Preparation/People to meet/contacts

Andrew Carrothers is the consultant who led the departmental induction and Chris Lawrence is the SpR who appears to coordinate and keep check on the junior's activities and well-being. They would probably be the first point of contact.

SpR Lynne Barr is currently responsible for CT and FY rota. The rota is updated online an can be viewed on www.traumadoc.co.uk (only accessible from Chrome on Trust computers). Lynne can be contacted via email and is happy to accommodate leave requests provided there are at least three junior doctors on the ward every weekday. In her absence Mr McDonnell can be contacted with urgent leave requests.

The Orthopaedic wards are D8 and C8. Orthopaedic theatres are part of main theatres on level 3.

Handovers are in the trauma seminar room on C8.

When you are the SHO on C8 you are also responsible for the Outliers in the Hospital. It is very useful if you and the other SHOs create an 'Orthopaedic Outliers' folder in EPIC which you all share and update regularly. This was when a new SHO starts on the Monday or for the weekend team they know which patients on other Hospital wards being to us / need to be seen. This avoids being bleeped at 1650 by another ward asking you to review a patient which was not seen all day!

There are more consultants, registrars and middle grades compared to FY2's and Core trainees. FY2's and core trainees are allocated to ward C8, ward D8, on call or in theatre/ clinic.

Most of your days will be a ward cover shift which is 7.45 - 5. Currently there are three bleeps you can hold: C8, D8 and the on call bleep.

C8 mostly an elective ward and all patients on the ward have to be MRSA negative. On C8 the specialist nurses should see the patients day to day and escalate any issues they cannot deal with up to you. Some are able to prescribe, most are not so they will bleep you to deal with TTOs and prescribing issues. If the specialist nurses are not there it is your responsibility to see the patients. The registrars are also expected to see the patients for their consultant everyday. However, due to their clinical commitments this is not always possible.

D8 is both a trauma ward and an orthogeriatic ward. When on D8 ward cover you are mainly expected to help the orthogeriatric team - which is like being a medical SHO (daily ward rounds + jobs). If the specialist nurse who is meant to be seeing the trauma patients is away you need to see those patients as well.

When you are not rotad to carry a bleep you are rotad to go to clinics/theatre.

Day on call hours are 07.45-20.00 and Night on call 20.00 - 07.45. When you are on day on call you cover A&E referrals and after 17:00 you also cover the wards. The oncall bleep is also a trauma bleep so you can attend all the trauma calls in ED. At night you cover both the wards plus ED. It's generally not too busy.

Currently annual leave is not fixed and as long as there is enough people present to cover all the bleeps you should be able to take time off.

Mainly ward work, but if there are enough juniors on the ward you can liaise with each other and attend theatre/clinc.

A typical day if you are not on call: Arrive at 7.45 am and attend the handover meeting in the morning. Patients seen on call the day and night before are discussed, X rays are reviewed and the consultants use this as a teaching opportunity for trainees and FY2s.

If covering C8 go and talk to the nurse practitioners at the beginning of the day and work out which patients they will see. If they are all being seen then ask the nurses to write a list of jobs for you and periodically check the list throughout the day. If some of the patients need to be seen then do your ward round of the patients at the beginning of the day. Nurses will bleep you throughout the day if patients become sick or need something prescribing.

C8 ward cover is responsible for prescribing the elective patients PTA medications. On the days that Richard (nurse practitioner) is working he may do this instead, but it is your responsibility if he is not there. On 'Merlin' there is a guide to peri-operative prescribing- search pre-operative medication in surgical patients.

If covering D8 then check that the nurse practitioners are going to see the trauma patients. IF they are then join the orthogeriatric team. If not see the trauma patients first, do any jobs then join the orthogeriatric team.

It's a little confusing working out who is going to see which patient, but talking to the nurse practitioners at the beginning of the day about who they intend to see makes life a little easier.

The most common patient you will come across is the elderly patient who's had a fractured neck of femur following a fall. Here we will go through the most important points when clerking and assessing them, managing them at admission, to managing them on the ward.

At initial assessment:

• When you are on-call you will often get called by A&E to admit a falls patient who's had a NOF. The very first thing you must do is confirm the fracture for yourself on XR. Do this by checking PACs. Do not accept a patient without a fracture confirmed on XR. Do not accept 'clinical suspicion of NOF fracture'. If the XR is unequivocal, you must insist that ED organize a CT hip and that orthopaedics will not accept the patient until a fracture is confirmed.
• ED will often 'fast track' a neck of femur fracture to orthopaedics. This means sending the patient your way without them being assessed by an ED doctor first. Please read and get acquainted with the 'fast track guideline' on Connect. The guideline requires ED to rule out any cardiac or any other medical cause for the fall and to ensure there are no head injuries/no other injuries. If the person referring you the patient cannot make these guarantees insist that the patient be seen by an ED doctor first.
• When assessing the patient, take a thorough history. The elderly rarely have 'purely mechanical' falls. Often there is an underlying cause, ranging from postural hypotension to silent MIs. Find out why the patient had a fall, whether they had any chest pain, palpitations or presyncope before or after. Was there any head injury? Loss of consciousness, fluctuating GCS, nausea or vomiting? If they had a head injury, are they on warfarin or any other anticoagulants? Any other injuries? How long were they on the floor (considerations for creatine kinase)? How were they found? What were their obs, particularly their BM, when they were found by paramedics? What was their ECG tracing at the scene? Remember, you are in orthopaedics, you may be the first and last person to ever make a thorough assessment of the patient.
• Assess the patient's general health, how they are, their last bowel motion, whether they are eating and drinking well.
• Check the patient's social status. It is very relevant to what surgery is decided on. Check how they mobilize normally.
• To assist with clerking of neck of femur fracture patients a .NOF clerking Performa is available on epic. This walks you through the steps described above and also prompts you to perform an admission/baseline AMTS.

Post op Hip replacements - Request and chase a post op check Xray and Post op bloods (FBC, U+E, Creatine). An Spr needs to review the Xray. Physio starts as soon as possible post op. Mobilise weight bearing as tolerated post op. Discharge instructions: 6 weeks of dalteparin post op, routine follow up not usually indicated unless stated in op note, wound review at GP in 2 weeks, (look at the op note to see if their is anything else to be done)

Senior support:

When covering the ward you are expected to see all your patients - everyday - this includes outliers. Whether or not your registrar will review these patients daily depends upon the registrar. To be on the safeside it is advisable to see all your patients by lunchtime so that if your registrar does turn up in the afternoon you have a good summary of all the issues relating to each patient. However, all the registrars are contable by bleep (many of them will give you their mobile nos) and the consultants are more than happy to discuss their patients.

If you are looking after a Mr Robinson patient (foot and ankle consultant) - you may have difficulty in getting in touch with him or his registrar. The team therefore have written out the registrar's telephone details on a stickynote in the C8 seminar room.

Handover:

Evening - Occurs at 20:00 in the C8 seminar room. Ensure you have printed off at least 2 copies of the day handover for the night team. The oncall handover list can only be printed from the trauma nurses' computer.

Morning - Occurs at 07:45 in the C8 seminar room. Some of the consultants like to go on a posttake ward round at 7:00 in which case the night doctor should have written an entry and laid out the plan for the day team doctors. The night doctor should have printed the take list (roughly 6 copies).

Clerking of ED patient when oncall

It is very important that when you clerk in a patient in ED during your oncalls, to prescribe all of the patient's regular medications at that moment in time. This prevents the patient missing their regular medications and it also prevents any bleeps from nurses asking you to prescribe the medications once the patient has been transferred to the ward. There are times when missed regular medications have only been picked up the next day or after the weekend by the ward pharmacist.

Standard FY2 banding with base+50%

When starting a new job, the myriad of abbreviations and terminology that you may only be superficially aware of may seem daunting and the requirement of an understanding that may be above the baseline post-medical school knowledge is of concern to new FY2 starting in orthopedics. With this in mind I have found the following resources extremely useful and straightforward: 1. Traumapedia (a small app that is available on iPhone will be your lighthouse during an on-call shift, contains main anatomical considerations in a fracture/dislocation, what to look out in an x-ray, classification of the fracture, and management options) - only disadvantage that it has a cost attached to it (around 10 pounds) 2. Orthobullets - an extended version of Traumapedia (useful to those that want a deeper understanding of all orthopedic-related topics, including basic science, materials and their properties, and biomechanics) - free 3. Wheeless' Textbook of Orthopaedics - extremely descriptive - free

Covering the Orthopaedic Trauma Unit:

Sometimes if the clinical fellow for OTU is on leave you may be asked to cover them for the week. Currently Lyndsey Brown in the Clinical Nurse Speciliast for the OTU team who is your most valuable assett in terms of knowing what to do.

Every Friday the clinical fellow sends out an email of all patients on the OTU list. This includes all polytraumas and NCCU patients, their problems, their progress and most importantly any plan for surgery the next week. It would be useful to get a copy of this so you are aware of your patients for the week.

Handover for OTU is in the library opposite the B-spur neurosciences lecture theatre (where FY2 teaching occurs). Starts at 7.30am. You go through the OTU list and present scans to the team. Discuss plans and update as necessary. Other teams will come and hand over any OTU patients admitted overnight.

The consultant in hand over each day will vary. They will do a morning ward round. Attempt to join them in clinic in the mornings. Tuesday and Thursday are theatre days, so attempt to get into theatre and see the trauma cases. Routine ward jobs will arise from the ward round including discharge letters. The CNS can help with these. You will also be asked to liaise with other teams in polytrauma cases, commonly plastic who have an equivolent fellow which mirrors your role but for the plastics team.

Friday morning is the MDT in the offices as you enter J2 on the left. You need to present an updated list of patients from the week. Bring their scans up in the meeting and note the discussion and plan for next week. Sumamrise the plan (including any plan for other speciality input i.e plastics) and then distribute the Friday email to the OTU as described above.