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we'll get started. So welcome, everybody to our second lecture of the series on this series is all about how to survive your first set of search. Long calls. Um, today with us, we have on Ben, who's wanted an F two doctor that I've had the pressure of working with on. He's had a great experience doing such good jobs, both in his one year and also now in his f Y two on so that further ado are handed to bend. Thank you again. And so you have one. Like Gen said, I'm Ben, and I'm just going to take you through a few common scenarios on the boards that you'll be faced with as f one doctors on the surgical jobs. And so we'll be going through in this lecture. Um, abdominal pain, vomiting on urine output. Um, so obviously quite a few topics to get through, and so I kind of split the lecture up into three with a case for each of those. I'm going to try and make it a bit interactive, if possible. Just it's not me talking you for 40 minutes or so and so to do that if you all stopped have the chapped box ready with just reply to all on. There's a few interactive slides that will try and get you involved in if we can say a bit about me. So I started a doctor in leads last year, and I did a general and acute medicine job first and then moved on to Trauma Orthopedics. The plan, then, was for a nice four months of community psychiatry with the weekends, um, more on that later, I then moved to Hargett on Joins Gen for Pete's and Neonate. It's human told you in oncology and general surgery last, which is what I'm on it. The main mint. So coronavirus changed my plans slightly. And so if anyone is at least med school, they've probably heard the rumors about dropping orthopedics at the allergy eye. And essentially, it's just quite a difficult job. The rumors are true, So I had eight months of that and then my hematology oncology job, which is actually something that I'm interested in, um, got turned into general covert wave to cover um, on a ward that covered stroke, neurology, general medicine and elderly medicines. That was quite interesting experience, say, like I said, I'm hoping to give you a structured approach to answer common surgical bleeps that you'll get on the ward and then we'll go through pain, vomiting and urine output. I just want it's off. Go through how I would go about assessing and making a differential diagnosis for these three common presenting complaints. What sort of investigations you'd be expected to get started with his left one. And what management to do is, Well, um, so you already old in better than May. I kind of wish hard joined something similar when I was. And finally year, just to get a bit of a first hand experience on surgical jobs at an F one level. Say, let's get going. So our first scenario is abdominal pain. So we've got a 59 year old male on the nurses, finding me to say that this patient is complaining of abdominal pain for the last few hours. Can you come and see them, please? So this is first attempts at interactive, So if you'd like to open up the chapped box I know you had a meeting recently on bleeps. Can you try and have a think about what you might need to find out down the phone about this patient with abdominal pain, and I just get the chance open. Well, so ops obs obs. Yes, the first three answers. That's probably one of the most useful things to get down the phone. Um, because you will be able to help prioritize your patient from the get gagged presents complaint and why they're in hospital background assessment. New school. That's brilliant. Someone starting to think about There s far. How severe is the pain in any recent surgery and the last time they open their bowels. Now they're passing flatus. That's all really, really good stuff. So to think about that in a structured way and if possible, it's really great to try and ask the nurses, and it can sometimes feel a bit rude. But if you do it politely, they don't mind ask for an s bar. All the nurses should know what that is on. And if you don't feel confident just asking for an SVR handover, trying to sort of take that information out from the nurse bit by bit. So, like you said, what they've come in to hospital with what they're working diagnosis is that the main mint on what treatment and surgery they've had so far. And don't forget the logistics, their name in the hospital number. Then you got to try and prioritized where on your list of people that you've got to review that you're gonna go see that patient say, asking us, Are you worried? Does this patient look unwell? What's their new score and what's that pain score at the moment? And then I just put that red flag in the corner to start thinking about worrying causes of abdominal pain. That would mean that you have to get to that patient before other patients. So first, surgical patients that's bowels, no opening a vomiting, tender abdomen or fever would be symptoms that would get me to that patient before another, and then a few more. Just logistics. Who's calling so huge ego and find When you arrived, the ward, where you calling from where you gonna go and sometimes you will just ask yourself why you finding me? It will be 3 a.m. On a Sunday, and they'll be failing about a patient that's had abdominal pain for three weeks. Um, and you ask them what their pain score is and they say it's four on. Do you ask them what their pain score normally is? And they say four and you ask them whether they've given that p r N energy easy and they say no. So some of these cases you will be able to sort of triage and just give her blood vise over the phone safety net and ask them to faint back if things change. And in the last thing before you hang up, just think in your head. Is there anything that's nurse can start doing for me to make my life easier? When I get that? Can they organize an E C G? Do I want them to do a urine dip? Do I want them to repeat the observation? So I've got repeats that ready when I arrive say you've asked all those important questions down the fame. Um, you, however you organize your less, you'll find the best way for you. You've got a little I have little squares on mine for each patient, and you've got their name, hospital number. What the nurse wants you to do and you're walking on your way to the ward. So this is what I call the walk thoughts, and it's just a process of going through in your head, almost running through what you're going to do before you get there. And this is really, really helpful, especially for slightly more urgent situations. If you have an idea in your head of when you get there, what you're going to do, um, you're gonna go to see the patient first. Or do you think that you have time to look at the notes? And if you do have time to look at the next, we'll get a bit more of a hand over that you may not have got from over the phone cause nurses don't always know all the answers to your questions, but they can start finding them out in a half day. Have they had this pain since they came in, or is this new? Is there anything else going on if they had a surgery, so I need to be worried about an infection? Has the nurse told me that they've got a fever? I'm just start thinking through what sort of investigations you might need on whether you'll need to discuss that with anyone on then it's not cheating. I am. You'll find your own naps that work for you. And I've got a couple of laps on my phone. I really find useful. I'm one of which is pocket Doctor on That breaks down a few common presenting emergency such a Z A g I bleed. Just pain on it breaks down. Although observation so low SATs, fast heart rate. And it just gives you a sort of check list of things that you should probably be doing at your level, eh? So that could be good to look at if you think that you need some prompts. I recessive brilliant as well for a less algorithms and ready cardio and all that things. And obviously, Doctor Google say what I tend to do when I get to award. If I've been called to see someone out of hours, first thing I'll do is gallons the ward, introduce myself to the nurse who's feigned. I'm just going to look at the patient, and that could just be really quick assess them. Say hi. You know, I'm been on the doctor has come to see I'm just gonna go get your notes and have a look through everything and come back. If they can talk back to you and say, That's fine, doctor. Then you know, you've probably got time to go and do that. If that if they're unresponsive or there is that they're on 15 liters of oxygen, you've probably not got time to get back home. Look at the notes. So if they are okay, I'm find the nurse, find the notes and just go through and get any bits of information that you've missed from the verbal hand. A va, um so especially important in surgery is what surgery they've had and how many days POSTOP they are, cause that changes what you might think in your differentials. If someone's unwell, you want to make sure that you check the front of the notes or, if you've got Elektronik notes what their escalation status is. And if you've got time, it can be really useful to look a recent blood tests on their meds chart. Have they got any recent P R N usage of pain relief or antiemetics? Um, and then once we've got all of that information ready to go, and you already have a pretty good idea of what differentials you're thinking off. I'm going to take a quick history from the patient. So for abductor pain, start with your simple stuff and do it well. So take a Socrates, um, and then go through associated symptoms. So if you get your chap box open again and can you have a think off what associated symptoms and abdominal pain would be really important to rule out brilliant Yet. So you nausea and vomiting Bowel Observe. Yeah. Vomiting, blood. Um, any blood in the stool Whether they passed Molina how they're feeling in themselves feeling light or dizzy, That's good. Um, on any signs of shock or update extension? Yep, there's already good and say, from the ones that we've said that anyone without paying you should be asking north and vomiting if they've got fever. If they've opened their bowels or if they do normally open their bowels, If they don't do they have a stoma? What's in the stoma? Is it normal for them? Is it different? And, um, what's the year and output like and then moving on to your a knee examination, which we can go through with this case, Say the information that you get from this patient. He's 59 is five days after hemicolectomies with anastomosis for cancer. Say that means he's had a laparotomy. So big cuts down the abdomen. They've taken out cancer from the bow, and then they've joined the two ends of the code on back together. And so he doesn't have a statement. He's complaining of worsening abdominal pain in the last four hours. He just says It's generalized everywhere it's 10 out of 10. It doesn't radiate. Nothing's making it better, and on moving is making it worse. He's unwell, Feel sweaty, Feels feverish is not being vomiting. Um, but he's not passing much year, and it was not taking his bowels. When you go through your 80 he's breathing fine, slightly tachypnea. But his stats are okay. You can't hear anything on the chest. He's got a fast heart rate, a low BP, a prolonged cap refill on his new cast, membranes of quite drying. He's got a fever, say already. You can start thinking that this patient is not well and he is alert, however, but when you get to his abdomen, he's guarding, so he's tensing all this up, doing the muscles and he's not letting you examine it, no matter how are how much you ask him to relax and you can't feel any masses through his abdominal muscles. But that's not very reliable sign when someone's guarding um, his wound from his laparotomy of dressed with a big dressing on. But you can't see any strike through, and there's no surrounding erythema of sneaking out. So you think the winds probably healing well and then everything else on this is really important. Say, split it any mind into something simple and easy to remember what's going in, what's coming out. So is there anything going into patient you need to assess? So any cannulas central lines, any pick lines, any NGO tubes? If there are any central lines, what's going in? Has it got a big bag of TPN running? Um, or is it fluids that's going in and what's coming out and from where? So just go through everything. Is there a catheter in? Is there a drain coming out of his abdomen and if so, what's coming out of it? What color is it? How much of it is there? And is there a chart that you can look at to see what the trend of that has. Bean has he got a steamer? And has he got any other tubes coming out like a riles tube? So the thicker mg wide bore that's draining of the stomach contents. So his news is a nine, so you can already tell that he's quite unwell. Say, breaking down your differentials for abdomen pain could be quite daunting. But there's obviously so many different causes of update pain. There's medical causes. There's surgical causes on. Obviously, for this lecture, we're focusing more on the surgical courses, but I just go through sort of different systems that some people might find useful. Um, so the first things think office, where is the pain on the exam and and what have you got from the history? Do you think it's related to what brought them in the hospital? Um, or do you think this could be something new and something different? If you're a complete loss, you could go through a surgical save on which I've got slide on later. Um, so everyone has different new Monix, but I use vitamin C E D f, which will go through the back and What system do you think this is related to? Do you think that this could be a POSTOP complication? So the common postop complications arrested here on But we will go through each one of these in a bit of brief detail, but we've got quite a lot to get through. So it will be a brief run through, um and then just little things to think about at the end. Is the wound infected? Is there a collection there It could that be causing pain. Ondas already mentioned Stoma drips and other bets. Same One of the ways to think through abdomen pain is where, and this is probably more relevant to clocking any d. You're seeing people with new update pain that isn't already known or isn't after a surgery. And so, generally, at the F one level, you'll tend to be responding toward sleeps on surgery jobs. So you'll probably be seeing patients that arrive, er, waiting for surgery or they've had surgery. And as an F two, I'm currently on their course surgical trainee rotor. So when I'm on call, I have a nephew on with me. He's covers the wards and then I cover any, like lock in new patients. So for me, this is more useful. New update. Pain Where? Where is it on then? Simple things. What age is the patient? Have a male and female eye which bits could have been affected on? Do I need to think off? And so I won't go through all of this picture? You've probably will be doing a recent Oscar revision so he could probably rattle off causes for different sections of the update. I'm so this is the Seroquel save that's going to quite helpful, especially if if you're at a loss for what you think's causing it, if you can't really pin down what's going on, The main things in surgery to cause update pain will either be vascular infection or trauma. So if you just pick every organ that you can think off in the abdomen or near the abdomen and think of what goes wrong. If it doesn't get enough, blood bleeds, what goes wrong if it gets infected or what goes wrong? If there's trauma, I have a local or massive, so local trauma could be, for example, a kidney stone causing trauma as it gets pushed down the ureter or big trauma could be, you know, a stab wounds, but of static. Obvious. Um, so going through the other one's less common reasons would be, you know, you missing something medical? Is this patient a type one diabetic in DKA? In presenting with Abdul Pain? Is this something that is quite benign and normal for the patient, like IV s or constipation? Um, or something more serious going on like an underlying cancer that's causing obstruction and then less common things such as congenital, which would only really be for Pete's degenerative thinking about other things. So the spine, the lungs, the testies things that aren't necessarily in the afternoon but can still cause abdominal pain. Um, an endocrine causes. So I thought I'd be useful just to go through the postop problems, cause that's probably something that on you won't be particularly confident with ongoing. You get into a surgery job, you will just see these time and time again, and you get a bit quicker recognizing the pattern and recognizing what you think's going on. So firstly expected abduct pain. I don't if anyone's bean to see a laparotomy, your appetite, a surgery or being see someone get there? Um, you know, appendix removed is quite brutal. They got a large incision. Bowel is manually handled, moved around, cut and, you know, burnt soon back together on. Then it's washed out, which literally is just water into the abdominal cavity. And then it looks like they just play the drums in the abdomen and wash out all that blood and mark say that gonna have pain. It's usually within the first few days that it's worse to probably get bleeped sooner rather than later after someone's operation i e. If someone's pain is coming on Day six after that operation and it's getting worse, you should be more worried than Day one. The abdomen's normally stopped, so there's no other signs going on. They may appear quite well on may have normal news, or they just be careful about tachycardia due to pain. Anastomose leak is another common one. So back to our example, there's a chap he's had a bit of his co enjoying back together. Um, contents can leak out on that, can collect in the abdominal cavity and become infected on. And that can make patients quite unwell so often present with fever signs of sepsis or shock. When you try and examine that afternoon, it's paraffin etiquette, and they may have a little or no bowel out put on their charts because their abdomen is where the bowel is basically in shock and they're not moving. So they're in. I'll ius him. Bowel perforation tends to be quite sudden onset, Really severe pain. On this will be a patient who does not move. They cannot bear any movement. So when you compare this to, say, the pain of a kidney stone, which is also severe, 10 out of 10 after pain kidney stone patient will be will be lying in the bed, writhing in pain they can't keep. Still, they're really, really uncomfortable. Where is about patient bowel perforation? Patient will just be lying. Still trying not to move a muscle. Um making often present septic parasitism collections and wound infections generally tends have localized pain. If it's become more systemic, they may have fevers. And if there is a palpable collection of past, you may be able to elicit that on your exam of the patient on then another. Slightly less worrying cause could be constipation postop. We give people a lot of morphine and pain killers. People aren't eating as well after operations on some patients might not be eating a tourist there might be on total parent or nutrition, and so they're about puts going to be really minimal. That's something to consider when you're thinking about that, Bausch are, and more wearing would be obstruction. So common things to look out for would be colicky pain because their path bowel it's trying to move things past. Obstruction is working overtime. Absolute constipation. So someone who's not opened their bowels a total for four days, and it's also not passing. Flatus is a lot more worrying than you know. 90 Rolled. He hasn't opened their bowels in a few days, but it's normal for them to go a few days without opening their bowels. Abdullah distension on vomiting, which, if it's a small bowel obstruction, that's bean going on for a while. It could be fecal, um, from it, and then the last common postop differential would be bleeding. So are they showing signs off tachycardia? Low BP shock? Um, we'll go through this off. Basic management of these in the second is well, and if there is any questions. I'm just pop them in the chat and we'll run through them at the end of each scenario. So investigations. I think you probably will heard of different frameworks, but it's really useful to go through a bedside Bloods imaging and special tests for anything. Just that you don't miss anything, and it will obviously depend on what you think. The difference diagnosis is to what you do. Um, but anyone that's really unwell, especially if they've got a compensating tachycardia it probably won't get any CT done. If there's any worry about a urine infection, you want to dip on an emcee s if that older generally return not to dip the year in him because it's not very reliable. And on day, while you're at their bedside, obviously parts of your exam there stoma and drain out. But can you look at any fluid charts there? Blood tests. If you're worried about bleeding, you officer, once in upstate hate to be. If you're really worried about bleeding, you want an update. You want an up to date hate being now, so you want to get a probably VBG Um, and then you need to look a dehydration if someone's not eating very much because of the update. Pain. And if you're worried about infection, you want a full set of bloods with the CRP in terms of imaging and simple tests that that you can think about ordering would be. Obviously, we'll go through when to discuss with a senior in the practicalities of these but Abdo X rays. A good for obstruction Iraq Chest X rays. A good for perforation to see if there's any air into the dye from on an ultrasound is good to assess a localized collection. How big is it? Is it big enough to drain? Does it look like it connects with anything? Do we need to image it further with the CT? If you've seen a patient on, you're worried, Um, and you know, you just asked the surgery job you're worried about when you think that they may need to see ti. If you're having any of those thoughts, you should be on the phone to your Reg because at the end of the day they're the specialist in the area. On day should be coming to review that patient as well, or at least giving you advice over the phone as to what investigation you should order. So coming back to these common problems first expected pain. If you've ruled out worrying causes, just go through analgesia ladder check what? They're one of the moment, what their prn's are on. Just go the next step up if you're in hours. Most hospitals were having acute pain Team, usually nursing glad, and they can be really, really helpful to come and review the patient. And if it's out of hours, obviously you've got your own registrar. But it might be more useful going through, say, anesthetics or critical pair outreach and anastomose leak. So obviously this patient is at high risk of deteriorating or they're already deteriorating in front of your eyes. So if in doubt, make the patient know by mouth in case they're going for the attorney. If you're worried about an infection inside the abdomen, start broad spectrum antibiotics like you would for any sepsis, and that would differ by trust that come ones for inside abdomen infections is a mg so amox metronidazole on gentamicin. Do they need IV fluids and they need that as a bolus or maintenance or both. Do you want to monitor their fluid output. You want a catheter? Discuss with your Reg because they're probably going to need either a drainage. So, um, leaks can sometimes just have a further drain. Pretends, try and drain the fluid coming out of that week. If the patient's well or if they're not well, we'll need to go back to theater toe. Have the leak sorts down on the management for bowel perforation on Do a Wound collection is fairly similar to above Um, so if in doubt, he'd want to make them know by mouth in case they need the attorney. Almost all cases of a bowel perf will go for a laparotomy on most collections or wound. Infections will be managed with antibiotics on do percutaneously, a niche so usually ultrasound guided drainage just to drain that collection way of possible and then no move to fear two later if they need for constipation. Just think about what laxatives they on our be even taking them. Can you add anything else? Um, if they're so constipated that they're not really opening their bowels, do you need to do a PR to see if their impact it? And if they are impacted. And then it's probably sensible to start with either a suppository on enema because if you think you've got big blockage in the rectum, that stopping other stool passing through, you need to try and get the body to clear that, Um, if it's got to the point that they've got overflow diarrhea, I loose stool is pouring around this blockage to get out on by. Probably get your Reg to have a look at them as well on we give people lots of medicines that constipate them. So can you look at their, um, look at that energies and see if there's anything that you can change to avoid constipation on. We've got more talks coming on. Allergies es a staging for that and another one in one obstruction say similarly, If in doubt, know by mouth and then the management are level is get a rise trip in on make sure you've attached the bag before you put it in. Otherwise, if someone is obstructed well, you will spray hose bowel contents everywhere. Andi drip so IV I make sure they've got catheter. If they are still vomiting, make sure they've had some antibiotics on board. Try and get that under control and obstruction, which usually go for surgical management. Um, depending on the age and comorbidities and then bleeding. Sounds simple. But if someone is bleeding from their weekend and it's fresh red blood spurting or least pouring out, someone needs to be standing next. That patient just applying pinpoint pressure over that bleeding point. And while everything else is going on, they just need to be stood there holding it because first eight is the first thing that's gonna help that patient. And if they're shocked, you could give on IV fluids if they're low and hate to be on the gas replaced, like for like so gives, um, HB give red cells get your senior involved. So just to recap, bring it back to that scenario is, and we've sort of diverted and gone through the differentials for a lab pain. So this is a 59 year old chap. He's five days postop. He's had a left hemicolectomy, and they've anastomose times they've joined it back together. He's got worse than average a pain in the last four hours, and he stepped in and he's got parasitic abdomen, and so just the chat box again, if you can. And what would be your top two differentials for this patient? So I can see there yet? We've got one. So anastomosis leak or perforation? Brilliant. And so those be our top differentials. So again, in the chat, there's obviously a lot of things that we're gonna do for this patient in wise in terms, investigation and management. Um, but between you, I'm sure you've got enough of you to try and name most of them. So if you go in the chat, it's quick as you can. And what investigations in management, which you like to do for this patient in the chat. And then we'll go through it on the next side. No. Yeah. Abdo's CT is what they will need. VBG for lactate. No, by mouth. Antibiotics. Call your senior ABG Bloods. Yep, Billion. I'm safe. You've obviously got a separate it patient, So if you do nothing else, think of your sepsis. Six. And go through and at least try and take them off. While you're registering, you need to keep them know by mouth, which sounds simple, but just take food and drink off their table because it could be really frustrating. If especially someone's unwell and delirious if they're reaching for there, you know, reaching for that water bottle or something to try and start drinking. Um, and you think this patient is on Well, he's going to go to the theater if that in this chap, he's got low BP and his tachycardia. So he's starting to not to compensate, managing his BP with this tachycardia. So you want to give him a 500 million bolus of IV's, um, in surgery, if and out. I always just go for Hartmann's, um, and then recheck the BP and 15 minutes. If he's not got a catheter already, you want to catheter in Roy's batch? My antibiotics. Blood coaches, which you need to take before you give the antibiotics. Um, you want a BBg to get a black tea because that will really help the surgeons decide how urgent this is on D. Think ahead. He's going to go to fear to, most likely. So you need to make sure there's an up to date group and save. If you're in doubt, you can phone blood bank usually, and I'll tell you whether they need another one. A clotting him and make sure he's having any see GI done. If you in any doubt in your seniors taking a while to come or not responding or you feel like you're not entirely sure, then you could get an erection, just X ray to see if there is a pneumoperitoneum. However, in reality for this patient, I would see if it was me. I was turned up. Take my quick history an exam. Do my 80 on Think Oh God, like I need my ranch like there's lots of things that I can do right there and then for that patient. But the thing that is going to help them the most is early surgical intervention, so I'd probably at least have taken some bloods in a VBG while I'm there, make sure he's got some fluids up as a bolus on day Zen toff. Blood cultures on behalf prescribe some antibiotics that they can at least start running. But once I've done, my basic things are gonna be on the phone to the Reds, give a good hand over and just confirm that they're happy for a CT and then hopefully the register, I will be able to help sort out the logistics for theater, so consenting the patient looking them and fasting them. Other things that you're seen you could be really helpful is if the escalation status isn't clear on you. Say, got eight year old with lots of co morbidities. Do you need to revisit the escalation status? Do you think they're going to deteriorate in the night on? Do you think the resuscitation is appropriate for them on Do if you're really worried and it is perhaps in someone that you think could die from this, do you need to find the family? Do you need to get them in to see the patient if you think that they're not going to survive the Attar, so I think that brings us to the end of the first case. If anyone's got any questions, feel free to pop them in the chapped now. But we can always answer more questions at the end, but that might just be easier to do. Case by case. I think you answered questions brilliantly, and you went along. Been there was just one witches we can start. We go along if that's helpful, which is when doing an eight week is okay to ask nurses to help you to work through it and take ups? Absolutely. If there isn't unwell patient and you're doing an 80 on that acutely. Um, well, I'd want the nurse there with me. You shouldn't have more than the nurse. Usually a hatred see, and a nurse. Because if you're if you're there and you're thinking I need a lactate, you're not gonna want to go leave the patient if they're critically. Um, well, to go get equipment. So and it's really still have a runner. You know, other people can request imaging if you think Oh, I need I need a chest X ray. Now, you could ask politely if someone go and request that while you do the bloods. Um, so yeah, and the nurse could be taking up today. Obs They can be getting the fluids ready, and sometimes they can even help. If you've got CSW on clinical support workers, they are lifesavers. So I've done eighties before and got to the end clinical support of arrived. And I've asked for a gas blood's blood culture, and they've done all of that for me, so yeah, definitely. The more hands you can get another better. Fantastic. Um, one more question on this scenario before we move on is what would the lactate tell you about severity? Say the lactate tells you how well organs in the body of being perfused to speak very simply from a surgical surgical point of view. So if you've got someone that you were failing your Reg about and you said, I'm worried that this person has perforated and I think they need to go to theatre on your registers, what's the lactate? And you say No 0.0.5. They're probably going to say we sure the diagnosis is right, whereas if you faint and say with this chop, I've got 59 year old. He's four days POSTOP. He's septic. Um, and the lactate is five. They're going to take you a lot more seriously and come see that patient quicker because it shows that the organs aren't getting the blood that they need because of the sepsis in the low BP. And say what time were on 35. That is the biggest topic to be fair up there. Pains quite big one to cover. And so next is Doc, Doctor this patient may stop being sick, say we've got a 35 year old female and she's complaining of nausea and vomiting. And she won't stop being sick. You've got the nurses on the thing. So wait, labor because we went through it last time. But ask for an Aspar what they came in with, Um, who's calling? Where from? Of a unwell. What's that New school? Red flags for the symptom that they're failing about so that you can prioritize. So for nausea and vomiting that would be. Is there blood in the vomit? Are they're choking on their vomit? Or there any other signs and symptoms that you're worried about now, before I arrive, please, Can you? So you've asked all the important questions and you're on your way. So my walk thoughts for a vomiting patient would be, um, how long have they been vomiting for? Um, I worried about them aspirating on their vomit. So I need to remember to listen to their chest, and I might need to get a chest X ray. Um And then what were the worrying causes of vomiting? Are they obstructed? How's the abdomen? How bad is this? Say we get there. I bought a patient, and they look okay, so you go to the notes and you look through what's brought them in the hospital. What they've had so far and what that escalation status is he looked through their recent blood. And you look through what current meds there on on defervesced. You'd want to check if they're on any anti emetics, and then you go to the patient and get history. So what? What are the most important things that I want to find out about vomiting? On what? The associated symptoms with vomiting? I've already mentioned a couple that would make you worried, um, in the chop, whoever failed them. Hey, if you want to see that, I promise there's not more interactive slides. I think this is the end. Coffee, ground vomit. Yeah. Violent blood. Yeah. What is coming out of their mouth? Um, if there is blood, how much there is it? That's good. How much? How often color blood. Who? Yeah, the taste of the vomit. Who? I like that on the volume. Get, say vomiting. Just think simply you want to know how long for how much they're bringing up? What the color of it is on their four. What you think it is, Is it bile food? Stomach contents? Is it blood? Is that pain? That is that as a starting point for your differential diagnoses on? Then, while they're vomiting, is there anything else happening? Are they in pain? Have they got a fever? You worried about infection on what's happening with their bowels there, stoma or their year in? So for this patient, you take her history. New examine her. She's 35. She's day one after having her pendants out. There were no complications in the surgery. She's been vomiting a lot through the day since the operation, but it's just stomach contents, and there's no blood. Her bowels open Fine. She's a febrile. She's passing urine, but she's noticed that it's a lot darker than usual, and it's stinging when you examine her airway and breathing fine. She's ever so slightly tachycardia on her BP for her seems to be normal, but slightly on the low side. But she's got dry mucous membranes when you look in her mouth on her. CRT is three D is fine on is fine on. She's needing a one so differentials for vomiting. Um, lots of different causes for meeting again. There's update pain, but try and break it down into something that makes sense to you. So every vomiting from pain I can. I treat the pain and make the vomiting better that way? Or do I need to give them an anti Matic? A. Swell? Is it something worrying, like an IV? Ast's s. So I This is when the bowels not moving on para styles in as well, and so that bowels will not be opening. Or are they obstructed? I, er, they in pain, this colicky pain with bowels and opening for meeting distension that works. We've done that. Is it to be expected of a half turn operation? Is it postoperative nausea and vomiting, which would talk bit more in detail about later? Have they just had a general anesthetic that can also make it worse? Is this a symptom of something else, like an infection that I need to treat or they on any medications that could cause formative? Essentially, do I need to be worried when you're trying to prioritize vomiting and be quite difficult? Because vomiting can be really serious? Um, but Usually the nurses are pretty good at telling you whether they want you there. Right now. I they're vomiting large amounts of bright, fresh red blood or they're fine, I guess. 35 year old day, one POSTOP. I probably wouldn't go and see straight away. I'd probably check, um, that she's got some anti emetics prescribed on. I'd see if anyone's dipped or sent her a year and because she said she had stinging urine on. That would help me decide where I see her in my list of patients. But if you compare her to the chapped before, she's obviously lower down on the priority list. So differentials we just go through a few of them. So postoperative nausea and vomiting it's very common, usually occurs about a day or two after the operation, and it can actually fax about 20 to 30% of people on go through, um, the risks of it and what can happen later? Infection. Then it's labor that I got fever is there? Is there a localizing source on the symptoms, signs or examination? And I liest like we said, the slowing or whole of intestine motility, So it's kind of like a function obstruction I There's nothing actually blocking the bowels, but the bowels aren't working. Um, it's It's an examination finding that's often throwing around. But absent versus tinkling bound sounds is the sort of classic way to determine between ideas and obstruction. But in reality, they're both, um they can be quite difficult to tell the difference between But for either of those patients, you'd be getting your registrar involved anyway. So it's just about getting exposure to them, and everything is you go obstruction and we've talked through already. Medication. Common causes include opiates, ondansetron checks, and we start a lot of people on metronidazole. Um, if I think about everyone that I admit through e d, I can probably say for those coming in under general surgery, so think appendix gall bladder diverticulitis, um, obstruction, things like that. Most of them will get started on a mg amox, metronidazole and gentamicin. So we love metronidazole, but the patient's day and then a couple of other things um, go back to your surgical save you missing something? Have they got raised intracranial pressure, you know? Are they just anxious? Is this normal for them? Um, bedside investigations for vomiting. And if they were tachycardia call you were worried about, you know, chest pain with vomiting. Um, Then make sure you get any C g if there any symptoms of UTI if they're young dip and that can help you decide treatment or if they're on send in M. C s. If they're old, just send an M. C. S. Um say ah, and then strain and steam up as well. While you're there Bloods we've gone through So infection white cells CRP Are you worried about patient VBG You worried about dehydration? You and he's in surgery. You can tend to get away with a V b g, um, as your gas of choice. ABG So arterial blood gas tend to be much more important if you're worried about the oxygenation of a patient, um, or if they've got CAPD. And we started him on oxygen and we worry about them retaining so generally for surgery, were interested in the hate to be the using these on the lactate, all of which you can get on a VBG venous by gas. And that's usually good. And it's good for us because I don't like doing a BG and it's absolutely have to on then. Use needs for dehydration. Seven investigations is before on CT would be chattering. It's a management for vomiting. Just start with simple, easy things first, and then work your way down towards the more fun stuff. So dehydrated. Do they need fluids really obstructed? Do they need a rouse tube? Um, to help avoid them. Aspirating that vomit aroused tube can decompress the stomach. And actually the patient will thank you for it because they're feeling so nauseous from there. Obstruction because they've got everything that's trying to go one way coming back the other way, and you put in a nice big tube that just brings it all out. And they usually start to feel better, quite quickly and night about CT's. If you are clearing obstruction and you're sending a patient for a CT, Um, it's really good practice that they have a rise to been before they go, because if you think about how a CT works, you're just lying. This patient flat, he's vomiting on your just asking for trouble and aspiration if you haven't decompressed their stomach or a least started that process before they go and then getting down to the active treatment. So antiemetics, which is useful to know what you're treating before you treat I. What is the cause of this? Form it in, um, analgesia to control the pain. Laxatives to treat constipation If that's what you think, the causes or antibiotics, can you switch the antibiotics to something that you think won't cause the vomiting? If you've executed all the other sources? Or do you need to start antibiotics for an infection that you think might be causing the vomiting? Lots of things to think about. Um, so just to bring it back to this lady. So she's 35. She's Day one POSTOP. She's got a slight Sinus tachycardia on the C G that you've done, and she's got dry mucous membranes she's paying. It looks quite concentrated on. It's stinging, So you do any see GI. You send an F B C and you and he's He send a year in depth, which shows leukocytes and nitrates when the nurses come back to you with the little piece paper with over pluses on it, and then he send it to the lab on D. Actually, I've forgotten CRP on that CRP. So the top differentials for her. She's got a likely UTI, so she's young, She's got symptoms, and she's got a positive depth. So for most hospital guidelines, that would be enough for you to start empirical antibiotics. I cover all infections that you can that would commonly cause a UTI and send it to the lab. And then if the lab comes back with a different bug for that doesn't cover, you can change it later. If her dip was negative and she was complaining of stinging year and and I probably wouldn't start her on antibiotics because it's quite common for concentrated year and to sting slightly as it passes because the concentration of your and things are higher. Um, obviously if she deteriorated or she had a fever, Um, well, there were other signs at the same time. Then you could start. But that's just a side new. That's a whole lecture in itself, probably. And she's day one POSTOP, so postoperative nausea and vomiting, and she's dehydrated, so to manage her, we want to correct all of those things. If we can correct the dehydration, give us and fluids, um, correct the pain from her stinging when she passed his year and give a pain relief. Try and bring that nausea and vomiting into control. Antiemetics good one to be on dansetron or cyclizine. Treat the cause of what he thinks causing it. Say antibiotics on Do see if she's already on analgesia and if she's using her p r N basis on Go Through, the Pain matters in ET and for her from that history, I probably wouldn't be doing an N g tube of the moment, but it's something that you keep up your sleeve for later, if things worse and say briefly, 2030% of patients after a big surgery will complain of nausea and vomiting. We've talked about the risk of pneumonia, but there's also risks of metabolic alkalosis on surgical complications because they're increasing that intra abdominal pressure through the act of vomiting, so that could make it more likely for them to burst. Their suture is and start bleeding. Um, it's more likely in young females. It's more likely in these you haven't got adequate analgesia on board more likely and longer operations longer anesthetics on more opiates, so the management for it starts before they even gone to theater, so try and plan to reduce the amount of a P it's that they have. You can give them prophylactic antibiotics before they even start experiencing this. So for all surgical patients, you should make sure that they've got Prn's on there meds chart ready to go on. The nurses can give that before they start experiencing nausea after an operation if they like. And there's some evidence that dexamethasone before an operation can help reduce this is well. And then we've gone through conservative off non pharmaceutical measurements would be rehydrate. Um, pain relief. Decompression on. Then the pharmaceutical side of the vomiting would be either sometimes on dance from It's like cuisine, a much better at targeting opioid induced nausea on Where Is Metoclopramide is better if you think that the bow isn't moving as well as it could do, which is causing a build up on their four nausea? A. A note. Do not prescribe that in obstruction because you'll make that pain worse, cause if you think about that, you've got something blocking the bowel about trying to push against it, and then if you give them a prokinetic, you're basically making everything worse say that was a brief tour of vomiting. Does anyone have any questions from that case before we move on to urine up? And so there were a couple on which I've kind of answers. We got along mostly about blood, blood gases. She can clarify just to mention monies with everybody that you can get an initial HB back on your blood gases. Well, ascending on to the lab on. Also, you can get a lactate on your BBg as well as you're on do ABG, and that's useful. But just quickly, there were a couple of questions, maybe about chest X rays, which being ongoing, which use more of the pain and vomiting so warmers can can use the chest X ray. How to use a chest X ray to assess aspiration? Um, se sometimes if someone's aspirated a massive amount of vomit that vomits obviously gone down metric here into their lungs and in the wrong place. So if you get a chest X ray, you can compare it to previous ones, or sometimes you don't even need to, and you can see that there's a consolidation in the lung that wasn't there before and and see if you are about whether that was from it. In those patients would be starting antibiotics to cover for a chest infection. It can be quite difficult if they've, if they've started vomiting and the nurses give you a sort of a history of all. They were vomiting and then they started coughing afterwards. So I think they've aspirated. That kind of then leaves you with a bit of a gray area. If you can't really work out with, they have done on small aspirations might not show up on a chest X ray straight away. So as long as you cover yourself in document that you know they have not dropped their SAT since the vomit and the patients not complained of any obvious shortness of breath or cough on. But if you think the chest X ray is needed, you've done a chest X ray, and it's clear then you'd be fine to sort of rule that out for the moment. But bear in mind for later if they were sitting here right, fantastic, and keep that, that's okay, and there's a couple of questions about Antiemetics on, and but I was just going to say that We're also having a prescribing lecture specifically on antiemetics laxatives on a lot easier, but about fluids in our third weeks on the eighth of June. So I'm gonna leave those questions for now Unless we've got time at the end of the left, then continue and because we'll be discussing antiemetics and all the different types and how they act in a lot more detail later. So continuing on, then thanks. Um, say we've got the last 10 minutes just to go through urine output it on, then any final questions at the end? So this patient isn't passing urine, so you get bleeped. It's what time should make it is 4 a.m. Um, you just tried to go to sleep in your sleep is going off on the nurse's of leaking you that a 75 year old man has got a low urine output on his fluid chart and they love sitting at the desk on doing fluid charts at four AM So 4 a.m. is a good time to get sleeps about about this questions for the nurse Red flags. Are they in pain? Does that tummy like to stand it? Has they got a catheter in. Is it draining? Um, but all I wasn't no urine output. Or is it no urine output? What's their new school? Do they look? Um, well, do you think this could be an infection? Things to do before you get there will come on t mainly catheter things if he thought it was blocked. There's quite a few things that you can ask the nurses to do before you arrive. Sometimes you can even ask the nurses to do and no arrive, and it usually starts itself out. But we'll get to that. So you've asked important questions to prioritize this patient in your list of things, the walk thoughts, any recent surgery. Have they got a catheter? You know, make sure you you keep it in your mind that you've got to look at that fluid shot. For some hospitals, that will be Elektronik, which is great for you. For some hospitals, like hair ago, it will be on a piece of paper, either the nurse's desk or folder somewhere, or the patient's bad side or the floor. All the doctor's office. So you have to find it or it might not exist. Have they got fluids running already. What's their recent kidney function is showing. Is this serious on, then? Just just to think in your mind. How how heavy is this patient? And how much would I expect that urine output to be? Um so anything less than NorthPoint three mils per hour per kilogram on would be worrying. So you get to the ward and you know, I bought the 75 year old man on. He's sit up in bed. You go and say, hi, that you're the doctor and you'll come back soon and he says, That's fine. And you think that you've got time to go to the notes. So you go on essentially just you just prepping like almost like a tiny little war drowned. Many review. So age what they came in with, what treatment they've had, what surgery they've had, and any catheter documentation that might be in the nurse's documentation or on the handover. So getting available handover from the nurse is really helpful. Um, I what catheter. If they go in, is it a long term catheter? Is this something that they always have in? Or is this a short term craft? It is this something that's only been put in for surgery and then the dreaded fluid shot and recent blood. Recent meds. So history for urine output. You want to think? What are the really worrying causes of a reduced urine output on what with those symptoms Be so fever, you know. Are they septic? Is there a infection that's causing low BP, low kidney perfusion and so reduced urine output? Is there a specific sign of symptoms such as long to growing pain that might suggest something else, like a kidney stone? And and then I like to break out from down really simply so that when you're stressed, you can remember. So what's going in? What's going out? So in Is the patient drinking? Are they allowed to drink that they know by mouth? And have they got fluids running? Have they had the correct maintenance fluids for the last couple of days? Or have we just let this patient turn into a crisp? What's coming out? Have they got any symptoms? Is it easy for them to we Does it burn? Does it sting? And how much is coming out? Is there blood in it is they're passing it Where's it coming out from? Have they got a catheter or have they got your ostomy a tube? You know, into the kidney? Or have they got a suprapubic catheter, a catheter coming out of their bladder? What's normal for the patient? So you go through all of those things for this man. He's 72. He's his second day after having a right hip. Hemiarthroplasty, Um, and he's had some blood loss in the operation, which you've noted on the up Nick. He's got hypertension on his own ramipril. Oh, he's being nauseous since his operation, but he's not being vomiting. But you notice from the fluid chart, which you think looks fairly accurate on Sounds accurate from the patient. He's only drunk 400 mils in the last 24 hours on these weeds. 700 mils. He is catheterize but was really done for the operation. There's no blood in the catheter bag, his bowels opening. He feels fine. He's not in pain, and he's not got a fever. You examined him airway and breathing? A fine, Um, he's slightly hypotensive. He's dry and on. There's no signs on examination on the catheters, draining really dark, concentrated looking urine. Not for him but anyone with richest year and out. If they're not opening their bowels, you really, really have to do a D, e r e or P R. Just to make sure that there's no impaction so lots of hard stool in the rectum. Because if there is, that can cause acute urinary retention and they'll need a catheter and they'll need lots of animals, which the nurses will love you for. So differentials for urine out. But I like to think of it is before the kidney problem kidney problem or after the kidney problem. Kind of like how you'd go through a K I. So pre renal problems Have they lost? Follow him. And have you got a low BP? Or is something wrong with the artery supplying the kidney in renal problems? So is there any drugs that are causing problems for this kidney, or is there any any kidney disease going on that's known or new Onda post renal problems, which is the most common in surgery? So is there something wrong with the urethra? So is there a stone in there? Is there a tumor? Is there something wrong with the bladder and in retention, or is that catheter blocked? Um, or is there something wrong with very throat? Is that a UTI causing irritation? So they're not willing, Um, Or if they got a massive prostate or if they got, you know, problems with strictures or fibrosis from previous urology surgeries and stuff. So the common ones that you see acute urinary retention, Um, in some patients that might be chronic. So they might have known prostate problems and say, You know, I always have problems. We're going, you know, it was dribbles. I could never get enough out. I always feel like I need a way in the middle of the night. They sort of problems in hospital. Constipation is really, really common him for reasons that we've already gone through. Unless common causes would be a prolapse like a rectocele, um, or kidney stones. And then just things to think through. If if in doubt, just think what's common, what I really need to be ruling out on that's infection. Low BP because of either low input or sepsis drugs that the kidneys don't like stones that the kidneys don't like, um, re retention a blocked catheter or an infection, Um, and then we won't go through those at the bottom, just if if they are hypotensive, so they've got a low BP on the low urine output. Just think through what's causing this low BP. Is there anything that I can treat, or is there anything that I need to investigate? Speaking off, um so dips and MSU. If you're worried about retention, ask for a post void bladder scan so the nurses will be really good to getting this done. Essentially, the patient will try to pass year, and so if they can't, that's fine. If they can, a dribble comes out or whatever, and then they get a bladder scan on different hospitals will have cutoffs for what they would call retention and needs a catheter. Commonly, it's about 600 or 800 mils. Um, is there anything going on with the obs that you need to escape with an E. C G? If you worry about infection or dehydration sense and blood tests, um, if there's constipation or impaction that's not resolving, do you need to be thinking, you know, is there really severe impaction going on that might need treatment from the top on the bottom. So normally, if there's just a small amount of impacted stool in the rectum, you can get away with an enema on regular black steps like Mobic all. But if you do an abdomen X ray for someone that's really struggling on, do you just see stool over the whole of the abdomen? You're gonna need to go with one of my Jerry's consultant called. The More vehicle bombs, which I absolutely loved, is eight more fickle sachets once a day until their bowels opening with animals. So basically hitting this really impacted stool from both ends to try and get the bowels clear out on diffuse right about urology issues. So any problems with with stones or they've got fancy your ostomies or they've only got one kidney or you think they've got a kidney infection, but you're not quite sure what's going on. They may need ultrasound of their kidney ureters bladder, or they may even need a CT. So the initial management, obviously, for hypokalemia hypertension, think about sepsis on manager. As we've talked about before. If they're on a K I and they're nephrotoxic, so you need to make sure those were withheld. Um, if you think they've got kidney stone, so the common presents complaint is severe loins. Growing pain on this is the patient that is right thing in pain. They can't keep comfortable. They commonly have blood on a deposition Well, and that's from the trauma to the year it is. You need to make sure they got adequate analgesia and these patients, we need a lot of pain relief and that often the ones that I just that just can't get comfortable in the D and say company that would be declawed fan back P R anti emetic and on they will generally need a CT. There's, um, some debate about which is the the first investigation that you should get for suspected kidney stones but generally kept urology involved early on. And they'll probably want to see T k U B for acute urinary retention, and you may be able to feel their bladder. And my friend was working in the combined assessment teams off route, less urgent than any basically clinic on had a patient come in with two liters in his bladder. On said that he palpated his bladder almost up to his if Eastern. Um so essentially, this patient was almost pregnant with the bladder and Onda. Yeah, just make sure your pace for a bladder scan and then catheterize them. Obviously, try and get that urine out and entry any causes off that retention locked catheters, Another really common call. Normally, the nurses have tried their best to get around it because it is a common thing for them to come across in the ward. Think about it in a patient who you think on exam should have a good urine up. I you know, they're drinking well. They look well hydrated, and you're just bit confused Why they're not passing urine. You can try flushing it. We just water's. Try and see if there's any blockage in the actual catheter to flush out. If that if you do flush it and it does manage to start draining and there's quite a lot of debris and you know, if they've had a really bad year and infection and there's lots of sediments, um, or puss or, you know, blood. If they've come in with hematuria that's coming out, you may need to start some irrigation, so that's fluids going in through a three way catheter into the bladder on just keeping a study stream of fluid running through so that any clots or bits of sediment can just pass out with that fluid running I'm And then just think of simple things. Is the urine bag below the bed? You know, if the if the urine bag is sat next to the patient, gravity is not gonna be right from very well for you. So okay, on the bottom bar, or put it on the floor, depending on what system they use. Um, and another common one is if the bag is completely stuck together, um, an air block, then you're on might not be able to get in. So just always making sure there's a bit of urine in the bag so that the bag is actually able to take more year. And And if you can't get anything and you're worried, you may just need to replace the catheter and then the final one that will go through finish management of bypassing catheter. So I'm weeding Doctor. So a patient that says, you know, I've got a catheter in, but I'm still waiting him and it hurts So that's if this diagram down here year in is coming between the balloon. The IV inflated to keep the catheter in the bladder, and it's coming under that balloon and around your catheter tube through the urethra on out. Um, so it's not going into the bag is going all over the patient, and it's painful. This usually happens because off spasms in the bladder. So this tip, um, could be irritating the bladder wall up here, which causes the bladder wall contract and contract. Um, which comes force year and under that balloon. So things that you can try before contacting urology is sometimes deflating the balloon slightly so, usually 10 mills of her 10. But with most most CAFTA's, you can get away with five mils, and that might just help reduce some of the irritation. A smaller catheter can sometimes help, Um, and if in doubt, refer to urology on. They may need to put a fancy catheter in which essentially doesn't have this tip down here. It just has a balloon with a hole in the top, which can reduce irritation, or they might start anti muscular. Next to try and help relax that bladder say back to our final Man. So he's 75 is two days after his operation. He's hypertensive on the Cinopril, but you have a look into it, and that hasn't been held around his operation. So he's still been taking that, and you have a look back through his obsession and you can see his blood pressure's been running really low since his operation. He's not drinking much. He looks slightly dehydrated. He's nauseous, but he's not vomiting. So differentials. Clearly, he's hypovolemia eso he's that's from two things. He's lost blood and he's not drinking much. Um, and then you've sent off some bloods, but you can be pretty sure that he's gonna have an A k I do to the above on because he's still on his face inhibitor. So for him, I only really got to do some simple things because it's quite clear from the clinical history and exam what's going on? So we'd want to send some up to date blood on get any CG management for him. He's got a low BP, so I'd probably give him a Bayless bet. Um, I might be more gentle with him if he's 75 you know, the only background we found out was hypertension, But commonly these people, elderly patients, can have problems with heart failure. So you want to be a bit careful with the amount of fluid that you give. So if they're very old, frail or have heart problems, I probably go for 250 miles Bayliss and then prescribe him some maintenance fluids on recheck his labs and 15 minutes he's nauseous. So try and treat that with what we've gone through before with hold his a centimeter. Um, on day one, those pellets come back. If he's lost a lot of blood, you don't want to just be replacing that with fluid. You want to replace, like for like so give him some blood. I make sure he's got some repeat bloods organized for the morning. So I think that's the end off urine output. Don't ask any questions for you and, uh, Pittman out. And then I just got a quick summary slide. Um, actually, I'll do the summary slide and then anyone? I just take a questions. So, um, I take her message for search. Gone calls would be the most three know the most helpful thing for you when you're on shift is to get really, really good handovers from the nurses because that's gonna make sure that you can prioritize these patients. Well, so take a good spot, ask for red flags, ask for simple things, and then please, can you What can this nurse do to help you before you get there? Our level. We're mostly on call. Gonna be doing really quick investigative work eighties and doing simple things Well, like fluids. He cg making sure they've got treatment for infections and then escalating to our regimen, We're not sure. Make sure you've got a differential at the end of your examination and history, even if you're not sure what was going on because it does it, it just makes you think. And it makes your investigations and management a bit more thought through if you if you've had an idea of what you're what you're treating, and then in terms of escalations probably something that we might get some questions on Mater. But some hospitals Do you have a sort of new school cut off that the registrar's meant to come and see that patient. So, in some trust, you know anyone using an eight or above should be seen on reviewed by a middle grade. Not that was happens. But you've got a lot of people available in hours on. Some people have able out of ours. You have your estate so they might be busy clocking. But they're usually be around to answer the phone or common. See a patient. If you're worried, you've got your surgical Reg and you've got the medical regimen. If if you think that US search correct isn't gonna be much help, well, they're not being much help in ours. You tend to have the critical care outreach team, which is often nurse lead. But they can be really helpful to come and, you know, do an 80. They can help with blood gas. Is there a good point of cool between you and I T U on? They'll often get the I T. U Reg to come and see the patient if they're worried Some hospitals have for the medical emergency team. Um, some hospitals only have there to to to to team. And don't forget, if you're struggling and you can't get hold of anyone, you have got the consultants on call a swell on then. Other things. Just remember you're only one person, you know. You can have a few people on the phone shouting down that you that you you've seen two hours and you've not come to see this lady who's got update pain. But you are just one person trying to do all of this work. So just try and be self. Where do you need a five minute break for a cup of tea? Just might make you more productive and respect the nurses because they can make your life so much easier if you get on with them and if you respect what they dio on. And I just worked really well with you on that sounds really cheesy, but just try and find fun in shifts because there is. There's always something to smile about work or even days where you're running a few feet on. You just can't believe that you've got, you know, five people left to see and it's one hour toe handover. Just you know, the nurses know that you've got really hard jobs and just have a bit of a laugh with them about, you know, how ridiculous is that the staffing so bad or, you know, just try and try and take these little breaks. Um, on. Yeah, you will be fine. So any any questions on the chat about anything? It'll be it. The urine output or anything, or surgery questions that you think I can help with that might not be coming up in lectures to come. Yes, amazing. If you just go to next light, then while everyone's still here, I'm just going to say, this is our feedback slide on down. So firstly, we'll get into questions. But just while everyone still here in case you want to listen to the questions and thank you so much, been, honestly, a fantastic lecture on Brady encompassed everything and I think and is really useful to Probably. If everybody the lectures will be on our website, you can go back over the slides. That's a really good detail there that would definitely have helped me out on my F one surgical jobs on D. So and just to say that you get certificates well, if you feed out the feedback, not only is it a must've helped to Ben on, but also it's really helpful for any STDs going through and for making his lecture series in the future. Looking at what you guys want and what you guys like you need on go while we're going through these questions. If you guys could use this beautiful QR code to fill out on some feedback that mean much, much appreciated and then quickly ask some questions, then if you're not too course on if I tell him no, absolutely. So there are a couple of ones that I thought might be easier to discuss. One was from Before that I missed just I was going through. And it was about another question about chest X rays. Basically say gas is pumped into the peritoneum during surgery. Would you expect to see some level of pneumoperitoneum on the erectile X ray in the short term? And with the so simple answer, yes, if they've had a recent laparoscope pick surgery. So if they've had their appendix out and you know that they're day one POSTOP and they literally just hard gas pumped into the abdomen, then they will have it. But if they're in that trap that we have this. The scenario for he was day four or five POSTOP a laparotomy. And so I'd be much more worried if I saw a gas under the diaphragm in him. Because by day, for one, he didn't have any gas pumps in because it was open surgery onto any air left in the abdominal cavity. By day four or five, I would have expected that to be reabsorbed. Yeah, that is a good thing to think about. And really good question. Yeah, if someone's had laparoscopic surgery, don't do interact chest X ray, because you're probably going to see gas room and a couple of other questions. So this one's talking about analgesia to give in kidney stone patients with a history of this gimmick heart disease. And so, to be honest, I don't whether this is your frankness, I think you can always give Dictaphone AC. The posture is is normally you go to Yeah, you have any experience with kidney stone patients with heart disease? Not that I've clocked in, so I've never had to google it. But this is where Doctor Google would be very helpful. Yeah, but yeah, if you had any doubts with diclofenac or, you know, patients had an intolerance to dictate for like and you couldn't give it. Just stick with your usual, um, analgesia pain bladder. There will be, you know they'll be on Paris that small I'm if they can have. I praise, make trouble instead or other end states and normal on if if in doubt, the pain team would be really helpful cause they're used to sort of more complex pain patients. Absolutely. There are lots of things you can try so periodic for neck is kind of go to and kidney stones. That's really, really helpful on. But someone's mentioned things like Basketball man can be Radius, which is depends on the patient and the pain, and that would also be covered in the prescribing that chair. And we'll go through analgesia and the pain, bladder and all of the different sort of options of managing surgical pain on October AIDS. Next question is about my past in catheters and why each babies anti muscular. Next, I'm say that would be You guys should be able to answer that better than me with your recent med school days. It is to do with the innovation of the blood wool on, but it just helps reduce the irritation of the bladder wall and helps reduce overactive bladder symptoms. So and cramping of the bladder wall, which squeezes the urine out, is my very simple and standing off it. I'm sure it has a better part of physiological explanation out there and you're getting there. Someone just mentioned why in the low urine output case, you probably get any C g. Is that due to electrolytes? Um, I think let me go backwards. They might just being touched Arctic Check with electrolytes. Potassium. If you're worried about, um, year and help it, he has absence. I just move my questions out the way. Um, I was probably doing the e c g just for the low bp if it was new, but that was being very safe. You could probably get away with not doing any cg for that for that. Happy? Um, yeah. If if in doubt, STD's just really useful to cover your back to make sure that you've not missed a cardiac cause for low BP or, you know, an algorithm for tachycardia Penis have reached back to the days people who were still here with us to you explained to me he eating in there, feeling in the feet? Back on the final question, I think you actually answered. This is he went alone, which was just that escalating on just to go to different types of escalation calls like a met call or a troublemaker. All I think you're actually spoke about this. You could just briefly we summarize point s o. Yes, escalation calls. Um, every hospital have a different system and that, well, you should be part of your induction as to how the different calls work. But generally for surgery, anyway, you can have different bleeps. So the trauma team is usually the orthopedics team on with the, you know, anesthetics. I t u on day will be called to Edie to see new trauma calls. So you know, someone gets hit by a car on the ambulance having to hold them in a C spine. You know, brace, that's a tropical. So usually it's the S H O. That's on the trauma team, so you won't be on that as the f one, and and you won't be putting those calls out on the ward unless your him any d as they don't worry about drama, calls. Met causes the medical emergency team. Some hospitals have this, and essentially, it's kind of like a softer version of a crash. Cool. So the patients not on you know, the patient's not dead. The patient is about to die on. But as the same team is the crash team, usually without the anesthetist on it's just really helpful if you need help now with a really unwell patient. But you don't think that you need the crash team because they have no arrested. And then the forties is obviously anyone that, um, has arrested or in hospitals without an emergency team. That is also the emergency teams. So if someone's, you know, bleeding there bleeding a lot, they've got really low BP. They start to complain of chest pain on. Do you think? God, this person could really deteriorate or even die on me and, you know, even got time to phone your Reg. Then you just put the tubes out. Amazing answer. Thank you, Ben. So that is the end of this lecture. Thank you all so much. Remember to fill out this feedback, especially if you'd like a certificate to, um show that you've been here on your attendance on but massively appreciate, even for doing this lecture. One of your help. If you guys have any further questions going on, feel free to get in touch with STS Fire, a website or email on but staging for the rest of the Webinar series so that every cheese day and there's a the first week is now complete. But I'll be, if the next and three weeks on. I know a lot of questions come about prescribing, so that's why we're going to do a specific lecture. But the next two next week will encompass some more cases on, But more things you get from the war along this theme on Denny thing else that you'd like to hear about during the secretary's just get in touch with Put it on your feet back on. Thank you very much. Food joining everybody on. Do you have a really good banker today? We can