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Um Hello everyone. My name is Prates. I'm now an F one which feels worth to say I was a final year, not that long ago. It feels like it was like five minutes, but I feel like I've been in F one for five years. So it's a really weird place I'm in at the moment, but I'm now on F one, I've got a job down in pool at the moment. Um The whole allocation process is kind of nuts. I can talk to you sort of through some of the things at the end of the lecture. So I think it's, we're getting to that point in a year where we're starting to think about it and I'm more than happy to talk about that a bit later, but for today, we're going to talk about lower gi um and this is part of me sort of ongoing series. My emails are there at the top. Um The IC one I think becomes inactive soonish. So if you do want to get a hold of me, then use the NHS one down the bottom. Um Cool. So, oh I'm, I'm also a bit of a boomer. So I've been pretty rubbish with uh tech, so I probably will fumble around. But, um, here's a classic me disclaimer um that you've seen on probably most people's slides. Um, but I just want to draw attention to the bottom in saying that I didn't get a formal MLA paper. My final year paper, two papers were made of MLA questions, but they weren't, they weren't official imperial, just chose questions from an M and bank. So obviously it might be a bit different from you. I'm hoping that that means that it's a bit more standardized and that they will sort of test breadth rather than depth imperial. Do you like to go with depth for certain things? Um And sort of ask you sort of third line management questions whereas I'm hoping the MLA because it's kind of a national paper should hopefully be a bit more, not go in depth in depth in some areas. But you can't guarantee that. Um Can I just confirm if anyone or anyone can confirm you can see my mouse? Mm I can't see the charge. I should say that as well. Um because I want you to raise their hand if they can see the, if they can see my mouse moving around, it's like currently sitting on his head. You can see. Oh, that's so annoying. Ok. Um I wonder if I share in a different way and I share my whole window rather than my slides, you will be able to, I'm going to give that a quick go if that's all right. As I said, I am a Boomer so I can only apologize. OK. Is that any better? Can you see my mouse now? Yeah, perfect. OK. Let's do it this way then. Um Because I do just want to point at things every so often. So yeah, I didn't say a formal MLA paper um but I obviously did uh MLA questions. So I have seen them. Um So let's continue, right? So how are we going to structure this then? So I'm going to start by just giving you a bit of pas advice. And this is something that Johnny Guo, who is now an F two gave me last year in this very talk and it really stuck with me. So I wanted to kind of reiterate it. We're going to split this talk into medicine and surgery. You will see that is pretty light and I'll explain why in just a second as surgery forms the bulk of this talk. And then towards the end, I just wanted to talk about some sort of life stuff at the moment of allocations, elective, working as an F one. Those sort of scary things that no one ever really tells you. So the reason why I decided to structure this session this way is that GI lower G, that's not what I wanted to get on to next. I've jumped ahead. Um I will jump ahead and come back. That's what I want to go see. So, the reason I'm structuring it this way and actually, it's quite light on a lot of topics in medicine is that a lot of gi is sort of third year content. And if you remember back to Sophia, if you remember her in third year, there were a lot of these topics on there. They just weren't usually in full completion. Maybe the management was sort of missing. You didn't really need to know it. But the reality is that when it was taught to you, you probably got taught the management or the management is actually something quite logical or that I wouldn't waste my time or your time, I should say in going over, I would actually just do questions on these topics and you would just pick up those, fill those gaps. There are lots of topics on here that you will have covered in third year or that you would have covered again in fifth year and path. I mean, IBD here, the D stands for death because you've been taught it to death. Crohn's. You see, you covered it in third year extensively again in fifth year. It came up in histopine. It even came up in immuno when you were looking at biologic therapies. So there's no point in us covering it in today's lecture. It's sort of a bit of a, a waste of both our times. I wanted to cover some of the more difficult topics. Some of the stuff that isn't taught to you well, tends to be the surgical stuff. I'm not saying surgeons aren't good teachers. I just think that obviously maybe Imperial were taught by some amazing medics. So the surgery stuff often takes a backseat and being on a general surgeon job at the moment. I think I'm seeing the outcome of that. So I thought that's where it's useful to direct this talk. This is a list of conditions that med gave very kindly. And I think they have highlighted areas where people struggle where they've highlighted areas where this talk could particularly focus on. I think this is a useful list for you to structure your vision. The ones involved underline generally are the ones that you might want to spend some more time on and then quickly go over the other ones and just sort of do question, as I said, there are you need to know management for a lot of these conditions and you might not have been taught it previously, but it's something that I would recommend you pick up from just doing questions rather than sit there and trying to read over all these subjects. I also want to draw your attention to the two in yellow. So eating disorders and mesenteric adenitis. If imperial were making of this paper like they did last year for me, he wouldn't sort of see this on this list because they would have already tested it in psychiatrists in fifth year, but just be aware that these topics with the MLA can come back up again and that could be the same for other topics. So just be aware, try and find this map. I think. I'm not entirely sure where me got it from. I think it's from the GMC U guide page. But try and find these maps for the other topics and identified topics that you might be tested on that you weren't expecting because it is weird to see eating disorders in a lower gi when you think of cancers and obstructions and IBD, etc, but just be aware of it. I would also recommend that you sort of don't spend too long on those again and glance over them. You covered them not that long ago in fifth year. You've only just gone into final year. So they should be sort of there once you read over it again, it should all just come back. So this talk is going to cover some of those difficult topics with a bit of paces and some F one content. Um, it's not going to really go over some of the third year content or stuff that you just, you need small amounts to build on. It's not going to go into ridiculous detail and it's obviously not here to get your, that's kind of your, your job and your effort to put in another disclaimer that I've not put in the slides, but I walked out of my exams thinking that I had failed and I did, I did fine. More than fine. People say people will tell you different things about fine. They say it's easy. They say you've just got to do bare minimum. I didn't finish pass med or anything like that. And I did absolutely fine. I think you've just got to have a good, you just do have to have a good breath. Um and you'll, you'll do fine. So don't worry about the and stuff just, just focus on knowing a good amount um about a lot. So, yeah, session structure. I reiterate that we're going over quite a bit of surgery and not so much medicine. I'm focusing on one medical thing. So I just don't think it was ever told to me. So I just wanted to talk about that. But before I do, I want to talk about pas. So as I said earlier, I'm going to reiterate something that Johnny mentioned to me last year, this time, this talk last year and it really stuck with me and I really needed to hear it. And what he basically said was that he sort of applied a logical argument of why you shouldn't be scared of paces. And I just want to, the slides is literally copied over because I want to reiterate it. So he was basically saying that this is, these are your 12 paces stations and five of these 12 stations, you know how to do. Certainly cardio arrest ABDO, you've got that and once you go over them, once or twice, they will be back up there. Um, breast and vascular obviously were formally formally tested on that in third year. So you might just need to have a quick look at it over again. But again, they are simple examinations. There's no, there's only sort of one way you can do them. So he was sort of saying, look, you need to pass six of the 12 and you've got five already in the bag, then you've got your two histories. So it's realistically more like 77 of the 12 GP. Obviously, you covered in, you know, you guys now have to take a general history. GP history was in cases I know it was more contextualized pas I know it was a bit more contextualized to peds and, and G but, you know, the bare bones of a GP history and the limitations of what you can do in GP. And that's sort of really what differentiates a GP history from a medicine history, you know how to take a medicine history. Um, a lot of the time the medicine history is something kind of diabetes and injury as well and the diabetes and endo tends to be a bit more secondary care. Um, weird and wonderful. Um So again, he, he was saying that seven of the T 12, you again, sort of got in the bag instruments in images. Half of this station is just about learning almost rote learning your images and instruments, how you do that. There is a few different ways there is a presentation that always circulates where there is kind of different slides, all the instruments and images on them and a little explanation. I think there is a good med learn page that has all the different instruments and images. And then there are lots of flashcard decks or you can create your own that have the images and instruments. And again, if you do 345 a day, every so often keep ticking in the background. You will be absolutely fine for that half of the station. The other half is about interpreting images. So it's your scans, there's often three or four and they usually get more difficult as you go along. So I sort of present you one, you tell them what you are seeing and they'll ask you some questions on it, then the next one and then the next one. but often there is at least one, if not two ones that you would have seen a lot in third year. So that would be your chest x rays with your consolidation or your um your infusions or your cardiomegaly, things like that, or you might see bleeds on the brain and you've got to describe them and say what it is and there are some questions on it or you might get some common one. So that, that's probably a bit more of a newer thing that I would recommend you. Look at, you, look at. So that's joints with osteoarthritis. Again, you want to describe your loss, your loss of joint space, your osteophytes, etc, etc, um, or common common fractures. So your collies fractures, your knots. Um So do just get familiar with them. But again, that's not a difficult station. It's kind of a rote learning one where you just sort of doing the bare minimum and placement and just like the bare minimum to get through each year, you should be have the knowledge to do to minimum pass that station, but you probably will do quite well. Um So that just leaves, the only exam left is M SK there are several MSK exams that you need to know and think this is what finally your students when it comes to pace to spend most of their time on because there are so many. Um and everyone always goes, oh my God, it's going to be a weird spinal exam and you sort of just, you know, it's not, you look over it but there are several, they often work around a joint and it's about testing the movements of that joint and all the muscles and ligaments and so on around it. There are plenty of good videos. You, the ki medics ones are more than enough and you can follow them. I think Chin May Gupta does some good ones as well that are on Medlen, I believe. And he does some talks as well. I think around Christmas time, they are really good and obviously they are sort of quite imperial specific. But that's kind of the examination that people spend most of the time on and then that just leaves diabetes endo which again, not insanely difficult. And we are taught by endocrinologists. So that that's the content there is taught well acute care. In my year, my day, there was a bit of a curveball throw, but it's not so much about the diagnosis. It's more about your approach to the acute situation. So making sure you are sort of trying to assess everything in an A to e um ways that kind of crux of that station and then your difficult conversation comes and they give you a few talks on these. The it can vary. I my patients station was a patient's relative who was really upset with the care that her mum had received. And it was about sort of talking her down from an angry point, understanding her concerns addressing apologizing the station kind of structured where you have this conversation with an actor. You turn to the examiner, you have a discussion about the issue at hand on what the ethical problems or professional problems are and then you go back and give a resolution if you will and it always kind of follows that broad structure. That's not, they will give you talks about how to approach that station. But it's not so much, it's difficult in the sense that you've usually got someone angry or a difficult ethical dilemma, but it's not difficult in the fact that you are all competent and can actually like, recognize issues of a situation and sort them out. So that's kind of what he said about paces. And I've added obviously my own two cents there to tell you why you really shouldn't be scared of paces. So I hope that's somewhat reassuring. I really needed that around this time last year. So I hope you found that a bit useful. So, moving on to the actual lower gi part then and as I said, I'm only really going to cover one aspect of medicine because a lot of gi medicine was taught to you well in third year. And as I said, it's just about going over it, but this never was. So this is a small bowel bacterial overgrowth syndrome or I think the Americans call it small intestinal bacterial overgrowth. Um And essentially, it's just an extra, uh you know, an excess of bacteria in the small bowel who gets it. So neonatal or congenital gi abnormalities, patients with scleroderma diabetes or if post surgery where you've got slow bowel motility, you can get an overgrowth of bacteria. I wouldn't worry about this too much. By the way, it's just that I was never really told about it and I saw it on the list and I thought, let me just do a quick slide. So people have got something to refer back to symptoms are very, very similar to IBS. Sorry, it's your kind of chronic diarrhea. You're bloating, your flat trench, your abdo pain. It's really kind of non descript. People might write it off as functional and it very much is a diagnosis of exclusion. You want to rule out the more causes first or certainly that's how it would be approached in GP land. You can do these hydrogen breath tests. We are all, you guys are all fine. I does it actually get done. No, you can also do this weird small bowel aspiration and culture or have we ever seen that? No, what probably will be done is that this is if you've been in GP Land, which you all have, you might try some antibiotics and then safety net them will come back if that doesn't work. And that's often kind of what happens with this management. Obviously, whenever you are approaching a Pacer Station, you want to kind of think you want to try and have a structure to sort of everything you do. You are doing a conservative medical surgical, there is no real room for surgery in this. It's sort of conservative and medical conservative would be things like diet changes in diet, food diaries, that kind of thing. Adequate hydration. If it's an underlying problem, something like diabetes, then of course, you want to manage the diabetes that should help manage the overgrowth of bacteria and then you can try antibiotics as well. So it could be a diagnostic trial but also has a management effect and there are some options for you there. So I'm not going to spend too much longer on that. Um It's, it's nothing too complex. It just was never told to me. And so I want to go on to talk about more of the surgical aspects of lower GIS. We're going to start with bowel obstruction because it is pretty much half the patients that I have on the ward at the moment, have some bowel obstruction or have come in with bowel obstruction or something along the way of that or it's in their recent history. So it's a big aspect of what general surgeon see of lower gi pathology. You. General surgery is quite a core job that an F one and F two will have. So I reckon most of you will have a gen job and this will be what you are dealing with in some form. So starting off with an SBA, then I've not got a mentee just because when I found last year that sometimes it's just a bit tedious when they are in talks like this. They are a bit more useful. Personally, I found them a bit more useful for lectures, but talks like this. I think it's OK just to sit there and answer it in your head or write it down and commit it to paper if you want to. But I didn't really see much benefit from a mentee in a meta talk last year. So I decided not to put them in. So the most common cause of a small bowel obstruction, boul, diverticular hernia, malignancy or adhesions. The answer is for small bowel obstruction is adhesions. So obviously, you're going to be wanting to ask in your history about previous surgeries. That would be the top question you want to ask also a previous history of peritonitis and pelvic inflammatory disease, things like that. So previous infections of the abdominal cavity can cause adhesions and that can cause small bowel obstruction, ankle is large as well, but small, more commonly large bowel obstruction. Then most common cause I'm not going to pause. It's the same options and you probably worked out, but it's not adhesions. Um It is malignancy, hernia is the second most cause for, for both. So how can you classify obstruction then? Um So you can broadly categorize it in mechanical versus functional mechanical. Is there is there is usually something a physical thing causing an obstruction, but the bowel is still able to contract against that obstruction. So, adhesions, hernia and cancer and carcinoma are sort of the three things that you want to be saying top. So when asked in five pas and fibers. Those are the three things you want to say. Quick side note when talking people get a bit worried about VR and Paces don't be by that point, you're probably pretty exhausted having done the station and all the ones previous to it. Just make sure you've got three sensible answers and you don't have to go and give more. And even if you draw a blank, it's fine. They are not scoring you on that. But questions like this, can you, can you give me some examples of mechanical obstruction of bowel obstruction? You should be, you want to be thinking of your most common, which are adhesions, which are cancers, which are hernias. Um There are some other causes that for an object, swallowed or up the back passage. I've had it, I've seen it a few times since working and I've only been working for about a month now. Um impacted stool often in sort of elderly senile patients or younger patients with learning difficulties. Um and then weird and wonderful other stuff, but also things, extrinsic compressions, things like pregnancy and ovarian tumors. The other way of thinking about it is functional obstruction. So it is not something a big mass of some sort of blocking it off the bowel, the actual lumen is sort of patent, but you've not got that contraction. So you are not getting movement of stool. So that's your paralytic and sort of nerve base problems. You hirsh problems down the bottom. That's that. And Ede, that was sort of Angl Plexus Meisner and al about Plexus, a lot of words to basically say improper nerve innervation. Um So I note as well. Gallstone ileus is not, is a bit of a misnomer because it is, it is actually a sort of foreign object in, in the small bowel. It's actually more of a mechanical obstruction than a functional. One closed loop obstruction is a particular type where you've got two areas of closure, two points of closure and then you have this middle portion that then becomes quite edematous and dilated. So this image shows in adhesion, one band is kind of across two, but it also could be two sort of bands. It could be a band say here and a band say here and then this portion becomes your closed loop hernias are another really good example of closed loop obstructions that sort of the point into the hand. And the point out if you will, they are the sort of two points of closure and then Boula. So again was a big, big topic to in third year sort of twisting of the bow. Um The reason I mentioned them is because of this. So what's the most common site of bowel perforation in closed loop obstruction? Is it the ileum? Is it the cecum, is it the splenic flexure, the sigmoid or the rectum? So I'll just give you a second while I have a drink of water, have a think, see if you can try and rationalize it more than anything. That's what you kind of want to do. Because when you sit there in an exam, you will have all these options, you will probably get it down to two and you will sit there in your head like I did and you will try and justify why it's one and not the other. And that's really how I approach exams. Um And then you will sit there afterwards and you will debate with everybody why you picked that one and you will see who agrees with you who doesn't, and then you'll feel really bad and think you fail, but you didn't. So the most common site perforation in a closed reproduction is um Cecum. Hello, explain why. So without going into too much physics and without bringing in too many names, it's Lala again. But basically what he is saying is that Cecum has the largest diameter and if it has the largest diameter, it needs the least pressure to distend. So in a closed loop obstruction as is here where you've got the growth here. But also the ileocecal valve that is competent. That's an important point. It's a one way valve. So you've basically got one point of closure here and one point of closure here. So you've got two in total. So you've then got this portion being your closed loop and where along this closed loop is this valve going to perforate, it's going to perforate at the point with the greatest diameter. And that is the cecum. So that's just an important point to recognize that the Z is a particularly vulnerable area. And that's why kind of on CT scan, you want to know what's happening with the Zim as well and we will come on to investigations and why CT scans are pretty good and why they are used. So bile obstruction for the sake of Paces and also has an F one history. Obviously, you're going to take your standard history. Um So I've been on call this weekend. So that means clerking patients in ed um and also going to theater um to assist. That's the kind of the core of what AF one does as well as obviously ward stuff. So a large part of that is asking questions is take your history and of course, you will take a history, a history of present complaint, but there will be some core questions that you want to ask. And this is this is the real difference between a third year paces and 1/5 year paces. I know you're not taking history, an Abdo history in the Abdo exam station. But what they want to see is that you are not just taking a history of what the patient has come in with and the symptoms, but actually trying to get to the, the root cause and ask the right questions those differentiating questions. So you want to be asking about past surgical history because you might be thinking about adhesions as a possible cause of bowel obstruction. Um You might be asking about masses for things like malignancy or hernia similarly change in bowel habit. Um And pr bleeds might suggest malignancy and flaws similarly. Um I forgot to put it on here, but obviously, you're presenting the plate with bowel obstruction will be things like vomiting. Um, bowels not open, no flat has passed ado pain. Um So obviously you want to be asking questions all about that. The vomiting, is there any blood in it? All those standard questions that you need to ask? But you also want to be asking these sort of core questions to actually show the examiner that you are trying to get to the bottom or show your registrar who then asks you to present the patient back to them that you've tried to identify some sort of underlying cause. And you recognize that they have a history of surgery to the abdomen and that it is possibly adhesional. It doesn't make a huge difference because you're probably going to scan them anyway. We'll talk about that in a sec, but it just shows that you are recognizing, you are not just doing a basic history, but you are recognizing some young blind causes, you will examine them. I mean, in reality, the examination is pretty crude. As I say, you do just sort of scan people. If everything is sort of pointing in that way, you would just scan them. But generally you will see patients that are in diffuse pain and tender. Sometimes you can get localized tenderness in bowel obstruction if it's kind of a mass, but often it's kind of more diffuse. You remember the abdomen is a funny place when it comes to pain and you get also referred pain. I'm not going to go into the embryology of it all. But the abdo pain is always a funny one. But generally you get diffuse pain and bowel obstruction and if they are peritonitic, so if they've perforated and now they've got an infection of the actual abdominal cavity, it may be rigid, but you rarely do see an actual rigid abdomen and it's usually distended as well. Not really an examination finding. But again, they will be, as I said, vomiting, they might be actively vomiting during their examination. Bowels won't have opened, they won't be passing later. And you get those things that I write it on here, but you in theory, get those tingling bowel sounds in early obstruction, but do and then silent later. Is that actually the case? No, not really. And it's not a very specific finding investigations, structure it, bedside bloods imaging like you did, I'm sure you did it in fifth year. Pace. Same again. Um, so you're going to do an ab exam. You may or may not consider apr exam. Have I seen this for about ruction? No. Um, it's not really done but you might, you might want to say that you would, you would consider it at least, I mean, you can get away with patients and you consider sensible things. Um, bloods when you are suggesting bloods, I'm sure you've been told this already, but you want to justify them or you want to have some justifications ready to go in your head. Um My, my thought process is, is that something like LFTs where I considering something like bowel obstruction, not that relevant unless you're going to sit touch at and say possible gallstone ileus and possible another stone in the CBD and it's causing a cholangitis. We are really going to grasp the straws. You might want to go there. So your best bet is to give a justification for why you want to do FBC and, and why you might want to lactate and sandwich that one in. So the examiner doesn't really then grill you and ask, well, why do you want NFC? So you might say something like I'd like a full blood count. I'd like to monitor their HB pre and POSTOP. See if there's any postoperative bleeds and also get a baseline HB and signs of infection for white cells. I do use you need if they've been vomiting, but also in bowel obstruction, you get edematous bowel walls, you get, you get a loss of intravascular volume of fluid into the wall. So you then you have a loss of circulating volume. You might hyper perfuse your kidneys, you might get an AKI, that's quite a nice justification for why you might be using these A G for lactate for inflammation. And then of course, if you're thinking any surgical procedure, you can't go wrong with saying to a group and say clotting. Um my consultant said to me the other day in practice, it's more for any cavity sort of procedure. Um What about obduction would be one that you want group and save if you were doing a kind of laparoscopic appendicectomy. No, you don't. It's not essential but for the purpose of paces, you say group and save and clotting imaging wise. Again, you do sort of want to be justifying things. So chest X ray, I often found this funny. I always thought, well, it's bowel and it's quite clearly bowel and it's quite clearly abdo why we are doing a chest X ray. You will find that lots of people just get chest x rays in ed generally. But for the purpose of cases, you want to justify things, you might say something like I would like to do a chest X ray to look for air into the diaphragm that might suggest pneumoperitoneum, um or they've been vomiting. Um And there are aspects in their history that may suggest that they have aspirated, for example, an Abdo X ray in third year, we saw lots of Abdo X rays for GI for lower GI. Do they actually are they actually used? No, not really. Um You would just do a CT A. Um You would just do a CT because it shows you a transition point, it shows you where that obstruction is. Um And it also gives you a better idea of the other structures around from what's going on with them. So most people do just get a CTAP. But you obviously, for the sake of Paces, could say Abdo X ray and it's fine to say in Paces, this is another thing that people are sometimes a bit scared of, is saying that what you've seen in practice and you say in practice, however, I've seen a CTAP be more common because that obviously demonstrates that you've gone into placement that you've seen this and you understand the reality of medicine, the upper limits of distention on an Abdo X ray in centimeters. So for small bowel, it will be three centimeters for colon is six and for a cecum, it's nine. So that just reinforces what I was saying before about the cecum having the largest diameter. So if you on an X ray, you can obviously add that tool and see the distance and, and the sort of measuring tool. Um So it's 369 is the rule you're following there in terms of initial management. So the bit B is what you as the f one would be expected to do and you, as a medical student would be expected to know. So it's immediately nil by mouth and drip and suck. So your drip is your fluids. Um, as I said a minute ago, you've got third spacing. Um, and you've got an edematous bowel wall. So you probably want to make sure you're preserving that intravascular volume. So you might give them a bolus, they've probably been vomiting. But even if they haven't, again, they are losing fluid. So replacement or bolus and replacement will form the large part of your IV fluid NG tube with free drainage. That's your suck aspect, that's deep and pressing the bowel and then um medications. So what you would be expected to prescribe would be largely analgesia and antiemetics. Prescription prescribing is different in different places where I work in my trust. There is kind of a surgical bundle that you prescribe for any real surgical patient that has analgesia that has PRN protocols for analgesia, for antiemetics, for PPI S. Um And then you've also got, and I'm not put it here. I like it upwards but VTE as well for any patient, any surgical patient on VTE. And it, it depends on the trust at minimum. You can get away with saying Ted Stockings, that's a form of VTE. Most patients will have enoxaparin 40 mg of par subcu once a day. So that's a nice little sort of extra thing. That you can get in that you can always can't go wrong with, with any surgical patient in terms of the management of bowel obstruction. Um, so if they are a stable patient and you sort of managed, you've drip and suck, they are not vomiting, you've managed their nausea with antiemetics, the pain is controlled with analgesia, you're replacing fluids, bloods are improving, etc, etc, etc CRP is doing well, then maybe you can manage them conservatively. You can watch and wait. Um, laxative, oh, laxatives as well are part of that, that uh surgical bundle I was talking about. Um especially if you think, you know, after your CT, they'll actually, it's likely that the, the cause isn't, maybe the cause isn't that clear? Maybe it's kind of uh impacted stool. Um You could probably watch and wait. Um Gastrograph is an interesting thing. It something I only just learned about on the job. So it's a water soluble dye that they can give and it's good for diagnostic for diagnosis. It's good. It shows up on X ray. Um You give it, you do x- them in about 4 to 6 hours. But the other benefit of it is that it reduces wall edema and move fluid into the lumen from the wall. So it actually can help con move. So actually for people with small bowel obstruction, specifically adhesion or small bowel obstruction, which as I said before is the most common cause of small bowel obstruction, sometimes gastrograph can be resolving and actually sort the problem out without the need to go for surgery. So, it's got a diagnostic and a sort of management effect and I wasn't aware of that, but it's sort of one of those miracle things that I think is worth you guys knowing about. And then of course, surgery usually to address the underlying course it's malignancy, a surgery to resect the malignancy or the bit of bone. And we'll talk about that in a bit. That's a kind of a core part of today's talk or, you know, hernias or so on. So, moving on then to colon cancer and surgery and the actual procedures. Um So just a reminder, I'm not going to cover it in too much detail because there are some great things like ki medics that cover all the surgical incisions and what they are used for, just be conscious of them, particularly your grid iron in your lungs for appendicectomy. Um But obviously most appendicectomy are done laparoscopically and here's a picture of where the ports come and go. So you will put your laparoscope and I've been doing, I did a few of these, these weekends. So you will put your, your camera will go through the umbilicus and then you put ports at varying areas. But common ones are suprapubicly and just here. But you can sometimes put one up here. It varies, of course, but just be aware of rough locations of where the ports go. It would be more of a vi type question and of course, be aware of your common incisions, your midline laparotomy, your and your LS. Obviously, this was more of an obs and gu thing, your hockey stick as well for your renal transplants. Um But do just be aware of those. So, colon cancer and how it presents um right versus left general, similar principles of um bleeding. So, but, but because right is obviously that much higher up in the codon, usually since mono deficiency anemia, the natural pr bleeds, the left might um masses, palpable masses um in the right or the left respectively. And obviously, right presents late particularly with that iron deficiency and that lack of bleeding or visible blood. Um And of course, pr bleeding can be picked up in, in uh fit testing and screening. Um but often symptoms tend to be a bit non description of flaws, questions again, ask them in your history. So an SBA then, so you've got a 65 year old man who presents with a six month history of intermittent abdo pain, um changes in bowel habit and occasional blood in the stool. So I know you're automatically already thinking of cancer. Um But unfortunately, the question already tells you that there is a cancer and it's in the distal transverse colon. It's an adenocarcinoma with nomad. So, what are you going to do? What, what surgery is the, is the general surgeon going to do. I don't expect you to know this. Now, it's these questions terrified me. Um When I first looked at them, they all kind of sound the same and there's just several different aspects to them. And if we break this down, there is left versus right, it's the same type of hemicolectomy. And then there are these different types of anastomosis. So I don't expect you to go them. I'll tell you the answer with these spas. And then we will do some, I'll do a bit of teaching and then we'll come back to the question and hopefully, by then it makes sense why it was that answer. So the answer to this one is that this is a lesion in the distal transverse colon. So if I actually just go back, um this is in the distal transverse codon. So it sort of more here, so more towards the left side. So the answer is a left hemicolectomy with a co colon anastomosis. And again, we will come into why? That is a bit another one for you. So you've got a 75 year old man who presents CED with um severe sorry abdominal pain, distension, vomiting, and bowels, not opening for five days. So, a quite a classic bowel obstruction picture that he has a rigid abdomen and the x- reveals pneumoperitoneum. Um The patient has a recent diagnosis of colonic adenocarcinoma and sigmoid codon and was awaiting elective surgery but because of this presentation, now he's undergoing emergency surgery. So what's the most likely immediate surgical outcome for this patient? So it essentially what's the kind of surgery going to look like? Not exactly the procedure but kind of the end result is it going to be a colorectal anastomosis, an end colostomy, an end ileostomy, a loop, colostomy or a loop ileostomy. And I fully appreciate that at this point. These are just words that you have some vague idea of what each one is, but like, you don't know why I completely get it. I was very much like that. Um And actually, until starting working, I was the same, I didn't really fully grasp this when I was doing finals. Um So the answer to this one is an end colostomy and we will come on to why that is in a bit. And if you got them, then what? So we are going to talk through resections. This looks pretty daunting and it's like, how am I going to get my head around this? But we are going to break it down. We're going to break down where the cancer is, why you're doing that type of resection. And then what two bits of bowel are going to join together again and we're going to break it down by color because it's sort of different areas. So we'll start with your hemicolectomies then. So in your hemicolectomies hemi, you are taking a sort of portion a half ish portion of the colon, right, colectomy. Um So your right hemicolectomies, you are going to be taking the right side or left, the left. It's pretty self explanatory. What is in the right? That means that you need to take bits of the right. So you've got the c you've got the ascending and you've got the proximal part of the transverse codon, you can do extended right. He this line is a bit further along. So you're taking just that much more of the transverse, if your lesion is that much further along, I use the word lesion because it's not always cancer. We are contextualizing this to cancer because that's the most common cause. But also things like Crohn's can, you can, you do right hemicolectomies because as you know, the Crohn's affects sort of the terminal ilium can affect a bit of the cecum as well. So you might do a right hemicolectomy. So I use the term lesion. Um but if your lesion is on the right, you'll do a right hemy. And if it's on the left, you'll do a left hemicolectomy in terms of the anastomosis, then, so you just need to think about it, of what, first half are you connecting to? What? Second half? So you've made your cut in the ileum. Um So you're going to be, or, or just just after the, so you're gonna be connecting healthy part of ilium to healthy part of codon. So Ileum Colic. And that's what it, and that's the simplified version of it. So you've attached the uh the Ilium to the colon um bit of a side note, but they've always depicted as in your head. Anyway, you always think of them as this would be an example of an end to end. So you are touching one end. I don know if you can actually see me, but you are touching one end to one end just like that and that sort of fits, but the air can actually do a few different ways. So you can do end to side. So this the end of the end can actually be attached into the side of this codon and you can do side to side as well where you kind of staple along this edge and this edge and you bring them together. But that's, that's a, that's an important, the important thing to appreciate that you are bringing the two sort of healthy bits together. Um distal transverse and descending. You are doing a left hemicolectomy and of course, you are touching a healthy bit of colon. So in this case, transverse colon to a healthy bit of colon and in this case, it's more of the sigmoid. So you technically call this a colo sigmoid, but the sigmoid obviously is part of the colon. So it's a colo colon anastomosis. Don't worry about these too much. This is more just for completion of what vessels that you are, are because he moving about basically. Um So to explain that question, then the malignancy was in the distal transverse colon. So it was here. So you were going to do a left hemicolectomy, imagine it was sort of here. Um You were going to do a left hemicolectomy with a colo colon anastomosis. The reason why you're not doing colorectal anastomosis was because if it was a bit lower down, then obviously you'd lose a bit more of the colon. And so you'd be left with the rectum. So if it was a bit lower down, you might want for clear margins, take a bit more of the sigmoid and you might then do a colo rectal anastomosis. So you've really just got to the approach to these is to think about the anatomy about what bit you're cutting out what two bits you've got left over and whether you're gonna put them back together, sigmoid colectomies. Um So for, for sigmoid uh cancer, you might do a sigmoid colectomy, you might also do something called a high anterior resection. We'll probably come on to anterior sections in the next slide, but I put them side by side. So you can see the difference. So a high anterior section is essentially a sigmoid colectomy. So cutting out the sigmoid with a little bit more going into the rectum. So coming into that rectosigmoid junction and then taking a bit more of the rectum is a high anterior section. That's basically if you've got sigmoid cancer, but to get clear margins, you might need to take a bit more or if it's sigmoid cancer, that's a bit lower. And the sigmoid may be affecting the recto sigmoid or near. Or if you've got a cancer here and there's polyps, you might then take a bit more to get clear margins and then you might, instead of doing a sigmoid colectomy for sigmoid cancer, you might do a high anterior resection. But the principle is very much the same of you taking the cancer and trying to get clear margins. Um and you will connect healthy colon to rectum basically because if you're doing a sigmoid colectomy, you will at the very least be taking the full sigmoid out. So that leaves you with just rectum. So rectum colon colon to rectum, colorectal anastomosis. And again, there's the vascular um supply anterior sections then. So I put low here for comparison. So you can see the difference between sigmoid to high to low. And there is sort of a progression. You can almost imagine an arrow here pointing this way. So you are taking a bit more and you're taking a bit more so high versus low anterior resections, then um high anterior sections are for the higher part of the rectum. So the upper one third, lower anterior resections are for the lower part. So for the lower two thirds, OK. But you are still as it's almost like a stepwise addition, you want to keep a cumulative. So you are taking the same as you were in a sigmoid colectomy in a high anterior resection and a bit more. And then in the lower anterior section, you are taking a sigmoid colectomy plus a high plus even more. And you are leaving just sort of the like for rectal sphincter into the anus. Um and then your anastomosis for a high anterior section, you're doing colon to a still a bit of rectum preserved in the lower rectum. You might have a little bit of rectum preserved, but often, um you need to do a defunctioning stoma. Um and specifically a loop bios will come properly to stomas, but I will talk to you through this. So you've got, uh you've got healthy codon. But if you've got, if you're having to do a low anterior resection, then you've got a cancer in the lower part of the rectum. And so all you're leaving is a very small amount of the codon left over, usually a tiny bit of rectum and a bit of the anus. So actually doing this anastomosis carries quite a high risk of that anastomosis failing. So, what you want to do is divert the bowel and give it a bit of a rest and then in theory, come back um and undo all that and put it all back together and sew them, sew them nicely together. Um So you will in an anterior section, low, anterior section, you will cut out this portion as you can see this, this uh blue bit here maps nicely to this white bit here. So that's the bit that you've cut out and you're going to form a defunctioning loop ileostomy. So, what you've done is you've cut this bit out, you've sewn it off here in the colon just before the sigmoid colon, you've sown off this anus and you have pulled the ileum. So the last part of the small bowel up to the abdominal wall and formed a stoma like this. And as I say, we will go into the specific nature of this in a little bit. But what you've therefore done is you've put this large bowel rest on rest, so no food, no, nothing is going to come into this. And then you let that all heal up, you let the inflammation die down. And then 4 to 6 months later, you will eventually, as it says, rejoin these two parts of from an anastomosis and then you will put this back in. So it will back to the codon as per normal. Um and then have normal bowel bowel function. But in the immediate setting that anastomosis, if you were to do it straight away, cut the spit out and fix these two together, you have a very high risk of that failure. Um So that's why you do a defunctioning. So you defunction about loop because you're taking a loop ileostomy because you are taking a loop of ileum, pulled it to the abdominal wall and your bowel contents are out coming through here and all this is large, bowel is under arrest for a few months. You defunction it. So Hartman's then Hartman's, you often hear the word Hartman's but no one ever really explained what it was. So it's actually essentially a high anterior section. So I've put it here for reference, but you are forming an end colostomy and a rectal stump. So you are not doing an anastomosis and you're also not doing what we did just before with a defunctioning loop. These are emergency procedures. These are not laparoscopically done. These are open laparotomy procedures. So you can see midline opening scar here. So these are for when there are things like perforations when the patient is critically ill. And you just need to get in there to cut that nasty bit out and bring the stool and safely bring stool, the contents of the bowel out. So you don't have the luxury of being able to form nice defunctioning loop bios. You've just got to bring this colon, this healthy part of the colon up to the surface, um bag it and then sew off the rectum and then you can go back in later once everything is settled and actually join these back up again. That's not always possible though. That's why you always see it's plus or minus anastomosis. In a few months. So Hartman's and anterior resections go sort of hand in hand. They are very similar procedures. It's just that Hartman's is a much more emergency procedure that can't really be done laparoscopically and it is not an elective. So you've got an elective emergency. And that's another thing that is sort of a general surgical principle is they are, they are considered two quite different things in the realm of general surgery, elective as his emergency procedures. And also the way we work as well is very much, there's a team that deals with the emergency side of things. A consultant, a reg whatever. There's a, an F ones, there's a whole team that deals with the elective side. They have two sort of quite different spheres within general surgery. So, although on paper, these procedures are quite similar, they would be done by different teams for different reason. So to explain that SBA then this first part of the stem of the question was basically telling you that this is a patient with a bowel obstruction who perforated, they've got a rigid abdomen, they've got pneumoperitoneum. So this is an emergency procedure that they're going for there. Their cause of obstruction is explained here. It's, it's adenocarcinoma of the sigmoid codon. Um, but because they're perforated, they need emergency surgery. So if they hadn't, if you didn't have any of this perforation there, and you just had, they've got a Codon Codon, adenocarcinoma and they're awaiting elective surgery. They'd probably have a sigmoid colectomy or they'd probably have um an anterior resection, probably a high anterior resection. But because of the perforation, you are having a Hartman's procedure. And as I said before, in that Hartman's procedure, you don't have the luxury of forming nice defunctioning loop polysomy. You've just got to bring the bowel up to the wall. So you will perform an end colostomy here, which is what has been distrain. I So this is basically imagine this is the outcome of a 75 year old man. This is what he will look like immediately after surgery. He will have um an endoclot toy. He will have this midline laparotomy scar. Um And he will have this pouch, basically this son off pouch. Um No stool will obviously be going into that rectum. It's not connected to the rest of the colon. And then later this, this man, once his information has settled down and we've dealt with this, he might then be able to have um an anastomosis procedure in a few months. Um, abdominoperineal excisions of the rectum. So these upper cancers are very, very low down. So we sort of worked through the bowel cancers. We started on the right, we went to transverse to left to sigmoid to rectum and now we are down at the very end with anal cancers. Um And you don't form an anastomosis of this because you have taken out um, the last part of the bowel. And you might be thinking to yourself, hold on. Anal cancers are very low down, but we're not just taking the anus. We are also taking all the rectum and even a bit of the, um, the colon, a bit of the sigmoid out. They are more aggressive procedures than anterior resections. The reason being is that anal cancers are, they have a different, um, histology. They are squamous cell carcinomas, Whereas rectal cancers tend to be adenocarcinomas, squamous cell carcinomas, as you remember from past, probably are more aggressive generally. So the procedure is that much more aggressive you are taking, it's sort of funny is in rectal cancers, you try and preserve as much of the normal bowel and you try and preserve the anus where you can. But in anal cancers, you don't do that. You take quite a bit because they are much more aggressive cancers, much more spreading. You are focusing on getting those clear margins. The other thing is when you find an anal cancer, unfortunately, the likelihood of preserving normal bowel function ie being able to pass stool through your back passage as per you've done most of your life is not really happening, whereas that can happen with rectal cancers and that's quite a priority. So that's why that's another sort of big difference is that the preservation of normal bowel function is, is much more of a possibility of rectal cancers. It's much more of a consideration by the general surgeon than it is for anal bow cancers. And that's why you do a so quite on paper, a lot more um aggressive surgeries, the lower the anastomosis as well, the higher the risk of complications. So, again, anal cancers that are very low down, you're just not even going to really think about trying to attempt anastomosis because it's just really just not going to work, you're going to going to have to go back to theater. Um Also chemo Raio forms a much, much larger um bulk of the management for anal cancers um than they do for rectal cancers. Rectal cancers respond quite well to resections and being cut out and usually do pretty well with just surgery. Anal breast cancers need a lot more. Chemo Raia, usually chemo Raia is first line and then you try to shrink them, control the spread, etc and then you will key resections and then finally your sort of radical total resections. So these lesser for cancer because cancer obviously usually stays a bit more in an area. But for these extensive s and process things like hereditary polyposis where you've just got lesions all the way through, you might need to take large sections of bowel out. So you've got total procto pan procto or just proctocolectomies. Um So those are where you're taking everything including the rectum. So you've got no large bowel at all. Your bowel very much, just ends at the ilium and you will do an end iost. So you will bring that ilium up to the abdominal wall to the surface of the skin. Um, and that's it. That's your bowel. You've got no large bowel. There you do or you do a total colectomy. Um If you can try and preserve the rectum and you will initially do a temporary ileostomy. So you will put that on rest, bring the ileum up, but then you might go back and actually connect these two. but we'll talk about stomas in a bit. I know we touched on it a lot already. It's one of those sort of chicken and the egg things. Where do you talk about stomas first? You talking about sections or what's the best way to do it? But, um, you would appreciate that this colectomies are a bit of a funny one because the contents of the ileum, they haven't gone through the large bowel to reabsorb the water. So, actually what you will pass out through the rectum will be pretty watery, unpleasant contents. So, actually, I've been seeing a bit with total colectomies, more permanent ileostomies. So generally speaking, if they are having total procedures, they tend to end up with ileostomies because they've got no actual large colon to reabsorb any water. Um, quick side note on some of general surgery principles, um, of your kind of POSTOP complications. Um, early on, particularly in general surgery, abdominal surgery. Um, patients are in pain. Um And obviously, when you inspire deeply, you increase your uh abdominal pressure. Um so that causes some pain. So patients don't breathe deeply when they don't breathe deeply, they get atelectasis um and they get chest infections. Um So that's quite a big problem. And the core part of that is managing pain and getting chest physio involved. Urinary retention is quite an early complication and then reactive primary bleeding, bit later. Um You get infections. So that's things like chest infections from not breathing wound infections, UTIs or secondary bleeding. And then a bit later on, you get things like pee where you've been immobile and wound distance and sto so on stomas then. So we've already touched a lot on stomas. Um So I apologize. As I said, there's no sort of like right way to do it to talk about stones first to about exceptions. I felt like it. I chose to do resections first because it makes sense to understand why you even need a stoma in the first place. Um But I'll start with the question then. So you've got a 24 year old man with UC and he's recovering on a general surgery ward after an elective pan proctocolectomy. So you remember um the P proctocolectomy from besides before what he had out, um this was performed due to extensive UC refractory to medical management and the stoma has been created, what feature is most likely to be seen when you're examining his stoma. So the question is basically asking you knowing the procedure that he's just had, work out what stoma he's had. And then based on that stoma, what the output of that stone is likely to be or where it's likely to be or what it's likely to look like. Ok, so I'll give you a second to have a think of that. And again, I think questions in the MLA are, are not, they're annoying because you sit there and you're like, I've got the diagnosis here and then they basically tell you the diagnosis and then they want you to do something around that. Um So they are a bit like this. Um where you think? Oh, I know, I know what Pantic colectomy is. I know what's happened here, but then they tell you that they've had a stone and you probably know what stone is, but then you need more information, um or they're asking you more information. So the answer is liquid out and we will, I will explain why in a minute as I've been doing with these SS. So Aoma is an artificial union between Conduits or between the Conduit and the outside funny definition that stoma is bringing the bowel up to the abdominal wall. Um And it depends on which part you're bringing up. Is it an ileostomy or is it a colostomy? If it's an ileostomy, you're bringing the ileum up. If it's a colostomy, you're bringing a portion of the bowel up. Generally speaking, ileostomies are found in the right. Iliac Foster where the ileum sits. Colostomies in the left, usually colostomies have more of a tendency to be in other places. So this is not a hard and fast rule. That's why it usually is there. But generally ileostomies in the right, they have colostomies on the left. Ileostomies have watery contents. They haven't that stool or it's not quite stool yet. The abdominal content hasn't gone through the large bowel. Um, it's been diverted away for whatever reason. And so it hasn't reabsorbed all of that water so that the content of what you will see in the stoma bag of a patient with an ileostomy will be much more watery. Also, if you are working the other way or looking in a bag and you see more watery content, you might be thinking more likely to be an ileostomy, but obviously not necessarily, the glossy would be more formed feces or more fent in nature and smell and so on because it has been able to go through the large bile, it has been able to reabsorb water. Um, the gut bacteria sort of act on it. So it's more figent in nature. Ileostomies are spouted, that's not because they are watery and they need a little spout to pour out nicely. But actually, because the contents of what is coming out of an ileostomy is more alkaline and more enzymatic. Um because it's just come from the small bowel, you need to bring the contents further away from the skin where it could cause irritation and dermatitis. So they are spouted to, to provide that sort of distance if you will. Um, colostomies can be a bit more flush because they are producing more solid um, content. Examples of a permanent ileostomy would be something like a proctocolectomy. So in the question before, um, where you've got no large bowel. So you are just having to end the bowel at the ileum and bring that to the skin to, to be able to empty the bowel. Um A temporary one would be something like an anterior resection, um which we discussed before, particularly in things like a low anterior resection way of doing a defunctioning ileostomy. So it's kind of you're just doing it to defunction the large bowel and then you'll go back in and you'll undo it. So it's temporary alost, a permanent one would be your abdominal perineal resection. That was, remember that was for your kind of anal cancers where you've not been able to preserve much of the, um we've not been able to preserve the anus or the rectum. So you are just having to bring the colon up, um where it's where it's healthy, you just have to bring that up to the abdominal wall. Temporary would be something like Hartman's. So that so similar to an anterior section, but emergency. So you've not had the luxury of making IOST. You've just had to bring your bowel up. You do a Hartman's and you can go back in and reverse it. So loop Ileos, I throw that word around. Um, and loop versus end end is pretty easy to understand. You are literally just bringing that, that tube up to the surface. Um, I sort of use this pen to demonstrate, you know, you've got an empty pen, you make your cut and then you've got this hollowed out tube that you will then bring to the surface. There's your stoma, uh There's your ileostomy, colostomy and you put a bag on the end. That's quite nice to understand. Loop is a bit more weird. Um So what you're doing with the loop ileostomy and for example, you would do this with a, with an anterior resection. Um It would be a temporary one is you bring this, you take a loop of bowel. So sort of from here, this line beyond is your nice loop of bowel. In this case, you're taking a loop of ilium. So you, and you brought it up to the surface of the, you build up to the skin and you've made a cut. So you've now got these dual lumens, you've cut down hair and you've got these two lumens. So you've got, I wish these images matched up a bit nicer and this image was reversed, but you've got a which is the one coming from in this case the J coming in, bringing your food in, it will drain off into a bag. And then you've got BB and everything beyond that is not receiving any food, any bowel contents. B will just put mucus into the stoma bag. It won't put any food content. So you've got a here which is your normal functional ilium that's working as it should, that will be doing its normal function as an ilium does. Um And then you've got your defunction ilium points, it's enterally deprived. So it's not receiving any food. Um And you can go back and reverse these. So as you saw with anterior resections, you, these are temporary, these are just defunctioning. So then you will go back and you will reverse this and you put this back into the bowel repair all this. Um And then your ilium is working as it normally is and it will go a round to be and then into your um large bowel that's probably been anastomosed at this point to the rectum, say because you did an anterior resection. So the answer to this question is the patient had a panproctocolectomy for UC. So that was um also quite a common indication for a panproctocolectomy. So they've had a whole large bowel out including the rectum. Um So the bowel is ending at the, at the ileum, they brought the ileum to the surface. Um and they've got an end ileostomy in place. And so the content of that is liquid. Um Bye, urostomy just for completion. Another stoma. Um you're forming because of uh often diseased bladder, bladder cancers and things like that. You have, have to sort of form an artificial way of you. You can't really store the urine anymore. It just needs to be drained out. Um And of course, if you're not allowing it to drain, you'll get um hydronephrosis and damage to the kidneys. So, what you do is use the ileum to form um uh a conduit. Um And you bring you connect the ureter to the ileum and then you bring that out to the abdomen and that drains into a urostomy bag and that's essentially your bladder but outside, but you are using the ileum to beat that tubing. So, yeah, I wouldn't worry about that too much though. It was just more for completion and you are using a bit of the, the gi check as well. Now, complications wise, again, in cases you categorize things the best way to do it is early versus late. Um You can never go wrong with most things by saying infection and bleeding. Even the simplest of things, things that have been a puncture if you explain you been a punch to a patient and someone is, I guess watching you, you might want to say to them complications of this are infection and bleeding, but it seems silly because you are bleeding, but you can never really go too wrong with that. And of course, with any real intervention, it could just not work. So in the case of a stoma failure is that it doesn't, you don't get B contents into it, you don't have any output um ischemia. So if the blood supply is compromised, usually in the process of forming that stoma um retraction or high stoma output, um high stoma output is defined a bit differently in different places, but generally more than 1.5 L a day out of the stoma into the stoma bag will be considered high stoma output and that will be on the flow balance chart. Nurses should be recording that um And then lots of these patients particularly soon POSTOP because this is the only complication you through balance should be excuse me, should be monitored to monitor specifically for things like this. Um Often trusts will have guidelines on how to manage high stoma output. I won't go into the specifics of things. But um general principles are you are losing your good high losses. So you need to replace those losses. So that's kind of replacement fluid, maybe even bolus as well if they are quite dehydrated. Um and they've lost a lot of volume and slow gut motility. So things like loperamide are the mainstay and of course, if this was a situation, someone asked you in a vi you would make sure you do your conservative medical, conservative medical and maybe surgical, maybe you have to take them back to theater and of course, make sure you are assessing their fluid status and checking if they are hypotensive and signs of volume loss, etc. But the crux of it is you want to replace what they are losing and slow down, got maternity later complications. Um stenosis of the stoma prolapse of the stoma big one and paradermal hernias. Um we operated on a lady this weekend, her parasal hernia amongst other things, but that was part of it. Um So because you've essentially formed by bringing the abdominal wall up and cutting through, you've essentially formed a defect in the abdomen. So you enable an area for bowel to herniate into dermatitis. So again, there is irritating bowel contents around the sty, even though you with the ileostomy, even though you have got a spout, especially if it's not being drained well enough, often you can get dermatitis and that does happen with kind of older patients as well who are struggling to cope and look after themselves. They can get dermatitis with their stoma and V as well. How to examine a stone paces. You want the patient lying flat as you do with an abdo exam, um, you want to take the bag off and actually look at the stoma itself. So you want to see where is it that can point towards uh what type of stoma it is, but it's not foolproof. So don't rely on it. Um, but obviously, it's something that you would describe. I notice a stoma in the right iliac fossa, which may be suggestive of um an ileostomy and then the appearance of it. So how many lumens? One or two is it end? Is it loop? Is it spouted? Again? That's a better indicator of what type of stoma it is. I remember spouted is ileostomies and flatter are your colostomies. And then the actual contents of the colostomy bag is a big thing. And that was one of the spas. If it's more liquidy and if it's more liquid, it's likely ileostomy. If it's more fent, then it's likely colostomy and also things like blood are mixed in mucus. Um if they are particularly fatty and greasy might suggest malabsorption and then palpate around the stone. So palpate for any masses, likely to be things like hernias, possibly if they are tender, it could be things like abscesses and collections. And so we obviously assess for your sort of or color heat redness, all that kind of thing. Um You might also want to, if you're assessing for hernias um past hernias, you might want to get the patient standing up you um and cough, but, but mainly for an abdo exam, you're, you're getting them lying down um to assess a stoma. So that takes us nicely onto her because we were just talking about them. Um Again, this was quite a big topic in third and I know I said at the start I wasn't really going to cover a lot of third stuff, but in, and femoral are quite important ones to know. Um, I think, and f one we operated on two inguinal hernias my weekend on call that I've just been on. Um, they are quite common. Um, and they make up a bulk of what the general surgeon sees in lower pathology. So I'll give you a question to start. So you've got a 52 year old woman who presents her GP with a new groin swelling, which she's noticed for the last two weeks. Mass is noted infralateral to the pubic tubercle. It's not tender or reducible. There's no soft tissue swelling or erythema to the overly skin. What's the most likely diagnosis? So, new groin swelling in a lady infralateral to the pubic tubercle. Um I'm not, if you haven't looked over this yet, I'm not expecting you to know this. Um It's something that you'll pick up very quickly and then you just won't forget it. So the answer is an incarcerated femoral hernia. We'll go over that in just a second. I'm not gonna go into the specifics too much. It's just more kind of the pertinent information. Um You've got a man who attends with the swelling in his groin. He's got a single soft nontender lump, supramedial to the pubic tubercle on the right side and the GP is able to reduce the lump and we'll talk about what that means in se um, how could he ascertain he or she sorry, ascertain the anatomy? Um, and some type of this swelling. Could he ask the patient to cough? Could she ask the patient to lie down? Could they measure the size of the lump? Could they press on the deep inguinal ring and ask the patient to cough? Or could they press on the superficial inguinal ring and ask the patient to cough? So, what are you basically, what's the next step in their examination? Uh or your examination? Um As the doctor and GP if you're going to press on the deep inguinal ring and ask the patient to go, I'm sure, you know, it's just to reiterate it. Um Or remind you if you don't, I'd forgotten all about it in um Whoever told it to me just to do a very good job and I didn't bother to blood. Um So a bit of a cheat sheet of he terms then incarcerated and strangulated are two different things. Sometimes they use interchangeably, but they are two different things. Incarcerated is the trapping of it, but the strangulating is the trapping of it. Plus the blood supply is compromised and obviously strangulated as you can therefore appreciate is much more of a emergency, producible versus irreducible, pretty self explanatory. Can you push it back in? Can you not push it back in by literally just pressing on that? Um They do usually require a bit of pressure though. And actually, um, a hernia might be, might be reducible, but you doing it with a patient, they awake, it might not be. So you would still present it as kind of an irreducible hernia. But then you put them under, under anesthesia. Um, maybe you put a laparoscopic port in and you can actually sort of see it inside and push from outside, which is what we were doing this weekend and then it's reducible, but it's just not tolerable. Um, awake. Um, Richter's hernia, not sort of important. It's just something I wasn't aware of, but it's, it's a hernia that actually involves part of the bow circumference. It's not full bowel in there. Um, only part of it. And then the key ones that I think you should know that I had in that red box on the first page were femoral hernias and inguinal hernias. The key difference between them, I know you know what they both are. But the key difference is that femoral hernias are below or inferior and lateral to infralateral, below and lateral to the pubic cubicle, females higher than males. And they have a high risk of strangulation. Inguinal hernias are above and medial. So, however, best do you think to remember that? I mean, I kind of do sort of ami morning and wake up in the morning with an hernia. It's a weird one. female f f female. Eho Feer, those two kind of go together and it's the opposite of an inguinal. I remember inguinal is above and medial. I remember a femoral is the opposite below and natural. And that was kind of a core aspect of the previous questions. Um indirect versus direct. So, indirect pushes through the inguinal canal. Um follows that kind of path laid out, I almost imagine and direct is through a direct weakness in the abdominal wall to the posterior wall of the inguinal canal. Um Again, how you remember that is up to you. I sort of remember it as if you are direct with someone and you're straight to the point. So you're not kind of going through the nice, nice, taking the long route round, you're going straight through it, you're going straight through a weakness in the wall. And this was sort of what the GP should have done in that previous question. So the issue should obstruct the deep inguinal ring at the midpoint between the A and the pubic tubercle, ask the patient to cough or to bear down or you just increase the pressure there in the intraabdominal pressure. And if you've controlled the hernia, you've got an indirect hernia that's coming through the inguinal canal and you holding your finger there has stopped it from, from pushing through. Um And if you've not controlled it, then you've got a direct because you've not, you're not holding that, that, that weakness in the abdominal wall. That's weird. I didn't mean to see that transition. Um But yeah, so this is why this one is an incarcerated, femoral hernia. It was incarcerated because it was so the non tender aspect was referring to the fact that it wasn't strangulated basically. So it was trapped there, but it wasn't, its blood supply wasn't cut off, it wasn't an emergency, it wasn't tender an immediate rush to theater because we were about to lose that bit of bowel and it was femoral, it was infralateral and this was a woman. I mean, it won't rely on that aspect too much, but it is useful to epidemiology wise. Um, and it's irreducible so that bowel is trapped in there. So it's incarcerated. And then this one, as I explained, um, you, you're person with a deep and you're asking the patient to cough. Um, and if it reappears, it's more likely to be direct. And if it doesn't, it's more likely to be indirect. Of course, that's actually the talk. I mean, good time. Um, so I've got a bit more to talk about sort of general f one stuff. Well, the main stuff is going to be sort of some f one takeaways I've had in the first month and things that sort of reflections on being a medical student, what you guys can do some elective stuff. And then first I was going to talk about sort of deanery stuff because I know that that's probably on a lot of your minds I've spoken to some of you guys and I've had some feedback of that's what's kind of going on in your lives at the moment. I think registration opens next week. I want to say for AO. Um So I was going to talk about that for a bit after I'm happy to stay on. Um If you don't want to stay for that, that's absolutely fine. There's the feedback form, please, please scan it. Um You, when you get to my stage, you start having to think about portfolio and apparently you can never stop thinking about it for the rest of your life or the rest of your career unless you leave medicine. Um which is devastating and this is one aspect of that um doing teaching like this. Um So please please fill the feedback in. It's really helpful and obviously amen it for the crazy sign so they can keep making good presentations. Um and good lecture series. Um Yeah, I'll give everyone a little break and some questions can come through if you have any, if I can't answer them. Um which I mean, my brain is pretty fried. So I probably can't. But if I can't, I can get them back to you, I can run them by my reg as well. Um Which is most of what I do as an F one is run things by my reg and actually get some solid answers. But I can also then head on and talk about the, the more fun, in my opinion, the more fun life stuff as well. Yeah, I will give it a few minutes to get some water or something or bite if you haven't eaten already and then we can talk about some of that stuff. Oh, so I don't think the feedback takes too long. Um, so I will just move on. Um, I should have said as well. If you were wanting to stay, then maybe don't fit it in just yet because the next part might be useful and you might want to add that to your fever, but that's fine if you have and I, I'll take another one if you're willing to. But yeah, so life stuff then. Um So you're all at the point where you think you're locking a bit into the final year. Um Fifth year was a big slog and now you're starting to think about what's next. Um And there are obviously some big things coming up. Um In terms of where you go in the country to practice medicine, you've obviously got exams that you need to do past before you get there. And then you've got this amazing trip where you're going to experience medicine. Um or not necessarily, you might, you might stay in the UK, but you've got this experience where you get to experience a different, different aspect of medicine or a different medicine to what you've been experiencing in imperial hospitals. Um And obviously commonly that happens on the other side of the world. Um So there's a lot of change happening and I remember being in your point and thinking, goodness me, in this time, in a year's time, I'm going to be in a completely different setting and I am. So I'm currently down in pool, which is in the Wessex scenery, which wasn't my top choice and I'll talk about that. So how it works. UK FPO, this new allocation system, this crazy weird system, you've got your 18 deaneries um that the country split up to and you will rank them in whatever order you see fit. We'll talk about that. Um And my understanding of it and I think it's going to stay the same for you guys is that this stupid algorithm runs down each person in this random order that it has put you all in and giving you this random number and it runs down in that order and it goes to person, the 100th person on its list and it says, is there a space in their first option? Yes, they can have it. And then it keeps going right. So Jack Smith whose 100th wants London, of course, he can have London. There's plenty of spaces but Sarah Patel um is 6000 doesn't have a, she wants London, but there's no more spaces in London. So she gets skipped and she gets held on to and then it keeps running down, everyone and there's a Zainab can at 8000 and she wants Northern Ireland. Well, of course, she can have Northern Ireland even if she's 8000 because no one, no one else has put it. Um, that's a joke. People out put it, but just, there's a space there. Then it goes to the second part. So it goes to all the skipped people of which Sarah at 6000 was, was one of them. She's put uh seven, she wants Bristol. So she's put the seven next. That's very, very competitive. Always has been, was this year probably will be again. So she doesn't get it. So she gets skipped again. OK. Now she's on the third sort of pass. Lots of people have been taken out because lots of people have got their first choice. Lots of people have got their second choice. She's on her third. She's put her third as Wales because she went on holiday there as a kid and really liked it. It's a big Deanery, but she's always liked bits of Wales. The algorithm goes down again and she's 6000. She gets it. So she's going to Wales. Um That's, that's essentially how it works for that first pass. That's how it puts you in different places. Um Once you're within a deanery, um you, some, some of them do it a bit differently. You keep that number, that's the important bit. You don't know what that number is though. So, Sarah doesn't know that she's 6000. She doesn't know that the person next to her is 6000, 1, 6001 and got their top choice and she got her third. So this is why MS And everyone will sort of tell you that the system is great and it, and it statistically looks great on paper because lots of people do get their top choice. Was it actually their top choice? Did they change the way they decided because of this new system? We don't really know. Um But equally, whilst lots of people do get that 1st and 2nd and 3rd choices, there are people that get shipped off very, very far away to places they put a lot further down than you really heard of before. And also that's completely outside of their control in the past. If you got your 14th choice, it was because unfortunately your performance and exams just wasn't good enough to get higher options. Now, it's completely random and you get some of the best and brightest that could have in the old system had their top choice not to get that. And I, the imperial students are obviously across the board. Very intelligent and would in the old system do quite well across the board. So it's unfortunate. But, um, the silver lining is, is that I've yet to find any people I've spoken to and people I've spoken to I've met here about their friends. No one is really having a bad, horrible time because everyone has sort of been distributed in different ways. Generally speaking, everyone is in the same boat and everyone is making the best of the situation and no one is really actually having that bad a time. We, which my pool, which is in the Wessex scenery. That was my fifth choice. Um, I actually wish I'd put it higher. I'm, I'm quite happy. I've come here, I've had the, the luck of coming down here with some other friends that also didn't put Wessex high up. Um, it was their fourth or fifth option and we've all ended up down here. Um, I had some other friends within Wessex that aren't in this specific, these two hospitals, there's Bournemouth and Po Hospital. Um, I've got a friend in Dorchester sort of next door. Um, some friends in Portsmouth. So lots of us have come down here when they weren't high up. We all sort of put similar ones 1st, 2nd, 3rd. and we've got our 4th and 5th choice. So what I'm trying to say is basically, don't worry about it too much. I know it's unfortunate that you've not really got SFP from what I understand. You don't have SFP, I checked the timeline and there was no mention of SFP on that. I checked the SFP 2025 UK FP page and it was sort of saying we'll update this soon, but I mean, I, II can't see that being a thing. So I don't know exactly what's going on with S FP. But just, it's important to understand what the normal system is and how it works because obviously there's every chance that even if you apply for S FP, you might not get it. So you might be in the normal system in terms of where you decide, I would say, just decide on the location because you've not because that choice has been taken away from you. Um There isn't really much of a point of trying to choose a place that has a really great t department or trauma center or something like that because that will usually be a specific hospital within a large deanery. So actually trying to choose a whole place for one specific area isn't the smartest. So when you are choosing a location, put actually what you want at the top, don't try and focus on one specific hospital, you try and focus on an area where actually you'd be happy with a few different place. Um Or even if you do really want one specific place, put it, but be conscious that there might be other places that you'd be comfortable with. I for example, really wanted north west, the northwest of England, specifically Manchester. I sort of got up this picture in my head of maybe moving to Manchester and what life would be like that didn't happen. That's fine. But I also was happy that if I didn't get Manchester. I had other options in the form of Liverpool and Blackpool and so on. And there were other places to do things in terms of how you decide what to put at the top, what you want. What is your favorite? Obviously, that's very person specific. Um But I would say that work is kind of the same wherever you go, everyone is going to be doing a gen med job at some point, a gen search job at some point, some form of GP or Ed, some sort of job where you're seeing like a variety and then a few specialties dotted in there. So everyone is doing the same job essentially and you're all kind of doing it at the same stage. So actually, it doesn't make too much of a difference for the job. So what does make the difference is what you're doing outside of the job? So you want to be choosing a place where you would be comfortable to live in where there's things to do. If you are someone who likes nature and long walks, then obviously try and pick locations like that. If you're someone who wants, I'd say myself who wants a vibrant nightlife and plenty of activities in that regard. Then try and think about putting that up top in terms of what you pick after that. Obviously, you've got 17 other deaneries to rank after that. My advice would be focus a lot on the top five, think also about the next five. So that top 10, but particularly that top five, how you choose 2345, up to you, lots of people do the one they really, really want and then maybe the Deanery that's home because then they can live at home, save money, etcetera. But my advice would be when you're sort of ranking other ones. 345 is maybe look at each de look at the areas. Don't worry too much about the hospitals and the jobs, but maybe just look at the areas and think, ok, what would be the best option in this area? What would be the worst? What's the middle and actually compare middle? Um, I'm in Wessex at the moment. As I said, I wish I'd put it higher. And the reason is because I wish someone had given me this advice because actually the middle one for me in Wessex would be Basingstoke, Salisbury, Dorchester. So there's actually quite a few whereas I put KSS high. Sorry Sussex, I only really wanted Brighton and I didn't really care for anything else. The middle for me was, was worse than the middle of Wessex. So I'd say pick sort of what you think would be the middle for you. Um, and then compare them to other deaneries and sort of use that to decide where you're going to put, um, clever people find a way controller has been taken away, but clever people which we all are, will find a way to find some order. Once you get your deanery, you then rank the jobs within that Dery. And your job is three rotations in your first year, three rotations in your second year and F two. And that's one job, jobs are often in groups of three. So it's the same job, same, same rotations just in a different order. So they come in these blocks of three and you've got to rank them. Some deaneries get a bit better. They break their deanery down by subs. So you get, you sort of go through another rank again and then you get given a sub deanery. Um So KSS, for example, I think splits it sort of KSS, East Kss, South Kss Central and then you rank jobs within those subd Wessex, for example, didn't you just ranked every job via invading stoke pool? The isle of wight, Dorge, whatever having people find a way. What happened in a lot of the Wessex one? And I know it happened in other deaneries as well is people, people get in these group chats when you get allocations and people make spreadsheets and people put their name, they put all the jobs in, into a spreadsheet. So they said if you are looking to put Portsmouth top, here's all the jobs in a spreadsheet in Portsmouth, put your name next to the job, you're looking to put top. So people put their name next to it. I did the same for the Bournemouth and pool jobs. I went back on and I saw that lots of people put their name next to the job that I was probably going to put top. And I thought to myself, well, Wessex was my fifth choice. So I don't know what my number is, but I know it's not that good and I know that there's probably a good chance that one of these other names next to mine who is also going to put that job top probably has a better number. So I switched and I chose a job that no one's name lives next to that. I thought I could reasonably do. It wasn't my top choice of job. Um, but I got it. So I got my top job and that's another thing with the stats as well that you need to be a bit careful when you look at the stats and go. Oh, no, the stats look great. The stats do look great. People get their top job, people get their top generate. Is it actually, or is it people trying to sort of find a way to gain control in a, in a bit of a rubbish system? So some things to think about, as I say, you to hear anyone having a bad time, you will make friends, you will undoubtedly make friends with the benefit of the system is you've just got a mix of people, but also we are all people who have gone through the same thing for the last six years. We've all done medical school. We've all lived a very similar experience for the last six years. It's very different from home friends that have done three year degrees. And so we're all in this, like in it together and we've all started a new life in this new place. So you will just make friends and you are working with them, you social with them and you will find people that are more like your people that you know now. So even if you go to new places with knowing nobody, you will just make friends. And I actually met some people on elective who I then was going down to do foundation with and I've made loads of friends down here and I've come with friends down here. So, but even people that haven't had any of that still just make friends. So don't worry too much if you do get a really rubbish option. Um You get your 15th 16th choice, you'll find people, you will just have a good time, you'll have to sort of just make it. Um So that's a little bit about UK FP O ranking de I'm more than happy to, for you to email me with more questions or anything like that afterwards. Um I like talking about this kind of thing. Um I find it interesting. I like having a chat um elective wise it will come to that point where you'll start thinking if you haven't already about where you want to go, what you want to do in terms of choosing where you want to go. I think you really need to ask yourself the question. Do I want to do an elective to further something career wise and pick it in a topic that I'm interested in a field I'm interested in? Or maybe they do this niche type of surgery or something here. I really want to go there. Or do you want to do it to have a break at the end of six years of medical school before you start working for the rest of your life? Do you want to do it with? You have a chilled placement where you go in for a few hours and then you've got most of your days to yourself. You can do weekend trips to other parts of the country. Um, or what, what are you wanting to get out of it? Um, that's not to say you can't do your elective kind of, uh, very subject specific career specific and then go traveling afterwards. Um, it's just really what you, what you kind of want to do. I think that's the most important question to ask yourself. Um, look at what previous years did the best way to do that is actually just on things like Instagram and see if you look at people in my year, what they were doing between April and May and you can see the ones that have like, been really in their placement and really not, you can sort of work that out, but also like what looks, what looks like, appealing to you. I've had people message me from your year being like, oh my God, I went to the Philippines and the Philippines looks amazing. And I said, you know, and I said, I'm more than happy to tell you how I did it. It's quite chill really. Attendance wasn't really that mandatory. Um No one was monitoring it. You went in for your own enjoyment for things you found interesting, etcetera, etcetera. And of course, word of mouth, you heard about someone who went to an area you were thinking of um popular areas are for career wise. People often go to things like Australia, New Zealand, um America as well. That's really hard to get into. Um But I think because if you want to work in America, um then they like you to have some experience in having been in the healthcare system, but it's quite challenging. Um But Australia and New Zealand is quite a popular one that people go to if they're looking to do specific types of medicine or they stay in the UK and they go to like other, other centers. Um and traveling wise, the, the ones that are sort of more on there for a trip you tend to find uh Southeast Asia. Um And that can be like the cities and places like Vietnam and Bangkok or like we did in, in the Philippines, which is also a city um or Australia, New Zealand or like South America. So they are kind of big, big places that you will find lots of people and people also just like meet up with other people that are traveling around. Um Do you want to self organize it or do go through a third party, self organize? Most people do and they'll email a hospital or a university and say I'd like to come to elective and things obviously, you know, they have their own processes that they've done many, many years. Um You pay them a fee but it's usually not an insane amount. Um or you do a third party, which is what we did. Um We did it because like, like my second bullet point, we'd seen someone in the year, we knew someone in the year above who had done it. Um We spoke to them about it and they said, look, we went through this third party, they put you up in a place, they cook, they cook two of your three meals a day, meet dietary requirements, you meet loads of other people. Um They'll help you organize trips around the Philippines, etcetera. So we, we signed up that was more expensive than organizing it by yourself. But there were lots of things in there that we liked the sound of, and for me that felt much more of a relaxed holiday vibe of having someone to do all the organizations while I was on board with that split electives as well. Do you want to do it in one place or two? Um, I've got a friend ari, she did a bit in Sydney, then she went to, I think either Fiji or Samoa, I can't remember which one. Um And so that's possible you just have to sort of do double the organization and make sure you work out flights and things like that. And obviously that's often a money dependent thing as well. And where you want to travel after I was someone who initially didn't want to travel around my lecture where I wanted to do traveling as a whole separate thing. But actually, I'm really glad I did the Philippines and then I went around and did your sort of traditional Southeast Asia traveling route. Think about that as well. Lauren, my housemate, she went to Imperial. She um the South East, sorry, South America. I did Costa Rica for her elective and then did Honduras Guatemala for traveling. So think about that as well. Um Maybe where you want to go afterwards. Um and then who you want to do it with? Do you want to do it in a big group? A small group by yourself or a mix? Again, if you're doing split electives, you might join one group, then go off and do a bit solo or join one group hh around um that, that also sort of mixes in with your traveling plans. You might do the actual elective portion in a, in a small group and then go off traveling solo, for example. So, so some things to think about when it comes to choosing your elective and how you want to do it. Um But yeah, again, I'm more than willing to take any questions after this or email or tell you about how I organize mine. And then F one finally, um F one F one is great. Um It's a steep, steep, steep landing curve. Um It's very different to being a medical student. I think everyone will say that um with being a medical student, you are there really to tick your boxes, you go to placement, to tick your boxes to go home and then revise for your heart exams, which do please keep doing type of thing. Um Don't worry too much about being a great F one at this point or knowing everything. You need to be a great F one. When it comes to like on the job stuff, you will learn it on the job. You will have to learn it from the job and you will also have um shadowing time that you actually get paid for, which is quite nice in most trusts. Um Before you actually probably start by yourself where you can learn, you can learn how to do the job. I would say that's useful for learning more hospital specifics. Learning how in that hospital you go about putting that referral in vetting that scan, how you go about, you know, all the ins and outs of that hospital and how things are done there. I'd say try and use your PFA or so, maybe some placement now um to try and appreciate what an F one's day looks like. And some of the key things that they do, um, your attendance to PFA is obviously gonna be placement specific you. I'm not gonna speak on that. But if I would say if you can get anything out of PFA, obviously do your minimum requirements but try and do a few clean scales and just get just before you go on elective, just get ok with doing your cannulas in your blood because nurses will bleep you, the ones that do them often will bleep you and be like I didn't manage the cannula. And if you've not done one in six months, neither will you. Um, discharge summaries just knowing what goes into a discharge summary. It's the bane of your existence and it is what you spend a lot of your time doing is getting people out the door and sending them home with the right paperwork. Um I had a patient who I took blood from the other day and she was like, oh my goodness, you're so good at this studio. So, and I said, no, I'm behind a computer most of the time and she asked me how I can switch from that job. And I said, no, love, you're not understanding like that is the job. Um So get, get used to what goes into a discharge summary. I had done two, I think before I actually had to start doing it. And then on the first day I had to do four. So it's not a big deal that if you haven't done one. But just be just appreciate what kind of information needs to go in it. Um, phone calls as well. It's actually a weird one, but it's really daunting when you have to call someone like for the first time or the first few times and they sort of ask you all these questions, you've not really prepared. Um So just get used to, if you are on the ward round or after the ward round, there's jobs and one of them is to do a referral to a team to ask advice from somebody. Just, it's daunting, but just be like, can I, can I have a go at being the one to do this and say hi is at the micro consultant. I just want to talk about this patient. They come in with this. We started them on this. Um Can I have some advice type thing? My advice actually is if there is an opportunity to speak to a non doctor over the phone. People like acute pain nurses, diabetic nurses, they are usually nicer people and nicer phone calls to make. But just try and if you can do that, it just helps take away that anxiety when it comes to actually having to do it in real life and out of hours really, really useful one to do on people. But if you do nothing else, I think you have to get them signed off. But if you do nothing else, try and do some out of hours shifts and just get an appreciation for all the hospitals. Like when it's like a third of the staff and you don't have some of the services that you need. And it's, you know, it's, you, you the F one and the so basically in the med ridges running around like a headless chicken just, just get, get an appreciation of that. But generally, I would say the actual clinical side of being of being a doctor and being an F one is better than being finally a medical student. You just feel like you have a much better sense of purpose. You are expected by somebody and you know, where you need to be and they know where you need to be. People say hello to you because they sit near your face. But more importantly, you've got access to things. I think my biggest bin medical student I hated the most was that you could never get through a door or you could never get onto a computer and you just didn't know anything. So you felt useless from that side of point, from that side of things. But I've got some medical students with me and they have been given some logins and it's actually quite nice that I can say, can you, do you want to have doing the discharge summary? Um, and they say, yeah, and I said, well, do you need access? And they go, no, I've got it all. Um And it's nice to have that as an F one. It's nice to be able to get through the doors and do something and make, make a difference even if it's something more like speaking to a patient who is in pain and say, look, I, I'll have a look at your pain meds. Um I can get into that. I can look into that for you. I can try and help you and in the meantime, I can do XYZ and I'll ask the nurses to do XYZ when you walk away from that. I had that within the first week. I sort of walked away and I thought I actually, I have just done something there and then II went back to the water bit later and the patient was like, oh, that was, that was so helpful. Thank you. And she was so thankful, but it's a nice feeling as well to actually do something and also be able to do something. Um So I hope that that's a little overview of some of the kind of life stuff. Um, that shouldn't say question. Well, it can say questions. Um but that should just more say thank you for, for staying on and um I hope that that makes some of the life stuff a bit clearer. Um, and gives you some advice, you don't have to listen to any of it. Um But yeah, so that's, that's basically all I know we're coming up to two hours now. So thank you for persisting that last half an hour. I just thought at this point last year, I was kind of stumbling in the darkness about loads of these things and feeling. They were all quite daunting. Um So I hope, I hope that offers some clarity. But yeah, I will stop speaking now and I'll stop sharing my screen. Oh, if you haven't filled the feedback in and if you wouldn't mind, I'll leave the screen up actually. Um But yeah, some feedback, we're grateful. It can be bad feedback. I'll take it. I've got floors.