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from the the F Y one who's leaving and handing you to bleed. It's clearly quite frazzled. Apologizes. They pull out a list and say, I'm sorry. That's still a few jobs Me to hand over on the register. Our says, Do you look, make sure you do take a least a 15 minute break it some point during this shift, so those are the things we need to think off. There's always the option of taking a break. So jobs handed over. If you want to make a few quick notes on a piece of paper, that's absolutely fine. But we'll come back to these frequently, so don't worry too much. Eso. The first job that sounded over juice is that we've got John Smith on Ward eight. He's had a chest X ray done, and if one says I'm not had time to chase it, could you please take a look and just act on? Whatever you can find on the nursing staff on Ward nine have also asked for an anti emetic for Harold Thompson. Could you just pop up prescribing something as well? Please, Vera Wang is just finished. A bag of fluids and the nursing starter bleed, asking if you can write another bag for her on then. Edward Angle has transport looked for 10 a.m. tomorrow morning, and the nurses have been chasing the uncle left one all day long for a discharge summary, but she's just not had time to write it and says, I've been really grateful if you could solve that out as well. So those were first starting cases. We've got a few ground rules. I've mentioned some of these already, but besides the basic information presented, you won't get further information a little specific about you. Want about what you want, so I have that in mind all the way. As we go through, they'll be more information areas where you'll see letter coded boxes used the trap function to call out things if you want, then we'll go into those on Tell you a bit more about these patients. Also, this is designed to try and emulate the real world, so there is often more than one direct answer to how you can manage a patient. There's no always a perfect answer. Sometimes there are multiple different ways that different people will approach these sessions on day one of piloted this with various consultants. Registrars s a chosen F ones. Lots of people have lots of different ways of approaching this. The key is to make sure that you are choosing safe options. Every case we'll have some options which aren't correct. Some options which of potentially unsafe. But as long as you as long as you think of a safe option, don't get too. Don't fret too much if you can't use between two options, which to you both seem like they could be correct. So with that being said 15 minutes later, we don't hand over. These are the four jobs that we've been given so far on. What I'm going to do is put a poll out to you guys for which of these cases you want to start with. We'll say option is that we go to John Smith and we have a look at his chest X ray and try to manage Jeff. Option B will be that we could go to Herald Thompson and sort of anti emetic out for him. Option C will be going to sort this discharge summary. Every single on option D will be going and sorting the fluids for Vera Wang. Say, if you guys just have a quick think about which of these you which prioritize first, I'll give you about a minute or so to think about and again. Even with the prioritization, there's not necessarily a correct answer. We'll go with whatever you guys think on their always multiple, different ways that you can approach. A shift is great. So interestingly, actually, that's there's two options, which are slightly favorite over another. But there is a good a good split of people who have done different things and probably fit from reasons. So, yep, we'll share those relapse. So actually, we got a 50 50 split between options A and B options. See India both valid. Anyone who's picked options C or D. Could you just let me know in shock? Any sort of thought process you had is why you wanted to prioritize those ones on. Remember, I'm not saying any of these Maurine Porton than the others. It's just interesting discussion point sometimes, and then we can talk about if anyone has gone with options C or D. If you could give me some sort of thought processes or ideas of why you thought this was the most important one. If you know if you know comfortable sharing, that's actually you find them, we'll just Maybe we got a 50 50 split between options. AM be so, Lily. Should we go with looking at John Smith, Stress secretary? Or should we go for the anti emetic? That one person, one person is sorry it's one person is just message and said, Go into the fluids could be quite important quickly if they're vomiting or have diarrhea. And yet that's a really good thought process on. It could be hypertensive as well. And so it could be that the fluids is just something really important. And also it's a quick job, someone said, which might be worth heading to in getting done and out the way early before you get tied up. And that's a really good point. Actually, I think is a really good point to think about sometimes quick jobs that could be done when you've not got any crashing Emergencies. Could be really nice to get out of the way when you know that. Easy. Brilliant. I'm sorry. Really. Okay. I'll go for the chest X ray just because that's a ton bit more interesting to me. So let's have a look then. So we've got John Smith on Ward nine. He was admitted from a nursing home with fever tachycardia on a hyperactive delirium. He's got mild dementia but no other chronic conditions. His focus of infection was unclear on, but he had an oxygen requirement to two liters. So yeah, it's just It's very requested is not passed any year, and so it hasn't given you a urine sample. But he is. Catheterized has been. Start is now catheterized directions say he's been started on vancomycin gentamicin the metronidazole on for Christine, sepsis of unknown origin. So that's our sort of starting point. I'll give you guys sort of 15 seconds just to get that in your in your head, but we can pop back to it if people are missing. Difference of information. Great. So way we have a little look at how John's progressed. He's needing four liters of oxygen to maintain his saturations, his heart rate and BP of improved with some fluids, but his respiratory rate is still 42. He's still spiking temperatures. His latest is 38.3 on he's got some right sided course crepitations on. So now this is the time for you guys in chapter. Tell me what more information you'd like to know about job. Any other investigations? You'd like any, Um, any simple bedside test? You want any examination? Things that you want to know about? So, yeah, someone said in a BG I've got an ABG in here. ABG. He is a BG eat. Be well, so we've got any GI with a pH of 7.38 PCO to 5.3. Appear to a 14 a laxative, 1.8 and an h c 03 26. Does anyone want to interpret up for me? So either in the chat work, if you want to on you on, give us an answer. What? You think that ABG? Yeah, everything is relatively okay. Popular rays lactate. Yeah. So I would agree with that. That's it's no, I lactate where I feel like Oh, my gosh, I needed a jump in and immediately address that, but it's more than 1.5. So it is an indicator of someone who's doing some amount of anaerobic respiration and probably six to a degree, but they're not acidotic. That's a normal pH on their PCOS is completely within range. They're always in. Ah, there we go. That's a good point someone's just raised. Is it a normal ABG because they're on four liters? So that's a really important thing to think about cries when you're interpreting an ABG the oxygen, so a normal excision is above roughly about 10 to 12. But you really need to think about how many liters of sort of oxygen someone's on, actually, for four liters of oxygen. 14 is not really high enough. Um, I don't remember completely by rote the formula, but there's simple ways of calculating how much someone's po two should be when they're on oxygen. If this ABG was taken with his oxygen paused, then that would be a reasonable oxygen if it was taken what he's on four liters and actually, yes, we would expect him to have a slightly higher oxygen than that. So knowing that this is on four liters of oxygen, how would you then, in perfect? That's what would you say about it? A relatively high bicarb to compensate for some respiratory issues? Potentially, I think the normal I think normal bicarb is 22 to 28 something that is still within range. A little bit. High pockets. I guess we would call it Type one Respiratory failure. So, normally, anything on oxygen if below 10 would be a a respiratory failure. Either type one or type two type one if there's normal carbon dioxide and type two if there's high carbon dioxide. But given that this is on four liters, we would expect it to be significantly better than 10. So 14 is probably still a type one. Respiratory failure. Good. So attention. We've got a bit of room to move those move the oxygen. Anything else you guys want to know about this patient's? We've had an ABG Uh, someone said in Echo. Yep, Latest Echo shows an ejection fraction. Greater than 55% is normal. Someone's asked for a blood or urine culture. We haven't had a year in sample way. Haven't had a year and culture back yet. They catheterized announce they have sent off a bit of urine, but there's no urine culture results yet. Blood cultures. Yeah, so I think we've got some blood somewhere Lily gym and reminding me with blood yet? Um, l they've got a white cells of 14. We've got a CRP of 68 good area of 8.7 and a creatinine of eight before we have had two blood cultures said, But there pending. What you guys think of these books? High CRP, Yeah, over the Greek infection. Yeah, I think that's I think it's worth saying these these sort of common sensible things. Yeah, it looks. That's the kind of blood you expect with an infection on. Some was asked if he's on antibiotics yet. We mentioned at a minute ago. He's on vancomycin, gentle, my Sinemet on the urea as high as and other things. I was printed out. Yeah. Do you wanna go into any more detail about why that high your ear is relevant in this situation? Because it's a good point. The high your ear is significant on. Why is that significant? Okay, I potentially I mean, the creatinine is 84. That might be that might be a high creatinine for him, so it's important to know is baseline. But we'll say that's normal for him on somebody said curves 65 or yeah, absolutely. Or dehydration Yeah, to really good point. So I urea with a normal creatinine is usually indicative of some sort of dehydration on, but it's relevant specifically here because of perhaps 65 score on. I think we've got a Curb 65 school behind one of these as this club six about. So yes, it helps you to to think about a Cup 65 score. So we've mentioned that is slightly confused already. Way said. He's got mild dementia, but he's got a hyperactive delirium, so that's new confusion. He's got a high risk, high risk period. Your rate of 42. He's got a high urea eyes. BP 118 over 84. What's the cutoff that you guys use for scoring a point for BP on perhaps extra five 90 Systolic it. I agree. So a systolic of rest 92 dozen school for his BP, but he doesn't go for his age. So actually, that's a Curb 65 score of four, which is indicative of really severe prognosis on it means this is definitely someone I would be worried about, eh? So this is someone who is sick and someone who needs really good attention and broad spectrum antibiotics and get management. So I was starting to build a bit of a picture. We've got someone who's in type on respiratory failure with what? Sounds like a just infection and pneumonia. Potentially with, Ah, high Cab 65 score. We definitely It's a pneumonia. What did we come to this guy for? Yeah, just X ray. Um, So there's this chest X ray. What you guys think of that? Yeah. Low by pneumonia. Yeah, right. Lower lobe, potentially right. Middle lobe. If you look at the right cost, a frantic angle is is clear. Potentially, actually quite well defined. Which consolidation of the middle lobe, Right? Middle lobe. But yeah, we we confidence say that. Yeah. This is definitely a pneumonia. I think we could be. I think we could be fairly confident with this on. So if you think of respiratory signs with consolidation or on a chest X ray and an infected pictures any bone year, isn't it? So I think we can We can say that. Yes, there. Initial suspicion of pneumonia is good, right? So Oh, any more information you guys want to make four. We made from? Yeah, that's, um it broke Grams in there as well. I agree. Okay, I think we're happy. So let's think about a management then and what you don't want to do about his antibiotics. So initially he was started on a broad spectrum vancomycin gentleman that's in a metronidazole because we weren't sure what the origin of his symptoms were. Now that you've gone to reassess him with the benefits of time, it's a bit more clear that he's got a chest source. He's got some bronchogram. She's got a pneumonia or what you guys want to do about it. It's antibiotics because we put him on some really broad spectrum antibiotics in a minute. What do you guys think? Speech and culture. Yet we could send one of those. Tough. Definitely. You could idea what was his renal function. So his creatinine was 84 which was saying for him, and put him in a normal, normal range. Any allergies? Yeah, that's really good. So that's why he's on vancomycin. Been on. I don't know if any of you noticed that, like my things usually not your first line antibiotic for a broad spectrum on, but he's on vancomycin because he's allergic to penicillins. So, as I said, you guys really important to think about any bits of information you might want to know? Because if you go by trust guidelines, you might want to give him a a penicillin or something. That's what you guys want a deal and say, Let's get a pole going So what's on his antibiotics? We've got a few options here. We could keep him on the antibiotics He's already on. Given that it's a night shift on that he's on quite broad spectrum. We could wait for some sensitivities. We could swap him to amoxicillin and doxycycline, which is a usual antibiotic regime for justice. We could change him to keep it as a demon IV vancomycin it broad spectrum cover we could swap him to. Levofloxacin IV is a standalone agent. We could swap him to doxycycline, followed by 200 mg start and then five days of 100 mg and add on some IV clarithromycin as well. Let me know what you guys think of this. What is you on either? Yes. And he's on IV vancomycin. Gentamicin A metric. Let me know when you want the whole story. I think there's still a few good a few ounces coming in. Yeah, we can start her on share. Oh, sorry. Yeah. So and Communist are you guys have given this to keep him on the antibiotics he's currently on on? Anyone wants to tell me what we've got with the option? Because I think it's perfectly safe option. Still not got sensitivity. So why don't leaving on broad spectrum is Yep, us. That's a good point. Nothing that's absolutely since sensible. The other thing you could say is that once you've started someone on an antibiotic regime, it's usually worth leaving. It's 24 hours, and he is still spiking fevers. But usually if you've started someone on an antibiotic regime, you need to give it some time to work. And that's usually at least 24 to 48 hours unless they're really deteriorating. Option B. We've mentioned that he's got a penicillin allergy, so I don't think giving him IV amoxicillin would be the best started here. So I think option B is the unsafe option here that we should avoid it on both thoughts. Anyone wants to make any comments about IV kept acidy. Yeah, cause reactivity. So Keppra's boring is actually you're in the in the group of I think they're in the group of red drugs. Actually, you shouldn't give with give with severe type one penicillin allergies, so we should be avoiding Catholics. Boring is in people with severe really penicillin allergies. Doxycycline father by with clarithromycin is not a bad idea. Yeah, I think I think that may for within some trust guidelines. I think the thing I would say about that is you may be no got the best of gram negative cover with that, but it's still probably a reasonable option on, but the person who's believe the Floxacin I'd be really grateful if you would share your thoughts on that. What made you go? Levofloxacin. That's actually levofloxacin a really good option, particularly the elderly patients with confusion. Levofloxacin, as a stand alone agent for chest sexes, provides really good wide cover on the What's the thing? We need to be careful off with four quinolones Such a sliver floxacin and ciprofloxacin, particularly IV seizures are not one that I had thought of. C. Difficile one. I was thinking off. Yeah, so see that for something to think of, but actually a lot of trust guidelines will tell you the Levofloxacin as a stand alone agent for chest sepsis is a really good option. So yet, personally, I think options options a, D and e are safe options, options a India, probably the two, which I think would be the best on party cover for them. So let's go ahead with people kind of getting the idea of how this works now with sort of having a few good safe options and then possibly some, Let's say, if one. So we've seen her first case, time moves on, and as a dynamic situation, we get a bleep on. I say, My doctor, it's toward three. I've got a gentleman essence be prescribed, please for Moana flowers. So whenever you got time, can you come up to do that? So move onto 10 20. So obviously we've seen John Smith know, so we'll remove him from the options. So our four options now option A will be Harold Thompson's anti emetic option. B will be Edward Ingles Discharge Summary option C will go Revere were very Wayans fluids on Option D is the gentamicin prescription for reminder for hours What, you guys? Where do you guys want to go? Uh huh. Ese anti emetic is the discharge summary. See, Is the fluids on D? Is the gentamicin? Yes, almost up there. So majority rules. You guys were going to be the destruction relaxed. So we got everything. Goes a 32 year old man who was admitted to the hospital with an acute exacerbation of asthma. And he was made military 50 discharge today. His discharge summary has been started by the day team, but they haven't added his medications, have not done his follow up plan and have not signed off the discharge summary. And he's getting really impatient to leave because it should be his week. Emily's daughter. And he just wants to get home to, uh, so get some more information about her. So he was treated with IV steroids. Nebulized albuterol nebulized ipratropium was reviewed by the respiratory clinic on their specialist, and she stepped up in small halers on. There was a concern about whether he might have a small infective focus on his chest X ray. That says a plan for him to be followed up in six weeks. What do you guys want to know about it before we do is just trust the MRI allergies. No allergies. He's stable on an antibiotic regime. How many exacerbations as he heard? Well, that's maybe you know something that's gonna be, um, relevance was now. But he's not thinking of treating and we just want we're just looking at distrust somebody. How long has he been on the stepped up inhalers? You're sensible thing. Is it safe to go? So we're going to assume that the decision to make it medically with the discharge is a safe and correct decision has been made by his care home opposite completely stable previous medical history. Is it all written on the discharge summary? Already So thinking about these things here, he's got IV steroid. Been on IV steroids. You got no extra requirement. He's definitely safe to go home. Is inhaler techniques been looked at by his respirations specialist, so he's still got some IV steroids going. There's a good um, has he got an appointment considering the recent step up on, So I think that's one of our options here lately. Can you remind me? Clinical followup is see? Yes, he's got some follow up arranged with the respiratory Kleenex for That's in. And that's good. That makes your life easier. So they have an asthma care plan yet that's been started by then their specialist. But think about the fact he's still on. He's been on some IV steroids. Yeah, they can switch the world. What's the problem with those? So you switched on IV to your private. There's no documentation about how long he needs to be on that pred for okay. Anything else? So, yeah, do we need to? So we get a news. Just transfer. May. Yeah. You guys wanna days destroy summary? That's fine. Um, what other things do we need to think about? So is there a steroid tapering down plan? If we've got a plan in place, what we want to do about this? What? What did you guys suggest? For a safe steroid plan? Someone who's had an exacerbation of asthma. How many days of steroids? But you want someone on if they had an acute exacerbation of asthma or reproach Five days yet that's reasonable. Okay, so let's do is distract somebody. Give them five days of prednisone and we'll get him on the, uh, We'll make sure that he's got his clinic follow up arranged. Perfect. That's fine. But so you had You see some of these samples little bit quicker. Next one's doctor. Wonder if you can come and prescribe a sleeping tablet for one about patient that she's not slept for the last three nights. So that was another one of the cases. So now we've got a few things on here, so we will put a pole up again on day next cases. We've got options. They It's to go and see Ramona flowers about her gentamicin. Option b, we can go in salt this anti emetic out for Harold Thompson. Yeah, Option D is all right. Sorry. I've just given the room the wrong follow up. I'm sorry. So the next patient is someone who was closed and bit too today had all the regular medications that hasn't got a start on the fur is my prescription, so they can't give it. Sorry. That's our our latest status case. So option is the gentamicin prescription option. These are anti emetic. Option C is that we can go fix this for a reason. My prescription option Deere's that we can go in salt barrel ones. Fluids? No. Yeah, great outlet shelters. So, comma, next answer from you guys is which you're going so symptomatic. Yeah, he's been sat there feeling sick. Quote what we're now. I think that's definitely reasonable. Say, let's have a liquid risk. I So Harold Thompson. He is an 87 year old man admitted to the Jerries Ward following a full secondary to postural instability. Mrs A presentation that you will see countless times during your off one year and he's been feeling sick throughout the day. But the dating was so busy they weren't able to get around to prescribe him an anti emetic on the nursing's. I really want to say it's up because he's got time Doral medications, and they're worried that he'll just bring them back up. He hasn't had an anti emetic, so let's get some background in for him to get a previous medical history of Parkinson's disease. He's got bilateral knee osteoarthritis, too. It's called postural hypertension. Atrial fibrilation historically had a hepatitis a infection, and he's previously had aspiration pneumonia on what more would you like to know about this guy before we give him some anti emetics? Yeah, medications. I think that's one of our options. Yeah, so Parkinson's medications of the ones I've written here, these are the crucial ones who takes leave a doper a matter park on. He missed a dose of both of these two hours ago. What else? I think someone said Allergies. I think that's what our options allergy is. De de. No known drug allergies. I spoke last attorney, Fine in range. We know about it compared mint note. So his latest Bloods haven't shown any any problems with these repose. I'll be happy to move on. Yeah, problematical histories. Here's he's got Parkinson's disease by like for me off writers. Postural hypertension Air historically had a hepatitis A infection. He's previously had a aberration. Pneumonia left. He's a completely normal. So the nursing staff so used to feeling sick most of the day. But the day team didn't get around to prescribing him anything, and he's vomited once. There's a couple of little coffee grounds spots that the next tells you he's been reaction quite a few hours, and when you try to examine our old, you find it really difficult to move him to examine him. He feels almost frozen in place is not able to pay any motor commands on. He doesn't seem like it's going to be able to swallow anything you give him. Thankfully, no, his observations are within range. That's one thing. So what we do about antiemetics for in that? So, um, let's pull this. We got medically from my 10 mg sport Roll on. We can give him medical my 10 mg IV. We can give ondansetron already 48 mg or we could give him some cyclizine 50 mg IV. Yeah, yeah. Okay. Give you guys a little bit long. Great. Yeah, let's start there and share results. So some of you got my options A C and D at this point, what we said it doesn't seem like he's gonna be able to swallow anything because of his and because of his stiffness tree to miss Parkinson's doses. Maybe if we go to him earlier before administers, Parkinson's does medications, then it might have been possible to give him something. Or really, that's not to say it was necessarily a bad thing. Not to go and see him is urgently. You won't necessarily know this information. Sometimes it's just the realities of practice, but no, I don't think we could give him anything already at this at this present time. So those of you who have gotten cyclizine why have you gotten that cyclizine safe in Parkinson's? Mm. What do we think about giving metoclopramide importance that yeah, you really don't want to give medical right apartments? And so the issue with metoclopramide is that it can cause acute dystonic reactions, which really unpleasant. If you buy the old majority crises, really? Net right neck issues on. Do you need to have some? Precisely. Dean, And if you're gonna give that eso you know, you don't have medical pride, some Parkinson's disease you can precipitate a lot of issues have done periodontics. One option is it's Parkinson's agonist. But actually, I don't think I would have done Paragon in Parkinson's either. What are some reasons we might stick away from cyclizine know sometimes I mean, in this situation, I think is the best choice of anti emetic. But with this, um, issues that we have a cycle is in one of the side effects for Caution's with cyclizine IV. There's a, um, Metoclopramide What was staring you away from cycle so it could be quite a sight. Quite Psychoactive s okay. Scene is one of the medications that people with drug seeking behaviors will sometimes come in requesting because it does get a real high. That's not necessarily always problematic in itself. In the sense of if someone needs an antiemetics, someone needs an anti emetic. But with older patients, it can lead to acute confusion. So someone who's older with Parkinson's, you may be a little bit concerned about you having some about about precipitating some confusion, but I think I'd be circulation is probably the best choice here. Those of you who wanted to give him on Dan's Atran. Yeah. So what do you guys think about down Strong. So they're both oral options here, which is the reason why I haven't suggested is one of the options because is unable to swallow tablets. But why do we like on benzo trying this situation if we were able to get it? I mean, there's no reason we couldn't give it IV. I've just not listed as one of the options for this scenario. But why would you like I'd be on down strong? That's okay, Mark instance. Absolutely. On the thing I don't particularly like about one dansetron is that it is very constipating s. I think if I can steer away from it, sometimes I do. If I could give a lower dose if I was, if he was able to swallow, probably try and start with the lower dose. One down the trunk first would be my first option. But because he's not able to swallow, I would go with the IV cyclizine in this situation escaping Another question is what we do by stiffness, fellas. Repola this, then So option A We've got we concern mg two option. Be within. Stop all of these medications to IV Option C. We can request a CT head. Make sure that he's not had a stroke. Given that he says different and I'm moving in bed. Option D We can give him some hyacinth. You too, Brian. Mind as the subject injection on option he we could call for the double to double to our government is so stiff that could be a real serious worried that Ray that shows results. So Communist answer is highest in future bromide. What's let's another store stuff was the thinking with highest in. Okay, What do you think? The cause of his stiffness? Yeah, Ms Meds. So if you miss, if you miss Parkinson's medication, there's a reason why they're really strict on timing's apartments, his medications on this. This comes from a really situation that I found myself in last year. It does not take long after a mist Parkinson's medication dose for someone to get really, really stiff and on moving on to the real solution to someone. Stiffness is to give to give those missed medications. I think if you were worried about a stroke, I think thinking about a CT head is is a sensible thing to do on. But what you'll find is, if you can give those missed Parkinson's medications, then you should quite quickly see a return to good movement on. Then what you'd be able to do is do that single intervention, giving the Parkinson's medications and then reassess and see if you're still worried about stroke. But I think in someone who has stiffness is there. So presenting issue is quite hard. Teo be confident about that being a stroke, and so I think before you're going to before you're going to subject him to a CT and that radiation does Everything is worse. Just giving those medications first. What do you think about Like the vest is MG wife. There's a few have gone with the IV when you come with that rather than the anti tube for absorption. Yeah, it might be absorbed quicker, easier for the patient and for us. Yes, it sounds quite cynical, but I suppose sometimes overnight and it may be. Actually, I think you find an N G Cheap will often be quicker and easier than getting a cannula in someone with sort of Krispy Kreme. Be skin and rubbish veins, but may already have, like the actors is a good point with it. With an N G tube, there's well, there's two holes you can go in, and it's quite quick to tell which one you got into. And if anyone's gonna be an f handy, do you know what the IV doses of leave it open matter partner. All you know, it depends on your trust in terms of checking mg tubes with X rays before giving anything down it. If you can aspirate gastric content, then you know you're in the stomach and that is in a way. Actually, I don't think there are IV doses of levodopa. Amount of hard. Don't think their IV formulations off them. So actually, this again. This is from a real scenario I've been in on the solution in the middle of the night was that we had to get the out of ours pharmacist to help us work out how to dispose of which of his medications were dispersal. So there are online leave. A dope equivalency character later is that you can use. You can plug in all of the different anti parkinsonian medication someone's on. It will convert their dose to leave it open. Quibbling. And it will give you options for dispersal medications that can be put down an n G tube. Or sometimes it will give you options for transdermal patches you can use. But actually, I don't think there are any IV formulations for leave a day for all matter part. And that's why I think the energy cheap is probably your best option here. Also, someone is stiff and unmoving. You might find you're running into some nutritional problems later on, and you might be quiet handy of that energy tube. Also, if the sickness and N T tube can be quite hopeful, which there's a reason if the reason for the sickness is something to do with the gastric outlet obstruction or a bowel obstruction. But I think thinking in terms of converting his medications, do IV. At least you're getting the core principle of this, which is that the reason why he's stiff is because of Ms medications in Solution that so the solution to that is to give those ms medications on. I've just been up there for any of you wanted Aleve, a doper equivalency calculator on That's what I use out of hours, if I have any to swap someone over often to over ticketing patch, but sometimes toe or a dispersal versions. So essentially what you can do is you can take the tablets, crush them into water, draw them into a syringe, and you can squat back down the end of an injury tube. And that could be really helpful for o'clock in the morning when you got someone has Ms Parker's and status is so third option, let's use that one for now. So that's how it comes in then, So you're just on 23 turns. So midnight 20. So we get a bleed through, says, can you come and do a sleeping tablet for us? Got a lady who hasn't slept for the last three hours on an As we're going up the stairs, we get another bleed on They say high. It's would three again. One of our patients was clock this morning. They don't have a treatment escalation plan. So if we don't know whether we should resuscitate him if they get really sick, can you come and do one place? So with Bill and seen John Smith and sort of, that is just X ray. We haven't been seen. Ramona Flowers about a gentamicin. We've seen Harold Thompson's anti emetic. We haven't been assorted. This for is, um, I it we haven't sorted these fluids on. We have done the discharge summary. Um, we haven't done the sleeping tablet or tap for So this time, then, let's say auction areas to go and do this gentamicin option B will be to go and prescribe some freezing might option C will be to solve these fluids. Option D will be the tech form on option. He will be that we can go and sort this sleeping tablet what you guys think, right? So I think there's a fairly clear favor here. So the most common answer here was that people want to go and see about these fluids. So let's go have a look at that. Severe is a 92 year old lady. She was admitted to the hospital acutely short of breath, and she's been managed to check success with IV antibiotics, IV fluids and oxygen. And she's had blood cultures. She's had a VBG and she's had a year and output taker on. The nurses have asked you to come and prescribe another bag of fluid on because the previous bags just run out. So how can I help you? A little bit of background here has had previous marriage bottle infarctions. She's got venous leg old says, Got heart failure of reduced ejection fraction anxiety, depression. She's had gall stones and she got chronic pancreatitis. What more would you like to learn about this baby? Just go back a little bit. Yeah, fluid balance. Electrolytes. Right. So And fluid. What flu shot so far is that one of our options? Yeah, that's up from be. I was in big so flu, but it's there in but help Her charges had two liters of IV Hartman since 10 45 with an estimated 500 miles in a little fluid on the 800 mils of urine output as well. Someone want to see a presenting complaint again yet, so she she presented acutely short of breath. She is being managed for chest abscess, she said. IV fluids and antibiotics. Oxygen blood cultures. TBT in urine output on the fluids. It just ran out. They want more social TV to survive the heartburn's 500 mils of all fluid, and she's peed 800 so far, someone else for her latest ejection fraction. Yet I'm sure that is one of our options. Yeah, they're close. And G eso yeah, her ejection fraction is 33%. What we think about an ejection fraction of 33%. Yeah, is reduced. Yeah, 33 is pretty rubbish would be my official medical terminology. Um, 55% is our normal so fit. And 33% think falls under severe heart failure. So what else have people ask for? I think someone's asked us and bloods and using these. Yeah, I think we've got that somewhere. That's Oh, so you got a white cells of 10. Your ear of 6.4 Creatinine is 94 a CRP of A. It's what we think of those bloods. Any comments on these bloods? Not too bad. Yeah, there's a general descriptor. I think it's always important to think about that. I know it doesn't sound particularly scientific, but it's worth saying really sort of initial thoughts. Not to be bad. Verses really bad. Need to look at her clinically with her three status on this fluid balance. Good for someone with Queery sseps this year. That's another Thoughts isn't actually, what do you think was her initial assessment? Particularly? Maybe Claritin was rushed assessment. Has the situation changed a bit? Has she responded really well to antibiotics? Was there maybe not an infection in the first place? Yeah, all things to think about. Was there another course for this? A key breathlessness rather than the rather than a success fulsomely craftsman need to see the trend. You a really important eso. Let's say her usual crafting. It's 48. What do you think about it now? you know. Um, is it okay? I Yeah, it's a daycare stage one. So it's a It's an increase of probably. Well, it's almost increase of percent of her normal baseline creatinine. So yeah, she's definitely got an a k. I there isn't. What else would you like to know about before we decide about these fluids? Is she overloaded? You have a good examination on here? Ah, walks to see a stands for c R. I was that meant to be like basement chest X ray. So there's the chest X ray. What do you think about that? Just x ray guys. Pulmonary dementia. We all agree. New nose that pneumonia or the meth oryx while actually interstitial Trace. Yeah. Congestion of pulmonary vessels. Yeah, that's called a little bit more. Yeah. Fibrosis, Possibly comedy Menomonee and cardiomegaly. Thought CIA, I think. Yeah, to me that is that Let's bond or for for a pulmonary edema, that's that's what pulmonary edema looks like, I would describe. It always is fluffy little bit of cough more when they're interspersed with some good air spacing. So congestion is usually quite solid. So you can you can usually draw a limit across consolidation up your infusion again usually has a sort of fluid level to it on quite clear demarcation, unless it's a complete white out pulmonary fibrosis at pulmonary pulmonary edema. Sorry is where you tend to get these little bit cysts, good air, space lung in between. Or if this fluffy looking fluid, whereas with the consolidation or pulmonary fusion that the wipe messes usually a lot more solid and often a bit better demarcated. So, yeah, I would say that looks like a pulmonary edema. Anything else would like to know about hopes. Yeah, we must have some ups in here. Your offices will be so we got a temperature. 37.2. She hasn't had any spikes since midday. BP. 102 over 68. Heart rate. 76 Respiratory. It's 14 on her. Spoto is 94% on room air. So with that in mind were given. Speak severe. A. She's slumped in the bed, sleeping. She's easily Rosabal bone. She's alert and chatty, she says. The breathing is a little bit access since they started the antibiotics, but she's still got a reasonable amount of breathlessness on my new examination by basal course reputations, which goes slightly higher up on the right hand side. What should we do? Have fluid then? So she's had two liters of Hartmann's. She's had 500 mils of oral fluid, and she's here in 8800 mil so far, So we could give her another liter of Norway 9% saline over eight hours. This time we're together 500 mils of saline. Instead, we could give her a liter of Hartmann's, another liter of Hartmann's over 12 hours, slightly slower. We could hold off on any foods at the moment on weekends, or we could hold off on fluids and go one further and give us a might be for Is he might as well again, really common scenario. Your comment. It's a fluid balance. It's very common for the nurses to very well meaning least. A lot of friends of run out, which in mind prescribing meat and more. But you need to be really careful before you prescribe flu. It's a that you think about what the indication is on B, whether they're still needed. Really good thing for, you know, prescribing for fluids on also about what type of fluids and over. How long you going to give them? There's not assume. So. This isn't just a simple scenario about yet. Let's get some more fluids. You need to think about what fluids you giving, why you're giving them or whether you want to get them in the first place. Yeah, I think people think that's much of the answers. Were getting your sugars. So those of you who have gone with saline while we're thinking saline over or those of you got my heart burns while we're thinking Hartmann's saline away while we're thinking happens every 12 hours UK, those of you have common option D no feather fluids. What's there? Wasn't thinking on Not just why no further trees, but why? Why are we thinking fluids? But not for his might? Thank you. I Grace crafted. And so I think, you know, freeze. It might, because of a cure. All right. And there's if you're thinking IV for his mind pulmonary edema. So I would agree that we've got some more commonly Do you know we don't want to give them any more food at this point. Any of those fluid options are probably just gonna worse than the pulmonary edema. I think it's those of you thinking, obviously someone needs some fluids. I'm actually usually would probably want to restrict someone with promenading in this bad teo elite or less in a day, probably even 750 miles. Um, in terms of options, DNA, both really good. Sinking either of these options is a sensible first starting point on. I've deliberately made it quite difficult in terms of deciding about four is a mild with this a k I on what is going to kill her Quickest promoted him. Yeah. So if you think if you think about what if worsening of a Kaiser going to do is going to if you have a recent ear right here or what's gonna happen is you're going to go into a metabolic derangement, you put it into an acidosis. Is your kidneys become a able to get out? Acid is a process that takes time and a creatinine night of 94 spots immediately going to tell you, uh, on a metabolic derangement can probably be considered more along the lines of circulation or even the for electrolytes rather than breathing on. If we taken a B. C d approach be is going to tell you much quicker. Absolutely. I think I personally would be giving the frusemide here. I think this would be a really good time to discuss things with your registrar if you're especially as an f one. This is a decision that when I was at the start of F one, this is a decision that I wouldn't have been comfortable making immediately. I would have decided not to give any fluids. I was definitely asked about giving for his. My first is I got more confident as the year went or not, have been more happy to get this free right Freeze might in a car wreck intention. Stop it. If someone is very reliant on for his mind, you do not want to cut back on the furosemide for a slight increase in creatinin if she becomes a man your age with a worsening. Okay, I If you do an I c. U job, you'll find that actually on your people get given frusemide to stimulate more on diary cysts on that slightly increased creatinine is just taken as a necessary start effect off that on the year and out, please. Actually, more sensitive measure of renal function than raise craft in in in its in of itself. And then you sort of think about why they've got that raised, crafting him because obviously you can have pre renal injury in or post renal Korso. Her reason for a K may not be anything to do with hydration. And so giving that frusemide and reducing her intravascular hydration status is not necessarily going to worsen the okay, I So lots of good thinking here is definitely the thing you want to think about, whether or not you get the frusemide and it and it's as an F one. It's a very difficult call to make to just go ahead and give someone IV for his mind off your own steam. But I think if you discuss this with the registrars, we definitely say to Yes, this lady needs to freeze the night on, then what we do about her stats. So she's got a sense of 94% on room air. What do you guys think we should do about that? So option A. We can reposition hair. It's been upright posture and not give her any oxygen. Option B. We could give it to meters of supplemental oxygen through some nasal cannula. We could give her six liters a minute by Red Venturi Master. We could give her four liters a minute by a green Venturi. We could get her on the non rebreathe. How do you guys want to handle this? That has saturations were 94% on the with pulmonary edema. Laderman restarted. Powerful? Yeah, like shadows. It's amazing. You go with Option A, somebody will end up being. There's a couple of others, I think, giving someone extreme by the non rebreathe giving 15 liters system or saturation of 94. I understand, and I thinking that I've got pulmonary edema. They might worsen quickly, but given the headsets and 94% of the moment, I don't think I would jump to giving 15 liters. There also problems associated with giving a 100% oxygen over long periods of time, one of which is basal it. Elective this, um so if you're giving someone exclusively oxygen, there's no nitrogen content, so everything that's going into their RV only is diffusing across into the blood on. Then what you've got is empty alveoli, so there's nothing to counter act the negative pressure caused by the surfactants. You get collapse about the only on a basal later. Lecter's This, um is it is the major reason why you get eight electricity after operations by patients have been on essentially understand oxygen for possibly in a provider hours. It seems to be great. Careful giving understand oxygen and then option day and be, I think, either of those sensible options. I wouldn't be angry at you for giving two liters to someone with a such a 94% with a with a pulmonary edema. But I think the main reason why I put this here is the highlight. The importance of posture. You were very often see patients with slightly suboptimal oxygen saturations who are really slumped chin on test like this, hanging down in there, bed really twisted with their ribs, pushed up and splinting their diaphragm. And you'll be really surprised just how much someone saturations can improve by sitting the bed up right, pulling them up the bed a little bit, encouraging them to stay, sat upright, maybe propping up with some pillows on. I think that's a really important conservative measure that you can take to improve patient oxygenation in a meaningful way. It's just something would really encourage you guys to do, because sometimes you might wonder why you're giving someone oxygen. But that's that's just aren't picking up. And it's because their diaphragm is just completely splinted. So they're getting inadequate ventilation. So just a thought process for you guys. Actually, yeah, absolutely. Either of those options will be a appropriate on. Venturing Masks are also a sensible way of giving the measurable amount of oxygen if you're going to be doing repeatedly. BeeGees Sorry, repeated a BeeGees on someone to assess their to assess their arterial oxygen saturations. Having a Venturi mask allows you to more accurately work out what they're P 02 should be. So if it's someone who's really acutely sick with a really swinging oxygen requirements, those venturing mosque can be really useful. But I think here we can get away with either using two liters or just getting some postural changes on. You can always do those postural changes and then reassess, but 94% is very poor to the line anyway. Great, So lost bit of the night say we're still got a few situations. We haven't been sorted. This gentamicin. We've done this for use in my We haven't done this route of my prescription. We've done the fluids. We've not done this test form have not done the sleeping tablet. So let's re pull that on. Will have option is the gentamicin. Option B is to go in salt. This for is my prescription option. C is attacked. Form on Option D is a sleeping tablet. What you guys want to do, and just a reminder for those tech form is a treatment escalation plan. So it's a discussion of things like whether or not to do CPR whether or not to escalate. Try to you great. Sure, it is also the most common one is a sleeping tablet. What's going to dress point? So Lily Wilson She is a 67 year old lady who was admitted with a full secondary to fester hypertension. For the last three nights. She's been wondering award into the early hours. She's got a tendency to talk loudly, even at four talking morning and wandering into other patient's bed spaces. She's needing one for one supervision overnight and the next, and start really struggling with her behavior. She's starting to upset some of the other patients is, well, I've been turned. They're struggling to sleep, but it's really creating a difficult situation on the ward. So the nursing staff oblique to ask a sleeping tablet. So a little bit of information. So really outside this dementia she's been medically fit for discharge for the last four days, but she's waiting on the care home because her husband's been struggling to cope their behavior and her other past medical history. She's got polymyalgia rhuematica. She's got mild aortic stenosis is just got a CKD two bilateral cataracts on What more would you guys like to know about this lady? Allergies. No allergies. Hopes we go there. No, we haven't called know, So she's stable options. Medically. 50 Destructions Not had any acute change blood, so we'll absolutely fine last time. Medications have anything about medications here? Efforts. Medication. If so, she's got memantine for her. Outside. Wants to take the amitriptyline for chronic back pain with prednisone. 5 mg of polymyalgia rhuematica she take ramipril once a day of hypertension. Any comments on these medications? Thoughts on the appropriate is, um um of Memantine for someone with moderate to severe outsiders. It's is the first line medication moderate. You're outside. Mr. Gives clothes on amitriptyline for chronic back pain. Common? Yeah. Steroids could cause insomnia. Yeah, really good. Yeah, really good thing to think about guys. Well, don't know. Steroids. 5 mg is is probably going to be quite low dose and less likely to cause insomnia. But actually well, thinking about the timing for that prednisolone was was it Mr A drug roundish end up getting it later in the evening because she was away having an investigation. So it's a really important thing to think about, actually. Yes, sir. Prednisolone so steroid to do is ideally be taken in the morning is that they don't interrupt sleeping patterns. Someone else has made a really good point, which is amitryptaline is an anticholinergic high anticholinergic burdened elderly patients could be quite harmful cause a lot of confusion. So, yeah, that's a really good point as well. So not something we're necessarily going to be able to fill with Sort of midnight. But I'm a trip feeling it might be worth just making this more note. Can I have a trip to be locked up and thoughts on the ramipril five Attention this lady. Anyone under geriatrics placement of the moment Have any comments about ramipril in the elderly? Small dose possible? Yeah, so Ramipril is in in a list of medications known us to stop medications. So if you're doing the geriatrics, placement is really useful to look up to have a goal of the stop medications. Their medications, which is suggested to avoid in elderly patients with various reasons to do with changing for the allergy ramipril and 18 habit is one of them. There's a really high incidence of postural hypertension with ramipril in the elderly, which can lead to force which community problematic in elderly patients again, not something we're really going to change at midnight. But it's something to certainly think about. What else do we want to know about really natural from her husband regarding her baseline behavior? Yeah, I mean, it's midnight, which is quite difficult. Is this a new confusion? You don't have anything about whether this is new. I think she's been she's been wondering for a while, and unfortunately, this is a normal part of behavior. This is why it's been so difficult to discharge her because normally should go home to her husband. But he's just he's unable to manage her this label. But you have really important to think, actually, Is this pattern of wondering a normal pattern or is this worse than usual? Collateral from Husband at midnight is gonna be quite difficult if someone is acutely sick on. There's a really good reason why you need to wake up a patient's family member at midnight, then that's absolutely fine. But you need that something to have a little better think vision problems, reduced sensory input or things that could be causing worsening of computer. I should go a new infection. It's worth thinking about all of those things. Yeah, any fevers she happening about your urine retention? Yeah, really good things. So we're going to say this is her baseline level of confusion. There's no obvious reason why she's worse. And another thing to think about in elderly patients who were confused and wondering is pain. So a lot of care of a lot of old age psychiatry specialists are really good at every strong advocates for regular low dose paracetamol with or particularly elderly patients with confusion, because often they can and have difficulties expressing their level of pains. It can be really useful tea. Just start a low dose of the safe painkiller like Paris epitome and see if that has any benefit. So how do you manage that problematic roaming? We've got a few options here, so we could request a side room for her so that we can stop running into by the patient's bed spaces on. We could prescribe her a low dose and stopping clone once a night to eight sleep or a slight higher doses of baclofen because she's wondering so much we could give a diazepam instead. Is a different sleep aid. Or we could increase the dose of fermenting to 20 mg once daily what you guys think go? Yeah, less. Most common option is to give the topic loan and why people steering away from diazepam, That's what Um, what? What a rattle. It's on a side room. Why, Why, why some of this going away from the idea being inside room, someone said about diazepam short term use because of addiction. Yet it's a good thing to think about my benzodiazepine. Withdrawing is pretty horrible, even if she's not gonna be doing drugs seeking behaviors if that gets left on a drug charge he was getting given it. If she has a one in 11 to 1 care aside from could be a safe option. Yeah, what's what's causing some people to steer away from using a side room thing? I think about what side rooms is. You have to remember that they can exacerbate delirium. Doesn't help patients. Any place inside room, sleep, black and isolation, converse and confusion. Yeah, absolutely. And if it falls, risk you're absolutely is a good point in someone's in a sweat drug. They may not be as visible in terms of fours. Risks. Ah, lot of words will have one side room, which is deliberately high. Visibility on. It would be very close to the nurse's station, where they can keep a close eye on them for four risk. But that may not be the side from which is available. It might be a silent talked away in the corner of the ward where she could fall and not be noticed. So, yeah, really good thing to think about guys from so we're going to win. So get to the end of the night on, um, right Lilly, which this is our fourth option, placed one side fours option. I asked our health. So we get a call back a little bit later from an award on They say, Hello, Doctor. One of our patients just had a fall in the world. Can you come in? Assess her, please on again. If you manage to do a single night shift, is the left one on Medical ward cover without least 14 that you need to go and refer. I will be very surprised. Typically at least 2 to 3/4 in in any overnight in any hospital with an elderly population. So you'll get really used to doing force assessments at four o'clock in the morning, kneeling in a puddle of a patient's urine. So Lilly has Alzheimer's dementia. She's been medically fit for discharge, but she's been waiting on a care home. Ah, yeah, this is with Lily. We still not too long ago we walked back on the ward on we find a lying on the floor in front of the nasty station. Oh dear. So we do an EKG assessment. She's lying on her front softly. Morning with a painted airway to breathing normally, but she's got some crackles on the right side of the chest. Equal air entry and chest rise a day or two is 96% on room air. Her heart rate 110 in irregular. Her blood pressure's 134 68 her cap refill is less than two. You do cheese? Yes, she's in the 45 6 with baseline level of confusion. She denies any pain in her head. She got no tenderness in the shoulders, elbows or rest. You lift a gown slightly to look her hips, and you can see her left leg shorter and next only rotated blood sugar 6.2. So, rather than any to be assessment person air, always. We always do an eight mg because otherwise I just figured blue coz it's my own personal learning point, so really common that patients have falls, they'll have varying levels of severity. Obviously, the key problem here is we got a short next only rotated leg on, but we've also slightly high heart rate as well. Any situation you get called to urgently such a fall on the ward I always advocate doing any to be assessment. So let's get some more info. So the nurse in charge comes over. It was hyped up from the notes in charge. I got her medical notes and then estimates. Do anything more. You want to know what you guys want to know? Yeah. Medications. We go back through medications and ARBs. Okay, Ops. Really? Where's the ropes, please? Oh, we have new full set of labs. Continue to percent 76 rest of 14. Heart rate 110. BP 136. 84 sets of 96 on room air. Someone said mechanism of four. Yeah, I think we got mechanism. And four somewhere. Uh, w w for witnesses. So therefore was seen by a sister in charge. She was walking to the bathroom, Usually has assistance of two, but she got herself out better on their own and try to walk without afraid. She fell and landed on the side, and she didn't hit her head onto calculation. I think that's one of these. Uh, we've got a for a s, I think. Yeah. So she does to take warfarin for her effort had last time. And now it's 2.3. What do you think of a nine or 2.3? Yeah, good is in range, yet 2 to 3 is arrange refs. Oh, uh, what else? What else do people want? Someone said he see a GI, which is, uh, sorry. Be see, there's RSCG Zemin a little bit on that for you guys. What do you think about that? Any thoughts on that GI guys? Yeah, If yeah, I agree. It's a tribulations. So we've got we've gotten It is a narrow, complex Carneiro complexes with irregular rhythms. That's that's a true fibrilation is not absolutely so it's in keeping. So there's no there's no new finding that we know she's got no, no after is on warfarin. So there's there's not a new CD, and someone else has said Escalation status? Yes. Oh, Lily is with escalations that she got a complete attack form. It's got a real quick squiggle on it. It says Doctor, that Doctor Smith and it just says four. Full escalation clean CPR with no other details on the phone. And again, that's a realistic form that you'll find lots of people with very slim, poorly filled in escalation plans Gray. So let's do some management then. So the nurse interest and she says, Well, what what we do now? Then I'm still got a few options. We could request for an urgent CT head within an hour. A CT head. Within eight hours on, we could ask one of the nurses to get the scoop oyster bed on blocks and safely move on to the bed. We could get in to cannulate er for the my V analgesia where we take an ABG, or we could put the double to double to call out. And it's the last case. Guys, Thanks for staying with us. And, uh, it's a slightly longer sessions Unusual, right? Yeah, Let's stop. Even so, we've got to split between two options. The communist option you guys have given us to get the scoop waste bed and blocks on. But second time, this is the agent CT head. So those of you who won the urgent CT head wearing on the urgency he had warfrin Yep, full clearly. Head injury query, please. Yeah, give you a stroke the coast, So yeah. I mean, that's no no terrible idea. I think you need to clinically examine them for for other evidence. Well, if you were thinking that it might be a stroke, what tools could use for assessment before making a decision? Any validated? And I addressed, That's Yeah, perfect. So if you were thinking that I think you need to justify within a range, that's that's obviously very difficult in a patient with moderate, they're outside. Mr. So there any tools you can use for making decisions about CT heads after falls to really helpful enough ice. Nice has Ah, fours head injury assessment tool. Which gives you very clear guidance on when you shouldn't shouldn't ask for a CT head on whether it should be within eight hours or one hour. I think the important thing to say here is this was a witnessed for and she was witnessed not to have hit her head, and she has not lost consciousness. So I don't think necessarily. We need to do that on anyone who didn't go with the infections. Good boys, bed and blocks, anything that would stop you from immediately getting her lifted. Because what? What do we think? What do we think has happened to her from from how we saw her in a clinical picture. Yeah, enough. If you had a broken fracture neck of FEMA, Do you think it would be particularly comfortable to the script in oysters on the bed? No, it would be Utterback it mates. But I think I think I said to me, Would be thinking about semanal geezer of some school first. Yeah, those of you who have gone with the double to double twos what's, um, what's the rationale behind that? And I think it's a good time, actually, you know, explain why I think it's a good option in a minute. And what's your thoughts on? Double to double, too? That's fine. We'll come back in a second, so we've got options. See what your sister scooper sister in charge fetches Scoop for your position. It place yourself in the head of the patient, and then when you ask, everyone is getting into position to safely rolling a number of the stuff that really nervous about rolling her on. One of them says, I'm sorry, doctor, I just haven't done this before, so we'll have to bail on that option, which is fine. We've got we've got a CT head on. Brady ology concerns that I'm really sorry, but not enough justification on that. And there's your CT head guidance for immediate CT head. You need to be. They have a GCS of less than 13 On initial assessment, we should. She had a GCS of 50 or less than 15 2 hours after the injury can, and we said it's good thing a suspected open or depressed skull fracture. We didn't have evidence of those. Any sign of a basil skull fracture Again? We didn't have those No posttraumatic seizure, no focal neurological deficit. And she hadn't form it it because that is your indications for media. It's eat yet again. If you went for the eight hours, they'd be happy with that. If you've got a good suspicion of head injury so we can go with the cannula yet Nurse in Charge has a tough time. Can't find a vein with it and find a humanities gain. A BG, and that's fine. So that double to triple twos it Does this mean we need to go back on, reassess a patient out of an F one stroke? Potentially hope? Yeah, really good thing. Remember, guys, um, ones dealing with the trauma like this is really quite difficult. Have any have you ever heard of the concept called Silver Trauma? Anyone had the silver trauma call? Also sometimes known as a war stroma. Okay, so a lot of hospitals will have a system. He, after known, is either a silver trauma ward trauma where you can pick up the phone dot double to double to you and say, Still, the trauma on ward nine of water on on that water didn't get you. Okay, A trauma. The on call trauma orthopedics doctor. It will get you a porter with a scoop on ah ha for jack and other methods of safely moving, a patient will get a site manager then who often will be able to help you with things such as radiology, and we'll also be able to coordinate. Lifting the patient on it often will get you some form of registrar from a medical or surgical specialty. Really helpful. One of the most helpful things about award trauma call is that it often gets you people who, such as a resource officer who are on Fidan in moving injured patients, something you'll find as you start your job is that not every nurse and HDL is confident in moving patients with skips. Harvard jacks and lifts. And it's not necessarily always part of the normal moving and handling training that staff get in a situation like this, I would say Absolutely, You're probably out of your depth to try and manage this completely on your own fracture neck of FEMA and doesn't can Anyone told me the one year mortality rate Fractured femur? Yeah, 30%. 30% of people with a fractured femur will die within a year. That's a huge mortality rate on. It's really important that neck of femur fracture is managed correctly. So absolutely. I think you are more than justified putting out the twos for this patient. So if you put a double to out for a war drama, you get Porter with skiing, you've been on mobilizing blocks, an outreach nurse or critical care nurse. You can help you safely call in a lot of transfer. What you got on the bed, Patrolman Orthopedics. FH arrives. We asked you to get a hip X ray while he gets um, equipment ready to administer a regional anesthetic block. Anyone suggest a regional anesthetic doctor might commonly be used for a neck of the femur fracture. If you're not done any drop, this might not be something. You know. Bupivacaine is Is there is the agent we would use yet. But anyone know the the regional? What? The regional block I'm thinking of is known as the weeds, the neck, a femur, fractures some of them. I've heard of a fashion iliac a block. If not, I might be something worth googling it. Something is a fairly straightforward process. Actually, I did it once a day and he has a med student. And certainly something I mentioned you could do on. That's our X ray and the trauma will be excessive stresses. Yeah, thanks. I'll take which first? Because that X ray Poor lady. Yeah, I've been my thought as well on Nasonex femur fracture. We can see a fracture line across here in the slightly year intracapsular neck femur fractures. There's no outside of the interest of the trick. Antara blind says here within the capsule. Yeah, says that was pretty bad prognosis of factual I. Then she's going to need a serious operation. So this would just come back to thinking about, um hypnotics in patients over elderly age. So the way I set this up was irrespective of what you guys did. There would be an emergency call. Depending on how you managed the night. I would pick it up from call. The reason we went with this one. You need to be very, very careful giving anything like Stop it alone or any benzodiazepine, totally confused patients. You will get multiple times during your F one year where nurses will ask you to prescribe sleeping tablets for patients they are struggling to deal with. It won't be the patient asking you for a sleeping tablet will be. The Nets use has been really carefully before. You do that, because that's always risk is astronomical. So I really think hard about stem simple conservative measures. You know, a side room is not ideal, but sometimes it's a reality. Are you need to practice. So that is the last scenario. Fair today's session. If you guys rejoin me for Thursday session, the plan is any of the scenarios we didn't manage to cover this time will be covered in the next session, along with new scenarios on a slight tone shift. So we laid out in a very similar way to this session with it hopefully continuing to be interactive is this session waas With new cases, it will be useful. If there are people who weren't at the first session to what's coming on to just the second one, it will still be useful, so I would encourage them to do so. Otherwise, if there's any questions people have that you wanted to ask me any immediate feedback you want to give me, that would be great. Now, how could stay around for a few minutes and answer any questions? Any sort of discussion points questions people have about on cause either in during the day or overnight things that worrying you about starting F one that you want to ask about. I'm happy to answer any of that sort stuff. Yeah, it's part of the back back link in there. Okay, Great. Linda, Thanks a room. All right. Thanks to almost see you back on Thursday. Thanks for much insight.