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right, so I'll probably make a start now, so hello, everyone. I'm judge from the Events team of widening Participation Medics Network to the young man. Thank you, everyone for joining our session. I apologize for the delay as some of us got back from work before we start. Normally, we have a sponsor coming in to talk about the organization. Looking at the attendance. Sounds like they're not here at the moment, so we'll just keep an eye on it if they ever come. So yeah, so, once again, thanks for doing it. And welcome to our first national teaching series, Foundation pearls. Over the next few weeks, you'll invite current doctors have different levels to share the experiences of the foundation years. We'll just get practical hints and tips on how to make the most of your foundation years and allow you to develop skills to tackle your own calls. Prepare for your rounds and keep on top of your portfolio on the right side of the screen. As you can see, it's a timetable of the rest of the session. So please, please do sign up for these events. You don't want to miss out on that so today's session will be an introduction of the role of an F one in the NHS, as well as some common scenarios in which you may encounter during your own cause. Ben and I will be hosting today's events. Uh, Ben graduated from Lester before beginning foundation training in the Northwest. He's currently working in Liverpool. A very busy surgery center was myself training the Northwest as well. Um, currently F one working in Nottingham. Before we start, I'll give you a very brief overview of how we usually run this Webinar so will be recording this session for the audience by continue to be in the meeting. You're consenting to be recorded. You would also like to ask the audience to switch off camera mutual microphone during the event to ensure that this is run smoothly. If you have any questions for us throughout throughout the events, feel free to popular chatter box will answer these questions in the end. Um, yeah. Okay, so, um, let's just get the start. So the transition from having to go to the wards or in foreign countries to the UK hospitals can be quite daunting to start with, So this is kind of a decision that I feel like I wish I had when I first started as an F one. So you guys coming on coming here, too? These sessions have all past medical school and you probably at the peak of your clinical deficiency of medical knowledge. However, being an athlete is, um, really about knowing everything as such, you will always have your seniors to make films difficult decisions. Um, so these series are designed to kind of help you to understand the many roles and responsibilities of enough help you to develop those skills to tree out and prioritize your structuring your cause. Learn how to perform for a clinical assessment and initiate the initial management plans for some patients and to know when to ask help when appropriate. So we'll give you some tips as we go along. So I'll just very quickly past two then. And I also let me introduce himself. And he will also talk about the date today and, of course, responsibility to the network. Thanks, Josh. A very nice introduction. Um, I'm going to assume everyone can still hear me. Um, I just found the chat function. Um, so yeah, I don't think I've probably met anyone here before, but my name is Ben. Uh, Josh mentioned work currently up in difficult entry hospital. Um um, but yeah. Um, so, as just mentioned, sort of this first session is sort of looking at a bit of an overview about, um how sort of hospital work. Sort of giving me the introduction about how hospitals work. Sort of in hours versus out of hours. Uh, as as well as covering a few general ways to cover unwell patients. Uh, and then some specific scenarios, uh, as well. Later on in the session. Um um, so, yeah, so that's sort of like the two sets have been two at the moment, so I trained at less medical school, uh, which had three hospitals within it. Uh, I've never worked at Entry Hospital for about a year now, so I've been through urology four months geriatrics for four months, and I'm currently at the end of my respiratory placement. Um, so the first things that sort of go through, uh, the first thing I want to go through is the date today Responsibilities, Um, and just to sort of hold the audience what sort of things. Um What? What sort of things do you, um, uh, people think might be in day to day responsibilities of an F one. Yeah. Discharging T t o is a good one. It's a very common one. Um, what else might you be off to do? Um, so I tried thinking of ways that rather than just listing jobs, eventually go to that later on. But I try to think of ways to sort of think about how to structure your days, Um, and sort of at this point, like like the day, like, uh, in our hospital. Seems quite simple in that there's a portion of the day where you're doing award round. There's a portion. That's where you're doing Ward jobs. Um, which, Um, which is sort of like quite a good way to, uh, give up your day. Um, whereas sort of the war drowned is very structured. You'll see pretty much all patients. Uh, you'll be given a list of jobs, and then the afternoon you should try to work through those jobs. Um, the And what becomes quite quickly apparent is that this isn't like this isn't the entire plan of your day um so I think quite quickly, within the first week or so, I realized that it's actually a good portion of the day that you spend doing, Um, some preparation in the morning before the war drowned. So that might be things like preparing notes before the war drowned. Happens, uh, as well as at the end of the day, maybe putting up a small amount of time to put our blood for the next day, handovers the evening team. And, um, just basically make sure plans are in place, but more unwell patients overnight? Um, probably. However, the biggest thing that I didn't quite anticipate was how important some of these jobs were. Um, and it feels kind of, uh I feel like I'm sort of eating my own words here, but because today I did pretty much neither of these two things during the day. I just had, um but you should pretty much always make time to, uh, eat something halfway through the day and make sure you, um if you need to start, you go to the toilet as well, because it can be very easy to slip into a routine where you work from 9 to 5, and you, like, quite often end up working late. Um, And you you don't eat anything during the day. Um, because whilst I initially thought of, like, more efficient, you end up being a lot less efficient later in the day. And so So if you have data responsibilities, the job, you also have to make sure that you continue looking after yourselves as well. And yeah, so this is what a bit when I go into what the actual list of jobs sort of is, Um, and whilst discharges and T T. O. S is one of the big things you'll end up doing, uh, try thinking of, um, lots of categories of different jobs you might end up doing, uh is by no means an exhaustive list. I'm sure Josh, from July making problem double my list that I wrote. Um, but, um, depending upon which, um, depending upon which hospital you work in, which didn't really work in, and even which department you work in the types of jobs you end up doing actually quite different. Um, And once you get started working, you'll you'll start getting quite good at the job. So you do quite a lot. So, um, I think in my job of urology, I ended up getting pretty good at being able to order CT urogram is or getting nephrostomy is booked because you just know what people will ask for. You know what information? They wanted the request. And you know what tests they want to be done beforehand. And, um, but sort of this is sort of the list of jobs you'll get, Uh, at the end of the war. Drowned. Um, but it's sort of in order to sort of everyone's processes these jobs in different ways. Um, rather tell you that, like, this is the exact way to go about it. This is sort of the way that I tended to think about jobs in the end. Um, and it's sort of it's not tried grouping the jobs in, uh, not what the job specifically were, but how I interpreted the jobs and how I could prioritize them. Um, so I sort of had, like, these sort of groups in my head at the time. Um, I try to explain what each of them are, uh, sort of the patient critical ones. The ones that you need to do urgently because someone's going to come to harm If you don't prescribe them soon. So one's like this might be prescribing an antibiotic. Um, giving someone glucose if they're having a hypoglycemia episode, Um, or if you're not sure what to do, It might be talking to your senior talking to a different department. Um uh, time critical jobs. It's a very similar concept, but the idea is that if you don't do something soon, then the knock on effect might be the patient might come to harm eventually, Um, coming back to sort of, uh, in the first job I worked in, I would have to probably all arranged for atrocities to happen. Probably a good five or six times a week. Um, and I realized that if I didn't order them during the war, drowned like, say, if we saw a patient nine AM, if I only ordered two PM, they wouldn't be getting until the next day if not the day after. Um, if I ordered it as soon as I saw the patient at nine, and I just and you just sort of slow down the water and a bit you can actually get that job done, you might be able to get their procedure done on the same day. Um, so as you sort of get these jobs and then also, as you make up this jobs list, it's quite good to try and think about things that you you have to do first simply because it will be other life or death for someone or at least very critical for someone. And then everything else sort of comes below it as well. Um, there's also this sort of idea of a delayed hit job. Um, and these are surprisingly common in that, um, scans and bloods that you take or quite often, fall into this category in the order, you'll order a set of bloods and just send them off, and they will take about three hours to come back. Um, and it just means that even though you've technically done the job, you've taken the blood, you still have to chase the results afterwards. And even then you might have to do more stuff based on what the results are. Um, so again, Well, this is sort of like very linked to the time critical jobs, so there might be someone who is quite unwell has not had blood done for quite a while. So they're sort of more time critical because you want to be able to action them before you hand them over. And then we sort of get into the other types of jobs. So the label jobs are ones that was important aren't really essential to a patient care. Um, the ones that sort of like linked to this ones are, um uh we'll talk to families. And updating them is always very important. It's, um It might not necessarily change how a person's care is managed. The other one is sort of is Santiago mentioned is, um, even though the hospitals will try and push you too. Discharge patients get the T. T. O. S ready. Um, if someone's start using a seven or eight, they definitely take priority over their discharge summary. Um, I've been amazed. Like I've sold a lot of like horror stories or something that people sort of demand. Teachers don't even though someone sort of, um, deteriorating massively. But really, people are very, very understanding if you just tell them that there's something else more important than that you're aware of it, but we'll get back to it, and and, uh, the last one is sort of delegates for jobs. I'm not sure if that's a word, but, uh, types of jobs that, um whilst you yourself can do them if you're quite busy, Um, you can always ask, uh, other other doctors on the wall to try and help the nurses. Um, depending on which did Your urine can do a vast amount of jobs. Um, So I trained in Leicester where, uh, it would be quite difficult to get a nurse to do an EKG simply because a lot of them weren't trained in it. Uh, and none of them were trained in cannulas catheters, bloods or a P GS, whereas here in Liverpool, pretty much all of them are trained in all of them. Um, even respiratory nurse can do material blood gases. So I've been amazed that one how able they are to do them and also to how willing they are to help you out. If you're having a busy day, um, and sort of at the bottom. I've got this thing called Hidden Jobs, and my sort of idea is that this is the main reason why you prioritize jobs. Because by and large, um, um, if someone gives you a long list of jobs to do it midday, if nothing else crops up during the day, you can probably get all of these jobs. You probably most of the jobs done. Um, the problem comes in the jobs that are given in the war ground, and these are ones like Pacer come unwell. Um, uh, family members come in demanding an update you might get the death certificates is quite a common one that comes up and the very hot on chasing you for them, a big one at the moment is, uh, gaps in the rotor. And so I think like, today it was just me on my side of the board. So it may sort of getting out of the time very difficult and getting anything else other than the job's done quite difficult as well. Um, And so, as I mentioned earlier, taking bloods um, doing scans can often find things that you maybe not expecting, and you then have to manage those as they come up. And sort of My idea is it's those things that end up pushing you into overtime or pushing you over the limit. And so trying to get good at prioritizing is what protects you from the hidden jobs affecting you. Um uh, the one thing I got done, there is bored rounds, which, uh, can be can take a bit of time, but also quite good, because it it sort of highlights why patients are still sitting in hospital. Uh, it brings sort of the physiotherapist, the nurses, and yourself together, trying to figure out what we can do to get people out of hospital. And it also works as a time to highlight people are overstretched or whether they're not managed to do things quick enough. Um, so that's sort of a bit of a summary on, uh, in our hospital stuff. Um, I've spoken for about I want to say about 10, 15 minutes, so I just want to check. Does anyone have any questions? I sort of written this bit in a in a way that explains my perception of it. And it's one way of thinking about it quite often. What you'll find is that you'll develop your own way of thinking about things. Um, I'm going to take this silence as you're happy. Cool. Um, so I have this list of jobs from earlier on, and I thought I'd copy them on to the next slide, and I crossed off all the ones that aren't really on call responsibilities. Um, and whilst the decisions about which which were and which weren't on call responsibilities or at least once that you wouldn't be expected to hand over, um, I was actually surprised at how little short list was. Um, so the only ones that really, um, probably be asked to do is chasing, uh, blood or results. Um, maybe doing clinical skill. So maybe asking someone to do blood doing bloods or a candle yourself, Um, and fairly often you end up being asked to discuss someone with a specialty after X result has come back. Um, but does anybody really have any ideas? What are the main on core responsibilities you might get? So you might get given two bloods to hand to blood to chase the end of the day. But that won't be what you spend your evening working on. So does anyone know what they might be working on the evenings or weekends or nights? Yeah, assessing the Androgel patient. That's yeah. So I like the answer, Santiago. It's a good answer. It's just it covers pretty much all of the answers. I get another example. Um, um yeah. So patient management. So on calls tend to be so at the time where people think it's still sort of real medicine in that you've got someone acutely unwell. You go and see them, you investigate them and you make a management plan. Um, it ends up being, uh huh. And it's quite personal. That ends up being a bit more interesting simply because you get a chance to sort of just, uh, improve skills. You maybe don't assess. You don't get to improve in war grounds. Um, I sort of came up with a few jobs list that I I've probably written down myself in the past before, um, so under the patient. So, um um, so, yes, I'm on patient, so there might be a spike in temperature. There might be scoring and use of six. Um, I have been eating quite as much. Um, um, you might have got some blood tests back that are going quite horribly wrong, and you might can review them and action that, um surprisingly, the top right talk to you on the right are the ones that I get asked about the most. So someone not being prescribed warfarin for a day and they don't have an iron are done for the last four days. And Liverpool, it's all done on paper charts. So, uh, you end up having it over to the 19 as well. Um, you end up chasing a lot of surgical views as well. And the biggest thing I called about the patient having falls. And then it falls reviews, which I I think at the start I was quite scared of. But by the end, it's it's they're pretty cutting are pretty easy to go through. Um, yeah. So that's sort of the main examples of things that I had and and I wrote sort of a list of jobs list you might you might get between each between in our jobs and called jobs as well. There are lots of overlap. So, um, I think a night I had last week, I got handed over. I think it was 12 bloods to chase for my night, which is more than I get for most in our jobs. So there are things that occur both in our hospitals and out of the hospitals. But the mainstay jobs will do are different. Um, so in ours will be doing a lot more, uh, family updates and discharge summaries, whereas on calls you'll end up seeing a lot more unwell people and plugging holes that appear. Um, sort of another way to compare in our out of our hospitals is in. Our hospitals will have typically have more jobs. In the end, they have more structure to your day. Uh, there's more support and there are more services. So you can't get an ultrasound out of ours in that you can't get an MRI out of ours. Difficult. Um, you'll have classically, you should have an S h o a register on a consultant for your team. Mostly, that doesn't happen, but that's what it's normally. They're, uh, you're on call jobs. You typically have fewer jobs. There's less of a rigid structure. Um, I'm not going to say there's less support, but it's very much a different support network. Um, obviously, in the medical team, especially at night medical. It's a registrar. A, um S H O and an F one, which can seem quite daunting. But when you also factor in that, there's, uh, in Liverpool, at least we have no clinicians who filter bleeps and support us during emergency calls. Um, there's also clinical support workers. You can help with any clinical skills we have. And at the end of the day, the nurses end up being like the biggest help. And so interval they can do bloods. Um, if you ask them to, um uh, like, double check someone's obs just to make sure things just to make sure someone's getting better. They're often very happy to do this. Um and then, as I said before, there's fewer services. So just, um, you can use that to your advantage, but it can be a bit of hindrance. So if someone needs an ultrasound scan, you won't need to chase it overnight because it won't happen until the morning. Um, which is quite nice, but it does. It does also mean your left in the dark little bit sometimes. Um, so that's sort of the first half of my section, um, the next we should go a bit quicker, but any questions at all. Probably going to the next bit. I'm going to take the quietness is, uh, questions. And so the next thing I would ask to talk about was approaching a patient with the news of six, Um, which is a bit hard to exactly approach because all the subsequent slides in this talk and we talked about each specific scenario. But it's trying to think of an approach to, um, if I get told over the phone someone's in news of six. What's my immediate response? Not even if I put the phone down. What's my immediate response on the phone? And in the first few weeks when I started last year, I pick up the phone and told them, When you have sex and say cool, I'll come see them put on the phone Now, at the moment, it's a bit different. Um, and, uh, can anybody sort of think about what is the main difference? So, um, what do you want to do if you get like a news of six? If you get told over the phone as a new patient with the use of six, what do you want to do with that? Yeah, Santiago is on it again. Um, so, um, I sort of I ended up having, like, a like a quote going around in my head. Um, I'll leave that up there. I won't tell you where it's from, but it basically means you need more information. And Santiago said, um uh, if someone tells you that scoring news of six can you come and see them? Um, you want to know more? So, uh, breaking down each of the obs is a very good question, Um, and asking Is there any other concerns you have about the patient? And again, they sort of leans on the fact that the nurses actually no, um, that often the very senior nurse is, um may even call you for patients who are scoring a two or three. But they just have sort of this feeling that they might be quite well, but it's it's important to ask. The nurse is like, Why are you worried about them? Um, um yeah. So what's your worry about them? Um, more often than not, someone will call you about a specific parameter being wrong. Um, so they might say, like, this person has become very tachycardic. Now, they're running at 120 Um, quite often and even say I've already done the CT to become Review it and the patient, Um, but then what's what's also important to ask is, um, if they if they tell you they're running very tachycardia, want to know what's the rest of the new score you also want to know more about? And the history, Um, because what's so what's new? And six is quite big. It might have been seen earlier on in the day, scoring in eight or nine, and this is actually them improving. Well, it's it's not. It's not good that they're showing the news or six relatively. It's actually quite good, might be improving, and you might be able to ask them if they've had any Bloods done. Um, but quite often I think it's quite nice and lyrical is that, um, you can sit on the computer and you can, uh, get someone's obs bloods history and, uh, any medications that are already, uh and you can sort of get a bit of an idea from the patient before you can go and see them. And, uh, yeah, so just generally the idea is trying to find out more information about the patient. Um, what's the big question? Uh, I've not given so far. And this is, like, an exceptionally important thing. Um, as much help raise the nurses. This is one thing that generally nurse and stuff aren't quite as good at, and it's something to not get into a bad habit about. So what's like the most important thing I missed out on this slide? Nope. Um, so the most important thing is, what's their name? And you'd be. I've been kind of amazing, almost shocked at the amount of times I ask who is the patient you're talking about. And I'll say, Oh, it's the man in 70 or the or the woman is Sergeant 12 and I go, I've never worked in the war before. I don't know who's on your ward, so just tell me their name. Um, well, again, this might seem like you've been quite and pedantic and annoying. It's more because patients will move around the boards and move within the ward's, uh, sometimes without anyone knowing. Because patients become curve is positive, they become Australian difficile. Positive. Uh, they either get transferred to a different service, um, and then just get moved around almost the sake of it. Um, so knowing their name means you know exactly what should have notes to look for. So I don't miss that it out. Um, okay, so I've got I think two or three more slides. Um, so trump read through these, and, um, again. So So the first case is trying to say someone who has a produced oxygen saturation. And so if you go back to sort of basic principles, uh, if the nurse tells you they've dropped the SATs to 80% Um, the first thing I'm going to try and do is you're going to try to bring up their options saturations. And you can very quickly do that by putting him on oxygen. Um, so if they've dropped massively, just whacked them on the 15 liters and then titrate them down. If they're just slightly below, you can just ask them to go up a bit. There are nasal cannula you put them up to. Eventually. If they're on Venturi's, you just escalating. Escalate as high as you can. Um, but once they once they finish, you can start thinking, um, what's going to what's causing this problem? Is it a problem? Getting air into the lungs is the problem getting the erection into the into the blood? Is it a problem getting oxygen to the tissues? Or is it a problem? Actually, using it the last to tend to be less of an issue. It's more sort of. The top two are looking at in dropping sets. Um, um, okay, probably saw that the next day. It was sort of asking about what do people think is the most likely reason that people end up getting falling? Saturations. It's a bit of a, um, pointless question I've given. I've just given you my answers. Um, but so I think I've been called out for like, um, for someone asking about the patient's dropping saturations about probably 23 dozen times in the last month or two. Um, yeah, perhaps a very good one or more general existing pneumonia so you can get your aspiration pneumonias. Um, if someone has been in for, like, a day or something, you can still technically be a cap. Um, yes. The pneumonia is probably the most common one. You think of any others as well um, So there's the list again. So and pneumonia is quite common. Pulmonary edema is probably the next most common one. Yeah, anaphylaxis is one that I've again not an exhaustive list, but it's it's not what I have actually come across so far. Um, the pre the reason I come across it is because if someone's having an anaphylactic reaction to the appropriate at either a pair of arrest or an emergency call, so that's probably why I've not been called to see it myself. Um, the top four are probably the most common that I've seen at the bottom of the small ones I've probably seen, but also less common. Um, so pneumonia is an infection? Seems to be the biggest one. Pulmonary edema is one that is, is probably the most common one that I've seen. But it's but pneumonias are the most common single ones I've seen because probably eczema tends to always be a little bit there. Um, unless the person is bone dry. Um, I'll talk to the medical register and I'll say, Just give him some friends of mine and see if that does anything, and quite often it does. It just clears up your lungs a bit. Um, what do I mean by patient factors? Said mucous plugging, which is just someone not able to clear the railways. But patient factors is sort of a group of things that, um, seem kind of obvious, but and they end up being quite common. Cause is dropping SATs. Uh, so it's very simple things like oxygen tubing not being connected to the wall. Um, the oxygen tubing being kinked patient not actually being on their oxygen mask. Uh, I might have missed there. Nebulizers. Um, patient sometimes is slumped down in their seats in their beds or chairs and start to ventilate properly. Um, so these are all quite common things. So if you come up to someone, you can If you look at them, they look slumped down and they don't have the option of just you should ask someone to set them up and put on the oxygen, and then quite often will sit right up and I'll pick it up. Um, pain and anxiety is very common, especially in respiratory, And these two quite an alarming amount of people that are on both, uh, morphine and lorazepam to try and treat their, uh, respiratory problems. All the other ones, Um uh, once I see fairly regularly, but and maybe not as common as top four. And what's the other question? I have not asked yet in someone who's got dropping situations. Um, we have the name. We have the location. We've asked the nurses to increase their oxygen. Saturations tha increase there auction? They've been given, and they asked us so. Uh, yeah. So what does the nurse want to know from you? I wouldn't get a very bad way. You want to know? They want to know what we're aiming for. So are we aiming for 1940 98%. You got it. Um, are we aiming for normal saturations or 94 to 98 or aiming for 88 to 92? Or is there a specific saturation that someone said to them, like 85 or more? Um, so uh huh. If you've been given all this information, you can program and see them, and you can formulate a plan. Um, what sort of things are you going to want to, um, like do to manage the patient with the foot with dropping saturations? What's your management plan going to be. It's sort of speaking, very general terms. These are These are things you might always do for someone. Um, so I wrote quite a small list. Um, because you end up treating whichever cause you end up coming up with. But the things you should always end up doing is, um, at every stage in you being you interact with this person, you need to ask yourself, Am I qualified to manage this? Do I need more hands or more help or someone more senior? Um, what the question boils down to is Do I need a medical or do I need to put out and rest? Call? Do I just need someone to come along and help me? Um uh, The other thing is always going to your eight. We approach, um, making sure there's not just something blatantly sat in their airway blocking the blocking, their ability to ventilate. Um should always listen to her chest. And if someone, if someone starts dropping your saturations, they seem to be infectious. Always get like a chest X ray, do some bloods. The important thing is also if someone is needing more oxygen, all of a sudden, there's no obvious cause for it. It's always good to get a PT as well. Um, especially for people like people who have COPD. You want to know? Um, they might have a history of being a CO2 retainer, but you want to know if they if they've been just about tipped into type two respiratory failure because they have to start thinking, Do I have to get, um, this person considered for intubation or maybe even, uh, noninvasive ventilation? And, um, this is this, like, these are pretty huge questions how to manage, like, dropping saturations that there is like it's a huge amount that goes into thinking about it. Um, and it's very specific to each of these different courses. So it's very hard to write a specific set of rules for each one. Um, um the the only other The last one I'm going over is sort of low GCS or sort of drowsy patient, which you end up being called about quite a lot as well. Um, again, this was like a very big sort of topic. Um, when you get called about them, the main thing to think about is what's the baseline patient. Has anything happened recently that might cause them to drop their GCS? Um, importantly, has it ever happened before? So one of the main ones that you called about is people that, um, sort of have this vacant episode, and you sort of have to ask how they had neurology been seen neurology seen them before. Is this just them after they've had a seizure? Have you been off the water at all? Have they taken the room? Drug supply? Um, do they have an underlying infection? Could this be a stroke, or could this even be just a bit of hypoglycemia? Um, again, this is probably is even bigger than dropping the saturation, because dropping saturation is one of the reasons for it. Um, uh, for someone who has a drop GCS I probably have a lower threshold to put out a emergency call or an arrest call. Um, simply because they were much more unwell at this time. Especially people who have seizures, like if it's the first time seizure, you want to have more hands. They're two other manage airway or, uh, figure out what's going on urgently. Um, the things I always remember is check glucose. Either they might have gone sky high or they might have plummeted off at the bottom. Check the medications. Are there any sedatives? Are you on too much morphine? Try and do a neurological examination in case there's a little stroke trying to fix any basic observations. And if you've got nurses or family hand, you can always ask the natural history as well. Um, sorry I sped up at the end there. That's my half done. So I will hand over to Joshua. Thanks, man. Um, before I moved from that, you got any specific questions about his presentation? Did you have a favorite to check box again? Yeah. Uh, you don't want to please. You know, the next life. Okay. Thank you. Um, so, yeah, I will. Now, I want to talk about a few other arrangements of parameters. Um, so the content that will be covering will be very similar to what is discussed. Um, they are by no means excessive. This is not a check list of every step that you need to adhere to. And according to this medication, um, so, yeah, I think the main kind of aim of this session is to basically give you an overview of some of the common scenarios that you encounter and hopefully share a few, uh, important point that you think would be beneficial to you guys. But I think when it comes to actual patient care, you should always consult your senior as well as local and national companies. Um, right. So the very, very common, uh, scenario that you have come to a patient with hae heart rate bradycardia. So there are few things that you need to consider when you see this patient. Um, so that's sort of the main things are this is a new tachycardia, or has this been ongoing for a long time, whether the patient is stable or not? And the first thing is to ask the nurse to do an EKG. Um, there's another one. You wouldn't be an expert reading and institute for sure, even for me. A lot of the times I always cross check with the register just to make sure that I'm not missing any important things. So when you're looking at the most important things that you're looking at, the heart rate, whether the heart rate is actually fast, the medication is actually happen to cardio. Generally, if the heart rate is about 130 I will be a bit more concerned about the patient. And the second thing is we'll get a PR interval, Uh, whether the interval is more than three squares. If it's a lot of PR interval or more than three squares and you're worried about things such as a beauty. So after addressing all these questions, you can immediately help you triage your management plan. So that kind of thing that you're looking at is, if someone has a broad, complex tachycardia and they are unstable, you have to call for help immediately. And the other thing is if patients present with adverse features. As for the areas, uh, under such as if they're presenting with short, uh, my heart failure or syncope. Then again, you have to call for help immediately because they may need to have synchronize the shock. So if the fast heart rate, on the other hand, is causing patients to be done well, being short of breath, having chest pain again, you have to call to help as soon as possible. Um, okay, so if you're able to work all these things and the patient is stable and asymptomatic, which means you get a bit of time that you can kind of, uh, go on to it and just perhaps focus history reviewed your BCGs, uh, looking at drug cards. Uh, discuss your final See your colleague. So some of the common triggers of, uh, fast heart rate or even a f include things such as, uh, any recent surgery? Uh, the patient having infections, Antiseptic, uh, looking at the blood test, The patient having anemia, uh, dissipation dry or hopefully make any potential electrical disturbance? Um, has the patient been stopped for a long time? Many G I losses, um, or any electrical in violence, which is low potassium moment. The same things like that on patients in the hospital. There are also added physiological courses of the tachycardia. So things, for instance, like, Are you having any pain? If they're having pain, you can simply treated by adequately. Analgesia are dehydrated, so drink a lot of fluids or encourage them to drink. Or have you just had a session with the physio, which makes the heart rate to be faster than normal. And the other thing is um after considering all these ones before, considering all these apart from looking into the adverse features and make sure the patient's stable, we also need to rule out things that are life threatening for some things. Such as, UH, A C s, uh, acute coronary syndrome, any PDE any kind of pneumothorax or structural cardiac disorders. So the approach to seeing a patient with a fast heart rate started with, you know, perhaps when the nurse called you about a patient a fast heart rate starting to get a set of vitals get PCG. Sometimes it's always useful just to get a man your pulse check. So instead of using those automatic machine, because sometimes it can be quite difficult to get an accurate reading. And someone who has perhaps a f as a corporate for health or poor profusion and what I always do is I would tend to avoid the patient first before looking at the medical notes. Um, the reason for that is in this group of patients. Normally they can deteriorate very quickly, so it's always using this to very quickly go to the bedside, have a look at the patients, ask him a few questions and head back into the doctor's office to continue reading your medical notes, looking at the drop card to see whether any medication has been missed. Um, and once you are happy with all your kind of, uh, once you have your reading, all the notes, uh, from the medical records and uh, perhaps a history, just make sure that patients not having any current symptoms look at their respective that will make them more susceptible to fast heart rate A or unstable, you know. Recently, um, assess the patient. Think about things that relevant in this scenario, such as do a full cardiac examination. Listening to the chest. Listen to the heart is make sure the patient doesn't act about the problems that sounds no signs of E. The patient doesn't look sciatic, breathless palate or no any of these signs of bleeding or anemia again. This can also contribute to bleeding, so investigations a whole range of investigations that you can do. But from a kind of core perspective, you think about what's the likely cause of the tachycardia. Uh, if you think it's perhaps anemia, or you just want to do some blood test the PSA will be able to start. Um, I will tell you the hemoglobin, Terry. Any signs of infections in the bloods? Perhaps use needs. Um, perhaps, you know, having low sodium having deranged electrolytes to suggest any precipitating, diarrhea, vomiting, fluid loss, et cetera. Um, if the patient has any previous or current signs of bleeding again, do things such as clotting group and screen um, if they can accept it considers that explained, if they have any kind of symptoms, such as chest pain or cardiac sounding pathology, that perhaps your opponent And they have also, perhaps, do things such as any chest experience, even CTP a after discussion with the senior colleague. So for the management again, it really depends on what the sort of triggers um, inpatient technically is really important that we need to address the trigger rather than flying, Treating the rate by giving basic blocker or Catholic Channel blocker and things like that and the beta blocker and Johnson Um, so again, the management, um so the first thing that determines you managed to see whether there is any adverse speech is the patient is stable or not. Any symptoms. If the vision is dry and then fluid. If the antibiotics, if they accept it, will have an infection. Electoral replacement There are electrolyte imbalance and and sometimes, if they are stable, if the heart rate is is sort of borderline but still stable patients, well, hemodynamically and clinically well and stable, we can consider observation after discussion with the senior. Sometimes the senior college also recommend using the rate control medications, like by stopping all the drugs in. This is not a decision that you have to make enough one. So when you're unsure, always need to register. Or someone that senior, Um, so the kind of main important things from this are you getting when you encounter a wide complex and the cardio if the patient has adverse features which has a edema and my or the patient's symptomatic So, yeah, if you don't mind, um, thank you. So compared to fast heart rate, uh, low heart rate, bradycardia is a lot less, um, common in the hospital setting, at least from my experience. Um, so there isn't really a university accepted value for bradycardia because we know that very healthy athletes can have a very low heart rate, especially during the sleep That doesn't mean that they are human, technically and stable. It could just be a normal thing, a normal variant to them, and therefore it's always useful just to look at the trend. So if someone has come in with a heart rate of perhaps 60 70 since admission and now the heart rate is about 50 just always use it just to compare the trends. If the heart rate is, is the heart rate dropped from 50 to perhaps 40? Um, while the patient is sleep and the patient is stable, then you probably let's worry about that. But obviously it depends on the individual, and you should always look at the patient's home and consider all possible factors before we can come up with that conclusion about So the assessment of medication with bradycardia heart rate essentially again very similar to the tachycardia, I think they will not any adverse features. If they are, they required urgent treatment. Um, the second thing is, are they symptomatic if they are symptomatic again if they have a pre syncope or syncope symptoms, uh, if they're short of breath again, they need to ask for help as soon as possible. if they're having any chest pain. Are you having an MRI now? Um, so some of the kind of life threatening course is that you have to consider are perhaps, um, and Syria, in theory of mind, um, hypokalemia or if they're overdosing medication, someone give beta blockers just Actos. When I didn't know that one was also prescribed a regular medication. And one thing that 1.2 is when you see bradycardia in a patient with some sort of neurology, for instance, people are equally reactive. Uh, GCS short acting. Uh, you need to consider things that just, uh, intercranial events because this is something this is the case that I've encountered, actually, during my location. Um, so what happened with the cartia as well as a very high BP, So it could perhaps be suggestive of an impending or severe intercranial event? Uh, sort of early scientific Christian response. So just something that we need to consider when we are trying to rule out all the life threatening courses cardia during the auto focus. So other courses of bradycardia such as a fibroid problems again, election disturbance, hypoxia, a counter. Well, you know, I think the patient. The main thing that you're looking at is the See, um, to kind of circulation. As long as the B, the airway and breathing are stable, we want to see do a flu vaccine. This assessment do. A very brief cardiovascular examination will always be easy to get a bit of prophylaxis and perhaps some bloods from them and review the drug card. Just make sure we just make sure we have to go. So you have a basic look at jobs in etcetera? Um, it's always useful just to review any previous cardiovascular investigations. Any previous echo. Have you got the baseline ejection fractions? It was low perhaps two years ago, that they suggest they are more likely to be symptomatic or become stable from a arrhythmia. And also just ask about any cardiac symptoms of the patient is experiencing, um, so again, in terms of the treatment very similar to the party again, it's very tailored towards the underlying course. So if the patient is asymptomatic, sometimes it's okay. As long as it's stable, it's okay to not treat them during out of ours doesn't require any emergency treatment, but I always discuss a senior this even because of the cardiology registrar. Uh, if they are symptomatic, if they are human erratically and stable, then we know that there are certain medications that will help, such as a tribute and things like that. But again, when it comes to these sort of medication, it's not. It's not something that you have to make a decision, or there should be something that, uh, uh, that that is identified a senior register that started by Cardinal Register. So you shouldn't be, you know, thinking about that straight away when you see a picture with the cardio, right? Yeah, but if you want to please do the next light. Yeah. Perfect. Thank you. Uh, so the third topic that I was asked to talk about was, uh, hypertension. High BP. Um, so a very important thing about hypertension is there is a huge difference between the treatment of intention of attention versus chronic hypertension and community. Um, so a few things to consider isn't a specific kind of range of an optimal BP patients, and it's to the hospital being able to also use the patients are more likely to suffer from secondary causes of high BP. so secondary causes as you know, things such as pain and stress. Um, any ongoing infections or have to skip the medication. And the same thing I think is really important is, uh, there are specific groups of patients which you will be worried about when it comes to type of pressure. So, for instance, a patient with the quality of the disease, the renal doctor would want to have a specific targets for them patients. Sorry, patients a pregnant woman again, Um, if the pressure is high again, they usually are managed by the obstetric renal MG team. So it's really important that when you see these people, you do speak to that. And then the kind of 3rd and 4th patients are usually a patient who had a recent stroke or a recent string of bleeding. So these patients usually have a very tight or they have a very They have the kind of target of BP that register, Um uh, that that that the parent team would want them to have, so it's It's really important that you clarify with the parents, you know, just to make sure they're happy with any arrangement of the blood pressures. So the fourth thing to consider is when you see some of the coaches you need to make sure this is not hypertensive emergency so and hypertensive emergency can be signified by things such as a patient presenting or showing signs of end organ damage such as any papilledema, uh, arrangements. Any acute neurology presentations, strokes any kind of acute heart kidney problems. And the last thing that you need to look at, UH, is perhaps you need to remember that just because some of the pressure is high or the highest side doesn't mean that it's a bad thing, especially in the elderly group, usually in the elderly. So I wouldn't really want to go too aggressive with controlling the BP is because there are higher risk of cultural hypertension and has full head injuries, many other complications. So as an F one, perhaps doing your first few sets a phone call, a nursery, ask you to. Regular patient, 75 year old gentleman recently admitted confusion and say, It's always so. Can you please give your head because it's professional? 191 110? So that kind of things that come to your mind apart from the sort of important that I mentioned just now would be a professional, really elevated, so you can ask them to repeat a set of observations. Can they do a manual BP? Is the BP too large or two small, which can overestimate your underestimate BP? Look at the trend. If someone's pressure has been 190 since admission or throughout the day, then perhaps if the Depression 995 I wouldn't be that significant. So this is the thing that you can kind of consider and compare, whether it's something that's significant or probably relatively less concerning. And then look at secondary courses are having the pain. Have you missed any medications? Oh, if this person has an unsafe swallowing and perhaps he was kept you by mouth the whole time. So maybe he has missed the medication and then stick to the patient. Um, is a patient symptomatic? Are they having the same provocations, chest pain and things like that? So when it comes to symptoms in a patient with hypertension, so the main thing that we are looking at, uh, four systems, so the neurological system, Uh, sort of cardiovascular system, Uh, sort of renal system in the forefront are whether the person is putting a lot. So because we're worried about some sort of any organ damage, like, uh, good professional need to integrate your events or stroke or bleeding things like that. Could that question lead to, uh, my, uh, other cardiac events? So we need to ask questions on these for many systems, and that's the same for examination. You'll be looking at these forces. So looking at any new neurology, sure, the sensation is entirely not confused. And also efficient is part of the university. Based on your examination as well. Make sure the efficient is not affected. Listen to the heart into the lungs. Ask about any lower urinary tract symptoms. Anything to really cetera, et cetera. So investigation is very much guided by the symptoms. The size of the patient complain of a percent with the patient as well isn't dramatic. And there's not much difference of the current. Numbers are compared to the trend since the admission or the transport a day. Uh, smoking, sit tight and perhaps modification as long as you're discussing. Registered with the senior complex. Happy with it? Uh, if, on the other hand, unfortunately, that presents with neurological deficits, then perhaps when you do the drops and do a CT head just to make sure there isn't any acute pathology is happening in the brain. Um, if they're presented with chest pain, shortness of breath and chest sounds very testy. Went very wet then perhaps the chest X ray and a BMP E g. These are the things that will be helpful and perhaps even ABG. They saturate. And for the treatment of these patients again, it's It's very much depends on whether there are any organ damage is because of the high BP, Um, and moving out secondary courses and dealing with that as well with the pain to make sure you get adequate pain control. Uh, just remember for high BP and a lot of the things that we discussed most of the time you're treating with, you know, the patient is in front of me rather than the number. So just making sure the number is correct. The patient is asymptomatic, um, and and the patient as well and stable. Um, and also remember that there are certain groups of people that we need to discuss with the parenting discussion is team, for instance. Uh, pregnant ladies, um uh, people who have just had a recent stroke use an entrepreneur event, etcetera, etcetera. Um, And if someone has a persistent high BP after this discussion with the register, sometimes they recommend giving a second dose of anti hypertensive, increasing the regular man. So you can do that during the night time. Please always head over to the day team and ask them to be the drug card with the patient's. Um, yeah. Okay, so let's move on to the next one. So it would be, uh, low BP. Hypertension in the ward. That's it. Thank you. Um, so when it comes when it comes to hypertension in the warden's, uh, the most important thing that should really come to your mind is, uh, you need to pay attention to go out. It was like a question, of course, is so hypertension could be due to things such as acute bleeding. Has the patient had a recent surgery? Uh, any trauma? Any background of GI bleeds? Um, respective for your nephrotic syndrome. Things like that. Uh, infection septic, any sort of infections. Have you taken the reason for the culture? Um, any kind of cardiac arrhythmia problems? Heart beat is MRI, et cetera. And, um, any kind of, um, hints towards an anaphylactic reaction and athletic shock have given something new to the patients have required by the patients and the status and things like that. So some of the common triggers that you will encounter that you should consider when dealing with patients with hypertension after pulling out those courses are perhaps hypoglycemia. Has the patient been dehydrated? Um, and you haven't been vomiting or having high school output, and the other thing is the general anesthesia. So if the patient has epidural, then, uh, because of the inflammation, which means that, uh, higher risk of, uh, hypertension and then other triggers are just sympathy Proportional hypertension. So the red flags of hypertension again similar to this sort of like putting course is any active bleeding Any signs of anemia? Uh, any signs of shock collapse fluctuating GCS to 80 mgs and raise Lactaid? Uh, things like that so similar to to have the pressure always repeat BP. Um, do a manual BP. If in doubt. Look at the trend to brief history. Any triggers any secondary courses? Has the patient been eating and drinking? Uh, recent surgery. Epidural. Um, any pain? Things like that, Uh, any history of cardiac problems? Um uh, as well as to review the rest of the systems to make sure patients okay, when it comes to hypertension, Uh, assessing the patient is important to consider doing, uh, doing a quick little status assessment, because there was. However, the patient is dry, wet or evening. Um, so things such as skin tone, the CRT mucous membrane give you things like that. Like the urine output input output. Drain out. Put a listen to the heart sounds, um, making sure that the patient is well and stable. So initial management plan would be, um, first again, make sure the patient doesn't have any life threatening forces. No signs of carry arrest, um, or no signs of hypoxia, respiratory distress and hypertension. These are the sort of scenarios where you should consider, uh, calling. The body is able to, uh, again. So treat the patients using the Viagra to see if there are approximately the oxygen. Uh, always get an IV access and participation because you never know they can benefit from some fluids If you think from your assessment that they're dry or their risk factors of happy medium using blood routine bloods if there's bleeding, do equipment safe? Um, what what? I always used to do a ppd. Um, so we can look at the hemoglobin looking for the actual imbalance. Um, looking at 02 and things like that. But the other thing that's important is to give you, uh, the magic value as well. So that's resected to suggest tissue hyperperfusion. So which again points towards, uh, the, uh the fact that patient perhaps will fill it. Um, yeah. If there skeptics have extreme treat them with antibiotics, they having any active bleeding, uh, consider transfusion reversal of the anti coagulation tranexamic accent and source control and pretty much the sort of same treatment, uh, treatment ibuprofen. So just go through the list from MTV. You, um, if they have a clinic, you can consider giving them a fluid bonus challenge as long as there's no active confrontations. If the BP response after the fluid bonus that perhaps just the initial diagnosis is right, Uh, there are certain scenarios that you should always speak to a senior, Um, or, if you have any doubt, please speak to the senior patient is having a heart failure. For instance, if there if the chest sounds very wet and and it sounds as if they're having a basic labs and very overloaded and do not give them more fluids, treat any fluid as a drug. Just don't give any fluids randomly to everyone. Always do a fluid this assessment before giving an influence. Uh, and if they're not responding to fluid fluid anticipation again, please escalate your senior. Ask for more help. Um, yeah. So the last arrangement of parents I would like to talk about is, uh, February or low urine output. Um, so that is really a university accepted range of what? What was your urine output? It differs depending on where you work, depending on any existing probability that the person has how the person is, um, from medical school. Perhaps the thing that we learned was doing it for less than 2.5 mils per kilogram per hour for more than six hours. Another good medication would be if the urine output is less than 400 miles over the last 24 hours. Questions that you get during the course of a cancer is now passing. Minimum is not a minimum urine that we need to assess the patient. Can you please give me a fluid? This, gentlemen. Um, so the first thing to do is say no. You shouldn't just randomly give back to Florida to someone which you haven't seen. You have an assessed, always do a fluid to his assessment before getting fluids treated by the fluids as a drug. So when you're approaching the scenario, think about the common course is, um, just remember that when patients are in hospitals, they are more likely to get secondary courses that we discussed that will discuss, uh, tachycardia. And hypertension is the same thing here. Uh, they're more likely to get secondary or physiological courses. Responses to illness, stress Australia. Which means that, uh, it's the body's response to stress. And sometimes it's not as worried as the generic pathology. They could be dehydrated. Um, which you can still examination how they look a bit dry. Uh, they're not really much water. They were even, but not because of the operation. Uh, you could, except it's such a shock, uh, again, try to assess the patient thing about all these possibilities could be competitively blocked. So ask the nurses to foster capita, do a bladder scan just to make sure that the bladder is strange effectively. Sometimes it could also be an early sign of renal failure. So, back to medical school again, thinking about sort of, um, early signs of an achy I, uh really no intrinsic or three quarters of it. I'm sure that you've got to go off, um, so other things to consider. Um, any urinary tract obstruction that can also contribute to 14. Uh, okay, I, um, any sort of medication, snapper, toxins. Constipation is our work is also an important cause during your attention. So the assessment would be focused more on whether there are any loss of certain patient demonstrated, thirsty, and try a vomiting, diarrhea, because your intake have you got a respected or obstruction? This gentleman has a background of positive cancer to perhaps they are at higher risk of of, you know, retention. Um, or obstruction. Have you got the background of BPH and the renal stones? Any lower urinary tract symptoms they got the urge to avoid, uh, any pain? Um, examination wise again. Okay. For the status that will tell you a lot about the courses of the urine output really define. So just to make sure they're not hypertensive, they are not experiencing the shop. Um, it's always used to listen to the chest. Uh, sometimes just to make sure that sometimes with some of the fluid overloaded with 40% with with your urine output something like kind of, you know, something, uh, all the time. Just to make sure the bladder is not the standard. Um, it's clinically indicated. The thing is important. Uh, do a quick digital rectal examination just to grow enlarged prostate. And then again, as I mentioned before, making sure that happens, it's not working. It's not blocking. It isn't, uh, saturating? Uh, um, investigations a nice and simple that side test, uh, will be a urine dip, sticks, uh, epilepsy and just threw up an infection. Uh, you have attention. Uh, look, um, sometimes, if you're worried about the about the patient's hepatitis status or if you're worried about an impending it here, I do a CBC with a quick one as Well, just to rule out any complications such as hyperlipidemia on this appointment. Sclerosis, Um, and, uh, if you're monogamous is suspected, uh, chest X ray and the and the echo and those things. Uh, once you have stabilized the patient and you identify the underlying causes of that and then the rest, you can actually head over to the dating, for instance, requesting any further scans and the ultra cycle, You should be a occupation stable. Um, so, yeah, treatment of longer and output is pretty much again guided by the underlying causes. So addressing underlying course is, uh, hypokalemia. Give him fluids. If they overloaded, they don't give him fluids, speak to the register and consider whether towards whether it's useful just to give them some diuretics and the restrictions or any obstruction. Consider catheter. This restriction, uh, Johnson's always speak to a senior center, and, um, yeah, so that's pretty much, uh, my part of this session, Um so as I promised at the start, what we'll do is we'll just very quickly look through the questions that you guys have raised it. Some of them haven't addressed or looked at. Yeah, you have any other questions for me to a question in the chat, he asked what set of actions would you recommend if you click the patient assessed a patient on call, but you can't formulate a differential, and you're not sure who to refer to. Okay, so, um yeah, I think so. If you want the patient to go and you can't really formulate different you're not able to refer to, um it depends on what setting you are in. Um, normally, when you are an admission, you know, there's always an actual, you know, especially someone that's more senior. You can always speak to them verbally, discuss the scenario and ask about the advice. Um, you rarely collect a patient in a ward. However, if at any point you are not sure, um, it depends on what other presentations of the patients and what the patient is if they are in a surgical ward is very likely that the case has been discussed with a surgical register who was admitted the patient. So you can speak to the surgical register or, uh, it's in the medical world again. Likewise, speak to a medical. So, uh, just, uh, it can be quite ready to start working as an F one thinking that you're on your own. But actually, you do get a lot of support, especially in the first few months. You will never be placed in a valley environment on your office, usually. And there's usually, um and that's actually a more senior review. Uh, most of the time. And there's always someone to ask questions from. Yeah, yeah, we're going to, um, add anything, um, benefit on me. I think, uh, the important to take away here is first of all, like the tank Ben and Josh. I think you did quite a good job. It's a bit daunting sometimes starting newly into hospitals, This responsibility. Um, I think the important thing to take away from this is if at any point in time you do feel like you're out of your debt, you're unsure of what to do. Always escalate. Um, I don't think anyone will, uh, fault you for that. Okay. I think, uh, it's important to remember that we don't know everything, and you probably won't know everything next year or the year after that. Um, medical training is essentially a journey, a journey of knowledge, and you essentially develop that knowledge year after year. That makes you more competent, doctor, as you like, continue to go along. So don't feel bad if you don't know something or you feel a bit out of your depth, I think always keep an open mind. Respect your colleagues and, uh, your seniors. I think, uh, once you have a good working relationship with anyone, there will be more than open minded to help. You always remember to try and support each other on the ward's, um, and on call, because there will be times when you would be struggling and you would essentially want your colleagues to help. Or it would be nice if they can. And and just having that nice relationship at work, um, where you can go to them for anything or they can come to you for anything. It just makes the job a lot easier. Okay, um, I think, uh, does anyone have any further questions? Our future sessions? I think we have 33 running next week on Monday, one Wednesday on Friday. The one on Monday is a surgery session about surgical on call, which again is quite daunting. A lot of responsibility. Um quite often. Uh, surgical F ones have a lot of responsibility while on call. So I think it's probably a good session to attend. If you're even. If you're you don't have a surgical job up coming in the next, Uh, yeah, eventually. If you have one within the next two years, it's probably a good session to get some some good pointers from, um, and the sessions on Wednesday and Friday will be medicine sessions part one into, um, there be a bit clinical. Um, I think you get some keys to actually, um, dealing with many things that you encounter while working jobs in these departments. Uh, and then we have some sessions from radiology. Uh, these things that you encounter quite often, um, while working, um, having to interpret abdominal X rays, chest X rays, I think, uh, those sessions will be quite useful. Something I wish I had a while, um, many years ago when I started training in the UK Um And then there's a portfolio session, ideally, at the end of the two years of training at the end of each year, essentially, you have an air and a ercp where they assess your portfolio and determine whether you're fit to move forward To continue your training and you've met certain milestones, these portfolios can be a bit difficult to use. They're not the most user friendly Softwares at times. Um, there are certain requirements that you need to actually fulfill. Um, this session will essentially help bridge that learning gap. Essentially, um, that comes with using the software and gives advice and exactly what to do and how to do it. Don't leave it to the last minute. Um, so we encourage you to join register for these sessions? Um, invite your friends, colleagues and we look forward to seeing you all on Monday for our surgery talk. Thank you for joining us. Please pull up the feedback forms and we'll see you on Monday.