My first week as a medical registrar ( ward and nights)

I have started as a ST3 trainee registrar in acute internal medicine (AIM) in Scarborough General Hospital.

WARD

DAY 1 AND 2

I had 2 days of induction whereby the local protocols were explained and I got my ID badge and car park pass.

Although I worked as a core medical trainee year 2 in York Hospital ( which is the same trust and has the same system), some things were a bit different and it is always useful to attend induction for this purpose.

DAY 3

I have been placed in respiratory for 6 months as part of my AIM training. The respiratory ward is shared with diabetes and endocrinology patients as well.

On my first day ( which was the 9th of August - 7th and 8th were induction days), I arrived on the ward an hour early and introduced myself to the nursing team, ward clerks and discharge coordinator.

The first thing as a doctor is that you want to make sure that there are no sick patients who need your immediate attention and then secondly, it there are any potential discharges.

Thankfully, there was no one unwell so the ward clerk gave my 3 discharge summaries to do ( from the past 2 days as most juniors were in induction). I quickly did them ( the consultants had very clearly summarised the patients' in their notes and hence it was an easy task).

By 0850 AM, the whole team arrived and we introduced ourselves. I took everyone's numbers and made a WhatsApp group for all junior doctors ( with their consent- and clearly mentioned to everyone NOT to share any confidential information there. This is primarily to ensure where everyone is as we have a few outlier patients and if anyone needs help, they can easily ask for assistance on the group/call the registrars directly).

We all divided ourselves into teams ( ie 2 doctors with each consultant).

At 0900 AM, the nurse in charge led the MDT in which all patients were discussed.

We started our ward rounds. I saw the consultants patients who were not here. The consultants had done a very thorough ward round the day before and hence it was quite easy. I was with a FY1 who was very keen to learn. We did a ward round in a SBAR manner.

Here is an example of a SBAR ward round.
S ( Situation):
75 year old gentleman, admitted with SOB.

B ( Background) :
COPD ( non retainer according to admission and previous ABG) , IHD, T2DM

A ( Assessment)

Events since admission

Day 3 of admission

Admitted with SOB, productive cough

CXR LLZ consolidation , blood cultures sent from ED (negative to date)

Started on IV ABx - day 3 today.

Bloods ( one day ago):

CRP: 100 ( down from 300)

WCC: 13.0 ( down from 18.0)

And any other relevant bloods.

EWS score: 0 , afebrile since 2 days.

on examination: chest reduced air entry left base, I+II+0

                          abd: SNT, BS+
                         Legs and calves: SNT, no clinical evidence of DVT.

Current active issues

1. on day 3 of IV ABx

- bloods done today. switch to PO if CRP, WCC  improving

2. Poor mobility

- OT/PT r/v ( aware)

R ( recommendation/plan)

1. A/w bloods today ( taken) - switch to PO after bloods.

2. OT/PT

3. prep EDN ( electronic discharge notification)

4. CXR as O/P in 6 to 8 weeks

We would make a list of the above jobs for every patient after seeing them ( and documenting the ward round in a SBAR technique).

We managed to see all our patients by 11 AM and then informed the nurse in charge about the plans.

Then we started doing jobs. I also helped with doing discharge summaries, difficult bloods.

We all went for lunch and then we delegated outstanding tasks ( the respiratory team helped the diabetes team and vice versa). Because everyone was new and there were a lot of discharges that day, unfortunately we all finished an hour later. But we were all satisfied that we had done all our jobs.

I personally felt that it was unfair on my junior colleagues so I decided to change things from thereafter.

DAY 4 ( after the weekend).

I came 30 minutes early and asked the nurse in charge about any sick patients- again, the ward was stable and there were a few potential discharges. So I started doing the medications part of the discharges and authorized them so that the pharmacists could sort out medications and the junior doctors would not have to be chased to do discharges whilst on the ward rounds and just had to fill in the narrative and follow up plan. I also asked the nurse in charge to ensure all discharge summaries were done before lunch time and to inform me if there were any outstanding discharge summaries to do. This helped significantly as no one had to chase doctors.

We had our 0900 AM meeting, we had a new respiratory registrar ( an actual respiratory trainee reg and not a 'pseudo- resp registrar' like me ) and we started our ward rounds. We finished early and started doing jobs.

Then we all had lunch together. We divided jobs among ourselves and then all of us finished by 4 PM! We continued doing small jobs like discharge summaries, some doctors went for their supervisor meetings and we all left on time.

DAY 5 and 6

Same as day 4. We all left on time.

I met my consultant supervisor who introduced me to the respiratory team. They have their office which is shared with the respiratory nurses. The registrars have their own desk and computer to do admin. The consultant made a PDP with me and we agreed that I would:
1. Do chest drains with the radiologists ( in Scarborough, chest drains are inserted under USS guidance by radiologists). You need to be signed off for USS guidance in order to do chest drains.

2. Attend respiratory clinics

3. See respiratory referrals

4. Attend bronchoscopy clinics

5. Do a QIP

6. Attend respiratory MDTs

7. Attend sleep study clinics

8. Learn management of NIV.

My other registrar colleague and I made our own rota to see who will do clinics, admin, bronchoscopies, etc and sent it to the consultant.

Overall, I really enjoyed my first few days as a registrar on the ward.

These are my tips:

1. Always come in a bit early - even 15 minutes early is fine. You will be able to do the urgent jobs first.

2. Greet your colleagues - be it the ward clerk or consultant. Introduce yourself on your first day. Ensure that your contact details are updated on the whiteboard.

3. Be friendly - a smile makes a huge difference.

4. Never refuse jobs. Even if it is a discharge summary. Remember, you were a SHO just a few days ago.

5. When someone ( ie the FY1) is struggling with a cannula, always volunteer to help. The SHO might be busy so do it yourself. Also, ask the FY1 to come with you and show him/her any useful tips and tricks.

6. Teach! My consultant said a very useful thing - ' Make sure that you have learnt 3 new things after a ward round. If you have not, then the doctor leading the ward round is not a good leader.'

7. Help everyone around you. It does not matter if it is not your speciality. See their sick patients if they do not have a senior person around. Of course, always ask them to call their consultant ASAP as they know their patients well.

8. Ensure your juniors take a break. Some, like FY1s are completely new and worry a lot. They may stress and may not be able to prioritize jobs. Help them by explaining what is important and even help them by doing discharge summaries.

9. Ensure everyone leaves on time. If they do not, ensure they exception report.

10. Encourage your junior colleagues to send assessments to you and keep reminding them to look at their curriculum and see if they can get anything signed off.

11. Be a nice person. We have all worked with horrible people. Please DO NOT act like them You are better than that.

12. Do not forget that once, it was your first day in the NHS and remember how people supported you. Provide the same level of support for your juniors. Pamper them, teach them. The FY1 of today will be the SHO later and then a registrar. Your guidance will shape the person they become ( The first team you work with makes a huge difference).

ON CALLS.

MY FIRST NIGHT

I was on nights one week after my first day as a registrar. I asked a few colleagues where the handover room was and came 30 minutes early. I introduced myself to a SHO and helped her with small jobs ( ie calling the radiology team to transfer images to another trust, etc).

We had the handover at 2100 and we did introductions. I introduced myself as the registrar on call for the night (I had been waiting for 3 years to say this - unfortunately I could not give a long philosophical speech as the day team was quite tired and wanted to go home). We went through introductions ( I found out that the FY1 and FY2 had not done on calls in the NHS before and the SHO had worked in the trust for 6 months ). We had a clinical support team ( to do bloods, cannulas, catheters, ECGs, etc) , a bed manager ( who would filter all bleeps from wards for the FY1 and FY2) and a clinical outreach nurse.  

I made an oncall WhatsApp group - and added the night team doctors to it. I gave my mobile number to all the doctors and asked them to call instead of bleeping me. I informed them that they should treat me as their 'on call support' and should not hesitate to call me.

We got around 5 patients in the handover to clerk. The SHO and I decided to clerk, the FY1 and FY2 would cover wards.

I started by reviewing the sick patients who were handed over. It was the same thing I had been doing in my core medical training year 2 post which was

1. Palliate the above 80's who were very unwell despite full ward based care ( ie IV ABx, fluids, etc) after discussion with the family/NOK.

2. Do sepsis screen for the patients who just became unwell and do the usual bloods, ABG, CXR, ECG.

3. Clerk patients - as a SHO, I hated it when the registrar would sit in the doctors office while the whole team was clerking the whole night. And when they would clerk a patient, they would not do the medications list, leave the VTE, etc. So I decided not to do what I hated.

4. Support my junior colleagues. As a core medical trainee, I sued to give my number to the FY1 on call and acting as their 'go to person' for everything and hence made it easier for the registrar as I did all the difficult bloods, cannulas, reviewed the sick patients, etc.

I got around 10 calls from the different team members that night most of which I could easily sort out on the phone.

The bed manager held a meeting at 0200 AM and asked how we were all doing. She even got us cake.

All of us managed to get enough rest as well. The team felt supported and I felt that this sort of 'support' worked well.

We handed over 1 patient to clerk to the day team and small jobs to the day team.

SECOND NIGHT

We got around 4 to 5 patients to clerk. Again, I went to see all the sick ones first and after 3 hours ( of discussions with families, examining unwell patients on the wards) ,I started clerking.

I was bleeped to see a sick patient on CCU who went into runs of VT and then lost consciousness for about 5 seconds. He did not lose output so we did not put the CRASH call out. However I called the critical care outreach nurse ( just for emotional support - it feels good to have them around). The CCU nurses were amazing in managing everything- He was started on IV magnesium and IV amiodarone. I called the anaesthetics reg who inserted a central line ( for amiodarone continuous infusion) within 30 minutes of calling her and then I spent the next one hour staring at the patient and the cardiac monitor ( the 4 CCU nurses and critical care nurse was doing the same).

Again, we handed 1 patient to be clerked.

The junior team got enough breaks.

THIRD NIGHT

We had 4 patients to clerk. This night was different. I had to call a medical consultant on call. I was worried about a ?dissection on a patient in CCU who had the book picture of a dissection. Given that it was a young patient, I just wanted to run it past the consultant ( as the patient would receive a lot of contrast and radiation). He was asleep - I did a quick SBAR and he agreed that a CT angiogram overnight would be appropriate. This conversation lasted less than a minute as I just mentioned the relevant history.

I discussed with the out of hours radiologist who also agreed that it was appropriate. Thank God it was normal!

I then received a call from ED which we all dread - the surgical team want a medical review for a surgical abdomen before seeing the patient! Rather than being that sort of person who tells them off on the phone ( I hate those sort of people), I went to see the patient. Of course, he was a surgical abdomen and the surgical registrar was concerned just because he had an extensive medical history all of which had been treated by doing scans, etc a few days ago.

We handed over 1 patient to clerk to the day team.

My tips for on calls.

1. You need to be a leader - you must delegate tasks but be nice about it.

2. Make a WhatsApp group - keep asking how everyone is and ensure they have had breaks.

3. Clerk patients ! And do it properly. You are not supposed to rest in the mess waiting for the CRASH bleep- you need to support your team.

4. Teach your junior colleagues - show them how to assess patients, show them how to do bloods/ cannulas in difficult patients and discuss cases with them. Ask them to send e-portfolio assessments to you.

5. Be extremely nice to these people: bed managers, AMU nurse in charge, critical care outreach nurse, CCU nurses. Pamper them like anything. If they ask for something, do it immediately. Because you will need their assistance. They are extremely supportive. Plus, they have been in the trust long enough and know everyone , including the senior management and consultants. It is always nice to have good feedback.

6. Escalate! I had to call the ITU reg to pass a central line for amiodarone in that patient, I had to call the medical consultant on call to discuss the CT angio. They are there to help. So do not be shy and contact them.

7. When you are on a ward dealing with a sick patient, always ask if there are any jobs for the other team members. Prescribe any fluids, analgesia therefore the poor FY1/SHO will not have to come all the way to do that. Please do not be that sort of registrar who says 'Oh bleep the junior doctor'.

 8. Do not forget the basics - A to E assessment, ALS, sepsis protocol etc.

 9. Please document a ceiling of care for every sick patient you see. If they are for full resus, please let the critical care outreach nurse know. Again, do not ask the nurse in charge to bleep the critical care nurse. Instead you should bleep her and do a SBAR as you have just assessed the patient.

10. When asked to review a patient from another speciality, review the patient! The poor ortho FY1 may not know what to do and you are their only 'go to person'

11. Make it enjoyable for yourself and your team. The only way you can do it is to support your colleagues, stay clam and confident. A shaky, perspiring registrar is not a pleasant sight. However, we are all human and it is natural to be tense when you have a patient going into VT and turning blue in front of you ( trust me, I have been there). However please do not make this your baseline.

WHAT HELPED ME

1. My 3 year SHO experience ( 18 months as a non trainee and 2 years as a core medical trainee).

2. As a CT2, I used to volunteer to see sick patients and used to discuss resus with patients/relatives actively. This boosted my confidence.

3. I used to clerk a lot of patients as a SHO ( I would try to see at least 15 patients in a 12 hour shift even with the regular distractions - ie CRASH calls, etc). This improved my clerking speed.

4. I used to volunteer to do difficult cannulas and bloods as a SHO. This improved my skills.

5. I used to be the 'go to person' for the FY1 on ward cover even though I was clerking as a SHO - this improved my leadership skills and I understood what their stresses are and I learnt how to help them overcome them.

6. My optimism - Ever since I have started in the NHS, I have been very positive and believe in this simple thing:

Do you have a problem?

Yes- then fix it ( and make a QIP out of it).

No - Then forget about it and focus your energies elsewhere.

I come to work with a huge smile and pamper my colleagues ( be it FY1s or nurses) like my own baby daughter. Because I believe that if you are positive, you spread positivity, you inspire people and they work with you to improve things. Their morale is boosted and this directly improves patient care. So smile, and spread smiles. No one wants to be seen by a grumpy, depressed doctor.

7. The amazing team - the really hard working FY1, FY2, SHO and nurses I had with me during my first set of nights and on the ward.

PS:

I am completely new to this. I have a lot to learn however I am blessed to work in an amazing trust where everyone is friendly and supportive.

When I was about to start as a medical registrar, everyone used to scare me about how horrible it will be, how I will be stressed all the time. Other than the VT episode, my heart rate has remained steady and I have been a happy bunny and I have tried my best to spread happiness.

It is not worth doing a job which you do not enjoy and feel stressed 24/7.