On the other hand, was, was, was painful was, you know, you're not getting paid, you're spending a lot of money. It's difficult, it's very difficult, but when the fruits come out, it's, it's very rewarding. It's very, you know, it's, it's quite nice. Um, hospital bank jobs I've talked about. No, it's just basically applying directly to the Trusts Bank doctors. And then I think sometimes they have an interview, sometimes they don't, sometimes I need to see the CV. Um and sometimes they'll have an interview and if you do well in the interview you put in the bank, you can get long term bank jobs as well. Not just like bank shifts, you can get like good long term contracts with the bank as well. So that's good. And the, the pay of bank and LO are quite similar, bank job is generally higher than they can pay. Even. Um as an F one and bank, you can earn close to 45 50 lbs an hour at the LO I think there's a cap at 35 but um it can be increasing like urgent situations to like 40 for a B job. You get very good pay um ridiculously good for um untruth grade on the choice grade job. Usually generally you apply to this on the, on the track website. Um There will be job listings for F one F two led, basically stands for locally employed doctors. There'll be, there'll be positions for F one F two. You just apply, you fill out your CV online and you apply to it and if you get short listed for the interview, they'll let you know. Um If you don't, then you just have to keep appliance to be honest. But those jobs go so quickly. Honestly. Um I remember once there was a job from King's College London, it opened maybe I saw the day it opened and they said the job was gonna close in seven in a week's time and I was of the mind I was gonna go home and then apply for it by the time I got home on the same day it's closed because so many people didn't applied to it and it was gone and I missed the opportunity there then then. So those jobs go very quickly. The competition is very high. Um Yeah, so you definitely definitely need to beef up your CD and your NHS experience as much as you can. And how can you do that? Clinical attachment to look and work? Even the clinical attachment sometimes is not considered as UK experience for some reason. And it would only consider local and work um which is quite frustrating. Um So with me, what I did was I had done my clinical attachment and then I did a local work and then, and my local work as a trust, I just kept a asking about if there's any, if there's any jobs, you know, I'm available, I'm here, let me know da da da, da da da. And then um I kept checking track as well and then the job opened up on track at my hospital and I was a locum there. So I applied for the job um amongst many others, got Sure Lisa for the interview and then had my interview. It's the doctor I've never seen before um from the ed Department and did my interview with him and it was successful. But prior to that for my clinical attachment, I had applied for an interview at Northern General Hospital in Sheffield and I completely flopped that interview. Um It was the worst interview ever. Um And that was, I had finished my clinical attachment at that point, but I was very much still like all over the place in terms of like, I was nervous and just in terms of patient as assessing patients, I wasn't as, as confident with it. So I was still very much all over the place. And I had an interview with an Fy one contract at Northern General Hospital in Sheffield for general Surgery. And I think they would have made it a rectal contract. But my last question of the interview was what would trust values and how have you implemented it in your day, day to day practice? Because they knew I had done a liquid attachment with them because I had mentioned that in my CV, I had memorized the, the trust values, but I had no clue. I forgot, I completely forgot because I was so nervous. And then it was just a thing of, unfortunately, you know, we couldn't give you the drops. But then my second interview at hospital, I was a lot more confident and I knew I had already been to an interview. I knew my big point. I knew what, what made me fail the last interview. So I covered all those ends. Um And they usually ask about audits as well if you've done any, I make sure. So I've done like two audits during my lo shifts with audits. Just make sure you ask around, just ask at your workplace. Do you have any audits? I can, I'm quite interested, I'll hop on, tell me what to do and I'll do it really. And so that, that helped with my application as well. And with, in the interviews, cos I asked about the orders during my interviews. Um and then finally the gateway program, now this is an N HSP program that has been designed to mimic the UK FP O program, you're basically in a trust grade position, but with a access to the facilities of UK FP O. However, at the end of the day, you get signed up for your Crest form, not the UK FP O form. Um but they give you three years contract, generally speaking F one F two. And by the end of it, you get signed up for your Crest form. I applied with them. So with them, you would do an initial interview to be able to go into the program after an induction, you have an induction and then you have an interview. Once you got the interview, you go into the program, the interview is your classic clinical scenario interview. Once you've done that interview, you go into the program and then the program will apply for you. The program will tell you when there's jobs available at different hospitals and then you apply through the program to those hospitals. You have another interview at those hospitals and then they basically employ you. So why is the equivalent of a trust grade post as well as an equivalent of KF ba pro Post? Um, when an Fy one and Fy two contract and it's a, it's a pretty good program, however, they are a bit slower. Um, and it all depends on when there's, um, job available and they tend to also give jobs in very remote locations as compared to like more England ba, they will give you jobs in like on an island. Uh 11 of the islands, I forgot what the island was. Um It's like af island off the coast of France, close to France more than it was to the UK Jersey Island. I think if you're willing to travel that far, then it's a good, it's a good job of opinion really because it's a two year contract. I don't see why not, but it's all down to you and your personal choices. Um I'd applied to them through, I applied through them as well for Shrewsbury, shortlisted for the interview. Um Yeah, but I just also applied directly to Shrewsbury as well for a trust grade post. So I had two interviews for the same job essentially. So I was, I wasn't, I wasn't, you know, I was fighting for this job, which is what you'll have to do out there. You know, once, once you're trying to get a job, you have to fight for it, you have to just take every opportunity you find, apply it as much as possible. Um So yeah, that would be all for me. I know this has dragging for so long. I apologize. I was not planning on it to take this long, but it took so long. Um If you have any questions, please don't ask. Um if you have any questions following this after this interview after this entire um talk, um you can, you can get in touch with BSN, they can put you in touch with me and we can probably have a conversation. Um There's a feedback form below. I just wanna say thank you so much for being here. Um I know it's not easy to just listen. I think this has gone on for what, four hours or something like that. Um I was not planning on it taking that long. I do apologize. Um Well, thank you so much um for, for taking the time to listen and if you have any questions, please do let me know um again, get in touch with PSN if no questions now. Um I really appreciate everyone and thank you so much PSN and Judith for this opportunity. Um Yeah, thank you doctor. She too and thank you everyone for coming and for sticking with us even though it was so long, everything was so useful. So thank you. Um And if you wanna go back on anything, if you wanna uh hear again what he said, then you can always find the video on the middle page. Um Please fill in the feedback form. It will be helpful for us and for doctor she too. But other than that, thank you everyone and have a good night. Thank you very much. Thank you. Bye everyone.