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Okay, so we're live. Hi, everyone. Welcome to today's Webinar. My mind, A bleed on preparing for on call and common bleep scenarios. This's a webinar spot about 10 parts Siris off the F Y one survival guide. Today's talk will be held by my colleague Doctor Nidal. Champion is an f Y y in the working the West Midlands, but this talk is also being recorded and will be available to watch on the YouTube channel the mindedly beauty of channel and medal. But also be sure to check out our other videos as part of our F Y one survival guide available on the YouTube channel. Uh, in the chat box will boast the link to feedback form. So on filling those out, you get a certificate of attendance for artists. Talk. Also, put your questions in the chat box and we'll try on to all of them at the end of this talk. And this talk is being sponsored by the B, M and the EMT. You from the DMV? We have Daniel who will give a short presentation, and then we'll run a video from the end and the UA swell before Needle goes on to deliver his talk. So without further ado about Prosteon to Daniel. Okay, Cool. You should be receiving my screen now. Just got something in the chart as well. So yeah, everyone, I'll be super super quick s So I'm I'm done with the, um a well done graduations once again on becoming doctors looking for the next couple of weeks induction more not to come. So just what we begin. You see, there's a massively overwhelming big big text on the screen on yet this is basically the big stuff we've we've ever had. If you know a member of the BMA already, if you use the QR codes on screen or the link, I've just been the chat. You get free membership until October. The first. That's 2.5 months free membership. What is a vital time to be a member? Yesterday muscle. We asked you to use that QR code or use that links that gets the same place on yet and just apply the membership. If it says any point, you're going to pay whatever a month, you're not the way it's going to get weight as long as you've used that link. Yeah, if you if you're unsuccessful, joining as the doctor's enough one. Just try as still being a student. We're just waiting the GMC of feeding through the GMC numbers, so we haven't quite got it yet. So you may may be a bit of trial and error joining us that one, but just joining us a final. A student still so sorry. This is a weird time for us getting TNT numbers. Um, yeah. So from October, membership will be 9 lbs, likely one a month. But it's 7 lbs like free after tax free. So you do get tax relief back on on on what you pay. Um, so you don't have to stay beyond October as well. So you can you can stay because that's when my membership yet and then the from then you can even really want. But yeah, I would definitely say at least join for next 2.5 months on and used to use the contract, check you some of the tools that I'm gonna talk about it. It's up to you whether you stay on that. Definitely best thing to do is just be part of the May for the statin. Next 2.5 months. Pretty vital time. Yes, I just a little bit about membership. I'm sure you are all members, or you remember some point. So you know what we do. What you get is is being a member is well, a little bit of a refresher and happy might find out something years. What about beer? Name what? We do essentially the same thing. What? We are the trade union. Fresh in association with talks in the UK eso we act as the voice the profession rep sent you individually in nationally on on the issues that affect you. So why should just like our patients are jobs? Toe? Look after you. You're gonna hear from M D U. Next, Sometimes we get confusion about we've been definitely were not on investment company, So not like empty. You were not like MPs. We don't deal with patients. Play to be your union. We're here to look after you your your working dishes to things like pay contracts, Your professional vermin also your well thing as well. And some of you who are who are members would have would have started to get messages about the ballot that we're gonna run day on the year. So we're looking for we're looking for full restoration of PE team. Is it 8% on their well, most likely be strike action and strikes off the start start next year with ballots off coming towards the end of this year. So even more reason to be a member. Um, so we'll be striking. It looks like. So start next year. Like, like, 2016. You guys come out that, um So just in terms of day to day stuff that you can use this fall, I'm gonna be in a library, which, which is a little sense off into the IV books now. We used it was mainly a postal service have used before. But now you just access things instantly from from anywhere. Yeah, you can just open for our website or in your phone. Finical keys is a new tool we've got Well, so as a medical search engine, you may have had a med school. I mean, tell me to use that True for being a membership. Um, it was a Lexus of our technical nonsurgical going to also got a Lexus to be M J learning, which has over 1000 clinical non clinical modules. As also course, is that really helpful for completing your people are earlier when when you start at one on, it's all very interactive and then kept up to date with obsolete. Practicing developments for any hard to do is where you can print off. Stiffness is proven, um, very thin your thing about your specialty options already him use especially explore it'll, which could give you a better picture of what's suits you best. So it's that one's an online psychometric. Testing takes about 20 minutes complete last. We'll sort of work life balance questions, and I'll give you a re detailed report listing all tops, especially because you've given, um, really, really easy to use uncovers, especially in the right. There are a lot of nights it, um, really good to do the different parts of different points as well in your career. So So do it now, and it's off a couple of months into into F one due again and see how your your taste change. Yeah, really good. We got really good well being service. So any time you like to see someone about your well being we got, we got ourselves. They're open 24 7, so it's all screwed up. This another choice. You speak to the counselor, appear sport doctor. It's telephone based on. We do a video calls Where further? I'm also make sure you speak to the same person of it's more single call to service committee Confidential is the free of charge. It helps everybody sauce. That one's regard is the Web. You remember Lots. It's open. So the biggest thing on tell you how important the big thing for you to use sort of the next month Or even now, if you if you got it was like contract checking servicing you might come across is already, um, yeah, we'll check it in five working days, comparing it to the national model that we negotiate with the government back in 2016 and then again in 2019. I'm never any issues. We can help get them solid, so it's always on purpose. But but extra bits come you slipped into your contract or or trust can change the wording to me. And so it's something opposite. What should say we find this is quite common? Probably. Yeah, we try to make sure it's correct and you're getting what you should be. So you see on the screens quite damning statistic. 20 Like 25%. The contracts we checked last year were wrong. One and four. It's just too high. A number for signing that was negotiated should be standard CSA. Let's get it. Let us check it before before you sign it. If you have signed it, it's fine. We can We can still check and get it. So it, because it should be, should be given a wrong contract. Yeah, just don't just don't let it be that one and four on Don't sign it thinking that's correct. Beside the one before last year weren't on. Yeah, well, so you can check your your roads compliant by using our road check. It also that when you can enter your right onto the online Till now, flag was wrong, right? Should be a bit more standard, so you should have less issues there. Yes, just a few figures in regards to that. We didn't check a small amount of contract last year. We checked 6000, So 25% of those being wrong just to higher numbers to do join. Let's check it. Preferably before you signed it. Like said, if you have signed it, we can still help when you still get it rectified. But yeah, we're good in that department of getting things sort. And we often get a lot of money back for doctors who have been on contracts for a long time, not knowing they're wrong. Checked it with us. And, you know, you could have 1,000,000 lbs back, but we drive. You just got it right from the from the get go to get it sent to us. Yeah. My a lot of lot of drama, doctor. Cases of marriage Last year was 21,000. So if you find yourself needing, some support counters will help you through. We've got people on the ground. Every trust got employment advisor got industrialization. Officers got lots of people that base that you trust and no hatred of know who to know to get things lives and help you support you, protect you on get 1600 road crews answered. So Rose again like that should be a bit more standards. But really, if there's nothing else you take from this Just get your contract. Talked of us a contract Checked with us before you sign or just get it checked about even after you signed it. Yeah, that's it for me. Like I said, that start if you remember. Good day to join, because you'll get 2.5 months free up to you. What you do after a table. See, that should be so ballot and ballot and potential strike action after October. So I hope you stay on for that. But just joined. Used that. You are code you get, you get it free until October. You get your contract check. Get your reject on. Start using the tools for F one. Yep, that's it. I'm gonna cut their thanks for this thing. And good luck with everything. Yeah. Enjoy a session too. Thank you, Daniel. So now I'm just going to play video from our other sponsor, the MD You. Okay, so now I'm gonna hand over to my colleague doctor, and then I'll change in your going to deliver this session on preparing for calls and common sleeps and hours again. Don't forget to put your questions in the chapel and, uh, fill out the feedback forms. Which wolf? We're dealing to get your certificate of attendance. So there's over to me. How? Hi. I'm sorry. Can you hear me and see my screen? Yeah, we can hear this. Perfect s o. Hi, guys. Mind isn't helping One of the few doctors working the West Midlands. Sorry about my voice today. I'm not very well, so my voice will be quite horse. I've got blocked nose and a sore throat. So the apologies before we start, um I try my best. So today's talks on on calls hard to prepare for them common bleep scenarios and how you respond to them. Um, this is our life Webinar in our 10 party for one. So I'm quite Siris. Um and, um, we'll get going. Just the shortness claimer. This session will not teach you how to manage acutely on well deteriorating patients. There is a dedicated web. Enough of that on Thursday, the 20th of July, purely due to the fact that that webinar needs to be delivered by someone more experience in ourselves. So it will be delivered by two medical registrars in our trust. Yeah, that would be on 20th of July. How to manage. The deteriorating patient is an F one. Um, so you are definitely used to ground for that one goes the contents of today's session. So I'll just give you an introduction about what one calls on how we go about, um, how to prepare for on calls, how to recover from, um calls a bit of general guidance, some of the common bleeps that you might face We're working on the ward's, um, on some scenarios will go through those end. So what is an on call shift? So Uncle Shift is a shift where you're expected to work outside of your normal working hours, often for extended periods of time. You expect expected to carry a BLEEP. Respond to all your bleeps that you get. Um, typically, muscle might remain on site adult times unless you're a consultant. There's many different variations of on calls. You could be on a day on call a not shift. Yeah, that's why, like shift the hours very between different departments. So, for example, surgery versus medicine. Um, again, there are different types of uncles, so you could have an uncle way your would cover or an on call where your parking new patients in. For example, if you have a medical clocking on call, you'll be seeing admissions from E. D. In the acute medical unit. Um, Andi, you know, prescribing. They're recommending medications and talking, been taking histories and exams exception. Whereas if you're on a surgical on call, we'll be seeing patients in SC you most of the time. She's a surgical missions unit. So what? The typical hours of an on call surgical day on cause Often start eight and 8 30 on guys, First of the night or calls start eight PM on D and 8 30 AM Medical Uncle start normally of it latest. We'll start mine and finish it 9 30 the night team will start at nine PM and finish 9 30 AM Twilight shifts very again. The general hours are for about four PM until you know on If you know between civil estate, the surgical day versus not on call. You know there's a 30 minute nap both from eight AM to 8 30 PM on 888 AM to 8 30 AM on eight PM to 8 30 PM on that 30 minutes at each side is just to allow the day team to have noticed the not team on the not team to have new to the day team in the morning. Okay, in terms of preparing from called make sure you bring some food with you, especially when you're working on a weekend or you're working night shift where they might not be any canteen or half a options available. Bring some healthy foods so good mixture of carbohydrates and protein often when you start on, causes a temptation. You know to just get a big energy Russian Biggio's of energy drinks like red bulls and fast food you could order in the middle of the night. I trust me. You'll feel rubbish. I didn't probably crush in the morning, which will affect your performance. Is doctor so being there? Don't not hardly recommend against up before you're on call, so you only allocated into a block of on call so you look for on cold days in a row or three Uncle Days in their own weekend. Friday, Saturday Sunday, you need to organize your personal life before the uncles and do anything like food shops. If you've got Children, arrange childcare cetera, because those days you're gonna be so tired when you come back home after 12.5 hour shifts or you're gonna want to do is go to sleep. So make sure you organize and prepare yourself much as you can before you start your shift. Um, other things to do are you know, you're gonna be walking around all day where some comfortable shoes make sure you have the relevant equipment ready, so you need to bring your stethoscope pen, torch, tendon hammer, things like that. Um, insurance a useful upside down. Load it. So we did have a a webinar on this school, preparing for if I want it's only metal page of the YouTube page. So it has a list of all the APS that you should download, and they're very useful for these on call shifts because they can save you a lot of time. So she went Clark in patients. Um, if your, um, art shift, you need to prepare your sleep pattern. Researchers showed that typically the best way to do this is to do that for Ah, night shift. Wake up late. Is your cancer does certainly loves the morning where couples ladies, you can try and, you know, relax. Good sleeper. A normal latest time. Wake up is letting you can during the day try and get another nap in just to ensure you're fully arrested. Few nights during the first night shift, you will feel very tired and it will take you. Sometimes you're just so normally day 2 to 3. You've adjusted on Day four, you know, so tired from a lot of shifts and your circadian rhythm so disruptive that you're crash again. But it's just how it is. See, I try to prepare yourself and get much rest is possible terms of recovery? Um, because he's a 12.5 hour shift. Sometimes it can be you can be to charge drive home. And if it is a level where you so tired, it's unsafe. The drive taken up. Most hospitals will have resting facilities of doctors, whether that be somewhere around the doctor's mess or something, you can arrange with your local department. But you know, if you're too tired, there should be resting facilities available for you guys. If you're gonna go to sleep, try and make sure that your sleep will be disrupted. So things that black up lines. I masks earplugs. Really, really useful to synthetically. Um, to make sure you know you don't wake up to three hours after going to sleep. Okay, Some general guidance about one calls. This is very general, and you pick up most of it when you actually do the work and you're on the job, so you need to learn from terms like Take post taken hot. Take take is when you as a junior clock in a patient. So for maybe you from, for example, your parking a patient. That's a take that. Patients who take, as we call it prostate is what it's been seen by a senior. So either a senior, just raw or a consultant. The different street of post taking a whole take is a post take is doing the next day after you've clocked in the patient. So you'll see a patient wrote for a management plan. Prescribed the relevant medications. The best do development of investigations. Get a series of steps for your management plan. Other. The patient might stay overnight without reviewed by consultant until the morning, so that will be post taken in the morning. Similarly, a hot take is just the same as opposed to take, but the consultant sees the patient essentially immediately after you've clocked in it, so I might be in the afternoon or the evening after you talked with. If you're clocking, there's often a separate former set up by the department. This is true for most, and it changed trusts. So they're being on medical performance for the new patients in a surgical performance for the surgical patients has lots of different sections, which remind you which pastor fill in. Um, so just follow that before where you probably go wrong. Remember to prescribe any of the patients regular medications. You can normally access these via the summary care. Of course, she use your smart card to access on again. Prescribe. Essentially, every patient comes in the hospital VT. Prophylaxis because they are a mobile. They are high risk of having a V t beauty and you to this, um, your ability. Obviously, if they're covered with a bleed, don't prescribe them TIMS apart because you're gonna find a precipitate, that bleeding. It's inappropriate in that sense. Typically, medical patients get a prophylactic tins apart. A little liquid melo black your way. Print um, surgical patients get little molecular weight heparin as well as Ted stockings. Um, keep it organized. Patient list again. The key to uncles preparing for all calls. Actually, doing young cause is to stay organized. I know it sounds cliche, but it will help you so much. Every patient you see keeping the name, the idea number. What? They've come in with the jobs you have outstanding for him. So normally, most of this could be on a patient sticker. So if the stickers of them in the notes of this paper notes so, yes, she had papers. Patient has declined, and right now, did he have something? Jobs. It will help you. Stay open. Honest. Make sure the shift runs a lot more smoothly. Take your rest. So in a period of 12 hours, you should have a minimum of 60 minutes rest. Um, you could bring this out into to ship it to rest breaks. So if you're working night until 9 30 you try and have a restaurant and want to pm and then another restaurant. 66 PM Should make sure you have your rest. Stay hydrated. Eat your food. It will help you be a lot more effective. Unfortunately, the doctor and trust me, I'll be in there where it's so busy that you don't have time to even have a drink of water during the day. You don't have time to eat, so yeah, By the end of it, you just completely nonfunctional. You're useless. 20 bodies. So make sure you take your rest and have your drinks. Drink makes you drink your water at the interview shift. Make sure to hand out how do you have any outstanding jobs? Use that spot 100 because you know when you're receiving 100. If it's not very nice and you don't know much about the patients so basic things when you have to get over a patient, the patient's name, the patient identification number that location bit about what this could be with. So this patient was admitted with, um, community acquired pneumonia. Um, a bit about that background. So what background your past medical history is. So do I have COPD? Do they have asthma? Etcetera. Then again, what you're sesame is what your investigations are, what you're the person to actually do. Is it to chase the job? Is it to do a job most jobs are programmed to hand over. There are a few exceptions. Things are normal vision that could be done in the daytime. I don't have it over things that would take longer future having over them to Doctor, do yourself something like a PR exam. It's not really appropriate to do a PR examine me. Nearly case when which PR example be emergency for you. Suspect it's a quarter quieter. In which case you better be doing the PR exam yourself. Yeah. Okay, Now we're going on to some common bleeps of these are some of the most common bleach will get what you're working in. The left one. Um, some of the most frustrating. Some of them are very important. And you'll get used to filtering out the important ones. So go through your patient needs to cannula. Patient needs bloods taking in the middle of the night for gentamicin of uncle. My PSA level patient needs a catheter. Patient has fallen. Any new review patient has lived with pressure. Um, patient needs antiemetics analgesia. Um, patient is scoring. So they got a you score greater for they've gotta use of two or three month promoter on There are many variations of this. So you could get called about patriots. Tuck it. The Kentucky Kartik. Hypertensive, hypertensive. Um uh, exceptional. So very many variations of this. And you learn to You don't have to manage each one individually, but I'll give you a quick whistle. Whistle Stop. All So the most common bleeps on how we sort of go about them. So patient needs a cannula. If I get this belly, I make sure to ask you a few questions. So if I wanna, like shift, I'll ask you why does the patient cannula? Um, so if they tell me it's for fluids, I lost, um um, last time for the patient details, for example. Fluids only really urgent if the patient is no my mouth or in kickin injury. So remember a consultant saying to me when I was prescribing fluids manically overnight? Do you drink fluids over night when you're asleep? So you don't So what? You prescribed the patient's fluids overnight and making sure they continue to have influence. You know, it's not something that Sergent overnight. If you have time to cannulate ablation for fluids, go ahead. Um, but if you've got other things that you need a prioritized you most likely will have because the ships are very busy. Then you shouldn't be doing that if the patient needs IV antibiotics. That's indication for a bit more of an urgent cannula again, No one bathroom mention before what's happened to the previous cannula. I always ask this has it falling out? Has it tissue? That might just so it's not working. It's zero flushing property, I think. Go and see the patient. Look at the cannula, flush it myself, and it flushes perfectly fine. So make sure to check that so time is coming. Is a working perfectly fine. You think, why we're having to recannulated patient? Um, again. Another important question is, Has, has anyone attempted to insert this canyon on the ward? So as a general rule of thumb, a national ways attempt to Can you love before junior doctor and F one? If a nurse calls me and says I've attempted this cannula have been successful, would you might have in the garden a see, absolutely, That's fine. A song that you've had a gun, you know, might be a difficult patient. There's no need to stop the multiple times I'll come and have a go on the general line of escalation for these sort of things that blends and cannulas is the nursery attempt. At first they failed the F four s, it show SPR. But if the SPR can't do it, the registrar, um, that would have to get the statistics that often I use ultrasound for these very difficult cannulas patients with collapsed veins, tiny veins called peripheries exceptional. But, um, yeah, the anesthetic registrars really, really cannulate patients If, uh, the prior people have attempted and failed so like so the nurse, everyone s it Show a reg. So make sure you know, you escalate appropriately if you can't do it normally, if it's an urgent candle, I'll have about three goes before I say this is enough. There's no point distressing the patient, especially that needle phobic. The point now continually stopping them. If if if you're not being successful, I get remember a prioritization if you got a patient scoring and eight, um, the nurse says you that says you were in the car dealer for another patient. What you going to do? You want to see the patient scoring in eight. So you're going to do a cannula. So again, you have to prioritize your jobs. Yeah, um, Cannulas They can be urgent, but they in some circumstances they're not so intense. So make sure you you find out what it's for. Um, another. Commonly that I'm getting at the moment is patient needs blood tests for gentamicin levels. So if you're on surgery for your first baseman, it afford you have a lot of patients on gentamicin vancomycin. Um, essentially, because we give a lot of patients with potential and abdominal infections triple therapy, triple antibiotic therapy. So that would be amoxicillin metronidazole gentamicin. Um, and so if you've got a patient who's had their or receive the gentamicin dose at four o'clock or four PM, every patient has gentamicin dose needs. Ah, post dose level 6 to 14 hours after the dose every three days. So the other does four PM but need a level. Check it 10 PM to six year again that will fall to the F were one on the light shift. So again is important because, you know, with gentamicin, there's risks of renal toxicity and total toxicity. So I always check the renal function dose every three days or up. You know, the line of escalation of millions. So has the nurse had to go taking the gentamicin level? Um, because you remember dreams, Uncle Shift. You are covering multiple wards. Multiple. Um, well, patients and nurses typically allocated a baby in the house of 69 patients. So you know, it's busy for everyone, but you have to prioritize and escalate appropriately. Um, similarly, with vancomycin, you need a pre dose level or a trough level checking every three days to monitor. You have to buy some doses. There's a risk of rebound pox. ISTEA sir, is again important again with prescribing these. Don't be, You know, scan. If you're not sure how to do these things, ask your situations. Ask you registrars. Refer to your local antibiotic policies on if it's drug daytime shift called up the mark apologist on court. You know, I wouldn't contact a consultant microbiologist three every night for a gentamicin level, Um, advice. You know that that would be inappropriate if it's during the daytime, when you need to get some advice. Go ahead, Estili. Remember about your line of escalation. Like I said earlier, remember a prioritization so yeah. Uh, next common bleep. The patient needs a catheter. So you get this quite a lot again on surgery, sometimes amounts of You need to ask some questions first, before you go to the water park catheter in. What is the indication for the catheter? Is the patient retention? Are the septic to have stage AKI, Do you have to Syria, for example? Some of these might not even be. You know, some of the things that they call you for money. I even require a catheter. We need to filter it out and find out what's going on. If they're a retention has a bladder scan good drug because, you know, the nurse might say he's in retention. Do bladder scan. There might be 100 mils of the bladder, so this is important to establish before he goes to a catheter in, um, again, there's different types of catheter in short versus long term to recaptures versus three or catheters with three weeks comforters. You know you're only yearly really Insert that essential. Definitely. Gatien. So if a patient has clocks on their passing clots clots, they get paid for painful stuck in the urethra. So you need to insert a three catheter to irrigate the you get the bladder on, wash out the clots, but this is something you should, if you're not sure about that's totally normal. I remember being asked to do a three week after my first week of being enough one, and I have no idea which deals that. How do you even do that? Um, I had to do two way, not three way, most essential oils. Reggie's will be happy to show you on definitive, you know, proper, um, difficult urology cases. There's loads of clots, you know, be worth contact with the urology, right? Because that really should be someone who should be escalating to it's instance. Generally around 500 miles, retention is considered to be significant with catheterization. Um, another thing that I I had once was Ah ah, Nurse told me there was two liters of urine in the bladder and are some thinking to myself two liters of urine in the bladder. That doesn't really make sense. That's a milk bottle. That's I continue mobile to us. That was a make sense talk turned out the patient had dead societies, and the actual the bladder's kind of was picking up the fluid in the abdomen rather than the bladder. When someone else had catheterized patient, no urine came out. So so you really come out? Is a couple of, I think $15 or something, but nothing much. But, um, yeah, make sure that the patient needs catheter if you ask to catheterize a patient on typically a nurses generally expected to have to catheterize patients in their agenda. So with female nurses, um, let it be expected to catheterize female patients again with male nurse is to be expected to catheterize male patients. If it's a nurse of the opposite genital, a patient that it's a program for you to be called to go catheterize a patient, we might need help from the nurse and hate. See a just act as a shepherd. In that instance, it would be appropriate future catheterize and, yeah, moving on patient has fallen over. This is a common scenario. Get every patient has a fall in hospital, needs to have a doctor of you. So the important questions to ask our was the four witnessed. Always Unwitnessed is the patient anticoagulated. Did they hit their head or injure any part of their body. And again when you actually go to the patient, you need to take a thorough history and your full body exam when I say a full body exam in full body exam, um, full msk a gram to make sure they haven't injured any of the joints. Your exam? Um, sister GCS. It might even be appropriate to do a cardiovascular respiratory pressure exam, depending on what part of the body they're injured. So, yeah. Three history, full body exam. Been arranging appropriate investigations if a patient's fall over by their head on the radiator, you need to read a CT head on me. Otherwise your protection liable to something there. So you know there are certain important, messy a shins. Get your range. Yeah, you're up to 40. Appropriate measures should be put in place to where it's coming again, so they should have a full risk respond. Um, and so nurses should be keeping a close on them because of the deity to the bathroom exception that should be escorted possible. That should be up to go alone. The bed rails, the bed rails on the sides of be up to prevent falling out of bed. Yeah, they might have the body of a low set. Bet so much A slow the floor to start falling over. Um, yeah. Another called Leap patient has low BP. So this is you know, this could be worried. One. You know, when someone says low BP, um, 90/50 or 80/60 yours. Think they go. They go into shock, different types of shops, septic shock hyperbole, my shot. Cardiogenic Urogenic shock. Um, you need to establish whether this is a normal BP drop or if it's something more significant. So most patients in hospital on a ward there, lying in bed, the state. Still, the BP is going to drop. Okay, This is a fact. That good, too. The can become Brennan card. They can be become hypertensive, lying in bed there, doing nothing. This is normal for them. Okay, So you're going to have a look at the patient. How do they look from, you know, the better the comfortable sitting upright reading a book? Are they sweating with their chest rising rapidly? Be a short of breath. You know, looking at the patient from the end of the bed is a very important indicator of how the day, how you gonna system. What's the patient's baseline BP? So if I believed to see a patient whose blood pressure's 95/60 and I look in the past few days, it's been 90 to 100. That's normal for them, so it does depend on the patient. It could be. It can vary depending on from patient to patient, sort of the baseline could be 1 60. Someone's could be 90. So just have a baseline BP in their previous observation. So again having their other observations. When the patient over the nurses have got moving precious. So are the tachycardia. So if someone's hypertensive and tachycardia now would make me worry, um, in terms of some some kind of shock look at the other office, So are they. Tachypnea car, they decide grating. The's sort of thing is going to sort of put you told the direction where you think Okay, need maybe I need to arrange for the investigation for this patient escalator. A senior is the patient. Any fluids so patient could have a BP drop, and actually, they're meant to be on the heartburns, or normal normal mates. A little sodium chloride. It's not been prescribed for two days. So you know you could think about giving you prescribing fluids. You know, typical fluids are described about a liter every two hours, or if the patient's more elderly that got we got a issue CCF congestive cardiac failure. We could extend it for really a teacher over 12 hours, or if they if they were acutely dropping em. BP would give her the Children 50 more bolus, as opposed to a fundamental bolus patient is in pain. So it's important to ask why the patient needs to Yeah, this is a commonly it's important. That's why the patient has allergies here. So if you know, speak Shins is my patient is paracetamol. You know why I'm having new chest pain now, believe me, this can and will happen. But it does happen. Okay, You need to ask why they want you to do what they want to do. So again, if this in this case, you go there immediately and do full work up for the patient, the g of blows in control and etcetera Yeah, you need to ask why they need the energy easier. The most commonly used analgesic and Oscal's paracetamol um, we don't give a gram. So two tablets four times a day. Um, unless they have severely duration liver function or they are underweight, so we'll be under 4 to 5 kg. Eat after a low dose. It's half dose paracetamol. That's not working. We can, you know, step it up to cocoa, double or codeine. Remember, if you give them cocoa DM or you have to cancel the prostate, essentially be giving you if you don't come to the procedure. Were being double dose. See that probably tomorrow could be fatal. So be careful with these. Was gone is codeine again? It's another good one. Remember, it's constipating, so you don't want to give it. Insert patients with Bell pathology on. Besides, could be useful. So, for example, your attack stones, certain forms of arthritis, etcetera, um, in surgery we to believe or or a little Sushant if pain is severe and so uh, get every 4 to 6 hours off 10 mg per five ml solution. Maximum 60 mg a day. Um, if the patient's having all these things paracetamol or remove and the students were paid. If you wanted to escalate this with you, read a straw, Maybe the case she needs, uh, a patch or a PCA pump. So, um, you know, if the patient said in severe pain after having morphine solution or really and there might be something more significant going on again, some patients are, you know, they're coming out of pain relief because it makes him feel good. Except your, um you have to be wary of that, but always investigate further. So we're going to run through some scenarios. Happens if I could invite to join back in with me. Now, I'm just going to us the audience and questions. And I'd like them to type in the chap what they think would be the most appropriate thing to do. Yeah, yeah. Yep. So we'll just make a start. So first scenario. Um, Hi, Doctor. This is one of the nurses on War 35. I need you to quickly prescribe some paracetamol for my patient. Well, it'll take one minute. She's spiking a temperature, so just read that and take it in. Okay? What questions? Do you ask that? Uh, So I'll give you guys a minute or surgery. So again, you're on. You're on a really tiny Well, your response is coming in me. How that really read them off some? Yeah. Name now has said you'd ask the nurses that. Any other problem? Amy has said you Dostinex watches the temperature. Uh huh. You'd also also, what's the patients later? So vital signs or new school? Yeah, yes or no. These are some of the questions we ask. So again, we want the patient details often. If you get a call from a BLEEP, you wouldn't have a computer in front of you signed in so you could get the patient. And I didn't research it up and look at the observations. And so forth from wherever you are in the hospital. Yeah, it's important. You can handle certain things over the phone of the things you need to go and see the patient. So patient details. We need to know what exactly the temperature is. Um, what is the patient situation, but ground? So what? The in for what medical conditions that have What's significant medical conditions now is a patient with the antibiotics. Well, the patient's observations. Okay, so the nurse tells you the patient has a temperature of 38.5. The patient is seven days post operative from the heartburn's procedure. Patient is not really an antibiotics or their observations are stable, aside from the patient's respiratory rate, which is 24. So I give you a bit to take that and read up. What do you do next? If you could have your answers in the chat box will give you a minute or two just to see if anyone has any responses. Remember, you guys aren't even if one yet. So I'm going worry. I'm just Anything that comes from one was probably in the shop. And for those you don't don't know, Hartmann's procedure is just a procedure, Uh, where you moved out of the bowel. So it's usually an emergency procedure. Could be true, too. Cancer or perforation When Yeah, thanks for car for labs. So we have a few responses community anyhow. Yeah, through the people saying you dysesthesia assess the patient, assess the the surgical site, uh, want you to also query for relief. You do a full eight to here assessment. You do some blood cultures it go see the patients uh, you thinking is this patient septic at the moment? And we have a few responses about blood cultures and doing a TUI assessment. Perfect. Soon yet, essentially this instance, you do a four history 80 examine the patient like you've been talking medical school. Like a lot of you know, patient tells you feel generally unwell, and they called point point. What is wrong with them? The abdomen is actually soft and nontender You do? However, here's some crepitations left lung base. What would you do from this point? I think you guys have what You mentioned this so we can run through the answers here, So, yeah, we need to do a full septic screen, blood cultures, chest X ray a year and dipstick and or unless you typically it in both you independent. Unless you, um pcr test bloods, including for blood, count you any CRP, If not recently done, the patient used to be starting on the antibiotics. So if they're spiking temps 38.5 was starting on. Typically for just infection to be amoxicillin. Uh, I will give him fluids and prosciutto. Little odyssey control the temperature. So in this instance, with other patients had a heart procedure. The abdomen soft nontender. Um, what is the most likely diagnosis? So again, put your own says in the chart You have any answers? Homes of a year. So we have eight electricity is and hospital Quite pneumonia. Yeah, So actually, it could be accepted this again. It could be the most likely diagnosis. Is hospital quite pneumonia? And again, they could actually, um, they could have a collection in the abdomen. It's more likely because, you know, you've heard cramps in the long on the abdomen soft, but it's always a possibility. So you know we need we need to do the chest X ray to rule out any sort chest infection on. Do you know when I seen his senior seasons patient? Next they'll see a documentation, but again, your view the patient and to check for any abdominal collection, anything like that. But in this instance is most likely hospital acquired pneumonia, so we'll run through the story. I was worried time because I knew we have Teo do a cure it, and it's coming up to the hour, and also you are walking off a wart. When you were here to health care assistance. Talking about how a patient has fallen out of that bed again. But it's okay. She got back up and got back into bed. Um, okay, what questions do you ask? The healthcare system, So Ah, nurse. Looking after a patient, if you just stop your outside of the chapel's wise Oh, do you have any answers? Uh huh. No, you're free tones. The guys this remember, there's no right or wrong answer. Okay? So, yeah, we have a few ounces now. You also about condition I d. What? They've come in to hospital for, uh, in the past medical history or anything that's happened. Uh, prior to that fall, Where's the for witness or no? Is the patient on anticoagulants and that they injure themselves? Oh, hit their head. Perfect awards. Things that correct is this patient patient epileptic. So I guess the boss medical history of anticipation. Yeah, it's already been on. Was the four witness doing with this to the patient at the head or anything? Is are the anti coagulated. You don't have a look at the drug card? Do you have a set of observations for it before? What's the situation? Background of the patient. So, like you said, we need to know we'll have details about what's been going on. They tell you before was not witnessed. The patient is known to have full due to be failing, being mechanically and stable. She's a hospital for medical management of pollen. Arthritis observations follow the four of the same as price before. What do you do next? This is quite uneasiness. One guy. So don't worry about this, is it's what you've been taught. Medical school. Yeah. Do you have any answers? Hum, uh, examined the patient or their fools. The force risk assessment. Uh, anything else You guys will do? Examination of the vital signs. Check for JC A Z, take a history Dubuque. Full body physical exam. So I guess that's an A DUI. Yeah. So then take a third issue. I'm probably to. The exam is the correct answer. So it's not complicated, guys. You guys will know this. You know the drill into your medical school 80 exam. But it really does come in to use on the ward's during your course of a lecture to use advice and you won't miss anything. So you tried to take a history from the patient, but she has very limited communication. You feel a so she's confused. Otherwise I've been spontaneously. And she's local with the pain, but not following commands. There's no actual focal neurology and other examination's normal. So what do you first need to establish on what you need to do next? Uh huh. Oh, so we have a few ounces coming in. Uh, is this patient hemodynamic is stable? Yeah. Anything else, guys you want to know? Is this new confusion? Yeah, that's very important. Yeah. Yes. So we'll run through the answers. So you need to establish the patient's baseline. GCS. This could be normal for her asses. The case. You know what? I've parked many patients. Many frail old patients in in you. Um, some of these elderly patients, they have courted confusion. They have to work, follow commands, and that's perfectly normal for them. So we could be you know, uh, this could be over rescue in this patient could be warranted. So, me to subject baseline assess what's available for them. Um, withhold any, um, trouble a shin. Want to pay? Let's place the patient on your abs every 30 minutes. That's quite bought it. The nurses should know that. But sometimes you will have to remind them on Document it in the notes. So any patient who's had a fall hit their head typically in your arms every 30 minutes to monitor figure Terry a shin. You know, the nurses should be monitoring this mission. Know about it, but yeah, make sure to document it, guys. Yeah, They'll do certain things available. SSTC s and assess motor function left and right side people's exceptional, but it's quite important with patient with injuries. If this is not how big splurges Yes, you need to arrange an urgent CT head scan. So the first tells you her baseline GCS is actually 15 15. So you go ahead and arrange. Know? CT head supported within 10 minutes on the emergency phone call from the encore. A day on a gist. The patient has an acute subdural hemorrhage. Uh huh. You know what? You meant to escalate this too? Uh, the stroke team. Uh, met Ridge neurosurgeons. The Reg? Yeah. So this patient has been admitted for medical management of pyelonephritis. Think he said Yeah. He said medical management part of the fragments of stable partner fries. There's medical causes of the surgical causes, so depending depending on the cause of it depends on which team they're going. So this patients and the medics for medical management. So we'd escalate to our medical registrar, Um, who would most likely tell you to also escalate to escalate to the neurosurgeon. So you escalate to both, Essentially, you thought your Reg and then also talk to the uncle neurosurgeon on We may be the case. I want to do something in this patient's and my clean. And we mentioned there a very frail elderly, mechanically unstable, pretty poor, functional status. Neurosurgeons are unlikely to do anything, but you have to escalate. That's, uh, that's the important part of drug. So you've escalate. This is the nearest There's a new medical register. All that will come into view. The patient. What did you what you need to do before you leave the ward. So you escalated. The relevant people are on their way while some last minute things you need to do before you leave the water. The document, everything that has happened in the nose. Yeah. Anything else? Uh, nothing at the moment. That's fine. So I'm not included in here, but what you just mentioned in the chart Documentation. Very, very, very important. Um, you essentially most things you do with things that the especially fools you need to document in the notes, You know, because if you don't document, it could be our liable. Essentially, I'm CIA. You see a patient, you form an 80 exam. You document that every single time I was. If it's something little like, I don't know, prescribing some paracetamol for some pain. You need to document that in the notes, guys, you insert canula for a patient. You don't need to document that in the notes. Okay. See, you have Teo see your learned this on the job, but certainly enjoyment document. So these your knowledge document And if you if you wonder, you're you know, what should I document? What's they're not document. You can ask your queries in the chart and we'll discuss those in the queue in a session. But essentially things I've got down here that you need to set a date X to any patient who has a full of it. So this patient was already falls risk. She was known to the stuff to have to be frail and elderly and TOB mechanically unstable on she's falling over again that least every day. Text. Because it's a patient safety incident, we need to prevent this from happening in the future. We need to submit a date X on Do need to be sure the relevant appropriate safety measures are in place of the patient does not fall again. So, like we said before a low set bed, the rails on the sides of the bed should be up. So the patient cough all over exceptions to now if the patient, you know, it was very agitated, doesn't like confined. It depends from patient patient. But you need to put the relevant safety measures the place double check any anti coagulation, anti plates or withheld. You know what further precipitate the speed? You might cross off the lecture Aprida and then 20 minutes later, the nurse might give them aspirin. Okay, so you need Teo. Be very careful with this and make sure you withhold those men's when a patient's having acute subdural bead like this one again and ensure the nurses are where the patient is doing to go in your office every 30 minutes to monitor for decoration. Yeah, with that one. You're obs for patients with neurological injuries or head injuries. Typically, you do the robes for about 30 minutes following the incident. And then after that, it very so it could be two hour before sleep. Very trusted trust. So just check your glucagon lines, guys. Um, so that's the end of the talk. I hope you find informative. I just like to talk about are webinar seriously? About 10 were webinars on. This is weapon on line of the 10 part Siris. The first eight webinars are available of metal and YouTube. Um, eso yeah, make sure to attend the big one, which is our final one managing that deteriorate patient. That's one of those in the 20th, in July and in that talk will have a dedicated 90 minutes. I think too many stars discussing you schools there, patients coordinate patient. Very well. This is what's going on. How do you have the letters in that form? So that's er you know, I wouldn't miss that talk for you guys, so yeah, make sure you schedule that one in your notebooks. You have also got a pathway for one course, it's free. They're identical. Course is based in Liverpool of that and Sheffield simulation based, lush air confidence. And if I want those significantly, it's almost sold on. Think some of the events are actually a period this weekend, so a few spots have come up from people with drawing late. So if you really want to go on this free pair for for one course, contact by the people Facebook face with messenger or by email, moderately gym on the cob probably Facebook is better to get a response. Yeah, that'd be quite good. Course to attempt on finally, any questions? You guys, here's a barcode to scan, uh, to get to give any feedback. Be a we can run through acuity, guys. Now, so happens that. Would you like to come back? Yeah, sure. I supposed link for the feedback for muscle Well, in the chart. So don't forget I'm filling out your feet back forms to get your sense of get a bit tendency which being used for your port for you. So now we're gonna have a kidney session with me. How I feel free to put any questions in the chart and see how well on to them. And again guys apologize My voice. I'm not very well right now, but, uh, I thought it pushed her and give this talk for you guys because I, um you know, being so much for the incoming doctor's next year, he's dedicated. I'm dedicated yet so question me, how we've had during the talk is someone just wanted to verification on the cannula those in terms of, uh, a level of which you would escalate. So who would first try the cannula? And then if you fail, who does it go into next? So the nurses should try the cannula first. All nurses have been trained, you know, whatever. Look on the degrees in taking blood and cannulas. So it should be. The nurse is doing it first. You might get a lot where you will get off bleeps from nurses asking you to do bloods and cannulas. But when there's three doctors looking after six or seven of surgical wards or medical wards, you can't be expected to do those things. So only if it's urgent. Okay, uh, and if someone else has failed so the escalation or is nurses that f y once than any S h O. So f y twos or f y threes? Um, course surgical trainees call medical trainees after that on def. They have tried to fail the desk eight to the register or they would escalate to the registrar. You would then, if they fail, did call the anesthetic rich. Worst case scenario is the anesthetic. Reg comes along with an ultrasound machine. Can't can't get IV access. They need to probably in Central Line or something. I've seen happen once or twice. But yeah, it's an interesting story. What happens because, you know, they are experts in calculating getting IV access. If they call you with ultrasound, then it's obviously a really difficult. So So, yeah, I think we have a case the other week were a patient with. He wasn't DKA. We couldn't get single country on patients with DKA need to cannulas fluids. One more French. So that was an emergency scenario where we escalated the line and I'm gonna get a another set. Reg do that should do it. And I think that that the consult into coming take a page 2. 30 IV access to central or so. Yeah, that's the order of escalation. So we have another question about documentation. When do you don't document certain medications you mentioned? No, Aristizabal. Any other medications you wouldn't really document it you would prescribe. I didn't document both medications. To be honest, you're low because you learn on the job So busy. Um, if you prescribe simply like PCA so patient controlled analgesia morphine often to do the only documented somewhere. Likewise, any controlled drugs. So as an f one you shouldn't be prescribing, is that methotrexate? But you will be prescribing things are a ball for Cody coding, you know, teach document or, um, or if you don't really need to document, it would be something like you're still a PCA. You need to document or being a plant. I can't really say you start the patient on fentanyl patch or a PCR. Those little things. Thank you. Uh, another question. If you're unsure about out, I already got the on call patients who get bleeped about. Who do you ask? Um, if you're unsure about to prioritize the uncle patients you get sleep about, Would you ask? So I'm sure you're saying you got many bleeps and you don't have to prioritize in the first instance, if there's no emergencies, I would ask my sexual and say, You know, I've got all these bleeps and it's sealed. These patients who do I brought times, you know, I go and see first, um, in the first few weeks of F one, you sutures will be happy to help because they have been there before. They know how it works. They know how you have been. Know how little they knew it started with one? I'm not medically, but just experience wise. So, yeah, I just get your shh. Oh, um, if you do have a patient who is very well, then obviously escaped, you're really shrunk any more questions, cause so do you. Take blood yourself while on call? Um, salmon cording surgery at the moment. I don't I don't take drugs myself. Sometimes I do. So, um, if they see a well, the nurse is busy, and I can see everyone short staffed. You know, while I'm parking the patient in taking history, I'll often just put a cannula in. Take bloods off the back of the cannula. Just saves every one time, isn't it? So sometimes I do it. You know, everyone's busy. Everyone's working hard, so sometimes I do it sometimes. I don't know. It just depends on the circumstance. And you learn that with experience. Um, if if it ain't bleed award to take blood, then that's not when you would you would do those things. Really? You get someone else to have a go first before you tried it. So if you're clocking a patient, sometimes you would. But if you're being beats the war's over your your walk cover, then you wouldn't normally be doing it. Now again, there are some circumstances where there are more patients. For example, the septic were in severe EKG. I, um, And in those instances, I would take Bloods myself just cause I don't want to get a result, but quickly, See, it just depends on the circumstance. And you learned that with experience again, this will depend on where you work, which once feels as well. Uh, for instance, I know some of the hospitals in London the nurses can do a lot, so they will take Bloods was in other hospitals a lot of the nurses and think that's but they're not certified by the trust. So they won't be allowed to do them. So then your for you and I was anyhow pointed in this presentation again. It depends on the situation of why you're taking blood if you're taking, but with something that won't change the management done during your night shift your core so don't want the a priority. But if it was being Herget, yes, you would take it. We have any more questions, guys. So someone is just also they have their rota. Uh, but how did I know which ones? The on goal days. Yeah. So, um, your rotor should have a key on different days. Should be confident in different colors. So you might have, um, your war cover uncles Call it in orange, for example, and in the cable say would cover and you might have your clocking on course shifts. Be purple on. That would say, uh, clocking way. Ambition. Your normal working hours are typically in surgery. It's eight or five in medicine. It's 95. So anything that goes beyond that or is in a weird cough working out times law is typically a little cool shift. So, for example, if it if it has the time it says 8 to 8. 30 or nine or 9. 30 then you know, it's an uncle if it says long till five. But we're being on call crazy things up. Any more questions, guys? Feel free to ask anything. There's no judgment from us. I knew absolutely nothing before I started for same here. I don't think we have any more questions on. No. And that's it. From cola A day? Yeah. So just don't forget to fill your feedback forms to get you a certificate of attendance. This session will be is being recorded. Will be available to re watch on the mind of the future channel. Yeah, thanks very much for listening, guys. Um, yeah. Good luck with that one. I remember to take now talking two weeks, which will be delivered by to experience medical registrars. Um, a lot of this. You're low on the job. It will come with experience, but you'll be fine. Okay. Good luck, guys. Thank you. Thanks. Take care. Okay,