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Okay. Welcome, everyone. As mentioned earlier. My name is Jelani. I'm from the Events team at W p m n. Welcome to our Webinar series called Foundation Pills. The transition from medical school to the wards or in a foreign country to the UK hospitals can be a bit daunting. Over the next few weeks, we invite current doctors of different levels to share their experience of their foundation years. We'll discuss practical hints and tips on how to make the most of the foundation years and allow you to develop skills to survive and do well on the ward's tackle urine calls and keep on top of your portfolio. As mentioned a bit earlier. I'd like to just draw your attention to the slide displayed. Uh, this is a list of our webinars which will show again at the end. Uh, please feel free to register for them. This series is the second episode in our series. It will be delivered by Dr Annabelle White and Doctor Ashish Tanya. In this episode, we will be discussing life on surgical wards and and call as an F one or junior doctor. We give you advice on surgical patients, post up and complications. Doctor Annabelle White is a core surgical trainee with an interest in general surgery. She completed her degree in graduate medical entry Graduate entry medicine. Sorry. In Cardiff, she underwent foundation training in the northwest of teams before completing course surgical training in Kent. Sorry. And so 16. Every she enjoys outdoors activities including running, cycling and swimming. Doctor Ashy Tanya is a junior doctor with interest in surgery and woman's health. She graduated from Bart's and the London School of Medicine before beginning foundation training in east. Can't Just a few housekeeping rules you have now will be recorded. You're consenting to be recorded by staying in this meeting. Audiences, please keep your cameras switch off on your mix. Muted during the event to ensure it runs smoothly. Any questions? Please use the chatter box and we'll address them towards the end of each, uh, speaker's session. Thank you all for joining. Welcome. And, uh, hi. Um, so thanks, Jilani. Yeah. My name is Anna. I'm one of the core surgical trainees in conquest at the moment. So we are going to cover this evening. I'm going to give a bit of a talk first, and then she's going to talk afterwards. So if we start with the introduction slide, if that's okay, um so very kindly, actually is doing the slides because I'm not that technological. Um, so we're going to start with talking about key considerations one reviewing POSTOP patients comin general and orthopedic operations and common beliefs to surgical juniors. So the aim of this is to kind of prepare you for your day One if you're really lucky and you're on call covering the world today, one of f one, hopefully, this will get you through. So I've chosen general surgery and orthopedics because they're the most common, uh, most common kind of surgical jobs that you get an f one. Sorry. Yeah, let's go. So you're seeing a patient. You're going to start with the 80 s, a t e assessment, no matter what the belief is for, because in the nicest possible way, you need to make that assessment yourself. So you take it, you do your 80 assessment. You take any relevant information you can over the phone. Why are they why is somebody calling you? What are they concerned about? Um, do they have an idea of what's going on? Or are they just concerned about this patient? They don't look well. What have they done so far? I think this is always quite a useful thing to be asking on the phone. So you want a full set of labs again? I was gonna say, regardless of the cause of the calls for a t t o Fine, whatever. But if the calls about another patient getting up to date set of labs have they got a cannula, have they got line? Do they need any oxygen? Any pain relief? The common things you'll be called for your patients in pain. This patient's got low SATs, this patient about hae respirator, Um, plus minus GCS and then the c G, depending what the situation is. So once you're on the phone, just get that information. Portray that information to whoever's phoning you and then make your merry way, and then we'll get that. As soon as you get there, you're going to see the patient first. So it's very tempting if you're a little bit nervous and you're not entirely sure what you're going to do to have a look at the notes, which is completely valid and understandable. But first you need to see the patient. Okay, There's no point looking at the notes and understanding what operation they had if the patient does in the interim. So go and see the patient. Even if it's a quick end of bed assessment, you're happy they're stable. Fine. Then go and see the next. Okay, so next, what operation do they have? When and why? So in terms of what you need to know as an F one on call, being asked to come and see these patients, important things are Was the operation elective or emergency? Okay, so this is important, obviously, because if it's an elective patient, they'll have been prepared Preoperatively thankfully, um, so they'll be in a slightly better physiological state. Um, you'll probably have a lot of information on the preop. You should have some imaging. You should have a nice kind of anesthetic chart. I mean, you have that if it's emergency as well. But, um, in terms of the preparation of the abdomen or the hip or the knee, whatever it is, you should have a slightly better um, you know a better starting point if it's an emergency operation obviously, they've come into hospital and well, so there's physiologically less, less. Well, so they've got a higher risk of becoming more and, well, postop complications, et cetera. So just be aware of what was a selective or an emergency procedure. It just changes the way you're thinking about it. Okay, next. Once you're stabilized your patient, you're happy. You're gonna have a look at the notes. Why did they have an operation? Was it an elective cancer reception? Was it for biliary colic? Was it for IBD? Was it for arthritis? Was it for a septic joint again? This will give you an idea of what you're looking for, of how well the patient may or may not be. And then if it was an emergency, was there something perforated? Was a bowel obstruction? Um, was there, um, was there kind of fecal matter or pus or anything else in the abdomen that was free? Was there a pneumoperitoneum was septic joint was a, you know, patella, or if or whatever. So, again, just in terms of giving you a bit of background as to why you're seeing them, what happened? Really important to know So laproscopic versus open obviously mostly applicable general. Or can we just pop back one or two? Maybe retreat, retreat. They're lovely. So laparoscopic versus open, obviously, in terms of your port sites, that's really important in terms of whether or not you're expecting them to have a bit of shoulder pain from the pneumoperitoneum. That's quite important. The size of the scar, the amount of POSTOP pain you'll be expecting, Um, and then, if it's not general surgery, if it's vascular, if it was endovascular if it was arthroscopic for orthopedics, minimally invasive, like just in terms of what kind of scarring and what kind of access your thinking about that's quite important, So reception. Have they had any bowel removed again? This is important for cancer operations for perforations, obstructions, etcetera in terms of receptions for cancer operations. Obviously it's planned, and it's expected to resect some of the bowel. If it's for a an obstruction, then they might have a look at the bowel intraoperatively. And so actually, that looks okay. We'll leave that in, or that doesn't look okay. We'll take it out, Um, and again that kind of thing will get you thinking of Well, if I'm seeing them postoperatively. They had a bit of how that looked unhealthy, but they thought would survive. Has that not survived? Um, and that leads me to anastomosis, which we'll discuss in the next slide. Um, so stoners drains again. We're going to discuss different types of stones you'll be expecting to see in terms of drains. Did they have any drains written about in that op note? Should they have drains and have they come out with a fallen out? Have they been taken out earlier that day? Two days ago, What were they draining? Are they still there? Um, and again that will give you a little bit of an idea as to what's going on. So if it's kind of frank blood, well, that tells you that. And that's a bit alarming. If it's, you know, post cholecystectomy. If it looks like bile, that's quite alarming. Um, if it's a fecal matter again, quite alarming. If it's just kind of serious angulus fluid, it's quite reassuring. So again, just kind of have a look at the volumes. Have a look at what it is, um and yeah, what's what's been going on and again? Postop instructions. Have they have they? They meant to be having Celexa and and have they actually been having it? Has it been prescribed? Has it been given? I'm sure you guys all know about the Swiss cheese model where you need lots of things to line up for harm to happen. Um, post up low molecular weight, heparin or VT from the Lexus from the prophylaxis is one of the really common ones for that. Have they been getting around? Are they meant to be on antibiotics? Are they on antibiotics again? Have they been given? Have they been having any nutrition? And again, this is important for your emergency patients. If they've been unwell for a period before presenting the hospital, they they and then they had a few days, You know, by mouth preop, they're still not really absorbing. You're going to be wanting to think about that. We're ready to discuss drains and IV fluids now. The other bit on here, which is quite important is that being managed conservatively? Now, this is quite common on your surgical. Take weeks or say you or you know, whatever structural hospital runs at, you'll get kind of a perforated diverticular disease with a kind of small collection that's managed conservatively. Fine. So we're not thinking about the operation notes, but we're thinking about what's What's the change. Been that Ask someone to come and see. That's prompted someone to ask you to come and see them. Okay. Alrighty. Next slide, please. So, anastomosis again. I'm sure this is all things that you've been through in medical school, but just something to refresh your memory is something that you know, If you're not particularly interested in surgery, it doesn't really stick. So definition is a surgical anastomosis is a technique used to make a connection between two body structures and carry fluid such as blood vessels or bowel. Okay, so it will be described in the operation note as to where the anastomosis is, what it's between, um, and again, it's quite self explanatory. Ileocolic between the ileum and the colon ileoileal between the two bits of the, um, colon colic, colorectal surgery, gastric et cetera. Now, again, that's important, because it gives you an idea of a where the anastomosis is and be kind of risk factors for leaking. Okay, So the most concerning thing to a surgeon after an osmosis is it leaking now. Most commonly, this will happen about day 4 to 6. Um, the first kind of sign of a normal patient is an increased respiratory it, But again, it could present you know, tachycardia as a bit of a fever. You've got to have a really high index of suspicion in terms of where it is being important. It tells you exactly where the pain might be, And it also tells you kind of how safe the anastomosis is. So in terms of the small bowel anastomosis to another small bowel structure, that's kind of the most forgiving. If it's colon colon, then that's a lot less forgiving. And by forgiving, I mean, if it's not constructive, an ideal circumstances, then it's more likely to stay together. If that makes sense, um, so in terms of things that would put your anastomosis risk if there's any tension on it. If the patients had severe hypertension, if it's been constructed around kind of frequent purulence matter, I If there's a perforation in the abdomen, um, other things are to do with if there's like metaraminol being used, um, and they're needing BP support. So again, just things to keep in the back of your mind. Um, they have an anastomosis. I'm now being called to see them because they've got pain, Got high respirator. And you know, they've been hypertensive for three days or heck, let's have a thing about this. Now, the other really important thing to think about is is it the functioned? So again, I'm sure you will know this, but I'm just going to recap the basics. So if the stone if an anastomosis is d functioned, then it's got a proximal stones to it to divert the Luminal contents away from the Testim OSIs. Now this is done to give them an estimate this time to heal, to reduce the risk of weeks. Now, that's not to say it can't leak. It still can be unlucky, but it still can. But that's a really important thing to be looking at as well. Okay, other things that can happen with the anastomosis, obviously, leaking is the big one that we worry about. It can become stenotic, but this is more of a long term thing rather than an acute postop thing. Okay. And as I said again here lately, assessment is the patient's stable or unstable blood lactate IV access fluid bolus antibiotics know by mouth. Talk to the senior's. Okay, this is not an F one decision to make. This is an F one. Recognizing sick patients starting basic management, phoning USH Oh, and all your edge. Um, just high index of suspicion all the time. Fantastic. So it leaves us nicely on stones. So again, you've always had finals. Recently, I'm sure you're aware of the definition of the stoma. So abnormal passage of communication from an internal epithelialized organ to the skin on the surface. But between two internal epithelialized organs. Fine. What does that mean? Practicality. Where is it? What should it be draining. So in very, very basic terms, if it's on the right side and it's spouted, it's more likely to be an ileostomy. It's on the left side, and it's flush with the skin. It's left less like it's more likely to be a colostomy Now, obviously, there's caveats to that rule, but that's quite a nice, simple want to go in with again. It should be written on the op note what it is. Yeah, I mean, it definitely should be. If it's not, then that's a bit of a pickle, but that's not your pickle to solve. So once you've been asked to come and see if you're looking at the stoma, you're looking to see if it's healthy. Is it pink? Does it look necrotic? Retracted, stenotic, ulcerated, etcetera. I put a picture here on the bottom left of a necrotic stoma. If you see that you're calling the bosses, you are again putting basic management in for a number of patient calling the boss in terms of what they look like. Is it patent? You can digitate it with your finger. If it's like a one or two POSTOP, it might be quite swollen and emitters that will probably go down. But we need to make sure they're not obstructed. You can. You need to have a look and see how many lumens it's got. Sometimes they can be double barreled if they're planning for reversal later. So just have a look at what you've got literally. Say what you see. Sometimes you'll see an ileal conduit and a urostomy. Now, in terms of what this will look like on the surface, it will look a bit like an ileostomy, but you have urine coming out and again that should be in that note or at the very least, in the medical history, somewhere in terms of what's coming out again. So you're thinking about Are they obstructed? Is nothing coming out at all? Is there air in the bag? Is there? Um, is there any poo? Is there anything else? Is there blood like what's going on? What's in there? Etcetera. Okay. And then if we pop onto the next slide, so common general surgical operations. So what I put here is the port sites for an appendix, which is underneath the writing so normally would have three ports. You have a slightly bigger umbilical scar and then two smaller ones in the left iliac fossa and superpubic Lee. And again, this is just what to expect to see POSTOP. And then, obviously the appendix itself was in the right iliac fossa. In terms of a locally so a cholecystectomy to remove the gallbladder, you'll have four ports generally again, an umbilical camera port, which will be a bit bigger and then some small three small reports, um, in the right upper quadrant, kind of going down the cost of cartilage in terms of the most common general surgical operations. On calls laparotomy for a small bowel obstruction normally abandoned. Her vision is one of the most common. I think it's the third most common general surgical operation on call. So in terms of that, if you've got a patient and that's what it says on the op note laparotomy, they've got a big scar in the middle. Small bowel obstruction. Fine. And again, I was thinking back to the previous slides. Was anything respected? Was it healthy and viable about that was left in there. It's a bit difficult to kind of further comments that depends on what what happens and what that looks like. And Hartmann's is something you probably hear about a lot. I definitely wasn't entirely sure what it was. An F one, Um, so excuse me. So essentially, it's a sigmoid colectomy with an end colostomy and a rectal stump left in situ. Okay, so that's what this diagram is over here. Uh, most commonly performed for perforated diverticular disease can also be an obstructing sigmoid tumor. Um, so the important thing is to know if you're dealing with a patient that's had a heart event is that they've got and end end stoma and end colostomy, and they have a rectal stump in there. But it's not not connected so they can have some rectal discharge. That's not unusual. So just kind of to be aware that that can happen. Okay, and then, if we can go to the next one so common orthopedic operations, A lot of everyone's go rotate through orthopedics. So DHS dynamic hips grew and a hip hemiarthroplasty again the kind of two most common operations for a fraction extima. So DHS if it's extracapsular and a Hemi, if it's intervascular broadly, obviously there are caveats or whatever. Uh, so the bottom crisis really stressed me, left and right. The bottom left, I think X rays. So a. D. H s in a row and then I am nail in B and then the diagram next to it shows a hip Hemi and a total hip replacement. So things that you want to be thinking about if you're seeing patients post um, post like a female surgery, whichever one they have is, do they have any neurovascular deficits? What's the perfusion to the rest of the limb like, What's the movement like, um, being aware that they may or may not have a spinal. So if you're seeing them kind of one or two hours POSTOP, they may have reduced sensation. And that may be due to the spinal. So just bear that in mind and then Or if, uh, so open reduction. Internal fixation, Uh, which other ones do on what seems to be everything, Um, So here, we've got a diagram of the tibial plateau. Or if I've chosen this one because that's the highest risk of compartment syndrome from the tibial plateau. Or if if you're suspecting cancer compartment syndrome, which will come on two later on in this talk from your boss is okay again. Um, well, patient management, as you well know, back to front by now. I'm from your boss. Okay, Next, please. Okay. So we're gonna whiz through some common cause to POSTOP patients. Um, just in terms of what you need to do what you need to be thinking about what you're kind of expect to do is number one. What, you're expected to get your bosses or your s h o u. Read your consultant to be doing so if we start with tachycardia again, I put this on every slide, a reassessment. Every time you called to see a patient, it will get really, really boring. But it will save you because you will be tempted to just look at the notes. And you just need to double the patient. Make sure they're okay first. So I've broken all all of these down into three sections. It's a little bit repetitive, so just highlighted as it goes on. But yeah. So your phone to a patient with tachycardia. If you're answering that bleep, you want to know how high What is their heart rate? How long has this been their heart rate? Are they hypertensive? Are they unstable? Um, super important. What's the cap refill? Are you thinking about sepsis? Are you thinking about hypoglycemia? It just gives you a few more things to think about are symptomatic. Do they have any chest pain? Um, what are the rest of the obs doing? Obviously, if you're tachycardic and the GCS is five, it's very different to their little bit tachycardic. And the D. C. S 15. So again, just things to be asking on the phone once you're then trying to make your way to the patient. So obviously, you need an EKG. Any type of psoriatic patient. You all know that blood's so all your usual things. Additional things to think about are your thyroid and your electrolytes, especially POSTOP, um, electrolytes. If they've been know by mouth, they've got a fistula. If they've got stoma is high output. Anything like that can throw your electrolytes off of it. So just keep thinking. Keep thinking about these sorts of things, and then once you have your patient stable, you can have a look at your notes. So are they known F Is this new? Have they missed their rate control? Do they normally have this up at all in the morning? We've been holding it, you know, just time to think a little bit more about the patient, and then things you need to think about. Obviously pain. Um, most, most probably most POSTOP tachycardia. Pain, pain driven. Um, which is say fine. Generally. Fine. Um, and something you can manage, but you need to be thinking about other things. So are there any signs of sepsis? Do you need to be doing your sepsis six. Um, already spoken about electrolytes, but your energy aspiration. Vomiting, stoners, fiscally diarrhea, etcetera. V T e m p a. P is quite common cause of tachycardia anemia. Have they had a lot of blood loss? Intraoperatively if you double check, double check. If you check the h p Post pre op, is there a big difference? Does that difference, uh, like, kind of tie up with what's the estimated blood loss in the note? Um, they could argue it doesn't really matter. Either way, they're going to need some sort of replacement. Um, and then think about your respiratory causes or your chest causes. So upper abdominal pain is a cardiac in nature because they're having a cardiac event. Do you need to be adding on proponents? Um, could be having a pneumothorax, um, and could be an aesthetic related. So if we just have to think about kind of your surgical things and then your general medical things Okay, let's move on to the next one. So high temperature really, really, really common call to a surgical junior doctor again. So slightly different things that we need to be thinking about here again. How high is it? How long have they been febrile? And are they hypertensive? Tachycardic with it? Have they got signs of shock? Have they got signs of sepsis again? So we see GI as we discussed before Bloods as we discussed cultures are the big change. The really big one. You need to be thinking about essentially the more things you can send to a microbiologist. Better. Um, obviously peripheral blood. So you need to take a fresh sample if they've got a central line, a PICC line, Hickman line. Whatever. You can take samples from that. Additionally, but it needs to be labeled separately. And you're looking for line sepsis. In that case, urine, sputum, drain fluid, feces, anything you can culture send it off and then have a look at the drug. Have a look at the notes and the drug chart. How many days postop are they? Are they taking antibiotics? Do you think they're appropriate? Does it sound like the right thing? Are you treating your chest when actually it's urine? Anything like that? Okay. So things to think about obviously sepsis. Um, you do your sepsis six, which you will know like the back of your hands are not going to re discuss it. You want to think about your site? Where is it? Where is this temperature coming from? Have they gotta pee? Is that what's causing it? Have they got eight electrolysis? How long POSTOP are they? Is it abdominal surgery? Have they been in pain? Have they been able to take deep breaths? Do you need to get a chest X ray? Um, obviously, if it's an early or alert as well, you want to have a look at that or an aspiration? Pneumonia you're thinking about Have they been vomiting? Have they recently had an energy removed? Um, all of these things, you probably need a chest X ray to think, to diagnose, and again look at the wound. Is it a hissing? Is there obvious pass? Is it cellulitic dip the urine Intraabdominal sepsis. Really, really broad. I think that's actually meant to be for the distinction is net or whatever. Just keep keep your index of suspicion nice and broad. Okay. Next one, please. So, hypertension, the big question, I always ask myself, and this one is Do I need to worry? How low is it? Hypertension of kind of 100 and 15 systolic. Very different to a 65 systolic. How low is it? How long has it been low for our the tachycardia with it again? Are they showing signs of hypoglycemia, Sepsis of shock, of whatever origin? Um, they bradycardic with it. Could it be a neurogenic cardiovascular cardiogenic shock? What's the GCS urine output? Are they perfusing the end organs? So obviously, urine output is the first one to go down. So the blood supply to the kidneys will be one of the first affected. Brain is pretty well preserved. So if they're getting confused and agitated with the hypertension, you need to be worrying. Okay, Cap refill again. Are they flushed and septic with the low BP, or are they peripherally shut down with low BP? What's the skin turgor doing? What's the mucous membranes doing that sort of thing? Okay. On the baseline investigations again. The same kind of things we've been talking about with blood, CBC, gs, large bore cannula in the A CF and start Food Challenge. Okay, again, I know you will know this, but it's just really important to keep reinforcing because you know, you will be doing this at six in the morning and you'll be tired and hungry, and you just need to know the basics so inside out. So you start your fluid challenge. 250 miles normally of normal saline and Hartmann's crystalloids have keloids start it. And at least once you're starting that. You can do the rest of your investigations plus minus urinary catheter of the hypertension if you're hypertensive, depending how low it is. So again, as we've discussed except six v e T O p. Obviously massive pee can cause cardiac dysfunction. Hypertension? Are they bleeding? What's the HB? Take a gas, See what it is? Any obvious bleeding, bruising, or bleeding again may not be related to the operation itself. Have they received heparin? Intra operatively. A lot of cardiac and vascular patients will have, um is there any obvious bleeding? Um, you know, is that if they got any p r bleeding, have you got any Melena? Is it not at all related to the surgery? But they are hypertensive, the unwell bleeding from a different course. Um, you need a PCG to be showing that there's an arrhythmia, a new heart block or anything like that. And then have they had a spinal anesthetic, which is quite common orthopedic patients. Quite common cause of POSTOP hypertension in the orthopedic population. Again, just to be aware of. Okay, if we can go to the next one. Lovely. Thanks. So tachypnea again. So, as I mentioned earlier, this is your first sign of a deteriorating patient. Very, very sensitive to pick up. Yeah, potentially on my patients. So if they've got a respirator 20 and above, I'd start getting a bit twitchy about it. So how high is it again? How long for are they saturating? Okay. Is it isolated tachypnea, or is it tachypnea with the saturation? And do they have an oxygen requirement? If so, is that new? Are the tachycardia bradycardic? What's the GCS? What's the BP? The rest of their observations. Are they distressed? I find this a really good tool for assessing the technique Patient. So investigations bloods, BCG as we've discussed arterial blood gash, blood gas, even you need to be known what their P 02 is, uh, lactate is obviously really important. Bicarb and ph. But you're really looking at the p 02 and the PA CO2 chest x ray. Obviously, um, again, once you stabilize them, have a look at the chart. How many days postop are They're really you're thinking about Have they had a P? Have they been having their low molecular weight heparin if they were meant to be having it, Um so the things that they want to do Well, score and the t t p a, um your Oh, gosh, what's it called d dimer? Your vagina is not very useful in the post dot patient, which I can't remember. Um, so that's probably not going to help you, But you're, well, school will, um, if you do so what you need to do if you're thinking about pee, request to see to be a talk to the red or the operating surgeon about whether or not to start anti coagulation In that meantime, okay, because it depends on what operation they've had, what the risk of bleeding is whether or not they'll be happy with you starting prophylactic anti coagulation with a suspicion of a pea versus a diagnosis of a pea. If that makes sense, it's a little bit different, so just talk to them. If the CT pa can happen, you know, in the next hour. Fine. It's not going to happen till the following day. Then you need to be having that discussion because that's not up to you to be making an F one again. Sepsis, chest success. Any other source of sepsis can give you a LabCorp near They got pneumothorax. Have they had a recent central line? Quite common. Especially gone to I t u postop HD you have. They had chest surgery. So even if they've had an ESOPHAGECTOMY that goes into the chest, especially if they've had a 33 stage one, they were going to the neck and into the chest. So even when you think you know, they haven't had a lung resection, they haven't had a cardiac operation. The chest is still accessed. Even if they're having kind of haters hernia surgery, you can get a pneumothorax from that. So just to be aware, I think outside the box are they bleeding? That can obviously give you tachypnea. Have they got Humira works? What does their chest sound like when you listen to it? Cardiac causes my heart blocks. Arrhythmias. Um, we've kind of infection up there, but Lexus as well. Okay, reduce the C s. So when you get a phone call saying all these patients drop their GCS What what is it? What is the GCS and what makes up the components? So if they say they've got to reduce the CFCs DCs GCS. But I can't calculate it. Then just say Okay, well, tell me the avenue, because if it's dropped in anyway, fine, you need to go and see them. But the time it takes for someone who, if they're not very familiar with the C. S, I think it's very common for people to say that they've got low GCS but not be able to calculate accurately. And even if you know it, it's quite difficult, sometimes illicit. So just stick to of poo in terms of your handovers. Um, it just makes life easier. Um, obviously, if they've got a respiratory rate a GCS of less than eight, we're worried about airway compromise. So just have that in the back of your mind when you see the patient, because you will know your docs. Um, what are the spring? What is that? Heart rate, BP. So all the jobs what the pupils doing? Are they constricted? Are we worried about opiates? Are they dilated? And we worry about internal bleeding. Like really useful tool. Are you confused? Is that new? What's the MTs now? What was on admission? Have they had any head injuries? Have they had any falls in a ward? Has anything Has anything kind of triggered this that you can think of? And how long was the anesthetic? If we're, like, two or three days afterwards Well, that's quite concerning. If they're just about recovering and they just come back from recovery because they were closing whatever. A little bit more understandable. Okay, so investigations again to do bloods important things and blood. So your electrolytes, your confusion screens blood gas. Um, obviously, we're worried about reduced respirator and SATs, so get you guys to see what your P 02 is and your p a CO2, and then have a look at the notes. So what I should have put in here, which I haven't, is obviously I said query to a compromise are tolerating a good l is a really good way of assessing how how low the docs is and how would you need to be? And when you need to be calling for help, they're tolerating the Goodell call for help. They're going to need a definitive airway. And that's not what you to be doing. So yeah, try Goodell. If they look like they might tolerate it, And if they do, great anesthetics, get someone to help you pretty pretty quickly. So, as we've said, how many days postop are they? Is this acute or chronic? Are they kind of known dementia? Are they delirious? Preop? Is this kind of their baseline, or is this new? I appreciate you might not be able to tell that. So if you don't have that information, you just have to treat it as new. Have you got any neurological deficits? Are they being anticoagulated important in terms of this chemical hemorrhagic strokes? Um, and also pes Have they had any falls on the ward? Did they present with a full, um, initial head CT was fine, but actually, they've been on the world for a few days, and now they're becoming confused. Do you need to re scan their heads? Have they been having any sedatives or benzos or opiates? Do you need to give them some naproxen, are they? Is that what's producing the D. C. S? So again, consideration 66 bleeding intracranial mainly or obviously, a ski mia. Are they hypertensive? They just not refusing the brain. Is that what's causing it? Have they got hypoactive delirium? Um, could there be having an opiate overdose? So again, things that you just need to be thinking slightly outside the box, Probably mostly inside the box. But, you know, just really, really wide. Um, with that cast, you're not really wide. There we go. Now I think that might be the last one. Yeah, there we go. So that's the last of the ward calls. Um, and then the common things are common, but don't forget these, so these are much rarer, but you need to have in the back of your mind every time you're going to see a patient who's POSTOP. So I put compartment syndrome and critical limb ischemia together. So pain, pain, pain, pain, pain, pain. So I'm doing an orthopedic job at the moment, and they will just keep talking about pain. So if your patient is, you can, you know, kind of post post any kind of orthopedic procedure or post fall. I'll be worried about compartment syndrome. Your answer should always really be yes, until at least you've seen the patient so pain on passive flexion of, uh, passive passive extension. Sorry of that myofascial compartment. So I have to think about where you're worried about moving the so if it's your say, it's a table or a tibial plateau, or if you want to be able to dorsiflex plantar flex your foot, especially at EHL, without a lot of pain. Um, obviously parasthesia paralysis, pulse business and perishing the colder or really late signs you don't want to be waiting until you get there. You need to be thinking about this when you're thinking about pain. What you're gonna do is keep the know by mouth IV fluids. I don't use your call your boss, so the diagnosis is not up to you to make. It's up to you to suspect it, think about it and think. Actually, I'm really worried. You need to prepare them for theater in terms of keeping it dry mouth, bloods, lactate, um, creatine kinase group and saves, and then get your bosses. It's not up to you to be arranging them to go to theater unless your boss asks you to. But it's up to you to be, um, escalated to the relevant people. So anastomotic leaks and intraabdominal sepsis. So again, we kind of touched on earlier about what the risk factors are for a week. Uh, a watershed areas where they've got kind of poor blood supply. Um, an estimation. Detention. Steroids, malnourished hypertension, BP support again. Basic resuscitation, which you can all do 7 to 6 if you need to. I would probably argue that you probably do, in most cases, because you won't be able to confirm that your source. Escalate your seniors again. Keep the nail by mouth. They'll probably ask you to arrange a scan, which is fine until you've got that scan back, and your bosses said, fine, we don't need to take them to the tonight. Keep the know by mouth, just in case. It's always better, you know, to keep your mouth for a few hours than to have to delay theater or have a risky integration. So this is one that you might not come across that much in medical school, so an expanding hematoma or airway compromise post thyroidectomy a parathyroidectomy. So this is when the so I think it's the inferior thyroid vein runs into the JV. I think it's that way around anyway. Um, so this occurs If there's a slip of that ligature of that clip of the future, you can get rapidly expanding hemothorax, uh, hemothorax hematoma in the preacher curl space, which can compress the trachea, cause airway compromise. You get called to probably recovery or the awards for a POSTOP thyroid patient with, um neck, uh, anterior neck swelling and a compromise. Remove all of the wrestling's pull out the future. It will probably be sutured in one, but it should be left open in case this happens. So you should be able to easily identify the future threat. Pull it out, evacuate the hematoma. While you're doing that, you're obviously calling for help. Okay, But that is one life saving intervention. You can perform as an F one which will need to perform if the time comes very intimidating. I haven't had to do it yet myself, but I never say never in one night tonight, so who knows? But just something you need to be aware of if you're looking after patients from an ent theater or general theaters. So yeah, removed dressings call for help, and that's it for me. So if you've got any questions for me before we go on to ashy, please put them in the chat Now If not, I will stop talking. That was a lot of talking and leave Ashley to you. Talk about introduction to Surgical. Everyone's No. Okay, I'll give it to you. Hi, everyone. So I am just rounding up F one this year, and I've been doing a general surgery and at the moment in stroke medicine. But I wanted to have a fairly informal session talking about things that I learned from being surgical F one, things that you're probably going to come across and more of a general. How how to do your job as a surgical left one. So obviously that that that we've just covered with an I was actually really, really helpful, and I would have really benefited from that myself maybe about a year ago. But I think the other part of being an F one is also just understanding that it is a big leap from going from a final medical year to becoming an F one, and everyone is going through the same thing at the same time as you know, and nobody expects you to know have all the answers. But knowing something or knowing a little bit of information before you start is going to really help you when you start. So in terms of specialties I These are the specialties that I know people who have been F ones who covered surgery. In general, I find general surgery is probably the one that's the most common. Almost all of my friends have had general surgery rotation at some point across barriers. Trust across the UK vascular and urology is you might have a surgical rotation in it, but it generally tends to be a more S h o lead specialty and similarly with E N T trauma and orthopedics again, most of these specialties you will have very similar jobs regardless of which specialty you're doing. But it's important to recognize that there might be slight differences. I'm mostly going to focus on general surgery today because number one I think it's one of the most common and number two that's the one I've done, but I will touch on site aspects of the others throughout my talk. So this is a sample voter. It's actually very, very small now that I'm looking at on the screen. This is actually my voter from the neighbors in general surgery. So our shifts were divided into extended days on call standard days and weekend cover. I averaged 47 hours a week across my six week block, and some weeks were obviously a little bit lighter than others. I worked in a trust that didn't have nights for F once, which meant that I never had to do a night. And I am actually going on tonight as an F two. But I haven't included nights. Obviously, some trust will do night. And just make sure that if that is on your greater that you're aware of when you're night schedules will be and that you are tight off before and after that period of nights. Um, the BMA is actually really helpful in terms of checking your rotor for you. So if any of you have already got your rotor and you know most of you should have by now that's a good thing for you to check in terms of how my week would generally look, I would say 45 in the morning to five o'clock on most days on weekends or on cold days. I would work until 8 30 and we had something called extended days, which basically was a relief for whoever was on call from having to cover the ward's, which meant that one other person would say until seven PM, meaning that they would only have to cover the ward's from 7 to 8 if you they wrong, call on on call shifts. We also you also might see things like SC A you cover, which is just the surgical emergency admissions unit. And that basically means you're looking and clerking in patients who are new to the surgical unit. So that's basically the same as the texture in general. Your standard day is you covering the surgical ward and surgical patients based on the world, so a brief break down of what your responsibilities will be on a day to day basis. So the main thing that you're responsible for is war drowned, and one thing that I was a bit of a shock to me is how fast paced the surgical ward round is. I think there were times where I saw maybe 20 patients with my consultant in about an hour, which is just not something that happens on medicine. But that means that you have to be very good at picking up the patients who are more likely to be on well. And that's why, actually, I think our shift start at 7 45 so our ward round would normally start at eight. But if I was there at 7 45 I would have a quick look through the new scores, and I would just make sure that anyone who was using highly there's a priority for me in terms of. I needed to have a clear plan for them throughout the day so that if they did get on well, I knew what the differential diagnosis might be or what my consultant would expect me to do. And in this way it was actually really useful for my consultant as well, because I would prioritizing. I would prioritizing the sick patients. So, for example, if they call the way to the theater in the middle of wardrobe, I knew that the sick patients have been dealt with already, and I had a plan for them in place. Other things like blood results and fluid balance is, while they're really useful, you might not have time to do them on your war drowned. But in general, what you could do is just grab drug charts as you go along and grab fluid charts. They usually by the bedside in my trust and blood results. You can review them at the end of the day and have them on your hand David sheets so that in the morning you don't have to worry about checking everyone's blood results. In terms of war jobs, it will really depend on where you are. Um, in my trust, actually, as F ones were not allowed to put in N G tubes, which was a bit of a shock to me, because in medical school that was something that we were trained to do. And there will be certain things that you are expected to do more commonly or not expected to do in general as an F 11 of the things I was most scared about was in an emergency. Would I be able to do X y Z thing. So, for example, cannulas at crucial moments. There is generally someone around at all times of the day and night who is really well trained who can help you. And in an emergency they are there to support you. So if you have, if you know that someone needs a cannula and there's a senior nurse right next to you and you're not able to do it, that's fine. Make sure that she knows that that's your plan rather than struggling alone for 15 minutes while the patient's getting worse in terms of other war jobs, you also want to chase scans and complete discharge summaries. And I found I was bleeped a lot about discharge summaries, more so than any other thing. And I think it's really important that as an F one, you recognize what is a priority, and whilst in someone is that doesn't necessarily mean it's a priority over your unwell patient, no matter how many times you get bleeding or called about it. Reviewing on the ward, we've already covered with an A in terms of your 80 e, but the other thing that you need to just be aware of is that if you six your a e, you will not go wrong. And a lot of the time I was very nervous about going to see a patient, and I wasn't sure what I would do. But the main thing you need to do is stabilize them. If you don't know the diagnosis or you don't know what you're going to do next, that's fine. That's what you're seeing is are there to help you with for on calls. So this really varies depending on where you are based in my hospital that I was working at, um, I found that my uncle chefs were basically S c A. You cover. So I would come in and I would just clark new admissions to a an E or new admissions to the surgical unit. And the surgical unit basically takes all of the patients who have been admitted from a D and E under a surgical specialty, and they get a clock by surgeon or the surgical team on in the essay you department with on calls, I also have the option to go to the theater and as an F one, you will have less data time than, say, your S h O. But if it's something that you really want to do, let your educational supervisor no, let your clinical supervisor know and they will generally find the time. My one of my consultants knew that I wanted to do surgery. So he offered to do a lumps and bumps list with me, which is just a really easy or short list for things like sebaceous cysts and things like that, where I could build up my face and my log book really easily without taking up too much time. And he was happy to support me with that surgery. Is that a really good rotation as an F one? Because as well as having all of these wars jobs, you tend to find that the surgical team is much more cohesive and work together quite frequently. So that means that things like audit and Q I projects are really easy to get done in surgery. There's always something going on in every surgical team that I've worked with, and in terms of teaching and having positions in leadership roles, you will always have something going on. So again, if you need as f one you have to get audited or accu i p done over the course of the year, so I would suggest hit the ground running. Basically, I know it's only your first placement, but once you've done that, audit or q u I. P. U no longer have to think about it for the whole year. I've just finished a ercp and a few of my friends or colleagues. We're still trying to get a Q u I. P. Or audit done in the last couple of weeks before Ercp. Um, for those of you who do not know what a R. C. E P is, a ercp is basically validating your log book or the things that you've done throughout the year. And it's one little assessment that everybody meats and discuss is your portfolio from the whole year at the end of F one, and it's necessary to pass to be able to go from an F one to F two. The other thing that I also had to do on my particular surgical rotation was prepare mortality and morbidity slides. This isn't necessarily norm, but it just involved me, lose the deaths we had all the morbidities that following surgery and basically picking up lessons that we could learn from that. And every single one had to do one for their consultant team. So this is my typical day as an F one. I usually would start about 7 45 and they would have hand over at that time in the 19 to the day team. This was usually a good opportunity to identify anyone unwell, so any one of my patients that have been that the team had been bleeped about overnight. So if someone had deteriorated over night, I also found that this was a good time to just collect all of the information I needed to the new schools while this hand over was going on. As I said before, Surgical Ward rounds really fast paced. Um, so for me, my wardrobe would normally be over by 10 AM if it was over by 10 AM and it's stretched on. It was because we had a lot of sense. So, for example, on the weekend, but we had one F one covering all surgical patients. Our ward rounds would sometimes finish at one PM or two PM, and that was because we were seeing 70 patients throughout that day. After your wardrobe finishes, you want to do your urgent jobs. So if there's a scan that's really needed for someone who's using highly or if there's if you've gotten bleeped by this point about a patient who's unwell, then you can go and review them between. I would say Do that as a priority before you do anything else. Lunch is a little bit fluid in that it was, I never had a set time for lunch between 12 31. It was just whenever I had a moment, and I would sort of structure my day around things that I could could wait until after I eat it and things that I need you to. Before I'd eaten after lunch, I would usually go and do the more, uh, less acute things. Basically so discharge summaries. If anyone had gone for a scan, review it and let my consultant know that they've gone for a scan and just finishing up any odd jobs that I had left lying around. So, for example, if I if my consultant mentioned they wanted me to prescribe something, but I don't have time in the world around. I used to do like a little drug around, just prescribing fluids for everyone overnight. And these sorts of things are really helpful because if you are the F one covering the ward's after all of your colleagues have gone home, you don't really want to be bleeped about having to go and prescribe fluids for everyone. So it's a good thing to do if you haven't had a chance already in the morning to, uh, around 4 30 so that you're sure that all of your patients are doing okay and you've reviewed everyone's drug chart before you go home for the day for long days between five and eight PM I would cover the awards for all of the surgical teams. So if you think about how it works in general, surgeons want to follow up the patients that they operated on and some places that will mean that there will be an on call consultant who covers everybody. But in my particular rotation I had a consultant team, which meant that anybody who was admitted whilst my consultant was on call or anybody that my consultant had operated on with my patient. This meant that there would be weeks where I would have 45 patients under my consultants name, and I would be the F one looking after my 45 patients. And there would be weeks where he had gone on annually for a month. And he only had two patients who were waiting package of care at the end of that. But between five and eight PM everybody's patients now are your responsibility, which means that you are generally covering 60 patients also in a busy department like minors, and your job mainly is not to review everybody but to review anybody who needs an urgent review. In general, I found that I was the only F one or one of two F ones or one of two junior doctors who would be covering the wars between five and eight PM and that meant that it was sometimes difficult to escalate. But it's important to know who your options are to escalate between five and eight PM so there is still somebody on call across the surgery and across medicine, so it makes you know who that is, especially if you're going on your first days. The on call F one doing nights know who you need to call if you need to escalate a patient. Okay, this is just a really quick slide I made about prioritizing jobs because this is something that takes a little bit of practice in general. I found that I would prioritize reviews, mostly because even if I got information over the phone about what the patient was like, I wouldn't know how well they are until I reviewed them a few times. I got bleeped about something that I thought was, you know, an easy fix. And when I reviewed them, I have to really worried. So sometimes non specific concerns from nursing staff are actually their instincts, that they know that this patient is unwell, and then you go and review them, and you also have the same instinct, and that's probably a good moment to actually go and review them. The new score is a good criteria for this sometimes. But for example, if a patient's been using five all day and then they go up to six, it's not really the same as someone who's been using one all day and has now gone up to six. So look at the trend of the OBS look at the trend of their new school, and if you have time to review them, rather than putting it off and doing it later in the day, then that would be my number one priority. After that, you would want to think about scans or bloods. Um, you want to get them done earlier in the day because if you get them done earlier in the day, you can review them and have a plan in place. So, for example, if somebody is waiting, might be a query theater. If they've had a CT scan in the morning, that will impact whether or not they go to theater that day and whether or not it's a prioritized priority for the surgeon in terms of skills, this is important because during the day you will have a lot of support. You will have five other F once, maybe on the same, uh, specialty as you. You might have things Vascular access team, which is the team that we have in our hospital who's main job is to put in cannulas, or lines for patients who are unwell and who everybody else has tried on and has failed and So I generally used to prioritize that because I knew that if I needed a cannula, it was more likely that getting it in before four o'clock would ensure that nobody would be being bleeped about it at six PM, when all of the other teams had gone home in terms of discharge summaries. As I said earlier, you will often get a lot of bleeps about this. And that is because even though you might be working till eight or you might be working till seven, pharmacy will shut at five in most hospitals, and that means that you need to get all of the drug chart um, submitted. This is really different in my trust because we still, although we use online documentation for everything, we are still using paper drug charts, which means that the drug that has to physically go down to pharmacy uh, the trust that I'm going on to work in for F two actually has everything online, which makes the whole process seamless. But either way, it is something that you need to do before you go home, because that patient is probably going to stay if you don't get it done in time. And then there will be odd things that pop up throughout the day. Like updating families. Um, you might get asked to address somebody's concerns or speak to a specialty or action. Another specialties plan. So if I have to break down what I've learned from F one into five things, um, it would probably be this slide. I think it's very, very easy as an F one to get overwhelmed. And I know I was always told this as a medical student, but actually surprised me how quickly I fell into the pattern of feeling like everything was on top of me and I had to. I didn't have time to take a break, but actually, if you don't get that break in when you need it, you're going to be in a worst position after be after or during the day. So, for example, if you're overworked and you haven't taken a break, you're actually going to be less efficient later in the day, And that implies that applies for annual leave as well. I know that it's really difficult sometimes to decide when you want your annual leave, but get it in the calendar early and trying to spread it out evenly throughout your four months rather than giving yourself three months of working really hard and then having one month that you get off at the end of that. The other thing that I found difficult in surgery, but it's really important is that often times your surgical seniors will be really great at dealing with the surgical side of things. So if you ask them about the stream output, you'll get an answer straight away. Um, antibiotics and things. They will give you an answer. But if it's a medical problem, they might not know. And at that moment, it's really important to know who else you can ask. So I think if you're not sure what to do and your seniors not sure what to do, the logical thing is to ask somebody who will know. And that could be the meds average that could be a referral to the cardiology team. That could be a referral to the endocrinology team, whoever you need. But you need to remember that the person that's most important for this is the patient that you're trying to look after, and in general I found that no one I've ever referred to has ever said, Why have you referred this patient or it's a bit ridiculous that you're referring. Even if you might feel like it's a silly referral most of the time, they're always really lovely, and they give you the advice you need. One of my registrars told me in my first week that if I was ever wondering if I should put out an emergency call, that was probably the right time to put out an emergency call essentially, if I fell out of my depth and I don't know what to do. And I tried to get a hold of my seniors and they were not on the other end of the phone. I should just put out that call because it's more important the patient gets the help or support they need. Um, in a few of the times that I have had to put out an emergency call, the team told me that I had called them exactly the right moment, and in both of those cases, actually, one of my patients went to the I. T. U and the other patient was eventually put on to the end of life pathway. So it's if you have instincts, that this is a really dangerous situation. It probably is. And the other thing is that no one expects you to know everything. Uh, so as an F one, remember that although you might have just graduated medical school, it's absolutely okay to have forgotten some of it to not know what to do in a situation as long as you're safe and you escalate to the right person and that generally will be your surgical seniors. As I said before in these sorts of situations, you will feel really lost, especially in the past couple of weeks as the left one. But you just need to fall back on 80 and I know that we've kept on going on about a to eat. But honestly, every single time, I wasn't sure what to do. A. T e really help me figure out what to do because it's so full proof. This is, um, just the things that I've been talking about. So in terms of what I really enjoyed, I love that surgery. So much of a team, Um, everybody helps out each other and because your patients will be variable in general surgery. I found that I was helping other reference and other reference for helping me with our work load. I became really confident at managing patients on my own, um, for medical things and the reason being that I would offer me the one looking after their BP or the heart rate and so on. And this meant that when I went on to my medical rotations, I actually felt really comfortable having to review my own patients. There's always someone that you can go to for advice in surgery. There's 100 registrars in in our surgical room at most basically any time of day, and there is always somebody that you can call if you're not sure. And as I said before, let somebody know. If you're interested in surgery is a long term as a long time thing because they will find opportunities for you to go to the theater. And there's always opportunities to build your portfolio as well. In terms of cons, um, it can be really fast paced, and you might find that you are feeling a little bit out of your depth if you're managing medical issues. But there is always someone that you can speak to. And I said I said this about 10 times now, but just know who that is, and your induction for your surgical rotation will be really helpful because they will give you a list of numbers or people to talk to that you can call. This is just my last slide, and this is just the only thing that I'm going to leave at the end of it. And these are just things that I don't know when I start the surgery, but things that I wish I had known about earlier. So in terms of gastrograph and this is very general surgery specific, but you I've never come across it. Other than contrast X rays being the only term I heard about but gastrograph. And it's often used for patients who have a bowel obstruction, Um, and you will generally need abdominal X rays for them to just ask your consultant when they want the X ray down and then request it at that particular time. High stoma output generally has a stone, uh, output protocol, and the Stoma nurses will have a lot more information about this, So check with your urge and check with the Stoma nurse, and one of them will be able to give you an answer if you're worried about some one stone out. But the other thing, I'm going to skip over analgesia ladder because I'm sure you guys all know about that in some way. But if you're in surgery and you'll think about a career in surgery, sign up to you, log book online and start logging all of the surgeries that you're involved with. Because when it comes to applying for surgical specialties later on, they will use that information to calculate how many surgeries you've been part of or how much interest you've shown in surgery already. So that is the last slide, I think. Which means that if anyone's got any questions for either of us, just let us know. I think, uh, that was a very, very, very good presentation. And she, um, on as well. They got the clinical aspects from Anna and the everyday life and important things to note, um, in terms of personal experience and challenges that you would experience as an F one on the ward's, uh, nice poodles at the end of the gastrograph in uh, It can be used as a therapeutic and diagnostic tool in abdominal, uh, obstruction due to, uh, particularly when there's like a band adhesion. And that's because it can have a peristaltic effect relieving the obstruction. Um, which is a good thing to note generally when you administer it, you have to do the yoga. Be imaging a few hours after that, something that you should confirm with the radiology department and the consultants. Um, because it it differs from trust to trust. Actually, I think pretty good. I would like to know a bit more about your log book, if you wouldn't mind, actually, a little bit more about that. So essentially, when you're applying for course surgical training or surgical training, one of the criteria is how many surgeries you've existed in. So if you get opportunities to do that as an F one, what you need to do basically is get some information about what sort of surgery it was when the surgery took place and information that shows that you were part of that surgery. So all you need to do is sign up to a log book. If you google it, it will come up and Jilani just posted the link for us, and you can write in all of the details of the surgery because obviously in two years time, or however long it is before you apply for surgical training, you might not remember every surgery that you're a part of the F one. So this is a good way to just have all of that information in one place, and you can keep using it for every year. Basically, essentially, it's a it's a good tool to use. If you would like to go into surgery as a field later on, Registrar is use it even at that stage as well. Um, it's, uh, one place to collect all of your surgical experience over the years, Um, and you can export that proof and essentially provided for applications for surgical training and whatnot. Um, it also is a good habit to get into from early on because, um, basically the format that it requests for you to input the data essentially is similar to how you would write up, uh, POSTOP note. So after you've done an operation or procedure, you write up your post of notice of patients or whatever procedure you would have done. Um, Ellen, what kind of helps to get you into that habit of doing it in that format? Um, and you can actually add surgeons that you've worked with on to it and they can actually sign off your operations for you. It's a really good resource you can link it to, uh, I think your surgical account with our C s. I think I think it uses your GMC just important note anonymized patient data. If you're using it, um, you can use the requests sitting things like the date of birth, if I remember correctly and the NHS number just for, um, like logging purposes. But when you get the information at the end, you can actually omit it if you have to print it out or provide it for someone. It's a very good resource. The only other thing I would add is, if you're on the fence and you don't know if you want to do surgery, sign up anyway. Um, it's free, and you can put all of your information in, but it's much, much harder trying to find all the information you need, but respectively, so it's better to do it. If you're not sure, rather than try and find it a month later, agreed. Any other questions? Okay, um, put the feedback link in the chat. We would really appreciate it. If you can fill out the feedback form after completing the platform, you will receive a certificate and that certificate you can use to add to your portfolio. Essentially, um, which is something you should get into the habit of building. Now, Um, when you do have a job that is in training, you have to provide proof that you've had education hours. You can use the certificate to provide you to prove that you've attended webinars. If you aren't in training, you have to get, uh, appraisals done by your trust on a daily basis. And these can also prove that you've actually attended these sessions, uh, to add to your essentially, you're you're self development, self directed learning. We've also just sent you in the chart. Uh, this is a summary with links to register for the upcoming sessions. Um, please feel free to do so, um, again, as I mentioned earlier, we have medicine one on Wednesday, medicine to on Friday next week. Tuesday and Thursday we have to really, really interesting. Radiology session's over Sought by, uh, one of the radiology registers and founder of W P m n. Um, so that would be very beneficial where she goes through her and her team, they go through how to interpret and request and and and understand reports for radiology. Um, common types of imaging modalities that you see regularly. Apologies. I can re post that link for you. Just give me one minute. That's the medicine one link. Sure, if that works should work. Brilliant. Any other questions or concerns? One last thing before we conclude, Um, I think the general just is as an F one. You can't feel quite out of your depth at times. Always go to your A to be when you're assessing a patient. If you need help, do not hesitate to call a senior or escalate. It's always better to be safe than sorry. No one is going to essentially crucify you for escalating a patient. But they will be quite upset if it is. You didn't, um because you rather overtreat than under treat. Um, because someone can become quite unwell. If it is, you don't escalate it when you should have, so we encourage, always escalate if you were quite concerned, uh, there's always someone to escalate to find out who that is. Sometimes, even if you can't get through to your surgical team, you may be able to get through to your medical colleagues, and they may be able to learn some assistance. Or sometimes there are Ms Clinician teams on call overnight that may be able to help as well. Okay, if there aren't any further questions. We look forward to seeing you guys on Wednesday for our next session, which is going to be quite interesting. Brilliant, well done car. Our session Wednesday Medicine one will be delivered by, uh, medical register. Um, and it's going to be very, very, very interesting, full of information and good girls to help you succeed in the wards and on call. Look forward to seeing you guys on Wednesday