Team member roles
Team member moles
The FY1 in Plastics
Role
The main role of the Plastics FY1 is to gain an understanding and experience of plastic surgery by providing care for the inpatients of the unit, and using spare time to attend learning experiences (outpatient clinic and theatre lists). You are encouraged to be proactive and make the most of the attachment. An overview weekly rota summarising the department’s activities for each week is widely available, and there is a copy behind the ward clerk’s desk in ward 18. All our juniors are welcome to attend clinics and theatre lists whenever they can.
Pre-admission and arrival of elective patients
Many of our patients are ‘pre-admitted’ 1-2 weeks in advance of their surgery date. Preadmission nurses are based on the first floor beneath ward 19. The FY1s on the ward are available to provide advice as required. FY1s will also clerk patients in the preadmission clinic if they are to be admitted for surgery on the morning of their elective operation. This will save time on the day.
As a guide for pre-operative investigations required:
No routine investigations for patients under 50 years
Patients over 50 years need an ECG
Patients over 60 years old need FBC, U&Es, ECG
Major surgery including free flaps need to have G&S (group and save)
Patients with significant lung or heart disease should have CXR & PFTs
Patients on diuretics need U&Es
Patients on anticoagulants may need INR
If there is any uncertainty, discuss the issue with the anaesthetist on call or preadmission nurses who are highly experienced.
The purpose of the clinic is as follows:
To document the nature and severity of patients’ medical problems so that any potential issues relating to their anaesthetic or operation can be identified and dealt with in a timely manner
Ensure any co-morbidities are optimally managed
Provide the patient with information about their admission
Plan discharge
Your role is to support the nurses in assessing the nature and severity of the patients’ medical problems through examination and reviewing the results of investigations.
You are not being asked to make an assessment of their fitness for anaesthesia.
Dr Murray Geddes or Dr Morag Renton, consultant anaesthetists, are in the clinic on Thursday afternoons to see any particularly challenging patients. Please feel free to speak to us then or page us on 3718 or 3605.
There are guidelines in the clinic to help decide who needs additional investigations such as echocardiograms or pulmonary function tests but please also ask if you are unsure. Most of the nursing staff have been running the clinic for a long time and are very experienced. They have a good idea of what is or is not required.
If you would like any advice about interpreting findings or investigations please ask.
Admissions
The schedule for elective patient arrivals is written on the whiteboard beside the nurses’ station, along with their ETA and bed number. The nurses write “ADM” once the patient has arrived and been admitted by them. On admission to the ward, pre-admitted patients do need a brief re-assessment. Other patients and any with medical problems will need to be seen, assessed and managed by one of the FY1s. Relevant blood results and Investigations should be checked for the following day’s theatre lists. Some of the elective patients are not pre-admitted so please check.
When you are clerking in patients, PLEASE read the letter by the doctor who listed the patient and cast an eye over the hand-written outpatient note; there may be instructions regarding pre-operative investigations that you should follow.
Emergency admissions
Emergency admissions are also listed on the whiteboard in ward 18, They are then assessed by the FY2/ST1/ST2 who makes the management plan in collaboration and consultation with the on call registrar and consultant. If they are to be admitted, the nurses will allocate a bed and the patient must then be clerked and investigations performed as required. Pay particular attention to any instructions left by the FY2/ST1/ST2 – for example, many will need IV antibiotics prior to theatre.
Consent
Junior doctors are now only allowed to consent for procedures which they are competent to perform, but patients will naturally ask you questions about procedures so we have appended a guide on common plastic surgery operations. If you need any advice, there is nearly always someone in theatre you can ask or you can contact any member of the on call team.
Results
It is the responsibility of the FY1s on the ward to check the results of blood tests etc. on a daily basis, signing and filing into notes for inpatients on the ward, or in the case of discharged patients, signing and passing to secretaries for inclusion in case notes. Recently, results must be signed off on TRAK.
Never just sign off a result without appreciating its significance and acting on it if necessary. If you are not sure, ask.
On-calls
FYs form part of the “Hospital at Night’ (HAN) team covering a variety of wards but with the exception of emergency calls, priority should be given to the Plastics wards.
Clinics and theatre
Clinic and theatre time is not formally scheduled for FY1s. However, the ward work can often be quiet, giving ample opportunity to go attend either as you wish. There are several, usually varied theatre lists each day. Minor operations also take place in OPD 4 at SJH. Please feel free to come along.
Additional responsibilities
FY1 and above may on rare occasions be asked to cover ward care for General Surgical day case patients who have required admission post operatively for unforeseen circumstances. This should be an unusual occurrence. If it turns out to be more frequent or burdensome, please let Patrick Addison know.
In addition, we have as a department, agreed to provide cover for Mr Matthew Barber’s patients (Breast surgery) over the weekend following his Friday operating lists. This is part of a reciprocal agreement for the breast team to cover plastic surgery patients at WGH.
Communication with consultants
If a patient needs to be discussed with a consultant out of hours, the SpR / ST will usually contact them directly. However, more junior trainees should feel free to contact the consultant on call if they cannot reach the on call registrar.
The FY2/ST1/ST2 in Plastics
Role and rota
These doctors are on the same rota despite their different levels of surgical experience and knowledge. They represent the old SHO grade.
You will field referrals from the region’s GPs and A&E departments as well as other hospital departments, and assess the emergency patients on arrival at ward 18, planning their subsequent management. Those who are not on call, will be scheduled for clinics and theatre sessions. A weekly rota is available on the ward and by email to all relevant staff. You should try to be in theatre (elective and emergency) and outpatient clinics as much as possible. You should also respond promptly when called to review patients whenever and wherever needed. In keeping with all junior staff, you should always ask for senior help if in any doubt or if patients re-present with complications following surgery.
RHSC
One FY2/ST1/ST2 and one SpR are based at RHSC during the week. Ward 3 is the Plastic Surgery ward, shared with ENT. If you are on call, please collect the pager from the reception on arrival, and return it at the end of the day. The weekly rota is available in the nurses’ station on the ward. Phlebotomy is not routinely required but a few emergency admissions may need bloods to be taken and IV access gained. In difficult cases, the on call anaesthetists are usually happy to help.
The on-call plastics team have an ongoing commitment to cover RHCYP at nights and weekends and so, on occasion, both the registrar and consultant will be busy at RHCYP. If any emergency situations arise this should be communicated to them but if urgent senior support is required at St Johns please contact the hospital at night team or ITU team as appropriate.
All emergency admissions to RHCYP should be notified to the clinical co-ordinator who will find and allocate a bed space to them.
Referrals from peripheral hospitals are initially taken to the A&E department unless they are retrieved directly to ITU. A national paediatric retrieval team is available to safely transfer sick patients from peripheral hospitals. If you have any concerns that a patient will need this service ask the on call registrar on consultant to contact this team via RHCYP switchboard.
Clinics
Clinics run at various sites, including SJH, RHSC, ERI and Lauriston Buildings. As well as general Plastics clinics there are specialist clinics, which are useful to observe; e.g. Hand Clinic at SJH on Friday mornings and Sarcoma clinic at ERI on Thursday mornings. Please liaise with the relevant consultant before attending, as they can be busy.
On calls
FY2/ST1/ST2s are now part of the HAN team at St Johns. At night and at weekends you will primarily care for plastics and ENT patients but can be called upon to help out elsewhere in the hospital.
Additional responsibilities
FY1 and FY2 may on rare occasions be asked to cover ward care for General Surgical day case patients who have required admission post operatively for unforeseen circumstances. This should be an unusual occurrence. If it turns out to be more frequent or burdensome, please let Patrick Addison know.
Cross cover
Breast Surgery cross cover
A full day breast surgery list is performed every Friday at St. John’s under Mr Matthew Barber. Many patients are day cases but the inpatients will be admitted to ward 18. Plastics juniors/FY1s are welcome to come along to this list.
The majority of these patients will need to be clerked in but many will have pre-operative investigations including bloods, CXR and ECG already completed. Those having mastectomies or flap reconstructions will require a Group and Save.
The patients will be looked after by the on call plastics team over the weekend as part of a reciprocal agreement with the breast unit. Most patients will require an FBC to be performed on the first post operative day but if this is satisfactory and there are no clinical concerns further bloods will not usually be necessary. The plastics registrar doing the ward round on Sunday will usually see the breast patients and check any specific issues if nurses are concerned. Mr Barber usually phones in to offer advice on drains if required.
If there are any concerns regarding bleeding or flap viability, urgent investigations and resuscitation measures should be instituted by the resident junior medical staff (FBC, crossmatch, IV access and fluid resuscitation as appropriate) and the on call breast surgeon should be contacted through switchboard.
ENT cross cover
Plastics FY1s/FY2s and ST1/2 doctors also cross cover with ENT at nights and weekends. Details of requirements for ENT patients are available in their departmental booklet and should be discussed with the ENT team.
Emergency patients for theatre
Any patient requiring emergency theatre should always be discussed with the on call Registrar. The patients’ details are then added to the CEPOD list as soon as possible by paging the theatre coordinator at the respective hospital and informing the CEPOD anaesthetists.
Day surgery hand trauma lists
The on-call plastics ST1 and ST2 need to ensure that the day surgery hand trauma lists on Monday, Tuesday and Thursday mornings are planned and communicated, for maximum efficiency.
Suitable cases for day surgery lists (for example, digital nerve lacerations, extensor or flexor tendons, fractures):
Should be entered into the hand trauma diary on the plastic surgery shared drive.
The first case should be ready to start at 9am (Clerked and investigations complete). Discuss with on-call registrar as necessary.
When A&E patients are referred and accepted for the list (see appendix 1), the ST should arrange for the patient to be given a photocopy of the A&E clerking in a sealed envelope which they must bring with them when they arrive for surgery. The envelope should state the details of where (DOSA) and when (for example, 7:30am and date) the patient should attend for surgery as well as their fasting time.
The ST should communicate the details of the list before going off duty the night before with:
Theatre co-ordinator (bleep 3541)
The nurse in charge of DOSA on 54105 in order these staff know who to expect at 7:30am the following morning.
Consultants
Our department has a varied workload of reconstructive surgery including trauma and elective surgery for a variety of congenital and acquired conditions.
Trauma constitutes a particularly large part of our work. Trauma patients are admitted under the care of the on call consultant which changes daily except at the weekend when it will be the same person from Friday until Monday morning. Some consultants have particular sub-specialty interests and may accept referrals from their consultant colleagues for complex cases
Adult burns are usually admitted under Mr Hilal Bahia or Mr Dan Widdowson. Major burns are often managed in ITU and smaller burns in the burns unit (ward 20). Paediatric burns are admitted under Ken Stewart, Patrick Addison or Will Anderson. All children’s burns requiring resuscitation will be admitted to ITU or HDU under the joint care of the intensive care team and plastics. Smaller burns are admitted to ward 3. All burns are treated under the Care of Burns in Scotland (COBIS) guidelines laid out at http://www.cobis.scot.nhs.uk/clinical.shtm. An audit form must be completed for each burn admission.
All Consultants undertake some ‘general’ plastic surgery or hand surgery but particular interests are summarised below:
Mr Mark Butterworth: skin cancer, melanoma, breast reconstruction
Ms Dominique Davidson: hand surgery
Mr Stuart Hamilton: sarcoma, open fractures, hand surgery
Ms Felicity Mehendale: cleft lip and palate
Mr Cameron Raine: breast reconstruction, melanoma
Mr Ken Stewart: ear reconstruction
Mr Hilal Bahia: breast reconstruction
Mr Patrick Addison: sarcoma, facial paralysis
Mr Will Anderson: genitourinary reconstruction, vascular anomalies, lasers
Ms Philipa Rust: hand/wrist surgery
Mr Dan Widdowson: burns
Mr Wee Lam: hand surgery, congenital hand surgery
Miss Claire Simpson: hand/wrist surgery