2 types of shift - Standard: 7.30-5.30 - Late: 11-8

Colorectal bleeps (there are 5, one each) - 154232 - 157465 - 152545 - 157606

General surgery: handover at 7.30am/pm in C7 doctors office (code 2363), where upper GI (bleeps 157248, 154659, possibly also 1562073) and HPB (bleep 152495) are based.

Monday morning: after handover there is a meeting at 8am in E7 seminar room (turn right from the main lift on level 7) where the consultants go through the list and briefly talk about each patient. Take the black M&M book to it (its kept next to the ward clerk on L4 ward or in the shared ward L4/M4 doctor's office) - we're supposed to write in complications etc in it, for use at the M&M meeting. The consultants will indicate during the Monday meeting if they feel a name needs to go in the book.

The M&M meetings are held every month, normally last week of the month on a Tuesday/Wednesday at 9/9:30am (dates are not fixed - Nicola Atkin who is the colorectal secretary will email you a week in advance). There have been occasions when FY1s have had only one day notice to write up the presentation! The cases from the black M&M book also need to go into the presentation. The data for these meetings is done from date of discharge don't include anyone who is still an inpatient who has had complications, they will likely roll over to the next month for discussion. For morbidity patients you just need a few lines on what went wrong but for mortalities use a whole slide of the powerpoint presentation. The consultants want to know the number of discharges per consultant but not the number of morbidities or mortalities per consultant, these should be tallied up to give a total for the whole colorectal team.

You generally want about 12-15 copies of the list on Monday mornings. One of the FY1s need to login in to the computer and bring the patients up on EPIC as they go through the list.

Other mornings: you need about 7 copies of the list (3 registrars, SHO, 3-5 FY1s). The days you are post take, sometimes the night FY1 prints the list as they are supposed to update it with any new patients admitted overnight or referrals. However this sometimes does not happen so I would head to the C7 office around 7.30am and ask the night team whether it has been printed or not.

Side note: check the colorectal services list as well as the colorectal teams list because very occasionally patients aren't always assigned the team as well as the consultants (particularly elective operations so you don't know the patient until after the operation). Sometimes you may get bleeped about these elective patients, to do a TTO) J3 is usually the pre-op place (except when the hospital is so busy that they're using it as a ward) so new patients that appear on J3 are generally pre-ops. Make sure post op bloods are ordered for the next day for patients staying. Also on the services list you see people coming in for outpatient endoscopy, which you don't need to do anything about.

Colorectal are on take 2 out of 3 weekends, Monday and Wednesday. So post take most Mondays, Tuesdays and Thursdays. The Colorectal consultant will be the admitting consultant (check on rotawatch) and every gen surg case being admitted in that 24 hours will be admitted under the colorectal team. The next morning (“post take”) some will get handed over to other teams as appropriate. So, you need to take note which new team the patients will be under and cross from your colorectal list. Normally you will need to map the route for which patients will be seen first in order of ward distance, so that it will be one smooth journey. You will then do the post-take round. This is usually the most busy round so if there are a few of you a round it makes more sense for two people to go on this especially now with EPIC as most will be outliers and it takes time to find a computer.

General surgery acute block: 7 nights, 7 ED days both split into 3+4 days. 2 ward weekends (usually one on main block and one on acute). Otherwise ward weeks

With regards to the format of the list, its useful to have the Room/Ward, name/age, actual length of stay, date of admission, attending consultant, summary, VTE. Each registrar will look after certain consultants patients, and when that reg is away one of the others will cover those patients as well. Make sure you exchange numbers with the registrars and the SHO because they don't have bleeps. Reception is patchy anyway but if you know they're going to be in theatre they are happy for you to stick your head round the door to ask questions (you don't have to get changed every time), and also endoscopy lists.

Patient on TPN need daily bloods including FBC, U+Es, CRP, bone profile, LFTs, magnesium PICC lines on L4 don't get bled by the PAs. The L4 nursing staff nurses will normally only do PICC line bloods if the patient is on TPN. They will do this only at approx 6pm just before they put up the TPN. Which means the TPN bloods are always handed over to the night FY1 to chase up. Some of the nursing staff expect you to print the blood labels for the TPN patients before 6pm. Ask the nurse in charge on the day and if they want you to print them out for them make sure this is done. If you want PICC bloods before this you will have to do it yourself. If you need urgent bloods for someone on TPN then you need to stop the TPN infusion temporarily to take a PICC blood sample, wait 10-15 minutes after stopping the TPN (do NOT disconnect it from the octopus) and flush with saline before taking the sample, then restart the TPN. Some of the L4 staff nurse will also do PICC bloods for patients with a PICC and not on TPN if you ask nicely, this is rare though.

To get PICC lines you need an inpatient referral to vascular access (just type in vascular access into the order section on EPIC), standard is dual lumen and I always try and find a reason to put power PICCs in because IV contrast for CT scans can't go through normal PICCs and patients with normal PICCs will need at least a pink cannula as well if they need a contrast CT scan. One reason for a PICC is TPN - you need to put in a “patient needs PN” nursing order for TPN, and to be safe follow that up by bleeping the nutrition nurse Helen on 152050 afterwards to make sure everyone has the details of the patient. If a patient needs TPN on the day you see them you have to put the order (referral to the intestinal failure dietitian) in before 12noon (before 11.30 is even better) otherwise it won't happen that day. With ehospital this is easier because you can put the order in during the round. Also you then need to make sure they get a PICC line that day as well, otherwise they won't have adequate access for the TPN - again the earlier you request it the better. Normally, vascular access is very good at picking up the request, but I would suggest to call them on their extension number for urgent requesnt to make sure they note the request and the urgency. L4/M4 doctors office is where you will be based. Specimen label printing for blood bottles: all doctors office computers should (hopefully, if the system and printers are working…) print to the static printer on the end nurses station (far end) Behind all 3 nurses stations are little drug rooms which also have useful things like saline and 10ml syringes etc, code is 125689 from the L4 side and 6655 from the M4 side. The store cupboard at the far end of the ward has stock of most things (except when we run out..) and has the code 125689. The cut off for phlebotomists visiting the ward is currently 3pm (make sure you put out the blood orders as soon as possible in the morning; try to anticipate the day before which patient would need bloods taken would be better as sometimes they come around 7am and difficult to get hold to thereafter).

Endoscopy: extensions 2515 and 6529. To be safe, call after putting an endoscopy order in, to make sure they have got the request, because every once in a while they don't get the request… When requesting outpatient follow up colonoscopies the standard prep is the first on the list, citramag and senna. For inpatients sometimes they use phosphate enemas which endoscopy will phone the ward about to tell them when it is needed, and then the nurses will find you and ask you to prescribe it. Endoscopy is based on level 3 ATC so sometimes it is quicker to go there in person! For flexisigs the preparation currently is a phosphate enema one hour prior.

XR

Inpatient XR. In cases of small bowel obstruction the team often likes giving gastrograffin orally and then doing an AXR 4 to 6 hours later to assess the flow of contrast to the large bowel - in these cases the hospital protocol states that the ward must bring the patient down to the XR department, they will not go on a porter list from the XR department itself. Make sure you put the indication on the request, the volume of gastrograffin and the time that it was given. The nurses on the ward know this, but if they're new find the sister in charge and let them know what time. During working hours, XR can be done just one level below L4 on the ATC building, thus easire and quicker. Out of hours it will need to be ED XR which is more of a trek. In some cases it is quicker to take a patient to XR yourself than wait for porters, but don't make it a habit!

CT

It is quite often on a colorectal ward round that you will get asked to organise CT scan for upto 7-8 patient's on a morning ward round, especially if it is a post take ward round. The key would be to make sure you put the order in on EPIC while on the ward round, and if there is more than one junior, one of you should go off and first ring the radiologist on 6718. The radiologist will often have a few questions, and it is important to summarise the current clinical condition of the patient, observations, summary of bloods especially creatinine if it is going to be with contrast and the question the surgical consultant wants to be answered by the CT - i.e ?diverticulitis or ?perforation. It is not good practice to call the radiologist and request a CT 'because your consultant' asked for it. For often than not, the radiologist will agree to the CT, and you then have to call 3219 to list it with the CT co-ordinator. The earlier you can ring the co-ordinator, the earlier your patient is likely to get their scan. Once a patient has been listed for their CT, it is important to ensure they have adequate access usually in the form of a pink cannula if contrast is to be given which is often the case. If the patient's creatinine is high they may need adequate pre and post hydration.

Analgesia

Generally patients will return from theatre recovery/HDU with a PCA prescribed. Any adjustment to doses should be discussed with the Surgical SpR or Pain Team. Patients can still have regular paracetamol alongside PCA. Rarely, patients will have epidurals which are handled exclusively by the Anesthetists. Of note is when these are to be removed, patients will need an up to date clotting profile and platelets. Step down analgesia - when patients are ready to be stepped down to oral analgesia, the typical regime is Regular QDS Paracetamol PO/IV, Regular QDS Meptazinol, PRN Oramorph for breakthrough. TTOs- Most patients are generally quite happy without analgesia on discharge. However for acute cases (appendicitis etc with a quick turnaround) it may be worth giving them some regular/PRN Meptazinol (1 week or so). Paracetamol is cheaper over the counter.

Discharge letters: when you're told a patient can go home make sure you know 1) what follow up (duration) or outpatient scans they need (typically will be 6-8 weeks, particularly colonoscopies after diverticulitis etc). Pts who have come in for resections for cancer will normally have a follow up to be decided after MDT. 2) any antibiotics or other extra medication. 3) whether they need to go home with dalteparin - all cancer resections go home with dalteparin for 28 days from the date of their operation (increased risk of DVT/PE). Occasionally consultants will also send people home with dalteparin that have had emergency operations where they suspect there is cancer involved. For any questions regarding follow-up then you can always ask the colorectal specialist nurses they are very helpful. For patients that had closure of stoma for previously resected cancer, they do not need to go home with dalteparin unless there is a specific reason. TTOs need to be informative yet concise. Avoid lengthy prose as this is unnecessary and can distract from the key points. You will be chased for the TTO's as we encourage early discharges and sometime turnover is really quick and they do need beds for this. So, please prep the TTO's the day before (especially medications, as this can take more than 2 hours to be ready from the pharmacy).

M&M - every month there is a meeting where morbidities and mortalities from the month(s) before are discussed. Get a template powerpoint from previous F1s, email the secretaries to provide you with the data and if this is proving slow then start with the black book. Things they like to know: consultant involved, length of stay, patient demographics (age, sex), presenting reason/operation/indication, complication and how it was managed. In addition to the above I would highly recommend preparing the powerpoint presentation in advance, as it can take quite few hours collecting the correct information for each patient. The consultants know there patients very well, so any inaccuracies will be noted and flagged during the meeting. During the rotation you will collect a list every Monday of any motalities/morbidities during the Monday morning meeting and record them in the black book (often referred to as the purple book!), you will also get a set of data from the secretaries - it is worth cross-matching the information as on occasion there are differences of opinion between epic vs consultant.

There is one surgical FY1, SHO, registrar and consultant on call. Often the SHO will be managing ED surgical admissions or helping out in theatre. Most FY1 jobs are on the wards. The shift is often much busier before 2am so it is important to remember to prioritise urgent jobs and leave less important jobs to later in the night when you are less busy. If you need help and your team is busy, there will always be someone in the doctor's mess to help. The bleeps are the same as the ED day on call team have (1560545 for FY1). Remember to eat and drink during the night! Costa coffee is open 24 hours.

The colorectal job was previously band 3. With the substantial cut in salary it is encouraged by both fellow juniors and by the consultants to submit exception reports for overtime worked. Currently, exception reports for legitimate overtime are readily approved. Even under the new contract it is a rare exception that all juniors will leave work on time.

Really useful: Follow this link to getting access to Haiku http://www.my-ehospital.org/support/mobile-application-doctors-and-clinical-nurse-specialists.

You can log in within the hospital with the generics details Username: ernie@addenbrookes.nhs.uk Password: 25october2014

To get it you need to 1. Fill in the Survey Monkey registration form: https://www.surveymonkey.com/r/?sm=VOdDGcLiYK7nRiKO%2f3zELHCsqhFkEmWTCQ%2fRkcaYNso%3d 2. Wait some time (1 week) 3. Download the app: Haiku for all devices android and apple except ipad (You need Canto) 4. Follow registration instructions on: http://www.my-ehospital.org/support/mobile-application-doctors-and-clinical-nurse-specialists#DeviceRegistration including pasting your custom configuration details and registration number received in the email

Try your best to be on the good side of the nurses. Respect them at all cost. You will learn a lot from them.

After the ward round, normally FY1s will be left to complete the outstanding jobs from the ward round and the seniors and consultants will spend most of the day in theatre. In case there is any sick patient, review them first(+/- discuss among FY1 and involve Rapid Response Team if required) and seniors can be contacted by meeting them in the theatre (you can enter the anaesthetic room and so long as you do not enter the theatre you can wear normal ward clothes and speak through the open door between the anaesthetic room and theatre).

As F1s, it makes your life alot easier if pts are discussed with other F1s in your team and to frequently update each other about pts you have seen, reason for admission as well as what has been/needs to be done. This will save a lot of time in future ward rounds when SpR/consultant is not familiar with patient. Ultimately, it ensures continuity of care and seniors are both impressed and thankful.

1pm boardround takes place daily in the L4 doctors office where the ward sister will run through all the patients on the ward and subsequently change their estimated discharge dates. This not only helps the nursing team plan discharge for patients requiring packages of care but identifies TTOs to be done which also works in your favour.

Evening boardround normally happens towards the end of the day, around 4-5pm where you go through the list with SpR or SHO and essentially they want to know if there is any problems or if they are stable. However, these days with the new contract and finishing at 17:30, it is advisible to go to theatre, if seniors are in theatre, and discuss pertenant issues.