Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

I need to log in on chrome as well. So the chat actually works. We're just going to wait a minute or two. Um, just to let everyone come in before we start. Guys. Hi, everybody. Amanda. Okay, I think let's make a start for it. Let me just share. Um, besides, okay, you guys should be able to see this. Yeah, So welcome to our fifth session, everyone. And today we'll be talking about clinical scenarios, and this is going to be our first session. Do you want to pitch this? Yeah. Just so standard disclaimer that we've been pitching every week, but it's still important. All views expressed in this talk and the series overall solely those of us, the presenters and do not reflect those of the NHS nor are employing trust. Now, this is a longer and more complex disclaimer than before. This is really important, because in this session we're going to be talking about managing medical conditions in the later part of the session. So the management guidelines that are presented are correct. As of the most recent addition of advanced life support, that's a less from the recess Council and reference with nice CKs as well as the nice guidelines. However, the the medical management that's presented in this lecture is not a substitute for appropriate medical training, and you should continue to work within your scope of practice. So basically, the contents of this talk do not constitute medical advice. If you have a medical problem, you should speak to your own doctor. Thank you. Hi, everyone. My name is Alex trained at you see a medical school now working as a junior doctor at Royal Free Hospital. Um, I am an honorary academic at UCL, and my rotation has shown, uh, career aspirations. Our technology. Everyone again, old news. My name is Ali. I trained at Warwick. I'm a current academic F two working up in Newcastle. With the rotation shown I'm looking at careers in neurosurgery or interventional neuroradiology. All right, that's a neat my mike. I'm aquaphor the University of Leicester, currently at Royal. Sorry, um, but also have similar to Alex. I'm an honorary academic with U C l, um, and like rotations on screen right now and similar to Alex again. I want to be an academic urologist. All right. As we briefly introduced the next two sessions will be based on the eight most commonly tested 80 Scenarios and SFP interviews. Um, these are also applicable to your medical finals Loski stations as well. And as we will explain shortly the reason these are extremely important, especially the SNP interview Um Taclonex. Or that because you are having one fewer clinical rotation when you reach CT one or ST one, you are expected to be just as competent as your colleagues who have done one more clinical rotation than you. So the format of this sessions will be will be going through some scenarios in the session for scenarios will be relying on your input and make it as interactive as possible and enjoyable PBL style format so we won't tell you up front and what we'll be covering that will be working through the cases one by one. So as I just mentioned, there is a greater demand and emphasis in the SNP interviews for your clinical competency, which kind of means that you need to be above average compared to your peers at this stage, when you're applying, often there are 2 to 3 scenarios, and you need to decide on who to see based on clinical priority. This will vary from academic units, academic units, interviews. But if we based on London, for instance, which is the most popular application, you tend to have 2 to 3 scenarios. You need to assess and manage the patients in turn and justify and defend your decisions at the same time. So possible scenario, obviously a clinically unwell patient. You could also have a clinically potentially unwell patients who has the potential to grocery it. But also don't forget that there is also a potential ethical scenario. So a patient who you know, has had bad news poorly broken to them. They're upset and angry patients, the relative of the patient, who is upset about the management of the relative and so on. So those other types of scenarios that you could be facing as well the general rule of these scenarios, just like an A C situation is doing a two e through each one. But also you need to do an 80 and decide what's going to kill the patient. First, the emphasis is on you to be a safe, reliable junior doctor, and in general you need to run through the 80 formats Airways, breathing, circulation, disability and everything else. You want to also evaluate new scores and clinical trends to help your judgment's, um, based on medical situations. They tend to be low on your priority list, but don't forget to come back to them and explain what you do. In the meantime, this is important for you to have your spiel memorized, so a standard one is showing here. I would prioritize these patients based on clinical urgency. I acknowledge there are multiple unwell patients, so I will therefore first see if I have colleagues to help. It's important to show that you are a team based, uh, junior doctor Very often the CRP you're on your own and you need to match the situation, so you need to move on to say this might not be possible. I will therefore assess patients 12 or three first, as maybe they have an airway compromise or breathing compromise. Then I will assess patients to three or four a second, as they are lower down to the 80 scenario, and I won't do it as quickly as the first patient. It is important to say that while you're on your way to see the patient or while you're seeing patient one and later seen patient to to say that you would like to involve the multidisciplinary team such as your nursing colleagues, uh, other junior doctors to try and see the other patients or one you're about to see, uh, ask them to perform a new set of observations, ask them for the drug chart, ask them for the history of the patient and have a new school ready. So that's when you arrive to see the patient. You're not waiting for them to perform an E g. You'll then say that you'd like to talk to a t e such scenario running through everything. Um, you need to make sure that you rehearse this, uh, until it's second nature. We will now be moving into the scenario. One thing to bear in mind is that after the scenario slide, we have shown you the e observations for each patient. Just bear in mind that this will not happen in the interview, you will run through a T E as in your skin, and they will provide you the information, maybe show you the blood results. Gas results on the CT, but we just show them to you to make it as easy as possible in the time provided, so I'll know the personality. Cool. Thank you, Alex. So, yeah, just to reiterate what Alex has said, we've got four scenarios for you tonight. You'll be given an opening. Uh, an opening stem, I guess, is the word. Isn't it the beginning of the question, uh, to give you a rough outline of the scenario and this is really common. This is also done in finals often, so it's good to know this stuff. And on the next slide, you'll get an A to A, but it won't have. It won't have all the information. It will have some information, because in reality, that's often all you get. You get some of the information, you know, maybe the EKG machine is broken, or the SATs probe is broken. Or there's no one around all of this stuff. Um uh, and, uh, not all of it will be useful. It's It's just to help you try and make a clinical decision with with what you have. And that's really what it's about. Safe decision making. So for our first scenario and get ready to type because we'll need your input. You are an f Y one doctor working on the respiratory Ward Gordon. One of the patients is 73 year old man who has previously had very little contact with the health service until a recent admission yesterday with a chest infection. So that's your your patient. He's just now, as in minutes ago, been switched from oral doxycycline to intravenous co amoxiclav. You are called to review him by one of the ward nurses as his breathing has gotten worse. Okay, so remember your opening spiel that Alex has has just gone through when you you'd be explaining what you would do. But here we go. So we should now have an A TUI. Yeah. Cool. So, for the A, we've got some swollen lips and some gasping noises. Respiratory rate of 26 sats running at 92% on air where I've used Oh, A In these scenarios, it means on room air, uh, with with quiet breath sounds in your skull. Take his chest. He's tachycardic. 120 with normal cap refill. Know radial delay. With the BP of 102 over 64 temperature is 37 to It's got blood glucose again for those unfamiliar bm his blood glucose got bm of seven, uh, pupils equal, responsive and reactive to light and accommodating. And on further examination has an urticarial rash to the neck and left arm with a soft nontender abdomen. So, based on everything that we've been through, um, what investigations would you like? What do you think might be going on? That's the These are the questions that will be leveled at you. Basically, in response. What do you think is going on here, or what information do you need that might help you decide what might be going on? So this is all about differential diagnosis if you just let us know in the chat As soon as you've got an idea. Mustafa, can you give us some differential? Yeah, Amanda, you need But remember, they'll ask you for differentials whilst Yes, we have possibly our diagnosis, but they're going to test you and see if you know your differentials. How do you know it's not? Something else is kind of as important a question. Or what makes you think it is that equally should give it another few seconds and then Okay, is it? A. And Amanda have written Amanda's written Get some blood for inflammation markers and an X ray to rule out pneumothorax. Ishida have said that the differentials are possibly penicillin allergy or a pneumonia that's worsening. Yeah, all pretty reasonable. Cool. Yeah. So if we if we move on So as as you've very astutely noticed, this is indeed anaphylaxis. So, uh, for each of the conditions that we're talking about, I think it's really important to remember. You know, everything is about anatomy, physiology and pathaphysiology. It's about going back to your your understanding of what the condition actually is. So anaphylaxis is a life threatening allergic reaction to a substance I've put mostly in brackets there because non allergic anaphylaxis is a thing. Um, but it's most likely when all of the following three conditions are met rapid onset after exposure to a possible allergen. So we had that medication switch here in, in this case, life threatening airway breathing or circulatory problems, um, as well as skin mucosal changes. And remember, it's the syndrome, the combination of these three things that makes anaphylaxis what it is if you for example, just had the urticarial rash. We wouldn't call that anaphylaxis. We call it an allergic reaction. Um, so it's all about those A B and C symptoms. Um, which are man here. I had, uh, and he has all three of these conditions. So this is one of the simpler A less guidelines to remember, But it's one of the ones that's really well worth knowing. I think. I think Can we just ask the crowd what is one of the one of the key treatment options for this? And if you guys don't know this, what are you doing in medical school? What is the management? How do you treat anaphylaxis? Give me one word. Yes. Exactly. Yes. Thank you. Yes. Issued A Yes, that's fair, but yes. Yeah, good. We're getting the key. Point is very good. Yeah. So this right here is the anaphylaxis algorithm, and this is straight from, uh, a L s. So some of you will do a l s as final year medical student. Some of you will do it when you're F ones. Um, I would hope that you would all do it before your f two, because that seems quite lace. Um, so anaphylaxis. The first thing called for help. This is a life threatening emergency. Possible respiratory arrest within within minutes. Um, remove the offending trigger, which she said, I think, in the chat. So absolutely, if that is a cannula with with something going through it either stop the the fluid or take the thing out. If it is, um, I don't know, a metal or something that they might be allergic to. Basically, take away the offending stimulus, whatever it is, because they will. They will keep reacting to it. And mass cells will keep the granulating, um, lie down flat with their legs up. So this is a time when you can use the flat on the bed button that a lot of hospital beds have for arrests, where it will literally just drop, um, and then get their legs in the air. Because the whole point of this is that you're bringing venous return back to the heart, back to the SV. See, um, if they're pregnant on the left side to avoid compressing the SV, see, because that would again stop your venous return. The big treatment I am. Adrenaline. Intra muscular. 500 micrograms of one in 1000 concentration adrenaline. This will be pre dosed in your crash cart. Um, so every crash cart should have adrenalin in it, uh, less guidelines again. Middle third of the thigh. The Antara lateral aspect of the thigh securing the airway, making sure they're getting high flow. That's 15 liters oxygen by non rebreather mask If there is no response within five minutes to that first dose of adrenaline, so you need someone to be timing. Uh, so you need a helper that you need a second dose of. I am adrenaline with an IV fluid challenge. 500 mils of crystalloid of your choice. Something like Hartmann's or saline. It doesn't really matter. And then, if there is no improvement, this this is one of the things that's often missed off the end of the algorithm. No improvement in B or C symptoms. So breathing or circulation after two doses, five minutes apart, then that is what's called refractory anaphylaxis. And the way you manage it is with an IV adrenaline infusion, and you are not doing that by yourself. You need senior help. Um, so that's why we call for help early. Yeah, I think if you haven't already called for help, I think by the time you've finished, let's say, um, you've secured the airway and given high flow oxygen like that's what you've spoken about in your management. If you haven't said you would escalate at this, then you should to get the brownie points. So this again is one of the things I don't know, what you guys will have been taught among the different medical schools. But when I was taught how to manage anaphylaxis, it was actually outdated by the time I did my HDLs, um so anti histamines and steroids used to be part of the anaphylaxis treatment protocol. They no longer are so that the most modern version of the guidelines they're not. The reason for that is that people were fasting around trying to remember the doses of the anti histamines and corticosteroids. Corticosteroids, as you know, do nothing acutely. They take hours to work, and again what they found when they studied it was it was delaying the administration of adrenaline, and that's the really important thing. So if you've got time, mention them at the end. But not important, and the test that you can think about afterwards is a mast cell trip days in the serum. This is a substance that's released by mass cells. And if you can again three times samples the first one, uh, immediately. So after you started your recess process within two hours, not later than four, and then at 24 hours because that gives you your baseline. So you're you're proving kind of retrospectively that that it was an anaphylactic reaction. Uh, for some again, Aqua was mentioning brownie points after care is a really important part of urgent, urgent and emergency care. You don't just leave the patient, you need to take responsibility for them. So with anaphylaxis, that's observation for at least six hours. Because if you remember from your 1st and 2nd year about I G mediated reactions, there is a biphasic response. Sometimes it kicks in again at about six hours. Your steroids will help with that. If they were given, um, send them home with an EpiPen and referral to a specialist allergy service. Try and work out what's going on. That's the anaphylaxis. Thank you. And I think we're gonna have Alex to go through our second scenario. Um and I think it's important just to remind you if you have any questions along the way, please type them in the chart we're monitoring. All right, so now moving on to scenario to, um so the R N f Y one doctor normally working the acute medical units. One of your patients, Julie's 26 year old woman who's been admitted admitted following a road traffic accidents. One of the nurses called you to see Julie urgently, as her breathing has become laborious and she looks unwell. Her blue and brown inhaler are visible on her bedside table. When you arrive, Julie is complaining of worsening chest pain. So before we move on, what do we think it could be happening to the patients at the moment? Given the typical scenario, what are your top? Um, I guess different diagnoses again. And just as a sideline advice, when any medical professional society a patient looks and well, that should be red flags because that means they're very concerned about the patient. Okay, so whatever on top differential was at the maintenance. Harris Mohammed, my boy Harass has said pneumothorax, hemothorax, tamponade and Olivia. Toby has said flail chest Mustafa has said asthma Pneumothorax. My shock. Very good. So I've got a wide, uh, differentials here. So we've got a traumatic orthopedic injuries, Got respiratory conditions, got cardio vascular conditions degree. All of them are fitting with the scenario. So now, in the actual interview, you know, start working through eight to eat. So if we go to the next side, so you, you know, look for danger, respond when it comes to a airways. So we've got a patient who's gasping, making gasping noises and breathing. The lips were swollen here. Now moving on to breathing. Respiratory rate is 32. So that's the technique. Saturations are down to 90% on room air. There is reduced air entry in consultation left side, and the chest is hyper resonance of production on the left as well. When an assessment of cardiovascular system my notes, the patient is tachycardic. Uh, there is a prolonged cap refill time, and the BP is okay. Slightly hypertensive. The patient is, um, normal temperature. Lucas is within normal range, is slightly on the lower side, and peoples are equal and reactive to light. The patient is complaining of central sharp chest pain and just the complete, um, observations. Examination. The afternoons and carbs are soft nontender. So based on our observations, and we've requested a chest X ray is part of this and the interviews of narration it to us. What do we think about this Chest X ray? Is there anything glaringly abnormal here? So any, you know, radiography, radiographic films you would assess, um, quality, uh, inspiration, etcetera. But, you know, in an emergency here, which can look up glaring abnormalities. So my staff has said you've got the left sided attention pneumothorax. Okay. Do we have any more? Um, Harris again is saying left sided absence of lung markings with triple deviation to the right, Potentially leaning towards the pneumothorax. Okay. As a conflict of interest. I know Harris from medical school. Yeah, so here I'm looking at the x ray. Um, slightly concerned on the left side. Looks very empty. Competitive. Right. Um, maybe African move the mouse to show you that, you know, there is a small blob centrally on the left hand side that normally should be up to the rib cage essentially, and that's the collapsed lung. So for some reason, has entered the lung and got a pneumothorax. Um, as people correctly pointed out, we've got some tricky or deviation. Um, that shifted everything to the right, you know, same with any kind of, um, brain bleeding. Any central deviations away from the what's normal is very concerning. So I'm concerned here that there is a left sided attention Insulin. So just briefly go over the different types of pneumococcal disease you can have so simple pneumothorax is gas or air within the pleural space within the thoracic cavity. So, as you know, the pleural space is normally pleural fluid, um, and that helps to maintain the pressures to help inflates and deflate the lungs. Attention. Pneumothorax is what we call a progressive accumulation of air or gas, and that's normally caused by trauma. So starves gunshot wounds, road traffic capital we've got here. So any kind of red fractures, um, communicating with the skin allows air to enter and as the patient keeps breathing I/O, essentially have a flat formation. That means that more and more areas accumulating within we can also further subdivided um, authorities based on primary and secondary. And this refers to whether the patient has existing lung conditions or in the absence of it. So primary is, um if I'm not mistaken in the absence of existing lung conditions and secondary is with lung disease. So how do we manage an accumulation of air in the space that is quite severe? As mentioned, the House of God. There is no body cavity that cannot be reached with a 14 gauge needle and a good strong arm. So the go to management here is to palpate the second intercostal space MIDCLAVICULAR line essentially puts the needle in, and you want to decompress the air out, and you should hear a hys of it as it steadily comes out of the chest. The patient should also report, uh, reduce pain on inspiration resolving respiratory, uh, complications. I do want to ask you, um, does anybody know what color a 14 gauge cannula is? Because I didn't really appreciate the different sizes and the different colors, at least at medical school. Obviously I know now as a junior doctor, but clearly not in medical school. Most of us correct. Not sorry, Harris. I thought that two oranges bigger than gray. Yeah. Amanda. Yeah, Exactly. Crazy, isn't it? Think about how big that is so if people don't really know, gauge is a system, which means by just a broad example is within a cheaper reply. How many can we fit inside there? So 14 gauge means within a you know, a circle. We can fit 14 of these canyons inside, so it means fewer compared to a 20 gauge cannula. We can fit 20 of them, so if you imagine the movements of them individually, they're a lot bigger. Um, the other thing, just a fact that you've not seen an orange or a brain cannula is your standard blue or pink cannulas. They're quite flexible. The metal part of the cannula, a 14 gauge cannula, is stiff. It's thick. Um, it's very big. So yeah, hopefully I can find one at some point. All right, so just some specific minutiae. Attention, pneumothorax management. The A less guidelines states that if you're going to do a needle decompression during CPR, you should either do a open thoracostomy or a chest replacement. Uh, and these are placed differently and open. Thoracotomy is making an incision to directly visualize Uh, the long face chest replacement is as stated, and I presume this is basically because if you're trying to put a cannula in while you're doing chest compressions here, uh, that's going to get in the way for one and two, there's a risk of it being dislodged and etcetera, whereas if you put it laterally, uh, you're more likely to have a big achievement able to drain the air more effectively as well. Yeah, and now we would like to hand it back to Ali as we go through the third scenario. Does anybody have any questions yet? Otherwise, we can just straightly move into the just before meals or liquid. One is tension in with the active medical emergency. Nothing should delay your management, which also means that as soon as you suspected you should not be delaying anything by even getting a chest X ray, you need to manage it there and then and with no further delay as well. Just remember that and make sure you mention that you escalate and inform the medical registrar you will lose points. If you do not mention that imagining the med Reg turning up and saying you did what? Without telling me you put a 14 gauge you don't even know what a 14 gauge is you put a gray and know it's an interesting point. Alex raises, actually, and we've got a bit of time. So it's a reasonable question to ask. You know, when I'm going through my a TUI, we we often get asked when doing teaching with the medical students about should I fix things, you know, as they come up in the in the A to eat. You know, if the oxygen SATs a low, should I say I would apply oxygen here? Um, my experience with the interviews with that it didn't really matter as long as you clarified what you're going to do. If if you said I'll do the management after my full examination or you fix things as you're going through the A TUI, Um, I think ideally, you should be comfortable to do both by that. By that point, um, so your interviews might want you to do something particular. Just ask them if you're not sure. And again with things like anaphylaxis. Definitely. With attention pneumothorax, you, you can either break your sequence and say, Okay, just based on what we've already observed, I am happy, or I think this is likely to be anaphylaxis, and I don't want to delay giving the adrenaline you know you can. You can have a bit of a clinical backwards and forwards with your interviewer and see what they want you to do. Um, anyway, let's go into scenario three. But I'm I'm just adding onto Ali's point, obviously. For London, for example, it will be dependent on your interviewer. But be mindful that you will only have 10 minutes, so your priority is just to get through this quickly. Use the information that you have in front of you, which you will have, like a respirator exercise. Exercise that, and if they choose to show you the X rays, they you know they might not. But you need to work on your most likely diagnosis, and then for extra points, you need to mention your differential diagnoses and then explain whatever the most common management is for whatever your top likelihood is because then you need to move on to your next patient, and then you need to move onto the ethical scenario, which you most likely get for London. In other places, they may ask you to do one patient. They might present to you in one because my other January I just had a P um, and it was very much like what Ali said. I asked them what they would prefer, and they said, Just fix stuff as you go on, We will tell you as you progress. So I did a nothing in a B and then found tons and tons of things in be asked for and then moving on to see I got on the CD and they showed it to me. You know, that's how it was. And that was just one patient. So Dean, very specific. But make sure you know how to do both. Cool. Okay, so let's let's crackdown scenario. Three. So you're an F one doctor working in the emergency department. This is, as a side note, a rare rotation. But it does happen. You are finishing some documentation work from your previous patient when you called to see Mick, who is a 52 year old builder who has developed some central chest pain. When you go and see him, he's sweating profusely and vomits into a bowl. As you approach his bed, he's clutching his chest and struggling to breathe properly. Does anybody want to give any differential diagnosis before we reveal the 80 just from the history? It's not a calming history, is it? It's quite quite should should raise some eyebrows. Four halves. Did you know that the incidence of, uh, poor houses one in one million? Wow, It's like I'm going up a G i O Oh, yeah, but not invalid, though. Very true. Very true. I know Amanda. I know, but yeah, let's go through the Yeah. So, um, so he's panting and talking in complete sentences, but struggling to do so When you get there to speak to Nick, He's got a respirator. 20 for his SATs, a 95% on room air, and you listen to his chest. He's got good air entry throughout. Nothing else that you can hear. Heart rate of 98 cap refill of less than three. Know radial delay, and he's hypertensive. 1 49 over 100 and 10. Uh, his temperature is 37. He's got a blood glucose of 11 millimeters. Pelita and his pupils are equally responsive, uh, and reactive to light. And I say he's I think the medical term is it diaphoresis He's just really like sweating buckets when you go and see him. Yeah. So what investigations would you like? What do you think might be going on and we'll we'll give it about 30 seconds or so. I'm just I'm wary that we've got another scenario to get through and then to leave some time for questions. Yeah, And what would you want to do to help rule out a C S? Harris has said it. Yeah, E C T troponin as well. What would you want to do if it was a P? I can't see the chart aqua. But if if anyone, or if anyone says d dimer, I wanted to kick them from coal, Okay, no TV has said, Well, score has C T p A. And also the CT chest, X ray blood and cardiac enzymes. Which is what Paris and Amanda have also said as well. Very good. Anyone who's know virtual kicking. Yeah, if anyone says d dimer before. Well, score get Your consultant will be very angry as well your med Reg. I feel like he's talking from experience, but anyway, so lots of you have very correctly identified that this is most likely to be an acute coronary syndrome of some sort. Um, because again, if you said, for example, I think this is a stemi specifically just based on the information you had, um, you might get a raised eyebrow because you can't know that definitively without more information. So we've got a little sort of a a memoir here. Uh, this is like the simplest barn door way of trying to classify the acute coronary syndromes, of which there are three the first and the simplest one. If there is ST Elevation on the BCG in combination with cardiac chest pain. And I'm being very careful about those words, then that's the ostomy. By definition, ST Elevation myocardial infarction. If you have no ST elevation or ST Depression or T wave inversion, other changes, um, with negative troponin, which you do sequentially. So you have two negative results. That's you're unstable angina diagnosis. If you get positive proponents and therefore cardiac my sight damage, that is your end stemi non ST elevation myocardial infarction. So, yeah, this is again. It's important to think about definitions for the conditions that you're diagnosing. Uh, have ST elevation in your myocardial infarction. You've got to have a transmural infarct That is complete occlusion of the blood vessel by thrombus. Uh, and that produces localized ST elevation in the territory that that coronary vessel supplies. Um, in turn, you get cardiomyocyte death resulting from malperfusion and that causes your troponin release. Most labs will test for troponin tea or troponin. I, um it depends on your particular lab. I think there is an E c g on the next slide. I'm hoping this is just a quick one, because again, you might be asked to do it. Uh, if I told you that this was a stemi which territory? If you were to try and describe where the location of the thrombus is just looking at this, would you be able to tell in the chat if you post your ideas? It might be a while since some people have looked at EKG, I don't even look like I just look at the CD, and I'm like, Yeah, that's That's the thing. Oh, yes. He's known a half right. Yeah, he's not a okay. Hmm. Oh, that's I think, maybe easier. Which leads Show ST Elevation. That's a good place to start. Fraser has said Anterior. Any advancement on that? Oh, Oliver, Toby has said anteroseptal. I think just to just to make sure we move on, I think both of those answers would be, um would be absolutely more than fair. Uh, your, um septal leads. They're being technically speaking B one and B two, and you're and you're purely anterior leads three and four, So, yeah, absolutely. Either of those would be fine. Well done. So, to run very quickly through the stemi algorithm. And again, all of these videos are available on demand both on the middle website. Uh, we'll make sure that they're all available and on my YouTube channel as well. It will be from tonight. But suspected stemi or confirmed stemi once you got your HCG 300 mg of aspirin to load them up, then this is the key question. Is this person going to be suitable for cardiac perfusion therapy? If it's within 12 hours of symptom onset and you can get them to Cath lab within two hours, uh, they need angiography with primary PCI. So that's going to be your clot removal, clot busting and stenting for which they would get prasugrel with aspirin I mean, this is all a less your local cath lab may have different guidelines. If it's within 12 hours of symptom onset and you can't get them to a cath lab within two hours, then you're instead going to fiber and fiber analyze basically break down the clock and to Calgary along with aspirin, which is commonly used for that. If you, uh if the above basically isn't true, so it's beyond that symptom onset. Uh, then you're going to medically manage them. Uh, the standard for that again in the UK is to gargle with aspirin. Um, so ticagrelor is an anti platelet similar to aspirin? Uh, if it's if if they've got a low bleeding risk, for example, if they're not warfarin ized or something like that or on on a dose, pack clopidogrel instead of take a grill or if high and then cardiac secondary prevention, you will all have heard a million times a day inhibitor dap dual antiplatelet therapy, beta blocker, statin and again thinking about aftercare, cardiac rehabilitation, lifestyle change, education screening for heart failure with echoes. All of that kind of thing be bread and butter. Tea. Yeah. Um, if you have any questions, Save them for the end. Because I would like to quickly was through the last scenario, which is quite fitting because of my rotation that I'm currently on. So you're an f Y one working in June search. You just started the evening on call and you walk into a bay just as a patient projectile vomit a large volume of fresh blood onto the opposite wall. And I have seen this. It is very, very graphic. He is a 64 year old male who had uncomplicated laparoscopic appendectomy three days ago, and he's currently receiving know anti coagulant medications. Does anybody want to have it? I guess. What's happening? Anybody Anybody wants to give any differentials? This man is projectile bleeding. Well, vomiting blood. Okay, Mr Yeah. Anyone else? Oh, should I say if we know that this is an upper GI bleed? Can anybody tell me the most common causes for an upper gi bleed? Yeah, exactly. Yeah. Esophageal viruses. Um, peptic ulcer disease. Anything else? Give me one more. That kind of links with peptic ulcer. This is me because I really don't know. Know this until I saw it on my rotation. A cephalitis cancer. Yeah, but you wouldn't get projectile. So essentially, um, the most common causes are some viruses, peptic ulcers, gastric erosions, And, um, we'll go through a bit more about what the pathophysiology after we do our 80 but moving on to our 80 primary assessment, blah blah. The patient you see is retching. That's pretty much the assessment for his airway, his respirations. 24. So it's quite raised. SATs have dropped a bit to 94. He's got good air entry throughout, but we do hear some crackles in the right base. His heart rate is obviously, he's tachycardic, his cap refill. Time is fine, and as you can see, he's very, very low with his BP, and his pulse is quite threatening. His temperature is now being elevated normal. Other things. Looking at him systematically, I guess. No rush. And you know that he's vomiting blood, and that's all in keeping with an upper GI. I bleed. So moving on as we've already identified, these are the most common cause is, and there are three key factors. Does anybody want to tell me clinically, what are some dead giveaways or associations with an upper GI bleed. What will we see on assessment as well? Potentially. First one is a gel related. Which patient? Population? In terms of age group. Will you see this more likely Over 50. Close? Yeah. And, um, in terms of their stools for the second one. What color do you think it might be if it's really bad? Yeah, exactly. It'll be black and related to that. Does anybody know anything about, Like, a creatinine ratio? Something to do with, Like the urea and creatinine. All because of blood, obviously being digested, digested and stuff. Yeah, exactly. You're going to get an increased your area creatinine ratio to push you some more. Harris, can you tell me why you get an increased ratio? I kind of alluded to it. Oh, yeah, yeah, yeah, pretty much exactly that. Like it's being broken down and increased. Yeah, exactly. Increase. You know, the nitrogen waste products or area. And with two or more of these, you're gonna you're gonna think that upper gi guy is more likely. However, you can see this guy is literally coughing up and vomiting out blood. So this is the algorithm again from the ls protocol. Um, in terms of scores. Hope. Well, now you've seen you've seen the slide already. But does anybody want to tell me which school you're going to use first and and what it actually looks at? Hopefully I didn't look at the side for two. Yeah, that's how you remember. That's so nice. But why? Why do you do that score first? Yeah, Exactly. Yeah. Well done. Yeah. Amazing. Okay. And then what's the second school, then? It's not. Rock will close. It sounds very similar. Yes, you have. The only reason why I know is because he's also the same guy who's made. Who made that score. Is a professor at my hospital and I literally walked. Passed his office every day, so he would literally kill me if I got it wrong. Yes, Rachael, It's the local school. Exactly. And what does that measure or look at close? It's looking at, like the risk of death. Morbidity, mortality, all of the post. Yeah, exactly. All the post stuff. So one is pre endoscopy. One is post endoscopy. So first step, we're going to do the bachelorette school risk assessment. Need things raised. You're going to want to do it. If you suspect a virus, it'll bleed. And in these patients with liver disease and alcohol excess, you're going to give them too early present. Obviously, with this chap, we know that his BP dropped and he was very tachycardic. And if we were to look at his H B, we it probably will like in a couple of hours. It may be may be dropped because obviously it takes a little bit of a while for it to reflect in the in the blood. But you would transfuse if necessary, if again. Same same goes with platelet and fresh frozen plasma. In terms of endoscopy, we can split this if we know that the patient is severely severely bleeding and he's unstable, his new score is off the charts immediately. Done Dusted CPA, Your support theater is going to be open and willing to take this patient. Then we need to make sure it's within 24 hours for everyone else. However, in your interview and maybe a ski, you're most likely going to get a really animal patient, and this is going to take your top priority. If it's very special, you need to start talking about and showing off your knowledge. And again these slides will be made for you made available for you on all these YouTube channel, and we will put it all on metal band ligation tips. If a gastric again n NBC A or tips if non vericeal again, we can give mechanical or thermal anticoag fibrin thrombin. You can literally just split it into very cell or non. Very well. These patients need to be on PPI or H two receptor antagonists. And again, in terms of aftercare, you need to split this out. You need to be able to roll this off your tongue. Low dose aspirin. You're going to make sure that they're not on any inserts because they irritate the stomach, obviously, and then you're going to want some specialist input. Um, if they have chronic diseases, for example, liver or alcohol problems and you're going to want to do the Rachael School, This is just things that you need to absolutely memorize, and this will also be in the back of the Oxford Handbook. There is a chapter on emergencies that I would heavily advise you reading it, and you read it until you literally get sick of it. and you memorize the positions of each word on each page. That is how how chronic, you need to just absolutely absorb it. Okay, you need to be obsessed. But as as we rightfully pointed out that feed first, then Rachael, I'm going to hand it back onto the only and Alex for They're concluding sentences, I guess. Sure. I'll, um this is just something I put at the end. I'm sure Alex has something more erudite to say, but, um, this stuff although a lot of it feels very academic and, you know and you guys are here on a Thursday night probably sick and tired of thinking about medicine. Um, and stressing about the AFP Sorry SFP applications. This is actually, I think, the part of the process that is useful and is a good use of your time because all of this stuff is finals level. Ultimately, it's very fair game for your written papers and your clinical exams. And most importantly, like, this is the practice of medicine. This is going to be really relevant for you guys when you become F ones. And when you're an S h o on call, the reason they're called common emergencies is that they happen commonly, and because junior doctors live on the ward's rather than elsewhere, you're going to be first on seen a lot of the time, especially once you've done your RLS. You you could, in theory, be leading and arrest so kind of it's worth knowing that's the first thing. And the second thing know the broad strokes and the general flow rather than if you've got a limited amount of memory space. It's knowing the big important steps rather than being able to say, Well, I know that if it's a gastric variceal bleeds, then I need to give NBC a then maybe do a tips that's less important than saying transfuse the patient that is bleeding profusely. Um, so big picture is better than the minutiae. Yeah, I completely agree with what he has said. The underlying emphasis of the people in our interview is for you to be a safe, content doctor. So the emphasis is for you to be above average at this point of your interview, because they need to know that you're good enough with one of your rotation to be managing, uh, more patients and no one to escalate. That is also very important. So I don't forget that even though we've gone through a t. E at some point, probably early on, you need to be calling for help because you need to a show that you're, um, team based doctor, able to work with all of your colleagues. And secondly, know when your competencies limits have been reached. So as a first, a junior doctor, first radiation, first night shift, upper gi bleed, Probably not going to manage that on your own. So make sure you call for help. Yeah, And I guess, um, as a recap, just quickly recap everything that we've re catch on. So we've spoken about how for your clinical portion of your interview, Um, you're going to have a couple of unwell patients If you're London or in other DAENERYS, you'll be given our scenario and remember that you can be given unwell patient, a patient who is about to deteriorate or an ethical dilemma. And remember, prioritize a over B and C over the for example, consider the clinical trends and make sure you have this memorized like this can. Basically, this is at least 20 to 30 seconds that you can secure in the bag. This will make you look so professional. That hell, they might even stop listening after the 20 to 30 seconds. Because I was like, Okay, this person clearly knows what they're doing or saying, and we then went through four common scenarios. Um, And when it comes to next week, we're going to go through the four other common scenarios and hopefully throw in some ethical dilemmas, which I feel like will be very, very worthwhile. Your time, unfortunately, brings me to beg you for your feedback, if you guys can. Yeah, it makes a difference, guys, you know, And when when you are doctors yourselves, Um, hopefully doing similar sessions on supporting people into the SFP, which I'm sure that lots of you will, uh you will want it as well. So it pays for words. Um, you know, we all need it at some point. Yeah, and your feedback directly helps to improve the sessions. So I think very early on, everyone likes the interactive pictures who continue that as a key thing. And after next week's session at the end of that, we'd like to hopefully run a mock scenario. So a couple of scenarios how to prioritize and how to work through those once we've got a couple more exercise as well. Yeah. And please, please ask any questions that you have will be around just for a few more minutes, uh, to try and tie up the loose ends, We've got some more questions. Um, Ali. So LH to the That's how you pronounce your name, right? Totally not a fake name. Are these lectures available on YouTube to? Yeah. Yeah, they are. Some people wrote to me saying that they were having some problems accessing the on demand videos on metal because we haven't put them up. So we've only got the ones up for the first two, but so we need to upload them. Basically, Yeah, we'll put them on. But they are all yeah, on on the YouTube channel as well. And this one will be up in terms of YouTube. Just type in Olive Burton med and it should show up. And then, um, JJ has asked Sorry for a final question. Is the clinical station for Northern similar to London? Um, it's a good question. Unfortunately, not not one I'm able to answer, particularly Um, just as I say to everyone, like virtually everyone that is applying to Northern asks me about the interview, The safest thing for me, especially as someone so that Professor Vance, who runs the Northern program, is my supervisor, Um and so I have quite a lot of insight into how how the process works. I I just have a flat kind of. I do my best not to discuss the Northern interview with people because it would. It would be a little bit unfair. So I have a look at what they publish on the website and that that's kind of all of the information I can give them afraid. It's very rare. And the only reason why me and Alex kind of feel free about the 2 to 3 patients scenario thing is because that's widely known. And if you look up on the London website, you'll see, and they usually give examples, so make sure you check that for if you're applying to London and J. J. I guess as a rule of thumb, just practice both practice every single type of 80 whether that's treating as you go along or doing your assessment first and then talking about your management, then going into different rules and why you think it is, um or and then practice 2 to 3, rapidly going through it within, like, 10 minutes or expanding on everything. Um, for 10 minutes for one patient. Yeah, completely agree. So practice is the key to sfp practicing with friends getting, you know, actual doctors remark interviews because coming off slick competent is probably the most important thing you can do. Uh, especially for the clinical scenarios. Managing all of the patient's given to you is quite important. So key advice is when you get the scenario, have a few minutes. I can tell you how many minutes you get to prepare. Start thinking about you know who's the most of my patients, and you're prioritization. So if you're given, you know, a chest pain patient, a patient that angry and you prioritize the amputation first, probably going to fail the interview. Um, and that's quite easy to, you know, get confused under pressure to do take a minute to think about it, Um, and also, you know, while you're going to see the first patient, you may not have enough time at the end of the interview to come back to see the second patient start having your safety net in place. Can you send one of the nurses or one of your colleagues to go? You know, hypoglycemic patient. Can they start getting glucose gel or glucose? What? You can manage the, uh, the other patient, angry patients. Can you get someone to, You know, try and speak to them as your away and not leaving them just waiting around the board. Can you call security, for instance? Uh, coming up slick and managing all your patients is important. Uh, don't be surprised. Last year, in my London interview, I managed to, uh, quite efficiently manage my patients. Uh, we finished early, actually. Threw in a new scenario. There's another patient who has this condition. Uh, yeah. So just be aware. You know, it's up to the interview is how far they issue they just stick to what I'm going to. You may push each other, so just be aware of anything is possible. Yeah, And then Harris has asked, Is there a prioritizing prior to that prioritization in every interview? So no, um, some daenerys will basically ask you one patient scenario, but they'll be very acutely unwell. We know that London and some other sceneries will, however, ask you and and present to you a couple of patients. I'm not going to go into depth with which other surgeries other than London, but there are a few. All of this kind of makes the assumption that historical trends follow because you've got to remember that SFP like recruitment processes, will be subject to review every year internally, in the in the different sceneries. And they may decide to just completely change it one year. And you don't know that, you know, this year isn't going to be the year where they do that. So it it's, um, as I think we all said before, it's better to know your stuff and be very well practiced rather than relying on kind of practicing for a particular set of scenarios and questions and then getting something outside of that that throws you. It's about being comfortable while under pressure that's going to be more helpful. Yeah, so you know, if you go to lots of different courses, lots of different courses give you a different list of what are the most common drowsiness scenarios. Just remember that in the SNP they want to test, you know, the most common, the most important. What's going to kill the patient type scenario. So, you know, are you going to be asked how to manage a Cushing's emergency? Possibly. But it's probably not the most likely compared to Upper GI I feed. A patient has a resting on the ward. Um, those are things they want the most. Um, you know, the average, you know, Doctor will need to manage. Um, going back to the question about how to prioritize. I'm sure there are lots of different ways to prioritize. You can re strategize, risk stratification patients. You can new score them, you know, prioritize. Based on new score, you can participate in the eighties. It really is up to you. But it is quite a straightforward, quick and easy one. So the patient at risk of airway compromise would probably go to see first competitive patient who is, uh, you know, hypoglycemic or has a low BP because someone who rests on the ward the airway compromise will die first compared to someone who has low BP. They've still got the BP. They may deteriorate, but you've got a bit more time to manage that competitive and classification, for instance. Yeah, and I just like to add, um, too useful tips. Make sure you refresh and review the Dean very specific website, because that is where all of your information will be like. I know. And it's annoying because some of these injuries might hide links in weird space is that you need to just figure out by yourself. Um, but London, for example, gives very, very clear guidance if they haven't already uploaded the applicant guide for this year. Um, and another tip that you can do is there is no harm in you contacting the delivery itself, and then you'll be referred to the academic unit and they will decide how much they can disclose to you as an applicant like that is probably your best shot of knowing and getting ahead because they are the ones that can give you all the correct information. And up to date, we're giving you not generic, though we're giving you like, I guess, informed information, um, and the different scenarios. But dinner reading very specific. I would contact them yourselves. okay, if if nobody has any further questions and thank you all for coming, um, should we think about drawing it to a close? Yeah. Do you guys have any further questions and do come next week as well? And do you feel in the feedback? Because next week we are going to go through some more scenarios and, um, really, really keen on going through the the ethical stuff, like the angry patient and then dolls. And, like, how do you assess capacity, all of that stuff and how to do it succinctly in within, like your 10 minute time frame, or actually, two minutes? Because that's going to be your least prioritized patient. I guess I'm going to send the link on school, and we're gonna draw your host. Yeah, we're just kind of training you to be F ones at this point is less about the less about the interview and more about how to be a doctor were really traumatized. All right. Thank you. Then we will see you. Same place, same time next Thursday. Here on that. Thank you.