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Ok. Well, maybe just get started because um it's not a super long presentation. Um, grand. Ok, so, yeah, hi, I'm Anna. I'm one of the final E um, and I'm gonna be talking tonight about emergency medicine. So if you have any questions, please just stick them in the chat. Sorry, if you say something funny, um, just stick them in the chat and I'll get them at the end or if you feel, feel free to email me as well and my email is there, I'll send these slides out as well. So, ok, so emergency medicine can be really hard to revise. It's so broad and it encompasses a lot of specialties and I always think that a stations can feel um pretty overwhelming. They're like one of the few stations where you actually feel like you're doing the job. Um So this presentation is just gonna take a general focus, um, starting with approaching every emergency with an ABCD E because then you just can't go too far on while you're doing your A to E if you find a problem, do something about it and avoid hypotheticals. And so you're saying like I would is very like third year when you get to vinyls, you need to be like, I'm gonna give 15 L normal reader oxygen. I'm gonna give a flu b5 100 M normal C line. So I'm confident um and continually reassess. So once you've made an intervention at B and you're moved on to C when you've done C go back to a think again. B say how the S ATS doing now I've given the oxygen. Um And the best way I think to appreciate an 80 E is just to spend some time on Ed. So at recess is great to see this in action and see the trauma team working together. Um OK. So you all know, I don't really think I need to go through like each part of ABCD but just learn all the parts and then obviously pick the relevant bits um to what the osteo requires. OK. So our first topic is A S um So again, these algorithms are great, they're so helpful. Um And I'm not gonna go through the whole thing either because he's probably all have seen it before, but just to draw some important points. So um the four Hs in the forties learn those really well and be aware that as part of your ABCD, you're in or out some of those causes. So for example, um like hypoxia or hypovolemia, things like tamponade, leave that to the end. That's very unlikely. It's more trauma patients. Um And then just some key points. So CPR, you're thinking has to be a rate of 100 to 120 BPM at 5 to 6 centimeters depth. In bigger people. You might need to push to nine or 10, but that's probably not important for MCQ S. Um, something I only learned recently was that CPR has to continue for at least 50 minutes if they give all to, please. Um So that's an important caveat in terms of hypothermia, you're not dead until you're warm and dead. So you need to keep doing CPR until someone is at a normal temperature and then be aware of the different intervals can depending on how cold someone is. Another thing to consider is your post recession, post resuscitation care. ABCD. So do a repeat ABG give them oxygen. They're going to have a really severe metabolic acidosis after being dead because they weren't, they weren't oxygenating anything um blood. So yeah, repeat your uni do your lactate chest X ray? Have you done any damage doing CPR? Do they not have a pneumothorax? Any broken ribs? Think about definitive care. If this person is at a ward level, they're not staying there. Still thinking, do they need PCI in terms of heart problems? Do they need an ICU transfer? And again, repeat their ECG um Most important thing I think and I'll have to learn is your adrenaline dose. So make sure you know that um your amiodarone dose as well. That's a really common MCQ. Um And then next is your tachycardia bradycardia again, algorithms. So famously, everyone says, I'll just ask for the algorithm and you can't always ask for the algorithms. So for example, in fourth year, we had an AY where it was a man SVT, they gave us the ECG, you had to say it was SVT. And then a lot of people including myself when they asked for the treatment said, I'd like the tachycardia algorithm and they said, no, what is the drug you're gonna give? Um So you had to know that it was a narrow complex um regular tachycardia. So you're gonna give adenosine, you also can't ask for them in MCQ S. So I really would just learn them. Um Again, I'm not gonna go through every bit of both of them because you have all seen them before. But an important point is the life threatening features. So this often comes up in MCQ S rather give you someone's vital signs and they'll actually be shocked. So you need to recognize that that's a serious unstable patient and that you're not even gonna go down the algorithm. You're gonna immediately go to a cardioversion and you can give up to three shocks. Um know that you're vagal maneuvers. So that might involve blowing into a 10 mL syringe or you can sit someone up and then quickly lower them back and lift their legs and they are all on youtube. It's just nice to have seen them and recognize what that is. Be aware that adenosine is contraindicated in severe asthma. You have to give verapamil. Um cause obviously you also can't give beta blockers and something else, adenosine, amiodarone and atropine or three A's but all very different indications. So just really become aware of when to use which one. Um and something about adazine that helped me remember it was that use it in SVT because it causes transient AV block. And that gives you that feeling of kind of impending people feel like they're gonna die. And if you've ever seen someone being given um adenosine, they'll warn them of that before they give it. And then I remembered amiodarone because it was part of your als algorithm for your VT VF um bro complex tachycardia. Um And then yeah, the last thing I wanted to say about that was just in the bradycardia is be aware of this. So no, they don't have life threatening signs, but then you kind of have a second stage here where you need to know if they're at risk of asystole and things like Mobitz two block. Um They might give you an ECG and say, does this person need atropine? And if there's mos to block, then yes, they do, you can't just observe them. So yeah, again, just know those algorithms pretty well. OK. Onto acute Coronary Coronary syndrome. So in this, the history is always key um unstable symptoms have to be admitted even if the ECG is not diagnostic and they have normal troponins, also be aware of special grips like diabetics and women can have atypical symptoms. Um So in an OSC, if you have chest pain and it's a woman, you might think this could actually be an mi and it might not project with that typical central crushing chest pain. So yeah, the spectrum of conditions um kind of stamm and stabby, unstable angina. So you need your serial troponins. So you're gonna do three troponins and your ECGS serial ecgs as well. And you're looking for any ecg changes or troponin rise and then immediate management, you're thinking mona. So morphine titrated to pain relief, oxygen if they're hypoxic, don't just whack on oxygen. Um it's not gonna benefit them. So you wanna titrate to 94 98% nitrates. But again, be really careful if they're hypertensive. If your systolic is less than 90 don't give a nitrate because it will only make your BP crash aspirin 300 mg and then think about your management. So sty presenting within 12 hours of symptom onset, you're thinking PC, if you can get it within two hours, alternatively, you can give thrombolysis and look to give PC later down the line um contraindications to PCI. So, consider acute hemorrhage, major trauma if you have a decreased consciousness level of uncertain cause. So, if you're suspecting maybe like an intracranial event, you can't have PCI. Um And then in terms of semi unstable Angina, I find this a really tricky one to learn for finals. So you base it on the grace score. Um I didn't learn the criteria for the grace score, but I did learn that three is the cut off. And if you're low risk, you're medically managed. And if you're over three, which is intermediate or high risk, you're considered for PCI and then your antiplatelet agents. So, Prasugrel agl or Clopidogrel depends on if you're gonna get intervention. It also depends if you're high bleeding risk or low bleeding risk, it depends if you're already on anticoagulant, it's really difficult and I think it also potentially depends on the cardiology, opinion of the hospital you're in. So I learned pass med for that the past med textbook um for finals, but it was really difficult and kind of bitty. So I wouldn't get hung up on the details. Um But just know you might have to give aspirin wet something else. OK. Moving on to anaphylaxis a really common emergency as well. One that they like to ask about because you see it all the time in the community. Um And also in Ed. So, anaphylaxis on your ABCD assessment. If this is an osk, you're very quickly gonna think if there's a narrow obstruction stride or a rash, um angioedema, you're thinking anaphylaxis and you want to give that adrenaline asap. So don't wait till b, don't wait till C just give the adrenaline. Um I did my als as part of FC on Monday and they said that if you suspect anaphylaxis, you should just give adrenaline because you're not going to kill the average person with a, the, the dose of adrenaline you're giving. But you will really see if they're alive if they're in anaphylaxis. So that dose is 1000.5 mg intramuscular and make sure that's going to the and lateral aspect of the middle third of the thigh. Um Other things to think about. So when you're a to e give oxygen, apply monitoring um and they need to go to the hospital because you can have the biphasic reaction and people need to go and get steroids and be assessed and be in a safe place if that should occur. Mast re can be helpful if you're not sure if it was a tree anaphylaxis. So it should be measured as soon as possible in recess. And then again, 1 to 2 hours after the onset of symptoms and again at 24 hours to kind of help that retrospective diagnosis. I've also highlighted there the adrenaline doses, um you'll need to know that for P as well. So again, just starting those doses, um there's nothing, nothing special about that. Um It's also gonna be helpful to know there's no single diagnostic criteria to diagnose anaphylaxis. Um It's kind of when you see those symptoms and mast cell tryptase is helpful, but it's not a diagnostic, like if it's negative, you might still have had it. So, um yeah, just give I am adrenaline and flu a challenge. And again, you can repeat that adrenaline after five minutes. Ok. Um, acute asthma. So this is like a pass med favorite. They love asking about this table. Um And again, unfortunately, it's just one of these things you kind of have to learn. So this table I think I took off the nice guidelines. Um Just learn those figures like the night before, especially the severe, like the respirate, the heart rate, um just learn them off and know to recognize what puts someone in each category and be aware that if you have anyone of a higher category, you're in that category. So if your aspirate is 27 but your P fr is 56 you are still a severe asthmatic attack and I'm sure you're all aware. But the PC two is the thing to look out for if they give you an ABG and an acute asthmatic. So if you have a normal PC two, that's really bad because in asthma, like they can't breathe, so they're breathing really fast. So you should be blowing off all the CO2 and it should be really low. If it's normalizing, it indicates that they're tiring and they're not breathing as fast, they're not breathing as hard. And then when it starts to go high again and they retain in C two. That's a really bad sign. And you're at the near, near fatal level of asthma, you're thinking immediate intubation ICU input there like that's really, really bad. So yeah, but just learn all those features. Um They're all in zero to finals and past me in terms of treating acute asthma. So you're gonna, this pneumonic is one everyone uses. Um So again, oxygen just 15 L, normal breather at 100%. Um because hypoxia kills in terms of nebulizers, you're thinking five and five. So 5 mg of salbutamol, 500 mcg of apium bromide and then hydrocortisone. So, steroids are the thing that reduce mortality, relapses and subsequent hospital admission, the earlier you can give them the better the outcome. So, yes, acutely, it's gonna be the nebs that make the symptomatic difference, but it's the steroid that's gonna dampen down that aggressive response and make sure that in the next few hours it doesn't get kind of reoccurring, get worse in terms of the offline infusion and myself. That's a senior decision which you will not really be like you won't give those drugs on your own. So remember that to say that you're gonna escalate for senior review and acute asthmatics are people that become really unwell really quick. So again, do they need intubation ventilation to protect the airway? Because um once that airway edema gets to the point where you can't ventilate like you're in real trouble. Um Postacute. So this has got a GPO type thing where postacute kind of review with the GP. So, before discharge, they should have an asthma plan reviewed with an asthma nurse, they should have their inhaler technique checked. Um You're given a five day reducing prednisoLONE course. Again, I think that's 40 mg. So um quite high dose steroids and they should be followed up with their GP. So it's not impossible that you can get an OSK where you're reviewing someone who's got asthma. And they've recently had an admission in a ra history where you have an asthmatic. It's really important to ask, you know, do you take both your inhalers? So it's really important about that steroid inhaler. Have you ever had any hospital admissions? And then specifically, have you ever had any ICU admissions? Because an ICU admission for asthma is like a severe risk factor for another ICU admission. And then in fact, of exacerbation of COPD, something again, really common to come into with. And that's quite similar to asthma just in terms of your oxygen and don't over oxygenate these people because it reduces their hypoxic drive. And again, they're gonna need regular ABG S if they're on oxygen to monitor that um with COPD, you're more thinking towards the cause. So like, is there an underlying chest infection that causes exacerbation? Do they need antibiotics? Are they septic and get the MDT involved? Obviously, they love that? In a, so think about the chest physio and then think about do they need more invasive interventions? So like, well, noninvasive ventilation, do they need bipap? Ok. Moving on to pe so again, a really common um presentation in hospital and again, a really good sy because um it can be quite hard to pin down the diagnosis of a pe. So think about risk factors. So in MCQ, they'll usually throw something in there about someone who's had like a recent surgery or neck, a feur fracture and increased age. Sorry, there should be a comma, increased age or pregnancy, um, or HRT the contraceptive pill and previous, like if they've had a DVT before, um, that's a high risk as well. Most P ES originate as DVTs and then embolize the pul like the pulmonary arteries. And yeah, considered like this as a top differential in a patient who maybe has a new oxygen requirement, who's post surgery or who's been lying in bed with a chest infection for 67 days. Um, and symptom wise. So dyspnea is the most common and then tachycardia and hemoptysis and pleuritic chest pain. And if you have someone who's hypertensive with hypoxia, think they might have a massive pe and that can cause circulatory failure really serious again and they'll become very acutely unwell in terms of investigations. There's no um like single noninvasive investigation for a pe. So you're kind of trying to do these basic things to risk stratify people and then from there decide if they need a CTPA or if they don't. So your 12 lead ECG usually shows sinus tachy. There is like a very specific um pattern they talk about on pam A and didn't learn it, wouldn't see it directly that like wouldn't know it to see it. And I think it just usually is sinus tachy. So again, don't get caught up on trying to find a pe on an A CG. Um the chest X ray is mostly just to exclude alternative diagnoses. So like a pneumothorax or infection, you can do an ABG if they're hypoxic, um routine bloods and ad dimer. So the D dimer is the test that's very sensitive but not specific. So it's only really useful if it's negative. Um And that would be considered at a level of less than 0.5 things that can raise your D dimer like pregnancy, like render the wells score which I'm about to talk about. Not suitable. So think about situations where um ddimer would be falsely elevated. You can also do cardiac proponents if you're worried about an Mr or they also have some prognostic value. So as I said before CTP is gold standard, it's not suitable for everyone. If you're renally impaired contrast, allergy pregnant, then you might need a VQ scan instead in terms of scoring systems. So when I was revising for finals, the pulmonary embolism rule out criteria wasn't something I'd previously come across. Um I think just be aware that it exists. It's basically a score where if you're considered low risk of a pe, then they do these criteria to decide basically that you don't need any further investigation. Not even a ddimer. Um Not really sure how much it's actually used in practice, but good to be aware of. And the score that they do like to talk about is the two level wells score and that's the pretest probability of a pe. So, no, I didn't learn the wells criteria for finals. Um But I know some people who did, I learned the cut off scores, so less than or equal to four is unlikely and greater than it likely. So if it's greater than you're going to get your CTPA, if it's less, then you're gonna get your D dimer and then go from there, there's a quite helpful algorithm about what to do. So then if your D dimer is positive, you might need a CTP. So learn that I think over actually learning the criteria again, it doesn't take very much for you to actually meet the four points. So if you're reading the questions then and they're asking you to calculate a well score, I think it will be pretty obvious that this person's immobilized had surgery and um like has a high pulse rate and then all of a sudden they're gonna definitely need a CPA treatment wise. Um It's a do a, I think currently it's AP or OX are licensed for use for ap three months if it's obviously provoked and this can be extended up to six months if it's unprovoked. Um You might wanna, I think they decide this based on the vte recurrence risk and your orbit score. Um Consider also anticoagulation can be different in some special circumstances like cancer, pregnancy and antiphospholipid syndrome. And I think some guidelines recently changed about that. So double check um pass med textbook should be up to date with that if you have circulate failure. So a massive pe you need immediate thrombolysis. So that's um my goal to place. OK. Uh Moving on to DKA another really important emergency. So some precipitating factors might be like missed insulin infection, myocardial infarction impedes decay can often be a first presentation of type one diabetes in terms of symptoms. Um abdominal pain, weight loss, polyuria, polydipsia, dry mouth, the deep breathing and the sweet smelling breath. Um I did learn the diagnostic criteria for finals for DK. Um I think endocrinology be can be quite kind of like guideline focus. So I probably would learn that and learn when to recognize when someone's in DK from a question stand. Um In terms of treatment, fluid resuscitation is your mainstay. You can see on the right there, the fluid regime is really aggressive and you're given that um li every 122446. And again, you need to monitor these people. It's a really like labor intensive process. You have to keep going back checking the potassium. The protocol is really extensive would really recommend you go and take a protocol off the ward and read through it. Um So that involves an IV insulin infusion at fixed rate, 0.1 units per kilogram per hour. And then you need to know that once your blood glucose is less than 14, you start a dextrose infusion alongside your fluids regime. You can see there, you al also add potassium chloride, um potentially from like the second bag, but this depends on your G results. So it is a little bit complicated. But if you read the protocol, it actually is very self-explanatory important to note that you continue, you, you continue the long acting insulin and stop the short acting and be aware of the risk of cerebral edema. So you're giving a lot of fluid in some of these people. Um like me, quite small people. So there is a risk of cerebral edema. So you need to set you out those symptoms and increase the observations. I've also put the resolution criteria at the bottom there and remember that you need to be eating and drinking to be put on subcut insulin. Um Other important thing to note is that you need a senior endocrinologist review. If the acidosis and ketonemia have not resolved within 24 hours starting the protocol and you need to be reviewed by a diabetic specialist before you're discharged. Ok. So I'm gonna just go through a few little extras and then I have some MCQ S and some osk things. So, seizures um basics if you get this in an sy, like you need to put them in recovery position, cushion their head, remove any glasses, remove any harmful objects. If they've got a tile, something around the neck, take it off, loosen it, um ABCD if you need to put an airway in, put an NP in if possible. Um If they recover from, if they kind of stop seizing, give them high flow oxygen, 15 L, nonrebreather when you go to someone who's seizing, if no one started a timer, start a timer if the seizure lasts more than five minutes or they have multiple seizures without regaining consciousness, that's classed as status. Um And the way to treat this is Benzos first line. So, IV diazePAM is your first option. Prehospital. They might have rectal diazePAM or sometimes these people carry buccal me as their rescue medication for ongoing status in hospital. You're gonna need senior help, but that'll likely involve phenytoin or PHENobarbital infusion. Last line is induction of general anesthetic. Really important to note that hyperglycemia can cause seizures. So in an ay make sure you said that you need to check their blood glucose, even if they're not like diabetic or anything, you still need to check it. Um In terms of meningitis again, more of ap emergency. But think of that non blanching rash, take the ad approach, whether you're in hospital or in the community for your community. Give im be pen an immediate transfer for IV antibiotics. Um But they always say like the antibiotics shouldn't delay transfer. The most important thing is to get to the hospital where you're gonna be given CAFA or Trax. If you're in an AY, you can always just say, you know, I follow my local trust guidelines or whatever. Um that does tend to be accepted, consider adding other medications if they're in different groups. So, ampicillin, if you're over 55 or potentially less than three months as well, but double check that. Um and you wanna give dexamethasone if it's bacterial meningitis is also a notifiable disease. So it's helpful to say that you would notify public health sepsis. So, like I put this in a very small box here, but it's actually a really important topic. Um Just it relates to like every infection ever. So just know your sepsis. Six hands down queens do like a sepsis ov where they give you a news chart and someone's clearly like becoming pyrexic and deteriorating. Um So recognizing that and then treating with your three out three in there's a helpful sepsis protocol as well online. Um So get to know that just one important thing to know is that you wanna give your antibiotics before you take your blood cultures and your lactate is really important um to determine the severity of your sepsis. And for a urine output, you're often gonna have to input, put in a catheter and then again, hypoglycemia. So that's when your capillary bug, glucose is less than four symptoms can go from sweating and shaking right up to confusion and convulsions. Treatment. Um depends where you are and what access you have and kind of the state of the person who is hypoglycemic. So if they're able to swallow, you can give them 50 to 15 g of oral glucose. So people carry like Dextros tabs or you can give some kind of orange juice and bread. Alternatively, you can give I am Glucagon. If they have a Hypo rescue kit in hospital again, they can give Dexter's tab, same as community I tag on or often what they want you to say is that they have IV access, you're gonna immediately just give IV Dextros um over less than 15 minutes and be careful saying if there's an M CQ and it says, you know, Glucagon is an option and IV glucose if they're receiving IV fluids and they haven't been eating, I Glucagon is not gonna do anything because they won't have the glucose stores to release. So usually IV glucose will be the right answer. OK. So this is the last one for the MCQ s and G CSI always felt like this was a minefield and it should be really easy marks because like you do know the MV and the different criteria, but it can be kind of difficult. Um And again, they love an M CQ on this because they're easy to write. So just know that your eye response. So are they spontaneous looking around, do you have to ask someone to open their eyes in terms of pain, to assess pain response? You want to do a trap, squeeze or apply pressure to the super orbital supraorbital notch. Um If someone's having like a jaw thrust performed and they're not opening their eyes, that's a really bad sign because a jaw thrust could also be considered a pain response, verbal response. So for that, in an ask, you need to speak to them, you say hello? Like can you hear me? Do you know where you are? Um Can you tell me what's happened to you? Do you have any pain anywhere? I need them to be orientated? They're confused but they're still speaking sentences and things that vaguely makes sense, that's a four inappropriate words. And then if they're down to sign. So if they're talking about someone's groaning or moaning, that would be a two and no verbal response is a one, I think motor response is the most kind of difficult to pin down sometimes. So think about really break this down and how this would look if someone was to do it in front of you. So obeys commands, um localizing the pain. So are they literally like say you're doing a trap squeeze? Do they reach up and grab your hand, withdraw from pain? Like are they pulling away from your trap? Squeeze? And then you can see up at this picture. So like abnormal flexion and extension to pain? So know that kind of decerebrate, decorticate, posturing and the difference and how that's described in words, in case it's in an M CQ and I'm sure everyone is aware that the lowest G CS you can have is three. So there's no such thing as a G CS of zero and three is the lowest you can get. OK. So moving on to MCQ si Hope um like you have been able to hear me. OK? So feel free to like jump in and shout out and answer if you want to. I know like usually nobody does. But um yeah, I'll give you some minute as well in between them to just have a think. So if we go for this 1st 1, 29 year old man is admitted to with a head injury and reduced conscious level on admission, he's opening his eyes to peeing but not to voice. He's not making any signs on an application of supraorbital pressure. He flexes his right arm and extends his left arm. What is his gcs? I also can't see the chat function but you're welcome to put it in. OK? So it's six. So make sure you take the best response from both sides. So even though his left arm is extending, he can, he is flexing his right arm. So that gives him an M of three next one. So you're the F one on the respiratory ward, you see a patient collapse down the corridor and you assess he's not breathing no pulse and clearly unconscious. You're starting CPR at 30 to 2 and ask for help. The crash trolley arrives, you recognize the patient is in VF but you're still the only doctor present. At what point are you gonna give adrenaline? So, um you're on the shockable side of the algorithm. Your patient is in VF um but they have no pulse. So you're gonna do three shocks and then give adrenaline and amiodarone. If you were on the non shockable side of the rhythm, you'd be given adrenaline asap. But um for VF shockable attempt of fibrillation three times first. Ok. So I'll give you a bit longer for this one. A 51 year old lady noted to have bradycardia during a surgical cle in for elective minor surgery. Her obs are there are shown. So heart rate is 49 regular BP is 1 50/73 resp rate is 15 and the ECG is performed and shown above what is the most appropriate management. So, um no intervention is needed. Her ECG is showing first degree heart block with that pr prolongation. Um However, she doesn't have any adverse features because yes, her heart rate is 49 but her BP is 1 50/73. It's regular. Um, and this is an elective LAR in. Um, so she doesn't actually need any emergency treatment. And next one, so 17 year old girl is in with her boyfriend, he reports that an argument and she took a lot of tablets. So investigations, her initial ABG is shown. So PH is 7.47 and that's the initial one, two hours later, she reports feeling unwell and hears ringing in her ears and her repeat ABG shows ph of 7.16. And um sorry, I actually should have probably given you the normal ranges, but you can see the picture from the diabetes. Um and what is the most likely agent that she has taken? So it's aspirin. So, aspirin overdose initially causes a respiratory alkalosis because it stimulates your central nervous system. So you're increasing your respiratory drive and low and off CO2 to give you an alkalosis. Um But then that's followed by a metabolic acidosis because you metabolize the salicylic acid and aspirin. Um So this is the last M CQ and then just a few ay tips at the end. So Jenny Green is an 18 year old. She has type one diabetes and she managed it using a basal bullous regime. So that's Levemir 20 units a night and no rapid with meals. It's really common diabetes regime. Um, she presents to eg with a two day history of vomiting and diarrhea. Her G results are as follows as you diagnose her with DK A, discuss it with seniors and the DK A protocol is commenced. What are you gonna do about her basal bullous regime doses? So you're gonna continue her Levemir because that's her long acting and stop the novorapid because she's, she got vomiting diarrhea, she's not really eating and drinking. Um, but you always continue that long acting insulin even in DKA. Ok. So um almost at the end, basic ay tips, I think um for emergency medicines. So just recognize your limits. Do your A to e and then know when you need senior help. It's like obviously in real life, you know, someone calls you to see someone sick. The only thing in your head is who's gonna come and help me. But it's surprising in an ay how easy it is to get so wrapped up and try to hit all the marks that you actually forget to say you need help. Um And it actually is very important because it shows that you're safe. So just make sure you say it out loud. Um And on that note, vocalize all of your thoughts. So even if you're like seeing things you're a to e it's so easy to get into the rhythm of airway breathing circulation and all the little things you look for. Um, have a system and follow the system every single time and you'll not go wrong, communicate with the patient. So in an emergency again, it's easy to get wrapped up in this like, oh my goodness, this patients really sick, they're gonna die. But actually often in an emergency, the patient is fully aware and they're also really stressed. So you need to communicate with them and do your A to e but also keep checking in and say, how are you doing? We're giving you some fluids, just your blood pressure's a little bit low or you know, you have a temperature. Are you feeling a bit shaky or anything? How do you feel and go with what the patient tells you as well, particularly in of because they'll be told to say it practice 100 million times under time pressure. Um Again, ae there's plenty on the internet. Um I would really recommend gy medics like paying for it. Um If you can for ay practice, we split it between like seven of us. So it really just a couple of pounds and it makes so much of a difference to have all those stations ready to go and keep the big picture in mind is another thing. So, um it's easy to get bogged down in figures and in finals, they'll hand you like three charts at this side of the station alongside the brief and you think flip like, I don't know what I'm looking at here, but actually, when you go in and speak to a patient, the history is always the thing that kind of leads you down a path. So, yeah, just keep the big picture in mind. And again, on that note in finals, um, I know you are fourth year and like your ay finals and maybe next year. But something that I think I would have liked to know sooner was that the final stations are like, quite different to 4th and 3rd year. So they're like multipart stations. It's not that much longer than the ones before, but get used to taking that focus history within one or two, maybe three minutes and talk about your relevant investigations and like you might have to communicate management all within that 8 to 10 minutes. Um, we station this year where you were outside and there was a lot of charts and then you had to go in and take the history from the patient, then decide what the diagnosis was. Had to prescribe something from the EBF and then had to start talking to the patient about the diagnosis and counsel them on it. So that was quite overwhelming. And I think I would have liked to be more prepared to, you know, um, like rationalize my approach. So yeah, practicing and like that type of station and then I took these feedback points off the ones that Queen's published. So it's a mixture of fourth and final years from, um, like the past five years and it's just stuff that seemed to come up again and again, so often they love to throw you a hand over in the last two minutes at that bell. So know your sbar approach. It's a really useful thing and they always say the best students use a, um, it's such a pain but check patient details on all your charts. Um It's an easy mark and I doubt they'd actually, I'm not sure if they'd ever actually give you the wrong charts. But um in my Antrim walk last year, they did and it really threw a lot of people. So check details on every single chart. Um avoid medical jargon, particularly when you get to that exam final stage, it's so easy to, you know, rhyme off all your criteria and things you're looking for. But then when you go and speak to someone and it's kind of hard to vocalize those things in a kind of layman terms. So get used to doing that when you're practicing with your friends. They also talked about how students find it hard to assimilate all the information, think about the big picture. So keep that in mind um be prepared to suggest action when you, you have a serious medical emergency. So if in an A you know, someone's like become unresponsive and they've got no pulse, start doing CPR like don't say, oh, I'm going to call my senior, like you need to be ready to do the basic life support tasks. Um And, but if someone's deteriorating and they're not, they still have pulse, you know, call for help early. Um you can never go wrong, calling for help. It's, and then they said this was a bit of a random one. I saw that um it's essentially essentially actually know how to assess D so pupils and then movements and they specifically talked about knowing how to calculate A G CS. So that was an OQ station that I thought could maybe come up. So maybe give that a practice. And then everyone's favorite thing, taking a focus history. I still am not sure sometimes what that means and how to do it. But I think, you know, go with the symptom that you're presented with, try and build a picture, maybe don't ask them how many pets they have at home and just try and do the relevant stuff. And I think you get good at this on GP placement when people are on the phone, kind of yapping away and you're trying to, you know, get to the point. So make the most of those telephone consultations and try and get good at um taking a focus history. So some things that I haven't covered that probably are important to go over. I just didn't wanna make this a really long presentation. So burns fractures, chest X ray, Abdo x-ray, probably all very good at those ct brains that come up in an ACY for us and it kind of threw a lot of people because you, you feel like there's not really a lot to say and there's actually not, but just read over maybe the geeky medics on a systematic way to do that trauma and c spine immobilization and maybe go to ee and get used to using the c spine colors cause they're a wee bit weird. Um And they can be difficult to size and I think it is on the medicine portal trauma again. Just think of your catastrophic bleed before you do your ABCD um drug abuse and treatment. Love for an M CQ pass me really like them, just learn them off. Um You don't need to know do this for them. I think just know the direct correlations and wound management. So like how you would manage kind of a minor wound like steri strips and different um ways to do that. So I don't have anything else I have planned to talk about if you please could give me two seconds until I can put the feedback form in. Um I would really, really appreciate if anybody could fill that out. Sorry, just a second. Um Any, yeah, any questions, any questions um please write them in the chart but yeah, give me two seconds. So I get this feedback for OK, I can't find the feedback for him, but I will put it in the fourth year whatsapp group. Chat and I would really appreciate if you could fill that out for me. Um Again, any questions like fire them in the chat, hang out at the end. I'll wait until everybody leaves and I hope that was useful. So, thanks for coming. Thank you. Um Yeah, so sorry. I just saw that question with suspected sepsis. Do you give antibiotics first or do you take blood first? Give you antibiotics first? Um Because if you get, oh, sorry, no, sorry. Get to take your blood first. Take your cultures and then do your antibiotics because otherwise your antibiotics will mess up. Um, your blood cultures. Apologies if I said that in the wrong order. But yes. Um cultures first then antibiotics. Thanks so much.