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Summary

This on-demand teaching session is relevant to medical professionals and addresses the complexities of working with unwell patients. It provides a comprehensive overview of the patient handover process, best practices for gathering essential information from nurses, key steps to move forward with patient care and escalation protocols. Learn how to recognize and respond to changes in patient conditions, how to structure reviews effectively, and ultimately how to approach patient care with empathy. Get all the necessary tools to practice with confidence and consideration.

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Description

RESCUDULED to 8th June

GUSS is proud to present our annual Zero to FY1 series helping 5th years transition from student to junior doctor!

In this session, we'll discuss the logistics as well as medical approach to an unwell patient from the point of view of an FY1 so you're prepared and have an idea of what will be expected of you working as a new junior doctor.

This series is aimed at 5th-year medical students but would be beneficial to anyone currently on placement anywhere in the UK.

Link to Join: https://uofglasgow.zoom.us/j/82328575901?pwd=YkFhcHlkNHY0RSt2T3pJRHVrbUt5QT09

Learning objectives

Learning Objectives:

  1. Identify signs and symptoms of serious unwellness in a patient.
  2. Sequence assessment tools for an unwell patient and recognize when a patient requires escalation.
  3. Articulate when to administer oxygen to a patient in distress
  4. Utilize the TIMTAM structure for documenting patient vital and medical signs on admission.
  5. Recognize the importance of family involvement in patient care decision-making.
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Computer generated transcript

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

Uh and um hum. Uh and essentially, yeah, so any and all patient information is being honest as much as possible, any kind of images and stuff aren't do the real patient, but I've tried to link um it's already got the info from for it, right. So, first of all, is kind of your most common ones. So the unwell patient. Um So it's kind of one of the most common calls. It will be about all this patient's using this, that or the other. Can you come see them? Uh So this is the handover got eight PM. Uh This was actually also a pretty horrible weekend because you had had to end up cross covering sort of two floors due to uh staffing gaps, which is a whole you'll get when you start working. But essentially the handover I got was there's an 82 year old lady on 11 be um she's a medical border today. What happened is she dropped us at a little bit. They did a chest X ray shows. She's got a hap and she's got a new stage three A K I which talks quite significant, but she looked fairly well clinically. So they started treating her. Um Essentially, they already put in, put on oral doxy. Um They've given IV fluids, they put her on the input output chart and bloods are out for tomorrow. So settled, essentially, the handover was just to be aware because as they were leaving, she was kind of a news about three. So she's a bit tachycardic, bit hypertensive, but she was fine. Otherwise, this is quite a common handover and the argument of the patient's, you'll get this hand over and then they will basically won't see them again, essentially. Um So um a phone call then from the nursing staff about 10, uh the patient was now using the seven. So that obviously jumped up quite a lot. And so you can see kind of hear that they were, they were tachypneic. That's, that's a job. Despite being on the treatment, the heart rate was up, the BP had gone a little bit worse. So essentially, if anyone wants to answer, pop anything in the chat or take the microphone off and, and answer what kind of information you want to know from the nurse over the phone, uh we can give about sort of 10 to 20 seconds if anyone wants to answer, if not having to move on. Um and just sort of run through some of the things that I would like to ask in that situation. Uh Yeah, she did ask at the time. So, yeah, feel free to, to pop anything or anything if you want, I think I can see the job. So give it 10 seconds or so. Um, so one just took something and if anyone wants to, uh, put anything in chat, anything like that, then feel free. Uh, but essentially, um, basically everything. But the main thing here is kind of what, how the news has changed. So whenever you, you normally just get told the news is this and that's just not very helpful and there's loads of factors to it and you want to know what it was before and how it's changed because you can have quite a soft news score change from like basically, if everything sits by one parameter, you can go from like a two to a six in like an hour and it seems quite dramatic, but often it's actually they're actually fine. So a lot of times go to review these patient's, they're actually fairly well and you can initiate the management and everything will be fine in this case. Um That was not the case at all. So I got into the ward had little with through the note to make sure that what Candida was the same as what happened. But as a brief aside, I noticed that in the blood which had we look at her grand had actually gone for about 60 to 70 over 300. Um So it's a huge increase. Uh obviously being stage one to stage three isn't necessarily representative how big it was. Otherwise she was fairly remarkable. Um Anyone just pop in the towel or something, how would you kind of structure your review? What uh assessment tool or anything have you been told? Structure reviews? Shout out or I'll just move on, give you a few seconds for someone to pop on the answering. So what we're looking for is basically a TUI um is how you should. Definitely. So even I know you're obviously talk here, but I didn't really start using it practice until I um basically about a month into work, my first job and started to make myself do it a lot more or to become more force of habit. Um And found that was really useful because you start doing it sort of by reflex and it's a really good way structure of use, even if you have absolutely no idea what's going on. If you do an 80 we, you can't really go wrong because it teaches the structure for you. And it's a really easy way to hand over to someone when you get help. Okay. Uh So you didn't a to we uh so she looked very unwell. She had a 15 liter mask on, she was, had increased work of breathing. She was alert, it clearly very tired and she could chat the in sort broken sentences. So because she could chat her Airways patent, she was on 15 liters of oxygen via trauma mask, SATS was saturating normal. At that point. She was scared one. Uh She was breathing quite hard when he listened to her. She had widespread cramps in both bases. She was tacky cardiac. She was sinus tactic. Got we C G um peripheral pulses were present but she was obviously a bit shut down. Um G C S was fine. She was alert people's all fine. BM was five. So obviously good to pull out the glucose. Um Everything else essentially was unremarkable and essentially what's always good in this situation which you should definitely look at is, are they for escalation? What stage they fought in an ideal? Well, that, you know, it would say in a TEP it would be like uh the H D you not for I T U or for both or for resource or not for recess with the D N A R form, the red form at the front. It doesn't always happen. Essentially, you shouldn't be panicking like this, but you will obviously, uh and with, especially in your earlier stages, um essentially, what's the first thing you're going to do is you should escalate, not, you've done this initial assessment, okay. Um So in terms of escalation, um first point of call, you'll be told on the shift. It's, it's a mid tier. Normally, in this case, it was an F Y to mid two, it can be kind of fy two is a general S H O. So F Y two I M T sort of early I M T S I N T one and I M T two G P S T s. Um Anything like that really? Um What we did is to get the flu is going, took blood cultures, portable chest X ray escalated antibiotics, put her on IV S because basically the sepsis six because she was septic Fy two came in, they basically pop the head in. Uh and then look at the patient and was like, right called Med Registry to way because she was getting worse. Um Mezrich came to have a look at her. He started going through everything, got the notes and everything. I went away to say the bloods, um and put them away and everything essentially came back to find that very quickly in that sort of our that we've been working sort of with her and assessing her after that. So she had nose reason to mask those kind of blood everywhere down the front, her left pupil would blown. Um She had a new sort of left side of facial droop. Um and she was conscious but she wasn't really responding anymore. Um So she'd very quickly gotten a lot more unwell um as indicated by donors of the emoji. Uh So she is, yeah, so she's gotten a lot more male very quickly. Um And in terms of the background, there wasn't really a lot at all, but she was sort of mid eighties. Um and she, despite maximal treatment wasn't getting any better. So what we thought it was, it was likely sets to secondary to a hat, the D N A R was put in place and the red essentially said we'll treat her for an hour as much as possible. So, maximal therapy. So she was getting fluid oxygen that we kept a catheterized. We're giving her maximum sort of IV antibiotics, but she wasn't for further escalation beyond that. So the red to put the D N A R in, not for H D you ready for and the husband because of the seriousness of the situation. Um We should probably prescribe a CPS, which I hope, I think you should have had a teaching session on or will do. Um But it's actually really handy. So there a protocol on Hep. MMA when you eventually prescribe it, if you are working in the sort of G C, you just gonna protocol and piping anticipatory and you click it and then there's different forms depending on the opiates. It can be morphine or fentaNYL oxyCODONE. But you, it basically describes them all for you um as P R N S all in one click, which makes things really handy. But so I won't go into a CPS because hopefully, if you haven't had a good thing that you will. Um So we prescribed those as a just in case to sort of go alongside the actual medication treatment after about an hour, she wasn't getting any better, it was getting worse. Uh So we pulled active treatment and we tried to make her as comfortable as possible. So that did involve kind of keep the option mask on for a bit, but then it started to stress her. So we took the option off, put on some nasal cannula, uh which she tolerated better. Um So it's one of actually the common sort of difficult situations is if, if a patient is kind of, you know, struggling to breathe or, you know, they drop their sats. Um Do we keep, if we, you know, if we're putting them on to palliative measures, essentially, do we keep oxygen on? Uh, the answer? I said what we, what I've seen from experiences. Yes, basically. Keep on what they tolerate. Obviously, you take it off and start to get short breath and get more distress and you can treat them with meds. But if they're tolerating a mask, we'll just keep it on. Um, the husband arrived about three hours later, the patient died. Um Very sadly. Uh And actually it turned out after that she was a medical board on the 11th floor and had come in for essentially a fall and a twisted ankle, uh and wasn't really coping at home. So she was basically a social admission because her husband couldn't really look after her. Uh And then this all happened. So it's actually very sad. Um And then basically the shift is carried on. So this all happened in the first kind of four or five hours of the night shift. Um, it's a very good example of how the news is both a blessing and a curse. We use it a lot and perhaps inappropriately to some extent. Um, but in this case, it was, it was good in the sense that it kind of treat me to go and look at her, but actually she was way worse than her new oils. Whereas actually sometimes you'll get someone who's like, using an eight, right? And then you go and see them and they were like a three or four before and like I said, every parameters shifted slightly. Uh, so they're just on the cusp of everything and they're actually fine. They start up in bed reading a paper, having a coffee, they're absolutely fine. They just got a bad news school. Um, so I said good kind of 80 90% of the time when, you know, you get called about new score changed and if the nurses aren't especially worried, it's fine. Uh, and that's kind of like what you can start to do overnight a lot is when you'll be very busy, get what's called about news. Uh, and the best way to do it is how has it changed? Are you worried about them? Find out what the news actually is? Um, because, you know, they could be right on the customer about to get a lot worse. Have a look at it on your we piece of paper and then just eventually with more time and practice should be more comfortable with saying that can wait, I'll see them soon. There's someone who's more unwell and this, that and the other. Uh, but it's like I said, a blessing and a curse. Uh So don't rely on it too heavily. Um And then after that, because it was quite difficult um following this, basically, just I wrote reflection and then part of that kind of reflection involved, basically creating this teaching session. So I thought was a very good example. Um It was probably actually think it was my first patient that I've seen from the beginning to the sort of end, so to speak, who was septic, um who actually deteriorated that quickly because you always learned that, you know, pay that sepsis killed really quickly and to be treated really seriously. And you should, but a lot of the time you go into clinical practice and actually patient's are you just escaped the antibiotics? You give them either fluid bonuses in some oxygen, they get better quite quickly or at least they get to a stable enough state that the antibiotics sent, starts kicking and then they get better. So a lot of patient's initially, I was like, well, it's not actually that concerning, but this is a very good example when sepsis can basically do what it says on the tin, so to speak. Um Are there any questions about that, uh, peaceful free to put in the chat? Um, and I'll get back to it or any questions at the end. Um, it's whatever you do or, um, can always, uh, ask my e mails and then do you have any questions if you don't want to put it on the chat? Anything like that, you want me to give that out? Um So unless anyone wants to ask anything, this point, I'll move on to the next one. Um So the next one is, is one of your most common and it is uh it can be very frustrating. Uh So this next one is patient X had a fall. Can you come and review them? Um And you'll get so many of these um lows is very job dependent. So I got very few when I was in denser parts, the one we're going to go through very quickly. Um And, but on Jerry's, it was like every other call was a full uh unintentional prime there. Um I have must read about over 54 reviews um only to have had serious sequelae, one serious uh had a basically had enough from a slip out of the bed actually, which was quite surprising. Um That one was a good example of just if you're concerned X ray, it doesn't harm anything, you might as well. And he had enough even though he was actually wasn't much pain at all. Um But the other one, what we'll go onto is uh a lot more serious. Um And it's kind of one of the reasons why we do forward reviews performers. So how a good hand over the theory is given and it does happen sometimes about fall is how they say it's patient has had a fall, it was witnessed, we saw it or it wasn't, they didn't hit their head or we don't know and they did or didn't lose consciousness. They're often tell you, um this is their current news. This is why I'm not worried. Can you come and do a review? That's like the perfect handover. Uh And it's a bit of a needle in the haystack, perfectly honest. Um But when you get it is great. Um And some of the things that are excellent at doing it. Um But often what you'll get is actually very seven. That last slide, which is they've had a full can you come and see them high up and you're like, this is useless. So I always try and get as much information again as possible over the phone like I did with the previous one um asking basically all those questions over the phone so I can categorize it. Um Because if they basically, if you get that kind of handover above, they're not worried about them, they haven't bang their head, they're not anticoagulants, nothing's concerning. You can often actually put it off and come review them after because you might well have. And that's obviously only if you've got other more pressing stuff, but it's, it helps me kind of prioritize it was initially like all falls and you get quite worried, especially when you're doing them early on, but a lot of them aren't that bad. So in terms of assessing a to be again, is a very good way to do it. However, G C has now got a sort of a performer. I couldn't find a picture of it, unfortunately. Um But it literally has it laid out for you and then what investigations you should consider based on a tick box after. Um But the most important thing is uh like I said, um quick examination top to toe, uh especially in Euros, you always do it really, but especially focus on it if it was an unwitnessed fall or they don't know if they hit their head, which is often and Jerry, cause they can't remember the fall. Um just to have a baseline in case things change. Um Always documents. Some of the key things, at least the beginning is where and when they felt how they felt a mechanism. Um if they remember or if anyone saw if it was witnessed or not, especially if they're on any anticoagulant. So it's good worth documenting that in terms of anticoagulant to say. So initially, I was like anything I was like, probably ct head, but eventually you kind of get to lender unless they're showing signs of it or bleeding or your concern, if you're concerned, just worth talking to the senior about doing it. Um, but if not, if they're on things like aspirin 75 or an ox 40 sort of your low dose prophylaxis then, but if they're on a doe ac almost definitely worth doing. Um, and if they're on treatment of doctor part and things like that or 300 meg aspirin and dap things like that, it's just definitely worth is to just, just, uh probably worth it in that circumstance. All right. Um Like I said, if possible get a history, it's not always possible, especially since a lot of these forms will be in geriatric patient's who would be able to remember if they got dementia delirium underlying cognitive decline, anything like that. Um And then a good way to structure the history, which I'm sure you've been taught, which is why I'm not really kind of, you know, asking too many questions. I'm sure you guys know a lot of this. Um But it's basically uh a good way to do full slash collapses before during and after. Maybe it's got respected questions that won't delve into unless anyone wants um me to go through that in which case pop up the chat. Um Basically do the uh red flag signs and symptoms under each heading. That's a really good way to struggle in your own head and on the performer and we're talking to the patient. Um And then the main reason we do the full performer, essentially, your most common squealing from it will be head injury or a basically fracture. Actually, the most common is nothing but those first two were kind of what you're worried about. Um So, in this case, so this was I was actually reviewing someone else on the ward. Um um, and the emergency buzzer went off, walked around into the room. Uh, there's a patient sort of lying on the floor, bleeding out his blood everywhere. I looked a lot worse than it was at the time. Um, it was found on the, uh, on the floor, he had a sort of frontal head injury. You can see we banged it on his, we saw a little desk wires by his bed. So he examined completely fine. Um, he was a man in his late seventies, uh, with widespread metastatic cancer for palliative measures due to hopefully go to's home soon or to hospice. Um, he was absolutely fine. He was chatting away, felt normal new zero. He can explain exactly what happened. We actually then witnessed him almost fall again, getting back into bed because he was just very weak in his legs. He's very deconditioned. Uh, the only thing was on the Aspirin 75 examination. Fine. No neurological deficit. Absolutely fine. The question is, would anyone do any further investigations at the time, if that's the information you've been given, um, again, feel free to copy in the chart. I know people aren't necessarily keen on doing that. Um, so we'll give a sort of 56 seconds. Just a yes or no. Otherwise we'll move on, um, a bit of a leading question to be fair. Uh, so essentially know at this stage. So he had hit his head but he wasn't on any sort of major anticoagulants or high enough dose. He was examining entirely. Normally I chat with the F two and he's like, don't bother, it's fine at this point. So it was correct at that particular stage, bandage, the injury documented everything and that noted further investigation changed, indicate this time. However, one thing I always should have popped on here, but I would just say for the sake of this one thing is always good. If you need something sort of niggling in the back of your mind, you're not entirely sure. Neuro obs is a real pain to the nursing staff. They don't like it, but it is good and it's safe and they'll just do checks. Every, there's a perform, they'll, they know to do your arms basically and they give them a certain number of times. Um They do it sort of obvious every, I think it's like twice every hour and then twice every two hours, stuff like that. So they can do it kind of stagger. What was weaning off? The neuro ops. It's a good way to kind of cover the patient's back, cover your own back. It's just not entirely sure. Okay. So that's what we did. We did your obs about three hours later. I actually just happen to be back on the ward as well. Um And then I was called when I was on the world and I was already here. So I came over to see them. Basically, he was acutely confused. His G C S very fluctuate in 10 to 14 previously being 15. Um and looking at his eyes when he reviewed him so often when they said, you know, people are more uh confused. Um It's always been like, well, what they, what were they before? And it's very difficult out of hours because the nurse and stuff might not know and you might not know if you don't know them. But luckily I've met him. Um So I knew that he was a lot more confused. So can I, when I just think my son might be on the pot in the shower? I have a little look in a second. But what I'm opening it, does anyone wanna suggest or something very quickly what your first line investigation um would be for the most likely diagnosis this stage again, we'll give it a few seconds and it's absolutely fine. Oh, that's a good question score and asking people just okay. Welcome to that. Uh But yes, so ct head Yeah, thank you very much for, to put in. Yeah, exactly. Yeah, exactly. So he'd had this lucid interval, uh, and then obviously had depreciated. So, um, that's what we did. So we got an urgent ct head and this was as close to what we could find, um, what I could find rather because I wasn't able to get the exact scan. Um, does anyone want to hazard a quick sort of, uh, guess or pop into the chat? What that might well be? I don't think I can see. Uh I suddenly popped up, I'll try to get the child basically. Um We got an urgency to head. Um and he had an acute on which we didn't know on chronic subdural hemorrhagic stroke, uh which is very unfortunate. Um So he actually had a sort of bilateral, which I didn't, couldn't necessarily get up in here. I don't think he had a bilateral sort of chronic subdural and he had a right sided acute uh bleed. Um So not very good, basically. Um And, and as someone mentioned on, on the, on the chat, obviously had this lucid interval and it started to get worse. Um sort of gradually, which is quite classic of subdural hemorrhage is which is also very common. Um Basically, it's the most common form of hemorrhagic stroke in older people who have falls. So it's always worth doing that mind, especially when you're, when you're suggesting your arms. That's kind of what we're looking for and that's actually what they really start to find here as you start to score. Um We then called neurosurgery urgently. Uh They listen to the referral is, is a nightmare to get through to them. But we eventually got through because of the co morbidity, palley of treatment of metastatic cancer. He wasn't for any intervention. He was also wasn't, especially he was quite frail um found who called, they came in, again, palliative measures put in place very quickly, very well. Um Comfort was prioritized as is with all sort of palliative measures. Um And he actually survived quite a long time, um sort of in this state. Um And thanks Daniel. Uh so he, he did uh quite a long time actually. Um He was very comfortable. We actually wasn't scoring much, some sort of a palliative measure. He was on sort of a rest of my string of nights. Um And family always with him, but he eventually passed away from this. Um which was very sad again cause he was about to go home. Um And I think that it might have had to go to, to um uh sort of higher ups from there because it was a fool with serious secrete on the ward, but it nothing could have been done. He was, well, he didn't need monitoring anything like that. And um and that's what happened with him essentially. Um So that's just the link to sort of the the scam picture. Um So the take home points from that and the whole thing really, the whole uh cork, so to speak. So you can only do so much as one person. I think that's really hard to come to terms with them. I can't say I definitely have um it's work in progress. I think everyone kind of balances with it, but especially out of hours, you can only do as much as you can as one person and you can't work yourself to the bone. It's quite being called by many people. And generally you'll be working with staff who understand that. And not, that's not always the case, but maybe trying to, if, if it gets a little bit confrontational and applied by trying to remind them of that, that you are one person often, often looking after over 100 people and most of them won't be unwell, but it only takes one and then a lot of your time is taken to that one person and then, and then everything can pile up. That's just the way out of hours. Medicine can go. But if you've got a good team supportive, it, it's definitely manageable, but just remember, you can only do so much. Okay. Um, the next thing is, well, really what I'm trying to do with this as well is reflects and learn. Don't take it home with you. And I think that's like I said, a lot, it's very easier. It's very easy to say, very difficult to do, maybe not the reflecting part, but, but they're not taking it home with you. I, I certainly found these cities happened in sort of subsequent night, essentially. Uh And I found it very difficult um part of which, you know, result in me doing this teaching session and doing a couple of reflections which do help. So I would recommend, you know, you had to do so many reflections, but sometimes they actually can be quite useful. And I think these couple cases were some examples of that. Um And following on from that is you can beat yourself about these situations and you can think what could I have done better and objectively, I think one of the best things you can do is just think if I had done anything differently, wouldn't have changed anything in both of these cases, know. So we followed everything basically to the t we did everything we could do and sometimes it's just not enough. I think that's a really difficult part medicine because often, especially earlier on you get a lot of cases where you make things better. Even if you don't think you are some antibiotic, you'll get a bit better. You given the fluids get bit better and basically never see them again. So you forget about it, but sometimes the treatment isn't enough. And that is just how medicine goes, especially sort of an Asian population. So I'm generally the opinion of the, and the philosophy that you can beat yourself up about these situations. But only to a point is guilt and sort of remorse about it useful because then you can reflect and learn, but it's quite narrow, sort of windows, so to speak. And it's very easy to go beyond that. And that's when you start to basically just only read the negatives and number of positives. And like I said, in these cases, I wouldn't have changed anything. No one would have changed anything. And having done anything earlier, wouldn't have changed anything. So we escalated for the first case, escalated the management at the correct time. Um, they were a maximum ceiling of care. We call the F to call the reg and unfortunately she passed away despite that this next one, nothing could have really prevented the four because he wasn't a risk, wasn't identified as a risk before even early scan wouldn't actually probably have shown an acute bleed. Uh, we would have needed to re scan him and even if we had, he still wouldn't have been for no research win puts that wouldn't have changed anything either. Granted, maybe we could put in palliative measures sooner, but he didn't really need them. He wasn't really requiring symptomatic treatment. So it's good to always kind of think about it and, and it's not, it's difficult, I think it's not, it's good to remember. It's not you trying to make excuses. It's, you have to look at it very factually objectively. Could I have done any better if you could have done why, how learn from it, talk to someone and if you couldn't have, it's probably the heart of it because you just have to accept that sometimes this is just the way that things are. Um, like I said, the majority of your out of hours medicine, a lot of it will not be like this. You get so many falls and they have a, have a we skin tear, they got no injury whatsoever. You never see them again. You can have loads of septic patient's who have been lying flat, sit back up, right. And the SATS are miraculously better, higher BP is better. They go to sleep. You never see him again. That's, that's a lot of what you get. Um, or you get people who are very middling, you know, who have a very mild grumbling sepsis and you start treatment and they get a bit better. Uh, and then you don't see him again, then they get better by the morning. Everyone just get a little bit more and we'll overnight. Um, or generally about, but it's just important. Think that about these cases here that I've walked up, uh which is wider this session because sometimes they can be more severe and it's good to just have that in the back of your mind, back of your mind just if you're a bit unsure about what to do, just think or should I do the investigation, if you're thinking about it worth running it by a senior. But often what I've been told is if you're, if you're questioning it, there's a little bit of doubt, just do the investigation, do the extra test, put in a little bit effort more for your own piece of mind. Often, not necessarily for the patient's because, you know, somewhere deep and they will be all right with it, but it's just worth doing it in case in these cases, for example, where that patient was actually quite well. Okay. That's it. Um So thanks for listening, it was a slightly different uh take on the, on this. I, I think overall and it was less medical but I thought sort of the, what we're gearing at is going to getting you ready for F one. I think some of the hardest stuff in F one is out of hours. And that's, but that's what you learn the most. I actually quite like out of hours. Despite what you might think in this talk, I actually really enjoy it because you get to practice good medicine. It's less kind of ideals unless uh rubbish jobs here and there, you get to do good medicine. Um You get to learn a lot. Um So enjoy them. They are good despite the fact they, you know, they are uh and tiring. Um But it's just like I said, it's good to think about what, uh some of the cases that can happen in out of hours, but a lot of times wouldn't be like that. Um There's any questions at all. So I think, than you might pop the, yeah, the feedback, I really appreciate some feedback if that's okay. Um Because quite, let's give this a couple times actually. And if I get positive feedback about it, that would be a good kind of way to see if I can make it any better. I can aim it slightly differently or change any bits. Um, but yeah, thanks very much for listening. Uh, there's any questions pop in the chat, you can, um, you or ask me, um, or I can always pop my email in the chat, then it was got any questions or you can sort of message on Facebook and someone will be able to, um, some will be able to thank you very much. We'll be able to give you my email address and I'm more than happy to, um, to, to answer any of your questions or have to have anything like that. But yeah, thanks very much. Have a lovely rest. Your evenings. I'm just gonna put my video and everything and you might, but if you have any questions I'll still be about until the end of the session.