Advice from recent Moore-Ridings F1 House Officers
by Emilie Elliot and Jamie Franklin
Advice to future Moore-Ridings F1 House Officers and interested parties such as medical students from two doctors who have recently completed their F1 attachment on the Moore-Ridings firm. (Please note that Mr Moore now leads a different firm with Mr Lamah and that his timetable has changed since this article was written).
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 house officers (foundation year one doctors, FY1s).
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, usually after the Monday morning ward round.
The team is always “on-take” on a Wednesday and every fourth weekend which means that any surgical admissions to RSCH from 8am on Wednesday to 8am on Thursday, or 8am Friday to 8am Monday will come under the care of Mr Moore or Mr Ridings depending on which consultant is on.
In general, Mr Moore does a ward round on Mondays and either Mr Moore or Mr Ridings will do a ward round on Wednesdays and Thursdays, depending on on-call duties and elective lists The ward rounds on Tuesdays and Fridays are registrar or SHO led (FY1s are not expected to conduct ward rounds alone). The post-take ward round commences at 8am on Short Stay Ward on Level 9 of the Millenium Building. All other ward rounds usually start on Level 9AS at 8am.
On Wednesday mornings, there is a radiology meeting at 8.15am in the Level 9 seminar room, where any interesting / complicated cases are discussed. All members of all surgical teams are expected to attend these radiology meetings.
A typical day begins with the morning ward round where your responsibilities start with confirming 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.
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 FY1 job is requesting scans (CT and ultrasound). In order to request these urgently, you frequently have to present the patient to a consultant radiologist, therefore it is imperative to know the history well. 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 and verify the history before requesting the scan. CT scans in particular all need to be protocolled 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
- Bloods are requested, checked, updated on the list and abnormal results are acted upon
- IV fluids, analgesia and regular medication are prescribed
- Discharge summaries are written (TTO’s)
- The nursing staff is informed of any changes in management; patients and relatives are informed and seniors are contacted as necessary.
- It is the FY1 daily role to update the patient list, which is located on the surgward shared drive in the Moore/Ridings folder, on all the level 9 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).
- FY1 doctors are also responsible for typing a summary to the GP for all of Mr Moore’s in-patients being discharged. This ensures good communication with community medical teams. A template is available on this website and completed discharge summaries are saved on the shared drive. Mr Moore’s PA on level 9A helps with this.
As an FY1 you are not expected to consent patients for surgery.
Geraldine Jenkins, surgical co-ordinator, will email the on call rota to all FY1’s starting surgery. During your 4 month rotation in general surgery you will work 3 weekends (1 nights, 2 days), 1 full week of nights, 1 full week of 12 to 12 and a few evenings..
On call days are 8am to 9pm, although on weekdays you are only expected to carry the on call bleep from 5pm to 9pm (with the handover meeting taking place in level 4 seminar room at 8.30pm).
On call nights start at 8.30pm at handover and finish after the post-take morning ward round, usually 9-10am. On the 12pm to 12am shifts, you are expected to fulfil normal firm duties until 5pm, when you collect the bleep and look after the surgical inpatients until handing over to the night house officer at midnight.
Surgical inpatients/wards(including vascular and urology patients), are looked after by the 12 to 12 house officer during the week, the ward-cover house officer (HO 2) at the weekend and the night HO at night. The other HO (HO 1) clerks patients in A&E and the surgical assessment unit. At the weekend, all general surgical patients are seen on a single consultant-led ward round. HO 1 and 2 both attend this round. 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 is commonly a simultaneous vascular ward round; one HO should leave to attend this round. 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.
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 (ask the team how to), 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)
A significant proportion of elective surgery takes place at Princess Royal Hospital, but some elective cases are done at RSCH under Mr Moore or Mr Ridings. Once the consultant has decided to operate, and a date is booked, the patients come to a pre-op clinic where a house officer sees them. Your responsibility is to clerk the patient and assess their fitness for anaesthesia. If you feel they are at high risk, it is important to contact the anaesthetist in advance (the sister in charge of pre-op can give you their details). These patients may need to be booked into ITU post operatively. You should also take routine bloods including clotting, write up a drugs chart, inform the patient of any bowel prep needed before surgery (details available in the pre-op clinic but phone the consultant surgeon if uncertain), and ensure that 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.
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 post-op complications. These are presented by the FY1s at the departmental M & M meeting every two months. It is therefore helpful to keep a clear record of these patients on the shared drive throughout the rotation.
Opportunities for Theatre and Learning
There are ample opportunities to learn as an FY1 on Mr Moore and Mr Ridings’ firm. In addition to the once weekly hospital-wide formal FY1 teaching (13:00-14:00hr on Tuesdays, bleep protected time) and the 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 (academic day).
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. The best experience is usually on Thursdays (Firm CEPOD day) and on nights.
There are, additionally, opportunities to teach, as there are up to 6 third year medical students attached to the firm during term time. You may feel that you have little to offer them to begin with, but you will find you help them acquire skills and knowledge quickly.
Needing Help / Feeling Overwhelmed
There is very good senior back up for FY1s. 8am to 5.30pm, there is always an SHO or a registrar from the team available to answer clinical questions, and out of hours there is equally good cover from on-call SHO’s or registrars. In addition, Sister Kingsbury, who is in charge of Level 9, is a valuable source of knowledge and help. The hospital intranet has extensive and very helpful guidelines on the management of the majority of conditions such as community and hospital acquired pneumonia, urinary tract infections and loading/dosing of warfarin etc.
Both the consultants are very approachable, and if you want support outside the direct team, all FY1s also have an educational supervisor who they can contact.
Hannah Bainbridge (FY1 Doctor in General Surgery, April- July 2007)
Reviewed by Emilie Elliot & Jamie Franklin (FY1 Doctors in General Surgery, April- July 2008)