FINALS REVISION SERIES 23/24 Imaging and Instruments recording



Attend this on-demand teaching session to learn about the Imaging and Instrument station on the PACES exam that medical professionals must pass. An F1 doctor who graduated just last week with experience in this station will go over three sets of images and five instruments. She will point out the main differences between them, as well as potential complications and show you how to easily differentiate a lobe from a zone when explaining images. Join to understand the basics of interpretive imaging and learn examination tricks for passing the PACES exam.
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Dr Coxeter will be giving a talk on the imaging and instruments Finals PACES station.

Learning objectives

Learning Objectives: 1. Identify anatomy in imaging (x-ray, CT scans, MRI scans) 2. Identify common medical instruments used in a Paces exam 3. Discern differences in airway instruments 4. Explain imaging/diagnosis to a patient in plain language 5. Coworker present imaging/diagnosis in medical terminology
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

OK, cool. So we're now recording. Uh Hi, everyone. Uh Welcome back to the finals revision series uh by Med Ed. So today we've got Catherine uh who is gonna be giving us a talk on imaging and instrument uh station, which is part of our final places. I'm sure you're all aware. Um So yeah, it's gonna be really useful and over to you, Katherine. Cool. Um So yeah, my name is Catherine. Um I'm an F one. I literally just graduated last week um from Imperial. So I was in your guys' shoes, like not that long ago at all. Um I'm working in Edinburgh at the moment. Um Fully recommends Scotland. Although I know it's all a bit strange for you guys this year and in the end they pass if you could please just mute yourself. Thank you. Cheers. Thank you. Um So yeah, as um as I said, I'm going to speak to you a bit about your images and instrument station um which is one of your uh station in your Paces exam. So we'll just, this lecture is, I think it will be about an hour. Um I'll try not to run over I know it's the end of a long day. Um So we'll just talk a bit about how that station runs. Um We'll talk and then we'll splitt the lecture up into two like the station will be. So we'll talk a bit about instru images. So we'll go over some X rays, CT S and MRI S and then for instruments, I don't know if you guys have seen the list yet already, but there's quite a big list of instruments to cover. You don't need to know each one in lots of detail, but I wasn't sure for this lecture kind of umm and ahing whether I should go over each one in like a tiny amount of detail, but I figured I would just focus on airways because there's quite a few airways and definitely as a final year, I didn't know them that well. And the differences between them and your anesthetics placement was a while ago, right? So hopefully that's useful if you guys have any other questions about instruments though, let me know. Um I haven't included mentee just because I don't trust myself flipping back and forth between everything. Um But it is interactive. So please write your answers in the chat or on mute, whatever, whatever you prefer. Um And if I'm going too fast or too slow or you can't see slides or anything or you have any questions, feel free to stop me and just let me know. Um I've got the chat on my phone. So hopefully I'll be able to keep looking down and seeing that. So, um just a quick overview of the images and instrument stations. So it's one of your 12 Pacer stations and like all of your stations, unless it's changed in the last year, it's 10 minutes long and it's usually divided up 50 50 into and instruments, but it's a really like examiner guided station. They really like tell you what they want from you and prompt you. Um So don't worry about timing or anything like that, you just answer the questions they want as best as you can if you're not sure, just move on. Um It's often quite forgotten in revision. Um I think just because final year is quite a busy year and um paces are quite early on compared to other exams, but it's quite an easy station to pick up marks in. So even though this year is like pass fail, I should focus on enjoying final year. If you're kind of just trying to get over the line of getting the six pass stations, it's a really good one and um to kind of get pick up some marks on. So for your images bit, so you get shown three images, they can be, they're usually like chest x rays, abdo X rays, CTS, Mris. I think there has been some pet scans in the past and they say that they increase in difficulty and the first image you explain it as if you're speaking to a patient. So for example, my one was an anterior shoulder dislocation and the examiner was like, oh, I've been playing rugby and now my shoulder really hurts. What do you think has happened? Doctor? And I had to say like, oh, the reason that your shoulder is in pain, you can't move it as much is because your shoulder popped forward. And he was like, oh, what are you going to do about that? And I had to say we're going to give you lots of pain relief. We're going to try and put your shoulder back into place. We'll give you a sling and then we'll follow you up and re X ray you. Um And then the other two you just present as if you're speaking to a colleague. So you would just say like this is a right sided pneumothorax. There's no tensioning um in, I know when we kind of learn about x rays and stuff we think about like ripe, for example, for chest x rays and like the date of birth and things like that. It's a quite a fast station often in my one. I definitely felt like they were like right onto the next thing onto the next thing onto the next thing. So really just like go in for the kill if you see what the diagnosis is, just say like it's an X ray of a 25 year old, the main finding is X or whatever. Um, so, yeah. And then for the instruments part, um, it's, you only get tested on the list of instruments which are on Medlen. And I've got a link to that or kind of how to find that later on when we get to that bit. Um, the way it works, it differs a little bit between sites, like all kind of pas stations are, but essentially either they'll have like all of the instruments on the bed and they just like, pick up the ones they want to ask you about. They usually ask you about five or six or they'll just have those like five or six instruments on the like examination bed and they basically like, pick it up and point to it like, because they can ask you like, how would you hold this or whatever? Ask you what it is, what it's used for and then maybe like any complications or, you know, some instruments have like kind of med school related questions that people would love to ask. Um, so yeah, and they range from things like Cannulas to airways to chest drains. I mean, they usually try and help you out. Like, I remember I had a chest drain and it's like in the sterile pack and it says like, like a cannula says it's a VFL across the top, it says chest drain across the top. So if you get stuck, always look at the packaging because it might tell you anyway. So hopefully that all makes sense. Do let me know if I'm going too fast or whatever. But if that's all OK, we'll move on to um images. So my first one, which hopefully I'm not blocking it too much. But if we look at this, this is I'm sure you guys all know this is a chest X ray. Um And what do you think this chest X ray shows? Um you can just, you don't have to present it. You just go for the diagnosis and then my follow up question to that would be if this patient is, if I tell you, they've just had a stroke, what do you think might have happened? Has anyone got any ideas? It's OK if you're not sure as well, like it's really good. The uncertainty in cases is a big thing. So. Oh, fantastic. Yeah. So you're thinking uh yeah, really good. Yeah. So secondary to aspiration, we've got hospital acquired pneumonia which are both um really good thoughts and I've just ok, really good. So yeah, so I think we had a bit of kind of right lower lobe, right middle lobe. So I would say that this is a right middle zone consolidation and I would think secondary to aspiration, but you're exactly right that this also could be secondary to hospital. This could be a hap because stroke patients, I'm on a stroke ward at the moment. And stroke patients stay in hospital for a very, very long time often if they're going undergoing rehab. So those are both very valid answers. So just some tips about chest x rays and hopefully, I don't sound like I'm kind of teaching people how to suck eggs. But when you're talking about chest x rays, think about it in terms of and when you're describing it, even though obviously anatomically, we're thinking about lobes of the lung. Um Think about it when you're describing it, think about it in terms of zones. And that's just because lobes are like, obviously, the lungs are 3d and we're just seeing them represented on a two D image. And it just means that the way the image is translated, it can be difficult to tell where kind of a lobe is versus like where one lobe starts and one lobe ends. And that's why sometimes you see people talk about getting a lateral chest X ray to follow up to see exactly where the consolidation is. Um Yeah. And so, so here, like we know that there is the left upper zone and the left lower zone. And then on the right, we have three like, like we have three lobes, we have three zones. Um I would say in terms of like right middle zone versus lower, the way I was kind of taught it, which helped me quite a lot was so on the right. Um If the heart border if the right heart border is obscured. So here, like you couldn't clearly draw, draw your finger around that, then that's the middle zone. And then if the right hemidiaphragm is obscured. So if you, I think here you can clearly trace your finger along that line of the hemidiaphragm, um, then that would suggest it's a lower lobe pneumonia and then it's a bit more obvious if it's like I keep, I keep saying lobe, but I should be saying zone. If it's in the upper zone, sometimes you can see the horizontal fissure, especially if there's fluid in it, if they're overloaded and anything above that is in the upper zone, um aspiration pneumonia throw back to second year, but it's more likely in the right. Um Because the right main bronchus is more vertical Sammy, did you have a question? Yeah, sorry to interrupt. I'm just curious. Um why you're uh referring to it as a zone? II believe like we've been taught to talk about lobes, but is there a reason? Yeah. So it's just um yeah, like you're exactly right. It is like there are like loads of the lung and if like radiologists have been OK with you talking about lobes, then I would go for that. It's just, I often got told when you're describing images even though you are talking about the lobes because lobes are like a 3d thing and you're looking at a two D image. Um It's better just to talk about zones because you can't like pinpoint exactly if it's in one lobe or another, if that makes sense. But if a radiologist has given you the, go ahead, I would trust them more. Ok. Thank you so much. No worries. Um, good question. Um, yeah. So, aspiration pneumonia, which this may or may not be and aspiration is like anything. So, stroke, it might be because they're like neurology, um, can be affected. So, um, their swallow can be impaired but anything where someone's dropped their gcs at some point previously, um, where they, they haven't been able to maintain their airway. So post cardiac arrest, often people get aspiration pneumonia and then things like post intubation, even though intubation is like, um, that's not about dropping their gcs. But even though we think about like some things like definitive airways, which we'll talk about later, the risk isn't zero. And obviously, if someone has been intubated for a long time, you think of it as like an accumulative risk. And then just a final thing just for completeness is that even though normally when we think about chest pneumonias, we think about respiratory bugs and we cover those with things like um, amoxicillin, camox, Clarithromycin or Doxycycline depending on what your curb score. Remember that because these are gut organisms that have kind of come from the gut and are now sitting in the chest. We need antibiotics that cover gut organisms. So something like metroNIDAZOLE which we usually think of as like a surgical, if you've got like ABDO SEIS, which would be appropriate on top of other things for, for aspiration pneumonia. Because those are the bugs we're covering and it's really good at gram negative gut and a road cover. Um, that's, you're less likely to get that in images and instruments, but because you still get x rays and things and you're like your written exams and things just in case you see things like that and they push you a bit more. OK. Really good. So the second one, what does this again? I'm sure we can all see it's a, an Abdo X ray. What do you guys think this Abdo X ray shows? Um I'm not 100% sure, but is it like really dilated loops of large bowel? Uh So it is, it's definitely dilated loops of bowel. So some people have said large bowel, some people have said small bowel. OK. Is there anything that like that gives, that gives you, gives it away as um either like what makes people I can see? Someone said Haustra and Yeah. Yeah, exactly. So is really good. So this is um I'm glad people are saying both because this is definitely like a common thing that comes out both in your, again, images and instruments and your written. And we did the um AKT like the online one exam, the online exam last year. So which I think you guys are doing and there were some images and there were ECGS in there as well. So this is small bowel obstruction and this is just the photo from before versus um large versus large bowel, so small bowel. So first thing on kind of location, um So small bowel is more central, which I realize it kind of looks like it's all over the place anyway. But I think when you compare it to large bowel, which just follows around the perimeter of the image a bit more. Um, we think about the different markings. So valvulae kind of ent span the entire width of small bowel, um versus Haustra only go partly part way across. And you think of that and kind of when there's inflammation, those how look bigger. I used to remember that as like because the small bowel is literally smaller, the markings are able to go all the way across, but large bowel, they're not able to go all the way across. I don't think that's actually accurate, but like that's how I remembered it. Um And then just remembering your numbers for small bowel can be like 3/3 centimeters. We say it's dilated and then large bowel, we say over six centimeters is dilated. Um, in large bowel, you can get small bowel dilatation, small, sorry, in large bowel obstruction, you can get small bowel dilatation as well or there's air in the small bowel. If you've got an incompetent ileocecal valve. So when valves are incompetent, just like when they're in the heart and they're incompetent, things can flow backwards. So if there's air in the large bowel, because it's blocked because of an obstruction and it kind of looks like, I don't know if you guys can see my cursor, but the obstruction is here, there's no air past that point. Um, if there was an incompetent valve at the ileocecal junction, ie where the small bowel and the large bowel meet air can flow backwards from that obstruction back into the small bowel, which I think can make things more confusing. But if you're not sure on the exam and you just mentioned that that kind of shows you you're kind of reasoning and you're thinking about it. Someone mentioned toxic mega colon, which is another like really good. I'm I'm glad you mentioned it because there's another like common um x-ray finding. I'll definitely add it to your guys' list of like x rays that you know the definition of. Does anyone know like what the kind of, what's the word like the buzzword phrase for like what that appearance is on a, on an X ray? Like what, what kind of object do you compare that to toxic mega colon? And what kind of disease do you find that in? Yeah, really good. So it's like a lead pipe. So it's really dilated and we can see when they, when we say lead pipe, we just mean, it's really smooth. So we can see here there's like Haustra. So it goes kind of in like this and this, but lead pipe, it is really smooth and it would be just a flat edge and it looks really like classic kind of large bowel. When you see in the drawing, it's like just going around the edge. And what disease is that associated with toxic mega colon? Yes. Really, really good. Exactly. So it's really important when you think about it for you see, that's one of the indications for surgery. So to get that on an X ray would change your management. Fantastic. Um Other things to see to think about, about Abdo X rays to be aware of the classic like sigmoid volvulus versus cecal volvulus. Um I think if they gave you this, it would be like a really classic one like here, like it's the obvious coffee bean because otherwise I won't like when I still see Abdo x-rays, it just looks like bits of air here and there. Um Other Abdo X rays I would look at would be like constipation like fecal loading. It's got like, I think you can kind of see some here, but it's got like a very significant appearance. Um And what else sometimes I guess like, just to be aware that you can see things like gallstones on x rays. Although it's just like a, obviously that would just be a like a incidental finding um what else? Maybe pancreatitis you can see it's like calcified on there. But yeah, not much else don't use ABDO X rays that often. Um Yeah. Does that all make sense? I'll assume so. And we'll move on to number three. So what do people think? Three questions here? What kind of scan is this? It's a bit blurry. Sorry. And then what do you think it shows even if you're not sure of the diagnosis? Like, can you spot something that looks a bit wrong? Um And then if you think, you know the diagnosis, do you think it's a chronic or acute? Oh, fantastic. People are, people are very good. Yeah. Really good. So, yes. So this is a, we'll just work through it because I definitely wasn't sure on CTS and things and when I was in this stage in years six, you guys are smashing it. So this is a CT scan. Um whenever you first things first, whenever you look at CTS, it's like you're looking at them from the end of the bed, looking up at there, like they're lying in front of you and you're looking up at them. So like with like with x rays, their left and right is switched. So again, hopefully you can see my cursor but like this is their left side and this is their right side. So and the same with Mris as well. Um We know it's a CT or I think of it as when I think about why I think things look like CTS, CTS are made up of X rays. There are just lots and lots of X rays put together to create a 3D image. So when we think of like bone is white on an X ray, so it must be white on a CT because it's made of the same thing. And then, and then MRI. So we usually use CT for things like bones. Um And usually CT brain would be your first instance before you moved into other things, MRI is a, is really good at like soft tissue things. So think about MRI S for things like Osteomyelitis, they're really good at like um cord compression when you guys um do your neurology for that and yeah, exactly. It shows a chronic subdural hematoma. So 0.1 that's just what I was saying before and then a subdural hematoma. So when we look, um when we kind of compare left to right, which is whenever you're stuck, just always look at, look at them from one side to the other. So like start at the top and go from this side and then work your way down, compare the middles of each one. And you can see that on this, on their left, there's this like dark gray kind of crescent um dark bit before you get to the actual brain like between the skull and the brain. And that's it all looks the same kind of color. Um And it looks like so it looks like blood and there's some like midline shift and loss of volume of the ventricle going on as a result probably. Um And we'll talk about the different types of hemorrhage and then just really good. It's chronic. Um subdurals can be chronic because of the way they present. You don't always like, spot them straight away like clinically and people don't always present straight away, but just radiologic radiologically can't speak. So like old blood on a, on a scan or a CT anyway, is dark, which I remember like old like clotted blood looks quite dark anyway, versus white blood is would be acute blood. So here and I don't think they'd show you this, but I've just put it in there to illustrate the differences. This would be like an acute on chronic subdural. So someone's had a subdural and then they suddenly bleed bled again and you've caught them when they just bled again. And you can see that there's like the two different kinds of like this is all blood, but you can see it looks different like different kinds of blood. So the different types of hemorrhage. So there's like four main types of hemorrhage. Um You probably should know some the scans for the three in that blue box are types of bleeding which happen in the layers of the brain, the meninges. So where there's layers, there's just bits, there's just like pockets where blood can collect. Um and then in an intra parenchymal hemorrhage, parenchyma just means like organs. So in this case, brain and it just means like a bleed in the brain, which is also known as a hemorrhagic stroke. So they're kind of in separate categories. But all of them, you do a non contrast CT head, you do a non contrast CT head because you don't need the contrast to show blood up. You can see that even like whether it was acute or chronic, that blood was lighting up and we could see that difference between the blood and the brain. So we don't need any contrast to help us light that for something like a CT PA. So a CT pulmonary angiogram where we're looking for a PA is a bit harder because we are looking at the vessels themselves to look for like a clott versus the blood flowing itself. So we give contrast for that and we see that there's a filling defect. So like the blood has got loads of contrast in it because we've injected it, but the clot will look different. So we can tell the difference a bit more. So most CT heads are like non contrast CT heads, which is really good because you can um don't have to worry about contrast and things like that. You can just do one quickly. So back to these three types of hemorrhage. Um again, I think we cover them earlier in the course as well. But just to just to recap how they look on scans. So we have um epidural or extradural, which I think makes it easier to remember which is between the Jura and the skull. So quite superficial. And I think you can see on this scan that there's some soft tissue swelling right by it as well, which makes sense because these are the ones where you um hit like the pterion and the middle meningeal artery bursts. It's an arterial bleed. So it bleeds quickly. And so you get symptoms quickly. Um with people like presenting after trauma with like reduced gcs or a pupil or focal neurology. Um And because the juror is like pinned in various places around to the, to the brain, the blood can only collect, it can't go beyond where the J has been pinned or collected to the skull. So you can see it's like really, it's pushed out because it's in a really defined place. And also because it's an arterial bleed. So it's quite a high pressure and then subdural is like one layer down. So between the, the Jura and the brain and between that, that space, there's lots of veins, bridging veins that drain the brain itself. Um And if you tear any of those veins, you just get a slow venous ooze into that space between the Jura and the, and the, and the brain in that subdural space because um the Jura just kind of like, as a complete circle just surrounds the brain. Um There's no, it's not like pinned down to the brain at any particular point. There's no like limitation um on like an extradural of where that blood can go. So that's why we see it's kind of, that subdural blood has just extended a lot more like all the way around. Um, and what kind of people would you worry about a sub and like in your exams and things, what kind of people are more at risk? The elderly? Really good. Yeah. So they're elderly and alcoholics. So we talk about kind of the dural space is here and the brain is here and we're worried about blood collecting between them. Anything that shrinks your brain makes like if you imagine like the veins are pulled tighter because the brain has shrunk. So you're more at risk of tearing a vein, a bridging vein. So your brain atrophies with age, alcohol, atrophies your brain. I mean, alcoholics, you atrophy your brain, you're more likely to fall over because you might be intoxicated and you might have deranged clotting because your liver synthetic function might be impaired. So, alcoholics, especially the elderly, definitely and you can have like fluctuating confusion which is why you can, you can walk around with a subdural for a while and then the final one is a subarachnoid hemorrhage which is just like on the below the arachnoid. So basically just like on the surface, very, very surface of the brain. Um Yeah, and this is like the classic hit around the back of the head. And you can see hopefully um this like white in these spaces of the brain. Some people say like so like arachnoid, it looks like a spider with the, with the legs here and the white just shows up as blood. Um It can like fill the CSF spaces which again makes sense because you can do a CT head for subarachnoid. But if you're over six hours since the headache started, you can't rely on a CT head. You need to do an LP to look for Xanthochromia. So you're looking, it's another way of looking at the CSF when you can't look at it using a CT scan. And then finally, that basically, essentially hemorrhagic stroke. I think when you look at that, it looks a lot more like irregular and it doesn't look like it's coming from the outside lining of the brain. It looks like like it's within the brain itself that that's come from. So that would be a hemorrhagic stroke. I would also look at what uh what, what do I mean in what ischemic strokes look at on CT. Um And what else would I look at? Um I can't think of anything else but I will, I'll let you know probably like abscesses. Um And like your uh what's the word like space occupying like uh ring highlighting regions. I've completely lost my words. OK. On to the next one. If that all makes sense, really good as well. You guys are doing so well. You definitely know more than me when I was in this bit of sex year. OK? So another scan of the brain, I'll give you that. Um What kind of scan do you think this one is? And what do you think the diagnosis might be or what can you see and what might just be kind of going on there? Yeah. Yeah. Really good. So an MRI I think this is probably brain Mets. Fantastic. Anyone know what kind of all? Fantastic. T one MRI. Um What kind of cancers give you brain mats? Yeah. Really good. Lung breast and melanoma are your top three. So yeah. So this is an MRI brain which I think the main difference when I'm looking at them again, not a radiologist, just, just an F one trying to look at the differences, like make it make sense in my head. But an MRI, we talked about being really good at looking at soft tissue like brain and I think you can tell the difference between the white and gray matter a lot better on this scan versus like these other scans. It looks, looks a lot more hazy but here I think it looks a lot more clear when you're differentiating everything. Um Yeah, and we can see like the, this, this on the outside is not bone, this is the skin um that's showing up as white. Um So yeah. So, exactly. So this is, this is an MRI brain looking at brain Met, it's probably brain Mets rather than primary cancer because um in adults that's much more, that's much more common. Um And it's probably secondary to either one of those, so lung, um lung breast or Melanoma. So if they asked you like a follow up, what would you do with this patient? Um You'd probably manage whatever symptoms they were presenting with. Um So for example, when I look at these like lesions, which there's quite a lot of, I think on here, you can see like, again, I'm sorry if you can't see my cursor, but just on, on the left at the kind of posterior aspect, the two lesions, I think you can see some dark area surrounding them, which is, that's what edema looks like, we can see it. Oh, good, good. Um That's what edema looks like. So there's probably some swelling going on secondary to that. So you'd likely manage that with dexamethasone, you'd definitely get the oncologists involved. Um And you'd probably go looking for a primary. Um So you'd probably do a chest X ray, probably a CT, do a breast exam and um do a skin exam as well. It kind of depends on the patient. Um You might, they might have presented with a seizure um with this kind of volume of brain mets. So you might consider like antiepileptics. Again, you can, you'd speak to the oncologist and probably um the neurologist as well for seizure management. Um Because so the other thing is that like another, it could also be like septic emboli, like septic abscesses from like an infective endocarditis any time you see like multiple of something anywhere, think like it's less likely that that's what are the chances that all of those have come from one thing, you know, like when you see loads of like cannonball mets on the chest X ray, what's the chances that someone's got mutated cells in all those bits of their lungs? It's much more likely that there's like a nasty source that's like spitting off cancer or septic emboli. So I think that this is probably like some, some things come from somewhere else and it's like come from the blood or the lymph and just kind of like, it's spraying off essentially these mets or these emboli. Ok. Really good. Really, really good. Um I don't with the terms of like T one, T two and like flare MRI Si wouldn't worry so much about that. I just, it's really, really good that you guys know it. Um But if you can just get your head around the different ones, other Mris to be aware of, like I was saying was like, um cord compression um is a, is a good one as well. Ok. Um So that brings us to the end of the images section. Hopefully, that was useful. Um My next steps would definitely be practice with your friends just like little and often the way me and my flatmates and friends would do it is like we'd like when it came to revision, like revise normally throughout the day, like do our examination and pas practice and whatever. And then in the evening, like we'd have dinner together or whatever and then after dinner, we'd all like bring some images and just like post them in our like house group chat and then just like go through them and present them. It's really good to get used to the uncertainty that comes with paces. It's really difficult to kind of stand there and be like, oh, I don't know what this is but you have to say something or you should say something because you can definitely get marks for it. And then if you're shown an image on placement, I have this all the time. And also, and they're like, oh, it's an obvious hip fracture and you're like, I've got no idea. I can't see that. Just ask because it's just worth them going through it with you at the time. It saves you so much time and going through it afterwards. And then finally just some other resources. So Radiology Masterclass has chest x rays after X rays and CTS to look at and they are quizzes. So like actively testing your recall, not recall. Just learning. And then if you want more chest x rays, this life in the fast lane is really good. It has like 150 chest x rays. It's got ecgs as well, which you do get ecgs in. I didn't have any cases but I had some in my written. So it's really good. Um Yeah, and just a final thing on images like if you're not sure, like a diagnosis straight away, honestly, just describe what you see and they'll like guide you through it like they really want you to do well and they want you to pass. So yeah, if no one has any other questions about like images, I'll move on to instruments, but I'll just give you guys a second. Mm And I don't for images, I, we always stress about whether they would give us things like ultrasound but I don't think ii think that was a kind of no, no, they won't because even um you know, people like doctors and stuff got on courses to read them and to do them and things. So it looks like there's no. Oh yes. Do you have a question? Sorry. With um subarachnoid um hemorrhages. I'm still a bit unsure about the CT findings. So, is it just going to be sort of in the middle, in the sort of basal cysts and uh or is it, can it be somewhere else like? Yeah, exactly. So it's supposed to look like, um, like a spider like arachnoid. Um So yeah, it's supposed to be like in the center. So this is quite a big one. I think a lot of them. It's just like where that center bit is. There'll just be like a little bit of white there. So, yeah, CT should normally just be like black and gray and the only white should be around the outside. So if you see any white start getting suspicious, basically. Does that make good question? Um OK. So onto instruments. So as I said, there's a list of instruments on MEDLINE. So you can either just search clinical skills and it will come up and if you go to the glossary tab at the top or the links there and you guys can are welcome to have the slides afterwards. They've got all of the instruments you need. And as I said, you, yeah, like you only get asked instruments that are on that list. The descriptions for some of them are quite brief. I would like, you'll likely be asked like a few more questions that are on there. Um But I would definitely take note of like the information that is on there. So sometimes like random things. I remember they had like a like a LP needle and then they had like a manometer, which is what you use for pressure. And they mentioned on there like what the normal pressure is and what high pressure is when someone's sitting and lying and then people did get asked about that. So again, like, you're not going to fail the station if you don't know the normal pressure of CSF or whatever. But, um, yeah, just, it kind of gives you an idea of like the general stuff they like to ask you about. And then a very kind of big, big asterisk on this last one, big caveat. Obviously, I'm just like one of 300 students just from last year. But I think that making your own list of instruments and things takes quite a long time and they're like the, what's the word like the reward from it is, isn't that great? I think there's already like really good resources out there. I checked on, on the, on ics M's Note Bank Lud has got a list of all of them and obviously goes into a lot of detail there. The list is unchanged from like previous years. They just keep it the same and there'll be loads floating around in like all of your clubs and societies and things. So at most, I would just consider like getting a list that's already there and just adding bits that help you out and stuff. Um But it's completely up to you, you guys like obviously know what works best for you at this point. Um So yeah, as I said, there's like a real range of things on there from things like Cannulas to like breast implants, chest strains to airways. So I thought we would just focus on the airways. Um But I know you guys had like a critical care placement, which we didn't last year. So you guys might have like be a bit more up to date in which case, hopefully this is just good revision and you can like tick this off because they almost definitely will ask you at least one airway And they like, you will ask you like the names of it when and like, when would you use it? How would you size it if that's like a common, common thing and then kind of the advantages, the disadvantages of it and the classic or a definitive airway is, don't worry about like they won't ask you like, they don't expect you obviously like as an F one, I'm not going around putting it in like tubes. So it's just like, you know, you don't need to know like all the details of how you would do anything and the same with things like chest drains, but just know kind of what kind of things you do and don't go like when, if they ask you to pick it up, don't go, like, do you know what I mean? Like pretend that you've, you're holding it like you're about to use one rather than like waving it in the air or whatever anyway. So types of airways broadly split into three types. So again, supraglottic, glottic just means like at the glottis. So like the um, vocal cords, infraglottic below the vocal cords and surgical, which we'll cover at the end. So the first bit we're going to cover are things called airway adjuncts. So we have two types of those. The first one is a nasopharyngeal. As the name suggests, it goes from your nose to like your pharynx. So just above your voice or your voice box. So typically you use it like all airways are used because um when people aren't maintaining their own airway, um you worry about aspirating but obviously like a need to maintain an airway first. So we can um oxygenate, et cetera, et cetera. So nasopharyngeal are usually used over oropharyngeal, the ones where you put it in the mouth, which will speak out in a second because for a nasopharyngeal, you can have an intact gag reflex. Um and it can still stay in. So usually it's like um people who are kind of like in and out of consciousness or just not tolerating an oropharyngeal um or when it's like, you literally cannot get to the oropharyngeal in. So we had someone the other day who was just seizing from like 90 to 2 a.m. and it was just like his, you couldn't get his mouth open. Like when you, when people see that, like everything locks up, right? So like you can't get them, get their mouth open, so you can put oropharyngeal in a nasopharyngeal and sorry. So to size it, it's called you go from soft to soft. So you go from the nose to the earlobe like they're showing over there, which again makes sense because that's where the airway is going to go. Just, just using surface landmarks and to use it. So you'd like you get the head in the correct position. So usually you're doing a jaw thrust or a head tilt chin lift anyway, so you get it. So they're like sniffing air. So their head is tilted up so you can see everything that you're doing properly. Um You'd size it up and then you like lubricate the end and there's ways to find the airways on the crash trolley, the drawers of the crash trolley go down in your at. So first draw is your airways and then you'll have your like cannulas and blood bottles in the like see draw, for example, blah, blah, blah, blah, blah. So you take out of the like crash trolley, there's lubricant in there and you lubricate the end and you just shove it down. Basically, it's, it's ok. Um And because it's an airway adjunct, often you still have to keep doing um like your airway maneuvers afterwards. So like your head tilt, chin lift or your jaw thrust, the classic, when would you avoid it if you're querying a base of skull fracture because it can go into there brain. So hopefully not these ones, these are the different sizes, they've got safety pins on the end. Um, although here it's quite like a flared base just so you don't lose it down the, down the nose, basically. Um, yeah. Yeah. Ok. So that, that was the first airway adjunct. Yes. Avoid nasopharyngeal airway. If basal skull fracture, the idea is, um, you, if you put it in, you can go, instead of going down the airway, you can go up because the bone is broken. You can go up into the brain instead and scramble it. But it's like just a medical, I think, you know, more medical school question rather than, you know, obviously you're not thinking that in most people. Um but good to be aware of. Yeah, agreed. Um So Airway adjunct number two is Oropharyngeal or also known or the one of the brand names is a Goodell Airway. So again, as the name suggests, Oro going from the mouth to the Pharynx, and you've probably seen these like um in the trolleys again, in the crash trolley in the a or the top drawer of the crash trolley again, reduced gcs. It prevents like if you imagine that is the same kind of shape as the tongue or like it follows how it goes round. So it sits on top of the tongue and it prevents the tongue going back and obstructing your airway. Um Before we talk about soft to soft, um these ones, the airway is hard. So I remember it's like these are the hard to hard ones. So you go from the incisors to the mandible. Again, it makes sense. That's where like the airway itself is going. Um, and so you'll have them in the correct position. You'll size it up by going from hard to hard in adults. You insert this upside down so this like curved bit will be facing upwards. So it'll be like a sea this way around. And then when you're kind of over the over the soft palate and you're into the hard palate, you rotate it 100 and 80 degrees. So it sits like curved following the tongue like as you would expect it to naturally sit. Um but in Children, you'd like this, this is a child who insert it the correct like this way, the normal way up again, you probably need to continue airway maneuvers. Um like jaw thrust. Um It's which is sometimes why like obviously, if in a in like an arrest, it's not ideal because someone is being not like almost used up doing a head tilt, chin lift. Um And these are not definitive airways. Does anyone know what definitive airway means? Does that ring any bells? Yeah, it Yeah. So intubation is like part of it. What kind of why is a definitive airway? Good as opposed? Like what's the advantage of a definitive airway? Yeah. Really good. It does go past the vocal cords. So it's the advantage over these airway adjuncts because it goes past the vocal cords, you're essentially closing off the esophagus. So no esophages or you, again, the risk isn't zero, but you vastly reduce the risk of aspiration, um, which not only can it cause pneumonia, but obviously, if someone's like, um, like aspirating, it can block the airway. So you put in all that effort and, um, you can still block an airway. So that's why um So these aren't definitive but they're really useful um for helping the the tongue not go backwards, reasons like things when you wouldn't use them like facial trauma. Um and then like any, any of these airways, the kind of not, not risk, but like, I guess, yeah, I think that you can like knock out teeth and things you can cause like facial injury, um etcetera, etcetera, and these people might not tolerate them if they've got an intact gag reflex, which people who are at high gcs can still have an intact gag reflex. Ok. So those were airway adjuncts. So we now move on to like a bit more, getting a bit more serious. So, supraglottic airways. So again, supra, above the vocal cords and these are basically the same thing but just slightly slightly different. So we have NS which you might have heard of laryngeal mask airways or eye gels. Um So again, in reduced. So these can either be like in emergencies. So in cardiac arrests, often like regs or like people more senior will put in um will put in an eye gel. Um or you can use it like I don't know if you guys on your anesthetic placement. Remember putting in eye gels like obviously with help from the ODP and anesthetists um because in short cases with like low risk of aspiration, they can be used. Um Yeah, you can use this instead of an endotracheal tube. You can see on the top they've got this attachment here. So you can attach a bag valve mask, which is the one where you're squeezing it. So for example, if you were in a cardiac arrest, you would do like 30 compressions. Someone had an eye gel in, you could attach the bag valve mask to that, but obviously without the mask over their face and you would do like two squeezes and then continue. Um And then in theater, you can attach it to the ventilator. So you can ventilate on an eye gel. You don't have to ventilate on an endotracheal tube, but we'll talk about why you might want to in a minute. Um colors correspond to different sizing. Um I didn't learn the different types of sizing, but usually you'd see a green one used and it sounds like you just get the head in the correct position. It's quite brutal. I don't know if anyone's been to like an arrest or anything, but they do just like shove the eye gel in because the airway is the priority. Um Yeah, last, the last one I went to was like teeth on the floor and everything afterwards. But um she did Rosc. So and then yeah, you can attach the bag love mask to the end. They're not definitive airways as we've mentioned before because they sit above the glottis because they sit above the vocal cords. So like on this picture, we can see that like we've kind of blocked off the tia but not exactly. And then the only difference like an LMA versus an eye gel, both under the umbrella of supraglottic airways, both like they look like this when you put them in, the only difference is this is an LMA here. So it has a cough and you, you put it in and you inflate the cuff and that's how it stays in place. And an IUD has like, it's like a newer version. So they just have this like thermosensing plastic, I guess around the edge, this green bit that warms to the warm, like the body temperature and seals itself in place because it's been heated and softened. So it doesn't have a cough. Yeah. And I think that's everything about eye gels and LMA S OK. So, onto like your definitive airway, which is an endotracheal tube or an tube, you'd use it in longer cases or if you're worried about like high risk of aspiration. So sometimes if you've heard people like or anesthetist talk about like rapid sequence induction. So that might be like this is an emergency case, but someone has um like eaten recently beforehand, there are increased risk of aspiration or if they were pregnant or something, um gives you like an increased risk. So using an endotracheal tube, which is a definitive airway over an eye gel in surgery, um you can, as we said before, you can ventilate on an eye gel or an LMA if needed. But with a endotracheal tube, you can ventilate at higher pressures and like I'm no intensivist but because of the, like they describe it as because of the cough is in place here. If you try and push really high pressure down this tube because of the cough, it won't, it essentially that air will, can get into the lungs. So when you have really resistant lungs. So like COVID, for example, you're able to do that. But if you didn't have the cough, the air would just go backwards if you're pushing it down at really high pressure. So that's why they're useful. They've got different diameters. Um Again, don't need to know much about it because it would usually be like anesthetics or ICU getting involved. This is why um on your, uh when you put out a two, when you put out a like a medical emergency, you don't necessarily get anesthetics in ICU. But if you put a cardiac arrest, you will get anesthetics. Um because you're much more likely to need like airways that not everyone can do so to put one in. You use another one. So a laryngoscope is another one of your instruments, which almost looks like a beak and it's essentially to like, push down the tongue and it's got a light at the end or sometimes they've got like a newer ones, they've got like a video, um, like camera and you essentially like, put, hold down the tongue with you. You hold the laryngoscope in your non dominant hand. You have the patient like sniffing air, so head up to the top. So their airway is like nice and open or as open as possible, you like insert the laryngoscope with their tongue down and hopefully you can visualize the, the vocal cords, they look like like this and you, with your dominant hand, you can pass the endotracheal tube down, pass the vocal cords and then you can inflate the cuff. You can then attach it to a bag valve mask or a ventilator. And sometimes like people will put in an eye gel and rest and then when it's all like calmed down a bit, like they'll intubate them and then take them to ICU or I'm sure you guys have seen people on it with like tubes in place and they're on a ventilator. Um It's a definitive airway because the cuff and we can see like on the drawing here, you can see it goes all the way down into the. So this calf is like fully blocking off the esophagus again, not zero but like big, like a big reduction. Um So more difficult to kind of block off the air rate or aspirate and unsurprisingly, um, needs like specialist training so often. Um, like anesthetists, it like intensivist or um, like in Ed, um the doctor in charge of Russ. So Russ in Ed is where people who you worry about their airways go. Um So the doctors in charge of them. Um ok, so last two airways, I realize I've been talking for a while now. Um Yeah, so last two airways are surgical airways. So the first one and they are like quite different in how you've used them. Um So the first one is a tracheostomy again with the name. Um So it like trachea, so trachea, it goes between the tubes of the trachea, between the 2nd and 3rd tracheal rings, you can use it for long term ventilation. So often if people have been on like an endotracheal tube being ventilated for a few days, they might switch them to a tracheostomy or if you've got trauma to like the upper airway where they can't like it, it's unsuitable. Again, usually anesthetics I like using but good to know what they look like. So they, they're quite short and they, they put that like this here which you can attach to straps and things. So they stay in place. Um So the way you like insert one in case they ask, so you again, back to back to second year. So to find the rings of the ea you look for the Adam's Apple, which obviously 50% of us don't have, but just the laryngeal prominence you go down and you'll find like a dip where it's softer and then it gets harder again. So you've then found the thyroid cartilage, the cricothyroid membrane and then the cricoid cartilage and then you find the 2nd and 3rd tracheal um rings and you insert it between the two. So where this X is here. So you're going quite far below. Um And again, like I said, require specialist training to insert. It can be like a long term airway like you, you'll see people on the ward. Um and just like in general, people are able to talk with them if you like, hold on the tel um tubes of the air can go past your vocal cords still. So, yeah, like a long term airway. But the main like takeaway from this is, it's usually done in like a very controlled setting. So it's like, ok, this person has been on the ward round, they've been on the tube for a few days now or, you know, a week now or think about a long term airway, let's think about a tracheostomy and it's done kind of very carefully as opposed to a cricothyroid airway, which is what you think of when it's like an emerg emerg emergency surgical airway or like on TV, when you see it's like a, they put a biro in there or whatever. So this is the emergency airway where people, they've tried usually to put an endotracheal tube in and it hasn't worked. They can't ventilate or. Yeah. So there's facial trauma or obstruction. So it wouldn't be appropriate. You go in between that like a thyroid me like membrane. You do it here like this one's the emergency airway because if you imagine that membrane is a lot thinner and easier to get to. So you like make an incision with the scalp or you can widen it with a pair of scissors. Um And then you can insert the, the tube basically and you can inflate the cuff as well and then attach to a ventilator. It's like um it's an emergency measure. So it's like less stable than the endotracheal tube if you imagine, like that's quite a long tube and it's like the preferred so often they'll follow it up. But obviously, again, like a to ea is first. So you need to do whatever you can to sort that out first. Um And again, would usually be done by the specialists. Um It's like a last resort kind of thing. So, yeah, so just to summarize, you've got two airway adjuncts, the nasopharyngeal and the oropharyngeal, you've then got the supraglottic airway, which was the eye gels and the LMA with the cuff. So there's like two sides of the same coin, but look very similar. And then you've got an Andro aal tube which if they give it to you, it looks quite obvious it's like a big white, big clear plastic tube. And then finally you've got your surgical airways. Um Yeah. Does that, I think. Oh, yeah. So just some tips on instruments. So, again, practicing with friends out loud little and often um again, we would just like do two images each and each bring in for each shower instrument, try and get them from like different sources because you never know, you know, they all look slightly different. Um And then I'm definitely quite a visual learner. So maybe this doesn't apply to all of you. But for things like, so some of the things they ask about are like chest drains, different kinds of lines and like picc lines versus central lines, which is really not that bad. Like once you just get your head around it and watch a few, I watched a few videos, but it's quite good just to see someone inserting it just so you can see, I definitely didn't see all of that kind of thing on placement and it just gives you a better idea. I'd almost have to like run through the video and they would say, oh how do you insert a chest ray? And I would just like go through the steps that I saw in the video. Um But if you, if someone says like on the rest ward, oh, do you want to see this chest rain? Probably good just to see one. Um If you're, you know, not, not doing anything and not in a, you know, waiting for, waiting for something else, it's not a bad idea but not the end of the world if you don't see one. But yeah, I think that's, that's me. Um Thank you so much for listening. You guys have been really, really good. Um Thanks so much for interacting. It makes everything go a lot smoother as well. So, and you guys have really, really good knowledge. So especially for this point in the year. Um I've got a feedback for men. I'd be really, really grateful if you guys could fill it in. I'd really keen to know like what I could do better, what you guys enjoyed. Um And I might be covering that, but that's my email down there. So if you have any questions, I can definitely give the slide. Um And you guys so you guys can have the links and everything. Um But yeah, if you have any questions either about um like cases or anything like that or I know like there's not that many people from London and P that go to Scotland and I definitely asked someone in the year above when I was moving up so feel free to let me know if you have any questions about that as well. I'm happy to get whatever. Does anyone have any questions at the moment about anything I've said or whatever in general? I mean, I'm happy to read out any questions in the chat. I hear you. There are some in the chart, um, are limb x-rays quite common. Yeah. So I, yeah, so you do get some, I think, like I was saying, my, my first one was of my three, my first one was anterior shoulder dislocation and I can't remember what my second one was. I think it was a chest X ray or a CT head. But my third one was a, it was a like an ulnar fracture, but a proximal ulnar fracture. So just remembering that at the, at the, well at the wrist, the radius is the bigger bone at the elbow, the ulnar is the wider bone. Um I didn't cover, I should have said at the beginning um because you all get an msk x-ray in your msk station. Um II haven't covered them today because I figured like there'd be some overlap there, but I would definitely, yeah, just make sure, you know, kind of what different fractures in different places look like. I think uh like a scaphoid fracture has come up a few times as well. You're welcome. And oh, sorry, go on. No, I was just gonna say like they have the in the year six, like Facebook group of all the past papers, people are quite good at putting in the images and things that they've got so worth having a look as well and seeing things like some people have said pet scans, but I think that's, that's not so bad. You just kind of see what's lighting up and what's not. Uh I just wanted to say thank you. It was really, really good and like really, really useful. Um, especially I think the instruments is something that we don't really get formally taught at any point. Uh So yeah, thanks for going through that. II find it really, really helpful. So, um before you guys go, please just fill out the feedback um because it's really, really helpful, Catherine. Um But yeah, other than that, if you have any more questions, just put them in the chat, I'm happy to read them out or just ask Catherine or email her. Yeah. Um I'm gonna stop the recording there if that's ok. Um We're gonna upload the slides to metal. So whoever just asked in the chat say they'll be updated. Yeah.