Mr Harper (Monday wardround at 11:00) Mr Liau (Tuesday wardround) Mr Jah (Wednesday wardround) Ms Anita Balakrishnan (Thursday ward/board round at 11.00) Mr Huguet (Friday wardround) Mr Praseedom Mr Jamieson (elective Wednesday theatre list)

Frances New and Lena Loia - HPB specialist nurses (number: 154 225)

Alison Deaves and Shona Rock - HPB consultant secretaries

Surgical case manager: Smadar Outhwaite (extremely helpful with social issues/complicated discharges)

The department

- The Main ward is C7. However, many patients could well be in other wards including ATC wards - Handover commences at 7:30 in C7 doctor's office (first door on the right when you enter C7, code 2363). Post take teams are Colorectal and Upper GI. There may be patients which will be allocated to HpB - thus ensure they are added on the list on EPIC (Right click→Treatment team→HpB) - Specialist nurses office in ward C7 - Secretary office is door on the right before entering ward - Consultant offices are on level 9 in department of surgery

Typical week

07:30: start in C7 Monday to Sunday

Monday HPB MDT (F1s do not need to attend) Morning ward round conducted by Clinical Fellow/SpRs followed by Consultant ward round by Mr Harper at 11:00 (in theory)

Tuesday Consultant (Mr Liau)/SpR ward round 13:00: X-ray meeting in the Berridge room - (follow sign for medical physics, go to the end of the corridor and up the stairs to level 5). It is expected for all F1s to attend. Keep a note during the morning ward round of which patients' scans are to be reviewed and discussed. Whilst in the x-ray meeting, ensure one of the F1s is making notes of what is said: the outcome and plan for each patient discussed. You will be expected to write these notes in EPIC later on. You should bring the names of patients undergoing laparoscopic adrenalectomy by Mr Jamieson the next day so their scans can be discussed as well (only if Mr Jamieson is present in the meeting) - look on the theatre list for the patient's name.

Afternoon consultant microbiologist board round with Dr Aliyu. He will come to the doctor's office around 2pm (time varies) to discuss patients. Keep notes of the complex patients on multiple antibiotics to discuss with him. (Dr Aliyu is leaving too so in future this may/may not occur).

Wednesday Consultant ward round with Mr Jah plus Clinical Fellow/SpR. This will start in the IDA office. Take the opportunity for one of you to take the IDA WOW into meeting room beforehand. Mr Jah first does a board round. Start preparing the ward round note (share each note) as he discusses each patient on the board round, whilst somebody else notes down the likely jobs for the day. Mr Jah will then go and see the patients on the ward round. Someone should go on the ward round, but the other F1 can go back to the office to do jobs. Social meeting with dieticians and physiotherapy at 12pm in N3 seminar room. Usually just 1 FY1 is needed to scribe. During year 2017, we had surgical teaching at lunch time (12-13), these are not mandatory but usually very clinically useful and highly recommended.

Thursday Consultant HPB liver MDT (F1s do not need to attend) Morning ward round conducted by Clinical Fellow/SpR. Ms Balakrishnan will join following the MDT at 11:00am. Similar to Mr. Huguet, Ms. Balakrishnan appreciates the FY1's presenting so be prepared.

Friday Consultant led ward round with Mr Huguet. This will start in IDA and Mr. Huguet usually likes the FY1's presenting.

Daily Board Round/Blood Round

The Clinical Fellow/SpR conducts a daily board round in the C7 office. The time varies but it is usually at around 4pm. All HPB patients are reviewed including vital signs, observations, any imaging from the day and any additional plans from specialist team reviews. If there are any concerns during the day this is the time to flag them up to the seniors. Try to ensure all bloods results are back for this (if not back, ensure they have been done – it is better to check this mid- afternoon). Typically the majority of our patients are on daily bloods - FBC, LFT, CRP, U&Es, plus Bone Profile and Magnesium for patients on artificial nutrition, and PT/APTT for patients having interventional procedures done the next day. These are done either by the nurses (for PICC bloods) or by PAs (all other patients). If, for whatever reason, a patient has not been bled, this will need doing before the day ends.

—

Tip: Identify early on who is on the twilight shift. Do a handover of all the tasks which need chasing, as well as informing the on-call of anyone who you are concerned about. Ensure that this information gets passed onto the night on call. Can be useful to make a handover list to give to the twilight person. Make sure your list to the twilight person has plenty of information on it about what particularly to watch out for and what kind of things your team would be concerned about from the investigation you have requested.

Tip: A lot of investigations can take a couple of days to get and some are not urgent. Keep a list of jobs which can wait till the next day or that need further chasing the next day. Also the ward round on mondays can start late so it can be good to keep a list from the friday of plans for the next week so you can be arranging EUS or interval scans to limit the workload after the later start ward round.

Tip: When seniors request for imaging, it is usually on urgent basis, so clarify when it is needed for and discuss with radiologist. For US guided drainage of collections, one needs to go to US department to discuss request with radiologist in person. Make sure you are fully aware of the reasoning for request and also know the coagulation status of the patient. Typically they are happy with a PT of <15.

Discuss with the other juniors in the team all of the jobs from the ward round. Work together to prioritise jobs.

Tip: Make one master job list, which has the jobs for all of the patients on it, and leave it on the table in the doctors' office. Divide the list into subsections - for example, scans, discharges, reviews, bloods, etc. Work together to start ticking the jobs off. Priortise to get the urgent scans and investigations in early and then work alongside the senior sister for the discharges for the day.

Tip: Aim to have requested and discussed all scans for the day with the radiologists by 11:00, if possible. This will help to get the scan done the same day. Can be useful to make a list of all of the scans needed and then discuss them all in one phone-call with the radiologist for that type of scan.

Tip: Identify the patient's that will perhaps be coming in, in the evening as elective admissions - it is best to get the patient's details, what procedure they are coming in for and discuss with the Clinical fellow as to what the on-call FY1 will need to do and whether or not they will require dalteparin prophylaxis that evening - this makes it very easy for the FY1 on call to clerk the patient and to do urgent jobs for the patient which may be needed before their procedure the next day.

For all orders placed on EPIC give a clinical picture of the patient so it may be appropriately prioritised i.e. recent surgery, septic, rising inflammatory markers. Also state what you are looking for e.g. ?collections ?post op anastomotic leak ?pseudoaneurysm.

Plan Film x2387

Gastrograffin + AXR: Gastrograffin (usually 100 ml diluted in juice or other liquid as gastrograffin is unpleasant in taste) to be prescribed and given by the nurses (clarify with radiology how much to give and how to dilute it). Arrange an AXR 4-6 hours later (any longer and the gastrograffin will have passed). Ward is responsible for getting patients down to XR department on time.

MRI x4462

MRI plus MRCP: If this is urgent you will need to discuss with MRI (gastro) radiologist before organising with the MRI co-ordinator.

CT x6718

If urgent (which they usually are) you need to discuss it with the CT radiologist followed by the CT co-ordinator. Typically all HPB CT abdomen pelvis are done with contrast unless the patient is really impaired (and even then contrast is often used, with pre and post hydration, discuss with renal if unsure).

Triple phase CT: order on EPIC as CT abdomen and pelvis with contrast. State in the order that you would like it done 'with triple phase'. Usually done to exclude a pseudo aneurysm and sometimes certain cancers/leaks.

CT guided drains: order on EPIC as 'CT guided drain'. This will need to be discussed in person down in the CT department. The patient should have a recent clotting and any necessary correction. Radiologists generally only ever ask two questions with respects to organising drains; patient's clotting and platelets

Ultrasound x2778

US scans/guided drains: After placing the order on EPIC all interventional ultrasounds (aspirations, drains) will need to be discussed in person in the ultrasound department on level 3. The best time to catch a radiologist is either at 9am or 2pm before clinic starts, otherwise you will have to wait and catch them between patients. The patient will need a recent clotting (PT should be <15).

Interventional Radiology x2337

Patients require antibiotics cover for interventional radiology procedures, usually Tazocin 4.5mg - one dose before and 2 doses after the procedure. They should also be given a bag of Hartmann's beforehand.

You will often be asked to chase when a procedure is happening - as IR is essentially an emergency service, they cannot provide this information.

PTC: Order on EPIC as 'Fl percutaneous trans hepatic cholangiogram'. For a drain to be left in, on the order state for PTC insertion and biliary decompression. Contrast is injected percutaneously into the biliary system to identify biliary obstruction. In HPB patients, a drain is usually left in to decompress the biliary tree allowing bile to flow out into the external drain. The patient will require a recent clotting result, corrected if abnormal. PTC output is monitor daily (see intake/output tab on EPIC). You will also need to monitor electrolytes - many patients require Dioralyte to replace losses

Internalisation of biliary stents Usually performed approx 2 weeks after PTC with drain, a stent is placed across the biliary obstruction, allowing bile to flow into the gut, and allowing the PTC drain to be removed. Beware of septic shower thereafter.

Order on EPIC as 'Fl percutaneous trans hepatic cholangiogram' but state on the order for internalisation of PTC and for stent insertion (specify whether a plastic or metal stent). Again, the patient will need a recent clotting

Rendevous This is where a PTC is combined with an ERCP to relieve a blockage in the biliary system - they meet in the middle where a stent is place, hence the term 'rendezvous'.

This needs to be ordered on EPIC in two stages:

1. 'Fl percutaneous trans hepatic cholangiogram': state in the order that it is for placement of a Cobra catheter prior to future Rendezvous
2. 'ERCP and sphincterotomy': state in the order that it is for a rendezvous procedure.

Typically this is done following a previously failed ERCP and stent. It is a procedure combining PTC with ERCP. A guide wire is advanced via a catheter through the PTC into the duodenum to be met by endoscopy at the other end, whereby a stent is inserted.

Barium Suite x2331

Contrast meal and swallow: This is done in the barium suite. It may be performed to identify gastric outlet obstruction or to visualise the potency of an enteric stent.

Tubogram: EPIC order 'Fl tubogram'. Contrast is injected through an existing PTC and the biliary tree imaged. If this is all that is required it can be done in the Barium suite. If any kind of intervention is needed, the procedure will need to be done in Interventional Radiology.

Endoscopic Procedures

Typically patients need to be NBM for 6 hours before endoscopic procedures

Endoscopy requests - if urgent can contact the follow consultants: Dr Corbett, Dr Woodward and Dr Carroll - call or face to face discussion

ERCP If not urgent, endoscopy triage the request, usually within 1-2 days. If urgent you may discuss with Dr Corbett, Dr Woodward, or Dr Griffiths (mobile via switch is best).

EUS +/- ERCP To be done in the same procedure. Endoscopy has lists on Tuesdays and Thursdays only. Dr Griffiths is able to do both EUS and ERCP at the same time. Otherwise, if urgent, you may liaise between Dr Carroll/Dr Godfrey (radiologists who do EUS) and Dr Woodward/Dr Corbett (gastroenterologists who do ERCP) to arrange. They generally prefer to be contacted on mobile via switch)

Cystogastrostomy A stent (often a Hot Axios Stent) is placed between the stomach and a pancreatic pseudocyst allowing it to drain as fluid accumulates. You will need to contact Dr Carroll or Dr Godfrey (on 6718 or their mobiles via switch) for their opinion before placing an order on EPIC. Once drained, the cyst collapses and the wall of the cyst adheres to the stomach.

EUS FNA After placing an order on EPIC, check with the endoscopy department when it is possible for these to be performed as they may only have couple of lists performed each week.

Other Orders

PICC lines EPIC order as 'Inpatient referral to vascular access. PICC lines are inserted Monday to Friday, usually the same day if requested on the ward round.Can be worth phoning/emailing if the request is urgent, or you need to discuss a specific patient.

For blocked PICCs you can contact Vascular Access, or you may prescribe urokinase (5000 units) for unblocking lines, however not all nurses may be trained in administering it.

Tip: Consider if the patient needs a power-PICC (i.e. if likely to need repeat CTs and is very difficult to cannulate - be sure to mention the reason on the request form, as if no specific reason for 'power' PICC requested the vascular access team will sometimes just place a normal PICC).

TPN: EPIC order as “Patient needs PN”. Requests for PN must be made before 12 midday if you want the patient to receive it the same day. Out of hours, you have to contact either the gastroenterology registrar or consultant to approve the prescription.

Octreotide: Prescribed subcutaneously after pancreatic surgery for 5 days. It is a long-acting somatostatin analogue which reduces pancreatic and other enteric secretions. It is used post-pancreatic surgery to optimise anastomosis healing and reduce complications.

Drain amylase/bilirubin: Ordered on EPIC as “Fluid amylase”/“Fluid bilirubin” - then specify “drain” as type of fluid. The results show up in the “Body Fluid” tab in “Results Review” on EPIC - you will be asked to bring this up on the ward round for a lot of patients. In post-op patients, a high drain bilirubin suggests some sort of bile leak, while a raised drain amylase suggests a pancreatic leak site.

Pancreatitis screen (if US -ve for stones & no history of EtOH excess):

• IgG4
• Total Ig
• Bone Profile (including corrected calcium)
• Fasting lipids – cholesterol and triglycerides
• Mumps IgG/IgM (under “Mumps serology” on EPIC)

Palliative care: Sadly many patients will have a poor prognosis, and sometimes it feels as if we are getting caught up with investigations and interventions when actually a patient just needs to get home or to somewhere more suitable for their final days - call palliative care. They are the friendliest team and happy to give advice, and even if it seems premature they can help to manage symptoms in patients who may not be in the final stages. Palliative Consultants bring focus and clarity to situations and seem to accelerate transfers and discharges and have a very positive effect on patients' care.

Discharges

When a patient is being discharged, find out the following information on the ward round that day:

1. If they are to go home with antibiotics, if so how long for?
2. Do they require any outpatient imaging?
3. After how many weeks should they be seen in HPB clinic, normally 4-6
4. Any need for a 28 day course of prophylactic dalteparin? This is usually for large open abdominal interventions especially if it for a malignant process
5. Any other follow up? e.g. HPB or liver MDT, follow up blood tests with the GP, outpatient follow up with other specialities (usually written in the notes)

Patients who have undergone extensive surgery such as a Whipple's, liver resection or laparotomy require a 28 day course of Dalteparin from the date of surgery therefore may require this on discharge

Patients who have undergone a Portal Vein Embolisation PVE will require an outpatient CT abdomen pelvis with contrast 6 weeks post-procedure to assess liver volumes. They will be seen in clinic following this.

For splenectomy patients, include a post-splenectomy vaccination schedule for the GP to review, also ensure to ask for the GP to continue lifelong Penicillin V and aspirin if needed (see below)

Discharge Emails

You will need to keep a note of the discharges each day and send a daily email to the HPB specialist nurses and secretaries (currently Lena Loia, Alison Deaves, Gail Scott, Shona Rock and Frances New). You should include the patient name, hospital number and any follow up (including anything which the GP needs to be aware of). If there is any problem with a discharge, they will let you know. Transplant Patients

Transplant patients occasionally appear on our list but are not primarily looked after by the HPB team - the only transplant patients looked after by the HPB team are those undergoing liver resection by Mr Gibbs. The transplant team are responsible for the patient unless specifically handed over to our SpRs. However you may be asked to do bloods/write the TTO to help the transplant team out.

Morbidity and Mortality meeting (M&M)

The HPB team has a monthly M&M meeting, the date and time of which will be emailed to you by the secretaries along with a lost of patients.

You are expected to prepared a PowerPoint presentation for these patients to present at the meeting (usually 1-2 slides per patient).

Look on EPIC discharge summaries for help with describing the complications with the morbidities

You will have 4 M&M meetings during your placement so you can either take turns to present or present as a team. It can be considered a Case Based Discussion for your ePortfolio.

There will be numerous requests made to interventional radiology especially for Percutaneous transhepatic cholangiogram (PTC). Relevant information to include in request include: - Level of obstruction; hilar or distal. - Whether mass if present is resectable; this will help to decide whether a billary metal stent is appropriate - Tissue diagnosis - Billirubin level and trend - Clotting results

Liver biopsy - Platelet level and clotting

Management of Splenectomy Patients

For patients who have undergone a splenectomy ensure the following:

• Monitor platelet levels and start aspirin if needed
• Start lifelong Penicillin V 250mg BD (Erythromycin if Pen allergic) and inform the GP
• Post-splenectomy vaccinations as follows:
• —> Pre-op or during admission: Pneumovax II, Menitorix and Bexsero
• —> 1 month later ask GP to give: Menveo and Bexsero
• If a particular vaccination is not available in Addenbrooke’s for any reason, let the GP know on the discharge letter, including when it should be given in the community.

It is helpful to GPs if you put a table like this in the discharge letter:

The Clinical Fellow/SpRs are readily available should you need help. They do not carry bleeps, but they are happy for you to call them on their mobile if you have any questions or concerns. If the seniors are all in theatre, they prefer for you to go to theatre in person to discuss any concerns.

Download the app “Induction” - it has every extension for the hospital and saves so much time!

It is useful to collect phone numbers for all of the Clinical fellows/Registrars early on (they will be happy for you to take these)

Paid on 25th of every month

This is a tough job. However, it is enjoyable and you will learn a lot. Use opportunities to get into theatre when the situation allows.

When you are off-duty try and enjoy it.

PTC: percutaneous transhepatic cholangiography. This is an interventional radiology procedure whereby contrast medium is injected percutaneously into the liver's biliary system under radiological guidance. This demonstrates any strictures or areas of dilatation in the biliary tree. The above diagnostic procedure is often followed by the therapeutic insertion of a biliary drainage tube which decompresses the biliary tree by helping the bile flow out into an external drain (inserted through the initial entry point).

You should read up on general surgical complications as well as the main HPB specialist complications. The most important ones are as pancreatic leaks, bile leaks, and pseudoaneurysms. You should read into how these are investigated as this will make the ward rounds make a lot more sense.

You should know about the 4 different drains used in a Whipples procedure, and what is normal and abnormal to find in them. Ultimately ANY fresh blood in a drain post Whipples is an emergency and requires urgent review by yourself and a senior.

Having started my working life as an HPB surgical FY1, it is a tough start. However, having done it I feel that I am a better doctor and it taught me to prioritise clinical needs quickly and assess and manage sick patients. Anyway, enough of the reminiscing - here are some hints and tips that I wish I had known before.

First and foremost in this job you need to remember to eat a proper lunch and take a break, make sure you sleep and that you plan relaxing and fun things to do in your time off. I know this is what everyone says on starting FY1 and you think that of course you will make sure you do those things but when the ward is busy and you have a long list of jobs it is the last thing you want to do- but make sure you do. Long days and high work load mean that you need to pace yourself. I didn't and it made it harder.

Secondly this is a really interesting specialty and there is alot you can pick up. Interpreting Surgical CT scans is something your seniors will do many times a day and they are always happy to teach you. If you are keen or budding surgeon, Mr Liau, Mr Harper or Mr Huguet have offered for us to come and observe surgeries so another great opportunity.

- Ask your seniors why they are ordering certain investigations. This will not only mean that you learn about the specialty but it will be INVALUABLE when you are discussing with a highly skilled and speacialised intervetional radiologist why your patient would benefit from a percutaneous transhepatic cholangiogram rather than an MRCP.

- Most of your patients will have a CT scan, in fact all of them- so ask on the ward round whether they would like it today because they are concerned about a complication or prior to surgery or within the next 7 days as an 'interval scan' looking for evolution of their known pathology. This will help the radiologist to triage the scan and you will develop a good relationship with them if you are clear. (each scan you book in HPB is pretty urgent so always call 6718 to dsicuss them with a radiologist and then 3219 to speak to the coordinator and book them into a slot (you need to do both things!).

- If you are trying to book a patient for an outpatient clinic or to list them for surgery or to add them to an MDT there are ways of doing this online (look on CONNECT) but in HPB there are two specialist HPB nurses called Sally and Lena who work in an office on the ward. Just knock on their door and ask. They are always happy to help.

- EPIC and jobs from the ward round. C7 is a busy ward and the patients have a high burden of nursing needs (many of them would benefit from an HDU bed but these are limited. SO… The nurses are busy- really busy and they all have their own patients in one of the bays. Sometimes one of the ward sisters will accompany you on the ward round but not always (it is curteous to tell them when you are starting the ward round for your specialty and invite them to come). Otherwise your job as a junior is to tell the nurse looking after your patient what the important jobs are from the ward round for them to do. You may think it is all on EPIC but that would involve the nurses constantly checking for your updates which is a little unreasonable. I used to make a job list which included nursing jobs and ticked them off when I handed them over to the nurses.

- The old adage, “my seniors are in theatre” is often something people are afraid of/resent seniors for but it is a surgical specailty so they would be. The problem is when you are worried about a patient. There are ways round this though. Make sure you have mobile numbers of all your seniors and dont be afraid of calling them on their mobiles. You are their eyes and ears on the ward so they want to know if there are any problems. Secondly, YOU CAN GO TO THEATRE IN PERSON. This sounds dramatic but it's not, you can change into scrubs and find out which theatre they are in by asking in nurses offic. Also, there is a little room oposite theatre 7 which is where the HPB team hang out and you can just wander in and see them. If all else fails (or concurrently) you can call the rapid response DOCTOR (the Rapid Response Team is specialist nurse led) and the doctor attached to the team is an ITU doctor so they will help you and let you know what you can do.

- IDA- this stands for Intermediate Dependancy Unit and is on the 4th floor of the main block (above ITU). It is a NURSE LED UNIT. Which means that YOU/ YOUR TEAM are the responsbile doctor for any patients that you have there. This is of course different to ITU where there are doctors who take over the day to day care of the patient (alothough you remaint he parent team). SO, you need to make sure that any medical jobs from IDA are done and that you prioritise these patients if you are bleeped about them. I used to go and see IDA patients if I was bleeped about them.

- “Enhanced Recovery”- these are patients who have come out of theatre that day or the day before and are still too unstable to be moved to a ward but do not need ITU. They are often transferred there by the anasthetists after theatre and they may have anaesthetics or ITU reviews regularly. SO. Again you may or may not be called to see these patients but if you do then assess them and involve seniors early because these will be cases that your seniors have operated on so they will want to know exactly what is happening to them.

- Your fellow FY1s. In this job you will get to know each other pretty quickly and you will work closely with them. You need to remember that if you are stressed/ working hard so are they. This job can be a bit of a melting pot so make sure you support and enocourage each other (avoid the temptation to moan) and treat yourselves to breaks and coffees and things to keep you going.

Finally I will reiterate that I am really pleased to have done it and that it will make you a better doctor.

Dr Cozens FY1 AddenBrookes