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eso I'm see you. Did you write? Got it. Thanks. Like now that's that's that's going life. I know everyone. I hope you're doing well. Welcome to our final mind. The weather now in the FBI. One survival guide, 10 part Siris. Um, before we start, I'm just going to welcome Fill, who is actually the CEO of metal for a quick look. Thanks so much for having mean the hell and Hamza, Chris and Chris. It's really pleasure to join you this evening on, but I just wanted to show a little bit about it. The work that we're doing at metal on, why we're doing it on, um, on to give you a little bit of acro into, uh, this platform that you're on, but more importantly, the community that your ah part off our goal in our mission that metal is to make healthcare training accessible for everyone on my background is as a medic on. But this is borderline of some of my own experience in healthcare training. We need to train 18 million more healthcare professionals by 2030. It's and things. Number comes from the World Health Organization, and it's being termed as a workforce, crisis and healthcare in context. We need to treat a third more healthcare professionals that we currently have on planet Earth on. I put some problems. Why? Because it's expensive and it takes a long time to train. The doctor takes 15 years and up to $700,000 uncoupled with war. The Lancet describe as severe institutional shortages in our healthcare training capacity poses a toxic combination, and for us that metal, we really wanted to solve some of these problems. Unfortunately, where the need is, the greatest resources are out there least. So they're 11 countries on the continent of Africa which do not have a single medical school there. 24. They only have one medical school, undergraduate or post graduate. But it's not a problem that's just limited to low income countries. We actually see the results off inequitable healthcare training in high income countries as well. Just this week we've seen in the news and BBC about I, we're facing the worst staff in crisis in the NHS is history that's replicated across the US and Australia. On many other high in come countries, Germany requires ah 100 fives, an additional nurses by 2030. India requires 3.9 million additional health care professionals to par What their terming the greatest move towards universal health care of the world has ever seen. China required hundreds of thousands of obstetricians to simply relax. It's single child policy, and all of that takes time and money. Unfortunately, even in high income countries Ah, lot of that comes I off individual trainees pockets. This is a study from the Association for Surgeons and Training in the UK It talks about the costs off. Completing You're treating CC teeing in surgery. It talks about the cost of up to 26,000 pines or 71,000 pines if you're on oral maxillofacial surgery trainee in the UK Much of what is it of pocket to the individual doctor on this, coupled with the richest buying par off our salaries as healthcare professionals over the last 10 years, up to 10% in some cases poses another problem. That's why why you were doing what we're doing. We want to make healthcare training accessible for people who live in rural parts of the UK for people who live in low income countries. For people who live in middle income countries. People who live in high income countries but simply can't afford to travel for the best course is on conferences. We don't believe that healthcare training should be based on who you know where you live or how much money you have. And we're passionately trying to solve this problem on the way in which we believe that that's best done is working together as a community rather than all of us doing our separate things desperately. We believe there's really part in doing this together. It means that I have a health care professional, confined teaching in training that I can attend really easily For organizations, amusing organizations like Mind a Bleep Learn with Nurses, Bread Association of Pediatric Surgeons, E N T. U K. All of him use metal to par. They're teaching and training For those organizations. Actually, reducing the administration on their side is really important. It stops selling on eventbrite pluses Um, plus a bugle form plus a certificate link, plus diluting things plus reablating things. To have your website reducing the administration so that it is just automated in a single place means last time in administration, more time doing teaching and training instead of having to pay for significant zoom licenses to hold more than 100 people. Actually, we're really pride that we can do stuff to 10 5 and people, and we've already reached that 108 number on this call alone. So this would have cost this organization money to run this teaching on training session. We believe in making free and open access events free and open access on our technology at new cost, too. The organization. Only by working together can we really begin to solve some of these big problems. This is something that Doctor Ted Ross said, Hey, needs no introduction. A tech conference, actually, a couple years ago. Ask yourself every day of your technology works to help the person, the world under a juice in qualities. And it's one of the things really passionate about here at metal. And that's why we also enter just on demand so the the organization doesn't need to dine Loader video. Actually add it somewhere else. Taken with one click. Actually make this weapon are available on demand. Why is that important? Well, actually, if you live in a country that doesn't have amazing broadband connection or if you do live in a country that has, um, using broadband connection. But you just happen to live in a rural part of that country like I do Then actually, being able to watch at a time on the Internet connection that works for you is really important. And so we really have prioritized on demand as well. What does that look like? Well, we're really pride. Over the last 12 months, we've helped 1300 healthcare organizations deliver over five thighs and free and open access training sessions. I'm. More importantly, those organizations have come from 20 countries, but they've been teaching healthcare professionals in over 170 countries. Many of those countries don't have a single medical school. This has a really impact. But does it work right? Does virtual healthcare education actually work? This is going to one extreme, right? Obviously, lectures can have an impact, but we actually were really, um, ears that this paper, which was was published by my tests for a very on David, not team from the David not Foundation Imperial College, London and what they actually did without telling us that's picked up metal and started using it to deliver a basic surgical skills course online on the compared that with running the same course face to face, they assess the competency of attendees afterwards on the conclusion of this paper was there is no statistical difference between the attendance is confidence. See whether the attended a basic surgical skills course meeting their hands. I was amused. I come from a surgical background and I didn't believe myself. This was possible, but these guys have actually studied it and find that was no statistical difference. In a really well part. Study of people were attending face to face versus online surgical teaching and training. Even more excitingly, their conclusion was there for the best sort of technology has the opportunity to scale up the A number off global surgeons that we can treat, and this has a really impact on global health. On, um, they not only did that for one or two people, but what they actually did was the trend over 500 surgeons in 20 countries with a single course, and I just blew us away. I want to tell one last story, and then I go hands straight back over to know how on the team for tonight's amusing session. The other impact of this is actually blew us away. As you'll see on the right hand side, we actually verify people's metal verified members. When you're joining an event, it means that we can keep this really see if it means that organizations congenial only make their event open access without any of the risks off spam that you see you another video platforms. We verify people using their healthcare email address or I d on that we occasionally, a few times a week get people to reach like, for whatever reason, to say, they kind of verify themselves, and we usually try to help them as best we can. On in 11 day we actually had 100 of 101 100 people can reach out and say, Look, I can't verify myself to join this session or join the chat and and to some of our support team actually reached like to them. And asked why they couldn't have verify themselves on, they said, Well, I'm a Ukrainian medical student on I have actually had to leave the country and I don't have access to my university meals, and actually, I didn't think it was that important for me to get. Uh huh healthcare. A letter from my healthcare institution to say I can join metal thanks very much were blowing away at what an organization that actually done. They picked up metal and started to teach him tree and Ukrainian medicals students on behalf of the Ukraine Medical School's kind. So whilst the war was happening did not only done that with one or two teachers, but they brought 250 volunteer teachers from the UK together to train 2000 Ukrainian medical students seven times a day every single day. That's awesome in and off itself. What they were actually doing was freeing up professors on the grind medical education. It's on the ground to retreat, and medics to no longer have to provide fierce two fierce medical education but instead provide fist if it's patient care to people on the grind. And this is what one of those colleagues of our said, I thank you for everything you're doing for the people of need pro. For all people who are trapped in this situation. That's sort of technology. This sort of collaboration when people are working together. That was an amazing organization called the Crisis. Reese Rescue Foundation had actually brought 250 doctors from around the U. K together, actually teaching tree. And when we do that, when we have that form of collaboration, when we're together as a community we are powerful on, we can make a really difference we need to treat and 18 million or healthcare professionals by 2030. Our goal is to use technology like this to enable us as a healthcare community to do that. And we only believe that by working together, can we really, ever achieve that? I am. If you want a hosting event, you can do that. Metal door slash host and you can run your own teaching and treating sessions. Open access on Dwell Come up to 10,000 people to each session. If you want to find out Event to join you. Find tonight's but metal door slash events. You couldn't find an event to join. Right there can watch any event on demand metal. That, or slash on demand on watching a time honored Internet connection that suits you could still give feedback. Still came a certificate. If the organization ads those two, they're on the mound events. I believe you with one quote, which is from a wonderful person called Sarah Fryer. She is the CEO at next door. She was on the board of Slack. In fact, she still is on the border. Slack. She's on the board of Walmart. She was Jack Dorsey, CFO, and she's backed us from day one, her brothers and anything just in Scotland on they really believe and making healthcare training, um, accessible. I'm gonna leave this one court with you, not WR on trumpet. But because there's two words in here that really means something to me. And it's the metal platform has enabled on, in part those two words enabled under impart the medical community deliver medical education on a scale never before imaginable. On If we can get that right, If we can not be not make everything about us, we don't want everything to be about metal. We'd rather in par and enable the amazing healthcare organizations you're already doing awesome teaching in treating like mind a bleep if we can simply enable you guys on this community to make your healthcare training easier and more accessible then we really can't skill up the mental health care education we can deliver and make it accessible free. You know, open access around the world. Thank you so much for letting us join this evening just to share a little bit by our heart on our mission on gonna hand straight back over to Neon. I hope you have a really awesome teaching and training session this evening. Thanks for letting me join. Thank you very much for that. Phil Metals. 70. Do amazing job. Um, on the best medical education platform. The of you. So thank you for support, nurse and pleasure. Thanks for not, um, So now we're just going to pay a short video from the M D u r A sponsor tonight. So hum zar your occasion. You play that with you for sure. Thank you. Okay. Yep. So thank you for us. Answer them to you today. Um 40. Their speaker couldn't be here today, so I just paid a video instead. But thank you. Now, without further ado, today's talk is on managing the deteriorating patient on spirit of delivered by Dr Crispy and Doctor Chris Penny for both medical registrars just her money that this webinar will be recorded in a note to meddle on the line of the future channel. Um, please remember to ask any questions you guys have in the chat will make sure to answer them all at the end. I'll also be available in the chapter. And so any questions about the Webinar run will also post a link to see back for me in the chat at the end of the webinar, which were a neighbor, you to get a certificate of attendance, which you can use for a while on for failure. Eso without further with your 100 Chris. Thanks Thing I'll and thanks Bill for talking about this platform. It's very interesting. Come across it before and it's great. See you vision on collaborative medical education. So I'm just going to shine my screen, bring up the slide show. They can all see that now I can't see the chop while we're doing this. If there's any questions, then he holds well, just let me know. Um, try not to those, but I think at the end of the talk between myself on DCruz on once a questions mainly at the end. So you've been asked to speak to you today about the deteriorating patient, Um, and the talks going to split in two. So I'm just think of a bit of a background, and then I'm gonna have to. Chris, you will give some specific examples in some case based on these, so slides on that. Okay, so just a brief overview to begin with. So, essentially, this talk mainly is about how to assess patients that you come across generally on call. Or maybe when you're on the ward who are well or deteriorating on display. One of the main things I was worried about when I was just starting out the doctor on, you know, being on my own and sings one second. What to do on it will give you a bit of a standardized way of seeing these patients and things to look out for. So the first part the talk talk about recognizing on the deteriorating patient and how to manage them. Um, we'll talk about prioritizing tusks. So what things do you need to do first? On what things can wait. Onda has escalated concerns briefly on been some examples which is going to go three things that we won't cover today really on because it's far beyond the scope of this is how to manage every potential medical problems everywhere on That's your entire degree on dot Also because of our backgrounds on bein the immense, and we're not going to talk about specifics. Surgical pediatrical obstetric more kind of logical problems on such a slight change of order, but we'll talk about prioritizing tasks first. So common scenario. You'll be on call on covering awards on down there in the daytime of the night time, and you'll get a bleep on. But they'll just just want to let you know some things on now. Usually, you know, most people will will have been taught some sorts of wave of handling things over or or, you know, escalating concerns to you on that. Often you'll need to prompt people who were calling you for specific bits of information, which will give you some guidance. Is toe how sick you think this patient is, how important this job is futon or it ties Onda. You'll almost certainly always be asked to do more things at once. Then you can possibly do on do you need to come up with a bit of a strategy is to help how to focus on the ones that are important on Really, that involves First all, is it a job that you yourself need to do? Or is this a job that you can delegate to someone else on? Gets a job that you need to drop everything for and do right now a week and wait until later. So I was actually on call over the weekend on night andare hospital. We had quite a lot of stuff. You're Tages on the No, there was no would cover my one on. There was no work of the S h O. So I was basically holding their form bleep on the regimen of the ward. So these are some of the things anonymous. The eyeglass today on on diet just want you to take a quick look at all of these jobs and of see if you can pick out the ones that would make you most worried on beach thing. You think actually, probably aren't important to do it three o'clock in the morning. And when you've got lots of sick patients to look after s o They range from someone being short of breath on need to be started on oxygen on someone needed fluids. Someone who's not had the regular medications prescribed someone who needs a discharge summary writing because they're going to go home at eight o'clock tomorrow morning on. But yeah, various tasks. So hope you can see that the ones that stood out to me anyway, the's ones in red. So this one who's short of breath and needing oxygen potentially is acutely on. Well, why they're needing oxygen. Why? You know what's going on with this patient Needs to needs to go and assess them a surprise e And then also this gentleman, Mister Jones, on that the first can't wake up. And I appreciate it is three o'clock in the morning on. But usually if they can't wake someone up that, you know, that could either be they're asleep, or it could be that they're unconscious. So that's something that needs prioritizes. Well, a point to make here is actually, if you get called to see these two patients at the same time, you can't be in one place that, you know in two places at one time, you might also want to help you on. So, you know, if you're on call was part of the team on you've got an estate Joe working with you or registrar working with you. And you need to see these two patients at the same time. It will be good to contact your colleagues on D. C if they can help you out on. This is just a probably seen something similar to this before. This decision matrix on that you can use to sort of prioritized tasks on it could be used for anything but using it for jobs that you get us to do our you're working on call. Um, and you can see that in the top left there on the category is tusks that urgent on dim porton and these things you always need to prioritize and do. First on do some examples. They're reviewing someone who's got higher the warning score chasing a scan for a patient who has fallen and there's more drowsy than normal. All of these things are quite urgent things, but they're also very important because they can involve harm to patients. Is there no 100 properly moving across on the right hand side on deal. Important jobs, but less urgent. So not things that are life critical but important on the less. And these are things you need to decide when you're going to do them what they need to be done in come they. How far down your job this come to go on day things like, You know, prescribing pain relief for patients is important. That is, that something that someone could do. The meantime, have the nurses given some medications that already prescribed why you're on your way on. But that's that's something you can decide on and then onto the bottom row. So things that are not important, not the things that aren't important potentially, you know, time critical things that you can generally delegate to someone else potentially or defer to later, so and example, is dating a patient's relatives. That is important because that so that is, that is urgent because the patients relatives are, you know, not going to be there the whole time. But it's not necessarily thing something that you need to do if the if the patient's stable on the nurse who's looking after the patient, update the family and give them a generic overview of what's going on with their relative, um, in similarly for, you know, a routine cannula in a patient who's know well or unstable. Has anyone else trying to put that in your in? You know, Is there a senior nurse on the war two cannulate patients? Can they going to do this job before you attempt it on? Then finally, things that aren't important and not urgent I would suggest you don't do so. The example I had on my previous list was doing a discharge summary for a patient with recall in the morning. I I think that, you know, unless you're literally sent around doing nothing on Berry. Very bored, then. Actually, no, that's That's not something that you need to be prioritizing andare some caveats to these things. So, you know, sometimes you'll get us to do something because someone is just worried about patient now that can sometimes on the surface of it, seem silly because actually, you know you can ask them questions about this patient and that on Do all of the information you getting back is potentially telling you that this patient might might be well, I might be stable. But actually, sometimes, you know, very senior nurse is working. Awards have experienced all of this before on actually, their intuition can sometimes give you a bit of a clue as to what's going on. So that's something that might might make you more suspicious about what's going on with the patient on but no all patients acting the same way. So we know that patients who are very young know patients who are very old, have different physiology and will react differently to an insult on day. So, you know, a little the patient may not score high, really warning score on their observations s so that might not sound Teo unwell over the phone, but they may actually very unwell when you go and see them. So these are all things to sort of bear in mind and sort of on the flip side of the first point. No, no, everyone is skilled is you will be picking up whether someone sick or not. You know, you actually probably need to go and see these people yourself. These patients yourself on the order of priority so you can make a decision about you know whether there are well enough. I wouldn't take any questions just because I think we're going to probably go through everything at the end. That that was just a brief overview of how I would prioritize jobs have been prioritized finding out which patients are deteriorating and who to see first. So the second part, we're going to talk about how to assess the second patient, a deteriorating patient. So I use a generic approach, and I'm sure you've all been talk very similar things. I mean your training so far. And maybe you've done a simulation training and maybe on the the ward's you've been seeing, you know, this sort of thing put into actions. So generally starting out by seeing the patient from the end of the bed will give you a lot of losers to whether they will come well. Are they wearing, you know, normally breathe oxygen mask. Are they talking, Nick? Do they look gray? Are they responding normally on blocks of these things, you will just pick up within seconds of looking in the patient from and it's important at this point, if you see that a patient is unresponsive or you know you filled for a pulse. A look for signs of life, and they aren't there. Obviously, you need to put an emergency call. This isn't a deteriorating patient that you should be managing on your own. You need a team. They're on. Do you need Teo? You know, potentially be starting resuscitation. If they're not like that on your moving onto it, start examining them. A general approach to your examination should be that this isn't a Noski on. And actually, you know, when you're examining the patient you're not looking for, you know, multiple different apartments, signs of my full regurgitation. You're looking for a key. Things that are going to show you tell you if this patient sick and what their physiology is doing, what do you think's going on with them on? So your examination should be focused on, but and it should be methodical. So you should be going through things from order importance on. But what's gonna kill the patient first on did should be very quick because you're trying to get lots of information, and we'll go on. But you should also be acting on things as you go on. But we'll talk about that in a few seconds. Um, And then once you've done your assessment and you've identified that, yes, this patient is deteriorating and there were well, when you started to act on that, it's important to feed back to the rest of your team whether it's the nurses in the day that you need help with acting some of your treatment plan Or is it? Actually you're worried about this patient. You know that your seniors now important point in this is that you know myself, is it is a register. I've one of my team has things and one of the water, and they're worried about them. I want to know about it because if I don't know about it and they continue to get worse, you know it's something that we should have been done earlier, and it's no, I don't want to know about it because I want to check up that what you're doing is right. I want to know about because I want to know who's sick in the hospital on what's going on. Then, once you I didn't find this patient sick, you need to think about what tests You might want to confirm this, but it's always important, so these shouldn't delay your treatment. So if you have examined the patient in short of breath on you, notice that they've got raised. JVP the technique they got crackles in both bases, got pitting edema up to their abdomen and they've probably got heart failure on Be waiting to get a chest X ray to confirm that Yes, this is pulmonary edema on isn't necessary. You should be giving them some oxygen. You should be giving them some fruits. And I didn't seeing if that's gonna improve their clinical picture while you're waiting for those investigations. So it's important to act on things that you see them on make Children. So the generic approach is your own at all. Noted, reviewing deteriorating patients is the eight weakness husband's on. I've taken all of this from the Cessation Council guidelines on this, which is the sort of training that get him sort of. You may have done aerosol ready as part of your medical degree on diffuses QR code you could see there pdf online on, but it's a good summary. I think of how to perform a brief assessment of a serious thing patient, and you can use this approach to all patients, whether they're in whatever situation you find them. If they just presented T Day. If they're on the ward's, if they're post surgery, you know it's a very good, quick, methodical assessment on do. It helps you, teo, identify and treat things each stage of the examination, which a life threatening and deal with the most you that you go along on. But it should be brief initially, so you know it says here 30 seconds. That's you know, once you become very proficient in doing in lots of times, but it's not. It's not a long examination. You're not there to test every single part of the neurological system you that save someone's dying on up on on day. So, yeah, treat things as you go along. You don't forget to involve people s. So if you're in the Bay of the Nurses in the baby baby doing some routine observations for the patient copies that you need to sort of get them to come with you and say, Look, you can be doing this patient's observations as I'm examining them on East, they're one of the pressure is now need to know what your options saturations are now and involved with people. And if you're struggling on your own on or you need in the union another pair of pants, then call call someone. Um, it's much better to have people there and then you don't need them. Then it is to realize 10 minutes into what you're doing that notching needed people really wrong. So I always involved people if you need them, and also you're not there to diagnose thing straight away, so you have to pick up what? What things are deranged. So you know it doesn't matter if you can't decide whether this is a pneumonia or heart failure you need to treat. What you see is you go and then then core if I think it's a bit later. So first part is processing the airway on dual know airway obstruction is it is an emergency on. So if you see this, this isn't something I would manage on my own. Expect anywhere else to manage on the road almost there, you know, in intensive care. And there are any statistic you generally need lots of people there to deal with this on designs of airway obstruction so signs of partial airway obstruction and noisy breathing. So snoring or strider? If you got a railway of structure, reduce their entry on on, then complete obstruction, you would not hear any sounds on the patient might maybe sign nose, and they may have six or movement of the chest. So that means when they're taking a deep breath in on, their case is moving up, but their lungs can't expand because of the blockage of their airway. On Do the Abdomen goes in as this as the Thor it's goes out on down part of school breathing, Onda A said. Don't mention your put a patient on some oxygen on. You may want to perform some airway maneuvers or put some airway up jumps in to try and keep the airway Peyton. And if there's lots of fluids, lots of vomiting in their in their in the mouth, you might want to clear this out. Take out dentures. I'm performed some suction and division using using the youngest, so get get help quick eso, then success breathing what? You're happy that the airway sorted? You want to look basically look for signs of respiratory distress on that might be sweating talking near, um, there might be a hobbyist chest deformity or unequal expansion, for example, in their intention. You, for X trait, little deviation. So this might be towards the problem. So in a collapsed lung, or it might be away from the problem. So a very large effusion or attention you muscle acts, breath sounds might sound from the end of the bed, wet or rattly. Or if there's a way, problems or that might be wheezed. Strider and treatments obviously depend on the course of problems on that Give oxygen to all patients who are having problems with their breathing. And even if you're worried that this patient is retaining so two, if they got severe COPD and that in quite attention, you're not going to kill someone about giving them oxygen on in a short period of time. Vial means target that oxygen saturation. If you later get more information in the initial assessment, give people ox to make sure they're oxygenating, okay, and then assessment of circulation. Essentially, here you're looking for signs of shock on which is, you know, the inability to reviews organs on on D. In almost all all cases, it's safe to treat shock as high blue Valium in shock. So even if someone's distributive shock because of sepsis giving them fluid, that's gonna help that as well. So and you want to find out what the cause of this is, you know, is there bleeding somewhere? And this could be concealed bleeding, you know, in trouble on the leave or into a compartment. Like if I If there's a fracture or it might be over, you know you might see millinery. All tennis is the patient might be pale or mottled. Peripherally should found they'll be cool to touch. Generally, they'll be talking Codec. They may have a threat. It pulls on. Your refills have really prolonged. You may see clumps of their central veins or peripheral veins on that. BP will usually be low, but can be normal in the immediate, you know, instance of shocked because people get a physiological response that getting a Drumlin driven response and their BP may temporarily be normal on. Then you can look for you in our so these are all things look for for shock. Once you've dealt with that on assessing the level of consciousness, so you can use tools like the preschool or glasses a coma scale on. You can quickly assess someone's level of consciousness so away from, you know, alert and talking Teo unconscious. And if you need to provide pain just to be aware, the even want to cause trauma. So pressing on the super orbital notch is a wave in inducing zar central pain. Response on do also doesn't cause much trauma. You always want to check their glucose because if they're unconscious, even if they're not diabetic, you're to make sure that they're not high life scenic on. And this is best done with venous or arterial sampling in that in a critically on well, patient because often they're capillary glucose doesn't correlate very well with their circulating glucose levels on on if they are hypoglycemic, you need to treat that on. But most patients that will be giving them a bolus of IV glucose and 250 miles of 10%. Because it's is a reasonable stop. Try not to use really concentrating really close relations. Like you know, 2050 simply goes, because that could be quite damaging. Extra visits on, obviously, some was unconscious. You need to try and maintain their airway. So, for example, the pages of seizure on always put the recovery position while you're assessing them and get getting help. Finally, you need to make sure you examine the patient fully. I'm sorry. With the, uh, the areas on. Do you want to make sure that, you know, minimize that he wants? So once you examined them, don't leave the sheets off them. Make sure they cover it because of the world patient Will not control were called temperature very long. That was a quick overview off on eight of the assessments on dimes. Sure, you've all practiced this before on, but it's probably not new information to you, but it is a very good tool. Teo Assess a deteriorating patient deal with what's going on in the immediate assessment period. Once you've done that assessment and you've got a bit of time and you might put in their action plan haven't started. Teo. Stabilize the patient. You want to make sure you know what's going on. So this is where you do that more delving it on. Look at the history, whether and hospital look any relevant observation charts. Look that drug charts have they been started on any medications recently Have we not given in their medications? So you have this only in patient who's not had their regular steroid prescribes, you know, they they could be having acute crisis and you to manage that on. So all of these things that are important that things that they want to have actually assess the patient and all of a Schintzius you want to consider if they continue to be on well, on deteriorate further. What is their plan for escalation? So is this someone that we should be involving the critical care theme with to support their organs on aged? You're right, You or is that appropriate? If is inappropriate, Do they have ah documented plan to say that it's an appropriate so things to consider when you initially assassination and again probably talk about questions at the end is on. Okay, so I'm gonna move on to talk about investigations, and I'm mainly going to focus on arterial blood gases because I was unsteady. Talk about that. But I'll give you a little bit of a rational about using investigations first, because something that's quite important to make sure that you're doing the right investigation for the right problem. Onda. So just me just telling you to do lots of investigations for the urinating patient is not always gonna be the right thing to do. Wait to have a little bit think about what the important things are. Eso This was a mantra that was drummed into me by a critical care advance critical care practitioner that I worked with on Did he always said, You know, don't forget to eight weeks before you do in a PG, because actually, one of the most tempting things do when you see a sick patient, this thing, I need to know exactly what's going on. I'm going to be lots of tests and figure out what's going on on. However, you know, blood guts isn't going to help if the reason the patient's hae pox is because they're always obstructed. So you need to do that. Eight to the assessment before you go delving into what test do I need? Teo? What? You know what imaging do I need to get for this patient? You do this. Do the simple things. First on down, stabilize the patient first. Um Okay, So the investigations that you want to take for a patient will very much depend on what's going on with them. And the's examples are not exhaustive and they don't cover everything. But you know, for example, if you're asked to see someone who's acutely short of breath, the bedside, you want to examine them and oxygen SATs Yeah, you may want to do some blood tests and that my including arterial gas, to see what their oxygenation is like. But also, you might want to do some of the blood tests on do if they've got a history that's compatible with this. Do you need to take a deep down into your lap? He It's important that, and I'm sure you've been told that medical. Actually, the sensitivity and specificity of tests you know very much depends on what you're looking for. On go. Doing a blanket test for everyone is not a good idea because it can lead to further problems. Um, on that imaging, you know, will depend on what you think is going on. A chest X ray is generally a good idea on them for chest pain. You know, some of bedside examination. He c g is important here. Blood test might include a troponin if they've got cardiac sounding chest pain. But, you know, doing a troponin someone he doesn't have cardiac son. Chest pain might not be beneficial on then, For example, in hematemesis. Then again, you'll want to decently examinations. But you want to make sure you know where they losing blood from If they got digested blood on P R. You have We got a very safe any cross much, but having a lot of these other things that you think about their different too, if you're assessing a short of breath on. But this goes on so these are not exhaustive on, but they're just example of how we need to tailor what we're doing. What we think is going on on on. Yeah, So doing an inappropriate test may lead Teo actually harm for the patient. So if you do a d dimer in someone who's got on, you know, very severe pneumonia, it's probably gonna be raised even if you've not got pee. Eso If they don't have any clinical signs or history, that would point towards them having a p. You're still gonna then have to do it. CTP on the That's potentially unnecessary exposure to radiation, so it's always important to think about what you're looking for. So talk about about arterial blood. Got something that so you probably even done this as part of your training on the wards or being shown how to do it in the in the simulated environment. So we'll just touch him briefly on boast patients. You'll take blood from their radial artery because that's the safest way to do it on day. Hate to see your eye T setting. The patient may have an arterial line in which you can just take a sample from. In most cases, you'll be using a prefilled syringe. I like to use a small cage needle because it's like pain for the patient. On speaking of pain now in a critically on while patient who is deteriorating, using local anesthetic may take up more time. I think it has benefit to the patient. However, the beat. Yes, Do you say that you're it will improve your chance of getting a successful blood counts, and it's obviously much nicer for the patient. I've not had an arterial look us taken that I can't imagine. It's very comfortable on do. Certainly, if you know, if I was putting an arterial line, I would always always use anesthetic. This is a bit more time, but I must have met him. Put 100 here that I don't routinely use local anesthetic against something, but it it's something to think about in your routine something, um, and and the other thing that is recommended to be done is doing modified Allen test. And that's just a check that there's patency of both the radio on the older artery. So you've always got comfortable flow to the hand in case you severely damaged the radio artery. Something may be causing a fax action or something like that. So that's just get the patient to compress the and you cleared both arteries, and then you open the 100 you should see a return of color to the under few. Open up one of the arteries in turn. So that's just the check that it's safe to sample. And then once you're taking is simply to compress thing. Actually, for a couple of minutes, no, actually put a decent time the Gianna. I usually make sure it's quite timely, stuck down on and then you make sure something you analyze it as per your guidance for whatever gas analyzer is used in your trust. And I'm sure on your injections you'll get shown how to do that. So going to briefly go through a way of analyzing the results on looking at what's what's wrong with the blood gas is it's a simplified way of doing it. It doesn't cover all of the weird, wonderful extreme cause of yeah, very cysts, and it's It's a bit of a bit of a light overview, but essentially, you want to look at the patient first and see what you think is going wrong with him, because that will often guide you. Is Teo what to expect on the book us when you get the results So fistful of the, um, well on. But if they are, um, well, what's what's wrong with them? So if a patient's got raised respiratory rate, you may well expect that they're going to be high proxemics on their guns on Go away. They might be the mix there. If they've got to be a metabolic acidosis to try and correct that, they will hyperventilate and try and blow off excess carbon dioxide. T compensate for that on. If they're comatose. There, they might might be hypercapnic if they've got time to your respiratory failure, and that's causing to be comatose on behind tense a patient you might well expect to be acid emmick if they're not confusing their organs. Got a lot to consider, so all of these things will give you a bit of a hint as to what you're looking for when you get the results. So, firstly, you want to start by looking at the oxygenation with the patient on the guns and nuts by looking at that possibly shirvell question now of written is simplified physical warning. So anyone who knows this in detail know this isn't correct, but it's a good rule of thumb on gives you a good good point. We're looking against results. So on airway with normal physiology of patients, partial pressure option should be between 10 and 30. That's because roughly you can take their percentage inspired oxygen on and take 10 off that number, and it will give you what their P O. T should be on day. So, for example, the patient who is on 40% inspired auction through eventually mask, you'd expect their periods you to be about 30 kilometers skulls. And that's in the normal setting, with normal lungs and a healthy patient. Anything less than that you'd expect that is a problem somewhere along the line with oxygenation, and it doesn't tell you where it where the problem is, has gone up shooting their airway. Or have they got massive pneumonia that's taken out half of the lung capacity, but it it gives you a point. So then, once you've looked at their exchange in, you need to look at their acidity. And to do that you look at the pH are you that you get on the bus on anything less than 7.35 is acidemia on, but you'll know that esteem. It can be caused by a respiratory cause so grazed oh two in the blood. Or it could be caused by metabolic causes, of which there are many of the company doctor Castleberry cysts on. And if the patient's alkalemia, that's a page of greater than 7.5 that could be caused by respiratory cause, a low in normal, spontaneous ventilation that is very, very rare on day one second on Byetta Bolic alkalemia could be caused by excess loss of hydro nine. So lots of vomiting. For example. Once you've looked at their since, even then, look at the risperidone, every part off their guns. On pilot, I mean looking at their CO2 level. And when you look about, if they're partial pressure, CO2 is increased so greater than six of hospitals, then they've moved, likely if their page is low, got over spiritually. And cervix is, but obviously patients a complex, and they have lots of different things going on at the same time, so they may have a metabolic considerations as well as this might be a mixed on today's is. If the seriously is reduced on then and they've got a raised pH, then that's a spiritual closest. However, that is a said, unusual investigations being mechanically ventilated, and we've increased their title boy Andre, the response rate on the ventilator too much. You know, the patient really needs to be probably hyperventilating. Teo become Alkalaj with it as well on. Do you look at the metabolic part of August and that was looking at the bicarbonate in the base excess. So thoracic, the MC pH less than 7.35. And they've got a low base excess. So that's what anything less than minus T on a low bicarbonate. Anything less than 22 and then they've probably got metabolic conservationists, I say, probably because actually, the states can coexist so well. Um, there is that the body will compensate Teo abnormal levels of of acid in the blood. So if someone's got a metabolic acidosis, they may increase the respiratory rate in compensation so they might have a compensate. Three risperidone answered ASIS and then my balance itself out. Or it might partially balance itself out if they're all clinic with with high basics s high bicarbonate got a metal metal like alkalosis on. But this is where things get complicated because it can be both at the same time. And but there's a rule of thumb. This this will probably give you the right answer most. Most of the time. Ondas his head in combination with looking at the patient, thinking what is going on with so just a few examples quickly. So looking at this patient, any D on the drowsy and the guy raised respiratory rate and they've got a background of COPD. This is that guys have a little look at that that's taken on 35% inspired oxygen five in Cherie. And looking at them, they're well, they're gonna raise your spirits a rate that drowsy on, got a history of of cough with speed. So looking at I got there, hypoglycemia can't make So they're here to is low 6.7. And that's even despite being on increased in spite options. As we said before, we would expect and normal physiology that pretty to be about 25 roughly, there are so the mix of the pages of some 0.1 t. So why are the acidy mix? So let's look at the respiratory component. Well, if we look at the c o. T that's raised so she knows you're 13, so that pretty much gives you the answer on looking at the metabolic component. There are carbs low on dot means that that trying to acute the compensate and actually, if you see a gas of a patient with type two respiratory failure, chronically when they're not acutely on well enough Demick on their bicarb you to be quite high of what you expected. That's crying compensation. So, yeah, So the answer is that this patient's got primary spiritually supposes, and they're partially compensating for this by with the metabolic alkalosis. But they're tied to your respiratory failure. Another example says patient with diabetes and gastroparesis, and they've been vomiting 12 times a day. Having this is the gas on on Aricept. So they look well on the dehydrated and they've got muscle cramps, vomiting, what's so look at their oxygenation first, so there's no issues of that. They're on remain on the pier to 12. That's fine. Um, looking at the pH that alkalemia. So the PH is 7.59. Why is that? We look at the respiratory component on, so they've got slightly raised part pressure of coming outside on. Do you look at them in there? They aren't breathing, you know, very rapidly on on. But if you look at the metabolic component, this will give you the picture. So they've got high bicarb on their face. Excessive, very positive. Not suggest that they've got a metabolic alkalosis and they're trying to compensate by by hypoventilating on these numbers are probably made these numbers up, so they're probably a little bit extreme. You know, they probably driven this year that high, but so the answer is that I've got metabolic, our closest from vomiting and leasing high nines in the national conference. Finally, a very common pitch that you'll see on the gas was cardiac arrest. So the patients on the 100% inspired auction they've you mechanically ventilated on. Do you concede we that they're obviously very unwell on d looking there that I said pitcher that, uh um I stopped sick. Medication 6.8 hypoc sick. This 500 bucks chin, they've got a raised to your tooth, so they're probably being under ventilates a little bit on, but they've got low carb basics s is very negative, and you can see the little black takes very high there, So they've got a mixed metabolic uterus proof basis because they've seen you had a downtime of 10 minutes. Whether despite CPR, been hyperventilated and hyper refused. So it's a quick run through and vial means it doesn't cover everything, but it gives you a good overview of hard to assess. Someone look us on on in a bit of a rational about doing tests. So finally, I just go briefly Touch of cancer. Activate concerns Just looking at the time that I'm Chris is going to go through some cases more interesting. So, um, essentially The'keeper's It's by stating concerns. Is that ever sufferance island state struggle and looking, looking at a sect, a shin thinking. I don't know what to do myself, and I'm sure Chris Worker this when we're the Red shrunk Well, we don't want our team to be, you know, feeling like they're not supported. And certainly Way would want to be supporting if this one says on the world, because we need to know what's going on with the patients on, you know, you may weigh or get to a point where we can't make decisions or we may become tired on, but it's important to escalate things in that situation as well. If you get any kickback from trying to escalate, your concerns of our patients, usually says something more about the person that you're talking to than it does about you. You know, we've all been in that situation on even even the person who's becoming a consultation, you know, they they get in situations where they need to escalate their concerns on this. It's a good practice to get into letting people know another appropriate way about patient to deteriorating on. I'll just put that some people reach. You know, people can be snappy, and it's usually because they're tired or they're busy. And it's not something you should put up with my colleague when when we just started Enough is that one's on. Once told a very angry and I read counsels, and then she called for advice on T. Just pause for a minute and talk to her like an adult on. I thought I was brilliant because, actually, yeah, on we are all doing a job on. But, you know, don't put up with people being green. Teo, if you're trying to escalate something on, if you think that something's wrong, there probably is, and you're right to be escalating it. So don't don't be worried about about that and make sure you're you know you're not on your own, and you got the rest of the team around you, so you should always contact them if you need, um so briefly about your team, did it? It will vary depending away work. What specialty urine they get to use of of the people who are experienced around you. So a lot of acute or call teams have lots of other our health professionals with them, like advance can transition is physicians associates. Critical care outrage teams away these people you can. You can ask about your concerns, too, or advice from on. These people have their own strength and benefits. Most most hospitals have. Your team will be split into looking after the acute. Take on whether that medicine or surgery on the ward's patients so familiar sight. Familiarize yourself with these teams when you start in contact. You worried about patient in the area that you're working in, and then these are just a brief overview. Have some communication tools that you use for escalating your concerns, and you probably come across them and use them already. So there's the Esparta will, which is very similar to the RSVP tours on the right there. Basically, you're starting out by saying where you calling from? What's going on on? Be a bit of a background about the patient, but that doesn't mean to realize their entire medical history, and I think Chris is going to go into this in a little bit of detail about actually what is important to get across that, your assessment of the patient and what you want to happen. So it's important to get across the person. You're on the phone, too. If you want them to come and see the patient, let them know because, you know, sometimes you might just be calling for advice. But actually, if you're worried about something, you want to see them and they have no identified that say, Actually, I want you to come to see this patient, and they will do that. If you need that, I'm finally getting a touch of people. So if it's a critical problem Power emergency call very self explanatory. And in every hospital, the calling to to to to not get you have gone there. Is it an urgent problem, but not, you know, a dying patient in front of you. Then in that case, you from sleep. If you need someone to come to you quickly, um, be aware that that person will have to drop everything and run to you. But that means that they usually get get. They're very quickly. And then you can ask them for urgent advice. If it's concerning that, you're a strong know. So this is anyone was deranged. Physiology rate the higher early warning school and then ask for help. You just need a hand. You got too many jobs on the go, and then you can escalate to you to your immediate colleagues or just talk to them about your jobs list, which it always helps on. So I've think I'm taking too much time. I'm gonna pass able to Chris. Now he's going to talk to you about some specific scenarios and how to manage them in deteriorating patients. On down. We'll take some questions at the end. Thank you. Right. Hello. My name's Kristen. Um, one of the fellow much drives. Probably working a wash. His hospital on their share. My story now there will be late. Get underway. View case based presentations Question you to confirm my screen charge. Of what? You have a line on it? Yep. I can see that yet. Hi. This is Well, it'll name. Oh, yeah. So I haven't really done a intro as such Because ago Tried working, freeze and cases and just sort of picking out some of the salient point about some of the aspects of your weight, either to pick up on how to approach, how to approach each aspect as we go through, essentially. So we're just jump straight into doing the case. So takes one that you have read up the the part of it, but I'll let you do the in between. But it says this is based on when you're on your war covers. Quest mentioned with your own cause or large to be split between being on the taken on the ward's on the take. You can often have a lot of people around you, but on the ward's is much more independent working. So this is where so if your A to reassessment in your management, the victory depression really comes into its own. It won't have this money. Edie doctors and take doctors around you. So Senator Jones, or 62 year old woman, admitted last night with dinner the she's hot damn be for the last four days on. Her husband had it as well, but he thought was okay. Um, she seemed fairly well and it's really cope about cable. And, uh, over the last 24 hours, she has become more refined, a little bit to the Jeep in. But that was quite low with the GP on, uh, GP quite likely sent it into a hospital. Blue light of her in hospital history is really minimal. Parts depression came on diverticular disease. You just have found some threat. Not much on the social history. So she's been started. Being treated fell off a quick. That's for enteritis that checks. She's had IV fluids. She tells him IV antibiotics needed because she came in and she was hypertensive. So she was worked out from the separates Prospective assign er of stock out The blood culture is being sent. So this is really trying to get out your your assessment of hypertension. So really, when we're assessing are high potential. Well, to this is going to, uh, see about 80 approach so soon with the A one B. Okay, this is when you want. When you got hypertension, your your causes could be spit into having a look at the volume assessment. So these will be on your examination aspect when you're looking at being such the couple weeks old time The mucous membranes, the JVP solvency This is dependent on the positioning of the patient and the patient is lying supine in bed. Then there's not much point in doing that. JVP You have to sit him up to be clinically new sport that to the like degrees and then before Dimas So this is looking at the legs and then putting it, but it pressure over the over the shin bones and shape. So this is what a problem officer in your come called to see her So she's pretence it talking Codec breast rate is a little bit higher dose. That's right. Okay, On a day on day, she's Marley football or just borderline low. So what could be going on with Sarah? So when you're assessing her born, um, status documentation is on layout of your documentation is quite key and making sure that your infringing what your rationale was thinking. Because if you're on a night shift on, you're doing a plan and you're doing this working independently, then your documentation is your is the key. To tell your rationale, you're thinking why you've done what you've done. So this is so over just a marker of what are my right if I have seen this patient. So I asked to see hypertension checked it your vitamin D, and they quickly write down the past, but most really bit more relevant or just so possibly united, or it's not that relevant. You can leave that out, put down the obs about what's the relevant bit, and then I want to do a little bit spitting to sort of investigations So you don't pick out this any point to this. You've got naked eye his hyperkalemic. You said it was a different layer of white cells. Mild elevated CRP additionally say, and then you've got your examination. And then this is where you want to thinking about your volume status for your hypertensive patients. So the volume in a lot of these will be a balance between what's going on, and what's going out will determine a lot. So this will be low chart 21 way you work. You may have to go and get this working, or I am. That's all the paper, which often with the nurse's notes the completion of this is variable. So it's important that in this case, in you to make sure that there as well is writing in the plan of doing a strict in for out. But you also let the nurse he's looking after patient. No, and in some places, that catheter might be appropriate. So example in this, like she's had two litters of IBM. Put her out, put his one heart liters you're seeing, and then you're that's that's your fluid balance and then you're doing your clinical assessments. You can overdo this part exam or do it separate to come showing how you come to your conclusion. So Davey's down know Dema Refill was just on the board 97. But, I mean, it's been basically dry. So the thinking this lady is hypertensive because of essentially being under filled or hypo believe make so hyper believe it or this under field status doesn't have certainly mean that there's not enough, um, fluid on board. But it's just not in the right spaces is not circulating around. So in this patient, we're thinking we need to start to drift. Throat is a station, so the initial boat in May, or what the numbers are 500 mils the flu again through stacks question or Hartmann's or or saline that wall cells. It depends on the degree of the hypoglycemia and also the, um, weight of the patient as well. So easy. Sometimes you see a patient comes in who's young, very unwell that much, but a little up and push it through a second tolerate up. If you're putting a saw the 95 year old another set of hypertensive, then the 2 50. But this might be a better place to started. The degree of hyper hyper Bolena isn't in extremist, so the important thing is this is This is often difficult directing called a ways to a Serious s on depending away working, York's charts could be online in lots of places, so you cannot make sure that the nurses you have a plan to reassess the patient. So that's good. If they left the hypertensive, you're giving about it, and then you might your so I want you to think about describing is in maintenance foods or continuing to Florida state them their bit slower, so you might write of your 2 50 bonus, and then my never banged. After that, they saw 466 out of the bag and you're wanting, the nurses say, when that 1st 2 50 or 500 mil finishes, can you repeat the opposite? But one system for May is that means even if they're a little bit, I preventive, say they say it's 110 or something and you're doing the 500 numbers in response to be in your court Sick. A patient, you can say, Can you put the obs on after you're done on our our look? If it doesn't pick up or it's getting worse, call me back on That allows you to look remotely and so reassess that that fluid bullet and know that you prescribed in continuous fluids it will buy you some time. It's all about trying to be so proactive in terms of maintaining and managing your time best. So when we're looking at probably really absences that deteriorated best for you to bring about escalation criteria. So if this patient is very low BP, but it's dropping rapidly or in some cases you might get on the board or a pressure, then you obviously need to put out on the media so off to to to to call and you need help. You know this will need the help because you need assistance, is doing things that you can't just one single pair of hands. It's not that you've done certainly can't know what to do, but you're just need more hands in doing it. So this is like getting our white board access, putting up more fluids, intentionally having towards a very aggressive chew a shin. The ever expect is this an idea of refractory hypertension? So you've got someone who is very septic, and that's a really raised dilated, then sometimes you could be putting a lot of like 23 weeks in them, and the BP is still not coming up. At this point, you need to think about where your map is that indeed you lean arterial pressure on there. The map is not responding to the fluids. Then you're going to start getting end organ damage because, you know, providing that perfusion pressure. And this is the time you to think about whether these patients are for escalation on. Used to thinking about that. Er, do you call? It is if you're putting some fluid any, you know, getting a response. That's That's the time to start scratching up, and I'd have it opposite that point we're calling your registrar on. Do they often will come and see the patient and then bring it to you. Or they might ask me to bring, like to you to anyone where you are. Oh, Lord, I think that's gonna think about what else we could try. So fluid is the thing that springs to mind when you see someone hybrid engine. But it's not the Allen's of every hypertensive patients. So it's important for you not to be a new jerk rationale given fluid. And then we'll see what happens. We have to think about the case. So obviously, if they're hypertensive and then in most most scenarios, nearly all than starting fluids in an initial hypertensive days, Well, not. It's probably sort of a safer option if if it's not entirely clear whether where the cause is coming from your stomach being about what additional treatments might needed to help. So it really depends on what the driving factor this hypertension. So for several, we need to be thinking about why she's hypertensive, so this could be hypertension. Sold 70 divine um, lots in terms of the diarrhea and vomiting. But we also use the weapon case itself. So could she. Actually she could she be sepsis? Could this be something that's causing a basal dilation response, or could it be something else? For example, could this be an Addisonion crisis that she's been having diarrhea, vomiting for several days, which is normally on prednisone for Caremark? She hasn't been able to take it. She's got the juice or intake. Then that would make us think that she needs to have some IV stores, which he might give you another surgeon crisis from that perspective. So it's all about having a having I think about is anything else in this case that that would make me think about unaltered one additional drive by this hypertension. So in this case, for so when we think about food station hydrocortisone correcting the hyper cleaner and then plus minus antibiotics, which is already on it, then you continue it for now, Um hum. Well, we're looking at, uh, hypertension with larger talked about hyperbole, MIT hypertension. But there's four main categories of hypertension on. We're thinking here we were going back to our sort of physiology of the physiology that the blood pressure's can use your cardiac output in your system times your systemic vascular resistance. So where where you've got a dropping and then obviously cardiac output spreading to your heartburn times straight for you. So if you start to getting one of these numbers dropping lead in your BP, I've always gonna start dropping. So we talked a bit about hypovolemia. But it's not always going to be leaving. Lose when you're losing something that in the body you're not losing fluid, you'll be losing blood. So if you're losing volume next ra extravascular raise a ting in effect, then you need to be thinking about what could history could make me think about this patient could be losing blood. This is you. Think about what? We're talking for money now. Do they have a history of cirrhosis? Is there known balance? Is that a previous would you do? That's confirmed. Listen, we'll have previous banding. Obviously you're not gonna have blood available immediately. Even that he put out the major hum respectable. You're not gonna have that blood this far. You're going to have fluid, so start fluid first and then start preparing to get blood. If the blood loss is severe in a developing shot, then obviously, that's when you want to be expecting to a major events protocol. And that's when you were thinking about putting out in the mode of all is well to get help. So that's hyperbole. MIT shot also need to think about just you two shocks. This is things like acceptance, but also allergic reaction. They haven't think about looking at the drug chart as well, so you don't obviously have to. If the if the cause is is clear and the patients got pneumonia and they be hypertensive, come in. And that sort of on the board line, you've got to be pragmatic in your response. It's not really clear why this patients with, um, hypertensive. You ever think about what the other driving factors? So have they seen actually being prescribed tablets in? But she's got a penicillin allergy, and now she's now she is developing a on allergic rash into this so and then Augmentin that know hypertension, a type of really mix, so you can't have cases that will be you believe it. So these will be being such a cardiogenic or obstructive causes. So these are the things that attention new before you really immediate start off shift blocking your output. Hey, if there was a large study, I am blessed. For example, you're gonna start getting here tonight. Instability certainly. Arrhythmias, whatever. Too fast or too slow, so interrupted your your heart rate goes too fast and it's not enough time. And actually for the ventricles to fill, you're not going to get enough up cardiac output and then another soft, just a touch on his decompensated heart failure is this is a tricky one. So you will get patients in. So then stage heart failure. Who will become hypertensive in the fact that this is when a straight volume can't keep up? Essentially, on these these points when you're starting to get hypertension heart very. The prognosis is starting to not be is good on. You need to be clarifying escalation status because if this is a cute event polyp farming, say, following um, I with an M off example. Then you need to be here About what? What a cute escalation might be needed in this patient to might need escalation. Talk to you. That's all those the best is eyedrops that it's important to have a thing, because in these places they going to likely be hypo believe it of a large amount of extra vascular fluid. So giving them fluid may only toe transient response to that knock dash. Or sometimes they respond to tell you everything About what? What is that? Orders objective and what is? I am due treatment. It's an essence, as I mentioned Hypo Hypertension Hyperpoly. Um, it just to be discarded, genital or obstructed. So, however, think about what today's is is your most likely in your in your history, and you saw great forward from there. You can obviously use fluids in the vast majority of cases initially, but have a think a swell about what other treatments might be needed. So we're gonna talk about hypertension. It's not so much is in the deteriorate patient or something that was mentioned in the in the talk brief. This is not so bad. Um, it's not so much deterioration, but it's quite common core. Fill my ones on the wars and do being called that quite a lot. And as a register on now, yes, why not asking me for advice about what to do with this patient who's got multiple allergies. We've got the pressure 170 180 or something like that. So when you're approaching hyper than you need to think about that. So it's free aspects that I I like to think about about the urgency of treatment. So it's gonna be the degree of the hypertension, any evidence of end organ damage that's being caused, and then, finally, the any underlying driving factor or cause this hypertension that we need to think about treating. What was it? Just a half of hypertension. So speaking this down, we're looking at the excitement. So we're looking for endorphin damage to these Going to be so cool? Um, your history examination investigations. So with the patient when you called to see a patient with high BP, for example, say never Pressure's 191 100 to understand story, you need to do a bit different and approached. Oh, what's going on? The nurse might just call you about because I hate shades done the obs, and this is what it showed, and she's called the nurse and the nurse is estimated to you. But it's important to just get enough quickest. Even the patient doesn't have to be a history of a clock in extreme but just a minute conversation of how are they feeling often? Er, just have no idea about pressure is that high? You got to try and make sure they're not with anything any concerning features such as chest pain, headaches or visual changes. You'd be looking into the examination and then investigations. So these depending on how high the BP is and how long it's been high, you'd be wanting at some point to have have any CG news. And he said, they're using these this that morning and that brought that has been high all day or it's gone up by 10 minutes of mercury. You don't really need to repeat the use knees, but often these patients won't have a year in depth. And it's quite important from, um, a renal perspective. It's developing, and you really haven't year and your injections done. Obviously, you're not necessarily going to get that immediately, but you're going to awesomeness to do that. So then you want to be thinking about, as I mentioned, what's the driving factor so is any clinical diagnosis but suspected that needs Sergent BP controlled. So this article, penny of chest pain Brady aching through to the back and the BP is very high, then you may be thinking about Is this dissection There's lead to this hypertension? Or is it like you and I? They want to be thinking about some of the more common causes, and these are big things. I just missed out on type retentive Who's on board that this could be either feel prescribing ever in the vote commas in the fact that they didn't know what medications their lawn so they just come in the night before they've been clocked in in their ramipril In their doctor, Understanding is being missed off the charts because they didn't know what they want. The time the Farms has made written it in the notes now but hasn't been put on the drug starts, and that could be very easy fix. So it's not come up with a bit of hypertension. Urgency Dummy does not come up with the title, but there's variable definitions for hypertensive urgency, improvement of allergic disease. So it's variable definitions for this. So, um emergency. Broadly speaking is it was 180 over 100 times a day. I start with 120 with evidence of end organ damage. So then you'll be one delivery hospital policy. And most offers do have quality about what is the preferred agent to start with on how do title it is up to duty and or Levitra or quite often used on there normally be acquire a while without guide on on how to start it, what dose to put in the syringe and how fast to start it and to try to drop according to response in terms of hypertensive urgency, where you've got someone who's got a high BP. But there's no evidence of any organ. Damage may be a symptomatic completely fine. Then there's not very good quality evidence on how quickly to bring the BP down you. You probably see much more hypertensive urgency. Then you will have a hypertensive emergency. So in urgency cases where the example, the BP might be up 178 over 106 or something like that, or perhaps high, but but no evidence of damage, then you'd be wanting to bring the foot, push it down over some hours days. You don't want to be rapidly low, so there's a few different methods how you can approach this on again. This is goes back to so pragmatic medicine level, and so so you be thinking about Are they normal? Other known anti hypertensive? I never It's three o'clock in the morning on there. No. 90 hypertensive, and they got more to be That's going to give it at six o'clock. You just ask the nurse to give it early and assess the response to that. Perhaps they have their dose early the day, and you might consider giving him another dose of their if they're on. Doctor was in and they had a few minutes. They had those in the morning. You could always give another days of your being called in the evening about it on bailing that then I'm not A bean is open, was against the majority of the patients you're going to see in hospital will be above the fresh off the nice criterion terms of the stockade counts and channel blocker first was ever sweet. Other impact such as diabetes, But I'm not a green. It's quite a quite an extra one. You've got to be a bit wary. The opposite. If you're giving him one thing, it takes time for it to work. So if the nurse calls you on our later and says Doctor, the BP is still high. Just got to explain that the AMLODIPINE will take time for it to work on. You've got to give it a good couple of goods off six hours, better toe, have a good effect, or is it a bit faster than that? But you got to give time for a number of being to work before you consider giving any other and you have a tentative. So move on to a second case now. So this is Mr Jones, 52 year old man. You. Do you mind? Just let you read that quickly? No. So, essentially 52 year old man with pneumonia background a ball gets sets, hypertension be behaved. His office show that he's hypo. Is that d saturating? Essentially on five liters of oxygen with their high respect. Your weight. How are we going to have sex? It's patient now. Initially, we're going to increase the option that we need to get this gentleman more option. At the moment. He's he's hypoc sick, but it's before SATs so increasing the math, increasing the oxygen flow on changing the market. Cordingly. Obviously, there's certain masks, a simple face mask, even increase up to 50 m. It's just good to blast it out of the air around the face masks, and you have to use the appropriate mask with the appropriate amount of oxygen I've seen. If you're so we're known you a to assessment because could have gone well. Patient partner on 50 m initially, watch you do your preliminary assessment on Get a bit of a history even if you put in the money on for a couple of minutes and unlikely cause any significant harm from that perspective, you were going for your 87. See, we're looking for and the airway problems. So a fusion Styler secretions Thank you breathing and then actually pretty mentions off moving do you 80 point do ABG but we've got additional hands. That one. You're doing your examination. Don't be looking at doing the ABG and then you'd be looking at being such a chest x ray. See, we've gone on. Well, patient. These might be times where you're considering contacting my George and ask you to come down to the patient as a portable testing, fill out the form watcher there and then usually give it, hand it to them as they arrive. It's actually so you can get that on X ray. Done sort of well, in 15 minutes. If you have you called them in a major to be done portable, and then you got to think about what? What need the wrench into that we offer for this type of the neck patient. So when you examine he's got course, crackles of both bases put you in the light would do just a little bit on coughin. There's no no wheezing from here, So be thinking about what we can offer this, and it's always the option is going to help when we're gonna titrate that up, going to accept. Then he wants me thinking about what do you have in your arsenal that you can be used to treat this gentleman? And this is where you got to think about the few different things that you could be news in different situations that will help. A lot of these treatments have been a little harm of that. If they don't it don't help so that they're worth having a girl if you're not sure what's going on. So saline NEBs instead of them might be quite beneficial. So he's got crackles that shifting on, coughing on. He's got back on the boom getting cysts, and he's got a good cough reflex, then always got good strength in his cough. Love, I should say, then saline have NEBs will help mobilize some of that sputum. Mobilize some of that mucus and beyond. Experienced a lot easier mucolytics service. See, these aren't that useful in the acute base, but are something that you could be useful going forwards and helping carve assistant office quite used. But we are seeing more recently, emotions of Earnestine Zof Short course is to help with that just physio. So these your often well, they have a 21 working. You're have chest physiotherapy. They're on call 24 hours or whatever they're called a day, but they can be really helpful in time for you to shift some of the mucus and help them to patients that experience and get them breathing exercises and that they are as well as sort of physio being used in terms of on the in the day in terms of getting a patient little better. They can also be very effective in the acute setting as well in terms of helping a patient whose music you know, Um, well, so don't underestimate that there years and then you're thinking about other things. Such escalation. Antibiotics, looking at their bark, a little response neck. A little response to a member. The current export. Expect pneumonia aren't working. Need to think about going up on this. It doesn't treat the the D saturation immediately, but it's all part of your arsenal of what you can even offer often other things you could think about in serves. There was there was weird things like Ativan is obviously your nebulizers your steroids from that perspective. So as I was mentioning what's driving the bathroom that defines the treatment so you got all right now and do you get in developing ways? This is when your nebulizers and your steroids will help, so you need to consider on energy, also driving their their way. Now you know, just not doing as much. If you've got, I'll be out of congestion example in Palm. A demon then this is when you were thinking about diabetics. Onda beware that sometimes we use can be cardiac, asthma and so to speak. So you might get some ways even in a patient is have a really make have Palmer edema. So this is well, so you need to be aware of that. And so I tell you approach, but bearing in mind history as well in that in the past. But, um, history if there is a lot of crackles going on the chest and and got background of sort of a a separate of lung condition for the ball book reps, it's then so NEBs and visited mucolytic. So, as you mentioned, quite effective. They've got their just sounds very clear, but they're they're quite the hypothesis on up. Straighten on. Got a high respiratory rate then you to think about what could this be? A confusion myxomatous necessarily the thinking about something like a pa, especially. It was quite a rapid deterioration of a normal chest X ray in normal examination, but all seem to be thinking about could there be a normal severity driver. So if you look back to solve the 80 and you're on your ops, a spiritual rate going up slightly is often one of the first part of your parameters. In a new start that will change when you got a cute young well patient, so it could be a completely normal, spiritually based problem. Need to think about other. Any other sort of normal is better drivers. More specifically, that might be driving this patient's time getting there, so these would be things after the metabolic acidosis. So in a K, I started became relating acid. Then you're going to try and compensate by this by hyperventilating blowing off your Syria to toe maintain your pH in in sort of normal homeostatic range. He might be thinking about. It's part of your, you know, a B Do we or you'll be doing having a look at the bicarb what the bike others day question, alerted to having it like it in the off, not analyzing in terms of Where's the Estrace? Is coming from? Another causes my weapons. That is anemia so good they're good. The respiratory rate be up because on the gas there hates being dropped from 110 72. Um, obviously, that bond is important to check. You haven't taken taking yourself from the drip on, But if it's a true reading, then you need to meet you leaning towards the fact that this is taking the knee is probably part of that part of the anemia and the additional getting all oxygen around because they haven't got enough cells to carry it. So move on to our third case. So again, it's usually use working as a war cover on the on the on the night shift, Miss Smith or 60 you are middle of money in there, which I know GI shows that the peptic ulcer, the NASA concern, is she talking Codec ops? Card it. But pressure is okay on your parameters. All right. How are your grades at the patients? So this is where it's all a bit of a vitamin D for patients, tachycardia and the nurses are should you see them? And obviously you can ask the nurse to do something for you to wash. You're coming to see the patient, so they ask you to see the patient even if they're evenly There's not something you need to come urgently. Four. So it's not that it's a it's 100 and 10 or something. They're completely otherwise fine. It's been 100 and 10 for a while. I was up and down. You can ask the patient that's the next like to perform in a C G for you so you'll have that at your ready. Essentially, really, for you to read, watch when you arrive at the bedside and also any CD, or provide a much more accurate reading or recording of what the true heart rate is compared to two beats or the optimist in In their in their the SATs pro that be picking it up you to prioritize, depending on the rate and also the presence of adverse features. So some people will not tolerate the same degree time guardia than others. Well, so somebody and they're young and I'll be fitting Well, then, so the heart rate up to 150 won't go off. They can. They can be batting along and be kind of other people who don't have the same miserable reserve. Or however couple babies won't tolerate that. That same right and obviously of the rate is very high, then that is another. It's off alarm bell ringing in your in your head that you to see this patient love Virginia. So they've got extreme tachycardia with that first teacher's present. These are things that going back to your a less out with, um, they need to put in at the moment. These are patients may require been such a cardioversion or or denizen via SPT Treatment to delineate what the underlying rhythm is. From that perspective, if you don't need to put out the, um and sickle, you're going for your normal 80 reassessment and looking at their cardiovascular status. So here's an example, for example, in in this patient what that used to do shows. So I will just one. That's all the breathing grants that you could see that the rate is irregular, irregular, so this would be consistent with diamonds is of any effort fast ventricular rate, how we're going to manage these patients with turkey wreck news. So in this patient or another patient, because this is an atrial fibrilation. But sometimes it could be quite hard to tell you a joke. The base urinate. Your front especially if it's quite fast. Angel. Better off world. Pending on the block. Be around 150 BPM basis. You can have slightly more complex cases where you might have a job battle available. Block. Well, it's so fast that you can't really tell the difference. You think about what is the driving factor, so it's important not to start tunnel. Originally, Inter is a, uh, my treatment options here are Do I give the shot? But I would do I'll give you a doctor because but in this setting is not probably the best thing to do. First, for this patient to you to bring about was the driving factor. If this patient wasn't a night after the heart rate was still the same, you would approach, it would be definitely you need to think about from that perspective as well. But why? Why are they talking about? They took me 30 just because there's a topic in the HR and that's developing Major fibrilation. That may be the case, but are there other factors need to consider you mentioned to me about be two droppers and stocks in, and then if you need to If it is a effort, there's not another driving factor behind it. To be thinking about commencing I would be to drop it dox in taking to count available factors and then reviewing for further doses up their Selves. See digoxin. There's a loading, so you need to load the patient with a dose of the jobs in spending on their weight. In the other factors real function, cetera and then you to reassess after about six hours and then consider continue loading the man's for banana into, you know, rate is controlled for Redenbacher's is not so much a loading, but you still need to make sure your setting the office once and giving up and never doubted if needed. If this is a poor response, if it's off six Hope in the morning, five in the morning and you've got some where atrial fibrilation and you're not sure about anti coagulation you can if you've got the time off during the chance basket. The orbits score is is useful, but it doesn't have to be a decision that you have to make now and then because it should be a decision that takes into consideration or the outside factors that from the dating or no, the patient and also a decision is made in collaboration with the patient and sort of cyclical in the morning when they're have bean fast asleep might not be the best time to start talking about long term risks and benefits of the population. Mrs. Miss, Miss Case, for example, you do a baby Jane, you find out that she's got a drop in hemoglobin from 90 to toe to 71. You send off blood bucks a swell just to confirm this biochemically. But in this case, giving her a beat a block or digoxin, although on on paper is the one treatment, they wouldn't be the first port a call, and I probably wouldn't be giving it initially until I tried with Born in the same situation with fluid and blood. It would be my main aim because this this would be this. This case would fit more with someone who's hyperbole minute. But it's driving a physiological, happy cardio sponsors. That means her heart rate is high, Marva, that it being, um purely the AFO itself. So you'd have a think about what is the driving practice of this place you can get fluid to start off with and then blood after that, when you can get that group and say it's off. So if someone is, for example, septic and sadly hypertensive and you don't want to be suppressing the hard way would be two blockers because what you'll be doing, then you you'll be suppressing someone's physiological response. So in these cases, you know it's hard to treat them as if it's a Sinus tachycardia, um on d, treating them as if you would if that was the case with for volume of replacement and then going forwards from that perspective. And I'm just going to catch a largely, just a big concept of six and practice way. No, I said assess. I'm sure you've all owned it from your medical school. First aspect of it is oxygen blood cultures, Very useful. Taken early on, will, on medicine to help your colleagues down the line in on also also help the patient as well. If you can send it by the book that's grown, you can narrow down your antibiotics much small quickly, but it's it's something that you're doing for the future benefits. Well, then, um, other than today's benefits. Some microscope be can suggest the court. That's the source. So you're looking at a cock I, for example, but you weren't necessarily bad to tell her Is a normally bill awaiting further sensitivities IV antibiotics. So when you start working all worlds, bet it's off on the hands are good to go to the hospital policy, and these do very, quite a lot trust, I trust. So where you been? Your last placement. Maybe very, quite a bit from where you're currently working now. Well, what you will be working on it varies a lot on what the local resistance is. I mean, fluid. And as we mentioned before, a lot of it is in a lot of importance is on frequent assessment on making sure that the effect is sustained urine output. So this is where your remaining first of a minimum of your 0.5 mils. Okay, deeper hour. Unique. Look, that's all the areas of the, um is that good? I go, uh, that situation by taking I got my life or come in which way around it is now, once for some of your criteria, AKI, in terms of what the urine output is is just important to some of the biochemical features, and then you're lacking taped. So this is this is raised, and it's open done when your country putting the cannula and you put the put the pen 11 you might take the blood's out for off the TVG and send off the full blood count. You sneeze, etcetera, so you should be taking blood cultures from the back of a cannula. But when you're doing the over the results, then you'll get your initial preliminary lactate result often. So I've done before. Any treatments done? So if it's high, then you to make sure that you you've got plan your place toe Europe, eat it to make sure that whatever you're doing is helping the perfusion. So just the cockpit on lactate. So what is that? It's so it's a part of a, um, a bit like all excess on, but it's produced when you have enough oxygen. See if you respond on aerobically and then it's metabolized knowledge e by the liver and the kidneys. It goes up. There's excessive production or those in PE Clarence, but there is a lot a lot of reserve for for clearing, like taking both your liver and your kidneys. So that is a much more minor. See, what goes in must must come out. But you do have large reserves for doing that. So shouldn't be the first port generate manual on your rand news, but mostly it's Bob to then it's It's It's raisins and it doesn't have quite you useful problems that you can use. Their levels were going so much harm than so towards. Nothing is done. The studies of it's bumpy thing is there is a high risk associated with the high mortality risk. So there's two types of blacked in acidosis, the latter one being a bit more niche that you're type a lack of oxygen. Dude, you're impaired Option delivery needing to do a spy on a moment, please. So what the settings could dispute. So this is this. Could be I would be in the right by the muscles. So, in the ears of seizures, are you doing a really jobless easier to come for that and the event of the Congo after you're exercising? Um, non athletic attack? That won't be so. You know, I always be quite as high tissue hyperperfusion so this could be generalized or or focal. So So what we're thinking about generalized hyperperfusion. This is off the septic shock, respective or hyper. I have a limit, I'm sure, but you need to remember that lap take could be produced by lots of August. A lot of areas. So even if there's any one area that's being hypo refused that or still lease or a very high latitude that we'll circulate around, just be picked up to you when you measure, I'll actually don't know where that takes coming up. You need to be thinking about focal causes, and a big one is It's amazing. Tokofsky know very high lactate. You know where, sure, where it's coming from that happen, the backing of mine. So mine also they be hypo profusion in terms of the actual blood getting there. But it might be that the the auction know getting there, so we can't just biologically. And these were being such a anemia and and cover Um, that was a poisoning and then finally sort of a bit more. There is your your type two diabetes accidents. This is this is more for completeness, but he's off certain conditions like lymphoma, leukemia. Some of the organ failure is, and then finally the dogs have you given someone a lot of lot of sappy. Tomorrow they can develop a slight, slightly raised like take. And then I quit is mentioned. It's a swell, but we'll just talk a little bit about escalating in about sort of how you put expire into practice. So has to live. When when I feel when someone's been scoring for advice, then I think a good ways to slightly more by your X box. And that's why it's been sort of use that hand day there. But when you're escalating up to the range or to the TSH Oh, then you want to, sort of, I think, get two points across century. So you really want to be almost changing your X bar from SBA are two s are be essentially so well you're really wanting to do. Is is put your, um, situation recommendation quite seeing on. So this sort of it's quite wordy. Yeah, so instead of your x box off way, so you're saying they can't trust pain? Background this in the pneumonia and watch headaches. This is what was going on It is my assessment where they're ops and my examination. And then they say, Well, give me two more bites or you say it might be that if you wanted them to have a look at the C. G or for example, then it might be easier to say that the beginning because they might say, Baby, be bring it to me. We can talk about it there. But when you've got other cases, you might want to socket around to make it a bit more prominent. So you're worried about. So I've just seen the chest pain that I like to have use. Options has has risen up quite significantly, and then you know what might so asking few more questions about what they tell me, but more the case. But I think so. That's so free, broadly free categories about why the ring in the register on one is your liver sick patient. You need help. He wished case starting off of saying what? Just seen someone who's got low saturations in low BP. Please, baby, come and help. But that no sure what to do next? I need I need some more support on. I think that's quite useful in my our say. What about pressure? What's the SATs? Because it might be in recess, Um, on. They want to know to qualifies, Do that still get themselves or do this and the Shh. But I think as to see that's better, that you don't want to be going into lots of their past history is this. This is what my examination was, because you can be needing them there. And the more time you spending over the phone, the less long it'll take them to get there. So if you want them to be coming because you're with someone sick, get that point across early, because after the time it's easier to for them to make that assessment. When they're there with you and you can go through things together. That's one. The reasons why we call it. The other reason will be for advice. So again, that's probably best off every year. If you're if you're doing the spirit from the top, then the person and then the phone doesn't know what points they do picking out, but they don't know what question is going to be asking, so it's quite good to say someone that I've been on since he's on with, Um, example. Chest pain on the opponent is if this on, Do you go about a patch testing for this long? And this is what these do shows. Do you think I should give them aspirin now? Which one? I should wait for another I wanted. I want to ask, Should I get the aspirin now? Or should I wait until after the second opponent, for example? And then you go into the history and the white and then that, then the regularly thinking about going three. What what points don't need to put out about what will help you make my decision, rather do it their way around. But then the not knowing what you're going to ask him to the end and then the the third sort of reason why you might, for the rate is for a new investigation interpretation. So friends are both chest X ray on the C G, and again, then it's It's quite important to, I think, to tell them that the beginning, so to say that I was on the chest pain. But the only CGM not sure where there's some ST Depression in some of the natural leads on And then you might tell them at the chest pain in the background. But we might just say, Oh, I'm in research. Um, could you bring me the couldn't put you? Bring these with you to me and you look at it together. Or you might say, I want someone who short of breath of just gonna adjust X ray. Do you think is this on until there's a small noon before works and then they can load up the the X ray and you can talk for the case about or they got that ground of COPD and they had a previous number for like, two years ago. It just helps the thinking process on the other end. But, I mean, the main part from that is that if you want someone to be coming to help you, it's important to get across early. So they're not spending a lot of time talking about the face, too. Then ask them to us off common anyway, So it's important to get across. You know, I didn't say that he wouldn't help on who you want. Help thumb. I'm sure they'd be willing to come and help you with that patient. So, bus, um, a whistle whistle stop tour of deteriorating patients a bit. They tagged on the end. I hope you found that useful. Probably Christian. Be here as well in the background. So welcome to answer any questions from either talk. I will low back up, close down my screen, but I will look through the chatter. There's anything that's come through. Thanks very much for listening. Guys think it was. There was a question, actually, while you were talking Chris from George, who was asking when you were talking about patient with hypertensive urgency on doing the urine debt. And you're right, George, you have. The reason for doing that is the protein urea, which can be a marker of bend organ damage often often the green or team, or, like they reduce your protein, your ear in the in, the in the urine dip. Then the next step would be looking at doing oven a CR send you off on our ratio or approaching craft. New. Make sure after the lab req takes a bit more time, but it will help your work up from terms of soft. The end organ damage to the difficult knees. All right. Thank you for this very formative talk crispy. Think we spend? It s so now we'll have the QNASL in the guys. Just put your questions in the chart. Any questions for Grace? Uh, we have to very experienced Michael registrars. Any questions at all about what you would do as an f one or anything about life in as an F one in general, You want it all scripts, you can spend it. We'll do that. Best to answer it. Um George, that that the urine dip I wouldn't normally do the owned it myself. I would normally ask that then asking him to do it. However, Sometimes if you want something doing quickly doing it yourself, it is it is a difficult bind. So busy your you are obviously a a resource that you might recovering a lot of devil there. War zone. Like I said, it's not. It's not a test that needs to be done that minute. A lot of cases, but it is important to not just doctor in the notes. It's important. Actually. Tell the nurse took enough patient could be peaceful, be doing urine dip on this patient when you get a chance. Movements off we don't want to see is when they're just wished, written in the notes. And then there were that it will it will never happen. And just a reminder in the meantime to do fill out the feedback forms at the end, Using the link posted in the chart, you get a certificate of attendance you can use for your port for you as well. Yeah, just put some more questions in the chart. Guys, if you have any more questions or medical registrars, science is quite, you know, that you're exactly right. Good. So I'm going to listen to this talk until Benicar Good night. Uh, we have one question. Can meddle talks be counted as part of your portfolio. See a lot of the f Y one survival guide. Serious. Uh, you can use these non called teaching hours. Uh, so you can use your certificate of attendance? Uh, as proof so it can cover is not for teaching hours for attending able questions. It'll anything about that one? Life left. One situation you deal with you have a question. How do I manage a patient who is not responding to voice or pain, but anyways, patient and breathing on their breathing. Okay, um, I'll take that one. So on. And I think the important thing is, obviously you would do it with one so that that they're always Peyton set up a few means there's no no airway noise is Do you want to figure out why? Why there unconscious was That's not normal on D and common things. So hyperglycemia always important to check for that even in patients who are diabetic on then looking at medications. So you know this is patient been given opiates on basically it in the context of you know, often you see patients who have come in that you feel well, and I've got range renal function, and they just had their routine, you know, long action, morphine prescribed like so more. And then this will be accumulating and causing toxicity. So or they want to check those sorts of things out. Um, is there any history that might just have a seizure from the nursing staff or they going to be epileptic fits? All of these things are important to look into, and in terms of how you manage it. It's important to, um, not just dismiss it. So off the computer, you can look reassuring if all of the articles on Define on be crystal. Probably we see a lot of these patients in elderly care. They just become unresponsive. And sometimes it could be a high park to delirium that it's always important. They probably need some imaging of the brain, and they've not had imaging in the brain. Nature have not had an acute bleed or something that might be making them on responsive. So I would say your initial assessment on Ben Speak with your senior about arranging some imaging and proceeding based on what you found happy that pretty much covers covers from our operation as well. Think that you say the drug chart is often undervalued resource in your assessment of the patient, and you need to be thinking about not only so additional drugs that being given. But the other physiological list parameters Is quest mentioned that might change so that even a normal day to draw board a drug that had been on for a long time may have quite a nymph act. The toxicity is not necessarily due to the increased dose, but might be due to the reduced occurrence. Any more questions at all on your audience? This Toprol also is also being recorded. Then we'll be available to you. You truth, general. Okay. I think that's all the questions we had or today. Thank you. Both creases with this. Very informative I'm trusting. It's going took. Um, good luck with your phone placement of run. Maybe see around the Lord's. All right, all right.