Computer generated transcript

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

All right, I'll give everyone um another minute just for people to um continue to enter the chat and then we'll get started, but let me know if you can't hear or see me um at all, and then I'll try and sort that out yeah right, so we'll get started now. Um even everyone thank you for coming my name is innocent, A Gorney, I'm a current uh ct one in trauma, orthopedic surgery um in Sheffield, and today, I'll be covering um for the court surgical training interview session which is the second session on the clinical station, which is a continuation of our first session, which we did last week on the management station. So let me know if there are any technical difficulties and I'll try and tackle them as we go along, but essentially um this is going to be quite short session where we will firstly go over the overview of the clinical station in the court surgical training interview. Um I'll share some of the tips collated for myself and several other current ct ones on how to approach the station and formulate your answers. Um. There will be time for some general q and a's and then we'll go through um several cases how to approach those cases in certain points that would be offered up for consideration, so the clinical station format and I'll just quickly overview this for those of you who aren't familiar with it um There are two clinical stations um which comprises half of your interview and there's 10 minutes in total. Um There's no break in between the clinical stations and the management station, so it's all a 20 minute interview um with with you going straight on at 10 minutes to the clinical station, previously, when the stations were done in person, you'll get two minutes to read the first scenario and make notes prior, but since the interview format is virtual uh three microsoft team, this formats changed essentially what they will do is They will read out the scenario. They'll ask you an initial open question with a large blurb on the management scenario and then they will ask you more specifically dawn questions. Um If you miss out on a detail when they read a scenario, essentially just ask them to repeat that part of the scenario from my experience. Generally, um they've split the clinical station into two parts. Part one has generally been a post operative ward based or amount see surgical presentation that you deal with um in day to day, which would likely follow the secrecy or start algorithm, and one scenario is likely to be trauma based, which would more likely follow the a TLS algorithm, however, that's not always the case in my specific interview, I had um to ward based um emergencies and no trauma based emergencies. So in thunder structure, um there isn't any particular right or wrong way um to, to approach the question, however, different people will say different ways on how to approach it essentially, I believe it's quite important to be structured, systematic and have a structure to fall back on um Because during the interval you'll be quite stressed and quite flustered um so in terms of answering questions, um If you're able to fall back on that structure, it makes things much more easier for you to deal with spies and stars are popular very much to fall back on there a little bit less relevant for clinical stations um Most of you most of you would have heard of um the c crisp approach, So in terms of the c crisp, um type of questions that you will get, they will most often be a blurb relating to um a emergency Surgical Award based presentation, so for example, there's a patient your a c. T. One on General Surgery and X patient is x days POSTOP, they are suddenly unstable for whatever reason what do you do um and it will normally follow follow that format. Now the way in which I think is a good way to approach this type of station is first the first thing you need to do is to identify the most concerning complaints and the most concerning issues within your differentials, so when I had my interview, um I had one um 111 of my stations, was you have a X gentleman who's been admitted um x year old gentleman who's been admitted after an ankle fracture um and placed in a in a bologna um back slab. He's been complaining on of pain, which has not settled with analgesia um and then what they're trying to guide you to what they were trying to guide me to, was a conversation about compartment syndrome and then one of the things I said and which they marked me positively on was I was able to identify um the key complaint and my key differential which was compartment syndrome and say I'm worried that I would be worried that this patient is exhibiting signs of compartment syndrome. Um If you're not, if you're not sure, if you're not sure, and if it's not a bond or diagnosis, then what I would do is. I'd list the key differentials and then from there you would go into your 80 assessment. Now the 80 assessment is one of the things which they will assume that everyone is quite fluent in because that is the thing that everyone will practice quite a lot on and one of the way in which I would advise preparing for the interview. In terms of doing the 80 assessment is finding a uh you know a speech or a way of combining those phrases, which works for you and that you're able to get all of the salient points of an 80 assessment off um in a smooth and slick manner, it will likely come that by the second scenario because every pretty much every scenario can be approached in an a two e, uh with an eight, we approach that halfway through, the examiners will sort of stop you because they know you can do it because you've done it once and you're just saying the same thing again um that that they will stop you and then move you on, however, um one of the things that um I was I was advised to do and um what's well for me in my interview is that everyone can everyone can say and eat 80 assessment off the top of their heads. Um. One of the key things that will distinguish you from other candidates um is within your 80 assessment highlighting things that are pertinent to um the differential diagnosis in question, so for example, if someone comes in following a, with a suspected numa for acs, then within within the step of breathing, you would mention what your examination findings would be you would mention that you would um what you would want to do um what you would want to do seeing that this patient potentially has a pneumothorax um what sort of blood tests um or other investigations or other adjuncts you might want to um add so moving on from the 80 assessment. Once you finish doing the 80 assessment, the Secrets algorithm um states that one of the things you should do is review the history, any operation notes and existing clinical notes, re, examine the patient and then review any other existing chance so they're obs, fluid, charts, drug charts, blood test results, and then from there, make the decision is the patient's stable or unstable. If the patient's stable, then you can continue the current management um and then review every so often, if they're unstable, then you need to um suggest additional investigations and come up with a definitive treatment plans plan and those investigations could be medical, they could be radiological, they could be um surgical um. It also mentions escalating to the team and s and one thing I would add is think about methods of escalating to the team, but also methods of escalating outside of the team by which I mean in your team is your registrar and your consultant that outside might be people like Cicotte or i t u, or a medical registrar or a specialist team such as cardiology, and then updating the family and next of kin as appropriate, so here's a picture of the Secrets algorithm and it basically just goes through um what I've stated and is a good way for structuring your ward based um answers. So in terms of when I received a ward based question um in my interview, the way in which I said it with the way in which I structured, it is that I firstly um state my immediate concerns and what my key differential was, so I'm concerned that this patient is exhibiting signs of compartment syndrome. One of the things that's also quite good um quite good. Um In terms of showing, initiative is depending on how the scenario is worded, So for example, if you are called by um some scenarios might be worded in the sense of you're called by a member of the nursing staff who says that x. Y. And Zed, another thing that is um which the examiners quite like is when um you you like you would, when you're working um on call, state what steps you would like to be done over the phone or what information would like to gather over the phone um because that that shows that you've worked in that environment before and that you're thinking ahead in terms of what treatment and what management you would like to give to the patient, so in two, so it would be staying your immediate concerns staying if there's anything anything in terms of investigations or any other adjuncts that you'd like done over the phone um and then going to review the patient reciting your a. T. E. While highlighting um the important points which are relevant to the question being asked um. And then after that you would then do the full patient assessment and then decide what treatment potentially um could be could be warranted. In most cases, they'll likely fall into the unstable pattern, so you need to think about what medical, surgical, and radiological treatment you would need the alter, the second type of question that you might get in your clinical interview is an a. T. L. S style question and the process of following the process of answering. An 80 less star question would be the exact same you need to identify the key, compare the key complaint and the most concerning issue, so within your differentials early on, because you need to remember that the examiners, they are examining multiple patient's throughout, not multiple patient's, multiple candidates throughout the day and you want to make sure that you have something that catches their attention and then it's a case of doing the simple things, so if someone comes in with a high energy injury um and the trauma court hasn't been put out, then making sure trauma call has been put out and that the patient is in an appropriate setting. So if you saw a pain. If you, if they said you were seeing a patient in minors who had you know walked in after being hit by a car, then you need to put a trauma call out and make sure they're seen in resource and that the trauma team is available and then from there, it's a similar um 80 assessment approach. However, within the primary survey and resuscitation does several things which are slightly different, so one of the things to be aware of is um with patient's who have high energy injuries um two triple and mobilize the see um two triple immobilize the c spine, recall a blocks and tape um and then after after that, then moving on to um assessing breathing, ventilation, circulation, and hemorrhage control, so thinking about on the floor and for more, for occult places where bleeding can occur moving on to disability and the neurological evaluation and exposure, they're all pretty similar, However, it's good to it's good to um know that there are some key differences, for example in the trauma setting, you might need adjuncts such as flop far scans um to detect bleeding, and then after the primary survey has been carried out, conducting the secondary survey, which um ensuring a secondary survey has been taken place, which involves a head to toe examination and complete history and then from there you'll do diagnostic investigations such as a trauma scan, so one of the questions um which was which I found which I found quite um important was how thoroughly should we talk through the 80 assessment um As I said the interviews will hear you know 10 15 80 assessments in a day um is very important to balance the amount of detail you give within your 80 assessment with the amount of time you have um in your in your, in your 10 minutes, you don't want to have an 80 assessment, take up 2 to 3 minutes of the five minutes for a question um It's more impressive as I've said to keep it relevant to your possible differential. So if as I said before if, if someone comes in with signs of a chest injury, then focusing more on on the breathing and ventilation aspects of it and making sure you stay any differentials which might be concerning, such as name a forex, hemithorax, so on, and so forth, so what I've got what what I've got now is. I've got several examples um what I'll do is. I'll read out the examples um if people could put down in the chat, how they would know how they would approach how they would approach this, what their main differentials are what their primary concerns are and what personal points within the a. T. E. Structure. They would, they would um want to highlight within um if this was their interview question and then we can go through um several of these and look at how you would structure your answer so what I'll do is. I'll give everyone maybe about two or three minutes um to go through that, and I'll look through the chat for any responses. Yeah we'll give it another minute even if you're not sure of what the answer is that's fine, it's about seeing where your thought process is right, so looking, so looking in the chat, I can see um Several people have said anastomotic leak sepsis uh the Hisense collection, so everyone's along the right track. Um So the points that are quite important that I've highlighted here is that the patient's five days post doc um so in terms of the complications that might occur POSTOP. As you know, um different complications more commonly occur at different time frames. The fact that they've had emergency open right hemicolectomy with a primary anastomosis. Um tell um is quite important as well, worsening abdominal pain and then the main thing here that sort of leads you towards the picture of um leak or sepsis would be fever and tachycardia, For example, if the blurb said that the patient had worsening abdominal pain and hasn't opened their bowels um and now feels nauseous and has started vomiting, then you would think along the lines of bowel obstruction. Um So yeah that's right so the way in which I've structured it, and it's quite easy to, it's quite easy to recognize um what the diagnosis is in this. In this sort of question, because they're diagnoses and um issues that commonly occur on the wards and that you would encounter working as an f one or f two in a surgical specialty. Um. The main issue so what i would say is that this is a patient displaying features of sepsis five days following emergency colectomy. The primary concern is and the mathematic leak until proven otherwise other differentials could include you know sepsis of another origin, think someone mentioned about having a hap um as well, but the primary concern is anastomotic leak. Um Most so, I would then say manages patient according to see chris principles, assess a. B. C. D. E, and then list out the parts of a. B. C. D. E, which are important, so um exactly what people have said um in, um in the various replies, into the chat, one thing that isn't here is um I think someone mentioned about the nursing staff to initiate certain investigations is not explicitly mentioned. Um You know it is actually a specific mentioned um that you're called by the nurse is concerned um so that's that's another thing which that's the thing that isn't here that I would perhaps have added in, so on the way to assess the patient are opt nurses too. Um To you know, initiate the patient on high flow oxygen and ersten, sitting up and bring the relevant charts and observations um op, notes to the bedside for when I get there um and then after assessing a. B. C. D. E. And resuscitating the patient ensuring the sepsis six but bundles fully rolled out and listing out the septic six bundles, so give free take, three high fluxion fluids, antibiotics, and then taking that tate, blood cultures, and urine output with a CAFTA, but that would normally fall within your um that would fall within your 80 assessment, but it's important to highlight those things in the context of an anastomotic um leak. Then from that, you would then going back to the secret algorithm, review the notes, and take a focus history from the patient, so why did they have a right hemicolectomy um Looking at the option it was there any parroting, you're so soiling or contamination looking at their obs and their war ground entries. Is this something that has happened suddenly, have they always been trending in this direction. What has there been what has the analgesic requirements been. What they're all intake been have their bowels been working um is there any other source of sepsis, so chest catheter, canula line, and cough um which are causes a post up pyrexia, So it's a case of it's a case of initially establishing this and then moving on to our definitive investigation, which would be a ct abdomen pelvis with contrast. Um At this point, you would um you would also want to escalate as I said within your team, so speaking to your registrar and the consultant who did the operation was responsible for the patient escalating out of team, so to seek or an i or I to you depending on on the observations either to make them a well for an early review um as this patient. If they needed to go back to fear to might require um i. T. U. Um POSTOP, and then depending on your discussion with the registrar if leak was concerned, they might need to return um to theater um so then calculating their neela or p possum score, contacting the anesthetist, contacting the theaters as I said, contacting critical care um as well and also contacting the next of kin is quite important and that's something that the examiners quite quite light. Um when when I I sat the interview because it shows that you're thinking um holistically um as well, not just about the medical aspects of this case, so some follow up questions that may be asked, would be, would include things such as risk factors for, for anastomotic leak, so the way in which I like to um um structure questions about risk factors in surgical patient's is that the patient factors um and there are non patient factors, which include operative factors um As well, so patient factors are factors that are going to remain the same pretty much regardless of the operation that that happens so um you know patient factors include advanced age, if they're smoking, if they're me know, suppressed, if they're diabetic, frail, uh malnourished, um If they have if, if they have any other co morbidities that might impact healing. Um operative factors include anastomosis under tension um really poorly done Nostrum asus, um tissue ischemia, um our contamination and soiling and then management options. If it's a localized like you can, um you can manage it conservatively with bowel rest, TBN, antibiotics. If there any collections, then they might need um an aspiration um if it's a massively, they might need a laparotomy um and um to be d um d functioned so moving on from that case. Um. Is another, is another case where a 72 year old man admitted following a neck of femur fracture and had an inter medullary nail procedure five days ago. You're called by the nurses. He has had a fall in the toilet on the ward. He has a background of hr fibrillation, osteoarthritis, and hypertension. How do you approach this scenario, so yeah again give everyone about two minutes. If you state what the differential you're concerned of is and then how you would approach it. In terms of the parts of the 80 assessment you would prioritize in this circumstance, so if everyone could put on the chat, what um differentials are yeah okay, so I've got several. I've got several um different suggestions joke, anal bleed, um paraprosthetic fracture, head injury, um p. E. E. Um stroke. So the parts that I've highlighted which are quite important is that it's obviously a man he's had um the neck of femur fracture um and he's had a procedure five days ago. Um He's had a fall in the toilet on the ward background of atrial fibrillation, so he was most likely anticoagulated preop depending on where you are, he might not have started a regular um anti coagulation for atrial fibrillation, but if not you would be on a high dose of low the low molecular weight heparin, so what I've what I've got written down is that this is a postdoc patient following a neck of femur fractures had a fallen award. My concerns would be the mechanism of the four. The injury sustained because you don't know exactly what injuries have happened or the exact you don't know you don't know what's happened at all and whether the patient is anticoagulated given the background of atrial fibrillation. So as I said earlier on the information that you would seek further early on from the nurse is about hr fibrillation, so I would say I would seek further information from the nurse on the anti coagulation status, oxin, do observations, and an e. C. G. And I'll go and review the patient and manage them according to Secrets principles and in terms of assessing a. B. C. D. E, you would give off your standard um recital of what ab, what steps you would do within your a. B. C. D. E. Assessment, However, some things you should pay particular focus too would be in this case including the c spine and a because this patient had a fall. You don't know exactly if they've sustained any c spine injury, which can occur in your elderly patient's who have low energy falls on the ward. In terms of see you're checking the pulse is irregular, is it tachycardic, what's the hemodynamics status um someone mentioned about potentially pe, it's a potential is a potential cause. Um If the patient was an antique wasn't anticoagulated um and then also checking checking the wound, checking the hips, checking the leg leg length if there's any discrepancy, um which might indicate either another um neck of femur fracture on the other side or paraprosthetic fracture and also checking if there's any signs of a head injury um One of the things that they would um they would somewhat expect you to know is um the nice guidelines for um ct scans and he would get ct head um with with a head injury so that's something that's good um to sort of revise and then after that reverting back to our secrets. Algorithm review the notes and take a focus history pre imposed for what happened um does. The patient remember what happened um whether any concerning features such as loss of consciousness, chest pain, palpitations so on and so forth, and then looking at the op, note how long was the operation was there long and aesthetic time, um whether any complications in um the operation was there significant amount of blood loss more than expected. Um Looking at the trends of the observation and pro, progress, did they need any transfusion postop um what were the analgesic requirements did they have a delirium, heavy opioid use that could have facilitated the four, then looking at the drug chart to check what anti coagulation there on um and then most trusts will have 1/4 performer that will need to be filled out with these sorts of patient's so understanding that and saying that you know you'll you'll then document this on on a trust according to Trust guidelines. Then considering a ct head if there's concerns that there is head trauma, then holding anti calculation and ordering a ct head and making sure that gets done is quite important and as I said before understanding the indications for a ct head is quite important looking at the e. C. G. Are they in, fast, AF is there any other uh rhythm um that's concerning escalate and notify seniors. I know this isn't something that you would necessarily do in in real life, so not every patient that has a fall under ward you'll tell your registrar or the responsible consultant about but in the scenario of the cst interview, um it's quite important to show that you're considerate of escalation pathways and protocols, so I would always say I would escalate at least to the registrar and all the consultant and then liaising with the author, geriatricians if available and if their concerns about any injuries, then x raying the relevant joint so some possible follow up questions as I mentioned before indications for a ct head and then the management for neck of femur fractures, so what to do if they inter, capture the neck of femur fractures versus extracapsular the neck of femur fractures and why you would manage each differently and what scenarios, for example uh would someone get a total hip replacement versus the hemiarthroplasty um versus cannulated screws versus a dhs versus an I am nail, um which are sort of standard questions um If you've done orthopedic job, um so we'll move on to a trauma question now, this will follow the same structure but a 40 year old man is admitted following a road traffic accident. He's complaining of left upper quadrant pain and has blood around his ear. If or metis, He is tachycardic and hypertensive. You are on call and ox by A and E to come and review this man, how would you proceed, so follow the same pattern, so what are so, if you can write down what the concerning differentials will be and then within the 80 assessment, what parts you would focus on I'm saying within the interview okay, so we've got several, we've got several suggestions now, so internal abdominal hemorrhage, uh spleen rupture, abdominal pelvic bleeding, splenic rupture, pelvic fractures, um urological injury Great, so in terms of your um possible differentials, so here's some points that I've highlighted um road traffic accident, so you know it's a high energy injury, left upper quadrant pain and blood around the urethra, meatus and tachycardia and hypertension uh tachycardia and a low BP. So differential diagnosis based on left upper quadrant pain. Essentially, it's testing your anatomy and your knowledge of what lies within the left upper quadrant um so it could be um uh some potential different the main differentials would be splenic injury or damage to the left kidney, bladder or your refill injury, but there could also be diaphragmatic injury, uh perforated, viscous or a pancreatic injury, the tailor, or the body of the pancreas, um and then differentials based on the context of blood around the urine for metis, as I've said renal injury, your ankle injury, blood injury um are the main are the main differentials um is when I'm when I mentioned differentials, it wouldn't be saying that he has bleeding or he has shock or he has hemorrhage. It's more about stating the specific causes you know that the person is shocked because they're tachycardic and hypertensive is what specific things are causing um the presentation okay, so what I would say this is a case of trauma, and I think people have said it on the chat ensure trauma cause been put out, ensure the team has been assembled, ensure the patient um ensure the patient's in resource and that seniors are alerted and given the presenting injuries and the mechanism we're concerned about splenic injury and injury along the renal tract. Sometimes at the primary survey. Um It's looking at the airway and c spine's to ensure that there's an adequate airway and if there isn't an adequate airway, then using simple adjunct adjunct um and alerting um and escalate and anesthetists um immediately um immobilizing the c spine triple mobilization collar blocks and tape um and then it's just going through your your your a. T. S. So um assessing the respiratory rate, sats 50 m oxygen and respiratory exam. The breathing and ventilation isn't the most important thing but things you need to be aware of our distracting injuries um that could compromise respiratory status uh such as your pneuma forex, eczema forex is flail, chess um So on um circulation hemorrhage control. That's the part that. If I was given this question given that you've been told he's hypertensive and tachycardic, I would focus the most on so ensuring that you have um monitoring monitoring of heart rate and BP. IV access initiate a bolus of crystalloids while sending off blood tests. So then this start some of the blood tests that you would use, so you'll want to cross matching for four units, full blood count using these coag, lfts amylase, v. B. G, and they're looking for other sources of hemorrhage and uh so uh the long bones theory for meatus in this patient and then if the hemoglobin is low and the patient exhibit signs of shock initiating the major hemorrhage protocol. Um One of the things I learned from my interview was the classification system of shock um So so knowing, so knowing so knowing that a patient is um so just going back here knowing that the patient's tachycardia can hypertensive, you know that he's in at least a grade grade free uh grade free of shock, um okay and then moving on to assessing the disability, assessing the g. C. S. Glucose, examining the abdomen, which would, and then within that explain what you're looking for so bruising pain, evidence of puritanism, and then exposure I think the point to take away from this slide is that even within uh 80 less based question, the thing that will get you more points rather than just saying everything out. It's focusing what is focusing the a two E on the specific presentation, and then from that you're you're your number one, your answer some follow up questions already and number two, it shows that you're thinking about what is being said rather than just saying the same thing that everyone else is saying and that bumps you up from a four out of 625, or six out of six. Um Then following resuscitation, carrying out a secondary survey and a complete history about the incident and the symptoms full head to toe examination and then if the patient's hemodynamically stable, a ct trauma series with contrast with a possible urogram as well and then thinking about people who you might need to escalate to based on um your differential diagnosis, so perforate viscous general surgery registrar, your uncle, general surgery consultant um i. T. U. Or urology um, and then if the patient's parity knittig and unstable, then it might need they might need to go to theater quite expect quite expectedly so, if the patient's alert and has capacity, then it will be consent from one, if reduce g. C. S, and the patient's unconscious, then it'll be a consent form for um the uh knowing about splenic injuries, which is written here. It is something that is nice and I think it's something that is examined in If you were to sit mos, yes um Part a. Um however, um there are some questions uh there's some questions that you um might get which, for some you know for some reason or other you've not done the job. Um You don't have knowledge about so. For example, I got a question um doing my um cst interview about someone who pulled out a central line and what sort of things um and essentially it was like a 74 year old lady um admitted with some random thing. Um you're you've gone to see on the ward. She's now confused and she's pulled out her central line how would you how would you proceed um. And I didn't know about the specifics um I didn't know about the specifics of you know what you would look out for if someone's pulled out their central line because I hadn't done, I've not done, I t job to be honest. I I've probably seen a central line up once or twice before um Before that point, I was like look, I was like to them you know don't don't have any experience in intensive intensive care. I recognize that these are the possible complications of um of um pulling out a central line. Therefore, I would like to do and then I proceeded to um to give my answer so if you for example, if you got a question where it said you know if the pay, if the subsequent ct trauma scan shows a grade 44 splenic injury, um and all the other investigations are normal. How would you proceed um the way in which I would structure question which I don't which I don't know is mentioning that you don't know, but you know who to escalate too, so. I don't know, I've not done a job in uh I've not done a job in General Surgery, so I'm unaware of how this would work, however, I would escalate to the the General Surgery Register on call. If this is a, if this is an injury that requires surgical intervention, then I would optimize the patient for theater, doing x, y and z by contacting x, y and z and and doing and um sorting x. Y and z out. If this is a um if this is a condition that can be managed conservatively, I would do this instead and that shows that although you're not, you don't know the answer as a, as a sort of ct one in whatever specialty, you're not expected to know the Internet of management, but you are expected to know who to escalate to and uh understand when patient's might need theater or or are unwell, might need intervention. Um So this is just a bit more about the management of uh splenic injuries, so essentially grades one too frequently managed conservatively. Um You normally get you know people that jump uh that sort of land on on their spleen or rugby players or things like that who get spending injuries and if there, if they're sort of grades 123, you don't read do much and then grades 4 to 5 class typically requires blood um splenectomy. Is what the books say, although from my General surgery job, they don't really do many splenectomy. Is they tend towards managing them conservatively um. So that is that is it um for now um what I'll do is. I'll put the feedback form in the chat, does anyone have any questions yeah All right, so one question um is should we get the details on the kinds of bloods we would take um should we get into details on the kinds of blood we would take during an 80 question was this best left a follow up questions um I would so when I when I answered my question, I gave a brief brief bit about what blood test I'll take and and what I was looking forward the blood test because that shows that you're ordering investigations and thinking about them so um you know you're doing a formula count to check the hemoglobin you're doing, user needs to check uh the renal function um You're doing LFTS to check x one z. Um rather than saying I'll do f. B. Cs. Using these LFTS. Clotting cross match a malaise. Um It shows that you're thinking a bit more about what specific blood tests you'll take um and why um where can I find a link to the first session. It should be it should be available on catch up. Um If you were to go on, if you were to go on your videos page, but I'm not 100% sure I can feel that back to the other members of the team to try and distribute um the links to the first session and this session, how long should we aim for when talking through um the a. T. E. Um there's not there's not a particular rule of thumb. Um If the examiners, if the examiners want to sort of, if the examiners know, you can do an 80 and it sounds quite slick, They will sort of stop you and then move on to follow up questions. However, when you're doing the a two e, you need to make sure that you cover all of your bases um rather than just trying to blast for it um and miss a lot of things, um So it is quite difficult to strike strike a balance, what I would say is practice doing it, so everything rolls off quite slickly um And then by the time of your interview, it shouldn't take it shouldn't taken a necessarily long amount of time um is there recording for these sessions um It should be recorded. I hope so um I noted you said we should tailor it to differentials yeah I think that's really important and um you really should be the take home point um from today, I think anyone can do an a. T. E. You know like med students and finals can do an 80 but what separates a, you know, a mediocre school from a good school is someone that's able to recognize the problem at hand, tailored their examination to that. Said problem like you would do in real life. If someone came in and they had a hole in their chest, you wouldn't spend a lot of time examining their legs for a DVT you're so at the hole in their chest, um so it's tailoring it to the differential that's important um and then you, and then I've got another question how should you split prep time between management and clinical um scenarios. They're both marked equally um I would I would advise classically a lot of people prepare quite a lot for the clinical scenarios and not a lot for the management scenarios um. So, if you're if you feel like you're confident in doing your a. T. E. And um your c crisp and 80 LS algorithms, then, I maybe focus on some of the stranger questions in the management scenarios because that's what I feel caught me out a little bit more was when they start asking me some of the weirder management questions, where's the clinical questions, they're more straightforward because you do them every day, um, but I would say do what you're weaker stuff um did everyone get the feedback forms um okay it was should I spend time reading through the 80 other secrets manimal Zipf, I've not done, no don't bother um They're they're chunky, they're chunky um manual's, if um if for example, you're an f one watching this and you're prepping for next year, then it might be worth um reading through the 80 Less or Secrets manuals or if you if you'd like absolutely completed everything else, but otherwise no just um no of the algorithm so you can search online um and then incorporate that algorithm into your answer. Yeah um for the two minutes on the management station is that tailored to our presentation or generic um or generic management questions, so you get five you you get the management station uh quickly cut 10 minutes, three minutes presentation, two minutes questions on the presentation, and then five minute, five minute management question, with a follow up question with follow up questions as needed. So those two minutes from the presentation will be based on the presentation. Um Are there any compilation of common management scenarios or are they often uh just quite left field. No no they are normally quite common common ones and there was a slide which had common uh common management um oh compilation of common management scenarios or they often quite left field. Uh No no um if you look at the management um session last week, I listed out some of the really common ones, so they're sort of you're drunk colleague you're absent colleague um colleague shows up late um bullying. Um Never events um w. H. O. Checklists There are lots of different things um So I would probably do well to find um that presentation and have a look through that okay are there any other questions. If not, then thank you very much for spending your evening listening to me talk about cST interviews um Thanks are you enjoying cst um yeah, yeah I'm enjoying it quite a lot to be honest. I think it's really good um I've seen so many different things and so many different presentations um and you actually start to feel like you're learning to become a a surgeon so um yeah, thank you for your time and best of luck with the interview, um and hopefully, uh look forward to working with you all as surgical trainees in the future, take care.