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Thoughts you can get started. There we go, go for it. All right. So um my name is Ria. Um Please take a look at, so I'm just gonna use a laser pointer. I'm not gonna use right. I think I'll use, I'll use pink, you know, I'm feeling pink today. So my short code is R V 319 if you have any questions at all. So please please do a go ahead and email me. I'm very happy to answer your emails. I am currently med a year four coordinator. So if you have any BSC related questions um or like any questions in general about murdered. I'm also quite happy to answer them. So I'm gonna be talking through news to an S bar. And the reason why these stations are very, very important is because of like as in this station is very, very important is it's on the C P but it's also something you might use likely as a medical student. Um So, and there has been like times what I've had to do an S Bar for a consultant. It's usually just been in a learning context, but you might have a situation where you notice a patient deteriorating and you feel the need to s bar. Um And this will be very, very useful for you, but obviously, first and foremost, useful for your say P A. Um So I'm going to talk to you about the session structure just quickly. So what I'm gonna do is we're gonna go through news to first. Um because that's the bit that you see first in the station where they give you kind of your news to chart. Um, and then I'm going to talk about what aspiring is and why it's important properly. We'll talk about what you do in preparation and what information you get because most likely you'll have a lot of papers or perhaps you'll have, um, one of the computers on wheels beside you and I'll tell you what information is important in order to kind of do your S bar, then I'll talk you through the process of it and then we'll go through some examples where, um, I kind of talk to you out loud and you tell me whether you think that that S bar was a good S bar or a bad S bar. Okay, because I don't really want to put anyone on the spot there and make them feel like they have to give me, um, an S bar of their own. So let's talk about the news to chart. Um, the, so in terms of this news to chart, what do we need to know, we need to know if the patient has COPD or not. If they have COPD, they need type two. They need the chart chart too. But for most patient's, it's chart one and it's very likely they'll use chart one. But I've actually got the scales from both charts in this one. So the important thing I'd like you to know is that someone could be presenting completely normal and be deteriorating severely. And this chart will pick it up. Alternatively, someone could be absolutely healthy but could end up with a score on this chart. So all of these things are meant to be taken in a contextual basis. And it's very important also to refer back to what the patient's news to Scott was before because if you notice with monitoring, it's deteriorating and you're watching a deterioration, that means that you can call the crash call team or as they like to be known, the critical care team quickly enough to catch that patient and to give them supportive um kind of treatment before that deterioration happens to the fullest and they actually are in trouble. So let's talk through respiration rate. So obviously, it's 12 to 20 it gives you a score of zero. So that's considered normal any less. And you're looking at a score. Now, the important one is that if they're respiratory rate is below eight, you will give them three. Now a score of three in any of these modalities, a score of three is really important because it means that you have to up your monitoring by a significant amount. We will talk about this in more detail later. So a score of 12 to 20 if it's 21 to 24 it's a two, if it's 25 above, it's a three. And alternatively on the other side of it's less than eight, it's schools are three. So you the normal one you're looking for in your 80 assessment and also you're monitoring of the patient is 12 to 20. Okay. And don't worry about remembering any of this, you will have the chart in front of you, but it's good to be familiar with the values. So you can quite quickly mark things as the station itself is time constrained. The SPO2 scale one is for people without respiratory failure. And then the scale too is for people with COPD who have type two respiratory failure. So the important thing is that on air. So you need to, whenever you kind of record your observations with specifics 202 saturations, you need to make sure that you specify if it's on air or on oxygen. Okay. And the thing is before you even take this, if you notice that someone sats are low, you administer oxygen and you see if those sat's go up, it might just be that they need a little bit of a helping hand. But if they're sats don't go up despite the fact that you're giving them a lot of oxygen, that's a sign that they're deteriorating quite a lot. So if we take a look, we want them to be between 88 92 for scale too. So that is the COPD scale. And the reason why is because they are CO2 retainers. So if you give them too much, too much ox surgeon, their blood will become, their blood ph will become acidic and that is also bad. Um So SPO2 scale one as, as a usual rule, 96% or above. Now, if it's any less, that's when you start to worry and particularly at below 91 on scale one, that is a severe deterioration and that scores three and below 83 on school on scale to but don't worry too much about this because again, you will have it in front of you. But can you see how it's specified here if it's on air or on oxygen? Make sure you record that when you write on the chart in terms of air oxygen here, it says below. If they're on air and they're maintaining normal sats, you can give them a score of zero. But if they require oxygen, they deserve a score of two or more based on kind of what SATS they're maintaining, they might need even more in terms of BP. Remember, systolic, diastolic diastolic, the low one systolics, the higher one we care about systolic. We don't really look at diastolic, um, and for systolic. So, you know, it's 100 and 20 is the kind of the value we're told is the normal one. It's 100 11 to 219. Um, on this news to school and the reason for this is we just want to know if they're adequately perfused, but any more than 219 and they are at risk of target organ damage, their risk of going blind, they're at risk of their kidneys going into kidney failure. So it's of great importance that you consider um or they could have even a pheochromocyto hma if they're reaching that kind of level as well, but that's a bit more on the rare side. Um any less than 100 and 10 and you get one. Now, remember a lot of us here will have a systolic BP of less than 110 resting. Now, that doesn't necessarily mean that we're in trouble. That doesn't mean that we're ill. And that's why it's important to consider the measurements in the context of the individual you're looking at, particularly if the individual as a young person, they are likely to have a low BP and that just might be genetically normal for them. Um So any lower than that. So 91 over 100 is a score of two and then any less than 90 is a score of three. Now, usually if it's below 90 they have severe hypertension and they're probably struggling to perfuse their head if they are sitting upright, which is why you would then consider that score of three here for the pulse. We're looking at normal 51 2 90. That's quite a big range. But of course, there are people who will have pulse is lower than 50 and will still be normal. So again, it's very important. But the point is it's a score of three requires you to up the monitoring quite a bit. Um hence the kind of color gradient as well in terms of consciousness, if they don't score alert. So if they are any less than alert immediately, that is a score of three and they require monitoring around every four hours. And finally, for temperature, um the the temperature ranges really small. And the reason for this is because of obviously the enzymes in the body and the the importance of kind of this specific measurement is that they need to take kind of measures in place, particularly with elderly people. If you, if they have a temperature of below 35 degrees C, they are they are severely kind of low in temperature and that can often happen in the winter months. So it's very important to consider that. And often after a fall, you'll have people who are elderly who are very, very cold. So that's very important and also a high temperature as well, you could consider sepsis in either of these scenarios and it's really important to consider separate throughout it's so noise. Uh So basically, the important thing to consider is that you should always consider sepsis. If someone scores three, immediately, your alarm bells need to ring and if someone scores seven or above, particularly that is difficult and you need to call the critical care team. Okay. So that is the important thing with this. So let's talk about the new school and the school, what it means. So if they get a score, like where you add up the kind of modalities that you've arranged and they got a score between zero and four, that is usually okay. We do award based response if someone has previously scored one or zero and you notice that their news to school has gone up to fall, that's when you would stay about doing supportive measures. So depending on if it's BP, you might think about fluids. If it's temperature, you might think about a warming blanket. Um it really does depend on what measures are kind of out of that normal range if they get a score of three, any individual parameter, which is what we were talking about before. So a score of three would mean any of these and any of these. Okay. That is an urgent ward based response. So that's when you start telling the on call. Um you would start considering the on call consultant or the registrar um to look after that patient and perhaps consider escalating an aggregate score where you add it up of 5 to 6, that's medium you need to consider depending on the patient and how they appear to look. Because obviously, clinical judgment comes into this as well. You might consider an urgent response and seven or more as an urgent or emergency response. And when we say an urgent or emergency response, we mean they need to be a critical care team, a team with critical care skills, you can do airway management because it's very likely this patient needs to be taken to ICU or H D you. So it's very, very important to consider that um in terms of the kind of aggregate score of 5 to 6, you would kind of look at a clinician who's got enough experience to know what to do with the deteriorating patient. So that would likely be a registrar particularly or the encore registrar at the time. So this is really small but effectively with the news to score of zero, you aim to monitor the patient every 12 hours with the news to score of 1 to 4. It's about 4 to 6 hours each, like each monitoring gap is about 4 to 6 hours. Um If they've got three in one single parameter, that is a sign of severe deterioration of one aspect, like if they've suddenly become confused, you would consider monitoring them each hour. Um If they've got five or more, you consider an urgent ward based response, minimum one hourly monitoring. And you'd also consider referring to a clinician with those adequate care competencies. So particularly someone who's kind of training grade S T six or a registrar that's quite helpful or a senior nurse as well will be very helpful. And then seven or more is an emergency response and you would consider escalating to intensive care or high dependency unit as well. And you would consider calling the critical care team. Okay. So the critical care team, okay. So in terms of news to, they might ask you on your S bar station, they might ask you to say, what do you think? What would you be interested, investigations or what investigations would you look out? They could potentially have a list of those in front of you depending on what they choose to do. The main things that you'll see if the patient has sepsis, which is the kind of main thing that the news to school will pick up is a change in their lactate, a change in their pa oh to a change in their creatinine changes in there. Billy Ruben changes in their serum glucose as well and it'll be increased in the absence of diabetes. But that's a bit of a niche. One, white blood cell count is really important because most likely that will be really high. That will be like seriously, seriously high or very, very low. And that's also good sign of sepsis. So I would say lactate and white blood cell count are the most important and CRP as well, which will also be increased. So those would potentially be the blood results you would be interested in either gaining or having a look at if available for the patient. So in terms of the criteria generally, this is what will score you a three, this is what will also score you a like a 12 or three for heart rate for respiratory rate, this will score you a 12 or three here as well. And for black white blood cell count, that will just give you an understanding of whether the patient might be at risk of sepsis. Okay. And with sepsis, the only way you can diagnose it is with a documented infection and with severe sepsis, you'll start seeing signs of organ dysfunction. So the kidney is shutting down urine output decreasing. Um you know, also cold peripheries, um and septic shock and then you've got mods which is multi organ dysfunction syndrome, okay. So, um let's take a look at the sepsis six. So if you do suspect the patient has sepsis or you want to do supportive measures in the case of an infection, these are the things that you would consider doing for this patient and you would consider talking about it on S bar or asking for those results on S bar administering high flow oxygen is usually always a good option. Uh It's rarely not a good option and maintaining their SPO2. As honestly, you don't have COPD, maintaining their SPO2 above um 94%. At least taking blood cultures for an infection is really important. Obviously, you know what the infection is, but in order to target them better, obviously, you'll give them broad spectrum antibiotics, but you do need those blood cultures to greater refine your response to the illness in place, potentially measure their cereal lactate levels. So this helps you see the progression of the infection or the sepsis. At most, a broad spectrum IV antibiotics until you wait for those blood cultures to come back, administer IV fluids to keep their BP up, to keep them hot, like their volume, their blood volume normal. That's also very, very important to ensure that their organs and their peripheries are adequately perfused and finally monitor urine output. So high flow oxygen, blood cultures, cereal lactate levels, broad spectrum antibiotics, IV fluids and urine output. But you're gonna say rhea, this is really hard to remember. I don't think I can remember six things like this. Well, it's an easy way to remember it and we call it take three, give three okay. So you take blood cultures but in, but in taking blood cultures, you give IV broad spectrum antibiotics to wait for those um kind of results to come back. So you can further refine your response, take the lactate but give oxygen and take urine output, but give IV fluids. So take blood cultures, but give antibiotics lactate but take lactate, give oxygen, take urine output and give IV fluids. This is a really good way to remember it. And I'm sure you'll impress your examiner if you do suspect that a patient is deteriorating and you suggest any of those things given obviously the clinical justification for it. So now let's talk a little bit about S Bar. Now that we've talked about news too because it does what it says on the tin, but S Bar is a little bit harder. So first and foremost, Esper is a crucial part of your C P A back when I did my CPA, which was almost two years ago. Now we had a station in our CPA called observation and it involved filling in a news to chart and subsequently using S BAR to escalate the care of the associated patient. Um And a little bit of a fact about S Bar that you might care about S Ball actually originated in the Navy, but it's been adopted in clinical settings for handovers, referrals and asking for advice. And what it is essentially is it's a structured method for communicating critical information that requires immediate Axion and advice from a senior. So make sure you learn the news too, um scores and the corresponding observation and monitoring intervals and who to escalate if required as this will definitely come up in your C P A. Okay. So it's a CPA station. It's a structured method for communicating critical information and it's used in these settings, but particularly for handover. And that's the one that you're probably going to get in your C P A. And why is s far used? Well in it's most primitive form. It stands for situation, background assessment and recommendation and basically what it is a quick and easy structure guide. So you are less likely to forget important information that needs to be relayed to the other person on the other end. Now, it's really important to be worried and flustered when a patient is deteriorating and it's comforting in the moment to have the structure to fall back on. So it is a really important thing to practice and also being on the other end, ok. Being on the other end of a good spot, feels fantastic because it increases the confidence of the other person. You've communicated the situation too and they feel concern like they've given, they've been given the information concisely with all the relevant information to make um the patient's care adequate for their needs. And some tips I would generally give you for a good s part of the following. Get all the information that you need in front of you before making the call because you'll be given like a phone in order to like mock do it in front of the other person who will take the other under the phone, make sure you introduce yourself properly. So that's who are you, where are you? And what, like what are you like? What is your kind of grade so that they know kind of what level of information to expect from? You don't forget to check who the other person is on the other end of the phone call. And the reason why I say this is important is because people often forget to do this in their CPA. And it's quite easy to forget because you just think, oh, I've got all this information. I need to just blurt it all out. Remember, you need to know who the other person is. Don't forget to check. Also just ask the person at the other end of the call if they would like you to do anything for the patient. In the meantime, before they arrive, is there anything you can do with your given level of expertise? Um You know, administer fluids? Do you think it's worth administering a certain antibiotic or do they suspect that you need to like do another check for rashes? What is it and stay calm while you do it? And don't forget to say thank you at the end of the call because it looks very, very professional and it also gives the examiner a good impression. So remember those things in terms of preparing to esper, I said, make sure you have the information in front of you. Um So what patient information would you access to the S BAR? I'm not sure if you're able to in um kind of, I'm just going to mute the chat actually for myself. Um Do you guys want to send messages in the chat and let me know what patient information you would be very interested in in order to carry out an S BAR. Um I think there's a few obvious answers and there's a few more niche ones. Please go ahead or you can, um, you know, as well and tell me we think of anything particularly. I mean, I could just list them, but I think it'd be a lot more fun if I can get a few answers in the chat. Brill. Sorry, that's my foot. So Jennifer says, age presenting complaint, brilliant. That's absolutely fantastic. And then Kim says age sex history presenting complaint, lactate crp Sats. Wow, this is really, this is really good. I'm impressed. BP and temperature. Yeah, those would be the most important ones out of the apologies for spell. Um Oh, I see. Yeah, so these are the most important ones through the um news to school. So very well done. I love these answers. I'm just gonna heart them great. Well done. So, yeah, we would be considering things like obviously the patient's nodes, the investigation results which you mentioned and the observation charts. Now everything is electronic, make sure you're logged in with the data open in front of you. This is probably more for a clinical setting. They'll probably give it to you as paper. You should have any kind of relevant examination results, which would definitely come up from lactate and CRP, special test results. Um, so CRP is considered a special test. So that's important. Any lab information, any allergies and any medications as well. If you've got their medication chart in front of them, that's important, particularly if they've got, if you suspect they've got sepsis and you find out they've got an allergy to penicillin, that's really important. And yeah, so the purposes of this CPA, you'll most likely be given a patient brief and the news to score that you have previously calculated to talk about. Um, and obviously you would talk about the most concerning findings first, but obviously, respirator and pulse rate are the most basic ones you can talk about. And that's, um, so in terms of the acronym itself, can anyone give me any situations in which they would consider doing an S bar? So we did talk about kind of handover inpatient settings. But when would you consider to do an S bar? What, what would prompt you to think about doing an S bar? Um, pop it in the chat or you can, um, you'd and talk to me if you'd like, Kim is carrying? Oh my goodness. Um, I've got a few visual prompts. So we've got, we've got a heart with an E C G thing. I've got the brain, put the lungs and we've got a cost. Anyone at all situations. Kim says a sudden decline in alertness. 02 sat. Brilliant. Yeah. So in ward and you're concerned about them because you're like, wow, they're getting confused really fast. There's something up the 02 SATS as well. Definitely. If someone is not saturating properly, that is urgent respiratory rate as well. And I think that's P P. Yeah, um and consultation as well. Yeah, from a consultation you might consider doing a handover particularly if you don't know what to do with the patient. Um well done, well done Osama and Kim gonna give you guys hearts and BP and not be Oh yeah. So background, what kinds of backgrounds might the patient have? Think of anything that you might consider important to bring up in a background if present in the patient? So you've got some prompts. We've got a builder, we've got some thing, something radioactive. We've got a car that is not moving in a straight line and we've got someone who has the baby bumped anyone at all. You're welcome to a news as well if you'd prefer um or use the chat history of rest for cardiac disease. Yeah, exactly. That is definitely something. So respiratory disease, we can think about things pulmonary embolism, pneumonia, cardiac disease. We could say heart attack, we could say chronic heart failure with pregnancy as well, particularly if you think they've got like other illnesses such as preeclampsia, um, or they could have be having a breech birth, usual level of fitness and activity. Brilliant. Very, very good, well done Kim. Um, so, and then what about assessment? So what assessments do you think you would like to bring up? So, we talked a little bit about kind of your, um, things that you would probably get in your news to chart things that you'd probably find out in your A T assessment. Um, but what would be particularly alarming that you would certainly want to bring up in your S bar? Okay. Oh, perfect. Again, like I said, there are, there are very few wrong answers here and, um, this is just for, would you look at neutrophil count? Uh, perhaps it does depend on what you're kind of after understanding. I mean, generally if you look at white blood cell count, it should give you kind of a breakdown. But unfortunately, neutrophil count doesn't tell us more much in the S bar setting, but it is a good one to consider. Um, and certainly you'd look at it, at least in a kind of outpatient setting, you'd probably be a bit more interest in it, but white blood cell count for sure. So, good. Guess that was really good in terms of other things you might be interested in. Um, generally it would be things like if you heard a murmur, um, or if you feel like if you check their pulses and their pulses are weak during assessment, that's also really bad. Um Also if they can't seem to talk to you, that's also really, really, um that's, that's quite bad. So if you say the patient can't string together coherent sentence, that immediately is alarm bells. Um in terms of other things, you could talk about the fact that if you've noticed any drugs on their table that you um yourself haven't administered or if um in their assessment, you notice anything about them that might suggest that they've taken drugs or pinpoint pupils, for example, for opiates and also just any blood results at all that you think are relevant and in terms of recommendations, what recommendations do you think? And we discussed some of them earlier. What recommendations do you think might be given to you by someone on the other end of your s park? All? What recommendations would you suggest to the person on the other end of the call that you could do for the patient? I've got some here. Uh Please go ahead and type in the chart. They might suggest changing or starting IV antibiotics. Fantastic. They might say, um what are they already prescribed? Um Could you please administer them these things? Um They could, they could even suggest, could you please um check if the patient has a D N A C P R because it looks like they might need CPR potentially blood cultures as well. They might recommend fluids or particularly giving them a certain type of fluids as well. So that's very important. So situation, background assessment recommendations, situation is what is happening to the patient. Now, background is what do the patient initially have. Um and how has that changed? Assessment is what you've noticed that you're particularly concerned about. It's kind of your ideas, concerns and expectations based on your assessment as well. And then recommendations are what you could suggest you think you should do for the patient and what they might suggest you should do for the patient as well. So, um fantastic. Thank you so much for typing in the chart. I really appreciated. Uh So when you're doing your situation, what do you do? You introduce yourself? So I would say my name and great, hello. My name is Ria Varma and I'm 1/4 year medical student. I'm on placement at Drayton Drayton Ward. Oh, I guess if they look ed um a tissue might suggest increasing diuretics. Yes, perhaps. Um Definitely you can also put in a fluid drain depending on kind of where the edema is. So if they appear to have cities, you can do an aesthetic tap and you can do an analysis of the fluid that comes out of that well done. That is a very interesting point. I like us. Good thinking. So I would say hello, my name is Dr um and I'm 1/4 year medical student. I'm on placement at Drayton Ward, for example, to name a random ward, um clarify the name and grade of the patient person you're speaking to. So I'll ask, can I ask who I'm speaking with with whom I'm speaking with? And then give basic details about the patient's their name, sex, date of birth and hospital number if available to you. And you'd say something like I'd like to speak with you about a patient by the name of Angela Smith Hospital number 1984673. She's a 67 year old woman. And then you say where she is? She's currently on Drayton Ward at Hillingdon Hospital, for example. Then you say when, so I'm just gonna put this up because I'm just talking. Um So then you say when, so the patient began to deteriorate 40 minutes ago when we completed her observations. And then you say kind of, I'd like you to review her and consider her for transfer to I T U for intubation. And then you go into your background. So who, where, who that's like, who am I, who are they? Where, where am I and possibly where are they as well? Especially when trying to organize the response. When, when did they start getting worse? Potentially, when were they first admitted when? So that's important with when and also um what, what has happened to the patient? Um What are you concerned about quickly if you want to talk about it and why, what do you think needs to come out of this? What are your expectations to see how it's kind of like an ideas, concerns expectations, but just a different format. Now, let's talk about background. So background is the section of S bar where you can provide an overview of the patient. So relevant medical details include things like admission, reason, the day of their admission. I'm just gonna put these um they're current diagnosis, they're relevant past medical and surgical history, they're relevant medications as well. For example, Warfarin, if the patient is presented with the bleed, so they might need to change the kind of the amount of Warfarin the patient is being given. Um Another thing as well as allergies, particularly the allergy may impact the choice of treatment. For example, an allergy to penicillin and usually the allergies that we're considering are things like not allergies that resulted in airway symptoms or significant symptoms that were of particular concern. Not I get a rash when I have penicillin uh because that doesn't usually impede the choice also relevant investigation results and current management and the patient's clinical response that management, for example, I've given them fluids and their BP has increased a bit, but they're still looking very poorly, something like that. And for you, it'll be mostly related to the news to school with additional information about what the patient came in with and that will be provided to you in the brief. So make sure you have a good look at it um in terms of your assessment as well, um obviously, you're looking at your vital signs, that's your BP, pulse, respiratory rate, and SPO2 as you've mentioned in the chat. Well done. Now, at this stage, you probably won't have any clinical examination findings to comment on unless they've already been given to you in the brief. So do read the brief properly and look for anything and on top of that as well, a clinical impression, what do you think they have? Um, I think you could just say, I think they're becoming severely ill or you could say, um, I think they are getting to a point where they might not be able to, they might need extra support. I think they need to be intubated or you could say, I think I suspect this patient might have sepsis. Um, well, that's very important. Uh, someone's put their hand up. Would you like to have a go? Yeah, good morning to some. Actually, I would like to ask you just back to the previous slide. You have mentioned that it is, uh, you might not have the results for your, uh, exams or whatever investigations. Sometimes we do have the patient since let's say that one week to these, uh, two days, more than 33 days like this. So we do have the patient has already admitted to the hospital, the floor or I see or whatever. So that time we do have the lab results in this situation. Should we put it in the assessment or not? Um So as in, are you saying, go to the lab results in the, in the assessment? Yes. Oh, yeah. I think lab results are really important to include, particularly if you think, um, if you think they're relevant. Absolutely. I would put them in. Absolutely. No, I think that's a very, very important point. So when you do do your S bar, um it's worth and you know, if, even if you feel if you feel that the lab results are really, really important and there's been a big change, for example, they're lactate has gone from, you know, okay, so the Lactaid has gone from 5 to 20. Um you could say in the background, the patient on admission, their blood was that they had a lactate of five. Uh Now coming up to today, they're lactate is 21 I'm really, really concerned. So that is also a really important thing to mention in your assessment, you should talk about lab results if given to you, if you don't have them though, which could be the case, um don't worry too much about it because your news to score is your kind of fundamental thing that you're going to talk about. But thank you for the question, Osama, that was really useful. So in terms of recommendations on this next part. You state your submission, you state kind of what your suspicions are about the patient's condition, what you think needs to happen and what time frame you expect those things to happen. For example, this lady has suffered with an acute interest, cerebral hemorrhage and has been given the ongoing um uh care, but she's got ongoing clinical deterioration and she needs an urgent review by the neurosurgical team. So you think the neurosurgical team needs to be involved? And you said it very clearly ask them if they can review the patient. And in what timeframe, just say, is it possible for you to review the patient within the next hour? Um or if they can be transferred to another clinical environment? Is it possible to our their spaces on I T U for this patient? Um And you can ask things like are you able to come and review the patient within the next half an hour? Um In the meantime, is there any other investigations or treatments you would suggest? Are you happy to accept this patient for transfer urgently to the neurosurgical high dependency unit? So it's kind of that's the way you would probably talk. So you'd say, is there anything you think I could do in the meantime, for supportive care for this patient? And are you happy to accept this patient at your ward? So these are very, very important things in your recommendations. So it's your recommendations and their recommendations, what you think needs to happen and what they think you can do in the meantime, and in terms of your aspiring, you get to review in response, which is the extra part of it. So check that they have accurately understood the clinic current clinical situation and check if they have any further questions if you ask. Um does that make sense? That's still pretty good. But if you say something like, are you, are you able to follow what I've just been able to tell you, let me know if you'd like me to clarify anything or you can also say, um do you have any further questions about the patient and clarify the expectation of the response? So after you've kind of said that, make sure, so you'll be coming within the next 15 minutes to review the patient or something like that and document the discussion in the patient's notes. If they do give you notes to document it in, they may not give you that chance because the station is quite short. And if you filled in a news to score and then on top of that as well, you're giving an S bar that does take up quite a bit of time. So, but if you do, but after you do your s bar, just say, um I would, after this, I would document the discussion in the patient's notes, including the details of those involved in the discussion. So the name of the person, they're grade their bleep if you have it there, advising their timings and obviously say, thank you so much for speaking to me. Um, and I'll see you in the next 30 minutes or whenever you said that you'd like them to come. Okay. So basically ensure they've understood what you said and ask them if they've got any further questions and clarify your, their response to you and what they think about the situation and documented if they do give you the option to or just say you would and say thank you at the end. So I'm going to give you two a sparring examples. So I'm going to do an s part to you. You're the doctor on the receiving end and you tell me kind of give me like a rating out of 10 and stick it in the chat. What you would rate me out of 10 based on my ESP are okay and I'll give you two. So as an example, a an example. B um I hope everyone's ready. I'll give it a shot and then if you could just rate it in the chart and tell me what you thought of it and what, what you thought went well and what you think I could improve. So I say hello, my name is Ria Varma. I'm calling to refer Alfred Banks, an 87 year old gentleman who presented to the emergency department with probably sepsis, likely secondary to a left foot cellulitis. Um, he has a two day history of worsening, redness, swelling and pain of his left foot. We've just done his news to school and it's a seven. So I think he might have sepsis currently has a pulse of 100 and 35 he appears to be in atrial fibrillation. He has a BP of 92/45. His temperature is 38.6 degrees and his respiratory rate is 23 but he's saturating well, on two liters of nasal oxygen, he's confused and agitated and seems dehydrated with evidence of cellulitis of the left foot. Like I told you, we've done some stuff, but we'd like you to come and see him. Now. Would you be able to come and review the patient as soon as possible, please? Is there anything else you would like me to do now? And then I'm assuming you respond and I would say thank you. Ok, give me, give me your rating. What would you rate it out of 10? Okay. Osama gives me five out of 10. Um Can I get more scores in the chat, please? I'm not gonna ask anyone to explain their scores. Um I'm just more interested and especially if you could tell me what you think went well or do you think there's anything I can improve? Ok, Kim gives me a line. Thanks, Kim. Um Do you want to explain it? Yeah, you can um, you and explain it to me. So I'm just gonna mute because I'm coughing a bit. Yeah. Osama. Do you want to add meat and explain to me what I did well, and what I didn't do well. Is it okay by Michael or should I chat? Yeah, you can do whatever you like, you can on me or you can chat as well, whichever is easier. Ok. Moving back to the as well. 1st, 1st of all, there is a way to contact the information. So the way that you contact information was very fast, then you should be slowly little bit. So I to make sure that you're passing the information the correct way and then the you mix up the information, you, you pass the information to the next part. Uh your partner, you mixed up the information. So when you give it the information, you should move with the style. That means you're starting the situation to patient, then by primary patient, you know, and moving with the assessment, then your recommendation, what you did is just mixed up the information one more point is that uh you use the uh concept of I think and we, we give the information, we don't say, I think we should be realistic and we should get facts. And uh if you would like to have any recommendations or if you have something in your mind, but you're not sure. Uh first of all, you give your facts. Then by the end of that, you could say that I think this patient would have 123. So after that, you can recommend something or you can ask their recommendation written. So this is uh these are some, some points actually, there are others, but I will give the mic for my colleagues so that they can super more well done know. So I think it's a really important thing. I I think you need to give a bit of information and back it up a little bit. And in this as far, I didn't really tell you why. I thought the gentleman wasn't doing very well. I repeated information and I also mixed up my information, but this is probably not the worst espe are you will hear, especially in your career. And it's certainly not that bad if someone is really panicked because I have still given a lot of information. But absolutely, I think it is important to give the facts first and then say based on this, I suspect. Um, so I, I do agree with you on that. Does anyone else have anything they'd like to say? Either, feel free to message it in the chat or feel free to even admit yourself if you'd like to say more. Anyone? Okay. So I think I'll move on and I'll do another S bar now and I'd like you to tell me what you think of this s bar. So this is a different one. Um And I'd like you to tell me what your feedback would be for me and also your score in the chat and please go ahead and give me your scores. This is more just for you to be able to pick out faults so that you can hear it in yourself when you practice. So, um, okay, so I'll say hello, I'm Re Obama, the fy one doctor on call. Is this the medical registrar? And then I'd get them to confirm, um, what's your name? And then I confirm that as well. I'm calling to see if you can come and review Doreen Jones, an 82 year old lady on Drayton Ward who I was asked to come and see by the nurses as she's become very breathless. She presented two days ago after a fall and has been receiving IV fluids and antibiotics for a uti she is known to have vascular dementia and heart failure and usually takes aspirin furosemide and Ramipril. Currently, her pulse is 100 and five and regular BP is 100 and 30/86. Respiratory rate is 32 she's saturating 88% on air. She's a febrile on examination. There is some peripheral edema and some widespread inspiratory crackles in the chest. I think she is fluid overloaded and has pulmonary edema. I've put it on some high flow oxygen, stopped the IV fluids and prescribed a stark dose of IV furosemide have you been able to follow all of that? And then is there anything else you think I should do to support this patient? And then would you be able to come and review her in the next 30 minutes, please? Thank you. And then that's the end. What do we think about that one? Oh, Salma asks, what is the background for your patient? Um So the background that I wrote for this one is she presented two days ago after a fall and has been receiving IV fluids and antibiotics for a uti she's known to have vascular dementia and heart failure and usually takes aspirin furosemide and Ramipril Osama gives this one a 10 out of 10. I'll take that Osama. Oh, the previous one. Oh, this is a pre previous one. There are two sounds in this uh Kim gives me an a of 10. Okay. I'll take that as well. That's nice. Um Yeah. So what we're getting from this is that this sounded a lot clearer and the reason why it sounded a lot clearer is because I told you the what, where, how, who, why of everything. So I told you who I was, I asked who you were as well because you're one of the other medical registrar. I told you who I want you to come and review where they are as well because you know which ward it is and what the initial problem was without going into too much detail so I can give you that background and then I can come back to kind of the assessment and what and just like Osama mentioned previously, um I told you the facts first and then I said what I think she has and that makes you able to make your kind of objective assessment of the situation. Okay. And then I'm able to tell you, I think she has this, I might be wrong. But if you agree with me, based on what I've told you, that would be um that would be important for me to know kind of thing. Um Grace gives me a 10 out of 10. I'll take that. Thank you. I'm pretending this is um this is exactly how I would deliver it. Um Yeah, and I told you also what I did. So this may or may not be applicable to you because in news to you can't really do anything in the news to an S Paul station sounds super structured. Only thing I would say is maybe like maybe last time established who you're speaking to. Exactly. Yeah. So this is really, really important. I need to make sure I know who I'm speaking to. And this is definitely something you could forget. I know because I almost forgot. I think the only reason why I remembered was because I said my name that I had a look. Um Who was it? It was, it was one of, it was one of the people, one of the people who's doing, I looked at him, I was like, actually, I don't know who they are in this scenario and then I asked, but it is really important to ask and definitely don't forget about that. Um I also told you the background and I gave you kind of a quick understanding. So, you know, that this is an elderly patient with a lot of comorbidities and she's had a fall, which usually like, and I've given you a lot of potential contributors to that initial fall as well by telling you that she's been uh that she's had a uti, she's known to have vascular dementia and she's also on a lot of medications. So Aspirin, furosemide and Ramipril in the assessment, I told you the most important thing. So remember that's pulse, blood pressure, respiratory rate and thats those are the most important things from news too. If they are confused, that is possibly one of the first things you should mention about a patient. So if it does say that the patient is confused, make sure you put that in, let them know the main finding you found from examination. So they very much could give you a paragraph of like findings from an examination. It's important for you to pick out the important positive findings. So what you think? So for example, if you hear inspiratory crackles, that's going to be a lot more important than the fact that the trachea is central and non displaced. It's the positive findings that are more important, not the negative findings when you do your S bar. Um And if you, if you have any information on what steps you've taken, make sure you say that. And uh Osama says, I want to add more point while delivering the S bar. We need to remember what exactly the patient drugs are. How long have they been in hospital? Yes, it is important to clarify the drugs. Um However, unfortunately, this person who's on the other end of the phone will be in a different ward and will have loads of other patient's to manage. So it's important to get a flavor of the situation early on. Unfortunately, you can't deliver every single thing on the phone because the time is constrained in the station itself. But then also the person is not going to sit on the phone forever. Um, and it is your job to kind of decide. And unfortunately you will leave out some information that could be important, but it's just important to give them an idea of what's going on if there is any related referral, consultation of any specialty. Yes, if you do have that information, um, the kind of the scenarios you get given at least from my understanding in news two and S bar stations in C P A, they're usually quite simple. They don't try and give you too much information because they understand the level of time constraint you have, I mean, filling out the news to chart will probably take you more than three minutes to do and then you give your S bar and you probably only have about five minutes to do that. Um, just within the time in the station itself and being explained the instructions. That's not very long time to tell someone everything, especially kind of just at the spur of the moment. So don't worry if you don't get it perfect, but make sure that you understand what are the most important things to do and it's all on my slides. So please, when you get sent them or I think when they're available for you, please take a look at them. Um So I hope that was helpful. Um That's kind of the end of the um that's the end of the talk. If you have any questions that will please put them in the chat, Aurand mute and um get my attention. I'm quite happy to answer them. Um And please please fill out my feedback as well. I think this is the feedback and then this is, this is the Instagram account follows. Sits up jazz. Didn't ask you this question. Can we have the video recording the video recording? I'm sure I think Mohammed has that. Yeah. Yeah. So thank you Rio for the, for the accident talk. Uh The recording and the slides will be put up on medal, just make sure to fit in the feedback form, either the scan the QR code or the link in the uh and uh you were able to receive the recording and the slides. So, yeah, and I'll stop the recording now as well.