COURSE GUIDE
Introduction to ST3
Edited by Kirsten Walthall
Chapter 1
Introduction
Introduction
Throughout your career in medicine you will go through several major transitions. You have already successfully traversed two of these. At least another two still wait for you. The first transition is one from medical school to being a Foundation Year Doctor - and we have this pretty well covered. You will all have done a period of “shadowing” prior to taking up your post in order to “learn the ropes” of the job. It is a protected role for the first 12 months (even if it didn’t feel like it) as some responsibilities are denied from you, such as the ability to independently discharge patients from hospital. For some of you, even with this preparation, it will still have felt like a baptism of fire - most likely very dependent on which speciality you started off in, as well as how well your medical school prepared you for life in the “real world” of medicine. Your second major transition is into a training programme, in your case for Emergency Medicine, even though it comes under the guise of ACCS. Perhaps you took some time out after 2
Foundation, or perhaps you came straight through. Either way, many people find this transition easier - you get to do a speciality which you have chosen - and therefore probably want to do as a career, leading to some self motivation, and you hit the ground running.
ST3 marks the beginning of your next transition. The Royal College of Emergency Medicine is very clear that trainees are not ‘registrars’ or ‘middle grades’ at this level. Yet you will find yourselves on ‘middle grade’ rotas. Often paired with an ST4-6 (or equivalent) when Consultant cover is not present.
Throughout your training so far, you will have probably enjoyed
Sometimes this pairing will feel quite distant - for example, when
some aspects of ACCS more than others. Some of your friends
you are the most senior doctor working in the Paediatric
and colleagues may have left the programme. You may have
Emergency Department at Royal Manchester Children’s Hospital
experienced the self doubt about whether you have chosen the
there will always be a registrar or Consultant in the adult
“right” speciality, that all trainees go through at one time or
department up at Manchester Royal Infirmary. They can be with
another.
you in minutes if required. Doctors junior to you, from other specialities and many nursing staff will find the subtleties of your new role difficult to understand. This year is your opportunity to develop into the registrar you want to be. There is a fine balance to tread between taking on too much responsibility and not taking on enough.
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Your fellow Emergency Trainees in their HST (Higher Speciality Trainee) years will understand your role well. It is a challenging year ahead. We all remember the transition, whether from this region or not.
This eBook has been written by enthusiastic and engaged trainers around the region. Many of whom you will have the opportunity to work with and learn from. It is designed to refresh and supplement the topics covered on the “Introduction to ST3” Course.
I wish you all the best of luck in negotiating the step up to ST3. Should you ever need any help or council do not hesitate to ask. Kirsten
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Chapter 2
Workshops
This chapter focuses on the workshops and lectures covered on the course.
Supervising & suporting junior doctors
This section is awaiting completion by Dr Alan Grayson.
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Supporting the struggling trainee
It has been estimated that 5-10% of Foundation trainees will at some point during the Foundation Programme be identified as a trainee in difficulty. Therefore it is likely that you will encounter a doctor who might be struggling or be having some difficulty with some aspect of their performance or conduct. Although the responsibility for the educational management of such a trainee rests with their named, GMC approved supervisor you might either become aware of some aspect of a concern or be contributing to the part of the agreed solution, when the problem is being addressed.
Often trainees are identified as a trainee in difficulty due to concerns relating to patient safety. It is essential that appropriate action is taken and the concerns are properly addressed. It might be another member of the clinical team discloses some concerns to you or you notice some aspect causing concern. After ensuring any immediate actions are taken to maintain patient safety then contact with the Supervisor is essential. It is the early identification and intervention that is important, involving others for advice and support in the immediate setting – such as the shop floor consultant or lead middle grade on the shop floor. By providing effective feedback and additional support than this should support the trainee in affecting improvements. Various factors can impair a trainee’s performance, such as personal circumstances, health, learning environment, performance. Often it is an interplay with several of the factors that can be the cause of the concerns. 7
Possible examples of concerns:
The general principles of supporting a trainee:
• Health -such as absence from work – with or without a pattern
• Not ignore the problem – knowing that they will rotate on in
of days absent, chronic ill health, stress • Lack of engagement with portfolio or meetings, failure to progress • Probity issues- not paying transport fares • Inappropriate use of social media • Conduct- late, attitude problem with staff or patients • Performance - serious single mistake, failure to learn and change, repeated complaints, gaps in knowledge or skills • Circumstances: travelling, family problems or relationship issues • Behaviours – is it a pattern of behaviour or just this time and is out of the blue Sometimes there is a need to clearly identify whether it is a performance problem or the issue requires the disciplinary
due course • Establish the facts and circumstances of the issue using as many sources as possible – but always consider the confidentiality of the doctor concerned. It is important to know the facts before taking action • Share the concerns with the relevant people if it is a significant problem: particularly the trainee and supervisor. The supervisor also has a range of sources of advice and support – such as training programme director, HR department, Director of Medical Education, lead employer, GMC, Medical Director. Local contacts will be involved first before any external agencies are consulted. • Developing an intervention – dependent upon the factors and the problems identified • Ensure that the relevant policy is being followed – the Trust and
process to be followed. All Trusts and organisations will have
all training programme will have detailed policies for the
relevant policies which have to be followed correctly.
management and support of trainees in difficulty
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How could we help and support the doctor?
• External reports – such as from a psychologist, Occupational health department
Accurate documentation must be maintained, which includes that the trainee has the information as well. The use of the portfolio is a convenient way of documenting agreed expectations and
• Not seeing certain types of presentations or restricting when they work
actions, progress to be made and outcomes that are to be
It is important that there is discussion with employer before more
achieved. The trainee has to be aware of the learning plan that
significant actions are taken, such as exclusion, restriction of
has been generated.
specific duties or sick leave from work.
Depending upon the nature of the concern:
Discussion with the employer is even more important if there has
• Use of WPBA to give effective feedback– with senior and
been a potential criminal act undertaken.
experienced clinical staff, MSF • Closer and effective supervision, including increased frequency of educational meetings • Mentoring • Increased opportunity to practice skills • Developing knowledge base, targeting learning • Opportunity to present clinical cases and review decision making
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Outcome
Acknowledgements:
Hopefully if there is early identification of concerns, with effective
With thanks to Gary Saynor for writing this section.
communication and then an agreed realistic learning plan put in place – with monitoring and regular reviews, the trainee will continue to develop and progress, subsequently not remaining as a trainee in difficulty.
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Potential pitfalls in giving advice
Does it matter?
BEWARE Prevarication Is it easier not to know? Tests take time
LISTEN
How do you know?
LOOK
harder than it sounds...
How to give advice?
Frequent fliers Previous assessments Triage Patients you don't 'like'
Does admission make a difference?
You don't know everything What don't you know?
ST3
What should you NOT give advice on?
be specific take control modelling understand WHY they need advice
Know your prejudices!!
Who to?
experience
What will they ask?
Role Model 'Do as I Do'
Non Clinical Easy simple boring
POTENTIAL PITFALLS OF GIVING ADVICE
Who writes the notes?
Responsibility Opportunity for assessment
How do you disagree?
FEEDBACK
DON"T MISS mini-cex notes
when?
Clinical
Demeanor Approach Respect
TEACHING
Diagnostic uncertainty
Sick patients - AAA -CAP - Trauma
How to spot the well appearing patient who will soon be dead??? 11
Tips for giving advice to junior
history. If you can’t physically see the patient, because you are
colleagues about paediatric patients.
advice, rather than giving it based on the junior’s history alone.
One of the difficult aspects of becoming at CT3 is that you will be regarded as a middle grade by your junior colleagues from day one. You will be asked for advice and opinions more than at any point in your career so far. This can be difficult to get used to
being called to resus etc, redirect the junior to someone else for
• Always think is there a safeguarding issue? Most times there isn’t, however the FY2 is unlikely to have even considered this aspect and hence easily missed. • Look and read the junior’s body language and non verbal cues,
giving advice, especially in area like PEM, which you are only
as much as listening to what they are actually presenting to you.
really beginning to get grips with seeing kids yourself in the CT3
If some one has no idea it is fairly obvious, however it is a skill
year.
to pick up the subtle lack of confidence or confabulation. This
Tips for giving paediatric advice to juniors • May sound obvious but be very careful. If you are not sure, don’t be tempted to give advice, because you feel it is expected of you. Always ask someone senior, after seeing the child yourself, so you can learn as well. • At your level always physically review every child yourself, even if it seems like a simple injury case. They may not have xrayed the right area etc. Do not be tempted to cut corners by just giving advice. 10 seconds of seeing the child in person, gives you far more information than 10 minutes listening to the FY2’s
helps you decide, when you see the child yourself, how thoroughly you need to retake the history or re examine the child. • It is good practice for you to document yourself in the child’s notes the advice you gave, rather than relying on the junior’s interpretation, which can be wildly different to what actually occurred. • Don’t ever be pressured by time to give quick advice, whether it is the child is approaching four hours or the junior his standing staring at you, waiting for an answer. You can always use “if you go and finish your notes I will find you in 5 mins” or “ I just need 12
to finish something and will find you in 5 mins” etc etc to give
Acknowledgements:
you some thinking time by yourself. With thanks to Damian Bates for delivering the first session on - Vin
“potential pitfalls” which inspired the infographic, made by Kirsten Walthall. With thanks to Vin Varughese for writing the section on giving advice of paediatric patients.
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Medical law and ethics
Why is this important?
Documentation
• Medicolegal quandaries are relatively common
Use simple, clear and unambiguous language
• Likely to be delegated to a senior decision maker
For every entry state your name, GMC number, time and date
• Good, up to date knowledge required to ensure that you are compliant and in line with current legislation
Ensure notes are accurate, legible, comprehensive and
• Join a medical defence union for your own protection
Document clear annotations of wounds – nature, size and
• Familiarise yourself with departmental / trust policies
contemporaneous
position Consider the use of body stamps or templates to assist with this documentation Document any discharge instructions, advice and follow-up care Take special care with the documentation of DVLA advice Do not make assumptions about the nature of injuries and do not make any forensic diagnoses
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Police Statements
• Detailed • Clear
My name is “ Dr …” and my qualifications are “…” and I am registered with The GMC (no. …). I am employed as a “grade” within the Emergency Department at “hospital” On “date” I was on duty in The Emergency Department and I
• Objective • Only report the facts as you know them • Do not offer opinions • Must only comment within your expertise
attended to a patient known to me as “…”
• Do not comment on behalf of others
They presented at …hrs having alleged to have sustained injuries
• Write in first person
to … The patient informed me that these injuries had been caused by … On examination there was “injuries described in layman’s terms”
• Assume it is a lay person reading the statement • Avoid subjective comments • Type, sign and date
These were treated … The patient was referred / admitted under / discharged
Any ambiguity or medical terms will likely result in you being called to court to explain.
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Documentation of Wounds
will try and conceal these injuries and will present a factitious story as to how wounds have been sustained.
• Describe the Site, Side, Shape, Size, Structures involved • Do not guess the age of wounds – can comment on the colour of bruises but do not make assumptions. • Opinions on age and cause of wounds should be left to an expert witness only! • “Bruise” – contusion / ecchymoses. This suggests the use of blunt force.
Bites are usually obvious visibly. Ensure that any concerns about domestic violence and child safeguarding concerns are explored. These injuries may penetrate and require consideration of Hep B vaccination and PEP if high risk. Facial petechiae may be the only visible injury from strangling so be vigilant and explore if any concerns. Burns should have a total body surface area documented and
• “Graze” – abrasion. This indicates the point of impact.
discussion with specialist burns team if large area or “special
• “Cut” – Remember that “Lacerations” are always sustained
circumferential injury. Ideally use a body surface map to
from blunt force. “Incised wounds” are from sharp cutting
areas” involved (face, hands, and genitals). Discuss if a document.
objects. Document whether there is any erythema (redness), swelling and tenderness present. Stab wounds and Gunshot wounds always mandate police notification and do not need the consent of the patient for this. It is good practice to inform the patient that you are doing this. They do not have to co-operate with the police. Some patients 16
When to refer cases to the coroner? • When there is any doubt about the cause of death • Sudden, unexplained or suspicious • All accidents
• Recent contact with police or prison In essence any death within the emergency department will be notifiable. If there is any suspicion of foul play then the police must be involved. They will act on behalf of the coroner out of hours.
• Medical mishaps, consequence of an operation or within recovery time of anaesthetic • Within 24 hours of hospital admission • All Emergency Medicine > ARCP and forms can be found there. 2. You need to complete all the paediatric procedures not just the 3 listed as mandatory DOPS. 3. You need a MSF with 12 respondents from all placement. 4. You must get your common competencies signed off again. 5. You can cross link practical procedures from ST1/ST2 e.g. CVC. 6. You need a paediatric based ESLE this can be done at RMCH or your additional 2months paediatric block. 7. Use FOAMed resources for linking: twitter, podcast, st emlyns, st mungos, BMJ learning. 8. RCEM learning is curriculum specific e learning modules. 9. Get your life support course booked early.
- Hayley Millar
Top tips for ST3 1. Look at the ARCP checklist & imprint it onto your mind ( or save it onto your phone at least). Its what determines your ability to progress so just read it and ensure that you get the mandatory sections signed off. 2. Paediatric's block. Its a great learning experience. To ensure a smooth ride at RMCH, always LISTEN to the nurses ( if they tell you they are worried about a child ,listen to them , they are always right) … bring them food (especially useful for a smooth nightshift). If unsure ask for help. Have a look at the pink proforma's too - they are very useful. 3. Courses - all the A's need to be completed. Ensure ALS/ APLS /ATLS up to date – essential requirement to pass ST3. 4. Complete your membership examinations. Needed to progress through ST3. Enough said. - Aine Keating 91
1. Print out the ARCP Checklist, and pin it to your forehead
This is what they want to see at ARCP, so just go through it. 2. Don’t be afraid to ask for supervision
You can just get on and see patients and do procedures, but you need to get things signed off. Grab a senior and then do it, it's what they're there for! 3. You don’t have to wait for the really interesting cases
Even minor chest injuries count as trauma, and you can do an airway assessment in any burns patient. Those big cases you're waiting for might not happen! 4. Do ESLEs properly
Try your absolute hardest to just work as normal, and ensure your consultant is in plain clothes and just there to watch you, without getting asked questions by others. 5. There are generally three types of children
The obviously well, the obviously unwell, and the ones in the middle. The first two are easy to spot (and make sure you get help quickly for the obviously unwell!) but those in the middle are tricky.
6. Observation is the best tool you have…
It’s definitely okay to put a child back in the waiting room, or onto the clinical decision unit, and reassess them in an hour, so don’t be scared to do it. 7. …but distraction is also pretty good too
Whether it’s bubbles, toys, or some dubious glove-balloonanimal-puppetry, distraction can really help you to assess a child properly, or perform procedures. Don’t rush into it. 8. Ask the parents
You’ve seen this child for maybe 15 minutes, but the parents have been with them for their whole life. What are their worries that made them come to the ED today? It's important they leave feeling like you've addressed these. 9. It’s ok not to know
A good amount of paediatric emergency medicine is about saying, “I don’t know exactly what it is, but it doesn’t look like it’s anything serious”, followed by some superb discharge and safety netting. But at the end of the day, we’re still trainees, we’re still learning, so if you’re not sure about something, ask for advice.
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10.Look after yourself
but can be daunting. Don’t worry, you’re never truly on your own,
With poorly kids it can be emotionally draining, so it’s
there is excellent paeds and anaesthetic/icu cover and Consultant
important to keep a good work/life balance, and to make sure
advice a phone call away.
you’re having fun and keeping healthy. Leave on time, hand your patients over, and take your breaks. You’ll be a better and happier doctor for it. 11.Be awesome to each other
A mantra for life. As a new ST3 doctor, you and all your new ST3 colleagues are in this together, so work alongside each other to be the best you can all be.
1. Print out or keep a copy of ARCP checklist for you to have at work/in your Notes app - it’s a WPBA heavy year 2. Use APLS, teaching sessions as ways to map to curriculum 3. Do your APLS asap, if it’s booked for a further down the year make sure you know it 4. Don’t get frustrated by all the well kids you see, it’s essential
Good luck!
to see so many well as it makes the unwell more obvious
- Chris Gray
5. Work with the nursing staff, they have more experience in
Top Tips (in no particular order) It can be daunting and scary for some people but you’ll come out the other end with a whole host of new clinical and non-clinical skills. You need to throw yourself into it. Those that didn’t get the
paeds than you and generally want whats best. If they’re worried about someone take it seriously. If you’re stuck on something in regards discuss it with a senior nurse. 6. Be proactive, try to get into resus and into the traumas as much as possible. You may not see paeds trauma again
most out of it or weren’t able to get signed off were usually the most reticent and unenthusiastic. RMCH is a really well run
7. I cannot stress enough how important safety netting is. Kids
department - try to make the most of it. This will be your first
will deteriorate quickly, what may be looking like a viral URTI
opportunity to run a department on your own, this is invaluable
may be something much more sinister in 24hrs. Sometimes 93
these patients will (rightly) get sent home, the parents have to
Any problems I’d be happy to give some advice through the year:
know what to look out for and when to bring them back in, my
[email protected]
standard spiel: “If you’re worried about them in any way just bring them back, I’d rather see a well kid with a worried mum
- Amrit Rai
rather than a kid that was bought in too late.” As well as more specific things: less than two wet nappies in 12 hours, no oral intake, NBR, new mottling, reduced consciousness etc 8. Be prepared to change your approach to history and examination, use toys, use a play specialist for distraction, be opportunistic - you don’t know when you’ll be able to auscultate the chest again without them crying 9. Do a full systems exam including ENT and lymph nodes for every patient thats unwell, there is no excuse, no matter how much they cry or how much mum hates their tonsils being looked at. You will learn to block out crying kids. You need to examine head to toe with nappy off and arms up for rashes (and document it). 10.For injuries, think if the mechanism is appropriate for their
Acknowledgements:
development, do you have any concern for NAI, examine head
With thanks to Hayley Millar, Aine Keating, Chris Gray and Amrit
to toe for other injuries
Rai for writing this section.
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