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Hello, everybody. Thank you for joining us today. My name is Sam B and I will be your host for the day. Um We will speak about respiratory conditions, but first we're joined by a special guest speaker, Daniel who will speak to us about the BMA. The floor is your Thank you. Yeah, hi guys. So I won't be, I won't, I won't take too much time out of, out of the session. Um So yeah, just, just a couple of messages from me. Really? Um you'll see on the screen a lot of texts, sorry about that. I it's just to explain the offer that we um that we started this week um to encourage more I MG members in the BMA. I'm sure you're all aware of everything that's going on at the moment in terms of the strikes and whatnot and yeah, it's just, we, we would like to see um sort of more I MG members join. Um So, so we've come up with this offer. Um Whereas II, if you're new to the UK as in, you've been here, you've moved here within the last year. Um And you've never been a membership before. Um you can actually get a whole year's worth of membership for free. Um All we have to do is scan that QR code or use the, the link that I put in the chat. Um And, and follow it through, um follow the application through. Um Just make sure you select the, the correct concession of, of I MG doctor uh in that first year living in the UK and you'll have your first year of membership free. We've never done anything like this before. We've never, we've never given a year's membership away before. Um So yeah, so this is exclusively for, for I MG um for new I MG members that have moved here within the last year. Um So yeah, do, do take it up um After the first year, it's up to you whether you stay or not, but hopefully we, we, we hope that you, you do. Um But yeah, at what sort of ap time it, it is good that we have um as much membership as possible. Um So I'm sure everyone knows what the BM is, what we do. We've obviously been a lot in the press and the news a lot of late. So we're obviously the trade union for Doctor Me in the UK. And it's good at looking at a sort of a free tier thing. Not only do we represent you on a national level. So things like the strikes and obviously pay restoration. Um but also locally as well. So, in, in your individual trust, you've got people on the ground, um, from the BMA. Um, and you've got reps who, who can help sort of local issues for groups of doctors and then there's obviously the individual side of things. So if you have sort of issues or problems with your contract or, or anything like that, um, you have, you have our backing. Um, we're not an indemnity insurer. So we sometimes get views of people like MDU and mps. Um We do, we're not, we're not indemnity at all. So, although we do recommend that you do have indemnity. Um So yeah, so, so we, we're mainly firefighting um issues for people. Um If you come to us, we tend to get a lot of issues um resolved quicker than, than perhaps if, if you were um sort of face to facing things by yourself. So, yeah, so whenever you get any kind of issue at all, um I'll go on to what, what sort of issues we're talking about in a minute. Um But yeah, it's always just good to, to come to us as, as the first point of call. Um You'll, you'll see there were 85% of the cases that we had um in last year were resolved within, within three months. Um Probably the biggest, biggest thing this time of year, especially with, with doctors starting new roles, um is our contract checking service. So for better or worse, we negotiate all the contracts in the UK. Um, and, and for that reason, we know exactly what should be in them and, and when things, um, are wrong and sadly, we checked about 8000 contracts last year and 25% of those contracts, um, were not, er, compliant with, with the agreements that, that were set out. Um, so, yeah, so it's worth getting a contract set set sent to us checked. Um, if you've already signed it, it's not like it's set in stone. If it was wrong when it was given to you, it was wrong. So even if you've signed it and sent it back, it's fine. You can still send it to us and if we find any issues, um, in that contract, we, we can take it up with the trust. Um, so yeah, so this is just an example of the work that we've done in the last 14 years we've covered over 18.4 million lbs owed to members. This could have easily gone under the radar. People who have just accepted the pay, they're on, accepted the contracts and believed they were correct. It's not always the case. Sadie, I'm not saying that trusts do it on purpose, but it's definitely worth sending contracts into us to check, obviously pay slips and whatnot as well. So, yeah, so you may find you're owed a bit of money. Um, a few, a few of the, the sorts of cases that we, that we dealt with last year. So we dealt with 699 cases of immigration support, um things around the states change discrimination, racism, sponsorship and, and revalidation. Um So these are the other sorts of things that we can help with. Um We have a really good um wellbeing service. Um Sadly, it, it does get quite a bit of use in, in this day and age. Um, and it's open 24 7 to everybody. So, regardless of whether you're a member or not, it's obviously completely confidential of, of the trust. Um, and you have the choice of even speaking to a counselor or, or a peer support doctor to someone who may understand about being, being in the situation that you been in. Um, as, as well as, as that you obviously get access to all the B MJ um learning modules that are online, er, and, and you can download the app. So, so you can rack up CBD points quite quickly. You get the B MJ magazine, er, the journal delivered through the post every, every Friday. Um, and then you've got the access to the BMA library, which is one of the biggest BMA, er, which is one of the biggest libraries, er, in the world. Um, a lot of it's moved, er, it's moved online essentially now. So, so you can access all of those books instantly um, through our website and then you have a, um, clinical key as well. I'm not sure if you've used clinical key before, but it's a, it's essentially a point of care tool. Absolutely brilliant. Um, you download the app and, and you can use it at point of care. Um, so that's it for me. Try to be as quick as possible if you've moved here within the last year and you've never been a member before, I would employ you to, to join you, get a, a free membership for a year. And like I said, we've never done this before. So yeah, it's, there's, there's literally no catch. Um So yeah, it would be great to have, have you join us? Thanks. And I'll let you crack on this session now. Thanks Daniel. That was very informative. Um I will now start our session on common respiratory con conditions that you may face at the hospital as a junior doctor. Um Before we start, I thought we could run through the a to e quickly to refresh our minds. So as a reminder, the A to E is arranged in a sequence of what can kill you first. So in a airway, um as a patient speaking, if yes, the airway is probably patent. Um if not, you should probably look for airway compromise. So this is things like seesaw, breathing, use of accessory muscles, diminished breath sounds added sounds, et cetera, check for uh foreign bodies or vomit in the oral cavity. Um And if you feel like the airway is not adequate, you could try doing the head tilt, chin lift maneuver and if that fails, you can try the jaw thrust maneuver. Uh Either one works next. B for breathing. So is the trachea central, is there equal chest expansion? Can you see a chest deformity? Is there bilateral, equal air entry on auscultation? Can you hear any added sounds? And have you checked the SBO two? Next we go over to see which is circulation. So what is the color of the patient's hands? Are they pink? Are they pale? Are they blue? Is the patient warm to touch or cool to touch? Um How is the cap refill time? Is it less than three seconds? Is it more than three seconds? Um How's the heart rate? BP heart sounds? Have you looked for hemorrhage? And also at this point, you can insert a cannula and take bloods for investigations. Next we go over to D which is for disability. So are the people uh pupils equal and reactive? And how is the patient's consciousness? So you use either the G CS or the A pu A BPU stands for alert, verbal pain and unresponsive. And then you also check the CPG S because uh hyperglycemic patient could um be have reduced consciousness and it could just be hyperglycemia. Next, we go over to e for exposure where you examine the general body surface. Um So I fast um case I thought we could talk about status asthmaticus. So, a known asthmatic uh will present to the ed with breathlessness not responding to the standard bronchodilator and corticosteroid uh inhalers. Um What would you guys do? Um Maybe you could type out in the chat box about what, how you would approach this situation. I'll give it a second. It will be really helpful if um it was an interactive session just for everybody. Ok. So um I'm just gonna get going. Um You do an A to E assessment. So does anybody know what you would see in a? Yeah. Yes. So, airway, hopefully the airway is patent. Um If not, you should probably escalate for intubation and ventilation and get a non rebreathe mask and V bag ventilate the patient. But um assuming the patient is uh has an airway that is patent, we can move on to b what would you see in breathing in a patient with status asthmaticus? Yeah. Exactly. Anything else? Yes. So you'd expect to see wheezing shortness of breath, a possible cough. Exactly. You'd also expect maybe chest tightness, um use of accessory muscles. Um Exactly. Fast, labored breathing, hyperventilation and reduced saturations and see what do you think would happen. So, probably tachycardia. Um if they've taken the salbutamol inhalers or even just because of um the fact that they're not able to breathe. Um the any ideas for disability. So, I'd say the patient would normally be alert. Um But the consciousness could be reduced secondary to hypoxia. And in e any takers, I think he would normally be unremarkable. Yeah, you could definitely check glucose. Yeah, you sh you should. But again, in status asthmatic as it go, I mean, as long as nothing else is going wrong, you'd expect the glucose to be normal. And um in ei think it should be normal except maybe you could potentially see cyanosis in a very um advanced patient. Um as in in terms of how bad the status asthmaticus is. Um So this is obviously a very life threatening condition that needs to be treated asap um complications of not treating it in time could include cardiac arrest and no respiratory arrest and a good pneumonic to um remember what you need to do is oh shit me. So any takers on what it stands for? What do you think the O stands for? Yes, perfect. O is for oxygen and S salbutamol. Exactly genius. And what do you think age might be? So, h is usually hydrocortisone, 100 mg IV or you could potentially give prednisoLONE for the mg uh po and then II yes, ipratropium bromide. You give 500 mcg nebulized and then tea. Have you guys heard of tiotropium? Uh sorry, theophylline and aminophylline infusions. Um And then M so M is for M GSO four infusion 2 g IV over 20 minutes. Exactly magnesium and then E is to escalate care. So intubate and ventilate but again, as junior doctors, we're not going to be going down this hall. Uh Pneumonic, we will be escalating to senior support early. So that's I think what's key when it comes to just being a junior doctor knowing when to escalate. Um If you guys would like it, here is the slide of um what I what we talked about earlier. Do you wanna read through it for a second? So our next scenario is an exacerbation of CO PDA patient with a history of CO PD will present to the emergency department with worsening breathlessness. You are on call uh or uh and you are called to the bedside of a patient currently admitted with an exacerbation of CO PD, complaining of breathlessness or the nurse complains of low saturations. Um They will have a history of a viral infection or a common cold and will have sputum slash a productive cough. Um So what would you expect to see in a, in this patient? Oh, I see your question. Um Do you mind if I answer the questions at the end of the session? Cause that would, I think that would just speed things up a bit. Um So in CO PDI think the airway would ideally be patent. Um Usually if it's not, you need to escalate that and B any takers on what B might stand for in CO PD, what breathing, what would happen? Um So the patient will have a cough, wheeze chest tightness and use accessory muscles very similar to previously. Um D Yeah. Yeah. Yeah. Yeah. V shaped chest. Yeah. I mean, that's not. Yeah. So in an exacerbation, what would you expect? Which would be different from normal in D, do we do? C sorry? C so, and c you probably expect query tachycardia. It would depend most likely. Yes. So in D um the patient will normally be alert but consciousness may be reduced secondary to hypoxia. And in e I mean, on exposure, the per patient might be normal, you might be able to see cyanosis and a barrel shaped chest and clubbing. So, um so how would you deal with a patient with CO PD oxygen? Remembering to maintain um saturations between 88 and 92% so that you don't cause any kinds of um respiratory failure and then salbutamol nebulizers, antibiotics. Um You should check your local hospital guidelines and prednisoLONE and worst case scenario, mechanical ventilation. Again, we don't, we don't get to mechanical ventilation as a junior doctor, we escalate on time. Our third scenario is a pe so this could present in two different ways. One, you're working in the A&E when you get a female patient with a pleuritic chest pain, this means it worsens with deep breathing and coughing. And she recently got off a long flight. She regularly uses an oral contraceptive pill or second scenario. You are on call in a surgical ward at night and a patient complains of chest pain following hip replacement surgery. What are you suspecting? Considering we're talking about? Ap ei assume you guys are, uh, suspecting a pe, um, can you guys tell me what some risk factors for a pe might be? Just type it out in the chat? Yes. OCP. Use, HRT. Use anything else. Yeah, obesity, post surgical patient, um, recent fractures, recent immobilization, clotting disorders, personal and family history of, um, malignancies, infections, pregnancy. Um So if you get a patient, exactly if you get a patient, um and you suspect an a uh uh a pe um you should approach it in an A to e process. So what would you expect in a probably me uh patent in the, if you had a pe patient who you thought had pe um what would you expect and be? Yeah, shortness of breath, cough, pleuritic, chest pain, either normal respirate or tachypnea, hypoxemia. And then usually there is normal, bilateral equal entry on C it could be normal, it could be tachycardia. D for basically a respiratory condition. Um consciousness could potentially be reduced secondary to hypoxia. But here, normally the patient would be alert and in e there's something fun in e does anybody know what that is any ideas? So you might find tender erythematous calves, which might potentially point at a DVT. In which case you'd want to do an ultrasound um Doppler of the calves. Um if you get a patient and you suspect a pe, you check the wells score. Um, it's on the screen now. Um Exactly. Uh I see cough swelling. Yes. On e you see that. Um So when we calculate the well score, usually less than four and more than four is what we're going for. Um, it depends, it varies but less than four is usually a low risk for pe and more than four is usually a higher risk. So when it comes to a patient with pe um you need to investigate. So you can do a DDIMER. And if this is low, it excludes a pe, but if it's raised, it does not necessarily mean that the patient is having a pe um to confirm you would do some imaging. So A C TPA, she s can you guys hear me? Could you just type out? Yes, if you can. Mhm OK, perfect. Thank you. Sorry cause my computer is acting up a bit. Sorry about that. Um OK, great. So where will we? Yeah. So after the C DPA, we need to start treatment, um we need to decide if the patient is stable or unstable. So how would you decide? Um if the patient is stable, you would give Rivaroxaban and low molecular weight heparin and speak to a med reg or the ed reg. If the patient is unstable, you might suspect a massive pe um this could be because the patient has collapsed or is hypotensive may have respiratory distress, distended neck veins and a right ventricular strain or an E CG. So if that is the case, um you move the patient to rhesus and I if you're in Ed, if you're in the ward, you call the med and you consider moving to ICU and um you give oxygen high flow from a non rebreather mask, you give an, you do an urgent bedside echo plus or minus A C TPA. If the patient is stable and you will have senior assistance here. So you don't need to freak out about that. You can give Heparin 5000 units IV unless since Heparin has already been given within five hours. And if the patient is not for thrombolysis, you can give dear 175 units per kilogram. Se in addition, thrombolysis is a senior l clinical decision. So it's not for us to um try and manage at this point. We definitely need um senior assistance. Um and also all the places will be given. Our next scenario is alpha pneumothorax. So a patient will present with a sudden onset chest pain, acute shortness of breath and a feeling of not being able to take a full breath. Um Do you guys know what is a pneumothorax? Could somebody type it out in the? Yes, exactly. So basically, yes. Um It's a collection of air between the parietal and vissel pleura of the lungs. So, in a typical chest x-ray, you'll see that there is lack of lung markings like in the one on the screen, you'll see that um there on the right side, there is lack of lung markings in the right side of the chest. Um Do you know what types of pneumothorax there are? So, yeah, tension. So we can categorize it as primary secondary and traumatic. So, primary pneumothorax is in the absence of underlying disease. Secondary is a result of lung disease and traumatic pneumothorax is tension, pneumothorax which is secondary to penetrating chest trauma. So great. A great, well, you know, good answer. Um If you get a patient with pneumothorax, who you suspect has pneumothorax, just like every other patient, you're going to approach it in an A to e um process. So A will probably be patent b any takers on what breathing would be like in a patient with acquired pneumothorax. Mhm Any ideas, shortness of breath. Yes. So shortness of breath and then um unilateral reduced chest expansion, unilateral hyperresonance, unilateral, reduced air entry. And then on C you might have hypertension secondary to the pain, but hypoten uh hypotension is a late sign. Um The JVP may be raised because of increased intrathoracic pressure. Um D the patient would probably be alert but they could potentially have a reduced level of consciousness secondary to hypoxia just like we talked about earlier and an e um active breathing. And also if it's attention, pneumothorax, there will be chest trauma, attention, pneumothorax is a medical emergency because of the um sudden rise in the intrathoracic pressure, which means that there is reduced venous return to the heart, which could potentially lead to cardiac arrest. So a pneumothorax of any kind is very, you know, it's an emergency condition and therefore, you need to treat it immediately. So if you are very sure that it is a pneumothorax, you should not wait for a chest X ray. Um You can do needle decompression, which is performed in the safe triangle which you can see on the screen today. Um So there's the safe triangle is between the lateral edge of the pectoralis major and latissimus dorsi and above the fifth intercostal space and below the axilla. Next, we move on to pneumonia which is our final condition. Um The patient will present with upper respiratory tract symptoms. So this is productive, cough, breathlessness, fever, sneezing. Um What would you expect in a probably patent just fy I um B in a patient with um pneumonia. What would you expect in B Yeah, fever. Yes. Anything else shortness of breath? Yes. So there could be reduced air entry into a lung or a lobe. Um There could be, yes, cough, dullness on percussion over the reduced over the area with reduced air entry, there could be added, sounds like crackles, you could have reduced saturations. C will probably be be tachycardia d again, the patient is probably alert but could be confused if very unwell or elderly. And the patient will probably have a fever at D. Um An EE is hopefully n normal. Um It's probab when it comes to investigations, it's probably useful to eliminate COVID at this point. So you could potentially do a COVID swab. Um And you could do bloods, which would show that the W BC count is elevated. Uh C RP is elevated, you could send off sputum samples for microscopy uh culture and sensitivity and you could do a chest X ray which could show um little bit or bronchial consolidation. Um How you choose to approach a patient with pneumonia really depends on the curve 65 which is on the screen now. So, confusion, urea respirate, um your BP and your age. Um So the treatment um is, I mean, it depends on the patient, but usually you start with oxygen. If the saturation is low, you could provide nebulized salbutamol if required. Ideally, you need, I mean, you give antibiotics if you believe it's a bacterial pneumonia and you follow the local guidelines for this. If the patient is having a lot of trouble with a cough, you could give a simple linked test and for the fever, you could give a pa uh give paracetamol or any antipyretic like that. Um That is the presentation I have for you today. Um I'd welcome any questions you have now, you could just pop them in the chat. Oh, there was one question previously. Let me just find it can excessive beta two agonists uh cause critical hypokalemia. Um in theory, yes, but because you do use um in uh beta two agonists to treat hyperkalemia. But I mean, everything has side effects, I guess. And you just need to find like a soft, a nice medium. You just, I mean, you have to give a beta two agonist for a patient with, I believe at this point we were talking about um status asthmatic good. So yeah, potentially. Yes, but hopefully you don't go that far any more questions. Does COVID infection leave any longlasting radiological signs and how you could differentiate the radiological ground glass pulmonary obesity seen in COVID-19 lungs from that of pneumocystitis, caring slash Duva pneumonia in immunocompromised patients. So that's a very interesting question. Um This is a session for junior doctors but I will, I will try to do this. Uh I will try to answer your question as best as I can. Uh as well as I understand, you cannot differentiate um the different ct um findings, radiological findings of obesities, ground glass obesities. Um just from radiological findings, I think you need, you know, clinical examination and investigations. Um you could send off sputum samples, you could um you know, just see who the patient had contacts with previously. It really, I think depends on a case to case basis as far as I'm aware. Um But yeah, and yes, beta two agonists cause tremors too. Yeah, thanks a lot. Um any more questions? Ok, so I'm going to assume there are no more questions. Um Thank you for coming to our session today. Please be kind enough to fill the feedback form um that I will release now um before you leave because once you do so you will receive a certificate of attendance to your email. I'm going to release it now. Please be kind enough to provide feedback.