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Okay. All right. So, ah, how everybody think it'll coming? Uh, let's just start by having a quick chat about ah, by the rules of the day. So, uh, I want to quickly, um, let you guys know about how the day's going to go. So, Fatima sell It is our, uh, speaker for the date in that we're working in northwest London. Um, we're going to be a collecting questions throughout the to presentations she's doing. Um, And then we might be having a snack section in the middle between the two as well. It'll be up to her and her timing. Ah, we sadly do not have either. The the MG. You were the BMA with us today, uh, to have a chat with us, but we'll be going through Ah, how the b m a How the end. You can help you next. Like that. So, uh, keep in mind the, uh your view foundation membership needs to be upped. Applied before you start shadowing. Unless you filled out the application, uh, filled in a foundation application form. Your student membership will cease in the summer. It's essentially have indefinite to cover, so check out the sign up links, which I'll throw into the chat in a second. Ah, contact. Um, and I'll give you email if you have any queries. Um, all right. On over to doctor saw that to start there. I don't Sorry. Five. So I think your muted Very seldom, but no. Yeah. Um, So, uh, there was a sweet and salty calls. Um, that is helped by the mind. The sleep team. It's really good. It's non line. Course on. We're actually offering you the chance to win a place on it for free. All you have to do is just, uh, enter on the website on the screen right now. We'll put it on the truck as well, but highly recommend it. It's free to put your name in for it, and it's it's a drawer, so we'll let you know as well. Ah, he's one. But I would I would say I'm due for it. Right, So we'll start the talk now. So today we're talking about referrals on one question scan spur, surgery, little talk about Feras, and then we'll do the other one. So, uh, just a quick overview. I'll do a little introduction, tell you why it's important, uh, that you need to know how to make a good referral, and then we'll go into the nitty gritty what you need to do before making a referral, uh, how to actually make the referral or what tools you can use and then dealing with the aftermath. So what is a referral? It's one. A team basically requires input on. Asks for that input from another medical team on it could be a bus. It could be asking them to take a little patient care. Uh, it can be about organizing a review. Impatient review. Outpatient followup, etcetera. Um, and it's usually done over the phone, but sometimes through Elektronik means or paper. But regardless, the principals will remain the same. Uh ah, regardless of the the mowed off communication. So why is it important? It's obviously you're gonna be part of your job as an F one year are part of the junior team on D. You are expected to act upon whatever is requested by your seniors on the morning walk around. So that's what I need to know how to do it effectively. Um, Andi, successfully, hopefully, uh, it's also important to you. Maintain patient care. So is essentially new, accepting that you're not in the best position on there's another team that's better placed two, uh, age with a certain aspect off that patients care. Finally, it's something that can be quite challenging your enough one. You're new to the job, and you're gonna be speaking to a senior in a non familiar specialty, and it will usually be a register, but kind sometimes be a consultant. But fear know, because that's the point of these presentations would try and give you tips on help, too. Make sure that it's not as hard for you to to make referrals. Hopefully, you'll you'll come out of this and we'll be quick, manageable thing for you to do so Getting into making a thorough before you make the referral, there are a couple of things you need to think. Well, first thing is the purpose. Why are we referring? What exactly do we want from the team on? Do if you if you're not quite sure, then they definitely won't know. So you need to always never be afraid to ask your Reg. Can I just clarify what exactly do you want from the team? Is it advice about X Y and said on how quickly do you want that advice? For example? Uh, second thing is you need to make sure you've got the patient's demographics on their background. You need to know their hospital longer. You need to know their name. You need to know their location, and you need to know what's going on since they've been admitted. Third thing is that you need to prepare, so, uh, we'll give you tools for that in a minute. But just as a general, try and think about what you're going to say on. But there's nothing wrong with writing it down even before you call, uh, just to help you structure it better or if you're bit nervous. Um, it's certainly something I still do. If there's been a patient who I've not seen that much and they've been in the hospital for months and months of monstrous so I can make sure I got all the information. Poor thing is, uh, sounds probably quite obvious, but make sure your contacting the right person. Uh, sometimes, you know, teams might be composed off a range called you already arrange that handles would stuff on their patients and there, but might be another wretched that handles referral. So it's things you will pick up on from your colleagues. You can ask them once you start your new job on be making the actual referral so again, sounds obvious. But check your speaking to the right person when you call. Just a quick Hi, Is this the anesthetic, Reg? Or is this the cardio Reg? It will save a little partic and time, probably for both of you. The next thing is definitely introduce yourself. Say your name. Say which team you're from, On the level You're right. You can say I'm one of the juniors on one of the F ones. Um, and the third thing is, uh, we tend to in the UK use specific framework, So the one that is commonly used is called SBR. Um, Andi would be giving you examples of that, but just to in case you're not familiar with it s ball is, as I said, is the structural framework is a communication tool to effectively communicate escalate problems on to, um, enable referral process is to be done smoothly quickly on clearly, So I'll just go through that briefly. So each letter in s for actually stands for, uh, a certain aspect of your phone. So s stands for situation on day in that part of your referral, you're going to identify yourself and identify the patient, and you're going to state the reason here. We why you're calling, they need to know right at the start. Then you'll go into background. So presenting complaint past medical history on relevant investigations and treatment doesn't need to be the most extensive thing. But everything that's relevant, next thing is assessment. So observations OBS or on, You know, depending on where you are, you might call them vitals. One good tool to use when trying to relay someone's OBS generally is the new school, so that's used widely in the UK, but not necessarily every hospital and probably not so much internationally. So it just just for a quick kind of overview. It stands for National Early Warning School. Um, Andi. It's basically an aggregate school based on scores given to individual parameters like heart rate. BP on the score is based upon how much they deviate from the normal range. Um, and it's been something that has been shown to improve detection on do response to deteriorating patients. Hence why it's used so off. It's a chart that you will find in the bedside. Notes are patients who usually if you're still using paper based systems in the hospital, you're up. The next thing is, you give your own impression on your concern so you can tell her son over the phone. I think they've got this. This is why I need you to come and see them. If you're really not sure, then you can still sometimes say, Oh, I'm not sure, But I'm quite worried because off whatever is that's going on with that patient, What? Generally you should have some. Some idea Brecca Munday Shin is the final part. So that's where you reiterate your request with an appropriate timeframe. Um, on you can make suggestions. Ask them if there's anything else that they could do to help that you can do to help. Sorry to precipitate the referral, so just going to go through some examples for you. So the first case is on example of a referral to the anesthetic stream, so I'm just going to get my colleagues have back on. He's gonna pretend to be the anesthetics registrar, and I'm gonna be a cooling, uh, one. So I just want you to kind of listen out for, uh, this is a bad example. I should say, um, just to make it obvious to you, the difference it can make. So he'll give me feedback as well, I'm sure. So I'm just gonna They're on the next flight, and if you can't see, I'll be saying it is also a ring ring. Hello? Why? Why is that the anesthetic register or Yes, it is. How can I help you? I so I'm from general surgery, and we have a patient who's known to you. Who needs an an inspector crib. You for surgery? He's very unwell. Could you come and see him now? Ah, I own um So you're from general surgery? Uh, who are you specifically? You the Reg? Uh, no, I'm one of the ones. I also I don't know who this patient is, so I'm gonna need to find out a bit more about that. You just say that he has no interest, but I know a north a lot of patients and you're saying is unwell. I've got four other patients to see an including a couple of people that just need simple access. So I need to know. Really? How one? Well, yes, if I can figure out when I when I should be able to come see him. All right. Why don't you go ahead, assess the patient, doing 18, come back to me and then let me know. Ah, bit more about the patient, and I'll see if I can come and see him for you. Okay. Uh, Okay, fine. Hopefully that that is a fairly typical exchange that you could have. Um it can be uncomfortable. It's a waste of everyone's time on. You can clearly tell from this example there's a lot to be improved upon. So now I'm just going to do basically going through each off the S four components on. Do our, uh, demonstrate. Perhaps a better example. So again, listen up for the things I mentioned, I don't time identifying myself on the patient and stating the reason for my call. So this time it helpfully will go better. So say hello. My name is Dr Galaxy. I'm one of the general surgery of ones. I'm calling on behalf of my consultant, Ms Oreo, who has asked if you could kindly review one while patients Mr Quality Street. Any chest number. 1234 Ward for bathe three but two is a 75 year old gentleman who we plant operate on today under a general anesthetic for a right obstructed inguinal hernia. So I've put her on the next flight as well, so you can come back to it on could, straight off the But I've mentioned who I am upset to. The patient is I've given the details of a patient location number, and I've said that we were gonna operate. He's going to go for, um, his hernia repair Onda. I'm asking for a review, so that's that section done. Then we'll go into the background so mentioned patient journey so again or carry on. And I'll say he presented today with sudden onset right Brian pain and nausea, but no other obstructive symptoms on a background off known right inguinal hernia. On on examination, there was a two by three centimeter tender, irreducible right growing mass with no overlying skin changes. He had bilateral total knee replacements under a G A foster off Ritis last June here on has no other past medical history, drug history or allergies with unremarkable bloods. Again, I'll just put that often of highlight of the key bits, I've said when he presented. Given the background on really important, it's so common to hear people referring and saying, Oh, this patient's known to you But it's not as useful as you might think because teams change all the time. Even if they don't, they're not going to remember a shin that well, so I'm giving context. In this example. I'm saying he's had bilateral total knee replacement. Osteoarthritis Life lost June. So this is more helpful to the anesthetics. They can look up their own records on. It will just make everything much smoother. Um, and then I've also mentioned possibly call history and investigations. So next I go to the assessment. So again, observation on my impression. So, uh, just the I listen up below something he's currently clinically well, with a new score. Zero. He's been reviewed by the consultant and consented for laparoscope it repair of the hernia on he's been know by melted 18. So again, up on the slide, I've given the new school of zero. So the anesthetist knows that he don't have to kind of rushed here to get her and see the patient. It helps him prioritize on important for such a referral to an aesthetics, which again you'll pick up on what kind of things they're looking for. He has been consented on his know by mouth, so he's good to go for a surgery recommendations and final thing. I'm going to make my request again, reiterates it. I'm going to give the level of urgency. So when I expect him to be seen, I don't make suggestions. So I'm going to say we think he needs Sergent Surgery and would appreciate on an anesthetic review as soon as possible to determine fitness for surgery under G A years next on our list. So clear requests are saying he's next. Honest unit Calcium Soon, fatty. Soon on I I ended by saying, I have already sent to through Penn Saves. Would you like me to do anything else in the mean? So again, something important to any statistic is the group and save bottles are sent. I don't know, said, Do you want me to do anything else? It will help everything go quick off on. Hey! Might say, you know, do any see GI because the patient is, uh, older than a certain age. Well, you can clearly see between that first example where I was Hold off by the anesthetist. Quite rightly So on this one, obviously it takes more time to construct this, and you need more information for it. But it's much better to spend that time a safe time. Uh, effectively, because then you know, not being having to go back trying to read through everything also never make things up. So, like, if they say Oh, but how is the patient now? How do I know? Don't feel pressure on on the spot to say, Oh, I think they're okay. Um because that can lend you and obviously a lot of trouble on the patient as well. Eso make sure you know everything before you make the referral or even have your patient notes in front of you have the computer screen up in front of you in case there's something you want to clarify while you're on the phone. So another case, uh, just one more to ah to illustrate the example. So This is a referral to be respectful. A Reg on DA. As I can see, I was keen to grill me on a bad example. A swell I'm ready. So ring Ring and I Hi. Is this the respiratory wrench? It is not gonna help you. I, uh My name is on one of the dents. Iran. Don't even tell you. My name is Stone. So I'm one of the general surgery of ones. And we have a medical patient who my consultant says you should take over. He's got a community acquired pneumonia, and our team just can't manage that. He's on base seven. Bed six or I ask. That's interesting. I love the you said that, you know, going to tell me who you are. Ah, great air. A mystery to the whole thing Also, I don't know. The patient is I don't know where the patient is what's going on with this chest infection, because if you're saying pneumonia, I mean, people can have pneumonia is outside the hospital. So I I want to know why the why the specialist respiratory team needs to get involved in this pneumonia. Onda, um, I appreciate the fact that your consultants reviewed. This patient thinks they should be under the respiratory team. Um, I will I'm going to do is you're gonna get some more information for me. And then I'm gonna figure out when I'm going to review this patient to be able to say whether or not I am taking over care. All right, cause you can just call up and say This guy's got a bit of a cough. Take over, please. We need to be more than that. Yeah. Oh, All right, then. Find it. I'll call you later. Bye. All right. Thank. So So this is something that your seniors might just say. Oh, cool. Call the medical team. If you're in a surgical team, for example, and tell them that they have to take over. We don't manage this kind of problem on that. First, is this courteous? It's not the way things run on. You will probably get a worst response than I've just gave me. So try to construct in a better way and articulate. It's such that they can't refuse the referral. Eso again, I'll I'll go through the whole again. Listen out for the specific things I'll put up on the screen. So situation identify myself in a patient on the reason. So it goes like this. Hello. I'm Dr Galaxy, one of the general surgery F ones on my consultant, Mr Yorkie has asked if I could refer one of our patients to your team for takeover of care. It's regarding Mr Kingdom. You know any chest number? 5678 War Database seven. Bed six. He's a 68 year old gentleman who presented with signs of sepsis and has a CT proven community acquired pneumonia with no other surgical issues. So I'm not gonna explain again. You know, I've I've highlighted the key things. I've mentioned her and you can come back to it. I just wanted to, um, high highlight or draw attention to one thing here, which is usually you would put in the background relevant investigations. In this instance, I've put a implication at the end of the situation section because it's relevant. So I've said he's got a CT proven cap with no other surgical issues. It's important here because I'm asking, but take over and it's a big OSK off another team on. They basically right from the start, need to know that I have evidence that it's a medical issue on that. I have evidence that there's no surgical issue. So I say in this situation, it's nice to kind of include that in this this section and then going on to background, So patient journey right from the start. So Mr Bueno was brought in by ambulance yesterday with a two day history of fever malaise and write a portrait pain. He was managed with fluids and IV tussin. A CT to check for colon cystitis showed signs off the right lower lobe pneumonia, but nothing else in abdomen and pelvis. His past medical history is Type two diabetes, hypertension and high cholesterol. His drug history has metformin amlodipine on atorvastatin, with no known drug allergies. So clearly, given the history clearly, given the CT findings, I've said he's been managed. So he's on the right management fluids and IV antibiotics. So the medical team knows they don't have to kind of rushed her to make sure we haven't missed something called. I've mentioned the past medical history and drug history on the allergies. So then we go into assessment. So again, observation is an impression, so I can say that on examination today, there are course crepitations in the right lower zone on a productive cough. His new school is, too, for a two liter oxygen requirement via nasal specs with saturations of 94% on respiratory rate. 20 other observations are normal On his Bloods show, The White Cell count off 18 from 16.5, compared to yesterday on a CRP of 280 from 319 yesterday. So little bit. How this is different to the previous one is we have a new school that isn't zero on, Like I said, that the new score is an aggregate school. So if it's not zero than you should explain why what parameters are contributing to that school? So I'm specifically saying it's too, because he's got on oxygen requirement on these. Are his saturations on again? I've included respiratory rate because it's relevant to his presentation. Other observations I can just say, are normal. It might be useful to say he's not got his a federal. He hasn't got a temperature right now, um, and then the other important thing is that I've mentioned the key bloods related to an infection So the white cell count WCC or white blood count blood cells, WBC. It might be called on the CRP, and I've compared it to yesterday's results. So they haven't idea of whether we're going in the right direction or no. All right. The only Z only had about a day of antibiotics, perhaps even less. Then I'm going onto recommendation finally, uh, where we are making your request on, we'll make suggestions. So I'm saying my consultant feels that Mr Bueno would be best managed by your team as pneumonia seems to have driven the sepsis rather than any surgical cause. We've sent two sets of blood cultures on disputed sample, and the results are pending. Is there anything else you would like me to send? So I've been clear about what I want that they need to take over chair in the situation. I I've changed it compared to the bad example where I'm not saying we can't manage it. You guys need to so out this patient. It's always better to say why the other team is better equipped to manage that patient rather than walls. So that's what I've tried to do in this example. I've also said that I've sent the relevant investigations. I've anticipated what they'd want me to send. Um, Andi, that we haven't got the results yet on. I've also ask Is there something else you want me to send? So on example like this. It would be pretty hard for them to refuse to take this patient and just just a one referral one call. You know, you You you take it off another job on your list. So, um, that that's why making sure that you do it properly the first time I can really say a lot of time for you, which you definitely need. Doesn't have four. So you made the referral, then what first thing is you document? Always. You know, it was kind of stress that you need to document things, because if you don't document, it didn't happen. So document I spoke to this road, destroyed his name. Was this off this team? Onda. He advised x ones. That or he has accepted this patient to be taken over by the respect treaty. Mom, it's important also for the nursing stop so they know who to call when they've got concerns about this patient. For example, The next thing is you need to complete the requests. If they asked me, do the knee sug for that preoperative patient. I need to do that. If the other team, for example, respiratory team asks for extra blood tests, Technically, if they've been taken over by that team, it will become their responsibility. But it's nice to kind off facilitate when you can't. But, you know, obviously you need to remember. You are our different team. You've got your own jobs, so only if your free. Otherwise they will technically need to deal with it. But usually your your you'll be able to kind of compromise on it. Third thing is to think about So you made your referral. It got rejected. What are you going to do about it? So three things first thing is asked, Why not just in your head, but physically ask them why? So at the end of referring to, um, for example, bad examples, I could have said, Oh, what? He gave me all the information. I need it. So first thing is that have you even got the correct specialty? A typical example is calling orthopedic, saying Hi, I've got an X ray. I'm not sure if there's a fracture. Can you do it? It seems like that would be reasonable. But actually, the radiologist is the one who interprets the scans, so you need to make sure you've got the right special to four for your issue. Basically, the second thing is insufficient detail. As we saw, I've often you for more information, and I gave it to him the second time around. Maybe there's further investigations you need to do, and then finally, it might just be a hierarchical reason. So sometimes that's acceptable. For example, intensive care or I to you referrals me to be done by a Reg. Typically, a register on, um, or higher, even a consultant. Sometimes it's unacceptable. They'll say, You know, I'm not speaking to the F one. I'm not speaking to juniors. Get your register, call me or something. And in that instance, it can be helpful to kind of explain you're still part of the team. I'm calling on behalf of them on. It's really beneficial for my learning. If you can tell me what went wrong or what I'm missing. Well, at the end of the day, if you catch someone on a bad day, Something like that can happen. Um, if they refuse, you know it's it's no acceptable. But you're, you know, ask for their details off for their consultant details, which you should do regardless if it's rejected for any other reason. Um, and discuss with your seniors if they're kind of refusing to speak to you just based on your, um, your level, because it it's not something that should be normal. Uh, so you get their details not to kind off incriminate them or argue or argue or kind of campaign about them or anything. It's so that when you discuss with your team what you should also do a soon as possible, um, it so that your seniors can directly liaise with them. Uh, they know who to speak to about the referral. So just a quick summary. So make sure you're prepared. Know exactly why you're referring, what you're referring for. Have the patient details the hand. Then you just need to get on and do it Texas week into the right person and use s ball, and then afterwards make sure you document do the tasks they ask of you and again if they reject Austin, why? Sometimes it can help. Um, And you can clarify things otherwise, you know, discussed with your team on, they will try and get it resolved. So, uh, that's one of the first trip. Um, if there are any questions, uh, is there anything we already know? We were to go a couple. Uh, whilst more people hopefully ah, think of a couple and sense. I mean, I just wanted to say that example of the orthopedics being used in the image interpretation of service definitely happens. And I have I have yet to ah, be bold enough. Say, I've known image interpreter. I've always looked at the x ray. Um well, uh, I even once a metric said, that s, you know ah, fracture neck of femurs. The you're the orthopod. And see them and the medics. Um, I once had the med right around and tell me, uh, well, you have medical license when you review them. Didn't really have much finance for that. Um, anyway, so my answer is always protocol knife. If not, give it in the guide. You can't. You can't argue with guidance. All right, So, um, question number one eyes since Do we assume they're ready to listen to the details when you call them or do you awesome The beginning. And how do you broke up? Um, so I asked that question. Actually, I think usually because you believe it. Some in some hospitals, you call them directly toe phone number. But I'd say belief systems are the standard, I guess, to most of the hospitals I've been to. So what happens is your send a bleep. So they have a little pager and it goes off on. They'll call you back. So typically they'll only call you back. They've got a bit of time on their hands. I'm not prepared to listen to you. Um, so I I kind of say if if I know it's something someone who's really busy, like a cardio ridge or something like that. I say, by the way, I just let's say the situation because you do take pauses and sometimes they'll say, right, Can I just stop you right there? Can you just call me back in 10 minutes or something like that? So they the registrar's will definitely tell you they don't have time. I want you to call back later. Yeah, yeah. Um, I agree. They Ah. So when you when you like, I I tell him a little bit, but I want to talk to you about this, like either. Well, person, we want to do this for like, like, even mini Mini Aspar. Uh, And then they'll be like, You have time for in the back? Yeah, or I'm in the middle of a crash. Cold maybe. Don't know, have you? I'm going couple that I had to think off because the ah, we haven't got enough yet. Ah, you mentioned earlier about making sure that you refer to the right team members in in the team. When you when you do call them like some things to do as a chose on those do reginal have you How do you find out which team member you meant to call like that's in the middle of the night? Yeah, So I guess in love, middle of the night, there's there's such a skull. It'll kind of team that it's it's hard to kind of cool or own person usually. Um Andi, it's the thing is you You You weren't in a lot of hospitals. You might not necessarily have a cardio Rogge overnight or anything like that. I I usually use those on, uh, which, which you should definitely, I think download when you start working. They haven't sponsored help aid me to say this or anything like that, but this the not sure from a lot of state. That's the induction up. Um, and you said that if it's not allowed, I've said it anyway. Now it's really useful because you can choose hospitals and it gives you all the numbers that you need to call. But otherwise you just. It's such a narcotic system where you basically have to ask around saying, Who takes this? Who takes this cool? Who do I refer to? But then again, I mean, if you call the wrong person, it's not the end of the world because they'll say you need to call the regimen instead of me. We need to call the essential instead of yeah, I mean, the only the only thing that was is Ah, switchboard. They're really good at saying that's true muscle. No, no, always know, always know if in generally, I would say, if they're if they're calling it was mobile phone really double check. If they're the right first knuckle, I would say definitely, especially in the middle of the night. You don't be ringing someone waking them up when they don't need to be. You'll definitely get someone shouting at me and, uh, the first one. They need their beautifully. Uh, do we have time for more questions or do you want to go to the next day? It's like I stopped seeing. I'm I'm doing crack on and then we'll we can just ask the rest still, I mean, I've got more of a question about is keeping to the end because, uh, the other thing that's more questions. Oh, hang on the way. We've got one more question before we go. Um, if you're bleeding someone and they are answering, how often is it reasonable to keep trying? And what's the next step? Probably with that, how long do you leave it? But between sleeping them? Yeah, so that's That's a common issue, I would say. Um, I think it really depends on her ginseng of what you need. You know, if if there's something super urgent, then you can call them. Maybe off the 23 minutes five minutes. There's also a system where you can force bleep them through switchboard. So you just say, kind of Can you fast sleep this person on? It's a different kind of tone that they get, so you know, it's something urgent. Uh, typically, it's not something, you know, super urgent like that. You can I I think I leave probably about 10 minutes. 15 minutes on, Then I bring them. But fuck, you do spend quite a bit of time trying to chase people. Go on at some point, I will sometime. It is not good practice, but sometimes I will just go to them in person. Um, if you know, if you know them already on there, Quite sure about it when you catch them on the woods. Why I don't give it a go. That definitely works. In my experience, it's sometimes a lot faster, though especially they're really busy. Um, I don't know where I heard. Ah, General rule of if you're bleeding enough one Give it five minutes. Bleeping an s h o. Give it 10 sleeping A Reg. Give it 15. There's nothing backing that off interest. I don't know. I've not heard of her right. Cool. Uh, we go into the next set of, ah, next presentation, then yet, So I'm just gonna take this off. Sure. So I can open up the next one. In the meantime, while he does that, guys don't forget fasting. Would love to keep monitoring your questions. Go ahead and send them during the, uh, during the slides were about to go into requesting scans on DA and then also hey, you know, immediately after, if you think anything else, go ahead and put it on the on the Facebook group, and maybe, uh, you should be able to get some more information to you. Um, and then there's also the website mind oblique dot com Web site that you can refer to that has a lot of this information as well. Oh, we're screen sharing. You don't look at my million types of them. Um, so next week is requesting scans on. I have structured this in a similar way to referrals. There is clearly some overlap. It's not deja vu, but I just used similar slowed so that I could just highlight the key differences between referrals on questions, guns, But it is pretty similar so again, Same kind off, uh, structure to the store introduction. Why is it important? And then making the request pre enduring on post What? All the things you need to think about So it's in the name requesting scans is a request on it is no a demand. You, your team, anyone from your team who's making a request for a scan you need to remember. It's no kind of very delivery service your radiologist in the hospital needs to authorize on except to do the scan. Um, so, Bill that in mind when you fall first start working again. This could be done. Paper. Elektronik just depends on the type of scan of which hospital you're in. Most of them will be Elektronik on, But again, the concepts only principles are similar. So why is important again? It is part of your job on. Typically, it will be things that your seniors are asking you to be on the ward rounds or when you're covering the ward's. You will be requesting things kind of independently, like a chest X ray or something like that. Nothing too high tech. Um, again, it's important for patient care, so it can identify the cause of a patient's condition. It can help rule out things like in our example with the chest infection. So identified the cause of his sepsis as the chest infection, and it rolled out surgical issues, so it was useful. In that sense, it can also help with planning. So preoperative planning. Sometimes they'll get a stun. It helps them to appreciate the anatomy better, um, or even four mg tease multi disciplinary teams when they're trying to, uh, manage a, uh you know, things like cancers. Um, Andi. Uh, yeah. So when when they're trying to decide on treatment plans, uh, it can be challenging, possibly more challenging than making a referral because it's usually a consultant radio. Just that you will be requesting, uh, on because, um and personally, I will say that I, uh, managed to get an S l e for my portfolio for four requesting guns. I was not doing a very good job of it over the phone with my regimen, the same room. And, um, he gave me some good feedback after that and got something for it. Um, for my portfolio is so there is a silver lining given if you know, perhaps doing as well as you should. So requesting a scum. Well, you need to make sure you got saw it before the scan. No, the rational on there are two key questions you need to ask us alone. Why this gun on wife of this patient on importantly, is this can actually gonna change management. Because if it's not, I can guarantee you it's not gonna get accepted. It is not going to change your management plan. What? What is the point? You're putting a patient on the unnecessary radiation you're using up valuable resources. The radio. This is not going to accept it. So again, make sure you've got this clear from your seniors. What exactly they want on why it's important. Next thing is the choice of us can make sure you've got this correct. So it's something you'll pick up on about what scan is appropriate for each condition. Ah, but regardless, your seniors wool be happy to kind of clarify exactly what she's going. They want. Sad thing is to prepare so again details of a patient in the same way to making a referral, Um, and then also preparing the patient. So That's kind of I'd say double fasted. So the 1st 1st way in which you prepare the patient is that make sure they actually know they're going for a scan. It seems really obvious and really simple. But the last thing you need on this happens fairly often. I'd say is you have a patient, you organize the scan, waste a lot of time trying to get them a slot, and then porters come to take the patient, and the patient says, Oh, I I don't know what what this is about. No one told me. I'm going for a scan. I'm not going. So you've lost your slow At that point, it's not useful. If they haven't been told on the ward round that you're going for a scan on after that, someone's decided they need one. Someone just take five minutes to go and tell them you're going for one. Uh, it will save you a little party the other way and what you prepare the patient, which maybe is not as obvious right now. But when you speak to the radio refers to organize the skin, sometimes they'll give you specific, um, requirements that they want off the patient to prepare them for it. So, for example, if you're having gone abdominal ultrasound for to look for gold stones, they'll say, make sure they haven't eaten anything in the past six hours. So that conversion allies it better, Uh, So again, something that you will be told by the radio prefers. When you organize this gun, you will pick up on it with thymus well on you, you can implement even before you make the request. Tell the patient don't be anything from now so that you have more slots available to you. Otherwise they'll be done right the end of the day. If even that so, Making sure request again. It sounds super obvious, but check you have the correct patient when you're making the request. It really is easy to kind of be checking loads of patient records on Elektronik systems on end up requesting a scan for the wrong patient. I When I was in, uh, to actually had a colleague who did that request is an echo for the wrong patient. The echo actually got done. Surprisingly, um, And then we were left with a report, you know, obviously my colleague category and tell the patient on Really Sorry. You didn't even need the scan. Um, thankfully, in that situation, there were no, there's obviously no radiation effects exposure on. Also, the results of the report were normal, thankfully, but you can see how that can become a big issue if you know they were exposed to radiation, plus the the fact that you might have picked it up on some abnormalities. So check double check, triple check will go through some examples in a minute on, you'll see that they loosely follow the S bar frame one. But it's much more condensed, only very specific on relevant information to a radiologist. They don't need to know as much as a t. A team that you're referring to needs to know, So we'll go through that in a second. The third thing is that when you requests guns, there's usually a little drop down books. Um, where you select how urgently you want this done on. It could be like routine or urgent on. In some places, they'll also have emergency um, emergency, typically used by a honey or four. You know, extreme, extremely unwell patients. Um, but the urgent ones, you will probably use most often. That is that is the standard. I'd say, uh, again, you know, check with your seniors when they tell you they want a scum. Tell them exactly what scan is it? What is it for? If you don't know already on how allergic need you want to. So we'll do, Um, couple of examples. So first example, you have a patient with renal colic. So if you're not aware your team might tell you anyway, the first line is gonna is a CT pe you be kidneys, ureters blood. Er, I might be CT urine retract or something like that, but it's no, you're a gram, but, um, just double check that you selected the correct thing on your system on the request Will probably read a bit something like this. So I'll read it out and just can't see it on your screen. So 48 year old male with sudden onset, intermittent left sided, going to growing pain past medical history. Off previous left sided renal stones treated conservatively on examination. Tender left, lower quadrant plus plus plus urine dip, trace of blood that nothing else. And then I've got query urine, retract stones So again, I've highlighted the key things that a radiologist is looking for, which again, your pick up on so unilateral as, uh, stones, usually all renal stones. I said, It's lopsided. I've put in the key phrase going to green pain and also a key investigation Result your injections a trace of blood and then always ended with a query off. What your top differential is. Maybe if you got more than one differential so again you can see it's much shorter than s bar, but kind of ticks off the same, uh, same domains. Second example, Appendicitis on going to say this for a young female. Uh, because it makes a difference, you might choose different scans for, uh, all the all the other patients with different kind of ah, sex or a judge. So for a young female who's off childbearing age, so you do typically do an ultrasound because you or she don't want to irradiate the pelvic organs where they have their, um, ovaries. So ultrasound, lower abdomen or pelvis. Ta slash tv transabdominally flash Trans vaginal on the request is as follows to 22 year old female with a two day history off worsening. Right idea, Kasabian. Last menstrual period. Two weeks ago. Leg, you alert. 28 day cycle. No menorrhagia noticed. Menorrhea know PV destroyed on no pas. Medical history of notes on examination. Guarding right on your faucet is tender plus plus. Plus bloods are unremarkable on. Then I've got to possible differentials. Query, appendicitis Query Rockford of their insist because she has mid cycle So they they can mimic each other quite well in this age group on. Some consultants will advocate for always getting an ultrasound for these kind of patients because you never know. No point in kind of putting them on the surgery if they don't need it. So those are 22 classic example's, I say. So you've made your request. This is a bit. The things I've highlighted here are bit different. The referrals, um, slowed. So the first thing is, you need to make sure you get it done within a suitable time for him. You might have clicked urgent. But the radiologist everyone's everyone's got herget scans on the radio, just got other things to do. There might be doing ultrasounds. They might be reporting scans so it comes up on their list. But by the time they get to your skin to try and get it, which means authorize it, that's what betting that means. Um, it might be too late. So I'd say if you've gone urgent scan, definitely call budget on call radiologist, um, and speak with them and get vetted over the fun. That's after you make the actual physical request. Once they've accepted to do it on their takes it off. Now you need to get an actual slot. So you you call the radiographers, and that's the team. Is that technically, performs this gun on Awesome kind of. You know, I've got the surgeon scan. It's been better by the radiologist. Can you please tell me when it it might be able to happen? And they'll give you a time strong usually. So you think you're you're competent, but not yet. So they've given you a time snow. But you still need to check that it was performed. You never know. Maybe another emergencies come, come up on. They take priority. Maybe the porter's are in shorts of blood on dumb that there's not enough to come and take your patients, so you need to check periodically throughout the day has it been performed, And then once it has been performed really important, you will have images usually straightaway off that's been performed or no longer after the report might take some time, but regardless, it is your responsibility as a person who requested it. The team that requested it to check the image is on the report because one might miss something that the other has. Obviously, if you're, you know, finishing your ships, then definitely hands over to the person on call. By the way, I've requested the scan. It's gonna be performed. Can you make sure that you check the image is on the report. The final thing is again some obvious, definitely informed patient off the results. So, uh, you know, obviously there are exceptions, you know, But in general, patients had a stone. They're probably worried they've got no idea what it showed. You go and tell them, by the way, your scan showed appendicitis. So we're going to prepare you for surgery, that sexual, So definitely make sure someone goes and tells them side thing is managing rejection, and this is similar to referrals. So asked why it again if it's the wrong scan you selected. If you've had the correct information on the request, the radiologists are really good at just switching the scan tight. Have you go insufficient detail? You can clarify that over the phone, and it's really important for radiologists have the right information. I know what you're looking for so that they can you know, they can interpret the images with some context and to make sure they, you know, report on the thing that you actually worried about rather than everything else that might be normal. Maybe they want another investigation before you do a scan. And again, it might be hierarchical in the same way, either unacceptable or sometimes it's except, you know, it's It's local policy where, for example, of worked in hospitals where only a registrar can request on BET scans CT scans overnight. So what? The policy is in your hospital. I'm sure you'll be told us. Well, um, but that that might be a simple reason why it was rejected again. Also for their details. The consultants name. Um, I discussed it with your team as soon as possible. Let them know. So, you know, I put in this request. I told them this. They still rejected it. Uh, perhaps they said I want to speak to your senior, Um, and then they can They can call each other and short now. So just as a quick summary, make sure you prepare. Um, So make sure you know the rational Oscar, uh, on and you've got the correct skin tight. Then you want to do the actual request check. You got the right patient. My cassettes, um Andi include relevant information, often not make sure it gets done within a suitable time frame. And definitely check all those things we talked about again. If it's rejected, asked why and if not, you know, discuss with your thing. So that's the end of uh um obviously ah, we do these webinars for your benefit. So to try and improve them every time to try, make sure they're kind of adapted to what you think is best or what might help you the most. We really appreciate if you give us feedback specifically what you think was good or carry on, which tell you I'm doing what you want us to improve because we really do. You check them and try to implement, um, for the next weapon on, um, on it again, you'll get a certificate for, uh, sending us feed. But use either that you're code or the link off. Up. We'll put one in the chart as well. On again. It's It's something we also need for our portfolio. Or so would be very grateful to give us a fever. Um, I'll keep that slide up there for now. But if we got any questions, maybe up can, uh, make very lying in and being front with them and you Ready? Yeah. Okay. Who I think near. I tried Dance one. I love this question. So much of highlights How much jargon medics used. I wanted to put it towards you. A swell. So one person also, if you go back to the appendicitis, don't go out at the site. But the idea with the pen incised referral with the where you said right, that plus the pain plus plus plus right, this is tender story. So, uh, they asked the plus plus Plus, is that just the intensity of pain and is that pleasant out of three? They're just wondering because they thought when you ask the patient about pain. You rate it 1 to 10, and I filled out such a good question. That is such a good question. Uh, that is true. You can put, you know, uh, I'd say usually, um, when I mentioning. So let me just say I I was trying to use abbreviations and all that things because I don't want to many words on the slide. So fair point. Um, I think out of 10 rating pain. So I do Sometimes when I'm giving the history of, say, pain rated whatever is eight out of 10 or something like that. But when I'm doing the examination, so pain is they're kind of subjective measure. Tenderness is when you're, um Well, I use it for examination finding, So if they're kind of jumping off the boat with pain, then I put more. Plus, is is a big arbitrary on be subjective from, you know, the Referrer or examiners kind of point of view how many process you put, but sometimes it conveys a sense of urgency that, um that you need when you want a scan. Frequently. I don't know. What do you think If you go below 33 plus if you're having a joke, make all right. I've never seen anyone say one plus or two Plus so like, Yeah, I know. Yeah, that's it. That's a good point. Yeah. You don't really like when you when you say tender, you say tender. If you say really tender, it's really tender. You don't try and downplay your symptoms too much, just because unless there is like, um, clinical, Uh, like they're not sure what the problem is. And that's when you want to say, Hey, it's really obscure. We don't know. But generally, if you go down the park there saying, Look, it's really looking like this we need a scan to actually find image it, then. Ah, Then you do the second one as well, Actually. So you did go over this, but they just wanted ta go over again the pathway specifically for vetting and then getting the slot. So you talked to the radiologist and then you talk to the radio, Refer. You just go over that again. Yeah, sure. So you make your request on usually a computer system. So you opened up that patient records you've selected, which scan you want. You typed in what? Your request is like one of the examples. Um, and then you've selected the urgency except to request it sent. So the radiologist, they have a separate screen where there's a whole list of all the requests that everyone in the hospital has sent them on. What I was saying was that they've obviously got a long list to go through. By the time they get to yours, it might take a jizz. So, as I said, it's a request and not a demand. So they have to authorize it or better. So what you do is you've got another scan. You've sent the request. You need to make sure they accept to do it. So you call the radiologist, uh, on dumb. You speak to me. Say hi. This is the patient hospital number. I just want to, um this gun, uh, you just basically discussed the patient. If they want a bit more information than the request that Oscar it and then they'll say right. Okay, are vetted it. So they're happy for it to go ahead, but they won't necessarily know what time it might happen. They're not kind of handling that logistic side of it. usually, um, so I've got it vetted, but I still don't know what time it is gonna happen. I want a bit off information about how quick it is gonna happen. Then I would call The radiography is a bit of a process, so we'll accept that. But then you call the radiography for on they will give you a time. So sometimes they might give you a time slot. That's way too late. In which case, you kind of go back and forth calling the radiologist, saying they gave me a really late time. Is there any way you can bump it up? Because they do have ultimate, um, like, priorities, prioritization rights. But typically, you know, call the make the request call the radiologist called the radio for I don't have anything. I mean, I'll I'm You're very right in terms of the radiologist who's actually the radiologist is the doctor. The radiographers and know go to medical license. Ah, they have their own trading, and they they do. The radiologist does have lost, say in terms of when they go. Um, but no, I agree with everything you said there. There is one last question they had and then I might have a couple more, depending on how much time we have estimated time frame of getting things done. I know that's really subjective. Based on which ah, hospital Europe, could you give us a timeframe is based on your own experience. Do you mean, like, come from requesting to to get what do we say to getting the images? Backslash getting the report back because they're two different things on this is a specific example was between chest X ray ct MRI, which are very, very, very things. So is it varies. It really does very between hospital, the hospital. Um, so I've been in the hospital Bickley. I'd say, you know, between the imaging modalities, X rays, it usually happen the fastest, um then CT scans and then MRI's guns that that's what my experience has been. Some places you request an X ray, and it just kind of happens so quickly you don't. So let me just clarify for X rays, you don't need to get them vetted. Usually, as for in my experience, I've never had to bet on X ray. Um, but eh, so so with X rays, I don't bother calling the radiologist I called the radiography. Only if it's a portable chest X ray on. I'm Obviously that means I've been in a situation where the patients to one world to come down for an X ray to the department, and I need a portable one as soon as possible. So I call them for that, um, on you have X rays are pretty quick, like within a couple of hours. Usually, um, sometimes they even do them sooner than we want them to. Uh, so in that case, then I I do let them know and say, Can you make sure you do it at this time? Uh, but yes. So that's what X rays see. Teas is variable, but you tend to call them and try and get it done. CT, they would say, Typically done on the same day. Um, even cause they can still do those kind of things overnight ultrasounds or bit different? Same with MRI's. They tend to have opening hours, so ultrasounds need to actually be done by radiologist or trained radiographers and that usually between, you know, 95. So if it doesn't happen on by five o'clock, it's not gonna happen. that day is gonna happen the next day. Ml rise all if I take probably the longest. I mean, sometimes they they'll say next week. It just depends on how many slots they have available. Uh, but you you you wouldn't usually be requested. Not many. I'm all right. On your way. So, um, yeah, I'd say if if you kind of chase them there, they will get done within a reasonable time for him. I will. I will agree. The MRI's of the bane of my existence. I mean, ah, sometimes it's so weird. People are just admitted because they need that MRI like query quarter. Quite a case is under the medical, so it's Ah, yeah, the waiting times. Do you get a little bit difficult for them? Um, the only thing I'd want to add about vetting X rays is the ones that require contrast. So gastrograph and follow through because they're giving, like, sometimes they do need that vetting some based on trust guidance. That's true. That's true. Um, what else? Uh, so do we have any more questions by the's guys? Another question for SETI's. You'll likely need their renal function right. Are there any other scans that typically also need an up to date biochemistry. So renal function is important for Seti's. With contrast. Yeah, on I think it's usually they want you tearful above 40 with 45 MRI's. Also again, they use a different contrast medium that, um, I think, typically either for more than 30. But we'll you'll have to double double check that, um, things without contrast don't usually need an up to date biochemistry. Of the only other biochemistry that you care about is your beat HCG and pregnant ladies, I assume with the, uh, Lien, Well, they well aren't They ask anyway, Like with abdominal X rays, for example, though there's usually so when you make a request, sometimes they're all, um, there's like a menu you have to go through. So, like, is this patient pregnant? Yes. No unknown. Um, on then, you know, sometimes sometimes hearing it will be like, when was there last menstrual period and you click a day or something like about so whatever they need to know, they will have it on the automated system. Got it. And high on a sec, I'm seeing another question for the spending. All done. You shift. Uh, we were in a hand over mentioned. Okay, so this is to do with ah, when you request the scan, uh, out of ours. And actually, I had a couple of questions about that as well, because I think that's really important, but the expense. Because if this if you request, it's gotten it's not done. Your shift. What you meant to do? Do you write off in the hand? Over. Dimension it somewhere. What do you do? Um, So ah, if you know, the scan isn't happening, That day is gonna happen tomorrow. When you're back on, then you know, you can just sit tight. There's there's nothing to 100 where? I guess if you know that the scan is gonna happen that day later on or before your next, your next on the next day or whatever it is, Um, then you should definitely speak to so this. I don't know how much experience people med students have all the kind of handle the process. Is that happen? Uh, but usually around five o'clock, there will be, um, barreled or cools to the poor. If one who's on would cover on, do you will be waking one of those calls and you'll say hi, this is the background again, similar to explore. This is my patient. I need you to trace this X ray. Make sure you look at the scans and tell them what to look for and what to do if the scan shows a particular abnormality. So you need to give clear plans to your if one's it. The quality off these handovers you notice start off with one is know as great as you know, a couple of months into the job. But also, don't be afraid of someone's handing that over to you. Say, what exactly am I looking for? And what should I do if it shows this because you need a plan? If it shows something abnormal, you can't just kind of sit there. And you know, I wonder what to do, especially if you're the five GM denying at eight PM tonight. Because then if the scan gets done over night and you're handing that over to another person, even requested the scan on, you know a thing, then it's so painful for the guy over night. You know, that's a good point, actually. So if you know a scan, for example, is gonna happen overnight, so it won't even be the person you're handing it over to you. You still have the hand it over to them. So you say hi. This person is gonna have a scan overnight. It's not gonna happen during your shift, but make sure you please hand it over again. So the night person. Exactly. Now there's, um there's a couple questions I had Ah, about just to try and make it mean a mirage. Jumpin when I meant to shut up. But, um, what about when you're requesting things overnight? Is there anything else to reconsider? Maybe regarding vetting or what have you? So yeah, um, so as an example that I do I am, uh, what's in the hospital? Where, uh, you as below red She con request on bet? CT scans, for example. Um, on some places will have, uh, kind of there's an outsourced, um, Grady ology kind of, ah, organization that you call, um, through the switchboard. So again, you need to know what the system is in your hospital. Is it the same radiologist number as during the day or on call Radiologist, or is it this next general number that you have to call through switchboard. So once you know, then you can make that call. But they will if it's basically only arranged. That's allowed. You're mean. I wouldn't bother Kind of wasting your time calling your regimens to do it. They'll call because they'll ask for than your name on your position. So, um yeah, that that can sometimes be a little bit of a snow Again. It's frustrating, but that's just how things work. Yeah, dependent backside. All right, so nobody said I'm down to my last question. I'm not allowed anymore. There's gonna pull me off off the air I'm having I'm having difficult starting the last question. Make you know what? Why don't we go with the the most difficult one, I think. Which is getting very fun for you. Imaging in unwell patients. I e. Though they're demented, known, compliant. Something like that. Let's say you want to do a CT scan for someone in there, just no holding skill where they got a tremor, What do you do? That is a really good question, and it's, uh, it's something that is not easy to also, I'm going to say, um, this has happened a few times. Uh, you need to think about the technical difficulties the patient might experience with taking us having a scandal. So it's not just, you know, dementia and that kind of thing. It's also things like Are they able to lay down flat? Still, if they've got loads of pulmonary edema, they're not gonna be able to breathe, for example, So just last one thing to think, Well, you your seniors basically will decide if you they'll they'll notice that this patient is not going to sit still. Sometimes they will send them down, and they'll just get sent right back up saying we couldn't do the scan because they're too demented or, you know, um, sometimes those patients have kind of intervals where they know as agitated. But other things that you kind of used, although I would discuss it with your seniors, certainly hasn't had one is, uh, you know, something to just calm their nerves a little bit just before the scan, Uh, something, something to help them relax. Uh, again, I wasn't one. I wouldn't have been comfortable to make that decision myself, like I would. I would not make that decision on my side. I love it. We have to. Surgical Junior is discussing how we'd give a lot of deadly patients with no geriatric. They didn't say that. That's exactly like I really think, you know, there's something, but no, even even even sometimes a bit of a crude as a scientific patients who are. You know, you've got a regimen going and you just give them a small PRN dose Well, within the guidelines, um, and send them down for the skin. Sometimes that's what you need to do exactly, very, very true. And, uh, nothing to mind would be that the, uh, hospital guidelines in terms of who is actually allowed to give that medication. And where do you get on the ward to give it in from the CT scan or what have you? I seen Iraq. Which means I think we're about pulled off stage a lot. Just about No, thank you very much. I've been fasting. I think that was I think this was one of our most anticipated webinars, and you definitely lived up to expectations and thank you both very much for your time. We've got lots of lots of very appreciative comments coming in. Somebody's just called both of you. Brilliant. So guess you're doing something right. A living, very charitable. Uh, well, that all right? I just wanted to mention actually, really sorry Neuralgia. I know. I know. Just, uh, just for the referrals. There's an article on there's treats, shoots which neurologist put up on the chart. In case you haven't seen that, um, cheat sheet is really useful. So it breaks it down by specialty. The important things you need to let him know. And there's also an article for requesting scan scans again. Just put it off on the chat. So I should have mentioned No, that's fine. That's all in the chat on guys. Keep your questions coming. We'll get a Fatima lab to to continue answering them until, until they're tired of odds. Were in question. Fatima Definitely. Great. Thank you very much, guys. Thank you by dryness that the next webinar just going to our Facebook page on two events on click going were interested so that you're notified when we next have webinar coming up. All right, Well, thank you