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That's, that's the recording started. Is everyone able to see my slides? All right, as I've had a few technical difficulties recently, if you could just pop in the chat, um I can't see anything in the chat, so I'm just gonna crack on. Um And if there's any difficulties in seeing my slides or with the sound or anything, then please just do, let me know in the chat. Um And we'll just pause and reload everything. Perfect. Thank you, Tom. Um So little introduction to the series to start off with and the series has been ongoing since the start of October. It's called Hello, it's the Fy one and it's run by mind the bleep. So he's in the F yy one team at mind the bleep. It's myself along with Manish and Viv and all of your deanery representatives as well. So this is a series of webinars um that the main aim is to help F ones through their on call shifts. Um run by F twos and anyone more senior than an F two as well. Um And it, the talk, the runs on Tuesday evening, 7 to 8 p.m. Usually we do have the odd talk that's on a Monday evening. Um So do just look out for that, but we always try and make that really clear when that's the case. Yeah, a few disclaimers. Um So all of the mind, the bleak content is intended only to be viewed by healthcare professionals. We've anonymized any clinical cases and we always try to make sure that any information provided in our content is as accurate as it can be. But as we all know, guidelines do change. Um And it's our responsibility to keep up to date with those um for our full disclaimers, um you can head to the page um linked up there. So what's coming up next this month? So, um earlier this month, we've had the ACP session. Um Obviously there's this session which is all about surgical on calls next week. We're going to be looking at wellbeing during night shifts with Dr Luke Austin. Um And if you'd like to sign up to that, um there's a QR code up there on the screen that you can scan and I'll just pause the SEC just so that you could do that if you'd like to f and if you'd like any further resources, we've got the whatsapp groups including Deanery whatsapp Groups. So if you scan this QR code, um that'll take you to a link um for all the mind, the Bleep whatsapp groups. Um Give mind the bleep a follow on medal. That's the easiest way to see all of our upcoming sessions and you'll be invited to any upcoming sessions that way as well. Um And there's obviously the lovely mind, the bleep website, which has lots and lots of articles on there. Um There's some really good um surgical on call, um, articles on there as well, which links quite well to this talk. So this is a talk about surgical on calls, um run by myself, Ramya. Um I'm an F two in the Northern Deanery. Um, and I've had two surgical jobs in F one. So plenty of surgical on calls. Um, so I've had upper gi surgery with gen surgery on calls as well as urology. I think it's also worth pointing out that I've got no desire whatsoever to be a surgeon. Um, but I still think that surgical jobs can be really good and they're on calls, especially for learning and managing a lot of medical things as well. So, learning objectives for this evening. Um So I'll start by just sharing some tips that I've found useful, um, especially useful for surgical handovers. Um We cover what to do with a POSTOP temp spike and we'll also talk through some post surgical complications that you might see on an onco shift. Um We'll next move on to looking at some emergencies that might be common on a surgical ward. Um, and then move on to just a quick section on practical skills as I think that's something that can be missed. It's really hard to teach obviously over a webinar. Um But I just thought I'd share some of my top tips for some practical skills along with just a section right at the end, which is just general advice for your surgical job, what we'll not be covering, which I think is quite important to say as well. Um Is um surgical presentations to the emergency department, for example, managing an acute abdomen on first presentation. Um as generally as an F one, you're most often on board cover um and managing a lot of postoperative patients or preoperative patients. So it's uh that's the reason why I haven't included it. I think this talk would just be hours long as well if I were to include all of that. Yep. So, um at handover, you're at the surgical handover. Um first thing to do is note down any jobs um or results pending any timings of relevant. Um I always used to find that on a surgical handover, you get handed over absolutely loads of things and you often have a covering lots and lots of wards um with lots of things to be chasing. So it's really important that you've, you've got a good list to start off with. I also used to make a separate list on a separate paper of just patients to be aware of. Um Just so it isn't a surprise if the ward calls me almost immediately after handover about a patient who's unwell next, just, just after the handover, the next thing to do is just agree which jobs each member of your team will do. Um So usually um you have an sho and a reg around um but you may also have a nurse practitioner as well. So just agreeing very early on helps to avoid any confusion or conflict later on. And then the next thing to do is to prioritize and triage. So sick patients always come first. Um Any urgent scans or bloods come next, I think and then everything that's routine. So especially if this is a weekend day on call shift, um there will still be discharges to sort but sick patients will always come first. Um Something which I thought would be useful to share is that I found very useful at least um was for each ward when the first time that ward calls you about somebody um try and get all of the jobs at that point that they have. So for example, if the nurse calls you about some IV fluids that need prescribing, um just ask, are there any other patients who need fluids or anything doing? That's that we know about already. And can you ask the nurse covering the other side of the ward if there's any jobs from her side as well? So that I think that's an easy way of just avoiding lots and lots of calls very, very early on. So, going on to our first case. So it's 10 o'clock on your surgical, on call shift. Um, and you're called about a 50 year old lady. She is day three post left laparoscopic donor nephrectomy. So she's given someone a kidney and, um, she got asked to see her because she has got a temperature of 38.2. So, what else do you want to know at this stage? Pop anything in the chat? Just have a go. Oh, perfect. News. Bloods. Yeah. All really, really good things. What are other odds? Perfect. So you just need a bit more information here. Absolutely. Thanks for everyone who put stuff in the chat. It's much more fun. If we just keep this very interactive and just have a go, there's no wrong answers usually. So just have a go with it. So yes, we do want to know some more. We want to know other obs so perfect. Getting lots more things through the chat, which is lovely. Um So yeah, want to no other. So blood pressure's all right and heart rate's ok. But her respirate is on the high side and she's on a little bit of oxygen. Um, they're giving her some paracetamol and you've also asked the nurse is, are you worried about the patient? Um, and they say she's stable. She just looks a little bit breathless and a bit flushed. So, so you go and review her and you do your lovely A to E approach um with a full systems review and these are your main positive findings. So you find she's coughing up yellow sputum, she's more breathless over the last 24 hours. She's got left basal crackles and auscultation. Um and she's in some abdominal discomfort after her operation, but it's soft. No real tenderness to palpation and she's got active bowel sounds. So, what might you do next? Yeah. So please, someone said chest X ray. Absolutely fresh set of bloods, chest X ray. Wonderful. All good suggestions coming through. Yeah, lovely. I like the BBg in there as well. Just if you're doing bloods anyway, can give you a good idea of some how sick someone is from looking at their lactate. So, yeah, absolutely. Get some bloods, a fresh set of bloods. You found her white cells are up a bit um driven by her neutrophils. Her CRP has gone up. Um Obviously she is a POSTOP day three. But last time her bloods were done, it was 100 and two. So it has gone up quite a bit that C RP and her lactate is 1.2. Um You've also taken some blood cultures because she's had temperature. Um and you've done a urine dip and a culture um and urine dip didn't show anything on there. Um And as many of you suggested, um you have ordered a chest X ray um and little top tip there that just have a very low threshold for ordering all those investigations when responding to a temperature spike. It's very easy to get a urine. It's fairly easy as you to get a chest X ray, um, and a set of bloods. So, um, that can help to really get an idea of what you do next a lot of the time. So her chest X ray, hopefully there's a big red circle around, but it does show some left sided consolidation and it's so we think it's likely a chest source of her temperature and in terms of management, she's got a hap. So we would prescribe antibiotics according to the trust protocol for a hap. Um she needs some chest physio because most likely she's got this hap because um of abdominal discomfort that she's mentioned to you. And so she's likely not breathing in very well. Um So a bit of chest physio and encouraging her to mobilize goes a really long way in preventing that infection from getting any worse. And we just monitor her obs um if she's needing increasing amounts of oxygen, then we might be thinking um about APG S um and things like that at that stage. Well, so a fairly simple case, to be honest, um but really, really common and I thought it was a good introduction to talking about POSTOP complications. So the way, oh, let me have a look at that. Um does the chest physio need to happen out of hours. Um So for this patient, um she was on 2 L of oxygen. You're not massively worried about her at this stage. I don't think the chest phys would need to happen out of hours for this patient. Um I'm thinking about the cases based on and it didn't. Um, but generally it's something that you can just hand over to the nursing staff to get it sorted first thing in the morning. So then it happens in hours. Um There's a lot of the time there are on call physios um overnight. Um But they're generally involved in starting an IV may be involved in some urgent chest physio. Um But that would sort of be if someone was much more sick than this. Does that answer the question a little bit? Hopefully that's answered the question there. Um So in a bit of an approach to POSTOP complications. Um So splitting it up in today's POSTOP can be a really helpful way of thinking about it. Obviously, any of these complications can happen at any time. So it's not a hard and fast rule, but I think I just find it useful in terms of the things that you have to be super aware of on that day. Um So you're gonna look for everything, but you want these things to be at the front of your mind on that time. So day 1 to 2 POSTOP um thinking about respiratory sources and immediately strokes and mis um, a temp spike day 1 to 2 POSTOP can be just a normal response to surgery, which is a big insult to the body. Um, day 3 to 5. That's when you're thinking about respiratory sources a lot. Um, and as well as urinary sources, um especially if they've had a catheter in, um, also thinking about venous thromboembolism, um, potentially starting to think about anastomotic leaks at this point as well. Um As well as still thinking about strokes in mis day 5 to 7. POSTOP this I like to think of as sort of the wound area that you're thinking about more at this stage. So surgical site infections, abscesses collections tend to develop around day 5 to 7. Um Obviously, other things like the VT and the strokes and mis as we've said. And then day seven plus, that's when you start to think more about later complications such as wound breakdown and dehiscence um as well as transfusion and drug reactions. So, a little Pneumonic um that some people use about to help them remember all of these things um is the wind water walk wound and wonder about drugs, Pneumonic. So if that helps, that might be a way to just remember all of those things. So just a little summary of POSTOP temp spikes, make sure paracetamol has been given. So the patient's comfortable when you're reviewing them, just go for your at E approach every time. Um It just helps you not miss things out. Um always consider sepsis in people. So if they're, if they've got more clinical signs of sepsis than a temp spike, um you should always just be considering that it should be at the back. Well, at the front of your mind, to be honest, um a one off temp spike, as we said, postoperatively day want to that can be normal. Um It probably still does require a quick review um but it can be normal. So if you don't find anything at that point, other than a temperature, I wouldn't worry too much have a really low threshold though for just doing some bloods, some blood cultures, a urine culture and a chest X ray. They're all fairly easy things to do, especially on the night time. Actually, um common things are common. So, respiratory urine and wound infections are really, really common. Um And just look at your local guidelines in terms of antibiotic advice for that when in doubt with any of this. So if you've been to see someone with a temperature spike and you're just not sure what's going on or you're just a little bit worried about them, um just give your sho or reg a ring for help. Um Something that I found when I did my surgical job as an F one is that on the whole, they want to know about it earlier rather than later. Um So seniors do want to hear about it, they do want to help. Um And often your registrar has operated on that patient themselves. They're really invested in their recovery as well. Um So we did mention venous thromboembolism before. That's, it is common, despite the fact that we tried to prescribe prophylaxis against it, it is still common on surgical wards, um can be associated with a low grade fever. So, something that you should have in mind when you're reviewing a temp spike, um As always doing your a three assessment for a DVT, likely signs are calf swelling, erythema, tenderness and warmth. I've popped in there that the guideline is to do a well score. Um And to consider then either doing a DDIMER or proceeding directly to a Doppler ultrasound based on that well score. The issue is obviously ad dimer is often raised postoperatively anyway. So sometimes it's not that useful. So if you've gone to see someone, their calf is really swollen on one side, it's red and it is tender, then often you would just go straight to going for a Doppler ultrasound scan. So if you've got a high clinical suspicion, um anticoagulation um should only really be prescribed on discussion with a senior for post surgical patients um due to risk of bleeding, I'd say, and then moving on to P ES. So main signs that you're looking out for with a pe are increased oxygen requirement, increased resp rate. Um and the patient complaining of pleuritic chest pain. Again, you can calculate a well score. But if your clinical suspicion is really high, then most people would proceed to a C DPA, just given that the D dime is likely to be raised. Anyway. Um Also considering alongside that a chest X ray and an ABG. Um so especially if they've got the oxygen requirement, an ABG might be useful there. Um As I said, discuss that these cases with a senior because you might just proceed straight to a C TPA with a lower well score. And as with DVTs, prescribe anticoagulation only after you've had a quick chat with one of the surgeons usually. Yeah. So moving on to our next case, um it's 11 o'clock at night. Um and you're called about a 26 year old lady. She is day five, post appendicectomy and she has been complaining of some abdominal pain and that's why you've been asked to see her. So past medical history, she's got type one diabetes. Um and a raised BM I and she presented to the ed five days ago. Um she had sudden onset right iliac fossa pain and she was septic at that point and she was taken straight to theaters to have her appendix out. Um Her recovery has been complicated over the last few days. She's had raised BMS, she's been in quite a bit of pain. Her abs are completely normal. Um and the nurses are still concerned and they feel that the patient is just not quite herself. Um You've gone to see her, you can't really find anything on initial examination. Her BMS are normal, her ketones are normal and low, but the patient just looks lethargic. She keeps complaining of abdominal discomfort. So, what is your next step? And I'm just gonna pop the pole up if I can get this to work. So that should hopefully have started polling. So, again, there's not really any right wrong answers here. Um, so I've stopped the polling there and very close between C and E here, which are probably, yeah, the two things that I would do. Absolutely. I would probably do both of those things. Um, so, oh, I'll go back to that, that kind of gives it away a little bit. So I would run through a, again. Um, and because it's day five, you're starting to think a little bit about wound infections because this lady, um, has, is diabetic. Um, she's had emergency surgery. She's got a background of a raised BMI as well. And all of those things are risk factors for wound problems. So definitely examining under any dressings. And as you say, I don't think it's at all wrong to just take some bloods for an F BCE EC RP and just do a BBg as well. So, yes, absolutely. Those things are the things that I would do. So this is a little way just to start talking a little bit about wound complications. So when I wrote the slides for this case, um I had wound infections in my mind. It's the most common thing, complication that you'd see a wound infection usually presents within about a week, presents with pain at the operation site. General malaise discharge, um and redness around the site. So things that you do are to take a wound swab or make sure that's done and treat with antibiotics as Pru P protocol for skin and soft tissue infections. Um The other complication with which you might see um from wounds um is a wound dehiscence that's most commonly after abdominal surgery can be superficial or full thickness. So, superficial means that the skin itself has split and that's just managed with simple wound care. Um but you can also see full thickness wound deists, um which have this kind of burst abdomen appearance. Um The whole rectus sheath has just failed to heal. Um and that's a much more serious um complication. Um So it's really important to recognize that really fast. It's quite obvious it's quite shocking to see. Um And so that's managed with broad spectrum antibiotics in the first instance, um immediate discussion with a senior um and urgent return to theater may be required. So risk factors um for wound dehiscence and actually wound infections in in general, um says patient factors including smoking, diabetes, obesity and steroids. Um There's the operation factor. So if this has been a long operation or if they've had emergency surgery. Um, and then there's all the POSTOP factors. Um, so if there's been poor tissue perfusion, um, so if they've had been very hypotensive POSTOP, for example, um, and if they've needed a transfusion, so that's wound stuff essentially. So I'm gonna move on to talk a little bit about emergencies that you might see on a surgical ward next. So this is our next case. So we have a 63 year old man. He is day four post right, hemicolectomy with an ileo colic anastomosis for a cecal tumor. And you're asked to see him because he's got a temperature. You've asked some more questions over the phone. Um His other obs don't look great, to be honest, his BP is low. He's tachycardic, his respirate is on the higher side. Um but his sat's er, maintained on rumor and he has some other symptoms. He is in quite a bit of abdominal pain and he's nauseous and he's Ry goring and the nurses are quite worried and they think he needs a review. You've gone through your A to e approach. Um The main things you find are that he is peripherally quite cool. Um His cap refill time is prolonged. Um He is alert and orientated, but he's quite clammy and uncomfortable. And when you examine his abdomen, he's guarding in his right iliac fossa, he's very, very tender. So what would you do? 00 gosh, that really does give it away. Sorry. Um What would you do next? Um I'll pop just ask you to pop things in the chat for this. Yeah, sorry guys popping onto the next slide there by accident but yes that did give it away slightly sepsis six senior review. All done. That's perfect. So yeah, you do your sepsis six and immediately call a senior. Um yeah, sorry stuff is still coming in. That's brilliant. So yeah, absolutely stabilize the patient is your first thing. So, moving on to the next slide now. So I'll pop this pearl up. What do we think is the most likely source of sepsis in this patient? It's really nice to see lots of people in voting in the poll as well. So I'm just gonna stop the polling there. So I should be able to see the results now. Um and the vast majority of you have gone for an anastomotic leak and you'd be absolutely right. So, an anastomotic leak um is the most likely source of sepsis. Um with those clinical findings that you've found on your a to um so anastomotic leak that is a leak of Luminal contents from any surgical joint. Um It usually presents day 3 to 5 POSTOP with worsening abdominal pain and a septic picture. Um as we've mentioned before, um you need to escalate immediately to a surgeon if there's any suspicion of this and they would usually investigate with a CT scan, you've probably popped a cannula in anyway, when you're getting your bloods and to give fluids and broad spectrum antibiotics as perps is six. But you also need that cannula in because they're likely to go for the CT and they may need contrast for that. Um They also may need to go to theaters urgently overnight. So keep them nil by mouth um and make sure they've got some fluids prescribed. But of course, you're doing that anyway, as part of your s apsis six. So that's anastomotic leaks. Any questions at all about that case before I move on f so I will crack on to the next case then. Um So this is the next case. You've got a 65 year old man. Um, he's admit, been admitted quite a while ago with pr bleeding. Um You're asked to see him because his BP has dropped to 76/50. Um And he's had an episode of hematosis. It's been a really long admission and he was initially admitted with pr bleeding. He required emergency surgery as he felt the pr bleeding is like from an ulcer and he put, so he has a past medical history of peptic ulcer disease. Um And you do your A to e um and you find a number of things he's very peripherally shut down. Um He has had a, he's got a low BP, as we've mentioned and he's tachycardic. Um He is alert, his G CS is 15. His abdomen is very tender to his epigastrium and he's got some rebound tenderness there as well. Um You do actually see the hematemesis yourself. Um So it's by the bedside, you see half a bowl of fresh red blood, but you can also see some bloods on blood on the sheets. Um And the patient tells you that he's a bit worried that there's some blood coming out of his back passage as well. So you're worried about pr bleeding as well. So this is quite clearly a very sick patient that you've got in front of you. What would be your first step here? I'm gonna pop the pole. Oh, I can see someone's asked in the chat, what fluids would you give? And is it 500 mils over 15 minutes? I was asked a couple of minutes ago. So I wonder if this was about, was this about the temp spike anastomotic leak case? Um, or is it about this one? I'll just answer it for both, to be honest. So the an asthmatic leak case that we've just seen, um, initially, if their BP is low, I would give, yeah, the anastomotic leak lovely. Um So if their BP is low, um I would give the 500 mils over 15 minutes can give 250 if they've got heart failure, for example, or if they're overloaded. Um If their BP is normal in the normal range. I think it was low in that case. So I would probably give the 500 mils over 15 minutes if their BP is normal and they, you're still worried about sepsis and getting some slower IV fluids, um, would also be a good idea. So I hope that answers your question there. Yeah, and normal saline or Hartman's both are fine that so I'm just gonna close this pole just trying to multitask you a little bit. Perfect. Glad that helped. Um So going back to our current case. Um So our first step, we've got a very sick patient with a low BP, um evidence of hematemesis and also pr bleeding in front of us. Um So actively bleeding. Um Absolutely. Your first thing is to call for urgent help. Um All of the other things definitely things that you should be going through your mind, but that's the first. Um It doesn't have to be yourself who actually calls for that help. Um Often it's easier if it is because you know the story you've done the examination. Um But if there's someone else around who can call, for example, if one of the nurses has the registrar's number, they can also help you out by calling while you do the rest of those things. So we're dealing with an acute upper gi bleed here, various causes of this. Um So the pictures on this slide demonstrate some of those causes. So it can be from esophageal viruses. Um It can be from Mallory weiss tears. Um And that bug that I've got on the screen there is H pylori. Um So that signifies peptic ulceration. Um Initial management. First thing as we say, you need some help immediately, do your at as always, um You can even actually call for help before you do your at E um if it's immediately obvious what's happened here. Um IV access and bloods is really important to start off with and your aim is to transfuse. Um So activate the major hemorrhage protocol if they are actively bleeding out and you're worried about their BP. Um Generally, you would have probably called your senior already and they will have told you to do that in this sort of scenario. Whilst you're waiting for the blood to arrive, you can give a little bit of fluid to resuscitate as well just to try and bring that BP up while you're waiting for your blood to come up to the ward. Keep the patient warm. Um Often this is this is a shocked patient essentially. So you need to try and keep them warm, however, you can um and you can calculate a Glasgow Blatchford score for an upper gi bleed. Um Then next steps, once you've done all those things, you've stabilized the patient, you've got hopefully with some help as well. Um You can proceed um to think about what we're doing to stop the bleeding and that might be an O GD. Um, it might be theaters for embolization of an active bleeding site. So that's just the initial management. So someone's asked, do we give ppi and Terlipressin? So it really depends on what is causing that. Um, generally I would discuss with a senior before doing those immediately. PPI possibly you might give, if there's high suspicion that this is an ulcer here. Terlipressin, I wouldn't give unless you've had a chat with a senior. Really. Um And that's been advised, hope that helps. That was a bit of uh a sort of a copper answer there, I'm afraid. But yeah, every case will be different and it would just depend on the patient's history there. So no worries at all. So it, I used to be really quite frightened of having to deal with an upper gi bleed um on my surgical, on calls as an F one. I think the first time it happened, it was pretty much as dramatic as this case. Um And then the more I've had to deal with them, you do realize actually your role um on the ward is to resuscitate that patient. And when you do activate the major hemorrhage protocol, it should also come with help as well. So in our hospital trust that comes with itu being informed about that, that protocol has been activated. So you should also get help very, very fast. So you're never on your own really dealing with this. So on to our final case this evening. So this is a case of a 75 year old gentleman. He is day two post, right. Total knee replacement. So he's on the orthopedic ward. You're asked to see him because he is drowsy and he's got a low respirate. So these are his ops. His respirate is low as mentioned. Um, his SATS are ok on room air um a bit on the low side, but ok. Um his pulse is 60 blood pressure's 96/67 and he is a paraxial past medical history. He's a type two diabetic, he's on Metformin and Gliclazide. So what is the first investigation that you should ask for whilst you're on your way over there? Oh, so someone's asked to think about the gi bleed case. Um If it informs other specialties for help, then do you not need to put out a Met call? I think that for this patient, I would put out a Met call. Um just because I'm thinking about the case, this is based on and um I think in the end we essentially did. Um However, the major hemorrhage protocol also came with the it help. So it was the same people essentially who turned up and so check what happens in your trust when you activate major hemorrhage. Um I would concurrently also ask one of the nurses to put out a Met at the same time. Hope that helps up. So, lots of replies again in the poll. Thanks so much. It's much more fun when people participate in these sessions. So I'm just gonna stop the polling there so you can see the results. So the majority of you have gone for a blood glucose. Absolutely. Um, he's type about diabetic. He's on glycoside. So this could be a hypo. Um, there's other clues as to what might be going on, but a hypo could have definitely explained drowsiness. So, and that's an easy thing. You can get that so that it's ready for you to, to look at um the moment you get there. So you go and review this patient. Um The main things that you find uh that his G CS is reduced. Um His BM is actually ok. So his blood glucose is ok. Um But his G CS 11, um that respirate is still quite low. What might you look at next or rather where might you look next? Um Again, loads of responses, which is lovely. I'm just gonna stop the poling there in the address of time. So you should be able to see those results now. So, yes, absolutely. The place where you're gonna look next is going to be the drug chart because you're worried about opiate toxicity in this patient. And so it's signs of opiate toxicity. We've got C NS signs. Um So the pinpoint pupils being the most commonly known sign of opiate toxicity, drowsiness, and confusion. So this patient is drowsy, they sometimes have slurred speech. Um and opiate toxicity can also result in seizures. There's respiratory signs that low respirate, that is probably what flagged a lot of you up to looking at the drug chart, um shallow breaths and there can be signs of aspiration due to low G CS. Cardiovascular signs include hypotension, hypothermia and bradycardia. Um So this patient was just ever so slightly hypotensive. So that would fit with this picture as well and gi signs. So, vomiting and reduced gut motility can also be a cause of opiate toxicity. Um Something that a lot of patients would complain of on the ward when they're given something like Oramorph is that it can be very, very constipating. So how do we manage opiate toxicity? Call for help. First of all, um You're going through your at E assessment and you're reviewing the drug, the drug chart to find out how much opiate they've actually had. So managing opiate toxicity. So, ventilatory support if the respirate is less than 12, you need to use bag valve and mask to make sure their SATS are maintained between 94 to 98%. And this is a situation where have a really low threshold, just put out the med called because these patients can get more and more sick very fast and you may need some airway help. So you're gonna need a bit of a specialist there, naloxone 400 mcg. Um once you've secured the airway and that can be repeated every 1 to 2 minutes until the respirate has gone up to 12. Um So you don't keep repeating it until they're fully roused. Um as that can result in acute opiate withdrawal. Um And if there's no IV access, actually, naloxone can be given by loads of different routes. It can be given subcu im and intranasal even. Um So after a couple of doses, you are definitely gonna be thinking about needing anesthetic support. So that's why I think if you're suspecting opiate toxicity, get the help fast, put out the medical almost immediately. Um If you're at all worried about this patient. So remember naloxone has a really short half life. Um so people can rebound into that drowsy state um with the low resp rate. So even once you've given it, keep a really, really close eye on these patients and keep rereview it. Yeah. So what else might you be called about on a surgical on call? Pretty much anything else? So anything that you'd find on a medical ward as well? And that's why I think a lot of people get quite worried about surgical on calls. Um So you can be called about af fast af that is um you can be called about acute confusion or delirium, chest pain, increased oxygen requirements and desaturation for those. I would always consider haps and P ES you would anyway, on a medical ward, but just really have them at the top of your mind because these are patients who have an operation a lot of the time and their risk is really high for getting those things. Um, don't forget, hypo and hyperglycemia. Very, very common phone calls to get on a surgical on course. So, manage as you would on a medical ward. Lots of practical skills. I used to find on surgical on course. So um you're often just putting in lots of cannulas. Um you're doing catheters and ng tubes as well or can also be called about self discharges, of course. So you can be called about all these things too. So this moves me on nicely too. I just wanted to run through a few tips and tricks for practical skills. Um just because it was probably not enough to do a whole extra talk on this. Um But I think it sometimes it's just useful to get some tips. Um So Cannulas, um we used to put in loads of Cannulas on our surgical uncles um especially as it comes to the morning and patients will do their antibiotics, but their Cannulas fallen out overnight. So always ask why do they need it. Um Is this somebody who's eating and drinking well has been prescribed some I VT for some reason, even though they don't have an AK I um do they actually need this Cannula at 2 a.m. Is this a critical thing. Can it be done a little bit earlier like early morning instead of at 2 a.m. So that we're not waking up the patient. So you will be doing lots of them but try and question it and think why I'm I actually doing this. Um I wish someone had told me as an f one that you will have good days and bad days with Cannulas. Um And that is not a reflection on how good you are as a doctor as to whether you miss lots of Cannulas on that day. Um After three attempts, generally good to escalate, that'll usually be to your sho um potentially to your reg if they're around. Um But to anesthetics really, once, once you're exhausted them, um consider midlines and picks for patients who've been on antibiotics of over a week. Um I mean, it's less sort, sort of relevant if you're on a night shift. But to be honest, even on a night shift, if you've had real difficulty cannul this patient, um overnight, you've had to get anesthetic support, considered just requesting a midline at that point. So the midline request is there for the morning team to just chase up. It's less likely to get missed that way and of course, learn how to use ultrasound. If you have the opportunity, it's really, really good for doing cannabis. So bloods, um this is a bit more relevant for sort of weekend on call shifts. So weekend, day on calls, for example, on surgery. Um, think about why the patient actually needs bloods over the weekend. Do they actually need bloods? Is it for? Are we thinking daily bloods for refeeding syndrome? That's a case where they definitely do need that test, make you a phlebotomists. Um, if they are present on the wards on a weekend and just have a little look at who else can help you out on the ward. Um Often nurses of health care assistants can do bloods. Um So definitely ask for their help when needed. Um a really good tip that someone gave me when I was an F one is just using a butterfly and a syringe rather than so a syringe rather than a vacutainer for someone with difficult veins. Um And it's really just actually changed things completely for me. I it's helped so much so just bear it in mind if you're struggling. Um ultrasound can be useful again. Um And always keep track of what bloods you've taken so you can chase the results. Um Really easy to miss things out, especially when you're really busy, uncle. Sorry, I'm just losing my voice a little bit. So that and then finally catheters. Um So when do we pop in a catheter if they're retaining in their bladder scan of over 500 mils? Um and, or severe pain or, and, or you need a urine output, um an accurate urine output for someone with an AK I um they are an infection risk. So definitely think twice before asking someone to put in a catheter, always ask who has tried first. Um most nurses should be able to put in catheters on a ward. Um And have there been any difficulties documented in the past as that can give you a good idea of whether is this somebody who you think you might need to be escalating to urology. So often some people will actually need already have it in their notes documented that they go to urology for their catheter changes because they are so tricky um to get in. So in that sort of circumstance, a quick phone call to urology is probably the first thing you do if you're struggling and once you've put the catheter in, always remember to document the output. Other things are NG riles tubes, um removing drains. Um Picc line blood sampling practical theater experience. Oh, someone's asking how long do we keep a catheter in average time? Really? Really depends. So people have long term catheters that are changed sort of every 10 to 12 weeks. Um by district nurses generally, if they don't have a long term catheter, we don't really want to send people home with catheters if they were passing urine normally beforehand. So it is an infection risk, as said, so you want to keep it in for the least amount of time? Really? Um Someone's asked could you please go over what you prescribed as a first line for hypo and hypoglycemia. Um, so I'll try and do this very quickly, but I mean, I'm aware that we've only got a few minutes left. Um, we've got a really, really good, um, talk, endocrinology, talk um, as part of this series that is recorded and it's on metal. So I would refer you over to that for a longer chat, but hypoglycemia think about getting fast acting glucose if their G CS is tolerates like they're able to swallow. Um followed by some carbohydrate, um can also give IV glucose as well. Um Hyperglycemia, I would probably refer you to that talk. Um As that would be, I think a more in depth discussion cos that would cover things like DKA as well. I hope that helps. Sorry, it's a bit of a cop out directing you over to that talk, but it's probably a little bit beyond the scope of this talk to cover problem. So finally, just some top tips and I'll pop the feedback form in the chat now as well just while we're doing that. So top tips for your surgical on calls just never be afraid to escalate a sick patient early to your reg. Um As I've said before, the registrars have often been in that theater with the consultant operating on that person. They're really invested in that care and they'd rather know if something was going on and someone was sick up on the wards quite early on. Um, rather than that person deteriorating further and then them being called in the very early morning. For example, organization is key for your surgery on calls, making a good job jobs list. I used to make mine sort of based on what ward they were on. Um, and that I used to find that quite helpful, have a list of key phone and bleep numbers to hand. Um things like being able to know the number for radiology registrars and CT is very helpful. Um, vascular access and anesthetics numbers, things like that are really common and sort of easy to have at hand and would really help you out. I think probably the best tip that I could give you is just to think outside the box if your seniors are in theater overnight, that used to really worry me when I was an F one that actually a lot of the time my reg and my sho would be in theater doing an emergency laparotomy at night and it would just be me um covering the surgical wards, but it's never just you basically, there are loads of other people in that hospital who can help you. You've got the entire medical team including a medical registrar and you can call the medical registrar for advice if you're really, really struggling. You've got someone in DK A or something like that, call the medical registrar about that. Um as we mentioned, you can call anesthetics, you can call itu um critical care outreach, nurses as well can be really, really helpful when you're managing a deteriorating patient on the ward. Um and never be afraid to just put out the Met call, put out the crash call. If you're really, really worried about someone, people would be more upset if you didn't put out those calls and no one would ever tell you off if you did. So, I think that's probably the main point that I want to get across is that you're not on your own. You've got a lot of people out there who trying to, who will be very willing to help you as well. Surgery from a welfare perspective, I guess for you guys, um, it's generally earlier start times and these are really long, long, long shifts usually. Um So look after your wellbeing, prioritize sleep, exercise and nutrition all really important. So we need to look after ourselves. Um, if we're able to, to make that we're able to look after other people. Our next talk um is actually the next Tuesday is a talk on wellbeing during night shifts, um, by doctor Austin. And I think that would be a really lovely talk to attend after this. Um, for some tips on how to look after yourselves during these on call shifts and finally enjoy it. So I found surgery to be a really lovely team environment. It was very social. There were lots of foundation doctors and it was really rewarding for me to see patients become a lot more well, POSTOP. Um, they'd come in really sick, they'd go into theaters and they would get better and be discharged a lot of the time. And there was something to learn from every shift, whether you want to be a surgeon or not. So, that's me. Done any final questions at all and the feedback forms there in the chat, I'd really, really, really appreciate it. If you could provide some feedback, it's helpful for me and the rest of the mind, the bleep team in terms of deciding what we want to include for later talks in the series. Um and how we can improve things as well. I popped up some references there as well if you want to do a bit more reading on any of the topics mentioned today fab so I can see a question in the chart there. Um If the BP is really high and the patient is nil by mouth, do we give amLODIPine with sips of water? Um So it's a really good question. Um I think nil by mouth can be quite a difficult thing sometimes to draw a line with um if that BP is really high, so high that you'd be quite worried. Um I probably would give the amLODIPine with a little sip of water. Um As actually if their BP is too high that might affect whether they go to theaters or not. So, I think that would be my take on it. Um It's something that for these kinds of questions your surgical sho is really, really helpful. So they're there to run things by, um, at the point where you're not really escalating it to a registrar, but you just want to check something. So, depends on the patient a lot of the time. But my take would be yes, but I would probably run it by the surgical sho as well. Um It would depend what kind of surgery, et cetera and how high that BP was, how worried we were about it. I hope that answers the question. No problem at all. F I can't see any more questions in the chat. Um, and we've just gone eight o'clock. So I am just gonna stop this session here. Thank you all so much for coming and really appreciate you guys filling out the feedback. Um It's so helpful for us as well. So, thank you all so much again. Um And I'm just gonna stop the session here.