Main Ward is N3. There are two teams - one for N3, and one for the Outliers - Patients on other wards but under care of respiratory. The ward juniors includes several registrars (including academics), 2 core medical trainees, and 2 FY doctors.

• Sign up for the respiratory smart links on EPIC (speak to a junior prior to switching for the best).
• Ensure you have access to the N3 ABG machine (email point of care for this)

Based on N3 (28 patients) outliers localed on D5-9, ITU & RRT (during winter months can have up to 50 outlying patients) B bay in N3 is the respiratory CCU equivalent so this is where the sickest patients are, the ones on NIV or with tracheostomys.

There is a consultant on inliers and a consultant on outliers. Then an SHO+FY + a reg on each team. Some rotations the juniors on inliers split the ward in half with 1 looking after A+B bay and 1 looking after C bay +side rooms. Its best to see what works for you. And usually you end up just helping each other out as it can get VERY busy and sometimes a little overwhelming so its important you support each other.

They Consultants tend to be happy for you to call them at anytime during the day. It is always worth checking out clinic letters as if a patient is well known to a particular consultant they often like to come and say hi whilst they are an inpatient. There are around 6 registrars that all rotate and cover different shifts. They also do lots of the pleural taps and drain so if you befriend them you have a great chance to try out some of these skills and also escape the ward to see some bronchoscopys etc.

The Ward Sister is called Asha and she is AMAZING. She does like juniors to be efficient with regards to TTO's and Discharges so this does take some coordination as the flow through N3 is rapid. The nurses tend to be very skilled a fair few can do ABGs and control all the NIV settings etc. They are good people to ask if you want to know more about titrating up NIV and how to use the machines.

There tends to be a few students attached to the ward. They do not have a formal teaching programme on resp so they are always grateful for any adhoc teaching you can give them.

Well supported by consultants.

MDT on N3 for inliers at 1130 every week day.

The Acute Respiratory Team (ART) are a group of specialist nurses, and invaluable for advice re: home oxygen/ nebs, and discharging people with asthma/ COPD. In particular for Early Supportive Discharge (ESD) in COPD patients who are frequent fliers to the team.

Pleural team - is Dr. Herre and Dr. Siva and specialist nurses - good for advice on pneumothorax/ pleural effusions. The specialist nurses will conduct, and help supervise pleural taps and chest drains if suitable patients for the procedures can be found. Good to approach them if you want to try some.

Half acute, half ward block as per other medical jobs.

Often work two ward weekends during the rotation plus lates.

Monday (lunchtime) - Pleural MDT

Thursday (lunchtime) - Lung cancer MDT

Friday (morning) - 8am Journal Club Friday (lunchtime) - Radiology MDT

Regular bronch lists if you want to see procedures.

SHOs go to medihome clinic for one afternoon per week.

Ward DFM on N3 every weekday at 11.30 and it goes for around 30-45 minutes.

Ward Rounds start from N3 doctors office at 8:30

First job is to add patients to the respiratory inliers or outliers list on EPIC who have been dished out at Morning Report.

Second job is to print the list!

Third job (if your on the N3 team), is to GET A WOW. The ward nurses will try and get them early for their drug round, but without one your N3 life will be a misery. So get a WOW early.

Then ward round starts. Outlier ward round is often chaotic, scouring many wards to try and find patients, sometimes over thirty patients on over 10 wards. Try and find a WOW if available, but on a weekday this is tricky.

N3 team have MDT at 11:30 - so aim for all the patients to have been reviewed by then (assuming you have any influence on WR speed).

Afternoons are writing TTOs, chasing CTs, chasing bloods, speaking to families.

Often consultants will do a verbal run through of patients about 16:30, to discuss results, chase discharges, and make any plans for the night.

After this, aim to get all bloods ordered for the next day, and write a list of anything to be handed to the evening SHOs.

Day finishes at 6. Handover to the oncall SHO at this time.

IECOPD - key factors are … what is their ABG showing? Is their T2RF worse than usual? What is the patients respiratory baseline – look at old gases, and old discharge letters.

Asthma - look through previous letters to find what their baseline is like.

Flu - ITS VERY COMMON. Respiratory viral swabs (RESP SCREEN order on EPIC) can tell you a lot, and you'll often find they are positive for flu. Isolate the patients early.

Pleural Effusion

Community Acquired Pneumonia

Pulmonary Embolism - go home on anticoag (often rivaroxaban), this requires follow up with the anticoag service so try to organise this a day or two before discharge to save yourself stress.

High turnover ward.

Patients may be followed up by acute respiratory teams in the community, liaise with ART nurses that they can visit when necessary at discharge as limited availability for the service at home over the weekend. They also help organising equipment such as nebuliser machines for patient to go home with.

NIV physios very helpful - they can do ABGs. Also highly skilled in chest physio and NIV settings. Good people to ask about how to set up NIV and how it works.

Lung function tests are listed seperately on EPIC, if you can't find them - log off and log in again setting your team as “Respiratory medicine” [Box spleg, spirometry, gas transfer]

Many patients go home with medihome support for IV antibiotics - they still need a paper drug chart - these are hard to find now, keep a stash handy. And also need follow-up in the OPAT clinic which you can order on EPIC.

DISCHARGES - There is no longer a respiratory discharge template, you will need to use the hospitals new standard template on discharge. You then need to order the follow-up, each consultant has their own clinic code which are up on the wall in N3. Prof Morell see's all PE's and Dr Gore and Prof Marcinak are Asthma specialists and Dr Stinchcombe and Dr Sander see lots of the bronchiectasis/strange infections. If any patient has consolidation on the CXR they will need a repeat CXR when they come to clinic. At the end of the day you need to email NEIL STARLING with all the follow-up appointments you need [patient initials, MRN, Consultant, in how many weeks you want it + whether you want a CXR]. He then ensures that they are arranged and also points out any patients you have forgotten to order follow-up on EPIC for.

Respiratory has excellent senior cover. Most decisions are consultant or registrar led, and during the day there is usually at least one in the N3 office (or nearby in their offices).

Evening handover - inform the evening SHO of:

1. Anyone very unwell 2. Anyone who needs further action this evening 3. Any outstanding investigations that will be happening in the evening that might influence a patients management overnight 4. Any bloods, or ABGs that need to be taken that evening 5. Any information that the night SHO needs to be aware of.

N3 Team - FY1 Bleep - 157534, SHO (+Medihome) - 154124,

Outlier Team - FY1 Bleep - 159 070 (159 007 also currently goes through to the bleep), SHO - 1562057,

On-call/Referrals Registrar - 157471,

Evening/weekend/night on call bleep is 154240 (note listed incorrectly on the rota at time of writing),

nb. During the week your on-call covers cardio and resp so you need to pick up the ARREST BLEEP from the SHO on K3 at 17.55. At the weekend you are Resp only from 8.15-2100. So if any nurses from K3 or CCU bleep you then do not take the jobs as they have their own cardio junior to do these.

You tend to get off on time whilst on the ward/outliers. If you ever do stay late the whole team is there sharing the work load.

However, during Winter, the workload on outliers is generally a lot heavier, so you may not leave on time. Ensure that you have your log in to exception report for the times you stay later.

ART: Acute Respiratory Team (specialist nurses)

ESD: Early Supportive Discharge (for arranging COPD patients to get home)

Good journal club on Friday mornings 8am. Everyone is expected to attend. Do read the paper before attending.

The insertion of a chest drain is a common procedure on N3, and the Consultants and SpRs are keen to involve the more junior staff in this. Do embrace this opportunity, as not only does it provide a means of getting core procedures signed off (e.g. anaesthetic infiltration), but more importantly gives you exposure to ultrasound-guided drain insertion and the all-important Seldinger Technique.

Lots of other exciting procedures going on - thoracoscopy and endobronchial valves - go and see some!

If in doubt …. do an ABG. Especially if you have an unwell resp patient, and your just not too sure whats going on.

Physician's Assistants (PAs) will take ABGs on N3!! There are often staff nurses and specialist nurses and physios that can also do ABGs!! This saves lots of time, especially whilst on call!

Prep all weekend discharges on friday, and leave time to do so! Otherwise letters will often get left until the following monday, when you have to write them anyway.

Dr. Sivasothy (an extraordinary physician!) is involved in the delivery of Ultrasound Day Courses by Addenbrookes, which are held several times a year. This is an increasingly useful skill to have, particularly in the acute setting, and the courses would be well worth exploring.

When discharging patient make sure you write the type and route of antibiotics, now that Tazocin is not available, there are different regimes and prescriptions (which might confuse some of the OPAT patients) , however, making sure that the correct antibiotic is written up is very useful for the GP and the patient.