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Finals Revision Series - Images & Instruments Lecture pt 2



This teaching session is designed for medical professionals and focuses on the use of a nasal cannula set and the common complications associated with its use. It also covers the basics of chest x-rays, including differentiating between foreign bodies, lung pathologies, diaphragm abnormalities, pacification and RVF. Through a combination of images, drawings and examples from last year, medical staff will be equipped to confidently identify placement, safety and abnormalities when analyzing x-rays. This session is perfect for medical staff wishing to further their skills and knowledge.
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The fourth lecture in our Finals Revision Series

Images & Instruments by Dr Marena Gray

Learning objectives

Learning Objectives: 1. Understand the potential complications associated with the use of nasal cannulas. 2. Identify and distinguish the principles of a chest x-ray and associated pathologies. 3. Describe the criteria for NG tube placement and be able to determine which NG tube position is safer to feed 4. Identify pathologies associated with COVID, sale sign, pneumothorax, and Kinka sign. 5. Demonstrate an understanding of how to interpret a CT scan and differentiate between four differentials.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

nasal cannula set. It is used for delivering oxygen. Common complications include pressure sores, dry nasal mucosa and the consequences of over oxygenation. You know, that sort of thing? And if they pick something that you don't know, just say you don't know because it's it is time pressured. And you'd rather talk about things you do know. Then once, then sort of stuff around and say, Oh, I don't really know. All right, um, if anyone wants to take screenshots, this is the screenshot to take or take a photo of, um I've tried to collect all the past stations, um, for images on this side and, uh, instruments on this side. Um, sometimes it's more than one in terms of images. So a friend of mine last year had misplaced energy tube in a patient with pneumonia, And, um, there was also, um I think something else going on today and a pneumothorax. I think as well, so you can have a lot of things going on. Okay. So first I thought I'd just go over a normal chest x ray. So, um, of really useful website I found quite helpful with my revision was radiology mask class dot com. They go through all the different types of imaging modalities Chest X rays, abdominal X rays and masks, skeletal ones as well. CT heads. And, um, they go break through all the basics. So a lot of these images are from there. So first, when you're looking at the chest X ray, you should be able to see the mediastinum. And she used to be able to trace it out like this red here, and see the Arctic knuckle left ventricle so and so forth. Um, Airways, you're looking at the trachea looking for the Carina, the level of T 45 see it bifurcate here. Um, the right is always straight in the left. Can anyone think of, um, the relevance of this? So we're looking at certain lung pathologies, Um, such as sort of foreign bodies, things like that. Any ideas? More like you to go into the right lung? Yeah, exactly. Because it's straighter, direct rather than sort of dip into the side. Thank you. Um, the other thing to look at in the Carina is it's a nice sort of sharp, acute angle. Um, if if there's a mass or the hearts and large. That becomes blunter. But this is quite specific. Hilar. You don't really need to talk about the highlight that much, except if it's normal. It's huge, Um, and then lungs, of course. Which turns out a bigger than what you typically see on an X ray. And, um, this goes into a quite a bit more detail than you need, but it's just good to sort of revise over specifically looking at the pleura Tracy edges, um, looking at the lung markings and, um, looking at the diaphragm. So an emphysema, the diaphragm is a lot more flattened than normal, and, um, so here, this is a nice, normal chest X ray. You see the diner, Fromm's nice and round. Of course, the women. You'll have breast shadows. So it's always good to sort of notice that, especially if someone, um aside a vasectomy, for example, that can be an abnormality on a chest X ray. Bit cruel, but it could be as well as the boats. All right, so any questions about sort of the basic understood, like the basic principles of a chest X ray. Are we happy to go through some examples? I can't see the chat, I'm afraid. No questions. Yeah, I think everyone's happy to go on. Okay. So you can one brave soul. Um, look at this chest X ray and sort of tell me what the glaring abnormality is going through the principles of just talk through What's the sort of big thing that we see here? Yeah. So we start the mediastinum. Nothing really too concerning here. But, oh, what's going on over this side? Yeah. So we've got some consolidation. We can't see the cardiac border on the right side, and we can't see the diaphragm. So this a pacification, um, is involving two zones of the right lung that's involved in the right lower zone and the right middle zone. So this is sort of inconsistent with global pneumonia. If you don't know what lobe is involved because it can be a bit of hit and miss just his own. You can't really go wrong. But again, um, there's some notes to review later on. All right. What's this? Mhm. Okay. We'll just get through. So again, we've got, uh oh. Hasn't changed. It's up now. Ok, Sorry. I just don't want to sit in silence for too long. So can people see the slide now? So, um, we've got a pacification in the left side, mainly in the lower part. As you can see, there's no sort of clear diaphragmatic angle and some cardiac shadow blurring, but this is still the left lower lobe. Can anyone go back to their sort of lung lobe a national? And think about why? Even up here, you still get some pacification in the higher parts of the lobe. So it's due to the fact that it's like a pyramid. It's like a triangle. Um, and so it's like, I can't I can't Can I draw? So, um, but if I sort of show the lung like this, the lower lung is actually sort of like that, if that makes sense, Um, so that's why that's like that. Cool. Okay, so, Okay, can you I've got two images here of chest X rays. Um, and there's a lot going on in both of these, and there's a few different things. So we've got some clips here. And what does anyone know what I'm pointing at here? What's this? Um, is that a Mm? Uh, it's not a defibrillator. I c D um I think it's just a dual chamber, but very close. So Yeah. So we've got a dual chamber pacemaker. So we've got one lead here and one lead here, but it's I'm sure you can appreciate. I've got a line running through here. Can anyone tell me what this is? If I draw it out, What do you think that is? Similarly, we've got one here. What do you think these are N g tubes? Yeah, Exactly. Which one? Option one. Option two. Would you deem safe? Uh, probably option one. Yeah. You know, well done. So, um, some trusts rely on F one's to interpret. Uh, n g tube placement. Um, some trust require consult radiologists. So it's just good to know, um, which ones are correctly placed, Especially in the middle of the night? Like, can I feed this patient? We'll go through it briefly. So this one is safe to feed because it crosses the carina so you can see the carina. I've got a different color pen, so you can see there's the carina bit lower down, and, um, it crosses the carina. It goes straight down past the diaphragm, which is here, and it's tip is in the stomach. You can sort of see these gastric bubbles here. So, um, that's how you know an N g tube is safe to feed. And, um, you will. I had one of these in my, um, in my images station. So it's very important to be able to sort of 100% note for tube is safe to eat. Feed or not, If you don't know, you say I'd like a second opinion. So in these two, we've got option one an option, too. Which one's the safe one to feed. So if I draw them out for you guys, So that's one. And that's two. Which one is a safe one to feed and speak up? Because I can't see the chat. Oops. And, um, is this the sides working? All right. Okay, fine. So it's option, too, as we went through before. Okay, um, I can't see if you guys riding in the chat. Um, well done. I just I can't see. I can't see the chat. Um, and then this is a one that was pretty, um, prolific. Don't see it as often now, but can anyone has? Guess, um, what's going on in this x ray. So we've got lots of mid lower zones, that of pacification, ground glass, sort of shadowing. We don't have any new math, Oris ease. And there's no sort of plural effusions or anything else going on. So and it sees are quite nice and clear. And it's an erect, which shows that this patient's often more sick than the ones that are pa. So, um, any ideas? Um, from the silence, I'll wait for the sense. So this is typical of covid. So this is what covid pneumonia looks like. On the chest X ray, you get all this ground class pacification. Um, your heart's typically normal unless you get a sub massive, uh, pe. But, um, that's, uh, that's you see more that on a CT anyway, fine. A few more. I'm happy to just sort of go through these. And, um, you can go and review these in your own time. So this is typical sale sign. So, um, this typically happens in left lower lobe collapse. Um, for various reasons, um, but that's typically what it looks like often due to cancer. See the nice example of aortic knuckle there. Okay, this one um is quite dramatic. I will admit, um, but can anyone has it? A guess what this one is? Yeah. Okay. Last chance. Is that a collapsed right lobe, or is it just a massive pleural effusion? It's a massive plural fusion. Yeah, it's complete. Massive because we've got the media style and shifted away. Um, if it was a collapsed lung, it be going the other way towards their the affected side. But that's a good differential. And here, um, this is a classic example of cannonball mets. So these are lots of little coin lesion's. Often, um, this is very I've chosen the quite significant examples here, but these are often secondary kidney cancer and things like that. Okay, Everyone should be able to see what this one is. Uh, pneumothorax on the left hand side. Exactly. And is it a normal neuro thorax or is there anything else going on? It's attention. Exactly. So you can appreciate. There's long, um, there's the rest of the air that's taken up and the mediastinal shift to the affected side. Cool. Okay, this is a bit of a road sign. This is called Kinka Sign. Because you can appreciate this sort of. Um well, according to some people, looks like the fronds or the King Kalief. Um, but this is an example of surgical emphysema. So often this can occur secondary to a fracture or a central line insertion. That's sort of cause some damage. And you can get some surgical emphysema that you can see the muscle a lot more clearly. Um, it feels like, um, all wrap on, pal patient. So it's quite a surreal feeling. Okay, enough of chest X rays. I think we've sort of exhausted chest X rays. Um, any questions on chest X rays from the audience? Um, I appreciate it's not the most fascinating of topics, but I just wanted to include as much, um, as many examples as I could that you could go back in review. Thank you. Any questions before we go to see t Hat's? There are no questions in the chat now. It's wonderful. Okay, So, typically, the extent of CT head interpretation will be limited to four differentials. Um, this is one of four. Um, if we appreciate cts, uh, you're sort of looking at the person feet up. So you're looking So for example, um, I think X rays upside down, but on the CT is upside down. But you typically are looking up towards the head of the patient feet first and, um, the right, it's typically right and left. So, um, which is a bit misleading? A bit confusing. But in this and blood is white on the city Had, um So in this case, um, can anyone tell me what is going on here? What? Differential or watch? And pathology is causing disappearance. Um, so if we've said that blood is white, we've got lots of white in the sulk. I in the ventricles. Um, and we've lost all the black in the ventricles. So this is an example of acute subarachnoid hemorrhage. Um, and and sometimes, uh, as as I've said there, you can't see the ventricles very well. Okay. Here, the other three. So anybody shout out or, um, I can talk through the remaining three pathologies here. So if we've got number one number two and number three, I think most people can't use their mix it. They just need a bit more time to type it in the chat because they are top. That's it. Okay, that's good. Sorry, I'll just wait. I can't see the chat. That's the only thing. Um, yes. Slight floor in this teaching design, I'm afraid slightly slide across and to, like, reveal the chat. Yeah, let me just Oh, yes. Yeah. Oh, here we go. Got it. So you'll be able to see your own chat, but that's fine. Okay. Epidural Subdural ABM very close. Oh, no. Epidural. You're right. Part of me. So yeah. So we've got all extradural subdural and intraventricular hemorrhage. Um, which could be due to an A V m. Exactly. Right. So we've got if I go, So we've got your typical sort of lemon shapes. Um, lesion in your extradural hemotomas. Um, these are sort of What's the sort of typical presentation can anyone think For extradural versus Subdurals, for example, what's your classic difference in pathology in the presentation? Yes, exactly. Jet. So, um, you get the lucid interval, and then, um Then you, um, deteriorate and drop your g c s. And this one's quite significant. You so you can see there's a lot of midline shift into. You've got your sort of banana shapes or moon shapes. Um, again, with some compression of the ventricles that you can see here and then three is just a lot of blood in, um, secondary to sort of an internal blade. Um, but cool. Some, um I don't think you'll be asked to interpret strokes or sort of, um s chemically Asians. That's a bit mean, But if you want to go a bit above and beyond, you can go that far. I haven't include that in these images today. Fine. Um, with abdominal x rays. Um, the way I used to remember it was B o. B. So bowels, other and bones. But this is slightly more, um, sort of detailed. You want to look at where the bowels are in relation to the abdomen? If there's any gas, what the soft tissues doing to some extent, um, if there's any obvious masses. But again, it's hard to see in an abdominal X ray and the bones themselves, because sometimes you can see broken bones. So, doing it like this, you see your answers that that's not the end of the world. So here, um, you've got the house, tre. So can anyone tell me the difference between house tre and valvular common mentors? I'll give you time to type, and I'll make this bigger in the interim. So how? Astra? Uh, don't go all the way across. I'll show you good photo. Um, uh, looking at small bowel later on. And this is a good image because you can appreciate regular sign or regular sign, depending on your accent, where you can see sort of both sides of the lemon. And that's a sign of, um, gas on both sides. There you go. Okay. Next. So here's your valvular convent is and you can see it goes all the way across. Okay, Those are typically and the other only sort of other, um, glaze. Abdominal X ray pathology. Might see. Is this, um, coffee bean science? The best photo I could find. Can you appreciate this? Vaguely. Looks like a coffee bean. Um, this is a sign of signaled volvulus. And, um, you also get I guess the other one is lead pipe sign. Can anyone think where you would find lead pipe sign And what disease? Yeah, exactly. Yeah. You see? Right. Well done. Oh, gave the game away. So this is a very rare example of what a foetus looks like in an abdominal X ray. So I'm sure you can appreciate There's this weird looking thing here, and that's the fetal spine. And if you believe me, there is some sort of limbs. But, um, yeah, we don't typically see this because we don't typically X ray pregnant women because of the effects. And this is quite a sort of late term baby. Um, but there we go. So, yeah, that's what a foetus looks like on abdominal X ray. He won't see that in your exam, but now you know what it looks like. Okay, fine. So those are all the images I've prepared? Um, all 25 of them, Um, and you can definitely go back and have a look at these and sort of try and practice presenting how you would explain this to the Examiner on the day. So if you what I tend to find and this is a useful tip for any, um, so the presentation or exam is have a script, um, have something. So it's like, um, today I'm looking at an abdominal X ray belonging to this patient at this time, they presented with abdominal pain. The most obvious pathology. Are these dilated small bowel loops as I can see the value, like on a vent, is blah, blah, blah, blah, blah, that sort of thing. Um, with the chest X rays. If I go back to some chest X rays, um, go through your A b C D e. We love the alphabet in medicine because it's the only thing we can remember after everything. So go through your airway, go through the bones, go through the heart, go through the diaphragm, go through the sort of lung fields and then do everything else. Is there a random central line which has caused this tension, pneumothorax, that sort of thing. And then you can go through your presentation and it'll be a lot easier for you because your mind can just operate on autopilot to an extent. And, um, it's also a lot easier for examiner because the negative tick, tick, tick, tick. Okay, so now instruments, I am not going to go through nasal cannula with you, but I'll use this as a good start. So the way to talk about instruments is by being super super basic, like treating the Examiner like they don't know a single thing about medicine you're going through your stating what it is, why you use it and what can what can go wrong and why it is used. So nasal cannula. You give it in sort of non acute situations where people require oxygen and the complications. As we've said here, um, and what it does. And I think on your method, you will have, um, uh, sort of a big, long table of lots of different instruments. Um, And if I go back to this table and if I make this bigger, you can see that there's a lot of different things here, and, um, it's worth just being comfortable in recognizing and going through all of these, Um, I will not will you and going through all of these in such detail today, but you'll have the slides to go through them in your own time. So if we zoom out, are there any particular, um, instruments that people would like to talk or me to talk about? I was going to talk about diathermy anyway, because one of the questions last year was sort of looking at the difference between diathermy ease and, um, how it's used in things like that But otherwise I'm happy to sort of go through some of the more trickier ones rather than boring you with what does a cannula use for and things like that Does that sound okay? That's good. Yeah. Okay, good. So if we a five start put diathermy at the bottom. So there are two types of diathermy we've got monopolar and bipolar. Oh, yeah. Um, we can go through central venous cafes. Of course. Um, we've got monopolar, which is where you have, um, a pad on the patient's often leg or sort of, um, arm. And then you've got a pen or a ball or something, and that sort of creates the circuit whilst bipolar is the circuits just between the two sort of probes very focused points. So this is a diagram. So the circuit here is between the pad and goes all the way through the patient to connect to the active electrode before going to the unit. So you've got quite a big circuit here, and there's quite a lot of tissue that the electric current can goes versus bipolar. It is just focused between the tips of the 24 steps that make the circuit so there are lots of complications that occur with monopolar. Um, which shows if you have metal earrings or if you, um, have, uh, metal devices pacemaker in the line of in the line of the current, then problems can occur. So part of the huge checklist in theater is to make sure that the pads in the right place to prevent such injuries from occurring and make sure pads dry so the patient doesn't get electrical bones, they occur. I haven't seen them, but they do occur, and they do happen. It's not ideal, Um, and and bipolar is used in more sort of niche. Very. Um, well, not niche, but sort of more neurosurgical and sort of find surgeries. Um, I'm in obstetrics right now, and we just use monopolar typically. And then we've also got the two buttons, the sort of blue and the yellow, um, cutting and coag. And they're just basically, you don't need to know this much detail, for example, but it's just more about, um, the different types of frequencies that occur. Um, through the electrical surgical unit. There we go. So, um, one of your colleagues has asked for central venous catheter So let's get back to that. Okay, here we go. Sir. This is the basic principle of the central venous catheter. Um, it's I'll see if I can find a far show later on. But it's basically, as the word says it's central venous. So it's just like a normal can you cannula? Except it's right in a central sort of bigger line, such as the internal jugular, the subclavian or the femoral veins. Um, and it can be used to deliver, said medications like TPN or amiodarone, which quite nasty drugs and can irritate the distilled veins. The smaller veins, um, and cause, like phlebitis, things like that. But it can also be used for, um, measuring fluid balance. Um, the best way in all things to describe complications is bring bring, um, part of me. It is breaking them up into immediate early and late. Um, so immediate is like when you're putting it in, so putting it in you can get a pneumothorax. You can cause arrhythmias if you push it too far, um, into the vein and, um, or you can damage the vein enough that you put it into an artery. And that's quite, uh, that is quite an error. But usually these ultrasound guided the way you put these in. Early on, you can get hemotomas. They become infected. Um, if you see someone who spikes a high temperature, um, who following, um, flushing them. Um, you could you could suspect that, um, it's due to an infected line, and it can become blocked. I'll get to your question a little bit. Um, and then late it can get You can get a clot. Um, they can be damage as well. These are quiet. Uncommon. You have to really done a lot of rummaging around to get this in, um, to cause that amount of damage. But there we go. So, to answer your question, what are the different ports for? Well, I'm not entirely sure. Um, to be perfectly honest with you, I think having more than one lumen means that you can control um, where you can sort of be precise about what you're taking from what and what you're measuring and things like that. So if one of these is attached to a probe, for example, um, but I am not entirely sure we can dig deeper into that. Um, if we go to the next one pic lines Similar. Um, these are sort of more long term. So as we go along, these, um, these can stand the body for longer. So, um oops. Sorry. We can, um, keep these in the body for longer. Often. If people have difficult venous access, they'll have a pic line inserted. Um, and you can take blood from these. So the way you take blood from a PICC line, unlike blood from a catheter, is you have two syringes. You take the syringe, the first syringe, you draw up 10 mils of blood and you discard, and then you take up 10 mils, and you can then syringe that into your blood bottles, Um, or whenever if you need. And each time you do something with pecan, you flush it through because you don't want drugs. So, for example, if you're delivering, um, like amiodarone or an antibiotic, um, through a line like this, you don't want to just sit in the tube. You want to make sure it's flushed all the way through into the system, See, always flush afterwards, um, again, complications from inserting it. So, um, we don't often insert these. It's usually specialist teams like vascular access teams and, um, they so they sometimes can have arrhythmias bleeding and similar to central venous catheters. Um, if usually we try, there's like an order to where you put PICC lines in. And, um so it is like order of treatment. So you try to do the non dominant arm first, and you try to go for superficial veins compared to deep veins, and you try to go to the ones in the limbs versus sort of one sort of in the body. So, for example, you want to ideally go for one of the Catholic veins, um, versus the deep, break your veins versus the auxiliary vein versus so on and so forth, and you're always prefer to have upper limbs over the lower limbs, and that's the same for any form of venous access. Um, I was on transplant and they were talking about making fistulas. So it's different, but sort of similar principle. Um, you obviously want fistulas, um, away sort of from the upper, like from the groin, because they can. Otherwise they'll get dirty and infected the principle for PICC lines. And, um, you don't want to use the deep big veins. Otherwise, you're trouble when you've lost the access and you don't have anywhere else to go to. So same same principle applies PICC lines, Higman lines. So again they slight difference. So it all depends about it. I'm sure you can appreciate. This one is tunneled. This one isn't, um, under the skin and that lays into the S V. C uh, kept question. So, um, I think it depends who's examining you. And I think it also depends on what time of the day it is, if that makes sense. So I was quite lucky with my instruments. I had quite straightforward ones. I think I take my line. I had an energy tube, and I What else do I have? And I think I had like, an airway device. Um, but one of my friends had to sort of talk about the ins and outs of diathermy, and so she got really bogged down in that. So I think, um, it can depend on what they ask you. I would be prepared to sort of if you know, if you know the four questions. You know what it is, what it's used for what are the complications, that sort of thing? Um, and there might be some special questions associated with, um these instruments, like your classic one is if I go back to do I have Oh, I don't have it here. But, um, for example, the classic use of, um, Canula for, um, that's not to do a blood taking is to relieve a pneumothorax. So that's some That's something they could ask. Or, um, what's the use for an A B G outside of, um, measuring sort of oxygen levels? You're measuring electrolytes. It's a quick way to you to measure HB, that sort of thing. I don't think that expect, um incredibly detailed or thorough, um, sort of pathways, because that's not the point of the station. The point of the station is to see if you can recognize what things are. So if someone says, um, Marina, can you run and get a 20% Venturi? You know what it looks like? That's That's the purpose of the station. Does that answer your question? That's a very long winded way of answering your question, I think, Um, but yes. Okay, So all right. If we keep going Yes. Okay, good. I'm glad. Um all right, this is a bit of a funny photo. There's something that, um, came up and that's not in the book. Is a port a cath? So Portacath is I couldn't find a very good picture. This is just a funny one. So it does look like this under a person's skin. It's like a little, um uh, sort of, uh, catheter that they've inserted, which has silicon in it. And you can, um if you pierce the silicon with a special needle, um, you can then take blood and you can give chemo and things like that. Um, so these are often inserted in in into people who are going to have long sort of regimes of intravenous chemotherapy Sort of like a scale of months. Two years? Um, that even a sort of tunneled line is too long for, um, there's very little, um, sort of risk of infection because it is such a very small breach of the skin each time you take blood from it or you put the needle in to give them medications, so it's quite a useful thing. So patient's are asleep when these are inserted um it's very delicate procedure. Um, but it's really nice for cancer patient's, because then they don't have to be stabbed with needles every time they go, um, to get their chemo done. Swan Ganz. So this is the complicated one. So, um, you would only really see these in ICU settings, and, um, these are all the indications I sort of went down. Um, the most important one is measuring. It's basically measuring sort of right heart stuff. So you're measuring pommery artery, um, flow, you're measuring the pressure. And then you also can measure cutting output that you'd only really see these in ICU settings. Um, if patient's a step down from I see you, these are removed because there is no need for this level of monitoring on award based setting, even in some way, like see, see you. Um, yeah, I've This is very sort of specific. A niche like, for example, a pap world. Papworth, where they do or PCIs. You'd see these, but otherwise, um, you know, normal. Um, not a primary cardiac center. You would normally see poverty catheters, brown's tube. So you've got slightly different riles versus feeding tubes. Um, I'm sure you can appreciate a feeding tube is a lot more bendy er and a lot thinner and a bit nicer to keep in, um, your nasal cavity versus a riles tube, which is a lot thicker, a lot more stiff. And it's also just got a lot of, um, more of these sort of bigger holes. Um, which, which are part of the sort of drip and suck of, um, sort of bowel obstruction. So often Patient's are uncomfortable enough to not really mind having this in as it relieves a lot of symptoms, but it is still uncomfortable to push in. Um, a lot of places now have special um, purple. It's often purple sort of purple sort of ends to feeding tubes that can only match with other feeding apparatus. So you can't, for example, accidently put the wrong syringe onto a feeding tube. If that makes sense, so you might see it as a purple tube or purple sort of Enter this. This is an old photo, but fine. Okay, Um, do what else did I want to talk to you about? Okay, so chest strains. So, um, chest pains, you will see in lots of different wards. You'll see them on surgical wards. You'll see them on medical wards. You'd see them in E. G. Um, they're quite They can be inserted in a few different ways, but the main ways with the trocar, um, and there are the sort of complications associated with it. But one thing that to go back to your question, Charis is what sort of follow up questions they might ask. It's like, How can you tell if a chest drain is in the right place and we can? There's a bit of the answer, is there? But anyone want to sort of type out? Um, what are the sort of, too? What do then What do I mean by swinging or bubbling? Yes, so a trocar is this metal thing here, so it's quite sharp, and it's used to, um, they sort of slide on top of each other, so it's like the needle in the cannula. It's used to insert the drain, and then you remove the needle, Um, or you move the trocar after you've inserted it in. That's a good question, and often they're secured with the skin stitch, so it's often a silk stitch that people use to secure it because it's quite different to other sutures, especially post operatively. Um, and it's It's not, too, Um, and it's easily removed afterwards. Um um, one of my main jobs on my surgical job was removing chest rains from people. So anyone have any thoughts about swinging and bubbling? What does it mean? Used to assess and hemothorax? Which one? Um, yes and no. Jed. Um, yeah, it means that drains work, so swinging a drain should swing. And what I mean by swinging is this is the chest drain, so the chest drain bottle is filled with fluid, so it's filled with sort of sterile water, and it's it's a vacuum. So when a patient takes deep breath in water comes up the tube and the patient takes a breath out, water goes back to the tube into there is not long enough that they'll breathe it into their lungs, but it's just effect of the vacuum, so swinging means the flow of the water up and down. This tube, um, in time with the patient's breathing bubbling is, um, air coming out of, um, the lung. So if the patient had a pneumothorax, for example, there would be bubbling because the air has come out of the lung and it's coming into the washer, and that's causing it to bubble. Does that make sense? Any questions about speaking and bubbling? But that is a question they will ask about chest trains because if it's not swinging, then either the train, the drain maybe sort of dislodged or out of place and could cause further damage. If it's not bubbling, it's either. But it's swinging. It's suggestive that the pneumothorax has resolved. And so that point, um, you could do a chest X ray to confirm that the pneumothorax has resolved completely or you could take out the drain. And, um, you can do that quite easily with not much discomfort to the patient. Okay, uh, to demonstrate another trocar. Um, this is a laparoscopic trocars. So this is just the port. Um, I don't have the trocar itself. Um, I couldn't have to find a good photo, but it's a similar sort of principle where you have a sharp sort of, um, piece of metal that goes within. The port is used to pierce the skin, and then you remove the sharp from, and you leave the port behind and you inflate port. You inflate the port. Um, there are different ways to gain entry in laparoscopic procedures. Um, you don't need to know the details of that, Um, because that's sort of more postgraduate. But it's more about the fact that there are complications associated with, um, initially gaining access in laparoscopic procedures, which can include perforation of internal organs. Because you're going blind. Really? Um, then once you're in, you can fill the belly with air and have a look around with the camera. So and carbon dioxide is the gas of choice because of these reasons. And, um, a bit of a red herring is patient's doing chest X rays after laproscopic surgery, can someone type in the chat? Why, um, people might panic about chest X rays and a son sign in a chest X ray after a laparoscopic procedure. Can anyone have a think, especially in direct chest X ray pneumoperitoneum? That's it. So that's the one time that pneumoperitoneum isn't, um, a terrible well isn't like Oh my gosh, they've perforated the, um, about it's. It's because they've just had a procedure where they've had belly's, which is, uh, several liters of carbon dioxide, and so it takes a few days to settle down. Fine. Okay, So are there any if we go through this list, go back to the list? Um hmm. I could talk through these for hours. I just want to go back to the principal's. So how to really do well in this station, um is you don't need to know huge amounts of content. Thankfully, it's not like your other, um, sort of pacer stations. We have to crown every abdominal pathology or you have to memorize all the respiratory sort of drugs and the doses and things like that. It is mainly just basic principles and working on your basic principles. Being able to go through your A b c D e in your chest X ray, and going through that structure to your examiner is all you need to demonstrate in this station. You need to be able to demonstrate that you can recognize the the big things is the n G. Tube in the right place. Does this patient have a white out pleural effusion, that sort of thing, The minutia? That's what a radiologists for, um, but it's these little Well, they're not little thing. These big, sort of, um clinical signs that you need to be able to recognize in this station and similarly with instruments. If you go back to your structure, this is a laproscopic port. It is used in laproscopic surgery. Common complications include, um, issues on inserting, especially direct entry to, um, the viscera, which can lead the damage to local structures. It can lead to bleeding that sort of thing. It's all about these basic principles, and as a result, it is one of the easiest stations to do really well in, um, because the examiners want to want you to do well, I want to help you. And if they see your struggling, they will help you out. Um, they don't want It's not a good time for them. It's not a good time for them anyway, because they're examining you. But it's not a good um, exam. If they're just watching you suffer. If that makes sense. If you don't know the answer, just say I don't know the answer and they'll move on and provide you an opportunity where you might know the answer. If that makes sense, Um, I don't know if there are any other things people want me to go over again. Um, again, There's a lot of content here, and I don't want to completely overwhelm you with death by 79 slides. Um, so, five. I just go back here and stop showing my screen. Um, how How does Does anyone have any questions at this stage? Yes, Um, I think hair if, um, I can share. I can send the slides as a pdf, um, and you'll be able to access those. That's absolutely fine. Um, but yeah, I didn't I didn't think this was necessarily a two hour talk. Yeah, no, of course. You'll get slides. Um, I hope that was useful. Um, I didn't realize not everyone would be able to have access to microphones, so the style of the teaching was slightly different, But I think it was okay in the end. And yeah, it was. Thank you so much. Yeah, no problem. And yeah, uh, if you guys have any questions at all about foundation or applications or things like that, I'm happy to help. No worries, guys. Okay, Um and yeah, please. Your feedback and yeah. All right. Have a good revision time, everyone, and yeah, I'll leave you also. You can watch the World Cup. All right. Bye.