You will see interesting pathology and sick patients. You will also have to work hard and the primary workload will be general internal medicine.

Email Dr Andrew Fry - he is currently in charge of the General Medicine Rota + a Renal Consultant. It is really important to get in contact with your clinical/education supervisor prior to starting this job. Especially if you are starting on your acute block, as it is good to establish a rapor and you have made contact with the person who is supervising you whilst you are working. The acute block can feel a bit lonely as you don't have a regular team of SHOs/SpRs to advise you on things, and work feels quite disjointed as you work on multiple teams. This is why establishing a relationship with your Clinical Supervisor on Renal is very important so you feel you are in contact with someone in case you have questions or run into difficulty.

Set your EPIC profile to ADD NEPHROLOGY - this will give you access to options for dialysis and their renal-specific parts of EPIC. It helps to revise metabolic disturbances in chronic kidney disease - this will make managing dialysis a lot easier. Revisiting immunology is also a good idea (from the practical point of view - you will be able to order the acute renal screen without asking anyone what to order - having said this there is now an AKI order set in EPIC which renders this bit of advice obsolete).

It is very common to do myeloma/vasculitis screens as part of the renal job. It would be beneficial to read up on these to know what these contain and then in practice - to know what you need to order on EPIC, although the SpRs/Consultants are happy to clarify anything on the job.

The “native” ward is C5. Renal also have outliers on other wards (see next section).

The dialysis set-up has recently changed.

There is now an OP dialysis unit on Newmarket Road, which registrars +/- consultants may cover on a day to day basis, however the juniors have no clinical responsibility for those patients.

Those patient's requiring IP dialysis will receive this dialysis in one of six 'dialysis beds' on C5. With the removal of the OP dialysis from the Addenbrookes site there is now less flexibility for scheduling and so it is important that you co-ordinate with the dialysis nurses on C5 each day as to who needs dialysis for the next day. It is helpful to ensure that dialysis is prescribed the night before and you can use the 'afternoon catch up' with the SpR to practice doing this independently before taking a list of planned dialysis patients to the nurses.

NB (The old main dialysis unit - is where some secretaries are still based. Some of the consultants (e.g. Dr Fry, Dr Ojha and Dr Pritchard) also still have offices there. To get there - go to the mess, exit via the double doors at the back it will be to your left.) HOWEVER - This is being renovated and currently there is no offices for the secretaries/Consultant's. They will I am sure clarify where you need to go for Clinical Supervisor meetings when you start your renal job.

The Team

Consultants rotate every two weeks on the inlying patients (C5), and rotate every one week on the outlying patients.

There are two inpatient teams (each composed of a registrar, a CMT SHO and an FY1/2):

• inlier team - looks after patients on C5 (renal home ward)
• outlier team - looks after patients scattered all over the hospital (including patients under the other specialties requiring renal input).

It would be ideal to split your time on inliers/outliers equally between FY1/FY2. Working on the outlying team often feels a lot more stressful, as you have to go to multiple wards and during the winter there can be a lot more patients on the outlying team (up to 50 patients on outlier during my job rotation, compared to ~25 patients on C5). It therefore often is the less favourable. The patients on C5 are generally Renal patients whereas the outlying team can sometimes have a higher proportion of general medicine patients. Splitting your time equally (on average) over the two months you spend on Renal between inliers/outliers is vital to gain a good amount of exposure to Renal presentations - you learn a huge amount and the Consultants and SpRs (often SHOs too) are excellent. FY1's can often get pressured to stay on outliers because they 'know the patients' and the FY2s/SHOs often rotated at different times - so beware.

The C5 team may get called about the outlying patients - politely redirect the caller to the outliers team (bleeps are on the board in the C5 doctors' office under “vasculitis”, bleep number 152970.

Vasculitis patients are usually under a separate vasculitis consultant but are looked after by the inlier or outlier team of juniors (depending on where they are) - you may be called by the vasculitis consultant to go on a ward round with them. During some weeks there is a separate vasculitis SpR who will look after all of the vasculitis patients, but you may still be called upon for junior jobs.

During working hours the C5 SpR covers general on-call and outlier SpR covers vasculitis on-call. There is usually also a dialysis registrar who looks after patients coming in for dialysis from the community.

The renal juniors (CMTs and Foundation doctors) also cover rheumatology junior jobs (as rheumatology do not have juniors of their own). The current set up is that the inlier team covers rheumatology patients on C5 (which is the preferred ward for rheumatology patients) and that the outlier team covers outlying rheumatology patients. The workload for rheumatology mostly involves TTOs and discharge summaries. You may also be called upon to clerk patients coming in for *mab infusions. These are usually outliers and fall to the outlier team but in practice this tends to be done by whichever team has the lower workload.

Renal transplant are a separate team with their own bunch of SHOs. The registrars cover both and will rotate around.

MDT There is an MDT meeting on C5 at 8.45 am - at least one of the C5 team will need to attend. There is usually the nurse in charge, a physio or two, an occupational therapist and a Cambs social worker. Other visitors include dialysis nurses and dieticians.

Dieticians are important for renal-specific nutritional issues as well as general dietetics

Other teams There is a close relationship with transplant - both the physicians side and the surgical side. Transplant (not vascular!) surgeons do dialysis fistulae and peritoneal dialysis catheter insertion in patients who need to have it done surgically.

The registrars will take a lot of referrals from the other teams (and hospitals).

Other hospitals Renal get transfers from other hospitals in the region when specialist input is needed (e.g. unresolving AKI, vasculitis). They also often taken patients who are stepping down from ITU in another hospital and may require intermittent haemodialysis once off CVVHDF.

There are satellite dialysis units at Hinchingbrooke, King's Lynn and West Suffolk but these do not do acute dialysis.

If you are discharging a new haemodialysis patient to an area served by one of these hospitals you will need to call the local dialysis unit to arrange slots for them (although sometimes the registrar or dialysis specialist nurses may do it). You will also need to ensure the consultant responsible for that unit knows about the patient - ask the registrar for advice on what to do

Typical rotation is half acute block and half ward block.

Acute block involves ED shifts (clerking) and joining often a few weeks of “service needs” where you are essentially plugging the gaps in the rota. Often this is on the medicine short-stay ward. Check the Excel spreadsheet of the rota to see if you have been allocated somewhere. If not then go to morning report at 8 am (G5/F5 seminar room) and offer your services to the highest bidder. The renal job is however a busy rotation and your fellow team members will appreciate if you are able to negotiate yourself allocation to the renal team.

Ward block - on your first day go to C5 Doctors office for 8.30 am - you will either join the C5 team or the outlier team. Whether you want to swap halfway through or not is entirely your call (but be mindful of continuity of care).

Annual leave has recently become non-fixed for FY1s under the new contract. It is very strongly recommended that you request your annual leave during your “service needs” block, although it may be possible to take annual leave during your renal block if there are no rota gaps. It is advisable to book your annual leave early - this is particularly relevant in your first job as you will be left with minimal time to book annual leave if you are starting on service needs. FY2s are currently still on fixed annual leave (swaps may be possible) although this is likely to change.

Study leave - you do not get any as an FY1 (although you do get time off to do your ALS course). You do get some as FY2 - get the forms from medical staffing, make sure there are enough people around (i.e. you and the CMT do not take leave at the same time) and get it signed by your educational supervisor and the consultant who will be on the ward during that week. Check with the current consultant on the ward who will be on during the time when you would like to be off and ask them for permission.

Mon - Fri

0830 start. The consultant will usually arrive soon after and tell you about new patients from morning report (where patients from the last 24hrs of the medical take are re-allocated to a medical team who will provide their inpatient care). If you are on the outlier team you will need to add them to the outlier's list. It is advisable to print lists (in bed order) after this update.

There is a C5 MDT meeting at 8.45 am if you are on the C5 team.

1230 to 1400 is patient protected mealtime - you will get told off for seeing patients on C5. As the outlier team you are granted increased access during protected meal times because the nature of the job means you will get to patients on other wards “when you get to them”.

Towards the end of the day (at about 5pm) it is good practice to go through the list of patients with the CT1/2, review all of the bloods from the day, review any outstanding jobs, and order bloods for the next day. Ensuring this is done makes the ward round the next day significantly simpler as the bloods will then be done on the PA round in the morning. This is also a good time to make a list of jobs to handover to the evening FY1/2. You can handover from just before 6pm to bleep 152241 - ensure you have to hand patient details, a brief clinical summary, the job to be done and a clear plan for acting on any results to be chased.

On Wednesday lunchtimes there is a dialysis priority meeting on C5 - you do not need to attend this but SpRs/consultants will.

On Fridays at about 5pm there is a handover to the weekend team and it is helpful to print fresh lists for this. It is also very helpful to print a “summary” list for the weekend with brief clinical details of each patient and a checklist of which patients have bloods out over the weekend and which patients require senior review.

Long days / weekends

Long days - Mon - Fri - come in at 830 as normal (this has recently changed) and join your usual ward team for the day. From 6pm you will then provide on-call cover for a few specialties. There are 4 juniors on-call in the evenings and specialties are divided between them. You will be allocated to one of those specialties on the rota - if you're not allocated to renal/hepatology/dermatology it might be worth trying to swap as it is generally easier to cover a specialty you know. You will get handover from the day teams at ~6pm when they finish. If renal/hepatology/dermatology you carry the 152 241 bleep from F/G5 seminar room. Realistically you will mostly deal with renal and hepatology inpatients although rheumatology may occasioanly throw in a googly. Often transfers/elective admission from clinic may arrive in the evening as beds are available and you will have to clerk these patients - often there will be a plan documented from clinic or the SpR on-call will have taken a referral, either way it is important to complete clerking and get important overnight jobs done. Handover to the night team is at 9 pm in the board room between Area A & B in A&E. When receiving handovers it is vital to specifically ask what actions the day team wish you to take (particularly with regard to blood results) as you may have to hand jobs over to the night team and they will want this information.

Weekends - Sat / Sun - Each specialty has it's own junior and again you will be allocated to a specialty on the medical rota (may or may not be renal and you may be able to swap as you will know patients). Come in for 0815 and go to morning report (F5/G5 seminar room) or straight to C5 if you know you are covering renal. You need to collect 152 241 bleep (from morning report or from night SHO) and get any handover. The consultant on-call will get there soon after with the registrar and you will see new admissions together. You will then see some patients with the registrar and some on your own. Patients who need a weekend review will have been identified in a Friday handover. Depending on your registrar you may be expected to see every patient over the weekend, or you may only see medically unstable patients. Handover to night team is at 9 pm in the same place (ED seminar room).

There are 2 SpRs working each weekend and they cover renal and renal transplant.

Teaching

There is a journal club every Tuesday at 1230 in the main dialysis unit seminar room - one of the registrar will usually present a paper. Usually there is free lunch. This is not an intimidating atmosphere and your attendance is appreciated.

There is registrar teaching at 8 am every Thursday - juniors are also welcome.

Fall into three broad categories:

Gen Med

Any of the usual suspects - acute confusional state, falls, heart failure, pneumonia etc

Renal

New AKI that is not obviously pre-renal / obstructive or AKI requiring dialysis. If these patients did not have a urine dip make sure they do! If they have proteinuria request an urine albumin/creatinine ratio. Use the AKI order set on EPIC.

Ultrasound of the urinary tract - NICE guidelines: Do not routinely offer ultrasound of the urinary tract when the cause of the acute kidney injury has been identified. When pyonephrosis (infected and obstructed kidney[s]) is suspected in adults, children and young people with acute kidney injury, offer immediate ultrasound of the urinary tract (to be performed within 6 hours of assessment). When adults, children and young people have no identified cause of their acute kidney injury or are at risk of urinary tract obstruction, offer urgent ultrasound of the urinary tract (to be performed within 24 hours of assessment).

Occasional admssions for biopsies, PD catheter insertions, problmatic arterio-venous fistulae etc.

Also includes dialysis and low clearance patients who develop a GIM issue - these are often complex and have diabetes with complications or peripheral vascular disease. You will get to know the diabetes team and the vascular surgery team well.

Vasculitis

Patients with vasculits. May have a vasculitis-related issue (e.g. a flare) or a GIM issue.

Patients come in from:

• the ED
• renal clinics
• dialysis units (both the Addenbrooke's one and the satellite units)
• vasculitis clinics
• district general hospital ICUs
• Papworth

Discharge:

• GIM patients often get held up by wait for care / nursing home
• Renal / vasculitis patients may have complex follow-up. Ensure this is properly arranged. Ring the relevant clinic if they need an urgent appointment.
• If patients require follow up at CDC (the newmarket road dialysis centre) it is advisable to email the current dialysis registrar to let them know.
• If a haemodialysis patient is discharged they need to go on the priority list - talk to the dialysis registrar to add them. If they are being discharged to dialyse at a satellite unit ring that unit and ensure the consultant looking after it (Hinch - Dr Ojha; West Suffolk - Dr Fry; King's Lynn - Dr Gunda) has them on their radar. Ask the registrar if you are at all stuck about how to approach these people (usually it is as simple as a call to switch board and asking them to put you through to the relevant person or hospital). It is worth noting that as of October 2016 the priority list has somewhat fallen off the radar (although is likely to be revamped) - but that it is still worth notifying the dialysis registrar about any particularly complex discharges.

Ordering dialysis prescriptions for your inpatients (both regular dialysis patients and those who are recieving it in acute context) The dialysis nurses will have a list of patients who regularly need dialysis and what the usual prescriptions consist of eg. Other inpatients needing dialysis will be identified on ward round or by SpR. Dialysis is prescribed via an order set on EPIC (you must log in under nephrology to access this). You need to state type of dialysis (haemodilaysis vs IsoUF), duration, amount of fluid removal, use of LMWH and citralock/taurolock (keep line patent) and additional instructions requests such as giving blood transfusion or taking blood tests. Most of this info will be on previous prescriptions or decided on a ward round and it is always worth clarifying with SpR. In general, juniors can prescribe for regular dialysis patients being treated for general medical issues or awaiting discharge. The SpR will usually handle more complicated prescriptions. Some consultants feel that dialysis prescriptions should fall to the SpRs, so it is worth clarifying this with the registrar when you start.

There may be any number of patients admitted under different specialties and so the renal team will not be leading the care of every admitted dialysis patient nor will the renal juniors be expected to perform the day to day care of these patients. However, the renal team will review these patients at least once or twice a week and it is important that you co-ordinate with the primary team dialysis planning and communicate clearly the renal team's plans. A typical scenario would be a dialysis dependent patient who needs a surgical procedure, which would often involve 'before and after' dialysis sessions. The decision for timing of dialysis will be lead by the SpR but the theatre teams, surgical team and dialysis nurses must be briefed to ensure a smooth procedure. The dialysis nurses are very helpful and will also help coordinate such scenarios if asked to help and can often ensure patients are portered to the dialysis beds when needed.

The registrars all rotate and so will of course vary however there is a good culture of helping each other in the department.

An important point is that the SpR may not be available immediately during clerking and it may slip their mind that there are patients who are being transferred to Addies. During an 'afternoon catch up'/'paper round' it is good practice to ask if any patients are expected and also ask for specific initial investigations/management and the reason for the patient's transfer. The answer is often 'the usual' i.e. VTE prophylaxis, FBC,U&Es and CRP. However, there may be more specific investigations needed and it is good to have that context and vital if it needs handing over to the night team.

The SpR complete 24hr on calls and so are available over night however will have clinical commitments during the days either side, so will be sleeping if they can. None will be upset about being called and often will come in to hospital to help, however your reg will appreciate you first calling the medical registrar on call in ED (1567000) as they are on a night shift on site, and will be able to help with most of the general medical problems that trouble a night SHO.

C5 junior bleep: 157604

Renal registrar bleep: 152803

Outliers registrar bleep: 152970

Switchboard (100) can put you through to other hospitals in the region who can then connect you to e.g. Hinchingbrooke dialysis unit. This seems to be the easiest route to reach the outlying dialysis units.

1A banded.

4/5 weekends in total during block (roughly 1 in 3 weekends).

Flexible annual leave for FY1 (strongly encouraged to be taken during service needs). Fixed annual leave for FY2, though this is likely to change imminently.

FY1s currently get a rota'd day off in the week preceding and succeeding their weekends. It may be possible to swap this day off to a different day in the week if is not convenient.

Renal is a busy job compared to some other medical specialties - particularly in comparison to service needs - and you may find yourself staying late. This is especially true when there is a rota gap. However, it is also a very supportive and close knit team and an educational foundation placement.