TSR Doctors society

Original post by Elles

We have 2am & midnight finishes - for the latter if I'm out the door on the dot can get the last train but no buses & driving not yet an option. So I'm thinking they'd probably prefer to give me an on call room than pay for a taxi?
Also turns out that 2 people on the rota with me are now pregnant-enough-to-announce-it-to-all so might be a bit 'voluntary' overtime-tastic too.. (!) :tongue:

Any specific words of wisdom?

I preferred A&E nights, they tend to be a bit quieter, the pace is a bit slower and the senior support is a bit more supportive.

I doubt they'll ask you to do overtime, they should just get masses of locums in,

Reply 782

RetiredAccount89

18

Original post by Elles

We have 2am & midnight finishes - for the latter if I'm out the door on the dot can get the last train but no buses & driving not yet an option. So I'm thinking they'd probably prefer to give me an on call room than pay for a taxi?
Also turns out that 2 people on the rota with me are now pregnant-enough-to-announce-it-to-all so might be a bit 'voluntary' overtime-tastic too.. (!) :tongue:

Any specific words of wisdom?

theyll usually pay for taxi - argue your case strongly and early on (even before starting).

Figure out who is worth asking advice from early on
And keep an oxford handbook nearby...

Reply 783

Advice? Dint be browbeaten by the medics, you're not their house officer and it is not your job to order investigations or chase results for them, referral is a one-way process.

Reply 784

Huw Davies

11

Any word on the ground about what the NHS "reforms" are going to mean for juniors? This article has me worried:

http://careers.bmj.com/careers/advice/view-article.html?id=20002222&q=w_bmj

Reply 785

edcourageous

1

Original post by Huw Davies

Any word on the ground about what the NHS "reforms" are going to mean for juniors? This article has me worried:

http://careers.bmj.com/careers/advice/view-article.html?id=20002222&q=w_bmj

this sounds awful!!!

Reply 786

randdom

Original post by Renal

Advice? Dint be browbeaten by the medics, you're not their house officer and it is not your job to order investigations or chase results for them, referral is a one-way process.

From the other side of this though (have been in AMU for the last 4 months) it is really frustrating to turn up to clerk someone who has been referred ?pneumonia when they have been sitting there for nearly an hour have been seen and haven't had some of the basic investigations like bloods and a chest x-ray sorted. My Reg tends to ask that they have that level of basic investigation (unless clearly very unwell and needs to be seen asap) put in motion when someone is referred which I don't think is that big an ask. Obviously it is different if we are talking about a CT or MRI which can be a bit more of a faff and should be sorted out by us.

Reply 787

j00ni

9

I'm with randdom on this, you need to do the necessary stuff to get the job done, not just the bare minimum. If you get a reasonable request from a referral specialty, you would be best off trying to accommodate it - both for the benefit of the patient, and to make future referrals easier. Remember the specialties can push back pretty hard if you are seen as being a git. Plus in my experience when the medics ask for you to do more than basic investigations or speak to your seniors, it's because they don't think your referral/clinical judgement is up to much.

Plus it's not just the medics, e.g. how many AXRs have you been asked to do by surgeons with no clinical indication?

Reply 788

j00ni

9

Oh, and as a tip, I find making a call to a specialty about a patient who is a bit borderline for discharge (eg social admissions, elderly LRTIs, syncope, etc) eary on in the process to 'let them know about a patient' who you are 'trying your best to discharge' just to let them know in case you aren't able to get them home. As long as there is then a reasonable period of time before the actual referral it tends to make them more willing to accept the referral.

Also, more than anything, it's much better to be friendly and not aggressive with referral specialties, as most people would go easier on a referral from a friend/someone they like

Reply 789

Helenia

Original post by randdom

From the other side of this though (have been in AMU for the last 4 months) it is really frustrating to turn up to clerk someone who has been referred ?pneumonia when they have been sitting there for nearly an hour have been seen and haven't had some of the basic investigations like bloods and a chest x-ray sorted. My Reg tends to ask that they have that level of basic investigation (unless clearly very unwell and needs to be seen asap) put in motion when someone is referred which I don't think is that big an ask. Obviously it is different if we are talking about a CT or MRI which can be a bit more of a faff and should be sorted out by us.

I would be ashamed if I was an A&E SHO trying to refer without those basic things. Also if they are very unwell then A&E should be sorting them out at least a little before referring.

My suspicion would be that if that is happening on a regular basis it's because A&E are being pressured into making incomplete referrals to avoid patients breaching. That was one of the things I hated most about A&E - I know it made me seem like a retard to refer without all the information but sometimes if you know they're going to need to come in and have requested everything even if it's not done, you just have to go ahead and face the wrath of the medics.

The stuff that I had more of a problem with is being asked to do e.g. serial ABGs on someone who I had started on treatment, referred and who looked pretty stable, or some people who wouldn't accept a referral without a serum rhubarb (insert any obscure test that won't change immediate management and will take several hours to come back). In my A&E we were only allowed to do CTs out of hours for head injury; anything else had to be requested by the admitting team, but some teams refused to believe this.

Reply 790

Original post by randdom

From the other side of this though (have been in AMU for the last 4 months) it is really frustrating to turn up to clerk someone who has been referred ?pneumonia when they have been sitting there for nearly an hour have been seen and haven't had some of the basic investigations like bloods and a chest x-ray sorted. My Reg tends to ask that they have that level of basic investigation (unless clearly very unwell and needs to be seen asap) put in motion when someone is referred which I don't think is that big an ask. Obviously it is different if we are talking about a CT or MRI which can be a bit more of a faff and should be sorted out by us.

I won't pretend that EDs are perfect or even all that good and I agree that basic investigations should be done.

However, I'm frustrated by Medical SHOs refusing referrals because results aren't back - if I'm referring a ?IECOPD with HR of 140 and RR 30, it doesn't matter that his WCC isn't back yet or that I haven't ordered a CRP, it's not going to change the management. Even if his WCC is 9, he's septic and he's coming in. And if his PaO2 is 9.6 with FiO2 of 35% and PaCO2 of 3.0 you cannot tell me that his ABG is normal.

And it's particularly insulting to be told that a patient is well enough to go home by a colleague (who often has the same, or less, experience) who hasn't even set eyes on the person.

Reply 791

Original post by j00ni

I'm with randdom on this, you need to do the necessary stuff to get the job done, not just the bare minimum. If you get a reasonable request from a referral specialty, you would be best off trying to accommodate it - both for the benefit of the patient, and to make future referrals easier. Remember the specialties can push back pretty hard if you are seen as being a git. Plus in my experience when the medics ask for you to do more than basic investigations or speak to your seniors, it's because they don't think your referral/clinical judgement is up to much.

Plus it's not just the medics, e.g. how many AXRs have you been asked to do by surgeons with no clinical indication?

I'm sure A&E SHOs hate everyone as much as everyone hates A&E SHOs. :tongue:

You're right, but there's definitely a right way to ask for extra investigations - "Have you got a repeat ABG? As you're nebulising this guy he might be improving and I'd like to know how sick he is so I can decide whether to get the med reg to review" is better than demanding serial blood gases.

Reply 792

And don't accept that a refusal on the grounds that 'It sounds surgical' - you're referring it to medics because you think it's medical, if they think it's surgical without seeing the patient ask them to call the surgical SHO themselves. :colone:

Reply 793

Egypt

9

I shall tell you a story about a spectuacular Gynae referral that happened on Friday.

18yr old female is having an asthma attack. Concerned friend calls 999. Ambulance crew arriev and are concerned enough to bring said femal to A&E. This is where it goes tits up.

A&E triage assess the patient as being vagina +ve (oh dear, can feel a gynae referral coming on) and then discovers the patient was seen on the Gynae assement unit 2 days earlier. Patient is immediatley bumped to gynae via a nurse to nurse referral ?ectopic! No obs done, no initial assessment. In the defence of the A&E SHOs there were not even aware the patient existed!

The problem with this masterful plan however is that the patient was not and still is not pregnant - which is why we discharged her 2 days earlier. I then got lumped with a stroppy 18yr old having a panic attack demanding a sick note for college.

I was very unimpressed.

Reply 794

Helenia

I wish my immune system would hurry up and get a grip on all the blood URTIs that I keep encountering. Both in A&E and GP I seem to be catching them at a rate of almost one a month. Never very serious but enough to make me feel like a snot-filled bag of crap each time. :frown:

Maybe I should prescribe myself some amoxicillin. :colone:

Or perhaps just a big dose of MTFU.

Reply 795

Spencer Wells

12

Original post by Helenia

Maybe I should prescribe myself some amoxicillin.

Must say I did do this the other week (though I was spiking and rigoring with a neutrophil count of 0.7)

Reply 796

RetiredAccount89

18

Original post by j00ni

I'm with randdom on this, you need to do the necessary stuff to get the job done, not just the bare minimum. If you get a reasonable request from a referral specialty, you would be best off trying to accommodate it - both for the benefit of the patient, and to make future referrals easier. Remember the specialties can push back pretty hard if you are seen as being a git. Plus in my experience when the medics ask for you to do more than basic investigations or speak to your seniors, it's because they don't think your referral/clinical judgement is up to much.

Plus it's not just the medics, e.g. how many AXRs have you been asked to do by surgeons with no clinical indication?

Heres an example of a medic vs me collision.

Cough, fever (38.4) tachycardic, increased resp rate 24. nil pmhx, 70yo.
I had seen cannulated and bled patient within 45mins of arrival. cultures sent off. venous gas done at cannulation - nad.
saturating 94% oa.

ordered cxr, not yet done (x-ray delays).
abx given. fluids running.

referred medics. new med reg who doesn't know me [hav been in same DGH hospital for nearly 2 years so everyone knows me.] I know of her. shes crap.
anywho, barn door diagnosis and referral.
she refuses referral until i catheterise and do abg.
I pleasently suggest that she is welcome to do unnecessary procedures with her patients, but I will not.
She tells me ABG is a must with pneumonia patient with low sats.
I point out VBG results - pH7.38, pco2 5, po2 7, lac 0.7.

She is thick as $%"" and doesn't understand.

Net result medical SHO comes and sees patient, performs unnecessary ABG and attempts catheter (patient rightly refuses).

Its a balance between keeping specialties sweet, and keeping professional inegrity.
But end of the day use evidence as a weapon.
2 tips...

Pneumonia may be undetectable clinically but very apparent on CXR.
Venous gases are awesome

Reply 797

Helenia

Original post by Spencer Wells

Must say I did do this the other week (though I was spiking and rigoring with a neutrophil count of 0.7)

That's almost as neutropaenic as the boy got on chemo. What's wrong with you? And are you better now?

And I don't think I really need amox - I'm considering taking out shares in lemsip though.

Reply 798