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we'll start. Say what? Everyone said. Part seven. All right. Parts were not. Siris has had survived first. That's cool. Today we're talking about. So then complications of some of the most common operations. You'll come across on on your search for jobs on the specific management strategies on down and escalation pathways. It's going to run by Dustan. He's colic mine on the says. So I said, Oh oh, as an anti applicants having done experience in Genser, George on the end teach s so we'll be taking questions by the Q and A function on Well, either on Stone must go along with the end on the on the volume on. But we'll have a cure code on the very life slide for feet back on. So if you guys been mind filling in that form text couple seconds on, do you get certificates on day showed that you've attended the syriza's Well, so, um, crossover to you. The shot Perfect chairs graph line production. So my name's do dance company work at in a any my three year, but I've done quite a lot of surgery now, so I've done or for John, Surgeon Ent and tried quite a cross cover. So today I'm just going to go over, Um, the most common sort of bleeps that you would get from the ward's on. Then really talk about your escalation plan. Went to involve your seniors on what to do before you involved uh, first case. So your nights and you've been bleeding patient on the ward is complaining of abduct pay on there, spiking a temperature. So you'll get this all the time when you're covering nights. So you ask more questions over the phone, obviously. So it is a 64 year old male. Four days post thought low anterior reception, complaining of increasing abdomen. Uh, they asked the OBS over over the phone on the nurse says heart rate 130. BP 90/63 rest rate of 24 SATs 95 on a routine on a temperature of 38.1. So the first thing you think of when you get red out some labs like these is this patient sounds very unwell. You're gonna probably drop what you're doing and go to assess his patient immediately. They're grossly human. Dynamically unstable. Um, hard. 1. 30 on there. Obviously shocked as well with the systolic 90. So you go over to the patient, get a brief history. So you find out that they're four days POSTOP, a low anterior resection with enter end of nasty, most sis they had to stun for proximal rectal cancer on the are suppression They've been complaining of. But what started off with quite generalized pain, Uh, for the last eight hours, uh, but now it's just getting of increasing severity. Ah, and you quite worried about this patient from the end of bed? They don't look so good on. That's one of the first things when you assess it was one of the key things you learn in your first couple of years after graduation. Just eyeball the patient and just be able to tell who looks on well and who? Who's okay? Yes, of course. You start off as of any sort of assessment. Uh, 80 examination. So airways, fine breathing is tachypnea resting? 24 sats. Okay, for now, do A quick listen of his chest is, uh, clear enough quotation, and you move on to circulation and you see, his heart rate is 1 30. BP 90 systolic uh, it's capillary. Refill those free seconds. So you see, he's not I, and he's He's clearly under filled These The first thing you're probably thinking is is this patient septic with this high temperatures? Well, you do, dear. Formality. GCS 15 on you move onto the most important part. This examination, which is a is, uh, you excesses Abdomen. You're trying to do this 80 in the first minute. Basically. Of course, by the time you get Teo setting his abdomen, you would have already asked a nurse to just put up a bag of fluids. Just do something to bring that heart rate down and get that systolic up a little bit. So the most worrying findings now is that his abdomen on power patient is completely rigid. There's generalized tenderness. It's defeat there. Signs of local person is, um with diffuse guarding and rebound tenderness on power patient. These are all absolute red flags at this patient in a POSTOP cancer resection patient. This patient clearly genetic on Ortho septic. So what was your differentials day? So you're going to get cause an award for abductor pain and fever? Quite a lot. Um, but with the that hemodynamic instability on with that rigid abdomen On examination, you're gonna think could just be anastomose leak on because his abdomen is rigid. You're thinking this is probably settle. Fecal peritonitis. The other thing, this could be. But if they were so unwell, you could think perhaps it's a postal abscess of collection, but we're probably going to go with the nuts. Um, optic leak. So what would you do? Uh, as an f one wasn't even after the S h o. This patients clearly very unwell. You want to speak to the registrar immediately? You want to? If they're not to hand, you have to fast sleep on let know about this patient. Ah, with the with those ups heart rate of 1 30 a systolic of 90. Your thinking is is actually Perry arrest. So depending on how quickly your registrar can get to you, they could be, for example, in theater doing an emergency case. Your S H O might be in any resource, and you could be left alone on nights with this patient. It won't. We were always happen by is a possibility. So you do always have the option of putting out a Metco, All for this patient, and no one's going to blame you for putting out on medical. When you think a patient so unwell on this, you could say this is a parry arrest on, To be honest, as an F one or s h o or you expected to do for this patient is just recognize the fact that they're seriously unwell. On that, you need help. A basically from far more senior people than ourselves basically. But in Maine, Wall, uh, you've already put up a bag of fluids this few start dialysis of any sort crystalloid of your choice. Um, on your gonna initiate sepsis sticks, at least try and start it, and your registrar will give you a bit more guidance. Of course, they'll be on their way, but you initiate sepsis. Six. You will start the antibiotics, give the fluids on to the other suspect. It's not high. Popped it, but you can give high fly option as long as they're not a retainer. Um, and at the same time, do the cultures do the VBG on measure? Well, see, they catheterized, uh, measured a year and out. Um, but by that point, you must. You would get senior help. Um, on everything from there. It's just really you get told exactly what to do. You just have to carry out the instructions. So this special be Neal by mouth. Ah, we'll get some sort of imaging for this patient to just confirm the diagnosis so they'll get a CT abdomen pelvis for this on at the same time. You're ready? Sure. Yes. H o might get you to go to theaters to make sure this patients booked the seaport. Let the any fittest aware let the fear to coordinator where I just get the ball rolling. Really? But as I said, the most important thing for any sort of junior doctor here is just recognizing how critically on well this patient is. I'm not delaying a prompt assessment. Basically, the Does anyone have any questions for that? Sure, your case, if also carry out. So the second scenario is quite similar, at least in presentation, or at least what you get told over the phone again. It's a 68 female, 68 year old female. So who's sending with abduct pain on a fever? So this patient is five days Postop left hemicolectomy, uh so from this point is pretty identical to the first scenario. Well, you ask for the ob as you do over the phone, and it's SATs and 98% on a respirator. 70 blood pressure's fine heart rate expired. They are spiking, however, so immediately, in contrast to the other patient who's, uh, grossly unstable verging on a period arrest. Sort of call this patient. You know, you have a bit more time to see them. You should still see him from because they are spiking, know, need cultures, cetera. Um, you need to see what you're dealing with exactly. But, you know, you've got a little bit more time. If you're doing something very urgent, then you can prioritize that over this one and be justified in doing so. So you go over to the wards and you got through the history and examination. Uh, it's I'm It's five days post off another colorectal section. Basically, uh, this patient you find out it's been spiking intermittently throughout today On the complaining of this peri umbilical pain is not quite generalized all over the abdomen. Like previous patient, I was a gradual onset, so again, start off with an a t A airways. Fine. Uh, breast restoration stop. So stable heart rate is 90. The warm well, perfused with gets a Starlix the cut refill time is normal. You don't worry. Just yes. 15. They are federal. However, uh, on you can see that they've got a soft abdomen, but tenderness periumbilical it. So again, in contrast, last one, no instability here. You could just rattle for your 80 and literally 30 seconds on you get to a abdomen soft. So it's not something that needs a media option. Uh, you have a bit more time, Teo down for some more information before talking to your Reg. So just elaborate on the examination finding. So the abdomen is soft, but there is tenderness on power patient to periumbilical region. So there's no signs of pattern. Is, um, there's no rebound. Tenderness, percussion, tenderness. Oh, any some guarding here. So, from examination point of view, this patient looks okay. Uh, just a little side. You think that's a bit of a fullness on how patient periumbilical e? Uh, she's sort of trying to hint a possible diagnosis for this patient. Uh, so, yeah, I mean, it's quite a similar presentation to the previous one. Ah, I started to differentials with babies. Same sort of same, too. But because of how well this patient is and because it's a local fullness that you could feel in power patient, you're more inclined to think that this is some sort of POSTOP abscess of collection on. This is probably one of the most common things that you'll get leaked about when you're providing ward cover night ast the F o s h o. So how do you proceed? So you have a lot more time with this patient than the previous one was a mentioned. No one would blame you if you decided to call your registrar again just straight away. But it is certainly no need to fast beat them. Or perhaps if your surgical registrars at home, which is very rare. But some sites do do that. You don't need to call them straight away. Perhaps you congratulate bit more information before calling, uh, so it's a spiking patient, always going to prescribe him some power seat. More some fluids. Just a maintenance for the intensity loss is from being corrected. Uh, again, you will do, um, order based live sort of investigations. So you'll do your bloods. You do your VBG look a lack. Take on. Of course. Do some cultures on at this point. Then you can call the registrar again. No one The Red wave blame you for calling them earlier on. But this is what they're gonna ask you to. Teo. Um, And then again, just like the last one, right? Sure will give you, uh, what to do next. Basically. So again, this patient will get a CT, abdomen, pelvis, and they're know, proceed, Uh, depending on what those signings are. So just to reiterate the differences between these two bleeds which from the outset look quite similar, it's just another abdomen patient in a patient with that don't pay spiking a temperature. You've got millions of these studies, so it's really important. Teo, find out quickly who's unwell and who's not so free things up. Just listed here. Two of them, Well, one you know, over the phone, which is their jobs. You can never go wrong with us to judging how your patient is from the obs on. Also didn't mention it here, But you can also just trust the nurses who have been on the ward for many, many years. If they say someone is very unwell, don't worry. Then you should probably go having two months of experience and then search. Uh, once you get the things are guiding you is your your eyeball assessment from the end of the bed with the patient lives just not very good that you're just trust that hunch basically and treat it with the appropriate level. Seriousness. Um, you can go off the obs on then, you next thing that we'll go ahead you is your examination on? To be honest, the fullness that I mentioned in the, uh it doesn't really matter if you don't pick that up. The only thing that really matters is this patient have genetic or are they not? Or even more simply, is this patient's abdomen soft or is it rigid on If you just do those things, you won't miss a seriously on world patient and again in terms of escalation, which is what this lecture source of about, of course, you're going escalate pretty much everything to Alicia. I think you know what? Maybe you're registrar, but it's about when you want to escalate to your Reg sublease. One it clearly going to be out of your debt. You want more hands on deck immediately and the red charges need. See? Get that a PSA whereas Leak Teo, you won't be faulted for calling the red sharp, but you won't go wrong with having a little bit more information so that you can give a wretch some sort care here and assessment What's going on on the ward's? Well, thank you for it. So the next one, it's not actually a gen surge case. It's an ulcer in case. Um, sometimes that was just when you're covering surgical wars, you're often expected. Cover the offer. Awards is well, so I thought, I'll just chuck this one in there as well. So your deaf a little after one night's the register off site, which they often offer orthopedics. Uh, you've got a 23 year old male complaining of leg pain. Ah, nurse tells you over the phone. He's got closed tibia fracture awaiting surgery on the offer. New York said you do so. Heart rate 105. BP. 1 30 Respirator. 18 sats, 98% on airfare. Bra. Uh, just when those odds. You know, I mean to worry there in pain, so the heart rate's gonna be up, but you So you want to go on assessing when they were young patients, So any sort of decompensation will happen late. So harbor, it's the first one to go. So you're gonna go see it And probably Anyway, the other big thing is the fact that it's a close tibia fracture, so come into that later. So you go to see this 23 year old guy is come off his motor bike on early that a sustained close to be a fracture. As I said on, he's got back slab on, putting on a put in by any so is admitted by the day on Call on or you really know is that this patient's gonna have open reduction term fixation next morning on the trauma list. So it's just about going through the night going for the night. But you hear his complaining of increasing pain over the last few hours. So you have a look. Look at the drug shop and you see it's got a lot more. Maybe 2 to 4 hours. Policy. Two more regular ibuprofen regular, maybe coding regulars. Well, so he's pretty much maxed out on analgesia, do you? Only thing you go from here is maybe IV morphine. Um, and, like, say, is awaiting surgery in the morning on none of these. The allergies has a lot. Being given is on maximum possible titration of these do quick 80 again you to be. It's just a rapid, rapid assessment. So airway own breathing? Ah, yes, it is a bit higher. Maybe because he's in pain again. Uh, chest clear. So that's a sign. Heart rate, 105. But you think it is warm? Well, perfused you don't think he's shocked like that? First patient was this lecture on this. BP is absolutely fine. You're hypertensive. Maybe because he's in pain. Uh, JCs fine, but you got help. Finger station is literally shrieking in pe on. You don't. You're gonna have a lot of patients on the ward. A sort of time wasted is I guess they just They're in pain. But this one, you really you think this is organic? You really think he is in a lot of pain? It's got the backs lab on on this lower leg. Um you do? An examination is warm. Welcome. Fused pulses are intact. Motor sensation intact. Distally so Well, good sign A little things that you would do for any sort of joint. You're always going to assess, uh, near vascular status peripherally by testing the motor and sensation and also, ideally, the pulses. But if you can't reach the pulses, you at least a capillary result. So in that regard, it's looking fine. So you just just complaining. Lots of lots of pain idea. Look, feel moves on. One thing that sort of okay, it's apparently is that the pain is especially bars on passive flexion off the joint. So it's door deflection to this ankle joint. So what do you think this could be? A. So this is a closed tibia fracture. Like I said, uh, which is the most common fracture to get compartments Enjoyment on compartments Enjoy is there's only two really offer pedic emergencies on that is compartment syndrome on next next izing. So it's important to be able to spot this one on board. Um, it's a close tibia fracture is just text book for developing compartment syndrome on then. The other thing is pain worse thing on a passive flexion is again is the earliest sign of compartment syndrome on. It's quite a good indicator. So what do you do? This is ah, sort of on the same same range is the 1st 1st scenario. And how serious is, uh, how serious condition is. So you would want Teo after doing your quick examination, speak to the registrar immediately. So if you're off the edges at home, say this is like three AM in the middle of night. You just called him. You just have no fear waking him up on. They want to be woken. Not that something like this on. And even if it's not compartments enjoy, they're not going to blame you. They would want to come incest. It's for themselves. Ah, I'm from there again with the same with the other cases. The most important thing is just recognizing how serious this matter is. Once you recognize and escalated to the red or whoever is, uh, you just get told exactly what to do. So after this point for compartment syndrome, ready would tell you, just make them Neil by mouth. You probably can't open the cast just opening up like a book and then elevate their leg. Uh, again, these Alvar very temporizing measures. This patient needs to go to fear to a sup, but the regimen is again this car get into get into the hospital. So these are the things that you do in the Meanwhile, And then if things are really useful to your seniors, are if you book this patient on see pods alert, fear to staff on alert, the on call or anything that you've got a seaport one emergency, basically, because this is no life running. But it's a limp, Really. So you get your concern you office. I can't concern is an F one. I said Joe. So you would just get a concern for ready? Let the patient know what's going on on. You might try and, um, treat or give a few more, um, panky list. Of course, your options bit limited, so bread will tell you what to do. You can even I needed to see you manage pain. This patient could warrant a little bit of IV morphine just a little bit about compartment syndrome. So this patient's Theo only treatment for compartment syndrome is from surgery. So this patient will get a four compartments, actually after me. Um, and without it, you only have a house to do this, uh, or you will lose a limb. So just to go back, you might have heard of the six piece for, uh, any sort of acute limb or for compartment syndrome as well. And that's classically, um no poles is no paralysis passed easier. So But to be honest, the only one that really matters is pain. Which is why I really reiterated it here. Because by the time you have a post list paralyzed leg, it's too late, and the only option is amputation at that point. So it's just really important to remember is a very quite specific some subset of patients who get this. So it's a closed tibia fracture, which is by far the most common one. And it is paying, which is far out of proportion to the examination finding is that you've got, uh, much, like is a bit akin to, uh, recent okay, scheme. You we know not much abdominal findings about the patient's really screaming and pay. So again, it's just about realizing how serious this case is and then just going to set him immediately on, then just waking up your register or escalating immediately. And then finally, the final thing is again. Just classic. It's a 44 year old female, uh, day to POSTOP. Uh, like, Holy basically again, your office. Um, obs heart rate 1 10 BP when I freed nobody's holding breast rate of 19 SATs of 98% on their temperature. 38.5. So I guess this goes somewhere. It was sticking with John Surgeon when, Between the 1st and 2nd scenario in terms of how well they seem over the phone, Um, systolic one oh, three is not to worry, but, you know, the POSTOP, the spiking, the turkey, You want him, you want to go pretty probably to go. In a sense, it's patient to see what's going on. So this space is obviously just there are no Jessica requirements is just going up and up despite financial on which easier, Um, got a history that day to post like Holy on again, just was just the same form that quick a t o. I always find justice clear bit tachypnea. Uh, they are tachycardia and hypertenses not to the cell of peri arrest levels of the first one. But, I mean, this could be sexist, but this could also be you learn once you're on towards that, this good dot You just be a normal working BP for a patient, especially the elderly. And it's like you being us, Uh, do your examination off. So they're spiking on. They've got rebound tenderness on guarding on. You look at the Dre. See? It's draining. What? How much violence? Training. So do you review? Here you look at the observations. You see it? Any previous spikes, What? The trend is looking a previous heart rate and BP. Like I said, this could be a working BP for this young lady. Best world. This lady, you look at the fluid goes out. God, I just, uh, depleted bit. Intravascularly have a look at that. In out. Put on. Then. Just look at a drug job. You do a lot of times get called saying all inspections in pain and you realize that I haven't actually received any energy easier in the last six hours. So have a look at the, uh, the drug shop. Have a look at, uh, whether they've had a lot of antibiotics, and so you're being very far you can go through order. Nose, look at the indication for the operation. Look at the comorbidities. Um, was there any problems? Intraoperatively. What was the POSTOP plan? Uh, the operating surgeon. Quite a lot of times tells you. So what to expect in next three days and what to do? I'm sort of more bone. Is this gradual or a sudden deterioration? Look it on again. Just look at any blood tests on any sort of energy. So I like the first one again. You have a bit more time, Teo. Gather yourself. Look at a lot. The or the information that you have to have before you make it, Make a decision. And again, you're due. This patient, everything, um, from bedside, such as you get nurses Tunisia. J You do your sepsis bloods, you'll do your VBG. Look, the lactate. Um, on at this point, you would have escalated to your senior. Oh, you would have. You could escalate it beforehand with this patient's. Well, at least you Shh. Remember your left one. You can always just escalate almost anything to Shh. Um, because their electric that a year ago, um and then so you need the red show will tell you again. It's the same thing for with his patients to get a ct abdomen, pelvis, which will guide further management. So a little bit further down line CT shows peri hepatic fluid collection. So it's just another, uh, another case of, uh, fluid collection. Ah, you've done all your better as the junior awards. You flagged up the patient rest your red shot does. So if they deny, it's wherever you make them know by mouth, you dysfunction for me isn't? Oh, not for Haiti. Your input, but they'll tell you huge. Uh uh. Whether you need to go to the fifth Coordinator where we need to, uh, let me anything know so on again, you just would have already done your sepsis. Six. Just, um uh, common point. So I think you've heard this from the other lectures before. Listen to the nurses concerns because they would have had a lot more experience than you, especially in your very early stages. Ah, Sets is Congar Don't need to tell. Finally have medical sense. But on get your genius involved. Really? Um, one thing, One thing. Imagination. If you ever feel in doubt or you're off the fourth off escalating goes through your mind, then just go ahead and do it. Uh, sometimes, Well, especially war cover you have. You'll be wondered. We have to put out Met court. Um, you're worried that the whole past you were going to come and you're going to look silly, But, uh, you'll just never really be blamed putting out a med call, especially if you're just one doctor. And you do have until patient. Ah, it's just a useful, useful tool. Basically, toys Half I'm, of course, uh, always prioritized most sick patients. The most unwell patients, according to obs Your examination first and then proceed with the rest of your jobs on that is basically it. So how I think you might read out some questions? Yes. So that's the most questions as we went along. So but feel free to with him in the urinary function. Now, do you know what can I do? Wanna stress is was a feedback here say she's kind of bar code or used to be a link on dialysis. Teo uh, survey Uh um, you get a certificate that's generated of plastic lately again, that actually recorded on going to go online on the website on on new shoe on signals for that survey later on afterwards, if you want to watch the video eso sleeping questions, that's a good question here yet What? What would be appropriate request in that form in presents with a map? Okay, Appropriate imaging I as an f one, I would say, if you're clocking, then doing the rectus X ray. Uh, just looking for pneumoperitoneum everyone awards. I think you don't need to do any imaging till your senior tells you to do it because more likely to know they're going to order a CT, a pee on CT, abdomen, pelvis. Uh, and that's going to be their decision. So just do the basics. Just do bloods on you. Get told what to do. Yeah, I would add to that by just saying, like if you can be a bit proactive and example if someone who's got a box standards on a course of status can't think about organizing another ultrasound liver, you know it's difficult states, so you know, it's very much depending on the setting. I don't need as an f one your mecca. An independent surgeon to see ti somebody each because you would have, ideally, before that stage discussed it with a senior. Um, yeah. So the basics would be a wreck Chest X ray. And if they're distended, you might get up the X ray on that stuff. So many good basics. Yeah, that's and I think I saw the rest were just on answered. You're in the during electricity. Thanks a lot Station. Well, we'll leave it there. Know where it's hope you found that useful guys.