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stuff. Start That's working. Yes, it's working. Hello on. Welcome to the aging healthcare. Serious money is Freddy Coupal. I'm gonna be moderating tonight because I'm not teaching. Set tonight session will be disabilities and exposure covering the final parts of the A T examination. If anyone's following it off the A B c d e here is D and eat the seeping will be talked by the wonderful David Walters. It was finally at war in medical school, and I have discovered actually to see this afternoon while making these slights new favorite feature about David. There are a lot of photos on his Facebook, which makes it very, very easy to plan. What I'm going to use was an image it some of the other people I've had teaching it is a nightmare. And you're like shuffling back through years of chats and stuff to try and fight any photo of thumb. Okay, this is David looking wonderful. Ah, every time I share this slide, because it is just a benefit, things you do to make the most that session do taking notes, it does help in still things in your brain, particularly physically writing notes, because there's just more function to your brain involved. It's more like to get stuck somewhere to ask questions. We love interaction in these things. It makes it so much more enjoyable for us, and it makes it so much more tailored. The you guys, If you've got questions, you can think of questions. Please do fire them away. And if you join the particular bits, please do send us emails and we're happy to find you more information or directed towards more information. If you want to keep learning any queries, that's my email address. Please do email may. You probably will got it because it's the one that I send all the mouth out from on that we also have social. We finally have someone taking over the social media. That's not me. So these things should start to be like good rather than just the thing that I neglect. Stay tuned because in a couple of weeks you should start to become used properly. Other than that, this is where we are currently in the scheme of where we are in serious things, start disabilities and exposures Lecture In couple weeks, time will be nutrition. It's a serious that's the one I've been trying to get running since about January. But the particular speaker I've been after four. It keeps postponing this time. I got there, like, nailed down to do that session on. Then we'll be finishing June with an evening with the nurse. Similar evening. The paramedics session had a while ago. The ones that have crossed out here, obviously, for those who haven't been able to attend, we have our airway and breathing on our circulation sessions. They're available. The metal page or anyone needs the links for any things that please to email me. Maternal definitely slide that. I keep it just in case off technical difficulties that they reduce by all hand over to David. David, have you got your slide? Sweet conquer with? Ah, something I see a David slides on. Do I do this? And this? They should be upset, David. Yeah, I guess. Like extra work. Thank you, Freddie. Well, that on tracking down my favorite photo of me, that is the only photo I looked good. It much is presumably why you chose. It s Oh, yes. We are going to talk about disability exposure. From this perspective off, I am a finally a medical student at university workers Freddie mentioned. And I'm also emergency ambulance crew for some John Ambulance eso I Occasionally I'm in the hospital seeing people, and I'm like anything outside the hospital bringing sick people to the hospital s So I get, see, look, but both, which is lovely. So in terms of disability and exposure, then it's the kind of for gotten unloved step child of the primary survey ever gets through a B C. And it's not exciting and they're doing things on. Then it gets to disability an exposure, and people get bored and wander off, quite literally, out the resource pay to go and do something else or, you know, go and do something on the computer or bleep someone on. You know, your poor patients is that I wondering what's going on. So disability exposure is very important. If nothing else, this evening session is me trying to market actually doing a full primary survey to you, so you can see in my lovely picture there there's some kind of trauma call. I especially love sign itch at the kind of end of the bed denoting who's where and what they what their jobs are. That's a brilliant bit of human factors, which is something for another talk entirely on. If we look at this, this poor patient here who's obviously not having the best day they've ever have in their lives, we can see the presumably some kind of promise. Er they might be taking place. You can see already that they might have sorted some A things on they might be looking at be currently or they could have completed promise that they be doing some interventions. They could look background, be doing it again. But we're gonna move on from where they're up to you and we're going to talk that disability in exposure. So you've already had some sessions on the primary survey. So if you've seen those a sessions already, my first question to you this evening is what is the purpose of primary survey? So if you watch those sessions already, you should already be an expert on the purpose of the primary survey. Why we do it, why we don't just crack on and slaps and bandages on or, you know, getting airway. What? Why are we doing a full primary survey? What what is the point of it? So feel free to pop some answers in the chat etcetera as we go through, Feel free to pop. As Freddie says questions in the chapter out, I'm delighted to answer questions because it means I don't have to listen to my own voice quite so much asset, I think I think it was in quite a lot of faith in mind, and Josh's teaching if you carry, was learned anything from it. The purpose of the probably seven is, too, is something to do when you're not sure what to do, especially prehospital. The the art of medicine is about looking like you know what you're doing, even when you don't. So the problem of it is really good for that and no simple system that we can work through it and it looks like we're doing medical things. How about there are a few more, slightly more official purposes of the primary survey, so I have a quick think about on. Then we'll reveal those in a second eso you should buy now. No, the elements of the primary survey on roughly we'll order they come in. Hopefully eso the purposes are then, to think about a systematic approach, we want to ensure that nothing is missed on the everything happened in the right order. It's really in a interesting, for example, to go to the patient with, like a D gloved foot if you not come across this term. D gloving is when all the skin is removed from part of your body. So if you've got big loved foot somehow normally a traumatic mechanism, the ulna skin has been peeled off your foot, and you've just got exposed kind of muscles and bones and tendons and things like that on. So it's really easy for pre hospital providers to get distracted and look at the D gloved foot. Well, we must do things with the foot on. Actually forget to assess the rest of the patient. You know, there's no point having a beautifully bandage D gloved foot if your patient isn't breathing. So since the fatty approach is really, really important, so we can check the most important things first and not get distracted by something shiny, Um and so, yeah, we got this focus on the most important inventions first, So we're not just checking everything, but as we go through with that premies ever. If we find a problem, we need to fix it. We don't just go. Uh, the patient's not breathing. Let me move on and check their circulation. Now we go, our other patients not breathing. I should probably do something about that now, depending on your clinical skill level. What? You're working as that particular day, etcetera. What you do to solve that problem might be very different. If you're a first data, you might do something as simple as head took shin lift, which you will definitely have been learned about your airway session. If you're on I t u registrar, you might look into baiting the patient Very different interventions. But both can be very effective at, say, maintaining the patient's airway. So most important interventions. First, we're not doing circulation interventions. If there's an airway problem with fixing the airway problem first, before we move on to be and C and things like that on, then finally we should know if I haven't already given the game way that your primary survey is this a B c. D. E acronym on there, a slightly different variations you may have come across Doctor ABC. So danger response. You may have come across Doctor CC, ABC for catastrophic hemorrhage and C spine consideration. But a B C D E is pretty simple, and therefore it's really easy to follow instruction for situations which you know if you've got a patient with a deep love for for a patient who stopped breathing or whatever else is going on, it's useful toe. Have a system that's very easy to work through on kind of looking and go into the workforce is a junior doctor. Quite soon, one of the things I'm consistently told is, the most important thing I need to know is have to do my 80. It doesn't matter if I don't I don't know the fourth line management for malignant hypertension so long as I know my 80. That's the thing that I need to know immediately. I can look the other thing up, so we've got a B C D e on usually about it. If you actually less is which we'll talk about in a second so I could ask you to pop in the chance what a B C D E is. But hopefully you should already know so I'm not gonna do the hanging around waiting for answer than the chat. But we should know that A is for airway and you've had a whole talk on that and the the years for breathing and you've had a talk on that and see is for circulation on. Unsurprisingly, given the title of this evening's talk deals for disability on Ears for Exposure and we're going to talk about what those mean, how we can assess these things, what we can do about the make center, as this talk shows on. But one of, uh, put these other letters up that well, one of the first things we want to think about in terms of disability and exposure is don't ever forget glucose. So one we're assessing a patient on, we've gone through, and we've done and check their airway and done any airway interventions. We need to do checked breathing and don't need interventions do with breathing that we need to do. And we checked circulation and we've done any relevant interventions. There is Well, um, what we get into disability. It's some of these things. I think you're quite easy to remember that we're going to talk about, but one that often gets overlooked is forgetting to check a patient's blood glucose levels. So please, please, please use that primary survey acronym A zoo. A little reminder to never forget to check glucose because it can be easily overlooked. And it can be a really useful indicator. What might be wrong with a patient s O? If you find a problem with the blood glucose levels, that might be the issue. So I also gave a talk. I can't remember whether it was for this channel or not, but I gave a talk on diabetes. So have boroughs of my own slides like a self plagiarism here. So we're gonna talk in varying levels of detail just a blood glucose regulation and things like that on their four week and then in first, and things about the importance of blood glucose levels in seriously unwell patients. So we eat food in this case, cooking months to eat, cook. It eats cookies, which is probably not shocked to anyone. However, what might be more of a shock to you is the fact that they were worried that the oils and the cookies would damage the puppet eso cookie monster never ate cookies. See eight painted rice crackers, eso as well as medical education. I'm also ruining people's chance. Cookie Monster's there with with what may or may not be a cookie on. When he eats this food, he gets two are kind of benefits from it. He gets energy release, so energy could be immediately released from the foods at four kind of cellular reactions such as you get with respiration, which can release energy, which allows the cell to do its job, whether it needs to process things or grow or change on things that that on, then we can also use the energy from the food on. We can store it for later, eh? So this is really important. If we released or energy from our food instantly, then we'd constantly having to be eating. So the energy storage point is just a simple Orton as the energy release, so a little bit more technical than as to how this works. So we've got some intestines here, specifically some small intestines on. We've got some it's, um, transmitters and hormones that are going to help us out here so you can see here that one called SGLT one. What I'm trying to indicate with my arrows here is that that helps us absorb sugars and food from the gut into the blood stream on. Then we've got a hormone here. Gloves, too, which what that's going to do is it's going to stimulate the release off insulin from the pancreas and specifically there you can see a little beat, a symbol from the Beatles cells in the pancreas. So basically, this go up to is a transporter. Excuse me, cause I called a hormone earlier was waiting for my brain to kick in. So the track has got to transporter allows the beach the cells in the pancreas to take up the glucose from the bloodstream. On this stimulates the release of insulin s. So this is what's then going to be used for energy storage. So there goes our insulin for my pancreas quite rapidly. As it turns out, I might need to slow that down a little diversion on. Then the insulin acts on individual cells. So it the minute you can see, we've got a glut One transporter down here on that slowly allowing insulin. Excuse me. That's slowly learning glucose into cells. But with the action of the insulin hormone on the cell and specifically on the cells of the liver, what on on cells of muscles as well. We can open up a much larger transport with this go up four transporter, which allows in which is good because I keep one center on wood allows the leukosis to move into the cells a lot more rapidly on allows it to be stored more efficiently. So as we've said, this is important. We don't now constantly need to be eating. We can store some of that energy for later. However, it's important to note some quirks off different parts of our body on their preferences for different energy sources so we can store. They're apologies for you on the animation was gonna come up. So we've got a glucose being taken into the cell. This insulin here opening up this kind of more efficient transporter and blood for transporting glucose into the cells really efficiently on then, in the liver and muscle cells, you've got glycogen synthetase, causing the production of glycogen, which is really useful for storing that energy for later release on. Then we'll talk about in a minute it being converted back again. So here we have it again. So glucose being converted to glycogen on. If you remember the hormone, we said for that that's causing that is insulin. However, if we want to convert it back again, the glycogen is converted back Teo glucose and it comes out of the liver. And that's due to glucagon. So we've got to We've got two different hormones here that are causing this storage and release of energy from the liver and from the muscles. This is really important to know, because one of the causes of low blood glucose can be that you've exhausted the current production off one of these hormones. So really important to be aware of this physiology and shows how this kind of theoretical classroom based knowledge actually applies to really life. Well, so only if we've got enough glucagon production, can we release that energy from storage, put glucose back into the bloodstream. So why stored glucose at all? Other than that kind of slightly silly exploration, I gave you the fact that we have to constantly be eating. There is another good reason for it. So we've got a we've got what is supposed to be a muscle over here, whether you think it looks like a muscle woman is up to you and then we've got a brain over here. And the way these to process on receive energy is slightly different on this is again really important for understanding our patient, who might be less responsive. So the important things did not tell. The muscles can store glucose. They can also use other substrates so they can release energy from other sources other than glucose on. Actually, if your muscles start working, most of them aren't necessarily intrinsically important for life. There are a few exceptions to this, such as your respiratory muscles and your cardiac muscles. But for example, if you are losing the ability to move your legs briefly unless you're running from a predator or crossing a road, you're unlikely to die quickly. It might become a problem in the long term, but short term loss of function is not quite so problematic. On the other hand, your brain cannot store glucose. It cannot release energy from other substrates. On loss of function is a big problem because it is controlling things like your heart rate on your Risperdal through drive and things like that. So what we're what we can conclude here is that the brain needs a constant supply of glucose because it cannot store it anywhere. The minute that supply glucose is interrupted, we're going to get neurological up signs and symptoms. We're going to get neurological problems, and that's going to lead to physiological problems because your brain is going to stop again a ting cellular reactions It's going to stop wriggling thing. Breathing and heart rate on all of that is going to cause problems with different chemical reactions within yourselves. So really, really important to aware that if someone suddenly has a less glucose in their bloodstream than normal, this can really rapidly lead to neurological problems due to your brain now, not having enough energy to work so again that D E f g don't ever forget to Blue Cokes really, really important in terms of testing blood glucose because I had my little blood glucose monitor back on that slide on. It's also really important there for to be aware of what is normal blood glucose monitoring. So we in the UK measure blood glucose in Millimoles, Polina that is an important distinction because in the United States they measure in minimal per deciliter s. So it's really important to know which units you're working in when you're talking about things like normal values and discussing patient results, because otherwise you're going to get a kind of mismatch in communication. So if you look at any kind of medical education from America, they can often talk about blood glucose levels that are 10 times higher than we would expect because their Met measuring deciliter instead of liters. So all their away, the measurements are sort of automatically increased by at 10 times as it were so just being careful with your units. But in the UK, then in minimal police know in millimoles for deciliter, we would say normally for someone who has no expected blood glucose level problems, so no diabetes. I know, for example, severe infection that's using up all the glucose in Neverland stream and things like that. We would expect the normal blood glucose levels to be somewhere between four and seven millimeters per liter, someone who is diagnosed with diabetes or has other problems regulating blood sugar levels. We might expect their blood glucose levels to be a little bit higher so it can be kind of 7 to 10. 7 to 12 are different. Patients will have been given different information by kind of that. Their diabetes specialist team s so often it's really important. Teo, talk to your patient if it's possible on get information that they've been given by specialists on that particular subject. But, yeah, we can expect people with ST diagnosis of diabetes that their blood sugar levels were normally run a little bit higher on part that is intentional at so we don't mind too much if people's blood glucose levels are a little bit higher than they should be in the long term, high blood sugar levels can cause organ damage and think damage to nerves and things like that. However, this is a really kind of long term thing. It happened over kind of months and years of high blood glucose levels. However, as we've talked about with this pesky brain and it's constant need for glucose, uh, low blood sugar levels can cause at problems in kind of minutes to hours. Low blood sugar levels concretely cause patients become unresponsive or have a decreased level of consciousness, our patients can become confused on it constructed cause other metabolic abnormalities as well. So you might have heard of, uh, in fact now, I'm not going to go into that. I'm starting starting my diabetes talk now. We haven't quite got time for that s why shall move on. Yeah, really important to know that actually, low blood sugar levels are much worse than high blood sugar levels. That's really important to be aware of on just one other thing to be a well, before I finish off. Talking about blood glucose levels is are a few different acronyms s. So you might hear this referred to as CBG or capillary blood glucose testing you might here for to his B g l or blood glucose levels on you may hear for to his bm I can never remember what the M stands for. Frankly, it's a German brand name, but it can be slightly confusing when we talk about blood sugar levels, blood glucose levels. Abso just be aware that there are several different acronyms that all essentially equate to the same thing. Uh, but yeah, so we can see here. Why low blood glucose levels. That can be a really significant cause off disability, inpatient And what I mean when I say disability in patients because we haven't talked to much around that, yeah, is any patient who's not responding in the way we would expect. So patients who aren't waking up well, patient to all waking up but aren't kind of making sense on coherent or behaving strangely. We might consider this a part of the disability problem. When we talk about disability here, we're talking about things where the patient isn't behaving as we would expect. We're not sure of matches. The patient have a wheelchair or something like that does a different kind of disability. So moving on another thing, we can check want quickly again. We've already checked out Airway are breathing our circulation so we can quickly do blood glucose testing. Something we can check even quicker is pupil reactivity. So you may well have seen on medical dramas or are on TV shows where they follow actual real life Paramedics prehospital ambulates doctors on a ramble. It's doctors on ambulance crews or in other settings as well. People shining a light in someone's eyes, especially uh, kind of quite early on trying to figure out kind of Is this person well unwell? Are they responding normally, etcetera. So what reaction are we expecting when we shine a bright light in Someone's on these? What are we expecting to change? So we give it a good 25 30 seconds just because it's just because there's like a little agnostic, really with teams. Unfortunately from thank you, Freddy is disembodied voice. I I must confess I do try and talk through the awkward silence. I normally ask a question. Carry on talking, then look back to the question. Just avoid sitting awkwardly here in silence. It's a little bit weird, the side effect of teams that mind so much doing it in in a room for the people. But it's weird in a room by myself, but yeah, I feel great property. Answer in the chat as to what you would expect to happen when you shine a bright light and someone dies. Now get ready for really creepy gift. Oh, who's that creeping gift? We are just like the creepy gift. We are expecting the black dot the pupil in the center of the eye to get smaller on what's actually happening is the iris. The colored part of the eye is actually constricting, so this is a little bit by the by. But because it may interest some of you, there's a circular Andre Diel muscle within the iris on These two are opposites of one another, so the people constricts as in the gift. What we've got is the circular muscle, and it's literally rings. It's constricting, so it's getting smaller and smaller on that's making the people the whole in the middle of the iris gets smaller and smaller as well. Meanwhile, the radio muscles are going outwards. They're like spokes of a wheel on Those are what we used. Teo actually make the people larger, so they're pulling outwards, as it were. So this is really, really useful on now. We need to try and understand why this happens at one thing, and I do apologize. This isn't the best gift. I couldn't find a good gift of this. What I wanted you to see actually was a light actually being shined in the eyes, and we can infer here they're always that the is a broad like that because we can see the reflection on the cornea. But what I really wanted was a gift of both eyes. The under is that we shine a bright light in one eye. Both. I should constrict the way I like to talk about this in kind of medical training on things that that is, that their buddies and you always do what your body does. So if your body is constricting, of making the people small that you're going to do exactly the same thing as well s o, they work together as a team, so both will constrict at the same time. But I understand why that happens. Oh, God, Freddie. Really rogue question it that I've come up with other direction. Your iris can completely close. Um, I would assume not because I want to see, you know, but how small couldn't get well, I would imagine we'll talk about, you know, patients with quite severe traumatic brain injuries. If we get enough parasympathetic stimulation, we can get very constricted pupils. So I would imagine if it was possible we'd either seat in patients with certain drug overdoses or certain traumatic brain injuries. So I've never heard it mentioned in medical literature. Is our ms You just doesn't. And I'm getting there, perhaps just isn't enough tissue to do it. But good question. We go read up on that for a second and you carry on. That's going to be very interesting literature. Is that a lot with that? So why, then, if I'm showing a lot in one eye, does the other eye constrict? How does it know on the answer? As with a lot of things in medicine, it's quite complicated. So let's have a little look. So, as always, we start with a horrendous diagram. I got rid of the eye there, just in case it was creeping anyone out. And I thought if I took through this diagram well, the only stairs that you that would be a bit weird. So first of all, it's Orient ourselves. The diagram, The eyes were the front, the head unsurprisingly on this is towards the back of the head. What we're actually looking at here is the occipital lobe. So that is the low at the back of your brain. So right, the backyard. So these nerve fibers are running through from the front of the skull all the way around to the back of the scale. Um, so that's why useful to know in terms of when we're thinking about why is this reaction abnormal? We've got to think about where the nerve fibers are running because actually different damage in different locations. The damage here on the optic nerve versus damage here on the optic chiasm will produce different results. So it's really useful to know where these nerve fibers that actually run because it can tell us useful things just from observing how the patient ranks to the stimulant. So So we've got a left of our right, I What I do want you to know, though, is we would have the rest in the back here, which isn't on this diagram for whatever reason. But you've got, of course, as we know lots of little photo receptors. You rather the new codes, which won't be surprised to anyone on these. Then send a neural impulses to your optic nerve on. Then what I want you to notice from here is that impulses from the right time, which are going to be in reds on this sort of ready orange, no fiber. They go to the right side of the brain, but they also cross over the optic chiasm and go to the left side of the brain as well on. Similarly, on the left side, from the left eye, we've got impulses going to the left side of the occipital cortex or the exception low. Excuse me on also to the right side of the occipital lobe. So we've got a crossover happening that so that's really important to be aware of, however. Eight. Sadly, not that simple. It's no, just that, uh, impulse is generated by the light source. Go to left and right automatically. There's also another and place where they cross over and again. This is really useful for working out from what we can see, if the patient maybe they've got one big people, one small people, we can then figure out where the damage might be. So you can see there. We've got the optic nerve fibers running into the occipital lobe of the back off the scale on. Then they're going into this place of the pretectal nucleus on from there. You've got purple nerve fibers now on. They're going to this Erding, a west foul nucleus, and it also says part of I. I know new tricks and we'll talk about that in a second. But we're going to the er thing a Westphal nucleus. So the purple fibers are from the left side. In this case, go to the left, earning a West Valley. Chris also cross over and go to the right address phone makers. So we've got another crossover happening here again. Really, really important to be aware off. And from here we are now in the evening, a Westfall area on. Then we're sign appsync with cranial nerves. Three. So that's what this eye is so most off your nerves at the control your body on what you're doing go through your spinal cord, Which is why we know that dramatic injuries to your neck and your back can be so damaging because if you sever those nerves, you lose control off very important muscles. So, for example, towards the base of your neck, if you feel from, well, your your spine leaves sort of the middle of the back of scaly or feel better. And then if you feel down your field, another know, believe it's just about that. Is that that second normally you've got your C 345 vertebrae on. This is where the nerves come off the control, amongst other things, your diaphragm on so control your breathing. So if we damage those nerves, we can potentially end up unable to breathe. And that could be really, really difficult for a patient and difficult to manage. Uh uh. That's what we need to start thinking about kind of artificial ventilation, and things are so this spinal cord on there for the neck and the back are really important. However, there are some nerves that come off the brain but do not travel through the spinal cord, and they have very specific jobs there. There are 12 of them or 12 pairs, I should say on, so they have different jobs. So the optic nerve, although it's not labeled as such here, is actually cranial nerve to That's what we call these runs in the gut. Don't go through the spinal cord. They are cranial nerves. To the optic nerve is cranial nerve, too, because these you can see it doesn't go through the spinal cord. It just goes through the skull at two. That occipital lobe, so not traveling through that the spinal cord any point because it doesn't need to. It's actually higher than the spinal court on then. Similarly, we've got cranial nerves. Three. Which again, is this I? I have because they just written. Is Roman numerals on again? It's not traveling through the spinal cord. It's just going back on where it's going to. You'll see a little bit. The hint. Here it's going to the Ciliary ganglion, and it's called the Celery ganglion because then this'll last purple know if I ever hear, is going to go and connect to celery muscles on. So the silvery muscles you may or may not have come across these control things like your eye movements but also control your iris construction. So that is how we can see the the stimulation off the light on the retina travels back through the occipital lobe through the pretectal nucleus to the er thing or West file nucleus on then, eh? So that's traveled to cranial nerve to then it travels back through cranial nerves. Three. Which the ocular motor nerve there is a silly, silly ganglion on, then to the Irish. So now we know the entire pathway it's taking from the retina all the way back around to the muscles of the iris on. So, like I say, damage in different places will cause slightly different results. I was hoping that that's my driving to can say, for example, then if we damage this area here, what do we think is gonna happen when were shining that, like in that left eye, all the people is going to get smaller? Are they going to get larger? Are they going to stay the same? So let's think about it. Let's trace it down. As you might have guessed, this one to start with is not the most challenging. So the lights coming in hitting the rest of hers, it's going down that at nerve fiber there on. Then there's damage. There is some kind of lesion or damage that nerve, however you want to refer to it on there for the importers can't go any further, and it's exactly the same with that set. At that point, we're going to get no response. We're going to shine a light in our patients. I, um we're not going to get a response, However, it's just if the damage is just in that left eye. If we shine a light into the patient's right eye, you'll see that because of where the damage is, it would help if I call it the nerve fibers. All the parts of the way from the right eye is unaffected and so actually will get constriction of the right eye will get constriction when we showing light in the right eye off both peoples because remember that pathway back to the left eye is separate and is therefore unaffected. But if we shine a light in the left eye, we won't get responsive either. People, if we move the site of damage, then days old income slide, huh? You have. So this time we're gonna move the damage. I'm gonna put it at the optic chiasm and let's see what happens now. So again, you're welcome. Proper answers in the chat on. We can see if you're right as we go. So I'm going for a different color like green. Let's go green. So let's let's stick with as the diagram has done it. So let's saying now that were shining light into the left eye. So here little blue and green is not going well. Let's go next door so that no fiber, we can't cross over as we would normally. However, this one, the left sided one, is still okay. Now, you might think at this point that we're just going to go to the left early. Westphal need Chris on back down. Cranial nerves. Three. That ocular motor nerve at only your left side is going to constrict. However, don't forget that, of course, up between the pretectal nucleus and the West Phony. Close. There's that other cross over. So actually, if you got damage where the optic chiasm is, we're gonna get constriction of both irises so really important to be aware of. So I could draw lesions in other places and we could trace out the pathways and see. But it's just to give you an idea that actually, knowing and neuro anatomy actually helps us to diagnose just my shiny lights on the dyes where there might be damaging their brain. So really, really important to be aware off the pupil reactivity again. Very quick way of assessing. If we're worried about someone's neurological functioning, if we're worried that they might not be behaving normally or something like that, we can check some pathways in the brain. Don't get me wrong. You can have perfectly reactive pupils on both sides of mine away shine the light cetera and still have, say, a traumatic brain injury. So we're going to go on to talk about that now. But you can see how people reactivity is a really quick way of assessing some neurological functioning. Some pathways within the brain that's quite useful. Um, so there's a question here. Leave, which is what's your favorite new monitor for the cranial nerves? And I've just realized that I've been spelling the word you Monica wrong for my entire life because I've been just get, like pneumonia and nose with an M money gnomic herbal. I at this annoys people all the time. A lot of the times, the way I remember something, is just by remembering, I'm afraid there are various ones out there. I can't remember any of them because I don't use it to memorize. In fact, that thing we're going to talk about next. I was asked the other week by an I T. U consultant how I remembered what method I used to remember this and I said I something else and I said, I just remember I'm really sorry. I I cannot tell you which is my favorite, because I don't really use one. There are various cranial nerve new Momix out there. So do Google. There are some rude ones and some not rude ones out this old Zeus on mental, in place or something on base one. That's oh, on so on and so on. So on which I will not be drawn on any further because I'm not gonna send the rood things on this recording. But yes, there are so rude. One's pretty much every medical student acronym out on you, Monica. There there is a rude version because that is what medical students do for fun, as it turned out. And I got back to a point. No, it soliciting as a mouse. And then occasionally you click and it becomes like a green. Yeah, I just think it's in the drawer dots. Anyway, we'll muddle through. I'll just keep matching space open to take folic. So go out, Go Coma school. Okay, let's go. Come to scale. Quite. You want to call it so I I think this is one of the things that pops up most in TV and films and stuff like that on Uh, because it sounds very wizard isn't it s so you can see the scoring system there. I wasn't gonna ask anyone to try and really off. If you do happen to know by heart well done equally, if you don't, it doesn't matter. Normally you can look this thing up if you need to assume is you Google GCS as you can see it, Very Viator, there is hope. With this light, you will get up this table. Perhaps not one that's quite this colorful. But you will get up the information from this table heartbreaking. This the only thing I memorized my exam yesterday and then when I got into it at the station that used it, they had given it to us. They just handed a bit of paper with it written out and I was like, Yeah, say things to note then other than just looking at the table. So if you are trying to memorize it, my opening is really easy. If you're familiar with another scale of responsiveness which we call after, which is alert voice pain unresponsive on Similarly, if you're alert your eyes open spontaneously. We don't have to do anything. You already looking around the room, you know, try to work out a way how to escape or what's on the telly or something. It doesn't really matter so long as your eyes are opening by yourself. If they're only opening to sound, that's the same as if we talk to you and your open your eyes. It doesn't matter of it's a voice. Or if it's another sound to pressure or two pains o P on, then, if there's no response, they are unresponsive. Please note here on the GCS scale that the lowest score you can get in any category is one on. The reason for this, as people have pondered, is because it was designed as a data order tool, so it was designed. The computers and computers don't really like the heroes. It's slightly more difficult process. If there's a zero in the field, did you forget to fill in a van? Yours, the value actually zero. It makes order sting a little bit more difficult, so instead, nothing is one. Just be confusing. In theory, the lowest score you can get on a GCS is three. In actuality, I believe now there are some modification. Did you have? No I So you don't have a nice score and things like that. So you I think there are some situations now where you can get lower than three. A verbal response. Hopefully, that's fairly self explanatory. But it took for it very briefly. So how do we check the patient? Is or in? All right now? Uh huh. This is I haven't spotted this earlier. I might have been tempted. Change it. So we're not actually taking the patient is orientated or intimate. It means there are they suitably rotated in the room with a pointing towards north. We actually want to check if there oriented so notated. Just oriented on what we mean by that is do they know where they are? Do they know what's going on? So you can have a perfectly lovely conversation with the confused person about, you know, the weather or where they came from or whether grew up on. Then if you ask them where they are, they'll tell you that they're on the moon or something like that Was one of my patients yesterday that they were on the moon, which is probably one of the examples springs to mind. So we need to be explicitly asking patients, like, Do you know where you are? Do you know who I am or this relative of yours is or whoever s So we tend to get or into a two person time and place? So do they know where they are? What year is and who a person that they probably should know is even if that's, you know, uh, you know, uh, who is this? It's the ambulance crew. They have to know them by name and their their life story. But they need to be able to make a reasonable guess that the person standing there who says ambulance on them is probably ambulance crew in terms of confused, I think we can all figure that one out. Possibly if I spend too long talking about on your own asthma, you'll be confused so you can experience that first hand. Verbal response at this particular table isn't very helpful because it says words at what it means is inappropriate words. So, for example, if I'm trying to check my patient is warranted on, I asked them what day it is today on they say blue, that is an inappropriate words. They've said a word. It's a perfectly well formed word. It doesn't make sense in context s so they don't even get a confusion point for that they don't get the four points of confused. You know, if you think you're on the moon, your least realized that I'm asking for a location, not a color. So inappropriate words. It's a well formed word, but it doesn't make sense in the context. On then, sounds should say incomprehensible sounds, So it doesn't sound like a word. So if I ask you what the date is and you say, Yeah, that is not a word you cannot play in Scrabble that you will not get any points for it on. So they are making incomprehensible sounds, but they are doing something on. If I, um whether it's Arcadia question or, you know, squeezing part of your body or something like that and you have no response, then you only get one point. You don't play the game. You don't get points at that goes I'm and then motor response. Normally, people are fine with the eye part of GCS that that all makes sense of them on there. Okay, with verbal, they might forget. Or they might need to look it up. It's cetera, but they get it all, makes sense them on. Then motor, we get very head up in motor on. The reason for that is we get very obsessed with these bits down the bottom on understanding them are making the make sense. I will say, if you understand when to give someone six points, five points in four points, don't worry too much about three into if they will talk about what they look like in a minute on, If we're seeing anything like that from our patients, we're just going to know that they're very, very unwell on. They need lots of help. So first of all, motor response, a base commands, so we want them to do something. We want them to move in a certain way. So again, feel free to pop in the chat. What kind of things might we ask patients to do? There are various different things s so I tend to go with something that I think is very difficult. Teo kind of fake or do by accident. If if the patient is kind of seems like they're going to respond to my voice, etcetera, I'll say, Okay, you just give me a thumbs up because that's nice and intentional your kind of flexing your fingers, but you're extending your thumbs that we've got a few different actions going on. However, there isn't one specific motor, um, performance that patients must be able to do. Maybe they've got some nerve damage in their hands, and they're not able to give me a thumbs up. It doesn't mean that they necessarily can't get six points there. So another one and this one especially gets used in TV and films and stuff like that. He's saying, Oh, can you squeeze my hand? That's good, because we we've got flexion off the fingers and the thumb here. It seems quite deliberate. However, we know from kind of quite brain injured people on kind of intensive care or Nero rehab units and things like that. Actually, you could be in a very deep state of coma and still reflexively squeezes someone's hand if they kind of put their hand in yours. So you are going to go for the PAP slightly more classic of Squeeze My Hand. What you then got to make sure your patient does is also let go on command. Because if they're able to squeeze on command and let go on, come on, you can be happy. That's deliberate. Have so the next one. It's localizing again. It's a bit condensed this table. What it should say is localizing to pain. So how are we going to check the patient's pain response? What are we going to do? Are we gonna kind of punch them in the face? Probably know that's not medical can. That's assault, and that's very different. So what we're going to do instead is there are a few different things, I think when Jesus was originally written, they were talking about applying super orbital pressure. So if you feel kind of around the area of your eye brand, you should feel be able to feel the edge of your orbital bridge, which is basically your eye socket, and you should feel a small nodule in a small little dip. On the only day it was originally the dig your thumb into that dip on press on. It applies quite a lot of pain without causing any damage were literally pressing skin on flat bone. So we're not damaging anything on. That is a very good way of a listing of pain response from a patient. However, there is a slight risk off your thumb slipping and you got in there. I are instead, so most people don't tend to do super orbital pressure. What they tend to do is the much more classic trapezius squeeze. So if you don't know your trapezius muscles on, if you put your hand flat on the top of your shoulder, that first muscle you're touching there is your trapezius muscle. So if we squeeze that again, we can cause quite a lot of discomfort and pain without actually causing any damage. On that reason, we're causing pain. Is a your patient who might be intubated, ventilated or have quite traumatic brain injury? As long as they've got no stimuli going on around them, they're probably not going to do it awful lot. However, if we cause them discomfort or pain, then we may elicit a response, and we really need to see their best response. So got GCS or Glasko. Coma scale is all about the best response we can get from a patient. So if we're applying pain on the patient's arm, comes up in trusted, pull a handoff or slap my hand away, their localizing to pain there are aware where the pain is, and they wanted to stop. Um, if not, then we've got normal flexion. It's also about withdrawing from pain I prefer talking about with throwing for pain than normal flexion. Basically, the patient is aware roughly where the pain is, but perhaps their brain isn't functioning well enough to control their arm, move up their body and try and remove your hand. But what they're trying to instead is just move their body away from the paint. Try, move, move around the badge, pull that shoulder away. Something like that, because just moving a few muscles to pull your shoulder down requires less motor coordination than squeezing top of the shoulder. Then we've got abnormal flexion on extension. So this is also has other fancy terms of decorticate on decerebrate posturing, basically decorticate posturing. You can see that this patient has got everything flex, so they're bending everything in their arms basically, so they're bending their elbows. They're bending their wrists they're bending their fingers on. It was described to me in intensive care as the patient almost trying to be a bit of a T rex. If they're arms over that way instead of that way, they look of it like a T rex. That's decorticate posturing. If you're trying to remember that phrase, it's like you've caught a cat. So you've decorticate. You caught a cat and you're trying to keep hold of it on. The other thing here is you can imagine that your arms rub it like chicken wings on so it remember that it's best to be a chicken, that a penguin. So we've got the cerebral posturing, so that is our two points. There are extension eso. Instead of everything being flexed, everything is extended, so they're stretching out there. Arms not necessarily stretching out there fingers, but they're really pushing their arms kind of a zoo long as possible on really kind of tensed. Normally a swell. So what we're seeing here at this low level of motor responses quite profound brain damage. So unfortunately, the motor parts of their brain are probably very, very damaged, and so it's just residual kind of neural reflexes and things like that that we're actually seeing. So yeah, if you remember, Decorticate, that and decerebrate the way I remember the story but is like, celebrate You're fully your arms. Why you're celebrating. And then then if I your sides on If you remember, it's better to be a chicken than a penguin. Then you're doing all okay. But like I say, if if you've got a little bit lost with the bottom of the motor school, they're just know that if you see anything like that, that patient is very unwell and requires a lot of help as basically tricking another penguin. Better to be a chicken than a penguin. Absolutely. Our voice said that. But if you understand the vase commands localizes to pain and withdrawals from pain, you basically understand all of GCS now the other thing that's really important here, so you'll notice the maximum schools from each category. Add up to 15. You may see in especially bad medical dramas, films, TV shows, whatever. That's a GCS 15 out of 15. Really, we should never be giving it as one school. What we need is it broken down. So I want to know if I've got a patient where I'm worried about their neurological status. So how their brain, their nerves are working. I want to know because actually the breaks down is useful. The total isn't if you tell me GCSF 12. I want to know where they've lost the points. So don't given overall school. Give me the breakdown, make me do the maths. So, however, the overall score is useful for one thing prognostication. So we can tell by at their GCS score what they're likely to have in terms of brain injuries on their four. Unfortunately, how likely they are to survive now. This isn't necessarily Oh, you get 90 you bed confused, only gone mild brain injury and stuff on that if we can, we're going to support all of these patients, but it is really useful for things like having conversations with families and things like that. I have seen patients on Icy year who were GTs three on, then suddenly, you know, a couple of weeks later they're practically back to normal. It does happen, but actually, if you've got say GCS of three, you're much more likely to have a poorer outcome on so GCS. The main thing is really useful for is looking things like survival to discharge and things like that say very briefly, uh, we can have a quick practice. So I've been mean here. I've removed. I think I meant to put the table up, but I've removed the table for you so I'll try and translators we go along. So the 73 year old patient is looking at me spontaneously, so we know she's eyes. She's getting four because she's alert. Her eyes are open spontaneously when you ask her the date, she says Blue. So remember, if she was oriented, she would be getting five points for verbal. If she was confused, she would be getting four. So if she said in a sec again, if he's instead, she was on the owner. We asked her the day if he said it was 1973 she'd be getting four points. But because she's said an inappropriate word, then she's getting where was out for three points for this on. Then it says, no left sided weakness when she grips your fingers. So the left side of weakness there is a bit to throw you off. What we're saying here is she has got almost respond. She is obeying command. Ideally, like I say, we want her to grip your fingers and then let go again so we can make sure it's deliberate. But in this case, she's getting six points for motor, so she's eyes for voice. Three motor six and you can see they're already how that's much more useful than just calculating a tackle. 24 year old male opened his eyes when you squeeze his shoulder, so he's not spontaneously opening his eyes. And he is presumably, although it doesn't say no, opening them to voice. So he's only opening them to pain, so he gets two points for that. Slaps your hand away on curses at you. So we're we're applying pressure to the shoulder and he's slapping the hand away. So presumably again because it doesn't say he's not obeying commands, but he is localizing to pain. He's identified where that pain is, and he moved it on today, so he's getting five for motor on. He's cursing at you, but he's unsure where he is, so he's confused, so he gets four points for voice on, then very quickly. Patient while right climbing as fallen. So we're doing a deep sternal rub here, which I normally wouldn't do is quite an intense pain response. They stole these examples from somewhere else. I think I changed that for a future talk. So is extending his arms and legs so he's not decorticate. He's just decent rebreak. He's celebrating, celebrating, falling while rock climbing. I don't know that that affecting the enjoyable broken sternum from way you just crushed it all the pieces to sternal roubles always get the drag s. So he's only getting two points for motor on no other response. So no, I response. No voice response. So he's getting one for each of those air his total would before. But again, the breakdown is far more useful very quickly because I've took more about Jesus than already intended to just to show you what's going on here. So motor six eso their hearing an instruction and obey command. In this case, it might be. Can you make your hand into a fist? What's happening is, uh, we've got the nervous impulses traveling up the spinal cord. That's know run. But we'll go with that. I don't know. I suppose it could hear waiters one come off. It comes up high. I think it might even be higher than that. Anyway. It's going up into the brain is going to the auditory processing center. Then it's going to the motor planning in the motor centers of the brain. And then it's going back down the spinal cord to produce the motor sponsor so you can see if they're most is six. There's quite a lot of complex brain. Actively. Lots of different areas of the brain are being activated as we go down the level. So remember that motor five is localizing to pain. So here there's no order story processing center. It's just going from the century area to the motor planning area on then back down the spinal quarter. Already, you can see much less broke brain activity used up for this different fewer areas of the brain being utilized on four even less so remember, four was withdrawals from pain, so it's pretty much just the century. Straight to the motor are not even really much planning involved there. If you're moving your arm, you got a plan where it's going to go. Where is my arm. Now you're withdrawing for pain. It's much more instinctive. You just moved as a much less planning involved. If we're doing three, remember, three is a collection. So you can see here. We know even getting up into the cerebral hemispheres, as it were, this is a the level of the brain stem. So if all of this is damaged, but the brain stem is and that's when you start to get moved to three on, then motor to that extent, suppository is even lower down. So I got the medulla up here on the palms down here. So if the medulla damages well, that's when you get your extensive. So again, like I say, don't worry about too much, right? Mm three and m two in the differences. And if you can remember which one goes before which one? Because all you need to know is at that point they got very serious brain injuries. Potentially on then n one. You've got stimuli. No response. So, in theory, you might have damaged both cerebral hemispheres on your brain stem as well, or there might be another problem. So really, really useful. Quick. Look there at how the motor response actually really directly relates to what's going on in the brain. I can't take credit for any of those beautiful diagrams. I stole them off this gentleman on Twitter. He does do some very interesting stuff specific, around kind of neurology and stuff like that. Eso do go and have a look at his his work on Twitter. He's got some really good things on there. So that was GCS very quickly to mention I mentioned already there. Actually, one of things we can do is predict patient outcomes. So, you know, in theory, this might have been someone who had, like, a mild at brain injury. They were GCS 13. When they came in, we stabilized. Um, we did a lot of the things we needed to do on, so they've had a better outcome. But like I say, eso intensive care Doctors who regularly work with kind of patients with brain injuries and again at near our surgeons and stuff never really say, Oh, this person will never do that because actually, there's always patients that can surprise you when you think there's no brain function left. Suddenly something can change, so they tend to talk about most likely outcomes and things like that rather than absolute certainty. The other one you may have come across and I must admit I try and go away and look up all the kind of rules of thumb that people teach you, and I haven't looked this one up yet. But for GCS, we said they got a geez, yes, below eight. Intubate. Or consider protecting the airway Additionally, because they may not have the reflexes to protect their own airway. At that point, I haven't gone away and look, look for any studies to say how accurate that is. But certainly you can see how lower GCS may have problems maintaining their airways and things like that. So we might need think back immediate interventions we need to do to prevent problems occurring there. That's that's enough on GCS. That's enough Neuro anatomy for now, I'm we're going to talk briefly about how disability could be precipitated by drugs. So what we've got here is a child of toxic drones. So one of the things that may surprise you if you don't know it already is that in hospital we can't necessarily test for a lot. Efren drugs in someone system. I saw a patient in the hospital the other day who had taken a mixed overdose of antidepressants on some other medications. Well, unfortunate. Forgetful. They have the medication. It might have been a lot of their prescription medication that might been some thyroid medication in there and things like that on some of those medications we couldn't test for we couldn't do a blood test and say, Oh, they got X amount of the antidepressants in their blood or whatever on So what things we have to think about then, is how weaken on, know when that's out of their systems that we could look at drug half lives and think that how long does it normally take for drugs to leave people systems? But also, if we've got a patient on, we don't know if they've taken any drugs or we don't know what drugs they've taken. We've got a how other ways of working out what these problems might be. So one of things we can use those toxic drugs which is usually looking for patterns of symptoms. So you can see here that anti colergic drugs suctions things like auntie history. Oh, no, Sorry. Excuse me and you're allergic to such as atropine. I was trying to go for once that were related, although I'm not sure actually needs particularly or anti histamine drugs. So things like your claw chlor um, floor. I was expecting that. Say chloramphenicol. Anyway, on he histamines like someone might take the hay be that if they've taken too many of them, can cause things like increased heart rate and BP, but aren't normally going to change our increase your risk for two rate, but we'll increase your body temperature and you can see here this pew pillory dilation on so we can start to look for these patterns and say, Okay, we haven't got the evidence that they've taken too much atropine or being given to my tractor. Be more likely or taking two of the anti histamines, But we can suspect that might be the case. Then we can think about problems that are likely to occur similarly with opioids, which will be much more familiar with the morphine oxycodone, which is ah, kind of, ah, medical painkiller heroin. Things like that, you can see we've got decreased respiration, decreased heart rate and things like that So, unfortunately, this talk is nowhere near long enough to start talking about all the different effects of all the different drugs. But just to make you aware that there are different patterns we can look out for and try make educated guesses about what might be causing this patient symptoms. They're low level of response, etcetera. Because patient with low GCS it may not be because of a neurological injury. It may be because off drugs or medications or things like that. So given a little the news coverage there has been about the opioid crisis in America. Talked a little bit more about opioids, just a zit sort of a case study. So here is a nice stock photo image off a row in, I assume my street drug knowledge is not great or it might be something like prescription painkillers. Whether this patient has been prescribed them, I'm just taken too many accidentally or intentionally, or whether they have acquired them from someone else who had the pain killers or stolen. There are lots of different ways that patients can get hold of medications that they are aren't supposed to have on. Then we need to look at what impact this can have. So I took this directly from a research paper looking act at the effect of opioid overdoses. So Subsys things like heroin and oxycodone might be talking about on We were talking about the brain stem in the GCS slides. So this is a different view off the brain stem. We've actually got some of the cranial nerves coming off their eso. The brain stem tends to control some of the most essential functions on. So even if you take, you know, huge back to the top of the head, you might go unconscious. But because your brain stem is a bit lower down, it's meant much more sort of back of the neck territory. Then you'll still keep breathing, even if you've temporary lost consciousness or at least should hopefully do so. So things like three, then control of heart rate tend to come from this brain stem area, and you've got your your kind of ponds and your medulla and shame on me cause I think I got the wrong way around LESI ponds higher than medulla and not the other way around it. Remember your near of Anatomy. And so here we can see that they said keep sites implicated in opioid induced risperidone depression on up here, they've got a little bit of a diagram showing that actually the model a tree mechanism. So the things that control the like, how frequently you breathe, how how deep your breath Sorry cetera on the century. Feedback and the rhythm of your breathing are all suppressed. So you get abnormal pattern of your breathing. Reduced response to things like your low oxygen levels do to reduce breathing on lots of breathing rhythm. A lot are acting to cause this Risperdal, the Depression, this decreased breathing rate on that is because of the impact on the ponds on the medulla. So this is where these drugs are acting to reduce your desire to breathe on your ability to breathe. So if we've got patients with reduced levels of consciousness, like I say, it could be simple trauma. We could have damaged your own, or it could be something like a drug action that is then suppressing respiration. And if they've got decreased breathing right, then they're not getting enough oxygen on. Therefore, we're not going to get normal cognition. That patient is it gonna be kind of sat up thinking, talking, making sense, etcetera. So it's really important to be aware. So, you know, actually go through your primary survey in the might. Well, note that the patient seems to be no breathing or breathing much, much more slowly than you would expect. Buck, when we get to disability, we've got to think about why so part of it might be, you know, has this patient got any kind of drug taking? Paraphernalia are their syringes? Are their pill bottles things like that? So again, disability giving us vital clues? You know, we we can find the clue from the from the symptom of the slow breathing, but actually looking for more cruises toe what's actually caused that symptom on their four thinking about how we can reverse it. So one of the reasons why I specifically chose opioids to talk about is we can think about how we can fix this. So if your patient is breathing less because, as we saw there, it is literally suppressing the brain, the part of the brain that triggers breathing that triggers taking a breath in. We can cheat on. We can do some breathing for that patient on in certain settings. You know, depending on the skill level of the clinician's and what medications and what other things they're allowed to use. That might be all we can do for that patient at that time until we can get more help available. So some ambulance crews aren't allowed to give kind of IV drugs. Some someone, even Lantus have say, I am so into a muscular medications. Eso that point. They don't just have to ventilate that patient, so breathe for them on because we've seen that that those opioids were acting on the the respiratory center in the brain. Actually, if we're making sure that patient is breathing enough ventilation them, actually we can prevent a lot of the damage that that drug would otherwise cause. However, there are medications specifically that will reverse the effect of opioids. So there are specific receptors in your brain and in your body for opioid drugs on so Narcan or lock zone, as the full name is, you might be able to see it on this little file here blocks opioid receptors that stops opioids binding to opioid receptors on so we can deliver that as a nasal spray. Or we can deliver that as an IV. Or sometimes you know I am injection on that will literally block the effect of the opioids. And if we give a large enough dose quick enough, we can literally have a patient who is essentially not breathing in a space of a minute or two. Be sat up on a lot of cases. Be quite angry. Uh, so you have to be careful. Uh, some medical institutions now are promoting that we should actually be going for a slow push of, Miloxycan said, providing the same dose, but over a much longer period so that patients don't rapidly come around and potentially be aggressive or violent towards medical stuff, but actually a slow push. So their breathing rates gradually increases and they're able to support their own body functions again. So really important to be aware of so thinking about drugs in general and just a little focus there on opioids, specifically s. So that's a few different things on disability. I have not tried to provide an exhaustive list of things we might check. There may be other things, different services. Different medical providers may look at other things in disability. But those are certainly the main ones that you know Allmerica will personnel should be thinking about checking on. Should be, you know, getting additional help to check if it's not within their skills. That so some first age is in some settings, not able to do things like blood glucose monitoring, not trained town to assess Glasko coma score and things like that. But if the patient it seems that unwell getting kind of additional help to then perform those assessments correctly in terms of exposure, then we're gonna talk very briefly about different meanings of exposure and aparotomy survey. So first we'll which with that exposure as it relates to the patient. So any patient that had any kind of traumatic injury, we should be thinking about getting this patient, what we call trauma Naked s Oh, I was surprised and maybe let that impressed with Google images when I such trauma naked. The first patient I that came up was very much indeed, Truman a kid. I was expecting people sort of with tactfully place, blankets and things that happen specifically for the stock image is, but no, they're awesome. That's good images that there are patients control. Make it so you'll see actual naked. We don't necessarily want patients to be entirely naked, but we want them to be largely as exposed as possible because otherwise, if we haven't got kind of the ability to have visualized bare skin, then maybe signs and symptoms that we're missing. So with this patient here, can you think off any areas that were not currently able to visualize? Because I've run going a few scenarios over Ah, few years now with medical providers of all different skill levels on when they're doing their primary survey on when we got through disability and they've checked blood sugar levels may be done. A GCS and things that are on we get to exposure were thinking about exposing the patient. There's a classic part of the patient that people forget to expose and inspect. All right, so feel free to pop answers in the chat. Feel free to have a think what classically gets missed when were exposed in the patient. I I, um don't aren't I couldn't find a picture quite like this. So, unfortunately, this patient is very much not trauma naked on. I suspect this is a training scenario. Also, I hope this was happening a while ago. Now if they were rolling a patient on too long board long boards, this orange board here have largely gone out of factoring. But if you were going to roll a patient on to a long board, you shouldn't be rolling them to about 15 degrees. So I'm gonna give him benefit of the doubt and assume that they have. We're doing this a while ago for the guidance changed. But the one thing that is good here is that they rolled this patient on, uh, I think we can see here. This gentleman in the middle actually appears to be inspecting the patients back. So it's quite commonly missed you, might you think, you know, if you've got trauma patient when they've been hit by a car or stabbed or something, you notice wounds on the back are well, surely blood will trickle out. Or, you know the paper will report pain. It can get missed. And it's just one of those things that's easily forgotten, literally out of sight, out of mind. So we must be thinking about for any trauma patient, anyone we think we might have sustained injuries that we might have missed etcetera. We need to be inspecting their back so you can see in the second picture here this patient. They have spinal immobilization or C spine precautions. They got a sparkle spinal color on on their being log rolled so they're body has been kept in a straight line and roll rolls. One. If your patient doesn't have a central C spine injury, you can just roll them over like you would by putting something in the recovery position or just grab them at the shoulder and the hip and roll them towards you and look at their back. So it doesn't have to be a special fancy maneuver involving 3 to 4 people. But make sure you are having look at the your patients back because that's where things get forgotten and things get missed. So yeah, exposure. The first thing think about is your patient. We need our patients to be trauma naked. This could often happen a lot earlier in the primary survey, but if it hasn't happened and you've got them to be, definitely make sure the trauma naked at this stage. If it is a trauma patient on. Make sure we're having a good look at the bank because you can get things like little tiny puncture wounds and things like that that otherwise might be overlooked. There's a comment in with shot shot. They also remember Exelon and Bottom. Yeah, absolutely, really good points, a swell. So yet anywhere that we can't obviously visualize and you can see a trauma naked patient. In that first picture, you could see that it's really easy to miss in the exhilaration in the armpits, on things like bottom as well. I don't know if it's gone at fashion. I don't spend enough time in kind of trauma, recess and stuff that they're waas trend among gang's at one point of bagging, which was literally deliberately trying to start people in the bottom because as part of the damage, they might end up with the colostomy bag on the the gangs thought this was, you know, suitable insult as it were, so that it was quite common for patients to be stabbed in in the bottom in that kind of area. So really, really important to yet definitely inspect these as a while. So when we're exposing our patient. We must make sure we're exposing and inspecting. So looking at all of our patient to make sure we're not missing anything on what kind of things do we think could be missed if patient isn't adequately exposed? So I've already said about kind of stab wounds, punctual what other kinds of things might be missed if you're not exposing our patients second to to think absolutely. I'll try to think myself a few things, anything that comes to mind for me. Although the first things come to mind Certainly interesting tattoos. Yeah, yeah, absolutely. Way you construct conversations around is they do not resuscitate, tattooed, actually legally valid or north and things like that on your find. Different people have slightly different opinions. The one that always comes to my mind and I think may not come to everyone's mind. But what about my mind? Is the rashes So for, you know, another cause of disability might be, you know, our patients having allergic reaction has a reduced kind of airway due to swelling and things like that. So rashes could be key at things like bruising's that doesn't have to be bleeding from stab wounds, but bruising things like flail chests. So anything on everything can be missed if it's covered up by clothing. Especially, of course, patients were in kind of oversized or banging clothes if they're wrapped up in lots of layers. So exposure is vital in order to make sure we're not missing anything. There's one here they had in his ulcers and then Gary toe and bad ankles. Which fair enough, you look and missing limbs. Hopefully have noticed that one earlier. But ulcers? I think it really use one of those two point out things like pressure damage, particularly with your sort of long lie. Patient had been on the floor a long time or bed about patients in the like. Because, you know, the reason that their heart might not be working on the reason they're brain might not be doing its normal thing is because they've been lying down so long. They formed a whole bunch of clots somewhere and firing them off all over the place. Yeah, well, they've got wrapped around my license and the kidneys of Paxil. Aw, eso yeah, really Good point. Yeah. Interesting. I'm looking at a shattered I got to Oh, should I be looking at the Q and A half. I've been looking at the wrong thing this whole time. Is it? Said Chatsworth Click Trap. I've done this for walking. You tell that so I can send you secret messages about telling him. Okay, to be fair. Oh, yeah. You've got 13 publish questions. Oh, my word. So I really pulled the others on. Thank you For people who have been putting stuff in the chat in. Thank you, Freddie, for translating for my stupidity. Eso yet missing limbs I would absolutely take. So it might be something more like a missing finger that you're later this than missing arm and also the one that doesn't necessarily get talked about If they've got a a missing limb or missing thing, it isn't newly missing or actually has this. You know, Is it an old sonny and actually that you know, we shouldn't be running around looking for a leg or whatever so really important to be aware of, and again missing teeth because it can, cause, you know, it can cause their way through. So all of these are really, really good points. Thank you. Everyone will put in the chat in bearing with me while I go write you a lot right now. I looked there. Let's be name school. Sorry. Working across two screens. Can't see what I'm doing right there again. So we also do you think that exposure to the environment now I was gutted, I could not find both on, like a Google images search. And in my own personal collection, this was the closest I could find Teo what I was looking for, which is a classic prehospital medical thing off screening off patients when we don't want people to see or protecting them from the elements. Hopefully, some of you might be able to guess what it is I'm going for here. So you congested about? See, on the left hand side of that picture, we got a blue blanket which is shading my plastic patient here from the sun. Now, of course, as up against a John Deere light loads trailer. Yes. This is from the National Prehospital um, training program, which is basically a lot a new air ambulance. Doctors go through this training before they relax, let loose on the helicopters and on the air ambulance cars. So this is actually a limb entrapment scenario. Which is why his lovely plastic arm has been bent back like that on why it's got tourney a slapped on it there because they're supposed to get the Gigli sore and chop it off. That particular trader is very easy to open. They weren't allowed to try training Marios, Surely ready to trade are pre hospital doctors and how to work trailers. To be fair, if I remember, the group who were attempting this did request additional assistance, Dude request like someone from the company to attend, only to be sold over there be here in about six hours. So they decided to crack on and chopping arm off instant. So yeah, um although it may not look like it's doing very much, just putting that patient in the shade is hopefully for renting. One less problem. Yes, they've got bigger issues in terms of their arms might be sword off. But actually we're still thinking about environmental exposure protecting them and similarly things like, you know, trying to keep the rain off patients where we can't move thumb at into the dry and things like that trying to keep patients warm or cool. All of this is really important, and it's, I think it's really easy to forget, especially when you've got, you know, exciting medical things coming out like a limb amputation sores. But they are really important on. Yet The team here did remember and did think and did ask, uh, for that blanket to be put up to provide some kind of temperature relief, some kind of shade. Or that I'll admit, as you can see with the kit around there, that that may just have been for them as much as it was for the patient. Um, and again, in terms of keeping patients warm, we need to wrap them up. So we need to get our patients trauma naked and inspect them if they're true or patient. But then, if we don't need to visualize an area it needs to be covered up on, we need to keep our patient warm so you can see here. This is actually a vacuum mattress on. So that has a suction has been used that has contoured to the shape of the patients that helps to both have mobilized thumb on keep them warm. It's a very useful pieces of kids, very European at looking ambulant on, then that this If we need even more active warming, this is something called a bear hug er on. It literally is a blanket that fills with warm air to keep the patient really warm, and you can see there how they split. This plastic blanket is in fact, see through, so we can still try and visualize our patient trip and you'll see it's a dog there because I got bored of pictures of humans. If I could do all the images in the presentation with dogs instead, I absolutely would. Okay. We also anything about exposure to the environment in terms of hazards and not just weather, so you may or may not have come across the remove. Remove. Remove advice on your noted specifically says hazardous substance. So it's not differentiation between Has this chemicals had a PSA, just biological materials and hazardous kind of radio nuclear materials? Because actually, this advice is useful for all of them. Now, I'm not going to read off the slides you can. You can read exactly what it says that what I want us to think. That is why each of these things is on this list. So, first of all, if possible, we want patients to remove themselves from the area on, it says, to avoid further exposed to the substance. There's another really key reason as to why we want them to remove themselves from that area again. Feel free to put the answers in the Cuban a new nose. I might actually see them this time on, uh, the, uh and still be to have a think as well. But there's another really good reason. Uh, Teo, remove the patient from that area so every two but it in the can if you want to on. But I wouldn't I wouldn't be too long causing that. So the other key reason is we want to think about ourselves as rescuers. If we go into the environment with the hazardous material without appropriate presented precautions, we become the next patients. So we think you are safety on that patient safety. If we can remove them from the house, this environment, we're reducing the risk to them on to ourselves as well, because bear in mind, it's all very well to say, or we'll get the heart teams the hazardous area response team or we'll get fired to put on their wonderful suits and go in and deal with the problem. They might not be there. They might be tied up another job if we're thinking for a hospital. So at that stage we need a plan that isn't just sit and wait for heart or sit and wait for fire. So if the patients who come to us with minimizing air exposure risk But we also April to start treating those patients in terms of removing out of clothing, then what is the reason for this? So you could be forgiven for thinking this is trauma naked. If your patient has both been contaminated by a hazardous substance on experience, a traumatic injury, certainly they're not having a good day, and it that is really important to be aware off. It's not. They're lucky day. They should not purchase any lottery tickets. But on there any other recent senses well, other than make it getting patients to make themselves trauma naked birth because actually, we're not necessarily talk about removing a layers here. We're specifically talking about removing the outside there. It's a swell, it's just removing, and he has a stuck on them Yeah, exactly what I think we're going for here is the idea, because I'm not a hazardous materials expert in case in your laboring and there any illusion that I was at this outer layer is most likely to be the one that's most contaminated. So we're trying to do an easy way of removing a large amount of contaminants all at once. You know, we're not selling paper to peel the skin off. If they can take that jacket off that's coated in acceded or whatever it is, then we can remove a large amount that substance very quickly on also, we're preventing them from re contaminating themselves, and we've decontaminated the patient. But actually, you know their jackets, Dakota, that they touch their jacket way don't really solved that problem with just we've just delayed. It's slightly on. And then, of course, removing the substance that one, I would hope, is fairly self explanatory. But what is useful to be aware of is eso is talking about using it. Remove the seven from the skin, using a drives off material to soak it up or brushing off. So that's for you, Mork kind of powder, solid based contaminants and things like that are so some chemicals that chemical plants it central will be in powder form. So you're brushing off very non technical, but again removing a large amount of contaminant quickly and easily, It says. Rinse continue with water of the skin is itchy and painful, so for some of it may be flanking up there. You know, of course, some chemicals, some substance is that patients may come into contact with may react with water. So that's why it's not the first line of advice. You know, if it's a dry powder, let's not risk it. Let's get rid of it another way. But okay, it's about the fact that if it is doing damage to the skin, so we're getting pain or we're getting itching that we know it's damaging the skin, and we know we need to remove this on. Yes, then maybe reaction with water, but actually we can flood that area with enough water quickly enough. We can also dilute the products of that reaction on their four, reduce the damage. But of course, there are experts, sources like talks base. If we can find out exactly what the substance is that they've been contaminated with. We can get rapid expert advice back. Exactly. Have to decontaminate these patients most effectively. So that's why things like Lawry's carrying big tanks of chemicals should always display the warning orange warning signs with the codes on that you could look up, work out exactly what chemicals any patients have been exposed to, so really important. To be aware. Also thinking through your remove, remove remove advice is really important on then I think I'm nearly done. I just want to recap it. Like I say when people do primary surveys and I have assessed in various situations I've watched on supervised everyone from first aiders to paramedics and nurses. Doctors? Yeah, I think. Well, I have watched them at the pre hospital. I can't program but assesses Go sound. Sure some people you assess before then becoming doctors are now it's Yeah, possibly. Yeah, it does get missed. People get very excited with ABC on Forget dealing, and hopefully, as you can see, it can provide really useful information that can be really important because it can instead of just like a B and C can allow us to find on at least attempt to correct life threatening problems. I'll admit diagnosing a patient with a traumatic brain injury isn't quite as useful as noticing that they're not maintain their own airway, but it still is useful to diagnose. And there are some things, like we say, like intimating to protect their airway, that we can do that a useful. And with things like GCS, it can allow us to predict the patient's prognosis. Is this patient likely to be fine? They just need to quit the hospital care or is actually this likes to be. A poor outcome on this isn't gonna affect the care that we give to patients but can affect the way that we talk to family members and things like that. Avoiding giving, false hope and things like that is very important, especially for kind of severely injured patients, on enabling us to prevent further deterioration. Like like we saw with that patient with the potential limb amputation. If you've gone arm trapped in a trailer, yes, that's probably the thing that most you know, doctors, nurses, paramedics, allied health care professionals are going to focus on that scene, but actually making sure this patient isn't going to get hyper thermy a so get too hot because it's a really warm day and the sun is shining directly on them is also an important part of their medical care and something that we can miss. If we don't think about disability and exposure as well, that is, it's That's all of my waffling. I know we're scheduled till half eight, but that is a waffling I have to do. I will have be delighted to take some questions. Shouldn't even have any. Thank you very much, David. Let me quickly Don't get really your slides and stick my ones back up again. Every just so that because I'm a pretty opening slight. I am currently in the moat midst of trying to redraw this heart, which is the one I drew about a year ago. Now, actually, um, I don't wanna make us letting Mawr clinical looking one, but as anyone bit of trivia for people I drove, I drew this hard on paint and term. Therefore, it's a bit of a fiddle to make it look, really, but thank you. Everyone has attended of shed the feedback form in the chat. If anyone wants to fill it out it taking out of intense, difficult to prove it came. It's evening. As always, we really do appreciate everyone's feedback. It's a great way for us to sort of structure how we improve and both his teachers, and it's a series and way we do appreciate it. If otherwise, I'll give people another sort of 60 seconds if they've got any questions. But if you don't, that's fine, too, or you're more like to email me them and we'll, uh, look at them later for you. But, um, acid, thank you to David for generally a session where I've learned things, which is a terrifying thought. But I think also I've forgotten all medicine. As of yesterday, uh, finish my house keys for the year yesterday. So now I have just It's a lot of my brain. I'll remember it again when I need to. I didn't think when I first came across it. The stuff on how linear the motor score relates to higher brain function is fascinating and not something we take. You know, we teach people how to do a GCS go. We don't really teach them the science behind it as well as medications. Think there's an odd amount of distrust of the GCS I find in actual clinicians partly probably is poorly done is you said if you know how it applies, people would understand it better also think, as you said because it started it origin as, ah audit to rather than a like a clinical feature. I think a lot people distrust it, which I I think you know the table on the screen makes it very easy, but actually doing good GCS is quite challenging. I spent three weeks in I t U on. I spent most of the time going Well, this is the D. C s I got, but I think I caught the patient at bad moment. I've trust the experience. I t you know, So you did it five minutes before May because actually, you know, especially in the nice use s in patients don't really have a stop day night cycle. They sleep when they sleep. But if you don't get these yes, on them when they're asleep, you won't get good a response. That's very, very true. It is to tell when you're intubated, ventilated patient is snoozing when they're not. But I'm not seeing any questions. I think I'll call it there. As I said, Anyone has got any queries. Please do feel free to email. And that goes for those watching the recording as well. More than happy to answer questions if you have them. But massive. Thank you, David. And I think everybody and we'll see you in a couple of weeks full on interest in session. Thanks very much, everyone. Apologies again for forgetting how the presenter mode in teams works. Live as I would normally do. All right, Thank you and good.