Anyone who knows me or follows me on social media will be well aware that for the past year I have been working at the Leeds General Infirmary as a Dental Core Trainee (DCT) in Oral and Maxillofacial Surgery. For the medics reading this, DCT is our equivalent of core training, and we are effectively a Senior House Officer in OMFS, with a dentistry degree.
Out of everyone who has done the job or is starting it, no one ever seems too phased by the time spent in operating theatres or clinics, it is the ‘on call’ that everyone dreads. Now the duties which fall under the remit of a DCT on call will vary depending on the region and hospital you work in. Having only done this job at Leeds my experience and advice will be based on this – although I am told our responsibilities were at the higher end of what is expected from a DCT, so you can probably assume you won’t be doing more than what I describe.
To give you an idea what was required as the DCT on call, I’ve listed the sorts of things you would do during the day (which for us was a 12.5 hour shift on paper, but usually a little more by the time everything was wrapped up and handover complete). Before I go on to the list, some of you might be wondering what is handover?
Depending on the department this will be done in different ways, but it is effectively the point where the team leaving (e.g. night staff) pass on to the next team (e.g. day staff) the details of all the patients under your teams’ care, all outstanding jobs for each patients’, tasks for the day and possible issues. For example:
“In bed 2 is a 34-year-old gentleman who was admitted under Mr Consultant 4 days ago for a large submandibular swelling associated with the LR7. He was taken to theatre yesterday for intra and extra oral drainage and removal of the LR7 and 8. He has two drains in situ and is to continue IV antibiotics for 48h.”
This gives the team taking over an outline of who the patient is, why they’re in hospital and alerts everyone to the fact that there will be two drains to keep an eye on plus the need to continue the antibiotics. I like to mention any key points of the patients’ medical history or allergies at this stage too.
After handover there is usually (or always on our department), a ward round, where the team go round every patient admitted under our care. We check they’re okay, examine them and document the current situation, whilst identifying any further tasks for the day to do with that patient.
Prescribing for ward patients – analgesia, regular medication, sleeping tablets, antibiotics, fluids
Taking blood from patients on the ward as required and chasing the results, then of course acting on these results
Assessment and treatment of acute GP referrals such as incision and drainage of infected sebaceous cysts (think ‘Dr Pimple Popper’)
Assessment and treatment (investigations, scans, etc) of facial cellulitis, infected facial insect bites, parotitis, sialoadenitis, occasionally trigeminal neuralgia (but this is normally dealt with on an out-patient clinic), bleeding extraction sockets
Facial fractures – assessment, diagnosis, planning theatre and review
Facial lacerations – assessment and closure under LA or GA
Extraction of teeth plus incision and drainage of abscesses (extractions usually only done if vision threatening or life threatening e.g. sepsis or significant facial swelling) – we did not see ‘tooth aches’ or A+E would become a dental service
Some things accidentally make their way to the OMFS team one way or another (often due to over the phone triage systems) so I have ended up with a few obscure referrals that were entirely inappropriate! Examples of these include an ischaemic colon and a DVT. Head and neck, right?
Before we go any further, whilst we are on the topic of ‘surviving’ the year, it’s important that you also contribute to the survival of your patients. Therefore, I would recommend the Oxford Handbook of Oral and Maxillofacial Surgery as a good reference guide. Nothing beats learning on the job and this is where you learn most, however the book is good for a bit of reassurance and it just about fits in scrub pockets, which is a bonus.
When starting a new job, there is understandably a lot on your mind. Everything is new (for most people), including colleagues, systems, the building/s, it is a lot to take in. I would recommend not only leaving extra time to do things compared to what you’re expecting (such as finding the ward on your first day…), but try to keep your diary free in the evenings at first. I found if I had plans after work I’d be anxious to finish on time and get home and to my next commitment. This may sound like I’m contradicting myself when in about 2 lines I start waffling about work/life balance, however for the first couple of weeks it is nice to have as few outside pressures as possible whilst you’re settling in.
OMFS becomes all consuming…if you let it. The service is truly 24 hours a day, 7 days a week and 365 days a year. I know, I worked a 13-hour shift on both Christmas day and boxing day – the dog bites alone would have kept me in a job!! Communication between team members is important and it is likely that the discussions between the team will continue whether you are in work or not. We had a Whatsapp group for the DCTs then another which had all the registrars in. This was active night or day, weekends, pretty much all the time. It was important as between us we could make sure all of the patients were safe (if someone had a question about a patient for example, whoever had seen them that day could provide an update), coordinate where everyone was to ensure enough help in theatre etc, plan the acute theatre lists to check there was a surgeon available and of course send each other memes for every single situation we encountered. I must admit the face palm and the eye roll emojis were firmly on the top of my most used list – hospital systems can take a while to get your head round and can be frustrating at the best of times. Whatsapp is encrypted but be careful when sharing images or information that you are maintaining confidentiality. I would sometimes ask a patient if I could send a photo to my registrar for a second opinion then delete it, no one objected and I would immediately delete the image. This really helped when I needed a quick bit of advice such as ‘should I attempt this under local anaesthetic??’ – que photo of lip hanging off. Que facepalm emoji.
It is really important to spend time with friends and family outside of work. Plan in time to rest and try not to take on too much at the start as you get used to the job. There will likely be plenty of opportunities for writing papers, teaching and other project work, but it can be easy to say yes to everything and take on too much. Try to think about what will benefit you most in terms of learning and developing yourself clinically and in your career. Following on from this I would recommend starting early, if you give yourself a full year to write a paper or complete an audit, you’re more likely to get it done with less stress than rushing to cram it in at the end.
Ask for Help
Ultimately, the clue is in the name. Dental, core, TRAINING! You are not an OMFS consultant, you are a dentist and a trainee at that. Be prepared to ask for help when needed. In my opinion it is better to ask for help and know for sure you’re getting it right from thereon in, than to keep guessing your way through. With this job, you have to accept that most things you do you will be doing for the first time, so sometimes you do have to use your common sense. Make sure you are safe and think about if there is anything else you could do to improve the outcome of the situation.
An example of this would be in a medical emergency and a patient needs a cannula for emergency drugs. You might never have a cannula before, so could technically say that this is outside your competency, however you’ve had the training for it and could potentially save the patients’ life, relative to the amount of damage you could cause. The key thing to remember is you are doing your best and acting in the best interests of the patient, so as long as someone is seeking appropriate help and you are initiating everything you can to help the patient, you’re all good. An example of not managing a situation appropriately would be taking a patient to theatre on your own without speaking to a senior member of the team, to do a non-urgent treatment which you’d never done before.
If there is something which you are finding difficult, try to get more practice in this field, either by asking for some teaching on the topic, looking in to it more at home, arranging some shadowing or actively seeking experience of this. An example might be surgical extractions or suturing. You will only get better with practice, so identifying these areas of difficulty area on will help you improve your confidence and develop new skills in a safe way.
Who doesn’t love a list? When holding the bleep you can be bombarded with jobs all day long and it important you don’t forget to get things done. Having a piece of paper on you with a list of outstanding jobs really helps, as there does become a point where you can’t retain everything in your mind! I write down all outstanding tasks and rearrange these as the day goes on, depending on the patients and their condition.
This is something which you will get better with over time, however learning to prioritise your tasks is essential. Look down your list of jobs and work out what can be sorted out quickly. At Leeds we had ‘EDANs’ which are the discharge summaries authorised when a patient is going to be discharged. In some circumstances these can take just a few minutes to complete. Initially, I would leave these until I was a bit ‘quieter’. I then realised this time would never really come. Because an EDAN doesn’t immediately affect the safety of a patient (they’re being discharged or transferred to another place), I didn’t prioritise this and get it done early in the day. However, I soon started to get these done sooner (provided my patients were all safe) as it meant medicines could be dispensed by pharmacy, nurses could get on with their side of things, the patient could leave and a bed would be available for a patient who may need it acutely. This relieved a stress for many members of the team and helped things run smoothly.
So, what else should be prioritised? I’ve listed an example of some jobs you may have, and then outlined how I personally would approach sorting out this list of patients (this is my opinion and might not work for you, equally it is important to take in to account all factors of the situation – this is a very simplified example for the sake of the post!).
EDAN for patient being discharged home who had a broken jaw plated 24 hours ago
Prescribe pain medication for a patient post-operatively
Facial swelling in A+E yet to be seen by a doctor, nurse handover says ‘it looks pretty big, life a golf ball’, they’ve just arrived in the department
Sebaceous cyst who has been waiting 3 hours, your colleague didn’t have chance to see them and handed it over
A small lip laceration who has just arrived in the department
A possible broken jaw (jaw pain, punched in the face, cleared of head injury) who has been waiting 1 hour in A+E
A general clinic referral for a patient needing to be seen in 8 weeks time
A patient on the ward needs a sick note before they can go home
Below is how I would tackle this list of jobs, all being simple with no complicating factors:
Out of all of these tasks, the first thing to do is ensure patient safety. No-one has seen the facial swelling except for a nurse, who isn’t an expert in assessing these. I’d prioritise seeing this patient, even if it just to ensure they are safe and not an immediate airway risk (e.g. Ludwig’s angina) and perhaps send them for some investigations (OPG/bloods tests [CRP, FBC, maybe U+E to check their EGFR in case a CT is required] and a clotting if relevant to the patient)
Next, I would clear the jobs that I know can be done from my office in around 15 minutes – the EDAN, prescribing pain relief and completing the sick note will take me hardly any time, but will mean the pharmacy can start getting medicines ready for patients to go home, another can leave, a patient is out of pain and plenty of tasks are now crossed off my list, which feels satisfying
Next, I’d see the possible broken jaw. This patient is likely to require prophylactic antibiotics, may need fasting for theatre (so the sooner I see them and make this decision the better) and imaging will be required which takes time. They may not have been waiting as long, but there is a longer process required to sort this patient out so I would want to start it sooner rather than later
At this point I have two patients waiting, the cyst and the laceration. Neither are life threatening in this situation, I would just see which ever has been waiting longest
Last but not least I’d do the referral. It isn’t urgent and can even be done at the end of my shift
I would recommend learning the correct etiquette for theatre as early as possible. Learn how to scrub, what you can and can't touch, the systems in place, everyones role in the operating theatre and how to prep/drape a patient. Watch what others do and be proactive in helping out. For example getting gloves on and help move the patient from the trolley to the operating table, hand gauze swabs back to the nurse who gave it to you and thank those who have helped during the procedure. These are all things that will help the rest of the team and ultimately improve your experience during operations.
Overall, I prioritise patient safety, then keeping the ball rolling for everyone else. If I know someone will require imaging before I can make a diagnosis or move their treatment forward, I will try to see them first to make this decision and then see the next patient whilst they’re in the radiography department, for example.