by Hannah Bainbridge
A Moore-Ridings F1 Doctor writes here about her post. (Please note that Mr Moore now leads a different firm with Mr Lamah and that his timetable has changed since this article was written).
Foundation year 1 (Fy1) Doctor’s Introduction
Welcome to Mr Moore and Mr Ridings team.
The RSCH has four general surgical teams, each with two consultants and this particular team works under Mr Moore and Mr Ridings. The surgical team is comprised of two registrars, one SHO and three house officers (foundation year one doctors).
Working under two consultants, who both additionally operate at Princess Royal Hospital in Haywards Heath, makes the team’s timetable slightly complicated, as it varies on a weekly basis. It is therefore helpful to discuss with the consultants what their timetable is for each coming week. However, in general, Mr Moore does a consultant ward round on Monday, Wednesday and Friday, and Mr Ridings does one on Tuesday, and Friday. The team is always “on-take” on a Wednesday and every fourth weekend which means that any surgical admissions to RSCH from 08:00hr on Wednesday to 08:00hr on Thursday, or 08:00hr Friday to 08:00hr Monday will come under the care of Mr Moore or Mr Ridings depending on which consultant is on. There is a post-take ward round on Thursday morning which commences at 08:00hr on level 11 of the tower block. All other ward rounds usually start on Level 9AS at 08:00hr. On Wednesday morning there is a radiology meeting at 08:15 on Level 9 seminar room where any interesting / complicated cases are discussed. All members of all surgical teams are expected to attend these radiology meetings. On days when there are no consultant ward rounds, the rounds are led by one of the registrars or SHO’s. Fy1’s are never expected to do ward rounds alone.
Of note: RSCH is commencing hospital at night in August 2007, and therefore the rotas will change. However from August 2006-2007 the following describes the Fy1 rota. Medical staffing issue a monthly rota which states when you will be on call. During your 4 month rotation in general surgery you work for 2 or 3 weekends, 1 full week of nights and various evenings. Evenings last until 20:00hr, as does weekend cover, and nights are 20:00hr to approximately 09:00hr. I understand that in August 2007 a further late shift is going to be introduced from 12:00hr to 24:00hr.
A typical day as an Fy1 on this firm starts with a ward round where your responsibilities are initially to confirm that the patients are still in the same bed as yesterday (they are frequently moved). You then gather the notes, and lead the ward round between patients, possibly presenting any new results (particularly scans and bloods) from the previous day. One of the house officers writes in the notes. There is a firm rule that every Moore-Ridings patient must have a house officer written entry in their hospital notes every day Monday to Friday. On the firm there are 2 bleeps (8082 and 8083) and on very busy days it is sometimes helpful if one house-officer acts as the “runner” and answers all the bleeps so the others can focus on the round.
Once the round has ended (and again throughout the day) it is always really helpful to go through the jobs and ensure that everyone knows exactly what is going on. This is particularly necessary on busy ward rounds (and post-take) because as a house officer you may miss seeing patients on the initial round. The jobs then need to be divided between team members. A particularly important job is requesting scans (CT and ultrasound). In order to request these urgently, as a house officer you frequently have to present these to consultant radiologists, therefore it is imperative that you thoroughly know the patient’s history. If you missed seeing them on the ward round, but have been asked to request a scan, it is often helpful to quickly scan the notes to verify the history before requesting the scan. CT scans in particular all need to be protocoled by a radiologist, and this can usually be done after 9am in the CT department. If there is no radiologist in CT, try their offices, secretaries or the USS department in the Barry Building.
As an Fy1 you are responsible for the housekeeping. Therefore you need to ensure that: scans are requested and reported on; bloods requested and checked (and recorded in flow charts in the front of notes); abnormal results acted on; IV fluids, analgesia and regular medication prescribed; discharge summaries written (TTO’s); nursing staff informed of any changes in management; patients and relatives informed and seniors contacted as necessary. In addition, an essential Fy1 daily role is to update the patient lists which are located on surgical patient manager on all the surgical ward computers. On a Friday a weekend plan must be made for all patients and placed in the front of the notes (forms available from ward clerks). As an Fy1 you are not expected to consent patients for surgery.
The Fy1 doctors are also responsible for typing a summary to the GP about any of Mr Moore’s in-patients being discharged to help ensure good communication with community medical teams when patients leave hospital. Mr Moore’s PA on level 9A helps with this.
As previously stated, with the introduction of hospital at night, on-call responsibilities may well change, however I will describe the duties of an Fy1 from August 2006- 2007. There are two house officers on from 17:00hr to 20:00hr during the week, or 08:00hr to 20:00hr at weekends. One house officer generally covers the wards (including vascular and occasionally urology depending on their staffing levels), and the other house officer admits patients in A&E and the surgical assessment unit. In general (but particularly at the weekends) the wards house officer is busier, and therefore it is helpful if the admitting house officer can also help on the wards. At the weekend all surgical patients are seen on a ward round which is commonly consultant led. It is very helpful if all maintenance fluids, analgesia etc can be written on this round as it saves subsequently re-reviewing the patient. There are commonly simultaneous vascular and general surgery ward rounds. It is essential that one Fy1 is present on each round.
CEPOD (confidential enquiry into patient outcome and death) is the name used at RSCH for the emergency theatre list. On a Thursday after the post-take round, any urgent cases are operated on, and this usually involves the consultant, registrar and frequently the SHO. As a Fy1 you may need to book the patients onto the CEPOD list, ensure they are prepared adequately for theatre with relevant bloods (including clotting, group and save or cross match depending on the procedure, FBC, U&E’s), a cannula, CXR if appropriate etc etc.
Pre-Operative Assessment Clinic (Pre-Op)
Whilst a significant proportion of elective surgery takes place at Princess Royal Hospital, some elective cases are done at RSCH under Mr Moore or Mr Ridings. Once the consultant has decided to operate, and a date booked, the patients are booked into a pre-op clinic where a house officer sees them. These clinics are commonly on a Wednesday late morning. Your responsibility is to clerk the patient, and assess their anaesthetic risk. If you feel they are at high risk then it is important to contact the anaesthetist (the sister in charge of pre-op can give you their details). Patients may then need to be booked into ITU post operatively. You should also take routine bloods including clotting, write up a drugs chart, inform them of any bowel prep needed before surgery (details available in the pre-op clinic but phone the consultant surgeon if you are uncertain), and ensure they are on your list of expected arrivals.
Mortality and Morbidity (M & M)
RSCH is a busy hospital with a large number of emergency admissions and not every patient survives despite best medical care. There are a number of criteria for reporting deaths to a coroner, or coroner’s officer, but important ones to note are post operative deaths, and deaths within 24 hours of admission. You may then be asked to issue a death certificate. In addition, for the purpose of learning and audit it is important to keep a good record of all patients who have passed away or who have had any complications and these are presented by the Fy1’s at an M & M meeting which occurs every month.
Opportunities for Theatre and Learning
There are ample opportunities to learn as an Fy1 in Mr Moore and Mr Ridings firm. In addition to once weekly formal Fy1 teaching 13:00-14:00hr on a Tuesday (bleep protected time) and a once monthly formal afternoon teaching in general medicine / surgery, the consultants, registrars and SHO’s are also keen to teach on ward rounds, particularly if they are less busy. Radiology meetings on a Wednesday morning are a good way to improve skills of scan interpretation, and the surgical department holds teaching sessions once a month on a Friday afternoon.
Opportunities for theatre exist, but you have to make them happen. With SHO’s and registrars all keen to learn, and the responsibilities of the Fy1 lying primarily with ward patients, this is sometimes difficult, but not impossible. I personally found that my best experience was on nights.
There are additionally ample opportunities to teach, because during term time there are up to 6 third year medical students attached to the firm, and although you may feel that you have little to offer them, I suspect you will be surprised by how quickly you acquire the skills and knowledge needed to be an effective Fy1.
Needing Help / Feeling Overwhelmed
As an Fy1 there is very good senior back up. 08:00hr to 17:30hr, there is always an SHO or registrar from the team available on site who you can ask for clinical help, and out of hours there is equally good cover from different SHO’s or registrars. In addition, Sister Kingsbury who is in charge of Level 9 is a brilliant source of knowledge and help. The hospital intranet has extensive and very helpful guidelines on the management of the majority of conditions such as the management of community and hospital acquired pneumonia, urinary tract infections and loading and subsequent dosing of warfarin etc etc.
Both the consultants are very approachable, and if you want support outside the direct team, all Fy1’s also have an educational supervisor who they can contact.
My experience of being a Fy1 in General Surgery at RSCH has certainly been an enjoyable one, and I hope you have a similar experience.
Fy1 Doctor in General Surgery, April- July 2007.