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RMO CLINICAL HANDBOOK

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Dear Doctor 24th March 2014

Welcome to the team of doctors at RMO International! (And to those of you reading
this during the interview process I hope the above will apply to you soon.)

This is the written induction material for RMOIH RMOs. We ask that even those of
you who are experienced RMOs to read the information in this Handbook carefully,
because it is updated regularly.

Appendix 1 of this Handbook contains examples of some relevant Hospital Policies,
which may or may not be in use at the time you arrive at work and are used here as
examples only. The best way to get the most up-to-date policies on escalation or
clinical issues like blood transfusion or major haemrorrhage is to speak to the clinical
lead at your hospital, and we ask you to do this when you arrive at work.

Please read the Handbook carefully and follow the video links. You will need sound
on your computer to watch these videos.

The Handbook is drawn from our experience of the learning needs of previous RMOs
and is designed to reduce your stress! If the information in this Handbook is at a level
that is too low for you, then I apologise, but please read it carefully anyway.

What I have written here is in plain English and is similar to what I would tell a doctor
sitting face-to-face.

Please contact me, or clinical manager Petio Anguelov, with any queries about the
information in this Manual.

Finally I must emphasise that while every effort has been made to make the
information in this Handbook both accurate and up-to-date; the advice, and
descriptions of medications and procedures in this Handbook are by no means
exhaustive or even complete, and are not intended as a substitute for experience, or
as a textbook. You must use your own professional judgment on all information in this
Handbook.

Warm regards


Dr Danny Barker
Managing Partner



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CONTENTS OF THE RMO CLINICAL HANDBOOK

1. The 12 Golden Rules for RMOs- please read carefully (p4-8)

2. The generic J ob Description of an RMO (p9-11)

3. Further explanation of your duties in the ward and descriptions of common
RMO procedures (like intravenous cannulation and IO access) (p12-26)

4. Advice on prescribing and list of common ward medications prescribed by
RMOs, and TTOs (p26-33)

5. List of common English medical abbreviations (p33-34)

6. Format when making medical notes and reporting to consultants (p35-37)

7. Filling in death certificates; DNAR orders and cremation forms (p37-38)

8. Policies and procedures (p39-45)

9. Hospital dress codes (what to wear) (p45-47)

10. British manners and medical culture; discrimination (p47-49)

11. Boundaries and relationships with patients and some advice on communicating
with patients and their relatives as an RMO (p49-51)

12. Revalidation of all UK doctors (p51-52)

13. Handover routine and hospital induction (p52)

14. Safety at work (p53-54)

15. Elderly patients, falls (p54)

16. Blood transfusion safety- check the patients identity (p54-55)

17. Wound care and a word on unusual post-operative complications (p55-56)

18. How to lead the resuscitation team (p57-58)

19. Safeguarding of Children and young persons and Safeguarding of Vulnerable
Adults (SOVA) awareness (p58-67)

Appendix 1: Examples of Hospital Policies, EWS Charts, ANTT diagrams (all external
policies are used only as examples and with permission of the publishers) and RMO
International Sexual Misconduct Policy (p68 onward)
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THE 11 GOLDEN RULES FOR RMO INTERNATIONAL RMOs

1. Firstly please note that there must be an RMO (by law) on the premises of the
hospital 24/7. Please under no circumstances leave the premises until you
have physically handed the bleep and keys to your replacement.

2. Every doctor is expected to behave and practice medicine according to the
GMCs Guidance- basically a set of descriptions of what a doctor has to do at
work and also what we are not allowed to do. To perform your contract with
RMO International to work as a doctor, you will have to comply with the GMCs
Good Medical Practice. Please see: http://www.gmc-
uk.org/guidance/index.asp or and then click on the links Good Medical
Practice and then begin reading. We need you to read through this
Guidance very carefully. If the link above does not work then please Google
GMC Good Medical Practice and read it carefully. A guide for patients to tell
patients what they should be expecting from you as the ward doctor is
available at http://www.gmc-uk.org/guidance/patients.asp so again please
Google GMC guide for patients and read this please.


3. If there is any deterioration in a patients condition, or if any new treatment of
management is needed, always call the patients consultant

If in doubt, check with the nursing staff, pharmacist or consultant. The
consultant takes responsibility for all decisions about a patients care
while the patient is in the hospital, so keep him/her informed at any time of
the day or night- all consultants are on 24 hour call for their patients.

Sometimes a surgeon is not 100% familiar with how to approach a medical
problem raised by an RMO. Surgeons are surgeons. Consider calling the
on-call anaesthetist first, or the anaesthetist who anaesthetised the patient
concerned. The anaesthetist, or a physician, may have a better idea of how
to deal with medical complications than the surgeon. That said, also make
a quick phonecall and let the surgeon know if you think the patient needs
to be referred, and call to update them.

Please speak to the director or nursing or the nurse in charge on the ward
immediately if a consultant is not contactable or not responding to your
attempts to get care for the patient. Follow up and persist until you and/or
the nurses have arranged consultant review of the patient or received what
you agree are appropriate instructions or advice from a consultant. Some
hospitals escalation policies (for example the BMI escalation policy in
Appendix 1 of this manual) allow the DoN or Nurse in Charge working with
you to call and arrange a second opinion or action from another consultant.
Make use of the on call manager roster if there is one, in emergencies.

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Only the consultant can admit, or discharge, a patient. The consultant must
also give discharge instructions (when the patient will be reviewed, for
example, what DVT prophylaxis to give) and these instructions can
sometimes be relayed by a nurse or appear as standing orders written
down in a file.

Consultants will usually have their mobile phones on, even at night,
although some of them turn their mobile phones off when they are at home.
If you need to speak to a consultant at night, remember to try their mobile
number first, and only then try their home phone-number; only if they dont
answer the mobile. Check the preference of each consultant with the
nurses.

4. Please imagine that the patient in the bed is you or a member of your family-
this will help to motivate you to make the call and inform the consultant as
above, so that the patient can have specialist care ASAP (as soon as
possible) and you can have advice on how to proceed from this specialist too.

Private hospital patients expect the RMO to provide them with prompt, polite
and helpful service. Please remember that the private hospitals are
businesses, and that you are expected to do your bit for customer service by
being polite, professional and helpful towards staff and patients, just as you
would expect in any other business.


You are required to:
Treat all people with compassion, care and respect
Respect each persons right to privacy, dignity and individuality
Take time to be helpful
Give clear and accurate explanations if asked a question
Dont talk down to a patient
Listen to colleagues and patients: What are people trying to tell you?
To work as part of a team in the hospital, when required
To look the part (please see advice on dress and grooming later in
this Handbook)



5. Always make relevant file notes:

If you assess a patient for any kind of problem or complication in the
ward, make a note describing the symptoms, the observations (BP,
pulse, temperature, oxygen saturation, respiratory rate and heart rate),
the physical examination findings, your diagnosis or provisional
diagnosis, what investigation/s you will perform, who you have informed
and what the consultants instructions were. Note the date and time and
sign the note with your name (printed) and GMC number. It is your duty
as a doctor to always make good medical notes. Please see section 6.
later in this Pack for further details about how to make a good note
and make a basic telephone report to a consultant.


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6. Keep good working relationships with the nurses, they are your best allies

Nurses in the UK are expected to be highly professional in their
approach to medical situations. They study medical subjects for years
and are well qualified and they take their work extremely seriously.

Safety critical point: If you get a phone call from a consultant and are
not sure of exactly what the consultant is asking for, please ask the
Consultant to explain again and ask confirmation questions. You can
ask the nurse in charge to take the phone and then confirm with the
nurse to see that you have understood the consultants instructions
correctly. If not, speak again to the Consultant again and clarify the
parts you were not clear about. The Nursing staff will provide support
but it is your responsibility to take instructions directly from the
consultant, and you are responsible for prescribing or carrying out the
treatment requested. Many nurses have worked in the hospital for a
long time, so dont be offended if they like things done a certain way; it
is what they are used to.

The Director of Nursing (or Matron) is the most senior nurse in the
hospital, and the manager of all of the clinical areas of the hospital, and
should do everything she/he can to make you feel at home and help
you settle into your role as RMO.

Nurses can advise you on what they would like prescribed for a patient.
They might say Doctor, please write up Paracetamol for this patient.
Please dont be offended by this. The prescription is your responsibility,
but if you let the nurses advise you like this they will save you a lot of
work over the course of your contract.

Please be aware that nurses in the UK are not allowed to cannulate
patients or take blood samples without having special training and
certificates. In most cases, they will not be able to help you taking blood
or inserting IV cannulas. This is very different from Europe!

7. Always answer your bleep promptly and make yourself visible in the ward
If you havent been called to the ward for an hour or two during the day,
please take a walk through the ward and check that work is not building
up- nurses may be keeping issues/drug charts or other matters for your
attention. They will actually bleep you a lot less if they know that they
can leave a chart in your diary for your attention the next time you take
a walk through the ward.
If you are busy when you bleep goes off, it is a good idea to call and
say that you will be delayed. This way the person bleeping you knows
you are on your way and they wont bleep you again. The whole idea of
these hospitals is service to the patient, so the nurses dont like to keep
a patient waiting- but, you cant be in two places at once!
You can cut down the number of bleeps you get by taking a walk
through the ward every hour or two and seeing if there are any jobs
waiting for you (like signing an X-ray request or a fit-note (previously
called a sick-note.)

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8. Always introduce yourself to patients- be polite and treat patients with dignity

I suggest saying Good morning/afternoon/evening, my name is X and I
am the Resident doctor or Ward doctor (you choose whether to say
Resident or Ward-doctor.) Doctors are hugely respected in the UK, but
in the past we have had a complaints from a patient where the patient
said some man I have never seen came in here and injected me with
something, I was so scared.

So, always introduce yourself to each patient when you enter the room.
If the patient knows that you are the ward doctor they will have much
more confidence in you, so please tell them you are the ward doctor.

9. Always explain what procedures you intend to undertake

As in the example above, say to the worried, stressed patient, after you
have introduced yourself: I am here to take a blood test, can I go
ahead?

Dont assume that the patient knows the difference between giving a
blood sample and having an injection, often they dont know. I often say
I would like to take your blood for a routine test that was requested by
your consultant so they know it is not an emergency or a test taken
because something has gone wrong. Re-assure the patient! Patients
will expect you as the doctor to have basic manners (see British
manners and medical culture later.)

If you have anything to say to the nurses about a patient, do it in a
private area or make sure you are not commenting in front of members
of the public. Remember if you speak in the corridor about an issue that
is personal to a patient you may be violating their confidentiality- be
careful of talking loudly in the corridors. Do not leave ward lists/theatre
lists lying about in the ward. These lists contain confidential patient
details and must be kept safely in your pocket, and then shredded.

Only the consultant can take formal written consent for a procedure, so
dont worry, you will not have to explain surgical procedures in detail to
patients. But, always remember that the patient needs to give you
consent to perform any examination or procedure, including taking
blood. If you say you want to take blood, and they nod to you and give
you their arm; that is implied consent. But, if a patient indicates they
dont want you to do something, then stop immediately! (Unless it is an
emergency and you are doing something to save their life; in which
case use your own judgement.)

10. All hospitals are now using formalised Early Warning Scores or EWS. The
nurses have to call you to assess patients if there is something wrong with the
patients observations. The EWS may be based on Temperature, Heart rate,
Oxygen saturation, Systolic blood pressure, Respiratory rate, Urine output and
level of consciousness (usually AVPU) of each patient. Please attend and
review the patients charts, take a history, ask the nurse to re-check the
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observations, do an examination, make an assessment, make a plan and
then write a medical note. Your plan in this situation (particularly if you are
not sure what do) would usually include the line Discuss with patient and staff
and call the consultant.

Two examples of EWS Charts are included (with permission) in Appendix 1 at
the end of this Handbook. Note that some hospitals will have a track and
trigger treatment guidance policy. This guidance should then be followed
when you make the plan for the particular patient.

Please note if you are reading this Handbook as a paper copy as part of the
RMO induction folder at your hospital, then Appendix 1 will be missing. Please
make yourself aware of what particular EWS is being used on the ward you
are working. Please refer to the electronic version of this pack which was a)
sent to you by email after the telephonic component of the interview and b)
provided to you in hard copy at you one-to-one induction, these versions
contain Appendix 1- examples of specific procedures and policies which may,
or may not be, in use at the hospital you are working.

Remember that as an RMO you may be called (or chose to) re-assess the
same patient multiple times: Be very careful of telling a nurse you have seen
a patient already especially if you are dealing with a symptom like chest pain
which could signify a rapidly evolving and potentially fatal condition, like
myocardial infarction or pulmonary embolus. We were told that an RMO
recently saw a patient with chest pain and diagnosed pain resulting from an
old, traumatic chest injury and the ECG was negative. By co-incidence, later
that day, the same patient with the longstanding (traumatic) chest pain had
symptoms that may have signified a pulmonary embolism or a myocardial
infarction, but the RMO did not repeat the ECG or come and see the patient
again and also didnt call the consultant. The patient later died of a massive
PE. Please remember to re-assess patients who have symptoms such as
chest pain that evolve, and have a very broad differential diagnosis- new
causes of chest pain could be occurring.

11. Remember the CAS Test (cardiac Arrest Simulation) test of your ALS and
EPLS courses in the UK? You were required to do everything in order and say
all of the right things to the resuscitation officer in order to pass the ALS/EPLS.
When you have a resuscitation scenario in the hospital the same is required of
you again. RMOIH frequently has to retrain or warn doctors who simply do not
take the resuscitation scenarios in the hospitals seriously enough. It is simple;
follow an SSS, ABCDE approach and review Hs and Ts during the scenario if
appropriate. Please also carry your ALS manuals to work with you and review
them regularly. Please take the resuscitation scenarios in the hospitals just as
seriously as you took your CAS Test to get your ALS and EPLS certificates.

12. And lastly, if you have any concerns relating to your working conditions or
personal or health matters which may affect your work, please raise these
concerns with the Director of Nursing or Matron at the hospital and RMO
International as well. We will respond immediately.



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J OB DESCRIPTION


Below is a general job description outlining your basic duties and responsibilities as
an RMO. When you arrive in the UK you will be issued with the specific job
description of the hospital at which you will start work. This will be very similar to the
one below, but will give some local details. As part of your induction you will have a
few days with the outgoing RMO to learn the job as a work-shadow. One of the
hospital staff (usually a senior nurse or the Ward Manager) will show you around and
do a non-clinical induction as well, so dont worry.


During the 2-3 day work-shadowing period when you arrive to start your contract ,
your contract has not yet started, and as such you are not insured to work yet, so
please just observe the old RMO. Please make sure that you meet everyone, find out
where everything is kept, have a look at all of the emergency and routine equipment,
and spend plenty of time questioning the old RMO. Everything will be made clear to
you and there are no surprises!



JOB TITLE: RESIDENT MEDICAL OFFICER


JOB SUMMARY

1. To be an integral part of the team responsible for the provision of 24 hour care to
patients on a routine and emergency basis, and to provide immediate first line
resuscitation to any patient, visitor or staff member as required.

2. To assist in the management of all patients (including outpatients) and provide
backup support to the consultants.


MAIN DUTIES AND RESPONSIBILITIES


1. To provide medical cover (routine and emergencies) during hours of duty and to
act, as may reasonably be required, on behalf of a consultant in his/her absence
when requested.

2. To assume the role of team leader in the event of a cardiac arrest.



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3. In conjunction with other RMOs to provide a service to the hospital during the
hours specified. To remain within the hospital premises whilst on duty.
In the event of an RMO not attending for duty at the hospital, the current RMO
must remain until a replacement is found, thus ensuring continuous cover.

4. To ensure appropriate handover including making appropriate arrangements to
pass on information to colleagues when changing shifts.

5. To clerk in and assess emergency admissions as required when the relevant
consultant is not immediately available (please see section 6. for a guide to this.)

6. To assist with preadmission clinics, if necessary, and review results of pre-
operative assessments. Some hospitals will also call you to the outpatients
departments to do simple tasks like looking at wounds and prescribing antibiotics
etc.

7. To supervise in conjunction with the nurse team leaders and under the guidance
of consultants:

a) the daily clinical management of all patients
b) the post-operative care of patients.
c) patients requiring critical care level 2, and above

8. To visit patients at the request of nurses in charge and to carry out an
examination of patients when appropriate, recording all findings in the patient
notes.


9. To dispense medications for patients when the hospital pharmacist is not
available, outside the regular pharmacy hours.

10. To be a named first aider and provide urgent medical attention to patients, staff
and visitors in the event of an accident or sudden illness in liaison with the senior
nurse on duty and to ensure completion of an appropriate Incident Form (the
nurses will bring this form to you and there is just a small block to fill in).

Please note the difference between First Aid (the occasional cut, twisted ankle, bee-
sting, whatever) and being a GP to the staff (sick letters, looking at skin rashes,
prescribing chronic medication.) You are required to provide basic First Aid if a
member of staff gets sick or injured on duty, but you are not required to be a
GP/Family Practitioner for any member of staff. Please call the office if you are
unclear in any particular case. You will be called to see the occasional acutely sick or
injured staff member.

11. To certify any death of a patient and to liaise with the consultant of the deceased
with respect to completing the death certificate. Please note it is best to ask the
consultant what they want you to write on the death certificate, as their opinion as
to the cause of death may be different to yours.

12. To review test results and communicate any medical problems or concerns to
consultants and other health care professionals as required.

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13. To undertake certain medical procedures as required by a consultant, or nurse in
charge, for example:

Blood taking
IV cannulations
Urinary catheters
Arterial blood sampling
ECGs
Insertion of naso-gastric tubes

14. To comply with all hospital policies and procedures in particular those relating to
Health and Safety at Work.

15. To maintain confidentiality with respect to the affairs of the hospital, its patients
and members of staff.

16. To comply with the hospitals Clinical Governance framework and included therein
the Complaints policy and procedure.

17. While bearing in mind that the busyness at hospitals can vary a lot, we require
you to report fatigue and excess stress immediately to the office. We will be in
contact with you routinely on a weekly basis (usually on a Tuesday.)






LIMITS OF AUTHORITY

1. To assist in theatre only for genuine emergencies and with the agreement of
the senior nurse-in-charge. An RMO's emergency and ward responsibilities
take preference at all times.

2. The RMO is prohibited from obtaining consent for operations or procedures
on behalf of consultants.

3. RMOs have no admitting rights to the hospital. All patients must be under the
care of a consultant with admitting rights.

4. Except in an acute emergency (e.g. cardiac arrest) all decisions about
changes to the management of any patient should be discussed with the
admitting consultant wherever possible








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3. FURTHER EXPLANATION OF YOUR DUTIES IN THE WARD AND
DESCRIPTION OF COMMON RMO PROCEDURES

Most wards will have an RMO book in which jobs and requests are written every
day, as they come up. The outgoing RMO must show you where this RMO book is
when you are having your induction.

Taking blood tests



Taking a few blood tests from some of the patients (usually less than 5-10 per day) is
part of the service provided by the RMO in the private hospitals.
In hospitals where phlebotomists are employed, the phlebotomist will expect you to
be able to take blood tests on patients where they have failed, so we ask that you are
an expert in taking bloods by the time you come to the UK.
If you have been asked to practice taking blood (phlebotomy) please do so and
provide letters to this effect if they have been requested by any of the clinical
managers. Claire from the office will call you to request these letters.
Some hospitals are testing for competency in blood taking when the RMO arrives, so
be ready to display your excellent competence in this skill! At the induction day after
the courses we will also carefully check this skill using a lifelike mannequin and
needles.


Procedure for taking a blood test:

Fill in the form (if this has not been done by the nurses) and attach a patient identity
label to all copies of the form (stickers will be in the patients notes which is a paper
folder with all the details of patient and their treatment.)

Remember to complete the form with all relevant details (include your name, your
signature, where it says private/NHS tick as appropriate, where it asks for your
bleeper number just say RMO or put your bleeper number if you know it) Also note
the date and time of the specimen in the appropriate block on the form. Include
clinical details in the appropriate block on the form. This is usually just a comment
like Day 1 post Right hip replacement.

Some hospitals are set up to perform so called Point-of-care testing (PoCT) using the
iStat of other machines. This is convenient and efficient and allows you as RMO to
have instant access to blood results, and report them to the consultant if abnormal.
There will be a member of staff trained to use the machines, but the sample tube
used for PoCT tests may be different (Heparinised or green tube for example.)
Please do not use the ID card of another staff member, and also do not lend your ID
card to anyone if you get trained to use the PoCT machines yourself.



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Continued from overleaf (procedure for blood taking)
1. Gather the appropriate equipment from the clinical room. This should include
alcohol or chlorhexidine wipes, a piece of cotton wool, the needle, the
appropriate vacuum bottle for the test/s you are taking, a tourniquet, and non-
sterile gloves. Some hospitals require that you wear a protective plastic apron
as well.

2. Most hospitals use some form of vacuum blood collection device, but you can
consider using a syringe if the patient has poor veins or if you feel this is
better.


3. Wash and dry your hands.

4. Enter the patients room, knock first.

5. Introduce yourself and ask the patient how they are feeling (be prepared to
listen).

6. Tell the patient what test you are taking, and if it is urgent or non-urgent.

7. Ask the patient if you can go ahead and take their blood.

8. Ask the patient to say their name and date of birth, check it is the right

9. Patient- you could also check the armband to confirm the ID

10. Gently apply the tourniquet while asking the patient to hang their arm
downwards (not too tight, not too loose.) Ask the patient if the tourniquet is
squeezing too tight.

11. Select a suitable vein, usually in the cubital fossa.

12. Clean the area with an alcohol swab or chlorhexidine sponge

13. Take the blood.

14. Release the tourniquet and ask the patient to press area with the cotton-
wool.

15. After removing or loosening the tourniquet completely, remove the needle
from the vein.

16. Dispose of the sharp in the yellow sharps bucket that you have brought
with you. Re-capping a needle using both hands is dangerous. Any
contaminated waste must be disposed of in the big yellow bins. No sharps
are to be placed in the big yellow bins, only in the sharps buckets that you
should carry with you to the patients rooms.

17. Apply a plaster, or tape over the cotton wool to catch any oozing.


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18. Label the tubes with a pen before leaving the patients room whilst checking
the details against the blood form that you have brought with you .It is not
acceptable to most laboratories in the UK to put stickers on the tubes- please
use a pen unless you specifically know the lab will take tubes with stickers.

19. Seal the tubes and form in the bag provided and give to the nurses to send to
the laboratory, or call a taxi for the bloods to be taken to the lab after hours.

20. Remove gloves and immediately wash and dry your hands after each
procedure like this, or after seeing any patient, or touching anything in the
room. You could also use the alcohol hand gel placed throughout each
hospital.


Common mistakes that you should not make when taking blood
Forgetting to confirm the patients identity (leading to blood being taken from
the wrong patient- not a common mistake but a very serious one )
Forgetting to label the tube completely, leading to the test having to be
repeated, the patient pricked again, and wasting your time and energy.
Please make sure you bring the form with you, and label each tube individually
at the bedside, with a ball pen and using neat, printed writing. Bag the tubes at
the patients bedside. Do not carry the tubes back to the clinical room with you
unlabelled- there is too much potential for you to write the wrong patients
details on them, for example if a tube is forgotten in your pocket and the
retrieved and labelled later after you have taken blood from another patient.
Applying the tourniquet to the patients arm when it is raised up (the veins
empty as soon as the arm is raised above the level of the right atrium, and so
the veins are empty and will take a while to refill, especially if you apply the
tourniquet tightly and reduce arterial flow- avoid this!)
Forgetting to remove the tourniquet before you remove the needle (blood
gushes out of the puncture wound and/or a haematoma forms under the skin
and the patient is left with an ugly mark (a contusion) for a few weeks.)
Injecting blood into a vacuum tube that has lost its vacuum (the cap pops off
the tube and covers you in blood)
Inserting the needle too deep and going through both walls of the vein (known
as blowing the vein, a haematoma immediately swells up as you withdraw
the needle, you cant get any more blood out and the patient tells you it is very
painful. There is a lump and a mark for a few weeks and the vein can
thrombose.) Remember to just insert the tip (bevel) of the needle through the
skin.
Taking blood from the side where a female patient has had a mastectomy
and/or lymph-node clearance, or from the side a patient who has had a recent
shoulder operation
Taking blood from an arm that has a drip running into it. The results will be
inaccurate and this is very dangerous unless spotted. If you must take blood
from an arm with a drip in it, turn off the drip for 10 minutes first, but try to
avoid this altogether. In some cases where serial blood tests are required
within a few hours (for example for a short Synacthen test) it may be
appropriate to take blood from a cannula inserted for this purpose (not for an
IV infusion!) but in this case remember to draw off and discard at least 5-7ml
of blood before taking the sample you will send to be tested. If your sample
contains any IV infusion fluid, or flush, the results will be completely inaccurate
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(you have diluted the blood.) Please make sure you understand the principal
here, and be aware that there is a lot of mixing of blood and IV fluid between
different veins in the arm. Veins branch and anastomose. Sending diluted
blood to the lab is regarded as a very dangerous mistake. Transfusions or
infusions (remember potassium) could be ordered as a result of your mistake.
The message to you is: Use the other arm to take the blood sample when
you see a drip running in.
Not signing the Group and Save Tube (for cross matching) leading to the
sample being rejected by the lab. Samples for cross matching or group and
save must be completely filled in with all the details. We also recommend that
blood forms for group and saves or cross match are hand-written to avoid the
wrong sticker being placed on the form. Please always check that you have
the right patient by asking their details as well as checking their wrist band for
their name and hospital number- there are further reminders of this later in this
Pack.
Using the wrong tube because of a failure to check the list of tests and the
appropriate tubes that will be available to you in the clinical room
Pricking the patient too many times: If you miss the vein two (2) times, take a
break from trying, go and have a cup of coffee, and explain to the patient that
you will be back in a few minutes to try again. This does happen very rarely
even to doctors skilled in taking blood samples, but remember after 2 failed
attempts to take blood give yourself, and the patient, a break and tell the nurse
in charge this has happened. The patient is likely to be very unhappy and
make a complaint if you have to prick them more than twice to get a simple
blood sample!
Looking for a vein (a mistake) rather than feeling for a vein with your fingertips
(the right way) is the main reason RMOs say there are no veins when in fact
there is a beautiful, spongy, large vein half a centimetre under the skin were
you cant see it. If there were no veins the patients arms would swell up like
balloons under arterial pressure. If you try to take blood from 1000 patients,
999 of them will have palpable veins, in the cubital fossa. Of the same 1000,
only 750 perhaps will have visible veins. Feel for the vein; dont look for the
vein.
Slapping the patients arm to make the vein stand out is very over-rated as a
technique and has been the subject of complaints from patients. You may also
hurt the patient and damage the vein. If you insist on doing this, be gentle, and
carefully explain to the patient why you think this is needed.
Compressing the puncture site with a swab when the needle is still in the vein
causing the vein to be lacerated and resulting in a large subcutaneous
haematoma
Forgetting to wash and dry your hands (or use alcohol gel) before and after
each phlebotomy

If anything goes wrong calmly explain to the patient that there has been a problem
and apologise if you see fit. If the veins are genuinely bad you could try using a
butterfly needle on the back of the hand. It is not usual practice in the private
hospitals to take femoral blood or take blood from the legs.





16
Please view these videos of blood taking:
http://www.youtube.com/watch?v=mmFOi8XQx_0 (with needle and syringe:
Note that gloves are not used in this clip. It is recommended that you use gloves.)
http://www.youtube.com/watch?v=kP48pCAzB74&feature=related (Vacutainer
system as used in most of the hospitals)

If Youtube is blocked on the hospital computer (if you are reading this on the ward
computer) this video may be useful (Label tubes with a pen, not stickers in the UK)
http://portal.med.muni.cz/player_ext.php?lid=63&link=odber_krve_EN_720.flv

A colour chart for which blood sample goes in which tube for which test is at:
http://www.bd.com/vacutainer/pdfs/plus_plastic_tubes_wallchart_tubeguide_VS5229.
pdf
Or see: http://www.hdft.nhs.uk/EasysiteWeb/getresource.axd?AssetID=4865&

Please note that most hospitals are using the Hemoguard (new) bottle caps and the
colours you will use every week are yellow, lavender, pink, blue and possibly grey.

Other hospitals do not use the BD Vacutainer system and have different tube colours,
and again this is something for you to find out during your 2-3 day induction period.




Intravenous cannulation






All doctors in the UK are expected to have the ability to insert an intravenous cannula. In
the private hospitals it is the work of the RMO. You will never be expected to insert a
routine central line. In an emergency only, if you cant get IV access, you can call the on-
call anaesthetist, but otherwise you are expected to insert cannulas/drips. The
anaesthetist is a consultant specialist in the UK and he/she will be very surprised if you
call them to insert a routine cannula, because that is part of your job, not theirs. The nurse
will do all the work hanging the bags of fluid up, but you have to insert the cannula.
Normally you will plug the back of the cannula with the bung provided with the cannula,
and then flush it with Normal Saline. Always remember to flush the cannula after you have
put it in. It is good practice to make a note in the medical notes stating when the cannula
was inserted, its size and whether the procedure went smoothly. Some Hospitals are
noting the date of insertion, on the cannula dressing- also good practice.

Please be aware that nurses in the UK are not allowed to cannulate patients or take
blood samples without having special training and certificates. In most cases, they
will not be able to help you taking blood or inserting IV cannulas. This is very different
from Europe! Please be prepared for this.
17

Procedure for inserting an IV cannula

1. Gather the appropriate equipment from the clinical room. This should
include alcohol or chlorhexidine wipes, a piece of cotton wool in case you
fail to get the cannula in. Choose the right cannula (blue or pink for general
use, pink or green if it will be used for blood transfusions, green or bigger
in emergencies or when the patient is bleeding.) Also bring a tourniquet,
and non-sterile gloves. Some hospitals require that you wear a protective
plastic apron as well.

2. Wash and dry your hands

3. Enter the patients room, knock first

4. Introduce yourself and ask the patient how they are feeling (be prepared to
Listen.)

5. Tell the patient that you are going to insert a drip cannula and why
(usually to give fluids.) Answer any questions the patient has.

6. Ask the patient if you can go ahead and insert the cannula.

7. Gently apply the tourniquet while asking the patient to hang their arm
downwards (not too tight, not too loose.) Ask the patient if the tourniquet is
squeezing too tight. This is to save you some time, because if it is too tight
they will ask you to remove the tourniquet while you are busy cannulating!

You must have the patients verbal and/or implied consent. If they ask you to stop
trying to insert a cannula or takes blood, then you have to respect that and stop
immediately.

8. Select a suitable vein, usually on the back of the hand or ventral surface of
the forearm, not over a joint, and avoid the cubital fossa except in
emergencies, because the patent will bend their arm and kink the cannula

9. Wash and dry your hands an apply gloves

10. Clean the area with an alcohol swab or chlorhexidine sponge depending
on what is used in the particular ward

11. Remove the white plastic bung (plug) from the back of the cannula
where it is stored and keep it handy, you will need it

12. Insert the needle through the skin next to the vein (This is a useful technique
when cannulating on the back dorsum of the hand or when the veins are
small. For larger veins, or if you have your own expert technique, you may
wish to insert he needle directly over the midline of the vein.)

13. Once you are through the skin steer the cannula carefully into the vein,
you will see a flashback of blood when the needle enters the vein

18
14. Advance the needle and cannula at least another 3-5 mm into the vein, so
that the plastic over the needle cannula is now also in the vein.
(Experts/anaesthetists tend to advance the whole needle and cannula into
the vein and then withdraw the needle, but I dont recommend this unless
you cannulate every day in your job.)

15. Advance the plastic cannula carefully over the needle into the vein (push
the plastic bit in while keeping the needle still.) It is best to use both hands
for this unless you are very experienced

16. Now release the tourniquet

17. Using the thumb of one hand compress the vein (block the vein)
downstream of the cannula (block the vein higher up the arm)

18. Then remove the needle, and dispose of it immediately into the purpose-made
yellow plastic sharps bin that you have brought with you

19. Place the bung in the back of the cannula

20. Flush the cannula with 3-5ml of IV grade normal saline (observing for
swelling.) Ensure all lines are flushed before any fluid is infused!

21. Ask the patient to tell you if it stings, salt water will usually sting if injected
outside of the vein!

22. Now stick the cannula to the skin using the made for-purpose dressing you
have brought with you

23. Greet the patient bedside manner is SO important

24. Wash and dry your hands, or use alcohol gel, after touching any patient

25. As with any procedure, including intravenous cannulation, you are required to
document the procedure in the patients notes

Common mistakes you should not make with cannulations
Most commonly, doctors who havent practised enough forget to advance the
cannula and needle together (point 12 above) into the vein. They see the
flashback and try to advance the plastic cannula immediately. The needle is
then in the vein and the cannula is sitting outside the vein under the skin. They
get a surprise when the soft, bendy plastic cannula wont advance. Have a
look at the tip of the cannula and you will see what I mean.
Trying to withdraw the needle of the Venflon before the cannula has been
advanced into the vein- Please note that the needle of the Venflon is like a
guide-wire. You need to railroad the plastic cannula over the needle into the
vein; think of the needle as a guidewire and please do not withdraw the
needle until the cannula has been advanced fully into the vein. If you make a
hole in the vein with the needle and then withdraw the needle 1- the vein will
blow because you have made a hole in it and withdrawn the needle that was
plugging the hole and 2- You cant expect the plastic cannula to advance into
the vein without the needle being there to guide it into the vein!
19

Dont take the attitude of it is easy, the nurses do it in my country because it
is not as easy as you think. You will need to practice if you dont have a lot of
experience (if you have done less than hundreds.) RMO International only
employs doctors who have experience with cannulation, and we think it takes
at least a few months training to get this skill right.
Thinking that you can practise on the job in the UK. If you arrive on an RMO
job and you cant cannulate the patients, you will be asked to leave the
hospital and return home to practice this skill.
Taking the needle out of the plastic cannula before releasing the tourniquet:
Blood pours out of the end of the cannula onto the sheets. Sometimes you
have to make this mistake in order to draw a blood sample from the newly
inserted cannula, just make sure you compress the patients arm downstream
of the cannula tip. Dont draw blood from a cannula that is not newly inserted,
as this increases the chance of infection and gives inaccurate blood results.
Not compressing the vein downstream from the tip (not shaft!) of the plastic
cannula when you remove the metal needle- blood pours out of the end of the
cannula onto the sheets which the nurses then have to change (press the skin
ahead of the tip of the cannula, up the arm from the cannula, before you
remove the needle.)
Removing the entire plug at the end of the cannula before you start, not just
the white part of the plug: Blood pours out of the end of the cannula onto the
sheets. Please have a look at the back-end of a Venflon and see how the
white plastic bung and see through plastic part come off separately. Only
remove the white plastic bung.
Pushing the needle through both walls of the vein causing it to blow and
giving the patient a lot of pain.
Being in a rush and trying to do the cannulation standing up: Take your time,
sit down and stabilise yourself before you try.
Pricking the patient multiple times without taking a break. If you miss the vein
(this happens to everyone) take a break, have a cup of coffee and come back
in ten minutes and try again (unless it is an emergency.)
Slapping the patients hand or arm to make the vein stand out is very over-
rated as a technique and has been the subject of complaints from patients.
You may also hurt the patient and damage the vein. If you insist on doing this,
be gentle, and carefully explain to the patient why you think this is needed.
Not washing your hands before and after the procedure


Please view these videos of cannulation:
http://www.cancernursing.org/forums/topic.asp?TopicID=74
http://imedrxtv.blogspot.com/2009/02/nejm-peripheral-intravenous-cannulation.html


Safety critical point: Extravasation: Certain intravenous medications (especially
chemotherapeutic agents) can cause serious tissue damage if they extravasate (leak
from a drip into the tissues.) Please see the local extravasation protocol and always
call a consultant if this happens.



20
Needle phobia:

Many people in the UK have allergies, and phobias.

If you work in the UK you will at some time take blood from somebody with a needle
phobia. The medical culture in the UK requires you to respect the fact that the person
is genuinely terrified of needles. The person will usually tell you that they are scared
when you enter the room to take blood or cannulate. Please re-assure the needle
phobic patient, and explain why the blood test or cannula is necessary, and how you
are going to perform the procedure.

EMLA cream (Eutectic mix of local anaesthetic) is usually used for children, but ask
the nurse if this is in stock and offer it to the adult patient if they are needle phobic.

Please do not make the mistake of getting irritated with the patient who is needle
phobic- the patient may be offended by this.

If any patient becomes scared and asks you to stop any procedure (like blood taking)
then please stop immediately.


Intraosseous access

The UK Resuscitation Council now recommends Intraosseous as first line in cardiac
arrest for children, and it is something to consider very strongly in a collapsed/
severely shocked/ bleeding adult too. Fortunately you are many hundreds of times
more likely to see an adult in shock as an RMO in the UK (happens quite often and
the person should survive) as you are to see a child in cardiac arrest (which would
probably be a national scandal if it happened in any private hospital.)

As the ALS and EPLS courses will emphasise: Intraossoeus access allows fast,
reliable access to the circulation, allows blood testing and most importantly allows
fluid and blood to be given, fast.

Many Hospitals are now using the EZ-IO System- basically a drill where the IO
needle clips on magnetically and you simply drill it into the tibia (the first choice being
a few 2cm below the tibial tuberosity antero-medially.) Have a look on the resus
trolley to see what intraosseous needle is used in your Hospital. Recently an RMO of
ours may have saved a patients life by thinking quickly, wiping the skin and just
drilling in an EZ-IO needle which allowed him to start fluid resuscitating a severely
shocked patient with a depressed level of consciousness he got an additional (IV)
line in once the veins were a bit fuller due to rapid IO crystalloid infusion.

Use of the EZ-IO will be covered in your ALS and EPLS courses, but a guide to EZ-
IO use can be found at: http://www.vidacare.com/EZ-IO/Index.aspx

The EZ-IO system is pictured below:


21




Urethral Catheterisation





Background to catheterisation in RMO hospitals:

You may be asked to assess patients who have not been able to urinate after their
operation. You will have to make a clinical assessment. If available, and if you
request it, the nurses can do an ultrasonic bladder scan, which will tell you exactly
how much urine is in the bladder.

If there is any doubt about whether the patient has urinary retention, you should
generally lean toward the side of catheterising the patient rather than waiting and
seeing while very excessive volumes of urine build up.

If the patient is not in severe discomfort from urinary retention, it is acceptable to ask
the patient to put their legs over the bed, run the water in the bathroom, or if the
patient is mobile offer them a warm bath if a bath is available in the room, or else the
nurses can just request and encourage the patient to pass urine into a receptacle.
Overflow of a few mls does not count as acceptable urination.

Different hospitals, and different surgeons, have different protocols for what
antibiotics (if any) are given at the time of catheterisation, and catheter removal, but
this is often a small dose of IV or IM Gentamycin (40-120mg IV/IM.) Please check the
local protocol or standing order with the nurses and prescribe the appropriate
medication, which the nurses will give. When you have completed the catheterisation
you must document the whole procedure in the patients notes; as with any
procedure you undertake- make a note of what you did in the patients folder.

22
It is a long tradition that the RMO (whether male or female) catheterises male
patients. In most hospitals this doesnt happen more than 1-3 times per week. As an
RMO you will not usually be called to catheterise females; only males.

Most nurses will prepare the catheter trolley for you. The way to ask is to say: Nurse/
the nurses name: Please will you prepare a catheter trolley for the patient.

The catheter size usually used as an RMO is a 14, 16 or 18. Have a look at the hub
at the top of the Foley (balloon) catheter. There it is written how much water you
should use to inflate the bulb of the catheter balloon after you have inserted it into the
bladder.

The RMO should not use introducers or do suprapubic catheters in the ward.

Procedure for urethral catheterisation:

1. Check that you have the right equipment on the catheter trolley. This is:
The special pack for catheters (catheter pack), normal saline sachet, yellow
chlorhexidine sachet for penis cleaning, the suitable size catheter,
anaesthetic lubricating gel, urine bag, catheter holder, sterile gloves, and
apron

2. Wash and dry your hands

3. Lubricate and insert the catheter using a clean technique, as per your
correct training and practise before coming to the UK.

Common mistakes that you should not make when catheterising:

Forgetting an item from the trolley (the nurses dont always do it right, so
check) like the water for inflating the balloon
Putting air, or too little water, into the balloon causing the catheter to fall out
when the patient stands up
Using a catheter that is too small: The larger catheters are usually easier to
insert, and trying to catheterise a large man with a size 14 catheter is often
going to be difficult, go for a 16 or an 18 if the patient is large
Critically, you must make sure that the catheter is in the bladder before
inflating the balloon. If you inflate the bulb (10-30 cc water depending on the
brand of the catheter) in the mans urethra you will lacerate (rip) the urethra
with untold consequences for the patient. To avoid this insert the catheter as
far as it can possibly go, and also observe for the flow of urine from the
catheter, before you inflate the bulb. Insert the catheter in as far as it will go
before inflating the bulb. Then pull the catheter outwards so that the balloon
sits at the neck of the bladder. Do not inflate the balloon of the catheter until
you have pushed it in as far as it will go!
Using the pink/higher strength chlorhexidine solution to clean the penis, this
will burn the patients penis. Use the yellow low strength solution.
The procedure is a clean procedure, for which you must use your best sterile
technique. If you use non-sterile examination gloves, or touch anything apart
from the penis outside the clean field you create with the drapes in the
catheter pack, you will introduce a greater number of bacteria into the bladder
than if a good technique is used
23
Unless you are highly experienced and have consultant permission (you have
done hundreds in other words) do not use introducers. If the catheter wont go
in, call the consultant, who will do a suprapubic catheterisation or use an
introducer as they see fit.
Failing to wash and dry your hands before and after the procedure

Please view the video below for a demonstration of catheterisation:

http://imedrxtv.blogspot.com/2008/09/nejm-videos-male-urethral.html


Many doctors like to be accompanied by a nurse when the doctor inserts a Foleys
catheter, particularly for holding the saline ampoule when filling the syringe to inflate
the catheter bulb, which is actually necessary for the best sterile technique. Feel free
to ask, if you want to be accompanied, but sometimes the nurse wont have time if
they are busy with their own duties; so dont be offended if a nurse politely refuses to
accompany you when you catheterise a male patient.


NGT insertion




As with all the above procedures this needs to be practised and we may have already
requested a certificate to this effect (We may make this request to you in writing at
the time of the clinical interview.) If you can insert a nasogastric tube already, then
you have nothing to worry about, but please note the important safety information
below, which is particularly important in the rare even that a patient in the hospital is
being fed via the NGT.

Safety critical point: Make sure that you aspirate gastric juices from the tube, which is
the best way of confirming that it is in the stomach. This is particularly critical if the
nurses are going to feed the patient through the tube. Testing gastric juices for Ph is
the Gold standard for confirming that it is in the stomach, or you could consider a
chest x-ray if gastric juices are not aspirated. If in any doubt at all, do not put anything
down the NGT. Please see the National Patient Safety Agency guidelines below.

Please view the video below for a demonstration of nasogastric tube insertion:
http://imedrxtv.blogspot.com/2008/09/nejm-videos-nasogastric-intubation.html

NPSA guidelines (2011) for handling NGTs are summarised below:

Nasogastric tubes are not flushed, nor any liquid/feed introduced through the tube
following initial placement, until the tube tip is confirmed, by pH testing or x-ray, to be
in the stomach.

24
pH Testing is used as the first line test method, with pH between 1 and 5.5 as the
safe range, and that each test and test result is documented on a chart kept at the
patients bedside.

X-ray is used only as a second line test when no aspirate could be obtained or pH
indicator paper has failed to confirm the position of the nasogastric tube and when:
X-ray request forms clearly state that the purpose of the x-ray is to establish
the position of the nasogastric tube for the purpose of feeding.
The radiographer takes responsibility to ensure that the nasogastric tube can
be clearly seen on the x-ray to be used to confirm tube position.
Documentation of the tube placement checking process includes confirmation
that any x-ray viewed was the most current x-ray for the correct patient, how
placement was interpreted, and clear instructions as to required actions.

Any tubes identified to be in the lung are removed immediately, whether in the x-ray
department or clinical area.

Whoosh tests [instilling air], acid/alkaline tests using litmus paper, or interpretation of
the appearance of aspirate are never used to confirm nasogastric tube position as
they are not reliable.


Arterial blood gas sampling



This procedure is not required very often (maybe once a month at the average
hospital) but, in an emergency, you will be expected to perform the procedure
immediately. As with all the procedures in this clinical pack, please revise your
textbook knowledge of this procedure (indications, contra-indications, interpretation
and etc.) especially if you do not deal with arterial samples on a regular basis in your
current work.

In an emergency only you can consider taking a femoral arterial sample, so please
revise your landmarks for this procedure. Routine gases are taken from the radial
artery.

As with all the above procedures this needs to be practised and we will be calling you
to get letters to this effect, if we have made this request to you in writing at the time of
the clinical interview. If you can take a radial arterial sample already, and have had
recent practice, then you have nothing to worry about.

Some people in the UK use a straight needle with a 45 degree entry through the skin.
I recommend a blue butterfly needle at 90 degrees over the maximal pulsation of the
radial artery. Please practice (if necessary) and have your own preferred technique.

In the UK pre-heparinised syringes are available, so you do not need to wash a
syringe with Heparin as some of us were used to doing.

25
Safety critical point: Compress the puncture site firmly for at least 5 minutes to
prevent a haematoma and possible damage to the artery. Do not cover the site with a
plaster as this will hide any haematoma that forms! If a haematoma forms, compress
it and inform the consultant. As with all RMO procedures, document your actions.


Please view the video below about arterial blood sampling:
http://www.youtube.com/watch?v=stxntv0KkBE



Fit-notes (previously called sick notes)


You will be asked to write fit-notes for patients. The consultant will have standard
instructions as to how much time to give off work for the particular operation, or may
pass instructions to the nurses for this, who then speak to you. A good time-saving
technique is to initially give the patient time off work until the follow up appointment
with the consultant in outpatients, so that the consultant has to decide how much
further time off the patient needs. Frequently the nurses will fill in the certificates and
ask you to review and sign them.

Safety critical points: Do not write fit-notes for staff members. You will be drawn into
being their GP, it is potentially legally dangerous because you have not actually
treated them as a doctor, and it will use up your time.

Also, never pre-sign a batch of forms, even if a staff member asks you to. Someone
can fill in anything they like on the forms, with your signature pre-signed, and you will
then have responsibility for those forms and whatever investigation (or time off work!)
is filled in later.





ECGs
You may be asked to do ECGs in the ward. Especially if you are working at a very
quiet hospital, this may be part of your work. You may need to shave a patch of the
patients chest in order to get good contact with the skin. You may need to clean the
skin with an alcohol swab (if the skin is oily) in order for the lead to stick. Please
make sure that you get the outgoing RMO to show you location and workings of the
ECG machine at your hospital; ask about this when you arrive at a new hospital.

Safety critical point: If you swap the Right leg- neutral and Left Leg- foot leads
around you may get a reading indicating an inferior MI. Please know your lead
placements, shown in the diagram below:





26
Diagram of ECG (EKG) lead positions:


Please see further advice on page 35 regarding reading of ECGs in the OPD, or the
pre-assessment room.


4. ADVICE ON PRESCRIBING AND LIST OF COMMON MEDICATIONS
PRESCRIBED BY RMOs, and TTOs


Please read the GMCs guidance on prescribing that can be found at:

http://www.gmc-uk.org/Prescribing_guidance_update.pdf_51250626.pdf

Or else Google GMC Prescribing Guidance 2013 which will give the above link.

Note from the above link (please read it) that prescribing any medicine whatsoever
for yourself or your immediate family is very much against the GMCs Guidance.
Recently an RMO of ours was reported to the GMC by a pharmacist and investigated
for prescribing a simple analgesic for his wife. I am sure this is a bit silly and perhaps
a misuse of the GMCs time but that RMO will now have a GMC investigation to
worry about- all because he wrote his wife up for a painkiller. Do not self-prescribe.

Prescriptions need to be written in full: The drug name, the dose, the route, the
frequency of administration and the length of treatment for TTOs. For example:
Tramadol, 50-100mg, PO, QDS X 5/7. You can write 4 times daily instead of
QDS, and 5 days instead of 5/7, no problem. But the short notation is quicker
and other doctors and staff members will use this notation when communicating with
you, so please learn the abbreviations in red on page 26.
27
Some other general rules are:

BLOCK CAPITALS are used in some hospitals when writing prescriptions-
please speak to your local pharmacist to find out what the local policy is. In all
hospitals letters need to be printed (no cursive handwriting.)
Ensure the allergy and sensitivity boxes are complete on all pages
A sticky label (addressograph) needs to be on all pages
Use the generic (international) name of the drug, not the brand name
For as required (prn) drugs please remember to fill in the maximum dose per
24 hours
When switching from IV to oral medications please use the BNF to check does
and frequency (for example this changes when switching IV to oral
clindamycin.)
Note the formulation: TAB (tablet) CAP (capsule) LIQUID, INH (inhaler) SC,
IV, IM
For regular medications time of administration must be circled
For weekly or alternate days or days to be omitted: Place an X in the boxes
against the days to be omitted
Cross out and re-write any prescription in full if you make a mistake: Crossing
out a word and then amending the prescription is not acceptable
Ensure all prescriptions are signed and dated
Inhalers
1. State brand name
2. You must state strength (for example 200mcg (per puff))
3. The dose is the number of puffs (for example 2 puffs)
4. Some RMOs have made the mistake of prescribing steroid inhalers
on the prn side of the drug chart: They are used regularly. Also think
before prescribing relievers like Salbutamol regularly: Relievers
are routinely prescribed prn unless indicated regularly
Insulin
o Here the brand name and not the generic name is used
o Write the word units on the prescription, not just U.
Note that oxygen is a drug and requires prescribing on the prescription chart

Does for slow release (SR) or enteric coated (EC) medicines, for example enteric
coated Prednisolone, may vary: Please be careful if dispensing.

You will also be asked to prescribe the patients regular medications. The names of
the tablets and the dosages will be on the boxes of pills brought into hospital by each
patient. Please ignore pre-packed pill boxes and dont prescribe tablets from the
patients memory while referring to/looking at tablets packed into a pre-packed pillbox
brought in by a patient: The patients memory of which drug is which (and knowledge
of the drugs) may be poor.

28
Self-medication: Some patients will be allowed, on request, to administer their own
medications whilst in hospital. Please ask the nurse in charge to explain and apply
the local policy on this, because it differs from one hospital to another.

You may be asked to prescribe patient controlled analgesia (PCA) or sliding scales
for insulin. Please follow local protocols (pre-written sheets for you to review and
sign) or else pick up the phone and get detailed instructions from the consultant
anaesthetist who is caring for each patient.

Patient identification: It is a possible, big mistake to prescribe these medicines for the
wrong patient due to not checking the name on the box. Some patients bring in their
wifes medications as well! Always check who you are writing the medication for. Also
check that the dosage written on the box of tablets has not changed.

Nurses may also ask you to double check the details of medicines issued by
pharmacy assistants: Please do this carefully, taking note of the patients ID, the
dose, the full instructions on the box and the strength and number of tablets issued,
and well as the medicines expiry date and check if the patient is allergic to anything.

At the induction day after your ALS/EPLS courses one of our clinical managers will
go over some examples of drug charts, so all will be explained. Please print neatly on
the drug charts (so that it is 100% clear to the nurses what medication, dose, route,
frequency and duration is to be given.) If you are unfamiliar with any medication (no
doctor knows every medicine!) then always look it up in the British National
Formulary (BNF) that you will find in every ward- do not trust blindly online
resources for example.

TTOs are to take out medications, that the patient will take home. These are usually
analgesics and antibiotics. The patients regular medications are dispensed by the
GP (family doctor) so you dont have to supply them with their regular medications.
That is to say TTOs are usually just analgesics, and sometimes antibiotics. Please
take time to check through all of the medications the patient is taking to ensure there
are no repeats, overdoses or adverse interactions when you write up the TTOs. The
consultant usually decides what the patient goes home on, but if they havent written
up any medicines for the patient to go home with, then you should choose for the
patient suitable medicines from the list below (usually the same painkillers and
completing the course of antibiotics they were on in the ward, so it is easy to decide
on which analgesics to use as TTOs.) Please make sure that a pharmacist/pharmacy
assistant/senior nurse checks all medicines that you dispense from the pharmacy
after hours- there has to be double-checking, and two signatures.

It is risky, and poor practice, to prescribe medicines for patients you have not seen in
the ward. Each prescription should be accompanied by an assessment of the patient.

Please memorise the list of common ward medications 1-18 below:
You must please look up in a formulary, be familiar with, and read up on any drugs
you dont know in the list below, particularly indications, contra-indications and side
effects. Please make sure you are familiar with the principle of step-wise pain
management. I have had some RMOs who get very surprised when they are asked
to prescribe Paracetamol for a patient who is taking morphine. Dont be surprised:
Paracetamol is used almost universally unless contra-indicated.
29
Look up any drugs you are not 100% familiar with in the BNF (which is available in
every ward) but you need to have the details of the drugs listed 1-18 below
memorised:

Analgesics:
1. Paracetamol is usually written 1g QDS prn PO/IV, maximum 4g daily. It
is the most commonly used ward analgesic in the UK and almost every
patient will be prescribed it.

NSAIDS=non-steroidal=anti-inflammatory painkillers:
2. Diclofenac sodium (Voltarol) 50mg tds prn PO, or 50-75mg IM bd, or
SR oral preparation is 75mg bd prn, PR is 75-100mg, maximum total
daily dose150mg
3. Ibuprofen is 200mg tds prn PO or 400mg tds prn PO , maximum dose
1,2g daily

Antibiotics:
4. Please note that unlike is some parts of Europe, Erythromycin is still
used in the UK (250-500 mg 6hly (=QDS.))
5. When using un-usual antibiotics like Teicoplanin or Tazocin please do
so under the direction of the admitting physician or a microbiologist, and
check the doses carefully
6. Common ward antibiotics are Amoxicillin, Co-Amoxiclav, Cefuroxime,
Ampicillin and Flucloxacillin, often similar to Europe, but check which
dose and route of administration (PO or IV) each consultants wants you
to prescribe. Check the chart and ask the patient in every case if they
are penicillin allergic- this allergy is a common allergy in the UK!
Remember the consultants may ask you to call and consult a
microbiologist if there is any doubt about the correct antibiotic regime.

Opiate analgesics:
7. Most commonly codeine phosphate-Paracetamol preparations (Co-
Codamol 30/500 2 tabs QDS prn, also called Kapake, Solpadol and
various other trade names)
8. Tramadol 50-100 mg QDS prn PO maximum 400mg daily
9. Morphine is the opiate analgesic of choice in the UK. The adult post-
operative dose is 5-10 mg (usually 10mg) IM 4-6 hourly prn. If you are
asked to give 1-2 mg (one to two milligrams) IV cautiously and repeat
according to response. Nurses in the UK are not allowed to give IV
opiates. Oramorph is given orally as 10- 20 mg starting doses 4hly as
required, or regularly.


In opioid-nave patients [patients not taking opioids routinely] you should not
prescribe (or be extremely cautious prescribing) Tramadol with codeine containing
analgesics as a TTO especially. It is a very common and usually needless error to
make in the UK, because even a few days after major surgery most patients post-
operative pain will be very well controlled with a Paracetamol/codeine combination
and an NSAID if appropriate. Beware of combining the effects of codeine and
Tramadol.

30
A recent fatal case in the UK (not connected to RMO International) has highlighted
the difference between Diamorphine (Heroin hydrochloride) and morphine (morphine
sulphate.) Diamorphine (Heroin HCl) is much more potent than morphine. Please
read the drug and dosage information carefully in the BNF and, as always, call a
consultant, before making a prescription of Diamorphine.
Another case, resulting from sloppy prescribing by an RMO who did not look up
doses in the BNF, involved confusing Oxycontin (A continuous or slow release
opiate given 12 hourly) with Oxynorm (given 4-6 hourly.) Please check doses of any
medication that you are prescribing, especially if you are not familiar with the
particular drug.

Oncology: Part of the RMO role at some sites is to check and sign for
chemotherapy- the nurse will administer the chemotherapy. You will only ever be
asked to sign for a chemotherapy dose that has already been ordered and initiated
by the patients oncology consultant. If you have any doubt about the course of
chemotherapy or the dose of chemotherapy on any particular day, then please
discuss this with the oncology nurse and the consultant over the phone. Also look at
the patients notes to see the consultants written instructions. Having made this
review it may be appropriate to sign and write "pp Dr [consultants name]" or write "on
behalf of consultant" at times.
The nurse will provide you the patients latest blood results for checking pre-chemo.
You will need to become familiar with some further opiates and how they are used in
terminal care (for example Fentanyl patches, Diamorphine S/C infusions, Oxycodone
etc.) Speak to the oncology nurses and speak to the oncology consultant, and you
will quickly pick up this information. As always: Check doses you are unsure about in
the BNF and with the oncologist on the phone.

Anti-emetics (anti-nausea)
10. Cyclizine 50 mg PO/IM tds prn (avoid IV)
11. Metaclopramide (Maxalon) 10mg tds PO/IV/IM (avoid in younger
patients due to extrapyramidal side-effects.)
12. Zofran 4-8 mg PO/IV (usually) tds prn
13. Prochlorperazine (Stemetil) usually 12,5mg IM once and followed by an
oral dose
For constipation (aperients)
14. Senna 2 tabs at night
15. Lactulose 10-20 ml bd prn
16. Glycerine suppositories 2 tabs PR
And for night sedation
17. Zopiclone 3,75-7.5mg nocte prn
18. Temazepam 10-20 mg nocte prn

Please be completely familiar with the abbreviations (bd, tds, QDS, prn etc.) and see
the list below. The consultants and nurses will speak to you using these
abbreviations. If you dont like these abbreviations, especially when you arrive you
can write our prescriptions as one tablet, three times daily etc. This is also
acceptable, but you must know the abbreviations in red below.

Placebos are not part of regular medical practice in the UK.

31
If you are asked to dispense a drug from the pharmacy after-hours, please check the
medication and the prescription carefully, and check the dose you are dispensing in
the BNF if you are not 100% familiar with the drug. Two signatures are required to
dispense- your signature; and the accompanying nurse signs too to protect you.


Penicillin allergy:
As always, check for any allergies that the patient has to any of the medications you
are dispensing to them. Consultants often forget to ask about penicillin allergy when
prescribing an antibiotic. This can be a rapidly fatal error as you know. Check the
drug chart, at least, to see that the patient is not penicillin allergic before you give
them any penicillin or cephalosporin. If there is only a minor allergy history (e.g. rash
on Amoxil years ago) or you want to use a cephalosporin in a penicillin allergic
patient, call the consultant for advice (as always when you are unsure) and also
make a note about this conversation in the patients file. As you know anaphylactic
reactions are difficult to predict, but giving a penicillin allergic patient a penicillin drug,
or cephalosporin, would be very difficult to defend if anything went wrong. The clinical
benefit must also always be weighed up. The consultant makes the final decision
once they have weighed up the risk and benefit of the antibiotic.
Gentamycin dosing
Gentamycin is increasingly used because of its lower rates of pseudomembranous
colitis. If you calculate the Gentamycin dose please use the lean or ideal body
weight, not the actual body weight. You can give the patient serious Aminoglycoside
side effects if you miscalculate the Gentamycin dose.

Confusing numbers on prescriptions:

It is important to write neatly and clearly when making prescriptions. Also, European
script or lettering can confuse nurses in the UK:

(15) mg can be read as 75mg in the UK, we suggest you use:

Similarly, the European 4 can be read as a seven in the UK:
(45) mg can be read as 75 mg to the UK eye
The recommended (most clear) lettering for 74 would be:








32


Use of Vials for IV or IM injections and infusions:



You may be expected to mix antibiotics in vials as pictured above. Details of how to
mix the particular antibiotic can be found in the BNF in any ward. Please note: If you
simply try to inject water into these bottles to dissolve the antibiotic you will create
high pressure in the bottle and the antibiotic will come out in a stream through the
hole you have made in the top, or the top could burst off the bottle. Please practice in
your work-place first sucking the air out, to make a vacuum, and then allowing the
water to flow into the vacuum you have created.

One or two doctors in the past (who were not used to mixing drugs up) have covered
themselves in antibiotics in this way- very embarrassing!

Dispensing of controlled drugs:

Nurses may ask you to counter-sign the release of controlled drugs (usually opiates)
from the ward stock, or to counter-sign the release of controlled drugs from the
pharmacy.

Be aware that these drugs have a street value, and theft of these drugs is not
unheard of. Be careful to count the number of remaining ampoules carefully before
signing off, and check that the correct controlled drug is being dispensed.

External or TTO prescriptions for controlled drugs need to be stated in words and
figures on prescriptions. For example the prescription could look like this (PTO):
Rx: Oramorph 10mg/5ml 10-20 mg QDS prn X5/7 (200ml.) Two hundred millilitres or
Oramorph, ten milligram per 5 millilitres strength. (words and numbers!)


It is a routine feature of RMO life that the staff will ask you to sign the controlled
drugs order book: To order Fentanyl/Morphine etc for the theatres for example.
A recent case reminded us that it is not normal practice for the RMO to dispense
controlled drugs from the ward stock to an outpatient- a pharmacist is required. Also
please make sure that you are accompanied by a nurse whenever you go to
pharmacy after-hours, so that you are not falsely implicated if anything goes missing.


The pre-assessment nurse will usually make a list of a patients medications for the
staff to refer to: Do not transcribe this list onto the prescription chart. You need to
actually see each box of tablets and sit with the patient to establish how and when
they are taking each medication or if they have discontinued any medicine for any
reason.


33
Prescriptions for Mr Nobody:
There have been several instances of RMO prescribing medicines on a blank drug
chart. Please write the name and date of birth and hospital number, or apply a sticker
to every chart on which you prescribe medicines. Every prescription chart must have
a patients name on it- usually the nurses do this, but sometimes they dont.


5. COMMON ABBREVIATIONS
(Abbreviations are discouraged and are only used according to the local hospitals list
of approved abbreviations, if there is one. Please ask to see it before using
abbreviations. The more common medical abbreviations you may come across are
listed below. Please note that when filling in an X-ray form, for example, you need to
fill in clinical details on the X-ray form and this should be done without using
abbreviations. For example write left total hip replacement, day 2, check x-ray not L
THR D2 check x-ray. If in doubt use the operation notes to check the details of any
procedure when filling in X-ray forms. Also if you are filling in discharge summaries,
dont use abbreviations, and please check that the nurses have written the correct
procedures on the discharge summary before you sign it.)

A&E accident & emergency
Abd abdomen, abdominal
ABG arterial blood gases
ASAP as soon as possible
BD twice a day
BNO bowels not open
BP blood pressure
BM ward glucose
CNS central nervous system
c/o complaint of
COPD Chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CSU catheter specimen urine
CT computer tomography (scan)
CVP central venous pressure
CVS cardiovascular system
CXR chest x-ray
D&V diarrhea & vomiting
DOB date of birth
DVT deep vein thrombosis
ECG electrocardiogram
ECHO echocardiogram
ECT electroconvulsive therapy
EEG electroencephalogram
ENT ear, nose and throat
ERCP endoscopic retrograde cholangiopancreatogram
ET tube endotracheal tube
FFP fresh frozen plasma
FU follow up
G+S group and save
GA general anesthesia
GCS Glasgow coma scale
GFR glomerular filtration rate
GP general practitioner
GTN glyceryl trinitrate (spray)
Hr hour
I&D incision & drainage
ICU intensive care unit
ITU intensive therapy unit
IDDM insulin dependent diabetes mellitus
IHD ischemic heart disease
IM intramuscular
IV intravenous
LA local anesthesia
34
Lap laparotomy
Lat lateral
LBBB left bundle branch block
LFTs liver function tests
LOC loss of consciousness
MI myocardial infarction
MRI magnetic resonance imaging
Mane mornings or tomorrow
MRSA methycyllin resistant staphylococcus aureus
MSU midstreamurine
NAD no abnormality detected
NBM nil by mouth
Neg negative
NG tube nasogastric tube
NIDDM non-insulin dependent diabetes mellitus
NKA no known allergies
No number
Nocte at night
NPO nil per os (nil orally)
O&G obstetrics and gynaecology
OD once daily
O/E on examination
Op operation
OPD outpatient department
OT occupational therapy
Path pathology
PE pulmonary embolus
PET positron emission tomography
PM post mortem
PMH past medical history
PO by mouth (Latin: per os)
PR per rectum
PRN as required (latin: pro re nata)
PU passed urine
PV per vaginum
QDS (or QID) four times a day
Rx Therapy, treatment
RBBB right bundle branch block
ROM range of motion
ROS removal of sutures
RR respiratory rate
s/c subcutaneous
s/l sublingual
sol solution
STAT immediately, once dose only
Stone around 6 kg
Supp suppository
T&A tonsillectomy and adenoidectomy
TB tuberculosis
TDS (or TID) three times a day
TFTs thyroid function tests
TKR total knee replacement
THR total hip replacement
TIA transient ischaemic attack
TOP topical
TTO to take out
TTA to take away
TURP transurethral resection of the prostate gland
U&E urea and electrolytes
US ultrasound
UTI urinary tract infection
VE (or PV) vaginal examination
VS vital signs
VF ventricular fibrillation
VT ventricular tachycardia
wt weight
yr, yrs year(s)


35
6. FORMAT WHEN MAKING MEDICAL NOTES AND REPORTING TO
CONSULTANTS

Whenever you see a patient, either for an emergency or routine problem, you are
required to make a note in the patients folder. These notes are the best protection
you can have to show (maybe years later) that you attended to the patient that day in
a proper, safe and correct way. Notes are a legal document and have to comply
with certain basic standards. One of the clinical managers will show you an example
a note on a patient at the induction day. Anonymise medical notes if you are going to
send them to any third party- block out anything that can identify the patient (name,
address) if you are faxing or scanning their notes for any reason.

Consultants will also expect you to use this basic structure when reporting to them on
the phone, and your medical notes can be a useful guide to read from when you are
on the phone describing a problem!

Of course, what you record, and in what detail, depends on the situation. What I
suggest is you record the following things every time you see a patient:
The patients identity (name and date of birth or folder number.)
The date and time of writing the note (in the margin)
The time of significant events and then, the clinical side of things:
1. What happened (the history) for example: I was called to see Ms P at
11h10 and she was complaining of chest pain.
2. What you saw on examination, including observations done by the
nurses. I suggest you divide the examination into: Observations,
general examination, chest, abdomen, CVS, CNS, peripheral
examination and write something for each one, as relevant.
3. An assessment (which is usually a diagnosis) for example: Possible
stable angina pectoris, ECG normal. Observations stable.
4. What is the plan you have made for the particular situation. For
example, write Plan: 1. Called Mr X /Miss Y the surgeon and he/she
instructed me to do J ,K and L. Your plan can also include any
relevant investigations. As mentioned earlier we recommend that you
plan could include the line Discuss with patient and nurse and call the
consultant and that you would follow this plan.
5. It may be helpful to include the line as per consultants instructions if
you are making a routine plan at the end of your notes, particularly if
some of these instructions may have been given to a nurse by the
consultant, for example the surgeon may have asked for drain removal
and you may not be aware of this.
Your name (printed legibly) and signature; or GMC number and signature

We recommend that you always record a history, examination, assessment and a
plan in the patients notes. Long paragraphs without these headings are often less
accurate and structured, and more difficult for the consultant to read. It may help you
to use a so-called SBAR system when reporting an acute case to a consultant on the
phone. SBAR stands for Situation, Background, Assessment and Recommendations.
An explanation of this alternative system (being promoted in BMI hospitals) can be
found at: http://www.saferhealthcare.com/sbar/what-is-sbar/

36
Please make a note in the each patients folder of any abnormal blood results you
receive, and what your plan for dealing with these is. Recently an RMO signed off an
MRSA positive patient to be admitted: What the RMO should have done is
immediately informed the infection control nurse and the nurse in charge, so that
barrier nursing could be instituted from the time the patient was admitted.
Please remember: You, the RMO, may be the only person in the ward who reviews
blood results before they are filed, so be sure to report any abnormalities. This
includes results for any group and screen samples which show antibodies. Tell the
nurse in charge, make a note in the patients file and call the consultant if you pick up
significant abnormalities when asked to check blood results.

Notes must also be easily readable (legible), an accurate and honest description of
events (complete) and also made at around the time of the visit to the patient
(contemporaneous.) Taking history and doing an examination is called clerking in
the UK. Make good clerking notes. Consultants sometimes ask you to clerk patients
when they are admitted, or they might do the clerking themselves.

Best practice is for the RMO to make a note in the file after every procedure, for
example if you cannulate a patient or particularly if you do a urethral catheterisation.
Make a note of why the procedure was done, what equipment you used and how the
procedure went. Note any problems you encountered. Recently an RMO received a
complaint about an IV cannulation he had done 2 years previously, and it would have
been helpful to him if he had a note about the cannulation to refer to in 2012,
particularly if he knew if had gone badly. Please consider this.

For more information on how to make notes in the patients medical records, please
see the Website of our insurers, Medical Protection Society (MPS) and particularly
the link below. We will arrange full MPS cover for you; always. The best way not to
ever need a lawyer is to make good notes on every patient you see. Very, very few
RMOs ever need a lawyer, because we hired/will hire you as a sensible and
experienced practitioner, who knows to make good notes.
http://www.medicalprotection.org/uk/factsheets/records

RMO ward-rounds:
If your hospital requires you to do a ward-round and see the patients every day, we
suggest you still use the format above. (A good medical note has a structure (above)
and includes relevant positive, and relevant negative, findings. It does not have to be
a long note, but it has to be complete with all the relevant information. In a surgical
ward, for example, in a routine assessment on a ward round the history component of
the assessment would be often be very brief and problem focussed. It might focus on
pain, mobility, going to the toilet, eating and drinking, sleeping, and how the patient
feels overall or anything they have noticed which worries them- it is not expected of
you to explore a full-clerking-style history when the patient is known to you and you
are doing a routine RMO ward round and speaking to a patient who is well after
surgery.)

Nurses will regularly call you to see a patient who has come into the OPD, for
example with complications following surgery. Seeing patients who have been
discharged from the Hospital recently but are returning with some complication is a
normal and everyday part of RMO work. Sometimes patients may attend wrongly, for
issues that are not related to their treatment or surgery at your hospital, and not
37
related to the care their consultant is providing them at the hospital. In this case
please DO NOT refuse to see the patient. Please go and see the patient, and if you
make an assessment and you feel the patient is better off seeing their GP for a
particular problem (for example, mildly high blood pressure) then please say so, but
only after assessing the patient. Similarly, if a patient calls in on the phone, rather
invite them to attend at the hospital and be assessed, after discussing this with the
nurse in charge. Dont make an assessment over the phone: This is legally very risky
and it is poor medical practice. As always, call the patients consultant ASAP after
you have made an assessment of the patients condition when they arrive in the ward
or OPD. At most hospitals nurses take these outside calls.

Perhaps the most common reason to be called to see a patient in OPD is not to see a
patient, but to review pre-operative ECGs. Sometimes you will have clinical
information about the patient who has had the ECG and sometimes not, and notes
for the patient also may be available, and sometimes not. The protocols and local
practice vary in different hospitals when assessing ECGs, but the safest thing to do is
probably to ask the nurse to fax any abnormal ECG to the relevant anaesthetist after
you have assessed it. The surgeon and anaesthetist then together do their own pre-
operative assessment and make the final decision as to whether the patient has
surgery on the arranged date or not, but you can help advise them if you find any
abnormalities on the ECG- ask the nurse to fax the abnormal ones.


A consultant may ask for further details on the phone, or ask you to return to re-
examine a patient. Recently an RMO wrongly refused to undertake a PR examination
on a patient, which was not appropriate. Please work within your level of experience,
gain informed consent, and do whatever investigation or manoeuvre is best for
diagnosing/treating the patient. Being an RMO (working under the admitting
consultants) does not prevent you from performing any particular type of
examination. When considering what to do in a particular situation, the questions you
have to answer are: Is the action you are considering in the patient's best interests?
Are they sure, according to their own medical experience, that the action is the
correct action? Can you justify taking the action- could you reason it out if
challenged? and finally: Is the action also according to the consultant's
wishes/instructions? Give the consultant a call and find out.

7. CERTIFYING PATIENTS DEAD AND FILLING IN DEATH CERTIFICATES;
DNAR ORDERS AND CREMATION FORMS

When reaching the end of their lives some patients may choose to have a Do not
actively resuscitate or DNAR order. The consultant (not the RMO) has this
conversation with the patient and counsels them about resuscitation. The consultant
then makes a note in the patients file to the effect that the patient must not have
CPR or intubation and ventilation; only if this is what the patient chooses. Please
make yourself familiar with the local DNAR policy as soon as you have any patient in
the ward who is known in advance to be reaching the end of their life- this will not
apply in all hospitals because some hospitals do not regularly admit patients for end
of life care. If you are not aware of (or if the nurse does not inform you of) this
advance directive (DNAR) it is safest to assume the patient is for full resuscitative
measures.

38
You may occasionally be called to certify a patient to be dead, for example if the
person was reaching the end of their natural life and did not want to be resuscitated.
Please examine the dead person. Death is a clinical diagnosis. If a patient has no
heartbeat, no respiration and is unresponsive and areflexic, then they are dead. No
investigation is required; it is a so called policeman diagnosis because a policeman
could tell you what is wrong if they were there. The ALS manual uses ECG criteria
(asystole) as part of the diagnosis of death. My advice is that for a patient who was
expected to die and now appears to be dead, use simple clinical examination to
confirm death- it is probably inappropriate to do an ECG for such a patient because
you would not apply a treatment based on the ECG findings, no matter what you
found on the ECG. Please record in the notes the date and time of death, which in a
monitored patient may be 5 minutes after the onset of asystole confirmed after
resuscitative efforts have ceased. When the nurse calls you to certify a patient they
will just be expecting you as the ward doctor to record next to the date: Called to see
patient, no heartbeat or respirations, unresponsive; pupils fixed and dilated; dead at
(time) signature and GMC number. You are just being asked to record in the medical
notes that the patient has died, and how you have reached that conclusion.

The nurse in charge, NOT the RMO, usually has the task of calling the family (next of
kin) in the event of a patient dying.

Filling in the death certificate is different (you usually have to do it) and the form used
is mostly self- explanatory. Use your full name as it appears with the GMC. Note your
qualification as MBChB, or MuDR or MD or however it appears in abbreviated Latin
on your medical degree. For the cause of death always ask the consultant what they
want to be filled in- there can be some debate on the secondary and tertiary causes
and your opinion might differ from that of the consultant.

Most patients who die in the UK are cremated rather than buried. This requires a
cremation form to be completed. The RMO is tasked with completing form CR4, the
Medical Certificate for cremation. Please fill this in carefully, writing neatly and
answering every question. Please also get a nurse to look through the form you have
filled in to try and spot any errors you have made. A second medical practitioner,
whom the nurses will help you to find, will fill in Form CR5, the Confirmatory Medical
Certificate.

Please always remember when filling in the cremation form (CR4) that if you make a
mistake on this form, the funeral may be delayed by the undertaker, resulting in a
grieving family possibly having to cancel and delay the funeral of their relative, and
upsetting a family who are already grieving. With this in mind please make sure that
you are contactable for at least a few days (on your mobile) IF you have filled in a
CR4 just before going off duty, so that the Coroner/undertaker can call you if needed
and query any mistake or omission you have made of the CR4 form. Please write
neatly and carefully to avoid any confusion.

Guidance notes from medical practitioners, and the form you will need to fill in (CR4)
can be found at:
http://www.justice.gov.uk/coroners-burial-cremation/cremation




39


8. POLICES AND PROCEDURES

ID cards for laboratory machines: Some hospitals will issue you with an ID card to
operate basic laboratory machines to do point of care testing. J ust to say this ID
card is issued in your name only so please do not swap it with other staff or RMOs

All of our clients put a lot of effort to maintain the highest standards of their services,
so all RMOs must follow the procedures and polices established by the hospitals.

At some hospitals you will find a folder containing all of the group, and local, policies
and procedures that apply to the RMO post, in the RMO room. Other hospitals have
a library or file of hospital policies that you can refer to. You will be expected to be
familiar with all of these local policies at the end of the extended handover and after
your induction to the site which will be done by a member of the Hospital staff
according to local policy. Among the policies and procedures you will be asked to
follow the most important are:

An Infection Prevention and Control Policy, which covers:
Hand hygiene: Wash and dry your hands before and after seeing every
patient, or us the alcohol gel placed conveniently throughout the wards
Use of personal protective equipment (gloves, aprons, gowns, eyewear,
masks etc.)
Safe use and disposal of sharps (to repeat: always have a sharps container
with you when using sharps, used sharps must be disposed of directly into a
sharps container)
Safe disposal of domestic and clinical waste (use of black and yellow/orange
plastic bags.) Contaminated waste goes in yellow bags, not black!
Maintaining a clean environment and
How to deal with the MRSA positive patients



A Prevention of Venous Thromboembolism policy
According to the NHSLA hospital acquired 25,000 people die annually in the
UK from hospital acquired venous thrombo-embolism- this is a serious
problem!
Each consultant will give instructions (verbally, or in the notes, or via a nurse,
or directly to you, or via a standing order of recorded in the file) about what
DVT prophylaxis a patient must have- please prescribe this
The local hospital policy will details other measures taken to prevent DVT/VTE
and please make yourself familiar with this
Please pay close attention to the standing orders given by consultants for
venous thrombo-embolism (VTE) prophylaxis. Each consultant has their own
standing orders written down for each operation. The nurses will show you
these instructions, and ask to see the instructions if they dont.




40
A Transfusion Management Policy- please see the transfusion policy in section 18

All RMOs are involved in a blood transfusion process by
Taking blood for crossmatch (if blood is required) and/or group and screen (to
find out the blood group including Rhesus, check for clinically significant
antibodies and the technician will save the sample in the fridge at the lab for
cross-match when blood is required.)
Diagnosing patients that require blood transfusion and calling the consultant to
report the clinical picture and check how many units of blood they want the
patient to have, if any
By prescribing packed red cells (blood) to the patients on the drug chart and
By dealing with the adverse effects of blood transfusions- please see the local
blood transfusion policy for details of how to deal with this. The policy on this
may differ to what you are currently practicing according to.

Any error leading to the wrong blood being given to a patient could be fatal. It is of
critical importance to identify each patient correctly when taking blood samples and to
label specimens correctly, as outlined in the section about how to take blood.

Always confirm the patients name and date of birth directly with a patient as well
checking these details on the armband. It is surprisingly easy to take blood from the
wrong patient. Please take a minute to think of how serious this mistake could be.


If you are not concentrating and take blood for group and save from the wrong
patient, and that patient is then transfused, you might kill the patient.

The label on the unit of blood may look something like this one below but will also
have the patients name on it:.

41
Note in the instructions in the label above- how nurses are instructed to check the
identity of the patient before they give the blood to the patient. They, not you, will do
this checking, above. But, if the original group and save for the patient who is getting
the above Rh +blood has been taken from the some other patient in the ward, and
not the patient whose name is on the bag of blood- there may be a transfusion
reaction/serious illness or even death of the patient!

Please, there have been near misses, please confirm the patients identity when
taking a sample for group and save or crossmatch. Simple as that.

Please take a minute to reflect on how you yourself would feel if a member of your
family was killed by a doctor in a hospital because the doctor submitted a group and
save sample to the laboratory for your family member; but took the sample from
some other patient in the ward? That is my only message to you- please take blood
sample from the right patient. Confirm the patients identity.

There is a repeat of some of the information above in the section Blood Transfusion
Safety on page 47.


You may be asked to attend mandatory transfusion training onsite once you have
arrived in the UK. Whether or not you will be asked to do the in-house training on
arrival depends on which hospital you go to. It is a quick course and a good
opportunity for some high quality, free training to put on your CV. Free, and
convenient, NHS Better Blood Transfusion training is available on the RMOIH
website will also be mandatory for annual appraisals in the year the year to April
2014- it is a crucial safety issue and the certificate will be a good addition to all of our
CVs! (More information about available training will be given to you at induction.)


A Management of Adult and Children Medical Emergencies (including Resuscitation)
Policy, or a Recognition and Management of the Acutely Ill Patient policy

Note when responding to a EWS that who the primary (first) responder is and who
the secondary responder may be different at different hospitals. What score on the
EW score or abnormal observation is reported you as the RMO is different at different
hospitals. If you are called and an EWS is reported to you make sure you have
attended and seen the patient within 15 minutes, or as soon as more urgent matters
have been dealt with- immediately if possible. As always, follow an ABCDE,
assessment and then management approach. (In other words assess A- then
manage A; assess B then manage B, etc.) Consider using a SBAR reporting
structure in an acute emergency. This means reporting to the consultant the
Situation, the Background clinical information of the patient, your Assessment and
your Recommendation or ideas about what you think should be done. As always the
consultant gives you the instructions about how to proceed- unless the patient
requires immediate treatment from you in an emergency. Please also see Appendix 1
for the Sepsis Screening Tool that some hospitals are using. Note particularly the
green box which has some reminders of observations and clinical findings by the
nurse that will require your immediate attention, as RMO. NEWS scores in BMI
Hospitals have 2 points added if the patient is on Oxygen- there is a weighting of 2
points to reflect this.

42
Because most RMO Hospitals do not have ITUs or immediate access to a range of
specialists, if a patient becomes acutely, severely ill, which happens very rarely, they
may need to be transferred urgently to a local NHS center with an ITU, either directly
to the ITU or via the local Casualty Department. Please make good notes and then
ask the staff to photocopy relevant parts of the patients file, or else write a referral
letter to the receiving doctor if you have time in the format described in this Pack. Of
course you must treat the patients condition with the drugs and facilities you have,
for example MONA for MIs. Inform the consultant ASAP to get their permission to
transfer and to get advice. Please familiarise yourself with the local policy on when
and how to transfer a severely ill patient when you arrive- it should be part of your
induction at the hospital site, but ask staff to show you and tell you about the local
policy when you arrive if it is not.

Press the crash bell earlier rather than later. Nobody will blame you if this turns out
to be the wrong decision later. Do not delay activating the emergency bell and
starting ALS until a patient becomes unstable- Remember the emphasis on the
seriously ill patient in the ALS course? Please apply this and start resuscitation
measures (by calling the team) before the patient decompensates. If nurses have
already arrived and have not pressed the crash alarm, as the ward doctor you can of
course press it yourself!


Note that many Hospitals (for example Ramsay Hospitals) are using Intra-Osseus
needles which you will find on the emergency trolley. Please be aware of this option
when seeking emergency vascular access.




Pre-screening of patients before they are admitted (done by nurses, not the RMO):
To avoid emergencies occurring at all in private hospitals each hospital has exclusion
criteria, or a list of conditions that would usually make it difficult for a patient to be
admitted to the private hospitals. Hospitals might not be able to admit:
Patients with blood disorders (E.g. haemophilia.)
Patients on renal dialysis
History of malignant hyperpyrexia (extremely rare.)
+ve for MRSA (Tell the nurse in charge immediately if you discover this!)
Patients requiring ventilatory or ITU support post-operatively
>ASA3
NYHA Grade 3 or more dyspnoea (on mild exertion.)
Poor controlled asthma
MI of CVA in the preceding 6 months
Angina pectoris Grade 3 or 4 (chest pain on mild exertion, or at rest.)

Discussions about paying for treatment/how much the patient paid for treatment are
NOT for the RMO to have. If a patient ask you about a money issue or a bill from the
hospital please politely ask them to speak to someone in the hospital administration
and tell the nurse responsible for caring for the patient- she can arrange for someone
to speak to the patient about the money side of their visit to hospital- not you!

43
The RMO is expected to lead the resuscitation team, which is a responsibility your
ALS and EPLS courses will prepare you for.

Please follow (and regularly revise; at least monthly) the ALS and EPLS protocols.
In an emergency, step forward and confidently lead the nurses and give instructions
on a loud and clear manner. You are the ward doctor and you lead this team in the
absence of any more senior doctor. Most hospitals also organize announced or
unannounced drills or practice-runs when the emergency alarm sounds and the
RMO is expected to lead the practice resuscitation for training purposes as well as in
a real resuscitation. Note that it is acceptable to leave the defibrillator machine on
AED mode unless you are 100% comfortable in the manual mode. Stand back, give
the appropriate instructions, and proceed through the ABCDE as per your training.

Please check the Early Warning Score (EWS) with the nurses when assessing any ill
patient. Please also always document the EWS in your clinical notes after making
your assessment of the ill patient. As always, be quicker rather than slower to call
consultants and to report the observations/EWS to the consultant.
If any patient is very ill or has a high EWS, remember you can press the crash
alarm just to summon the team and have all available equipment ready in the
event of the patient deteriorating further, if you feel this may happen. Please
press the emergency bell yourself if staff have not done so.
More information on the NEWS (already in use in BMI) is available on the
Royal College of Physicians website at
http://www.rcplondon.ac.uk/sites/default/files/documents/national-early-
warning-score-standardising-assessment-acute-illness-severity-nhs.pdf
and we recommend you read it.
We ask all RMOs to have their ALS/EPLS manuals with them at work and to
revise the algorithms regularly; at least monthly.
To lead the resuscitation/emergency team is at times the most important duty
of an RMO. Please request additional re-training from Petio or Danny on how
to be the resuscitation team leader if you feel a lack of confidence leading the
emergency/resuscitation team. Please expect your skills to be tested in
practice scenarios at the hospitals, and please revised section 18 of the RMO
Clinical Handbook How to lead the resuscitation team. A copy of this is
attached to this email for your convenience.
If you have any safety or procedure concerns relating to any aspect of your
work, particularly if these concerns you have affect your work as an RMO in
any way , then please report this to Petio or Danny at the office and we will
make sure your concerns are addressed; and finally
Many hospitals are now automatically testing the RMO on basic ALS and EPLS skills
on arrival. You dont have to be a genius: you just have to do your ABCDs, know
when to shock, know how many compressions and ventilations to give and know your
Hs and Ts and basic drugs (as you will be taught in the ALS and EPLS courses.)

A surprisingly high number of RMOs in the past made the mistake of recommending
defibrillation of patients with PEA during practice resuscitations, which was
concerning to us. The most common cause of PEA in a surgical ward is probably
heamorrhage causing hypovolaemia, which requires correction of the underlying
cause (remember the Hs and Ts.)

44
You are the team leader, but always be prepared to take advice from any member of
your team. Use the AED function on the defibrillator unless you are 100%
comfortable in manual mode, do your ABCDEs and search for a cause of the arrest
(Hs and Ts.)
Please also see section 18. How to lead the resuscitation team.


The ALS and EPLS protocols are the most important protocols for the RMO, but
please also read the local Management of Medical Emergencies Policy and be sure
you know the location and content of the emergency trolleys and the use of the
particular defibrillator in your hospital. The lingo is to call the emergency equipment
the crash trolley. If you are concerned that a patient might arrest call for the crash
trolley.

Do not hesitate to ask for additional training if you feel you need it - resuscitation
instructors or co-coordinators locally in the hospitals and clinical managers at RMO
International are always ready to help you improve your resuscitation skills.

A Fire Alarm Policy

You will be usually instructed by a responsible person at the hospital what to do in
case of fire. A knowledge of the local Fire Alarm Policy is mandatory.

A Needlestick Injury Policy

If you or other staff member prick (or scratch) themselves with any used sharp
(usually a needle) please refer to and follow the hospitals Needlestick Injury Policy

If there is a needlestick injury, it is recommended that blood is taken from both the
staff member and the patient, to be tested for blood-borne viruses and/or for future
reference. Please see the local policy which will tell you exactly what to do. If in doubt
ask for the microbiologist on call at the local NHS hospital, and always tell the nurse
in charge on the ward what has happened.



In the very unlikely that the patient involved in the needlestick injury is high-risk for
bloodborne disease (e.g. HIV) then post-exposure prophylaxis will be available to you
at the hospital. RMO International is your occupational healthcare provider, so please
inform the Clinical Partner or Managing Partner of RMO International of any accident
or needlestick injury at work, so that we can follow up.

Non-responders to Hepatitis B vaccination: If you have been a non-responder to Hep
B vaccination and you have a needlestick injury at work, please call the RMOIH after
hours number immediately. For your safety we recommend that you immediately are
given Hepatitis B Immune globulin (HbIg) and we will need to make sure you are
given this- call us immediately 24/7. For responders to Hep B vaccination (HbS-Ab
above 100iu/l (or miu/ml) HbIg is not generally required: Call us if you are in doubt.




45
A Complaints Policy

This will detail how a complaint is handled. This complaint could be from a patient or
their relatives or carers, or a member of staff. Note that RMO International has its
own complaints management procedure which follows the latest GMC and other
Guidance for managing doctors, and you are welcome to request a copy of this
procedure from us. The hospitals Complaints procedure is likely to focus on listening
to the issue, responding and then improving the service and procedures of the
hospital. If you are asked to respond to a complaint you are expected to do so
promptly, fully and truthfully, and to participate in the process of making the service
and procedures of the hospital better, via your own actions.

9. HOSPITAL DRESS CODE AND GROOMING (WHAT TO WEAR)

The dress code is different at different hospitals. Culturally, clothes are an extremely
important part of British culture. Grandmothers might tell you that you can tell the
character of a man by looking at his shoes. This might be nonsense, but it is the
culture. The first thing that a British person is likely to notice about you is your clothes
and grooming, right or wrong, this is a big part of how you will be received in the
hospital.

There have been repeated outbreaks in the UK NHS of highly resistant bacteria
(particularly MRSA and Clostridium Difficile) as well as winter vomiting sickness so
a lot of hospitals are asking the RMOs to dress according to their infection control
policies to prevent any of these infections being transmitted in the private
(Independent Sector) hospitals, which do NOT have a reputation for harbouring
much of these dangerous bacteria, but can be affected at any time particularly by
diarrhoeal virus outbreaks.

Please co-operate with the dress code and infection control policies, see later in this
pack. Almost all hospitals have banned wearing neck ties, to try to stop the spread of
germs. Before that, neck ties were standard uniform for male RMOs. This gives you
an idea that a smart appearance is required, especially for male doctors.

Please make sure that you are dressed appropriately when you first arrive in the
hospital. You may not be on duty yet, but you need to look like a doctor please. I
have seen doctors arrive at work wearing shorts, before they change into scrubs.
This will make you seem very unprofessional. Please arrive at work looking
professional. We recommend that you bring a few changes of smart clothes just in
case- a very few hospitals still require male doctor not to wear scrubs but to dress in
a classic style with ironed trousers, a collared shirt short sleeve and brown or black
leather shoes.


There are two basic options when it comes to clothes, and each hospital specifies
what they want you to wear:

Option 1:

The hospital would like you to dress in theatre scrubs (blues) with or without a white
coat (both of which the hospital will supply to you.) Almost all hospitals ask the RMO
to wear scrubs and no white coat. Consider bringing a vest or other suitable
46
undergarments to wear under your scrubs- this may help you to feel more
comfortable so that when you bend over, people cannot see under your scrubs- just
a tip: Consider wearing vests, because scrubs dont fit everyone perfectly.

Option 2:

The hospital would like you to wear neat, clean, ironed clothes of your own choice
with or without a white coat (which the hospital will supply to you if a coat is required.
You will not be able to wear your own white coat from home, so dont bring it.)

All doctors must wear a name-badge that will be provided to you Doctors always
dress bare below the elbows.

To prevent cross-infection, please wear your work shoes only at work.

Dress advice for male doctors:

Unless you wear a beard or moustache, you will be expected to be clean
shaven. I get complaints from staff regularly that the RMO does not shave and
has stubble. It is a cultural requirement in the UK that doctors should be
clean shaven unless they have a beard or moustache.
Bring with you a few collared shirts and trousers. I suggest that your bring
some short sleeve collared shirts- long-sleeved shirts are an infection risk and
cant be worn in the ward.
Please dont wear jeans of any type at any time on the premises of the
hospital, even when you arrive at work for the first time.
No trainers (please do not wear any sort of athletic footwear) at any time on
the premises of the hospital. No sandals are allowed.
Please bring at least one pair of leather shoes with you. Leather shoes are
regarded as smart and protective in the event of someone dropping a needle
on your foot.
Hats/caps are not allowed while on duty
Anoraks, shirts embossed with logos and jackets with lots of zips and buttons
are not regarded as suitable attire for a doctor at work
Please take the time to brush your hair. Better we just say this.I apologise if
you are already in the habits of good grooming, but years ago we had a lot
had lot of complaints about doctors who dont present themselves neatly in the
past; since then the male doctors have smartened up a lot; well done.

Dress advice for female doctors:
J eans are not allowed
Trainers are not allowed, also do not wear high heels
As with male doctors, wrist watches and rings are contrary to the local
infection control policy: Please ask the staff about the local Uniform Policy if
you are in any doubt. Most hospitals allow staff to wear a single wedding band
(without stone) but no other jewelry on the hands or wrists. Necklaces are also
an infection risk and should not be worn. Please make sure your hair is neat
and tied back/ tied up if it is longer than collar length. Ear-rings must be
studs and if you have more than one ear-piercing, one pair only is the
norm.
47
Bare midriffs, very short skirts, and tight stretchy leggings are not regarded as
suitable attire for a doctor arriving at work
Generally our female doctors have always had no trouble presenting
themselves and grooming themselves well
For practical reasons, and infection control, finger nails should be short, and
false finger nails are not acceptable. Nail polish is not allowed
Do not routinely wear jackets, cardigans of fleeces over your scrubs
Muslim female doctors should feel free to wear head scarves. Discuss
appropriate arm covering with the DoN /Matron if this is an issue for you.
(and by the way, if you do become pregnant during you contract with us,
please tell us because we just need to check your working environment to
make sure there are no unmanaged risks to you or your unborn child.)

Some further helpful advice for the male doctors (with tongue in cheek):

If you arrive dressed like this, your life will be easy from the moment you walk in the
door:

OR OR OR

But, if you arrive dressed like the men overleaf, then your life at the hospital will be
difficult, and it may take longer for people to like and respect you. PTO:

OR (note trainers) OR (like a tourist)

By the way, if you smoke, please find out about the hospital's smoking policy. Most
hospitals have a designated smoking area. Smoking is not allowed inside any of the
hospital buildings (by law in the UK.) Some hospitals ban smoking altogether, even in
the garden. Do not smoke in your work clothes within view of the public- this is
regarded as very poor behaviour for a doctor; just be discrete please. Needless to
say, no alcohol may be consumed whilst on duty.

Support for those wishing to give up smoking is available at many hospitals, or call
one of the clinical managers at the office if you are struggling with nicotine (some of
us understand better than others.)


Men particularly, please take my advice and use the way you dress to open doors
for you in the UK. It may be a while since someone told you what to wear, but please
understand I am giving you this advice to make you stay in the UK as easy as
possible for you- the same way I would like you to tell me about the culture if I visited
Bulgaria/Greece/ Poland etc. Its a cultural thing. Clothes are very cultural.
48
10. BRITISH MANNERS AND MEDICAL CULTURE; DISCRIMINATION

J ust a few observations from me (as a foreigner who lives here):

British people like to be very polite (and smiley) and careful about what they say to
you, so do not expect them to speak straight to you. In 2008 we had one doctor with
body odour during a heatwave and the hospital manager asked him every day for a
week: Is the hot water in your room OK, doctor? because she wanted him to take a
shower. Doctors are very respected in the UK so she would never have said to him
Patients have complained so please take a shower very day and use a deodorant!
She would never speak to a doctor like that. I was called half way across the country
to ask the doctor concerned to freshen up. He was quite embarrassed and
surprised that nobody thought they could talk straight to him. He thought he was
very approachable despite being a doctor, and he was hurt that people had not
approached him directly. People had been afraid to speak to him.

Consultant surgeons in the UK expect to be addressed as Mister X (or Miss J ones
or whatever if they are female surgeons.) They are quite proud of this and get
irritated if you call them Doctor. I am told that this is a tradition dating back to a time
of the barber-surgeons when the surgeon was just the only man in the village who
had sharp knives, or something along those lines. Physicians are called Doctor Y.

A common complaint we have is that RMOs answer the phone by saying yes! as is
the custom in most of Eastern Europe and Russia. In the UK this is regarded as rude
and abrupt, so please take the time to say Hello, this is the RMO or RMO (name)
speaking. It is also expected to say goodbye or bye before putting down the
phone at the end of the conversation. This may feel awkward if you are not used to it,
but try it a few times- if you try this you will notice that people say goodbye back to
you at the end of the conversation. This is expected in the UK.

UK medical culture (and the rules the GMC expects all of us doctors to practice by)
are outlined in the GMCs Good Medical Practice. The GMC would have sent you a
copy of this and there is a link to Good Medical Practice in this manual. If you follow
this you will not have problems, and you will be expected to comply with Good
Medical Practice.
Please not that if you are working outside of your chosen speciality while doing RMO
work (for example a surgeon assessing a gynaecology patient) you are required to
make a basic assessment (history and examination.) This is referred to as clerking
the patient. Even if your training is as a surgeon, dont be surprised if you are asked
to clerk a medical patient. If you are not sure about the assessment/examination you
are being asked to make discuss this with the admitting consultant. You are not
expected to know everything but you are expected to make a basic assessment (=
history, examination, assessment and plan =clerk.) Recently an RMO without much
ENT surgery experience did not call a consultant when assessing a patient who had
a haemorrhage after tonsillectomy: If the RMO had called the consultant then they
would have known such a patient should have been re-admitted to the hospital.

Your plan at the end of the clerking must always be discussed with and approved
by the consultant. I recommend that at the end of clerking a patient you write: P: (or
Plan:) As per the consultants instructions. You can then list any verbal instructions
from the consultant that you are aware of. The end of your medical note might look
like this:
49
P: As per Mr J ones instructions: He asked me to start Normal Saline 500ml over 20
minutes and he will come and see the patient.

Again, to repeat: Please call the consultant at any time of the day or night, especially
if you are working in an unfamiliar area of medicine or surgery. The consultant is
responsible for the care of the patient, but you have to keep him/her informed. This,
and good medical record keeping, see section 6. are very important medico-legal
protection for you, as they would be in your home country. All of the consultants
phone numbers are available in a handy booklet at the nurses station.
DISCRIMINATION: Please note that as a doctor in the UK your colleagues, and the
patients, may react very badly and may complain if you express attitudes that are
racist, or show bias or bad feelings or prejudice towards any race or nationality or
gender or sexual orientation or towards people with disabilities or learning difficulties.
Be very careful of what you say: expressing this sort of discrimination, for example
against Gypsies, is not acceptable in the UK. It is RMO Internationals policy to
investigate and act on any such reports. RMOIH also draws your attention to the fact
that we have an Equal Opportunities Policy which we can send you on request.


Bullying and harassment: If you are being bullied or harassed, report it immediately.
RMO International will take a no-nonsense approach to ensuring you dont have to
tolerate unwanted attention from anyone, or be bullied. These activities are obviously
completely unacceptable. Similarly, if you encounter violence or aggression at work
(highly unlikely!!) report it to the Managing Partner of RMO International or the
Director of Nursing/Matron of your hospital immediately- we will take a zero tolerance
approach to any of these activities and we will investigate them immediately. Any
incident will also be made the subject of a local incident report, and investigation.

11. BOUNDARIES AND RELATIONSHIPS WITH PATIENTS AND SOME ADVICE
ON COMMUNICATING WITH PATIENTS AND THEIR RELATIVES AS AN RMO

Please dont repeat the mistakes some RMOs have made in the UK (mostly
applies to young male doctors.)

Please do not use hospital internet facilities to surf adult sites. The hospital
internet is monitored for the use of adult sites.

Do not under any circumstances give your contact details to a patient, or ask
for a patients email address or phone number. Generally, doctors must not
use their position as a doctor in any way to make personal approaches to
patients. While we accept that RMOs may feel affectionate to or protective of
patients, the medical culture in the UK generally advises against the doctor
seeking to establish contact or any sort of private communication with a
patient outside of the hospital. You can use your own professional judgment
on this or course, doctor, but be extremely careful. It might be best to politely
refuse all personal advances from patients. Links to more detailed advice and
GMC Guidance on relationships with patients in the UK is also provided on
page 4 of this Handbook.

Avoiding accusations made more often against male doctors: Doctors must
take a chaperone (any member of staff, usually a nurse, who accompanies the
doctor) to the room if they are going to do any sort of intimate examination of a
50
patient, or any examination which involves exposing the patient. Patients are
usually OK to be examined alone for non-intimate procedures but even then
they should be asked if they are comfortable with the examination and offered
a chaperone. Record the examination and the name and title of the chaperone
in the notes. There was a case in 2008 of a young woman making completely
false accusations of improper touching against the doctor, so be careful. The
doctors reputation and standing were saved because he made good medical
notes and took a chaperone who could confirm later in front of a committee
that he did nothing wrong. The GMC has more specific advice about
Chaperones in their Guidance on maintaining boundaries which is available
online, and we draw your attention to this. Remember taking an ECG involves
exposing the chest; so be aware that this may also be uncomfortable for the
patient- particularly female patients should be offered a chaperone.

Do not touch patients unless it is a neutral body area (the shoulder or
sometimes holding the patients hand) unless examining a patient. Of course,
you must use your own good sense in these matters, but remember that any
unwanted physical contact can be scary or make patients uncomfortable (for
example, touching a patients face or neck is likely to be very offensive to a
patient. You might not believe it but some doctors have made the mistake or
touching a patients face or neck. Dont do this.) Please do not let this advice
stop you from holding a patients hand or even embracing a patient or relative
if they need the comfort and the person invites this with their body language-
use your judgment. Showing common human care as an RMO is extremely
valuable and enriching and can give added meaning to your work, and
showing care may include physically touching a patient.

When cannulating a patient, make sure that the patients hand does not rest
on your lap. This was perhaps the subject of a recent complaint.

But avoid touching any member of staff unless this is invited. Never touch a
member of staff if you are angry or irritated: In these circumstances any
physical contact is likely to be taken as an act of aggression from you.

Please knock on the door of the patients room, then enter and introduce yourself to
the patient. Then please explain why you have come to visit the patient. Please take
a few minutes to ask the patient how they are: J ust say How are you today? and
then listen to them. Then ask another question if you need to like Tell me a bit more
about what happened this morning when you fell over please? If you are seeing the
patient to gain some particular piece of clinical information the patient is likely to be
so happy to have your attention as the ward doctor they will tell you the story of what
happened in what may initially appear to be excess detail- dont interrupt the patient.
Our insurers MPS, in their workshop Mastering Your Risk describe how research
has shown that within a very few minutes, even if you listen to the patient for 1 minute
without interrupting, the patient will usually tell you most of what you need to know
clinically. Also, because you appear to be listening the patient is likely to feel positive
towards you and is highly unlikely to make a complaint against you, even if you make
a technical mistake later. Even if you are having a terrible day, act like you are
listening and let the patient talk- let them do the work. Some of these patient
monologues (which last only a minute or two) end with very important clinical
information you were not going to ask about. The patient might say My neighbour is
looking after my cat, whose name is J erry, she is a white Persian cat30 seconds
51
laterand when I worry about my cat the pain in my chest gets so much worse. The
ECG is done in 5 minutes and indicates myocardial ischaemia and your visit and
diagnosis of the problem (unstable angina) has taken 10 minutes from start to finish.
Let the patient talk to you for just a minute without interrupting- this approach will
reward you.

The family of a patient have no automatic legal right to have any details about the
patients treatment or condition disclosed to them. But in reality/in practice it is often
the best thing to do for the patient to answer questions posed by the family. But do
this in the presence of the patient and never on the phone, unless you are sure the
patient has consented. Use your own judgment, keep your responses to family
questions general enough and stick to what you know. You could respond by saying
something like Yes, your mother has been feeling very sick. I have been caring for
her according to her consultants instructions. I spoke to him today [if that is the case]
and we gave her some medicine. These are not particularly confidential or sensitive
details to give a family member. If you face further questions and lets say you are
not comfortable discussing the patients condition (for example if you have just
arrived on duty) you could offer nurse or consultant attention to the patients family by
saying, for example: I will go and find the nurse who has been taking care of your
mother. Maybe we can find out when the treating consultant is next in the ward and
he can answer your questions in more detail? Then go off to find the nurse
nominated to care for that patient.

My point that you are not expected to be an expert on the treatment of each and
every patient in the ward (you cant be) but please entertain and answer any question
from any family member politely and caringly- family members may be
brokenhearted, and scared and worried about their relative. When you care, it shows,
so just answer the question as best you can and your eyes and body language will
say the rest.


12. REVALIDATION OF DOCTORS BY THE GMC

RMO International has designed in a system to assist all of our doctors with
Revalidation by the GMC. RMOIH is a Designated Body and our Responsible Officer
is Dr J akub Trefler.

The GMCs programme of Revalidation was launched in 2012, and RMO
International is ready to support all of our doctors with Revalidation, particularly by
offering each doctor an annual appraisal.

GMC Revalidation will be based on a system of Annual Appraisal. The
documentation you will need in minimal and will be explained to you in detail at
induction. Until further notice all contracted doctors get free annual appraisals.
Please note that you will need to have an appraisal every year, and not only in your
year of Revalidation.

All GMC registered doctors are required to keep a folder of evidence on their practice
and ongoing training. Point 14 a) of Good Medical Practice makes it clear that all
doctors must keep a folder of evidence that their practice is up to date.

52
Claire McNaughton (our Clinical Administrator) and Heather Drew at the office are
available to explain RMO Internationals appraisal procedure to you if you have
questions.

RMOIH has a dedicated clinical webpage which you will be provided login details to
at your induction day before starting you contract. You can download and start
completing the appraisal form as soon as you start work. By logging in to the RMOIH
clinical webpage you will get access not only to the appraisal form but also to
relevant GMC guidelines, RMOIH appraisal/revalidation policies and procedures as
well as to the RMOIH training materials and courses.

Pease start collecting documents for your appraisal as soon as possible. J ust about
any letter, reference, proof of any training, anonymised medical notes as well as your
updated CV are relevant for your appraisal, so please begin collecting this
documentation (supporting evidence of your good practice) in expectation of having
an appraisal every year.

RMOIHs policy on this is the RMOIH Medical Appraisal and Revalidation Policy
which is available on request from our office. The good news is that RMO
International will provide you with simple, clear and step by step instructions to
complete the appraisal, for free, and with free access to some required online
courses.

13. HANDOVER ROUTINE AND HOSPITAL INDUCTION

When a doctor arrives to take over from you, it is necessary to hand over key
information to the incoming doctor. If the doctor knows the hospital, then you can
keep to the information on clinical details of patients. If the incoming RMO is new to
the hospital, then it is necessary to take them on a tour and follow the list below.

If the doctor arriving is new at the hospital please tell them details of:
Reception and pager arrangements
The kitchen and food ordering
Location of resuscitation trolley and basic details of the defibrillator device and
location of emergency drugs
The pharmacy keys and codes
Clinical room/s and clinical equipment
Basics of the fire policy and practice alarms
Location of files and forms at the nurses station
Patient rooms and clinical areas (e.g. HDU.)
A summary of the duties of the RMO, particularly if anything is un-usual in the
hospital compared to others
and, most importantly, a brief summary of the patients in the ward using the
ward list

The hospital does not provide you a stethoscope, so one will not be provided to you
on arrival. You cannot do the work of an RMO without a stethoscope and so please
purchase one and carry it with you at all times when on duty.

Further induction will be provided in an induction by the Director of Nursing, Matron,
Clinical Services Director, Nursing Sister or Ward Manager on arrival (a member of
53
staff will show you around the hospital and introduce you to some key staff
members.)

It is good manners amongst RMOs to arrange for the cleaners to clean the RMO
room and do the ward-work before your colleague arrives (just as you would
appreciate this being done for you when you arrive! This is an important courtesy and
we encourage this as part of teamwork amongst the RMOs.




14. SAFETY AT WORK

To repeat, please report any needlestick injuries and any accidents or concerns
about your safety at work (including being tired) to the office. Please note that any
inoculation incident (for example if body fluids splash onto you) should be reported.

If you are tired we will call the hospital and arrange some rest for you.
If you get sick while on duty please also call the office and tell us. We will arrange for
you to be relieved and then you can attend the local Accident and Emergency
Department for treatment.

For your safety (and because ethical guidance is against this) please do not self-
medicate, this can be dangerous. Doctors who are UK residents (living permanently
in the UK) should sign up to a GP practice to avoid the need to self-prescribe or self-
diagnose.

RMOs do not usually undertake, and are not usually asked to do what are called
exposure prone procedures (EPPs) for the transmission of sicknesses. These high
risk procedures are things like open-chest cardiac massage, deep suturing to arrest
haemorrhage, insertion of chest drains or per rectal examinations in the presence of
pelvic fractures etc.) It is highly unlikely that you will do any of these EPPs because
there are no emergency units in the RMO hospitals. You will also not be asked to
assist in theatre except in an absolute emergency and then only with the permission
of the nurse in charge. We carry very good indemnity cover, to cover you whilst doing
RMO work, but it does not cover assisting in theatre, so we dont allow this except in
emergencies with the co-operation of the nurse in charge. Please feel free to
observe operations in theatre after introducing yourself and asking permission from
the surgeon: Pre-arrange such a visit with the surgeon concerned.

Also, there have been viral dairrhoeal outbreaks in some hospitals in the past. If you
have persistent diarrhoea, especially if accompanied by nausea and vomiting please
report this to RMO International immediately, and also inform the Matron, Director of
Nursing and nurse in charge.

It is very important that all RMOs use universal precautions (always use gloves, and
sometimes plastic gowns and face masks where bodily fluids may splash) to avoid
hospital acquired infections, and transfer of bacteria or viruses between you and the
patient.
The best way to avoid blood borne infections is to carry a yellow plastic sharps bin
with you to the patients bedside and always immediately dispose of all needles by
dropping them into the sharps bin, at the patients bedside.
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Manual handling: Lifting or handling patients or any heavy objects or equipment is
not a daily part of your work as an RMO. If you are helping to lift a patient or any
heavy piece of equipment please be guided by the nurses- all nurses have manual
handling training. For example, if a patient is on the floor the appropriate means of
lifting them onto the bed (is they cant stand up with assistance) is to use a hoist
designed for this purpose.

Stressful incidents at work and stressful life events: Your mental health may suffer if
you are exposed to stressful medical incidents or if something happens in your life.
Doctors or administrators will call you at least weekly and visit you periodically
throughout the contract, and will usually ask you how you are, as a starting point.
Please take these opportunities to let us know if you are suffering any worry or
anxiety, or any excess stress at work, and we can then talk it through and decide
together on what to do to improve the situation for you. Please also report to the
managing partner or clinical manager (Danny Barker or Petio Anguelov) if you feel a
colleague needs help from us with personal problems.

And lastly, a word on MRI safety: Please tell the scanner manager or radiographer on
arrival at the hospital if you are pregnant (especially first trimester) or if in the unlikely
event of having a pacemaker, ICD, any sort of metallic implant including heart valve
clips, a cochlear implant, shrapnel, or if you have any MR-unsafe device.

15. ELDERLY PATIENTS, FALLS

Some doctors have not had a lot of experience dealing with the elderly.

Falls are a major hazard in the elderly as you know, especially after orthopaedic
surgery. If a patient falls in the hospital, you will be asked to come and examine the
patient. Please be especially careful to exclude any fractures or other injuries, to
keep good notes and to call the admitting consultant in the morning to tell them what
has happened, and review the management of the patient with them.
To prevent the patient falling out of bed, remember to put the cotsides up if you have
lowered the cotsides to examine the patient, for example.

If you have any condition or problem with your mobility that puts you at more risk of
falling, please call the Clinical partner or Managing Partner of RMO International and
discuss it with us. Be aware that falls account for 62% of major injuries to healthcare
staff (NHSLA.) Similarly, if you identify any safety problems in the hospital that you
think might cause you to have a higher risk of falling while at work, please report this
to us as well.

16. BLOOD TRANSFUSIONS

Please note that most patients have a post-operative check Hb or a FBC on day 1
or day 2 after major surgery. Remember the days pass as day 0, day 1 and day 2
etc. Anaemia is common. A few RMOs have seen cases of intra- abdominal bleeding
after minor or major abdominal procedures, including laparoscopy. Young patients
may show few or no signs of shock, as you would know. An isolated tachypnoea or
tachycardia with a normal blood pressure can be the only sign of impending shock.
My point is: Please consider doing the post-operative Hb/FBC earlier, or ordering one
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in the following days if it has not been requested, if there has been any sign of
possible bleeding. Unexplained abnormal observations, and unexplained or excess
pain often require careful thought and assessment from you. Remember patients who
are bleeding acutely often have normal Hbs at first; the Hb only drops after a few
hours, so there may only be subtle physical signs at first. As always, make good
notes and call the consultant.

We will demonstrate how to prescribe packed red cells (blood) and how to write the
patients details on the specimen bottle at the induction day (after your ALS and
EPLS course in the UK.) Some hospitals have a specific Major Haemorrhage Policy
separate from the main emergency policy. Please make sure you are aware of the
local procedure for gaining blood in the event of major haemorrhage. The nurses will
hang up the blood and do all of the checking that it is the right blood and the right
patient. But, what if the group-and-save sample has been taken from the wrong
patient? We have had some near misses where RMOs took blood from the wrong
patient and sent it for group-and-save. Luckily it didnt, but it could have resulted in
the wrong blood type being cross-matched for the patient when blood was requested.

Patient identification: To avoid an ABO compatibility reaction (death or serious illness
from getting the wrong blood) follow a few simple rules listed 1-3 below, and to
repeat from earlier in the Handbook:
1. When taking the blood sample for group-and-save check the patients name
and date of birth verbally (by asking them Please could you say your name
and date of birth) and also
2. Check that you are taking blood from the right patient by looking at their name
and date of birth on the wristband and checking patient details against the
form
3. Put the patients details on the pink blood bottle while you are at the patients
bedside. Do not exit the room carrying a blank tube.


Patient identification when taking blood and when giving medicines is crucial, please
remember this.


17. WOUND CARE AND A WORD ON UNUSUAL POST-OPERATIVE
COMPLICATIONS

WOUND CARE:

The full NICE guidelines for surgical infections (especially for you surgeons) are
available at the link below, or by Googling NICE surgical site infections 2008.

http://www.nice.org.uk/nicemedia/pdf/CG74NICEGuideline.pdf

This Handbook is not a textbook, but please observe the following general principles
when you are asked to see a wound when the nurse or physiotherapist says she
thinks it is infected doctor.

Use an aseptic non-touch technique for changing or removing surgical
wound dressings.
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Use sterile saline for wound cleansing up to 48 hours after surgery
(Please do not do what some RMOs have done and reached for the
Lugols iodine or Betadine! J ust use saline to clean a wound.)
Use tap water for wound cleansing after 48 hours if the surgical wound
has separated or has been surgically opened to drain pus.
Do not use topical antimicrobial agents for surgical wounds (that
cytotoxic iodine for example!) that are healing by primary intention to
reduce the risk of surgical site infection. Again, to repeat, no
chlorhexidine in a wound, and no iodine in a wound: These cytotoxic
solutions are generally used for skin preparation only, to reduce bacterial
load on an intact epithelium.
Consider prescribing antibiotics (you can) if there is a cellulitis or a frankly infected
wound- as always get consultant surgeon and/or microbiologist advice. As an RMO:
when you diagnose a wound abscess, talk to the surgeon responsible for the patient
before you go ahead and try and drain the abscess in the front room. Consider that
the patient may have a need for analgesia (gas and air perhaps) or even
anaesthetic; and also consider that the surgeon may wish to rather take the patient to
theatre and do a definitive procedure/debridement: In these circumstances dont go
ahead and drain any pus- leave it for the consultant.

The nurses and consultants, not the RMO, will take down dressings and inspect
patients wounds routinely.

A WORD ON UN-USUAL POST-OPERATIVE COMPLICATIONS

This Hand book is not a textbook. Also, you are being hired by RMO International
partly due to your experience and expertise in post-operative management.

That said, just a word about un-usual post-operative complications:
Firstly: Not all of our RMOs have experience with spinal surgery. For example after
microdiscectomy there may be Dural tear, or an ex vacuo subdural haematoma,
especially if large volumes of CSF are draining. Nerve root damage and Cauda
Equina syndrome, as well as formation of a haematoma or meningitis (often with mild
clinical features) are other possibilities. Recently we heard of one of our RMOs being
in a ward where there may have been some controversy about the diagnosis of
subdural haematoma after spinal surgery. Please, if you are not familiar with the
complications of spinal surgery, please read up on the above, and if you are worried
about a patient, then carry on alerting the consultant particularly if there un-usual
features like depressed level of consciousness.

Finally, please also dont be caught out by not being prepared for those very rare and
un-usual complications of orthopaedic surgery. We are used to palpating calves to
screen posteriorly for DVT, but recently one of our RMOs diagnosed anterior
compartment syndrome. Anterior leg pain on the operated side may be an early sign
of this. Common things occur commonly or If you hear the clipety-clop of hooves it
is probably a horse (VTE) and not a zebra (compartment syndrome.) But be
prepared for the unexpected too and read up on all of the complications of
orthopaedic, general and urological surgery please, including the compartment
syndrome.
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18. HOW TO LEAD THE RESUSCITATION TEAM

In a practice resuscitation, or in the real event, the team of nurses will look to you as
the RMO to lead the resuscitation team. Every resuscitation team needs a leader to
organise the group. The nurses will hurry around and begin preparing things and
bring the crash trolley.

Your role in leading the resuscitation team is to:

Organise the group and assign tasks never jump to the patients chest to
provide CPR as the team leader when you have other team members around
you will not be able to lead the team effectively and provide good quality
CPR or manage airways at the same time (For example: There is no pulse:
Start chest compressions please Christine.)
Observe the actions of each team member
Lead the ABCDE assessment as per your training
Call for assistance (for example alerting the anaesthetists in theatre, if the
arrest occurs in daytime hours) or asking a nurse to call the theatre and
summon help
If you do not resuscitate on the daily basis consider switching to AED mode
from the start. This may help you to control timing more effectively and using
the AED mode is 100% acceptable
Ensure the safety of team members; especially when delivering shocks!
Remember the Hs and Ts and verbally list and go through them to find a
cause for the arrest- just as you did in the ALS/EPLS courses
Speak and tell the team as each event happens (OK, we have given the 1mg
adrenaline or Shock delivered; resume chest compression please.)
Allow your team members (nurses) to question your orders if the slightest
doubt exists about a prescription- do not give 1mg IV adrenaline except in
cardiac arrest!!
Relieve any team member who is tired or are not able to adequately perform
their tasks
Insert the IV line (if needed) and take blood tests while simultaneously leading
the team
Ask for suggestions or advice from your team if you feel you are unsure of how
to go on- but remember: The nurses are looking for YOU to lead the team
Repeatedly review you own actions and check if anything has been missed
Speak calmly and clearly and observe that what you have requested is being
carried out. (If someone cannot or will not carry out your instruction during the
arrest then ask them why they are delaying. There is no place for shouting, but
a directive and firm but polite approach is needed, always remembering
that some of your team members are also ALS-trained, so they can question
your actions and they will expect you to discuss things with them if they do not
agree with your instructions for any reason.)
Participate in or even lead the post-arrest discussion (often done by a
resuscitation trainer to ensure that everyone has learned from the training.)
And finally (on resuscitation)

Please revise your ALS and EPLS protocols, at least monthly, while you are on duty
as an RMO keep the training you have received up to date- it is just a matter of a
58
few minutes of reading a few times per week while you are in the hospital: Bring the
ALS and EPLS manuals with you when you come to work. Remember that you are
expected to take any cardiac arrest scenarios just as seriously as you took your CAS-
test scenario you took to pass ALS: Please take a structured SSS, ABCDE approach
and know your algorithms- or the Hospital may question your ability.

Please do not make the mistake of missing out A and B in a patient who has
apparently collapsed. You then run the risk of starting CPR on a patient who has
recently gone into pure respiratory arrest/respiratory compromise!

There is an increasing move to using LMAs in both practice drills and real-life
resuscitation situations. Please revise your LMA technique, and see:
http://www.youtube.com/watch?v=96e46PyARaU




19. SAFEGURADING OF CHILDREN AND YOUNG PEOPLE AND
SAFEGUARDING OF VULNERABLE ADULTS (SOVA)

(NB: At your induction you will be provided login details for the RMOIH Clinical
Webpage and you will be required to complete brief and informative online course in
adult and child protection/safeguarding. If you wish to skip/not read Section 19 at this
stage please do so. Please focus you attention on Sections 1 to 18 at this point!)

Safeguarding of Children and young people

The Royal College of Paediatrics guidelines ask that every doctor who is in contact
with children has awareness (Level 1) training in child protection. As an RMO you will
occasionally encounter a child as a patient for minor surgery in the hospital- although
some hospitals do not admit children at all.

Remember in the UK any patient less than 18 years old is legally defined as a child.
To help you imagine the child patients you may see in UK private hospitals you can
imagine a child between the age of 3 (the minimum age allowed) and 18. They are
only admitted for minor or day-case surgery and they are highly unlikely to have any
significant current medical illness. That is to say paediatric patients who have
significant medical problems are not admitted in any current client hospital of RMO
International- most children with significant medical illnesses have surgery in the
NHS only.

The GMC has published Protecting children and young people: the responsibilities of
all doctors which can be found, at www.gmc-uk.org/childprotection

The vast majority of children are in a safe and secure home environment. But if you
even slightly suspect that a child may be being harmed in any way, in or outside of
their home, it is your duty to report this. Please see the box overleaf:

If you have any suspicion that any type of abuse of a child is happening it is your
responsibility to report it to the Managing Partner and also the most senior nurse at
the hospital (usually the Director of Nursing, Matron, or Director of Clinical Services.)
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The report can be an initial phonecall followed by any details you have in writing.
Your report will be taken seriously, you will not be blamed or suffer any detriment if
the investigation later rules out abuse, and you will be kept informed as to the
progress of any investigation following. As with any problem you might encounter in
your working environment whatsoever, RMOIH and its officials will not act in your
detriment if you are a whistle-blower.

Much child abuse still goes unreported. This may be due to the fact that the child
sees the abuse as normal due to a lack of life experience and that the abusers may
go to great length to protect the abuse as a secret.
Denial that abuse is happening may affect the judgement of people who should be
aware of, and report, the abuse. Child abuse also does not follow a set pattern.
Every situation is which a child is abused is different.

Due to the power imbalance between adults and children, all children are at risk of
being abused.

Every child has the right to live without coercion, fear, or neglect, and to be protected
from any form of abuse. Protection is loosely defined as any method by any agency
(be it Police, local authority or caring professionals or all of these working in concert)
to protect the child from harm.

There is no clear definition of abuse of a child, but broadly actions that deliberately or
negligently damage (cause significant harm to) the physical, psychological or
emotional wellbeing or development of the any child can be termed abuse. Note
that if an institution (like a hospital) fails in their duty defined in the law to protect
children then accusations of child abuse can be made against that institution.

This chapter will explain:
The concept of child vulnerability; and
Will contain some reminders about how to spot child abuse, and mention the
different forms of abuse of children to be aware of; and
There will be mentions of the law on protecting children and what to do if you
feel abuse needs to be reported
There is legal requirement for hospitals (as well as any institution providing any sort
of service to any children) to protect the children for which they have responsibility
under what is called a duty of care in UK law.

A child is considered vulnerable if they are at risk of exploitation or abuse. The main
types of abuse are sexual, emotional, psychological and physical, or else there can
be abuse via neglect.

Do you think, as you speak to the child that the child has basic emotional or social
needs that are not being met? Do you feel someone, in or outside the family, young
or old, is harming a child? If there is harm to a child, their physical, emotional, social
or intellectual development could be affected and it is your duty as a doctor to act if
you find signs of this. Intervention in the life of the child in severe cases (if there is
significant harm) can then be taken by the local authority or Police.

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General signs of abuse or harm to be aware of are unusual behaviour, severe anger,
sleep problems, withdrawal, sexualised language or behaviour, self-harming,
irrational fears, mood swings or repetitive behaviours like rocking- all of these could
indicate emotional distress. New or unexplained fear of a particular person of
situation may also be in indicator or abuse. Children may be wary of adults or afraid
to go home, but also beware when a child is excessively submissive or seems to
think they deserve to be punished.

Be particularly aware of unexplained injuries , injuries in different stages of healing,
unexplained or typical skin markings, possibly hand marks, bruises, and generally
any child with any unexplained injury such as this could indicate physical abuse of
the child. An inconsistent history of how an injury was received is also suspicious.
You are highly unlikely to see any child with any sort of fracture: report immediately if
you do see any patient like this in a hospital linked to RMOIH unless there is a clear
and confirmed history and explanation and no worrying features as listed above.
Parents who are abusing a child may refuse to allow anyone else to speak to the
child alone, or be nervous at this prospect. When physically examining a child the
presence of any burn, particularly in an unusual location on the body is highly
suspicious- truly accidental injuries are often located over the bony prominences of
the knees, elbows, wrist or forehead. Defence injuries on the dorsal fore-arm may
be non-accidental, for example.

Bed-wetting, headaches and nausea, and a range of obsessive behaviours (even
excessive neatness) may result from emotional abuse, where the child may become
withdrawn or else exhibit aggressive behaviour, or else appear normal on the
outside. Emotional abuse may cause feelings of worthlessness, a loss of all sense of
importance and extreme emotional pain brought on my mocking, name calling and
often constant hurting of the child in this way- sometime by placing extremely high
expectations on the behaviour of the child, and then hurting he child emotionally
when they do not comply. This emotional abuse is not to be confused with normal
parental or adult disciplining of a child, which is consistently applied, and does not
affect the childs confidence, sense of self-worth or trust in their own judgements.
Discipline is also not hostile and does not leave the child feeling in danger. Emotional
abuse however is usually dressed up as advice, guidance or help from the adult
perpetrating the abuse.

Child neglect is defined as: The failure to provide the support, care and help needed
causing a serious impairment in the childs development or health. Again the signs of
this form of abuse may by physical or emotional or behavioural or reflect in the childs
ability to attend school regularly or develop normally- the most obvious examples
being failure to thrive, or a child who is undernourished or unkempt.

Be aware also that bullying of a child (by another child or group of children or even
an adult) may be ongoing. This form of abuse often involves picking on a
characteristic of a child (their race, height, hair-colour, accent etc.) and is often
sustained and extremely hurtful, leading to any of the above signs of abuse. Bullying
may also involve physical abuse, or physical threats.

All forms of child abuse may intersect with drug and alcohol abuse by members of
the childs family, or the child themself.

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Note that significant harm can be caused by omission or commission in other words
the damage to the child does not need to be intentional in UK law.

Children who are disabled, have poor communication skills, or language problems, or
are socially isolated, or have learning difficulties or who have parents who
themselves were abused are more likely to themselves be vulnerable to abuse.

Denial (individual or group denial) that abuse is occurring can help to hide abuse and
a cycle or denial and increasing or ongoing abuse of a child can develop. The
majority of abuse occurs in families, but any adult, often but not always an adult in a
position of authority can be an abuser.

Seemingly trustworthy adults may display behaviours that can be indicators of abuse,
for example finding reasons to spend time alone with child or not allowing a child to
be alone with other adults.

Local policies and procedures for detecting and preventing abuse of children vary at
different hospitals: Please see the RMO information folder at your local hospital for
the local policy on child protection.

Laws in the UK designed to protect children are the Childrens Acts of 1989 and
2004. This legislation can be viewed at:
http://www.legislation.gov.uk/ukpga/2004/31/contents

In the 1989 Act, Care and Supervision Orders can be issued which allow the child to
remain in their family with supervision by the local authority (the local government
which his commonly called The Council in the UK.) The 2004 Act builds on the
1989 Act and defines a multi-agency approach for the care and protection of children.

Offenders or people adjudged to be unsuitable to work with children may appear on
the ISA Barred list, which is one of the things checked as part of the enhanced CRB
disclosure necessary to work as a doctor. The Sex Offenders Register contains the
names of anyone cautioned, convicted or released from prison for a sexual offence
against adults or children since 1997.

The abuse of children should be detected and reported as soon as possible.
Research shows that most children do not tell anyone about abuse, and if they do
talk, most tell 4 adults about the abuse before being heard- in other words they are
either disbelieved or usually the adult they tell does not effectively act on it.

If a child discloses abuse to you, listen and then make good factual notes of the
conversation. Please see the list of dos and donts later in this chapter for a guide as
to what to do if a child discloses abuse to you. These notes you make can then be
used later by a Child Abuse Investigation Team (CAIT) linked to the local Social
Services. Referral by the hospital once you have reported the issue will be to Social
Services. Do not take it on yourself to inform the parents of the possibly abused child
and do not try to manage the situation yourself, alone.

In rare circumstances it may be necessary to make a report of abuse of a child (or
adult) directly to the local authorities- use your judgement on this.

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Children do not normally lie about abuse, so do not let this cloud your judgement. Do
not fall into the trap of thinking someone else will report the abuse or that it will just
get better on its own. Another trap is not reporting for fear of exposing the child to
further abuse or breaking up the family- abuse needs to be reported.

The Local authority and multi-disciplinary team (including Police) will then proceed
with a strategy meeting, investigation, child protection conference, paediatric
assessment and child interview as appropriate.




Safeguarding of Vulnerable Adults


There are 20+Acts in UK law which may have an impact on the safeguarding of a
vulnerable adults, depending on the on the particular situation. An example of this is
the Safeguarding Vulnerable Groups Act 2006 which can be viewed at:
http://www.legislation.gov.uk/ukpga/2006/47/contents

For your awareness training RMOIH has provided a summary of the most relevant
information below:

Who is a vulnerable adult?

The commonly accepted definition of a vulnerable adult is:

A Person 18 years old or over who is or may be in need of community care services
by reason on mental or other disability, age or illness and who is or may be unable to
take care of himself or herself, or who unable to protect himself or herself against
harm or serious exploitation.

(Taken from Who Decides, Lord Chancellors Department, 1997.)

Please note that according to the above definition, any patient who is ill in hospital, or
any patient recovering from surgery could be considered a vulnerable adult. A
personal is not considered vulnerable simply because of their age or because they
are being cared for at home, for example.

You need to be aware when you work as an RMO, or in any healthcare setting, that
you are dealing with potentially vulnerable people (patients) who are afforded special
protections and considerations in the UK.

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What is abuse?

Please note that there is no typical pattern or typical act of abuse- each case is
different. Also, while common negative effects of abuse may be more clearly
identifiable for people with physical disabilities, older people, those with learning
difficulties, people subject to domestic violence AND those with dementia, in
residential care home populations it is said to often not be possible to identify
common negative effects of abuse.
Abuse may occur for power or control reasons, for material gain, or in a bid to punish
the victim.


The Department of Health (No Secrets DoH, 2000) defines abuse as:

The violation of an individuals human or civil rights by any other person or persons.

Abuse can involve a single act or multiple acts, it can be physical, verbal or
psychological or sexual abuse and as explained in the paediatric abuse chapter
above can be via act, or by omission. Significant harm and/or exploitation of the
vulnerable person can result. A key issue is whether the vulnerable person wishes to
or is able to give consent; for example to a financial transaction or a medical
procedure.

Discriminatory abuse (for example racial abuse, or abuse based on gender or
sexuality) and institutional abuse, are other categories.

Definitions of these 7 categories of abuse are provided below:

1. Physical abuse may be defined as:
Any physical contact that results in discomfort, pain or injury. But also note that
withholding or misusing a persons medication is also classed as physical abuse.

This definition also could include omissions (or purposeful withdrawl ) of something
the person needs for their physical and overall wellbeing, most obviously food and
fluids. Some authorities have a very broad and all inclusive definition of what could
constitute physical abuse, for example the withdrawal of hearing aids or glasses for a
person.
Please see above for some hints on spotting physical abuse.

2. Sexual abuse can be defined as:
Coercion, trickery or force to take part in sexual act

Please note that sexual abuse includes exposing the unwilling (and/or vulnerable)
adult to sexual imagery or pornography (non-contact) as well as contact (actual
physical contact.)

Signs of sexual abuse may by obvious (for example pregnancy in a woman who is
unable to consent) or may be any one or more of the danger signs listed above.

3. Psychological or emotional abuse can be defined as:
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Actions or inactions by others that cause psychological distress or anguish.
Verbally abusing someone for example is classed as psychological abuse.
A carer or family member who refuses to leave the family member alone with another
adult for no good reason may be a sign of emotional abuse.

As with all forms of abuse the range of reactions to the abuse (from withdrawal and
submissive behaviour) to overt aggression, to loss of normal bodily controls (for
example incontinence) is so varied that sometimes no particular symptom of abuse
can be identified.

4. Financial abuse can be defined as:
Misuse of money, property or materials
Remember that in these matters you will be judged as a doctor working to the
professional standards of Good Medical Practice, and please see the GMC Guidance
copied below. As mentioned earlier in this chapter it is probably wrong for you to
have any financial dealings with patients or ex-patients whatsoever, in your role as
RMO.

It is very important that you do not have any financial dealing with a patient
whatsoever when working at the hospitals as an RMO, barring some sort of
exceptional circumstances, for example if a patient at the hospital happens to be a
family member or pre-existing business associate of yours!

5.Neglect can be defined as:
Failure to identify and/or meet the care needs of an individual

This may include failures in food, clothing, hygiene, medical care, personal care,
social needs, heating or shelter. The risks to the vulnerable person should be
assessed in a risk assessment covering at least this list of needs.

6.Discriminatory abuse can be defined as:
Abusive or derisive attitudes or behaviour based on a persons sex, sexuality, ethnic
origin, race, culture or age.

RMO Internationals policy regarding you approach to discrimination is mentioned on
page 43 of this Manual. The point of this chapter however is to make you aware of
your responsibility when working as an RMO to report any such suspected abuse.

7. Institutional abuse can be defined as:
Failure by an institution to recognise the individuality and rights of a citizen
Please note that this includes institutions with poor care standards, unacceptable
practices, and lack of appropriate training to staff. This from of abuse has a very
broad definition and can occur for example if patients in a care home are denied
access to stimulating activities or left in their rooms for long periods.

This is a very broad category and may include such things as institutions that deprive
an individual of access to personal possessions, or place other restrictions on them
which are not within reason, for example inflexible waking or bedtime hours that do
not recognise the individuality of the particular person.

Some further notes:
65

In general, the claimed intention of the abuse is taken into account much less that the
experience the vulnerable adult has of the experience: The process of investigating
the abuse is centred on the patients experience of the abuse.

People tend to want to believe like to believe abuse is not happening, sometimes.

Please note that you have a duty to get involved if you suspect abuse is taking place,
and to intervene by reporting it.

Abuse can occur in any context, in a hospital, the home, or any other setting; for
example on the street. Abuse is not confined to any particular part of society or any
socio-economic level. Be aware that the abuser may be a professional (for example a
carer) a member of the family, a friend, or a stranger: Each case is different and there
is often no easily identifiable pattern to use when being vigilant for signs of abuse.

People categorised as vulnerable adults do not lose their right to self-determination:
People caring for vulnerable adults (for example those with a mental illness) have
difficult dilemmas deciding when intervention or protective actions may be necessary,
if any.

Please note some GMC Guidance on relationships with patients (who are all
vulnerable people when you meet them as an RMO in the hospital) which can be
found at:

http://www.gmc-uk.org/guidance/ethical_guidance/maintaining_boundaries.asp

The most relevant section of the above document advising doctors on how to
approach relationships with patients are copied below. The GMC advises:

Sexual and Improper Emotional Relationships with Current and Former Patients
1. In order to maintain professional boundaries, and the
trust of patients and the public, you must not establish
or pursue a sexual or improper emotional relationship
with a patient. You must not use your professional
relationship with a patient to establish or pursue a
relationship with someone close to them. For example,
you must not use home visits to pursue a relationship
with a member of a patient's family.
2. You must not pursue a sexual relationship with a former
patient, where at the time of the professional
relationship the patient was vulnerable, for example
because of mental health problems, or because of their
lack of maturity.
3. Pursuing a sexual relationship with a former patient
may be inappropriate, regardless of the length of time
elapsed since the therapeutic relationship ended. This
is because it may be difficult to be certain that the
professional relationship is not being abused.
66
4. If circumstances arise in which social contact with a
former patient leads to the possibility of a sexual
relationship beginning, you must use your professional
judgment and give careful consideration to the nature
and circumstances of the relationship, taking account of
the following:
o when the professional relationship ended and
how long it lasted
o the nature of the previous professional
relationship
o whether the patient was particularly vulnerable
at the time of the professional relationship, and
whether they are still vulnerable
o whether you will be caring for other members of
the patient's family.

Please be aware of the above Guidance and bear it is mind when approaching
relationships with vulnerable people (patients) as well as those specifically regarded
as vulnerable adults.

As is the case with children mentioned above, most abuse of adults also goes
unreported.

To repeat the advice above:

If you have any suspicion that any type of abuse of a vulnerable adult (or any patient)
is happening it is your responsibility to report it to the Managing Partner and also the
most senior nurse manager at the hospital (usually the DoN, Matron or Director of
Clinical Services.) The report can be an initial phonecall followed by any details you
have in writing. Remember that putting things in writing may be more likely to result in
appropriate action being taken. Follow up in writing and re-contact the appropriate
authorities if action has not been taken. Your report will be taken seriously, you will
not be blamed or suffer any detriment if the investigation later rules out abuse, and
you will be kept informed as to the progress of any investigation following. As with
any problem in your working environment whatsoever, RMOIH and its officials will not
act in your detriment if you are a whistleblower.

Dos and donts if a child or adult patient discloses abuse to you:

I am not aware of any RMO having abuse disclosed to them in the course of their
surgical/medical hospital work. But, if this happens there are some dos and donts:

Do: listen; ask questions only if you suspect there is an immediate risk to the patient
(to avoid leading them); make signed notes with a date and time and signature;
discuss with the person who you plan to disclose the problem to; preserve any
forensic evidence; record the conversation with a pen and paper and note any
repeated phrases used by the patient

67
Dont: Dont confront the alleged abuser, dont make opinionated notes (the notes
must be factual) and dont launch into a forensic examination of the patient without
the proper training and equipment
Also, dont promise to keep any disclosed information confidential.

What happens when abuse is reported:

Actions taken (often by a safeguarding team) will be patient centred, individualised to
the needs of the vulnerable person and designed to maintain the persons privacy,
dignity, choice, independence, rights and fulfilment.

While the right to self-determination by the vulnerable adult will be respected, the
interests and safety of the vulnerable adult will be the first concern of these teams.
The overall goal is that professionals should work as a group to care for the
vulnerable person, treat them sensitively, and minimise their distress during the
process.

Anyone from private healthcare providers, you as the RMO, the patients consultant,
the Police or the local authority is then involved, often in a multi-disciplinary team
approach to investigating the abuse and providing safeguarding to the vulnerable
adult. This might be led by a local Safeguarding Adults Board. It wont be your role
as an RMO to investigate beyond reporting the initial disclosure, which it is you duty
to make.






















This is the end of the Handbook: Please note that no amount of theory or reading can
substitute for experience and practice of practical skills. The advice, and descriptions
of medications and procedures in this Clinical Handbook are by no means exhaustive
or even complete, and are not intended as a substitute for experience, or as a
textbook. While the Handbook and Appendix 1 below are the written component of
your RMOIH induction, you must use your own professional judgment on all
information in this Handbook. The Handbook is built up partly as a collection of
68
anecdotes from actual mistakes and issues that RMOs have had, and is meant to
stop any of our doctors making the same mistake again! I repeat, the job is easy and
enjoyable, and we hope this Handbook is useful to you.

Christine from our office will contact you to provide confirmation in writing that you
have read and understood the above information.

We look forward to having you in the team of doctors at RMO International!

Warm regards



Dr Danny Barker and
Managing Partner
for and on behalf of
RMO International Healthcare LLP












Appendix 1 follows: EXAMPLES OF HOSPITAL POLICIES- A BLOOD
TRANSFUSION POLICY, AN ESCALATION POLICY, AN EWS CHART, NEWS
CHART, SEPSIS TOOL, AN ANTT CHART and 5 MOMENTS OF HAND HYGEINE,
and SOME INFORMATION ON THE MENTAL CAPACITY ACT ARE ATTACHED TO
THIS HANDBOOK. PLEASE READ THESE CAREFULLY. WE HAVE ALSO
INCLUDED RMOIHs SEXUAL MISCONDUCT AND INTERNET USE POLICIES

Please note that these policies are provided for example and for your information
only: They may not apply in the hospital or hospital group you are working within.
Please refer to your hospital induction folder or RMO file in the RMOs room for
copies of the key Policies that apply in your hospital at any particular time, or
request these from a member of the management at the hospital.


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Transfusion Committee
Guideline Version 3
September 2010 Page 1 of 4
Transfusion Guidelines for Resident Medical Officers (RMOs)
Policies
All Ramsay corporate transfusion policies are available on the Intranet/
Policies/Clinical/Clinical Laboratory Medicine. Hard copies may be available
within the hospital. Please obtain a copy of the Transfusion care Pathway.
Transfusion Requests
The blood transfusion request form will indicate the essential details required
by the supplying Blood Bank;
The patients unique hospital number, surname, forename and date of
birth
The location of the patient
The number and type of blood components required and the time and
date required ensuring that a minimum of 48 hours notice is given to
the supplying blood bank if patient is known to have red cell antibodies
or the patient requires any Special Requirements
Details of the patients past obstetric and transfusion history is desirable
The patients diagnosis and reason for request (anaemia, low Hb or
pre-op is not acceptable as reason for request)
Any special blood requirements e.g. irradiated / CMV ve if indicated
from patients transfusion history
The person completing the form and the phlebotomist must both sign
and date the request form
This is the minimum standard to be met on the request form and Blood Banks
have a zero tolerance policy for specimen rejection if the essential identifiers
identified above are not met, see local policy for the exact requirements of
blood provider.
Phlebotomy
It is essential that all patients are positively identified through questioning
where possible and the patient is judged capable of giving a reliable
response:
Ask the patient to confirm surname, first name and date of birth
The information must be identical to the patient details on the request
card
For In Patients the information must be checked against the patients
wristband and found to be identical, note that if the patients name is
difficult to spell ensure the spelling of the name is identical to the
patients spelling of his / her name
The sample tube must be labelled immediately after the blood has
been drawn at the patients bedside by hand, by the person who took
the sample
Transfusion Committee
Guideline Version 3
September 2010 Page 2 of 4
Essential details on the sample tube include first name, last name,
date of birth, unique hospital number, signature of person taking the
sample
Addressograph labels must not be used on the sample tube
Blood providers have the right to reject sample requests if the
essential identifiers are missing on either the sample or request form
or there may be discrepancies in spelling.
From May 2010 all staff involved in the process for taking blood
samples for Group and Save and Cross-match must provide evidence
of competency assessment updated every 3 years
Patient Information
There should be documented verbal consent for all transfusion
episodes in the patients medical notes; signed consent is not currently
required
All patients receiving a blood transfusion must be fully aware of the
indications for transfusion, its risks and benefits and their right to refuse
The patient (or the patients parent or guardian) should be informed of
possible adverse effects of the transfusion and the importance of
reporting them to clinical staff immediately
Prescription
Blood components must be prescribed on the prescription sheet for IV
infusions and specify
The type of blood component to be administered including any special
requirements, e.g. irradiation
Prescribed as Red Cells and not Blood
Prescribed as Autologous Red Cells for the re transfusion of salvaged
blood
The quantity to be given
The duration of the transfusion, Red Cells not to exceed 4 hours from
the removal from blood bank fridge, Fresh Frozen Plasma
30 60 minutes, Platelets 30 60 minutes
Any drugs to be given at the same time as a unit of blood must be
separately prescribed on the medicines chart and not given through the
blood IV giving set
Documentation
Medical staff must indicate in the patients medical notes why the
transfusion was indicated, the date and the number and the type of blood
components used, the outcome of the transfusion and any adverse events
The nursing staff must complete a blood transfusion care pathway for each
unit transfused
Transfusion Committee
Guideline Version 3
September 2010 Page 3 of 4
Administration
If the patient is not wearing a wristband they must not be transfused
Bedside identification of blood product must be completed by 2 members
of staff deemed as competent to administer blood and blood products
Red Cell transfusion should commence within 30 minutes of the unit being
removed from the blood fridge
Red cells should be transfused through giving sets dedicated for blood and
blood products
Platelets or Plasma must not be transfused through a giving set previously
used for red cells
Drugs or I.V. fluids must not be added to red cells components under any
circumstances
100% traceability of all blood and blood products is required, see local
policy of how to maintain traceability
Overnight transfusions are not advocated between 22.00 and 06.00 unless
the patients clinical needs indicate emergency requirement
From November 2010 all staff involved in the Administration of blood and
blood products must provide evidence of competency assessment
updated every 3 years for sampling for group and cross-match and
administration
Please refer to Ramsay Transfusion Care Pathway for Administration
procedures, observations and transfusion reaction advice
Use of emergency O RhD negative blood
This may not be available on site please check with nursing staff
O Negative blood is not universally safe for all patients
Emergency O RhD negative blood must only be used in emergency
situations where there is insufficient time to obtain group specific or
crossmatched blood for a patient
O RhD negative blood is a scarce resource and should not be
transfused if group specific blood can be obtained
The decision to transfuse must be taken by the most senior member of
the medical staff involved in the case
Obtain advice from the supplying blood bank if the patient is known to
have red cell antibodies before transfusing
Arrangements must be made to obtain crossmatched blood for the
patient and to replace the O RhD negative blood stock on site
Training
Ramsay Health Care UK requires all doctors to have evidence of blood
transfusion training to meet BCSH 2009 and BSQR and BBT3 requirements.
Training requirements may be met by using the following;
Transfusion Committee
Guideline Version 3
September 2010 Page 4 of 4
Learn blood transfusion is offered in three courses:
1. Safe Transfusion Practice (8 sessions)
2. Blood Components and Indications for Use (8 sessions)
3. Good Manufacturing Practice for Transfusion Laboratory Staff (9
sessions)
Topics include:
ABO blood group system and serology
The correct procedures for each step in the transfusion process
Blood component and derivatives and their indications for use
The management of massive transfusion
Recognizing and managing a transfusion reaction
Good manufacturing practice
Each session includes a self-assessment exercise and a certificate when you
score 80% or more
LearnPro can be accessed through;
www.learnbloodtransfusion.co.uk
References:
Blood Safety and Quality Regulations 2005 (MHRA)
Better Blood Transfusion 3
British Committee for Standards in Haematology guidelines (updated) 2009
Last name:
First name: or
Patient Label
DOD:
All patients to have EWS observations
recorded on this chart until discharge
EARLY WARNING SCORE
OBSERVATION CHART
DATE
TIME
220
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
Resp. Rate
SpO
2
O
2
%/LPM
Heart Rate
Systolic BP
Resp.Rate
SpO
2
Temp.
CNS AVPU
TOTAL
Initials
40.0
39.5
39.0
38.5
38.0
37.5
37.0
36.5
36.0
35.5
35.0
34.5
34.0
Temp
o
C
Please enter Early Warning Scores below
Score 3 2 1 0 1 2 3
Heart Rate <30 <40 41-50 51-100 101-110 111-130 >130
Resp. Rate <8 8-11 12-16 17-20 21-29 >30
Temp. <35 35.1-35.9 36-37.5 37.6-38.2 >38.3
CNS AVPU A (Alert) V (responds to voice) P (responds to pain) U (unresponsive)
SpO
2
<88 88-89 90-93 >94
BLOOD PRESSURE
CALCULATION
Record pre or on
admission
Patients baseline
systolic pressure:
200 190 180 170 160 150 140 130 120 110 100 90 80
200 0 0 0 1 1 2 2 2 3 3 4 5 5
190 0 0 0 0 1 1 1 2 2 3 3 4 4
180 0 0 0 0 0 0 1 1 2 2 3 3 4
170 1 1 0 0 0 0 1 1 2 2 3 3 4
160 1 1 1 0 0 0 0 0 1 1 2 2 3
150 1 1 1 1 0 0 0 0 0 1 1 2 2
140 2 2 1 1 1 0 0 0 0 0 1 1 2
130 2 2 2 1 1 0 0 0 0 0 0 1 1
120 2 2 2 2 1 1 0 0 0 0 0 0 1
110 3 3 2 2 2 1 1 0 0 0 0 0 0
100 3 3 3 3 2 2 2 1 1 0 0 0 0
90 4 4 3 3 3 2 2 2 1 0 0 0 0
80 4 4 4 4 3 3 3 2 2 1 1 0 0
70 4 4 4 4 4 3 3 3 2 2 2 1 0
60 4 4 4 4 4 4 4 4 3 3 3 2 1
50 5 5 5 5 5 5 5 5 4 4 4 3 2
PATIENTS BASELINE SYSTOLIC BLOOD PRESSURE
M
E
A
S
U
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E
D

S
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Last name:
First name: or
Patient label
DOB:
EWS TRACK AND TRIGGER FLOW CHART

RECORDER (HCA, RGN, ODP)
If patient scores 1-3
Repeat observations within 15-30 minutes
Carry out ABCDE assessment
Report to Primary Responder
If patient scores 4 or more
Report to Primary Responder immediately

PRIMARY RESPONDER (RGN, ODP)
If patient scores 1-3
Carry out ABCDE assessment and treat accordingly
Repeat observations within 15-30 minutes
If patient scores 4 or more
Carry out ABCDE assessment and treat accordingly
Repeat observations within 15-30 minutes
Alert secondary responder (RMO, Consultant Surgeon/ Anaesthetist) to review
patient within 15 minutes

SECONDARY RESPONDER (RMO, CONSULTANT SURGEON/ANAESTHETIST)
Review patient within 15 minutes of being alerted
Liaise with clinical staff as to management and treatment of patient
First name:
Last name:















































t label Patien
or
















































































































































: DOB
Carry out A
Repeat obs
If patient scores 1-3
(HCA, RGN, ODP) R RECORDE
EWS TRACK AND TRI
















































CDE assessment B Carry out A
ervations within 15-30 minutes Repeat obs
If patient scores 1-3
(HCA, RGN, ODP)
GER FLOW CHART G EWS TRACK AND TRI
















































ervations within 15-30 minutes
GER FLOW CHART
















































































































































If patient scores 4 or more
Repeat obs
Carry out A
If patient scores 1-3
PRIMARY RES
Report to Primary Responder immediately
If patient scores 4 or more
Report to Primary Responder
















































If patient scores 4 or more
ervations within 15-30 minutes Repeat obs
CDE assessment and treat accordingly B Carry out A
If patient scores 1-3
R (RGN, ODP) ONDE P PRIMARY RES
Report to Primary Responder immediately
If patient scores 4 or more
Report to Primary Responder
















































ervations within 15-30 minutes
CDE assessment and treat accordingly
R (RGN, ODP)
Report to Primary Responder immediately















































































































































with clinical staff as to e Liais
Review patient within 15
SECONDARY RE
patient within 15 minutes
Alert secondary responder (RMO, Consulta
Repeat obs
Carry out A
If patient scores 4 or more















































management and treatment of patient with clinical staff as to
minutes of being alerted Review patient within 15
ONDER (RMO, CONS SP SECONDARY RE
patient within 15 minutes
Alert secondary responder (RMO, Consulta
ervations within 15-30 minutes Repeat obs
CDE assessment and treat accordingly B Carry out A















































management and treatment of patient
minutes of being alerted
URGEON/ANAEST ULTANT S ONDER (RMO, CONS
nt Surgeon/ Anaesthetist) to review Alert secondary responder (RMO, Consulta
ervations within 15-30 minutes
CDE assessment and treat accordingly















































management and treatment of patient
HETIST) URGEON/ANAEST
nt Surgeon/ Anaesthetist) to review
















































nt Surgeon/ Anaesthetist) to review
















































































































































































































































































































































































































































































































































































































































































































































EWS Chart v2.0 Issue Date: Oct 2011
DATE
TIME
Bowels (Y/N)
Pain (0-10)
Nausea (Y/N)
PCA
Rate
Tries
Good
Total
Epidural
Rate
Bolus
Tries
Good
Total
Block level
Pressure
Area Care
Mouth Care
Blood Sugar
Initials
OTHER OBSERVATIONS
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1
1
Your 5 Moments

for Hand Hygiene

May 2009
1
2
3
4
5
WHEN? Clean your hands before touching a patient when approaching him/her.
WHY? To protect the patient against harmful germs carried on your hands.
WHEN? Clean your hands immediately before performing a clean/aseptic procedure.
WHY? To protect the patient against harmful germs, including the patient's own, from entering his/her body.
WHEN? Clean your hands immediately after an exposure risk to body fluids (and after glove removal).
WHY? To protect yourself and the health-care environment from harmful patient germs.
WHEN? Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patients side.
WHY? To protect yourself and the health-care environment from harmful patient germs.
WHEN? Clean your hands after touching any object or furniture in the patients immediate surroundings,
when leaving even if the patient has not been touched.
WHY? To protect yourself and the health-care environment from harmful patient germs.
BEFORE TOUCHING
A PATIENT
BEFORE CLEAN/
ASEPTIC PROCEDURE
AFTER BODY FLUID
EXPOSURE RISK
AFTER TOUCHING
A PATIENT
AFTER
TOUCHING PATIENT
SURROUNDINGS
1
2
3
BEFORE
TOUCHING
A PATIENT
4
AFTER
TOUCHING
A PATIENT
5
AFTER
TOUCHING PATIENT
SURROUNDINGS
B
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F
O
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E

C
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A
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/ASE
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ID EX
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Y
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind,
either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO acknowledges the Hpitaux Universitaires de Genve (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.
SomeinformationontheMentalCapacityAct(MCA)2010andDeprivationofLiberty
Safeguards
Mentalcapacitymeanstheabilitytomakeadecision.Thisabilitymaybefixed(asmaybethecase
insomeonebornwithaseverelearningdisability)oritmayvarythroughoutalifetime(asin
someonewhosuffersfromrelapsingmentalillnessbutishealthymostofthetime)orthroughouta
day(someoneunconsciousduringanaestheticlacksmentalcapacity.)Eachdecisionateamina
hospital(forexample)mustmakemustbeconsideredatthatpointintime.
TheMentalCapacityAct,2010isdesignedtoprotectpeoplewhoarenotabletomakedecisionsfor
themselves,andprotectstherightsofthosewhointhepasthavenotbeenabletomakedecisions
forthemselves,butnowcan.Alladultsmustbeassumedtobeabletomakedecisionsfor
themselvesunlessitisshownthattheyareunabletodoso.Apatientcentredapproachtodecision
makingmeansthatthepatient,andNOTthedoctor(RMOorconsultant)willdecidewhatisbestfor
themafterbeingwithrelevantcounsellingand/ormedicaladvice.Inotherwordsthepatientmust
givevalidconsenttoanyprocedureortreatment.Notethatitisthepatientsconsultant,andnot
theRMO,whogainsthisvalidconsentineverycase,exceptfornormalRMOprocedureslikeblood
takinginthewardwhereverbalorimpliedconsentisappropriate.But,astheRMO,youshouldbear
inmindtheprinciplesoftheMCAwhenworkinginthewards.
The5coreprinciplesoftheMCAarethatapersonshouldbeassumedtohavecapacity(tomakeany
decision)unlessitisestablishedthattheylackcapacity;thateverythingpracticable(doable)should
bedonetosupportthepersonismakingadecisionbeforeadecisionmightbemadetosaythe
patientcannotmaketheirowndecisions;thatapersonisnottreatedasunabletomakeadecision
merelybecausetheymadeanunwisedecisioninthepast;thatdecisionsmustbeinthebest
interestsofthepersoniftheyaredeemedincapabletodecideforthemselves;andthatinallofthis
processithastobeconsideredifwhatisneededforthepatientcanbeachievedinawaythatisless
restrictiveofthepersonsrightsandfreedomofaction.
Thebackgroundtolegislation(onthefaceofit)isalongBritishtraditionofindividualfreedomanda
resistancetogovernmentoranyofficialsmakingpersonaldecisionsonbehalfofaperson,although
itisknownthesefreedomshavebeentransgressedformanypeople,andperhapsstillare.Carrying
alabel(likeschizophrenicforexample)hasmeantthatrightsmightbewronglyignoredandthe
individualsfreedomrestrictedbyassumption,duetothelabelalone.Pleaseconsidertheprinciples
intheaboveparagraph:Avoidmakingassumptionsbasedonthepersonsage,appearance,
diagnosis(label)oreventheirinitialbehaviour.
AnexampleofwheretheRMOshouldbebearinginmindorconsideringtheaboveprinciplesisif,
forexample,apatientwithalonghistoryofAlzheimersdiseasewhoisthoughtnottohavemental
capacityfordecisionmakingwishestobedischargedfromhospital,bytheconsultant.Canthis
patientunderstandinformationgiventothem,retaintheinformation,weighuptheinformation,
andcommunicatetheirdecision?(Evenapparentlycomatosepatientsmightcommunicatea
decisionbysqueezingofahandinresponsetoyes/noquestions!)
AsRMO,youcanhelpinanydecisionlikethisbyaddingyouropinionaspartoftheteam(the
consultantmustmakethefinaldecision)andasalwaysrecordinganythingrelevantinthemedical
notes;andinformingtheconsultant.Doestheconsultantspatienthaveanimpairmentor
disturbanceinthefunctioningoftheirbrainormind;anddoesthisdisturbancemeantheyare
unabletomakespecificdecision?HospitalsyouworkinintheUKshouldhaveaMentalCapacity
Policyandanassessmentformtohelptheteamanswertheabovequestion;andtoreviewthe
situationaspartofeachpatientscareplan.InallsituationsinRMOworkitwillalwayshelpyouand
protectyouifyouhaveachattotheperson/patient(andanyfamilymemberspresent)andlisten
carefullytotheiropinions!
ThebestexampleinRMOworkofapersonrefusingcertaintreatmentinthefuture(whenthey
expecttheywilllackmentalcapacityinthefuture)isaDNARorder:Counselling,andsignatureof
theDNARorderisdonebythepatientsconsultant,nottheRMO.Somepatientsmayalsorefuse
lifesustainingtreatmentbyadvancedirectivecleardefinitioninwritingofwhatthismeansforeach
patientisneeded(forexampleapatientmayspecificallyrefuseartificialfeedinginthefutureshould
theynolongerbeabletoswallow;anotherexamplecouldbeapatientrefusingbloodtransfusionsin
thefutureunderanycircumstances.)
InEnglandandWalestheCourtofProtection,thePublicGuardianand/orIndependentMental
CapacityAdvocatemaybeinvolvedindecisionsaspartoflocalHospitalpolicy.Anotherindividual
(oftenafamilymember)mayhaveLastingPowerofAttorneyforcertain(orall)decisionsabouta
personintheeventthattheybecomeincapableofmakingdecisionsforthemselves.
TheDeprivationofLibertySafeguards(DoLS)aimtoprotectpeopleinhospitalsorcarehomesfrom
beinginappropriatelydeprivedoftheirliberty.Thesesafeguardsdonotapplytopeoplebeing
detainedundertheMentalHealthAct,1983.Deprivationofliberty(wrongly)maybebeingapplied
if:
Apatientisrestrainedinordertoadmitthemtohospital
Medicationisgivenagainstapersonswill
Staffhavecompletecontroloverapatientscareormovementsforalongtime
Staffrefusetodischargeapatientappropriately
Staffrestrictapatientsaccesstotheirfriendsorfamily
MosthospitalsyouwillworkinasanRMOdonotnormallytreatpatientswholackcapacityto
consenttotreatmentbutthiscanchangesuddenlyforexampleifanelderlypersonwithdementia
deteriorates.AstheRMOyouwillbecalledtoassessthepatientandyoucanaskforthepatientto
beheldinthehospital,orinextremecasesevenrestrainthepatientintheshortterm(with
proportionateforceandforthepatientssafetyonly)untiltheconsultantarrives.Psychiatric
referraland/ordischargeofsuchapatienttomoreappropriatecareisusuallyneeded.
Furtherreadingonthisandrelatedsubjectscanbefoundat:
TheCareQualityCommission(CQC)websiteat:
http://www.cqc.org.uk/sites/default/files/media/documents/gac__dec_2011_update.pdf
ortheAlzheimersSocietyat:
http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=1327

DrDannyBarker
ManagingPartner20June2013
RMO International Healthcare LLP (RMOIH) - Sexual Misconduct Policy
1. The GMC defines sexualised behaviour as 'acts, words or behaviour designed or
intended to arouse or gratify sexual impulses and desires.'
Policy relating to patients
2. RMOs must not use their professional position to establish or pursue a sexual or
improper emotional relationship with a patient or someone close to the patient.
3. RMOs must always treat patients with dignity.
4. Making any intimate examination of a patient where it is not medically required,
or initiation of a sexualised discussion out of context, may be viewed as sexual
misconduct.
5. The safety of patients must come first at all times. In this light if an RMO
suspects that a colleague is guilty of sexual misconduct they must report it to
RMOIH.
6. If RMOs are unsure whether their actions may potentially harm a patient or be
conceived as sexually inappropriate they should discuss their situation with an
impartial colleague, the Managing Partner or the Clinical Partner of RMOIH or the
GMC.
7. If a patient displays sexualised behaviour an RMO must treat them politely and
considerately and try to re-establish a professional boundary. If the RMO finds it
necessary to remove themselves from contact with the patient, then he/she
should seek immediate advice from the Matron, Director of Nursing or Ward
Manager as well as contacting the Clinical Partner or the Managing Partner of
RMOIH.
8. RMOIH recommends the use of Chaperones both verbally and in writing to each
new RMO before they start work. In the event of an intimate examination, and
particularly if the examining RMO is male and the patient female, a Chaperone
must be offered to each patient and be used in all cases unless the patient
refuses to have a chaperone present. Female doctors performing intimate
examinations on female patients should also offer each such patient a Chaperone.
Policy relating to former patients
9. RMOs must not pursue a sexual relationship with a former patient, where at the
time of the professional relationship the patient was vulnerable, for example
because of mental health problems or because of their lack of maturity.
10. Pursuing a sexual relationship with a former patient may be inappropriate,
regardless of the length of time elapsed since the therapeutic relationship ended.
This is because it may be difficult to be certain that the professional relationship
is not being abused.
11. If circumstances arise in which social contact with a former patient leads to the
possibility of a sexual relationship, RMOs must use their professional judgment to
assess the potential harm to the patient. The GMC website has published further
guidance on these circumstances.
Commitments of the Board of RMOI
12. RMOIH will confirm in writing any reports of sexualised behaviour as defined by
the GMC and involving a patient and an RMO. Thereafter the Board of RMOIH will
meet at the earliest opportunity to decide whether the RMOs conduct was
sexualised behaviour. If it is so decided, the matter will be reported in writing to
the GMC Fitness to Practice Directorate and consideration will be given to
reporting the matter to the Police depending on the circumstances of the
particular case.
13. Breaches of trust by a doctor when the normal boundaries between an RMO and a
patient are broken, particularly where there are indications that a power
imbalance between RMO and patient has been exploited, will be considered by the
Board of RMOIH for reporting to the GMC or to the Police at the earliest
opportunity.
14. In cases where sexualised behaviour relating to a patient is identified or
suspected, RMOIH will notify MPS of the circumstances and provide the RMO with
access to appropriate legal advice.
15. Patient confidentiality is to be maintained at all times. Any reasonable assistance
RMOIH can provide to a patient via representatives of the Client Hospital will be
given without undue prejudice to the RMO concerned.
16. Disciplinary actions taken against doctors who are guilty of sexualised behaviour
will be dictated by the terms of doctors contracts of employment. In principle the
Board of RMOIH regards sexualised behaviour towards a patient or former patient
as gross misconduct.
17. Responsibility for ensuring that the above courses of action are taken lies with the
Managing Partner of RMOIH and with the Board of RMOIH in his absence.
Dr Danny Barker and Dr Jakub Trefler
1
st
November 2011
These Policies are based on the GMC Guidance Maintaining Boundaries- guidance for doctors.

RMO International Healthcare LLP (RMOIH)
Acceptable Internet and Email Usage Policy
Internet Use
Use of the internet by employees of RMOIH is permitted and encouraged where such use supports the
goals and objectives of the business.
However, RMOIH has a policy for the use of the internet whereby employees must ensure that they:
comply with current legislation
use the internet in an acceptable way
do not create unnecessary business risk to the company by their misuse of the internet
Unacceptable behaviour
In particular the following is deemed unacceptable use or behaviour by employees:
visiting, uploading, downloading, publishing or transmitting internet sites that contain obscene,
hateful, pornographic or otherwise illegal material
Sexually explicit messages, images, cartoons or jokes
using the computer to perpetrate any form of fraud, or software, film or music piracy
using the internet to send offensive or harassing material to other users
downloading commercial software or any copyrighted materials belonging to third parties, unless
this download is covered or permitted under a commercial agreement or other such licence
hacking into unauthorised areas
publishing defamatory and/or knowingly false material about RMOIH, your colleagues and/or our
customers on social networking sites, blogs (online journals), wikis and any online publishing
format
revealing confidential information about RMOIH in a personal online posting, upload or
transmission - including financial information and information relating to our customers, business
plans, policies, staff and/or internal discussions
undertaking deliberate activities that waste staff effort or networked resources
introducing any form of malicious software into the corporate network
Company-owned information held on third-party websites
If you produce, collect and/or process business-related information in the course of your work, the
information remains the property of RMOIH. This includes such information stored on third-party websites
such as webmail service providers and social networking sites, such as Facebook and LinkedIn.
Internet Monitoring
RMOIH accepts that the use of the internet is a valuable business tool. However, misuse of this facility
can have a negative impact upon employee productivity and the reputation of the business.
In addition, all of the company's internet-related resources are provided for business purposes. Therefore,
the company maintains the right to monitor the volume of internet and network traffic, together with the
internet sites visited. The specific content of any transactions will not be monitored unless there is a
suspicion of improper use.
Email use policy
Use of email by employees of RMOIH is permitted and encouraged where such use supports the goals
and objectives of the business.
However, RMOIH has a policy for the use of email whereby the employee must ensure that they:
comply with current legislation
use email in an acceptable way
do not create unnecessary business risk to the company by their misuse of email
Unacceptable behaviour
The following behaviour by an employee is considered unacceptable:
use of company communications systems to set up personal businesses or send chain letters
forwarding of company confidential messages to external locations
distributing, disseminating or storing images, text or materials that might be considered indecent,
pornographic, obscene or illegal
distributing, disseminating or storing images, text or materials that might be considered
discriminatory, offensive or abusive, in that the context is a personal attack, sexist or racist, or
might be considered as harassment
accessing copyrighted information in a way that violates the copyright
breaking into the companys or another organisations system or unauthorised use of a
password/mailbox
broadcasting unsolicited personal views on social, political, religious or other non-business
related matters
transmitting unsolicited commercial or advertising material
undertaking deliberate activities that waste staff effort or networked resources
introducing any form of computer virus or malware into the corporate network
Email Monitoring
RMOIH accepts that the use of email is a valuable business tool. However, misuse of this facility can
have a negative impact upon employee productivity and the reputation of the business.
In addition, all of the companys email resources are provided for business purposes. Therefore, the
company maintains the right to examine any systems and inspect any data recorded in those systems.
In order to ensure compliance with this policy, the company also reserves the right to use monitoring
software in order to check upon the use and content of emails. Such monitoring is for legitimate purposes
only and will be undertaken in accordance with a procedure agreed with employees.
Remote Users
Users may sometimes need to use Company equipment and access the Company network while working
remotely, whether from home or while travelling. The standards set out in this document apply whether or
not Company equipment and resources are being used.
Sanctions
Where it is believed that an employee has failed to comply with this policy, they will face the company's
disciplinary procedure. If the employee is found to have breached the policy, they will face a disciplinary
penalty ranging from a verbal warning to dismissal. The actual penalty applied will depend on factors
such as the seriousness of the breach and the employee's disciplinary record.
Agreement
All company employees, contractors or temporary staff who have been granted the right to use the
companys email services are required to sign this agreement confirming their understanding and
acceptance of this policy.
........................................................................................................................................................................
Enforcement
Any employee found to have violated this policy may be subject to disciplinary action, up to and including
termination of employment.
I have read and understand the Acceptable Use Policy. I understand if I violate the rules explained herein,
I may face legal or disciplinary action according to applicable laws or company policy.

Name: ..................................................................................................................


Signature: .................................................................................................................


Date: .................................................................................................................