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Okay. Well, thank you, everybody, for coming to our fourth lecture of our Siris. How to survive your surgical on call on. We hope you guys were enjoying as much as well on. Be really excited for days. Webinar, which is Ah, Doctor, Doctor, this patient isn't breathing well on. So we're going to take you through auction requirements, atelectasis, peas, things like that. Um, as always. Like, if you have any questions, please put them in the queue. And a we'll be monitoring that throughout rather than in the champ Onda. Also, just to let you know that your videos and Mike's or automatically turned off, So don't worry about that. Um and so our electric today, I'm really excited to introduce because he's actually one of our committee and newest committee members. He has been organizing the small group teaching, which, if anyone was interested in doing it's basically taking what we're learning from the webinars on DA teaching you on more of a small, small group scale. So, um, you you kind of put everything you into practice put you under a bit of pressure, but he is called a Bronco. I and he went to medical school at Bart's. As it says here. He did his foundation program in northwest London on day he had so placement in breast surgery, which I know is something that he is definitely considering on. He's also just got a very competitive CST post just on the outskirts of London that PSA Peter's. So I'll hand over to Brian my hope you guys enjoy the lecture. Thanks, Kate. Um, hope everyone can hear me. Okay, So as Cape mentioned, we'll go through some again, some common complications that you might encounter a zoo, a junior doctor or F one working on a surgical placement in particular, focusing on some breathing issues. So moving on to the next light again, we're going to cover some key learning objectives. So we're going to go through trying to cover some common bleep scenarios, looking a practical aspects of what? How to approach certain bleeps. And then, um, again covering low saturations when somebody is tachycardia and a swollen leg. So starting with the first scenario we've got, well, you'll be on call. You'll be covering the surgical wards out of ours and you get a bleed from the nurse and they're saying, Doctor that have got patient. Who is dropping their saturations on? Possibly they're such rating. Maybe 90 91 92% on. So this is this first scenario. We have a 60 year old female. They're saturating 92% on there on they are postoperative in the postoperative period. Now, of course, an important part of any on call shift is to triage your bleeps that you get. I'm sure you can imagine that, um calls sessions. Congrats, super, super busy. And so when you answer a believe, that's really good opportunity to pre on them on. Do ensure that you're getting a good amount of information over the phone to help you a sense a set. Essentially assess how acute issue will be. And then off the back of that, you can be prioritizing. So for anybody who's dissection waiting, regardless of whether than a medical patient, surgical patient, you want to get some key of the information. So and just as a point, of course, if anybody has any questions throughout, just put them and as Case said, but you want to essentially look for any of the other observations because that would be important in terms of how you catheterizing on the level of acuity. Have the nurses actually put any oxygen on? If they were decent rating, how long has it have they been since they've been to saturating? Where are they In terms of the post operative period is a day one or is it day six? Because the number of complications that you can develop post operatively will can differ in terms of how common they are, depending on how many days you are based operatively. Also, it's important to just, you know, ask the nurse, what operation did they have? There's gonna be many, many surgical patients that you're going to be covering, and you're not gonna You're not necessarily going to know a lot of them. So gets a smudge information as you can. Wonderful over the phone. So you've essentially triaged a little bit more about what's been going on, and you've been asked obviously some of the questions that we've just talked about Now, when you do, you go to the ward. Uh, you're going to be thinking of a few things now. Of course, I'm gonna just go through here in terms of your initial thoughts. Could this just be because the patient is very frail. Their positioning is really poor. There, slumped over there, not taking adequate deep breaths. Furthermore, it could also be because patients will be in a lot of pain after, particularly depending on the type of operation or procedure they had, and so that pain might stop them from taking adequate breasts. UH, which might lead to them to be separated Drugs is another important, I think. Like I said, for the pain, you'll need analgesia for that and often opioids on. But I used a lot. Now, patient controlled analgesia is something that's very, very helpful in the postoperative period for patients. But of course, you've got the risk off using it too much, and so people will hype over ventilates. And that could lead to dissect aerating patients, particularly in the elderly. The next question is, could this be an infection or essentially eight? Electricity is now. Infection generally will come a bit later on in the postoperative period would be very rare for patients in if the day zero today, 34 to develop any hospital acquired infections. But of course, if they aren't adequately positioned if their pain is in control to allow them to adequate eventally. Then there'll be a increased risk off developing those chest infections. Another one is eight electricity, and this can be a very common cause of patients who may deteriorate Indy such rate on. But it's essentially a collapse or closure of a lump that essentially will reject that result in a bit of a reduced or absent gas exchange in that part of the lung that could cause the patient to decide terrain. But again, elderly patients are particularly at risk of this, and this is mainly a Xylo complication to on general anesthesia invented and tubing or again inadequate ventilation postoperatively now getting kind of towards VT E and P E risk. I'm sure you don't know that a lot Hospital patients should have. Their risk of venous thromboembolism assessed on surgical patients in particular, will be a high risk because they often will be in pain. It bedbound, especially orthopedic patients, may not be fully weight bearing, and so that's something really important to consider in any patient who is de saturating on. But if you've got it, all of this information in terms of when you're triaging the calls and you have patients who would be saturating a lot, then it potentially it could be quite serious. And so you're going to go to see the patient, you get a bit more of a history. So as we mentioned, there was a six year year old female. They're 24 hours after an open cholecystectomy on down. She's struggling to breathe and is complaining of a bit of chest pain. Now it's important to go into that a little bit more. And so you might be asking, What kind of chest pain is it is a cardiac sounding? Is it central crushing doesn't radiate into the jaw or of the arm? Or is it paretic? There's a change on inspiration or certain position, and that will start to after your thoughts in terms of pointing well, gathering a differential list of diagnoses and then essentially ruling either in out. And for this particular case, you examined the patient. And for any acute patient, you would take your atria approach. So you assess that airway now. If the patient's speaking to you, could be quite happy and you'll get very used to assess and be airway, although it could be very scary when it doesn't. Isn't Peyton to assess the breathing, which is really key here given they are decent rating on. So they're respect. Your rate is 40. So they are very ticket Nick and 90 there saturations and 94% whilst on 15 liters that the nurses baton. So again, given that they're only saturating 94% and 50 m, that's really concerning. And this should be bringing some alarm bells in. You know, in your mind, as you go through this examination now, doing a focus examination of the chest, you hear some crackles in the right lung base on. Then you're gonna assess their circulation. That one, well, perfused. So you know, you're not concerned that that they may be in peripheral shock. The country Phil is good normal. However, the blood pressure's slightly low and their heart rate is also up on. You know, putting that together with the fact that they're saturations are quite low. You're gonna be more concerned at this point that this patient maybe unwell. The rest of the examination was remarkable there. And so, in terms of thinking of our list of differentials, whether it's an MRI of course you're gonna be then asking for further investigations that will get onto. But from this set of information and your examination findings for me, I think definitely a P would be fairly high on that list gift in that they are decent rating. They've got some chest pain. And if that is, pleuritic will be increased the likelihood of a B as well as the fact that they are tachycardia on patients who have pecan be in shock, and often it will be distributed shop on because of the conclusion of the embolus with in there and affecting with venous blood flow back to the heart. So you would be worried about a P E. Hear you hear some crackles in the chest as well, so you can't rule out a chest infection. Of course, these days you need to always be checking for Cove It. Patients who have eight electricity generally don't develop such systemic symptoms, such as evidence of hypertension and tachycardia. On the de saturating of 94% despite being on full 15 m is a really concerning feature, and you get that less so with eight electricity is and again it's the same with Of course, with positional and inadequate pain relief. At this point, we want to think about the next step you've done your initial assessment on your going to be thinking about. Some of the investigations now has the F for me at this point, if you've done your initial history and a good, thorough examination and you're worried at this point, it's enough. Very good time to then escalate this and let your seniors know now in surgery, they often aren't immediately available. They may be stuck in theaters, Um, or, of course, if it's out of values, they make it. A surgical registrar might not be on site, and so what? You what your job is? The F one is to gather information and distribute that to your team members. You know, if you're not sure about what investigations to order, what treatments to give. That's okay. As long as you relate a key information to your seniors on escalators at a time, the myelin you'll be supported and you'll you'll do the right things. But thinking about Bedside Investigations Festival. Of course, we need any C G because they aren't tachycardia. We've already got some observations going and It's a good idea to start thinking about monitoring in that is this. If this patient has really, really unwell, is the world that they are on going to be able to provide the adequate care? That's the That's thinking a little bit more further forward, though I think for this patient, given that decide rating, it's really, really appropriate to do a B G on. Do you want to see at what level is the p A. 02 at and determined the type of respiratory failure there in is a type one where they just had pox. It was it tough to where they're retaining. Some seem to a swell, Uh, I'm just having a look at the Kia name would be appropriate to start investigations and then escalate. Or is that too late in this patient? So I think as as you're going along, if you if you're by yourself, you're probably going to be doing the examination first. Uh, on then, once you've done that, I think you you would definitely be asking the nurse to help you set up some investigation. So immediately you'll be asking the nurse, get any CG you able to do some blood etcetera, and that's completely reasonable to do on. But if you're feeling more and more confident, you can, of course, do those before you escalate. But often, you know you've got time on Denise scenarios. Often when you do kind of that med school, you're doing simulations. You might think that everything is 100 miles an hour. You've actually got quite a bit time with these patients. So, um, more time that you might think so. If the net What stenosis Setting of the GI. And you ask someone else to get some ABG kit or bloods for you. During that time, you could just send a message to your even if it's not a full phone call or an s party or registrar or your S h O U might just be sending them a quick text message saying Listen, I've got a patient who's really unwell. Let them know about it. Can we talk about it soon? Understanding any see GI done, etcetera. So an ABG is really key in this patient and then is worth if you're gonna bleed them, doing some repeat bloods as well. Now. Hey, every say which ones. I'm sure you know, everyone would be sending a regular panel of blood, so afford repeat, full blood count and a CRP to check if there are any raging inflammatory markers going on, um, checking, they use the knees, and the LFT is checking their hydration status. That's all important, but really, the key here is the A BG and then imaging. This patient would definitely need a chest X ray in terms of because CT pa is the definitive investigation of choice for on gold standard for a P E. But generally a lot. Patients will need a chest X ray in the first instance, because that will be formed as part of your kind of well score in tallying of the risk that risk of a natural beauty. And often, if you're going to vet a scan, the radiologist will always ask when you're discussing a CPA, whether you've already obtained a chest X ray. Because if a patient has really massive um, union actual consolidation on a chest X ray and it's quite consistent with a big chest infection, then you need to treat that and see if they're if they're situations in clinical medical problem improves but of course, if the chest X ray comes back is very normal or one remarkable, then on the next stage would definitely be to get a CT pa in the hospitals and on calls. Just have in mind if you're going to request a CT PM, have it vetted. Always have the real function to him because they'll use contrast on Also ensure that the patient has a least minimum but pink cannula. So the patient only has a blue because they have bad veins. The radiographers and the radiologist will ask you still to put in a pink annular. Okay, so this patient's already on the high flow oxygen. And at this point, as we've discussed you would be a particular patient on. Um, sorry. This it's just check a culture. So, yeah, you be escalating to your seniors at this point just to get some further guidance on what to do as an F one. You want to get the ABG fairly early to determine how bad their respiratory failure is on D. Because this patient is very unstable in terms of the vital signs that they start writing. Despite the high flow oxygen, they are hypertensive. The tachycardia and so this patient should really have a portable chest X ray. They shouldn't be going down. Although he's going down, the lifts down to the radiology department. They should have a portable chest X ray. Now, of course, if you cannot get in touch promptly with your surgical register because they're operating or you just didn't have found some deck then as a P is essentially a medical issue, then it's completely well. It's completely reasonable for you to then get help from the medical team as well. So even if you just call the medical registrar and just explain the situation that you've got on Guantanamo some advice or whether even if they could kind of come and review the patient, that would be also appropriate. Onda again, this essentially says that a CT pa will be the definitive mode of investigation, but you need to either confirm that treatment and then went ordering a city be. And if you're going to query a p e, then always start the patient on tree. So loaded trust world use different types of low molecular it happen to treat on PPIs. This's particular example is using tens parliament at 1.5 mg. Big kilogram. I've worked a trust where last year they used Delta Parent and this year they used the Nox apartment. So always be sure that you've got local guidelines. A turned onda Just another note is always look at the notes in check. And if this is just for if it wasn't this acute situation, ensure that patients are having chest physiologic your early if you feel that there are risk, so if they're frail, if they're a bit elderly, court. If they've got the disabilities, just physio really be useful in preventing either chest infection or intellect. A cyst that we mentioned. So I'm I'm keeping an eye on the questions. Do. Radio just allows, it appears out of ours. Yes, it's a scan that has done really frequently of hours, particularly after Covitz started. They are. Do that are handing them out Really, really loads more than you think in any chest hospitals out of ours. Radiologists aren't on site. So after depending on the cutoff at your hospital after about 7 p.m. A. P. M. And it will go to a privately sourced company that will deal with the scans vetting on reporting. So there are lots of different companies where there are radiologists working essentially from home or in other offices around the world. You have to call them through switchboard. Essentially, the one we use currently at our trust is is Medica. So you call Medical three switchboard. Say you want to bet a scan. Then the admin person who you speak to will take the patient details the exact location there in, and then they will forward. You want to a radiologist you were. Then discuss that scan. They will say, Okay, yes or no And then it's your job. Then Teo. Call the scanning department again because it's out of hours. It will often be one or two a day, your office who are on call so you might have to beat them and say, Listen, I've got a scan to do. Can you please do it urgently and then we'll be done and then you'll have to rate for the reports. So it is done very frequently up of hours, especially in a me during these covert times. It's been really, really common for that to happen, but if, for example, this patient you would definitely get that scan overnight because they're all they're essentially constabulary. And there were in a bit of shock. Whereas if you had a patient who was just the saturating at about 94% they were very mildly tachycardia, but they were completely well on the other. Vital signs were Okay. It may be appropriate to do the scan in the morning provided that you have started the treatment for the pee. Okay, so just moving on to the next scenario, we've got, um, someone who's called you and they've got a heart rate of 130 on. But that's why they called you. And often you'll find that when you're wrong, call nurses will do this a lot. Or even healthcare assistance might call you. They'll bleep you and say, because when they take their observations every four hours on their rounds, they in put them into a system that would automatically generate the new school for them unless they're using paper charts. So if it's Elektronik that will automatically go through an algorithm, and if their scoring, let's say a three or more than one on one single parameter, essentially, their job is to them escalate that patient, and that means essentially calling the F one about it. So they've given that accountability of the patient to a doctor on. You'll find this quite frustrating test because you might get a call. The patient is tachycardia. Get around. Ah, 100. But when you then look at their friend of observations, they've been tachycardia for four days. 100. But the blood pressure's completely fine, and nothing really has changed. So when you get this sort, of course, always if you can. If you're logged on the computer whilst your answering a call, just look at the trend of their observations or ask the particular nurse. Okay, how has that changed? When has it changed? When have they been Kentucky? Card it? So in this instance, we've got a 45 year old female. She's she's tachycardia it around 130 we're getting some similar information, Really? So again, that's the nurse that how does the patient look to them? Because they they're the ones who have been looking after them since the start of the shift. Do they look certainly drastically changed? Are they very pale now? They still talking to you fully? What the rest of the observations because that will help guide again. How cute. This patient, maybe what details the patient s. So what clinical details can you find from the get from the nurse on Be given there tachycardia and this is something to notice. Well, once you triaged and received a BLEEP, it's a really good situation, not only just to receive information, but also then ask the nurses to prepare things or do things before you get to the patient and arrive. That so any patient who's talking Coumadin or could be any patient who has just been it would be standard for the nurses to do it. He see a GI and have that ready for you on your arrival. But make sure you give that information over the phone. Otherwise, there will be times when they don't do it, and it's very reasonable also to, you know, ask them to prepare a bag of fluids potentially, and you will prescribe it on arrival or on. Can they prepare a set of blood tests, or can they get a cannula ready, for example? So you've essentially triaged that bleep and you're on your way to the wart and you're thinking Okay, this is a paste. Ah, patient who's tachycardia? What? They're sort of differentials that we need to think off. Yeah, they do. They have any chest pain? Like, for example, in the previous scenario, if they've got pleuritic just been in a tachycardia. You have to again think of a pea on. Was the BP okay? Was that were they in evidence of shock? So if they were hypotensive, untucking carded in your lip going through your mind kind of shock of that yet, is it? Hemorrhagic stroke has accepted Trunkal of these things will be running through your mind again. If you're thinking of a septic shock, you clearly is thinking of source of an infection where they might be tucking. Call it from pain, stress, anxiety. All of these things that come with operations on will also need to tachycardia in itself. But 100 thirty's quaint is really fast food up on, But again, think about pain relief because really good adequate pain relief in surgical patients will lead to good outcomes. Onda um, moving on. So giving a little bit more of a background information this patient's actually got is admitted for small bowel obstruction on they currently being managed conservatively, so they're having ever spelling are there, but they're on dripping sucks. So they've got essentially an N G tube into their stomach to decompress, and then your essentially giving a drip in, giving them fluids to maintain that because essentially there'll be no by mouth on. They are waiting for gastrograph in, which is both diagnostic and therapeutic, to be honest. Nowadays, they're used more for therapeutic purposes for small bowel obstruction because all of these patients will get a CT abdomen, pelvis on arrival. If you're querying small bowel obstruction and the CT will tell you and the radiologist will report on there if they've got a transition point that they can see where the proximal bowel is dilated in the distal and okay, and that they've got a essentially an obstructed point within the bowel gastrograph in. If you're going to order it while stone call, it will be near on impossible to do If you're not out of hours on day, essentially, you would need to go down to the radiology department. You would have to speak to the radiology affairs essentially where they stock it because you'll have to bring that up to the ward or essentially called porters to bring up on. But you will need a chest X ray or abdominal films in a director sex right before on after giving the gastrograph in. So it needs to be coordinated quite well on go, often because it's not used frequently. It will be a a task getting that. But the patient she's still in pain. She's got discomfort and distension in the stomach and abdomen. She's just feeling really unwell, understandably with foam obstruction. So you then assessed a patient again. A to patient beings that the airway is patent. They're tachypnea on often patients with small biopsy big if particularly if you get if they've got a lot of abdominal distention, there gonna be quite two kidney because you know, you can still get all they really you know you won't get full on splinting. That you would with the scientists is you will still get that pressure on the diet from which will cause you and Teo take more rapid, shallow breaths. But you're fairly reassured, essentially by the fact that they're saturations and 95% or now the rest of the you examined the breathing on ditz Valium. Remarkable. Now when you test the circulation there a bit clammy and a slightly cool on, although when you check for peripheral country full time, it's less than two seconds left. Pressure's off 100 over 75 which isn't too bad, but they are tachycardia. And on my new assessed, um, it's 125. That pulse is regular as well when you examine that. And although heart signs were no felt normal, um, the neurological status is completely fine on the abdomen when you examine it. Although it's really distended in quite painful, there's no essentially, it's soft, so there's no guarding business rigidity. And you're not worried about this patient, then going on to potentially develop complications of obstruction, which could be a perforation and developing Peritus, um, hands there apyrexia so moving on now, in terms of the differentials, we've essentially got a few things going on here. They're tacky comic, but they're holding their BP just about, But they're your significant significant finding here was that their pulse is a regular no in surgical patients, particularly in patients who come in with bouncing bowel obstruction, which you would get very commonly. If you're on a general surgical foam on, they can be really prone to electrolyte abnormalities. On be in such a case, you would need to be thinking off. Could this be an arrhythmia? Given that the heart rate and the pulse when you examined it was regular? Of course, the most common cause is atrial fibrilation. But again, you're gonna be thinking about other things now, just because of patient doesn't show signs of peritonitis. Um, it doesn't mean they haven't perforated. It could be a very small local perforation dot com, so that should still be in the back of your mind. And that's something. When you discuss with your senior, you know, that is it? Does this patient? If something has changed during the clinical cause, have they suddenly become really talking carpet? Then it may be worth, or if the pain is just in increased just a little bit where the patient is telling you, Actually, the pain is worse. I'm having the same level of energy easier, but the pain is just works. It may be with rescanning depiction. They are just about hemodynamic stable. They've got a normal country full time on a BP 100 over 75. But of course, you want to be monitoring that carefully. Another question here do you get, uh So I'll leave that to Kate, but I assume that this will be recorded. And if, despite the patient in terms of their saturation, is there such a rating 95% without oxygen. But they are talking new. The restaurant it started to I'm there tachycardia on. So you know, you don't wanna be too quick to rule out a peep. But again, given that they're pulses of regular and they've got some more bowel obstruction, I think in this scenario, we would need to think strongly about whether this is arrhythmia. Now, again, you the key here would be drink as part of your assessment again, you. And before hopefully before your arrival, the nurse would have given you your SED on. Do you would want to assess that along with their vitals. Terms of blood tests. So here we're going to do some more specific blood tests compared to the previous patient. So in any sick patient, always get a gas now because this patient isn't hypoxic. on their saturations on room air. You'll be reasonable just to do a venous blood gas. So on that blood gas, essentially, it's a point of get test, which you'll be getting some really useful information that so you'll get essentially a lactate. You be concerned if that locked. It was really high, particularly if you're worried about a perforation. You want to check the acid base balance, ensuring that they're not acidotic with it. If it and you want to, you know, correlate that along with their level of lap it. Eight. And you want to be checking on the glasses. Well, because you'll get a new media level off electrolytes on there, so you'll get a sodium level. You get potassium level on. That will help ascertain whether electrolyte abnormality is contributing to this potential arrhythmia football camp. Use the CRP LFTs a role reasonable things to send off, and you'll get those formal birds back. And of course, you would deal with that when they come back. The reason why both profile of magnesium is on there because you're checking essentially for magnesium levels on phosphate levels because again, with patients with small bowel obstruction, they are often prone to having lots of electrolyte abnormalities that include phosphate in my museum. And if they are depleted, these you want to replace them and on call. As a practical know, in terms of what you frequently prescribe, magnesium can be given. Some trust will want them to be on a cardiac monitor. But a frequent dose initially to give is eight millimeters of magnesium sulfate, and you would write this on a prescription chart on the fluid section. So typically you would put eight millimeters of my museum sulfate in the 100 mils of saline given IV, and it can be given over around 30 minutes to an hour. Any quicker, you would want them on a cardiac monitor in terms of replacing phosphate, because you'd often do be finding yourself doing that in the surgical rotation to they would standard come in. Essentially, they come in a standard set off being called a forfeit pollen fuser. But that's run over at least 12 hours toe 24 hours in reverence quite slowly through. So that's something to think about. The next stages imaging on D disease patient and a nap during Middle X ray probably won't have a great deal because they're pretty hard one when they first arrived. If that had a bit of a balance dilatation. And you've already you already know this patient a small bowel obstruction. It will really had a great deal. However, they will need a city up the pelvis, potentially if, but that decision won't be guided by yourselves. You wouldn't be doing any city of the purposes for any surgical a shins, Um, without running that buying a senior first. And now that will come from them. Uh, that was the question. We have to state that there is one blood back rapidly. What is the procedure? So any hospital that you request bloods for now, pretty much all hospitals use Elektronik, it least for bloods. Even if you have paid the notes on we use said, Well, I be you, certainly. But other systems that just ice there will always be an option as a click box for urgent bloods. So you can take that edge and box and it will come back. Hopefully within 40 minutes or so. You want to ensure that the blood's arrive at the lab. So, um, now I'm sure most places will have blood systems, but otherwise rather than just leaving, sometimes nurses might just put it in a port, a box where it will sit there for about an hour or two before it even reaches that love. You have to either give strict, ah, direct information to a nurse to run that, uh, those bloods to the lab or ensure that there's someone has actually pulled them off. Okay, Onda, um, sometimes, if you want, you can always just call the biochemistry or hematology lab directly. And just to say, Listen, I've got really sick patient. I need these bloods turn around a sap and they often will do it for you when they'll be with, They'll be back with you within half Anonymous. So you can do that on Got a question from Josh. So no city questions, but how do you do a VBG? Essentially, it's a normal blood test so you can use the same syringe. Is that the you do the a beegees with Okay, But essentially, you just take it from a vein rather than going into one artery. What I like to do is just because I'm going to take all the rest of the Bloods. I would use a but to fly needle connected up to the syringe directly. Pop it in a vein, get some bloods, get the VBG the blood venous blood into the ABG. Some syringe sampler. Send it off for the Gus. Usually the nurses will run that for you, and then while so you've got them, Butterfly in the vein, you can take all your the rest of your form or bloods. Okay, so moving on. So this is your e c g on. Um, see any of this? I can't see anyone because this is a webinar function. But essentially reading this gun, you can see clearly it's ah, tachycardia strip. Um, but going through yours systematic approach reading these injuries, um, on the most striking abnormality is essentially when you're checking a rhythm of the strip is the regular, isn't it? So there's no, uh, regular interval between B r. Waves on. If you look closely, it's there aren't really any plea wave. So again, this isn't a Sinus rhythm, Andre. This is an arrhythmia, which the no discernible P waves. Um, it's irregular rhythm. So by definition, that's atrial fibrilation onda a f, whether it's a pre diagnosed conditions. So you know the patient has a half or even patients who are not known to have a A can still develop atrial fibrilation, particularly if patients have really on poor fluid. Balance is on there really dehydrated because patients with small biopsy you can get really you hydrated quickly because of third spacing of fluids. So really here. If you have assessed this patient on your own call shift, you've done your initial assessment. Taking history, taking their eggs, examining the patient, ordering on your in relevant investigations, discussing it with a senior in terms of whether to do any more further tests on. Then you were document all of that. What I like to do is essentially, you're gonna put something like a tsp us to see. This patient on the tachycardia of 133 lists some of the issues, so issue one there in the small bowel obstruction issue, too, could be that they may be on some of the recent blood tests on arrival they were they had a bit of an a k I so in a car would be also relevant on their needle by mouth and then you want to essentially write a focus history, then your examination findings. I always lay out in an eight to a system on Ben. Essentially, your you can write out any relevant investigations that you've got at hand. So I took your VBG results. Write out your observations, right, Right. Kind of your reading of the GI and then your impression. So here we know that this patient has a Could this be secondary to various cause it So it's a dehydration. Electrolyte abnormalities What? Maybe because all if they've already known to have a if they've just gone into fast A f uh, and now we need to essentially manage the patient if they're dehydrated. You want to be replacing that food, make sure they're on the correct maintenance in there. If they are essentially showing some hypotensive shock, then you want to really replace that This is fluid. Resuscitate them, particularly if part of your examination, you know, especially if you've got a elderly patient who has really dry skin. They've got poor skin turker that mucous membranes are also drying. You want to be giving them more fluids, but again let that be guided by blood test results replace any electrolytes that on. That's why it's important to do own profile and magnesium. And you'll find that patients, especially in surgical patients who obviously you've got kind of medical reasons when patients may have seen essentially starving for a computer time. But if you've got surgical patients who have been nailed by mouth for this huge amount of time and this you're certainly introducing a TPN or NGO feeding there is that risk of developing be feeding central so you'll get doctors who won't ask you. Make sure you put out the feeding bloods on the blood star. Part of your be feeding bloods is, Does that mean mentioned you're using these own profile in magnesium to check for essentially potassium phosphate and magnesium on again? Make sure they're in pain now if they're still running fast. Okay, if you've already done and if you've done a medical job is enough. One. You get a bit more comfortable later on in your year. Next year, when you see when you guys start, you get a bit more comfortable in kind of prescribing some initial medication to try and control there. Fast heart rate, which is a regular. And so you want to ensure that the hemodynamic is stable the next step? Essentially, if their BP is good enough, Um, then you can try a little bit of bizarre below. So we'll beat. Blocker is starting off. That may be 1.25 to 2.5 mg. You would really be wary, though, of giving 2.5 straight away in an elderly patient. His BP might be bored line. So maybe all consists the stolen pressure 100. But by all means, if the blood pressure's around 141 130 then you can try a a bit of bizarre below to see if that will bring down that fast. A F Patients with a background of heart failure can often be given digoxin, so load them on the digoxin. Okay, on you can see. But if this is one of your first in our you know calls, you're going to just call for help us for senior in but again, like the P scenario, atrial fibrillation and managing that essentially will be a medical medical issue. And so medical issue in a surgical patients would be entirely reasonable for you to call the med veg. Give them a good s for hand over on gas them if they could come under, review the patient with you or if they can give some good recommendations. OK, so just looking at the time, this's just a quickie C g putting in a unexamined of hypoglycemia. So sort of the patients condemn up electrolyte abnormalities. Hyperkalemia is a common scenario that your face on your uncle shift if you've got the CT changes and just a bear in mind. You see you changes with potassium levels on a fairly A fairly rare so I haven't seen over the course of two years. I've only seen to be CD's, where they've seen some easy changes, like pizza t rapes. I've never seen anything as bad as this. This is just from the little, but of course you want to treat it as soon as possible. You want to see why they're potassium so high. So just review their medication review. Potentially, they know by mouth. Have they got renal failure? Have they got a good urine output? All of these things and again you be guided by seniors in thinking about all the reasons, but your job is the F one is detect that they've got hypoglycemia. Maybe do a quick medication review and make sure they're not on since like, you know, exacerbating things like spironolactone, potassium, sparing diuretic. And then what you want to be doing is check your local guidance. Every hospital will have the guidelines on how to manage her, proclaim you and just follow that. Follow it so you'll make sure they have any CJ. You will give them calcium gluconate to stabilize my cardio. You would. Then this will be clearly stated in the local guidelines. It will be giving you insulin to bring that my potassium level standard is always act up it with 10 units. My trust uses 100 mils of 20% X rays. I've seen another trust where they use 50% extras just checking in the local guidelines. That would be your initial phase. And then you could also consider given salbutamol depending on the level of potassium. But the example of use here 6.5 is pretty high. So you might consider doing that and always, always get a repeat VBG during your uncle shift. Now, um, we've got about 10 minutes left. So I just want to finish on one more scenario. This patient has a swollen leg. We've got 45 year old lady, uh, also with an increased respiratory rate, and we're gonna look at some of their observations again. You're going to triage up early with the information that we talked about before. So if you've triaged that information and you passed in s okay, they've got a swollen leg. Is it How swollen is it? Has it changed? When did it change? Are both legs swollen or is it definitely just one name? Doesn't look a bit read to you. Um, is the patient complaining of pain in the leg? All of these questions are really relevant on, but of course, getting the clinical information of why they're in hospital. What if they have? Don't. And you're gonna be, you know, making your way to the war to review this patient. I'm just thinking about some of the possible differentials now. Have they had a form? Now, that would be really obvious, because the nurse would definitely tell you they found a fall or they've landed on the leg or something. Okay, sometimes positional less likely if it was, you know, a lateral legs running. But let's possibly maybe they've had an orthopedic surgery where they've hard a knee replacement and they've just got normal surgical Dema on. But he Mettomo from an operation, so that could be potentially normal. Is it infection? So if they develop cellulitis again, um, check the background of the patient. Have they got a history of diabetes, diabetes? If they got a history of peripheral vascular disease and if they got risk factors for developing circulators or of course, with any unilateral leg swelling, we're going to be thinking about a DVT. So here we've got a 70 year old male with lots of comorbidity. So they've got diabetes. I've got the scheme of heart disease, hypertension, and they've been admitted for right, well, the neck of femur fracture. And so, uh, this patient is really frail. They don't move about much. They've got a package of care where care has come in three times a day and they're not very mobile. And so he's not going to be eligible for a total hip replacement. So he's being listed for hemiarthroplasty on. It is now day for after that now, four days after a major orthopedic operation, particularly with those risk factors, you're them definitely gonna be thinking. Actually, this could be a DVT. So you want to examine the patient? They're a bit touchy. Card it, but they're saturating 94%. And, you know, for someone with the scheme of heart disease, given the 70 year old, that's not bad at all, 94% is acceptable for that. And also they're speaking for sentences to you. So you also worried about them being in respiratory compromise. When you check their circulation again, they seem to be pretty stable. On that front, they're a bit tachycardia. How it reads 100. But the blood pressure's fine. And there W W P sorry is one. Well, perfused. That's, um, something you'll see often then in hospitals. That's but when you then check their right cough is tender when you squeeze it and it's swollen. But otherwise the rest of your examination is pretty remarkable. So again, I think really, in any swollen tender leg you're gonna be thinking, Is it either DVD or is an infection of the leg on? If this patient kind of chronic well 100 placement of the leg, possibly a knee operation, and I had a knee replacement. Cetera might be thinking of a prostatic infection, but that's that's a pretty rare as particularly giving that This is just a recent operation on. If you're always going to query a DVT, always think about pizzas. Well, so we're gonna be getting our vital signs because the tachycardia we're going to get that cg again on day. In terms of our blood panel for this patient, we're gonna be getting VBG again. FBC Usually crp LFTs to as a baseline of blood tests, fbc and CRP will essentially let you know. Has this patient developed a big infection if they got a cellulitic leg or worse, if they got infection of their operation sites on but then you would you would request the D timer in this instance. Of course, we all know that D dimer is a fairly rubbish test in terms of diagnosing anything, but it is a good negative predictive value on defense, completely normal. Then you worry for a DVT will go down massively, Onda Essentially, what you would be, um, thinking off is what my going to do. So in terms of investigations. First line imaging would be an ultrasound scan of the leg, so it would be a doctor scan of the Venus systems in that affected leg to see if there's a clot there on. If you're going to request that again, you want to then make sure that you have started this patient on treatment. This whatever low molecular have print your trust uses. See GPA only if you think that the patient is in respiratory failure. Like we said, the breathing was completely find. The saturation was 94%. I think it's reasonable to hold off on that. So as an f one, I think it's reasonable for you to be expected to think about well, schools And do The MD Culp has is a great resource is if you just Google MG cock. They have so many different scoring system. So everything from Chad scores well. Scores your sent or criteria. If you've got a crease scoring for Glasgow scoring for public titers all of these things. You could just quickly get it up on your phone and just Yes, no. Yes, ma'am. So this patient didn't have any active cancer. They had seen. So this is just a default. No, no, no. But they have bean bed ridden because they've been had a recent hemiarthroplasty cough is swollen compared to the other leg. Let's say they didn't have any superficial Bates on their leg. Wasn't entirely suing him. It's just a cough. You've got tenderness along Davina systems when you squeeze that carpet was painful When I'm sure about Peter, you living? But even if those few things were positive, that would essentially give you a a well score that would essentially tell me to get that ultrasound scan requested. Okay. And then you want to stop them on treatment. Dose? Um, treatment does on. So sorry. I hope that end wasn't to rush. Has anyone got any questions they want to put in the queue in a at this moment? Thank you. So much grown. If you want to, um, check on the next slide, we'll just get her on. Please do the feedback. We really appreciate it. 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