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Hey guys, we'll start in about four or five minutes. Okay. Hello. I hope everybody can hear me. I'm Natasha. Um We'll start in next couple of minutes if that's okay. Okay guys. Can I just ask? Um, can you hear me? Okay? And can you see the slides? Do you just drop a yes on the chat? Brilliant. Ok. Hello, everyone. I'm Natasha. Um I'm currently in Fy to here in Durham, Darlington in the UK and we're going to be talking about F one on calls and the common things that you're going to see. So, congratulations. You're all gonna become a phone soon. Um Have fun. So learning objective wise. Um and just to make sure everybody can see the slide changing. Yeah, I'll just wait for confirmation and that's okay before I keep talking. Brilliant. Thank you. All right. So what is the purpose of today's presentation is being aware of some of the common tasks that will come up on your own call, shift and developing an approach to any of these tasks? Now, this is a one hour talk and realistically you're going to be a doctor for much longer than this. And we can't cover every single task that comes up because there's a multitude of tasks and people will keep coming up of random things that we can well review. So what we're going to do is develop an approach to them. We're gonna find out and discover how we're going to look up and use our own trust protocols and we're gonna have just a brief whistles, top kind of like introduction to handovers and escalation and developing the skill of prioritization. All right. But most importantly, it's just not to panic going into this on call shift. That will always be things that you're unsure of. But I think what's really important is that if you develop an approach to it and you are system like systematic about things you get through it. So I don't know about everybody else, but I moved from Aberdeen and I came here to Newcastle to work. So a lot of people do change the hospitals where they did their um shadowing years or where they did their medical years and when it comes to a new hospital, it's a new system. So fundamentals that we're going to go through, right? It may seem daft. But how do I document and how do I prescribe? We're going from either, is it on paper or is it online? And if it's either how do I do that? Especially if it's online. Do my logins work? Do I actually know where it is that I need to press to document something and do I know how to prescribe stuff or do I know where care plans are that I need these things to be there? And do I know where to look at a drug chart summary on my online system? Where is my patient summary care records? And these are your GP records? Because most of the time if you're on a night shift or your after 5 p.m. you don't have a pharmacist that's there to help you. If you're patient, can't really tell you or is not corpus mentis enough to explain to you or just basically does not know what medication they're taking. You just need to know where to find this on your system. And where do I find the trust internet? Because in every hospital or trust policies can slightly differ compared to what we study for like 50 years and things like that. So it's really important to know where your trust internet protocols are for antibiotics or even electrolyte replacement or even just referrals like who do you refer to? And what's the process? How do I bleep? Someone seems like an awfully daft question. But it's literally even just understanding what the numbers are that you need to put into your phone before you get to somebody's bleep number. So for example, in my trust, what we do is we press the numbers 88. And then for example, the med reg bleep is 43146 hash and then you have to put down the number of the phone that you're calling from. So for example, then it would be 55103 hash, put down your phone and you're waiting for your med reg to call you back on that phone. And is there a handover that I need to be there for? And who is on call with me? And why is this such an important one? It's because you need to know, is there an AI team? So this is an acute intervention team. This can be what we have here in minorities as a acute advanced nurse practitioner. We've got healthcare system and they, plus as this F ones, we've got one medical F one and one surgical F one, we represent the AI team and on top of that, we've got one med reg and we've also got as many medical acid shows there around. Reason is you need to know how many bodies there are around floating around the hospital because if you need to escalate to them, if you need to discuss something or if you just need extra pair of hands, how many hands do you actually have with you? Also? You're on call. So you need nutrition and you need caffeine or you need sugar, you will develop your system in no time. But it's really important to bring something with you so that you're fueled. Although the adrenaline might feel you enough depending on the task. So I'm gonna talk you through how we do an on call system in my area, which is north east of England. This is a zebra pod and basically what it is is I carry my bleep and I carry this pod and I live in a hospital where everything's electronic, prescribing and documentation and people send me task for things that I need to review or no or whatever through this pod. So we are going to pretend that we are on an on call shift together and we're gonna go through stuff um Bear in mind just pop any questions that you have inside the chat box and I have it right beside me. So if I'm looking, I'm just looking at the chat box. Uh So yeah, so let's start. So, oh, we've got quite a bit actually coming through. Um Do you guys see all of that? Yeah. All right. So read it out very quickly. All right, you've got person complaining of some tooth pain, somebody's not sleeping, they needs, they'll be cloned. Somebody scoring a tree for low BP. And this is asking, do you need IBT few more pain? Oh, somebody's complaining of chest pain over there and asking you to review and somebody else has reduced oral intake and need some IV tea and somebody's a bit constipated and they might need laxative. So, and this is ideally some of the normal things that you will see on your pod or you will get bleeped about. So you'll write all of this down. So I'm gonna ask you which task would you deal with first? So, just pop it inside the chat box. Any answers? Nobody. Maybe the tooth pain, maybe not. Oh, thank you. Yes. Chest pain. Right on the dot I'm glad. Okay. I think I would agree with that. We'd want to go and see this chest pain fuss. So we've gone up to the orthopedic ward and we've got a 78 year old guy that's complaining of chest pain. You're the only person there. You've gone on to him, he's holding his chest. What do you want to do? Do you want to ask him questions? Do you want to read his note? Just drop it down however? Yeah. Okay. All right. Fair enough. It was the first test. So, what we're gonna do and how we're going to develop an approach to. This is very simply, let's take a history, let's do an A te let's get some observations, get your nurse that's with you or the healthcare system. And I want them to do your observations and we're going to consider things like the investigations that you can do for them. So whether this is right beside them bedside or radiologically and you want to know a little bit more about their admission. Why are they in hospital? And with that, you want to know about bit more about their past medical history, what medications they're on their social history and everything. The reason why those two are in asterix at the bottom is because all of these entangle each other, whether you want to read up about their notes before you go and see them is your preference. You will develop your style for it or whether you want to do it after you have a look at them immediately. But regardless, you need to do both of it, whether you do it before or after. And that's just something that you need to keep in mind. So you find out after reading his notes that he is a 78 year old guy, he had a fall, he had a pubic rami fracture and he's just on conservative management, but he's awaiting a social sort because he came from a care home. So there's a bed situation and he can't go to that same care home. Yeah. Yeah. Yada. But let's focus on the chest pain. So something that's been instilled a new since med school, probably since first year of second year. How do you take a chest pain? History? There's an acronym and I will sit very, very silently until I get that acronym spelled out for me on the chat box, Socrates. Yes. Absolutely brilliant. Yeah. So let's get right into it. Um He's complaining of this center of his chest just went off 20 minutes ago while he was in bed. He was just resting. It is heavy. It feels like someone's sitting on him. Know. Of course, it's not radiating anywhere because he's just saying that he's feeling short of breath, he's feeling sweaty. Yeah, he's had some productive cough off and on. But the pain is constant and it's, uh, it gets worse when he's moving. It gets worse when he's talking to you. He's a bit of a grumpy fellow. I mean, you meet all of them at like one or two in the morning and when you ask him severity, it's about five out of 10. So you've taken a history. All right, well done on you. What do you want to do next? And I mentioned it before and I wanted to be regurgitated to me and instilled in your brains after this talk is a way to examine someone that is acutely unwell or just unstable. But it's a five letter approach starts with an A. Yep. Yes, we want an 80 E. So when I say the words regurgitate, I expect you to just say a BCDE immediately. So with that comes your observations and we'll run through an 80 later very quickly. So his airways Peyton, he's not in any obvious respiratory distress. You have a listen to his chest nice. He's got equal air sounds, you know, coming in true, bilaterally. No crackles know bees. His heart sounds are fine. He's got a regular and a very strong heart rate pulse. Um his cab refills about three. his calves are nice and soft and he's got no catheter. So as GCS is 15, you felt this tummy, it feels fine. His pupils are equal and reactive and his BMSR eight so well done, you've done a glucose at two in the morning, you should be doing it. Um, but for the sake of this, you've done it okay. So with that history and with a normal examination, which you've done so far, what are your differentials bear in mind? You're just standing here in front of this man who's complaining of chest pain. So what do you want to do? We've taken a history. You listen to his chest, what are you worried about? If he's complaining of chest pain you're going to be worried about? Yep, you want an ECG Exactly. You're still worried about an M I. Yeah, definitely. So first question that I want you to have when you're looking at a patient inside award approach, wherever it is, is is this patient unstable? Why? Because if they're unstable and they're unwell and you only have two hands, do you need extra pair of hands? So what you can do sometimes is put out a medical emergency call or you just ask for help and that is just something not necessarily, you have to do it right now for this patient. But what I'm saying is something that I want you to keep in mind when you approach a patient. So yes, cannulate them, take some bloods. Somebody said, am I we're worried about cardiac sounding chest pain. What blood's do you want? Taken specifically a marca that we all love the cardio? Yes, we want a troponin. Definitely. So somebody said, ECGS, we're going to come to that. We're going to consider a chest X ray because this man has gone and said he's got a productive cough and we're gonna think about analgesia. Now. Bear in mind it's all good and great that you are such an amazing doctor. And you want to get to the bottom of this diagnosis. Never forget. Don't leave your patient in pain. Give them something dulling down there. Pain and bringing it down to zero does not change your approach as to how you actually come to them and talk to them about the pain. All right. So document, document very clearly what you've done as well. So let's go to ECG one. All right. So this is your first CCG. Let's just say it's the first case scenario and I'll give you guys just a few seconds. Okay. Just have a look at it too. Anybody wants to drop a little comment in the end what it looks like. Do you see anything out normal? And we've got a long limb lead to at the bottom there. I know it's on a CG session. Not, probably can't spend too much time going through ecgs but have a look. Anything stands out to you. Somebody is asking whether there is sc elevation in V 22 B six. Okay. So no, and somebody else has also said that it looks like a normally see G Yeah, so bear in mind this is a normal ECG with normal sinus rhythm. I see where you're coming from with the ST elevations and B to the V six. I don't know whether you guys can actually see my cursor. Can you see it? I think what you're pointing for is very quickly. It's the J point and that J point is exactly the same as to where the line is here, the baseline rhythm. So that is actually just a normal in dent in your um in your ECG wave. Okay. And very quickly, you will see T wave inversions and a VR and V one that is normal. It doesn't have to be pathological, it can be physiological. So ECG one was normal sinus rhythm. So in this scenario where you've seen this man that was complaining of chest pain and you have a normal looking ecg what is it that you're going to do now? So some lovely people have told me that they have taken a specific blood marker and you're going to be waiting on those bloods. Yep. Now, if it comes back, if your troponin comes back is under three, guess what? At least you can breathe. It's not a stemi, you don't have to deal with this person in front of you that's having a stemi, but you should consider other things. And so can anybody give me any differential diagnosis for somebody that was complaining of this central chest pain with a normal looking ecg bear in mind? I do appreciate obviously, the observations were not hypoxic, he was not tachycardic but just shouted out just a couple at least and then we can go through them. This is more so for getting you to just think on the spot when you've got this man in front of you that's complaining of chest pain. So he mentioned the words productive cough and we were thinking about doing a chest X ray. He's been here in hospital, um worried about him picking up a bug, maybe. Yep, lower respiratory tract infection, pneumonia, brilliant. You could be even worried about peace, but we're going to go through that, hopefully another long time later and another separate presentation. So as per what you're saying, you would consider other investigation. So a chest actually would help you see whether it's like a pneumonia. Do you see any new consolidations? His bloods with a CRP or his white cell count will also help you differentiate if that was the case D dimer P route MSK. It could just be, you know, costalcondritis, it could just be how he had a fall. He might have a, you know, stone or fracture, things like that. So, analgesia just really, really important and something that you can do for, we're going to talk about the troponin when it comes back in the mid area with a normal looking ECG something known as a heart score. And please just discuss with the senior at any point. But what is the heart score? So heart score was designed when you have a very cardiac sounding history with no ischemic features on your ECG and you've got this troponin that's between eight and 100 and 20. This is when you use the heart school. Okay. So how it's broken down with is within 8, 220. You look at the history, the ecg age, your risk factors and your troponin levels based on that based on your heart score. If it's three or under, you've ruled out an INSTA me and you can think about other things. If it's more than three, you can still be a little bit more concerned of an insta me. So this is why you go and speak to a senior and take it from there and you see how he is. You'd see how he has, you know, recovered with analgesia. You'll see whether the pain returned and you would most likely have to repeat the troponin within two hours after your first sample and see whether that increases or decreases or stable. And very likely you'll discuss with somebody a bit senior before you make this decision, which lies a little bit in the gray area. So we've got similar guy, he's has exactly exactly the same guy. Actually, he's having that chest pain but he's got a different ECG you guys ready for this one? So you take your time. Have a look and shout out if you see anything that's different. Something's jumping. Yep. Yeah, we've got marked ST elevation. We do. Does anybody want to tell me which leads they are? And does anybody notice sometimes with ST elevation? Yep. Yep. Exactly. It's a stemi well done with ST elevation. Sometimes you can get reciprocal changes. So depression in other leads. And can anybody see where they are before I change the slide? Oh, I know you guys know what? So it's fine. So just go through the leads itself so I can get my cursor. We see ST elevation here, here, here, here and here. Yep. Brilliant. We've got antihero lateral ST elevation with reciprocal ST depression in 23 and a BF. Yep. Brilliant. So, we've got this guy in front of you right now. He is having a clear stemi. What do you do? What do you do with a STEMI that's in front of you. She's you staring at the CCG and you know that this is a person that is unwell. Do you want? Yep. Yep. Yep. Brilliant. Go for it. Yeah, we've got the acronyms but also Marist Ically more realistically when you're standing there at the patient, you put out a Met Coal and you get some help. Okay. Just make them aware that this is going on because the incidence of someone having a stemi and relating it to if they were to get a cardiac arrest is extremely high. Yes. First thing you want to do make somebody else more war. Then you go on with your semi for a skull, which I'm so glad that you guys already, you know, brushed into it. We've got, we're going to hit them with all the big drugs in the world. So you've got Aspirin 300 as for your hospital policy to Caligula 180 we've got analgesia. There is this query for Fonda paradox, whether you reach the 12 hour window for a PCI depending where you are. So if you're in a district general hospital like me, you, your PCI, your nearest PCI place is about an hour away. So you kind of have to scan your ecgs and discuss with them over the phone. In the meantime, you will do Monarch and you will do serially CGs, why a nurse has to be with them and what you want to see what the serially cgs is. You want to see whether those ST elevation are they getting bigger, are they getting worse? And that's the reason. So Monarch, I know you guys already know it, morphine oxygen if they need it, nitrates aspirin reperfusion therapy is basically they're PCI there. Percutaneously coronary intervention call political or Takagi low. And Heparin is your funder paradox. Whether you have that 12 hour window. Does that all make sense? Yeah, I hope so. Oh, look, we are back to Arpad your pod of death. All right. So, look over here, look at that chest pain you've got and reviewed it and you've settled it. This patient was, well, the normal sinus rhythm patient was buying, you treated him for a pneumonia. That's what it was your second patient. He's been whisked off by a blue light ambulance and he's off to get his PCI. So that goes away. That's great. No. Oh yeah, this is what happened. You tend to get more tasks. So we'll now take a look at these tasks. Okay. So you've got a failed cannulation. So, failed procedures are often comes to you. So if you do have an AI team, like what I've said, sometimes they will try and if they fail, it comes to you as a doctor on call, now, we've got a lot of pain reviews that's there and we've got a lot of I VT reviews. Uh So what we're gonna do is we're gonna group them up and we're gonna talk about them as an approach. So we're gonna talk about pain and analgesia. All right. So what's his pain seems easy enough. But I had to look up what the actual definition would be. What exactly is pain apart from the fact that you have to go and review it not to pain in itself. Sometimes it is signals anybody. Nobody. It's fine. That was a bit of annoying question, to be honest. But what it is is an unpleasant, sensory and emotional experience that could or resemble, that's associated with any potential tissue damage. And it is multifactorial because it's based on biological, psychological and social environment, like environmental factors as well. Can anybody drop into the box? What types of pain there are? And if you just think like, um, just like any illness, there is sometimes there is an immediate phase. Yep. Oh, brilliant. Look at that. Yep. Yep. That's great. Ok. So like I was saying the illness, how we group them is acute chronic nociceptive, neuropathic and ridiculous. So acute phase of pain is obviously something that is soft tissue injury, illness related and that can change into a chronic pain. Nociceptive is the idea of itself is is because acute and chronic work is in a bit of an umbrella and nociceptive actually sits underneath them and that can be just things such as an external injury causing it and that's your perception of it. Neuropathic has obviously got to do with your nerves and radicular is based on your nerve root like for example, sciatica pain, very ridiculous pathic. So we have got people that you have to go and review and they look like this, okay. They don't look like Matt Leblanc, but they look like they're in a lot of pain. So when you go and assess someone from pain. What information do you want from them? So drop it down inside. What questions would you ask somebody in pain that you have to review? I think somebody said the magic words they did. Yes, you would literally just ask for Socrates. And that's just an approach that you would do for any type of pain. It doesn't matter, doesn't matter whether it's from the A tete, it doesn't matter whether it's from their leg or their toes just use that. And you also just ask and you look into their history, what medications are they currently taking? What? Analgesics? All right. So we've got the Who Ladder, right? Pain Ladder. We've seen it in med school and we have to just now basically use it in real life when we're practicing medicine. So, indication for analgesia you've want to know, obviously the type of pain that they're having and what's the pain actually targeted for the site and the severity of the pain. And that's why we've got this lovely Ladder here that we will talk through as well and look at their drug cardiac. So this could be either, you know, a paper or online. But what you're looking for is, are they actually taking their medications? Are they refusing it, has it not been given? And when it's PRN, has it actually ever been given? Because you'll soon find out a lot of PRN medications aren't being optimized as much as they should be. And can you step up the analgesia? So let's talk about this lovely ladder that we have here starts out really simple. Right. Starts at, at one we've got mild pain and we've got a non opioid plus minus adjuvant therapy. What does that mean? That means everybody's favorite paracetamol. Okay. It starts with paracetamol and what you add on are things like nsaids. So we've got selective of choice. You've got naproxen, ibuprofen, diclofenac, other more uncommon ones in the medicine and like meth anemic acid, not things that you would normally give people in the hospital. And you've got selective and said, which are the ones that ends with Coxib. So like, uh Celecoxib and things like that. No, that's for just mild pain as you move up to mild and moderate pain. We've got this visit, commas week opioids plus minus your non opioids. Can anybody tell me what you would consider a week opioid that you would step them up too? Something that you will see very commonly and you'll see a lot of us prescribing it to people. Um, starts with a C. Yep. Codeine, brilliant. Yep. Exactly. So codeine dihydrocodeine traMADol don't necessarily ever expect ssf ones to start somebody on traMADol. You would normally do that with advice, but that's what's considered a week opioid and you would do that in combination and then we've got to moderate and severe pain. So, what's your next one? What's your next step? That's considered a very strong opioid, it starts with an M. It does. Yes, it's what codeine actually metabolizes into in your body morphine. Yep. So, now this ladder was made in 1986 and it's been amended and modified was initially meant for cancer patient to try and control their pain. But the principle applies. And your approach when you go and see someone in pain applies as well. All right. So when you're thinking about that, that's actually a fort step and that you'll see that in surgical patient's, you'll see that in surgical patient's and that can be like things like nerve blocks for the rib feature pains and things like that? Okay. So are there any precautions that I should consider? And oh, I see. We have questions. All right. So why do we have to seek advice before prescribing traMADol? So it depends on hospital policies. But actually, when you're comparing codeine dihydrocodeine traMADol and morphine, they all work. And I say morphine as an oral morphine. So, or a moth traMADol has a higher, slightly higher rate when it comes to seizures and when it comes to basically respiratory depression, compared to the other three, that's just the only reason. And again, these are just all the oral availability. So you wouldn't necessarily always start someone on traMADol, but it mostly depends on trust wide guidance. That's just why. So if I talk to you about precautions before prescribing a medication, there are a few things I want to remind you of allergies and sensitivities that patient's have does adjustments. So, if they're underweight, if they're under 50 kg can't really give them four g of paracetamol. Their renal function. You want the medications to be renal protective. Morphine is not as good for your kidneys. You would normally convert it to oxyCODONE. And after that, you'd also think about contraindications. So, for paracetamol, you think about liver cirrhosis for nsaids, you think about upper gi bleeds, asthmatics. Um and morphine just the renal protective issue. But also remember ABC. So the side effects of giving people analgesics like this. So giving them antiemetics, considering their breakthrough medication and considering the constipation because that these are normal side effects that you need to think about. Also, you need to think about overprescribing. So things like opioid toxicity can happen, respiratory depression can happen and false risk for the elderly. So we've got little mini cases for you. Okay. So what we can do is talk through this. So we've got a 56 year old female. She's coming for pancreatitis. She's just on paracetamol PRN and she's on codeine PRN. Anything that you'd want to do for her, she's in agony. You found out that a PRN medication she's only been given. It may be both the doses have been given maybe about like over eight hours ago, hasn't been repeated since. Bear in mind. Hepatitis is an extremely painful thing. Yes. To your question. You would cover nsaids with PPI, we would talk about that soon. Yes, you can increase the dose of codeine. Definitely. So, something that you would do. Hepatitis, extremely patient, extremely painful. And you'll find that they're on a lot and they can actually go all the way up to Ivan morphine, especially in the, on the surgical wards thresholds a lot lower. So, first question, first thing you do make it regular, right? Both of it make it regular, increase the dose of codeine. So codeine can maximum, it can be 60 mg four times a day and you can even start them on or um off if they're using that all the time four times a day and it's still not right, not enough or um off. So you can go five mg based on how you know how much they weigh, how do they look? And if they opiate naive um qdsprn every four hours, think about that and what you can do when you've reached maximum. For example, you've gone up to 10 mg of Armagh, most most hospitals have a pain team review. So you can think about that okay for the next day, for the day. Team to basically task out second person, 48 year old male rib fractures, tibial fractures. She's on press press cetamol orally one g, four times a day. Codeine 60 mg four times a day or um off 10 mg every four hours and he's been using it maybe twice a day you would say, would, can anybody think about what they would add for him or what they would change for him? So you've got someone that's fairly young, he's a sustained, quite bad injuries. There was something that we can even think about like because his can be a lot like muscular pain as well that he's going through so we can think about this NSAID at this minute. So option one, he has no contra indications, think about your insides. And like Dr Addy mentioned with nsaid, you always want to cover with PPI cover, it would be a short course and you would try to help him with that. Me too. You can also try increasing the frequency. So instead of every four hours of or um off, you can make it every two hours of or um off and see how much at least the last time through the night and the day team can review that and three for rib fractures, lidocaine patches are a great alternative to help. You can prescribe them. It's one patch. It's kept on to wherever the area is the most painful and it's left um every 24 hours and change their four. So we've got a final lady. She is 89 year old. She came here with Falls. She's got an AKI on CKD, she's got horrendous EGFR and she's on Paracetamol PRN and she's on or um off 2.5 mg every four hourly and she's just complaining of pain just everywhere is a little bit a key and she hasn't been getting either one of these things. Is there a problem that you see here with the renal function and what she's being prescribed? So I think the paracetamol would be fine for her renal function. But the arm off the arm off, we wouldn't want her to be on with that EGFR. We would want to swap her to Oxy norm, which is basically oxyCODONE. But what I would say, first office, just change the paracetamol to regular and just knock off the arm off and definitely put oxyCODONE but put a tiny dose as well. I would say that you'd find that paracetamol regularly for an elderly person tends to help a lot more than you would think. And you just be quite precautious about the type of opioid medications that you put for them. A lot of them are tiny, they're frail, they're false, risk are insane and they're petite and the opioid naive. So just a little bit about pain in analgesia. Every case is very situational based. And I want you just follow a system start low, go slow and if you're unsure if it's too complex because there are so many different types of pain killers. Are there so many different types of situations? Ask somebody a bit more senior with help if you're stuck. So next time we're gonna talk about a little bit more about IVT or intravenous therapy. I know you guys just had a talk, I think. Um was it yesterday or day before by EBN? She's already gone through this. So we, we don't necessarily have to talk about it too much. It's just to run you through it. So, indications for IVT and we're going to break it down into the three main indications as to how you would prescribe it. We're going to talk about resuscitation, maintenance and replacement for recess. You're gonna think about shock sepsis maintenance. You're gonna think about, you know, is it reduced oral intake? Um the nil by mouth, they've got, they've nil by mouth, no energy, things like that. That's probably the task. The reason I keep saying these things, probably the task that you will get as well like literally and replacement is, for example, darien vomiting or um third space losses in surgery as well. Pancreatitis is great. One obstruction, hype hypokalemia, you need to replace the electrolytes or just basically even like glucose and things like that. But when you go and you have a task for IBT it's very easy, especially electronically to just electronically prescribe something without seeing your patient. It is very simple. It's a two second task. The risk of that however is um and what all a little bit culprits of this is because you end up just causing people to have overloads and unnecessary fluids. So review your patient go through their fluid status. Can anybody tell me in the chat, things that you would look for in their fluid status. So when you do a fluid examination on the things that you would look for, so you can even just start with their hands where they are. So things like I was kind of hoping you guys would fill in the blanks. Yep. On physical examination, when you review them things that you would look that would help you understand their hydration status because you're going from either. Yep, cat refill. Yep, JVP. Brilliant. Brilliant. Absolutely brilliant. Yeah, because you're going either from you. I don't want to see whether this patient is two extremes dehydrated or overloaded and you can see that by looking. So look at their hands, do your skin to get their cap refill time, central cap refill where your sternum is, is probably the best for refill. Um Feel the pulse observations are great. Sunken eyes, skin turgor. Yeah, brilliant. Have a listen to their chest. Look at their JVP, auscultate their lungs. Um Adama sacral edema, pedal edema. And most importantly, look at their catheter. They have one. Look at their fluid balance, see that it is documented if it's not documented and they're on IVT. Tell your nursing staff. Look, you need to document it, please. And obviously, if they're unwell, regurgitated 80 the fourth and final question about IVT that you need to ask yourself, is it actually very necessary for a person that's eating and drinking as well as they are overnight. Um And you look at their fluid intake, they look fine, they look fine in themselves when you have a look at the fluid status. Do they really need fluids through the night? Because you and I wouldn't eat drink at night. So it's very circumstantial based. So use your judgment. But I would like to think that if you just do these four things, it gives you a rough idea about whether you should prescribe it or not and why you're prescribing it. This beautiful, nice algorithm helps break it down like what we were talking about earlier. So we've got resuscitation, we've got maintenance and we've got replacement. And this can basically give you a better idea about what you're prescribing and cvs talk through this about, talk through all of this about two days ago. So it's great. Um Just in the green section, we've basically discussed a bit of the clinical examination, your observations and even it's mentioned, obviously, your blood will help you with your user knees and your EGF artist to see. Uh Now we're gonna talk about failed procedures because you will get tasked about different things like this. So as an F one or an F two, can you tell me any examples of procedures that you would be expected to do at your level? Yes, I know I've given you a picture there and slide. But even that can say that Yep, venipuncture. Great cannulation. Yep. Um, we've got a BGS, we've got V BGS, we've got catheters as well. So, all of those. Yep. Brilliant. When you have a failed procedure. Thank you guys. Absolutely great. When you have a failed procedure, what is really important is that you need to find out, what's the indication for this procedure? Are these bloods necessary? Why are you doing them? Did it need to be done now? Right. Once you find out all of those reasons, do them if it's significant enough. But what we're going to talk about now as well is what are you gonna do when you're unsuccessful? It might seem like the worst thing in the world at the time, but genuinely don't worry because it happens to all of us and also we all have bad days and sometimes honestly, nobody can get them. So there's a chain. All right. So you've tried and lots of your limit is three tries. That's my limit. Sometimes it depends how urgent the bloods are as well, right. Who I go to next? I've got my A I team on call so I can ask them, they can't get it as well. What I tend to do is there's basically my med ridge he or she normally very, very busy, fairly understandable. So sometimes there is an sho that's working around there, you can ask them as well and you can take it from there if it's extremely urgent, patient is extremely unwell they've tried and they failed. One, don't feel too good about yourself, although it does help your self confidence. We've got any statist and you can actually bleed them, have a discussion with them. Explain the matter of urgency, explain how many people have tried. Those two things are most important and explain where they are and they will surely accept. It. Thought is basically having confidence and practicing when you're starting. It's okay. Like listen, we all start somewhere. Sometimes you will have off days, some days you will not get a single blood done, right? If you're in the geometric would or something of the sorts. Some days you're a BGS will just be horrendous. That is okay. You have to practice. So just run through what the procedure is like and just develop, you will develop the skill over time and we've talked through escalation. So that's basically the escalation chain as you go. And this is why I would say I know your team on your own call because when you do have a failed procedure, something of that sort, it's good to know which bodies are around and what their skill sets are because you can actually just talk to them. So very quickly, you're going to get a lot of tasks about new scores and I'll just pop up to you saying this person's got a news of so and so for this, please review so we all know this. So I'm not going to basically drawn on for too long. We've got all our different parameters just out of interest. Does anybody know what the maximum news score is? Because I've seen it once and it, it does make your heart go about pumping. Um So you can get a maximum of three in each category. The six categories, but basically maximum score that you can get is 20. So you got six different categories over there. TL I left maximum is three. And if you add supplemental oxygen, that's a plus too. So sometimes what you will find is somebody will send you a new score for somebody that is scoring a three in just one parameter. For example, our little old lady earlier maybe that's getting an 85 out of like 50 for her BP. 85. Yeah, something. Uh so go and have a look and see and we've talked about IBT so when it comes to new scores and when it comes to when it's, you know, high or low or what the reason is, depending on what parameters you want to regurgitate, you're a to ease. So very quickly, we will just go through what A to Easa and this is how I group them in and you will find that the more that you practice this, the best that you will become a doing it. Is Elway, is there a way patient? Are they talking to you? Are they snoring? Are they grunting, snoring bear? In mind they might be sleeping. But you know what I mean? Are you worried that their airways lost? If you're worried you would obviously do your head tilt, chin, lift, jaw, thrust manoeuvre and you would be concerned about the airway. So you'd get help immediately. And if you're comfortable enough, you've got the airway, their drugs like your nasal pharyngeal and your allow for or referring jail. Sorry. Um I wouldn't expect you to put an LMA unless you're confident doing that. Now, that's good at breathing. How are you gonna break up breathing? And this is how I break it up. Observations. So, observations, we've got oxygen saturations and respiratory rate, physical examination. You're basically gonna puppet the trachea. Um listen like pop it for chest expansion, have a listen to their chest. Um Nobody just percussion anymore but you know, there you go. Um And also you're gonna think about investigation. So you've got your A BGS and your chest X rays. Think about them. Then you got to see your circulation very similarly. Think about your heart rate, your BP and your fluid balance. And when you're going to look at the patient, you're gonna basically look at their hands again, feel their pulse, the temperature, the cap refill, have a listen to their chest, look at their JVP, see whether they catheterized, look at their calves. Are they soft? You know, and is there any edema? And right now, let's see, you're gonna think about cannulation. You're gonna think about bloods that you want to send off. You're gonna think about now that you have access. Are you wanting to give them anything like I VT IV? Antibiotics? Um Are you going to do your ECG now? D is your disability? This is when you can either do your A VP you or you can do your GCS score, you would have a look in the pupils. You can do the BMS right now and do a neurological examination. You're basically trying to see what their neurological baseline is, right? The minute and easier exposure, do a head to toe about everything else. So similarly, your eighties will come with you naturally having questions with an unwell patient and that means having a chat with the Med Ridge on the phone and having a chat with somebody bit more senior on the phone because you might need help. And realistically all of us were at a point where we need help. So everybody knows about spar situation, background assessment and recommendation. They've updated it this year. There's A D at the end of it. This is your decision. Um I'll be honest with you as an F one, I didn't always have a decision. Sometimes I just didn't know I just knew that I was examining and I had a good history and I had a few questions. So my advice is collect your thoughts, prepare, write it down, right. Your right yet what your question is because you'll have tasks at the same time. You are multi, you're, you're trying to juggle so many things and sometimes you might just get distracted. So write it down to more. So you don't forget and be honest because I've seen sometimes what can happen when you are giving a handovers, they're asking you so many questions and you don't have answers to those questions because you haven't done something. Don't lie. It's easy to just say like, oh yeah, it was fine. Don't do that. Um Just say, I don't know, you might even find yourself in the beginning saying I don't know a lot. That's fine. Just go and find out and then bring them back again. But uh we're back to our pod because you guys have actually sorted out so many things well done to you, right? So, well, that can be low is gone because you sorted it all those pain task all gone. You've sorted it as well. And we've talked about I VT so I VT is kind of gone as well. So that's great. Oh, somebody had a bit of a fall. Please come to review them. Okay. So somebody needs an anti emetic. So kind of gave it away that. But who would you go and see at the minute with these four toss? Just stand staring at you anybody. Yep, you go and review your fall. Brilliant. So we've got an 84 year old that's obviously having a fall and she's from the Geriatric ward. What I would recommend is that you have a look at their notes before you go and see somebody with a four reason being is because it's better for a fall that you have a better idea when you're going to face them in front of you. So you know what drugs you're on and we'll talk about why, you know what the escalation status is. So she's come in here for generalized weakness, being treated for a uti, she's got a long list of medical history in a longer list of drug products and she is a DNA are. So she's gotta do not resuscitate and she's award based care for Met calls. So she's on Apixaban. She's on Momento Einen, Ramipril, amLODIPine. She's on Ourumov pregabalin, amitriptyline, uh Ferris and some statins. So history wise for assessing a fall. What do you want to ask her any specific question? And it kept me anything really? Anything you guys have in mind? What do you want to know when somebody's fallen? Do you want to know? Yeah, that's good. What happened before, during, after? Yeah, perfect. So mechanism of injury, right location. Where were they was a witness or unwitnessed that they have a head injury? Yep, you guys are getting it. What is their baseline? This is important when they speak. Obviously you might not, you might not know your patient, this patient because this might not be your award. So you want to know what the neurological baseline is and what their mobility baseline is. And very likely as what you said before during and after you want to ask whether they had any presyncopal symptoms, did they have any loss of consciousness? And what's your consciousness right now? Any amnesia about it? And that's basically a good false history in terms of a physical examination. Sometimes you'll find that they're sprawled against the floor. And what you want to do is just have a quick feel at their c spine. So there's just whether cervical spine as the boney part have a quick press in between, see whether there's any tenderness and see whether their range of movement is okay. And if they're complaining of any parasthesia going through the upper limbs of their lower limbs, that's okay. Regurgitate. You're 80. There's something known as a silver trauma that athletes asked us to do. But basically what that means is you're having a nice good look from top to toe and you're having a good prod at any one of the bony bits because you want to see whether they've broken anything so very quickly, just through that list, all you're going to do is palpate, do a quick range of movement examination and see whether there's anything that you're worried about. A lot of patient's that do fall, end up having this externally rotated hip and you're worried about enough. And we've got our investigations that you'll go through, like you, if they're extremely worried and things like that, you, uh, extremely delirious, you'd worry about blood's catheter, things like that. And radiologically, I will talk about CT heads and we'll talk about neural observations. Other things to consider once you've done a fall and you've reviewed them is elements such as their polypharmacy. Like our lady right now, she's on so many things that is probably precipitating a fall. So it's good to document in your plan, you know, would stop this. Have a look at her BP. Has it always been low because it is low. Your morning dose is I would just suspend it temporarily and then ask the day team to review and write down in your plan. Why you've done that discuss with the senior after a fall depending on city heads that you need to hold order or if you're worried about them and document your plan thoroughly. Other things about a fall is that if they're agitated by things like a catheter or a cannula and do they really need it? Would it be better if you just take it out and they'll become less agitated and trying to pull out things and also cohort ing so you can ask your medical staff. So basically your nurses and your health care assistance to cohort, that means they keep eyes on the patient, depends on staff numbers, but they'll do the best that they can. So this is a very beautiful, nice diagram about CT heads. And right at the top here, what it does is that it just tells you the immediate factors. If any one of the patient has that, that it's an immediate ct head with protocol, this depends on your own trust policy. But if you just go through this, it doesn't differ too much where you're working, I'm just gonna, gonna bring your attention to these two things. So if there was no, none of these risk factors and there was no signs of loss of consciousness, but there's a head injury and they were taking things like this. So, Warfarin dough ax clopidogrel, but low molecular weight happens are automatic city heads. If they've had the GCS drop, that should follow protocol. Aspirin alone does not follow protocol and you obviously have to go through any risk factors that are present or why you're concerned about things to get it vetted overnight. Normally we use a third party here in the northeast. So you have a ring them and talk to the radiologist at the nighttime and explain why you need this scan and if it's accepted, then it'll get done. Now, when you are confident at CT head is not needed and you're happy that your seniors happy with that as well, you've discussed it with them. That's when your observations or a thing. And this is the thing that the nurses do and what your observations are. It's done. Either based on your trust is done either for a total of 12 to 24 hours. And they basically just do, they check the eyes and they check their cognitive skate and things like that. So they do it half hourly for the first two hours, one hour late for the next four hours and two hours for six hours until that point. Just remember you as an F one cannot stop neuro observations before it's done. It has to be a consultant, a registrar, a consultant to stop that don't get bogged down by anybody, stressing down your neck, you're not allowed to stop them and just explain that. Now, coming back to your results, don't forget whatever you do order, make yourself a task or write it down somewhere. You need to chase your investigations, you need to chase your results for the CT head, not saying that she had all of this, but these are a number of things that can happen. And we've got a beautiful subdural over here that you can look at. What do you do? So here in the UK, obviously, you would discuss with the senior, but you'd also use this website. Well, basically it's a referral form. It's called referral patient. And it's basically where you list down all your details and you talk to neurosurgery about it and you transfer the scans across for the neurosurgeons to have a look at everything. But most importantly, you relay all this information back to the patient, make sure that they're family are kept aware. So either nursing staff can do it or you can do it if you really want to as well. Depending on the time, depending on how busy you are and the nursing staff are aware of the plan and document, document as you go. So well done, you have reviewed the fall. No. Oh, as a 93 year old male that you need to go and verify the death and the tasks just keep coming. So we've got failed castor. We've got a bit of a sore throat which considers this pain. Got abdo pain. We need some heartburn and somebody is really trying to self discharge at the minute. Final poll on, on the chat. If you don't mind putting it down, who would you want to go and see first? You've got a long list there. It's been a long night. I am afraid that sometimes this is what happens. So, does anybody know what they would like to go and see first? Yeah. Abdo pain and 33 year old. Yep. Abdo pain. Yeah. Brilliant. Yeah. So anybody else that would think? What would be your second person that you'd want to go and see right at the top there. Somebody's trying to leave the hospital. They're an inpatient that wants to actually just leave and Behrman, nobody will stop them. Yeah. So we've talked about pain and chest pain. Obviously not the similar types of differentials of abdo pains. We're not going to go through that. But the point of all of this, the point of all these tasks appearing is to say that sometimes it's not as easy as to what you want to see because you might get bleeped about the same patient while the task is coming up as well. So, yes, abdo pain, definitely. You want to make sure. So it depends on what their obs are gonna be, but you're getting bleeped about the self discharge and very quickly, we're going to talk about self discharge is because they tend to be extremely strenuous and very, very time consuming. Unfortunately. So what's the difference between somebody that wants to make a bad decision and somebody that is enable to make a decision, what changes something and basically, it's a long winded way of saying that we're, we're trying to assess when somebody wants a self discharge. Yep, let's say capacity. Exactly. And this is why sometimes it can be higher up on your prioritization list from earlier because what this person lacks capacity and something just let them leave the hospital and they are actually really, really unwell and you need to have that chat with them. That's where we're here. We need to ask, we need to number one, we should always presume somebody has capacity. But when somebody wants to leave the hospital at four in the morning, you need to go and find out why, what's going on, what's happened? So what exactly is capacity of everyone just very quickly, let me know in the comments we will finish soon. I promise it goes actually with their ability to, and how we're going to assess and what it means is that what we're going to assess is can they understand the information? Can they retain it, can they way up the benefits and the risks and can they communicate it back to you? And you're gonna assess this by having a very long and thorough chat with them. You're gonna talk them through. Yeah, brilliant. Thank you. You're gonna talk them through their admission details here, their risks and the benefits of leaving the hospital and you will find that you are kind of bordering on being a bit anxious using the word dying. So you're gonna basically say if you leave the hospital, there is a chance that you can deteriorate and sometimes that could even mean death depending on the case. But you have to actually say these words because you have to document it later and you need to wait, understand whether they can retain that information. Can they weigh this up and can they communicate it back to you? And based on that, if they do have capacity and you feel like it's appropriate, you will sign a self discharge form and they'll basically use up all of these things if you don't, if you think that they are lacking capacity. There is a mental capacity act form and there's a doll's form. You will basically fill this up and you basically summarize everything that we've just spoken about here. Those main principles. No, you're not alone when you have to deal with someone's capacity. All right, you never have to be alone. Get help, your nurses will be there with you. Security will normally be there with you because these patient's can be a bit aggressive and can be quite distressed. Sometimes. Call your Mezrich and make them aware as well. Have them assess as well if you're unsure and it's completely fair to be unsure. You don't have to be responsible for this decision alone. Does that make sense? Yeah, one second. All right. Your last one very quickly verification of death. Now you'd go in and what would normally happen is that this person has been unwell for quite a while and I think it was a palliative approach and sometimes it has happened in the DNA are and they would get, you know, a bit more cleared up and cleaned up and you're just there to verify the death and your night shift or you're on call shifts. So your steps can be on geeky medics and what your steps will be is that you'll go in, you'll introduce yourself, there will be no verbal response. You'll explain to the person that's passed away. This is how I do it and you explain that what you're gonna do as you're going along with it. So the steps are confirmed the identity of the patient. So the name, the date of birth after that, you'll explain what you're gonna do and you're just going to start by feeling the carotid pulse. You're going to have a listen for heart sounds, you're gonna listen for breath sounds, you're going to have a look through the pupils and you're gonna do all of this within five minutes. There's also painful stimuli. So basically, all you do is either trip squeeze or a super orbital push here. You will document very clearly what you've done. Geeky medics is a great response to have that with you later. You can have a look and it can sometimes be a little bit off putting for some people. So take someone with you, obviously, if you need to and things like their certificate and the cremation and the coroner's referral can wait for their day team or their parent team to review. So we're back to our pod. I know, I know I'm sorry for being overrun. I'll honestly finish in like a couple of minutes. You've sorted out this self discharge, well done. You, you've actually, you've talked to him and you found out that he had a little bit of an issue and he was just a bit upset with how things have gone, but he's staying so well done. You've done your debt verification. And because we've talked about ecgs earlier from chest pain. You sorted that out too. You know, that nurses are better at catheterization, real talk. So, you've asked one of the nurses staff, like one of the sisters that's on call to basically help you with this catheter and they've done it for you and you've basically sort it out quite a bit and it's hand over time because you've actually made it to the end of your shift. Well done. Yes. Those tasks are still gonna be there. But that's why you're handing river. That makes sense. You had a busy, you had a busy, busy shift. So at the end of your busy shift, I'm going to talk you through some of the main things that I want you to go home with. When you start your own call shift, you're not alone on a shift. It might feel like it sometimes roaming around the hospital, but alone, you've got people to help you. Sometimes failing procedures, not the end of the world, as much as you might think of it. At the moment you'll practice and you will get better. Everybody does. You will develop prioritization and you will develop doing your task as you go along, you will feel the burden sometimes of it just coming up of people bleeping. You, you will get the hang of it and you will get through it and be very kind and considerate during your handovers. Sometimes like today's shift, you still have quite a lot of tasks that you need to hand over. And that happens. Sometimes it's a really bad shift. Sometimes it's a great shift but be kind to the person that you're handing over to or from and please don't forget, 80 80 everyone. So very quickly, these are some of the apps that I would suggest that you use when you're on call. Um I use them a lot, a lot of people use them. So it's great. We all, all of us end up having a little bit of a folder. I think a lot of people will know talk space for drugs and overdoses. Induction is an app for bleep numbers when you want them quickly. Instead of waiting for hours on a switchboard and the cult calculated everything under the sun. BMJ and your BNF. And these were just some of my references that we've talked about. Always use geeky medics. Extremely helpful and nice guidelines help you a lot. Don't forget to fill out your feet back if that's ok. It's right at the top now. You must just posted it. Um If you guys have any questions whatsoever, you can pop them down the chat and I'll answer them as best I can. But if that's okay. Thank you very much for your time. Thank you very much. You guys take care. Yeah, I would think it's a positive session. We don't have questions, but also if you did, no worries, we'll try, we'll try to answer them. Thanks again, guys. Don't forget to um provide feedback. It'll just be really, really important. Thank you.