A day in the life of a medical registrar on call in a teaching hospital - Managing ED and ED resus

I am going to share my on call details ( patients details have been changed to protect their identity- ie age, comorbidities, investigations). I was the medical on call registrar responsible for ED and ED resus on a Friday. 
I woke up at 0600 AM 
Left for work at 0720 AM 
Got to work at 0745 AM 
Took a handover from the night registrar at 0800 AM and took over the bleep from him. 
He mentioned one patient whom he had already clerked in ED resus- Low GCS, high CRP,WCC, pyrexial, started on IV ABx for meningitis/enecephalitis. CT head NAD. As she had a low GCS (12 to13), the registrar wanted to wait for it improve ( rather than get worse) prior to transfer to the acute unit.

I went to ED and introduced myself to the ED consultant - My heart and soul is in ED and I, as a medical registrar prefer to work in ED with ED as I find it easier to manage medical patients quickly. Rather than interrogating someone on the phone, I prefer to talk to them face to face by going to the person making the referral and discussing everything in the detail. And the whole ED team is aware of my love for Emergency Medicine, improving patient flow and ensuring all medical patients get to the right speciality at the right time while ensuring there are no breaches. 
How basing myself in ED helps:
1. I get a detailed SBAR of the relevant issues I need to know. It normally takes me less than a minute to get all the necessary information. 
https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html
2. I can suggest a quick management plan which the ED team can easily do ( However I usually avoid doing this as I know they are exceptionally busy and take over the patient- unless it is something basic like an ABG/catheterization) 
3. This process helps me clerk the patient faster as I know the whole story ( although I still take a detailed history and examine the patient in detail myself) 
4. I get to make some excellent friends in ED. 
5. They really appreciate a medical registrar being there in ED for advice. 
6. I learn a lot. I get to use this experience whilst leading CRASH calls and dealing with unwell patients on the wards. 

THE ED DEPARTMENT IN MY TRUST
We have a 10 bedded ED resus and 24 bedded ED majors, 10 bedded initial assessment and ED minors. The PAEDS emergency department is seperate. So as you can see, the ED department in this trust is huge. There are usually 2 consultants in ED responsible for ED majors, initial assessment and resus with 3 to 4 ED registrars. There are loads of junior doctors ( FY1s, SHO's), ACPs and physcian associates who support the team.ED minors and PAEDS has its own team.  It can get extremely busy at times with most of the patients being medical. On top of that, this trust is a major trauma center and has all sorts of services found in a teaching hospital. 

I then went to ED resus and listened in to the handover there - 
There were 2 medical patients there:
1. The first patient was the same one which was handed over my the night registrar. That patient was now safe for transfer to AMU hence I had nothing else to add at that point. 
2. The second patient was:

PATIENT 1 ( 0830 to 0930 AM)
Handover from ED nurse:
This 70 year old male was found to be short of breath - his wife called for an ambulance. We have cannulated him, done bloods including a trop and D dimer. His heart rate is 36 BPM. Can you see him? 
As I was present there and had nothing else to do, I decided to see the patient directly instead of the ED team. The reason being:
1. This was a medical patient and I would have to see the patient anyway 
2. An ED reg would see the patient and then a medical registrar will see the same patient again - this is duplicating work and hence waste of resources. That ED reg could do something else ( and she actually did - as there were 2 non medical patients there as well). 
3. I prefer seeing patients directly at the front door - I have a bit of ED blood in me. 
I first opened his medical records, the ambulance handover sheet ( this always helps - it has critical information like BMs, BP, HR, temperature, a brief but very relevant history) and started filling the clerking sheet with the following details :
1. Ambulance sheet OBS 
2. COVID injection status ( There has been a recent announcement/guidance that certain COVID vaccines can cause prothrombotic state. This statement may/may not be correct so please check your trusts guidance/current evidence on this )
3. Past medical history including previous admissions. 
4. Drug history 
5. Current OBS 
6. Investigations which showed a high trop, D dimer, ECG showed 2:1 block ( I quickly showed it to the ED reg just to confirm if this was actually a 2:1 block)
I then went to see the patient and took a full history:
He had been suffering from shortness of breath since a few weeks, more on exertion, orthopnoea, bilateral leg swelling, mild discomfort in his left chest- non radiating, but worse on exertion. 
He usually walked upto 5 hours a day prior to this and was otherwise fit and healthy. But since his breathlessness, he sat at home most of the time. 
On examination: his chest showed fine crepts bilaterally, JVP was raised and he had pedal oedema up to his thighs.
My impression: ?NSTEMI resulting in CCF and 2:1 Block 
My plan:
CXR - I called radiology and they came immediately for a portable CXR - I had a look at the scan on their screen which clearly showed overload ( I checked this later on the ED X ray screen as well as sometimes the images on the machine are not the best quality)
IV diuretics - I prescribed 80 mg IV furosemide ( BP was above 160) 
Add a BNP
For full escalation ( This is very important. As a medical registrar, we need to have a clear plan for every unwell patient we see) 
Call cardiology ? pacemaker at some point 
Treat as ACS 

I called the cardiology registrar on call who had just started. She was my registrar when I was a core medical year 2 ( the perks of doing specialty training in the same deanery- you know everyone!). She heard the whole story and said she would come in a few minutes. She was there in 5 minutes. Before she went to see the patient, she asked me to request an urgent CTPA ( breathless, chest pain, more sedenterary since the past 5 weeks, history of prostate CA, high D dimer). She then assessed the patient. In the meantime, I called the radiology reg who agreed this was a reasonable request and accepted it. I then called CT scan room and they said they would be ready for the patient in 10 minutes. 
By that time, the cardio reg had done a quick bedside ECHO and then called her consultant who agreed to take the patient over to their cardiology unit directly ( a bed was available). So the patient had a CTPA and the ambulance crew took the patient to the cardiology unit directly from the CT scan room . 
The cardiology team was happy to review the report later on ( and informed me that I did not have to wait for it) 
I saw this patient at 0830. This patient was transferred to the cardiology unit at 0930. Directly from ED. The patient had come at 0820 AM. 

Tips:
1. ALWAYS check the ambulance sheet. It has very useful information.
2. When confused, ask for help. I wanted a second opinion about the ECG ( despite doing medicine for 5 years). I asked my ED reg to confirm my findings and I was assured that what I had learnt in the past 5 years was correct. 
3. If you are free, clerk medical patients directly if the ED team is busy. The ED team can focus on other unwell patients. 
4. Get a specialist opinion early. 
5. Give a good SBAR - in this case: to the cardiology reg and to the radiology reg. 
6. Do what is best for the patient. Had I not called the cardiology reg on time, this patient would have ended up on AMU (on telemetry) and then transferred to the cardiology unit later on in the day ( IF a bed was available).
7. Help your colleagues - Had I argued with the cardiology reg that the CTPA can be requested by her team upon transfer to the cardiology unit, I would be obstructing safe management of the patient - the cardiology team was keen to get this done to rule out a massive PE which would change their management plan. 

PATIENT 2 ( 0930 TO 1015)
This was a 65 year old patient admitted to ED resus with ?seizure. He had left sided inattention post fit. 
This patient had not been seen by ED as they were getting busy. A CT head had already been performed ( The ED team is very good - they immediately request investigations as soon as such patients - ie with seizures come through the front door). Again, I had nothing to do so I decided to see the patient directly. 
When I was about to see start clerking the patient, the ED nurse handed the VBG to me which showed a Hb of 55. 
I quickly checked his previous letters and found out he had suffered from symptomatic anaemia a few months ago and was discharged with O/P investigations after being transfued.
I immediately requested the ED nurse to do a group and saves- They were already on it!
I then repeated the same process I did with PATIENT A
1. Ambulance sheet OBS 
2. Past medical history - He had been admitted twice in the past few weeks. 
3. Drug history 
4. Current OBS 
5. Investigations - for now he just had a VBG. CT head - normal 

I went to see the patient and he was confused - possibly post-ictal. Hence I decided to take a detailed collateral history from his wife ( documented next of kin as per electronic records) once I was done. I examined the patient: I could not find any positive findings apart from a GCS of 14/15. I noticed his left ear hearing aid was not working ( which explained his left sided auditory inattention). 
My impression was:
1. Symptomatic anaemia 
2. Seizure ? cause 
My plan was:
- 3 units blood transfusion once FBC back 
- Collateral History 
By then the FBC had come back which showed a Hb of 55. I then quickly did a PR which did not show any malena. 
I then called the wife. She was quite worried. 
Her husband had been admitted twice already with low Hb. He had recurrent falls and had been complained of right hip pain, more on walking( I was unable to elicit any pain on examination and he was too drowsy to ask to stand up), she was unable to cope with caring for him ( they lived alone, she was helping with everything and was tired). I then took a detailed history of the seizure and it was a tonic clonic seizure which self resolved in 2 minutes followed by post-ictal phase.  
I assured her we would try our best to get to the bottom of this. After this collateral, my plan changed:
1. Blood transfusion 
2. OT/PT 
3. Find out cause behind low Hb ? CT TAP/upper +/- lower GI endoscopy 
4. Monitor for seizures. If no further seizures, for O/P first seizure clinic ( Does not drive) 
5.For full esclalation 
6. X ray pelvis 
7. Chest X ray
8. Add on bone profile, magnesium, phosphate levels.
9. Fit for transfer to AMU once X ray performed.

Tips:
1. ALWAYS Take a collateral history - please DO NOT wait for some other junior colleague of yours to take it when the patient is transferred to the ward, especially during day hours. 
2. Always make a list of problems :
In this case it was:
- Witnessed seizure - CT head, bloods normal
- Low Hb - unkown cause 
- Right hip pain - X ray pelvis 
- Wife struggling with care - needs OT/PT 
Such points help you identify and problem solve to avoid missing anything important. 

1015 TO 1200 
There were no more medical patients in ED resus. I gave my bleep number to the ED resus nurse in charge and registrar to let me know if any new medical patients come- unless the ED team wanted to do their own teaching ( some ED consultants and registrars ask their SHOs/FY1s/ACPs/PAs assess unwell patients coming through the front door under direct supervision on a regular basis - I prefer not to intrude here as they need this sort of teaching)
I then went to ED majors. The team there had no queries for me and as there were beds on other medical wards, patients were being transferred quickly. Hence there was no point of me clerking them there ( I avoid clerking patients in ED unless they are unwell/ED team is concerned if the initial management has been done and they are stable- The ED team here is very good in identifying stable patients- CAP, had IV antibiotics, on IV fluids, EWS 2 because on 2L O2 and are happy for them to be transferred. This avoids breaches. Unless the matrons want me to clerk all patients in ED because there are no beds) 

I then went to the COVID screening AMU and non COVID AMU - both wards had loads of juniors, ACPs and consultants with no unwell patients. There were very few patients to be clerked as the team were very proactive.
So I went to ambulatory care where a registrar asked me to help with a difficult lumbar puncture. Which I helped with. 
Then I had a nice lunch and relaxed in the cafeteria. 

Tips:
1. Always check AMU/ admission ward/ambulatory care if they are struggling. We sometimes forget how busy it can be there and what a huge help we can be. 
2. Here are some tips for lumbar punctures:
https://omarsguidelines.blogspot.com/2020/02/procedures-sho-is-expected-to-do-in-nhs.html
3. Take a break when you can. I had a nice lunch in the sunshine in the dining room for 30 minutes. 

PATIENT 3 (1200 to 1230)
I went to ED resus ED after lunch and there were no patients for me there. Hence I went to AMU where the cirtical care outreach nurse had just arrived. The junior doctor there mentioned that he had just bleeped her for an unwell patient and was about to bleep me as well. 
I quickly went to see her and did an:
A to E assessment 
I then went through her notes 
She was a middle aged lady who was admitted overnight with a wtinessed seizure. She was known to be epileptic and was in a post ictal state upon admission. CT head, bloods, CXR were normal. 
Her GCS was 7/15 
The critical care outreach nurse was called the ITU registrar at that time and I called neurology ( who saw the patient 2 hours ago) who advised loading her with IV anti-epileptic medication. 
The ITU registrar came down within 5 minutes and took over the care of the patient. He advised that we should do repeat imaging , so I requested an urgent CT head, discussed with the radiologist and called CT scan room and they were ready for her to come. The critical outreach nurse, ITU reg took her for CT and then transferred her to ITU. They were happy for me to not get involved at this stage as they would manage everything.

Tips:
1. Always assess the patient in detail when you are asked to see an unwell patient- an A to E assessment always helps. I usually talK to my SHO/FY1/nursing colleagues whilst assessing the patient as well so that I do not miss anything. 
2. Invove ITU ASAP when warranted. A GCS of 7/15 warrants an urgent ITU review and possible transfer to ITU 
3. Get the specialist doctors involved. The advantage of working in a teaching hospital is that you have 24/7 support from all specialists. In a district hospital, you have similar support on the phone. 
4. Request scans yourself! All the doctors on AMU were doing other jobs. I could have very easily left it to someone else. However as this was a priority, I requested the scan myself, called the radiologist and CT scan room myself to arrange the urgent scan. 

PATIENT 4 (1230 to 1300)
This care home resident was admitted with a choking episode and vomiting. He was seen by the ED registrar in resus and had got a CXR, sent bloods and given IV antibiotics. 
I first opened his medical records, the ambulance handover sheet ( this always helps - it has critical information like BMs, BP, HR, temperature, a brief but very relevant history) and started filling the clerking sheet with the following details :
1. Ambulance sheet OBS 
2. Past medical history 
3. drug history 
4. Current OBS 
5. Investigations- The CXR showed a consolidation, Bloods showed high CRP, WCC. 

I then went to see the patient - he was extremely frail and was on oxygen. I could not take a history from him as it looked like he had delerium secondary to aspiration pneumonia on the background of dementia. 
My plan was:
1. IV antibiotics
2. IV fluids
3. Nil by mouth 
4. Speech and language therapist review 
5. Collateral history
I called the care home staff and found out that he was found on the floor coughing and vomiting a few minutes after they had served snacks. He never had this epsiode before. I asked them about any injuries like head injury and they said it was an unwitnssed fall. I asked about any advanced care plans and they said he did not have any. I got the next of kins details to discuss about DNACPR. 
Unfortunately I could not get hold of the next of kin hence needed to make a best interest decision. I went back to the patient and did a capacity assessment ( to determine if the patient was able to share his opinion about DNACPR) and he lacked capacity. 
So I filled out a DNACPR form in his best interests ( in my plan, I mentioned that the parent team should re-attempt to contact the next of kin later on in the day) and also requested a CT head. 
The CT head was done within a few minutes which did not show anything acute. 
I deemed him for for transfer to the medical wards. 

Tips:
1. ALWAYS take a collateral history 
2. When dealing with an unwell patient, escalation plans are the most important. You, as a medical registrar will be leading the CRASH call. And if you plan to stop CPR/deem the patient unfit for intubation after a few seconds/minutes of CPR ( by then a few ribs would have cracked in a frail patient), you might as well prevent this from happening by putting a DNACPR form in the patients notes. 
https://omarsguidelines.blogspot.com/2020/02/teaching-session-ceiling-of-care-in-nhs.html
3. ALWAYS call the next of kin when it comes to DNACPR. If they do not answer, the patient lacks capacity, fill out a capacity form and make a decision in the patients best interests. It is very easy - all you have to think is what you would do if that patient crashes infront of you - would you do CPR/stop it. If you would stop it, then fill out a DNACPR form immediately. Document everything clearly. 
4. Fall, vomiting - scan their head. The last thing you want to miss is a bleed. 

After 1300, there was nothing much to do. The other acute units were not busy and there were no acute issues elsewhere. As there were no more patients in ED resus and ED majors was fine, I went to the AMU doctors office to do some e-portfolio stuff. 

I received a call from a GP during that time: A patient was vomiting, had loose stools, was confused. His sodium levels were 124. What should I do? I informed them that this patient needs urgent admission as he has possible hypovolumic hyponatraemia secondary to dehydration most likely due to viral gastroenteritis. And advised them to ring for an ambulance and bring him to ED. 

Tips when it comes to discussing patients on the phone with the GP:
1. Write everything down - you will forget otherwise. 
2. Repeat what you have understood in a SBAR format ( it literally takes a few seconds) 
Some examples here:
https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html
3. If GPs are worried about a patient, you should be worried as well. So take them seriously. If you do not think it is serious and can be managed as an outpatient, consider requesting them to send the patient to ambulatory care. 
4. GPs do not have access to all investigations - hence it is best to bring the patient in for urgent investigations 
5. GPs always document your name and role at the end of the phone consultation and that is a legal document. Be careful of what you advise. 
6. If you are not sure yourself, ask the GP to send the patient to ED/ambulatory care ASAP. 
7. Do not interrogate them a lot. There was no point of me asking the patients social history, smoking history, family history, drug history as I had already decided that this patient needed admission. 
Our phone conversation lasted less than 2 minutes. 

I stayed on AMU/ambulatory care, socialized with SHOs, consultants and nurses as there was not a lot going on and then decided to head off to ED resus which did not have any medical patients. So I was about to head to ED majors to see if I could help when I got a call from the medical consultant on call ( The medical consultant on call take referrals directly from ED from 0800 AM to 10 PM - this way they give medical input if necessary) to review a patient with a Hb of 65 and malena

PATIENT 5 (1600 -1630)
This was a 70 year old gentleman who had been feeling short of breath, had black stools and hence was admitted to ED. The doctor who saw the patient did all the relevant investigations ( including a VBG, Group and save, coagulation and a PR examination). 
I first opened his medical records, the ambulance handover sheet ( this always helps - it has critical information like BMs, BP, HR, temperature, a brief but very relevant history) and started filling the clerking sheet with the following details :
1. Ambulance sheet OBS 
2. Past medical history 
3. drug history 
4. Current OBS 
5. Investigations
Upon taking a history,he mentioned that he had a syncopal epsiode a few hours ago. After examining him, I calculated his Blatchford score which came to be 15 ( warranting urgent investigating). So I called the gastro reg on call - I informed him that I have a patient with Blatchford of 15, mentioned the relevant investigations and he was there within 5 minutes. 
He asked me to prescribe IV PPI and he consented him for an OGD and the plan was that he would go directly from ED to endoscopy unit and from there to the gastro ward/acute unit. 
He went for his scope in 30 minutes directly from ED and was then admitted to the gastro ward.


Tips:
1. Remember your risk assessment scores: PESI for P.E, Blatchford for upper GI bleed, etc. 
2. Get the specialists involved immediately - even if you are in a district hospital ( There is always a bleeder rota in a nerby trust - be aware of these local policies) 
3. Always do a PR - do not wait on this. The endoscopist on call will need to know what the PR shows. And yes, as a medical registrar it is still your job and do not delay this. 
4. Do not wait - I called the gastro team 30 minutes after I was referred the patient. However have all the relavent information : in this case it was his Blatchford score, history and examination ( so always clerk the patient yourself)
5. If ED refers a patient like this to you as a medical registrar, you are expected to see the patient ASAP and contact the medical specialists yourself. Do NOT expect a busy ED doctor/ACP to do these medical referrals/discussions. 

PATIENT 6 (1645 to 1715)
I then went to ED resus where I was referred a young male with overdose. The ED team had done bloods, CT head. 
I went through his:
1. Ambulance sheet OBS- It mentioned that he was found with empty boxes of a phosphodiesterase inhibitor , gabapentin, a few more drugs 
2. Past medical history - his previous discharge summaries showed similar admissions along with alcohol excess
3. drug history 
4. Current OBS 
5. Investigations - paraectamol, salicylate levels, CK, CT head along wth other bloods were normal. A urine toxicology screen had been sent. 
I then went to see him - His GCS was fluctuating between 12 and 14/15 hence I could not take a history from him. On examination: I could not find any bruises, elicit tenderness, pupils were reactive to light and not pin point. Neurological examination was normal as well.
Once I had clerked the patient, I opened TOXBASE and printed out the details of the drugs ingested. 
My plan:
1. To stay as an inpatient given his fluctuating GCS 
2. IV pabrinex 
3. Not for chlordiazepoxide as has low GCS ( however bleep me if he becomes more alert and agitated) 
4. Chase toxicology screen 
5. Follow Toxbase guidelines - observe for 12 hours as per printed guidance ( I had printed it out and underlined those points) 

This patient then recovered and self discharged against medical advice in a few hours. 

TIPS:
1. Never take overdoses lightly - they can be fine one minute and can deterioate rapidly within a few minutes 
2. ALWAYS do a CT head in a patient who is confused/has a low GCS - I have seen occult bleeds / other pathologies which could have been picked up- DO NOT assume it is drug overdose ONLY. 
3. ALWAYS check paracetamol , salicylate levels, CK, liver function tests along with routine admission bloods ( which include FBC, U and Es, CRP, coagulation screen) 
4. Check TOXBASE - every trust in the UK has a username and password ( usually in the emergency department). Check if there is any management plan you have missed upon. The most important thing is to see how long these patients need to be observed for and any other investigations you need to do. Print out the guidelines and underline these important parts. 
5. Send a urine toxicology screen 
6. See if you can take a collateral. Usually you will get to hear the street names for those drugs and you can use Google to search the generic names ( although toy can use Toxbase to search for even street names) 
7. Sometimes (usually a consultant) will ask you to call an on call toxicologist. You can ring the toxicologist via Toxbase ( there is a national helpline for healthcare professionals working in the NHS). I have done this ONLY in ITU when an ITU consultant asked me to discuss the possibility of managing an unknown overdose patient with intravenous lipid. 
8. If patients start kicking off, be wary that it could be drug induced psychosis ( and hence a medical condition) so not all agitated overdose patients are 'like that' - please do not generalize. They might need a formal capacity assessment. The ED team usually helps here especially if the patient is in ED. 

I then went to the cafeteria to have my evening meal. I had a bleep free meal for 30 minutes

1730 to 1830
There were no more patients in ED resus and ED majors so I went to AMU. There were not a lot of patients to clerk or any procedures to do so I loudly announced that I am bored - an ACP colleague of me asked me to do a difficult cannula and bloods which I happily did. 5 years of working in the NHS and I still love getting blood from a challenging vein ( even though I am severely needle phobic)
https://omarsguidelines.blogspot.com/2020/12/cannulation-venepuncture-and-doctors-in.html

1830 to 1900 
ED, AMU was fine so I went to the doctors office where I met an IMT trainee who is about to sit in her PACES exam. I discussed my experience with her, also shared the cases I had seen that day and did a bit of informal teaching. I kept an eye on the ED patients board ( which we can access remotely) and it remained stable. 

1900 to 1930 
I went to ED resus, ED majors and did a final 'sweep' to see if there was anything I could help with. There was one new patient in ED resus but the ED registrar who was happy to see the patient himself as he was not sure whether this would be a medical admission or not. 

1930 to 2000
AMU was fine so I went to ambulatory care which was not busy either. I spoke to the ambulatory nurse in charge regarding new pathways , I then went through the investigations of the patients I had clerked and handed over the bleep to the night registrar at 2000. 

I came home at 2030. 

Some general tips:
https://omarsguidelines.blogspot.com/2021/03/progressing-from-sho-to-registrar-in.html
1. Work with ED instead of against them. They are very helpful. 
2. See patients they are concerned about ASAP 
3. When you are confused, get a second opinion. I knew it was 2:1 heart block in patient 1's ECG but I was assured after rechecking with my ED registrar colleague. 
4. Get a specialist opinion (where appropriate) ASAP. If I had delayed this in patient 1 with cardiology or patient 5 with gastroenterology, they would have ended up on AMU for a few hours before getting the treatment they needed.
5. Clerk the patients fully. If you fill the ED history sheet, they will end up being clerked by the team on AMU AGAIN which is duplication of work load. 
6. Mention in the plan clearly if you need any investigations to be chased. I usually write in the plan :
TEAM ON AMU TO KINDLY CHASE:
-Repeat VBG 
-Repeat sodium levels in 4 hours, etc 
The AMU team will not know this patient and will assume that since this patient has been fully clerked by the medical registrar on call, there are no jobs. 
I also try to personally handover such patients when they are transferred to the AMU doctors so that nothing is missed. 
7. Maintain a balance - if the AMU team is not busy, let them clerk a few patients. However if there are 10 patients to clerk and one doctor who has not had a break, they will need assistance ( not only by helping with clerking but escalating this to management so that they are able to sort out staffing). 
8. Take care of yourself - take breaks, eat well and keep yourself hydrated. 
9. Listen to your GP colleagues rather than slagging them off - They are extremely busy ( like us) and do not have access to all investigations. If they are worried, you should be too.
10. Enjoy your job. I love working as a medical registrar on call - I see loads of interesting cases, learn a lot, make loads of friends and meet like- minded colleagues and we get to discuss ways of improving things in the NHS. 

I hope this post helps. Not every shift of mine is like this and I will continue sharing my experiences ( including a hectic shift- if I remember the cases).