Vascular Surgery - FY1 Manual
Introduction
Vascular surgery is a branch of specialist surgery, managing disease of the blood vessels. The
John Radcliffe is a tertiary centre for vascular surgery, meaning that it takes referrals from other
hospitals and GPs from Oxfordshire, Buckinghamshire and Berkshire.
Procedures performed include both arterial and venous interventions. The most common
operations include angioplasty and other radiology-based interventional procedures, bypass
grafting, endovascular and open aortic aneurysm repair, carotid endarterectomy, lower limb
amputation.
There will be a mixture of patients presenting for elective or emergency surgery. There will also
be some patients presenting with a vascular emergency for whom surgery or endovascular
intervention is not an option, and as such will require a palliative approach.
As would be expected from an elderly population with vascular diseases, patients often have
multiple comorbidities. These include diabetes (and its complications), hypertension, smoking
related pathology, renal impairment, cardiac disease, cerebrovascular disease and COPD.
While the intensity and complexity of the above will sound daunting, you will find that you learn a
lot of this job. Remember, you have senior colleagues available to consult for advice and
support.
As the junior (FY1/FY3) you are responsible for the day-to-day running of the ward and
completion of most ward jobs. This includes looking after patients both pre- and post-
operatively. This will be discussed further on in the booklet.
The Team
The vascular surgery ward is 6A, located on the 6th floor of the main John Radcliffe building1.
There are ten consultant vascular surgeons, who will lead the care for their elective patients,
and one of the consultants is emergency consultant of the week and will lead the care for
emergency patients.
There will be an on-call registrar who will take referrals from GPs and other hospitals - they are
also the first person to turn to when you need help or advice.
1 (During the first two waves of the COVID19 pandemic, the team had been split with some nurses
remaining on ward 6A as a redeployed COVID19 medical ward, and some nurses moving with the
patients and doctors to Specialist Surgery Inpatients [SSIP], in the West Wing of the John Radcliffe.)
You are not expected to contact the consultant directly, although all our consultants are very
approachable should you ever need to do so.
There are several vascular nurse specialists who are amazing members of the team. Please
utilise their depth of vascular knowledge!
You will also get to know many of the staff nurses, who provide excellent care for the patients.
They will alert you to any patient needs, e.g. analgesia or a review when observations are
deteriorating. Many of our nurses have been working on 6A for many years and are very familiar
with unit and individual consultant protocols and well as management of Vascular problems.
Use their expertise as well as that of the ward pharmacist, diabetes specialist nurse, podiatrist,
therapy team etc. We are a multidisciplinary team, don't forget to ask for help or advice from the
appropriate member of staff.
An acute Vascular episode frequently leads to or highlights a change in mobility and care needs
and our discharge coordinator Anca will manage this. This is often a delay in patients being
allocated a nursing home, or care package at home or transfer to their local hospital or
community hospital. There are a number of Specialist Physiotherapists, Occupational therapists
and Podiatrists on the ward who you will get to know well.
Shift pattern and cover
Shifts:
Short days 07.45 to 17.00
Long days 07.45 to 20.00
Weekends 07.45 to 20.00
Nights 19.45 to 20.00
Week day shifts
On the ward: You + Another junior + Vascular registrar on referrals & triage (may not always be
on the ward) + Peri-op consultant/fellow (easily reachable, if not already on the ward).
Take morning handover from the vascular night FY1 (except on Monday when it will be the SEU
F1)
Give evening handover to the vascular night FY1 (except on Friday when it will be the SEU F1)
Night Shifts
On the ward: You + Vascular registrar on referrals & triage.
Take beginning of shift handover from vascular day F1
Give end of shift handover to vascular day F1
Weekend shifts
On the ward: You + Vascular registrar on referrals & triage.
Take morning handover from SEU F1
Give night handover to SEU F1
Weekends are similar to long days, although ward rounds may begin later (and is often slower!).
There are usually no elective procedures planned, and the days are usually more manageable.
Days to be aware of:
Monday
Usually when wounds reviews happen with the podiatrist on the ward round.
The junior team will change from your FY1/FY3 team to another FY1/FY3 team. Therefore, for
Sunday night handovers, it may be worth flagging anything extra that the night junior should
mention to the morning team. In addition, it may be wise to mention such information on the
handover sheet itself.
Friday
When the consultant for the week changes - the ward round is often busier as there will be two
consultants plus the rest of the team. Ensure you print plenty of lists on Fridays (6+)
09.00: Vascular/Interventional Radiology MDT in seminar room on Lv2/virtually. You do not
need to attend this but be aware that others may have to (vascular consultant, registrar and
peri-operative consultant).
10.30: M&M (morbidity and mortality) meeting in ward 6A seminar room. Again, you do not need
to attend this but be aware that others may have to (vascular consultant, registrar and peri-
operative consultant).
Planning your typical day
Pre-ward round:
07.45-08.00: Handover
Receive handover from night junior and collect the bleep. Handover tends to be concise with a
summary of the night junior’s involvement and outstanding jobs - go through the list, highlight
who’s new, who’s sick overnight, and which investigations to chase.
If you have another junior (FY1/FY3) with you, then it may be sensible for the short-day junior to
hold the bleep, and then hand it over to the long-day junior at 17.00.
Ideally the night FY1 will have printed the morning lists and prepped the ward round for you
(please ensure you do the same when you are on nights). Over the weekend, when the night
cover is an SEU F1, they will not print the lists or prep the ward round - ensure you are in early
enough to do this (or do it from home before coming in, if you have access to EPR).
Another priority before ward round starts is finding a working (and charged) Computer on
Wheels (COW) - these are dotted around the ward and you will soon find a favorite that works
for you.
Ward round:
08.00-09.00: Ward round
There is at least a vascular registrar and nurse-in-charge present. Often there will also be a
vascular consultant, a peri-operative consultant/fellow ± medical students.
Ward rounds are fast paced, and preparation ahead of time is invaluable.
It may not always be possible to check everything, but try and ensure that observations, drug
charts, bloods (including capillary glucose) and advice from other teams are at least reviewed
by the end of the day.
The most important part of ward round is writing the plan for the day - this is referred to by
yourself and nurses and is invaluable for team communications. Make sure to write down the
plan for the day, sign your name and submit each document on EPR.
Please ensure that any concerns with weight bearing restrictions are documented. This is
important, especially for post-operative patients.
Documentation is hugely important so please try and document important discussions such as
operation plans or patient requests.
If the patient is going for theatre in the next few days make sure they have up-to-date pre-op
bloods including group and save and a negative COVID swab in the last 3 days.
Often the perioperative team will advise on drug changes, which they are making, but which
need documentation in the WR entries.
If you notice that something has been missed out or overlooked, mention it - you are an
important member of the team who often knows the most about the patient's ward care your
efforts will often be appreciated. The WR entries include some checklists e.g. VTE
prophylaxis/anticoagulation to help us not miss things.
Try to complete ward round entries on the ward round itself, so as not to leave this for later in
the day. This helps not just our team, but often also other teams reviewing our patients.
Once you’ve adapted to the fast pace, see if you can safely complete other small tasks on the
ward round itself, such as prescribing familiar drugs.
Often there are a few outlying patients. Please remind the SpR/consultant about them and
whether they need a review.
The registrar often goes and sees them with the consult but sometimes will request you join
them to document.
09.00-09.30: Board round with the wider multidisciplinary team (MDT)
This MDT includes nurse-in-charge, peri-op consultant/fellow, vascular registrar, all other
nurses, physiotherapists, occupational therapists and other ancillary staff. The purpose of the
Board round is not just to handover the ward round plans to the wider team, but also to address
areas that had not been discussed on the ward round- for example discharge planning.
Here, make sure to document any additional plans/ amendments that are flagged.
Also, participate if you have something to add- again such contributions are likely to be helpful.
At the end, the registrar usually highlights the planned pre-operative and post-operative patients
(post-op via TDA). Use this opportunity to ask the registrar for details as you will likely have
some involvement with these patients. For example, the indication for ward admission/ the
surgery they have had and if anything in particular is required from your end.
Post-ward round
09.30-12.00: Jobs
Ideally, sit down with the other juniors (maybe the SpR) and go through the list- divvy up jobs
fairly. This is an opportunity to plan out how you will approach the day.
An idea on how to prioritise your jobs:
(although you will likely find your own system that works)
(1)Sick patients/urgent reviews first if any
(2)TTOs for people leaving today
It is often worth asking the nurse-in-charge/discharge coordinator, who is a discharge
priority (you’ll find that, often, it is the patients with confirmed transport/ booked
ambulance transport for repatriation. The carotid endarterectomies- who often only
spend a night-usually only start making a move after midday.)
(3)Radiology requests
To increase the chances of a same-day turnaround. You may find that doing these after
completing all the TTOs and imminent EIDDs is wise
(4)Prescribe the easy stuff
(5)EiDD (discharge summaries) for people leaving today
(6)Talking to other specialties
(7)Other
If you know you have some bloods to do, it may be worth preparing trays and tackling them all
early in one go. If there are many to do, you can kindly ask for help from the nurses or
healthcare-assistants (HCAs) who are trained in venipuncture. However, bear in mind that they
often have their own fair share of work to complete.
Lunch:
Please try and take a break for lunch – the vascular FY1 post has historically been one of the
busiest FY1 posts in the hospital, and some days it may seem like you don't have time to break
for lunch but bear in mind that you too need some time to yourself to collect your thoughts and
fuel your body in order to tackle the day.
Do not dismiss your own respite needs.
Try and attend any scheduled teaching that you may also have (F1 teaching at 12:30 every
Tuesday)
If leaving the ward for lunch/ teaching/ something else, it is usually wise to let both your junior
colleague as well as the nurse-in-charge know at a minimum. Also, it may help to agree on a
strategy for others to reach you on, if needed urgently.
Afternoon:
Aim to finish off your morning jobs e.g. EiDD & TTO for tomorrow, talking to other specialties
14.00-16.30: Post-ops & new patients
Post-ops from the morning/TDAs will start arriving in the afternoon(around 3pm). Aim to review
these patients as soon as they arrive on the ward (or as soon as possible).
Elective patients for clerking will usually start arriving at around 4pm
In addition, you may receive handover of intensive care step-down patients.
Try and review all new attendees as soon as possible as they may be unwell, or at the very
least require their post-operative plan initiating
Post operative patients
Have a read of the post op note (it is in paper form - often in the note trolleys or with the nurse
caring for that patients) and attend to these as appropriate.
Document a post op review on EPR with the post op plan, patients most recent obs, A-E
assessment/dressing assessment/vascular assessment
If the post op patient was not previously on the ward (ie new admission) they will also need their
regular medications prescribing.
Further information on post-op reviews is provided below.
New patients
There is a Vascular Clerking Proforma - utilise this to ensure you cover all aspect of clerking.
Patients may also require a cannula, bloods, G&S, COVID swab (as the nurses), ECG (if not
already done in triage) and a plan from the SpR. If they are 70 they will also require an AMTS.
Complete a VTE assessment.
Further information on clerking is provided below.
ITU step-downs
ITU will often call you to give a verbal handover. They will also write a very clear and extensive
discharge summary which can be found on EPR. Please review this (as there may be parts of
the discharge plan that require actioning).
Then review the patient - A-E assessment/dressing assessment/vascular assessment and
document your findings on EPR.
Note that some patients may need timely IV Heparin prescribing or other anticoagulation to
reduce the risk of graft failure - there is a very comprehensive MIL for Heparin prescribing,
monitoring and titration. You will become very familiar with this over the next few months.
In addition, do not forget that these patients will likely have certain parts of the admission
proforma still pending completion (usual medication prescribing + review, VTE prophylaxis,
analgesia, AMTS).
Evening:
Possible wardround/boardround at 5pm with SpR +/- consultant.
Preparing for tomorrow – order tomorrow’s bloods (Phlebs on Monday/Wednesday/Friday),
make sure patients going for theatres have up-to-date bloods/G&S/COVID Swab (in the last 3
days).
Prepare the list for the night junior – try to complete all day jobs and start updating the list by
7pm (unless dealing with an emergency).
Priority is to print an updated list by 7.30 (you usually only need 2 for the evening shift)
Jobs such as post op reviews who have not yet arrived onto the ward are to be handed over
16.30-17.00: Handover
You will likely have been communicating with your junior colleague throughout the day--keeping
them posted on the status of jobs, the results of bloods/ investigations and any new
developments. Use the last few minutes of the short-day junior’s shift to get a formal handover,
so that nothing is missed.
If you have not already done so, it may be worth reviewing the morning ward round entries and
ensuring the required jobs have been completed.
17.30-19.30: Post-ops & new patients & outstanding jobs
As above, continue seeing new admissions and post-ops that may arrive/ have arrived.
It is likely that you will have some jobs outstanding so prioritise accordingly and complete. If
some of these jobs can be held off until tomorrow, then it may be worth prioritising the new
admissions and post-ops, so as not to overload your night colleague.
As it nears 19.45, try and update further changes onto the handover list and print 2 copies of the
list for the night team.
If you find that there is some free time, perhaps consider completing TTOs and draft EIDDs for
patients that may be discharged soon. If doing so, try and highlight it as draft clearly on the
EiDD and make a note of this on your handover sheet.
20.00-20.30: Registrar handover/Night handover
This is when the day registrar hands over to the night registrar. It is wise for the long-day junior
and night junior to be present at this handover to update your colleagues on the status of ward
patients (if they had not been updated already)
Handover the patients and the bleep to your colleague.
At handover, highlight:
1) any unwell patients;
2) any jobs that need attention (and their priority);
3) any likely planned overnight admissions or patients still in theatres that will require a review;
4) any planned operations tomorrow (and what time they need to be nil-by-mouth, IV fluids, IV
insulin, IV heparin morning, holding medications etc.)
When handing over bloods that need to be done for the next day, try and be sensible about the
workload. If a patient should have these bloods first thing in the morning (for example post-op
and likely to have an early discharge), then it is appropriate to hand this over. However, if there
are 10 post-op patients in need of bloods, then ask yourself if you can do some of these during
the day shift when you usually have two juniors on.
Nights
Shift pattern: 4 nights starting from Monday.
Responsibility: Ward 6A (Vascular) and SEU (cross covering with 1-2 SEU FY1s).
Night shifts are a little different as you are responsible for looking after all the patients on 6A as
well as the Surgical Emergency Unit (SEU) patients.
This could be pain control, fluid management, and reviewing acutely deteriorating patients.
Nights are a mixed bag – some are very quiet, and you may even get a couple of hours rest
whereas others are much busier!
Useful contacts/ support:
The Induction app should contain the most recent contact details.
Check at handover who is on and who to contact for help. It may be worth getting the mobile
numbers of the Gen Surg SHO, Gen Surg registrar and Vasc registrar.
Ward 6A: 21804, 62481
Vasc Reg: 40421
Ward 6F: 21840/1, 31764.
SEU Triage (where Gen Surg SHo/ Reg may be): 23238, 23781.
Gen Surg: SHO #4049, Reg #6829 or 26462 (referrals phone).
19.45-20.00: Vascular handover
The vascular night handover occurs on 6A and often involves the day FY1, day registrar, night
registrar and you (the night FY1). Receive handover from the day FY1 and collect the bleep
(#1726). Check in with the night registrar- they may want to discuss patients they are expecting
to be admitted overnight or discuss any jobs required of you. Ensure you have each other's
numbers so you can communicate with them throughout the night - as they are not always on
the ward.
If you foresee any questions that you may need to get in touch with the registrars about
overnight, then it may be worth asking them now.
Make sure you check who the nurse in charge is overnight on 6A and SEU as they will be a
great support to you. Introduce yourself (you will get to know the 6A senior nurses) and liaise
with them to identify any jobs or concerns.
Then head over to the Surgical Emergency Unit for the general surgery handover
20.00-20.15: SEU (outliers and gynae) handover
SEU handover takes place at 20:00 in the SEU handover room - between ward 6E and 6F
(code 2009), on the 6th floor. Often the juniors hand over on the ward and you can find them on
6D and 6E. Receive handover and collect the bleep (#1743). SEU does not have a conventional
handover sheet, instead opting to use the Workflow list on EPR - ensure you write down the
MRNs of the patients they hand over to you!
If you have time it is interesting to sit in on the senior hand over in the seminar room and listen
to the general surgery cases presenting that day. If the night SHO and Reg are present in the
doctors’ office, it may be worth introducing yourself.
You do not have to stay for the complete SEU handover, as usually this does not affect your
shift. If asked to stay, it may be worth explaining that you are covering the vascular ward and
that you have things to attend to there as well.
After handover, it may be worth heading to ward 6F.
Here, try and introduce yourself and liaise with the nurse-in-charge to identify their thoughts.
Ask specifically about anyone that is unwell, they would like an early review on, or any
admissions/ bed manager patient moves that they are aware of.
You may find that establishing such communication early, especially on a ward where the
nurses are not familiar with you, helps highlight that you are accessible and perhaps offers
some reassurance for your nursing colleagues.
20.15-00.00: Jobs
As mentioned previously, it is recommended that you head to the SEU outlier wards to make
contact with the nurses. They often have a few requests over night such as prescribing fluids or
TPN- so to prevent being bleeped at 3am to prescribe 5 TPNs it is best to go and ask early on in
your sift to prevent being bleeped later. The nurses can then highlight any patients who may
require a close eye on overnight.
For SEU, your usual route of escalation would be to contact the SHO first and then the Reg.
Both are usually awake and on throughout the night- either in triage or in theatres.
The most common vascular jobs that are handed over are post op bloods, post op reviews and
clerking new patients. If you get handed over lots of blood to do overnight I would recommend
splitting them down the middle and doing half in the evening and half in the morning. Some of
the nurses on 6A can also bleed patients and can help you out if you ask nicely and they are not
too busy.
Try and complete post op reviews and clerking promptly in order to help your night run
smoothly.
New admissions:
As we are a 24 hour service, some acute patients may be admitted overnight. The night
vascular registrar will alert you to any new admissions (often having presented to A&E or
transferred from another hospital) and the plan for that patient. You will need to clerk the patient
in, site a cannula, take a set of bloods (including a G&S) and prescribe their regular
medications.
The vascular SpR may also want to see the patient with you on the ward, remember to
communicate with them and let them know once the patient has arrived to the ward.
00.00-03.00: Break + food
Some nights will be busier than others. Try and have a break around this time before attending
to the remaining jobs.
05.00-07.45: Final jobs
Towards the end of your shift you may find that this is when things may begin to get busy again.
Aim to start taking any morning bloods at around 0600 on days where there is no phlebotomy
service. (Note, that you may be asked to do bloods on patients with PICC/ CVC/ other lines, as
phlebotomists are not trained to use these).
However, to reduce the workload of bloods, it may be worth proactively seeking other
opportunities to do them. For example, if already seeing a patient overnight and they need
bloods in the morning, then perhaps consider doing it at the same time.
Also, if the nurses have to wake up a patient for observations or medications, and you find
yourself free at the time, then perhaps considering doing the bloods then.
By being proactive like this, you can find that you have easily completed the sometimes over 10
sets of bloods that needed doing. Also, bear in mind that some nurses and HCAs can do
bloods, so it may be worth asking them for their help.
Around 0500-0600 is when nurses do observations and medications. You may get bleeped with
questions about either of these.
Around 0700 aim to have competed all your jobs and start prepping the ward round for the day
team - this means creating a ward round note, writing the consultant of the week at the top,
updating any information about the patient and checking their VTE prophylaxis/anticoagulation -
this will help the day team immensely.
Then turn your attention to printing ward lists for the day team – print 4-6 out (double sided
preferably!, more if it’s a Friday morning).
If Janus crashes, quickly make it on word/ photocopy the night HO’s list/or print a list from EPR.
07.45-08.00: Vascular handover
At handover, mention patients whom you had significant involvement with, highlight any new
patients, highlight any bloods/investigations that need chasing, any changed/ implemented
plans, and outstanding jobs remaining (if any).
08.00-08.15: SEU (outliers and gynae) handover
Return to the doctors’ office between Ward 6E and 6F (code 2009).
The content of the handover will be similar to that of vascular.
Peri-operative medicine
Peri-operative medicine Consultants and Fellows will often join ward rounds and provide input
on the medical aspect of the care of the Vascular surgery patients. On days where they are not
present on the morning ward round they may do a separate ward round at a different point of
the day, or email/text you with jobs for patients. It is helpful to join them for their ward round,
both to reduce their workload and to provide a valuable learning experience for yourselves. In
addition, it will help see more patients in a given amount of time and you’ll be familiar with any
additional plans that need attending to, resulting in better patient outcomes.
Jobs created by the peri-operative team often include medication optimisation (ensuring patients
are on the correct dose of statin, optimising anti-diabetic or anti-hypertensive medication),
review of delirium / cognitive impairment and frailty, and coordination of discharge planning.
They are also a great help if you are concerned about a patient's health and would like them to
be reviewed by a medical doctor. Often their input avoids the need for frequent minor queries
with specialties such as cardiology, diabetes, general medicine/geriatrics, microbiology or renal
medicine.
In general, the peri-operative medicine team are incredibly supportive of the FYs and ensure
that the management of patients across the peri-operative period are cared for in a holistic
manner. They do have other commitments across the hospital however, so work with them to
make the most of the time they have on the vascular ward.
Some patients will have co-morbidities beyond their vascular disease. If you need help with
these components of their care, you may be asked to contact the relevant registrar, such as the
renal or liaison psychiatry registrar (more information provided later).
Navigating Janus/Printing Lists
Janus: http://oxnetjanus/ This is our ward list management software.
On your first day, get someone experienced to show you the basics.
Select: Vascular Surgery: House officer → Password: 123456 → Go to View/Edit ward list.
FY1 doctors are responsible for maintaining the patient list. Here, you list the patient
demographics, their specific diagnosis, any important information, and ongoing jobs. We use
Janus to audit department activity and complications.
When a patient is discharged from vascular, change their location to ‘TDA’ from ward ‘6A’, room
0 bed 0, and add the date they were discharged in the comments section. Do not click the
discharge link, as usually the registrars need to add a few things. The registrars will then
‘discharge’ the patients from the list at regular intervals.
What to do if you can’t print out the list via the ‘Print Ward List’ button: (A common problem at
around 7am or 7pm – i.e. handover time). It’ll come up with ‘server error’…
1. Make sure you can still get to the View/Edit ward list screen
2. Go to print preview
3. Alternatively, copy the list into a word document and print from there.
4. Or print from the patient list section on EPR. Ensure the EPR vascular patient list is
ordered in terms of ‘Location’. There is a print button on the right hand corner of the
screen. - Unfortunately this mode of printing the list only provides patients
names/MRNs/Location and therefore will not have any of the other information that the
Janus list provides (such as operation and jobs)
Common tasks
Discharge summaries:
Use the following discharge proforma located on EPR.
As a minimum include the following:
1) operation and date (and perhaps indication/ nature of presentation/who performed the
operation);
2) other significant events during the stay;
3) follow-up arrangements; check follow-up arrangements for each individual patient in the
operation notes and on ward rounds. If in doubt, ask your registrar. You must ask for when,
where and which consultant is following up, and if any further outpatient investigations are
required.
4) other significant discharge planning. Any ongoing actions required related to inpatient
investigations. Make sure these investigations are requested and note this in discharge letter
(i.e. patient was booked for colonoscopy (requested dd.mm.yy by KG)
5) Information for the GP:
● Medications changes.
● Duration of antiplatelet therapy.
● Any suture / clip removal required and when.
● If there are (additional) non-urgent issues you can request the GP to investigate/refer for
the patient accordingly. (i.e. incidental hypertension, microscopic hematuria,
consideration of anticoagulation for paroxysmal AF)
● If you request the GP to do something for a patient on discharge e.g. repeat blood test,
explain why and make sure you tell the patient that they must make the appointment and
you are not relying on the GP to do it. Set parameters for the GP to do something about
the result and instructions on what you are expecting to see e.g. If the repeat Hb is <80,
please refer to….
TTOs
1) Some patients have no medications changed, and have enough of their own supply. They still
need a TTO, but the ‘amount supplied’ box can be set to zero, and there is no waiting time.
2) If on dual platelet therapy add PPI
3) Check ward round entries to see what peri-op say about the discharge/ ask periop team if
they want medications that were stopped during admission restarted
If you anticipate that a patient is going to be discharged soon it will be a great help to the
nursing staff if you ensure the TTOs are completed early. TTOs can often take 1-2 hours to be
processed and organized, so the sooner the TTO is completed, the better.
New admissions:
When elective patients arrive, you clerk them in. This is done using a proforma, which includes
all the important questions to ask.
Make sure to:
1) Take a thorough history, including PMH and SH (this will especially be useful for the peri-op
consultants). Values like baseline creatinine in CKD or past echo reports from the clinic notes
would likely be useful.
2) Medications and allergies. Here, remember certain medications may need to be held or
reviewed peri-operatively. This includes (I LACK Op & Steroids):
a. Insulin/ oral hypoglycaemics/ metformin,
b. Lithium,
c. ACE-inhibitors,
d. Clotting treatments (like apixaban),
e. K+-sparing diuretics,
f. OCP/HRT
g. Steroids
h. Also, consider analgesia
3) Examine patients, including full systems and record all pulses (if not palpable then Doppler
findings). You should check with your registrar before removing any dressings.
4) AMTS if appropriate - All patients >70 should have a baseline score. This is important as post
operative patients may become confused. Each department in the trust is scored on the
percentage of patients who have dementia scores recorded on admission as well as being
assessed for VTE risk.
5) VTE Proforma.
6) Insert cannula and take blood (blue, green and purple tubes minimum--looking at Clotting/
U&Es/ FBC/ CRP/ G&S). It may be wise to send a ‘chemistry save serum’ (yellow tube) in
certain patients; this allows a retrospective troponin to be added. Please attempt to site a pink
cannula fist- remember that blue cannulae are inappropriate except when the last resort. Try to
avoid the cephalic vein in the wrist especially in renal patients or those with diabetes as they
may be required for fistulae. The back of the hand is a better place!
7) ECG - Request, view and sign.
8) A covid swab - necessary prior to surgery(patients should have a negative swab within 72
hours prior to surgery)
9) Janus - add their details.
10) Anything extra suggested by the registrar or consultant, like echocardiogram or CXR.
Post-operative patients:
No proforma is available for this. The standard format used is:
Post-op review:
● Read through the paper op notes for details of post-operative care
● Frequently the baseline from theatre or recovery will be recorded e.g foot pale no pulse
but DP signal heard with handheld Doppler.
● Check the post-operative plan for anticoagulation.
● Patients may be on an intravenous heparin infusion post-surgery for an acute
thromboembolic event. You will be asked to check the APTT at intervals specified by the
MIL. This must be prioritised!
● Registrars often review these patients post-operatively, so it is worth tagging along.
● If something is wrong, such as hypotension, or a bleeding wound, or limb ischaemia you
need to contact the registrar.
● You should check any wounds as well as look at the patient's feet!
● In the event of an angioplasty remember that access may not be via the operated site so
you must check BOTH groins and feet.
● If admitted via theatre-direct admissions (TDA), then they will likely need:
○ Regular medications prescribed
○ VTE
○ AMTS
● Some patients will have co-morbidities beyond their vascular disease. If you need help
with these components of their care, you may be asked to contact the relevant registrar
or perioperative team
● You may be asked to book imaging – NB to book an angioplasty you need to prefix the
EPR request with ‘IR’.
● Write clear and legible plans when you review or post-op patients. The clearer the plan,
the fewer the bleeps.
Plan to add to post-op plan:
Angiogram/Angioplasty
● Bedrest 6 hours – as directed
● (High risk of haematoma if patient mobilises before instructed)>
● Check puncture sites
● Neurovascular observations
● Omit Metformin 48 hours
Fem/Pop Bypass (femoral/popliteal bypass)
● Bedrest
● Sit out/mobilise when instructed by Surgeon.
● Monitor wound – look for symptoms of compartment syndrome pain +++ - may require
fasciotomies (cuts in the calf muscle to release the tension).
● Monitor urine output
Amputation
● Wound R/V – 3-5 days
● Sit out Day 1
● Neurovascular Observations
● Pressure area care – needs a Nimbus
● Analgesia and Neuropathic analgesia
● Monitor urine output
● OT/PT – wheelchair ordered
Specific Carotid Endarterectomy
● Bedrest 24 hours
● O2 therapy
● Wound R/V – check for swelling SOB, bleeding
● Monitor redivac drain output
● Maintain BP – IVI if needed – monitor for hypertension – risk of stroke
● Neurovascular (Limb) Observations
● Neurological Observations 1hrly
● Monitor urine output
AAA (Abdominal Aortic Aneurysm) Repair
● Wound check (abdomen)
● NBM day 1, Sips day 2, Light Diet day 3 (High risk of Ileus due to ‘bowel sleeping’.
Watch for symptoms of ischaemic bowel – high lactate on ABG, increase in pain.
● Chest physio (rolled up towel held on abdomen, encourage deep breathing and coughs)
● Neurovascular Observations – High risk of paralysis with FEVAR and TEVAR due to
their complexities.
● Monitor Urine output
EVAR (Endovascular Aneurysm Repair)
● Wound check (bilateral groins)
● Bedrest 24 hours
● +/- O2 therapy
● Neurovascular Observations (high risk of paralysis with FEVAR (fenestrated
endovascular aneurysm repair) and TEVAR (thoracic endovascular aneurysm repair).
● Monitor urine output
Embolectomy
● Bedrest
● Check wound
● Neurovascular Observations
● Anticoagulant therapy
● ? Cause of clot…?CA
Femoral Endarterectomy
● Bedrest, until surgeons review
● Monitor wound
● Monitor urine output
● Neurovascular Observations
Thrombolysis
● Strict Bedrest!
● Strict one to one nursing care
● NO IM injections
● Monitor groin sites with arterial sheath
● Vascular SPR only to remove arterial sheath
● Strict Neurovascular Observations
● Neurological Observations – high risk of stroke!
● Patients must be compliant with treatment.
● High visible bed on ward.
● High risk of bleeding ++
● Analgesia for revascularisation pain
Referrals to other teams:
You will likely have involvement with many other teams during your time on vascular. Common
referrals to other specialties:
● Med Reg – make sure you see the patient before referring. Gather your thoughts and
know exactly what you want them to help you with before calling.
● Micro – if not an emergency, do an EPR consult. If urgent call via the number provided
on induction. Make sure the drug chart summary page is open – know which antibiotics
they are on and how long. Know the operation they have had (turn to the op notes), and
whether any graft/stent was put in.
● Renal – a lot of our patients have ESRF (secondary to diabetes). Make sure you’ve got
a recent urine dip handy, and know the patient’s fluid balance (on ‘Interactive View’ on
EPR).
● Psych – Do a MMSE, have a recent AMTS and their baseline AMTS ready. Establish
whether they are currently delirious. Hx of dementia? Past psych hx? If someone is
depressed –established their risk to self, and others.
● Resp – They use this online ‘resp consult’ system. See this document on how to do it
(http://ouh.oxnet.nhs.uk/AGM/Document Library/Specialist team referrals/Using EPR to
make Respiratory referrals at the JR.pdf)
● Haematology – remember to examine lymph nodes, liver and spleen...
● Cardio – Prefer consult unless emergency (not haemodynamically stable). Make sure
you have recent and baseline ECGs handy. If you require and ECG uploaded to EPR,
kindly ask the ward clerk in SEU triage to upload it to EPR for you as 6A does not have a
ward clerk.
● Gastro - Prefer consult, unless emergency
● PICC line – EPR vascular access request
● Diabetes - EPR referral
● Dietetics - EPR referral
● Plastics – might need frequent reminders for them to come and see the patient.
● Dermatology – they’ll almost always ask for photos to be taken. Simply ask nurses to fill
in ‘clinical photography’ form. Like plastics, may need frequent reminders for them to
come to see the patient.
● Palliative – very helpful. Just make sure you actually see the patient and establish what
symptoms need palliating before referring.
● Pain team – EPR referral
● Anticoagulation referral – Can be found on the homepage under (Anticoagulation and
Thrombosis link). http://ouh.oxnet.nhs.uk/anticoagulation/Pages/Default.aspx
● Radiologists – the line is often busy so attempt to call them throughout the day if they
don't pick up initially).
● CXR and USS – usually go through without a fuss.
● CT angios – usually go through without much fuss. If you want it urgently, you need to
call the duty radiologist to discuss.
● Getting scans reported – if they don’t happen automatically, call the duty radiologist.
● Getting a portable XR urgently – order it on EPR, then call the Portable XR radiographer
on bleep 1762. They’ll ask for a reason why you need a portable XR – the most common
reasons are – triggering like 4 or above /very sick/reduced consciousness. Reasons that
might need a bit of negotiating…’not enough nursing staff to accompany the patient
downstairs’ (here, use your judgement).
● MRI scans – these usually need to be vetted by specialist Consultants. The most
common one would be ordering an MRI foot – you need to talk to MSK consultant for
approval. (Make sure you know the clinical details of that foot, and if they took a sample
from theatre – where exactly was it taken from)
● ECHO request – EPR request
Referrals to other hospitals:
This is typically done to repatriate patients to their local hospital, for example for ongoing
rehabilitation. Not all these patients may have been directly admitted from their local hospital. As
the JR Vascular surgery unit is a tertiary referral centre, there are regional agreements in place
to repatriate patients.
To refer, either go via switch (and ask to be put through to that hospital) or google search the
switchboard number and phone directly.
Ask to be put through to the medical registrar for referrals. You may find that you, instead, have
been put through to the bed manager (this is standard policy for some hospital). Provide all
requested details and take down the accepting consultants name. Document this and then pass
the details onto our discharge coordinator.
If the patient is somewhat complicated or there are certain things the receiving team should be
aware off, then it may be worth phoning the accepting team on the day of transfer to notify them
of this (i.e. give a proper handover). Make sure to document this discussion carefully.
JR
Diabetic Foot Clinic:
● [email protected]
● [email protected]
Inpatient Podiatry:
● [email protected]
Vascular Secretaries JR:
● [email protected]
● [email protected]
● [email protected]
Vascular Secretaries HGH:
● [email protected]
Waiting List Office:
● [email protected]
Jackie Walton Vascular Studies: 01865 223091
Bucks
Diabetic Foot Clinic:
● [email protected]
Podiatry
● [email protected]
Bucks Vascular Secretaries:
● [email protected]
● Mr Northeast Secretary: [email protected]
● Miss Wilton: [email protected]
● Mr Lintott: [email protected]
Please email ALL Bucks secretaries AND general BHT address in all correspondence as each
secretary works different days and they crosscover.
Vascular Nurse Specialist:
● [email protected]
Vascular Surgical Care Practitioner:
● [email protected]
RBH
Vascular Secretary:
● [email protected]
Vascular Nurse Specialists:
● [email protected];
● [email protected]
Tips
Communication:
● Practice closed-loop communication. It is a valuable asset to add to your arsenal (if not
present already) and to develop. For example, if a job warranting informing has been
completed from the ward round, then perhaps send an anonymised text message to the
registrar. If it needs attention more urgently, then consider contacting the registrar
directly (40421). Such jobs may include bloods done specifically to look for something
(such as Hb if suspecting bleed) or scans that have been requested.
● When asked to do a task, perhaps say when you’ll likely attend to it (considering the
current workload)--such as, when a nursing colleague asks that you prescribe
something. This ensures that everyone is clear about when something will happen, and
invites discussion if one party feels something should be done sooner.
● Try and keep the team informed. If something comes up, try and inform your registrar at
an appropriate time and in an appropriate way. Likewise, if you are changing medication
prescriptions near the time of drug administration, then informing the nurse looking after
that patient will help avoid any confusion or error.
● Inform nurses when you make changes to plans/medications/ordering investigations that
have not been made during the ward round. Also Keep the sister/ co-ordinating nurse
informed about changes to discharge plans.
Documentation: You may find that the location of patient notes/documents is not consistent, at
present. For example: Ward round entries are on EPR. Vascular surgery operation notes are on
a physical copy in the folder by the nursing station or in the trolley). Admission clerking is on
EPR. With time you will become familiar with this, so worry not.
Group & Save: If a patient is due to go for an operation in the next few days, check that they
have a valid G&S ahead of time. Likewise, if a patient is due to have a transfusion, check that
they have a valid G&S (plus working cannula) before prescribing it.
Medical students: There are usually a few 4th years (1st clinical year) or final years on the ward.
If able to, find time to teach them. In return, maybe you could ask them to help with small tasks
like taking bloods or performing cannulas.
Prescribing: Help exists. For example, the MILS and EPR PowerPlans are a good source. This
applies for analgesia (Anaesthetic PowerPlan), digoxin, intravenous heparin (IV Heparin
PowerPlan), warfarin--to name but a few.
Be wary of patients’ weights after an amputation. They should ideally be re-weighted and certain
medications may need their dosing corrected as a result.
Phlebotomy: Ward 6A = Mondays, Wednesdays, Fridays. (Ward 6F = Tuesdays, Thursdays.)
When putting out bloods for phlebotomists, make sure to: select ‘Planned’; set the time for
’06.00’ on the day you want collected; select ‘No’ for collect now; and do not enter the printer
details. Otherwise, you’ll find that the bloods may not have been collected.
If some bloods need to be done urgently, it may be worth asking the night junior to do these.
Before doing so, it may be worth asking, could I do these now instead of handing it over?
Remember, phlebotomists are not trained to use lines such as CVCs/ PICCs, so for these
patients you may need to do them.
Blood gas machines: The nearest blood gas machines would be on SEU side D (ward 6D) or
ward 7E. I found that obtaining access for these ahead of the placement was useful. Note, these
machines do not measure creatinine (only ED ones at the time of writing this).
Teaching: Teaching on the ward is opportunistic. If you want teaching, then be proactive and
ask--most will be more than happy to do some teaching.
CBDs and mini-CEXs: These are usually quite easy to complete. For example, you can discuss
the triage patients, new admissions or post-op reviews with any appropriate willing set of ears.
Theatres: If you are interested in attending theatres, then try and agree a time with colleagues
to go.
Finally, good luck! This job is difficult, but if you put your best into it can be very rewarding, and
you will come out a much better doctor after four months.
