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Hello, everyone can, can everyone hear me? Yeah, we can hear you. All right, I'll uh whilst Luke's just loading his powerpoint. Uh Good evening, everyone. Uh Welcome to PMS launch session on me. We're thrilled to have Doctor Luke Thomas an F two doctor and then you graduate here with us to discuss advanced life support. Doctor Thomas will guide us through what a involves. It's important to the NHS and how to get started in this field uh without further ado if you just wanna get started. Sure. Thank you very much. Um Hey, guys, like uh like you heard my name's Luke. I'm a local F two and I just wanted to talk briefly about the A LS. Uh I just recently passed the A LS uh a few weeks ago. So I thought it would be a good idea to um kind of share uh some things and make you guys aware about it and why it's important. Uh So before we do that, I want you want to go through uh a quick case. Um Just so we all kind of woken up. Um If anyone has any questions saving until the end, uh we'll go through some there, but this is a generic, this is a generic case uh that you will encounter when you start working. Um And um let's just, just run through it. So we have a 65 year old male uh presenting to Ed with uh fever confusion and uh weakness uh recently has been, was hospitalized for UTI and was discharged on oral antibiotics. However, he was brought back in because his symptoms worsened and he's become more kind of unresponsive over the last couple of hours. So, you know, what do you do? And you know, if you're in a hospital, you are on your own, you might have to go see his patient and manage him. So, uh you know, you might have to examine him, see if he's going, uh, if he's showing some signs of shock, you might want to consider some IV fluids, uh maybe some vasopressors. Um But yeah, the main thing here, the, the clue here is UTI, it's an infection for which he was recently discharged with and came back. So he, he might present with pia, uh might have a high body temperature and showing signs of sepsis. So you might have to enact the sepsis six protocol for which if you're not aware. Um There's a sepsis six protocol which is standardized across the UK and NHS. Um where you have to, you know, give free, take three, give oxygen, uh give fluids, give antibiotics, take um, blood cultures um take a lactate with ABG or an ABG. Now, ABG is more precise, but it's very time consuming. Uh So uh most people will do a G for lactate because you want to assess um the hypo uh hypoxi uh hypoxia and its effect effect on the body, uh possible ischemic damage and inflammation. Uh So you take that um and you want to take a urine output as well. Uh because reduced urine output also has an effect on the circulating uh blood uh volume of blood hypervolemia and uh therefore, BP. So as already uh that in itself is quite a lot you have to process and act on. Uh but then, you know, as you're managing this patient, they, he becomes unresponsive. And then what do you do? Now, this part when the patient becomes unresponsive is what the A S um looks at and more specifically the algorithm when it comes to deterioration. Uh So, you know, like I said, we're mainly just gonna talk about uh the A LS very briefly because, you know, I I'm certified but I'm not an instructor. So I'm not at uh I'm not gonna go into detail at length, er because it's not my place but it's more to make you aware. So you do your own research and look into it and uh consider taking it closer and well after graduation is probably best, but we'll discuss that later. So the what is the A why you should consider it, when should you do it and how do you book it? So, you know, this is some brief info um Ingrams. So you see on the left that's the A S guidelines as per 2021 for um er life support in an unresponsive and not non breathing or not breathing normally patient. So um I'm not gonna go into too much detail but this is it, uh the long and short of it is down responsive. You shout for help. You have to then you know, attach the relevant D FB pads and immediately start. First thing you should do is start CPR attach it to EF and, and monitor the, the um the kind of um the heart uh to see if it, the rhythm is shockable uh or non shockable and then you act uh as per the protocol. Um There's a lot more at the bottom. You see there's identify and treat reversible causes. So the als goes into a lot of these things in detail for you to consider an act on. Um and the considerations for uh further interventions that you might have to consider an order. And even at the end after ROSC, ROSC is return of spontaneous circulation where there is a heartbeat, there are signs of life. Um You then also have to uh talk about what happens after you've achieved success with resuscitation. What then do you do and how do you manage a patient. So um yes. And you see the two diagrams showing it the bottom one is we don't really use Metal Def F it's all adhesive, but I thought just throw that in there. It's all basically showing scenes of resuscitation and the shock of all waveforms that are on the bottom, right? So what is the A LS? Um the A LS course mainly teaches uh the knowledge and the skills required to recognize and t and treat uh the, the, the deter patient. And this is using an er structured A to e approach um universal. You should all be, you know, aware of it and by the time you graduate, you should be very clear on how to work through your ATS and examine the patient thoroughly. Um So you don't miss anything. Um And with A S you're managing a cardiac arrest and there's importance here because you are working uh in a multidisciplinary team. Um and you have to deliver standardized CPR in adults, good quality compressions. Um And you know, the emphasis on working in, with, with other people in the MDT. Uh So you're utilizing non technical skills um for and as leadership elements um uh involved which you have to show as well. So going into a bit more um the A S isn't just for doctors, you know, it's for paramedics, nurses, um even dentists can do the A LS, there are accreditations for that. But you see if you have a look at the acute care areas. We're talking about Ed CCU ICU I two HD U. And if you don't know the acronyms, uh look it up, you know, you have the emergency department, you have the critical care unit, uh or the intensive care unit, high dependency unit, the ors operating theaters, operating rooms or theater um and the uh the acute medical admissions unit, it can happen anywhere on the ward as well. So it's always good. It's a mandatory thing that we should have as doctors. Uh But obviously for most of you guys, you haven't gotten there just yet. So you might want to consider the LS. Uh We'll kind of briefly talk about that. It's um not as tough as the A LS. Uh but uh it's something you should consider if you're in sixth year. Um uh So you have something on your CV. Um So, you know, why should you do it? Why do we subject ourselves to this? Um Let's focus, you know, on the non health uh nonmedical side. Well, you know, it trains you into personal skills including leadership and I'll tell you, you know, working for a year uh so far. Uh There's so many times when you have to display that not just between your peers, your colleagues, your seniors, but also your nurses. Um your nursing staff are your so, so valuable um to give you information and do things which you are not really prepared to do. Um So, you know, it, it trains your leadership and communication skills for which you need to have good communication skills. Um And overall, after I, you know, before I did the A S I've been working for a year, there's been many like acute moments. I haven't attended any arrest calls, but there have been many uh uh deteriorating patient moments where, you know, I've had to do an at E and all this uh to kind of manage the patient. But after doing a LS, that's just given me that extra bit more confidence in managing them, including cardiac arrest scenarios. Um Yeah, in the current job market, um you know, if you're a normal UK student, you consider A LS as you're entering F two after you've, after you've had some political experience. Um and it's mandatory after an F two level or sho level uh for you to have an A S um beyond the A S, you can train to be an instructor, which is a good way to balance some money, but also it's an education opportunity for those who are interested. Um So going on a bit more so, like I mentioned earlier, there's CPD points uh that go towards doing this exam, which is valuable, but most trusts and organizations when they're advertising a job, just wanna see that you have passed it more than a accreditation threshold uh in my experience um showing that you haven't done. The als shows that you have uh competency in managing an a, a deteriorating patient. So, if you have an A LS, um uh it's quite valuable. There's different courses, there's a two day, there's uh which is the standard kind of course people go for. Uh There's an EA s which is online which has less offerings for points. Um And there's uh you know, modular as well. It's not mentioned here, but there's a modular form for flexibility. But most people do either a two day or you can get a one day course. Um And you recertify this every four years and you'll get points for that as well. Um So, you know, this is the thing which is kind of dependent on yourself. So when should you do this exam? Uh Now I tend to tell people um after having done it myself, that you should have done some clinical attachments. Ideally an ed or A&E or a critical care unit is kind of setting where you can at least visualize and see how cardiac arrests are managed or how deteriorating patient patients are managed. When I did the exam, I was with actually another post grad from Sophia uh who well, hadn't gotten work yet, but she had been doing placements for several months. Um And most of them were in A&E and HD and uh some and an ed and she passed, you know, um it's not mandatory that you have a job to get the a but what I would say is having some kind of clinical experience is probably the most important or you are, uh, way out of your depth if you haven't entered, uh, a clinical scenario, uh, where you're managing or dealing with a, with, with a deteriorating patient where you're not competent in a toy or assessment and management of a deteriorating patient, it's not really gonna end well, uh, for you because you're not gonna have the clinical know how, but it's up to you, you know, you have to be driven to experience a lot more um and see how far you can get and gain the confidence by starting a job or getting a clinical attachment. Um So, yeah, otherwise by all means do I LS. Uh it's nowhere near as tough as A LS, but it covers a lot of those are the main things that I've mentioned before, like a two ES and assessments. It's like I alluded to earlier. It's a two day course. There's E LS, there's, they're modular ones here. But now, yeah, the cost is a lot. Uh It's between 306 150 lbs depending on where you go. Um Obviously, if you're in a training program, this is factored into that, but we're not. So, um you know, you have to kind of fork out some money for this exam. So don't take this exam halfheartedly only take this exam when you think you've experienced enough clinically and you are confident in handling a deteriorating patient uh before considering moving forward. Um Right. Yeah. So when you sign up, you get a, a manual. Let me see. I've got it around here. Yeah. So you get this nice big manual uh which is fairly thick and it goes through a lot of info information, there's camera, a lot of information, it's a lot of words as you can kind of make out there, a lot of words, a lot of diagrams and useful things breaks down everything you need to know for the theory part of the exam. And also the pra practical you get this sent to you one month before the course starts. And you also have access to an online portal where there are some more like uh videos or like highlighted points for you to take in. And uh there's a pre um there's a pre course M CQ that you have to take before you go to the course so that you won't pass. If you don't pass that, that's fine. You don't have to. But um it kind of gives guidance to the instructors on your progress with the reading material. Um So what else? Yeah, that's basically that um and the the course duration is two days where it usually mainly comprises of the practical workshops and the exam itself, right? So the format of this is, you know, you you usually enter, there's various different like training uh places that, that cover the A LS, they might have their own little ways of doing things. But essentially, you, you go in with a bunch of people, you divide up into different rooms and the instructors will generally cycle through and, and um and work with you through these workshops, focusing on different skills, like um you know, inserting an airway um ECG or like, like a lot, a lot of things basically um how to kind of. And the most important things here is that you will eventually have to demonstrate a man and manage a cardiac arrest, a simulation of that. Um And they'll build you up to that point and it's, it is, it's quite rigorous and the instructions will be on your case if you're, if you're not up to scratch and they'll be watching your every move at the end of your demonstration where every participant will have a go, you'll be debriefed on what went well, what could have uh done better? Um What the team as in the other people in the room who have come to do this course with. You also think about your skills. You'll be assessed on all angles and the your performances. During these workshops, each one will be assessed and that has weight uh towards the grade in the end uh after the exam. So during the workshops take up most of the day along with intermittent lectures and breaks. Um That's basically that. So, you know, the exam format uh is mainly um MC Qs True False in, in format. Um They will also include, um you know, cases, there'll be cases there will be, you know, rhythm strips, you'll have to recognize what the rhythm is and uh kind of what treatments um you'll have to do what considerations you have to do. Any of those kind of questions can come up. The MS Qs are based on the textbook so thoroughly reading that is also advised and the C A test, the cardiac arrest simulation test. So the, the general format without giving you too much information uh is, you know, you will go in, you'll be briefed on the patient and the case and you'll be asked to proceed, approach the patient and work things out. Now, if you haven't been good enough doing the workshops, if uh if the instructors aren't too happy, then they will uh kind of pull you, they'll give you some, you know, like try and build you up a bit more. But by the end, by when it's exam time, if you, if they don't believe that you'll pass and you, you will not be allowed, you'll be told that you're not allowed to do it. Uh You can do the MC Qs but you can kind of move D defer the practical element to later. So let me talk about my case. Um Sorry, let me just get the door. So my case. Um I went in and um the instructor was there with two other instructors. Uh and the other two are there to kind of help you uh as your helpers, as your extended team that you call in. So I had this guy Daniel, 56 male having dizzy spells while standing up. Sounds like syncope, uh feeling some abdominal pain. Hm. And generally unwell, go and off you go, you're supposed to act. So you, you do an A to E you get a treatment plan for his deterioration and you, you call for help, you ask for assistance to help you run through the A two E or get things for you. If you want an ABG, they have the results of the ABG right there. Uh You know, if, if they, as you auscultate, the instructors will say that it's clear or consolidated if there any sounds. Um and you do a thorough at and for me, you know, I found there was some uh pr bleeding. So there's a, so this patient had some abdominal pain and now he's got some bleeding. So he's having some uh becoming like unwell and kind of woozy. He might be showing some shock signs. So I would, you know, uh have to consider IV fluids how to stabilize him. Um I want an E CGI want a chest X ray if there's any signs, but the chest was clear. So I don't really consider I'm not really considering that. Um So, you know, you work through and you kind of speak out loud to the instructor of what you're thinking and what you want happening uh to kind of demonstrate your thought process. But then, you know, more, the patient will always generally become unresponsive and you'll have to act uh enact a less algorithm. You know, we're talking about uh initiating CPR calling for help um assessing whether it's a shock or not and then leading the team whilst treating and managing the patient. Uh And you might also have to command certain treatments to individual people. Uh And you also might have to anticipate treatments like if someone needs a certain drug at a certain time, you have to, it would be good if you, if you say, you know, directly ask someone, can you prepare this or at this time, we'll need it if it is, you know, shockable or nonshockable or something else, you know. Yeah, you have to demonstrate your thought process quite clearly. Um And the at the end, you know, either the patient uh wakes up achieves risk or patient dies. You know, cardiac arrest, there's a high, high incidence of incidence and mortality uh in cardiac arrest and a lot of them, you can't really do anything about it. Um There's multiple reasons for that but um that's how it goes, unfortunately. Um from my awareness and the statistics are there, if you look as well, it's not great which is why A S is very kind of pushed upon people to do cos at least we have the skills to try and manage it as best as we can to prevent the patient from dying. So the outcomes after this, you know, you um pass them both, you'll then wait up to a week to receive a certificate digitally through the post. Uh And if you pass the, the pass mark is usually 75% for Mc Qs and the CAS test, you will, you don't know how they grade it. Uh I don't, I didn't know uh how I uh how I was graded. I know my, I got 85% for the CAS test, but uh the specifics they didn't have time to tell. Um And obviously, like I mentioned to earlier, you have to demonstrate your competency during the workshops um especially with airway management, maintaining good quality CPR. Um There are certain red flags that if you do not display or show during your C test, you will fail regardless of whether you do everything, right. So the basics, if you pa if you learn the algorithm, that's good. That, that covers the basics. And if you learn the basics, you're more than likely to pass. And if you fail the practical side, that's fine, you can reattempt it on the same day. And if you fail again, you can reschedule within three months to do the practical side again. If you've passed the Mt Qs. So it's not just uh you know, if you fail, you have, you fail and you have to pay another 305 100 how however much it costs uh to do it again, you do get some allowances. Uh and like I alluded to earlier, if you fail the skill stations, you'll be given additional practice opportunities. However, if you fail these before the exam, you will just fail the course um because you will be deemed not suitable, uh not ready, you're not safe. Um I'll be concerned there are concerns I have uh because you can't do certain things that we expect you to do. Um And it will be that candid if they have concerns and quite direct. So it's quite a lot now, like, you know, like I said already, you know, if you know the algorithm, if you learn things, you're diligent, if you study the book, study the demonstrations, there's videos, one of which I'll try and see if it works, I'll show you otherwise youtube it. Uh There's a video um you can pass the first time. Um Now studying the book, you know, it's a lot of theory, it's a lot of material. Um And it doesn't really help you that much in the practical because you have to physically simulate it. Um And therefore, you know, that's what happens during the workshops, you simulate it, you see what you're missing and you kind of plug those holes and fix up what you're missing out on. Um, and just don't, you know, think you're gonna learn everything during the course, it's two days of intense teaching where, like you're, you're expected to be aware of these things. It's more about tightening up and making sure there's nothing, uh, that you're really missing. Uh, they don't want to have to go over the basics every single time that will frustrate everyone, including the instructors and you may not be able to do the exam. So learn the book for the MC Qs and try and learn how to do it. Practically, you can even demonstrate it. Um And even, and this is the thing where I come back to clinical experience. So assessing with an A two E, do you know how to do that physically? Have you ever done that on a patient or on another person? Um Do you uh do you know exactly what you're looking for in a hospital environment? Have you experienced that? This is why I say, you know, having some clinical experience is quite key. Now, I understand um had a chat with the boys uh from paramedics, you guys are doing O osk assessments and practicing your A threes. Good. Do that? Keep that up? Uh Consider certain scenarios like sepsis, look at sepsis six. Uh and you know, look up common F one you know A at SPS, uh common A T SPS for F ones are asked to see patient. Um And, you know, look at if you're not that confident and you have, you know, um, you know, trying to improve your communication skills, look up how to improve your communication skills. Even if you don't know a lot, if you don't have good commu communication skills, everything falls apart. If you, even if you know a lot, if you don't have good, good communication skills, everything can fall apart very quickly and easily you might accidentally give a drug uh too early or improperly, you might have missed something uh or highlighted something to the team. Er and that may not help you and might, you know, contribute to failing uh resuscitation. So it's very important on that. Um That, that you do that. OK. Um Fine. Uh So let me see if this works. I pulled up a video, this is a demonstration. Um Can you guys hear that? Let me know if you can hear it otherwise I'll just stop it then. Mhm Yeah, I don't, I don't think they can hear it. So you're just on the, so this is basically uh I'll just quickly talk through it. Uh and you can have a look for yourselves. So this is a demonstration video by the council um that you can find on youtube, you send this through the portal. So, you know, here we have the team leader and this is the, the, the, the, the, the pre team meeting to kind of go through your roles. Meet people, ask what they're good at uh, what each person is responsible for. Uh, so everyone's clear from the start what's going to happen. Um, so everyone's introducing themselves here. Uh, and then they go off like about their business. Now, when uh, someone finds a unresponsive patient, they call, you know, the hos in hospital recess team usually. Um, sorry, usually, er, by, er, double two, double two, sorry, it must have kicked me out one second. Um Yeah, so the re resource team, there's a number and it's usually double, sorry, one second. It's not playing ball with me today. Uh It's usually double two, double two. You call them, put you through immediately to a switchboard operator for uh Russ team who will ask you, you know, uh which uh ward, which bed of the patient so they can communicate that to the reco team. Uh So they can come through and uh write exactly where they're needed. So, after the team meets, uh this is a nurse, this is the case, Bernard 65 has ischemic heart disease and diabetes and he's, you know, looking kind of unwell, kind of unresponsive. So a nurse comes by hits, the buzzer, gets him down, er, maintains an airway, listens and assesses for any signs of respiratory effort, breathing, pulse help comes, he starts CPR recess team are called, uh you get the recess trolley, you ask for the resource trolley to come in, brings it in and, you know, take over CPR. Um, so take over CPR, airways maintained DFIB pads are put on. Um, and you know that they put, they look at the uh the heart, uh the heart wave, the waveform, see if it's shockable and you know, making sure everything's safe, shocking. Um, and you know, back on CPR and they continue over the and then this is the situation where the head, the team leader uh who's come over SAR handover situation, background action uh recommendation or response. Er So the handing over of about Bernard 65 ischemic heart disease, all this. So and then she takes over and basically leads um and coordinates the whole meeting uh the whole recess effort and it goes on to kind of show each stage. Um So I'd advise you look it up. If you look up Council UK demonstration, it should come up on youtube. Um It's a very good video to kind of give you a good insight as to how uh cardiac arrest is managed. Um So yeah, other resources. So resource council UK is the channel name. Uh There's loads of youtube resources like IC advantage has good coverage for cardiac arrest and how to manage peri arrest, like uh hyperkalemia, hypernatremias, all the rest of ito medicine. Uh X finals is also good E kinetics is grand uh especially for the sys. Uh They have a lot of information there, you might be already be aware. They also have an area for A LS. So have a look at that, look up the research you uh council site. There's some uh guide the, the guidelines are there as along with the courses, information and professional resources. Now, when you look to booking it, it will show you different courses, you'll then have to email, call up, they'll have the numbers there and request that you book one through and they'll guide you to booking it through. Um Now, one thing I wanted to raise up with you cos you can just look at it now um is the uh Reco IOS app. So it's a guidelines app with all the infographic algorithms which I believe, I'm not sure. II think it's for everyone. Yeah, it's for everyone. So you can download it and have a look at it uh for more information and to get a head start, you can kind of look into the algorithms for certain situations to make yourself more aware. You can even run that alongside the demonstration to kind of see what's going on and follow it even if you don't understand fully a guideline. Um Like that will kind of give you an idea or what's happening. So that's, that's it for me. Any, any questions, we'll just wait a few minutes to see if any questions come up in the chart, but it's not right now. Yeah. So, you know, I just briefly, so the re remember like A LS, this is more for post grad. Uh but this is something you should consider uh before you graduate, er, and prepare for, before you graduate. Um because things are quite tough in the market right now. Uh jobs wise. So boosting A CV is always the way to go. Um um but an A L is quite valuable uh at the beginning of your clinical uh career, uh your medical career. And like I said, if you don't, if you don't have the clinical experience, then look into the I LS um as an alternative. Um that's absolutely reasonable because it shows at least you have incentive enough to do I LS. And even if you don't have the clinical experience, you can always mention in, in, in, in an interview uh that um you have um got the L I intend to do the A S at a certain point of time after I've got more clinical experience under my belt or something of along those lines. Um Yeah. Uh the, the main reason for this is kind of give you guys uh a bit of a heads up on things that you might need. Uh when it comes to working in the UK, there's, it, there's a lot that is demanded from you from the jump um uh when you start work and if you are, if you are at least able to um you know, make you build up your clinical skills and become more confident then uh that'll be better for you in the long run. Uh Many times, you know, I've been called um by a nurse. I'm alone. Uh patients starting to deteriorate. I need you to assess him and see him and manage him. So, you know, I've been, I've been alone at times when people are away or busy and you'll be expected even day one expected to assess the patient. Now, obviously studying block, there's certain limitations um as to the level of teaching that we, we get. Um and, you know, practical experience is a bit limiting. Uh which is why I'm really happy to see uh organizations like, like these like take opportunity to conduct s and practical elements that would put us up to a UK standard. Um So, you know, this is mainly to make sure you guys are well prepped when it comes to, um, you know, applying for jobs and applying for work. Um If no one's got any questions, I can still talk a little bit. Um Let's see. Yeah, we're good on time. So fine if there's any other uh like advice I can give is that, um, you know, like I alluded to earlier, the job market is quite tough. Um A lot of people are fighting over placements because there aren't, there aren't barely any jobs. Now, I'm a lo F two. And, you know, I've worked long term um for long placements like for seven months in general surgery, four months in acute stroke. Um, but, you know, around middle of, yeah, like middle of this year, money really started to tighten. So, um, you know, jobs really dried up and there's a lot more people coming from abroad, not just us in Bulgaria, but from, you know, India, Pakistan, from African nations, a whole host of people. So you have to be more ready. We've just got one question. Um Monta asks, how have you found the transition to the NHS as a positive graduate? Right? Uh Yeah, the transition was, is not smooth unless you're prepared to put it bluntly for me. II was because of the year before me, I kind of took a lax approach cos the year before found it quite straightforward to get in. I took it a bit lax. Uh But uh there was uh issues with me personally kind of setting up with the GMC. There was some uh some documentation that was being delayed. So and that delayed things and if you delay your GMC registration, you delay your applications for jobs, right? Um So after that point, you know, the transition when it came to work. Yeah, it didn't, it took me roughly two when I started work, it took me roughly one or two months to settle in because there's a lot of aspects um of, of UK medical practice and how the UK students are taught that we haven't ever experienced So there is a gap initially, but you do make it up. Uh You absolutely do make it up and you have to remember as a doctor, you're not just going to, to hospital coming home messing around. You gotta be studying and reading. Otherwise all your experience that you've experienced during the day and all the shortcomings that you've experienced has gone down the drain. So I'd come down uh come back from work. Um During work, I would make some notes, just make a port like just jot down some areas I need to revise or look up or look at. If there's protocols which are drilled into UK students, I'll try and drill that into me. I'll ask for certain protocols and read it, understand it, ask questions in the hospital and everyone is usually quite helpful uh because they understand that you haven't graduated uh from UK. If you're able to demonstrate your uh willingness to learn and catch up, then no one's gonna criticize you. The rest is up to you uh to learn and progress. Um So you can build yourself up to a UK level, right? Let's see. Uh One more question, what was the most challenging part in this transition? The challenging part, the challenging part um transitioning from positive. Well, for me, it might be slightly different because my fourth year and fifth year was affected by COVID. So I had more limited practical um elements there because we weren't allowed to go to hospitals a as a lot as a lot of, you know, um So the, the, the the most challenging part was getting to grips with properly assessing, doing an a to e of the patient getting a proper the basics really because I was a bit limited and lacking. So, um, but over time, like I said, 1 to 2 months studying, uh studying at home, um at my flat, um I just built myself up. You make friends, you know, you make friends with the other F ones or the other staff, other team confide in them, uh, ask for help, ask questions if you don't ask for help. If you don't ask questions and you're not learning anything from, uh, your job. After you go home, everyone's gonna notice that and see that, right? And then when everyone can see and if everyone is seeing that you're not really improving after you've started work, especially as an I MG, then that's when people start to raise questions. Everyone that I've spoken to when they started work, they have an element of imposter syndrome, right? Like you don't really feel like you're, you're, you're, you're validated or you're doing, um, you're, you're, you're like s, you don't feel that you're supposed to work in UK, but you build up quite quickly after one or two months. So don't worry too much. The challenging parts you'll get old for them. Let's see. So, yeah. Do most Bulgaria graduates go into FY one or Fy two. And also, which do you think is better to do? Right. Uh, do most. Ok. So this is the thing, right? And I alluded to that with the kind of the times, um, of the job market. So most people's understanding, uh, would be that you graduate, you, you register your GMC and you apply for jobs. What jobs can you do? Worlds F one and F two. Now, reality is F one jobs. You will not find them, right. UK graduates would have all taken it. They're extremely rare, rare for me. I was quite lucky but I had to wait till that point. I waited several months. Er, because I didn't feel, I didn't feel right to do F two. I wanted to do F one and I was adamant on that. So I got a local F one job and general surgery as my first job. Um, and I would, for, for those who may not be as confident like I was, I would suggest F one but currently the market is not kind and it is nigh on impossible to find an F one job. F two, you need to be ready and prepared. You really need to be prepared. F two is no joke. There was a big, big gap between F one and F two. Uh, in terms of responsibility, you might be placed on one ward, but then you'll have to also, well, if you're on call, you might have to cover another department. Right. When I was in surgery, the F twos, you would have to cover pediatric surgery overnight. Or if you're on call during the day, you might get a call from the pediatric assessment unit that, uh, the team there, they believe that, that they have, they have a child with appendicitis. Right. And you, you, as the sur general surgery, F two will be asked to come all the way down, assess the patient and escalate to the pediatric surgeons. If need be, there's a lot more responsibility there. And the expectation is quite high because at an F two level, you're expected to then progress into I MT uh internal medicine trainee or a CST called surgical trainee. And that's when things get more serious. So your senior colleagues will be looking at you to really test and see if you can handle yourself and if you're ready for further training uh in, into a general specialty. So F one is better but real realistically, the the truth is is that it's quite hard to get. So if you build yourself up as, as much as you can for F two and look into what it requires and what the gaps are and what you need to fill it, um then you will be probably more prepared. And also, you know, if you know, post graduates reach out to them, ask them as well, they'll also say the same for me, I got a, uh, into, er, one job and the main thing here is that you put your foot in the door, you have to get, you, you, you just have to get starting somewhere. You have to be ready to, you're not gonna be working close to home is the highly likely, you know, thing that will happen to you if you do more power to you. Very good. Um, very lucky, especially now, but you need to be prepared. We're talking about northern Ireland. For me, it was Scotland, right? So you have to be prepared to move out and live anywhere to start, at least working in the UK. Um You know, you've been in, look, you guys, you've all been in Bulgaria for six years. You can handle working in, in, in an English speaking other part of the country for 4 to 6 months if you're doing a long term placement, right? Don't hold on to the idea that you can only work near home unless there's obviously a, a very good reason for that. And there are, but for those who are thinking they're just gonna come back home and get a job near to the house, it's highly unlikely unless you've got connections or you are incredibly lucky. So be prepared, you have to cast the net wider than you think, right? Um It's better to do so to answer your question, it's better to do fy one than F two as your first job, always. However, the market doesn't really accommodate for that right now. So you'll need to be kind of pushing even harder during your sixth year to look up and understand what an Fy two does and prepare yourself accordingly. Uh Is the reality of the situation. Um Things changed and went south like this so fast, but there, it, it usually is attributed to peaks and troughs of demand and supply of jobs in the NHS obviously with the elections and all the political stuff, there's a lot going on in the background. So uh you have to be prepared for fy two. be prepared for everything, consider Gateway. But you know, it's quite competitive from what I hear. So, you know, you need to have at least some clinical experience and this is where, you know, is will be very heavily weighted and those I can imagine A S two. But uh I would look at Gateway see how it is, see if that's viable for you standalone F two. Again, you can apply for that but you have to do your research and prepare accordingly. OK. I've got a question myself. Mhm How did you adapt to the differences in medical protocols and practices in the used in the NHS? Say that one more time? How did you adapt to the differences in medical protocols and practices used within the NHS? Medical protocols and practice use in NHS? Well um protocols. A protocol is instilled by a hospital for a standardized process of care. If you say, you know, have a common one, you should guys should be aware of is VT E venous thromboembolism. Uh It's a very common protocol, assessing bleeding risk in patients. If you look up BTE like assessment form, you'll see a bunch of information, do your own research. Um Now, protocols are put in place by these hospitals to ensure that standards are being met and maintained. So there's no gaps and make sure pa patients are being treated adequately. Now, coming from Bulgaria where you know, there, we weren't really told about protocols and how to manage in hospital stuff when I came over, when I was asked to do certain protocols, this and that I was not sure. I just said, II don't know, cos I'm not, I didn't study it and all of these things are found online when you start work, you'll get a email. Um A NHS email. There's usually an intranet intra net kind of portal which will have the hospital guidance up and ready. Nowadays, there's apps where they have the hospital guidelines there for quick access, especially for antibiotic therapy. There's something called right decisions um which is a UK kind of organization compiling. Um uh Yeah, right decisions. I've got it on my phone. Um To uh I think this is basically for Scotland mind you, but they have loads of guidelines there for you to look at. So you can find them on within the hospital. A lot of them will be will be printed and scattered. So I just took photos, read them up at home and asked questions. When I went back to work, you adapt quick. And as long as you understand the reason for what you're doing, uh everything else will follow suit you, you will have to do these protocols many times. So through experience, you will also learn um how to, how to like administer, administer them. Uh It's part of the experience. All right, thank you. Um I don't think that there's any more questions fine. Um If I can end with um for those who in sixth year, you know, sixth year is um your, your, your state exams, uh you will have certain opportunities to kind of employ the use of your own time to revise and prepare, use that time wisely. You do not want to be unprepared coming out of university post grad. It's caught a lot of people off guard. A lot of people from previous years from what I've heard from the younger years, um from last year's lot, haven't got work. It's the honest truth, right? So don't be er, underprepared coming out or post grad. Don't think you'll get a job 1st, 1st thing straight away. Other pointers look up how to register for GMC early, understand what it is you need and the documents so that after you've finished your exams, uh, you know, you're not standing around thinking what do I do next? Think, what do I need before I graduate? Right. Prepare yourself, um, by at least knowing what you need, the earliest form of preparation is understanding what you need. If you are able to do that, you're already in a good position than most of your peers. It's not a competition to see who gets a job first. Right. It's about getting yourself prepared. Withholding resources around GMC, er, or withholding resources around A LS. There's no point, everyone has an opportunity to do it. Uh And in the grand scheme of things, we're just from Bulgaria, you have 100s of people who are way more clinically experienced than you from India who might have worked in a hospital for a couple of, couple of years, uh from Pakistan, from African nations, wherever you will have much higher level uh, competition you'll have to fight against. And we're talking about 100s of people applying for one job, right? 100s of people applying for one job. It's very tight. You need to really be up to scruff and be up to the task. Um Having said that, you know, balance is always key, enjoy your last year. Um make sure you do things you don't regret not doing uh like a, you, you think you may regret if you don't do like after graduation, we're in Bulgaria, there's only so many things that uh we can do but a lot more than you think more than UK students. Um And that experience that you have in the UK, they will ask you about that in interviews. They'll ask me, oh, you know, you said you studied in Bulgaria, what was that like? What did you do? You know they want to understand how being in Bulgaria added to your like personal qualities. What did you, did you travel, did you experience things, experience, language, experience, culture, those are valid points that may be brought up in an interview. I've been asked about it during my work and, you know, if you're able to at least experience some things before you leave Bulgaria, that'll only add to your life. Um, moving forward. Right. So what sources, er, or sites come? We used to read up on registering GMC? Um. Right. I truthfully don't have an answer for this because I did not really find one for my situation. I asked around now, what I will ask you to do simply is you can email them. If you look up the GMC, there is an email that they will cite or there's a number, a UK number granted, but there is a number you can call in. They're very receptive. You explain your situation. I'm an I MG studying in Bulgaria and I'll be graduating at the end of next year if you're six if you're, if you're 1/5. Well, well, yeah, you're starting sixth year. Right. Yeah. So if you say like I'm graduating next year, I've just started sixth year. Uh What do, what forms do I need? How do I go about filling or preparing for that process? Once I have my degree, they will absolutely shower you with uh resources and the forms, the correct form and I'll type this in as well. So in case people miss it, um it's called an I MG 23 form. Now, let me just dig this up from my fold as well. Just so I'm not um making things up. Uh I believe it is an I MG 23 form. If you quote that when you contact them or email them, um, then it will come up. It's very hard to navigate the site, send an email, give them a call, they'll be, it'll be much easier to get a straightforward answer and bear in mind admin like takes a long time. So they will take time in responding to an email. It might be better to call. Um It's, the GMC is not really a medical place, it's an admin place and you're dealing with admin people. So, you know, deal with it early. Uh You'll get things sorted. Um Let me just have a look through and see in my forms uh and be organized when it comes to these forms as well. Um Keep everything together nicely. So you don't miss things between passports and, you know, prepare if you're able to go in to the hospitals and the different departments show face cos a reference is what you need. If you don't have a reference, you won't get a locum, you won't get a job, right. Secure, good rapport with your um your teachers, your professors, no matter how frustrating or annoying things might be, you have to get on with it. It's all for your benefit no matter how tough things are. Um So work with your professors. Show face, ask beyond the basics. Don't just turn up and sit and get a lecture and be told to leave, ask questions, ask, you know, ask to show me things, go in, in outside the designated hours, see things experience practically um you know, different things, all these add to your experience. Um and there are things to talk about in your interview. Cos this is an internship guys, it's not AFA teaching year, it's an internship. You're supposed to be in hospitals most of your hours. So they'll ask you, what did you do during your internship? You know, what did you see? Tell me a case you saw in an internship and what happened to the patient is all things that can happen. Yes. All right. I've got it. It is an I MG 23 form. Obviously, mine's already filled. I can't upload it. Um But you know, it asks for your general stuff, your qualifications. You have to make an epic account for validating the um qualification Um And you have to make a note of which will be provided to you on your degree, but you have to make a note of your dates of your placements, locations of the placements like Sveti. Um and what the departments were, there's a lot so speak to the gym. C right. Um Also, when should we think about applying to Gateway? What skills experience I experience are I expecting? I can't answer that cos I did not apply. Um, at the time I thought, nah, I'll just do locum and I'll make my way through it, but things got tough. So I would reach out to them. Uh I can't comment on that unfortunately, but Gateway from my understanding is essentially an, an, an a modified foundation pathway for us and coming from abroad. They want to know what we have done here. So, like I said, it's your sixth year. What did you experience in your internship? What practically were you able to do in your internship? Cos they want to see from my understanding, they want to see what you have experienced and how they can convert that experience and see how you would get on in a UK setting. If you've just gone to classes, gone home, done the exams and gotten the degree, that's not good enough. It's not cos they'll look at you and say, yeah, you've got the degree about what can you do? Have you done anything during that year? No, then why should we consider you for Gateway? There's only like so many places and again, competition is high, you know, skills experience, you know, like you're, you're doing the sys and stuff, obviously in the UK, it's mandatory that you do them and you get, it's a credit, it's an exam that is done in the UK, which we don't have the opportunity to do. But, you know, attending osk sessions, improving your clinical skills at ES and you know, if you demos demonstrated it and that you are confident and competent to AAA like a medic as a, you know, post grad level, then that's good enough. You know, look online, look for courses, look for presentation, looks uh presentations on medal, look for different uh workshops in London. If you're close there, maybe in Manchester Birmingham there, there's workshops that they offer. Um So there's always things and look it up, look up. How do I, you know, build up my CV as a junior doctor or as a sick, final year medical student, there's always an answer if you look right. But for Gateway specifically, you'll have to ask gateway email in uh I'm assuming they will have a contact in the email for us. They did a like a talk, you know, they did a talk for us um talking us through the process and there was AQ and a there. So uh reach out to them, they might do one. It is November. They might do one this month, um, or maybe just towards December. So, yeah, that, that's all I can say on that note. Um, but yeah, guys buckle up. It's a, it's a rough, it's a cruel, it's a rough, like, ride post grad, right. You have to take it seriously. Um, like, and I was quite lax and I'm, I'm, I'm not saying this as someone who was strict on myself. You know, I'm not the brightest, I wasn't the brightest person at uni so to speak, but I'm fine. You know, I got out um I worked hard, I covered my weaknesses and I learned from them, which is something you're expected to do as a doctor. Uh So, you know, at your level, you guys should be kind of thinking a lot more forward because of the situation at home in the UK with the job market, think forward, think, what can, what do I need uh to build up my CV? Right. I get a, I get the competition element, I guess you can apply that to gateway, then think independently and use your own thinking to kind of sort yourselves out and to be proactive in your lessons. And if it's a surgical lesson, if it's an internal med er medicine lesson, see if you can at least experience cannulation man, because I'll tell you what, when you start work and you're asked to cannulate, you'll be, your hands will be shaking like mine were when I was asked and it's not a fun experience trying to cannulate for the first time. Um So, you know, at least experience cannulation. I understand uni does some dummies. They're, they're not real. No one is that like, you know, perfect. So if you're able to cannulate and help out at least ask to see cannulation that already gives you such a big boost in your experience and therefore your confidence when you start work um make the most out of your situation. We are in Bulgaria but you have to figure it, you have to figure it out your final year med students and that sentence final your your that and that statement alone is asked of, of UK er students, not just us, right? The expectations are high for everyone. The UK med student is kind of uh frazzled a senior would say. Come on, you're a UK med student, what do you do? So you can imagine there is a higher kind of expectation but you are, you will be able to get over it as long as you know, for me, I've gone through trial and tribulation. But for you guys, if you prepare early, you should be fine. Um at least to be at an appropriate confident level to start work the job situation that is out of my hands and it is certainly out of your hands, right? But if you're able to at least do everything that you can till that point then you've done what you can, it's a waiting game from there and you have to be absolutely religious in applying to jobs. You have to be abso just, you have to be rabid, uh, and unrelenting only then. Will you get a job? That is the truth. Um, and, you know, chat to post grads and, you know, keep in touch with them, ask what's going on, um, because they'll be able to tell you more, especially the more recent generation of graduate uh graduates uh from the year before. But yeah, um you know, I talk to the boys. Uh if you guys want me back, uh we can kind of think about discussing these questions more um later on. Uh maybe if people are more free, then then they can join, then we can kind of discuss things a little bit. I can kind of go into A to E and offer because I am clinically experienced uh more than you guys in the UK. I can at least go through some scenarios and kind of walk you through some things to consider that would be expected from the fy one. But yeah, that we'll have a chat about later otherwise. Thank you all for listening to my presentation. I hope it's helped. I hope my words have helped you guys. Thank you. Thank you. We'd love to have you on for another session perhaps. Um And thank you for your valuable session on the A Ls and your insight into transitioning from positive into the NHS and also your tips on registration with the GMC. Thank you very much. That's all for today. Thank you guys for attending grand. Thank you very much guys. I uh if you leave some feedback as well for me, uh or if there's anything that I've missed or want to bring up next time, uh or any points or suggestions leave it and I'll have a look and I'll discuss with the boys as to what we can offer next time. Or is there a way if anyone wants to contact you? Can they get through to you? Yeah, you can contact me on Instagram. Um um master underscore underscore underscore T or contact the boys if you can't get through to me for some reason if I'm at work, if I'm not replying, it's probably because I'm working. So, so by all means get uh leave it with the boys. Um and with, with paramedics and uh they'll get it through to me. All right. Thank you very much. All right, thanks. Goodbye.