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Hi, everyone. Thanks for joining. We're just waiting for a couple more people to join the talk. Um And we'll get started shortly. Hey, everyone and welcome to our first episode of the surgical series. This webinar is part of a series designed for new doctors and medical students who are considering a career in the NHS. Today's topic is a day in the life of AF I one in Surgery about BSA. So our aim is to build a more connected community for the international medical students in Bulgaria and to make it more accessible for students to reach out for help and support and we understand the unique challenges faced by international medical graduates studying and graduating from Bulgaria. So our goal is to simplify the transition to professional practice and equip you for your medical career. So I'd like to introduce our presenter for the surgical series which is Doctor Sarana. He is a foundation year two doctor having completed his medical training at the University of East Anglia and approaching the end of his foundation training in East of England. Please join me in welcoming, welcoming doctor Saran to the stage. Hi guys. Uh Thank you. For coming tonight. Um, so like I said, um, my name's Doctor Saran. I'm one of the, um, foundation year two doctors. Um, I'm currently working in the east of England in Norwich. Er, I, er, did my training in the, um, at the University of East Anglia in Norwich as well. So I've just stuck around for a couple more years. Um, in terms of my surgical experience, er, I've done four months in my F one on general surgery and I just completed four months on vascular, um, in my first rotation of F two as well. So, um I'll just be taking you through what an average day um, for a surgical fy is like. Um, so that brings me on to what will be covered today. So I'll be taking you through the patient list, um, prepping the notes, what the ward round is like on surgery and how to take notes, uh, effectively uh common jobs that you'll be expected to do after the ward round and preparing for the next day. So it's a whistle stop tour. But if you guys have any questions, um, then you know, if you save them to the end and we'll kind of go through, er, anything at that point. Brilliant. So if we go to the next slide, please. So the patient list, um, before I started work, I didn't really have any, any clue about how, um, I was meant to prepare for ward rounds. Um, on surgery. So the way it works, it's, it's not just in surgery, but um, so the surgeons put a big emphasis on the patient list. So it's like it says on the screen, it's a comprehensive list of all the patients under that relevant specialty. And what I mean by the relevant specialty is, um, you know, you don't always have um general surgery as one big thing. So you might have general surgery, colorectal vascular urology, that kind of thing. So, um, depending on your trust and your hospital and how everything works in that particular hospital, um, it might just, it'll be kind of, um, tailored to, to that, um, department. So what you'd be expected to do as an fy at the start of the day is just to compile a list of all the patients that are currently under that specialty. So it, it will usually be as a word document and you'll, and there'll be some kind of system to check, um, all the patients under that specialty as well. So what you do, you go in at the start of the day, open the list, open the, the patient finder system, um, make sure that every patient that's under the specialty. So for example, let's say general surgery, um, is on the general surgery list. So the list is basically a quick way to, er, kind of check people on the ward round to make sure everyone's been seen and, but you can also kind of put uh recent blood test results and investigation results. So when you look at the list, you can kind of get an idea of what's been going on with that patient and what's happened recently. Um So the next point I may make is don't forget any outliers. So outliers are basically any patients that aren't on, that may not be on the typical surgical wards. So if, if, if it a as an example, you know, the general surgery ward is known to be ward A and for some reason, you have patients um on wards B and C, uh the patients on ward B and C that are under your team would be classed as outliers. So it's quite easy to forget these patients, but make sure you um don't forget any outliers if you're um, you know, uh kind of making the list in the morning. Um So depending on your trust, there may have systems in place to, um, you know, make the list automatically. But based on the hospitals that I've worked in so far, it was a manual job that the F Ys had to do in the morning. Brilliant. So, next low, please. Great. So this slide here, um is it just shows you what the average, um kind of note looks like for a, um for a ward round. Um I'm just gonna move on to the next, next few slides quickly, but then, well, I'll come back onto this once I've explained how to do note taking. So once you've done the list in the morning, you may have a bit of time to prep the notes. So I think the thing with surgical ward rounds is that they can be very quick, they can be very intense. So if you've done some preparation for the w er for the notes beforehand, it just means you can do the notes um in time for each patient. So what, what um prep preparing for um the Warra means is uh it's just putting in information that um you can kind of get the um kind of get the information for so you don't have to be writing it during the ward round. So things like that can be the new score. Er, so that's the um you know, early warning score, er, recent blood tests, um, recent investigation results and summary of other relevant em entries. So this could be from other, other teams such as medical teams. It can be from physiotherapists, occupational therapists, that kind of thing. So anything that you think might be pertinent for the ward round, um just write it in, er, you're not expected to write out the full entry again, but um anything that you, that you think might be relevant, just write it in quickly, er, and then move on to the next patient. So what you need to do is leave space for the actual ward round entry as well. So on the ward round, you'll be expected to scribe what the um person doing the ward round is saying to the patient. And just, just so there's a um a good record of what's happened and what's been discussed and don't forget to add a patient identify sticker at the top of the page. So uh that's and that's ob obviously doing electronic note taking in which case, um it will kind of populate that information already. Perfect. So, um I think the next few points are from the previous slide. So, apologies for that. Uh brilliant next slide, please. So the ward round on surgery is usually senior led, so that u usually means um at least a registrar is doing the ward round, but a lot of the time consultants are quite hands on with the ward round. Um Like I said, they can be quite quick, they can be very er quite intense. Um And you know, they, they, they kind of um hit a few points and you just have to make sure that you kind of capture the important information. It's one of those things when you start work, you, you're still figuring out kind of what's important and you maybe, maybe tend to write down too much. But as you, you guys go through um a surgical rotation, you'll get a bit better at um kind of picking out the most important points. It is OK to use shorthand to speed up the writing provided everyone understands what the shorthand you're using means. So I've just put a few examples of common shorthand that I use, um which I've seen other people use as well. So, um W slash R is Ward round, er, B slash G is background, er, ABX for antibiotics and R slash B for review. Um, when you, if you guys do um, kind of, er, get a job in the UK and you look at other people's notes, you can kind of build up a, you know, a little, er, kind of collection of short, er, common shorthand that you might also decide to use in your um er, in your note taking. So, like I said, you make a note of the kind of conversation between um the doctor that's or the surgeon that's doing the ward round and the patient, uh they will examine the patient hopefully. So you'll, you'll be able to, you'll need to write down the examination findings. It's very important to, you know, make it obvious when there's things like pain, um any, you know, any scars and things like that. Just because um you know, it's, it, it's, it, it's good practice for record keeping and also for whatever reason, if people have to refer back to the notes, it helps to build like a timeline of what's, what's uh happened, then that's pretty important and a few important points as well. Um Don't forget to put a date and time on the, er, left hand column. Um, because th this is a, er, bug bear of many um, er, kind of, er, medical professionals, er, especially consultants when they see notes without a date and a time. Um, they, they can get pretty peeved just because it's, it, it's, it's very important to know exactly when a, um, a note was written for whatever reason, let's just say worst case scenario something. Um, you know, goes to a coroner's court. It's important to have a good timeline of events and you'll see a lot of people just put a date and no time. Um, but really get into the habit of putting a date and a time er, on that left hand column. So, um it doesn't leave anything um up in the air and then once you're, once you're done, you sign your name at the bottom, um and you put your grade and maybe your bleed number if you have one. if, if we could go back to slides, please to the um, example. Um Yeah, perfect. So I'll just talk to you guys through this um, example um note here, um, that I just mopped up. It's, it's, this is what I do. Um Everyone's got their own kind of way of doing it. Uh This, I, if you, if you do it this way, then you kind of capture all the um kind of important information. So, like I said, on the left hand column you've got the, the date and the time, er, it's very important and then on the top line there, er, you can see I've written wr, so that stands for ward round and then what I usually do is put a colon after that and then after that you put the name of the person that's leading the ward round. So it'll be the name, name of your, um, registrar or consultant and then underneath you uh put a little triangle. So the triangle means er, diagnosis. So at that point, you list all the kind of relevant things that has been going on in that patient's journey in this admission episode. So for example, I've put here number one acute cholecystitis and number two cholecystectomy on the 20th of February. So below that, what I usually tend to do is write the bloods. So it's important to date the bloods. So the bloods um are from the 20th of February. So, uh it's just got a list of all the most recent blood tests. So if the numbers are in the brackets, that's the er kind of result that came before the most recent one. So maybe on the 19th of um February, the white cells were 12.8 and they've gone up to 17.6 on the 20th, uh and the same with the hemoglobin. So on the 19th of February, it was 100 and four and it's dropped to 98. So it, this is stuff you can do whilst you're prepping the notes because pe you know, the your surgical registrars consultants might ask you not just for the most recent blood test, but um what the trend is just because that kind of helps to build a better picture of um the current condition of the patient. So, on the right hand side, I've um I've written the new score. So the news is important because it gives an idea of how the patient's doing. So, um what I tend to do is I write the, the kind of um the different a uh kind of aspects of the new score that are kind of er scoring for the patient. So um for this patient, the, the new score is two because the BP is a little bit low and they're slightly tachycardic. So you can write the whole thing out. But if, if, if the rest of it's normal, then um I just kind of join the ward round tend to say uh just the most important P points and you know, say the rest of it's normal, say below that is the actual notes from the ward round it um itself. So what I always tend to kind of start by saying, you know, if the patient's lying in bed or sitting in a chair or, you know, if they, if they were mobilizing and they've kind of come back to their um their bed space. So it just because it kind of gives an idea of how the patient's doing, uh, especially, you know, post surgery. Um, you know, I, if they're, if they're just kind of bed bound, it, it may suggest they're not doing too well, but if they've been able to sit out in their chair then it shows, um, that they're kind of starting to mobilize again. Um, and then the common things that, er, surgeons ask about during the ward round is pain, whether they're eating and drinking, er, whether their bowels are open and whether they're, there's any nausea or vomiting. So I've just written here reports and pain around the port sites. Um I put E plus D for eating and drinking, uh bo for bowels open and denies N plus V for nausea and vomiting. So I think those are things that people would understand if you, if you wrote them, a lot of people use that shorthand, er, it just speeds up your note taking as well. Um, and then obviously, if, if, if there was anything else that was mentioned, I would have written that as well. So that brings me on to the examination findings. So the for, for a general surgery ward round, let's say the most common examination will be an abdominal examination. So what you can do is just to speed up the, um, kind of, er, note taking for an examination for examination findings is draw this diagram here. So it's basically a hexagon which represents the er abdomen. And so, you know, the different areas of the hexagon corresponds to um the different areas of the abdomen. So, um you know, you got right upper quadrant here, epigastrium, er left, upper quadrant. Uh you got the flanks here, licus, um the iliac fossa and then the er s pubic area and then you, you, you denote the um umbla with a dot here. So any scars I just tend to draw, draw them out just as, as the li as you know, lines. And then um you can put like almost like suture lines through them as well to indicate that they're scars and then I dunno pain with a cross. So um for best practice, I always think it's important to write what the um the diagram signifies. So if you just dr drew that diagram without explaining what the, the lines and the crosses mean people might not understand it. So that's why I always, you know, write um some pain in the right upper quadrant as indicated by the cross and three port sites, which means that people don't think it's just a um a moody looking face um as opposed to, you know, examination findings. And then that brings me on to arguably the most important part of uh the entire er no entry and that's the plan. So one thing I'll say about the plan is if you're unsure about what the plan is always double check with the person doing the ward round. It, it will just take, um, you know, a minute or two just to clarify the plan if you didn't kind of get it properly. But it just makes your life a lot easier because if the ward rounds finished and you're not sure what the plan is, the nurses will come up to you and they will ask you what is the plan. And if you're unsure, then you just, you've just gotta contact the, you know, the registrar or the consultant again. Um It's just easier to catch them in the middle of the ward round whilst they're there to, to double check what the plan is. So, you know, make it clear that um you know, you're writing out the plan and then just number them. Um you know, just um you know, want to whatever so common, this is just a kind of basic plan um that you might write down during a surgical ward round. So continue IV antibiotics. Uh I vi which is IV fluids, um ee plus D eat and drink and immobilizers able. Um So what I, what I tend to do is just follow along with the person doing the ward round and just write the plan in. Um you'll, you'll get better as, be better at it as you do it more. But I in the, the f in the, you know, when you're getting used to a new award, it's just always double check the plan just to make your life easier. Well, and then like I said, you sign, you know, you sign your name, put what specialty you are, what grade and then write your bleep number. Perfect. Um, if we go on to the next slide, please. Great. So after the ward round, that's the time to do all the jobs. So common jobs that come up are bloods, cannulas ng tubes if you know, um, if you're on surgery, er, ordering investigations, vetting and chasing investigations and clerking. So it, depending on your hospital or your ward, um, things like bloods can be done by phlebotomists. But sometimes, and the, um, the phlebotomists do a ward round in the morning, um, usually before the ward round starts. So the bloods for that day won't be back in time for the, for that day's ward round. But, um, you know, if any issues arise then you can, you know, always, um, you know, don't, er, escalate to a senior, uh, a bit later on but sometimes bloods get missed. Um, for whatever reason the phlebotomist can't do it. So that's either because, um, they miss the bloods or the Cannulas, um, and that gets escalated to, um, to doctors. So that's a common thing you might have to do Cannulas. They, um, unfortunately they fall out all the time. They, um, they stop working for various different reasons. So you, you will be expected to do Cannulas. Um, routinely, um, throughout the day. So it's not something you have to go looking for. Um, nurses will usually come up to you and tell you, uh, the cannula for, um, ex patient has fallen out. So you'll have to, uh, put a new one in ry tubes that they happen less commonly. Um, but, you know, if a patient's got bowel obstruction, for example, um, and they don't have an angio tube in, you'll need to put an NG tube in, um, as a matter of priority. So, um, it is a skill you will have to, um, get used to doing. Um, so with, with NG tubes, it's, there's obviously different protocols if it's a, uh, a feeding tube as opposed to a ar tube just for decompression, um, but II won't go into too much, uh, into that too much. Uh, now, um, ordering investigations, er, is, is very common. So whether that's ordering blood tests that were, weren't potentially done, um, you know, in preparation for the ward round, er, scans. Um, you know, eee even reviews by other specialties that can be done on, um, this system called ice, which is, um, where you, I think it's quite, quite a commonly used, um, investigation, er, system across the UK. Um, and especially for scans, some, some of them will need vetting. So, vetting is basically a process where you speak to the radiologist, um, after you've put in the request and you're basically explaining why you want the scan. So in hospitals where, you know, the the scanning capacity is limited, um you can imagine the hospital's always busy. 24 7, there's always a lot of radiology requests, but there's not the, the, the time or the capacity to do all those scans. So, um the radiologist, um you know, depending on the hospital, actually, you may need to vet the scans to um allow the radiologist to prioritize the most important scans and, you know, use the resources accordingly and appropriately. Um So that's something that um as an fy you'll be expected to do. And, you know, even if you've gone through that entire process, you know, you've booked the scan, you've vetted it, there's no guarantee it gets done when it says it when, when, you know, um when the, at the allocated time that's, you know, usually due due to delays, um you know, um more urgent kind of situations arising from, you know, er, from Ed, for example. So you will have to chase, you know, you will have to call the um imaging department to try and find out when the scans going to be done. So that's quite a common job you have to do on a daily basis. And um II, one thing I forgot to put in as well um calling microbiology as well. That's a very common job um for an fy. So there, there are, you know, there are kind of guidelines available um, to guide use of antibiotics. But sometimes, you know, uh, patients get put on antibiotics and they don't work and it's, it's your job as the fy to call up microbiology to, um, get their advice. Um, and then finally clerking as well. So, um, I think there's a, I'm doing a talk at, um, in the future about surg clerking. So I'll touch more on the exact process there. But, um, yeah, that's, those are kind of common jobs on a daily basis. Perfect. And the next slide, please. So, you know, if, if all goes well, um you know, you'll do your jobs that were generated during the ward round. You've, you know, you've um you've taken any bloods that were outstanding, you've put in all the cannulas, er, you've booked all the, all the scans that need booking, you vet them, er, chased them and, you know, you, you've done all your jobs. So at the end of the day, what you need to do is prepare for the next day. So the next day, um usually comp preparing for the next day, usually comprises of booking bloods for tomorrow. So not every patient will need daily bloods, but if someone's been unwell for, you know, a number of days and you know, you're trying to f um kind of gauge their response to things like antibiotics, it's important that they get bloods booked in for the next day. Um and then handing over any urgent scans or blood that knee chasing to the on call team. So what I mean by that is, let's say during the day, you were asked to see an unwell patient. So sometimes this can be very late in the day. So you you may have gone to the patient, reviewed them, decided they need a, you know, a fresh set of bloods um and an urgent scan. And by the time you've assessed them, you know, you may have taken the bloods and sent them off and you've confirmed with the imaging department that the scan is going to be happening later that later that evening. So it's perfectly ok for you to go home once you've done the initial assessment escalated to a senior. Um but it's important that someone chases up those scan results after you've gone home. So there will be a dedicated on call team um that evening. So what you do at the end of your shift, you call the on call team um and do a handover with the patient details, um and anything that needs chasing. So, uh you call them up and say hi, this is doctor Savana. I'm, I'm calling from the general surgery team, er, at the Nool Noh Hospital. Well, you don't need to say that because they won't be working in the same hospital as you. Um, and then you say I've got, I'm just calling about um, a patient that's under our care and then you give them the name, date of birth and hospital number and then after that you say, um, kind of give like a brief, you, you do something called an SBAR, um, which I won't touch on too much today. Um, but it's, it's basically an effective way of handing over. Um, and then you give them a quick outline of what's happened and anything that needs tracing. So, um, please, could you chase the CTA P results and the, er, the blood tests that we've done and, you know, um, er, kind of um, treat them accordingly. Um, and then the final thing I've written is, um, um, you need to add any new admissions to the list if, if, if there's time. So, um, during the day, the team that's on call in your hospital, they'll admit new people under your, under your team potentially. So, um, well, just going back to the list that I mentioned on the first slide, you'll have to keep that updated. So you can either if you know what patients have been admitted during the day, you add them to the list uh, in, before you go home. Alternatively, you can also do it the next morning before you prepare for the new day. Um, so, yeah, that's just a general outline of um, a day in the life of a surgical fy. Um, I think one thing I'll just quickly mention is um, er, the kind of roles and responsibilities um at like an F YT level. Um So I know um if you're studying abroad and you come to the UK, um you know, you, you may kind of work with a full registration so you may go straight into Fy two. So, you know, the difference between Fy one and Fy two really depends on the hospital you work at. So um the first hospital I worked at in F one was a like a small district general hospital. So there was quite, you know, it, it, there was a fair distinction between Fy one and F YT. So Fy ones do everything that's mentioned. Um you know, um like on, on, on this presentation, um they do nights and on calls, but when, when you do those kind of shifts, you're just covering the wards and, you know, reviewing patients that are sick um and escalating appropriately. But if you're an F YT, um you may have to, um, you take the, er, the surgical sho bleep and you'll be called from A&E with referrals to your team. Um So that is kind of a responsibility that you may have to kind of um, er, er, have as a, as an Fy two in some hospitals having said that it, it really depends on the hospital. So in my current hospital, an Fy two and Fy One do the same, same job without any difference. So I don't take referral, I II didn't take referrals um as an F two. I, in my, in my, in the big teaching hospital that I'm working at, at the moment. Um, but it really depends on the hospital. So, um, you know, it's, uh, it, it's, it's obviously quite hard to tell to get there. Perfect. So, yeah, that concludes, um, the kind of, er, a general day in the life of the surgical fy. Um, I'll just hand it back to pfizer. So before you transition to the Q and A session with Doctor Savana, I'd like to kindly ask for a brief pause to take a moment to fill out our feedback form. You can either scan the QR code on the screen or follow the link in the chart. The feedback form is valuable for our presenters who have contributed their free time and resources completing this form will help enhance the doctor's portfolio and also enable us to continue offering these talks are free of charge. After a few minutes, we'll move on to the Q and A section. So if anyone has any questions, please feel free to ask them now, just while people think of questions, um I just wanted to ask um just, just one question. So I know that uh when handing over jobs, um of course, like things come up throughout the day and sometimes you're not able to do everything. So things get delayed and you do hand have to hand over things. But I know that there is also an etiquette of what to hand over and what a good job to hand over is and what a bad job to hand over is. So, uh, I was just wondering if you could, um, maybe comment on some, some handovers or some bad handover etiquette. Absolutely. So, this is quite a common gripe that, you know, everyone here will experience at some point you'll get handed over something really, um, like, not annoying, you know. Um, but it, it's something that doesn't really need to be done, you know, that evening. So something that's, you know, very important to be handed over. For example, is like the example that I used if someone's unwell and there's a, an important blood test result or a, um, a scan where, where you need to know the results of that investigation. So you can, um, you know, either alter the management that evening or actually start, start some treatment. That is a kind of important thing to hand over. Things that aren't good to hand over are routine bloods. So for example, let's just say the phlebotomist has um, not done the blood test that morning and the blood test gets done, gets done a bit later on in the day if you're not expecting anything to, if it's just routine bloods and it's not going to affect the treatment at all. Um And you, you expect them to be um, normal or unchanged. Um, don't have the routine bloods. Um It's just things that are very urgent because the on call team they, um, it's kind of like a, a, like a skeleton staff almost. It'll be, um, you know, one f, one, maybe one F two, um, some level of sho and re, er, registrar. Um, they'll, they'll have the responsibilities of looking after all of surgery that evening or overnight. So, they've got very limited time. So if, if they were, they don't have time to be chasing lots of blood test results that, um, that are ren, for example. So just, um, you know, uh, things that are kind of ill patients or unwell patients. Thank you. Um, another question that I had was, I know for some specialties, um, the F ones don't do on calls, uh, just the F twos do on calls. Um, so I was just wondering, is that the same for surgery? So if you're an F one on surgery, do you work out of hours? Um, or is that only if you're an F two, the way it works really depends on, um, where you, um, where you, where you're working. So it's very hospital slash location dependent. So in my, in my hospitals, um, even as an F one, I was doing general surgery, uh, on calls, I was doing general surgery weekends and general surgery nights. So, um, I've heard in London F ones don't do, um, you know, out of hours, er, such as nights, er, particularly until they get to the ft um, stage. Um, but even then, uh, even if you're doing, um, out of hours as an F one, like I mentioned briefly, your, your main kind of, er, role will be covering the wards. So any, anything that goes wrong overnight on the wards, um, you'll be expected to, er, kind of go there, do your initial assessment and, um, escalate accordingly. So it may feel like quite a daunting prospect um when you first start doing these out of hour shifts, but it's important to realize that you're not alone. It's um you still have um kind of, er, members of the team that are further up than you. So if you're unsure about anything, it's always good to ask and escalate and, um, and you know, instead of trying to deal with it all yourself. Thank you. Does anyone else ever have any questions? I think there's a question in the chart. Ok. Yeah, I've just seen it. So it says, hi doctor, thanks for the talk. Could you talk a bit about what the best ways to prepare before the job starts to be in the best stead for a surgical F I rotation? Could you also touch on some common pitfalls from your doctor's face and how to avoid them? So, um in terms of the best way to prepare for um a surgical rotation, it's um, you know, it, it's, it's quite common sometimes to have a, if it's um you know, your first job, er, in that kind of, in that year, I, it's quite common to have like a shadowing week, er, like an induction week. So you spend a bit of time on the wards, potentially. So I think getting to grips with, you know, um, how the system works because as, as a surgical fy you're not doing, um, you're not always doing, um, er, kind of surgical related things or medical related things. A lot of the time, it's kind of sorting out the admin side of things. Uh, like I said, like, you know, chasing, um, chasing results, um, er, chasing investigations, er, getting other, um, er, departments to come and review your patient if there's a medical issue, for example. So you're kind of getting to grips with how the, um, the admin side of things works. That's really important and, you know, just, um, kind of common surgical emergencies that could, um, you know, pop up. So, um, you're not, you're not expected to do, um, kind of treat the patient completely by yourself. So your role is purely for the initial assessment and, um, you know, just knowing that you can contact your senior. So, you know, being comfortable with your kind of a, to e emergency assessment, that's a very good way to, um, kind of prepare, um, for your role as a surgical fy. Um, and then just, you know, um, making sure you're fairly confident with, um, things like bloods, Cannulas. Um, that's, that's, um, that's kind of the thing to be doing on a daily basis. Um, common pitfalls, new doctor's face. So, I guess it, common pitfalls is, um, you know, may maybe not escalating things when things should be escalated. Um, in your first couple of weeks you'll always, um, be faced. It's, it's a very steep learning curve regardless of, you know, what, where you've done your education. Um, how good you are. So you, you know, you, it's always good to ask all the, um, all the questions you have at, you know, in the, in the first couple of weeks. So people, you know, might be a bit, um, scared to ask and then it kind of leads to mistakes, don't worry about, you know, any questions you may have. People are usually quite um sympathetic um, in the first couple of weeks and, you know, really take the time to learn, um, how, how everything works. Um, so, yeah, just, uh, just ask, um, if you're unsure, I'd say that's the, probably the best way to avoid, um, the common pitfalls. Another question is, um, how can you improve your CB or portfolio for the F I surgical rotation for, er, if you're interested in surgery? It's, um, you know, there's, I'd say there's a couple of ways um, of kind of improving your portfolio. So the first one is, er, getting involved in audits. So it's, it, it's a very it's quite an easy thing to do. Um, generally when you're in Fy, because, uh, there's always lots of audits going on, especially in surgery. Um, I'd say with audit audits, it's, um, you know, it's, it's about maximizing the, um, the kind of impact you have, uh, with the amount of work you do, some audits are very kind of painstaking in terms of the data collection process. Um, what you want is something, um that's, you know, um not too much um in the way of data collection and things like that. So, um and then I will say one thing is it's not just good to do one audit if you re audit the same one, just to, er, for kind of maximum, maximum points for applications, er, that looks good as well. And if you have the opportunity to lead the project, um definitely do that as well. And then a second way is um if you're interested in surgery, you'll need to build up a surgical kind of uh case portfolio. So, um the best, the only way to do this is by going into theater. So as an fy your kind of main priority is on the, on the ward that you may um er, kind of be asked to go into the theater sometimes if they're short staffed. Um if the wards are looking fine after a ward round, um you know, as long as you've double checked with your colleagues that there's enough cover on the wards. Um You know, it's, it's absolutely fine for um one person to go to theater to get their cases up. Um, but it should never be at the um expense of your clinical priorities. So just to add here, um I'm actually uh providing a ta a talk on CV and portfolio building on the first of March at 10 in the morning Bulgarian time. So if you wanted to join that talk, we're gonna go um more into detail on what you can do as students to improve your C CB and how, how to build your portfolio as medical students before coming to the NHS. And then once you're actually working and applying to specialty training, so the different specialties. So core specialty training, internal medical training and all of the different specialties and, and what you can do now. So yeah, so join us on Friday for that talk. Moving on to the next question. It's what are the adequate and procedures of escalation in essence, without looking incompetent and ruffling any seniors fevers potentially for a handover is don't ever call without knowing exactly what you, what you kind of want to hand over. So, um you know, if you imagine whoever you're handing over to might be having a really busy day um just for their, just for everyone's ease if you have all the information on hand um before you call, that is the best way to hand over. So um II won't go too much into this now, but I'll potentially cover it in a later talk. Um the kind of handover kind of gold standard to use. So it's called sbar. So um Sbar stands for situation background assessment recommendations. If you use that sbar, um then you will cover everything that you need to cover and you kind of won't ruffle any feathers, so to speak when you, when you were calling your seniors. Um Yeah, II think, yeah, just ii it, it just being systematic about it is the kind of best way to ensure that you do the most effective handover. Sorry. Um, just 11 quick thing as well. Um So in terms of the uh who you escalate to, um, it, so the, the kind of general rule of thumb is you escalate to the person above you. So let's just say you're an fy one. you, you'll escalate to your sho um, and then they might escalate to the, to the registrar from there. Um If for whatever reason, the sho is unavailable, you may have to escalate directly to the registrar. Um And then depending on how, how, what your department's like, you can escalate certain things straight to the consultant themselves. So when I was an F one in general surgery last year, um the consultants told us, um, they used to do the ward rounds most days and they, they gave us their phone numbers and they said, you know, any issues just tell us directly. So, um, you'll kind of gauge how to escalate things when you start work because it's very department specific. Does anyone else have any questions? It doesn't seem like it. So I'd like to say a big thank you to Doctor Savana and thank you everyone for attending. Thank you, Evelyn for joining.