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Him. Thank you very much. Um So as Eliza said, um this sort of series is, is all about trying to get you guys comfortable with surgery and a bit more knowledgeable and prepared for the surgical jobs that you may be doing or to give you a bit more information about surgery. Should you decide that that is a career choice that you'd like to pursue? So, although it doesn't feel a long time ago for me, apparently, I've been told it is a long time ago. I graduated in 2018 and I've been working in surgery for about five years or so, passed my exams and done course surgical training. So I like to think I'm in a good situation to give you guys some hints, tips and a good general approach to feeling comfortable in your surgical jobs. Um I'm just gonna close my windows, someone outside has just started the motorbike up. Give me one sec. Sorry about that. So what I'm hoping that you guys get out of today is that by the end of the session, you'll be able to apply a generic approach to any situation on a surgical ward with any surgical patient and you'll be able to undertake an assessment that will not only give you good acute information and basic interventions to take, but give you a bit of a better idea of what it is that you can take away in a surgical assessment and how you can communicate that to your senior and best deal with the situation and escalate appropriately. The level at which you may be at yourself is going to be different based on the previous experience that you have and based on your general level as well. So I was asked to prepare this for a range of people from fifth year up towards f two year. And as we all know, within foundation years themselves, your jobs are very variable. So even though you may have had experience on TN O, for example, you may have been on Ortho Gerry and a bit under exposed to the surgical side of things. If you've been on Genser, you may be asked to cross cover vascular if you're on urology may be cross covering ent so having generic skills to apply to a generic situation can be really, really helpful. And I will be hoping that you guys will engage with the chat as we go along. Cos there are gonna be a lot of cases to discuss and I've tried to simulate this in the most realistic way that I can with the technology that we have. So first off, let's talk about our patients, anyone that's done a medical job and a surgical job will be able to say that, you know, there is a massive difference in the cohort of patients, not just in terms of what we do, but how they are in general. And as a bit of a baseline surgical patients generally do have a better baseline or better physiology than their medical um than the medical um outliers. And that's good for us because they need to be fit for surgery in the first place and they need to be optimized for surgery. So what that means is that generally, these patients are able to compensate with their physiology a little bit better than medical patients. But it also means that if they do start to deteriorate, we want to intervene early to make sure they don't deteriorate further because people compensate to a degree and when they stop compensating things fall off a cliff quite dramatically. So when it comes to surgical patients, broadly, we've got elective or emergency. Generally, your elective patients will have a much better level of physiological fitness and general fitness to withstand surgery. They should be pre assessed and selected by a surgical team so that all their comorbidities and everything is stable when they come into hospital. And that's to facilitate a good intraoperative and postoperative course. But sadly, not everything can be elective. And we have obviously emergency patients that come in with various lots of different kinds of problems and their physiology is gonna be variable. It may be that they've got a previous surgical history and they're deteriorating much later on in their lives with a complication from that. And their physiology is at a much lower, unstable frail level than we would like them to be. But the balance and risk and benefit in the emergency versus elective scenario changes and sometimes we are obligated or we feel that that balance shifts in a way that we are able to or have to intervene when it comes to literally life or death. By the nature of an, of an emergency presentation, these patients usually are unstable on presentation and will need a good amount of resuscitation to get them to a point where we can think about doing anything. And as such with that, their comorbidities may not be in the best managed state or in the most stable state given the fact that they're unstable. And one thing that is very important to say, although people are thinking about surgery or people that really enjoy surgery, obviously, we love to operate. It's the bit of surgery that you can get your hands dirty with that, you feel you can physically do something in and it's a wonderful experience to see anatomy and to be able to physically change something, but you don't get a patient in theater unless you look after the patient outside of theater. So, preoperative and postoperative care is really, really important and for those of us, you know, myself as a recent sho and sometimes covering as a registrar, you know, the ward care does fall to, you know, the non registers, essentially. Um obviously the registrars get involved and will see everybody but the burden of workload is spread so far around ed and emergency theaters as well that junior colleagues are the eyes and ears on the ward. Usually the first people to attend to any thing that needs doing with patients. Therefore, you are the first people to really get in there do initial resuscitation and management and escalate as appropriate. Because ultimately, surgical seniors want to know if somebody's unwell, they want to know if there's a complication because we do ultimately care about our patients. So when it comes to the preoperative care of patients, as I kind of alluded and mentioned to you before, there are different things that we need to think about. And these are things that you need to have in your head when you come to assess somebody in an acute setting on the ward, because you want to have a good idea of what their status is like preoperatively. So you've got an idea of what their baseline is or what their preoperative state was to compare it to what you're seeing at that moment with your elected patients. That's usually quite easy to see because they should have a thorough anesthetic assessment. They should have a hopefully thorough clerking that details all their comorbidities and any medications and that can start to prompt questions in your head about not only what their history is but how well controlled it is. And if there are any other letters on the system or any other inputs from other specialties, that might give you a clue as to how well controlled or delicately controlled, some of their comorbidities are. And a really good example of that is patients with type one diabetes or insulin dependent type two diabetes that have very lab control and have very in depth plans around their sugar control perioperatively. So as well as looking at comorbidity status and anesthetic assessment, have a look at how these patients are gonna be prepared for theater. So what's their nil by mouth status? Is there anything we need to be doing for them? Like I mentioned insulin control? Um and are these patients gonna be ready to go to theater in the emergency setting? You don't always have that wealth of information available to you and sometimes you have to do a little bit of digging. You won't really have an anesthetic assessment or a preassessment to go with. But generally you can get a good idea by talking to the patient or looking through some of their notes, even their GP records about their general day to day life and their performance status as to how fit they are at baseline and then the onus comes on to us to think ahead about how we need to prepare them for theater and make sure that they're resuscitated adequately. And often times simple things are simple antibiotics for infection, blood for blood loss. And then we get into the more fanciful world of things like heparin infusions for ischemia. If you're on vascular and if these patients are for theater there, not everybody that comes to emergency to an emergency surgical service does need theater, We then need to decide how urgently do they need to go to theater? What availability is there in theater to match that level of urgency and do does this patient need resuscitation first? So there are quite a lot of things to think about when you see a patient in the preoperative setting. And there are quite a lot of things that can give you help about their preoperative status when you come to see them in the acute setting in the postoperative setting. So once the patient's gone into theater, they've had all of that wonderful preoperative planning, they come out of theater and in the ideal situation, they get better and go home, we see them in clinic and we've done a wonderful job. But again, we know that's not always the case for everybody. Sadly, things that you need to have in your head when you go to see somebody postoperatively, every single person, if they've had an operation needs to have a post operative plan and you will find that in the operative note. And if you don't find it in the operative note, although you should do, it should be on the ward round plan. Every single person should have a daily review by a senior, if not by a consultant. And looking through all of those will give you a good idea of what the current plan is for that patient. Right down to the more nitty gritty things that you might not feel confident with dealing with by yourself. The most common thing that I get asked about is drains. For example, if a patient has drains, you want to know where those drains are. You want to know how long they need to be in. You want to know how much is coming out of those drains and at what point it is safe to take them out and all of that should be in the operative plan. So make full use of all the information that you have to hand to better prepare you for how to deal with your patient assessment and make your decisions as to where you need to go. And at the bottom, I've said adapt as needed. So, complications are inevitable. Sadly, you can have the best patient selection in the world. You can have the best surgeon in the world, the best theater team and the best ward. But complications are inevitably going to happen. And it's not a comment on any one of, of those teams in any sort of fault these things sometimes just happen. But it's our job to assess thoroughly in context about everything that we've spoken about above to decide what we need to do. So, common causes for deterioration on surgery. If you guys wanna throw a few answers for me in the chat, if you've been called to see an unwell surgical patient or thinking back to medical school, if you were to think about things that might happen to cause a surgical patient to deteriorate, what sort of things would you expect to go wrong? Right. From the common through to the weird and wacky. Tell me what your experiences are. Ok. Yeah. So pe pe is a really, really important 11 of the reasons why we have low molecular weight heparin BT prophylaxis. Yeah. POSTOP bleeding. Sadly, yes, it does happen. And that's when you it can happen in any situation, but obviously vascular is a bit higher risk for it. If you've got an infection around a wound or a graft, you can think about any neck procedures where you might have to do any sort of release of incisions. If there's been any bleed or hematoma formation, I tend to group it out into systems. So patients can have cardiac respiratory endocrine infective or coagulopathic problems. And all of these things are fairly common things that you will have encountered. So this kind of brings me on to my next slide. You know, although with the best intention in the world. We do surgery with a purpose. Surgery ultimately is damage and harm on the body. We cut people open, we rip things out, we sew things in. We put a lot of foreign material into the body. We expose it to an unfamiliar environment that although it's sterile is never gonna be 100% free of any microbes. So we have to consider with these patients not just the fact that we're doing surgery to them and we hope that long term they'll be fine. But what their response to surgery is going to be around the perioperative period. And the three main things to bear in mind are that patients are gonna have a sympathetic, an endocrine and an immune response in the postoperative phase. The patient's gonna be tachycardic, they may have a raised BP and thus an increased cardiac workload and some of that is gonna be secondary to pain. Some of it is gonna be secondary to the massive insult they've just had on their body. Another big thing that you'll see is that the stress response to the body of surgery means that cortisol production goes through the roof. And especially in the 1st 24 to 48 hours, you'll find patients have a lot of water retention and particularly insulin resistance. So even uh patients that aren't diabetic and may have some labile glycemic control around the time of surgery because of that massive cortisol surge and as you will have all seen in the times that you've done postoperative bloods after surgery, you know, patients that have had trauma essentially to the body that we've inflicted. They will have an immune response to that. So they will have a white cell rise, they will have a CRP rise. But it's much about the trend of that and fit it in context with the patient that we get answers to the questions that we're asking. Because there's always that discussion that ends up being had about, you know, what is the value of a postoperative day one C RP. What is the value of a postoperative day? Three CRP. And the answer is that we need to look at the trend and we need to look at it in context of the patient because doing postoperative bloods has been shown massively to correlate quite well as a prognostic factor for indicating further infections or further deteriorations. Later down the line, the most well researched of which would be anastomotic leaks and bowel surgery. You know that patients that have a sustained or increased C RP after surgery are more likely to have an anastomotic leak or more likely to have an inflammatory response that raises the risk of an anastomotic leak. And although doing those bloods is repetitive, it is far cheaper than doing other invasive testing just in case or just to screen for people that may have an anastomotic leak. So it's always good to question why it is that we're doing these routine things because although there is a routine to them, generally with surgery, there's a lot of good, good evidence behind what we're doing. I say generally there is still some anecdotal experiential sort of decision making that goes on as well. So how do I approach a patient or how would I expect somebody to approach a patient on a surgical ward if you're asked to go and see them? And the honest answer is that it's, it's not necessarily rocket science. You want to take a nice systematic review to the patient and not just jump in without any clue of what you're doing. Like anything in medicine, like anything in surgery, you need to have a system, you need to have an approach that you can follow and that gives you the information that you need to prepare you to make the decisions that you need to make. So straight off the bat, you wanna get the observations for the patient to set you up for starting your A to E assessment. I'm not gonna ask you guys what an A to E is because that's very patronizing. I know that you guys know what an A to E assessment is, but the biggest and best bit of advice that I give to anybody in foundation training, anybody in medical training, anybody in, in training in general is that if you were ever called to an acute assessment or an acute deterioration, no matter who it is or what it is always do an A to E assessment. The reason why is not because you'll necessarily find the issue and fix it there. And then, but the A to E assessment is there to tackle the most life threatening problems. First, it's a systematic stereotyped approach to examining patients to elicit life threatening problems in the order. They are likely to compromise or kill them. And it gives you really simple but effective interventions and that you can execute off of your own back as a foundation doctor with a good level of confidence, that also allows you to, to buy yourself time to gather information and to go back and do a further more in depth exam once you stabilize the patient. So always, always, always get a brief handover, get some observations if you can do an A to E assessment because even if you don't fix the problem there, and then at least you can be reassured that there is either something that you can do for that patient to stabilize them or there is nothing immediately life threatening. That means you can go away and look at the notes and check everything out. One thing to have in the back of your head whenever you go to see a surgical patient, especially if they've got drains in whether that's a urinary catheter. If it's a stone bag, an NG tube wound drains, always be thinking about fluid balance because these patients can often be dehydrated from insensible losses in surgery. If you've had an abdomen, that's been open, these patients can lose fluid to the environment rapidly without even meaning to. And we are often quite bad at replacing that. Even with, you know, anesthetists on standby to make sure these patients are still getting fluid, they can become profoundly dehydrated or intravascularly depleted postoperatively without any sort of, you know, without it being too difficult. So making sure that you comprehensively review these patients um fluid status to make sure that they're not dehydrated or even overfilled. We mentioned about water retention from that cortisol drive being able to categorize your patients into those two broad categories is very important and to know if they're having excessive losses um that you may need to replace. So thinking about NG output urinary, output, any edema drains and any oral or IV intake. And when it comes to reviewing notes, again, you wanna give yourself the best chance to actually fix and find a problem. So go back as far as the clerking to see how they were when they came into hospital, were they well, were they unwell, were there any significant abnormalities found at that point? Everyone always gets scared to look at operative notes, but the operative note is gonna give you the best information about what actually happened in that surgery. It's written by the people that did the surgery at that time. And there may even be pictures to go along with it to show the pathology or diagrams to show how they've done certain things if it's a more complex procedure and we'll go through an op note. So you can have a go at picking out what the most salient information is to prepare you with what you wanna do going forward and you want to make sure you build up a good timeline of events of how this patient has progressed postoperatively, what medications they're on, if there's anything that has been omitted or changed, so that you can then go back and reexamine the patient, do a really focused exam with all the information that you have to try and gain a clear idea of what's going on a clear differential diagnosis, a pathway to make some investigations and try and diagnose and then speak to your surgical registrar, not because it's any comment on your skill as an individual doctor, but you have to think of it as a service. So you are working within a service. If you are running a service, you want to know if somebody is unwell, you want to know if somebody needs a bit of extra attention or care or somebody that you need to see. So even if it's purely just to flag up to the registrar that somebody is, is unwell, you should always make sure that someone is kept in the loop and in the worst case scenario, they will ask you or tell you something extra that you should do or could think about doing which you wouldn't have otherwise known, had you not called them? So you'll never be criticized for escalating a patient. And I would always do it as a matter of good practice. But with all of that being said, we'll go through a long case to start and we'll go through a few short cases just to get you guys into the idea of that systematic approach of evaluating patients and forming a differential and making a plan from there, which those of you in F two perhaps are far more confident with um those of you that are not on surgery yet. This will be something helpful for you and for the potentially astute among you that are thinking about applying for course surgical training or taking time out and doing surgical jobs. These are these sort of viva type scenarios that will come up in your interviews, whether you're interviewing for a junior clinical fellow position or if you're going for co surgical interview, you will always have clinical visors as part of your interview process. So getting used to working through these scenarios systematically and presenting your findings is always a good practice exercise. And I've tried to, without shunning any colleagues, I've tried to make things as realistic as possible with the information that you will get. So you are the fy one on general surgery and you're called by one of the surgical nurses to review a patient on the ward and she calls you in and says, are you the doctor on call? I've got a patient here who's just had his appendix out. He's got a temperature and he just doesn't look right to me. So you go along and you go and see Mister Jones. So, answers in the chat, please. What's the first thing that you're gonna do or what are the first things that you're gonna do when you go and see Mr Jones on the surgical ward? Cool. I will move on in the interest of time. Cos again, you're gonna go and do your A to E assessment. So he's speaking to you clearly, but he sounds breathless. He's got out of 90% on room air with a raised respiratory rate. You maybe you can hear some crackles on the right or the left side, but he's a bit distressed and the ward is noisy. So it's difficult to hear. His heart sounds are ok. But he is tachycardic. He's got a cannula in with some maintenance fluid. BP is a bit on the low side and his heart rate is a bit high. B M's fine. He's still got a temperature. His abdomen is a bit tender around his wounds, but he's so, but it's soft bearing in mind if that's all the information that you have at present, what kind of interventions would you like? To put in place or what would you like to do for this patient? And yes, er, Anouska John, you were correct. Get a full set of s and do an at. So now that we have done our, at what interventions are we gonna put in place to try and stabilize this patient and gain us a little bit more time? Now, I know that this is not rocket science and I know that some of it is gonna be teaching you to suck eggs, but this stereotyped intervened. Um Exercise is very important for you guys. Now, I'll give you a minute to put some answers in the chat before I move on. OK? So oxygen second cannula IV bolus chest x-ray 15 L of oxygen via non reb OK. These are some good things coming through and I'll emphasize there is no such thing as a wrong answer here. You can say whatever you want if you wanna say it anonymously, absolutely fine. If you just wanna have the talk to yourself, not a problem. This is all an exercise for you guys. And yes, Caleb, we will get to that point. So my first priority is gonna be for this patient. Start oxygen. As we've said, the classic thing that you would start is 15 L via a non rebreath mask just to make sure that you're getting that oxygen as high as you can trying to offload some of that respiratory workload. You can always titrate it down later if you need, but 15 L by a non rebreather again. Is that good stereotype tactic to get you, um, into a good place, managing breathing? We're noting that he has a low BP and a high heart rate. Um I don't know if you guys will have covered this yet, but we think about classes of hypovolaemic shock, tachycardia is your initial response. But then once you start having a reduction in BP, that's when you start to go into higher classes of hypovolaemic shock. And you really need to think about getting fluids on board. So administer a fluid bolus. And the standard that you would administer is a crystalloid um crystalloid fluid such as Saline or Hartman's. And you would give 500 mils or 250 mils, generally guided by how convinced you are in your initial examination that this patient has some significant cardiac disease. So your standard would be 500 mils and you can just run that through as fast as the cannula will allow. I would usually say 1520 minutes at a push 30. If it's a small cannula and just to manage the temperature, we can add some IV paracetamol. So once all of that is running bearing in mind that the oxygen will take time to take effect, the fluid bolus will take 20 minutes to go through and the paracetamol will take time to check, draw up and give this is where you can go away and sit in the room outside and get all the patients information together. So sit with the notes, sit with the computer, get all the systems up that will inevitably take at least 10 minutes to start up and start to put together what's actually going on. So you open up the notes and this is the larking that you see, I'll give you a few minutes to read it and then we'll move on to the next piece of documentation. And again, I've tried to replicate this as best as I can for you guys. So just for those people in the audience that are fifth year medical students, that might not be as familiar with all of the acronyms that are present. Again, I wanted to make this a bit realistic. So this is a patient with type two diabetes, hypertension osteoarthritis who's had a previous left total hip replacement in 2018. He's on some medications appropriate for his comorbidities with no known drug allergies, NK DA and in terms of other things to take a note of. So it's 74 years old. Bear in mind. The date today is the 14th. So this gentleman is postoperative by four days, I tried to keep this in real time. He had a CT confirmed appendicitis with raised inflammatory markers and subsequently then had an operation. Now I'll give you guys a minute to read it, but I have picked out the salient findings. And then this will again be something that you can stereotype across all operative notes that you look at. So I have a little read, become familiar because you will see a lot of operative notes like this. If you're on general surgery, I'll give you a few minutes. And again, if you've got any questions or anything you wanna ask, feel free to put it in the chat and I'll come back to it whenever I can. So on the next page, I've highlighted the important things that when I'm looking at this operative note, I want to take away if I'm considering this patient in context. So what I want to know is the ti the date and the time that this operation has happened, I want to know exactly what procedure has happened and how it has happened. Was this an open procedure or was it a laparoscopic procedure and what exactly was found? So everybody, not everybody that goes for an appendicectomy will have a confirmed appendicitis. It might be mildly inflamed with no real sort of evidence of, of horrid inflammation or infection that only then gets confirmed weeks later in histology or sometimes even still reported as a normal appendix. Or it may be that you have an appendix in this case that's wrapped up with inflammatory tissue, that's got an obvious hole in it and has pus present within the peritoneum, an appendicitis itself just as one condition that you'll deal with comes in a massive spectrum of severity and acuity and that's just one thing that you'll deal with in your time on surgery. So, knowing exactly how severe it is, is quite important. Now, at a more senior level, it probably is quite useful to know exactly how the procedure is done to be able to pick out the minutia of what might hint towards it being a difficult procedure. But for, um, an on call, junior doctor, you probably want to appreciate that the appendix was removed whole and in one piece, so they've not left any bits behind. They managed to take it out safely. This patient has had two drains inserted, doesn't matter if we don't understand franch izing or you don't know what Robinson drain is. The important thing is that, you know, from this operative note, this patient has had two drains inserted into the abdomen and usually when we put in drains, it will usually then put where they are draining. And you can see from this that the drain that's in the right iliac fossa. Um Sorry, you can see that the drain in the suprapubic port site is draining into the right iliac fossa and the drain in the left iliac fossa is draining down to the pelvis. And this will help you not only to visualize anatomically where these drains are, but to understand if stuff is draining, how much might be draining. So we would expect that things are gonna move by gravity. So I would expect that the pelvic drain, for example, would drain more than the right eyelid. So, postoperative plan, as I said before, they want to continue antibiotics in the context of infection, we should be looking for some postoperative bloods. And there was a plan to take the drains out once they had minimal amount of fluid defined by this particular consultant as less than 50 mils of serous fluid. So then we go on to looking at the ward round so that you can see exactly how this patient has progressed in the postoperative period. Ok. And I'll give you a minute. Ok. Then, so again, the things that are standing out to me from these operative notes, not only am I getting an idea of how far postoperative we are? So I can double check that the dates are accurate, but I know that this patient is on IV antibiotics and what antibiotics they are. I know that they've been stable postoperatively with no other fevers or concerns and that the amount in the um drains has been decreasing each day. I also know that their bloods have been improving since admission, but that they are still showing some inflammatory response and that they wanted to complete a full five days of antibiotics. So with all of that in mind, we then go back to rereview our patient. Not only to see if our A to e assessment has worked and reassess that and we can see that there's been some improvement there, but also to do a further in depth examination in context of what we've just found out to try and supplement our information and guide our diagnostic process. So if we think back to the A to e assessment that we did, we weren't too sure if we could hear anything on his chest and his stomach was a little bit tender. Obviously, with him being a surgical patient, there is concern that he could have something in his abdomen. But again, whether that's a red herring or not postoperatively, people will have some pain. This is where your clinical examination and your history taking comes in very important. So when you listen to his chest, you can better appreciate that he has some crackles on the lower right hand side, but that his heart sounds are actually ok. And it's much easier to hear than now that he's a bit less tachycardic focusing in on his abdomen. His wounds look ok. He has not got any exudate or dehiscence around his umbilical port site. And in terms of his gi system, he's been doing ok. He's been eating and drinking and opening his bowels. His drains don't contain that much fluid and he's got a little bit of guarding around the right iliac fossa and he reports that he's been getting a little bit of a cough and it's been getting worse since yesterday afternoon. So please feel free to put some answers in the chat. What, what differentials do you have here or what do you think may be going on? And if you're feeling extra brave, you can comment on how exactly you might want to investigate that. So Anushka is saying that there may be a hap going on. I can neither confirm nor deny any other differentials or things that you may think might be going on. A hap is definitely a valid differential and it's one respiratory differential. But I would definitely say it's not the um only thing that I would be thinking of in this case. So thinking back to his operative note and knowing that it was quite an inflamed and a horrible appendix, knowing that he's had laparoscopic surgery. There's always the chance that he's got a good going amount of peritonitis and that could be impinging his ability due to pain in order to fully expand and contract his chest appropriately. So the temperature that he's having could still be a reactive peritonitis and the crackles that we're hearing could be more representative of an atelectasis. So his chest could actually just be underinflated and he needs some chest physio. Um, and the problem is actually within his, um, is actually within his abdomen. So we still need to cast the net wide so that we can then gear our investigations to narrow down the problem. So what next steps would you want to take in terms of investigating this. So you've done a very good job at stabilizing the patient. But how do you want to investigate this? And what are you gonna do to the patient in the meantime, to make sure that they're stable while you're awaiting those results? And again, no answer is the wrong answer. But any answers that you like, it's fine, I'll move on. I know it's late on in the day. So, yeah, once you've stabilized him, inevitably, your nurse is gonna turn around to you then and say, what would you like to do? What do you think has happened to him? It's always good at this point to clarify exactly what you think is going on and how you're gonna deal with it. So how I would go through this case is to say, I'm worried he's had a complication after surgery, given his abdominal tenderness, I'm also worried about his chest. So, what I'm gonna say to the team currently looking after the patient while I go and do other things is can we keep him on fluids and antibiotics? Keep his saturations above 24? We'll get 94 not 24. Um, take some fresh blood to see if there's been a change since his previous ward round and arrange a chest X ray. And then because I'm a diligent doctor, I'm going back to the registrar on, on, on call in the shift just to make sure there's nothing else that I might be missing Thanks mm to go on to yours and make sure you communicate. Ok. My s mm deep. Sorry. Then you're breaking up a little bit you can veil care of now. So I've taken bloods and arranging a chest X ray again because you're diligent and you follow this extensive system. The reg is actually quite happy with you and they want to wait for the results to come back and see if there's anything else that we need to do. Bearing in mind the one that they may add further things to do, but not something that you need to do on this shift. So these are the results that have come back. What do you guys suspect may be going on from what you can see on the screen bearing in mind the previous blood results that we had. And again, I appreciate not a lot of this is rocket science or extensively difficult medicine, but it's good to have that systematic approach. So hopefully, you can appreciate that these white cells at 21.6 are a bit higher than when they were previously taken on the ward round of about 17. And the C RP that was down in the sixties is now increased. And previously this patient's completely normal, euthanize are now slightly deranged with a high creatinine and a high urea. And if someone and has, as Aia said, you can see on this chest X ray here, there's some increased opacification on the lower right hand side, which could be reflective of focal consolidation, impairing as a pacification with the raised white cells and the history that we have, it would seem like the most logical conclusion to draw. So now that we know this, is there anything that we're gonna change with this patient that we've just done now? So we've taken bloods, we've continued antibiotics, we've given fluids and oxygen. Is there anything else that we can think to do? And again, this is always gonna be the question that is asked of you. Once you've done the initial resuscitation and the initial investigation, you still then need to revisit and put a plan in place to make sure this patient will improve or remain in the condition that they are to prevent deterioration. So, from a respiratory point of view, chest physio is always great to have patients that have had any extensive laparotomies or even laparoscopic surgery with high pressures. We need to think about incentive spirometry so that they're inflating their chest and really utilizing all of their chest muscles to prevent atelectasis and prevent or reduce the incidence of postoperative pneumonia. This patient would fall under the category of having a hospital acquired pneumonia because of the timing of onset. And we need to consider for this person that he is already on three quite intensive antibiotics. He was on A MG, which is a classic cocktail that we use of amoxicillin, metronidazol, and gentamicin. So if he's still got a hospital acquired pneumonia with those three antibiotics on board, we have to consider if this is quite a resistant pneumonia. And if we need to be thinking about involving microbiology and getting some samples to send off, always, always, always explain to the patient what's going on and the staff looking after the patient, whether they retain that information is a different thing entirely. But as part of good practice, it's always good to keep your patients in the loop as well as the teams looking after them. And to answer initial questions, you probably wouldn't call microbiology overnight for this patient. But you would want to make sure this patient's on appropriate antibiotics as per your local micro guide, it may be that A MG is not the optimal thing that this patient would need to be on for a hospital acquired pneumonia and you may need to add something in. But it's also important to make the day teams aware that that is something that's in your thought process and something that you might need to deal with. So we deal with this quite a lot in surgery as postoperative fevers and any of you that have watched Grey's Anatomy will have heard this before. What are the five causes of postoperative fever? And this is a real thing and it basically stratifies common causes of fever based on the number of days postoperative that people are. And as with anything in medicine this is not set in stone, but it's a very good um, way of hedging your bits and what you think may be causing these things. So, for our particular patient, he wasn't quite in the time frame for um, Atal or pneumonia, but that still was the case. But we should definitely be examining systematically to make sure that we're not missing something like a D VTA pe or cellulitis. So, although it's something you might only see done in the AM UI would always make sure to document that a patient's calves are soft and nontender and have a good look at them just to make sure that they're not swollen or asymmetrical. And again, we always worry about wound infections or abscesses and collections. Even if you're not the best person at describing wounds, being able to comment on the obvious things about whether the wound is intact, whether there's anything coming out of it or any redness around, it is always really, really helpful. Ultimately, the management of your patient who has acutely deteriorated in surgery depends on the cause. If they have a respiratory cause that will require more respiratory input. If they have something abdominal, it may even require emergency surgery. But ultimately, what I'm trying to get across to you is that if you've never worked on surgery before or if you're unconfident on surgery, these are the steps that anybody can take in any situation to put themselves in the best situation to make sure you're working safely um for yourselves, but also for your patients. So I can't emphasize the importance enough of doing an at e it buys you time, it buys the patient time and always put that in context of the patient that you're seeing, get as much information as you can, especially. Um now we live in an era where so many notes are electronic that we have so much community information available as well. Try and get as best a picture of this patient as you can to pair what you're seeing clinically with the information that you have to guide what you're doing and always chat to your registrar just to make sure that you're not missing anything. It's never a comment on your own ability or lack of confidence or overconfidence, but it's just about making sure that you're escalating appropriately and getting a second opinion essentially just to make sure that you're not missing everything because we don't expect you to be surgeons because you're foundation doctors, you're rotating round lots of specialties, learning lots of different things. The reason that you're on a surgical attachment is to learn about surgery. And the reason that there is a registrar is because they are a surgeon and they can deal with the things that, that you're not able to or expected to. So I don't feel like you have to deal with everything yourself as long as you can do simple and basic things to help people then that's what we need to take away from this. So I did have a few more cases to go through just to give you guys the shorter cases. Um to give you guys a bit more of an idea of going through these things. I'm aware that it is 10 to 8 at the moment. So what I might do is just skip through those cases unless people do want to go through them and wrap up the talk now because that's really the main take home that I want to get is that you guys need to have a really systematic and thorough approach. Surgical patients intervene early to prevent deterioration and give yourself as much information as you can. Um So I was just reading what Mr Makar has written. Um But yes, that that is basically what I wanted to get across to you guys that you will put yourselves in the best position by giving yourselves the best preparation. So if you have any questions or if you do want to hear some of these other cases, please put it in the chat now and I will be led by you guys. Otherwise it's vital, ok, then we'll quickly go through them. Um I promise these are much quicker cases. I wanted to make sure that we got through everything in a more drawn out way for the first two. So these should only take about 1015 minutes. So you are the fy one on call covering surgical specialties. You are called by a nurse from the vascular ward who has a patient called Missus Waterhouse, who's two days after a AAA repair, she was deescalated from itu earlier today and she's now complaining of chest pain. Can you please come and review her? So again, we go back to the start. This is the A to e assessment of Missus Waterhouse. She, her airway is patent but she's a little bit breathless. She's got low saturations and her chest is clear to auscultation anteriorly, but she's got quite labored breathing. Listening to her heart sounds. You think you can hear an ejection systolic murmur and you note that she is tachycardic and has a low BP, she's alert Afebrile and with normoglycemic BM, her abdominal dressings are clean and her calves are soft and nontender. So, what would we like to do? Um Again, I'm just noticing the chat. Um if anybody needs to go or wants to go, that's absolutely fine. Anybody that would like to stay uh will go through these cases and not keep you too long. So Mrs Waterhouse, again, we're gonna do the basics. We're gonna give her oxygen, we're gonna give her a fluid bolus, perhaps a more cautious 250 mil er crystalloid fluid bolus in the context that we suspect she may have some um cardiac issues, an ejection systolic murmur. And while we do that, we're gonna go through her notes. And what we find is that as suspected from her ejection systolic murmur, she does have a cardiac history. We also know that we're on a vascular ward and a lot of these patients do tend to have systemic vascular disease along with the other presenting issues. So this patient has had ischemic heart disease, aortic aortic stenosis angina with previous PCI does have peripheral arterial disease and is on a number of different medications. The ones at which stand out to me are isosorbide, mononitrate and clopidogrel, which has been held in the perioperative period. We check her operative note and we check her itu notes and we know that she's had an uncomplicated procedure and has been deescalated with no intensive vasopressive or inotropic support. So we rereview her. We find our interventions have made some improvement and reading what is on the screen. If any of you can tell me any differentials or any things that you think may be going on, then we can progress on and find out what we would do next. So she's got central chest pain which is tight and severe causing her to vomit. Once. Now that you've listened to her chest properly, you can hear she's got some vassal crackles. And now that you're examining her legs properly, although her calves are soft and nontender, you can appreciate that she does have some pitting edema and very helpfully, just as you finished examining her, the staff nurse comes up and hands you an E CG. So have a look at this E CG and tell me what you think may be going on and I'm seeing some really good answers in the chat. So obviously, I am not the cardiologist. I am not a cardiologist, but I know what I need to know about EC GS to make sure I don't miss anything awful. So looking through this E CG, the things that stand out to me are the fact that we've got some ST elevated segments in leads 23 and a VF everything else looks acceptable, at least to me. So that should clear you in as Anushka has said to thinking about an inferior semi and for those of you that aren't aware of EC G lead territories, there's a quick little reminder for you now that I stole from UK medics.com, I am not sponsored nor endorsed by them, but we have to consider what we want to do for this patient. Now, with the information that we have, like you guys have said, this patient has decompensated heart failure secondary to an acute M I. And so we need to think about what we do from here. So practically what we can do while we escalate and get help. And this may be a situation that some of you have been in before where you have a surgical patient that has a very obvious medically related problem. And this may be the response that you get so diligently, you've taken some bloods and you've ordered a chest X ray. What do we think is this X ray showing you're showing some sort of general fluffiness across all the borders? There is a bit of a blunted angle on the left hand side. I think this is a good going x-ray for pulmonary edema. So putting all this together, we need to manage the patient's cardiac issue, but we also need to manage their symptomatic heart failure. So if you remember your Darth Vader Pneumonic for complications of an acute M I, you know, fluid overload or, or you know, fluid um decompensated heart failure is definitely something that can happen, especially in someone with a previous cardiac history. They do need fluid offloading, not only to improve their symptoms but to try and help push their heart or their myocardial contractility. Back up on that Frank Starling curve back to a more optimal place. I haven't gone in depth about antiplatelet and low molecular weight heparin usage for um acute mis because as I said, I'm not a cardiologist, but I know enough about cardiologists to know that local guidelines vary when I was doing foundation. People favor prasugrel, but locally people may favor something else. So I would always contact your local cardiologist or local guidelines to see what they advise and manage the patient. In the meantime, ultimately, this patient is gonna need some medical involvement. But the frustrating thing about these patients is where their best place to get that care. Because medical wards don't like looking after postoperative patients. And surgical wards don't like looking after medically complex patients if they're needing things like uh GTN infusions or furosemide infusions or telemetry monitoring. So one thing that you will probably be saddled with as the more junior colleague within the team is trying to arrange an appropriate place for this patient to be monitored and to get the care that they need if they're not going straight to the Cath Lab for any further intervention. And in all likelihood, that will probably end up being in a HD or an ITU setting. So this is where surgery ends up becoming a bit of a team sport where you as the sho um or the F one on surgery, end up communicating with the surgical reg, the cardiology reg the itu reg the bed coordinator and the ward matron all to make sure that this patient can get the care that they need, which ultimately is frustrating. But sadly, is the rigmarole that we need to go through to get to this patient to the place that they need to be to best look after their condition. So last case of the evening that we'll try and go through quickly so you guys can get up and enjoy yourselves on this Wednesday night is Wednesday. So same nurse again. She's a bit of a pests now. Good evening doctor. I've got Mister K on the surgical ward, he's had an anterior resection and he's complaining of abdominal pain. Can you please come and see him? And as you all know from on call, that's usually the wealth of information that you get with nothing else. So we go and see Mr Khan on the surgical ward and these are the observations that we have. So his airway is patent, but he's got an NG in situ. He has a bit of a high respiratory rate and he's already on some oxygen via a nasal cannula and he's breathing quite shallow tachycardia in a bit hypertensive, which is becoming a trend in these unstable patients and he's got a good going temperature and you note and your e examination that his abdomen is generally tender with some guarding and peritonism. So what are we gonna do about that? I'm not gonna quiz you guys any further. Cos I think that you're probably um all thinking what I'm about to say anyway, so we need to give him some oxygen via a face mask. Increase that as much as we can to try and offload some of his excessive work of breathing. Even though his snaps are at 98%. Give him a good going fluid bolus to try and bring that tachycardia down, get him some paracetamol and given that he's nil by mouth rather than giving IV morphine, which in most ward based settings, people will be uncomfortable to give as in nursing staff, you can give IV traMADol as a good effective um means of pain relief that the nurses will then be able to give again and again as part of a routine. Now you can give as, as a doctor, you can give IV morphine. I would just give it in one ml aliquots and flushes in between and titrate it to good pain relief. But obviously you need to be there to do that, which distracts you from doing other things. So, although IV morphine may be good initially to get on top of pain, you want something to run in the background to make sure the patient's pain is addressed while you're not there. And IV traMADol is a very good and effective pain reliever. So, reviewing this gentleman's notes, he is a generally fit and well, 57 year old male patient who had um an elective admission for an anterior resection that was open. So, not done laparoscopically for rectal cancer, looking through the operative note, the things you wanna take away. It was an uncomplicated procedure and he's had a colorectal anastomosis. So he's not had any stomas brought out. His gi tract is in continuity and he's had an anastomosis between his rectum and his large bowel. He was due to have 48 hours of postoperative antibiotics and any drains were removed at 48 hours and reviewing his ward round notes, you can see that he had an ileus develop at day three and that's when he had an NG tube in and it's just been nil by mouth waiting for his ileus to blow over up until press his bloods have been normal. So reviewing him more in depth, doing our fluid review and further in depth abdominal examination, this is what you find. Now, urine output isn't often, although it should be worked out as mils per kilo per hour. But for an adult, we want anywhere between naught 0.5 and one mil per kilo per hour. For a child. You want anything over one mil per kilo per hour and you basically just want to see that the input is matching the output. But as we all know, sadly, the input output charts are not always as accurate as we would like them to be. But the important thing to take away from this are that this gentleman is maintaining a good urine output despite having an extra 2 L out um of his er gi system, but he's still not opening his bowels or passing any flatus and he's getting some good going abdominal distention. So you take some blood and a gas and arrange for a portable chest X ray. This is what you find. So what do you suspect might be going on and looking at the chest X ray on the right? I want you to tell me if this is a concerning chest X ray or not. Hello, I didn't expect there to be a pole. That's quite fancy. Ok. So we can see that this gentleman has got some raised inflammatory markers compared to his previous bloods. His es are normal, which is good. It means that we've been maintaining his good, um, fluid balance, which we can see by his urine output. And a blood gas that we've done has shown that he's got a lactic acidosis. Now, we can see that this gentleman has er, under his diaphragm. And yes, there is a pneumoperitoneum. Now, to better ask this question, if I did chest x rays on every single patient that had open or laparoscopic surgery, how many of them would I see a pneumoperitoneum in? And the answer is pretty much all of them. So for laparoscopic surgery, we inflate the abdomen full of gas and for open surgery, we don't deflate the abdomen afterwards to get rid of all the gas. So, is this chest X ray concerning in context, potentially not actually five days post operative? I might still expect there to be a residual pneumoperitoneum from this procedure. Now, does this mean that I should ignore this completely? Absolutely not. But it does mean that you've got to again, consider this in terms of the patient. Does he have a reason for having a pneumoperitoneum? Absolutely. He's just had abdominal surgery. Is this pneumoperitoneum pathological, maybe. Yes, maybe no. So again, we have to consider what the underlying diagnosis is for this particular patient. So rationalized in terms of what you think may be going on. What is the most concerning thing that could be going on? He's had a colorectal anastomosis. He's got an ear. So a lot with a lot of distended bowel and abdominal distension, I'm worried about an anastomotic leak, but there's a number of other things it could be. So the question then becomes, how can we plan to make sure that we cover the worst case scenario but still address other things and gain our diagnosis along the way. And this is where the the common sense or the clinical reasoning comes into it and where you're best placed as a junior colleague to start putting, laying the groundwork to make sure this patient is safe while we do that diagnostic process and get the answers. So we want to make sure we're not missing this the anastomotic leak. But we also wanna make sure we're not missing any of these things. Of all the things on this page. The anastomotic leak is probably the thing that is one gonna kill him quickest and two, the thing that needs the most drastic intervention. If you have an anastomotic leak, if it's a very small leak, you can potentially manage conservatively. But if it's a very big leak that might be causing a newer peritoneum might be causing a massive inflammatory response and fevers, he might need to go back to theater, have his anastomosis taken down and have a stoma pulled out, which is obviously a big task and a big undertaking. So catastrophically, I always like to say, prepare for the worst, but hope for the best. So by preparing for the worst, we need to make sure that we are managing this patient for sepsis. Secondary to we don't know what yet, potentially gi potentially respiratory, potentially something else. We want to prepare him as if he's going to theater in case he needs to go to theater, we need to plan to rule out a few other things escalate appropriately. And then once we've done all of that de escalate as needed, I know you guys know what the sepsis six is. I'm not gonna teach you to suck eggs in terms of preparation of the theater. On top of what we've already done, make sure if I'm gonna stick a knife into this guy that it's safe to stick a knife into this guy. So make sure he's got a good coagulation status again, if I'm gonna stick a knife into him and there's a risk that he's gonna bleed. I wanna make sure I can give him blood. So make sure he's got an up to date group and safe if he's not already nil by mouth, which this patient is, make them nil by mouth because that will expedite what we do. There's nothing worse than someone needing emergent surgery and then finding out they've just had a sandwich because then it delays them six hours and they're not gonna get any better. And by that point, make staff aware if you think this patient might need to go to theater, just let the nurses know that you think they might need to go to theater, make the patient know, just say to them, you know, you may need to go back to theater if this is as bad as I think it is, but we're gonna address everything as we go along and try to exclude that possibility. Um So that if you do need to go, we make sure that you're ready to go. And on that topic, if this is an unwell patient with a postoperative complication, are they gonna be managed on the ward? Probably not, they're probably gonna need escalation. So if your registrar hasn't already done it, you need to talk to ATU yourself. Ultimately, if we think he's got an anastomotic leak, he needs act. But if that CT comes back negative, what are we gonna do, then we've said that it's not on anastomotic leak, but we still need to go down the avenue of making sure that it's not an infection from another source by taking all of these things. We hope and hope and hope and hope in the best case scenario, it's not an anastomotic leak and we want to do our best to prove it's not an anastomotic leak. If it is a leak, we'll deal with it. But it's much more in the patient's best interest that they don't have an anastomotic leak. So if there is a problem, we'll get to the bottom of it. And again, escalate and involve people, we can deescalate all of this if needed. But if it is the worst case scenario, then everything is already ready for this patient to go to theater. All the right things are done. All the right people are involved, the patient is appropriately resuscitated and they're good to go and that chain of response is kept intact and you've done the best job possible for that patient. If they don't need to go to the theater, just cancel it. That's fine. People will take the theater space that patient can stay on the ward and they can be resuscitated and treated appropriately. So thanks for bearing with me. Um But again, just a refresher, I can't emphasize it enough A to e assess every single patient. It gives you things to do and it gives you time so you can review the notes and investigate, reexamine with that information, make basic but effective investigations and interventions and escalate. Can't emphasize that enough. I will never be angry, mad, upset, or in any way negative about being called to see a patient that is ultimately fine. I would much rather be called to 100 people that are well than be called to one person that I should have been there to two hours ago. And that is the way that I would always like people to feel that they can approach um, seniors to talk to them. Because ultimately, we care about patients. We do, although some surgeons can be one cos we do care. It's, it's true. And the last point I wanna get across to you guys, which I said before surgery is a team sport. There are a lot of phone calls, there's a lot of triple checking and you can feel like you are on people's back a little bit. But ultimately, it's all about facilitating what you need for the patient because surgery has a big impact on the body's physiology and it's one of the biggest reasons for deterioration, primary cause it sadly is always surgeon or surgery. Um Just a quick question from aicha. Yes. The high lactate would maybe be more concerned for a leak or perforation, but also high lactate can result from any kind of infection or any sort of anaerobian. So it might be secondary to an infection or secondary to some level of hypoxia if he does have a whack and great pneumonia. So high lactic and pneumoperitoneum, yes, does raise suspicion for an anastomotic leak. But until I have diagnostic certainty with a CTI would always keep the net open. Ok, then, so that is everything that I need to torture you guys with. Hopefully you've learned something. Hopefully you've enjoyed it. Um If you have any questions, please put them in the chat. If you have any questions you'd like to email me with. There's my email address. If you have anything, you would like to send me for your portfolio as this is a teaching session. And when we've done case based discussions, please feel free to. Otherwise I will hand back over to elite and say thank you for your time. I really appreciate you guys coming. Thank you ad and I really appreciate you doing the same.