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Okay, everyone else I'm missing one of that, please. Currently is Belfast Trust in your surgery and in the roles? One of the girls that runs this since currently on lights. But I think she actually gave the talked last week on temperature and few boxes. Great. So hopefully this one can live up there Standards as well. Today's session is gonna be on doctor repetition, isn't p. And on what to do when you get a people about that was commonly we're gonna focus mainly on surgical problems and because they're the ones you're probably gonna get, like the bike, most medical patients, movie and PM, and just be expected. But the majority of your Penis weeks will come from patients that are admitted under surgery. So just this before. What is your bait for? It's a device that looks like this. It has buttons that no one knows what to do with us. Press thumb on the noise. Horrendous noise that is made will stop. Oblique should not be there to make you cry. A little light reading. You might want to cry. Whenever you get a plea, you might want to throw your plate against the wall on. It's also a cool fashion accessory, pregnancy or divorced Christmas. You will find yourself holding a couple of weeks him, I think, selected for like a day and then you want to cry. So, as I said, bleeps should really be for sick patients and urgent tasks. This is sort of been the recurrent thing for the last couple of sessions we've done on. It's a way for people to contact you about patients that are sick. It's a way for savory ology or and biochemistry microbiology to contact you about urgent results. For example, someone's hemoglobin to come back for 49 or the potassium 7.2 or the calcium 1.0, and that's a way for them to contact you. If I thought originally asked, you should really go in action very quickly. So take it off with scenario. Well, I appreciate that. It says here, metal, ask your Children to connect to the audio so you might not be able to, um, you do. But if anyone wants to type in the chat someone seriously, you're 56 your your urine at all, not a 50 section or you might be. And on the nurse sleep she about a 56 Your meal. He's complaining of a bellman. O p. In What else would you like to find out over the phone? And do you type in the chart box? If you don't want it on mute, that's completely fine. But I also appreciate that might be some issues with them getting connected to the older You? Yeah, you're right, Socrates. So you want to find out that Like it? And in terms of if you just got the first, please. Well, of the things would you like to hear and find out it with food from the nurse or the health care assistance is sleeping. You was certain things are definitely things we thought it would be. You want an aspart? You want to find out? Why did they come in the hospital? You know, did they come in with abdominal PM That their diagnosis for this patient, you know, do they have appendicitis and the reading on theater? But they POSTOP Do they have a hip fracture? Do they have ah, not obstructing kidney stone, you know? Did they look, um Well what? They're new scores, then? You want to do What's the peons? Was anyone else that by about pee and is And that's obviously but subjective. You know who is calling you, where they calling me from and another noon to the patient, you know, estimation noon to them. But the American after the the last two days have been in and I have why here and people will be calling me because they typically need something from me. Other concerns their patient. Sometimes it could be that Cardec stages of stuck together and they just don't see the pain relief section. And that's completely fine. That happens to all of us. I have done it. Other people have done that for, um, I'm just not happy in refills fried by ever Cartman. And that could be the reason why they're being cold. Why you're being called in certain things. You're gonna ask the phone as well. So before I arrive qd So it's good way to have a phone call and specifically really get a bleed. Quite something. It's always good to try and get a mask for her and they were from somewhere and just from someone I just to find out where the patient is, what their hospital number is because of your stuff in a ward with someone else Sick. Quickly look up based on their blood's and asked whether you score more. Got her quickly and he told me So you also your questions. You're on the way to the board on your initial thoughts, and you're going to see someone with all my pain. Is a good present with a little milk in for the medical patient or surgical patient? Are they a patient? He's not comparative treatment that maybe they just don't have the proper palliative care. Medications prescribed have been assaulted. Operation. Are they going to get an operation him high and whale or this? This helps to prioritize your tasks, particularly out of origin. Quickly. You need to go and see people. Is this being referred? You know, Do they have a little pain? Because the blood sugar one did the abdominal pian because the vaccine or lower lobe pneumonia on it's just really in rind and giving them sort of signs and symptoms of maybe colecystitis. You think on you will never be faulted for saying you're thinking you're just too tired, you're human, and when you're gonna be a phones and it's busy, Stressful year. And if you can't think What What's going on? Looking up the ups that you, me and I really recommend would also be foundation skills, pocket doctor. And they always got Doctor Google. If you use so focus in on your assassin, you go to see you go to the would always try and eyeball the patient before you actually don't see them. Because unless you have, um, well, there are what we see. If their tribe boarding, you're going to go in to see them right away. You're gonna drop everything you're gonna read there now that you're gonna go and you're gonna assess the pressure in. But if they look to be fairly comfortable sitting there, it's really by your couple of minutes. Just look at their blood's and look at what was said in the world and this morning, like their new score and try and work out what's going on before you went to see them. Also, make sure you try and review their cardiacs on. You're gonna look at the nurse's notes violent. Try and find the person that leaked you because they might do the patient and and no, if this pain has been getting worse, if they've been able, to my knowledge it with a bit of paracetamol before. But it's getting worse. Or if this is just new PPI and out of character for this patient, as one of the said they're yes, Socrates, for European is very. That's what we all use work on. Also remembered. Ask for any associated symptoms with, say they have done a little bit under their nose in vomiting. Other boils. Opening is a preferred PM. Is it radiating through the back? Do they have a nominal been reading up into their chest again? Don't ever forget about it. Any CD insulin with a P in because could be an MRI. What was he with your 80 assessment? Airway breathing, circulation, disability, everything else. And please don't ever forget because I'm just a mess. I don't like a fluke to patient who was Day three. A post Hartmann's procedure for a rectal concert on You couldn't work out what's going on with them up to pee and sweaty here, Doctor. And just on his blood sugar was one him. We were going through everything, couldn't but what was happening didn't ABG on UM, it was a bit short of breath and discovered that his BM was one and he got some IV Dexter's, then miraculously recovered. It doesn't a little pencil, so don't ever please pick like was that something that is always drilled into this? But it's so easy to forget about it and overlook it. Doctor, your scenario 56 year around so you find out from the history is Day three postoperative me on. He had a small ball in Austin, OSIS. For a small, mild obstruction, which is secondary to that. He's been through a previous surgery. He's been completed a fortune of normal being up the little pin for the past four hours. He looks a bit miserable, the feelings about on while he's sweating on unison when you start. He's been spiking temperatures the last week to order show he has no zero, but he hasn't vomited yet, and you noticed your nicknames. Tap it honestly, return to be said for your people that I sort of 4 to 5 hours on his Biles haven't been since his operation, which isn't uncommon. Whenever you examine the patient on your 80 assessment, deserve a spinning, dizzy patrol, Kuwaiti and finish sentences. So you don't worry about this respect. Your weight's up a 20 it his oxygen is up to 98% on room. Urgent dispute are entry bilaterally, but this point, you're fairly confident that it might be his chest is giving him the issue more than I think. Is is a little pan where his abdomen, which is causing the PM even on to see if it was heart rate's 100 fifteens. He's a bit talkie. His blood pressure's 95 50 so it's hypertensive. Capillary refill is three. Felix is dries a stick Missay CD. Sure, she's Sinus Talking is cheesy aspects. To 15 is blood sugar, 5.8 people's record active, too. Like he was, the temperature is 38 6. Get a previous temperature to yours before and which would say 38? One on it came down with paracetamol. Start back up again. Whenever you examples tell me it's tender. He's guarding in certain areas, and he's ready, basically right, because when looks to be healing well, he's only Day three. We start skin clips in, and there's no sort of gross our theme er swelling around it. He's on some IV foods, and he's got a copy of her present. So when we look at the news to chart, it looks a little bit a score of it. So it could anyone I appreciate you again. You might not be able to, um, eat. But if any animals to, um, eat or just type in her chart, what you might think you're differentials would be for this patient sepsis ship. It's good one to consider. Yet he's pregnant, IC, you know, could be colds on this part. Like this, please. Day three postoperative me. And he had he had an anastomosis? No. Okay, so sort of talk differential. Shouldn't think off. Here. Would be. Yes, it could be expected PM after surgery. After you have an operation, you're gonna be so worked. So sometimes having a bit of pee. And after it is, you just have to accept that he could have it. Unless tomato Week You could have a POSTOP collection. It could be a boil perforation. Insulin without do pee in. Is it an obstruction? He hasn't been This boils. Is he just constipated? Are they bleeding internally? That had a big operation has unordinary or being unexpectedly been Compton theater. What does he have? Site infection. These are sort of talked. A French is you think of when you go to examine someone, either for your POSTOP with a little pee in. We've been told. I'm sure this diagram is potentially triggering for some of you giving that you just finished finals. But it is very good diagram. And just divide the abdomen into the four quadrants and sort of right upper quadrant Pee in your thinking part of battery. Is it gold? Bladder is the liver, you know, do that helped me be in renal stone. You never forget about your your nerve in the movies am or do they have a kidney infection? Even going to the right? Yeah, boss, for the regular record in appendicitis again could be a renal stone, which is making three. Do they have a hernia? And could this be cruise or colitis? No, I just have a urinary tract infection. Do not ever forget it. Right to stick your version or in a very important sort of left upper quadrant. Your thinking stomach. Judean. Um gi. And do they have an ulcer? There's kidneys on the left side as well Did have colic. Do they have a pilot? Afraid us. Even going to the left we'll record in is when you get into your diverticulitis Texan area. You're to refer minute clients. Do they have heard it on the other side again? Portion. Don't forget about my body like you just simply uti other things to be careful about. Sort of epigastric region. Could this be a pancreatitis? Are they have a heart attack? Is that where the PM is coming from? And again, you're peri umbilical. Could it be small boil obstruction? Do they have a large bowel obstruction? And do they have respirator up to triple it, just calls and then pee in something you probably all heard about? It is the surgical city. We've all heard about America. But if your finals and then we forget about it on my I forgot about it until I was making this presentation. So it is very good top in your mind. Just the surgical say that would be good. A example. Dictation there sass a surgical patient for things that could be wrong with them when they're on. Well, just working through it so vascular or the bleeding? Do they have on a skim? It got Always think about the skin that got in a patient so long, said Abdominal PM, The history of a F Regardless of the fact, if they're on apixaban home or therapeutic taxi and warfarin, they can still get in the skin. It come from this. And is it me a trickles? Morbidity, mortality and surgery? Living on? I could be an infection so they have a POSTOP I loose and he's right on my list is very common postoperatively. They'll start to be malicious. Um, I start development the best thing you can do for that patient snakes milk them. I give them some IV fluids. Bit of some, but you've been on just a decompressed. There's some I can give the boil time to hear from the surgery and just get used to having and get used to sort of functioning again. It's a traumatic, you know, isn't renal. Colic did have a kidney stone. What could it be used for pancreatic from the local surgery? They're just had you to be over. I mean, do they have a transplant which is causing the rejection. Do they have a number two Mild disease, which is causing this PM is a medical look. You know, do the medicine, the disease, or then DKA Damn, It's very important to remember decay. And these scenarios of oil, Could it be idiopathic and you know, is it just constipation? And to have a little mild disease? Do they have an obstruction secondary? Say erectile counselor. Cecal tumor Congenital. Unlikely to see a pediatric patient in Africa in your bladder After you know she specifically do you pee? It's part of your medications. Janitor. You will benefit ones in any or anyone to people that whenever we have chronic lower back, so important just take some of them And consider, actually, is if you need it. Sort of mine actually lost its fine. Actually. Think about your differentials. Could be endocrine. Unlikely, but it might be on. Is this just a functional symptom that they have So for expected pee and you don't expect to get P and the worst being maybe 123 days POSTOP the news A little bit. Give You know what might be a little bit tacky? Just sort of physiological response to be, and it could be feeling, well, just sore. Do they have an anastomosis leak? Insulin, Right, we said that could be It could be signs of sepsis. Three, Which this man is starting to display. Patients of the last people typically have a fever. It would be partner, and they will develop a nihilist. Anyone that has a collection, particularly if anyone's going to do you have one. Surgery and pains of pancreatitis can get pancreatic pseudocyst and Granick obsesses. Being interviewed little collections. They will more than likely have a sending fever despite being on antibiotics. It's always important to remember that. And someone with the spinning favor think, Does this person have a collection, particularly if the POSTOP is there being localized? And do they have a powerful sort of swelling, like a just a collection or pockets fluid? In fact, it clear, which may need a dream likely perfect for that severe pee and receptor is the part is, um, you know, is there is there? Told me. It doesn't feel like a board. Are they obstructed the make a colicky pee in that could have absolute constipation. Patients with an obstruction may also be passing wind. I haven't incompetent ileocecal valve initial passing wind. That's fine. It's almost better if they have that. And is it panic, too? Because to I'm in G. I, um, hepatology at the minute blood of our patients have ascites. It's very low every now and again, whenever you possible with an obstruction that would be in like, sort of to panic. Things like your topping on the drum early bleeding where the tachycardia to give you BP or they shocked even on the appropriate investigations you can do is in half one of the bad side. Get your E C G. Get a urine dip, a little occasional abdominal pain. Keep you do two years. That's just make sure you get a B and we'll get him a quick finger. Prick it goes. Or if you're doing a blood test, well, that may be shocked. Knots nasty. They're diabetic. Just get a B B G on them or tickle test. Often if you need to be, um, right away gave the nurse the healthcare system. Whoever's got the B m seeing a sample of that blood just to see you stopping the patient twice and do they have any stool was enough to do. You have a strong with Jack to see working and husband active. Yet POSTOP is really bleeding coming from it. Doesn't a pink and healthy, Or is it starting to come? Sort of dusty peel and the called a clicking. Do they have any dreams that a third of the dream? How much design of the dream? How much is that changed over the last 24 hours to ship bloods that are important to take and you get a little blood clot in any any you look for any sort of bleeding or your hemoglobin. Drop your knees good for dehydration. Check your white cell. Count the CRP Unless you see the infection workers, you can do a B, B, G or in a baggy. You get a result within 2.5 minutes, but it's very, very useful. That's a very good revenue into banking on, well, patient very quickly. Well, not VBG get their electrolytes to get a rough hemoglobin and get locked in sort of images. You can do it. The beds they can get in a wreck. Chest X ray. You can't get in a moment electorate the bad side. They have to be doing work, but in someone that's quite unwell. Do you think you need another directory? Sort of. Think yourself day to contact senior into the new CT doctor patient. He's 56 year with meal. He is Day three post laparotomy, first normal obstruction. That small Milanov smokes is, he said, worsening of a little bit over the last four hours. And he's septic with a partner. That a compliment. So I don't think we talked to differentials. Could be here. Yeah, it's a nasty, like should definitely up there to long see Yeah, to talk to you would be in less than a week or in a structure of preparation of someone with sort of acute owns that worsening of the little pin. I'm talking about the monitoring. So this month we met him. Know about my give him some IV fluids. You only get him under Bill. It's normally patients here. Postop in about major abdominal surgery will be on on two biotics and surgeons, and most people are guilty of just getting people Tosteson or whatever. The penicillin allergic version of ladies and you gonna get the Bloods awesome if the day three POSTOP, they will normally have had a grip on hold and we'll be on the system. But it may be Day seven. This could happen. It could be doing If you can't find one on the system, there's no hormone forming blood bank and just checking if they have one name. So you don't get, uh, hungry meal home saying you need to reading some training or just send little and your sugar coat. I make sure you check the routines routine boats Just put your foot book you need and a CRP imaging. Try and get in a wreck. Chest X ray. It takes a while to get things sorted for a surgical patient, and things don't just happen instantly. So in the interim of, say, someone taking bloods for you, you trying to work out what's going on. Looking through the records you could just fill in a pit three request for erectile stick trick. Need an answer for me quickly, mister, this could be a perforation if it's a chest infection, causing all of this done. Please, please, please make sure you give patients a little Jesus. We'll talk about allergies and I you wanna get nervous and your view from sort of sick septic surgical patients might need a CT of your pelvis. It might need to go back to theater on something that, um I don't have to do an afternoon depending on where you are, Something my duty. Just update the family and you can watch yourself. If you're relatively your little forms taken into theater overnight. Did you find out the next day to be a quick could be, you'd be able to the rights to be a bit in order, upset that no one called you to tell you they were going in for emergencies. Better. Oh, geez. And POSTOP patients. General principles would be a regular simple energies You should be prescribed, and that would be personable sort of one ground four times a day. You make that p R N or regular The spoke, um, regular allergies just with a POSTOP period. If the number might give my be and seeds could be considered. If there's no contraindications sports, for example, they don't have her industrial function. No history off, you know, peptic ulcer disease or Judy. An ulcer disease. Um, anything without and we could be excluding is good medication. But again in the surgical patients, one likely going to constipate them, which isn't what you want, do you? Who stopped you? Get the bowels moving, so just stunned. Sundered regimes you will see on a surgical ward. You'll find people on big PCA morphine pumps on. We'll have to sort of pumps and knocked gauges and bombs depressed to get a short burst. Recent more thing that helps to control the pain for them might also see they got some regional block infusions, and so they get a PC and theater. I'm looking at a reasonable confusion. Didn't know about Looked like it's just too little catheters going in this sort of directors sheath. And that gives them an infusion for the 1st 24 to 48 hours. Takes away the pain from the surgical site, which means there but mobilize and sit up in bed and eventually get up to walk, which is when he had the recovery or loopy oId regimes. If someone's had their appendix taken it, it's trying to give him a bit of coating. Coding is approximate attempt out of more things. Quitting is obviously gonna be metabolized into morphine, so it is a good little Jesus. But just be careful that they're starting to use it. Morphine Standard regime You'll see and hospital computer surgery they'll be on short and long time. Long Check urine or low a regular allergies. A short checkup, urine. A short take a short acting. It's fast release, and you're typically see people prescribe to the house to 5 mg, 4 to 6 early pee or an and then they will be on regular long check either 5 mg in time. Other rooms, 12 orally, the normal starting that almost starting reading from a low tech would be 10 mg speedy, and you were just 5 mg of their free Other. If the very opioid sensitive and of course I've been washing. So you're bleeped. This is my scenario. So I was enough one in the Ulster. It was a Tuesday morning. It was 10 to 11. We had been on take since the Friday, so we had 39 patients on our take sleeping with just finished the border and in the butt just under three. Yours, my Wendling to the issue. Get kind of juice to give me a better energy to continue on, my friend. We have little. We have blips and serious certain whole supposed to be serious about walking talkies that people can contact you very slow. Throw some hundreds because it's another sources. It's another point of contact for you. But my colleague let me and said, Look, your patient up here isn't very well. Just don't do pee in. So what did I find out with some? I find out who she was, one where she was. I remember her from the water. And But if he didn't think, just ask you ever calling me again? Genetic. Um well, wants to be sports a pain score because it's calling you to the new deficient. Before I arrived. Funny piece the money to buy Medusa around straight up to the ward. Didn't 80 assessment of the patient. And you your shin 73 year old hum never since, right? Yeah. So my initial thoughts going to see this city where I've just seen her on the water and juice. Very stable in the What has happened in the last year since we saw her. And you're quite well. She took three CT scans and three days because she was sort of deteriorating and we couldn't work out what was going on. And I thought, Really old, You're going to kill me because she's already had three CT scans in three days. That's a lot of radiation. My next thought was my entire thing, my entire team just going to be a two for the day. That a fib. Emergency respect. She wasn't letting me pee in a year, so we'll just change slowly. I was thinking to myself how she got another septic and July she had been admitted. Three expiring in September and she was manage conservatively. But I was thinking hard. I eat, manage that if it is this. But I was also wrecked. That's we looked up certain things you can do for a patient with abdominal pain. It's in terms of this thing keeps going. So just back to the assessment. Driving on the ward, what do you do? You have all the patient. Look at the notes in the nursing. Let's look at her bloods and revere cardiac. Since he is she still on P. And what medication is she on? The shin of morphine has shown a little easier. Does she need more? Your Penis acid of, um, using Socrates, um, into your 80 s s. So I did this. She was 75 year old lady. She was Day three, admission for a recurrent infection. And she had a background of the contained sigmoid diverticular preparation of September, like, three weeks prior to that which is not it's conservatively lively on two products in the dream Dream was taking, like, the week prior in the surgical hub, You know, some new onset peeing within the last hour. And she felt quite a whale. She was sweating. She look peel, just call me. And she was starting to spike temperatures. She was nauseated, and she wasn't vomiting, and she was in severe pain. And I still remember the city. She was 75. Very store. Did he never complained about anything. And she looked like death when I went into the room to see her. Well, my 80 assessment her ESPN, but she was able to talk to him. Her respect? Yeah, it was. 35 sites were 92% 1 reamer. And despite this, she had good our entry bilaterally. For her. It was 140. Still, it was 82/50 recovery films. Three. And she was just trying to stick. We managed to get a CT. Don't want her dispense her, sweating What should just passed? A Yes, GCSE is 15 for pupils. Were you? Culture is reacting to like and they were wrapping like her blood sugar was 5.800. Temperature was 38.1 when I examined her abdomen, choosing a little PNG was guarding her. Tell me it was a rigid I couldn't hear model side first person I've ever seen where I couldn't actually hear a milestone your nutrients present chairman Any operations and she don't have any IV future her new score on her knees terms of. So I was starting to get worried about this patient and then went back and reviewed the history. Because it's 7 39 patients on the take shoot dot No. Just made it the whole school for for the last three days and chef CT on each day, which is a lot of radiation personal. There were new change in her CT. Shouldn't interval reduction in size of the collection from ER CT, which is three weeks prior rodeos. You started getting annoyed because we were actually doing anything for the patient. We were discounting her. She was on Tustin agenda mice and French of normal sepsis. When she was admitted the last time, she hadn't hold on. What? Your ejection. Fraction of 25%. She'd had tuna milligrams of short check 4 mg by the ondansetron. When she was on apixaban. Her puzzle erections should say after a little pick somebody for this. Um, this is such to therapeutic, Lexi, not admission. So can anyone think you're just type in what you think the differentials would be for this patient? What you think might have been going through my head? Well, I've been trying not to pry. Sample is, um get you be an embolism. You think of it if someone's gonna happen and listen, which is gonna go to the Boyles? What could happen to their bile esteem? Yeah, Yeah, exactly. It's my differential is for the city. We're Has she perfect? Does she have a skin doctor, or does she have another collection? Didn't say how you add manage this patient. And what would you do if you refuse? Because I was first. That's Mary. And, um Hi. I'm just came to know how you guys have management now is incoming, eh? Forms in control it. Heavy foods IV, antibiotics in the sitting on ties in general. But if she wasn't, you could certainly give er stopped. Um, $700. I need one image. Or exactly you could do if I stand on her. We typically we aren't trained to do that. Unless you're in an e. Remember, they're going to be any doctors that will do that because they have ultrasound machines on wards. Sometimes you were going towards my shoulder's been working a CT machines. You do it. You come the equipment that you've got. Let me see. I should have a potent for this if I can get this toward, um, just sort of interest. Want analgesia? Would you give this patient? This is all anonymous, by the way. So I don't know what his answer, and I appreciate it might not work if you weren't able to. So the options would be every personable. Have another 2.5 of short check. You give her 5 mg of long tech. The option would be 30 or 60 mg a coating or would you give to treat with IV morphine? There's no right or wrong answer here, but you want to think about the pee in this patient has, um whether you would get this patient. So in this scenario, I initially thought right, let's just give her another two now. Short tech reason I didn't go for a normal tech was because it's gonna take it sort of in the knee. Um, law. So it's long acting, but it takes quite a bit of time to start working. So the onset of action for nondetected be about in order to yours to keep people lost For what? 12 worse short tech. A short acting, a toxin in the 1st 20 minutes of getting it in the interim of trying to get someone to try and get me short at a slight new one. I just get this one. I'd be more thing. That was the first time I'd ever getting IV morphine to my monitor it over her because it was like, all right, we don't need to do anything with that Peter and 50 m high oxygen. I got a neighbor GI owner, and she could are injury by a doctor, I said, Well, okay, she doesn't get a chest X ray at the minute. It was the first only time I ever got a great combination. A patient I have tried since it's been a disaster to go off some bloods from the cannula because of rejection fraction. I give her 250 million doses of IV foods, and she was in Boston a half. So I give her 2 mg of magnesium try and super hard time to give you some IV. Morphine would never give him working before it so quickly went. I asked the pharmacist meant to do this, but this woman needs IV morphine. She's like, That's the first things first, give her enough demand. But it's the most important thing you can do for someone. You're going to give IV morphine to give him a dose about the sickness. Before you do it, you could give them cycles and you give them and downs of trying to give them at a proper right. Him. Give them up. They will think you've worked in your shoes. Well, thank you for it. So that involvement on you once you give them working, talking your head again. I've been working in a minute, going back to the There's nothing really there are. So I didn't do anything for that. And then for my Reg, there was no answer because she wasn't better. So then, for my eyesight, you won't surprise surprise. There was no answer. She wasn't dated with the ranch house was a consultant. I need There's something not right with someone, and I couldn't quite work out what it was. But I thought she's probably either perfect or she's got this chemical given her history, her locked in spine and her ABG. It was one of the best data to use of. Everything looks completely normal, and it doesn't reflect the clinical picture that was in front of me. So I put a request through for a CT of develop a sniffle in radiology to discuss a try and get it done on everybody from them. You get around, I got to consultant be created at me for requesting another CT stand for a lady before CT scans and four days, and he said, What has changed your own after one? No one else has seen this person Do you really think that little scanner when you use the balls work and said, Look, I appreciate I'm a half one. She's nowhere like I'm getting. I see you to tell moms here she's not on well, her optimum is rigid. She's got cording. They're new ball science. I think she's perfect. I did. I think she had parked. I thought she might have been a scapegoat, but my inclination will. She has perforated and so eventually got a CT scan approved. I was I was with my phone call to get this point, and with Border we took her going to CT Boone CT and said we were on our way. They went to CT. I took a shortcut, went to theater, walked into theatre on my team, just looked at me and said, What has happened? I said, This lady's of reward. She's deteriorated. She's honor it to the Styler. I need help like have stabilized her, but I need help to the ranch left. The other she described became with me two CT. She just looked at the stand clear, and we both went up to the word cold woman's family and to wonder that she was very, um Well, she was probably going to be an operation, because what we could see from the CT scan, Um, she had perfect your bile, and she also had an element of in the skin. It cut. We got I see you to come in. Assassinated. Yes. She would be a constant for intensive care. But multiplication. You didn't operation on your CT scan Came back. Which should she had a perforated see. Come on. She had my skin got on Radiology, Believe it. Or no bleeped to say. Well done. Um, but ultimately, you should never be in a scenario where you're after doing with us on your do not feel bad or do not feel anxious about going into theater. I'm getting someone to help you. Getting someone to come. Um, helps ask someone with you because she should. It's fine. Just ask someone on your, um Do you need help and your team and theater to school and tell them you need help in the need to come and help, you know? I mean so for being monitored. Most patients have said for her undergo major abdominal surgery will have the PCA pump on a regional block infusion can use. Make sure you tried Parsi double. For them. Personable is wonderful. It's really good. Analgesia him. People sometimes think it's just like pop in Smarties. It works for you meant for people. But if he said, it hasn't happened, the desired effect for the contact, the acute p and t More honest, that expert, like it was an F one. You will never be asked to prescribe that PCA pump. It's always prescribed by anesthetics them in the middle of the operation. They will set it up for her on they will be reviewed dealing by the acute p and T much more consistent with somebody. Cyst on the keep and marshes if you think someone needs peace. A pump, for example, for acute pancreatitis in the Pianist manage with short tempered on tec contacted. Keep peeing team because they come in fasting. Patient on. We'll start, you know whenever the years old doesn't have one more after you just start someone on a PC. April if you're having minor surgery having the goal, but all right, they're having the repetitive home things you could describe. It would be a girl, Parsi, two more right thumb up for 36 30 or 60 mg of coating, or 30 to 60 mg of quoting short check. It's gonna have to 5 mg or five a half or 5 to 10 mg. Jenna milligrams isn't little. Talk to him. You're cardiogram person, sort of base it off when the eyeball, the pitching. Do you think you're not milligrams of short acting, really gonna work for this pressure in? It also might work for them. That could be very Billingsley's To start off. It's a a prescription of 2.5 to 5 mg, and then you can review it the next day. And if they're using, say, 5 mg every 4 to 6 hours, then made them open, say, well, that can happen in five and 10 mg. But when you get from 10 mg, if they're in our shirts, certainly long tech patients will eventually come off PCA. So let me have a PC appointment for, say, 3 to 4 days maximum and a Q PM will then stop it sometimes in the world and they'll say, Let's get PCA pump doin Let's try and get you up on mobilizing. See your prescribe short tech Puran Long tech, either five or 10 mg BT on patients that have renal strings in support, not allergies. You can give them a sticky family PR. It is a wonder drug for them, so every morphing and can be used to kids of European don't pre selected dose. If I be more thing, don't say we're gonna give you size because you don't know five could be too much for them. Then you just take a nitro prescribed 5 mg. Now, do you have some of it? Sort of Ask someone to get you can make up 10 mg of I've been washing and 10 mg inability to make it up to 10 miles in a syringe. And, you know, student, it was no 100.9% saline and you administer it to the patient and you get them 1 to 2 mg Bolus is at a time, so you just connect the syringe into their cannula. Plus they're kind of give him a nontraumatic, flush it and then titrate them with doses of one between other rooms made the peak time from working to take effect is 20 minutes. So you're not going to be expected to stand to treat morphine for 20 minutes after, but five or six minutes will start feeling effect. And there's no harm in giving someone say, 2 mg to start with in a couple of minutes. Give them another two. It might take up to 10 mg or someone to actually get proper analgesia. From what if they have perforation if they have really about obstruction. If you have to get more than 10 mg of IV morphine after 20 minutes, you've given 10 mg of IV morphine is to nothing to the patient. Contact restituted. Contact you and definitely you can ask the anesthetics for advice. But please, please, please remember to give someone one on the matter if you're gonna be giving them IV morphine and if you get in someone working or short, taking a little technique is that before you need to know how to manage the side effects? The medications. You're starving. It's this thing management group. You're toxicity on us. Ask people Best investigation. Score in the respect your it so sedation sport confined on the GCS start or a neurologist, right zero over. See if they're alert. Other week. Well, no surgeries. Eat that. They're easy to rise there. Been asleep. But you talked to him. The pickup Very difficult, Difficult to rise. And it would be number two. Let me see. You got a score of three. If your ovaries a ball or unconscious. So how you manage a pure toxicity so mild of your toxicity. If you're expectorants test in tandem with sedation score of one. You're gonna want to get some oxygen. You're gonna increase the frequency of their own observations. Patients obviously going to be alert. They're chatting D advisable to use as much PCA or if they're haven't. If they're continually pressing that sometimes people just get in the habit of pressing PC able because they were free of experience being just advise him to reduce it, because if they don't be one of ticked PC away from and consider removing the PCA, but from a patient, you know if they've got a five bursts in and or that's a lot of working for someone to have, so just take it away from them, don't see how they get all motor opioid toxicity would be if the respiratory it is less than 10 of the best sedation scored two to do about give monster and increase the frequency of their observations. Remove the PC able and you would consider would be treating the locks. Um, if you could even if you think they need it, severe would be if the Risperdal has lasted me it on the Prevacid. A shin score of three. You want me to, sister? Been dilation. Be bugging them with my class mouth bag mask. Well, you gonna have to give them milk. So on contact your senior or anesthetics is the Aloxi lasts for approximately 30 minutes. But most all be retired a half life of longer than that. So you will give someone blocks and you think you've done your job and you'll get a pot to say they're still drives it. If you diagnosis one as having a P or toxicity and you give someone new box, um, just make sure you increased frequency of their observations in case you need to give him more. Look, somewhere you might need to start the moment. It's an infusion. Vienna's an apple. A night is not something you will ever be doing when your own someone will tell you and show you how to describe it blocks. Um, infusion. But it's important to have an a one c this. You're gonna be the first point of contact for most of my people in a ward. No locks in. Well, reduce the senator affects of opioids on, um, over juice. But that should say, Sorry. We'll hold on the reduced sedative effects, but low. So reverse analgesia. Donald Jesus. Effective a period. So if you're going to give someone meloxicam on reverse two week, the more you think therapy or toxic, they're gonna have a respect to your ass. You get a little you have to remember you're going to take away their pee in. Don't know you're going to bring back the PM because you're taking away the pain relief. So it's a very mild little up. So how do you give meloxicam? When were you treated? See, you dilute the 400 micrograms. Them was no 0.9% saline Optivite Tambor's and you you have it in both doses. If there's no effect, you repeat it until you do get an effect. And if you've had to give someone 400 micrograms, consider that that might not be a very toxic there because there could be something else going on, and you just got the wrong diagnosis. If you've got non responsive patient with severe respiratory depression, you just give a little oxygen. Don't dilute it. Just give it a 400 microgram bolus. And if you felt no response that after seven minute you can give them a further two doses or they might need to go in the infusion. But if you have to give someone locks and technically as an F one, just call your senior and say, Look, I had to do this. Can you come and help me? Or what would you recommend if you're starting to get into given doses of the 800 mg? And you should have someone were saying, You're with us and we'll even is it after you have to call someone? If I was doing that and because you might be honest attics and when the critical car stuff to help you check it if they're going to do another way, certain things breath one of the game. We aren't sponsor banning, but these ups that we find incredibly helpful that saved our lives. Um, probably our patients lives during at home will be pocket doctor. Be an F. Microgram is fantastic. It was only antibiotic. She could need to civic for your trust. What Today if they're allergic to something I was in the Southeastern Trust. They also have a P M guide and they have a cool good guide, which is great hustle of particles for https, as someone with covered Who needs that assistant maturation medical cause. Very good foundation Doctor is fantastic. It you can look it up if you're going to see someone short of breath and you can't remember what to do. It tells you essentially hard to assess one Certain differences to consider a resource is very good and it has a lot of urologists and it's gonna get an induction is not a medical up, but it's typing whichever hospital you're gonna be working on hustled contact numbers and the numbers of specialties that you might need. It's the PSA. Probably be at the end of your first on the whole, and we're going to first weekend in quotes on. I think you will look like that at the end of our first year working and thank you. This has been recorded. So we're gonna put it on two metal tonight the gay. And if no one has access to just drop anemia when we can try and get it emailed white teeth If you ever seen the Method West or their students, they reviewed my discount on the QR code. No ticket. If the backseat on metal, ma'am. Just that's his new. We asked for Allyson open feedback, and if you don't session was useless. Tell us, and we can try and make it better if you won't different potency to be involved or slow getting used to do. And it sounds ridiculous after two years of not mine. But we have, um, have toast is anything in alliance and just like it used to working on how to use it. And if there's any different sessions, you it wasn't covered next because Easter. So there will be a session next week. But after that, we have sessions almost twice a week just to get everything tightens for check it in the after year was on for anyone else that wants to treat, and they're always very well, um, Lantus, still in the er code, fix it if it back for Ms said on. Have a nice Easter. Terrible. I'll see what effect? Almost ask any questions, but I'm probably get some luncheon. It's really the end of the day. Thank you.