Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay. Welcome back. Everyone thought lecturing final lecture Siris was a mass effect. Is everyone in the joint so far? I hope you find it useful for last night you were talking about referrals. Any d So you just like taking a useful if you have a search for jobs left too, or you have any jobs. That too. Oh, you're interested in says you're in general and the definitely get down that route and definitely taking a furrows some points on s Oh, well, we'll have. We'll have a cure Care of the end again for feet that incredibly useful and shouldn't take 20 minutes on. But we'll also do questions on chat Say Okay, well, we can often as we go along. Or we can do that at the very end, pending on depending on the volume of questions on. So we've got How doing structure. How is three member on the national social creature inside to an education roll on D is doing? If it will be to get three in orthopedics, come August, say over to you how that's called. I'm how on currently have to in reading on the ent on my had a solid six months off, then search off acute admissions gen search in my left one thanks to cope with it. So, uh, being being through a little bit So this such day is all about the referral. A scale said, I know that even in my trust, even f once on jen Surge actually carry referral sleep, and they take controls from GPS, um, and sometimes paramedics up with beauty. So if you have a gentle job, depending on where you go, uh, you might be dropped into this situation. So our objectives say are basically we'll we'll be using clinical scenarios. But the focus is really on how to deal with referrals from the CT, especially when the diagnosis is unclear on also thinking about how urgent infection isn't clarify sting according to kind of lotion. See, before I start with with scenarios and disease as a general void, just bear in mind that some diagnoses can have identical clinical presentations on that. Actually, your bill home without the pain, for example, on actually the most common diagnosis for activating BD isn't on specific active pain, um, which you never get to the bottom off but especially is safe with it, so it would always be immediately clear to you what's going on. But as long as you can sure that you're safe, that you see help when you're unsure and you're thinking in some way systematically, then you'll be fine. There'll be some coverage off well, how the individual conditions and managed, um, in so far as this is relevant for scenarios. But it's really the focus is on how to take the barrels have to triage them on how to be safe, choosing to admit cool. So there are some. There are certain things that, as as a responsible person, you want to make sure you know before your shift with a mask pneumonitis before or when you get infection. Start of your stuff in hand. Um, and let's let's have a little bit little bit think so. If you guys want to make this quick, I want to make this session interactive as much as possible. We'll get your first thinking. So if you guys go to this URL be doxapram dot com slash student and the room code is their food. 5675. So let me just check that we're alive. Yeah, um, it's again the room code for you through 5675 feed of secretive dot coms a student and just, you know, simply an ominous just put down some ideas, but in what you think things things you need to find out to make your life easier, I'll just give it a couple of minutes. Um, on. We'll have what people thought doesn't have to be comprehensive. Let's just get a few ideas in there. I'll give it a couple of more minutes, just few more answers, and then we can have a look called 10 seconds. Okay, It's a bit now. And what have we got? What else is on the shift? Um, how many patients you've got? Nothing. Child consultant. What you're covering, who is urgent, where the natural is? Yeah, and sixties on the ward. So pretty good ideas coming through here. So what if we got you can basically split this in half This half? Here at the bottom are things that you should really be finding out before the day. So local admission policies, For example, if you get somebody coming in with most scientists, obviously you give the antibiotics, but you want to know whether your trust does hot like all these or whether they just diagnosed it's toe, because that will change. For example, whether you trying it center, um, in different trust, pancreatitis might go into the medics if they're recurrent and known to be correlated on everything else or, if you're not sure, comes in the surgeons. Or maybe they were just going to the surgeons in the upper GI I bleeds versus allergy eye bleeds. Things like that also cross cover out of hours at night. What tends to happen in a lot of trusts, especially in smaller DH, is is that you have a social call. You cover multiple specialties because the department something enough to put on there and I'll call rotor. So if you're covering urology, if you're covering the ENT, you should know that ahead of time, hopefully for induction. But you know, so that you can prepare a zoo. Just time allows, and you want to know what kind of presentations you can angulated on. Whether there's a player, local pathway in place, for example, of my trust. If somebody comes to eating overnight with, what do you think on examinations biliary colic? There's a clear policy that if they say if they can go home, come back the next morning fasting one for a dedicated surgical ultrasound. Stop eso these sorts of things that you should you should find out and being wear off. Then in the top half, these are the things that you need to know a sort of hand over. So you need to know who your seniors are, how to get a hold of and where they'll be. Also, is your Reg just doing the night shift of flowers? Or are they doing like a 24 hour on call? Because that also changes your threshold a little bit for for waiting them up are in practical terms. Um, uh, what your coverage, Whether you're doing wards as well as referrals on Dove Course. As you guys all said, the city's on the ward. What you need to chase for them. What's their escalation on what you need to cool. So, having set yourself up very well and found out what you need to do, you see double shift and you've been called by E. D. Has been a patient waiting to be seen for 3.5 hours and that's it. Before we Only further, before we talk about the actual scenario and MD and the clinical stages in patient, I just put a pause and cover the distinction between accepting and reviewing patient eso. What is the distinction? Why is it important it? Let's go back to request and 30 seconds. I've been what you think. Why do you need to distinguish between accepting on reviewing good? Got a few answers coming in couple more and then make you move on? Okay, let's have a look at what you said exactly. It's about the responsibility. So the distinction is, um, say say, you've been a patient who's use a bit non specific. They've got a bit of a real angle pain, for example, that sort of radiating around or they've got a little bit of bleeding on a little bit of vomiting. There are patients who are ambiguous, and if you accept thumb, what it means is that they're under you, that your responsibility, and if it turns out not to be surgical, then it's your job to refer onto the medics or the urologist still here for us rather than BG. Because Edy referrals are a one way system. Once they're out of BG, they don't go back. So if this is sounding like something that is likely not be surgical, then you need to make absolutely clear that you will come and review the patient on, See if the surgical give give your input Burt's that you're not accepting the admission I'm having. This discussion will also help you understand. It is like of thought I might bring up different differential that you had initially for smell. Um so there are some unwritten rules with the Trivora. Most importantly, don't take incomplete referrals. I'm aware where allows where it since the allows. So unless it's an emergency, Edie's job is to make sure liver examine the patient that they've had some bloods on ending. If it has, um, appropriate urging requested, um, similar things before your fucking, um, definitely proven safe. Um, then you want to ask the referral what they correri what they've done so far for the patient on bake Sure that they've basically done their bits in saying that that that sounds of it adversarial. And yes, it can. It can get that way sometimes, especially when it is under pressure. Are trying to offload patients are trying to make sure they don't reach on. Ultimately, you sometimes do need to send your ground because reaching is not your problem. That CDs problem your job is to is to your specialty and to give good care of the picture. All that being said tried to maintain a relationship. PT stuff, Um, when you're not busy, when the referral comes in, go see the patient immediately. Be nice to them that keep them in the loop on just generally, be polite. Having that relationship will make your life a lot easier. They'll be able to do stuff for you if you're giving everybody a hard time. Eventually somebody will call your consultant Andi. Well, you might be right, but that is not a good book on finally medical. Legally, if somebody asks you to review the patient on this is absolutely clear. Like this is obviously the wrong system on the wrong specialty. You should go and see them because your medical colleague is not sure and is asking for your expectations. Oh, so we have the first scenario, which is a 34 year old female presents with her, um, blood. You want to see you to see we'll just So what else do you need to find out over the phone with feeding? You want about the the 3% from going Obviously positive history. Any previous surgery? What? That what they're like on examination? What? They mean what they've had so far. Whether that's in terms of Bloods Imaging IV's and treatment, um, what their blood results in obs so on. This will obviously guide the urgency. Um, so if they if the blood's back, the white cells and 20 let's see, uh, piece 200 on the lactate eight. That's a very different picture from somebody who has, You know, grumbling crp of 50 white cells are just on the borderline. You know, it tells you how sick the patient years now fast, you should get off there. And finally, of course, there's a a female patient off from bearing age. You always want to have a pregnancy test. Okay, so more information about this patient on their abdomen is soft tender all over. Um, but but soft and open, their sense of parenting is, um, have been a low grade fever. Um, that otherwise not really septic on the roads. There's some leukocytes were no nitrites on their urine dip. The HCG is negative. Um, and of course, you've already started this narrowing down that list differentials. So you that's with blood tests on you about model here, a crp A Z Well, as lactic white cells are a bit up, Um, and they've done a chest X ray for completeness. And that's what would be normal snow our life from which is quite uncommon finding. Anyway, um, and they have not done anything else at this point. Who So you've asked important questions you've gone down to BG on. Do you want to verify? I watch the TV has told you. So. You see the patient, um, and she's got a two day history of off label, but be defeating. Generally a bit unwell. They're off their food and drink. Um, with Arctic on a little bit of mild to Syria, be dumping bowels. Regulate. Last time was yesterday, it was normal. Um, hopes are over. There is. You can see. Well, on examination, ABC, I'll let you have a look through, um, little bit of voluntary guarding. Um, but otherwise fine on this is that they're after being is actually settling with a bit of a process will encoding meaty on. It's, uh, much improved from what it was before. So what's next? Want to be thinking of you differentials? So let's go back. See the colitis on D in Um uh, type in your top three differentials a little for how many vehicles? Let's have a look. So for people who have joined recently, I'm going to be postoperative com slash students in the room Food is here Food 5675. That's got a few of these different pills. 30 seconds. Type away. Five seconds. Okay, let's have a little bit. You come up with constipation, pregnancy, pancreatitis, earlier. IBD I bs Triple A soft diet is exactly so. This is a vague presentation. There's nothing bombed or there's nothing particularly that's narrow you towards a single system, and your differential is pretty wide on after it in general has a very wide differential. It's where the top three reasons that people come to daddy and you should be really with it and use about a classic arise so you can spit it into the organ systems could be vascular, so on the Triple A's you're talking about could be a medical issue. So your diabetes I bs is kind of a logical urological. It could be probably Gina. So as we were saying, this actually comes back to what we were saying earlier that because it is a a, um, on a non specific after pain is one of most common, I guess conclusions or things we were discharged with, you don't necessarily need to come up with the definitive diagnosis, especially especially as as the as the junior on call us or your job. So if if nothing is uh, standing up in the presentation and you don't have a diagnosis, then you switch the other way of thinking. You think What are the dangerous things? What if I ruled out and therefore, is this patient's safe? Okay, so So you're on the night shift. This patient, you decide whether it would do you admit them I want you to do is, um um, at this way, if you're feeling unsure, I would speak to your registrar. Come. And the other thing is, um, how how you speak to them? Um, let's say you're rich. Ours at home, but available by foot. Um, you're thinking this could be early appendicitis. It could be a UTI on the patient's pre stable. So when you when you call them up, Um, it's best if you don't just say the dump the patient information and say, I don't know what to do If you can take a moment before you send them and formulate your presentation with a nice, orderly history our examination results on, then talk about your differential. You say, Oh, they've got two today for, um, black or pain. My lifting body raising function market is low grade fever. We've given them X Y and said they're not settled. And then you say I I think we should either admission, observe or regulate on. I think that given up half way, we can bring them back tomorrow for a ultrasound. Um, it's very for for another Sunday morning and repeat Bloods interview So that sort of thing, where the registration and then go yes, no on get the conversation of over With responsible. They can get back to sleep, and they're impressed that you are switched on Junior Ondas. We said before, if they feel certain criteria, then they'll be able to come back to and billitteri care of the next day for warts. Um, imaging on before a senior review. Denounce. Cool, mixed up. We have the next referral for media, which is a 75 year old nursing home resident. Has been blue lighted with vomiting on a normal pay 80. Thinks he's pretty tender. It's pretty surgical, and they're thinking he's obstructed. So over the phone you're wanting to ask about the clinical findings, concentration, things to ask about this really morbidities. Where they had a little surgery before we had to farm on the Bloods and the OBS. So how their jobs saturating 94 on 10 beaches, which is not a good sign. Little bit tachycardia be bees. Hold it. Um, on the VBG most important thing is even on his activity X the rest of the bloods on disability along braces on your port for just tree. Um, but not you know what I mean. Probably vomited on. So we know they wanted to Probably aspiration pharmacy. Um, Andi there that potassium is a bit low. Just keeping with that one since Well, so what does What does all that tell you? You're thinking this is a pretty unwell patient. Sounds like they're in some form of balance structure. Any should have done the basics for you, especially giving them fluid recess. But they don't always do everything, so make sure you tell them seriously. That actually needs to get aroused. Toobin's Decompress the prestige in the system and make sure that there are some people who is running on the pain relief anti medics, antibiotics on that they are catheterized. You'll also be thinking about what the baseline of patient is, so they've come in by ambulance and they're obviously confused. So there's not much of a history. But you know that they're a resident, a nursing industry, and so that gives you an idea off. What their what? Their level of function it's It puts a ceiling, shall we say, on the full function on the reason this is important is not because your registrar will be asking, but because it it takes how you treat the patient at what they're fit for. Because a 75 year old that is really share bound and has got dementia will not do very well for lacrosse. Me? Um, so this one you probably want to give your Reg heads up about the patient and say, Look, I've got this patient in research three going back to see on Dave Electric eight. They sound very well on the ridge. Might decide to come in straight away on dart. Start making the way into hospital. Um, or they might be happy to be at the end of phone until we've got a different diagnosis. Cool on. The last thing about C part is that if when it's decided they need surgery, it's a bit of asthma that you need to do to put them into the list, and we'll come back to that later on. So you go down there, you want to stick a history patient is confused until the headaches and not able to not able to give you anything at all. The care A called the ambulance When the patients have a multi on, they noticed that the active So having a look at these examination findings, you can see the airways fine. Their breathing is compromised, which is in keeping with this shit with that chest X ray. Um, looking at the obs, they are looking a bit septic. Um, and you can see that they've got a previous doctor, actually scar that distended. Um, Andi, they're looking pretty dehydrated, obviously, because you're thinking about about balance truck shin, and you're very thorough. Uh, gentle s h o u will do a PR which will reveal an empty rectum. That's fine. Still worth doing. If you put your finger in it, you put your first in it. You then go over to the computer and have a look at that blood on. And you can see pretty stocking white cell and, uh, good going CRP um, and there's one Helmick I coming off there now that troponin rise. Even though the patient complain of chest pain many times, you'll find that ET was sent off a probe in in triage Nurse that can be used to put most patients. I would obviously have a BCG, but I wouldn't necessarily go down the the the avenue off off a, uh a C s. Because, as we know that people who are critically on well can have a stress. The elevated troponin a swell in terms of imaging. We've got a CT abdomen which is requested on on the way. So there's obviously a patient who's pretty unwell on. You need to make sure you've done all those basics that we mentioned before. So see, she comes back on. They say they have not obstructing sequel cancer of operation, Which explains what's been going on. What are you thinking? What are the next steps? This picture it on there for? What should you be thinking about? That's how I look at what you think. 30 seconds. Some quick fire response is cares. Okay, let's have a look. Call your Reg and six DNA. Our surgery. Urgent laparotomy. See? But mission. Yeah, so are you are entirely correct. So at six Decompression Institute. So those are the basics you have to do. You obviously have Teo alert your senior colleague on a stick this off the chain on. Then the next thing is theater. Now, this is where you want to have a look at the big picture on Step back a little bit. Obviously your regimen making the decision. But you need to You need to have an idea of where you're registered and go. Because if you think about this patient in an accident mention class. Do you have a look and check do they have a d a r. Do they have treatment? Escalation? Have they already said I don't want any my saving treatment? So that's the first thing. Then you're thinking, What is their baseline? And what are they likely to survive an operation or be fit for one on that? Therefore, therefore, whether whether you want to actually bring in theater so they are a nursing home resident. Um, say they were about and they have quite advanced outside, Mr Mention. So those are not good signs. Surgeons will often use a validated scoring system like people. Some score, which is something that you should you should be able to get as a capitation, the Internet, if you if you search something like be possum or neither mortality on. So while you register on the way and the useful thing you could be doing is Teo is to put the patients practice in on calculators. Then what else mobility with this with this person. So in this case, just real life case, just his decision was made for the regiment started. The rife on the issue was not appropriate for immigration. Look relatively. Certainly I if I had one on the end, the best thing to do for them was palliative on. In this case, it becomes your job to refer patient to the medics of amounts of county. Um, I wasn't sure if it management off that situation. I'm sorry. So, next, Mario, we have a 47 year old female who presents with the right eye, and he didn't want you to see her closest. I just so with right wouldn't pain. And, of course, since you've got three things in mind, um, you've got biliary colic. You've got closest. I just call in practice. You need to think about the different presentations and flus and the escalating level of risk, Um, or on mortality, Morbidity with the different conditions. So you're familiar with this final? Don't need to repeat it. Um, find out. Well, the usual information from ET having a bit more of the things about this patient. She's feel she's in her forties on day. She's therefore got some got some risk factors already for Goldstone's on Do it with that Russian much in pain. Um, it is an entirely entirely possible, entirely likely type basis. So, um, thinking about this while you're on the phone robs a stable with the month of March. More texture on. These are lots. So she's definitely got an infection. Some thought with families. And 40 she's not likely to have. Try Tous on that LP, um, is something that you should that that is should be talking about. So, what are your differentials for? The expectations? I have a quick fire sec seconds, five seconds. And this Have a look. Pancreatitis just goes to start. Just come on, Judges. Yeah. So everybody is sort of focusing up on the biliary system on the on the liver on that sort of very, which is entirely reasonable for the reasons we discussed, um, in terms of before you seen the patient. You want to try and keep your keep your differential board and keep your mind open, because sometimes what's referred us? Russia got pain, actually sensitive to be frank, paying really ankle pain. Good. End up being something gynecological. Um, do you need to be thinking about hepatitis and the and the hours? Fine. Okay. So when you go and see the patient, um, she's in student pain. Jesus. Um, she's had a lot of nausea and vomiting with the pain radiating from the back on. You can see here this is a history that's classical. Um, on examination herbs. If I She's not septic, she is Memphis. Positive. So we're very much thinking it's a bill. It authority, um, on this foot because the patient isn't, um, basically and well, so even even actually thinking back to when you take in the referral to who's up to stable, they're in pain, but they're But that's something that he and monitor What? I'm not overly unwell. I have not sent it. So it's not something you to rush out of fit for. It's certainly not something about you leave the side of that patient will actually eight, um, and again you talk to a D and make sure they're doing the basics. Which buys you time to tie up here on the jobs and go see the patient. So getting a plain chest X ray, um so even though wouldn't diagnose ability with ology helps rule out things such as a perforation with free after life from giving them IV fluids, giving the night politics given him analgesia. Um, making the examination bit easier on because this vision isn't terribly. Um well, I would definitely I would definitely go see them first before talked about before talking to my seniors. Okay, so, um, how would it be different if this is the picture that you got so respectfully? System is fine, but they are tachycardia on a little bit. Little bit hypertensive. So not not not not a stable with the last patient. They, uh, very, very much February. Visibly jaundiced on you've got these bloods here. So infection mark is very much raised, and this time they're going to raise the bilirubin off 78. So, uh, when you have to think about this one, uh, this is clearly, um Well, this is it. This is classic for acute space and ink over And judges, um, you can see the bilirubin tells you that they've got a stone. Certainly. Very system, which is then it got infected, and they tell you their septic, and this is confirmed by the stopping very Marcus. So, in some hospitals, this would actually come under the medics because it's the gastroenterologist who do the ercp. So this goes back to knowing what your local policies are in terms of, um, in terms off managing this patient. What would be your Yeah. And of course, needless to say, very different from the previous patient. This is somebody. You would drop some more jobs and rush to go see. Okay, so good answers coming in very quickly if you have a little bit longer. Five seconds. Let's have a look. Blood coaches set to six obsessive. Accepts it. Six. Very good. Um, and cool gastrin. Exactly. So, um uh, 76. Making sure that you do the basics. Oxygen esporte, six aggressive fluids on. You would also be thinking about having a really discussion with HD You. I see you as appropriate in your trust. Ercp is the definitive management or what? The TV is the next step here on you would be talking to guess room out that they've got obstructing stone that's causing all the problems on. But in this case, you need an urgent decompression on. If you end up talking to gastro on, they tell you that there are available they can't do it in the next day. On Meanwhile, the patients on Well, then you'd be thinking about decompressing the very system from the other end and therefore talking to. I are about drainage. Perfect anus least so something like something like a PT. See? Okay, Onda final scenario. A 76 year old lady The fall on a suspected enough also heart failure prize. So heart from all the usual things that you need to find out from the Pharaoh. Um, the thing was different in this case is why did they full? Um, there's a massive differential of things that can make people fall. Whether that's cardiac were last sickle, busy vagal one that had something more more serious vascular, e or any of these things that you can see here, Um, those those air important to pay attention to do because you're not really need to address the actual fracture. Somebody needs to address the reason they fell on some of these Some of these causes of all, as you can see, it would need to be treated before they can actually proceed to have an operation. You don't You don't want to take somebody who's hypoglycemic did to better and spend all your time team on the theater without realizing that they're less suffering the hypoglycemic brain injury, um, and similarly for for a stroke, Um, or ongoing arrhythmia. We're going to too much detail there. Um, but that's something where you have to be aware off. Okay, so this this sort of patient, when you're when you're thinking about going to see them, they might well be very sick to my ankle was before then on day. It's a natural village that I have the basics done that I need to use on the X ray Teo structure habian natural on. They need to have to see Jesus for North. Um, e d will not do a fashion high like a block, which, if you go across it, is an injection of a little anesthetic into the compartment in the groin, where the femoral nerve on the tennis wrong? Um, it is very effective. It is part off the quality of off the national enough standards, and it is easy job to get it done, So I don't get them from that off on you. They'll definitely need to be admitted with a surgical bed. You may have to the AIDS with the manager, and you'll definitely have to book them on the sea. Gold on. Actually, a lot of hospitals will have a pro former for not such as quite easy to follow. You just go down the checklist, make sure they had all the investigations necessary so that the anesthetic review of the operation and go ahead swiftly, likely? Well, the Jerries is your friends. They have their best best practice terrorist. They are very keen to see the patients quickly on. Do they usually get medical reviews with broken off the vessels? History. Um, this is really important because these Jared patients will often have a lot of little babies, as we've seen in this scenario is have to go to for a heart failure. A. C s also a lot of things going on. So you want to try and get the medication to see the media of possible? Um, certainly make sure that they're on the list for an ultra we can review and all their terms with you in the morning. About 10% of these patients, because their liver mobilities died within a month in about one month. Who So that's it for our scenarios on be thinking about speaking about priorities, taking variables, just bearing in mind that people will be on a variety of jobs and that there will be cross coverage in your own Gorgeous. We've got a slide about conditions questions for for for us. So she for for us, um, tell you more risk your specialties quickly run through them. So if you're on also when you're up, you're fickle. Are the easiest things that you need to ask of the phone on neck. Make sure make sure that you you know what? So then you're okay, Sam. The anal tone on the first for the last half. A quarter a quarter. If you're being referred and taxes, you want to know whether they're already answered calculation, whether it's stopped your ongoing, whether it's one side or both sides on whether it's come from the mouth first or anteriorly first, because that will dig a little dictate whether it's actually had accessible for you ST on whether they have at the first sicknesses. If you're being recorded torture, then you need to be thinking about. And then he started on how to use this. Always on our church is, um, if you're being third the ultra in your stomach, the PR findings and you want to know whether they have any surgery before because that will tell you what's what's causing it, whether it's a recurrence of the previous condition or lesions on. Just remember that when you're talking about, um, a previous abnormal century, it's not just inside. It could be any. It could even be urological if they've had across the sent to me, for example, hand injections on Ortho or plastics. So you want to know about their culture where they've got a payment past extension. But if you refuse from swelling and tenderness along the tendon, chief, well, the truth indicates on deficient acting longer. She's oh, she is very urgent sent out, Um, if you're being referred to be, But then you want to be thinking about how how severe the bones are. The heart. Partial thickness, full thickness. You think What? What area is being bet on their four with it with these fluids and how you having touch like that? And will they carry? She's so she with the burn center. We're even transfer that you want to think about what's in globin. Um, so COPD is sitting on the risk factors that on. Do you want to see whether it would be bone marks on their face, which would indicate a my risk for inhalation burns. And therefore I need for early inspection. And finally, you're thinking about skinning limb. What's No. The refill on the backs of speech is when it started. I want us about six piece. Think I will. They got a mild syndrome, if if, but, um a an ischemic limb, and it's been more than six hours, you don't have mountains and drink with what the surgeons will do. A lot of the time is that they will re three revascularized the limb and at the same time do a prophylactic fasciotomy because there is a high risk of developing capacity. Moments in treatment situation. Cool. So in conclusion, we've talked about a few scenarios. We talked about our organization. It's, um, take away stuff that your experience come across as the Rudeness PD. If you don't know whether a patient is coming under, especially it's a so talk to your rich. Be aware, humble. Be aware that the IV edges. The consultants are very good at their job. A lot of the time on a lot of more know a lot more than you on that they can do a lot of things that perhaps you can't say. For example, ah, lot of single factor dislocations will be reduced before you even see a patient. Um, you will. You will be a bit You will struggle and flounder a little bit of start and that's okay. But experience and getting around and being told off will mean that eventually you know exactly whatever especially wants to know about their patients. Um, remember that you do have, in some sense again keeping roll from a specialty. But if you are rude, if you are obstructive, somebody will eventually call your consumption. And that's not good. On. Finally, make sure the referrals that you are receiving are reasonable and are completely that CD. Have done what they need to do. There's a lot of EDS a chose to, uh, experience to my left hand slipped on. Also, there are a lot of them referring, but only one of you accepting. So you, my my needs to stack amount by time and make sure that they help you. Ast much is as much as then roll dexa stick tastes ablation. Thank you very much for listening, guys. Thank you. So much. How for that? Those were very real live scenarios on day one has been on the same table. Know that most things aren't barn door coming in. So So there's a big complex there with all the cases, and that will be a case a long time. But like you said, how long as you show that you're safe on you saved a message on you Ask for help and you documented that you have escalated. Then you should be fine on s so we'll take questions on the chat function on. Go over them out to you how a minister and you touched on it can it can drop the rays and balance traction Anyway, it should be raised in bowel obstructions. Essentially, drops can be non specific on a patient is septic. If if if that that that that patient with a laxative eight robs, then yes, they could have a sort of miles. My other skiing although the information could be, could be triggering it. If you're worried, I would definitely get the city. Um And if if If you're worried school, then call the medical cardiologists. Ultimately troubled. 120 is probably not going to be a proper full on a C s. They will give you Trump's of 809 100,000 a lot more long. Exactly. Eisenson sensually neither here nor there. And someone who's got a k i subsets. They will have a sepsis driven trop. Right? But that is the reality of the referral. You you will get it will have a multitude of things that blood testing It's up to you to make heads and heads or tails that pearls on. But if you think there are very medical patient, they're very cool. Morbid patient asked for a medical review uh, some blasts a um so Yeah. Thanks for that on. Do you go question here It says surely the e d doctor will most likely know what to do. Compare to F one search for long call. Do you think so? I mean, yes, the ent doctors, especially if they're really consultants. They they are pretty on top of it. But you would be surprised at what sorts. So obviously, if you're stuck there a good person to ask for help. Very definitely on dare Really good at knowing what patients are sick on, but what we need to do to keep them alive. That said, you'd be surprised at some of the some of the, um, blind spots that doctors could have, especially for some of the more obscure specialties. For example, I was on call at one point on the e d. Reg refers somebody saying they've got Quincy use. Come drain it. It's the big squinty I've ever seen on when we went down there and had a look. There was no Quincy whatsoever. Just enlarged tonsil. So, um, uh, they are they are. They are about a call on Devard disrespect that there were off knowledge, but perhaps take what they say a bunch of salt, especially in the obscure specialties. Oh, I'll just I'll just I'll just caveat bats. But by saying you don't get referrals from in any Reg most of time again, referral from an A S h O. That any regimen with that to run the department on D, It's your job to make sure that they've been giving everything. So if you come down, let's say that building your colleague patient wants see and they're buckled over in pain. It would be impossible to examine how can you tell the difference, too Involved into involuntary guarding parents it in some in the next. And when you're in experience, almost impossible to tell if they're in so much pain. So maybe you can make your life easier for making sure they get appropriate. Energy is, uh, so that when you come down a calmer and then you will tell the abdomen soft or not really on. But yeah, so you just, you know, stress that most most like those things will be done. Your body fluids analgesia, antiemetics just It's just it won't it won't hurt if you if you stress that over the phone. We've got a comment in the chart here saying pretty sure if one's don't even cover search for barrels. If that's the case, kudos to you that you've been lucky. I have as a left one. I have known times when my jobs had to help him better on I've been having the referral sleep on in this trust. What I'm left with the moment they have ones, take if their job to take the referrals come out hospital. So from the paramedics to the GPS, so it does just dependent trust trust. Also you. You almost like having any jobs Enough to say, Um, lots of the info here or supplies when you are giving her for saying, Yeah, we'll leave it that Thank you so much. I'll on guys.