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welcome everybody to brims with basic life support. My name's Jack Dander. I'm going to put the web cam on very briefly so you can see us. Uh, and you see our sharing screen as well. Um, just a brief introduction by myself. First of all, um, my name's JAG, and I'm a consultant, maxillofacial head neck surgeon, and a clinical read that brightness is in medical school. And, um, I'd like to go with a very warm welcome to introduce David Words. Who's a consultant? Nurse resuscitation, uh, an emergency officer and has his own organization, company resuscitation consultancy, medical services and is very kindly agreed to do this presentation. Uh, and demonstration in virtual reality, first in the UK for basic life support. I hope he set a precedent for future. Course is, this is quite an important slide. You're going to see a lot of it. Uh, there's a QR code on the screen. Uh, the QR code is the way in which you can enter the livestream virtual reality livestream. So all you will need to do is point your phone at the QR code and it will take you directly into a YouTube stream which is in the arm. Okay, I'm going to give you another demonstration video of how to convert your phone into a VR headset. And hopefully you'll have bought one of the two options that I sent out in the previous email on the types of headsets to get. Uh, and again, we'll give you a debrief on that. And once that's finished, we're going today's presentations and then interjecting at certain points throughout his presentation, which will be on the go to, uh, webinar that you have this slide come back up on again. And that's the QR code. Uh, and your cue to use your phone scanning the code go into the stream will give you a little bit of time to put your phone into the headset. And then you'll be able to hear Dave giving instructions in virtual reality of key steps. Basically, I support in general dental practice, So I've been running courses at Brighton, got a very perforate a free flap courses HealthNet reconstruction courses for a few years now. And, uh, of course, the pandemic, uh, significantly affected all of our ability to to deliver face to face teaching. Uh, and in fact, so much so that we all have start to think about adapting to new technologies and how we would use these to deliver something a little bit more immersive than the conventional webinar. So, of course, the idea of having a, uh, any course with proximity Uh, certainly the beginning a pandemic was a big no no, because we just didn't know what what that that would have on people's health. Um, and so putting my thinking hat on and I certainly think about how I could deliver educational material that was more than just a conventional webinar but realize the importance of social distancing. And so we have this webinar overload the beginning of the pandemic. But of course, there are lots of other ways of delivering more immersive educational material. And so we set up an organization, uh, virtual reality medicine surgery set free for end user resource, for free, for training, free for trainings, resource. And, of course, virtual reality is nothing new. It's been around for some time, but we've just applied in a certain way. That's worked well for us. It's not taken off previously because of the early commercialization, but also learning to run before you can walk with quite complex techniques and tactics, and they are which we're now starting to incorporate into brims. So what you're not going to get is something as sophisticated as that. That's a long way away from being realized. Uh, but we I did realize very early on I had lots of potential applications, both in terms of demonstrating instruments. Set up 3 60 simulation. Got a very dissection of surgical techniques as well as the medical surgical education. Also utility for patients, and that's been published. Uh, is in the literature. So the first video is how you would watch the content on your desktop. You don't have to watch any of the content on a in a headset on your phone. You can just go to the Veteran's Dot TV link, which are post for you on the very much dot TV link is a live page, and you can just click on that page and see the stream. But what we're doing is we're streaming in multiple camera angles, so that gives you a better perspective of what date is trying to demonstrate the basic life support. So just tap and scroll to get perspective you want? Uh, early on iteration of the course, we sent out lots of these free headsets, but realizing that they were going to be quite uncomfortable, uh, and not adjustable. The recommendation for, uh the participants, of course, was to purchase one of these. It's only 10 or 20 lbs headset, but it's got an adjustable in particular distance and and an adjustable focal depth. And it gives you a much better, more comfortable VR experience using your phone as the headset. So a short video have to do that again. You've had this link already sent out to you have to set up your phone for the RV and headset. Make sure you downloaded the YouTube back. That's really important. Some of the contents of the data that it was 18 plus, you get a YouTube back and brings dot TV link. Uh, you have you just click on the link and it takes you into the street. And then the important thing is to you can tap and squirrel on your phone if you want to see it that way again, not putting a headset on. If you want to watch it with a headset, you need to enlarge the image billions landscape mode and then click on the link on the bottom right, which will give you the goggles icon sign. And then then the binocular vision put in your headset. Make sure your line is in the center. Okay? It goes okay. And that allows allows correction of the distance. So I'm going to go to the end of this footage because I want to show you how to improve the resolution. The default resolution. Some of your bones will be quite low as the settings, but on the top, right, auto is 4 80. But we're going to be streaming into K four K and you can watch and 10 80 if you want, and that's quite important. So what we've got now is a way of demonstrating a new training. Or you need to get on the Internet connection, your mobile phone and a cheap headset, and you've got an immersive experience that we can share with anyone in the world. Uh, some of the early work with a lot of Eric and you're not seeing that this is just a demonstration of a flat being raised, and we can show it's great utility, and we run now three courses and they have a fantastic library. Uh, and in the footage that you're seeing here, this is a dental implant in place in one, of course, is we ran. You can see George places I chromatic implants in with multiple camera angles. This is a flat food version of what you're going to see in the ER. There's multiple camera angles, allow you to stream in the content, and you just pick the view right by turning your head to the desire. So this is a clamshell thoracotomy. Apologies. If you some of you may find this squeamish, this is the hems team. Raises your chest. Open your chest. Within that view, you turn your head to the left. You got a camera angle from the side. You turn your head to the right. You got a camera angle from the other side or from the top, and you turn your head all the way around and you got the camera angle coming in with a bullet camera inside the chest. But we're not going to be doing very well today, So that's our camera set up with the multiple camera angles and we put all that together with a nice library of content, which we switch on the switch off when we host our brains. Course, there's lots of surgical specialties with lots of techniques. And you're more than welcome to attend the next course, which will be three in July. So I'm gonna hand over now today. Just give me a moment. What? Mhm. And you can now see days presentation of the day. Thank you very much. Uh huh. For any, um, I suspect so. As Jack said, Welcome, everybody. Thank you for giving up your evening. Um, as Jack said, I'm Dave Edwards, Um, a consultant, nurse in resuscitation and emergency care. For many years, I was a resource officer in the Northwest. Uh, now, about the past 20 years have been providing medical emergencies training with in general dental practice is, um, a number of NHS organizations. So I hope you enjoy the the session. It might be a bit new for you, and it's a new for me, so I hope you enjoy it. And I think there is a box where you can ask questions. Feel free if you want to ask questions during the session and I'll give you time for that. Equally if you think of any questions you'd like to ask, Um, later on, when you have reflected on the session because part of your COPD is that reflection. What do we need to do differently? What are we doing? Well, um and so that will certainly be an opportunity that you can email me and I can answer any questions later on. So we'll, we'll move forward. There we go. So? So, as I said, that's who I am. And you can see my website address there and my contact number, So please feel free to take that down. And if I can help in any way, please don't hesitate. So I suppose the question is, you're attending this this set, uh, and I assume that is to gain some COPD. But more than that, it's about hopefully gaining some confidence and hopefully being a bit little bit more empowered to manage that medical emergency in practice. Um, certainly, um, for the last 20 years that I've been teaching in practice is I would I would suggest that people don't feel that confident. It's not your comfort zone. Medical emergencies don't happen that often, but when they do, it can be a real challenge. So I posed the question to you. How confident do you feel? Um, and perhaps just asked yourself that question. How confident do I feel in managing the medical emergency? Um, you may have CPR training every year, but of course, when we're doing CPR, it's a little bit late then because the patient has already died. What we want to do is spend a bit of time looking at actually recognizing that poorly patient and hopefully prevent that deterioration so that we actually don't need to do CPR in the first place. CPR is very stressful, but it's very straightforward. I would suggest the challenge for most of us is when we're faced with that patient coming into the dental surgery, and the receptionist comes to you and says, Oh, I'm a bit a bit worried about Mr Jones. It doesn't look very well, so we end up with that first impression that that patient isn't very well, and then the challenges we potentially may have to deal with that. So how confident do you feel? And you may say, Well, I'll call for an ambulance, but what you've got to remember is your healthcare professionals in the health care environment. So how long is that ambulance going to take to get to you? 88 to 12 minutes is a fairly recognized sort of time for a response for an ambulance. But unfortunately, we all know that with stretched resources, um, it may well be a lot longer. And, of course, your call will be triaged. But because you are healthcare professionals in the health care environment, you could be waiting a lot longer than you would like. We might have somebody who is wheezing and breakfast and the dental practice who might have somebody who's wheezing and breathless in debate. Being Ireland. Same. Who's going to take priority? Well, unfortunately, it's going to be saying is not the dental practice because you've got equipment and skills to manage that situation. Hopefully, what we're going to do today and for this session is hopefully improve that level of confidence and skill. So I'm not going to go through these learning outcomes because you've already been sent these when you signed up for the session. So, uh, for time wise, we'll just skip that for a moment. I suppose one of the things we probably do need to talk about very briefly because I think we're all familiar with personal protective equipment and a GP and non A GP, um, precautions. So all I'm going to say to you is obviously as part of that assessment of that patient and that recognition we do need to be making sure that we've got some appropriate pee pee on depending on the procedures that you're doing, do be aware that CPR is considered to be an aerosol generating procedure. Um, for most of you, if you're seeing patients, you're going to be in an appropriate level of pp level to PP or non a GPP. But if you got if you're having to start CPR on somebody, please make sure that you have the highest level of PP be, and that may be a G. P. P. Um, there is an action plan there that, uh, by all means contact me, and I can always send that to you. That may assist in practice, but I think most of us are familiar with this now. I started doing, um, as Jack said webinars and online training about, you know, two years ago. Uh, thankfully, we're in a different position now, So when I'm talking about your GP and on a GP, this is what I'm talking about. You can see the filter mass there and the gloves and the gown, the aerosol generating procedures. But ideally, we should be wearing from performing CPR and any airway management. So coming back to that poorly patient, then, um, it's not just about the blowing and pressing this course if we put it into a nutshell. This this session is about the live person who is poorly and the dead person, and I hate to use that to that dead person. But unfortunately, when we have to do CPR, they are dead. There's two types of death. There's clinical death, and there's biological death. Clinically, dead is when the patient looks dead, there's no pulse. Biologically, dead in simple terms is when there's no brain, some activity, and the patient is what we call dead dead if you like. What we want to do is stop that patient deteriorating by recognizing that patient is poorly, and that's where you can see on this chain of prevention. The education fits in. It's about monitoring patients and recognizing that well. And that can sometimes be a challenge in the dental practice, Recognizing that for the patient, because I think over the years we've always we've always been taught that we have to make a diagnosis and it's not about making a diagnosis. It's about recognizing that for the patient and doing some something about it in a structured way. But using that structured approach or hopefully keep you focused and hopefully prevent is missing anything. So it's about education, monitoring, recognition, and that recognition is that light bulb moment where things turn on in your head and you think this patient isn't well. I may not know what's wrong with them, but I know they're not well, and that may well be. Then, when you call for that help that maybe call for help with in the surgery for a colleague and your emergency equipment, or it might be calling for the emergency services. But as I said before, do you remember what that response? Maybe that response maybe delayed so it could be You've got that patient who's having chest pain there hot and sweaty and breathless, and they're in your dental chair and they're they're and they're they're not 8 to 12 minutes, but they're going to be there for 20 minutes. I dealt with the cardiac arrest My street about 18 months ago obviously dealt with many cardiac arrest since. But as a layperson on my street, I waited 15 minutes for an ambulance to arrive, and I was dealing with that cardiac arrest. So please don't learn yourself into a false sense of security. But when you call for help, that help will arrive very quickly. Hopefully it will, but it may be delayed. And what you got to say to yourself is, What am I going to do while I'm waiting for that help to arrive? And that's when we look at this chain of survival. So it is about you recognizing that for the patient to recognize that their own well to try and prevent that patient deteriorating using that structured approach that I alluded to before we're going to talk about it a bit more detail in the moment. Um, if the patient does deteriorating collapse, then it's a case of recognizing that patients collapse and starting CPR. But good quality CPR there's more to it than just a bit of blowing and pressing, but it is simple, but we need to do it well. We know that quality CPR is a key determinant of survival, and we know that early defibrillation can really make a massive difference. And we know that if you we can do defibrillator within three minutes to that patient side that the chance of survival is as high as about 60% so we can make a big difference. And every minute we waste waiting for that defibrillator to arrive can reduce the chance of survival by about 10% between seven and 10%. So you've got these first three links in the chain, and that's what we're going to focus on, Hopefully the fourth week. You can see there that if we've got a patient who we can salvage and hopefully resuscitate them, then it doesn't end there. Resuscitation is a continuum, so it's about that patient then going to incentive care, colony care, rehabilitation, occupational therapy, physiotherapy, trying to return that patient back to both tax pain status. But if we don't do something appropriately, that may not happen. So I've got the skills challenge for you Now imagine in your mind. You've got that poorly patient in your practice. Any poorly patient might be a wheezy, breathless patient. May be a patient sitting on the floor. Um, your first impression, I would assume that patient is, um Well, how do we know the one Well, what you can ask them. You may see by the general demeanor how they look just like this patient isn't very well. And then I would suggest if you're thinking this patient isn't very well, you're then think, what am I going to do? And that is the challenge. I think so. Think about that for the patient. Think about what you're going to do. And hopefully what you may have in your mind is a structure. And hopefully you may well have downloaded this a TUI action plan. You can, uh, mention this again, but hopefully you'll have the reaction plan that you can follow through. So the first thing we need to do is check the danger response air way, breathing, circulation, disability exposure. If we use this approach, hopefully that will keep the patient alive. And if you think how you spell the word alive a l i B. If you use this approach, that's exactly what Hopefully it will be okay. So what I'm going to do now is move on to, um, let's just go through this a two way approach on the flip chart. And let's explain that in a bit more detail for you. Okay, so you have a QR code in front of you. If you want to scan that into your phone, Uh, that will take you into a 3 60 stream. Your job. Mm. And the alternative is to watch this on rooms dot TV, the live section, and you can watch that on your desktop and tap and scroll. Or you can put your headset on and watch the demonstration with your phone as the headset. I'm going to give the delegates a little bit of time just to get their headsets on and get the stream on, so we'll just wait a few minutes before that happens way. It's just a couple of questions that have come in, so I'll answer those, um, if what to do if you don't have a a headset. Carly Clark has asked. You can watch this on your desktop or on your mobile phone without having to put it in a headset. The next few demonstrations will make you realize the value of having multiple camera streams running within the the view where we're demonstrating a clinical technique where you can watch it on your mobile, all on the desktop bye dot TV and the live subsection. Next question. Has it started yet? Uh, yes, it has. Uh, we're going to go back today now and move forward to the next to this presentation. That's our hand back over today. Okay, thanks dot So, uh, this is the action plan you can see on your screen now where we followed that A B C D E approach. It's quite a simplistic approach, but it actually keeps us all focused, uh, and prevents us missing anything, um, and certainly have this on the back of your throat. It also gives you not only just an ache, need to what you should be doing, but it's a good documentation tour as well as a clinician myself. You know, when I, um attending emergencies and picking up patients, it's really good to get a nice, succinct handover. So you may be familiar with the term as far situation background assessment recommendation. I quite low, like the term you can see on the bottom of the hand out there RSVP, which simply means the reason I called the emergency services the story. So far, the vital signs and then the plan of action and the plan of Action is probably for those emergency personnel to get that Prolia patient out to be a practice. But it gives a nice, succinct handover. So here we go. We got Mary. She's 78. She presents the reception. You notice she looks, um, well, she's sweaty pain or lethargic breath, complaining of low abdominal pain. So that's your first impression. I would suggest you probably think she she looks a bit unwell. The partner say she seems a bit confused now. She's not normally confused thinking about that, that that a VP you that I talked about, Um, and the partner says she's not right. I think she might die. I've never seen her that well, so think about for a moment what you would do in your area of work. We haven't got five minutes to discuss it, but think about what you were doing, your area of work, and if you ask me what I would be doing? I would be grabbing my action plan to help me remember what to do and how we're going to reassess Mary using our action plan, because I would suggest your first impression is that she's unwell. Because, of course, as we alluded to before, it could be a patient with sepsis and, you know, how do we know the patient has got sepsis? Well, unless we can do some blood, which we can't do in the dental practice, we're not going to know. But what we do know is that she is unwell. Remember, it's not about you necessarily making a diagnosis. It's a about treating what you see using A to be using this, a TUI action plan. That's what we really need to focus on because it will keep us focused and stop us dressing too much and hopefully manage that patient. Well. There is some good guidance from the G, D. C, um, and sepsis dot org, and lots of other organizations that can help you manage these patients. But some of them are very complicated. You're not used to doing blood pressures and that sort of thing, I remember most of you You're not, um And if you are, you probably got an automatic BP machine where you press a button very unreliable. So stick to the simple stuff, completely relief. And these are these action plans that will go with your emergency bag there, color coded. So if you are dealing with that wheezing, breathless patient you'll see on the green flow chart there on the top, it says asthma. But underneath it, says the wheezing patient, How do you know this week? Easy patient in your surgery is asthmatic. You don't hear wheezing breathless and they're struggling to breathe. We don't need to make a diagnosis. Let's treat what we see using a two because that will keep the patient alive. So here we go. We got our first patient here. What's your first impression? And you're probably all telling me, Oh, it's a stroke. But remember, it could be involved palsy. Or you could have just numbed up with some local anesthetic, so but you're absolutely right. If you're thinking stroke, I would suggest it probably is what makes us think it's a stroke. While remember fast. It's a time critical emergency, so facial weakness, arm and leg weakness. Speech problems. It's a time critical emergency any one of these symptoms. Then let's just assume that the patient is having a stroke. We may not know for sure, but at the end of the day, far better to over treatment under treat. And one of the things I'm going to say to you about managing poorly patients is this. Also, see, See something very strange. But I'm going to say to you in any poorly patient, remember the fingers. Remember the fingers. Remember that term? Remember the fingers because by the end of this presentation, remembering the fingers will really make a difference for this patient. And I'll explain what I mean by that in a bit more detail. So there's our action plan for the management of a stroke. You'll notice in my emergency bag that they're actually is no color coded pouch for a stroke. Because, to be fair, there is no intervention that you can provide for. That patient is having a stroke, other than making sure their oxygen is okay and making sure that we work through our action plan and check to make sure they're not hypoglycemic. So follow the action plan. And again, I can share these with you. They do work well with training rather than just having them. It's far better to have these with some appropriate training. So you're used to using it. So we've got another patient here. Um, what's your first impression of this patient? You may think that he doesn't look too, you know, he looks probably okay. You probably think he looks a bit hot and sweaty. It might be that he's just had a phone call from the practice manager saying you're coming off for low leave now, and it's time to get back to work. Or of course, it could be You've got a patient who is perhaps hot and sweaty and maybe hypoglycemic. And when we're looking at hypoglycemia, remember, we're looking at mild, moderate and severe, and I think we've probably all been hypoglycemic. I'm beginning. I'm not diabetic, and I'm probably feeling a bit hypoglycemic because we're getting late into the evening now, as perhaps some of you are. But you're not diabetic. So what I'm trying to say to you is anybody can be hypoglycemic. I've been to me many a police cell where people have been arrested, and they've been confused and disoriented and aggressive and have assessed them and actually been arrested because they've been considered under the influence. But in fact, the hypoglycemic and it's probably one of the most common emergencies that you may see in the dental practice. So think about is that patient hypoglycemic? And of course, we've got that hypoglycemic chart that we can follow and you've got some drugs in your emergency kit to manage hypoglycemia. But how do we know that patient is hypoglycemic? Well, this is when we really ideally need to be doing a capillary blood glucose, and we can check their blood glucose. Some of you in practice may well have a glucose meter to check the blood glucose. But how many of you feel confident in actually using that machine? Or is it there just gathering a bit of dust? So in a moment, we'll I'll demonstrate the use of your glucose meter and the contents of hyperglycemia patch. Now, if you're one of those practices where you've got all your emergency drugs just in one bag and you sort of it's a bit like Pandora's box, can I suggest and you separate your drugs into color coded pouches or into, you know, the color codes to match those flow charts. Because that will really help you manage that. Patients, uh, effectively and hopefully start picking up the wrong drug. So remember, everybody patient, we do the eight we approach on, we're going to check the blood glucose levels, which we're going to do in the moment. We may need to give some glucose or glucose gel, or maybe need to lose the Glucophage n, which is the injection, and we may need to call for an ambulance. So this is the time that you can, uh, put on your headset again, if you wouldn't mind. So again, we'll give you a few minutes to run into the 3. 60 stream, and we're going to be demonstrating. So you're going on mute now and scan the QR code on your mobile phone or go to the front dot TV live website. Okay, welcome back to your go to presentation, and we'll go to Webinar back on today. Thanks. Thanks. Okay. Thank you very much. Okay, so we're back onto my presentation. So we've got a patient here again, remember? I said to you. This is about your first impression. It's not about making a diagnosis. So your first impression is this lady on the screen? Well, well, well, well, well. We probably haven't got enough information. She looks a bit pale and and, you know, by the way she's holding her chest, we might be thinking it's chest pain. We might think she's just had a fright. Who knows? It's just that first impression. So we've now got to start assessing this lady using that assessment process that a to reaction plan that we've been talking about during the session because we don't know what we're dealing with until we assess the situation. So these are some signs and symptoms that we can see here. Um, and you might not be able to say it's an asthma attack, but you might say, Well, she's wheezy and breathless And remember the green pouch said asthma. But it said easy patient. So if you've got somebody who is wheezy and struggling to breathe, they're easy and they're struggling to breathe. You can call it asthma if you like, you can call it syndrome X if you like. The fact is that we easy and breathless, and we need to manage them so we can follow this structured approach. We can follow our action plan and we can grab Our inhaler We can do are a to re approach. We can sit the patient forward if they're in the dental chair. People generally feel much better, sat forward with their arms elevated. I know if I've been in the in the gym and I've been doing a bit of exercise, I tend to sort of go back to the change in the room and sit forward. I'm struggling to breathe. So sit there. Patients don't be tempted. I go too many emergencies where the patient has been laid down and I really don't know why people like them down. I think maybe, you know, do they think it's closer to God or something? But we just need to sit them up. Generally, patients who are struggling to breathe will adopt the best position for themselves. We can then assist with some salbutamol and the spacing device. Please remember, if you've got salbutamol, you do need to use the spacer device. If you use the inhaler on on its own, it's probably not going to work And remember, we could give the patient oxygen depending on our pulse oximetry readings. That's one of the other things I mentioned. Um, and of course, we can call for help. So now this is another opportunity. I'm sorry. It's lots of on and off, on and off, but it's a good way of actually seeing in greater detail what I'm doing so well. Now, guys going to pop your headsets back on, and we can now go to our next emergency pouch in our emergency back. So again, switching back on QR code is on screen. If you want to scan that into your phone or go to the brain, Stop TV live link. Okay, so just another couple of questions in Do we have to scan the QR code each time, or will it just continue? We're pausing the stream, but the QR code is for the same stream, so you don't need to have to scan it every time I've got Jimmy asking, uh, hijack. The brain is taking you to YouTube live yet, So you need to go to the YouTube live, which you can do via the QR code which are open to YouTube live or you can go to the rims dot TV and brims dot TV has a drop down menu on the right hand side with live, and you just click on the live link to go into the live stream. Uh, not able to see the demonstration, please let me know how to watch it on my computer. So just open the link up, as you would normally do. Go to, like brims dot TV, click on the drop down menu live and that will take you into the YouTube stream to watch on your desktop computer. And one final question, um, just re scan the QR code. It's not playing, We're not playing at the moment. We're going to do another demonstration. We'll go to one to go to a webinar, and then we'll put the next QR code ready to go. Okay, so welcome back, everybody. So I briefly mentioned anaphylaxis so you can see on our screener. We perhaps had this lady who initially presented with a bit of a wheezy, breathless episode, she's now come a bit blotchy. She has now got a bit of facial swelling there, and her lips are swelling and her eyelids are closing, so I I would think at this point you're thinking, What are we dealing with here? And you might be thinking it's anaphylaxis, But do you remember it could just be an allergy. So when we're talking about anaphylaxis, we're not just talking about allergy. Anaphylaxis is a massive allergic reaction where the body goes overboard and protecting itself. And when we're looking at using that ABC approach were saying, Well, airway, we think about what's happening with the airway, the breathing and the circulation. So it's a combination of these things, and you may actually have a patient with minimal swelling but still losing their circulation and struggling to breathe. So, if in doubt, then treat the patient as such. Adrenaline is very safe. As long as we give it intravenously, remember, it must be given intravenously. Don't be tempted to give it intravenously. The dose of adrenaline you're giving the strength is one in 1000, so it's a massive dose of adrenaline. When you think in dentistry, you might be using one in 80,000 or one in 100,001 using one in 1000. So it's a massive dose of adrenaline, but very safe when we give it intravenously, be given by anybody. And if you need to, we can repeat that every five minutes. In in practice, I've only ever had to give 22 doses of adrenaline, so it does work very well, but still remember the fingers. So we're still thinking about oxygenation. We're still thinking about checking blood sugar. We're still thinking about checking the circulation by doing the capillary refill. So again, remember the two fingers. And don't just remember the two fingers if the if you if the patient's holding two fingers up to you, you think that's a bit rude, so make sure you put a finger on their forehead to check their capillary refill and to see what is normal. And that should pick up in about two seconds. But also remember, look at the patient's color, and particularly in Children. We might see that that peripheries are modeled and feel cool, all indicating a poor circulation. And remember when we talked about sepsis, Don't forget the temperature. So the two fingers for the the pulse oximeter and the glucose and your fingers on the patient to check their completely refill and to check the temperature. Sorry, This is what we're talking about those signs and symptoms of anaphylaxis or a combination of them. And that is our action plan with the anaphylaxis flow chart. And I haven't updated this flow chart with the current European guidelines because they're still they're not actually in the sort of public domain yet. But remember, I alluded to that 00 to 6 month dose so But what I would recommend is going on to the UK Resource Council website and downloading the latest the latest recommendation. And I will be updating the so please feel free to contact me, and I will certainly send you an updated action plan. So these are the auto injectors that we talked about. Remember, blue to sky, orange to thigh. You can also see the Emirates. They're now the interesting thing with the Emirates. You can see there's actually three doses because they fit into the guidelines as they were before last week. If you like, and the chance of you seeing 0 to 6 month old in the practice, I would suggest it's probably fairly rare. So 1 53 105 100 the MRI is great because they come in the dose that we need, and you're not going to get them the wrong way around. You just pull off the cap and we can stand the patient. Some of you may have the one mil syringe that you can see on the screen. Been there with a blue needle. Remember, Green need Lipitor particularly large, but just worth having a little bit of a play with that equipment, Obviously safely. But just think about what do I need to draw up using that syringe? And it's worth practicing that with, you know, the practice team. So everybody's familiar. Okay, so I think we probably don't need to do on on a headset for this one, because I think, um actually, yes, we do need to do on a headset. This one. I do apologize. I'm just going to add the rims dot TV forward slash live link on this slide for you in a moment. But if you want to start QR code and scan in a while, we're waiting for Dave to set up. Okay, You've got the link now for the rims. Dots, TV forward, slash live. If you just want to type that into your, uh, into your, uh, Internet search engine or the URL, and that will take you to live stream if you prefer to watch it on your desktop rather than on your mobile fathers of your head. Uh, another comment. Thank you for, uh, tell. It's working fine from her. And that's good to hear. I do appreciate that. You know, we've given Dave about 2.5 hour's worth of material to give in an hour and a half. The, uh, I will extend it beyond eight o'clock to probably 8. 30 so that we can try to get as much content because I think the next half of this presentation and the our demonstration is probably where it's the greatest value where we get to demonstrate. Basically, I support Mannequin so back over today for the next part of his presentation, Thank you very much. So I've already talked to you a little bit about conversion. So when you see this patient, you're probably going to think they well or are they unwell? Well, it may well be that this patient, you know, you can see this patient is sort of, uh, you know, got some contractors there, that might be normal. But this picture is really trying to depict that this patient is having a fit. And you, you may say, Oh, it's an epileptic seizure when it might be, But it might just be a fit, and it might be a bit due to might be a federal convulsion. It could be a tumor. Who knows? It's about assessing that patient. And the priority, of course, as we said, is managing that patient's airway. And there may be some signs and symptoms that the patient is going to have a seizure might be a blank episode. It might be a funny smell, flashing lights, that sort of So there may be some warning signs, but if you follow the convulsions flow chart, you really can't go far along. But of course, you are probably thinking when we're talking about the midazolam, how much am I going to give? You can see on the action plan there that goes with that black pouch that there is the doses that you can give. Do remember giving that midazolam will sedate the patient. So please, if you do give it, the patient doesn't need to go to hospital because 10 mg for an adult is quite a hefty dose, so they probably will be pretty sleepy. And if they have been fitting, they're probably going to be posted to them. Probably pretty exhausted after that fit, because, remember, they're using the oxygen supply and they're using glucose supply, which is why our priority of management has got to be airway and breathing to protect the brain. That was the cheapest a tous that I demonstrated. So a point where we get into five minutes. This is the time to think about. So moving on to the patient is having a heart attack. So I think the question to ask yourselves is, How do we know the patient's having a heart attack? Well, the simple answer is we don't if they've got signs and symptoms that are different to what they would normally have, or they never had this pain before. And you're thinking it might be cardio cardiac in origin, and it can be difficult because you might be thinking, well, is it indigestion? But, you know, they they've taken perhaps a bit of Gaviscon or some Renese or something like that. The pain hasn't gone and you're a bit worried about them might be a bit breathless. They might be pouring the sweat if, in any doubt, let's get an ambulance on the way. If there were no no angina patient, they will have probably taken some of their GI tiene spray. Generally up to two sprays Do remember GTM spray does lower BP so they can sometimes get a throbbing headache and really drop your BP and feel very faint. So just be aware of that. Because, of course, if they're having a heart attack, there will be some cardiogenic shock there as well. So may well have a poor circulation. But if any doubt that's give aspirin 300 mg pushed or tude and get the patient off to the hospital. And this is where it is probably quite important to think about checking the oxygen for most of us, and we you know, we're always told if their own well, give them ox. But really, the guidance now is we should give oxygen based on pulse oximetry where possible, if in doubt, or you haven't got a pulse oximetry and then I would give oxygen. But we do know given oxygen to patients who don't need it, causes free radicals within the circulation and isn't good. So really, we should be titrating oxygen accordingly. Um, so if we need it, then we're going to give it. But again, we follow that a TUI action plan and follow the yellow flow chart that links in with the yellow color coded pouch in our emergency bank. Um, so we talked about oxygen if needed, nitrates, aspirin, and obviously the next level of treatment would be that morphine from dialysis or actually the gold standard will be direct access PCI to get that class out and think about stenting those vessels. So we now move on to the bit that you may have all been thinking this was all about. And that's that poorly patient, poorly patient who now deteriorate. But I'm not going to apologize for procrastinating about the poorly patient because actually, it's about stopping the patient getting to this point. But if they do get to this point, this is what we now need to think about reassessing that patient and starting CPR. Now there are some new guidance out from the UK Resource Council Resource Guidelines 21 but you'll be pleased to know there is very minimal change and there's certainly no change as far as basic life support is concerned for adults, which I'm going to demonstrate the moment. So we're now going to move on to the CPR element and the poorly patient. So what we're gonna have a look at is some CPR de fib, a little bit of airway management that is appropriate for you guys in the dental practice. For most dental practice is you. The only airway adjunct you will have is the oropharyngeal airway. Some of you may have nasopharyngeal Airways and, of course, the appropriate size bag, valve, mass device. Um, all of you will have a fib. A e d. I've got one particular type of a d here. They all work in a similar way, So be familiar with your defect in your practice. So coming back to that chain of survival, then we looked at that poorly patient to hopefully keep them alive to stop them needing CPR. But if they do need CPR, then we're hopefully going to do good quality CPR and get that defibrillator. We know getting that defibrillator really makes a massive difference. But Of course, there could be some people in your practice that actually, it may not be appropriate to perform CPR. You may come across some patients who have a do not attempt CPR ordering force now notice, I said, Do not attempt CPR. I didn't say not for resuscitation, because not for resuscitation implies we're not going to do anything for them. Um, but of course, this only applies to CPR, and I'll give you an example of that. You may have a patient who's got a terminal terminal disease, terminal illness. Who's actually had a do not attempt CPR already discussed and agreed. They come into the practice. They're still, you know, just because they've got to do not attempt CPR, or it doesn't mean to say they're not entitled to dental treatment. But then they collapsed. But it's been documented and communicated that this patient is not for CPR and in that situation would be appropriate not to start CPR, but what I would say. It needs to be documented, and you need to see the form and it needs to be communicated effectively. If in doubt, the take home message is, if in doubt, resuscitate, okay, but you may come across this, uh, this purple form. Um, I'll allude to the action plan again, because remember, we need to think about CPR being in a GP procedure and thinking about our personal protective equipment. And then, of course, we need to think about assessing the patient and starting CPR so you can see, uh, the theory of of CPR and and the rate of chest compressions and the depth of chest compressions. Quality CPR is really important, so you'll notice when I do a demonstration, I'll be mentioning about the compression depth, but not just about compression. It's about the recoil of the chest as well. And why we're doing that. It's about getting that defibrillator on the way. Rescue breaths. We can still do rescue breaths, but in practice we would be recommend using the bag valve mass device. I wouldn't recommend you using the pocket masking in the dental practice at the moment because they're a bit to up close and personal, so we should be using the bank valve mass if you're out in the community. The recommendation is to cover the face and just do chest compression because every time you press on some of these chest, you will push air out, and as the chest naturally recoils, they'll suck air in. I can sit here and say, Don't do ventilation But of course, if it's your nearest and dearest and you've had your mouth around them already, then I would suggest it's appropriate to put your mouth around in this situation. It has to be your choice. But just bearing in mind as part of that risk assessment, do think What am I putting myself at any risk? But of course, in the in the dental practice, that isn't too much of a concern, because you should have the appropriate equipment to do that. So you should have an adult bag valve mask and a child back valve mask. And with a selection of, um, sizes of masks to fit those patients, do you remember when we come across somebody who needs CPR, it's very easy to sit here and say, Oh, start CPR, But how do we know we need to start CPR if you come across somebody who's collapsed in your waiting room? How do you know you need to start CPR? So it's about assessing the patient. But do be aware that if a patient collapses, they may be lying on the floor collapsed. But actually you're thinking, Oh, they're breathing. But it may not be normal breathing, agonal breathing. So the last sort of dying gas where the patient is sort of you might think that's normal breathing. But in fact, it might be the the last time gas and I've been to many situations where relatives have not been resuscitated, because there, you know, the nearest and dearest Oh, they're breathing, but they're not breathing effectively, so just bear that in mind. So we research council really sort of de emphasize the pulse. Check a little bit because, actually, if you think about it, how many of you could really reliably check for a pulse? So what we say is if the patient is not breathing normally and they look dead, I'm thinking about any movement, any normal breathing. If they looked at and then we're going to start CPR. Don't worry too much about the portion. It's very difficult to feel, and that is the same in Children now as well. Where in Children, we used to say, if the pulse is less than 60 we would start chest compression. Now we say the same as adults. If the child or adult looks lifeless, with no movement ignoring the gas, then we're going to start CPR. Of course, the priority in Children is breaths and the priority in adults. His chest compression. And get that defibrillator because in Children remember, it's not likely to be a cardiac problem. It's more likely to be a respiratory problem. Well, I also talked about how you know how important it is for that defibrillator to arrive. So every minute we waste, we're talking about between five and 10% reduction in survival. So time is of the essence. Really. Let's get that defibrillator connected to the patient, but that sounds fantastic. But in your practice, is your defibrillator accessible? I went to a dental practice not so long ago where the defibrillator was sleeping, and, of course, that indicated it was a low battery, but because it was bleeding and it was getting on the nerves, they talk the battery out so it does need to be operational and make sure you do have plans that are in date and have a spare set of pads, because if I use this defibrillator today. What do we do tomorrow and also think about the consumables that we might need with that defibrillator, such as the razor cloth scissors. You can see a pocket mask on the screen there. But remember, I've already said we probably ought not to use that pocket mask because it's a bit too up close and personal before you put the defibrillator on. Do make sure the chest is dry. So that's why we need that that ready kit with the cloth in and the scissors and gloves. And we might need to shave the chest with pastors. Be aware of any pacemakers, jewelry and, of course, be aware of the safety of you as the rescuer and any bystanders. Remember, you're going to be resuscitating, possibly in the dental chair, so we also need to get the chair flat and we need to get the chair low. And ideally, the dental chair should be supported with perhaps the stool that you were sitting on because lots of dental chairs are very wobbly. And if you're doing see beyond the dental chair and you're pressing down on some of these chest potential, the chair will be wobbling all over the place, but you won't be very effective. Your chest compression because remember quality chest compressions really important. Be familiar with how you check your defibrillator. Most have a light to tell you the operation or they're a bit like you smoke alarm at home. They'll bleep at you if there's a problem, so you know if it's bleeding at you, don't take the battery out. It probably needs a new battery or the pads around the date. Be familiar with your kids. You can normally use a defibrillator by opening the lid or pressing the switch. I'll demonstrate this for you shortly, and we just follow the audible instructions. Remember, you don't need to recognize rhythms. It's not advanced life support. It's simple, straightforward stuff. The defibrillator is a simple, intelligent shot box, so turn it on and follow what it says. I mentioned pacemakers before, and you can see a lady here with a nice raised area, and that's a pacemaker there, but you can see the position of the defibrillation paths. Um, they are away from the pacemaker, so as long as the pads are away from the pacemaker, not a problem. One of the things I do want to mention here. That was highlighted in the guideline changes last week that the disease guidelines 21 is the position of that lower defeated pad. Evidence would suggest that most people who put the defibrillator put that pad too low. And the guidance now is that pad really should be under the armpit. What? We would probably sort of the five g six position when you did any if you were doing a 12 e d c g. So it needs to be higher up and a bit more under the armpit. And what we've found is lots of people put that pad far too low or in the wrong position. And, of course, we're then going to miss quite a lot of the myocardium. We're not then going to defibrillate that critical, massive, mild cardio and that will hopefully convert patient. So just be aware of that pacemaker. Sometimes the pacemaker's can be implanted on to the same side that you can see where the top defib pad is there. Um, if that happens, then we would need to put the pads front and back or side to side under each armpit of the patient, but most most pacemakers are implantable. Defibrillators are in the position that you can see on the screen. Obviously, things to know before you put the defibrillator on, make sure the chest is bear and you may need to remove some hair. Obviously, if there's a little splattering of hair, we don't need to worry too much about that. Remove any jewelry out of the way. Be aware of that pacemaker, that implantable defibrillator that mentioned any patches. Um, and it stands to reason that we only put pads on the patient who is in cardiac arrest or you think they are. It's very, very safe and also removed oxygen from the vicinity. Be very clear with your instructions, and you know, it's very simple, very straightforward. And there's a full algorithm for the management of cardiac arrest. So I'm mentioning Children. So I'm going to do the demonstrations in a moment. I'm mentioning Children. It's five breaths first, and, um, if we are unsure, then we're going to start CPR. The guidance for CPR and Children has changed with the 21 guideline changes. So for clinical staff, we would still recommend five breaths 1st and 15 chest compressions, two ventilations. But for those people who aren't seeing Children very often or a bit unsure, we would say five breaths for me and then 32 2. So the same guidelines as adults, except for those five breast first at the beginning, five breast first. Absolutely crucial. If you're unsure, just apply the adult guidelines. People often say to me, How do I know it's an adult? How do I know it's a child? How do I know it's an infant? Well, you've just got to use your best judgment. The guidelines would be 0 to 1. Okay, one to the guidelines say now, probably about 18 and anybody above that sort of age range. We say an adult. But I think the best advice is because you might have somebody collapsed in the street. You don't know how old they are. You got to look at them and think. Actually, I think this is a large child, so I'm going to treat as an adult or I'm going to treat as a child. And again do I use two fingers? Do I use one hand? Do I use two hands well, with Children? Now we recommend a hand in circling technique for small Children. Infants, um, for the larger child than the one hand or two hands if you need to, and Children are getting bigger. So if you're unsure and then apply the adult guidelines, and I'm going to do a demonstration on this shortly, so five rescue breaths 1st. 15 22. Clinical. If we're not that, sure, then we can apply the adult guidelines at 32 2. But remember, five breaths first, um, infants, these arbitrary sort of figures. Really, um, it's better to look at them and think, What am I going to do? Do remember the head position in infants? We don't overextend the airway because, well, I think the trickier because the C shaped rings of cartilage aren't fully formed, so we're very easily to bend that trachea and in a child, larger child. Then we go into the sniffing position or the larger child. Still, we can go into extension of the airway, so adult defibrillation in Children we can use child pads. I will demonstrate those for you in a moment and show you those. But if in doubt, or you haven't got any child pads, then we can use the adult pants, but we might need to place those anterior posterior front and back or under each armpit, because the chest is quite small. Okay, so we're now going to move on to some demonstration. I'm gonna mention Airway. A bit of airway management first before we move into the CPR. So again, I'll put the QR code with the link on for everybody to get to the stream. Yeah, yeah. Uh huh. And you'll see the link on the QR code on your screen and go to with the URL as well. If you want to headsets on and we'll demonstrate airway management and, uh, chest compressions. Okay, welcome back for the last few minutes. Now, with Dave, I'll have back and back to Okay, guys. Thank you. I'm sorry. We've probably gone on a little bit longer, but I really won't keep it very long now at all. So remember that safe approach calling for help in Children? It's five breasts. First, there is very little difference between CPR and getting the defense, but actual crucial difference for the patient. So cpr get the dpt and follow what the deep it says. Take home message for Children. Five breasts 1st 15 Chest compressions. Don't worry about course jacks. If they look dead, let's just start CPR. Obviously, we might need to think about the recovery position and in simple terms, the recovery position is just when the patients on their side, and that might be the position that you can see here. It might just be literally pull them over in the dental chair. Most dental chairs is quite sleepy, so we can get them on their side and maintain the airway and do some suction. It's just about stopping anything going down into the patient's lungs and aspirating. So that's one way of turning the patients into the recovery position. I'm not going to spend lots of time on that. It's just a case of getting the patient on their site. If you come across somebody who's choking, I'm sure that probably most of us are right the choked or come across, and he's choking. Remember, if somebody's choking, just encourage them to cough. So what I tend to say with people who are choking, let them choke. Hopefully, they will remove that structure themselves. If they're struggling, then of course we can assist them by back clothes or abdominal thrusts. Um, um, So hopefully that covers most things that you were hoping for and achieve the objectives in the learning outcomes. Obviously, if you do need to contact me, I am more than happy to answer any questions. Um, so obviously this is an online presentation, so I've not been, you know, I've not been there, but this This is a fantastic medium, I think, to be able to offer some remote training. Um, but in summary, um, there is some really good apps that I would recommend. Um, but the key thing is, remember, life support is simple. Remember that we approach. Remember those two fingers for the pulse oximeter and the glucose. And remember, because the patients have two fingers up to you, you're gonna hold two fingers up to them by using one to do the temperature and another one to do the capillary refill. Do you remember your limitations of your role? Be familiar with your emergency equipment. In my experience, it's the equipment that sometimes can let you down. If you're not familiar with it. There is a really good app from the UK Resource Council and that's called Life Saver. And that's really interactive and can compliment what we're doing today. There is also a good Sam. Good. Sam. You can see a picture on your phone there that tells you where all your nearest defibrillators are and what you can't see on there. But I would recommend is an app called what? Three words. What three words? Imagine you were walking in the Cotswolds and somebody collapsed and you needed a defibrillator and contact the ambulance service. But you weren't sure of the exact location. If you use what three words on your mobile, it will pinpointed you to your exact location. So it's it's worth the download. But I hope you enjoyed the recession, guys. And if I can help in any way, as I said, don't hesitate to contact me Resuscitation consultancy, medical Services. We are on the Thank you. Thank you, Dave. We're going to end the presentation of the web Cam on. We are grateful for your time today. Uh, for the first pilot in the normal course, this is just a new way of living. Um uh, an immersive approach and training. Um, the feedback will be important. You need that as part of your COPD. You know, it's interesting that we had 50 delegates participate and 70% of you joined in the stream. 30% of it didn't. So I'll be interested to hear why that what was the reason for that? And finally, before I finish this whole course today will form of the brief for us to develop a true VR. A difference between what you've just seen is a camera with with the lens in the front and the back of the truth. Er is a is a a completely digitally, artificially generated but immersive VR experience which you can move within that VR world. And we're gonna, uh we're going to develop a B A B l s competency assessment and position. Great impression that the progression using this, uh, course this evening. So I'm really grateful for David this time. Travel quite a way to get to us. Have a good evening. And we look forward to your feedback. Thank you very much. Thank you, guys.