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Hello. Good evening. Everybody is joining us tonight. My name's Freddie and I will be the first teacher this evening. Welcome to session five with the atrial healthcare Siris. I'll start about opening. Slight Tonight is on diabetes and medical emergencies. You have myself at the top here, teaching the first part on diabetes and David at the bottom there, uh, teaching the second bottle. Medical emergencies for clarity. He hasn't just been married. I put that around his neck because I found it and I thought it was funny. This is the final meeting of our Siris that this go round, we have another Siris coming up. We've just put out sort of plans for that. If anyone follows us on the instagram that of Senate, otherwise shirt just a second, as usual. Any questions, please to email me and follow us on social media. We now have social media. I'm really pushing this because I put effort into making these things. Please follow them. Here is thebrainmatters of the of the new serious. We just announced this is going to be what we call our once a month series. So this will run alongside any other serious that we put on the first session Really personal statements for healthcare. We're going to do that on the 21st September. These sessions will be slightly different. That should be 18 30. That shouldn't be 18, 23 18 30 top time. These systems bit different. These going to run on a Tuesday evening once a month. That'll basically feature things that we want to do. But we couldn't necessarily find a place to fit them into our other teaching with me. Now stop sharing this side and start sharing this. Yeah, there we go. That was a very actively smooth transition for us, so that would you move onto diabetes? So we'll start with a question. Fill free to put this in the queue and a part if you've got a really good answer. But what is diabetes? This is a question that I think various how how much you need to know that it's actually quite a complicated question when you think about it. Because if you're given this in an exam, for example and it was worth three marks, can you think of three things you're going to put for? What is diabetes? Can you think of what? Three things. You're gonna go for it? It gets a bit complicated, really. Is trying a boil down what is actually quite a large thing into into just a very brief overview? Here's some points, really, that do, Sort of a sudden need to focus diabetes itself is a failure of the body's ability to regulate its blood sugar levels or blood glucose levels. Those two words get used. Intermission. Lay here. Sugar is the sort of generic word glucose. Is this like more scientific word? Commonly, it's associated with insulin, although actually insulin levels. What's they are a major part of it is, they're know all there is to it. Insulin is a hormone that's produced in the pancreas, so I'm going to talk a bit about the pancreas for a minute. This is your pancreas. I thought it was really worthwhile people actually knowing where it is because for the longest time, and actually I think even now some people might cause probably don't know exactly what your pancreas lies. It lies behind your stomach, so it's It's still just below the rib cage on buying behind your stomach. It's got two major body parts. Three really It's got a head and it's got a tail. Sometimes you can split it into a head, a body in detail. Some people even get very advancing. Given neck, really, it's a head in the tail. What does it do? It produces hormones. It also produces digestive enzymes. Two main functions, actually about 90 something percent 98% 97% off the pancreas is for the production off digestive enzymes, primarily amylase, protease and light days. So the duchess of carbohydrates, proteins and fats it'll screw. It's hormones into the blood, particularly insulin and glucagon there to most relevant to this session. There are other hormones that produces well, but they're not so relevant for diabetes. Most of it is that this is a just of enzymes. About 2% is hormone production, off which about 60 to 80% are. You are for the production off insulin. Insulin producing cells are called beat ourselves. There are also alpha cells and yeah, that that all the different hormones are produced by a different Greek letter cell. The beat cells of the most important ones for this that they produce the insulin. They are aligned particle islets of Langer hands things just cause a guy could. Langer with surname. Langerhans is the one who first realized they were thing and they were called islets because when he stained it, the beater cell clusters appeared to save a little islands in a notion which is, I think, quite romantic way to remember it. This is a slightly more complicated picture of the anatomy of it that I stole from a place called Can Hub its place. I like to go for my anatomy pictures. They're really good website. If anyone is interested in going on there and looking for a nasty pictures, ultimately you're pancreas lies next you'll Judean Um duodenum is the first party of small intestine on it will secrete digestive enzymes into the duodenum as well as biliary acids from the gallbladder. We want to be screaming into the Judean and via a sort of common pathway that the pancreas and the gallbladder share. This isn't so important in terms of how the the insulin production and the glucagon production occurs, that that is just done through other cells and secreted directly into the blood. This is another question. I'm not necessarily expecting people to have an answer to that. If you haven't answered your Morgan, welcome to put it in the chat again. How many types of diabetes? Two People think that Ah, people can hear me. Sorry. Two. So there's a question saying they couldn't hear me. I've seen That's all right How we talk to diabetes are there. Realistically, this is one of these questions that I don't really think anyone would ever perfectly agree with. The same answer. A lot of people come out with two. Actually, that's quite a lot more than two. Here's a little list I've put together. They Ah yeah, they are extensive, basically, the what we talk about in this session in particular Type one type two gestational and a little bit about double diabetes. These, ah, terms that you'll probably come to understand a little better by the end of the session. We're not going to really touch on, but I'll mention them briefly at this point. Steroid induced diabetes and brittle diabetes. These or two you do see a bit in in medicine. Steroid induced diabetes, in particular, is patients who are on steroids for other reasons. They can end up with Iraq. Poorly controlled blood sugars, they get very, very high. This is a type of diabetes. Therefore, brittle diabetes is excessive reactions to small changes in blood sugars. We'll talk a bit about how people react changes in their blood sugars later on, phrases like diabetes ladder and diabetes Madi they are more or less extinct these days. You still see them about a bit, purely because the quality doctors have trained a long, long time ago on they still use the phrase is they learned that med school people used to not afraid of the land in nursing school wherever they trained for depression. Now, so these are still about a lot, but they really shouldn't be there pretty ancient, this point term tight three Diabetes is still a thing, and it's becoming more of a known thing. And secondly, diabetes is something you're unwell with something else, and it causes you to have problems of your pancreas really important. Actually worth mentioning here is diabetes. Insipidus is not actually a diabetes. The diabetes insipidus is a condition that causes excessive production of urine. You do or don't produce an excess of one of the hormones affect your kidneys. I can't remember off the top of my head was terrible. Off may produce excessive. You don't respond to 88. Actually, don't concentrated urine, so you're not making lots of dilute urine, and you get really dehydrated. It can cause effects on your blood sugars, but in the same way dehydration does. So it's not a form of diabetes as you traditionally as a you know, all the rest of these are conditions that affect your blood sugars, primarily diabetes. Insipidus is sort of a secondary problem, so it's not a form of proper diabetes littering. So probably anyone who's come across a diabetic before we'll have some idea about sugar monitoring. Diabetics can't normally control their own blood sugars, or they have problems controlling the blood sugars. Therefore, they need to measure the blood sugars to have a better idea of what they're doing with them. Traditionally, we have the thing to prick testing, which is the picture of the top here. This simply is. You make a small scratch on the finger using thing called a Lancet or using a pen needle that caused a little bit of blood little large. You put on this stick and it tells you how much sugar is in that little bit of blood. The bottom here is a picture of this screen for one of them. It's quite fancy one. I have to admit that you can get some really very basic ones that just show you numbers, and they look like an ancient video game. They don't like Tamagotchi also know that. But then nowadays, and this is something actually really worth noting is diabetes is an area with a lot of money. There's a lot of offer at the world is a lot of diabetics and ever increasing number diabetics on. So actually, a lot of companies target this population with with new gadgets and new developments. Such a wearable glucose monitors, which is what this little white. But the thing is here because ultimately there are. It's a very viable mark. If you make a gadget lots of diabetics want to use, you can sell it to a lot of diabetics and therefore, you know, make a lot of money out of it that ultimately patients have to figure out what works for them, because if you you know, there's no point giving the fanciest new technology to a known to your old woman who might not be able to handle it, whereas vice versa. If you give the old fashion needle stick, think of blood testing to, ah, a young teenager. They might just not bother doing it properly. So how people look after themselves up to them, but it's it's worth giving them what technology they need. Symlin. Likewise, the giving of insulin. So some some types of diabetes We're going talk about that bit more in a minute. Brick wired giving of artificial insulin supplementary to what their body produces again. These are becoming a bit more varied these days. It used to be very often a needle, which would be jabbed into your abdomen or another very fatty area on, then an injection of the insulin that you're going to take. This goes under the skin. It gets absorbed and then slowly released over a period of time. Nowadays we get all sorts of really fancy gadgets. The bottom one here is an infusion pump, so this will contain a cartridge of insulin, and you press the button to tell it how much insulin you wanted to give you over what period of time and it will slowly give you the insulin. Likewise, the top here is a really fancy set up. It's the combination glucose sensor and insulin pump, so it will monitor your blood sugars and tell your pump to adjust itself accordingly. Things don't necessary work beautifully at the moment, so I think that's probably is the future of what diabetics will commonly be seeing with because of the fact that, you know, technology is advancing. But they're not exactly perfect yet. Give it time. They'll be pretty good. They already pretty good. Give it time. They'll be very, very good. This is something I wanted to show you at this point just to compare. So for a type one diabetic, this is traditionally the kits they have to carry with them at all times. Basically what this set up at the top here is replacing. So in this, we've got your blood sugar monitor at the bottom. You've got your needles right in the bottom left. You've got your actual insulin needles to give yourself the insulin down bottom, right. You've got your rescue medications, which the hormone glucagon in a syringe. You've got some actual glucose glucose tablets, glucose gels. You've got the monitor. You've got all the ability to some people, even traditionally. Some people even carry a small calculated to work and much insulin I meant to give themselves. You have your needles. You have a SHARPS box somewhere to put those needles safely the means to clean your finger, you need to think of Ketosteroid. There's a so I'll describe it later on. You understand a bit better later on, they can see this quite a little kit for some time to carry around, purely just to keep the blood sugar in check so they can eat and drink and have a normal life. So you could see why this sort of wearable, much more discreet, much more livable technology is quite popular and why people want it. This is quite a lot of hassle to have to deal with at the top is it packed up, but the bottom is it all unpacked, but it's quite a hassle. Reason it toe have to carry around and manage. So I'm going quickly. Check the shot. Assuming David's answering questions, David's a wonderful human being. We're all good on questions at the minute. Fab. Thank you, David. So, uh, talk about some terminology, basically, to help understand some of the things I'm going to talk about with the different sorts of diabetes. In a second, we'll start insulin. Like I said, it's a hormone secreted by your pancreas on. Actually, it brings your blood sugar levels down. So that's important. Remember, is insulin brings the sugar levels in your blood down? Glucagon the other way around brings the sugar levels in your blood up blue gown is another hormone secreted by the pancreas is well, they sort of counter act one another, and they stopped, the other one being scripted. But they also do different things for the body. There are than three times about insulin that sort of primarily hard to understand these areas. Diabetes. You have insulin resistance. So this is your normal tissues. Don't react in the normal way to insulin, so you can produce just a much insulin to do before you can have just a many tissues, as you did before. But they're just know acting to it anymore, and this is quite common in older age. This can also be quite common in people have a really poor diet. They have far too much sort of sugar intake, so the body is producing too much insulin to counterbalance that on that can cause is this buildup of resistance. You had an incident insufficiency, and this is something I find very, very interesting. But it your pancreas has a limit to how much it can produce. That limit is different from person to person, your jeans and things that that will affect how much insulin your pancreas can produce. Basically, every island cell, that cell could produce a certain amount, but also the amount of islets cells you have. A swell varies from person to person, so if you've got a person who is very, very skinny and they produce plenty of insulin, that would probably be fun. But if you start to get a bit bigger, so you've got Maury body master toe the insulin to work on and your pancreas can't produce enough insulin, you're going to start having problems. So this is one of those ones is quite common with as well, describing a minute later on Type two diabetes patients offensively too large for what they can produce. Insulin wise, you don't have insulin dependence. This is where someone requires additional insulin toe What their body produces. This is someone has to inject insulin in order to control their blood sugars, as well as what the pancreas might be able to produce. So we'll move on to type one diabetes. This is a bit where it gets quite, uh, if anyone gets confused with this, please do to say in the chat, then we can stop and chat about a bit longer. Type one diabetes is that a patient is no longer able to produce sufficient insulin. It is an auto immune disease, so this means that your body is damaging your insulin producing cells so they're no longer able to produce insulin. So it's an auto immune. Diabetes sometimes used to be called juvenile diabetes or diabetes. The young This is no really done any more. Patients could develop Type one diabetes. Older is becoming quite common for teenagers. More so, more so than it used to be. Used to be quite a lot of sort of Children. Teenagers get it more often these days, competitive the portal days and then, I mean, I've had a patient who was in his thirties when he developed type one or type one diabetes, so you can be a little bit older. It's not very common for someone in this on 60 seventies eighties to develop Type one diabetes, so it's still somewhat the younger crowd. But it's no Children. It's not juvenile anymore. Type one diabetes is also called insulin dependent or IDDM. If you see those two, they tend to be used interchangeably. So sometimes people just put IDDM rather than type one diabetes myelitis t one GM. Actually, they shouldn't because insulin dependence as well talk about that later on doesn't just come retired. One diabetes that could be other varieties have that as well. But sometimes you might see that written as as, ah, alternative. Um, damage. The beach itself is not one off. This is the other really important thing to come across. So there was a belief for a while that you might be able to just substitute the pancreas, give a pancreas transplant, and no people won't have diabetes anymore. The problem is that actually, the immune system continues to damage those beater cells, so you will. Your body will actually try and repair them slowly over time, but again your body will come along and smashed them up again. So actually, this this damage isn't a one off occurrence. It will continue to happen. So the Persian even if you get lots of nice new islet cells from somewhere mostly beater cells, they're gonna get smashed up again. And they're not going to really be very functional. So this is just a little bit about diagnosis of it diagnosed. Normally, the symptoms you see in an uncontrolled type one diabetic will be this high first and fatigue, excessive urination and unexplained weight loss. That's because a lot of Type one diabetics will present with high blood sugars normally in childhood, sometimes in teenagerhood, sometimes it adult hood. But it's basically your blood. Sugars are going unchecked. They're getting higher and higher because, like I said earlier, insulin is what brings it down. And insulin is what these patients don't have. So they're going to get the symptoms of having high blood sugar, which, if you think about it, will involve things like you need to talk about more about why these come about in a minute. But basically this this What is this? The picture you've got here is that they've got a lot of sugar in their blood. Which makes it Was Modica the not very great because now I'm gonna push all their liquids into their kidneys. They're gonna urinate them out. They're going to get dehydrated. They're going to be. We're going a lot. So therefore they're very thirsty and they're gonna be very tired and haven't explained weight loss because the other thing insulin does is it makes sugar go from the blood into the tissues. So about insulin. All your sugar is just going to sit in your blood, and it's not going to go into tissues. These patients were quite tired and lose weight because they just aren't absorbing the sugar from their blood. It's sitting in their blood and floating around and doing nothing very useful. Type two diabetes, on the other hand, so Type two diabetes, about 90% of diabetics type two. This is slowly on the rise that this a belief that eventually or peter out about 95% in the next 10 years. Type two diabetes is a is a big thing at the moment. It's a big problem, really. It's sometimes called later onset diabetes or adult onset diabetes. Even that is silly These days you do get younger and younger people being diagnosed with it. And again it's patients unable to regulate their blood sugar. But their pancreas, for the most part, is still working. The three main features of this is insulin resistance, so basically the patient's tissues no longer reacts to it. This could be because they're too old. Or it could be because they have just so much exposure to insulin because they have such a poor intake of sugar over a prolonged period that their body just sort of that issues just wear wraps. They're no longer reacting the way they should. You have insulin insufficiency talked about this earlier on. Like I said, this sort of genetic, um, limit to how much insulin you can produce. So if your body can only produce so much insulin, and now you're over two large, so you've got to produce more than that to cover all your tissues or you're still in taking far too much sugar. These patients now can't meet that their pancreas can't meet the demand of their body, and that again because type two diabetes and they finally pancreatic destruction. So this initially isn't what happens in Type two diabetes, your pancreas should still be fine. It's just your body isn't reacting to the insulin the way it should, or there's not enough insulin, but the continued demands on your pancreas so your pancreas is still working as hard as it can to produce is much Insulin is possible. It starts to burn out. Pancreatic burnout is also another good word for this basic. As it starts to burnout, it starts to damage, and those beater cells start to break down and they stop working. And so this becomes a bit more like the Type one diabetes way mentioned a minute ago. Now this is sometimes called double diabetes because you're now type two diabetic but also sort of type one diabetic. Double diabetes have an old term again. This is field that's evolving and getting beyond this sort of thing. But double diabetes? Sometimes you might see, and that normally refers to a patient who has Type two diabetic with pancreas damage. Insulin dependent Type two diabetes. So Type one diabetes used to be the one that was known for having patients on insulin patients injecting insulin type two diabetes. It wasn't a common these days. Actually, more patients are going on insulin as a type two diabetic. This's mostly because other said, going back to this slight, this insulin insufficiency. If their body isn't producing as much insulin as they need, we can talk it up. It's it's gonna work sometimes. Does it not necessary work? It's a very, um The problem is, though, as you add that extra insulin, the chance of developing resistance gets worst. And also then, once they've developed resistance, we can't really fix it. The drug metformin slightly improves it, but it doesn't necessarily fix it. Um, what's best for Type two diabetics I'll show you in a second. Here is just also quite nice Diagram of ALS, the symptoms that come around again. This is predominantly with hyper. It's a high blood sugars. That's that's commonly what you see control. So the main thing to help type two diabetics and actually probably is the best thing, certainly with the younger side. When you get very old, maybe it's not necessarily the perfect answer, but Type two diabetes. Often it's linked to a poor diet and 70 lifestyle. This leads to high levels of sugar in the blood because you're taking in too much sugar, and it also leads to you having more tissues for the incident. Work on because you're bigger, you're obese. Management type two Diabetes can be done for a diet, certainly at low as you become if you're not as severely diabetic, so you're starting to get bit bigger, and your pancreas is starting to struggle to supply everything you need to supply Dodger control is a very good first step, as actually be anything where there's a problem with obesity. So things like low carbohydrate, high protein and high fat because this means you're having less is sugars in your blood and your body is having to produce the sugars itself. Talk about more about that in a minute, and the other is exercise as well, because this can help you reduce weight and use up some of your energy's ultimate. Yeah, that this this plate here was a produced by I think it's from diabetes dot com. On that was the website that this is the sort of idea of what you should have on your plate for if you type two diabetic, obviously there is. You know there's no point forcing yourself to eat stuff. You're not going away. But any time getting any time to diabetic really should have a a discussion about diet and a about exercise with someone in order to get, you know, help get on top of this prediabetes. So I mentioned in the previous slide there that that point we're starting to become diabetic, and that's called prediabetes. This is where you're not yet diabetic, but you're beginning to struggle to control blood sugar. This is done for a blood test. They hate to be a one C. Anyone who wants to the medicine. Please remember that word. Because if you're just gonna have to, um, this is basically looks at how much sugar, How much of your family tree or red blood cell? How many of your red blood cells in a sample have sugar attached to them and how much sugar is attached to them. So it's how much what's the word? This glue glycerated gluconate. It said, uh, that I've gotten Is that word, uh, hemoglobin you have in a sample of red blood cells. This should be carried out basically for any patient who's potentially at risk of being diabetic. Some of the main things that put someone at risk are as well as being obese, obviously, on giving a sedentary lifestyle. But also certain ethnicities are high risk of diabetes, South Asians, Caribbeans, Africans, family histories. So that would be, You know, your parents are both diabetic. It means you're more at risk. Whereas if you've got like a second cousin who is diabetic, you're probably not as a risk. Obviously, that puts you at more risk than having no family anywhere near your diabetes, but having yeah, those family more risk than family and then more risk then no family, it'll polycystic ovary syndrome. This is a condition off the pituitary gland in the, uh in the brain. The pituitary gland secretes hormones. In this case with your polycystic ovary syndrome. It produces certain hormones, which then cause problems. I won't go into it because it begins to get a very long and it's got a long session. And finally, older people, obviously the older you are, the longer your tissues have been exposed to insulin, the more likely they are to become resistant. Also, just actually get older. Everything starts to wear out. Your pancreas might wear out your tissues get used to everything, and generally diet becomes worse because you're not able to eat that sort of very complex proteins and fats that you maybe were when you were younger. And people tend to substitute them in for carbohydrates. Simple carbohydrates later on to stational diabetes. This is yeah, this is just a stress stational diabetes, usually gestation diabetes developed in the final two thirds of pregnancy on it normally disappears sometime after birth within the first six months of the baby's life. And it's basically diabetes caused by being pregnant. It's linked a weight gain during pregnancy. Like I said, if your pancreas can only supply a certain amount of you if you're suddenly a lot bigger, it's not gonna be able to supply all of your tissues very well. Similarly, it's also linked to the fact that there's a lot of bad diet control in pregnancy. This old idea of eating for two is still around, and it really shouldn't be that the science suggests that the maximum amount of additional calories you need a day is about 3 to 400 that's only during the final trimester. So the last sort of third of your pregnancy. Prior to that, you don't need to add a single extra calorie during the first two thirds of a pregnancy on a lot of parents. A lot of people don't really get that, and you tend to get quite a lot of sort of early term mothers coming in who actually gained a lot more weight than they should have. They blame it on the baby, and actually, it's the fact that they're eating an extra 1000 calories a day because I think they meant to station diabetes. It can develop into Type two diabetes in the ways we also discussed how type two diabetes thing with gestational diabetes. Hopefully, you give birth that reduces the weight. You also then lose a lot of tissue and lot of blood. Not. Then you bleed a lot, but actually, when you're pregnant, you increase the amount of blood in your body. And then over the few first few months of being of having had the child, you slowly reduce that. So actually you get a lot less Macias. It's not smaller ones that you get less tissue in your body so your pancreas can certainly sufficiently cover the tissue you've got. But the other problem is actually those who put on weight because they've been eating too much throughout the pregnancy might not go back. And they might go into Type two diabetes and carry on as Type two diabetics from there on a car over the exact proportions. But it's something like 25% of patients who developed stational diabetes will develop. Type two diabetes have been a couple of years because obviously the pancreas has a limit. That limit isn't as high as maybe they would want it to be. And so they get that limit a lot quicker. Yeah, Master station of diabetes downs. Okay, David, any questions at this point? Take that. Restaurants currently fat, thank you very much So ups and downs. This is where we start to play into David session on medical emergencies, which is coming up next because this is where we start talking about sick people in the cute sense. Diabetes we have to emergency states in the keep side were too big problem now, problem which I think I first raised really badly. The to emotion states we come across particularly first aid are hypers and hypos, hyperglycemia blood left blood sugar too high, hyper high and hypoglycemia. Blood sugar levels too low. Hypo Low hypos should really only come with one variety of diabetes. I mean, I said which anyone who wants to answer it you're welcome to, but I'm probably not gonna hang around to wait for lots of you to send the answers. Hypoglycemia is more common in well should only happen in type one diabetics type two diabetics shouldn't have. Shouldn't get to the point where their blood sugars get that low. We maintain our ability to maintain the ability to detect where our blood sugar levels are. Answer Patties. There's a couple different ways we do that there too. Processes glucose near glucose General Isis and blue like a General Isis and Gluco Neogenesis. Like a general Isis means the breakdown of glycogen our sugar reserves Put that in inverted commas in my hands. I can't see that on gluconeogenesis, which is the conversion of other sources into glucose. So fat eventually protein on these basically allow us to produce glucose and release it into our blood is for these reasons, actually don't really need to eat carbohydrates. You could go with just eating lots of protein and lots of fat. Your body will make it for you. Does it work perfectly? Maybe not. Sometimes it Yes, I know that I could sense nutrition. We'll talk about that in another session. The other two things. There are three things we do to help bring our blood sugars back up. We eat your your body mechanisms will trigger you to feel hungry. So you go and have a snack or you go and have a meal. And this obviously brings up your blood sugars by filling you up with new sugars. Are new new fuel to for the other two processes we impede incident release. So actually, we stop releasing insulin so we let our blood sugars get back up release This other hormone called glucagon glucagon is the opposite of insulin. More or less. Glucagon raises your blood sugars because it helps stimulate these two processes at the top and helps you produce more sugar from your body's natural reserves. And it will also stop into them being released, because that's just what it does. So why can't I post happen? So there are a couple different reasons hypos might happen, obviously, in this diabetes session, we're going to talk about type one diabetics. Other cases, obviously, is if you've got no ability to raise your blood sugars so you're starving. For example, you run out of your natural, but you run out of your sugar reserves in your glycogen. You run out of any sort of fuel to produce glucose from, so you've burned out your fat well. You've burned out much fat is you can break down reasonably. Um, and then you've not eaten anything, and so you now have no sugar to produce. It's also in this too much insulin. There's also one or two other thought cases. Sometimes when people are quite sick, they have very high energy demands on their body isn't wanting to eat in there. They're just not producing enough glucose to to match the higher demands on there. What is also endurance athletes, because they will do a lot of exercise, use up a lot of sugars on just not take enough in so they can often to go into sort of a low level hypo. But we're going to talk normally here about too much insulin, so with insulin dependent diabetics, they are a risk of hypoglycemic and episodes if they give themselves too much insulin. Obviously, they're insulin is in a syringe. They put that into the fatty part of the body and push it, and I was in their body. You're up for a couple of reasons. Often it's quite common in newly diagnosed diabetic. So patients who haven't had a lot of practice with their needles and haven't had a lot of practicing giving themselves the insulin. So they just don't do it as well as someone who's been more experienced on, they can end up with giving themselves too much. You also get sometimes in young adults, so sort of older teenagers and people newly going to university because they've had their diabetes medications that they were six, but normally their mother, their father, they're guardian there, very older sibling. Whoever it is is in charge of that and tells them to take. It tells them how much to take, and now they're starting to have do it themselves. They don't necessarily get it right. It's quite common thing if you're going to clubbing medicine anytime where nights out the questions of young you know, students who probably are okay at managing their diabetes normally and managing how much insulin to give themselves. But now they've had a bit of alcohol. They suddenly forget, and they can't do maths. And everything goes wrong on the give themselves too much. It's also, unfortunately, sometimes used as for abuse by patients. I I put here to get the get themselves too little insulin. So they give themselves a hyper because this means they lose weight because their body is absorbing the sugars. It just sits in their blood. But you also get patients who will take it as a means of self harm. You get patients who will take too much insulin, um, various reasons, but yet self, uh, it being used being abused. They're it's it is being abused as a means of harming themselves. It's no as common, is not very common. More common is accidentally giving themselves too much insulin. But you will see this sometimes on. Yeah, just be aware that might be a thing. If you ever go and see a patient who's got far too low blood sugar, what is too low? So in the UK, we measure in millimoles police, some parts of the world use milligrams per deciliter. I'm going no, that all together because it's nonsense. I never understand it. Minimal relief and for a low were reading four or below. That's four millimoles per liter or less. Here is actually quite like this diagram. I put quite of effort into making this. It's a bit weird, so let me explain it. So as your blood sugar levels drop, there are different points where different symptoms occur. We have the hunger point is the point. You start to feel hungry. You start to get the autonomic symptoms as highlighted and red, so that's somewhere between about three and four millimoles per liter. As your blood sugar gets that point you get, you know, you start feeling hungry, you stop in agitated. You want to go and eat as it drops even further. Between about two and three minimal, you get this sort of brain dysfunction point on. This is where you get the neuro glow Compatic symptoms. So it's your confusion. You're drowsy. Nurse, you start acting weird. Be starting badly. Quarter native. You start struggling to speak, and that's basically because you just not got enough sugar to run your normal brain functions that somewhere between about three and two as you drop even further, you then hit what's called the coma point. So your coma point is yet somewhere in the sort of the ones, maybe the low twos. And this is the point. We just don't have enough glucose to stay awake, and you end up in a coma office in the wilds. If you were, you know, on your own somewhere that would ultimately lead to death. You can't take on any more sugar, and so you're just going to die. Obviously, in the Western world, we're lucky enough that we've got lots of lovely hospitals and ambulances on people who can come along and give you sugar into a vein out of Iron IV bag or Viagra gone into a thigh or some of this Onda bring your sugars back up again. But ultimately, somewhere around one millimoles, probably a bit below it's no point. Eight is what's called the death point and ultimately, the point where there's just not enough sugar in your body to keep your brain alive and you die. Yeah, so this diagram Ultimate just shows that sort of cascade. As things get more serious and different symptoms coming to play as your blood sugars approach. Zero. Like I said, you would hope all of these things never really happened. They could happen if someone is starving the capsules overdone it with endurance athletics. If that was very, very sick in the hospital bed and not eating here, it's a non specific headache and nausea, so you can start feeling really sick and really low appetite at any point when you sort of go below about four millimoles of sugar, of glucose in the blood and then ultimately, with these patients, have taken too much insulin over by accident. Poor deliberately. Um, yeah, I thought. That's why I'm not tired. Ground. Put it all into one place. Management. So your management of the hypoglycemic episode is sugar. What does that mean? We give him sugar, so this might be they eat some sugar. So a short acting carbohydrate, like some sweets or a meal, something a bit more substantial, maybe, like carbs. Meal with a protein and fat in it is also really good. I've been a bit longer lasting, carba longer lasting sugars. If it's gotten so low that they're not able to safely swallow, you could start thinking about other things. Things like sugary drinks and glucose. Scott Clucas Stop gel or glucose gel can be used for a patient who's still able to swallow so those normally whatever they drink them or you rub it into their guns if they can't really swallow safely, you have sort of judge whether or not it's okay to put the gel in their mouth, because if it pulls up, they might need to swallow it to not a 68 not choke. But if they're not alert enough to safely swallow, we had a health care professional. You need some like an ambulance. Some, like a paramedic on ambulance on a doctor in the hospital to come along and administer either blue Gone, which is artificial version of the hormone glucagon that should help you release your body's natural sugar reserves on improve the processes we talked to my earlier or intravenous glucose. I've given the exact bowl Issing here. 20% glucose in a bag of saline. Bolus is about 7200 mL, and then repeat is needed basis. Just a nice from Russia, sugar straight into a vein on boost your blood sugar's very quickly. He's already go ahead. There's a question that I think a lot of people we were wondering about so I can aren't in the tract as well. But I've got a question here. What does autonomic mean? Autonomic Okay, So awesome know Where is that? Is that here? Autonomic is What's the best way to define autonomic? There you go. Good definition to mind, because I'm going to think about it for a second guessing. This is not going good definition to mind like I can. I can think and type away. I sure being lazy. I'll be honest. No, that's probably the right answer because I don't give a half half minded one autonomic. Your autonomic nervous system is like your body's natural. No, I don't recall that you got a reaction, but you're sort of you have no control over these. They happen. Whether you choose to or not. You don't make these things happen. So the autonomic, in this sense, it could be linked to your stomach nervous system, which then causes you to start sweating, palpitations, shaking the hunger. So these basically symptoms that occur whether you choose them to or not. and as your body sort of natural reaction to things that are happening with sure, David will have a farm or eloquent answer for you in the chat in a minute. I'd wait for that one if you want a proper answer, but that's a very short explanation of it. Um, so I'll go back to my lovely sweet things here. I've got glucathione up here on the left. This is if you do such and ambulance, you'll see this. This is what we use in first aid kits, and basically, it's just a very highly sweet gel. The pushing rub into the gums or patient. Let's swallow. You have a glucose drink the top here. This is some I don't know what brand it is, but anyway, basically very sweet, sugary drink at the bottom. You've got glucose shots, which again they're horrible to drink. They're incredibly sweet, so much sugar in that in just a very small quantity of liquid. And then another version of glucose gel. Over here glucagon Just it's again. It's the same thing. It's just a different brand. Um, really worth noting, actually is well, it's just know all things have asthma sugar as you think so? It used to be very classic in this country. Reduce leukocytes glucoside was brilliant, basically was, exactly is a glucose based drink. But then the sugar tax came in. And now Lucas. They changed the recipe rather than start changing, charging more money. So, actually, now Lucas eight is entirely sugar free across their entire range. Minus certainly has aides sports. Some of them are still sugared, but not all of them, which I think has really weird for a sports drink. Likewise, the right enough brand squashes because that's a part of the Lupus, that company. They don't have any sugar in them, either. So you've got a check what's actually got sugar in it before we start giving it to patients. It's one that sort of classic things in a ward of you tell someone to give a patient lots of sugar, and they give them the sugar free squash because they don't read the bottle. So you had double check what you're giving them if you think it's got sugar in it. Likewise, remember the large any sweets or sugar free now they're also not necessarily great because they become really gummy and really difficult to swallow if the patients got back. Swallowing jelly babies is still a classic. They're still very full of sugar on Got the lovely, sugary coatings that get absorbed from in the mouth before it even swallowed. Like why should get things like glucose juice and other high glucose drinks that is still available. Or you can even get glucose tablets, which you basically chew up and swallow eso the still plenty of ways to get sugar. You just have to double check what you're using. Now where am I doing for time? Okay, I've still got a little bit, so we'll go through high person. I think that's pretty much the end to think of my session so hypers the opposite of hypos. This is too high blood sugars, but these are far more common. This happened quite common move in your type two diabetic group. It also can happen a lot with type one diabetics. You haven't given themselves sufficient insulin. Um, insulin works in four different ways. It stops glucagon release, so it also that stops your body producing more sugar for itself. It also causes glycogenesis glyco genesis. So the building of more sugar reserves in the body. It also promotes the production of protein and fat. So you start making more tissues of yourself. Um, and it also promotes the uptake. But look into liver, your fat and muscle. So the cells that take up the glucose, those ones only do so when insulin tells them to, or any do properly minutes intelligent. I think a little bit gets absorbed without that, but not much. So hyperglycemia This could be that someone hasn't taken enough insulin or they don't produce enough insulin. Uh, and so that electrical levels go up. The lack of insulin can also cause they're to not be any sugar in your cells. So actually, you've got very little sugar in your cells and a lot in your blood. Not really where you want it. And we work also without the insulin. You also continue to make more blood, make more sugar from glycogen. So this means your blood sugar might carry on going up when you're not eating any more, and you're just sort of sitting and waiting for it to chill out. So, yeah, you want insulin is the best thing for you to bring down hyperglycemia. The management is quite deaf in is quite variant. Know if your patient has a slightly high blood sugar, they might be able to just sort of wait it out. They might also to do about it. It was called a bolus, a quick in so basically an additional injection of insulin and and this will help bring it down. If they're a type two diabetic and they're not on insulin or some of this, they might need to just wait it out. Um, it is very, very high. You need monitoring proper monitoring, regular monitoring of the blood sugar, regular monitoring. I think all ketone key turns out of slide on in just a second, so I'll explain them a bit better then. This is best done in hospital. It's done on what's called a sliding scale. That means you could put insulin in, and we can measure what Blucas is coming out. And it also means that we can, uh, replace uh, the electrolytes because actually start having problems with things that your potassium and sodium when you have hyperglycemia, ketone, ketone are one of two sources of fuel your brain will accept. Your brain likes glucose and your brain will take Keaton's. It's Not Ideal, but it will do. If you have no sugar being taken up by your tissues, your body will start making key toes. You don't need insulin for key tones to get absorbed so your body will think, Well, I've got no sugar because all in my blood I will make ketones as well. They're not necessarily a problem a little bit. Keto. A little amount of ketone is is not necessarily a problem, but the problem is they're acidic. So if you have a lot of thumb, you start to get acidic blood, and that causes quite big problems. So basically, if you've got no insulin, so you got lots of sugar in your blood. You then get he tones, which they'll make you acidic blood, and you start getting more more problems. This leads to think of diabetic ketoacidosis or D K. A. Yeah, and this is a hypoglycemic emergency. So what? That means? It's very bad. There's a mortality of about 1%. So one in 100 patients who go into DKA will die. That's not a nice ratio. I don't like that ratio. We need to fix that ratio. Uh, it's sometimes to find us a complex disorders metabolic state to to absolutely relative insulin deficiency. Ensure not enough insulin. Therefore, it's more common. Type one diabetics because actually type two diabetics still produce insulin just not enough, but enough to sort of keep their brain going and prevent them having to make these key tones. So it's not enough insulin or no any insulin on. Then you produce these key tones on that it causes you to become acidic. There's some symptoms I've put on here there. We'll talk about them a little bit in a minute, but the one I want to mostly point out is a single Christmas breathing on dot. How it's not something we can rely. Not cause I took breath is the other one. You can't rely on ketotic breath or cathartic. Further further, settle some of that. Also, in a second pregnancy you DKA. So the diagnosis criteria are a blood sugar greater than 11 11 millimeters per liter, or if the patient is also known to have diabetes, then also have to have blood ketone, which can measure, I think ketone strips. I mentioned them basically earlier on in that little kit that the diabetic had to carry. Um, your blood ketone is greater than three, or ketone is in your urine greater than two. Yours had to have low bicarbonate. We don't really talk about my car, but it's basically how you measure how much acid is blood and basically have to have a pH lower than 7.3, which means they have a more acidic blood than they should do. Here are your signs and symptoms I want go through all of these for the sake of time because I realize I need to get through this to let David on God. Do you want to mention this acetone or ketone? Breath cathartic. Foetal on the problem with this is that a lot of the time you get talked about it, but actually only about 30% people can smell it. So you could be told, Oh, smell the breath and see whether or not it smells like acetone, nail varnish remover or ketone that that sort of breath smells like apples or pear drops or nail polish remover in a sort of very light sense of you. Dilute it a lot, but actually there's only about 30% of population who could smell that smell? There was so 2% cult. So don't worry too much about trying to see if their breath and then go well, the breath doesn't smell. They're not got DKA diagnosed with something else. Mostly do a blood sugar treatment. This'll one I will go through very quickly, but basically you want to give them lots of water to not more water. Lots of sailing to dilute down the blood to dilute the acid and the key tens in the blood getting insulin replacements to give them insulin to get rid of that sugar into the body and potassium replacement. Because doing all of that the way insulin works, you end up losing potassium because it uses a potassium said bring the sugar into the tissues so you end up losing potassium and low potassium can cause heart problems. It also puts you at a big risk of developing clots. So you want from both ambulance and prophylaxis basically stuff that prevents the formation of clots. So I'm like a heparin or yeah, So I know that, uh, low molecular weight heparin, I think, is probably the standard, um, the other diabetic. They have a hypoglycemic emergency. I'm going to go through your girlfriend's very quickly. It's quite rare. Thankfully, is your hyperosmolality hypoglycemic state or hate change s. It used to be called honk hate showing K, but apparently that was too childish. Your some of that that sound like a goose. So now it's called hatred chest. People still call it honk. And basically this is more common in type two diabetics, not type one on. This is basically you still have enough insulin production to prevent the formation of key tones. But your blood sugar is still crazy high like crazy high. So this is diagnosed as greater than 30 millimeter police. Oh, hyperosmolality. So your blood sugar, your blood. It started to get really concentrated and thick on also without any key tones. So you don't You're not making any key tone, but you got loads of sugar and your blood starting to get thick. Because of it, this comes were 15 to 20% mortality, so 15 to 20 people in 100 will die. It's really quite serious event, and it really does need to be looked after, probably in intensive care. This diagram I will very quickly explain. But this is basically how you hate it. Just cuts your blood sugar goes up in the top left. Because of that, you end up losing fluid into your basically. Your osmotic pressure increases the amount of water you lose into kidneys. Your kidneys produce more urine. Urinate that out, See? Get volume depletion. So, basically, you've got less fluid in your blood. Because of this, you get thirsty. So you have a drink. That drink you, then drink is very full of sugar because that seems to be very typical. These patients with type two diabetes, some of them have quite poor dietary control. Or because they feel, um well, they might naturally think they need a sugary drink basis. That then adds more sugar to their blood so the blood sugar goes up again. The other thing that happens is that your volume depletion causes your body to go to become stressed, you get physiological stress, release your stress hormones. That's things like adrenaline. That then triggers further leukemia genesis. And like a general Isis. So you make more blood sugar, you make more sugar and your blood sugar goes up again and you start the horrible look over and over. And basically the the bits that cause trouble here is your blood sugar goes up, which means that you lose blood, you lose blood volume, you lose liquid into your kidneys and eventually end up with what is effectively treated for blood symptoms of this away. Your typical hyperglycemia symptoms. You're weighing a lot of our thirsty of the blood vision. You start to get weak and dehydrated. Your BP starts to come down, your heart rate starts to go up and you start getting those confusion on drowsiness Symptoms management, uh, gradually to renew. Normalize again. You don't want to do it very, very quickly because that can cause problems. But basically you want to increase the fluid in the blood and you want to decrease the glucose levels. You also want to stop this being very rapid because it can make them very, very sick. So you give them IV saline so fluid into the blood, you also give them small amounts of insulin. This is not as common as it used to be. Apparently, people don't necessarily go for these these days, but a little bit of insulin just to promote better uptake of that sugar into the tissues, uh, and then basically treat why this is occurred in the first place. Most the time it's a Type two diabetic who has also got some sort of infections has been poorly managing themselves. Sometimes it's because they've not been diagnosed as diabetic previously, and so weren't looking off themselves at all. Sometimes it's because of over cute illness in select walls, those things non infectious. But various things go into that on, then the last thing is noncompliance. So you've been told your diabetic, but you're not acting on it. You're not looking after yourself as a diabetic. Like with DKA, also the venous thromboembolism prophylaxis. This is two basic prevent production of lots of blood clots. His adenoids comparison of the two in terms of what separates thumb DKA, mostly Type one diabetes hatred chest mostly Type two DKA can happen to any age will hate HS because it's Type two. Diabetes is mostly a little bit older. A DKA can happen very, very quickly. Hate HS is a lot slower than normal. Takes several days to build up DKA roughly 1% mortality hatred just 10 to 15, some massive difference. DKA comes with acidic blood, Pedro. Just no civic blood, No key tones. DKA lots of ketone on the blood sugar variances greater than 11 for DKA or greater than 38 THS. So we're talking very sweet, sweet blood and lots of acid for DKA Incredibly sweet blood. No acid of hs. I think this is actually my last bit. I just want to quickly go over this because it's something that I didn't think that people are going to know. This is what's called sick day rules. So these are a set of rules that any type want any insulin dependent diabetic should be made aware off. This is things they should be doing. And this is basically for when they are ill. So when they have another another problem as well as the diabetes first one, it's just not stop taking their diet, their daily insulin. You've got to take your insulin even if you're being sick. You've got to check your blood sugar more often every 2 to 4 hours, not just at mealtimes. Check the key tones even if you don't necessarily think you've got hyper. Um, no, see me? Just check for in case they are forming. Take any extra insulin you need. If your blood sugars go high or if you start forming lots of ketone, try and keep up your fluid intake systems of drinking of water. Take, uh, take insulin according toward carbohydrate. You do eat. Don't take this office if you aren't eating. And then lastly, if you develop any diarrhea or vomiting, or if you start developing high blood sugars or ketone, then you need to go and get medical help. So this could be something like your diabetes Nurses could be an A in the This could be an ambulance, but this is basically the rules that should be followed if you have other problems as well as the diabetes. So you know, if you've got some sort of infection of whatever else is going on that might be making you on, well, complication. Diabetes quickly go over this because I've taken out the slides to do that. But basically it can lead to vascular damage and uropathy nerve damage. There are eight main areas to get damaged. The big three of your eyes, your kidneys and your feet, so diabetics should always check that have their eyes checked regularly and look after their feet. Kidneys. Obviously, it's quite hard to measure that, but if you start having problems with your urine, get that checked out later. You can get problems with skin, the heart and hearing on in the final To that happened, nor more common in older age outsiders and depression was to do two basic damage. The nerves in the brain problems you get with long term diabetes that's badly controlled. Good control of your diabetes will ultimately mean that these are far less likely on perfect control. Should mean that none of these that happen. But these are the risks that, if you have, if you have badly controlled diabetes, um, that's a summary. Like I said, blood sugars between four and seven. Hypoglycemia is hopefully rare that managed by sugars hyperglycemia is not as rare, actually managed based on how bad it is on. Diabetics are increased risk of damage to the nerves and vessels and then damage their tissues. Because of this, it's also need to make sure they have a regular checks finished with the's Anyone in the chat You're welcome to try and to say what you think these creatures are, uh I'll mention what they are later on, but they're they're quite cute. But I think that is it with that. Any questions? Quickly, David, I was Ah, hand over to, you know, and no new questions as yet. Um, you know, animal, these are today. Are I minimized you by accident? I'm getting their sugar gliders spot on their sugar glider, which are not the right sort of sugar to make people sick. Um, yeah. Okay. David, do you have to load your one up? I certainly Well, we'll see how well it goes this week. I've got my technical difficulty slide ready if I need it. Leave on cute animals for the time being. Cute animals or worth watching things that happening on my screen. Ah, there we go. Right. All mute and leave you with David. Excellent. This actually works quite well. I've got it nicely set up this time so I can actually Ultram back to the questions so I can, in theory, check in as well. But yeah, you could also see my slides and you can't see me, which is probably just a swell because I'm in coronavirus isolation. Hello. Good evening. If you have the misfortune of joining us at this time last week, I walk along to you about surface anatomy. Tonight I'm going to awful on to you about medical emergencies. As you can see from the picture, I do have ah, little bit of an ambulance background or although know what much of one we're going to talk about? Medical emergencies, morphine, Um, an in hospital perspective this evening. So things are going to be a little bit different on it. In a few minutes, I'm going to get you think about why those might be at just to recap kind of where we are So far, though eso, of course these are were the other sessions in the Siris. All those have now happened, as someone asked in Freddie session earlier. If you've missed any sessions, you can go back to those session links and see the recordings for those sessions. We're quite fortunate the teams up records the sessions automatically for us, so we don't even have to remember to hit a button so you can go back and watch those recordings. You may also find that Freddie kindly sends out around up of all the links to all the fashions so that you could more easily track down those recordings. But if you've missed any if you missed surface Natsumi last week, which is definitely the best session, I may be slightly biased. Then you can go back and watch the recording, and therefore you can fast forward every time I'm boring as well. But tonight we're going to talk about medical emergencies to finish up this little Siris with so in the hospital emergency. So, like I say, a focus tonight, then on how medical emergencies are managed in hospitals. Eso What? What is that focus or or what? What are hospitals? Well, hospitals or a big building full of medical professionals? But that's not important right now. That is the only terrible joke of the presentation. But I had to get one in. So if you've ever done a first aid course basic life support, training, CPR training or have any kind of medical background, you have probably come across the primary survey tries. I might. I wanted to kind of break away from it this evening until about some other little bits I haven't quite managed, because I think the primary survey is so important that it is the kind of thing we should really be talking about, and it is kind of the universal approach we can take to any source of medical emergency. As Freddie was talking there about the kind of emergency management of diabetes and things like that, you can see that with specific medical conditions, the management can get very specific very quickly. So the management he described for DKA, for example, you wouldn't give that drug regimen for pretty much any other medical emergency so short of picking random medical emergencies out of the air. To talk to events at the where I can kind of talk to you about a lot of them is by talking about a primary survey, I am happy to set questions on other things. If you have a really obscure question on, you know, the management pen like Shaun home preparer or something that will do our absolute best between Freddie and I t. O R. Answer it for you. But we are going to keep it fairly generic. These are the things that we want to ensure for all patients, especially those having kind of medical emergencies so I've put up a model of the primary survey here. As you can see, I've got questions on this lighter. How is this different to any other primary surveys you might have come across on? Also, why do you think it's different? So I'm more than happy for questions to be popped in the question box tramped. So feel free to aren't those questions in the question box if you like to, or just post any any questions that pop into your head as we go along. But yeah, very quickly just to think about how do we think that's different to any other primary surveys on Why do we think it's different? So hopefully, if you have done the first a course or something like that, you're thinking that actually, there's no checking for danger, and there's no checking for responsiveness on the reasons for that are generally, hopefully in a hospital environment. We can assume that there is kind of minimal danger. I'm still going to talk about it as part of the primary survey because I still think it's important to consider, but actually, when we talk a lot about kind of in the hospital management of medical emergencies. We don't tend to explicitly talk about danger. Even though I am going to this evening again, we don't tend to express that. You talk about checking the first part. I think the only reason I can find is that we kind of assume that most kind of medically trained stuff have some idea of how to check if a patient is responsible. Not, but I am gonna touch briefly on both of those, depending on your kind of previous level of experience. With primary severs, you may not have also seen catastrophic hemorrhage, but in there you may also C c. Spine put in there on. I didn't want to talk to much trauma. I want to focus on kind of medical emergencies with the title, so I haven't put in too much right c spine consideration. I will elude to it briefly as we go through. So why do we have the primary survey on what problems can help it can? Can it help prevent on? Just flipped back very quickly. If you hadn't seen the primary survey before. That's what we're talking about here. This catastrophic hemorrhage, airway breathing, circulation, disability and exposure, and you can see from kind of the clipboard on the right hand side. Well, I'm trying to introduce this. This is kind of a checklist, A swell. So why have we got this checklist of things we need to check up on on what kind of problems does having this checklist help us proof prevent? And again, you can put those ants in the chat if you want, or you can just have a think both. Both are perfectly valid strategies at this stage. So hopefully what you were thinking about is that the promise of a provide us with a systematic approach on that is really, really important in medical emergency. There are lots of human factors to be considered. There may be kind of anxious relatives, family members, whether it's kind of partners or kind of it may be kind of mother, father of the patient or some daughter or other relatives is well, eh? So it's really important to realize that emotions might be running high for this and for other reasons, the medical staff might feel like they're under a lot of pressure. Lots of stress on might be more prone to making mistakes, so we take a systematic ordered approach. We can make sure that we don't miss anything out on. All of this is in priority order. So we're doing the most important things first on. Also additionally, these way, we do it in a way that's easy to remember, because again, high stress situation. We don't want to miss anything out. So those are the main reasons for the primary seven. There are a few others, but those the main reasons why we've adopted this structure and it's used pretty much universally. If you've done like a first Aid course or anything like that, I've been a first a trainer for a few years now. You will have learned a primary seven there we using a very similar approach to in hospital medical emergency. So it's a fairly universal. So, like I said in the hospital, we don't tend to toe quite so much about danger. But what are the possible sources of danger on? What can we do if there is danger? So I have a quick think, especially in the hospital environment. Hopefully, you're not expecting the building to fall down on you. Hopefully, you're not expecting to be struck by lightening or mall by our wild bears. But what kind of possible sources of danger all there on also, what kind of things can we do to mitigate the danger? So, for example, if there is danger in hospital, we could run away. However, the other patients might be less able to run away, so we might just be leaving them in danger. So we might have to have a slightly different approach if we're kind of inside a hospital building, too, compared with kind of a pre hospital approach to this problem where running away is sometimes a very valid strategy. Say, one thing I did want to make you aware of is when we're summoning help in hospital. Uh, we don't, for example, call 999 because we want to kind of trained medical personnel. They're very, very quickly on. You know, not all hospitals have a tablet station based next, um, s so sometimes the response times could be quite long on. Of course, they've got other kind of called all across the geographical area to consider, however double to double two or 2222. However you prefer to set, that is the kind of in hospital emergency number on a bit like when you call 999 and you get asked what service you would look when you call double to double, Do you have to specify the type of emergency, which means that we can customize the response to what is required? Some hospitals have a separate security number. Sometimes they use double three Double three. At some hospitals were off the double to double to system. And but so you might be specified that you need security, but also in terms of medical assistance on different hospitals. Use different terminology for this. I did some shifts in one hospital where they called it an act call, and I was like, What? So yeah, be aware of different terminology, but when you call double to double to, they'll ask you kind of what you need. So you might say, You know, we've got a cardiac arrest or a pediatric cardiac arrest. You might say at things like we need additional airway support, which would then kind of activate the unique the tests as well to come and support that arrest things that that's also you might ask for something like the major hemorrhage protocol to be activated, which I'm going to talk about a little bit later on. But, yeah, one really important point is knowing how to call for help effectively, because it is different. In hospital on, I have seen a flow chart in the hospital. It was a B L s low chance of basic life support flow chart that still suggested calling 999. Even they were they were in the hospital High dependency unit. I would I would not recommend doing that. I would recommend calling double to double team. Instead, I got vague, curious? Well, researching this presentation looked up. Why don't you to double To was used on the only good reason other than the fact that they found that one digit was best. I think in Sweden they were using hash 33 your 33 hash, and people couldn't remember which way around they came. But the only good reason for using double to double to was they said lots of hospitals were already using it. So I still don't know why they picked up to double too, in terms of the possible source of danger. Then I like to think about it is three distinct categories, so there are possible sources of danger from the environment. So despite our best efforts, there is the possibility that the hospital could fall down around us. Or we could trip over cables or get electrocuted or slip in a puddle on the floor or something of that. The people Orender us could be a danger. So maybe it's angry family member or someone who's confused or something on that on the patient themselves. If you consider those in theory, you should have considered every possible source of danger, although we don't tend to put it in and a to approach which will get onto very shortly. It's really important to always be considering danger if we ourselves, this kind of medical personnel are in danger that we can't help the people in needs really, really important to consider that lovely same. We need to check for a response on the way we conduce. It is quite simple. Unlike a say why they don't normally teach it in kind of hospital eight s, so we can. But first, Well, why are we checking for a response so you can see that I'm saying hello can you hear me? Can you open your eyes on then either tapping their shoulders or pinching that ear lobes? Why am I doing this? To check for a response. What possible mistakes could be made if I don't check for a response? The key points here are checking for response is a good, quick and easy way to determine if that patient is in any way responsive. So we'll talk about levels of response in a little bit. Idea. They actually put it on this slide. I noticed that's an emission on my part. But most of you, hopefully at the minute our alert none of your form of sleep. So you're kind of looking around the room independently and reacting independently to stimuli. If we turn bright light, you're probably showed your eyes kind of. If we tapped me on the shoulder, you're probably turn around those kind of things. If I'm not sure if someone is alert, I can use my voice. Hello? Can you hear me? Open your eyes. So I'm asking a question and giving a commander make it really clear what I want this patient to do. If this base it doesn't appear alert, but respond in some way when I use my voice. So when I tell him to open their eyes, they then do open their eyes if we're going. But they're not then keeping their eyes open. Then we say there, voice responsive on if they're only responding. When I tap there shoulders or pinch their lives in their pain responsive, we don't tend to it, trying to inflict too much pain unless we have to. Sometimes other methods can be indicated by my own. Again. Talk about these tonight and if there is no response to the patient, is unresponsive. So this is the AFP Ooh scale to alert voice pain and unresponsive. It is spelled out another slide for you. But why are we doing this then? Quite simply, it's quite embarrassing if we call a kind of a major medical emergency and get kind of doctors and staff running from all over the hospital on it. Turns out the patient is asleep or had close their eyes and have their hearing aids off. So it's really important that we check for a response is re. It gives a really quick, easy indication of what's going on with this patient on what we need to worry about on what we need to do. The next thing on our scale then. So it's the 80 we approach. But we also need to think about catastrophic hemorrhage because remember, I said, these things are in priority order. So it's the speed at which these things kill you. So catastrophic hemorrhage, then The reason I put warning on this slide is it's I could probably talk about catastrophic hemorrhages without kind of graphic pictures of injuries and stuff for that. But I don't think it would necessarily convey exactly what we're talking about. Austin Gory pictures. Most of the gory pictures are done in simulations. There aren't really injured people, but some of them are real. Are won't really point out which ones are really which ones are not. In case you don't like the thought of these real injuries, but there are gonna be some gory pictures. So if you don't like that, look away. I'll get our try and give a big shot once we moved on from the pictures. But there are gonna be a few of these First of all those we need to use a concept that Freddie I'm hoping to patent. In fact, we're going to use the home Simpson scale of hemorrhage, which I've come up with. I'm very proud off. I think lawsuit is probably incoming, however, so at which point do we think is a catastrophic Cambridge? So, does this look like a cancer? Stuff it, Cambridge, Hopefully those gifts are working. I did test on a mini live event earlier to make sure. Do we think this is a catastrophic hemorrhage? You know, just to be clear, thank you very much. Order. We think this is a catastrophic hemorrhage. So I was a definitions. Might Very And of course, this is a cartoon, so we're not seeing a lot of detail, but I would say for the first two images. So the knee on the on sort of the multiple skin abrasions, he looks like he's covered in almost to march. A catcher doesn't, I would say there's no active Henry. We're not seeing any spurting of blood. Have it in that last image. On the right hand side, we can see active arterial spurting. The blood looks like it's coming out under pressure, so I would say that is potentially catastrophic hemorrhage especially when he starts waving is arm around. That looks like he's losing a lot of blood very quickly. So the other two, we would actually come back to you and probably think about more in circulation. But these catastrophic hemorrhage on the right hand side, this is what we gotta fix right now because otherwise, if we don't fix it now, we're not gonna have ah, patient alive long enough to fix any of the other problems. Some slightly more realistic images. You would probably agree, hopefully that the patient on the right is definitely gonna have a catastrophic hemorrhage. Assuming that's a new application injury, it could be an existing amputation injury that has now been kind of injured again. The one left one side. It's difficult to tell from that image. You could argue that doesn't look to be any kind of arterial spurt sing and things like that that it's quite a significant wound. I said this patient would definitely be being conveyed to hospital if we saw them prehospital e. If in any doubt, I would treat it as a catastrophic hemorrhage to start with on, I could always kind of de escalate my management later, but that that that's what we're going to assume. So we're going to a run the safe side if we not sure and treat things the catastrophic hemorrhage just to be safe. Okay, so now we're aware of what they look like with grateful. Thanks for home or Simpson. We need to think about what to do about these things. So this here are in the bullet points is the hemorrhage control ladder. So it says direct pressure on DellaVedova in brackets, so direct pressure could be from lots of different things. In the first instance, it should be from the casualties, own hand or similar body part Ethan is possible on. The reason for that is it allows pressure to be applied wild kind of rescuers, you know, sort out other equipment, like bandages like corn, a case eccentric Central Central. So we can apply direct pressure with the hand. And then we can think about other devices when I go through the rest of the slide. The cats, Tropic hemorrhage. I'm not I haven't got a picture of a hand on a wound, So please, do you remember that is the first step, but I just ran out of space on my slides, you notice Well, it says and elevation. So there was some previous thinking that if I had a cut on my arm and I raised above my head, that might stem the bleeding, that they have not found that that doesn't really significantly contribute to stopping that bleed. But it's still considered because it may in some instances provide some benefit. But it's not really making significant difference, So the emphasis is on the pressure. I've put in direct pressure as the next step, because sometimes we may not be able to apply direct pressure. So think about wounds where we cannot put a hand or a bandage directly on the wound, where that might cause more harm than good as it were. So things I tend to think about for this are on either things like, you know, a wound with glass or other embedded objects where putting a handle, my last, my injure, say the rescuers hand or the patient hand, but also course push that glass further in, but also things like if they've got a wound to the front of their neck, we're applying kind of direct pressure of the neck that may cause problems as well. You might have to, but it's kind of a weight management and blood loss there. But sometimes we might need to think about other things. So indirect pressure can be further up the circulation if we're going all the way back to think about, and that's been using an atomic attempts so more proximately so into the arm, certainly it would be further up into the leg. The further up we can apply pressure and therefore restrict the flow of blood to the wound, or sometimes, depending on the wood, we might just be able to squeeze the signs of the wound. So if we've got one kind of embedded objects a one piece of glass or one stick sticking out, we might just be able to squeeze the sides of the wind. We not going to remove any embedded objects from the wind because that could make bleeding worse. Other things we can think about then he most static dressings. He meaning blood status, meaning stop. So these are dressings that help stop the bleeding, so direct pressure, like is they can be from a hand or can be from a dressing or bandage hemostatic dressing actually have special chemicals in them. A lot of them come from shellfish. I believe Freddie may know more than male known, but it the chemicals in it encourage the blood to clot and actually stopped the bleeding faster on. Then we can also think about it or not. These have that I've already talked about. How example. Applying direct pressure to the front of someone's neck might be a bad idea. Equally, there are some places on the body that we cannot apply to on a case to the gentleman with the wound on his forehead. We're not going to talk, okay? His forehead, it's It's not a good plan. As a general, we definitely not going to talk. Okay, anyone's neck. So we need to have a bit of a system for dealing with our major bleeds, and you'll see a very nice promotion image here on the right hand side that one company has come up with. So tourney a the limbs. So the reds sort of droplets parts show where the lymph should be. Tornado cage on on, then packed the junctions that these blue dots were going to a pack. The wound so we can actually push dressings into the wound. And it's It's not just any old dressing. It is specifically kind of packing goes on, seal the box now. Actually, I haven't talked about Jesse because I'm trying not to spend too much time on Castro hemorrhage. I did a whole hour long talk on catastrophic hemorrhage the other month, so I could easily have talked for now on just this. But ceiling the box so you got lungs and we can get things like once we get a or blood or anything else into the box over the lungs are that can cause her lungs to collapse. So we need specific ways of sealing the box ceiling, the chest cavity. But I'm not about that tonight and skip that over that one. I'm afraid so. Different ways we can manage this. Then, like, say, a standard. You might call it a bandage. Technically, it's an ambulance dressing or similar. So if a hand pressure hasn't worked or simply we want to free up that hand to do other things, we can then put an ambulance dressing on instead. The next thing we might try. Something called Colace dressing sometimes called Israeli dressing. The's ones are big stretch you bandages so they apply their pressure and you see that little, almost plastic knuckle on that's designed to dig in and provide even more pressure on the wound. Hopefully, this gift will work. I'll be honest. I forgot to test the ones after home, a symptoms that might not work. I apologize. If that does work, you'll see a gentleman applying Ole, stressing to an arm. I believe it started midway through. Was it again? So he wraps around on. It's just round and round and round around on. You might be able to see it's quite stretched years well, and applies with lots of pressure very, very easily, and you can see how quickly and experience practitioner can apply that dressing. So the next thing to think about ignore the black boxes to make my two videos sort of slightly more symmetrical. Like we said before, we can think about wound packing. And again, hopefully this is working. If not, this gentleman has got a big, long string of white gauze on. He's just shoving it into a wound. There is a slight technique for this. We're basically getting thumbs on. We're just kind of gradually burying mawr and more dressing. And we're not trying to shove it all in at once again. Little by little by little. Basically, if you think about, say, a blast wound, for example, which is actually taken a chunk out of someone's tissue, we could put a bandage over the top of that. But that cavity will start to fill up with blood. So, actually, we need to fill that character with something else to stop it filling out with blood and reduce that blood loss s so you can see here how effectively that constructor fill that cavity and stem that bleed. The other one is the hemostatic dressing. This one is sell our schools. Other manufacturers are available on This is a yellow chemical panel day. You can get it infused directly into dressings. In this case, they're hacking the wound, then apply in the cellar and then applying morphine and packing, and you can see how quickly the blood drives up. You can see the pulled blood on the kind of lower abdomen. In case you're wondering why that looks weird. It's a pig, so you can see how quickly the blood pooled blood on the abdomen starts to clot s. Oh, yeah, that just comes as a powder or infused into a bandage. So there are few other things to think about is well, So if a hemostatic dressings aren't working like I say, the next step on a hemorrhage control ladder is a tourney. Okay, Now, hopefully you're vaguely familiar with them. If not, this is a quick example of how to make a home maid one. I had a limited amount of time. I could make the gift display, so that is a sock that's been tied around some of them. They then tied a pen into it on. Then they twist the pen and it makes the stock go really tight around the arm. And if you think back to kind of anatomy, what we're doing here is we're applying lots of external compression to the artery on were literally pushing it shut on. We'll make it very difficult for additional to blood blood to flow. Now. We don't want to put a tourniquet on anything that isn't a catastrophic hemorrhage, because it can start to cause tissue damage. But these patients are so one Well, They're losing so much blood that actually, if we don't stem that bleed, they're going to be dead very quickly. And therefore the tissue damage is of secondary concern on our primary concern is a hypovolemia shocks or low blood volume shock and death. So we've got to stop that bleed very, very quickly. But yeah, While you can make homemade tourniquet from very simple items you confined around the home, you absolutely should not be applying these to anyone who hasn't got to catch struck that camera, it can cause harm. So please take note of that safety notice. But yeah, you can see how quickly and effectively a tourniquet can be applied on if we let that give her on longer. You quite quickly see that person's arm going pale below the tourniquet as we stop getting blood flow. So those are all things that could be done pre hospital. They can, of course, also be done in a hospital. If someone manages to come in with a really bad, catastrophic hemorrhage, that hasn't got to order count, there's nothing to stop the hospital stuff from putting into it. Okay, all Although, if your patient is survived that long with the cats. Tropic hemorrhage it. It might not be catastrophic, however, of course it could have been not as bad. And now something is dislodged or something has changed, and it's now gotten worse, eh? So we should be doubting the price of our pre hospital practitioners. Things may change on on route while the patient being conveyed. What other things could be doing? Hospital. Well, I mentioned earlier. We can call double to double to on activate the major hemorrhage protocol. Now what does this do? It depends on the hospital. Some places will send you a box with lots of blood in. It's a refrigerated box is a bit too much like your your picnic cooler or whatever that's designed to keep your drinks in your food. Cool. It does nobody say emergency blood on, so no one's trying to eat it, but, yeah, normally, they'll send a few banks of blood on. The idea here is we're placing blood with blood. You might be thinking about IV fluids, but we know in general patients do a lot better, have much better outcomes of replace blood with blood. So yeah, interesting major hemorrhage protocol on getting blood for this patient is better. You'll see on the blood packs, there's a vory kind of square looking Oh, when we're not sure what blood type of patient is we're going to give them Oh, negative blood, which is the universal donor. Everyone can have a negative blood, but if we can type and cross their blood so we can either cross match, which is when you're requesting blood or you're doing a group and save, which is saying we want to test the sample for later on. Then we might be able to give their specific type of blood because what we don't do is use up the hospitals, whole supply of negative blood. They might need it for the next patient coming through the door. However, as I've said, this protocol can vary between hospitals. One of the hospitals I'm based in you activate the major hemorrhage protocol and you get this a porter which may sound very unhelpful. It's not. It is very helpful with this Porter can Then go and get you blood on also the The idea is until the emergency is over, they will stay with you. So if they go on, get you four units of blood on, you know, two units of plasma on what else on then you need more. They can go back and get more, Uh, some other places. That way they do. It is when you activate the major hemorrhage particle, they will send you blood on. They will just keep sending you blood until you you remember to tell them to stop. So do you remember to tell them to stop? Otherwise, your your emergency department is going to be full of blood. So be aware of that, but yeah, just to see where they're slight variations between hospital. Sometimes you'll be expecting a bag of blood and you'll get a person instead. So try not to be too confused when that happens. So if you don't like door, we are free of Gore. Although you are going to see some on actually pictures and things like that. But we're not going to see any more kind of missing legs and things all that once we've corrected catastrophic hemorrhage on a really important point. To note with things like Promise Airway is we need to fix problems as we go along. We shouldn't. We shouldn't, uh kind of leave a problem. We shouldn't identify a catastrophic hemorrhage and then do nothing about that. We need to do everything we can to fix that problem before we move onto the next problem. Once we have resolved a catastrophic hemorrhage, then we can start thinking about airway. So what airway problems do you think could occur on what kind of things could we do to try and fix them? I'm short of times. I won't give you too much thinking time on that. I'll just quickly check. There are no questions. Please. Do you feel free to ask us there? So I deliberately was kind here. That could be vomit. That could be blood in the mouth. It could be something else. Who knows? But we can have kind of obstructions caused by liquids or solids or things like that. In this case that this person has got green goopy all over them. You might see some clues there which might think it help us think about things we could do to try and result of the problem. This poor lady here, Eisner not having a fun day. Presumably this is a very severe anaphylactic reaction to a very severe allergic reaction, which causes swelling. You concede around her Ronnie's and around her lips that there is a large amount of swelling. So the other place that we're concerned that might be swelling is her airway. A part airway swells. It reduces the diameter. It reduces the amount of air that could be moved through. On. This can get to a very critical stage where especially worried about airway swelling in younger patients of pediatric patients because they have small airways to start with. If they then swell the volume of air, they can move through the airways start producing very, very rapidly. Eso We get very worried about any kind of airway swelling and Children the other thing as well. You can see there we've got a blocked airway because the tongue has fallen back. So if a patient is is unresponsive enough, then actually they lose some of their reflexes. When we go to sleep and we learn, are back at hunger doesn't flop back and recruit airway. That's because we still have some degree of unconscious control over our tongue. If a patient is unconscious enough or unresponsive enough, then they lose control of their tongue and it can block their airway. So we need to think about ways we can resolve these problems. So, first of all, when you think about opening the airway on, let's say we've checked on whether there was all wasn't a catastrophic hemorrhage. We buy the fixed. It always moved on. There wasn't one we get. This is also how we open the airway to check. We can, either. Sometimes this is for her to his TLC or tilt left chin. So we can put two fingers under the person's chin, one hand flat on their forehead and tilt their head back and you can see their Their tongue moves out of the way, their airway allowing airtight flow S. So we do this on any patient who kind of isn't able to talk to us, Really? Because that way we can be certain that they're airways clear of their tongue. However, if any of you done any kind of first a training or anything like that, you might be aware that some patients we don't want to move their head and neck if possible. So the other thing we could do is add your thrust Now, where this diagram is terrible, so I deliberately left the description of the bottom as well. I'm going to do my best to describe, so you can see the mandible. The lower drawer here is represented by kind of an outline on. You can see the line is intercepted by that person's fingers because it's terrible diarrhea. What we're century trying to do is move the mandible, the lower jaw forward. Almost if we're trying to slide it forwards out of their face on what this does again is it moves the tongue after the way. The key point here is we're not tilting this person's head on potential. Make it spinal injury worse. Eso really important for us to bear in mind. So if we've got any concerns about spinal injury, we use a jaw thrust from a left chin approach. So those are some things we can use. We can also think about these things. So we've got a brilliant of general. It's trainer there on. He is doing something specific to this patient. He's rolling them on their site, but hopefully some of you might know what that particular position for a patient is called. So he's put this patient in the recovery position. So hopefully you've learned about that at some point. First day trains are very good at talking about the recovery position. What we aren't necessarily so good at talking about is why we put patients in the recovery position. The idea here is a We will make sure that they're not colluding their airway. So by lying on their side, their tongue isn't blocking the back of their airway. Also, we can use postural drain so their head is on their site. If there was any vomit and he blood any other liquid in the airway because their head is slightly tilted towards their mouth, it should drain out of their math and therefore not cause problems, no obstructive airway and cause them to stop breathing. So the recovery position is really, really important. All the other bits with sticking arms out and flopping legs over and think that that is just to make it easier to stop that person rolling back over again. But the key point is it helps the main taking their airway so really, really keep want. If you don't know how to the recovery position, the best thing I can actually do is go onto YouTube off this talk and just learn how to the recovery position. This simplest things are sometimes the most effective. I got to talk to an air ambulance doctor on a training course Recently, he was training new air ambulance doctors in. He reckons the most effective medical intervention he ever did was off duty. He attended a car accident. He sat in the seats behind the driver on because they were unresponsive. Just did a did your thrust on them until the ambulance arrived. So simple interventions can be really, really vital in saving patient's lives, which is why we're spending so much time talking about kind of what you might consider being more low level things with actually really important. So another way we can use to clear People's airways is something like a suction unit like this one that is commonly found on kind of ambulances. But also in the hospital is a swell on kind of recess trolleys, which we'll talk about right the end of the talk. Hopefully, so this generates a vacuum and allows us to suck out of the patients, make the liquid B it blood, former etcetera and it collects it in that little kind of plastic you bang it in the middle is that could be really useful as well, so we then need to think about maintaining the patient their way. You're showing a variety of devices that condition this. This is not an exhaustive list, but they do go up in terms of kind of difficulty on kind of protection for the airway. So first of all, this is called Goodell Airway or or phone GL away Fix. It goes in the or a fax on. When you see the picture will hopefully start to make a bit of sense, you can see that little what it's doing. It's going in the patient's mouth or in there or Frank's. If you prefer on what it is doing, is it simply holding the tongue? After the way on, you can see the hollow tube in the middle allows air to flow through, so this patient can either continue breathing for themselves or if we need to. We can start thinking about breathing for this patient. However, if those kind of vomit and things like that, it could potentially a clue this patient's airway. So we might think about other things as well, so we can suction the way clear of vomit. But it then, if this patient vomits again, for example, then the airway could become include again with an aura from jail airway. So we might think about placing some like an eye gel on when that's properly placed, it looks something like this, and you can hopefully see there. How it down a kind of a sfar down as we can see on this patient's neck, the front compartment in the neck, the front pinky space is protected on the back pinky space, which is going to be the esophagus. So the food tube, if you like, is blocked off. So if this patient vomits, they're not gonna end up with vomit in their lungs and get either pneumonia or have it block their airway and stopping breathing S oh, really, really important. So on gel is a better approach. When we can use that, sometimes we use step wise approach to airway management where we go up or we'll put in an O. P. If we don't feel like that's adequate, will put in an eye gel and so on and so on. How about sometimes we will go for the tool we think is most appropriate. Straight out of the box again? Yes, Another device we can use. This is an E t. Two to give you some context. It's longer and thinner than the others. Which, when you see the lovely diagram I found this one it will make a bit more sense. You'll see on one end a bit like the eye gel has got the green bit on the end. This one has got a cuff, so it looks like a little balloon on the end without the syringe attached at The idea here is once you've got it correctly placed, we inflate the cuff on that stops that you coming back out again very easily. So the idea is we can put this in, secure this patient, the airway on, then it can. It is protected nothing and nothing come out. And it also stops things going in an effect in the airway as well. So really, really important. Please also notes that there's a syringe attach that's used to inflate the cuff. This is why you got to kind of tubes coming out the other end because the next diagram doesn't make it particularly clear. So you can see here on this diagram that this each you This endotracheal tube goes all the way down almost to the lungs. So it goes down at technique to the carina, which is the bit on your bronch, where your drink er splits into your left and right main bronchus. So it's going down almost to the lungs. So by then inflating that cuff, we've sealed off the lungs from kind of the esophagus, the food tube. So there's very little chance of any kind of food or vomit getting into the lungs on. It's just going to be a kind of oxygen or air that we supply from outside that gets into the lungs. So we're keeping that airway nice and secure. Nice and six. So generally, for very unwell patients, we will pre emptively intubate thumb So person endotracheal tube in. We don't wait for them to develop an airway. Problem will off the airway sports were getting anything cysts in. So if you don't want anything, do you may you may be aware that they kind of put you to sleep for operations and wake him up again. That is a big part of a role, but essentially, they're also responsible for keeping people alive during their operations on So they are the airway experts. So if we're struggling with the patient a way, or we think we were likely to will call in the anything tests and they can come and secure the airway on a lot of times. Their preferred method for doing that will be an endotracheal tube to seal off those lungs and keep them safe for anything else just to mention it. A lot of those first three devices we mentioned all go in through the math. Sometimes we may not want to use that technique. The first step on there with management ladder is a nasal pharyngeal airway. Eso these tubes here go in through the nose instead of that, you can think about if patient you could have a paper trismus that are unable to open their jaw. We might not be able to get in on put in on ET to run I gel on or a friend really away. And so we could use a nasopharyngeal on nph you. Then you can also dio nasal pharyngeal intubation as well, so that it is possible to pass something similar to an ET tube through the nasal print. So we have got options there. But just to make you aware that not all their way cheap have to go through the mail, just my little rant here. I don't like the fact that this picture has size six all the way up to size nine np's. We very rarely used anything over than a size six, recites seven np. If you've got a size nine m p and you're either an elephant or you've annoyed urine ethos ist, I think of the two answers for that one. So after Airway, we might have used various tools for his techniques to secure away. Once we're happy with the airway and there are various ways we can check since is listening for breath sounds and stuff that we need to assess breathing. So if the patient is not breathing, So let's say we check for their respiratory rate just by looking, listening and feeling so looking for chest rise, listening for breath sounds on feeling for any breath coming out. Of course, we don't do in the cove it here uh, But certainly before we would consider this kind of feeling the breath on the cheek and things like that. If they're not breathing or not breathing effectively enough, then we would look at starting CPR. I'm not gonna talk about that too much. I think all of you will have a little bit of knowledge about kind of basic CPR. So I've kind of skipped over it for this talk very much. If your patients not breathing, we're doing CPR. Eso If we get to this stage, assess breathing and find no breathing, then we're doing CPR. But yeah, if this patient is breathing, we want to figure out what their respiratory rate is. Ideally between 12 and 20 breaths for a minute. Like they we can just do this by looking in and feel if we if we're struggling and can't kind of visually see the response rate, we might just kind of rest a hand on their tummy or something. That, and feel it going up in them, know on things that on oxygen saturations so one of my favorite devices ever. This is a post oximeter. It shines a red light through. Your thing is that's completely non invasive, and it looks at how red your red blood cells are. If they're very red, then they've got the oxygen bound to the on. If they're less red, then it means they haven't auction bands thumb on. We can work out what percentage of your red blood cells have got oxygen band Um, it uses a technology called near infrared spectroscopy. It's very, very cool, like it probably took for now, just on this one of my favorite medical candidates, but quickly and easily by popping a little gizmo on someone's finger, we can tell their oxygen saturations how that you'll see the mentioned sinosis. We also shouldn't rule out other things, such as just looking at the patient, seeing how they look, because that can give us other clues as well. We could also check their breathing pattern s so here is kind of a chain Stokes breathing pattern, so start slow, gets faster and faster on day, have a little period of back me a sword, not breathing, and then starts again. I haven't got time to talk nearly as much about that as I would like, but just know that breathing pattern comptel us a. lot terms of cyanosis. It's when people's tissue start to go blue or purple. That can be a sign of low oxygen saturation. This patient here, it's specifically in their fingers. That might be more likely to be something called Reynaud's phenomenon, where you get poor circulation specific. Just your hands that certainly if they have Sinosteel, it's their their lips looking kind of blue or purple or kind of general. Be sign Ozel. Their skin starts or purple that can be a son of low oxygen saturations accessory muscles usage. You might think this is a picture off. Just a very skinny baby. What? This is actually a picture off is just This baby's taking a really deep breath in because they're working so hard on their breathing. Actually, in between each rib, the skin is sucking in. This is nose intercostal. Recession s so we can see accessory muscles usage. We can see if they're working very hard to catch their breath on. We can also assess chest expansion, which I believe I've got picked. Oh, no, I've got a picture. Here s so you can see that by putting that handles. It was just we can see how much it moves when they take a deep breath in so lots of information, we can gather very quickly. I'm going quite quickly because I've got lots more to go through. Still things we can do to help. We could give this patient oxygen or sometimes medical airport normally oxygen. We can also look at breathing for a patient if we need to. So this here is called a bag valve mask on so we can squeeze the bank to breathe for the patient if they're not breathing for themselves. We can also look at hooking up to event later, but certainly in the short term, we're just going to use a bag of mass nice and simple and just squeezing to breathe for that patient on this can be helped by the airway drinks we saw in the airway section. I'm just other things as well, so it's well, it's just supply on street. This is a nebulizer mask, so below the kind of green blob there is a chamber where we can put various kind of liquid medications on. They can be aerosolized. They can go into the oxygen or medical air on be, breathe directly into the lungs. So especially for kind of asthmatic patients, it's very similar to their inhaler, but slightly more effective than nebulizer can help kind of give medications that can stop their airways from swelling up and actually reverse some of that swelling in terms of breathing in the hospital. If you've learned kind of pretty hospital management and things of that in hospital, we go slightly more in depth so you can do on the left hand side with how painting for the trickier, said the air pipe with palpating. So we're feeling on this patient to see if it's deviated. Does it bend to one side or the other? If it did, it might look something of it like that. But I could only find a picture on X ray on that might indicate there's a problem with the lung, so you can see in this case you can see the are, which indicates the right side You can see in this case the trickiest deviated to the left side, and you can see the left lung looks a bit weird and funny. Actually, the problem here is with right lung so you can see the little white lines on the left lung. There are no little white lines on the right lung that that's likely because the whole long has collapsed. This is probably this is a pneumothorax. Might be attention. Pneumothorax might not be probably attention pneumothorax because we can see the heart. Everything is start to shift across from the midline. What we see in the right hand side is percussion, so we could also tap on the patient's chest cavity on the sound it makes tells us what might be underneath so you can have a gout tapping on your own chest cavity on listening to the sound it makes. If it was a dull found that might tell us that there's a lump there, some kind of could be a tumor could be a collection of fluid. There's all sorts of things that it could be very quickly. We can also listen for breathing sounds and things like that. I haven't actually got time, and I'm not sure. Sadly, if I shared my screen the correct way to share my audio, I'm not gonna waste the time factor around with it, But you can go on YouTube and Google things like normal lung sounds and things like that. The other two I had for you were crepitations, which are crackles, which is when someone has a chest infection on also a week. So you can go on YouTube, those and here what they sound like that I'm short of time to further assess kind of breathing problems and things that we can be mean to people. But you can shove big needles into their arteries. What we're doing here is an arterial blood gas. So this is showing a needle directly into an artery which is not recently trying to avoid strings. It's quite painful to your arteries. Have nerve fibers in them waking actually measure the amount of oxygen and the amount of carbon dioxide in the blood directly on. This is a bit like a pulse oximeter, but even better. And it can tell us, for example, of our patient is retaining carbon dioxide, which can make their blood Sediq. We can also measure the acidity of the blood directly through this test just to moan about this procedure. I don't like this picture. That person doing that procedure is almost certainly going to stamp their fingers. If they're not careful, so they need to be a bit more careful. Another thing we could do. As you saw on the previous line. We can do a chest X ray as well, which might give us a more clues back problems with the lungs that might be causing breathing problems. In this case, this isn't a pneumothorax. This is actually a hemothorax, which means there's blood in that chest cavity on. That explains the line you can see on the right hand side Teo for comparison that you normally chest X ray. So circulation again have a quick thing about what problems with circulation occur. What signs might we see on what kind of vital signs can we check on the patient so we can check signs such a demon, which is swelling, sometimes with circulation problems? Water can literally be forced out of apple and vessels, and it can cause swelling. Here is a brilliant picture of a Dema because you can hopefully see that foot looks quite swollen, but you can see the other key feature, which is can actually cause your skin to dent. So basically, when you push on this swollen skin because it's water, the water just moves out your way on leaves a big dent in the skin. That can be a big clue that it's a demon or swelling as it were. You could also get power, which is when someone looks very pale. That can also be a key sign of a circulation problem. We can check their heart rate on one of the simple ways we do. This is simply by feeling their pulse. You can see again the ideal heart rate for most people were gonna want between 60 and 100 BPM. We can check your BP and again for most people want that to be 100 20/80 millimeters of mercury or below on. We can check their temperature as well, which can indicate circulatory from some people. Put it in exposure. Some people in circulation whatever you prefer, we can. Did he see GI an electrocardiogram, which is on the electrical tracing of the heart? It doesn't necessary test about the heart rhythm, but it can tell us about the electrical activity because we can get something called post this electrical activity where all the electrics are fine. But the heart isn't beating properly, but we can infer a lot about what's going on in the heart by what the electrics air doing. We could also auscultate or listen the hearts and again I was going to play some heart and unfortunate again. I don't got quite enough time that you can search for a normal heart sound on. Then the other one I was going to play you was mitral regurg s so you can look at those. There's a single lead of any CG showing you What are the electrical tracing of the heart's activity months look like obviously you get variations in that. And that's what we're looking for when we do the EKG in terms of listening to heart sounds were going to do that trustee step escape to do that. Okay, there's a correcting circulation problems. We can do things like cannulation s so we can put a little plastic tube into someone's brain. So a lot of people think, and I mentioned this in mind, actually talked last week. Lot of people think that cannula is a needle going into a vein. The needle is only there to introduce the tube. We then remove the needle and leave the plastic tube. The reason we can you like patients is to put kind of intravenous medications of medication threatening into the veins. But also let's just give IV fluids on blood replenishment as well. So can you Lay Shin could be really important for correcting sick kelation problems. We can also think about catheterizing patients, so the end of the balloon is the end that's going into the patient's bladder. On the other end is where the urine drains from and you can see a bit like an E T. Chief. You also have a balloon port, so that inflates the balloon a bit like we have a port of inflate the cuff on the ET tube just to give you an idea of hand that's inserted are male patient. You can see we're going directly up the urethra that goes through the Penis. So not a very pleasant procedure for lots of patients, both male and female, the female one procedure is very simple at actually have shorter urethra. Women are getting, we considered slightly eat sorry. People with female on that people with shorter urethra because they have a kind of a general and the cervix are generally considered easier to catheterize, but it can be more difficult to actually locate the urethra. But once the catheter is inserted into the bladder, the balloon should be inflated to stop it accidentally being removed on this. Is that HCG in progress? I just wanted to get a picture in there so you could see what it looks like. I'm not 100% happy with the limb placement, a limb lead placement on this image. But it was the best one. I could find the study being done, very disappointing. Another thing we can think about. And there are a few other things we could throw in here like bladder scanned. Another thing we think about is a pregnancy test. If someone has a sick, is it? Someone with kind of female anatomy has a, uh ah, an X optic pregnancy, for example, the an embryo implant in the wrong location. As it grows, it can cause hemorrhage that can cause bleeding is actually a pregnancy test. My indicate that we might need to suspect that is a problem. Equally, problems during pregnancy can also cause issues with bleeding. One of the reasons why I want to put that picture in there is because the pregnancy test we use in the hospital do not look like the pregnancy test that people use outside of hospitals. So just to make you aware of that, so other things to be aware also in terms of fixing circulation problems. Like I said before, we can give IV fluids equally. If we think some was losing blood, we're gonna look at giving blood instead replace blood with blood. No, pastor water. So no salty water, which is what we normally give for kind of trauma where we've got lots of blood loss. The outcomes on the skin is, if we're able to give blood, you can see here this is a B sample rather than on a lot of other circulatory problems are sold by giving various medication. So, for example, if a patient is having a heart attack, we care. So that's where when the coronary arteries is included, a blood clot, eh? So that's an artery supplying the heart muscle. We can try and use medication to break down that clock. If the patient has an arrhythmia is the heart isn't beating regularly. We can try and give medication to resolve that arrhythmia s so there are lots of medications. We can give it this stage to try and solve different problems in terms of disability. Then eso here, as promised, is your A VP. You again if we haven't assess their level of responsiveness? We definitely want to think about doing this. This stage S o r. They alert. Are they just want to voice are late response to pain or are they unresponsive? We can also check pupils reactivity, eh? So we can see this patient here has got people's of different sizes Eso that might indicate a head injury. It could indicate a potential stroke. There are quite a few different potential causes. There can also be other things that can cause that kind of long term as well. So we need to consider if this is like to be a new problem. But we're checking pupil activity by shining a little light in each of the patient. Eisen turn and noting when we shine the light in the pupil should get smallest. The black dots in the middle of the I should decrease in size. We can talk a week. It took about kind of blood glucose and key tens that kept Freddie has already done that expertly earlier on. We can also review what medications the patient is on because certain medications can make people less responsive. So, for example, if we've just given them a really big dose of morphine, or maybe some was miscounted and they've had an extra dose of morphine that might make this patient really sleepy and unresponsive, it might also decrease their breathing rates are actually identifying a medication that might be causing a problem is also really, really important at this stage on then we can also think about imaging as well, so we might do something like a CT head. So a series of X rays, lots of slices through things, patient heads to look for any structural abnormalities that might give us a clue if, for example, they had a head injury, but we weren't aware will then see evidence of it on the scan. There's disability. What can we do to fix these problems? It depends. If they got a massive neurosurgical injury from a blow to the head, they're gonna have to go and potentially have surgery. The neurosurgeon actually like to wait a lot of the time and see, because sometimes the surgery can be a band is doing nothing, and sometimes the problem might resolve on its own. But certainly they need nurturing near a special assessment. Or if, for example, they have nobody dose of morphine or heroin or fentanyl or other opioid based medications that we might anything administering something like naloxone, which will block the action of these opioids. This one gets lots of mentioned because it works so quickly and effectively that you can have a patient that's basically almost in a coma, who will then wake up within seconds two minutes of this drug being administered. So Knock Zone gets a lot of love, and it potentially saves a lot of lives as well of people like heroin users who have overdosed. If a patient is hypoglycemic, we can give things like Glucophage. I'll as ready talked about. There are other things we can do is well, whether it's giving IV dextrose or if it's in a less acute setting. We might just get even, give the patient some kind of sugary food or drink on things that that glucagon is really useful, though, because you can eat it when you're alert, unconscious, etcetera and maintain your own airway. But we also we can kind of rub it into unresponsive people's gums and things like that. Equally, if we've gone too far the other way as ready talked about his talk, we can look at giving insulin for patients in, like DKA diabetic ketoacidosis and things like that. Obviously, if there are other specific conditions, we suspect we can look at management for those and appropriate testing. But this is more of a generic answer. So if I exposure then and this will take us to the end where 80. So one of the reasons why we need to fully exposed the patient is to find the injuries we might otherwise miss. So hopefully you can just wrap see on this person's back there is potentially a stab wound or certainly a wound to the back. If we don't expose that patient, if we don't roll them, we might miss that injury, especially if there was a big injury on the front as well. Be very easy to get very distracted, treating the injury on the front on miss the injury on the back, so we need to be exposing patients fully on examining them fully to make sure we're not missing anything. Hopefully, units fancy in this picture, the pouring rain s so we'll say anything about exposure to the environment as well. This'll patient might have a normal temperature if we change in see or retention in a But actually, if they're interested or rain or exposed to very hot, some their temperature might start to go out of normal range. And that might cause additional problems that happen with protect them from exposed to the elements. This ambulance current and brilliant job shoved the patient in the vehicle, get them out the rain on, then the other thing we can think about as well. You could argue you should absolutely also going to You're dangerous Essman, but also might need to think about this stage exposure to the environment. So, for example, it might be something simple. It's extracted this patient and are we going to take him to a dangerous area? Is there a safer way we can get that? But also, you know, if they've been exposed to dangerous chemicals, it might be that we assess that indeed for danger. As part of our environmental assessment. But now we're we've treated this patient will keep yourself safe. We need to think about what happens next. Well, you know, for example, we're treating this patient outside because they're covered in a contaminated chemicals or whatever. We can't keep him outside forever. What's that? What's the next plan? To avoid exposing other people as well? So that's a very whistlestop tour of the 80. I know there's a lot of overlap between in the hospital out of the hospital there, but I think it is the most important thing to talk about in terms of medical emergencies very quickly in terms of equipment and stuff like that. Unlike kind of pre hospital, where kind of ambulance crews will carry big banks of equipment, stuff that we tend to go for the faithful crash truly also available in red not only have ever seen one that wasn't blue or red, I don't know what, what, whatever and shuns other colors. So you can see here. This has got a defibrillator on. This has got a drip stand and it's got drawers full over equipment. It might have a suction unit mounted to it. Various other things on oxygen canister, all sorts of useful things. And then inside the drawers might have medications all drawn out and laid up or vials of medication ready to draw up. We might also have piles of equipment. One thing this picture doesn't have is the drawers or beautifully labeled. Normally they will be laid out in. The problem is they're they order so airway equipment, equipment, help with breathing equipment, help with circulation according to assess disabilities and help with disabilities and things like that. So normally they'll be laid out in that nice, beautiful logical order so that we can go. Step one is solve problems as their care. One last thing to say as well, so I probably survey if we're not sure or something changed with that, we'll go back to the top. One will reassess, and we'll just keep reassessing and keep dealing with problems as they come up, because the patient will change over time. That is it, because I knew I wouldn't get any more in in the time, and I have literally only just crammed in in the time I am Morgan happy to answer any questions that may have come up. I can't see any in the session of the minute that Freddie hasn't answered on. I can see most of the questions about sessions lineups. A lesson about double to double too. Ah, yeah. Donnatal To who comes? Yeah, just just a mention that one. Not least I find it still mildly hilarious. So you've mentioned that pages or some people call them, then more commonly called the hospital bleeps. But you're right. They are pages. So there's a normal bleep where your bleed makes a noise and you society it on. Then it gives you a phone number to ring back box. When you're activating apartment team in emergency, you get a crash sleep on. That is when your BLEEP gains the power to speak, and it will tell you exactly what you need to do. There is a pediatric cardiac arrest in the pizza ward side room three Go, go, go on. So you can then go exactly where you need to go. You don't need to ring a block where the emergency or something like that on normally when you're here, crash sleeps. Is they test them or every day at the same time every day, so every morning. You normally hear about three or four. This is a test of the emergency, you know, pager system or whatever. On then. Each person with who's on the emergency team has to ring in and say, I have got the test bleep that proves that the system works each. That's more than you ever wanted to know about. Some hospitals are now modernizing and moving over to like Cordless phones, also known as decked phones on things like that on those could be really useful. Because, of course, you can still kind of speak to people directly, even if it's not quite a surgeon, a situation and so you can even get kind of limbo advice and things like that. But many places are still using bleeps, even though the technology is decades old, shuttering so many cysts every day. And they they're trialing What's AP as a means of emergency again fasting. So they just basically have what's up on their own personal phone about attached to, like the crash account. Also know that, and then it it triggers thumb. Yeah, uh, that is it. Yeah. So the trial in various different items, um, in answer to the questions they just can't hear just about general admin that comes under me more than anyone else. So the once per month sessions, I've just put the link there. I didn't realize I had locked it, so it was only available to people who had a Microsoft account. I'm sorry about that. I have just changed that. I didn't realize I had to. Um, so please do go and sign up for that. If you're interested. Other ones coming out Let me, uh I got it on my power point. That's a valid question. Sorry, David. I'm going to quickly take over the back screen here for two seconds. So anyone who was a part of last week's session would have got the sneak peek of our anatomy session that will be coming out in the end of October. So we we will have one that comes out then the best place to keep track of it will probably be if you join. If you sign up and we'll follow us on Instagram. I have no idea how Instagram works entirely. I am very much learning. So I apologize for the low, low quality of our content this far. Just Paxil. The buttons. That's sort of what I did that I shared. Yeah, I ended up with pictures. At one point I shared a picture that's just your face. Massive. Had to correct it. The So If you want pictures a day, that's that's the place to follow Onda. Yes. So that's for the rest place to stay aware of that I will also email around. So the previous mailing list as soon as we have it confirmed. Who's teaching? What when? So then we can obviously have it all nice and neat for the time being. The once a month Siris should what? I'm hoping we are good here. So the sessions up that presently in the next six months worth of it. Um so, yeah, during during thie end of October through November. I think the first week of December is the plan for the next series. That will be anatomy. So, yes, in in November, there will be one week where there are two sessions for those of you really wanted to join. But just to talk about this series, I'm hoping the case discussion ones should be really interesting. I'm gonna try and get people who know lots of lots of experience in different, different worlds, by pre hospital and in hospital to come and discuss some patients. They've had more patients that sin normally that primarily they're going to be more from a student point of view than from a fully qualified point of view. So, you know, learning opportunities and how to learn from patients. You see, yes, I think there were really interesting the nutrition. One should be really good. I am not. Yeah, they're They should all be really good sessions. They're just really good sessions that would. We wanted to run, but we couldn't fit into. We're trying to make the rest of the sessions a bit more themed. This's Siris was vitk optic in terms of titles, so there's a lot of random stuff, whereas now the plan will be much more themed on streamlined, uh, Siris, but just kind of aspiring medical students. Traditionally, medical schools don't tend to teach nutrition or dying and pounds of care very well, eh? So I would highly recommend attending. I mean all the sections in general, but definitely those as you'll find a lot of benefit. That's the hope. I think it's the same for most really, Most course is to be honest, there's not a lot of it's nursing pyramids and all them dying a palliative care and nutrition are two very neglected topics, which is part of why we wanted to put them in here, but also because we have access to some brilliant, very experienced individuals in those particular fields. So we hopefully can to good sessions on. So yeah, that should all be good, I hope lots of your sign up to that and see what they're like then. Yet our anatomy Siris will I will publish that to the assumes like basic Got confirmation. I've got 11 session. I'm yet to finish nailing down a teacher for as soon as that's nailed down. That will go on the instagram. And then it will go on the emails. Like here. Yeah, basically that no one wants to neuro I've made a PowerPoint for it, but it it's to try and make it a bit more attractive to someone to come into group. Teach it half that works done for them. But if you've made it, 11 actually think you quite like it. Given what I put in there. But it's taking maybe even something stupid like three hours today to cut those lines. Thank you ever so much, David. So you're wonderful stuff. Those who haven't met David before he is fantastic, is what it is. A true asset. But yes, the otherwise. Any questions? Please Put them in the chat, or I will end the recording in. Oh, let's give him a minute. You have 60 seconds toe ask any questions. You keep doing this and not having the countdown music. And I'm just don't Oh, no, that's the point. Yeah. I don't have to make that work. You got to teach me that. I had just black in the background of UTI of what? Being migrated. I have to look out for you. That's sensibly. Oh, what? What? Here? Sorry, it's something like I'm playing on my laptop and I couldn't tell if it was you or that work out. Don't make me do this. I don't know that I wouldn't worry about it. I think I think mostly a minute is up. I'm just saying for future section if there's no questions. Thank you, everybody. Which hopefully see all of you in September