BRIDGING COURSE

/ MASTERCLASS, SECTIONS / By

Topics

  1. Workplace Etiquette
  2. Clinical Notes: The CHERIAN System
  3. Early Warning Score (EWS)
  4. Blood Tests & Results
  5. Prescribing
  6. Venepuncture
  7. Interpreting X-rays
  8. Consent
  9. Operating Theatre Etiquette
  10. Scrubbing, Gowning & Gloving
  11. Common Instruments & Handling 
  12. The On-Call Masterplan

INTRODUCTION

  • Overview
  • Breakdown
  • Practical x Theory 
  • Breakdown 12 modules roughly 10 minutes each 
  • One module roughly 40 minutes Q & A 20 minutes 
  • Take Notes if possible
  • Add questions to chat box
  • Email me later admin@juniordoctor.net

0. DAY ZERO

  • Before
  • In Hospital
  • BEFORE
  • Essential Apps: BNF, Accurx
  • Nhs.net email 
  • Download sitemap 
  • Save hospital switchboard number Favourites
  • Call Parking – Payment after or Pay on display
  •  
  • IN
  • 2 days shadowing
  • Shadow FY1 & Registrar  
  • Identify Clinical Systems – Results (ICE), Radiology Images (Synapse), Prescription (Wellsky), Theatre (BlueSpier), Patient Letters (Medisec), ED clerking (Symphony)
  • Keep bag/belongings – Theatre Locker/Drs Mess 
  • ID badge
  • Car parking permit
  • Wards  

1. WORKPLACE ETIQUETTE

  • Timings
  • Sequence
  • Patient Review
  • During the day
  • Reach 30 mts early esp first week – early bird – Parking sweet spot 7.30-7.45 night shift finish
  • Go to theatre – Change into scrubs 
  • Switch on PC (Sign-out after use on each ward)
  • Print patient list
  • Get Consultant, Registrar, SHO name & numbers
  • Jobs Book – Ward, Patient label, jobs
  • Patient Review – attend with Ward Sister
  • Gloves, Gel, Marker pen
  • Confirm Name & DOB 
  • Draw Curtain – Have Chaperone
  • Leaving use Handrub
  • Review Jobs Book – Prioritise & allocate jobs
  • Document everything you do
  • Lunch from 11am
  • Chase results by 2pm – update Hierarchy SHO/Reg Bleep/SMS/Theatre
  • Handover to on call team 1/2 hr before finish time
  • Confidential Bin – Dispose of handover sheets everyday

2. CLINICAL NOTES: CHERIAN SYSTEM

  • Background – Ccrisp Course
  • CHERIAN Technique
  •  
  • Charts 
  • EWS
  • I/O Input=PO + IVF Output = Urine + NG tube + Drains. Optimal output 0.5ml/Kg/Hr
  •  
  • History (+PMH, PSH, Drug History)
  • 1/7, 2/52
  •  
  • Examination
  • Chaperone – use clinical person e.g. HCA, Staff Nurse etc (not ward clerk/auxillary or nurse on drug round)
  • GMC guidance – intimate examinations 
  • Safer guidance – Any situation where you need to pull the curtain around
  •  
  • Results
  • Date everything
  • Bloods 14/04 Hb 92(104) Not just isolated value
  • Urine 
  • Imaging – USS/CT
  •  
  • Impression – Diagnosis 
  • Differential Diagnosis
  •  
  • Advice – Plan
  • Management – Tests, Treatment
  • Update Nurse looking after patient/Ward Sister
  •  
  • Name + Bleep + GMC Number

3. EWS

  • 7 Parameters
  • Remember 322 
  • 3 Respiratory – Respiratory Rate, Saturation, Oxygen
  • 2 Cardiac – Heart Rate, Blood Pressure
  • 2 Other – Temperature & Consciousness
  • Remember what makes Zero (0) – you should be able to identify which parameter abnormal
  • Pitfalls Temp 37.9 HR 89 – don’t score
  • Note – Rise in Resp Rate & Supplemental O2 increase score straight by 2. Non alert patient = 3
  • Alert Doctor at 5 
  • Alert Senior/Critical Care at 7

4. BLOOD TESTS

  • 3 sets of blood tests
  • FBC & CRP
  • U&Es
  • LFTs
  • Other tests 
  • FBC & CRP: 
  • WCC 4-11 Lower/Higher = inflammation. Very low/very high ~ Malignancy
  • Hb 
  • Gradual drop – Right sided colonic malignancies
  • Sudden drop – Trauma/ GI bleed Malena x Lower GI bleed Mgt: Bloods(Urea rise), OGD, CT Angiogram
  • Indication for blood transfusion – Absolute value 70 or drop of 20/24 hours  
  • CRP esp imp if >100 +/- ProCalcitonin
  •  
  • U&Es
  • Us: Ur, Cr, eGfr  
  • Creatinine 100 ~C = 100
  • eGfr most important. Not for Contrast CT if <40
  • Es: Na, K – know treatment especially for hyperkalemia
  •  
  • LFTs: Acronym

  • 2345 L=50 (Roman)

  • Bilirubin 20
    ALT 30
    GGT 40
    Lipase 50

    ALP=Amylase 125

  • Pancreatitis
    Amylase 2 days
    Lipase 2 weeks

  • Others Tests
  • DM: Glucose (BM Boehringer Mannheim Blood Glucose Test Strips – Capillary Blood Glucose) , HbA1c
  • MI: Troponin (+ ECG)
  • PE: d-Dimer (+ CTPA)
  • Ischemia: Lactate >2
  • G&S – Anaemia, PR bleed, Laparoscopy, Any major operation
  • Coagulation: Platelets, INR, APTTr
  • General info
  • One off high/low value repeat 
BM = Boehringer Mannheim, a company that produced blood glucose test strips 

5. PRESCRIBING

  • Patient Label or 3 Parameters
  • Allergy Status
  • Analgesia, Antibiotics & VTE
  • Prescribe and tell nurse
  • Analgesia
  • Analgesic Ladder
  • Regular (Eg Paracetamol) + PRN (Oramorph)
  •  
  • Antibiotics
  • Check C & S
  • Start date / End date 
  • BNF App
  • Renal dose – Reduced
  • C Diff Cause – Cephalosporins, Co-Amox, Tazocin
  •  
  • VTE 
  • TEDS & LMWH
  • LMWH @ 6pm – delayed if late finish theatre
  • Prolonged LMWH 28 days following Bowel Malignancy Operations
  • Prescribe and tell nurse

6. VENEPUNCTURE & BLOOD GAS

  • Modes x 3
  • Equipment required
  • Anatomy 
  • Blood amounts required
  • Syringes
  • Needles
  • Difficult access
  • Do yourself and others a favour – leave out blood forms/requests for next day
  • Benefit of reaching early – last minute blood requests
  • Phlebotomists don’t do blood gas
  •  
  • Cannula most distal – dorsum of wrist – bifurcation
  • Blood sample – antecubital fossa 
  • Get all equipment before you start
  • Vein names ABC
  • Handwritten bottles
  • Blood required
  • FBC 1.5ml Biochem 5ml Coag 2ml = 8.5ml
  • G & S 4.9ml
  • Roll bottle 
  • When you can’t get a sample
  • Surgical Registrar – Femoral Vein Puncture
  • Anaesthetic 1st on call
 

7. INTERPRETING X-RAYS

CXR

  •  Reading Chest X rays – ABCDE
  • ABCDE
  • Airway
  • Breathing
  • Cardiovascular
  • Diaphragm
  • Everything else
  • The Cardio-Thoracic Ratio (CTR)  greater than 1:2 (50%) is considered abnormal.
  • The carina represents the inferior termination of the trachea into the right and left main bronchi.
  • Chilaiditi
  • PTx 3 treatments – Venflon, Seldinger, Surgical
  • Hemothorax, Pleural Effusion, Empyema
  • NG Tube/Ryles Tube – Position, Indications, Tests

AXR

  • Reading AXRs – BBC
  • Bowel – Upper limits of normal
  • SBO & LBO – differentiation
  • BBC 
  • Bowel
  • Bones
  • Calcification
  • Ryles Tube – indications, tests
  • NJ Tube
  • AUD – Commonest 2 causes – PUD Perf, Divert Perf
  • AXR: BowelBonesCalcification(Stones)
  • The upper limits for the normal diameter 3,6,9 rule (SBO >3cm LBO >6cm Caecum >9cm)
  • LBO & Ileo-Caecal Valve Significance
  • Projection of the abdominal X-ray: AP supine & AP erect
  • BBC approach
  • Bowel and other organs: small bowel, large bowel, lungs, liver, gallbladder, stomach, psoas muscles, kidneys, spleen and bladder.
  • Bones: ribs, lumbar vertebrae, sacrum, coccyx, pelvis and proximal femurs.
  • Calcification and artefact (e.g. renal stones)
  • Bowel Diameter: The upper limits of normal diameter 
  • Small bowel: 3cm
  • Colon: 6 cm
  • Caecum: 9 cm
  • This is often referred to as the ‘3/6/9 rule’

  • Caecum ruptures at 12cm, so important to check whether patient has competent ileocaecal valve  

8. CONSENT

  • Normally SHO and above consent
  • To consent you should know about the procedure well
  • Label
  • Procedure + Proceed
  • Indication: Test/Treatment
  • Risks: General (Common), Specific (Bile Leak, CBD Injury), Life threatening (Heart Attack, Stroke, Risk to life) 

9. THEATRE ETIQUETTE

  • Theatre Lists
  • Briefing
  • Checks
  • Jobs
  • BlueSpier Access – check theatre lists – to attend what you are interested in 
  • Read up – Lap Chole – Biliary System & patient specific details
  • Theatre equipment
  • Cap, Mask (Tape prevents fogging), Scrubs, Cloggs
  • Leave out Gown. Gloves (+underglove = Double gloving protects) – Open only within 20 mts of use
  • Daily theatre briefing – order of list 8-8.15 am
  • Briefing before each case – needed equipment etc
  • Checks – Time out before case, Sign out after case
  • Jobs – Fill micro (fluid/pus) & Histology forms (tissue)

10. SCRUBBING, GOWNING & GLOVING

  • Timing for Opening Gown & Gloves  
  • Scrubbing
  • Gowning
  • Gloving
  • Open Gown & Gloves (Under glove & normal) within 20 minutes of the operation
  • Scrubbing
  • Usually 3 times and 5 minutes
  • Gowning
  • Two techniques – hand out or within
  • Gloving 
  • Double glove
  • Hold right glove fold with left hand and put in right hand
  • Put thumb in first

11. COMMON INSTRUMENTS & HANDLING

  • Tissue Forceps 
  • Artery Forceps
  • Scissors 
  • Blade Handle 
  • Needle Holder
  • Needle Loading
  • Types of needles
  • Types of Suture material
  • Tissue Forceps – Toothed & Non toothed
  • Artery Forceps – Roberts & Mosquito
  • Scissors – Suture cutting & McIndoe Tissue 
  • Types of needles
  • Cutting & Round bodied
  • Types of Suture material
  • Monofilament & Braided – Knots 5 x 3
  • Absorbable & Non-absorbable
  • Needle Holder 
  • Thumb & Ring Finger
  • Loading needle – don’t hold the needle with your hand
  • 2/3 1/3 OR 1/2

12. ON CALL MASTERPLAN

  • What are you referring patient as – what is your Diagnosis?
  • The CHERIAN System