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How to Survive FY1

How to Survive FY1. Lauren Gowland, Olivia holland & rebecca wilson. Objectives. Practical Tips On Calls + Bleep Cardiac Arrests Night Shifts Prescribing On Call Common On-Call Scenarios. ‘Hi it’s the FY1 on-call, did you bleep?...’. Most important points.

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How to Survive FY1

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  1. How to Survive FY1 Lauren Gowland, Olivia holland & rebeccawilson

  2. Objectives • Practical Tips • On Calls + Bleep • Cardiac Arrests • Night Shifts • Prescribing On Call • Common On-Call Scenarios

  3. ‘Hi it’s the FY1 on-call, did you bleep?...’

  4. Most important points • You will ALWAYS have support – do not be afraid to ask • Have confidence – you DO know things • BE ORGANISED! – lists, lists, lists • Make friends… nurses, HCAs, porters- will make a much happier environment – Don’t be a dick • Appear willing to get involved – Have a go…within reason • Reflect on your work regularly – Just get your reflections done • Keep a note book/ your handovers

  5. What is this on call?! • Evening (AMU) (5pm – 9pm) • Night Shift (9pm- 9pm) • Twilight (Surgical) (5pm-midnight) • AMU on teaching days

  6. On Call • Eat well • Rest well • Keep in touch with 600 • Tiring/ lonely • Keep notebook • Eat/ drink when offered • Be nice to the nurses • Take detailed handovers- give advice over the phone • PRIORITISE! (you don’t need to do EVERYTHING!)

  7. Types of on calls Clerking Ward cover Know which wards you cover May have 600 (hospital at night team) Will receive handovers Organise the calls and jobs • AMU • Clerking new patients • Post take ward rounds • Jobs Crash Bleep

  8. SURVIVAL KIT • Notebook • Extra pens • Bleep • Reference guide • Useful numbers • Possible equipment (Tourniquet, cannulas...) • FOOD ON THE GO!

  9. Handover • Be on time • Keep note of patient name, number and ward • Clinical details • Note things to chase (BOXES) • Know plan if abnormal • Know what Reg will see and what you will see

  10. ‘Did you bleep the FY1 on call?’ • Make note of all bleeps • Call back in order they called • Take exact details of caller and patient • Clinical information • Background • Last review and plan • Current observations • Give Instructions where possible • New obs • Prepare notes and drug chart • Prepare equipment/ put cannula and take bloods • Actions: ECG, re-position, suction…

  11. SBAR • I am the FY1 on call. I have a patient in T2RF. • Known COPD, came in with an infective exacerbation 2/7 ago, not improving despite 48 hrs of IV antibiotics + steroids • Saturating at 75% on 8L oxygen, tachycardic, hypotensive. • ABG: pH 7.31 PCO2 16 PO2 3 lactate 2.6 • I need you to come and review the patient because I think they will require NIV

  12. Prioritising calls/ jobs • Clinical urgency • Acutely unwell (think A to E) • Scoring on NEWS • Ask staff on ward to do as much as they can • Consider immediate need for job • Could it wait until morning….remember you are the EMERGENCY GO TO • Too many calls…speak to manager or registrar

  13. Who to see first? • 56 year old man with chest infection needs a new cannula for IV antibiotics • 65 year old woman with COPD, SaO2 89% on RA, RR 18 • 60 year old diabetic on metformin, BM 20, no ketones in urine • 30 year old woman with asthma reporting DiB, SaO2 90% on RA • 78 year old male with ca prostate, not passed urine since TWOC 2 hours ago

  14. Who to see first? • 56 year old man with chest infection needs a new cannula for IV antibiotics • 65 year old woman with COPD, SaO2 89% on RA, RR 18 • 60 year old diabetic on metformin, BM 20, no ketones in urine • 30 year old woman with asthma reporting DiB, SaO2 90% on RA • 78 year old male with ca prostate, not passed urine since TWOC 2 hours ago

  15. CARDIAC ARREST WARD 17!!!!

  16. Cardiac Arrest • Usually nurses on ward doing compressions • If you’re there first CHECK PULSE • Compressions • Be familiar with crash trolley • Day time: resus team • Night time just on call team • Have a role you are comfortable with

  17. Assessing unwell patient • ABCDE!!!! • Review notes + drug chart • Review any investigations (bloods, imaging…) • Do the basics and ask nurses to help • Obs, cannula, bloods, ABG, ECG, XRs • Give O2, fluids, analgesia, antibiotics • GO WITH YOUR INSTINCT- you feel somethings not right then you’re probably right • Get help EARLY • Write the main points before you call • If you’re busy, ask nurse to bleep them/ tell them what to say

  18. Prescribing on call • ALWAYS CHECK ALLERGY STATUS • Confirm antibiotics with local guidelines • Use BNF – you’re tired so don’t rely on memory • Fluid prescribing • Check fluid status • Reason for fluids (how much oral intake) • Bloods • Re-write drug charts…. Can it wait for day team?

  19. Fluids • Fluid balance • Skin turgor, JVP, peripheral oedema, crackles on auscultation • BP, HR, urine output (>0.5ml/kg/hr) • Colloid vs Crystalloid • 0.9% NaCl/ Plasmalyte/ 5% dextrose • Gelofusin • Maintenance • 3L/ 24 hours • 40mmol KCl

  20. Case • 82 year old admitted 3 days ago with NSTEMI • PMH: HTN, T2DM, 1 x previous MI (CABG) • Received 0.9% NaCl 8 hourly daily since admission (poor oral intake) • ATSP: SaO2 90% on 4L O2, RR 30, BP 100/60 UO: 0 for 4 hrs • WHAT DO YOU DO?

  21. Examination • Patient lying flat; JVP not raised • Chest: bilateral reduced air entry • Abdo: not distended, soft, no bladder palpable • Legs: bilateral pitting oedema to calves

  22. What would you do? • Slow the fluids to 12 hourly and increase O2 to 8L 2. Give 250mls bolus of gelofusin 3. Insert urinary catheter to measure hourly UO 4. Stop IV fluids and consider giving furosemide 5. Increase rate of fluids to 4 hourly

  23. What would you do? • Slow the fluids to 12 hourly and increase O2 to 8L 2. Give 250mls bolus of gelofusin 3. Insert urinary catheter to measure hourly UO 4. Stop IV fluids and consider giving furosemide 5. Increase rate of fluids to 4 hourly

  24. ALWAYS REASSES AFTER INTERVENTION • Ask nurses to keep strict I/O chart • Need to know fluid status • Do they respond to fluid challenge? • Monitor Obs • Monitor U&Es

  25. Analgesia • Regular • Combinations • Target TYPE of pain • Treat the cause • Reassurance! • Paracetamol - PO/ IV 2. Weak opioids - Codeine 30-60mg QDS - Tramadol 50-100mg PO TDS 3. Strong opioids - Oromorph 10mg/5ml Alternatives - Gabapentin, buscopan, patch

  26. Warfarin • Indications - AF, metallic valve, recurrent VTE • Pre-procedure - stop and ? Convert to LMWH - requested INR range • Ask patient regular dose • Look at INR trend • INR reflect 2-3 days after dose • Monitor medication + for signs of bleeding

  27. Warfarin Case 1 • 48 year old man on warfarin for MVR (INR range 2 -3). INR yesterday 1.4 and today 1.5. Warfarin dose increased yesterday from 3mg to 5mg • Increase dose to 7mg • Continue at 5mg and check INR tomorrow • Call medical SpR on call for advice • Continue at 5mg and ensure patient on LMWH • Recheck INR

  28. Warfarin Case 1 • 48 year old man on warfarin for MVR (INR range 2 -3). INR yesterday 1.4 and today 1.5. Warfarin dose increased yesterday from 3mg to 5mg • Increase dose to 7mg • Continue at 5mg and check INR tomorrow • Call medical SpR on call for advice • Continue at 5mg and ensure patient on LMWH • Recheck INR

  29. Warfarin case 2 • 77 year old man with AF (INR 2.0-3.0). Admitted with cellulitis. Day 3 of admission, INR 5.6 on 2mg warfarin daily. Not bleeding. • Give 1mg warfarin • Check local hospital policy for high INR • Call Haematology SpR • Hold warfarin, recheck tomorrow • Hold warfarin and give 10mg IV Vit K

  30. Warfarin case 2 • 77 year old man with AF (INR 2.0-3.0). Admitted with cellulitis. Day 3 of admission, INR 5.6 on 2mg warfarin daily. Not bleeding. • Give 1mg warfarin • Check local hospital policy for high INR • Call Haematology SpR • Hold warfarin, recheck tomorrow • Hold warfarin and give 10mg IV Vit K

  31. THE NIGHT SHIFT!!

  32. Getting through • Sleep the day before • Bring plenty of food + drinks • Use the night team • Don’t rush • Don’t need to finish ALL jobs – just give clear handovers • Prioritise

  33. TAKE POWER NAPS!!

  34. Common calls from nurses • ‘Doctor, Mr Z had a fall and needs a review’ • ‘Mrs T is on gentamicin, should I give it?’ • ‘Mr Z is on warfarin but it needs prescribing’ • ‘Mrs B is having chest pain and doesn’t look right, can you review’ • ‘Mr G just came up to the ward and is scoring a 7’ • ‘Ms N had an NGT inserted this afternoon, can we start the feed?’

  35. Case 1 • You reviewed a 76 year old gentleman at 3am with new onset confusion. He has been confused for the last 2 nights. After discussing with the night SpR, he suggests getting a CT head • Wait until morning to get CT head • Call the on call radiologist to arrange for an urgent scan • Continue neuro obs for now and get CT if GCS starts falling • Give 2mg haloperidol then call the on call radiologist for the scan • Call the SpR back and clarify the urgency

  36. Case 1 • You reviewed a 76 year old gentleman at 3am with new onset confusion. He has been confused for the last 2 nights. After discussing with the night SpR, he suggests getting a CT head • Wait until morning to get CT head • Call the on call radiologist to arrange for an urgent scan • Continue neuro obs for now and get CT if GCS starts falling • Give 2mg haloperidol then call the on call radiologist for the scan • Call the SpR back and clarify the urgency

  37. Case 2 • A nurse on ward 12 calls you to see a 42 year old man with increasing confusion. He has a hx of ETOH abuse and cirrhosis and is admitted with ascites + alcohol detox. He is on a chlordiazepoxide detox regime. O/E: GCS 13, tremulous, BP 98/54 (baseline 130/60), HR 100. Nurse mentions patient has also had black stools but is on iron tablets. What do you do…? • Re-assure nursing staff that patient is exhibiting signs of alcohol withdrawal and start neuro obs • Stop chlordiazepoxide as it is causing the drowsiness • Give extra stat dose of CDPx now and increase regular dose for tomorrow • PR exam, cannula + bloods (FBC and clotting)

  38. Case 2 • A nurse on ward 12 calls you to see a 42 year old man with increasing confusion. He has a hx of ETOH abuse and cirrhosis and is admitted with ascites + alcohol detox. He is on a chlordiazepoxide detox regime. O/E: GCS 13, tremulous, BP 98/54 (baseline 130/60), HR 100. Nurse mentions patient has also had black stools but is on iron tablets. What do you do…? • Re-assure nursing staff that patient is exhibiting signs of alcohol withdrawal and start neuro obs • Stop chlordiazepoxide as it is causing the drowsiness • Give extra stat dose of CDPx now and increase regular dose for tomorrow • PR exam, cannula + bloods (FBC and clotting)

  39. Case 3 • A 56 year old man has just been started on his 2nd unit of blood for a presumed upper GI bleed. During the transfusion he develops a temperature of 38.5. He is haemodynamically stable. What should you do? • Give IV chloramphenicol and continue transfusing • Contact haematology team for urgent advice • Stop the transfusion, take blood cultures and provide supportive measures • Take blood cultures and continue transfusing • Start broad spectrum antibiotics

  40. Case 3 • A 56 year old man has just been started on his 2nd unit of blood for a presumed upper GI bleed. During the transfusion he develops a temperature of 38.5. He is haemodynamically stable. What should you do? • Give IV chloramphenicol and continue transfusing • Contact haematology team for urgent advice • Stop the transfusion, take blood cultures and provide supportive measures • Take blood cultures and continue transfusing • Start broad spectrum antibiotics

  41. Case 4 • You’re called to see a 72 year old lady on the surgical ward. She had a R hemi-arthroplasty for a # NoF today. She’s c/o increasing pain from R hip and seems very confused. PMH: DM, HTN. O/E: GCS 12, HR 105, BP 98/45, SaO2 98% on 1L O2. Wound is dressed, no evidence of active bleedings. Urine dip: Leuc ++ Bld + She hasn’t had any analgesia. What do you do? • Start antibiotics for a UTI, send MC+S • Check the wound, repeat Hb, inform Reg • Prescribe regular analgesia, re-review following • Prescribe IVf and hold morning anti-hypertensives until BP improves

  42. Case 4 • You’re called to see a 72 year old lady on the surgical ward. She had a R hemi-arthroplasty for a # NoF today. She’s c/o increasing pain from R hip and seems very confused. PMH: DM, HTN. O/E: GCS 12, HR 105, BP 98/45, SaO2 98% on 1L O2. Wound is dressed, no evidence of active bleedings. Urine dip: Leuc ++ Bld + She hasn’t had any analgesia. What do you do? • Start antibiotics for a UTI, send MC+S • Check the wound, repeat Hb, inform Reg • Prescribe regular analgesia, re-review following • Prescribe IVf and hold morning anti-hypertensives until BP improves

  43. General FY Tips • Enjoy your time • Communicate well • Be organised • Don’t be afraid to say no • Ask for help • Don’t be afraid to look things up • Stay on top of your portfolio!! • Get a new hobby/ make plans to hang out • Eat, sleep, exercise and relax

  44. Things to ask about the day job… • E-Referrals • Discharge Letters • Bloods/Radiology Requests • How to Bleep… • Who to call when you haven’t a clue • The best sandwiches in M&S

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