Vascular Surgery

• Get access to the Vascular Surgery Master List - email either Mr Manjit Gohel or Mr Hansoo Lee to get added
• Read this guide and also those on the wall in the L5 office.
• Review your arterial and venous anatomy
• Find out the names and locations of local hospitals, as many of our patients are from out of region - although it is often easiest to transfer consultant to consultant (most commonly from West Suffolk or Peterborough).
• Get an @nhs.net email address here: http://connect/media/pdf/4/n/nhs_net.pdf
• Make sure you have a working printer fob - you may need a PUK code to activate it

• Ward L5 is the vascular ward.
• It's divided into three (1a-6d, 7a-12d, 13-17d). Each section has their own nursing team look after the patients.
• The doctors' office is on the right past the first nurse's station (code 123456).
• Part way down on the right are the stationary cupboard (code is 1478), stock room and equipment room.
• On the right before you enter the ward is the vascular lab reception. The vascular scientists work closely with the vascular team, performing mainly arterial and venous duplex ultrasound scans.
• Angiography is on Level 4. Access via level 3, heading towards outpatients. Vascular MDT is in lecture theatre near here
• Clinic 4 in outpatients is the Vascular clinic
• Tuesday morning meeting is by the consultant offices on the F6 corridor
• Pre-op patients are generally admitted to either J3 (along the corridor from ITU opposite main theatres) or L5
• The main operating theater for vascular surgery is theatre 23 (and Theatre 6 on Wednesdays)
• FY1 bleep is 157 207/157 208, FY2/SHO 152 509, Reg on cal 154 416

• Addenbrooke's is a tertiary vascular referral centre and many of the consultants work at other hospitals. Lots of patients are transferred here from other hospitals for specialist vascular surgery, and are then transferred back there afterwards.
• The vascular team is consultant led. The consultants are on call Monday to Thursday and then another takes over from Friday to Sunday. There are theatre lists every weekday except Tuesday, the day of the MDT. The consultants do not mind if you contact them needing advice about patient management.
  • The team is often happy to share mobile numbers and it's usually the easiest way to get in touch. There are bleeps (FY1: 157207). The SHO (152509) and registrar (154416) also have bleeps.
• Unlike colorectal and upper GI, and like HPB, vascular is not involved in the general surgical take.
• The juniors are expected to deal with most medical issues, however Dr Biram is a DME consultant who advises any surgical teams who require additional medical input for their patients. Referral is via EPIC/telephone.
• The number of juniors on the ward varies from week to week. Some weeks there is only 1 FY1, during other weeks there are 3 FY1s and 1 SHOs. Check the rota. If you are overworked you should talk to Surgical Staffing, your SHO and your consultant. The FY1s usually look after the L5 patients only; the SHOs cover the outliers too.
• There is a nurse in charge of L5. The vascular specialist nurses are excellent and also accompany the ward round.
• The vascular department works closely with the diabetic foot team (ward F6). A multidisciplinary diabetic foot round takes place every Tuesday at 5.30pm. Patients can be referred to the diabetic foot round by contacting the diabetes registrar. Vascular juniors do not attend this ward round but should take note of what's recorded.
• The angio department may admit patients under vascular overnight as interventional radiology do not have inpatients. Be prepared to clerk them in post-angio just before you finish the day. Many inpatients wait days for their angiogram/plasty, and may go home whilst waiting.

• Like all surgical rotations juniors take part in an acute block, involving nights, weekends and ED shifts.
• Surgical weekends are preceeded by a week of 11am-1930 shifts, whereby you are on call from 1730. You'll need a bleep and switchboard need to be told the number. You will often be on call for general surgery in ATC, which can include patients from L4, L5, M4, M5 and day surgery (L2). You will be expected to hand over any unfinished/outstanding jobs to the night team at handover at 7.30pm in C7 doctor's office. Ensure that urgent jobs are your priority, and as things can get miscommunicated during handover, make sure all relevant details (including how an abnormal result should be acted upon e.g. asking night SHO / calling vascular reg on call) are handed over.
• Unless you are allocated a colorectal or UGI surgery job, your time on ward nights, lates and ED days are your only exposure to general surgery so make the most of it (e.g. diverticulitis, appendicitis, cholecystitis, post-op general surgery patients, etc.)
• FY2 acute block is with the general surgical team. Mostly, acute vascular referrals are via the registrar on call.

• Monday (new consultant on call) - print a few patient lists for the ward round, get handover from the weekend team, prepare for Tuesday's Vascular MDT by printing the theatre lists for theatre 6 for the following Wed/Thu/Fri/Mon (at present we are copying and pasting them from EPIC into a word document, can't generate printed lists).
• Tuesday - update the list with any changes overnight, print off 15 copies of the list and take the patient lists, theatre list to the F6/G6 seminar room by 8 o'clock. After the consultants discuss the plan for the week the FY1s/FY2s are expected to briefly present all vascular patients' current medical and surgical issues.
• Wednesday/Thursday - normal ward days. Have a lower threshold for putting out bloods for Friday morning as you'll want to limit the number of blood requests over the weekend (the FY1 on call has to take them as there are no phlebs).
• Friday (new consultant on call) - as above request bloods for the weekend and monday, and also prepare an updated patient list to handover to the weekend team. You must write all TTOs for any patients who might be going home over the weekend as the weekend FY1 will not have time to do them, and is not familiar with the patient. The more TTOs you can do before the weekend the better.
• Weekend - 3 FY1s cover 4 wards rounds (UGI, Colorectal, HPB and Vascular). Usually the actual vascular ward round is done by consultant and on call SpR. Following vascular ward round, the FY1 covering the ATC will be expected to follow up/execute any jobs generated during the ward round. However, every weekend seems to be different. The consultant may do the vascular ward round alone, may bleep the ATC/ED FY1 when they want to do it or may agree to do it after the other ward rounds, like at 10am. If one of the vascular FY1s are working weekend days it makes sense for them to do the vascular ward round, if possible and the rest of the on call team are happy.

• 7.30am - arrive, check for new referrals on the 'vascular team referrals' list on EPIC, print around 5-8 copies, make sure blood requests are on EPIC for ward patients. Check the theatre lists on EPIC for the J3 admissions, and check that pre-op patients have 1. 2 valid G&S, 2. Other recent bloods (ie clotting time) 3. ECG if warranted.
• 8am - ward round starts (sometimes 8.30). The ward round starts in bay 1, continues to 17 and then see the outliers. Unless there is no SHO, the FY1 usually departs the ward round after the inliers have been seen, allowing the SHO to see the outliers. Juniors may be expected to present the patients if the consultant is new (Mondays/Fridays). Try and make sure you get a workstation early for the ward round, as there are only 4 for the ward, and nurses use them for their drug round. Sometimes there aren't many pairs of hands on the ward round. Mention to the consultant at the start of the round if you might struggle. Allocate jobs in advance; ie. one person can write in the notes, another can write the jobs down on the patient list, another can start TTOs/discuss referrals. Without this, grumbling sepsis, slipping renal function, missed DVT prophylaxis, overlong AbX prescriptions, can all be missed on the ward round. Make sure you're clear of the plan; some ward rounds can be fast and the consultant won't mind you clarifying what leg needs a duplex, what CT scan is needed, what follow-up is needed.
• 9am-10am - inliers ward round finishes. FY1 starts doing jobs in order of priority (first deal with any unwell patients, then request investigations, make referrals and co-ordinate patient discharges, etc.).
• 11am - if a vascular FY1 is on a late shift they'll arrive now. They could bring coffee…
• 2pm - start thinking about what admissions are coming in and who is going home tomorrow. The nurse in charge or ward clerk will know. Also call the angio department (2337) and ask them if they're bringing any patients in under vascular. You're expected to do admission clerkings for patients pre-op/angio, post-op/angio and those coming from local DGH hospitals (mainly King's Lynn, Hinchingbrooke, West Suffolk, Peterborough and Papworth). In addition to an admission clerking, patients pre-op/angio need at least their regular medications prescribing, a group and save (2 if new to the hospital), routine pre-op bloods, a cannula, an ECG and will need IV fluids and to be nil by mouth from midnight (sliding scale if diabetic). Most patients admitted before angio come in for pre-hydration. Put new patients on the patient list and also prepare TTOs for the patients going home the next day. Angio patients only need a brief clerking.
• 3pm - start thinking about chasing the day's bloods, and acting on them. Prepare TTOs for the next day. Clinical notes and medications. Print the drug reconciliation charts and as the nurses to do a pod-check, where they compare what drugs the patients has in their locker to what they need from pharmacy.
• 4pm - update the patient list and also add patients who are coming in for theatre the next day (see theatreman). Request bloods for the next day, including any patients who may be coming to the ward from theatre.
• 5.30pm - the evening on call FY1 starts at 5.30pm so start thinking about handing over any sick patients, outstanding investigations and expected admissions. The bleep is on rotawatch or via switch. The consultant on call may pop in before you go home to get an update on the day's proceedings.

• Common cases - acutely ischaemic limb, chronically ischaemic limb, neuroischaemic foot ulcers, thoracic/abdominal/popliteal aneurysms, AAA rupture, pseudoaneurysms post-angio, EVAR/TEVAR, aortic dissection, embolic disease, trauma, carotid/femoral endarterectomy, osteomyelitis. Most vascular patients have many medical comorbidities, particularly multi-system atheromatous disease.
• Workup - normal surgical workup with a focus on cardiovascular disease, US doppler, arterial/venous duplex scans, CT angiograms, angiograms/plasty (stop metformin for 48hrs pre & post and consider pre/post-hydration), foot X-ray/MRI (?OM), swabs, cultures, CTA/echo/24h tape (for ?embolic disease?), heparin infusion (with 6-hourly APTT ratios, see monograph on Merlin for dosing instructions)
• Typical management plans - anti-platelets, anticoagulation, statin, PPIs (lansoprazole if on clopidogrel), analgesia, physio, mobilise, removing lines/drains/catheters, dressings (e.g. honey, VAC), lavae therapy, surgical debridement, antibiotics.

• Routes of admission are from the ED, vascular clinic, local DGHs and GPs.
• Admission clerkings should include at least an introductory summary, PC, HPC, PMH, DH (inc. allergies), SH, a cardiorespiratory examination and as assessment of the leg pulses. Please use the EPIC admission proforma, and ensure VTE assessment and home meds are completed. The lead consultant for a patient being clerked in via A&E would be the consultant on call. For elective lists, it would be the consultant doing the operation. To change the lead consultant, type in 'change consultant' on orders.
• Patients can stay in hospital anything from 1 night to 100 nights. Usually between 2 and 10.
• Patients will need follow up either with their usual consultant, they're admitting consultant, the consultant who did their operation or their discharging consultant. Ask the consultant during the ward round these details as they're difficult to find out later.
• Discharging - lots of things are required for a smooth discharge and it is the FY1s responsibility to get this right; delays and discrepancies affect many members of the team and of course the patient:
• 1) Prepare TTOs in advance, especially before the weekend. There is increasing pressure to discharge before midday. You can put much of the patient's story in the “presenting complaints” section and leave “progress and complications” blank until the day of discharge. ITU discharge summaries are helpful. 'Gen Med Dis' in EPIC smarttext is a useful proforma
• 2) Follow-up: This is traditionally done quite badly. You can usually figure out from the patient address what their local hospital is. Most patients are reviewed in their local hospital at discharge. They may have one appointment at Addenbrooke's and then follow-up in their local unit. Review locally where possible. Addenbrooke's vascular clinics are clogged up. Find out from the consultant or registrar (on the ward round) about the follow up appointment (which consultant, which hospital, how long, what will be reviewed). On EPIC, type in 'Clinic follow up' under new orders and follow instructions.
• 3) Op notes should populate automatically.
• 4) Completing the drugs section properly: use the automatic drop downlist of drugs by preference, use words and figures for controlled drugs, avoid latin abbreviations (once daily, not OD). Tramadol is now a controlled drug, codeine and oramorph are not. You need to print the controlled drugs prescription at the time of saving the drugs list.
• 5) Anticoagulation: Make a concerted effort to (re-)start warfarin loading a patient sooner rather than later as discharging a patient to warfarin load in the community needs dalteparin cover and frequent INR blood tests, which take time to organise. Record on the handover sheet who is normally on warfarin and as your seniors if you can restart their warfarin after their operation. Bear in mind that for patients from outlying hospitals, it may be more appropriate to organise warfarin monitoring with their local hospital. The 'yellow book' or personal anticoagulation record (they are usually stocked in the stationary cupboard) should be filled out for the patient to take away with them to their next GP/anticoagulant clinic appointment.

Sporadically patients will turn up on L5 the day before an operation and will need to be clerked. This often happens late in the day and can delay you getting home on time, it's worth checking with the nurses to see if they know anyone is coming in so you can plan jobs accordingly. It's a good idea to take a list of the pre-admissions in the weekly meeting so that you know what to do about e.g. warfarin, LMWH, antiplatelets - if in doubt contact the registrar. Make sure to request an ECG and take a set of routine bloods including a group and screen (or 2 if the patient does not have a historical result on the system).

Surgical Repatriation to Peterborough Hospital As our consultants work in different hospitals, (WSH, PCH, King's Lynn etc.) we occasionally get transfers from these hospitals for operations, for example AKAs. In May 2016, a new referrals system specifically for patients going back to Peterborough and being accepted under surgery has been developed. Four people are to be emailed, including the general surgery secretary, and three general surgery consultants who work in Peterborough, with anonymous patient information, alerting them that a patient is due to be transferred. Then a formal transfer summary can be sent from @nhs.net to @nhs.net email address (as this is deemed 'safe') or from a fax (as this is also 'safe'). One of the consultants (who ever is on take) will accept the patient back, and then the patient usually leaves the following day. It doesn't happen frequently, but it is very useful with longterm patients requiring rehab.

These email addresses are: - brandon.krijgsman@pbh-tr.nhs.uk - peter.taylor@pbh-tr.nhs.uk - robert.dennis@pbh-tr.nhs.uk - karen.pearce@pbh-tr.nhs.uk

It is worth noting that repatriation to local hospitals after an AKA should be referred to the medics not surgeon for OT and PT input

EPIC

There are some tricks to making life easier on EPIC
  * .wrv will bring up the ward round proforma in the notes
  * Search for 'duplex' to get arterial/venous scans - these are done by vascular labs, not radiology
  * If editing a note, select from the menu at the top right hand corner of the notes window 'move to sidebar'. This will allow you to review other windows whilst typing
  * Warfarin - the default position is to prescribe for one day only, make sure this gets renewed! Will also need inpatient warfarin order as well
  * Antibiotics often expire without much warning - can change course length to 'indefinite' to avoid this
  * Angioplasty - search for 'IR angio'
  * Theatre cases - book all inpatient/emergency theatre cases as 'MAIN THEATRE EMERGENCY' (not 'other theatre list'), as this allows the theatre coordinator to transfer them to other inpatient lists.
  * CT & MRI requests still need to be phoned through
  * Need to hand-write G&S requests as well as ordering & collecting (under 'Procedures' on EPIC). Bottles must be hand-written if you have not scanned the patient.
  * For crossmatch, fill in the 'Adult Blood Component Request' form under 'order sets', select 'Prepare RBCs' and fill in the relevant details

 
* Find out a consultant's name for transfer back to a DGH - this can be difficult. Speak to the other hospital's switch board and tell them what you're trying to do. You usually speak to the medical consultant/registrar on call and they accept the patient back there once the patient has few/no surgical issues.
* Make a transfer letter - write a normal TTO but pritn 'Inpatient Transfer Summary'. Print and fax it to the accepting hospital once the patient is accepted. Revert the TTO and then update it again only once the patient has a bed there (can take weeks).
* The criteria for successful repatriation of a patient from Addenbrooke's to their local hospital are: 1) No ongoing vascular surgical issues. 2) Patient agreement (they often refuse). 3) Name of accepting consultant/registrar at local hospital (usually whoever is on call; call hospital and ask for advice; they are used to such requests). 4) The local hospital's bed managers have been informed. 5) Tranfser letter written, printed and faxed to local hospital bed managers (revert TTO after so patient isn't actually discharged). 6) Addenbrooke's hospital surgical bed managers informed. 7) Patient added to "Critical/Waiting Acute Hospital Bed" list on EMR. 8) Write in the "Communications" section on their EMR record who accepted the patient and on what date. 9) Tell the nurse in charge you've done all this.

Heparin infusions-these are “APTT ratio” adjusted - the APTT ratio or heparin ratio is crudely analagous to INR for heparin. These patients will need APTT ratio samples to be taken every 4-8 hours to adjust heparin infusion rate and avoid over- or under- anticoagulation, with adjustment to the infusion rate in accordance with the heparin infusion pro-forma which the nurses can see on their MAR chart.

• Lots on the wall in the vascular office.
• Vascular SpR Pager 154 416

• 1b banding
• You usually leave the hospital around 6pm but sometimes as late as 7.30pm

• Run-off
• Crural vessels
• The trifurcation
• Duplex
• Doppler
• CT angioiogram
• Pseudoaneurysm
• Eshkar
• Critical ischaemia

• Learn your arterial and venous anatomy - you will be asked on ward rounds to “drive” the imaging of the patient. This will involve you talking through the various vessels seen or not seen on angiograms. It is also useful for when students present themselves to the ward as this a common question they ask to be taught on.
• Learn about the various anticoagulants
• Group and saves x2 per patient who may need angio or theatre

• The list - put in the patient's consultant, their home hospital, their main surgical and medical issues, the current plan and any important results (e.g. duplex, CTA, etc.). Before printing the list, go to page setup and make all the margins “5” and delete the header and footer, all to save space on the page. Print double-sided and landscape.
• Phlebotomy - PA's now do the phleb rounds in the morning - the timing varies each morning, but give the PA's a call via switchboard if they don't show up by end of morning to give them a gentle reminder. It is also useful to run the bloods down to the haematology lab yourself as this ensures that the blood results are available before the end of the day. Also make sure that you know who the PA's haven't been able to bleed and which patient's have PICC lins as the PA's do not bleed these patients. Either you can rint the labels and ask the nurses to collect when they access the line or do it yourself.
• Sick patients - always know who are your most unwell patients and pay them close attention. Do not be afraid to ask for help from your SHO, SpR or surgical consultant. Relevant medical SpRs, the medical registrar on call or Dr. Biram are happy to be called. The junior team must take care of many of the medical issues and let seniors know, so check bloods carefully, etc. Rapid response team is also a useful resource for advice or for them to help review an unwell patient.
• ED day - if a vascular FY1 is on an ED weekday, they should join the vascular ward round and help with jobs as they usually do not get bleeped until late morning.
• Go through the list with the other doctors on the ward at least a few times a day just to update one another on new issues, who's doing what and what jobs are complete.
• Anticoagulation - almost all patients are vasculopaths who are not only prone to thromboembolism, but will also be worse affected by it due to already compromised perfusion. Take careful note of what anti-platelets and anti-coagulation your patients are on and be prepared to change it around relatively frequently. Warfarin prescribing can get easily left out on EPIC system as it is not on the 'current meds' list if prescribed once off. Make sure to check INR and to prescribe warfarin accordingly. Do not overanticoagulate!
• Pharmacists - as important as they are on every ward. Will help you with discharges and will often suggest medication changes. Pharmacists and Pharmacy technicians will help with patient's drug history and document the correct medications and doses on epic. Do look at pharmacy entries.
• Gas machine - the nearest one is in the day surgery unit on level 2. Go straight down the main corridor and it's through a door to the right of the second nurses station. Code 120407. You'll most likely need access from POC - ring them if your log in isn't working.
• EDD - have a rough idea of what a patient's estimate of discharge is, so you know when to do the TTO. You can record on your patient list if you've done the TTO.
• Bloods/cannula - you have to put in all the cannulas (unless the PAs are on the ward when the phleb is away; you can ask them nicely) but there is the morning phleb round every weekday. You share an equipment room with the vascular specialist nurses so try to keep the trolley tidy. Due to PA cover on medicine this may be if you have two medical and one surgical job the major learning experience when it comes to cannulation and venepuncture. It is easy to allow the PA's or nurses (occasionally) to carry out these jobs, but remember that you will be alone on a nightshift in DGH in the not to distant future and if you are calling your med reg for cannula placement because you didn't learn the skills during FY1 then you will not be a popular figure. Usually nurses will take PICC bloods, but not always.
• Morbility and Mortality meeting - there is one MM meeting/audit every month, usually in the begning of the month. You will receive an email with a patient list from vascular secretary a few days before the meeting. You need to go through the list and prepare a powerpoint presentation. You will present the story during the audit. Try to go through the presentation with a registrar before the meeting as some patients on the list might not have morbidities that are worth discussing.